Nutrition magazine issue 2 may 2006

Issue theme
Breastfeeding
Viewpoint
Give breastfeeding
a chance! 4

Ghana
Seeing is believing 5

Thailand
Challenging industry 8

Ethiopia
Time for breastfeeding 10
A family affair 12

Kenya, DRC and
Indonesia
Surviving emergencies 14

Vietnam
Pressure of work 16

What would you do?
The condensed milk baby 17

Research
Resources
Pull-out poster

Issue 2 May 2006

WHO Global Strategy for Infant and Young Child
Feeding 2003
www.who.int/nutrition/publications/infantfeeding/en/
The global strategy builds on past and continuing achievements in
particular the Baby Friendly Hospital Initiative (1991), the International
The nutrition symbol is derived from the

Code of Marketing of Breast-milk Substitutes (1981) and the Innocenti

three key areas essential to nutrition: food, health and care.

Declaration on the Protection, Promotion and Support of Breastfeeding

Out of each of these, seeds of ideas and experience disperse.

(1990). Governments need to achieve the following targets:
1 To develop, implement, monitor and evaluate a comprehensive

Editorial team

policy on infant and young child feeding, in the context of national

Lourdes Fidalgo (guest editor)

policies and programmes for nutrition, child and reproductive

Carmel Dolan, Kerry Selvester, Fiona Watson

health, and poverty reduction.
2 To ensure that the health and other relevant sectors protect,

The themes of coming issues of nutrition will be:

promote and support exclusive breastfeeding for six months and

• Iron deficiency anaemia

continued breastfeeding up to two years of age or beyond, while

• Growth monitoring and promotion

providing women access to the support they require – in the family,
community and workplace – to achieve this goal.

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3 To promote timely, adequate, safe and appropriate complementary

Contribute by sharing your own experiences, both successful and

exceptionally difficult circumstances, and on the related support

unsuccessful. We will provide writing and editing support if needed.

required by mothers, families and other caregivers.

Send articles of up to 1,000 words, with photos or illustrations:

feeding with continued breastfeeding.
4 To provide guidance on feeding infants and young children in

5 To consider what new legislation or other suitable measures

by post 7 Winterbrook Road, London SE24 9HZ

may be required, as part of a comprehensive policy on infant and

by email

young child feeding, to give effect to the principles and aim of the
International Code of Marketing of Breast-milk Substitutes and to

Letters and emails to the editors are also welcome. Please write!

subsequent relevant Health Assembly resolutions.



Acronyms
Statistics on children under five provided at the start of each of

BCC

Behaviour change and communication

the country-based articles in this issue use the following definitions.

BFHI

Baby Friendly Hospital Initiative

• Underweight refers to weight-for-age less than minus two

EBF

Exclusive breastfeeding

standard deviations below the median of the reference population.

FAO

Food and Agriculture Organisation

This results from wasting or stunting or a combination of both.

GIFS

Global Initiative for Father Support

• Wasting refers to weight-for-height less than minus two standard

HIV

Human immunodeficiency virus

deviations below the median of the reference population.

IBFAN

International Baby Food Action Network

Wasting, or thinness, develops as a result of recent rapid weight

IYCF

Infant and young child feeding

loss or a failure to gain weight.

MDG

Millennium Development Goal

NGO

Non-governmental organization

• Stunting refers to height-for-age less than minus two standard
deviations below the median of the reference population.

UNHCR United Nations High Commissioner for Refugees

Stunting, or shortness, develops over a long period of time.

UNICEF United Nations Children’s Fund

USAID

United States Agency for International Development

WABA

World Alliance for Breastfeeding Action

Front cover: A mother and her child at the entrance to their home in Ethiopia

WFP

World Food Programme

Save the Children UK / Venetia Dearden 2005

WHO

World Health Organisation

Issue 2 May 2006

NUTRITION


Securing children’s future
Lourdes Fidalgo
Senior nutritionist
ANSA, Mozambique

Welcome to the second issue of nutrition, in which we

The article by Kerry Selvester and Okechukwu Aniche indicates the

we focus on breastfeeding, the best start for children.

importance of involving all influential members of the family, with

Looking at the articles in this issue, it is clear that a critical area

particular emphasis on the role of fathers. For decades, the main

for action is for a strong health sector position that provides positive

responsibility for child health has been given to mothers, and the

messages and leads by example in terms of good breastfeeding

influence of other members has been ignored. This has led to less

practice. This needs to be coupled with a policy environment that

successful breastfeeding promotion programmes. Examples are given

allows families to opt for breastfeeding. Families and communities

of men’s involvement in Nigeria, Bolivia, Ghana and Sweden.

are the key providers of care to a mother and her newborn child and

The challenge to protect and promote breastfeeding is also met by

counselling and education should work with all providers to achieve

CARE-sponsored projects in Kenya, the Democratic Republic of

positive behaviour change for good breastfeeding practice.

Congo and Indonesia, where counselling on breastfeeding was seen

In Viewpoint, Annelies Allain points out that we are still far from

as an essential part of emergency interventions. Emergencies present

having adequate monitoring and compliance to the International Code

a threat to breastfeeding and specific measures were taken to ensure

for Breast-milk Substitutes. Although 76 countries have legislation

that good practice could be maintained. Readers wanting to improve

based on the Code, only 32 countries are fully implementing the

their emergency interventions please see the Resources page where

legislation. The article from Thailand by Yupayong Hangchaovanich

there are details regarding training in infant feeding in emergencies.

illustrates how even in a country where the Ministry of Health adopted
the Code in 1984, compliance with the Code is still a big challenge.
IBFAN believe that countries need to move beyond the Code

We have not included a specific article on breastfeeding and HIV in
this issue, as it was discussed in Balancing the risks in Issue 1, which
focused on nutrition and HIV/AIDS.

and towards legal measures with sanctions that enable mothers

A wide range of research on breastfeeding is being carried out at

to breastfeed. Options for enabling mothers to stay at home to

present, namely in the areas linked to the physiology of breastfeeding,

breastfeed are highlighted in Tayech Yimer’s article from Ethiopia,

breastfeeding and HIV, the benefits of breastfeeding in reducing

stressing the particular needs of poorer women. This theme is also

morbidity and mortality and the economic impact of breastfeeding.

taken up in the article by Trinh Hong Son from Vietnam, where

This research will support the design of policies and guidelines as well

exclusive breastfeeding is still a big challenge as women make up

as answer some of the practical concerns of implementers.

a significant proportion of both the formal and informal labour

The magazine includes a selection of resources, with technical

market. In this context, the passing of laws in the areas of maternity

reviews, guidelines, course materials and training courses available.

leave protection and the Code are seen as an essential part of any

Please use this information to improve the implementation of

breastfeeding campaign.

your own activities.

The problem case from Laos poignantly shows the real life

Our main objective is to provide an opportunity to those working in

constraints to good breastfeeding practice; hard physical work of

the development field, to share practical experiences of implementing

women, often away from the home, cultural beliefs and readily

nutrition activities. We have been pleased to hear from our readers

available breast milk substitutes. However, in the article based on

after the publication of Issue 1, both in print and on the web

work in Ghana, Joan Shubert and Luann Martin give us hope that

(www.nutritioninternational.org.uk) and we look forward to future

breastfeeding practices can be improved in a relatively short period

letters and articles contributed for future issues.

through partnership, training, behaviour change communication and

Enjoy the second issue of nutrition. Please be encouraged to

support to the whole family. The article describes the practical steps

share your experiences of the challenges and successes of community

taken by a national programme.

nutrition initiatives.
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NUTRITION

Issue 2 May 2006

Viewpoint

Give breastfeeding
a chance!

Annelies Allain
Director
The International Code Documentation Centre, IBFAN, Malaysia

May 2006 marked the 25th birthday of the International

The Code, if fully implemented, will remove advertising for breast milk

Code at the World Health Assembly. The Code has served as a

substitutes, free gifts etc and babies worldwide will get a chance for

reminder to governments and health workers and policy makers of the

the best start in life. Breast milk substitutes may then be used for those

life-saving benefits of breastfeeding. Some believe that it has been

rare cases of medical need where they can save lives.

1

overtaken by different or more urgent health interventions such as

Companies spend millions to get their share of an estimated US$20

the battle to reduce HIV infection or the need to vaccinate as many

billion market and find ways to get around the Code. One thing,

children as possible. Yet The Lancet in a series of articles in 2003

however, is clear: where a country has a strong national law, properly

identified breastfeeding as the single most effective intervention to

implemented and enforced, Code compliance improves. This should

prevent child mortality and morbidity.

spur more governments to implement the Code at the national level.

It is often forgotten that breastfeeding provides long-term

Some 76 countries have made the Code into national legislation,

protection and that colostrum is the first and the most important

32 in full, the others partially. Monitoring and compliance however, are

vaccination in a child’s life. A recent study in Ghana on neonatal

far behind the ideal. Twenty five years of studying effective protection

deaths calculates that if mothers start breastfeeding within one hour

of breastfeeding has taught IBFAN that legal measures with sanctions

of birth, almost one million neonates could be saved. The same study

are the only real means to give breastfeeding a chance.

shows that babies that were fed only breast milk were four times less

All nations, big or small, poor or rich, can act to enable

likely to die than those who were also given cows’ milk or solids.

mothers to give children the best start and the best future.

2

Cows’ milk is made for calves whose body weight has to increase
rapidly after birth as opposed to human babies who only grow half as

Summary of the International Code

quickly but whose brains experience the fastest development during

• No advertising of breast milk substitutes, feeding bottles & teats.

the first three months. If we think of a baby’s growth this way, it

• No free samples to mothers.

becomes quite clear that human milk is very special.

• No promotion in healthcare facilities, including no free or

How did people turn to formulas based on cows’ milk? More and

low-cost formula.

more mothers started bottle feeding thinking it was the same thing or

• No company personnel to contact mothers.

believing it was better. One of the most powerful factors behind this

• No gifts or personal samples to health workers.

has been the promotion of artificial feeding. By 1965, only 25 per cent
of babies in the richest countries were breastfed. And the same pattern
started in developing countries with disastrous results.
WHO and UNICEF realised they had to stop the drift to bottle
feeding and, with others, developed the International Code (see box

Health workers should never pass samples on to mothers.
• No pictures of infants or words idealising artificial feeding,
on the labels of products.
• Information to health workers should be scientific and factual.
• Information on artificial feeding should explain the benefits

for summary). Governments were asked to make laws to reduce or

and superiority of breastfeeding and the dangers associated

eliminate commercial promotion. Many have done so, but not enough.

with artificial feeding.

Some are not convinced while others think of breastfeeding as so
natural that it needs no protection. Mothers ended up being confused
and losing the confidence and support that they need to breastfeed.
Although formula makers know that formula cannot match the real
thing, they keep this information in the small print and aim marketing
at convincing consumers that the latest formula is better than ever.

1 The International Code of Marketing of Breast-milk Substitutes was adopted
by the World Health Assembly on 21 May 1981, as a non-binding public
health recommendation.
2 Delayed breastfeeding initiation increases risk of neonatal mortality.
Edmond KM et al. Pediatrics 117; 380–386; 2006.

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Issue 2 May 2006

NUTRITION


Seeing is believing
Mobilizing community support for
breastfeeding in Ghana
Nearly all mothers breastfeed in Ghana, but infant feeding practices are sometimes
inappropriate. A large-scale behaviour change and communication project has been

successful in changing practices.

Children under five in 1998
Underweight

25%

Wasting

10%

Stunting

26%

Breastfeeding practices can be improved over

Programme interventions included training and

a relatively short period and on a large scale

BCC through radio programmes, print media,

through partnerships, training, behaviour

interpersonal counselling, community events, and

change communication (BCC), and support. The

mother-to-mother support groups. By 2004, the

Ghana Health Service and the USAID-funded

programme reached all 24 districts in the northern

LINKAGES Project, jointly implemented a national

regions plus seven districts in four other regions.

programme to improve the nutritional status of

Surveys to measure progress were conducted every

Ghanaian children by promoting early initiation

year and the three indicators used were exclusive

of breastfeeding, exclusive breastfeeding for the

breastfeeding, timely initiation of breastfeeding,

first six months of life, and timely and adequate

and timely complementary feeding. All rates were

“The yellow milk

complementary feeding.

higher at the last survey in 2003 (see graph).

is God’s way of

Commonly though, initiation of breastfeeding is

Infant feeding practices in programme areas

welcoming your baby

delayed, water and other liquids are introduced

in Ghana

into the world”

1

Nearly all mothers start breastfeeding in Ghana.

early, while semi-solid foods are introduced late.

UNICEF Global database on child malnutrition

The three northern regions of Ghana, where 16

Counselling card

per cent of the population live, have the highest

message

rates of malnutrition and are the most remote,
sparsely populated regions in the country. More
than two-thirds of the women in these regions have
never been to school. The majority are engaged in
agricultural activities.
The programme, begun in nine northern districts
in 2000, used existing networks and communitybased approaches. Programme partners included
UNICEF and their local government counterparts,
radio announcers from three local stations, and
10 international and local non-governmental
organizations. The partners were involved in
a variety of activities such as child survival,
community development, mothers’ clubs, microcredit, water and sanitation, growth promotion,
food distribution, and mobile clinics.

5
NUTRITION

Issue 2 May 20 06


Messages, materials, and media

broadcasters resulted in entertaining and

From the beginning, the partners were actively

technically accurate programmes that appealed

engaged in the planning process, including initial

to listeners. Some radio programmes broadcast

research, a two-week message and materials

songs and interviews with mothers that had

production workshop, pre-testing of materials,

been recorded during training exercises in the

and a six-day follow-up workshop to refine the

communities. Over four years, approximately 500

messages and establish the strategic direction for

radio broadcasts were made. The programmes,

the programme. The research provided insights into

broadcast in English and eight local languages,

deeply ingrained beliefs. For example, giving water

used a variety of formats such as radio call-in

early was the norm and some mothers discarded

shows, quiz programmes, dramatic comedies, panel

colostrum because they were told it was ‘dirty.’

discussions, and interviews with traditional chiefs

“In the beginning it was terrible promoting

and community leaders, both male and female.

exclusive breastfeeding” reported a mother
support leader from the Upper East Region.
Frequent, unhurried feeding

“Mothers-in-law and husbands would ask, ‘When
you were born, were you not given water? How
can you not give this child water? Do you want to
kill him?’” Resistance to exclusive breastfeeding
started to break down when people saw that
babies of ‘early adopters’ of exclusive breastfeeding
were healthier than those who received water:

Position well

seeing was believing.
The project developed a set of counselling
cards with culturally appropriate messages for
pregnant women and mothers, and another set
for grandmothers and traditional birth attendants.
Messages for fathers were placed on posters,

T-shirts, and calendars. The following are examples

Fathers’ support

of messages focused on specific behaviours for
priority audiences:
• Mothers, put your baby to the breast
immediately after delivery to ensure a healthy
beginning for both you and your child. This will
help reduce bleeding and protect your child
from infection. The yellow milk is God’s way of

Breastfeed exclusively

welcoming your baby into the world.
• Fathers, a wise father encourages exclusive
breastfeeding so his baby grows up to be strong,
healthy, and intelligent. Give your wife the time
she needs to breastfeed your baby.
• Grandmothers, breast milk has everything
your grandchild needs through six months of

Women’s group
Counselling cards

age to satisfy and quench hunger and thirst.
Consistent messages were communicated through
the media and interpersonal communication.
The close working relationship with local radio

Mother-to-mother support groups
Women’s groups, including micro-enterprise and
credit groups, Red Cross mothers’ clubs, and
breastfeeding support groups, served as another
avenue for breastfeeding promotion and support
(see example in box below).
Red Cross mothers’ club in the village of
Deega, Ghana
Twice a month a group of 20 mothers gather
to sing, discuss a health topic, and share their
experiences. They are mainly farmers, most of
whom are illiterate. Some are co-wives and share
the same husband. The youngest person in the
circle is two-month-old Amsha; the club’s second
‘experimental’ child because she is only the
second one to be exclusively breastfed.
The leader of the group (Amsha’s
grandmother) came back from a Red Cross
training telling club members that children up
to the age of six months need only breast milk
and that the tradition of giving water to young
infants leads to illness. Club members started
hearing the same new message on the radio and
at the antenatal clinic, child welfare clinic
and hospital.
At first many in Deega doubted that a child
could survive without water. Amsha’s grandfather
was one of the sceptics. When he saw that the
first exclusively breastfed child was healthy,
his resistance broke down, especially when he

realized that the family could save money by not
having to buy drugs to treat a sick child.

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Issue 2 May 2006

NUTRITION


participating in mother-to-mother support groups,

1 The LINKAGES Project is funded by

remember: no standing, no lectures, no knowing it

USAID and managed by AED under

all. These groups are for sharing information.”

the terms of grant HRN-A-00-97-

World breastfeeding week
During the annual world breastfeeding week, the
radio campaigns intensified. Community activities
provided an opportunity for celebration, advocacy,

00007-00. The opinions expressed
are those of the authors and do
not necessarily reflect the views of
USAID or AED.

community mobilization, and recognition of
community health volunteers. Activities during the
week included parades and community festivals
featuring skits, original songs, drumming and
dancing, poems by schoolchildren, testimonies by
mothers, and speeches by dignitaries. These festivals
frequently received television coverage.

Lessons learned
The experience of community mobilization in
Ghana showed the importance of engaging a
diverse set of partners and a variety of forums to
keep the partners involved and motivated. Annual

Ghanaian woman breastfeeding

monitoring of programme progress also served to

Joan W Schubert

motivate partners.
Another mothers’ support group composed songs

When the programme ended, the partners had

warning “Only foolish women do not exclusively

print materials and skills in BCC and mother-to-

breastfeed. They run from clinic to herbalist to treat

mother support methodologies. Close working

their child’s diarrhoea.” Group members visited

relationships had been forged with the radio

women after childbirth, offering their support and

journalists and stations who, due to popular

encouragement and inviting new mothers to

demand, continued to broadcast extensively on

their meeting.

infant and young child feeding issues. The materials

The project provided training to the partners

and approaches developed through the programme

in mother-to-mother support group methodology

are currently being adapted for promotion of infant

for breastfeeding and complementary feeding.

and young child feeding in southern Ghana.

The partners then conveyed their information and

All the activities played a role in helping

Joan W Schubert

skills to women’s group leaders. The project also

create a positive environment for breastfeeding.

Academy for Educational

organized annual exchange visits for group leaders.

Alongside the community-based programme,

Development

The visits included message reviews, technical

LINKAGES supported advocacy activities, training

Country coordinator, LINKAGES

updates, planning for world breastfeeding week,

for health staff, assessments of baby-friendly

Ghana office 1999–2003

and songs, dances, and dramas on breastfeeding.

hospitals, and revision of the curricula of all

Luann H Martin

medical and paramedical training institutions in the

Academy for Educational

at the time was the Regional Health Educator and

country to ensure that they adequately addressed

Development

Chairman of the Upper East Red Cross, said “I used

breastfeeding.

Information development

At one of the exchange visits, Gaston Bozie, who

to like getting large groups of women together

Experience shows that a comprehensive

specialist, LINKAGES

and talking to them about health. I was sceptical

programme that engages partners and focuses on

of mother-to-mother support groups, but now I

these aspects – community-based promotion and

For further information on

see their value. It doesn’t mean that health talks

support, health services, and policies – fosters

the LINKAGES Project

and health education will end. But when you’re

long-term sustainability of results.

www.linkagesproject.org.
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NUTRITION

Issue 2 May 2006

Challenging industry
Opposing misleading advertisements
in Thailand
Children under five in 1995

Thai mothers are being told that their babies’ mental development can be promoted

Underweight

through the use of formula milks. Campaigners are working to oppose advertising of

18%

Wasting

5%

Stunting

13%

UNICEF Global database on child malnutrition

baby milk formula and promote a renewed culture of breastfeeding in Thailand.
Many mothers in Thailand are abandoning natural

one year of age found that almost half had seen

breastfeeding in favour of cows’ milk formula

advertisements for DHA and AA powdered milk

products. This is the effect of advertisements

products. Of these, 65 per cent said they were

claiming that products rich in docosahexaenioic

convinced of the health benefits to their infants.

acid (DHA) and arachidonic acid (AA or ARA) are

The claims wildly exaggerate the value of DHA

important for a baby’s mental development. Thai

and AA. “Actually, the most important factors in

powdered milk manufacturers started fortifying

brain development are genes and breast milk”

their products with DHA and AA four years ago

notes Dr Werapong Chatranont, a paediatrician.2

and have been conducting an intensive advertising

DHA and AA can help brain development, but both

campaign. The box below illustrates some of the

nutrients are found naturally only in human breast

claims made about these products.

milk. Manufacturers therefore add linoleic acid and

Information on Similac product
Brain Development
Develops visual and mental ability,
promotes learning

linolenic fatty acids to the milk, which the infant’s
body can turn into DHA and AA. It is not known
what harm this may do in the long run.

Implementing the Code in Thailand

• DHA and ARA

The Ministry of Public Health (MoPH) adopted the

• high omega 3, 6, 9

first Code of Marketing of Breast-milk Substitutes

• taurine and choline

in 1984. It was revised in 1995 and renamed the

• high iron
Bone Development
Improves bone strength and a healthy body
• no palmitic oil
• high calcium and potassium
• high vitamin C and D
Immunity Development
Supports immunity

Thailand Code of Marketing of Foods for Infants
and Young Children and Related Products. The new
Code and a Memorandum of Understanding (MOU)
for its implementation was signed by the MoPH
and a number of companies. A 1992 agreement
stated that “the Royal Thai Government and Trade

Association of Breast milk Substitutes and Related
Products have agreed to cease all free and low-

• nucleotides 72 mg/l

cost supplies of infant formula to ALL hospitals in

• high zinc

Thailand from February 1992.”
Code compliance is voluntary, however, though

All photographs by the author 2006

There are worrying signs that the campaign has

Thailand does have a national law concerning food

been successful. A poll carried out in February

advertising. The Food and Drug Administration

2006 of 733 Bangkok mothers with infants under

(FDA) is responsible for monitoring food labels

1

8
Issue 2 May 2006

NUTRITION


and advertisements while the MoPH is responsible

Opposing advertising

for monitoring information distributed within the

In 2004, the FDA took steps to improve compliance

health care system.

with new regulations, as follows.

Weakening the Code
In 1997, the MoPH signed an MOU with four baby
food companies, which limited the applicability
of the voluntary Code to products for babies less
than a year old. The MOU lapsed after a year but
following representations by more baby food
companies, another MOU was prepared in 2001
that reversed the position taken by the 1995
Code. This contravened the World Health Assembly
Resolutions 39.28 (1986), 45.34 (1992) and 47.5
(1994) by allowing free supplies of milk formula to
children over one year of age.

Breaking the Code
Four surveys carried out on Code compliance show

• Advertising food for infants
and young children is
prohibited, including infant
and follow-up formula and
complementary foods with the
exception of advertisements in
medical journals.
• Advertisements should not claim
to mother’s milk. They should not encourage
feeding babies or children with manufactured

Mothers reported that

food products.

they had received

• Pictures portraying babies or small children in
advertisements is prohibited.
• Advertisements should include statements to the
effect that a mother’s milk is the best food for

1 In 1992, a survey by the Consumer Protection

her baby.

Association of Thailand found extensive evidence

As a result of training given to health care

of free and low-cost baby formula supplies

workers on the Code, baby milk donations and

to hospitals.

advertisements to BFHs have now ceased. However,
representatives are friends with the doctors and

facilities and outside the healthcare system.

nurses.
2005 by the MoPH. This includes:

Thailand was found to have the largest number

1 Training of Code watchers to report incidents of

4 In 2003, the MoPH and Thai Breastfeeding
Alliance surveyed 84 hospitals and clinics. A

from health workers in
hospitals and clinics.

A plan of action on the Code was developed in

Monitoring carried out a four-country study and
of health facilities receiving free samples.

free samples and gifts

one barrier to change is that many milk company

country and found violations within health
3 In 1997, the Interagency Group on Breastfeeding

for medical practitioners

that the product is better, equivalent or similar

that code breaking is common.

2 In 1995, IBFAN surveyed four regions of the

Example of an advertisement

violation.
2 Approval by the FDA of all baby milk company

Free sample gift bag given to new
mothers, containing a tin of formula
and brochures.

materials before distribution.

significant portion of the hospitals (84 per cent)

3 Meeting between the MoPH and companies to

were part of the Baby Friendly Hospital Initiative

announce the policy and the measures that will

1 ABAC poll. 8–16 February 2006.

(BFHI). Around 80 per cent of the hospitals and

be taken when violations occur.

2 Report of a meeting convened by

clinics received free supplies from baby milk
companies, most commonly unsolicited. Almost

4 Strengthening BFHI through appointing a

the Thai Breastfeeding Center in

re-assessment team at the regional level.

cooperation with the Thai Health

all of the advertising material was not approved

Thailand has the opportunity to emulate countries

Promotion Fund Organization.

by the FDA. Of 700 mothers with babies under

that have banned powdered milk advertisements

Bangkok, 21 February 2006.

six months, half only breastfed. A third of the

for infants and children. This will protect the fragile

mothers who used formula reported that they

physiology and underdeveloped immune systems

Yupayong Hangchaovanich

used a specific brand of formula based on a

of young babies from becoming prey to products

Vice Chairperson of Thai

health worker’s recommendation. Mothers

bolstered by suspect claims. This would lead to a

Breastfeeding Center

reported that they had received free samples,

new era of breastfeeding culture in Thailand.

gifts and company materials from health workers

For further information

in the hospitals and clinics.


9

NUTRITION

Issue 2 May 2006


Time for breastfeeding
Supporting mothers to stay home and
breastfeed in Ethiopia
Children under five in 2000

Exclusive breastfeeding protects babies from malnutrition. Yet in Ethiopia, it is the

Underweight

47%

poorest mothers who face the most constraints in being able to exclusively breastfeed.

Wasting

11%

Can supporting them to stay at home longer improve exclusive breastfeeding rates?

Stunting

52%

UNICEF Global database on child malnutrition

Ethiopia is one of the poorest countries in the

exclusively breastfeeding by the time their baby is

world. The majority (80 per cent) of the population

five months old (see graph).

lives on less than US$2 a day while recurring
drought, famine and epidemics have caused

The rate of exclusive breastfeeding

countless deaths over the years. Malnutrition is

by child’s age

also high and around half of all under-fives are
stunted. Save the Children United Kingdom (SC UK)
is working in Gubalafto woreda, North Wollo Zone
in Amhara Region on a project that aims to reduce
dependency on external assistance and improve the
resiliency of chronically food-insecure households.
This article describes research undertaken by SC UK
in Gubalafto.
The research aimed to assess the causes

Babies who were not
exclusively breastfed
were five times
more likely to be
malnourished than

those who were.

of chronic malnutrition in children aged 0–24
months. A total of 1,471 children were selected
for weighing and measuring and their carers
were asked to complete detailed questionnaires.
Extensive focus group discussions were conducted
(carers were divided by wealth group and

Mothers’ time

educational status).

Exclusive breastfeeding depends not only on a

Breastfeeding pattern was found to be the

mother knowing that exclusive breastfeeding

most important determinant of malnutrition in

is best, but also on her ability to spend enough

babies under six months. Babies who were not

time with her child to provide sufficient breast

exclusively breastfed were five times more likely to

milk. The survey found that among women with

be malnourished than those who were. The rate of

children under six months, those who spent more

breastfeeding is high in Gubalafto (almost 90 per

than two hours a day away from their babies were

cent of women interviewed were breastfeeding

significantly less likely to exclusively breastfeed than

their children at age six months) but exclusive

those who spent less time away from home.

breastfeeding begins to decline after two months.

Focus group discussions revealed that,

It is also common practice for women to give

postpartum (after delivering a child), women

rancid butter and sugar to their children in the first

from poorer groups have to leave their home to

few days of life. Hence only 60–70 per cent are

undertake various activities earlier than better-off

10
Issue 2 May 2006

NUTRITION


Ethiopian mothers and children

Save the Children UK / Boris Heger 2005

women and for longer periods in order to obtain

Supporting mothers to stay at home

food and income to look after their families (see

Wealth, or rather poverty, is an overriding factor

Poorer women are

table). This means that poorer women are less likely

in the development of malnutrition that has to

to be able to exclusively breastfeed.

be addressed in order to improve the situation

less likely to be able to

of young children. Every effort must be made to
Numbers of days postpartum after which

improve the food and cash income of poorer groups

women leave their homes to undertake

in the community, either through income generating

certain activities

activities or social support mechanisms.

Better-off

Medium /
poor

exclusively breastfeed

Women from all wealth groups should be
enabled to spend at least the first six months of

Fetch water

40 days

30 days

their child’s life at home with their child in order to

Go to market

140 days

90 days

be able to exclusively breastfeed. Different methods

Do farm work

180 days

120 days

to encourage women to stay at home during this
critical period need to be considered. One idea is
to provide women with the cash or food equivalent

In many cultures, women stay at home for 40 days

of their earnings outside the house, so that they

after delivery and other family members support

do not have to leave the house for long periods of

them. In Gubalafto, poor mothers have to go to

time (more than two hours per day). Alternatively,

fetch water prior to the 40 days. Better-off women

women could be encouraged to take part in income

do not undertake farm work with an infant of

generating activity that they can undertake at home

less than six months, but women from poorer

so that they do not have to leave their children.

households start to work on the farm after about

Through the current project, SC UK is working to:

three months. Thus poor women have to leave their

1 Promote wealth in poor households in the

children at a young age.
When a mother has to leave her child in the
house, someone else has to look after him. Normally

project area through food and income activities,
such as goat loans.

2 Lobby the government to allow lactating women

this will be the grandmother or a teenage child. But

who are eligible for employment generation

the best person to look after an infant who needs

schemes (Food for Work) to be paid to attend

to be breastfed is his mother. If the mother is away

health and nutrition education lessons instead

Tayech Yimer

for a long time she cannot breastfeed, unless she

of being forced to do physical labour. This

Nutritionist

has expressed milk before leaving (a practice that

represents a major breakthrough with the

Save the Children UK

is unheard of in Gubalafto). To improve exclusive

Government of Ethiopia.

Ethiopia Office

breastfeeding rates and decrease inappropriate

So far, there has been no documented impact of

feeding practices, ways need to be found to keep

the programme, but it is continuing and a final

For further information

poor women at home for longer postpartum.

evaluation is planned.


11

NUTRITION

Issue 2 May 2006


A family affair
Strengthening fathers’ support for
breastfeeding worldwide
All family members need to be involved in the care of the newborn infant. In particular,

fathers need to actively support good breastfeeding practice. Some organizations
therefore target men and other influential family members, as well as women.
In many societies, breastfeeding is regarded as
a woman’s business. As the example in the box
illustrates, even educated men may have very oldfashioned views about breastfeeding. Recognition
that a supportive family is an essential part of good
breastfeeding practice has led some organizations
to focus on behaviour change that targets men and
Support for child care during

other family members with influence as well

breastfeeding

as women.
Drawing men into the breastfeeding debate is
a challenge in communities as far apart as Bolivia,
Ghana and Sweden. In each of these countries
different methods have been used to encourage
men to support breastfeeding proactively.

Nigerian men’s views on breastfeeding
A selected sample of 25 Nigerian men who have
attended higher institution in Lagos were asked
for their views on breastfeeding. The men were
25 to 45 years old and 13 were married, while
12 were single. All knew that breastfeeding is
good for a child’s health but seven did not agree
that men have a role to play in breastfeeding.
Only five mentioned that men should provide

nutritious food and support to their wives. Only
one mentioned that men should provide a stressfree environment to a breastfeeding woman.
Okechukwu Aniche, who conducted the survey
especially for this article, comments:

Involving men in breastfeeding

”My general assessment is that only one fifth of

In Ghana, a LINKAGES-led campaign appealed to

the men sampled really know what breastfeeding

men’s sense of responsibility and pride, with the

is all about. Some even declined from partaking

theme of ‘Breastfeeding: A wise family choice’

in my questionnaire (as they think that

which included posters aimed specifically at fathers.

breastfeeding is exclusively a mother’s affair) and

A man helping his wife to put the baby

In Bolivia, LINKAGES found that the majority of

wondered why a man like me would be involved

on the breast immediately after birth.

health promoters were male and that over half of all

Counselling cards from Bolivia

births were attended by family members including

LINKAGES Bolivia

fathers. Behaviour change work concentrated
on improving the men’s understanding of the
importance of immediately starting breastfeeding,
relieving women of domestic duties so they have
time to breastfeed and becoming involved in
complementary feeding of older infants. Messages
were passed through the male health promoters
during family visits on Sundays when fathers were
present and through radio and TV promotion. All
images and messages stressed the importance of

in such a survey.
It is a true reflection of our society. I am residing
in Lagos where educated men are found. But
the majority still believe that men have no role
to play in breastfeeding. This lack of interest is
linked to African beliefs and also to our policy
formulators and implementers. Most employers
still find it difficult to grant the required maternity

leave and some even disallow newly employed
females from getting pregnant within the
probation period.”

12
Issue 2 May 2006

NUTRITION


the role of fathers in supporting the women in good

milk flow and results from being worried or afraid,

breastfeeding practice.

pain or if the mother feels embarrassed. Fathers

In Sweden the project Pappagrupperna (‘Dads
for Real’) targets first-time fathers, offering six
counselling sessions (one before the birth of the

can help to provide a stress-free environment for
breastfeeding.
Finally, there is increasing recognition that

child and five after the birth) to:

good breastfeeding practice requires a national

• focus on the child’s interest

legislative framework that is supportive of family

• increase gender equality within the home

rights. The fight for maternity and paternity leave,

• strengthen relationships in the family

breastfeeding time allowance or provision of

• support fathers to be active parents.

workplace crèche facilities are issues raised in

There are a number of key issues for family support

various countries where women in the formal sector

initiatives around the world, namely:

are denied the right to breastfeed their infants due

Support for good nutrition

• increasing awareness of the demands of

to employment policy.

during breastfeeding

breastfeeding, focusing on physiological,
emotional and time management issues
• enhancing understanding of good breastfeeding

The Swedish fathers support project,

Pappagrupperna, lobbies for increased take-up of

Counselling card from Ethiopia

LINKAGES Ethiopia

paternity leave and equal sharing of child care and

practice, including the importance of exclusive

support. Currently Swedish men take 19 per cent

breastfeeding

of the parental leave allocation (almost double the

• lobbying for a supportive legislative environment.

amount taken in 1995) and the group would like to

Men need to be aware that mothers need blocks

see this increase.

Fathers can help to

Conclusions

provide a stress-free

In order to ensure that all babies are given a

environment for

of time to sit and breastfeed. Women often feed
‘on the run’ if they work outside the home, or have
many domestic tasks such as collecting water, child
care and food preparation. This affects the quality
of the feed. Re-organisation of family activities and
sharing of responsibilities for domestic chores are
needed to provide time for breastfeeding.
Take time to optimize the nutritional value
of each feed
Foremilk
• Secreted at the beginning of a feed
• Contains more proteins, vitamins and
minerals
Hind milk
• Secreted at the end of a feed
• Contains more fat and helps baby
gain weight

Creating a supportive environment for the mother
has a physiological effect on the quality of

healthy start to life, the message is to involve all
adult carers. Whether your interest is in promotion

breastfeeding

of good breastfeeding practice at the household
level, greater equality for women in the workplace,
or improved fathering skills, communication and
information is the key to success.

Useful contacts
• Global Initiative for Father Support (GIFS)
Ray Maseko

Arun Kumar Thakur

or go to:
www.waba.org.my/fathers/index.html

Kerry Selvester

• LINKAGES
www.linkagesproject.org

Senior nutritionist, ANSA

• Pappagrupperna

www.pappagrupperna.se

Okechukwu Aniche

Mozambique
Department of Chemical

breastfeeding. The hormone oxytocin is produced

Engineering, University of

during the feed and ensures milk flow. Oxytocin

Lagos, Nigeria

is often referred to as a “love hormone” as it is
associated with good feelings, thinking lovingly,

For further information

and being confident. A poor oxytocin reflex reduces


13

NUTRITION

Issue 2 May 2006

1

Surviving emergencies

2

Support for breastfeeding in Kenya, the
Democratic Republic of Congo and Indonesia
Children under five
Underweight Kenya

Wasting
Stunting

Breastfeeding is at particular risk of disruption in emergencies. Training on breastfeeding
20%

counselling has been carried out in three different emergency contexts. The focus is on

DRC

31%

clinical practice sessions where participants have a chance to work directly with mothers.

Indonesia

26%
Emergencies (droughts, floods, wars, famines) cause

particularly vulnerable in difficult circumstances.

13%

terrible hardship and can have lasting impacts

• Stress can affect a woman’s ability to breastfeed

Kenya

31%

on breastfeeding. For example, WFP and UNICEF

DRC

38%

carried out a rapid assessment of the food and

Kenya

6%

DRC

Years of data: Kenya 2003, DRC 2003, Ind 2002

nutrition situation following the earthquake that

No data on wasting and stunting for Indonesia

struck the northern part of Pakistan in October

UNICEF Global database on child malnutrition

2005 killing over 80,000 people. The assessment

1 Kenya

found a decrease in overall breastfeeding rates of

2 Democratic Republic of Congo

20 per cent among children under 24 months.

3 Indonesia

1

One of five priority actions in the WHO Global

or the quality of her breast milk.
• Tired and malnourished mothers cannot produce
enough milk.
• If a mother breastfeeds while ill, she will transfer
the sickness to her infant.
• Once breastfeeding has stopped, it cannot be
re-established.
• A mother who must leave her infant with other

Strategy for Infant and Young Child Feeding

caregivers for extended periods (to farm, obtain

“Now I have

(IYCF), is support in exceptionally difficult

food or gather wild foods, water or firewood

wonderful new

circumstances, including emergencies. CARE, an

in insecure environments) cannot continue to

international NGO, is therefore building institutional

breastfeed her baby.

knowledge. I am

capacity to address IYCF and care in emergency

Just as damaging is the belief that since “all

going to teach my

situations (IYCF-E) by including special training

women breastfeed” no special assistance is

in breastfeeding counselling as part of a more

required, and that infants under six months of age

daughters.

comprehensive programme.

are protected from malnutrition.

As refugees, we are

These beliefs have resulted in the distribution

The risks to breastfeeding
in emergencies

of infant formula and inappropriate milk products

only thing we will

There are many risks to breastfeeding during

failures to:

emergencies. The uncontrolled distribution of

• include young infants in anthropometric surveys

carry back to Somalia

breast milk substitutes may unintentionally

with us is our new

create dependence.

knowledge.” Somali

of Aceh nine months after the event, CARE staff

• integrate breastfeeding protection and support

observed that infant formula had been given to

into therapeutic care of malnourished infants

poor people – the

elder refugee and
women’s leader

During a field visit to the tsunami-affected areas

during some emergencies. There have also been

and IYCF practices in emergency assessments

• implement special interventions designed to
protect, promote and support breastfeeding

new mothers by midwives as a ‘precaution’ in the

• address the special needs of mothers who have

event that the mother experienced breastfeeding

been raped or who suffer from depression,

problems.

stress, poor diet or malnutrition, all factors that

2

There are a number of myths, misconceptions
and half-truths that suggest that breastfeeding is

may impact either their perception of their ability
to breastfeed or their willingness to do so.

14
Issue 2 May 2006

NUTRITION


The CARE Infant and Young Child

Feeding Initiative

Building breastfeeding counselling
and communication skills

CARE has a broad, three-part strategy:

CARE is building the counselling capacity of staff

• capacity-building of staff and partners

and partners who work directly with mothers

• contributing to global learning

(using an adapted version of the WHO/UNICEF

• actively supporting inter-agency efforts to

breastfeeding counselling course and modules

develop common guidance.

1 and 2 of Infant feeding in emergencies – see

This article describes innovative CARE IYCF-E

Resources page). The distinguishing feature is the

activities in three emergency settings.

emphasis on developing counselling skills during

3

1 Field Exchange, Issue 27,
April 2006.
2 Report of observations by Endang

In the Dadaab camps for Somali refugees in

four clinical practice sessions in which participants

Widiastuti, CARE International

northeastern Kenya, CARE, GTZ and UNHCR are

have practical, hands-on experience with mothers

Indonesia and Mary S Lung’aho,

implementing a comprehensive programme through

and babies. They learn by observing and talking

CARE Initiative for IYCF-E Aceh,

both the community development and health

with mothers experiencing different challenges:

September 2005.

care delivery systems. Initial in-service training

for example, a mother with a low birth weight

is reinforced by ante- and post-natal counselling

infant, twins, or a breast problem.

schemes and communications strategies to
encourage behaviour change.

By the end of the two-week Training of Trainers,

3 Addressing high malnutrition

rates in protracted situations:
The nutrition and food security

there is team of up to eight qualified trainers, and

situation in selected refugee

up to 24 participants are trained as breastfeeding

camps in Kenya.

prone West Timor, Indonesia and on tsunami-

counsellors. Both male and female participants

A Joint UNHCR and WFP Mission

affected Simeulue Island off the northwest coast

have been enthusiastic. As a Kenyan Somali male

17 November to 2 December 2005

of Sumatra, CARE and the Ministry of Health are

nurse noted“It is important that we involve men

working to protect and support breastfeeding

to help fathers understand the importance of

during the rehabilitation of malnourished infants.

breastfeeding. They are the individuals who have

This includes guidance on ‘supplementary suckling’,

been negative in the past… We must communicate

a method of giving milk supplements to an infant

what we have learned to other men.”

In three districts of food-insecure and flood-

who is unwilling to suckle at a breast that is not

After the training, additional activities are

producing milk. The infant draws a milk supplement

undertaken to support behaviour change among

through a tube while suckling at the breast, which

mothers and families, the community, service

stimulates the mother’s own breast milk production.

providers and programme managers.

In Maniema Province of the Democratic

A joint UNHCR/WFP evaluation recently

Republic of Congo (DRC), a post-conflict setting,

concluded that the training in Dadaab was

CARE is integrating breastfeeding support into

“at a very manageable and reasonable cost …

reproductive health activities. The focus is on LAM

Even health workers with years of experience found

(the Lactational Amenorrhoea Method), which

the training extremely informative …

supports improved breastfeeding as a family

They now have practical tools to support good

planning method.

breastfeeding practices.” 3

“We no longer wait
three days before
putting a newborn
baby to the breast.”
TBA in Dagahaley
Camp, Dadaab

Clinical practice session in a Dadaab camp

Mary S Lung’aho 2005

Joan Jennings
Child Health Team Leader, CARE

Anne Njuguna
IYCF Coordinator, Dadaab
Camps, CARE Kenya
For further information
care_iycf&
15
Issue 2 May 2006


Pressure of work
Exclusive breastfeeding in Vietnam

Children under five in 2003

Only one in 12 babies under six months are exclusively breastfed in Vietnam.

Underweight

Mothers face work pressures and lack the confidence to breastfeed.

28%

Wasting

7%

Stunting

32%

UNICEF Global database on child malnutrition

It is difficult to
create a balance;
encouraging
breastfeeding and
promoting high
income-earning
potential for women.

Most Vietnamese children under one year old are

of breastfeeding.2 Furthermore, decisions regarding

breastfed, but a recent survey found that only 12

breastfeeding within the family depend a lot on the

per cent of infants under six months are exclusively

opinion of family members and the community.

breastfed and 39 per cent of mothers give food as

The baby food industry which promotes its

well as breast milk in the first week of an infant’s

products on television and which shows healthy

life. Nearly a quarter of babies are bottle-fed.

looking babies on milk substitute product labels,

1

Pressure of work
A number of factors have been identified that

breastfeeding.

explain the current pattern of breastfeeding. Firstly,

Moving forward

the survey found that mothers who have to go back

The Baby Friendly Hospital Initiative (BFHI) was

to work before the infant is six months of age are

started in Vietnam in 1993 and, so far, 53 out of 80

14 times more likely not to exclusively breastfeed

hospitals have been awarded BFH status.

than mothers who stay at home for longer.
By Government law, maternity leave lasts until

A new Government Decree in February 2006
on the marketing and use of formula and nutrition

the infant is four months of age. The majority of

products for infants and young children illustrates

women, however, who are self-employed (those

the Government’s commitment to the protection

involved in farming, handicrafts, small business etc)

and promotion of breastfeeding. The Ministry of

are forced to go back to work soon after giving

Health and other agencies have a duty to promote

birth to sustain their livelihoods. Women employees

BFH nationwide and to advocate for baby-friendly

of private companies may lose their job if they stay

work places for lactating mothers, such as

at home too long after giving birth. They will not

breastfeeding rooms at the office or factory and

receive bonuses whilst on maternity leave and they

breastfeeding time (at least one hour per day).

feel the pressure to return to work early in order to

Although mothers in Vietnam face many

get promotion and a higher salary.
Baby milk formula on sale in Hanoi

exerts a negative influence on attitudes towards

Policy makers have found it difficult to create

challenges, we must seize the opportunity to
promote breastfeeding. Children have the right

a balance between the two benefits; encouraging

to be optimally fed and cared for in order to

breastfeeding and promoting high income-earning

reach their individual potential for growth and

potential for women.

development in later life.

National Institute of Nutrition,

Confidence to breastfeed

1 The situation of maternal and child nutrition

Hanoi, Vietnam

Maternal confidence in having enough breast milk

NutritionWorks 2004

Trinh Hong Son

is another important factor. A study has shown

1994–2004. NIN and GSO. 2005.
2 Report on assessment of breastfeeding policy.

For further information

that mothers are not confident in their capacity to

Promotion and practice in Vietnam. Gupta et al.



breastfeed and do not understand the importance

NIN/UNICEF. Hanoi. 2004.

16
Issue 2 May 2006

NUTRITION


What would
you do?

Your chance to share and
tackle real-life cases

In each issue of nutrition a problem case will be presented. We invite readers to write in with their suggestions of how
to deal with the case. The best answers will be published. These are all real-life cases. If you have your own examples of
problem cases that you would like to share, please do send them to the editors.
alone in the forest. Although breastfeeding is initiated immediately,
women are expected to go back to work in the fields within one to
two weeks (as early as three days in some cases). They believe that the
babies should not be carried to the rice plots by mothers as it is too
hot and the risk of malaria is too great. Rather, babies remain in the
villages, cared for by their fathers, grandparents or older siblings.
Babies as young as one week of age are fed pre-masticated sticky
rice with water when their mothers are away, and breastfed when their
mothers are home. There is a widespread belief that breast milk is not
enough for babies: “How can a baby survive on breast milk alone?”
The father of this baby is the Village Health Volunteer. He knows all

The

condensed
milk baby

about the importance of breastfeeding and passes on his knowledge
in group and individual education sessions in the village. His baby is
strikingly larger than the other babies in the village. When asked how
he managed to have such a healthy looking baby, he said that as
culture dictates that his wife must work in the fields all day, it was not
possible to breastfeed the boy. Instead, knowing the importance of
milk, he had bought condensed milk from the local market and had fed
it to the baby from birth using a cup with a teat attached.

This baby (shown with his grandmother) is five months old and lives in

What can be done in a community with such strong beliefs to

a remote village in Nong district of Savannakhet Province in southern

promote exclusive breastfeeding?

Laos. Conditions are poor in the village. Water is fetched from a well,
there are no latrines or electricity and houses are made of bamboo.
He is a member of the Lao Theung ethnic group, who make up about
20 per cent of the population of Laos. The women in the village are
largely responsible for subsistence farming; growing rice in slash-andburn plots deep in the forests near to the border with Vietnam. When
the rice runs out, the women collect forest products: vegetables, fruits,
roots and insects to eat, bamboo, dyes and barks to make medicine to
sell. Women work extremely hard and are away from the home for up
to ten hours a day in the heavy work seasons.
Cultural practices among the Lao Theung are strong. Men and

women have particular roles prescribed by tradition. Women give birth

Condensed milk being sold in local shop NutritionWorks 2006

17
NUTRITION

Issue 2 May 2006


Research

Highlights of past and
current research projects
into breastfeeding

Exclusive breastfeeding

before six months. Studies have found that when breastfed babies

Exclusive breastfeeding for six months is optimal for the

are given solids before six months, they take less breast milk, so that

health of mother and baby.

unless the foods given are more nutrient-dense than breast milk,

The old saying “breast is best” has been with us for many years,

there is little net nutritional gain.2 Severely malnourished mothers are

but the new millennium has seen greater emphasis on exclusive

unlikely to have the resources to feed their babies more nutrient-dense

breastfeeding (EBF), where babies receive no other foods or fluids

solids. WHO concluded that “in all circumstances, these risks must

except breast milk (including expressed breast milk or from a wet

be weighed against the benefits provided by exclusive breastfeeding,

nurse), vitamins or medicines. In 2002, WHO and UNICEF extended

especially the potential reduction in morbidity and mortality”.

the recommended duration of EBF from four to six months, to six

In 2005, the influential American Academy of Pediatrics (AAP)

months (see box 1). The main reason for the change was evidence that

updated its policy statement on breastfeeding.3 The AAP stated that

most babies under six months don’t need more nutrients than can

EBF is the ideal model against which all alternative feeding methods

be provided by EBF, and that giving additional solids doesn’t improve

should be compared. The evidence in terms of the health costs of not

growth but does increase the risk of infections.

being breastfed is summarised below.

1 WHO Global strategy for infant and young child feeding

“As a global public health recommendation, infants should be
exclusively breastfed for the first six months of life to achieve
optimal growth, development and health. Thereafter, to meet their
evolving nutritional requirements, infants should receive nutritionally
adequate and safe complementary foods while breastfeeding
continues for up to two years of age or beyond.”

The health costs of not being breastfed
There is evidence that not breastfeeding increases the
frequency and severity of infections in babies, and increases
their risk of some chronic conditions later in life. There are
also health risks for mothers who do not breastfeed.
For the baby:
There is strong evidence that not breastfeeding increases the frequency
and severity of a wide range of infections in babies including:

These recommendations have not been universally well-received.

• diarrhoea

Some commentators argue that the greater risk of infections is only

• respiratory tract infections

relevant to developing countries. But a sick baby puts a great strain

• bacterial meningitis, bacteremia

on a family whether they live in Nairobi or New York. A recent study

• otitis media

in the USA compared infants who received EBF for four months with

• urinary tract infection

those receiving EBF for six months. It found that the extra couple of

• late onset sepsis in preterm infants.

months of EBF halved the risk of ear infections, and quartered the risk

Evidence also suggests that non-breastfed babies are at increased risk

of pneumonia. It is not that mothers ‘should’ breastfeed exclusively

of developing the following conditions, as a child or adult.

for six months, rather, that for the optimal health of mother and baby,

• autoimmune diseases such as type I and type 2 diabetes

there is no need to do anything else.

• lymphoma, leukemia, Hodgkin’s disease and inflammatory bowel

1

When revising the recommendation, WHO did caution that there

disease

was insufficient evidence to rule out some concerns about EBF in

• overweight, obesity, hyper-cholesterolemia

mothers with low iron status (medicinal iron drops might be required)

• asthma

and among severely malnourished mothers. But in practice, this

They may also have slightly lower performance in cognitive

doesn’t mean malnourished mothers should start feeding other foods

development tests.

18
Issue 2 May 2006

NUTRITION


For the mother:

EBF babies is plotted it often appears to slow down and drift from the

There is strong evidence that mothers who do not breastfeed have:

centiles at around four to seven months. The new breastfed growth

• increased postpartum bleeding and slower recovery from childbirth

curves will show that a slight deceleration in growth about this time

• earlier return of fertility

is perfectly normal. WHO hopes that most countries will decide to use

• increased risk of breast and ovarian cancer.

the new growth curves.

Evidence also suggests that non breastfeeding mothers may have:
• slower postpartum weight loss

The physiology of breastfeeding
The growth of EBF babies drives milk production.

• increased risk of hip fracture and osteoporosis in

Babies from 6–12 months need fewer calories and their ‘normal’

post-menopausal period.
A recent study suggests that women who have breastfed have a lower
risk of developing type 2 diabetes.4

healthy weight is lower than was previously thought. When babies are
EBF, infants’ growth potential drives milk production, so energy intakes
will match energy needs. The problem comes when behaviour, cultural

Breastfeeding and HIV transmission

or social patterns interfere with achieving good EBF, for example,

The risk of HIV transmission from mother to baby during the

delayed initiation of breastfeeding, or women’s work leading to long

first six months of breastfeeding is only around five per cent.

intervals between feeds which reduces milk supply.

HIV can be transmitted by breastfeeding, but most babies who are

Another factor can be misinformation from health and nutrition

breastfed by HIV-infected mothers do not become infected. The

professionals. Breastfeeding physiology is rarely included in nutrition

average risk of infection from mother to child during breastfeeding

training. The new understanding of breast milk physiology challenges

is 10–20 per cent. This assumes that breastfeeding is prolonged for

some older ideas about normal patterns of breastfeeding. For example,

18 months to two years. The shorter the duration of breastfeeding,

left and right breasts do produce different amounts of milk (right

the lower the risk. The risk of transmission during the first six months

usually more); size does matter (babies will feed more often from

of breastfeeding, is around five per cent (1 in 20 risk). The risk of

small breasts but take the same amount of milk as babies feeding less

transmission when breastfeeding is exclusive is likely to be even lower.

frequently from a larger breast); on average around two thirds of the

In areas where infant mortality due to infectious diseases is generally

milk available in the breast is consumed at each breastfeed so breasts

high, there is a trade-off between preventing transmission of HIV by

are not ‘empty’ at the end of a feed.7

5

not breastfeeding but exposing the baby to risk of death from other
infections (see Issue 1 of nutrition).

Public health potential of breastfeeding
Breastfeeding saves more lives than other

Breastfeeding and the new growth curves

health intervention.

WHO has released new growth curves based on the growth

After a decade when support for breastfeeding promotion

of breastfed rather than formula-fed babies.

programmes was seriously damaged by concerns about transmission

Two significant events have occurred since the recommendation

of HIV through breast milk, a number of recent studies provide striking

to increase EBF to six months. Firstly, FAO has published revised

evidence of the potential for breastfeeding support to save lives and

estimates of human energy (kilocalorie) requirements. For infants

help reach the Millennium Development Goals (MDGs) (see boxes 2

over six months, the requirements are around 15 per cent lower than

and 3 overleaf). Interventions to improve breastfeeding practices have

FAO’s 1985 figures which are widely used in text books. Secondly,

been shown to have the greatest potential to save lives. Estimates

WHO’s new Breastfed Growth Curves were released in April 2006

suggest that interventions to support breastfeeding could prevent 13

(see www.who.int/childgrowth). These growth curves confirm that

per cent of deaths in children under five years, saving more lives than

breastfed babies have a different growth pattern from formula-fed

anti-malarial measures, vaccination and vitamin A supplementation

babies. They grow faster in the early months, then slow down, so that

together.8 The WHO Choice project ranked the cost effectiveness of

by 12 months of age, breastfed babies are leaner, weighing about half

interventions to achieve the MDGs.9 Increased community support

a kilogram less than formula-fed babies. This has huge implications

for breastfeeding mothers and low birth weight babies ranked 7th

for the global obesity epidemic and the growing awareness that over-

for Sub-Saharan Africa and 4th for South East Asia, behind measures

feeding babies in early life can predispose them to chronic diseases

aimed at managing neonatal pneumonia and prevention of HIV.

such as diabetes, heart disease and obesity later on.

Studies show that it is possible to increase EBF rates, particularly

6

In practice, most countries currently use growth curves which are
based on formula-fed babies. This means that when the growth of

where there is sustained postnatal support. The challenge is how to
create an environment where EBF is the norm.
19

NUTRITION

Issue 2 May 2006


2 Risks of infant mortality
Recent analysis of data from more than 10,000 mother-infant
pairs in Ghana, India and Peru indicate that the health costs of not
breastfeeding are much higher than previous estimates.10
Previous studies such as those by WHO have only been able to
compare non-breastfed babies with those who had any breast milk.
This study analyses infant death and hospitalisation according to
different feeding modes: exclusive, predominant, partial and nonbreastfed between six weeks and six months of age. The study
found that non-breastfed infants were 10 times more likely to die
compared to those who had been predominantly breastfed. Partially
breastfed infants were more than twice as likely to die.

1 Full breastfeeding duration and associated decrease in respiratory tract
infection in US children. Chantry CJ, Howard CR, Auginer P

Pediatrics 117(2):425–32, 2006.
2 Low nutrient intakes among infants in rural Bangladesh are attributable to
low intake and micronutrient density of complementary foods.
Kimmons JE et al. The Journal of Nutrition 135:444–451, 2005.
3 Policy statement: Breastfeeding and the use of human milk.
American Academy of Pediatrics. Pediatrics 115(2) 496–506, 2005.
4 Duration of lactation and incidence of type 2 diabetes. Stuebe AM et al.

The Journal of the American Medical Association 294:2601–2610, 2005.
5 HIV transmission through breastfeeding. A review of available evidence.
UNICF/UNAIDS/WHO, 2004

6 Human Energy Requirements. Report of a Joint FAO/WHO/UNU Expert

The authors conclude that the extremely high risk of infant mortality

Consultation, Rome Oct 2001.

associated with not being breastfed needs to be considered when

Food and Nutrition Technical Report Series 1. FAO, 2004.

HIV-infected mothers are being counselled about appropriate infant
feeding options.

7 Volume and frequency of breastfeeding and fat content of breast milk
throughout the day. Kent C et al. Pediatrics 117:e387e395,2006.
8 How many children could we save? Child Survival II. Jones et al.

3 Risks of neonatal mortality
A study in Ghana examined the impact of feeding patterns
immediately after birth on neonatal mortality (deaths in the first
month of life). Neonatal deaths account for 36 per cent of deaths in
children below five years of age, and this is one of the first studies to
look specifically at the impact of breastfeeding at this time.
Although breastfeeding is the norm in Ghana and 70 per cent of the
approximately 11,000 mother-infant pairs in the study exclusively
breastfed, delayed initiation of breastfeeding is common.
A total of 29 per cent of mothers did not start breastfeeding

The Lancet 362:65–71, 2003.
9 Evaluation of current strategies and future priorities for improving health in

developing countries. Evans et al. BMJ

(British Medical Journal) 331:1457–1461, 2006.
10 Infant feeding patterns and risks of death and hospitalisation in the first
half of infancy: multicentre cohort study. Bahl R et al.

Bulletin of the World Health Organisation 83:418–426, 2005.
11 Delayed breastfeeding initiation increases risk of neonatal mortality.
Edmond KM et al. Pediatrics 117(3) 380–386, 2006.
www.pediatrics.org/cgi/doi/10.1542/peds.2005-1496

within 24 hours of birth.
The study found that the later breastfeeding was started, the greater
the risk of neonatal death. Babies who did not begin breastfeeding
within the first day of life had more than double the risk of dying
before one month of age. Even when breastfeeding was initiated
on the first day, if babies were given foods or drinks before
breastfeeding was started (pre-lacteal feeds) this increased the risk
of death among non EBF infants by 60 per cent. Babies given milkbased drinks or solid foods as well as breast milk were more than
four times as likely to die below one month of age.
The authors conclude that 16 per cent of all neonatal deaths could
be prevented if all infants were breast fed from day one, and by 22
per cent if breastfed within the first hour.

20
Issue 2 May 2006

NUTRITION

Dear editors...

Letters
from around
the world

Nutrition and HIV/AIDS

Africa Forum on HIV/AIDS and food insecurity

I was delighted to note that you dedicated the first issue of nutrition to

I would like to commend your outstanding magazine for highlighting

HIV/AIDS, an important health issue that has significantly affected the

the critical role that nutrition plays in the world’s efforts to confront

practice of nutrition by bringing in new challenges.

the HIV/AIDS pandemic. Specifically, your September 2005 issue

In our commitment to advance knowledge and promote skills in
the management of HIV/AIDS, the Department of Home Economics
and Human Nutrition at Bunda College of Agriculture of the University

presented many of the key challenges of integrating nutrition into the
management of HIV/AIDS programs in developing countries.
The timing of this pertinent information could not have been

of Malawi introduced a 2.0 credit-hour course on ‘Nutrition and HIV/

better as we at Project Concern International, together with our local

AIDS’. The course was a swift response to the August 2002 workshop

and international partners, convene the Africa Forum on HIV/AIDS

on ‘Integrating Nutrition and HIV/AIDS in Pre-service Training in Africa’,

and Food Insecurity, to be held in Zambia May 8–12, 2006. We are

which was held in Mombasa, Kenya. Among other commitments, the

extremely grateful to have received complimentary copies of nutrition,

workshop participants resolved to explore opportunities to incorporate

which will be distributed to over 240 participants coming from 22

nutrition and HIV/AIDS in pre-service tertiary curricula.

countries. I know our delegates will find this a uniquely relevant and

The Home Economics and Human Nutrition Department at Bunda
College of Agriculture of the University of Malawi was probably

valuable resource.
Ultimately, the mission of the Forum is to change the way HIV/AIDS

the first institution to implement a full-fledged credit course in its

and food security programs are conceived, managed and funded as

curriculum within one year following the Mombasa workshop.

dual epidemics – and as a result, save more lives. The Forum will both

Our course is offered over a period of 15 weeks, and comprises one
hour lecture and two hours of practicals each week, and is offered to
final year BSc degree students who are enrolled in the Nutrition and

strengthen collective efforts and inform policy decisions based on
practical, field-based realities.
Project Concern and partners believe that we need to keep people

Food Science option. This placing enables students to apply knowledge

living with HIV as healthy as possible, for as long as possible:

and skills gained in other courses, to understand and appreciate how

• to keep family members from resorting to desperate economic

nutrition and HIV/AIDS affect each other.
Other option students (particularly Family Science) have requested
to audit the course. Our Nutrition and HIV/AIDS course will continue
to be closely monitored and appraised to include new knowledge
and important practical issues that can help our students to be better

coping strategies that put them at risk of HIV;
• to enable people to take and tolerate life-saving antiretroviral
therapy;
• and most importantly, to keep parents alive and families together.
To do this, we need to make sure people living with HIV and AIDS

prepared to face nutrition and HIV/AIDS in practice.

have the food they need – the right food, the most nutritious food

Alexander Kalimbira

– every day / all year round / in constant supply.

Lecturer in Human Nutrition
University of Malawi

Thank you again for your excellent coverage of the challenges and
opportunities currently confronting efforts to integrate nutrition and
HIV/AIDS programs.
Kate Greenaway
On behalf of Project Concern International, Africa Forum 2006

21
NUTRITION

Issue 2 May 2006


Resources

A selection of accessible
resources, courses and
contacts for practitioners

Most national agencies produce their own leaflets and posters on breastfeeding.
Check with your national breastfeeding committee, baby-friendly initiative coordinator or breastfeeding group.
Alternatively search on www.unicef.org/infobycountry/

Technical reviews and summary sheets
WHO
Materials available FREE:
• Global strategy for infant and young child feeding
• Guiding principles for feeding the non-breastfed child 6–24 months
• Breastfeeding and maternal medication
• Evidence for the 10 steps to successful breastfeeding

World Breastfeeding Week
1 to 7 August 2006
Produces an annual calendar, briefing
pack and poster. Archives of previous
years’ themes are available.
This year’s theme is Code Watch
– 25 years of Protecting Breastfeeding,
marking the 25th anniversary of the Code

LINKAGES

of Marketing of Breast-milk Substitutes.

Produces a series of fact sheets that can be downloaded or requested

www.worldbreastfeedingweek.org

FREE for residents in developing countries (in English, French, Spanish
and Portuguese):
• Birth, initiation of breastfeeding, and the first seven days after birth
• Recommended practices to improve infant nutrition during the first
six months – Facts for feeding

International Baby Food Action Network (IBFAN)
Produces a wide range of information relating to the marketing of
breast milk substitutes, and Breastfeeding Briefs that summarise
current scientific research.

• Feeding low birth weight babies

Guides

• Breastfeeding – protecting a natural resource

Health workers’ guide to the Code: Protecting infant health

• Breastfeeding and HIV/ AIDS

10th edition. Produced by IBFAN and

• Breastfeeding and maternal nutrition

available from Baby Milk Action. An

• Breastmilk: a critical source of vitamin A for infants and

easy-to-read and comprehensive guide

young children

to the Code and all the subsequent

World Alliance for Breastfeeding Action (WABA)

World Health Assembly resolutions.

Coordinates the annual theme for World Breastfeeding Week and

The breastfeeding answer book

produces a wide range of leaflets, briefing packs and posters which

Produced by La Leche League International.

can be downloaded. WABA has an email question / answer and

A comprehensive reference guide for

discussion group which can easily be joined. In addition, WABA

counselling breastfeeding mothers. Also

provides small seed grants for local initiatives to mark World

available on CD and in condensed form.

Breastfeeding Week.

La Leche League also produces a wide range
of leaflets, booklets and updates, aimed at
mothers and breastfeeding supporters.

22
Issue 2 May 2006

NUTRITION


Course materials
Breastfeeding counselling: a training course
(1993) Produced by and available from WHO.
A 40-hour in-depth counselling course, which can include a Training
of Trainers component. It is usually organised in liaison with national
health authorities.
Infant and young child feeding counselling:

Infant feeding advocacy and practice course
Infant Feeding Consortium (IFC) London, UK
Flexible two-week outreach training programme for national and
provincial-level trainers, coordinators and resource personnel. Held in
partnership with host country and regional breastfeeding coordinators.
For more information email the IFC on

Useful contacts

an integrated course

Baby Milk Action,

(2006) Produced by and available from WHO. Combines breastfeeding

34 Trumpington Street, Cambridge, CB2 1QY, UK

counselling, HIV and infant feeding counselling and complementary

Phone +44 1223 464420

feeding. The latest edition is on hold pending the release of the new

www.babymilkaction.org/shop/publications

WHO Growth Reference Standards. The current material is available on

Centre for International Child Health (CICH)

CD, on request. The Breastfeeding Promotion Network of India (BPNI)

Institute of Child Health, 30 Guilford St, London, WCIN 1EH, UK

has an adapted version known as the 3-in-1 course.

Phone +44 207 905 2122

Breastfeeding promotion and support in a baby-friendly

www.cich.ich.ucl.ac.uk

hospital

Emergency Nutrition Network (ENN)

(2006) Produced by and available from UNICEF. Draft versions are

32 Leopold Street, Oxford, OX4 1TW, UK

available of the new updated 20-hour course aimed at health staff

Phone +44 1865 324996

implementing the Baby Friendly Initiative.

www.ennonline.net/ife/

www.unicef.org/nutrition/index_24850.html

IBFAN

Infant feeding in emergencies

Five regional offices, in Africa, Asia/Pacific , Europe,

(2001 and 2004) Produced by a core group including UNICEF, UNHCR,

Latin America and Caribbean North America

WHO, IBFAN and the Emergency Nutrition Network (ENN). Designed

See www.ibfan.org to find your local office

to prepare emergency relief staff for appropriate infant feeding in

La Leche League International

emergency situations. Module 1 is for general staff, policy makers,

PO Box 4079, Schaumburg, IL 60168-4079, USA

managers and administrators. Module 2 is for health and nutrition

Phone +1 847 519 7730

workers in emergency settings. Available from ENN.

www.lalecheleague.org

LINKAGES

LINKAGES

Training modules available for order or download, including:

Academy for Educational Development (AED), 1825

• Behaviour change communication for improved infant feeding

Connecticut Ave, NW Washington, DC 20009, USA

An 11-day course
• Mother-to-mother support group A 10-day course covering
methodology and infant feeding Training of Trainers. Available in
English, Spanish and Chinese.
• Integrated prevention of mother-to-child transmission of HIV and

support for infant feeding A 12-day course for health professionals
and six-day course for community motivators.

Training courses

Phone +1 202 884 8221

Fax +44 207 404 2062

Fax +44 1865 324997

Fax +1 847 519 0035

Fax +1 202 884 8977

www.linkagesproject.org
World Alliance for Breastfeeding Action
WABA Secretariat, PO Box 1200 10850 Penang, Malaysia
Phone +604 658 4816

Fax +604 657 2655

www.waba.org.my
WHO
Dept of Child and Adolescent Health and Development and/or

Breastfeeding practice and policy courses

Dept of Nutrition, 20 Avenue Appia, 1211Geneva 27, Switzerland

19–30 June, 3–14 July 2006 Centre for International Child Health,

www.who.int/cahd or www.who.int/nutrition

Institute of Child Health London

UNICEF

Annual MSc-level courses for senior health professionals who train

UNICEF House, 3 United Nations Plaza, New York, NY 10017, USA

others, coordinate national or local programmes, or are advocates for

Phone +1 212 326 7000

optimal infant feeding.

www.unicef.org

Fax +1 212 887 7465/7454
23

NUTRITION

Issue 2 May 2006


nutrition is produced by Nutrition International, in collaboration with:
• ANSA (Associação de Nutrição e Segurança Alimentar), Mozambique
• The National Institute of Nutrition (NIN), Vietnam.
nutrition has arisen from the growing acknowledgement that while
technical nutrition problems have largely been solved, problems of
implementation remain. The need to identify nutrition initiatives that
work in practice continues, yet there is little documentation of nutrition
initiatives at a grassroots level, let alone any detailed analysis of the
ingredients that make them work or not work.
nutrition is a new FREE tri-annual publication specifically for
nutrition practitioners. It aims to provide an opportunity for those
working in development to share valuable practical experiences (both
successful and less successful). Nutrition practitioners are encouraged
to write up their experiences and can be given help by the editors to
ensure that their contributions are clearly written.
nutrition is produced thematically, so that the magazine can be used
as a resource for a particular subject area. We welcome ideas on future
themes that you would like to see covered.
Nutrition International is a company limited by guarantee
and not having a share capital. This company has been set up by
NutritionWorks for the purposes of the nutrition project.
Registered in England and Wales number 5448510

Directors: Carmel Dolan, Jeremy Shoham, Fiona Watson
This publication was produced with funding from the
Department for International Development. However, the views
expressed within it do not necessarily reflect official policy.
We are very grateful to Carol Williams, infant feeding specialist,
for the Research and Resources pages and for assistance in the
development of the pull-out poster.
Design by Platform 1 Design, with web development in partnership
with Moonshine Internet, UK.
Printed in the UK on chlorine-free recycled paper
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