1. Promotion, Protection and Support of Breastfeeding
Dagmar Schneidrová
Department of Child and Youth Health
3rd Faculty of Medicine
Charles University Prague

2. Nutrition and Child Health
Infants and young children esp. sensitive to external factors (e.g. nutrition)
First 2 years = a critical period for:
- growth and development
- health in infancy and childhood
- health in adulthood

3. Breastfeeding = a normative model (American Pediatric Academy, 1997)
Breastfeeding is a preferred mode of feeding
considering benefits:
Nutritional
Immunological
Health (morbidity, mortality)
Developmental
Economical a ecological

4. Nutritional benefits of breast milk
Composition changes in the course of development (preterm, fullterm infants), single feeding (foremilk, hindmilk), in relation to exposure to infection (e.g. IgA)
Optimal concentration of nutrients, high
bioavailability, lower intake of calories
Growth factors – epidermal growth factor, hormons
Protective factors - immunoglobulins, lymphocytes,
leucocytes, macrophages, lysozym, bifidus factor etc.

5. Risks of artificial feeding (in developing countries risks are elevated above these levels)
Increased risk of acute illness:
Gastroenteritis: 3-4x risk (developing countries x)
Acute otitis media: 3-4x risk
Lower respiratory tract infections (e.g. pneumonia)
Bacterial infection requiring hospitalization: 10x risk
Meningitis: 4x risk (e.g. Enterobacter sakazakii)
Higher mortality from sudden infant death syndrome (SIDS)

6. Risks of artificial feeding
Increased risk of chronic conditions and illnesses:
Allergies - atopic dermatitis, asthma
Type 1, type 2 diabetes
Obesity
Crohn’s disease, ulcerative colitis, coeliac disease
Childhood lymphomas (5-8x risk), leukaemia

7. Risks of artificial feeding
Dose-related difference in mental development:
Lower scores of mental development tests at 18 months
Difference in mental development and school performance at 3-5 years
Lower scores in prematures on intelligence tests at 7-8 years
Deficits in neurological development (lack of essential fatty acids)
Difference in visual acuity

8. Risks of artificial feeding
Effects on mother:
Increased risk of anaemia due to early return of menstruation
Increased risk of new pregnancy
Higher risk of impaired bonding, abuse, neglect and abandonment of the child
Increased risk of breast and ovarian cancer

9. Breastfeeding and health of infants and mothers (Agency for Healthcare Research and Quality, USA 2007)
Systematic epidemiological research :
43 studies on infants health
43 studies on mothers health
29 systematic metaanalyses (400 studies)
compared health outcomes in infants breastfed and artificially fed (breast-milk substitutes) in developed countries
Ip S, Chung M, Raman G, Chew P, Magula N, De Vine D, Trikalinos T, Lau J. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No Agency for Healthcare Research and Quality, April 2007.

10. Breastfeeding = lower morbidity
Mothers
Diabetes (type 2)
Carcinoma of breast
Carcinoma of ovaria
Infants
Nonspecific gastroenteritis
Necrotizing enterocolitis
Acute otitis
Infections of lower
respiratory tract
Sudden infant death (SIDS)
Atopic dermatitis
Asthma in young children
Obesity
Diabetes (type 1, 2)
Child leukaemia

11. Optimal Infant Feeding Practices (WHO Global Strategy on Infant and Young Child Feeding, 2002)
Based on the evidence of nutrition´s significance in the early months and years of life
Lack of excl. BF during the first 6 months of life - important risk factor for infant and childhood morbidity and mortality (scientific and epidemiological evidence – News - Breastfeeding Briefs)

12. Optimal Infant Feeding Practices (WHO Global Strategy on Infant and Young Child Feeding, 2002)
Exclusive breastfeeding for 6 months
Complementary feeding with continued breastfeeding from 6 to 24 months and beyond
Timely
Adequate
Safe
Appropriately fed

13. Acceptable medical reasons for use of breast-milk substitutes (WHO, 2009)

14. Health problems in the infant (WHO, 2009)
Contraindicatins of BF
Galaktosaemia (infant formula without
galactose)
Maple syrup disease (infant formula without leucine, isoleucine and valine)
Fenylketonurie (infant formula without phenylalanine)
Breastfeeding and supplementation
Very low birth weight (below 1500 g)
Premature birth (before 32nd week)
Hypoglycaemia (hypoxic stres, mothers with diabetes, etc.)

15. Health problems in the mother (WHO, 2009)
a) Contraindications of breastfeeding
HIV/AIDS infection
HTLV-1, 2 infection (India, Africa, Japan)
b) Temporary interruption of breastfeeding
Serious illness (e.g. sepsis)
Herpes simplex virus 1 infection (HSV-1)
Varicella
Active TBC
Medication in mother (sedatives, antiepileptics, opioids, radioactive iodine – J-131, cytotoxic chemotherapy)
c) Breastfeeding and management of the problem
Mastitis, abscess of breast
Hepatitis B, C, TBC (posit. tuberculine test)
Using addictive substances

16. Risks related to using powdered infant formula (PIF)
WHO Study (35 countries)
- found patogens (Enterobacter sakazakii, Salmonella) in 20% from 141 samples of PIF
- E. sakazakii – rare, but lethal cases of menigitis, NEC and sepsis (40-80% mortality)
European Council for Food Safety and WHO (2007)
- issued guidelines for health workers and parents
– information on risk, hygienic preparation and proper use
of PIF products
Study at the 3rd Faculty of Medicine (2009) – survey at 10 hospitals (20 departments)
- found shortcomings in awareness of possible contamination of PIF and its preparation

17. WHO/UNICEF Global Strategy for Infant and Young Child Feeding (2002)
The goal - to improve the survival, growth and development of children during the first years of life through protection, promotion and support of early and exclusive breastfeeding for the 6 months, followed by continued BF for up to 2 years or longer with age-appropriate, complementary feeding (

18. WHO/UNICEF Global Strategy Guidelines for Implementation
Develop National Policy and Programmes
A national BF coordinator and a multisectoral BF committee
BFHI (Baby-Friendly Hospital Initiative) - all maternity services should fully practise the Ten Steps to Successful BF ( – BFHI)
Ensure multisectoral support for optimal BF -provide consistent messages from all sectors

20. WHO/UNICEF Global Strategy Guidelines for Implementation
Support proper complementary feeding
Address exceptionally difficult situations - HIV/AIDS, emergencies, etc.
Maternity Protection - legislation to protect the BF of working women (ILO Convention 2000/No. 183)
Support implementation of Internatinal Code of Marketing of BMS and subsequent relevant WHA Resolutions (

21. Breastfeeding promotion in CR (since 1991)
Collaboration with:
Professional organizations at national and international level (WHO, UNICEF, IBFAN, LLLI):
* Education, training, publications, campaigns (WABA)
Ministry of Health, Parliament of the CR:
* Guidelines for health care based on BFHI (MoH)
* Law on advertisement (BMS)
* EU directives on marketing of BMS
National Lactation Centre (FTN Prague 4 - Krč):
* training lactation counsellors (800 health profs, 250 mothers)
* evaluation of „Baby-Friendly Hospital“ (66 from 99)

22. The ten steps to successful breastfeeding (BFHI)
1. Have a written breastfeeding policy that is routinely communicated
to all health care staff.
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within one half hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation even
if they should be separated from their infants.
6. Give newborn infants no food or drink other than breast milk, unless
medically indicated.
7. Practice rooming-in – allow mothers and infants to remain together –
24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers)
to breastfeeding infants.
10.Foster the establishment of breastfeeding support groups and refer
mothers to them on discharge from the hospital or clinic.

23. Impact of marketing of BMS (breast-milk substitutes)
Advertisements in antenatal clinics (Howard, C. et al, 2000)
- associated with BF discontinuation in first 2 weeks
- negative impact on BF duration in women who decided to BF less than 12 weeks or did not decided about infant feeding

24. Impact on marketing of BMS (breast-milk substitutes)
Commercial hospital discharge packs (Donnelly, A, Snowden DM, Renfrew MJ, Woolridge MW (UK). Cochrane Database Syst Rev 2000):
Research in medical electronic databases
Analysis of 9 clinical studies (3730 women from North America) showed that:
- exclusive BF was reduced in the presence of commercial hospital discharge packs (preliminary introduction of complementary foods)

25. Case study (Prague maternity hospital)
Commercial discharge packs :
* Distributed by the company PROSAM to new mothers upon the card filled with personal data, agreement with further mailing of promotional materials
Hipp - sample of instant tea (from the 4th month)
- sample of complementary foods
Avent – promotion of aids for BF, bottles and teats
- bottle and teat
Happy Baby – information brochure on care for the baby

26. Happy Baby (brochure)

27. www.mojedite.cz (Nutrilon, Milupa, Hamilon, Hami, Deva, Ben)

28. Advantages and disadvatages of commercial complementary foods
Comfortable
Saves time
Lower nutritional value (compared to fresh food)
Similar consistence does not suit developmental needs of the infant
Costs money
Burden for the environment (production, transport, adverts, waste)

29. Complementary foods (promotion versus WHO guidelines)
Promotion materials, labelling: instant sweetened teas from 1 week
- vegetable/meat and fruit mixes, juices, instant cereals from 4 or 5 months
WHO guidelines (Global strategy, 2002): complementary foods after 6 months (early introduction – increased risk of infections, allergies and caries, no advantages in terms of weight gain)

30. Complementary foods (World Health Assembly Resolutions)
WHA 1996 – CF should not be marketed or used in ways that undermine exclusive and sustained BF
WHA 1986, 2001 – product labels and adverts should not state that products are suitable in the first 6 months
WHA 2001 – recommends using fresh nutritious foods

31. BF Protection Regulations
International Code of Marketing of Breastmilk Substitutes (WHO, 1981)
Subsequent Relevant Resolutions of WHA
EU Directive No. 141/2006
National legislation (see -

32. International Code of Marketing of Breastmilk Substitutes (WHO 1981)
Art. 4 Information and education
Art. 5 Public and mothers
Art. 6 Health care systems
Art. 7 Health workers
Art. 9 Labelling

33. Art. 4.2 Information and educational materials for pregnant women and mothers
Should be distributed via the health care system
Benefits and priority of breastfeeding stressed
Importance of healthy nutrition in mother
Negative impact of supplementation with a bottle
Health risks related to infant feeding
Instruction on proper use of infant formula
Financial consequences of artificial feeding
No texts, figures idealizing infant formula

34. International Code of Marketing of Breastmilk Substitutes (WHO 1981)
Art. 6.2 – „No health care facility should be used for promotion of breastmilk substitutes, bottles and teats…“
Art. 5.2 – „Distributors should not provide samples of products to mothers“.

35. Art. 7 Health workers Should support and protect breastfeeding
Should not receive any financial or material incentives for promotion of BMS
Should not distribute samples of products to pregnant women and mothers

36. „Important statement“: stressing priority of BF
Art. 9 Labelling
„Important statement“:
stressing priority of BF
product use should be consulted with health professional
instruction on proper preparation
warnig against health risks
no texts or figures idealizing BMS

37. EU Directive No.141/2006
Regulations for promotion, labelling and information on infant and follow-on formula in accordance with International Code of Marketing of BMS
Prohibits free or low-cost products, samples or gifts provided via health professionals
Urges member states to transform the directive into national legislation

38. Protection of BF in CR
Directive of MoH No. 54/ on foods for special purposes (standards for composition and labelling of BMS)
Law on advertizing No. 138/2002 on infant feeding

39. Births in BFH and percentage of BFH (EU) (Cattaneo, Romero, Lhotská, 2010)

40. Excl. BF Infants in BFH, other hospitals

41. Long-term breastfeeding in CR (6 months nad later) (IHIS CR, 2010)

42. Further reading
Infant and young child feeding: Model chapter for textbooks for medical students and allied health professionals. WHO, 2009 (
(Sessions 1,2,3,4,5,9, Annex 1,2)