InfantFeeding..................................................................................

Guidelines for New ZealandHealth Workers

based on the World Health Organization’sInternational Code of Marketing of Breast-milkSubstitutes

HEALTHMINISTRY OF

MANATU HAUORA

Published in June 1997 by Ministry of HealthManatü HauoraWellington, New Zealand

ISBN 0-478-09487-6

Infant Feeding i

Contents

Foreword i i i

Preface iv

Acknowledgements vi

Introduction 1

Promoting the Aim of the WHO Code 2

Protection and Promotion of Breastfeeding 2

Benefits of Breastfeeding 3

Possible Contraindications to Breastfeeding 3

Medications/drugs during breastfeeding 3

HIV infection and breastfeeding 3

Practice of Breastfeeding 4

Cup Feeding of Expressed Breast-milk 5

The Role of Breastfeeding in Fertility Regulation 5

Decision-making chart for women wanting to use breastfeeding for birth-spacing purposes 6

Nutrition for the Breastfeeding Mother 7

Breastfeeding -Women and Work 7

Smoking 8

Sudden Infant Death Syndrome (SIDS) 8

Alcohol and Breast-milk 8

Appropriate Use of Infant Formula 8

Developing a Supportive Environment to Promote Breastfeeding 10

The Scope of the Code 11

Definitions for the Health Guidelines 12

Information and Education on Infant Feeding 14

Resources for the Promotion, Protection and Support of Breastfeeding available from the Ministry of Health 15

Resources for Distribution to the Public available from the Crown Health Enterprises Authorised Provider Network 15

Advertising and Promotion of Infant Formula 17

Promotion of Breastfeeding 17

Health Care Systems 18

Policy Development 19

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Recommendations for Promotion and Support of Breastfeeding in Health Care Systems 19

The Steps to Successful Breastfeeding 20

Ten Steps to Becoming a Breastfeeding-Supporting Practice 20

Recommendations for Postnatal Advice and Support in the Community 21

Health Workers’ Responsibilities Under the WHO Code 22

Recommendations for Training Institutions 22

Recommendations for Health Workers in the Health Care System 23

Quality and Labelling of Infant Formula 25

Implementation and Monitoring 26

Complaints Process 27

References 28

Appendix 1 Flowchart of Complaints Process 31

Appendix 2 Articles of the WHO Code 32

Appendix 3 World Health Assembly Resolutions 43

Appendix 4 A History of the World Health Organization InternationalCode of Marketing of Breast-Milk Substitutes 45

Appendix 5 Consumer Information Services 49

Appendix 6 Submissions Received on the Draft Guidelines 52

Infant Feeding iii

FOREWORD

The purpose of these guidelines and of the World Health Organization’s InternationalCode of Marketing of Breast-milk Substitutes (WHO Code), is to protect the nutritionalwellbeing of infants. Breastfeeding is to be encouraged and should be protected frompractices that undermine it. Health workers are seen by the public as an important sourceof advice on infant feeding. This advice should be available to all mothers, regardless ofthe feeding option that they have chosen for their infant.

When mothers do not breastfeed, or do so only partially, they should use a suitableinfant formula. A key objective of the WHO Code is that there be adequate informationon breast-milk substitutes and that they be marketed and distributed appropriately.

The WHO Code is intended to be interpreted in each country based on the local situation.The WHO Code states that ‘countries should take action appropriate to their social andlegislative framework’ to give effect to the principles of the Code.

The policy in New Zealand is to look at the intent of the Code. The promotion andprotection of breastfeeding is the primary aim or intent of the Code. This intent is theguiding principle for the Ministry of Health in deciding to develop voluntary guidelinesfor health workers based on the WHO Code. The infant formula marketing industryhas developed a voluntary self-regulatory code of practice. Both the health workerguidelines and the industry self-regulatory code are supported by a complianceprogramme. The Ministry of Health has responsibility for monitoring compliance withthe WHO Code.

Dr Gillian DurhamDirector of Public Health andGeneral Manager, Public Health Group

Guidelinesiv

PREFACE

Breast-milk is the ideal food for infants. Promoting breastfeeding is a public healthstrategy that is central to infant care practices in the prevention of sudden infant deathsyndrome (PHC 1995f). Breastfeeding is supported in many Ministry of Healthdocuments. Practical information on breastfeeding is included in booklets written forparents, Your Pregnancy, Tö Hapütanga (MoH 1996b) and WellChild/Tamariki Ora HealthBook (MoH 1996a). The food and nutrition guidelines which promote breastfeeding andinclude information on formula feeding are the Food and Nutrition Guidelines for HealthyPregnant Women, Healthy Breastfeeding Women and for Healthy Infants and Toddlers (aged0–2 years) (PHC 1995c; PHC 1995a; PHC 1995b). These are available as background papersfor health professionals and as healthy eating pamphlets for the public.

In 1981 the World Health Assembly adopted the World Health Organization’sInternational Code of Marketing of Breast-milk Substitutes. The purpose of the WHOCode is to promote breastfeeding and to improve infant feeding. To achieve this itrecommends, as the basis for action, various requirements and restrictions in relation tomarketing and distributing breast-milk substitutes. The New Zealand Minister of Healthadopted the Code in its entirety in 1983, ‘through consensus and discussion rather thanthrough legislation’.

The Code is to be implemented in all countries within their existing social and legislativecontext. In New Zealand, advertising restrictions on infant formula may contravene theCommerce Act. Article 5 of the WHO Code specifies that there should be no advertisingof products within the scope of the Code. The benefits to an infant of receiving breast-milk for the first six months of life are, however, so widely accepted that the infantformula companies comprising the New Zealand Infant Formula Marketers’ Association(NZIFMA) choose not to advertise infant formula to the general public.

Initially, the WHO Code was monitored by an advisory committee; however this wasdisbanded in 1991 after a review, and an independent consultant was sought to monitorthe WHO Code. In 1994 the Public Health Commission issued a draft discussiondocument to a wide variety of interested groups, seeking comment on the interpretationand monitoring of the WHO Code. As a result of the information received, an initiativeto proactively monitor and promote the WHO Code in New Zealand was undertakenwith the development of two self-regulatory codes of practice.

The draft health sector codes of practice was developed and disseminated for discussionin May 1996. Sixty-six written submissions were received and a hui at Te Ngira Maraein Papakura was attended by 45 people. The hui agreed that Mäori views in regard towhängai ü (breastfeeding) and the issues raised in terms of the Code needed to beconsidered in terms of a holistic approach to health and wellbeing. This includes therecognition of the diverse needs of Mäori and the opportunity for Mäori to make theirown choices. On a broader level, the hui noted the fundamental position and applicationof the Treaty of Waitangi to the improvement of Mäori health.

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Infant formula and follow-on formula are currently described in the New Zealand FoodRegulations 1984. On 1 July 1996 the Food Amendment Act 1996 came into effect. Itprovides a mechanism for setting joint Australia–New Zealand food standards, forexample, a standard for infant formula. A proposal to review the infant formula standardis under consideration by the Australia New Zealand Food Authority (ANZFA). Theproposal includes some labelling and information clauses taken from the WHO Code.Consultation is a requirement of the joint standard setting system before the Minister ofHealth will issue a joint food standard.

While this publication Infant Feeding: Guidelines for New Zealand Health Workers focuseson promoting breastfeeding, safe infant feeding practices and the intent of the WHOCode, it also details how the WHO Code will be monitored. A compliance panel will beestablished to further interpret the WHO Code within New Zealand. The Ministry willretain overall responsibility for monitoring the WHO Code.

Breastfeeding targets were set by the Public Health Commission in 1994 for the suddeninfant death syndrome policy advice paper (PHC 1995f). The targets, to increase fullbreastfeeding at three months and full or partial breastfeeding at six months, have beenmonitored since then in the Director-General’s annual report on the state of the publichealth. Because the targets were originally set and subsequently monitored usingdifferent methods and indicators it is not possible to interpret trends. Later in 1997, theMinistry will revise targets for breastfeeding when clear definitions have been developedand a method for monitoring established. Infant Feeding: Guidelines for New Zealand HealthWorkers should have a positive impact on the rates of initiation and maintenance ofbreastfeeding in New Zealand.

These guidelines for health workers are intended to be a resource document for publichealth service providers who are actively involved with infant feeding.

The New Zealand Infant Formula Marketers’ Association self-regulatory code of practice,which accompanies these guidelines, is intended for manufacturers, marketers anddistributors of infant formula. It will also be of interest to retailers and the health sector.

The Ministry of Health would like to review the suitability of these guidelines for healthworkers, and the process for dealing with complaints, after they have been in use in thefield. To carry out any refinement which may be necessary the Public Health Group inthe Ministry would appreciate comments from providers and others during this period.

Please address your comments to:

Nutrition AdvisorFood and Nutrition SectionPublic Health GroupMinistry of HealthPO Box 5013Wellington

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Acknowledgements

The Ministry of Health acknowledges the contribution of Healthlink South (NutritionSection), Gendy Brown, David Forsythe, Marcia Annandale, John Birkbeck, JacintaCreagh, Penelope Janes, Riripeti Haretuku, Belinda McLean and Winsome Parnell.

The Ministry is grateful to the 66 people and organisations who made writtensubmissions on the draft document, and to the 45 people who attended the hui in May1996.

The Ministry wishes to thank the Royal New Zealand Plunket Society, the MäoriWomen’s Welfare League, the New Zealand College of Midwives, the New ZealandDietetic Association, the New Zealand Lactation Consultants’ Association, the NewZealand Infant Formula Marketers’ Association (Abbott Laboratories NZ Limited,Bristol-Myers Squibb (NZ) Limited, Heinz-Wattie Limited, Nutricia Limited and WyethNZ Limited), regional health authorities, Natural Family Planning and Crown healthenterprises for pretesting this publication.

Infant Feeding 1

Introduction

These health guidelines are intended for health workers, health care institutions, healtheducation institutions and community support groups. They give effect to the articlesof the World Health Organization’s International Code of Marketing of Breast-milkSubstitutes, the World Health Assembly (WHA) resolutions that relate to the WHOCode, the Innocenti Declaration (WHO/UNICEF 1990) and the Joint WHO/UNICEFStatement, The special role of maternity services, 1989.

The health guidelines reflect the Ministry of Health’s commitment to implement theWHO Code, to promote breastfeeding and to address the public health objectives set in1994:• to increase full breastfeeding at three months to 70 percent by 1997 and 75 percent

by the year 2000

• to increase breastfeeding (full or partial) at six months to 70 percent by 1997, and 75percent by the year 2000.

The Plunket National Child Health Study (Essex et al 1995) found that whilebreastfeeding rates were high at birth, they declined significantly with time after birth.The reasons varied, but in many instances arose from difficulties which could beovercome by education and sensitive encouragement and support. The challenge, then,for New Zealand is to educate all health workers on the advantages of breastfeeding tothe mother and baby, to further increase the number of mothers initiating breastfeedingand to increase the duration of exclusive breastfeeding.

Recent research has found that there are increased benefits to infant and mother withincreased exclusiveness of breastfeeding during the first four to six months of life. Atthis time complementary foods are introduced, but the benefits continue with increasedduration of breastfeeding. Programme interventions can result in positive changes inbreastfeeding behaviour (WHO/UNICEF 1990).

The WHO Code and the WHA resolutions are concerned with the protection (WHOCode), promotion and support of breastfeeding (Innocenti Declaration, and the JointWHO/UNICEF Statement 1989).

The health guidelines will outline New Zealand health workers’ responsibilities undereach article of the WHO Code that is relevant to health workers.

The health guidelines do not include those articles that are specifically for manufacturersand marketers of infant formula. The New Zealand Infant Formula Marketers’Association (NZIFMA) has developed a code for industry. Additional copies of thiscode may be obtained from:Executive DirectorNZ Infant Formula Marketers’ AssociationPO Box 1513Paraparaumu Beach

Guidelines2

Promoting the Aim of the WHO Code

Health workers should apply the aim of the WHO Code when dealing with breastfeedingand formula feeding issues. They should:• protect and promote breastfeeding• ensure appropriate use of infant formula by giving adequate information.

Protection and Promotion of Breastfeeding

The protection, promotion and support of breastfeeding is fundamental to achievingoptimum health of the nation.

Appropriate nutrient intake is more critical in early infancy than at any other time oflife. This is so because of the infant’s high nutritional requirements in relation to bodyweight and the influence that improper or faulty diet during the first months can haveon future health and development. Moreover, the infant is more sensitive and lessadaptable than in later life to different types, forms, proportions and quantities of food.

Breastfeeding is an unequalled way of providing optimal nutrition for the healthy growthand development of the infant, and forms a unique biological and emotional basis forthe health of both mother and child. In addition, the anti-infective properties of breast-milk help to protect the infant against infections.

The World Health Organization recommends:

‘that infants should be fed exclusively on breast-milk from birth to 4 to 6 months ofage; that is they should be given no other liquids or solids than breast-milk, not evenwater, during this period. Given the worldwide variation in growth velocity, an agerange is an essential element of this feeding recommendation. Mean growth Z–scores are indeed observed to begin falling at different points within this 4–to–six–month range in breastfed infants from different populations worldwide. WHO andits partners are in the process of refining the definition of ‘optimal’ growth, asmeasured by accepted functional indicators of infant health and well-being. Afterthis initial 4–to–six–month period of exclusive breastfeeding, children should continueto be breastfed for up to 2 years of age or beyond, while receiving nutritionallyadequate and safe complementary foods. Starting complementary foods too early ortoo late are both undesirable. Ideally, the decision when precisely to begin will bemade by a mother, in consultation with her health worker, based on her infant’sspecific growth and development needs’ (WHO 1995).

Infant Feeding 3

Benefits of Breastfeeding

Important differences exist between the composition of breast-milk and artificial infantformulas. Epidemiological evidence convincingly indicates that breastfed infants are atsignificantly reduced risk of infection, particularly gastro-intestinal infection, especiallyin less than optimal environments (Howie et al 1990).

Breastfeeding is important for low birthweight infants. Reduced mortality associatedwith necrotising enterocolitis and advantages in cognitive function have been associatedwith provision of breast-milk. A plausible mechanism for brain maturation in breastfedinfants relates to breast-milk lipid composition, although this is still being debated (Langet al 1994). Other studies suggest that the method of infant feeding does not have abearing on intelligence (Gale and Martyn 1996).

Further reading on the benefits of breastfeeding

PHC. 1995b. Food and Nutrition Guidelines for Healthy Infants and Toddlers (aged0–2 years): A background paper. Wellington: Public Health Commission.

Possible Contraindications to Breastfeeding

There are a number of situations where infants cannot, or should not, be breastfed. Forexample, women who have had breast surgery, cancer or tuberculosis may not be ableto breastfeed. In general, the circumstances in which infants are not breastfed are of twotypes, physiopathological and socioeconomic. They may be temporary or permanent,and they may be related to the mother, the infant, or both. Where breast-milk is notavailable, nutrition requirements should be met with an appropriate infant formula.

Medications/drugs during breastfeeding

Almost all drugs are secreted in breast-milk. Some drugs may be contraindicated duringbreastfeeding due to either the amount that gets into the milk or the toxicity of the drug.This is a complex subject and advice given will depend on the usage of the drug, durationof treatment, other drug therapy, the nature of the illness and the age of infant.

For more detailed information about drugs other than those listed in usually-heldreferences, practitioners are referred to the Drug Information Centre in Auckland,Wellington, Christchurch or Dunedin.

HIV infection and breastfeeding

In New Zealand the Ministry of Health advises mothers with HIV infection that, giventhe ready availability of safe and effective alternatives to breast-milk, breastfeeding theirbaby is contraindicated. Breastfeeding increases the risk of HIV transmission by 10-20percent (United States Public Health Service 1995). This is supported by the UNAIDS/WHO/UNICEF statement, HIV and infant feeding, issued in May 1997 which states:

Guidelines4

‘When children born to women living with HIV can be ensured uninterrupted access tonutritionally adequate breast-milk substitutes that are safely prepared and fed to them,they are at less risk of illness and death if they are not breastfed’.

Maternal-infant transmission is the primary means by which young children becomeinfected with HIV (Newall and Peckham 1993). The World Health Organization estimatesthat over 1.5 million children worldwide have been infected with HIV through mother-to-child transmission (Bulterys and Goedert 1996). The risk of transmission from aninfected mother to her child varies 15–45 percent. Transmission may occur in utero,intra partum or postnatally through breastfeeding.

Up to June 1996, a total of six children in New Zealand has been identified as infectedwith HIV by mother-to-child transmission.

Further readings on contraindications to breastfeeding

Begg EJ, Atkinson HC, Darlow BA. 1996. Guide to medicine use in lactation.In: New Ethicals Drug Information Guides. Auckland: Adis International Ltd.

MoH. 1997. HIV in Pregnancy: Risk screening guidelines and information for healthprofessionals. Circular letter to health professionals. Wellington: Ministry ofHealth.

National Health and Medical Research Council (NHMRC). 1996. Infant FeedingGuidelines for Health Workers. Canberra: Department of Health and FamilyServices.

PHC. 1995b. Food and Nutrition Guidelines for Healthy Infants and Toddlers (aged0-2 years): A background paper. Wellington: Public Health Commission.

UNAIDS. 1997. HIV and Infant Feeding: A policy statement developedcollaboratively by UNAIDS, WHO and UNICEF. Geneva: Joint United NationsProgramme on HIV/AIDS

Practice of Breastfeeding

Many women need counselling and education on breastfeeding. Efforts must be madeto help women acquire the necessary knowledge and practices in order to breastfeedsatisfactorily. In traditional societies the skill is passed on from mother to daughterthrough the generations. In New Zealand society many new mothers require professionalexpertise and support to learn this skill. Many older mothers are unable to assist theirdaughters as they themselves did not breastfeed.

Further readings on the practice of breastfeeding

La Leche League International. 1988 or 1991. The Womanly Art of Breastfeeding.Illinois: Franklin Park.

Infant Feeding 5

La Leche League International. 1991. The Breastfeeding Answer Book. Illinois:Franklin Park.

National Health and Medical Research Council (NHMRC). 1996. Infant FeedingGuidelines for Health Workers. Canberra: Department of Health and FamilyServices.

The New Zealand College of Midwives. 1992. Protecting, Promoting andSupporting Breastfeeding. The breastfeeding handbook. Dunedin: Right Words NewZealand.

Cup Feeding of Expressed Breast-milk

Cup feeding is an alternative to the bottle and teat method of feeding infants. It providesa simple, practical and effective solution to feeding the healthy term infant who isrequired to be fed on expressed breast-milk. Another perceived benefit is that the infantdoes not have to cope with a nipple or teat in its mouth. The infant can pace its ownintake, as long as the cup is held so that the milk is just touching the infant’s lips and notpoured into its mouth. As the pace of sipping is dependent on the infant itself, respirationis easier to control, and swallowing occurs when the infant is ready (Lang et al 1994).Cup feeding fosters early positive body and eye contact.

Cup feeding is promoted by UNICEF as a more appropriate infant feeding method forexpressed breast-milk than the bottle and teat. However, it remains a controversialpractice for infants who have immature or impaired suck or swallow coordinationbecause of prematurity or other reasons.

Health workers should be able to teach a breastfeeding mother how to feed her infantexpressed breast-milk by using a cup or spoon.

The Role of Breastfeeding in Fertility Regulation

Oestrogen-containing hormonal contraceptives present significant disadvantages forbreastfeeding mothers because they affect the quality and quantity of breast-milk (WHOTaskforce on Oral Contraceptives 1988).

In 1988 an international interdisciplinary group of researchers gathered in Bellagio, Italyto review the scientific evidence and reach a consensus about the conditions under whichbreastfeeding can serve as a safe and effective family planning method. They developedthe Bellagio Guidelines which are summarised as follows.

The maximum birth-spacing effect of breastfeeding is achieved when a mother fullybreastfeeds and remains amenorrhoeic. In this instance, full breastfeeding is baby-led,that is, there is no other food or liquid than breast-milk. This is referred to as theLactational Amenorrhoea Method (LAM). For those mothers who meet the criteria, theLAM offers 98 percent protection from pregnancy during the first six months postpartum(France 1996). The method requires proper supervision by a qualified teacher who is

Guidelines6

able to discuss fully with the individual mother her type of breastfeeding, changes inthis over time and her feelings about continuing to fully breastfeed. It is essential toidentify the time to change to another family planning method for successful avoidanceof unplanned pregnancy.

The New Zealand Association of Natural Family Planning (NFP) teachers are qualifiedto discuss and carefully supervise individual mothers wishing to practice the LactationalAmenorrhoea Method.

Yes

Yes

Yes

Is the mother amenorrhoeic?

Is the baby fully breastfed?

Is the baby less than six months old?

The mother does not yet need a complementary contraceptive method.

The mother should choose another contraceptive method

because her chance of pregnancy is increased. She should

continue breastfeeding for her baby's sake.

No

No

Decision-making chart for women wanting to use breastfeeding for birth-spacing purposes

Taken from: WHO 1992 Facts about Infant Breastfeeding

Infant Feeding 7

Nutrition for the Breastfeeding Mother

Nutrition requirements during breastfeeding are discussed fully in Food and NutritionGuidelines for Healthy Breastfeeding Women (PHC 1995a). Lifestyle issues such as alcohol,caffeine and cigarette smoking are addressed as well as the effects of maternal nutritionon allergies, wind and colic in breastfed infants.

Breastfeeding – Women and Work

Generally, there is no paid parental leave in New Zealand. Regardless of their eligibilityfor paid parental leave, many women for economic or personal reasons return to paidwork before they want to stop breastfeeding. They commonly find their workplace lacksthe flexibility and facilities which would allow them to combine breastfeeding and paidwork, such as work-based child care or time and a suitable place to express and storebreast-milk.

Because of this some women who want to return to work may feel discouraged frominitiating breastfeeding and others may feel that breastfeeding has to stop once paidwork starts.

Health workers need to be well informed and positive in their advice to parents aboutcombining breastfeeding and work. Several options are available when it is not possiblefor the mother to go to her baby during working hours:

• replacing breastfeeds during working hours with expressed breast-milk from a cupor bottle

• replacing breastfeeds during working hours with food from a spoon and a cup (forbabies six months and over)

• replacing breastfeeding during work hours with infant formula from a cup or bottle.

Health workers are aware of the negative effect on breastfeeding of introducing partialformula feeding and should encourage the mother to develop strategies to maintain hermilk supply. For example, they can suggest to a mother that she expresses breast-milkduring her working day, or feed her infant more frequently in the hours she is with herchild.

Health workers should also support a mother who elects to combine breastfeeding andformula feeding. Using formula does not mean the mother has to abandon breastfeeding.When formula is used during working hours, breastfeeding can continue before andafter work and during weekends. A combination of both expressed breast-milk andformula can be given to the baby when there is not enough expressed breast-milk.

It is important for health workers to give women every assistance in the first six weeks–three months of the infant’s life to get breastfeeding well established because that willgive the mother greater flexibility in considering her options. Correct advice inexpressing, storing and using frozen breast-milk, as well as guidelines for formula feedingare necessary.

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Health workers should assist workplaces to develop policies to enable women tobreastfeed on returning to work (Galtry 1995). Such policies mean flexible workinghours, work-based child care, rooms in which to express breast-milk or breastfeed andrefrigerators to store expressed breast-milk (NHMRC 1996).

Smoking

Cigarette smoking can affect the milk supply and may cause gastrointestinal upsets inthe infant. Maternal smoking was shown to be one of the principal modifiable riskfactors for sudden infant death syndrome in the New Zealand Cot Death Study (Mitchellet al 1991). Mothers are advised to give up smoking but, if this is not possible, theyshould reduce their smoking as much as possible. There should be no smoking in thesame room as the infant because of the dangers of passive smoking.

Sudden Infant Death Syndrome (SIDS)

Some groups in New Zealand society are at an increased risk of SIDS. The reasons includesocial, economic and demographic factors as well as infant care practices (PHC 1995f).Mothers’ smoking and babies sleeping on their tummies are major risks for SIDS.

Breastfeeding should be encouraged. The New Zealand Cot Death Study (Ford et al1993) found that SIDS rates were twice as high among bottle fed infants compared withthose exclusively breastfed. Exclusive breastfeeding was more protective than partialbreastfeeding, which in turn was better than no breastfeeding. The reduced risk forSIDS in breastfed infants persisted during the first six months.

Alcohol and Breast-milk

Alcohol should be avoided as much as possible as the full potential effects are not known.Occasional moderate intakes by breastfeeding mothers may be acceptable but not directlybefore breastfeeding as the alcohol may pass into the milk.

Infants tend to consume less milk after their mother has drunk alcohol. The level ofalcohol in the breast-milk is the same as in the mother’s blood. Larger amounts ofalcohol inhibit the let-down reflex (PHC 1995a).

Appropriate use of Infant Formula

The primary objective of the WHO Code is to provide safe and adequate nutrition forinfants by protecting and promoting breastfeeding and by ensuring the proper use ofinfant formula when it is necessary, through adequate information and appropriatemarketing and distribution.

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Some mothers make a decision not to breastfeed their infants, are unable to breastfeed,or try to breastfeed without success. When a mother chooses not to breastfeed it isimportant she decides on the basis of objective and consistent information, and that sheis conscious of the potential health risks for her infant and the economic implicationsfor her family (WHO 1986). Infant formula should be used in the first 12 months of lifeif an infant is not fully breastfed.

Mothers should receive the same attention from health workers, the health care system,and community support as breastfeeding mothers. Peer support is positive in helpingwomen overcome the guilt they often feel when they do not breastfeed (Basire et al1997).

In some medical situations, establishing breastfeeding is not a priority. Health workersshould show an awareness and understanding of these situations and reduce the stressand confusion for the mother by giving appropriate information.

The WHO Code states that only health workers or other community workers shoulddemonstrate to mothers and family members how to prepare and use infant formula.Health workers should strengthen the health and nutrition education of these mothersand their family members in order to foster preparation for initiation and maintenanceof breastfeeding of any future infants that are born.

In antenatal classes information on formula feeding should always be presented in thecontext of breastfeeding being the better option. Expectant mothers should also be toldthat if they want to formula feed then information is available. Ideally, formula feedingtechniques should be taught on an individual basis, usually postnatally, to those whoneed to know. However, formula feeding techniques can be taught in a class situationto those who have decided to formula feed.

Mothers who are breastfeeding may also need information about sterilising bottles,should they need to express breast-milk. It is important that they learn this informationfrom a health worker. Mothers should also know there is a cup method of feedingexpressed breast-milk.

Further readings on appropriate use of infant formula

National Health and Medical Research Council (NHMRC). 1996. Infant FeedingGuidelines for Health Workers. Canberra: Department of Health and FamilyServices.

PHC. 1995b. Food and Nutrition Guidelines for Healthy Infants and Toddlers (aged0–2 years). A background paper. Wellington: Public Health Commission.

Stufkens J. 1996. A Food and Nutrition Guide for Under Fives. 2nd ed.Christchurch: Crown Public Health.

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Developing a Supportive Environment toPromote Breastfeeding

Health workers need to work with women in a way that increases women’s confidencein their ability to breastfeed. This involves the removal of constraints and influencesthat create negative perceptions and behaviour towards breastfeeding, often by subtleand indirect means.

Health workers can reinforce a ‘breastfeeding culture’ by eliminating obstacles tobreastfeeding in the health care system, workplaces and in the community.

The Ministry of Health will continue to monitor the attainment of national breastfeedingtargets. During 1997 a complete review of breastfeeding targets will be undertaken.Establishing clear and consistent indicators for breastfeeding will be a priority. Validatedmethods for collecting these data are also required. The Innocenti Declaration 1990suggests monitoring indicators of exclusively breastfed infants at discharge frommaternity services, usually between 28 days to six weeks, and again at four or six months.

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The Scope of the Code

The WHO Code applies to the marketing of infant formula products. It does not coverinfant (complementary) weaning foods as they are not considered to be substitutes forbreast-milk.

Follow-on formula which is designed for infants over six months, is not covered by theWHO Code interpretation in New Zealand.

The WHO Code does not cover bottle sterilisers.

The New Zealand Infant Formula Marketers’ Association has developed a self-regulatorycode of practice for the marketing of infant formula.

A code of practice for bottles and teats will probably be developed by manufacturers ata later stage.

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Definitions for the Health Guidelines

The WHO Code definitions are appropriate in most cases for use in New Zealand but,some have been changed to suit our environment.

The breastfeeding definitions are sourced from the WHO Global Data Bank onBreastfeeding 1996. There is little general agreement nationally and internationally onsuitable breastfeeding definitions. The Ministry will be reviewing the definitions it usesfor breastfeeding as indicators for monitoring the Ministry breastfeeding targets in 1997.

exclusive breastfeeding The infant is fed breast-milk (including milkexpressed or from a wet-nurse). Drops, syrups(vitamins, minerals, medicines) are allowed (WHO1996).

predominant breastfeeding The infant is fed breast-milk as the predominantsource of nourishment. Liquids (water, water-baseddrinks, fruit juice, ORS), ritual fluids and drops orsyrups (vitamins, minerals, medicines) are allowed(WHO 1996).

breast-milk substitute Any food, manufactured or represented as a partialor total replacement for breast-milk, whether or notsuitable for that purpose (WHO 1981).

complementary food Any food, manufactured or locally prepared,suitable as a complement to breast-milk or to infantformula when either becomes insufficient to satisfythe nutritional requirements of the infant. Such foodis also commonly called ‘weaning food’ or ‘breast-milk supplement’ (WHO 1981).

early discharge after childbirth Discharge up to 48 hours after delivery (Kilgour1990).

formula feeding Providing infants with proprietary infant formula,either exclusively or as a supplement tobreastfeeding.

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health care system Governmental, non-governmental or privateinstitutions or organisations engaged, directly orindirectly, in health care for mothers, infants andpregnant women; nurseries and child careinstitutions, also health workers in private practice.For the purpose of these guidelines, the health caresystem does not include pharmacies or otherestablished sales outlets (WHO 1981).

health worker A person working in a component of such a healthcare system, whether professional or non-professional, including voluntary, unpaid workers(WHO 1981).

infant formula A food in liquid or powdered form intended for useas a substitute for human milk as a sole source ofnutrition for an infant (Food Regulations 1984).

‘lead’ health professional A midwife, a doctor or a specialist.

support person Husband, partner, mother, friend or other familymember.

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Information and Education on InfantFeeding

Health workers should give accurate information and educational material onbreastfeeding and formula feeding to the general public.

Parents are entitled to choose how they wish to feed their infant. Therefore health workersshould discuss the benefits and problems associated with the different methods offeeding. Health workers should check all materials carefully and use only those whichare objective and consistent with current knowledge. Information should comply withthe WHO Code and be consistent with the NZIFMA Code on infant formula.

Parents who decide to use infant formula need accurate information on the correctpreparation of infant formula. One of the aims of the WHO Code is to ensure the properuse of infant formula. Health workers may provide information about different typesof formula such as cow’s milk versus soy milk and formulas with different whey tocasein ratios, giving brand examples. Health workers should not promote a specificbrand of infant formula.

Information on maternal nutrition and preparation for breastfeeding should reflectcurrent knowledge (NHMRC 1996).

Information on the negative effect on breastfeeding of introducing partial formula feedingshould reflect current knowledge on the relationship between milk production andfrequent milk removal. It is difficult to reverse the decision not to breastfeed, andalthough relactation is possible it is not easy.

In antenatal classes information on formula feeding should always be presented in thecontext of breastfeeding being the better option. Expectant mothers should also be toldthat if they decide to formula feed, then information is available. Postnatal informationon formula feeding can be given in a class where all the women have already made aninformed decision not to breastfeed. Ideally, formula feeding information should beprovided on an individual basis to the mothers or family members who need it.

All material, whether written, audio or visual, dealing with feeding infants must clarify:

• the benefits and superiority of breastfeeding

• maternal nutrition and the preparation for, and maintenance of, breastfeeding

• the negative effect on breastfeeding of introducing partial bottle feeding

• the difficulty of reversing the decision not to breastfeed

• the proper use, when needed, of infant formula.

Information on the use of infant formula should include the social and financialimplications of its use, the health hazards of inappropriate feeding methods and the

Infant Feeding 15

impact of formula feeding on the maintenance of breastfeeding. No pictures or textshould idealise the use of infant formula (WHO 1981).

Manufacturers and distributors who are asked to give advice on infant feeding willdirect the parent to contact their health worker. Appropriately qualified industrypersonnel will respond to complaints and requests for information from the public.

Health workers should promote and contribute to the dissemination of breastfeedinginformation in the community, local magazines, newsletters and newspapers.

Resources for the Promotion, Protection and Support ofBreastfeeding available from the Ministry of Health

PHC. 1995a. Food and Nutrition Guidelines for Healthy Breastfeeding Women: A backgroundpaper. Wellington: Public Health Commission.

PHC. 1995b. Food and Nutrition Guidelines for Healthy Infants and Toddlers (aged 0–2 years):A background paper: Wellington: Public Health Commission.

PHC. 1995c. Food and Nutrition Guidelines for Healthy Pregnant Women: A background paper.Wellington: Public Health Commission.

PHC. 1995e. Preventing Child Hearing Loss. Guidelines for public health services. Wellington:Public Health Commission.

PHC. 1995f. Preventing Sudden Infant Death Syndrome (SIDS): Guidelines for public healthservices. Wellington: Public Health Commission.

Resources for Distribution to the Public available from the CrownHealth Enterprises Authorised Provider Network (see Appendix 5)

Breastfeeding – Giving your baby the best you’ve got. Code 4881. 1990.Answers to breastfeeding questions. Code 4891. 1990.Expressing milk – breastfeeding facts. Code 4890. 1990.Inverted nipples. Code 4894. 1990.Sore nipples. Code 4893. 1990.Sore breasts. Code 4892. 1994.Well Child/Tamariki Ora Health Book. Code 7012. 1996.Eating for healthy breastfeeding women. Code 6003. 1995.Eating for healthy pregnant women. Code 6002. 1995.Healthy eating for babies and toddlers. Code 6004. 1995.Starting solids. Code 6014. 1995.Glue ear pamphlet. Code 4390. 1995.Glue ear flyer. Code 4872. 1995.Your Pregnancy (Tö Hapütanga) Code 4146. 1996.

Guidelines16

These educational resources are updated regularly and are distributed to the publicand health professionals through authorised providers in the public health units of theCrown health enterprises (see Appendix 5). If a specific resource is not available onrequest, ask the authorised provider to order it for you.

Infant Feeding 17

Advertising and Promotion of InfantFormula

A key feature of the WHO Code is the restriction on product promotion and samplingto the general public. (Refer to the NZIFMA code of practice for information onadvertising and marketing of infant formula.)

It is important that infants who are not breastfed are fed an appropriate infant formularather than unaltered cow’s milk. Within the current interpretation of the Code infantformula can be offered at a discounted price to consumers. Ideally, these products shouldbe offered at a lower price on a long-term basis.

Companies sometimes employ health professionals in an advisory marketing capacity.It is not appropriate for these employees to address antenatal classes, give instructionon the preparation of infant formula, or meet with mother-support groups. Theseeducational functions should be performed by a health professional working in thehealth care system. On hospital open days, social functions for mothers should notinclude company representatives, even if they are health professionals (NHMRC 1996).

Infant formula companies should not give free samples of infant formula to the generalpublic, pregnant women, parents or caregivers.

Promotion of Breastfeeding

Health workers should promote the benefits and practice of breastfeeding in a culturallyand socially sensitive way to mothers, partners, support persons, and families. Healthworkers can be involved in studies or surveys on target population groups that evaluatethe present knowledge, attitudes, beliefs, and behaviour towards breastfeeding.

Health workers can facilitate the development of multi-media public educationprogrammes to assist social change in attitudes towards breastfeeding. This will includeidentifying existing barriers and potential barriers to breastfeeding and designingappropriate health messages.

Health workers may support public policy that reinforces a ‘breastfeeding culture’ andencourages baby-friendly workplaces in businesses and city council facilities.

Guidelines18

Health Care Systems

Health care systems and health workers play an essential role in guiding infant feedingpractices. They do this by encouraging and facilitating breastfeeding and providingobjective and consistent advice to mothers and families about the superior value ofbreastfeeding. When needed, health workers also advise on the proper use of infantformula (NHMRC 1996).

Health workers should not be involved in the promotion of products used for infantfeeding. Companies may not use health facilities to promote their products althoughthey may provide responsible scientific and factual information to health workers ascovered in the section in these guidelines on information and education on infant feeding.

Health workers may meet individually or collectively with company representatives tobe informed about company products.

There may be no displays of infant formula, bottles or teats in a health care system, norposters, growth charts, calendars or formula preparation charts which refer to anyproduct within the scope of the New Zealand interpretation of the WHO Code. Dischargepacks should not contain material concerning these products.

Mothers or family members who will be using infant formula need responsibleinstruction on the preparation and safe storage of infant formula, feeding techniquesand types of formula available. Formula feeding should be taught by qualified peopleand teaching should include information about health issues associated with formulafeeding as outlined in the section in these guidelines on information and education oninfant feeding.

Infant formula may be purchased by health care organisations at wholesale prices.

Infant formula may not be given by manufacturers or distributors to organisations orinstitutions within the health care system except in circumstances of emergency reliefor poverty. Then donated supplies may be given but only under the following conditions:

• infants must be medically required to be fed, or are already being fed on breast-milksubstitutes

• supply must be continued as long as the special circumstances continue

• the supply must not be used as a sales inducement.

Health care facilities may accept donations of equipment or materials from companiesbut only the name and logo of the company supplier may appear on the material.Educational materials for mothers should meet the requirements outlined in theinformation and education section of these guidelines.

Product-specific information, particularly in relation to the uses of infant formula orsupporting products and their composition, may be provided to health workers.

Infant Feeding 19

Policy Development

Health workers should develop infant feeding policies reflecting the Infant Feeding:Guidelines for New Zealand Health Workers. To receive widespread local support the policiesshould be implemented in collaboration with:

• all local professional and voluntary groups providing education and support servicesfor women who are breastfeeding

• primary health care

• maternity services

• local authority social services to encourage a baby-friendly environment

• local consumer and children and women’s groups

• education interests.

Providers should have in place policies which protect, promote and supportbreastfeeding. These ensure that women who wish to breastfeed receive the help andsupport they need. These policies should be extended into the community and wherenecessary updated in collaboration with Well Child/Tamariki Ora, for example, andPlunket, Tipu Ora and General Practice.

Support groups and organisations specialising in breastfeeding are listed in Appendix 5.

Recommendations for Promotion andSupport of Breastfeeding in Health CareSystems

Health care facilities and programmes providing maternity services and care for newborninfants should review their policies and practices relating to breastfeeding.

Funders and providers are encouraged to make sufficient breast pumps available forloan.

Each facility should introduce a written policy that addresses nine of the ‘Ten Steps toSuccessful Breastfeeding’. (Step nine concerning the use of dummies is now controversialand until there is clearer direction it should be excluded).

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The Steps to Successful Breastfeeding

1. Have a written breastfeeding policy that is routinely communicated to all healthcare 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 breastfeeeding.

4. Help mothers initiate breastfeeding within a half-hour of birth.

5. Show mothers how to breastfeed and maintain lactation even if they should beseparated from their infants.

6. Give newborn infants no food or drink other than breast-milk, unless medicallyindicated.

7. Practice rooming-in, allowing mothers and infants to remain together 24 hours aday.

8. Encourage breastfeeding on demand.

9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeedinginfants. (Research suggests, however, that dummies may not interfere withbreastfeeding and may be protective for SIDS (PHC 1995f). Until clearer evidenceemerges, step nine is debatable and should be excluded. Dummies must not replaceoffering the breast when the infant is hungry.)

10. Foster the establishment of breastfeeding support groups and refer mothers tothem on discharge from hospital or clinic (WHO/UNICEF 1989).

Health workers may promote the introduction of the Baby Friendly Hospital Initiative(BFHI). The BFHI has been launched by WHO and UNICEF to encourage hospitals andhealthcare facilities to adopt practices that fully protect, promote and supportbreastfeeding. The criteria for the BFHI apply in all countries. BFHI are recognisedinternationally as providers of the highest possible standard of care for breastfeedingmothers and their babies (UNICEF/UK undated).

Health workers may encourage the promotion and support of breastfeeding incommunity group practices by promoting the following ten steps. These will involveall members in the group practice; the various health professionals as well as supportworkers, receptionists, social workers and secretaries.

Ten Steps to Becoming a Breastfeeding-Supporting Practice

1. Engage colleagues and agree to become a breastfeeding-supporting practice.

2. Establish aims and objectives.

3. Audit breastfeeding in your practice: incidence, duration, reasons for stopping.

4. Educate the group and endeavour to eliminate conflicting advice.

5. Establish a breastfeeding policy.

6. Agree to a protocol for resolving problems.

7. Monitor and evaluate the effectiveness of the developed programme.

Infant Feeding 21

8. Designate an enthusiastic and interested team member to keep everyone up todate with current research and new developments.

9. Provide a welcoming environment in your premises for breastfeeding women.

10. Refer mothers to breastfeeding support groups.

(Home and Health Department 1995)

Recommendations for Postnatal Adviceand Support in the Community

The first 13 weeks are particularly important for establishing breastfeeding since this iswhen babies receive the immunity they need to protect them against illness. However,it is also a time when a breastfeeding mother is the most likely to give up.

Postnatal support services need to be particularly proactive, therefore, during this timein identifying and responding sensitively to the needs of the breastfeeding mother.

A simple breastfeeding support system is that provided by other members of theantenatal group to which the mother belongs. Alternatively, women who share the samehospital room may form a support group.

The lead maternity caregiver should liaise with the appropriate community supportservice or groups when the woman passes from her care to community care.

Providers of postnatal support services should consider implementing the followingstrategies:

• updating their knowledge and abilities to assist mothers maintain breastfeeding

• providing sound advice consistent with current best practice

• assisting, preventing and resolving the most common problems which cause mothersto stop breastfeeding.

Mothers on transfer from hospital should be given details of local breastfeeding supportgroups and information for obtaining breastfeeding advice.

Further information on support groups, services and organisations specialising in breastfeedingcan be found in Appendix 5.

Guidelines22

Health Workers’ Responsibilities Underthe WHO Code

• Health workers have a responsibility to protect and promote breastfeeding. Forparents to make an informed choice about infant feeding, health workers need to bewell informed.

• Health workers may accept and distribute material such as pamphlets, posters, andbooklets from infant formula companies providing the material is factual andeducational. All material, whether written, audio or visual, must clarify the benefitsand superiority of breastfeeding and explain how formula feeding may impact onthe maintenance of breastfeeding.

• Health workers should keep informed about developments in research in infantformula and associated products from scientific journals in addition to readingmaterials provided by manufacturers (NHMRC 1996).

• Samples of infant formula may be provided to health care workers for the purposesof professional evaluation and research or for educating parents on the correctpreparation of formula.

• Representatives of infant formula companies may call on health workers to providefactual educational information on products or infant nutrition in general. Likewise,a health worker may contact an infant formula company for factual or educationalinformation.

Recommendations for Training Institutions

All initial and in-service training facilities for training health workers in breastfeedingshould review their curricula regarding their policies on breastfeeding.

Health workers should encourage and support the revision of their training curricula.Where necessary, the infant-feeding content of health workers’ training curricula,textbooks and other learning materials should be revised in conjunction with those ofrelevant international and voluntary organisations.

These materials should include the principles and aim of the WHO Code and healthworkers’ responsibilities under it. Health workers in maternal and infant nutritionshould make themselves familiar with their responsibilities covered in the section inthese guidelines on information and education on infant feeding.

All initial and in-service health workers’ training in breastfeeding should include:

Infant Feeding 23

• information and advice regarding the responsibilities of health workers under thenational measures adopted to give effect to the WHO Code

• the summarised and operational targets of the Innocenti Declaration 1990

• knowledge of the 1989 joint WHO/UNICEF statement on breastfeeding and the roleof the maternity services

• lactation management

• information on how to establish breastfeeding groups in the community

• guidelines on how to educate, support and assist women who are formula feedingtheir infants

• knowledge on applying the Treaty of Waitangi to improve Mäori health

• awareness of cultural differences.

Health workers must be provided with enough breastfeeding information during theirtraining to give them the knowledge and skills to support breastfeeding women,especially those experiencing problems. Training institutions and in-service trainingshould include practical clinical training in their programmes.

Training programmes should designate a minimum time for a trainee to work withexperienced professionals in postnatal wards and in the community observing andtalking to breastfeeding mothers. A special assignment on breastfeeding to bring traineesin contact with breastfeeding mothers would be an appropriate way of giving thisessential experience.

Recommendations for Health Workers inthe Health Care System

Successful implementation of local policies on breastfeeding will require the activeinvolvement of general managers, senior clinicians, lead maternity caregivers, supportstaff and receptionists, together with general practitioners and community health careteams fostering and promoting a positive attitude to breastfeeding (NHS 1995).

Health workers are accountable to client, employer, and professional body and:

• each health care system should have a breastfeeding policy and set of standards andprocedures in place to enable health workers to establish objective and measurablehealth care plans for their clients. There should be regular peer review of casemanagement, and regular reports including breastfeeding statistics to management.

As part of their continuing professional commitment and development, health workersneed to be up to date in their knowledge of infant feeding and breastfeeding. In particular,they should:

• be able to give clear, consistent and accurate information about the benefits ofbreastfeeding

Guidelines24

• encourage mothers prior to the birth of their infant to make an informed choice onthe feeding method they will use

• give educational materials on infant feeding and weaning, which are sensitive andrelevant to the local population, to mothers, husbands and partners, and families

• encourage the participation of husband or partner and family, when appropriate, inantenatal education and the birth.

Health workers should be able to identify psychosocial barriers to breastfeeding and,when necessary, refer their clients to appropriate health professionals or agencies forassistance.

Infant Feeding 25

Quality and Labelling of Infant Formula

All infant formula sold in New Zealand must conform with standards for quality,composition and labelling set down in the Food Regulations 1984 or in the AustraliaFood Standards Code.

Since the introduction of the joint food standard setting system on 1 July 1996, dualstandards operate in New Zealand. This allows products which meet the Australia FoodStandards Code to be legally sold in New Zealand.

Any of the standard infant formulas sold in New Zealand are suitable for infant feedingwhen an infant is not breastfed or is breastfed only partially. Modified or specialisedformula should be used only on the advice of an expert in infant nutrition or as part ofthe management of a specific medically diagnosed condition.

Guidelines26

Implementation and Monitoring

Health workers should comply with these health guidelines derived from the WHOCode. They should meet their obligations for giving information and advice to parentsof breastfed and formula fed infants.

Health workers have an obligation to educate and inform the consumer on their right tocomplain about activities which are incompatible with the principles and aims of theNew Zealand interpretation of the WHO Code so that appropriate action can be taken.

Health workers should be aware of the complaints process for use when they areconfronted with breaches of the health guidelines or NZIFMA Code.

Infant Feeding 27

Complaints Process

Any complaints about possible contraventions of the WHO Code as it is applied inNew Zealand should be made in writing and sent to the Food and Nutrition Section,Public Health Group, Ministry of Health, PO Box 5013, Wellington. The complaint willbe forwarded to the executive director of the NZIFMA, if it relates to non-complianceby an infant formula marketer, or to the health worker or relevant health associationconcerned.

NZIFMA companies or the health worker concerned will be called upon to respondwithin twenty days to any complaint received. If the issue is not resolved to thecomplainant’s satisfaction, it will be submitted to a three-person compliance panelcomprising:

• an independent chairperson

• a representative from the health sector

• a representative from the infant formula industry.

There will also be present a Ministry of Health observer. Secretarial support will beprovided by NZIFMA and the Ministry of Health.

Three public representatives (the chairperson, the health sector representative andadjudicator) will be appointed after calling for nominations from interested parties.The Ministry will approve the appointments before they are confirmed.

The panel may convene up to four times a year, if necessary, to consider complaints.

Either party may appeal the decision of the panel if new information is submitted. Arepresentative from the health sector will be appointed as an adjudicator. Theadjudicator’s decision will be final and binding.

All parties connected with a complaint will be notified immediately of the compliancepanel’s decision and, if necessary, the appeal adjudicator’s decision.

In accordance with the Letter of Understanding the NZIFMA will report twice yearly tothe Ministry on the outcome of complaints received by the Ministry or NZIFMA andconsidered by the panel or adjudicator.

The compliance panel and the adjudicator may make representations to the Ministryand NZIFMA on suggested changes to wording in the Code of Practice.

All compliance decisions will be reviewed by the Food and Nutrition AdvisoryCommittee (FNAC). The FNAC is a technical expert committee that provides advice tothe Ministry of Health on food and nutrition issues. This committee will also considerrecommendations made by the compliance panel or adjudicator.

Guidelines28

References

Basire K, Pullon S, McLeod D. 1997. Baby feeding: the thought behind the statistics. NZMed J 110:184–7.

Baumslag N (ed). 1989. Breastfeeding: The passport to life. New York: UNICEF.

Begg EJ, Atkinson HC, Darlow BA. 1996. Guide to medicine use in lactation. In: NewEthicals Drug Information Guides. Auckland: Adis International Ltd.

Bulterys M, Goedert JJ. 1996. From biology to sexual behaviour: towards the preventionof mother-to-child transmission of HIV. AIDS 10(11): 1287-9.

Cunningham AS, Jelliffe DB, Jelliffe EFP. 1991. Breastfeeding and health in the 1980’s: aglobal epidemiologic review. J Pediatr 118(5): 659-666.

Dewey KG, Heinig MJ, Nommsen-Rivers LA, et al. 1995. Differences in morbiditybetween breastfed and formula fed infants. J Pediatr 126(5): 696-702.

Essex C, Smale P, Geddis D. 1995. Breastfeeding rates in New Zealand in the first sixmonths and the reasons for stopping. NZ Med J 108: 355-7.

France MM. 1996. A study of the lactational amenorrhoea method of family planning inNew Zealand women. NZ Med J 109: 189-91.

Ford RPK, Taylor BJ, Mitchell EA, et al. 1993. Breastfeeding and the risk of suddeninfant death syndrome. Int J Epidem 22: 885–90.

Gale C and Martyn CN. 1996. Breastfeeding, dummy use, and adult intelligence. Lancet347: 1072-1075.

Galtry J. 1995. Breastfeeding, labour market changes and public policy in New Zealand:is promotion of breastfeeding enough? Social Policy J NZ 5: 2-16.

Hinson V. 1994. Discussion Document on the WHO International Code of Marketing of Breast-milk Substitutes. Wellington: Public Health Commission.

Home and Health Department. 1995. Supporting Breastfeeding in Your Primary HealthCare Team. Edinburgh: Morton Ward Associates Scotland.

Howie PW, Forsyth JS, Ogston SA, et al. 1990. Protective effect of breastfeeding againstinfection. Brit Med J 300: 11-16.

IBFAN. 1996. State of the Code by Country: Update No.2. Penang: International CodeDocumentation Centre.

Kilgour R. 1990. Early Discharge after Childbirth. Health Research Services. Wellington:Department of Health.

La Leche League International. 1988 or 1991. The Womanly Art of Breastfeeding. Illinois:Franklin Park.

La Leche League International. 1991. The Breastfeeding Answer Book. Illinois: FranklinPark.

Labbok M, Krasovec K. 1990. Toward consistency in breastfeeding definitions. Studiesin Family Planning 21 (4): 226-30.

Infant Feeding 29

Lang S, Lawrence CJ, Orme R. 1994. Cup feeding: an alternative method of infant feeding.Archives of Disease in Childhood 71: 365-9.

Marmet C. 1993. Summary of institutional actions affecting breastfeeding. J Hum Lact9(2): 109-113.

Mitchell E, Scragg R, Stewart A, et al. 1991. Results from the first year of the New ZealandCot Death Study. NZ Med J 104: 71-6.

MoH. 1996a. Wellchild, Tamariki Ora Health Book. Wellington: Ministry of Health.

MoH. 1996b. Your Pregnancy, Tö Hapütanga. Wellington: Ministry of Health.

MoH. 1997. HIV in Pregnancy: Risk screening guidelines and information for healthprofessionals. Circular letter to health professionals. Wellington: Ministry of Health.

National Health and Medical Research Council (NHMRC). 1996. Infant Feeding Guidelinesfor Health Workers. Canberra: Department of Health and Family Services.

Newell ML and Peckham C. 1993. Risk factors for vertical transmission of HIV-1 andearly markers of HIV-1 infection in children. AIDS 7 (1 suppl): S91-7.

NHS. 1995. Breastfeeding: Good Practice Guidance to the National Health Service (NHS).London: Department of Health.

Nutrition, Health and Medical Research Council (NHMRC). 1996. Infant FeedingGuidelines for Health Workers. Canberra: Commonwealth of Australia.

PHC. 1995a. Food and Nutrition Guidelines for Healthy Breastfeeding Women: A backgroundpaper. Wellington: Public Health Commission.

PHC. 1995b. Food and Nutrition Guidelines for Healthy Infants and Toddlers (aged 0–2 years):A background paper. Wellington: Public Health Commission.

PHC. 1995c. Food and Nutrition Guidelines for Healthy Pregnant Women: A background paper.Wellington: Public Health Commission.

PHC. 1995d. Guidelines for Interpretation of the WHO International Code of Marketing ofBreast-milk Substitutes in New Zealand. Wellington: Public Health Commission.

PHC. 1995e. Preventing Child Hearing Loss: Guidelines for public health services. Wellington:Public Health Commission.

PHC. 1995f. Preventing Sudden Infant Death Syndrome (SIDS): Guidelines for public healthservices. Wellington: Ministry of Health.

Statement from the International Planned Parenthood Federation. 1996. London:International Medical Advisory Panel (IPPF, IMAP). IPPF Medical Bulletin: 30 (3).

Stufkens J. 1996. A Food and Nutrition Guide for Under Fives. 2nd ed. Christchurch: CrownPublic Health.

The New Zealand College of Midwives. 1992. Protecting, Promoting and SupportingBreastfeeding. The breastfeeding handbook. Dunedin: Right Words New Zealand.

UNAIDS. 1997. HIV and Infant Feeding: A policy statement developed collaborativelyby UNAIDS, WHO and UNICEF. Geneva: Joint United Nations Programme on HIV/AIDS.

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UNICEF/UK. Undated. UK Baby Friendly Initiative. Self Appraisal: A step towards BabyFriendly designation: London: United Kingdom Committee for UNICEF.

United States Public Health Service. 1995. US Public Health Service recommendationsfor human immunodeficiency virus counselling and voluntary testing for pregnantwomen. Morbidity and Mortality Weekly Report 44(RR–7): 1–15.

WHO. 1981. International Code of Marketing of Breast-milk Substitutes. Geneva: WorldHealth Organization.

WHA. 1986. Guidelines concerning the main health and socioeconomic circumstancesin which infants have to be fed breast-milk substitutes. WHA39/8 Add.1. Geneva: WorldHealth Organization.

WHO. 1988. Taskforce on Oral Contraceptives. Effects of hormonal contraceptives onbreast-milk composition and infant growth. Studies in Family Planning 19: 477-96.

WHO. 1992. Facts about Infant Breastfeeding: Issue No.2. Geneva: World HealthOrganization.

WHO. 1995. Nutrition. Weekly Epidemiology Record 17: 117-20. Geneva: World HealthOrgnization.

WHO. 1996. Global Data Bank on Breast-feeding. Nutrition Unit. Geneva: World HealthOrganization.

WHO/UNICEF. 1989. Protecting, Promoting and Supporting Breastfeeding: The special roleof maternity services. A joint statement. Geneva: World Health Organization.

WHO/UNICEF. 1990. Innocenti Declaration on the Protection, Promotion and Support ofBreastfeeding. Adopted by the WHO/UNICEF policy makers’ meeting. Geneva: WorldHealth Organization.

World Alliance for Breastfeeding Action (WABA). 1992. The Baby-Friendly HospitalInitiative Action Folder. Malaysia: WABA Secretariat.

Infant Feeding 31

Appendix 1

Flowchart of Complaints Process

Two illustrations of the complaints process for non-compliance with theWHO Code

Complaint about a health worker's action Parents' request for information on infant formula from a health worker is denied

Ministry writes to health worker seeking comment on the complaint

Ministry acknowledges letter and actions process

Health worker replies and Ministry notifies complainant of explanation (20 days for process)

Complaint about a marketer's actionUnsolicited infant formula product informationis distributed to pregnant women

Ministry acknowledges letter and actions process

Ministry forwards letter to NZIFMA

NZIFMA seeks comment oncomplaint from marketer

Marketer replies and NZIFMAnotifies complainant and Ministryof explanation (20 days for process)

Complaint is lodgedwith Ministry of Health

Either

Or

Either

Complainant accepts decision

Or

Complainant told original decision is final

Adjudicator notified

Adjudicator decides

Complainant and health worker or marketer informed of outcome

Or

Either

Complainant satisfied. Complaint is recorded in report that goes to the Food and Nutrition Advisory Committee (FNAC)

Complainant is dissatisfied. Complaint is referred to compliance panel to consider

Compliance Panel:independent chair

health sector representativeindustry representative

MoH observersecretary

Complainant notified of outcome in writing by chair

Complainant submits new information to chair

Chair considers whether decision should be reviewed by an adjudicator

Decision becomes part of a report submitted twice yearly by the panel to the FNAC.Adjudicator or chair seek advice from the FNAC. Panel may convene four times a year if necessary.

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Appendix 2

Articles of the WHO Code

The following appendix has been taken directly from the WHO Code and has not been furtheredited by the publisher.

WHO Code Article 1 – Aim of the Code

The aim of this Code is to contribute to the provision of safe and adequate nutrition forinfants, by the protection and promotion of breastfeeding, and by ensuring the properuse of breast-milk substitutes, when these are necessary, on the basis of adequateinformation and through appropriate marketing and distribution.

WHO Code Article 2 – Scope of the Code

The Code applies to the marketing, and practices related thereto, of the followingproducts: breast-milk substitutes, including infant formula; other milk products, foodsand beverages, including bottle-fed complementary foods, when marketed or otherwiserepresented to be suitable, with or without modification, for use as a partial or totalreplacement of breast-milk; feeding bottles and teats. It also applies to their quality andavailability, and to information concerning their use.

Infant Feeding 33

WHO Code Article 3 – Definitions

For the purposes of this Code:

“Breast-milk substitute” means any food being marketed or otherwiserepresented as a partial or totalreplacement for breast-milk, whether ornot suitable for that purpose.

“Complementary food” means any food, whether manufactured or locallyprepared, suitable as a complement tobreast-milk or to infant formula, wheneither becomes insufficient to satisfy thenutritional requirements of the infant.Such food is also commonly called“weaning food” or “breast-milk”supplement.

“Container” means any form of packaging of products for saleas a normal retail unit, includingwrappers.

“Distributor” means a person, corporation or any other entityin the public or private sector engaged inthe business (whether directly orindirectly) of marketing at the wholesaleor retail level a product within the scopeof this Code. A “primary distributor” is amanufacturer’s sales agent, representative,national distributor or broker.

“Health care system” means governmental, non-governmental orprivate institutions or organisationsengaged, directly or indirectly, in healthcare for mothers, infants and pregnantwomen; and nurseries or child-careinstitutions. It also includes healthworkers in private practice. For thepurposes of this Code, the health caresystem does not include pharmacies orother established sales outlets.

“Health worker” means a person working in a component of sucha health care system, whether professionalor non-professional, including voluntary,unpaid workers.

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“Infant formula” means a breast-milk substitute formulatedindustrially in accordance with applicableCodex Alimentarius standards, to satisfythe normal nutritional requirements ofinfants up to between four and six monthsof age, and adapted to their physiologicalcharacteristics. Infant formula may alsobe prepared at home, in which case it isdescribed as “home prepared”.

“Label” means any tag, brand, mark, pictorial or otherdescriptive matter, written, printed,stencilled, marked, embossed orimpressed on, or attached to, a container(see above) of any products within thescope of this Code.

“Manufacturer” means a corporation or other entity in the publicor private sector engaged in the businessor function (whether directly or throughan agent or through an entity controlledby or under contract with it) ofmanufacturing a product within the scopeof this Code.

“Marketing” means product promotion, distribution, selling,advertising, product public relations, andinformation services.

“Marketing personnel” means any persons whose functions involve themarketing of a product or productscoming within the scope of this Code.

“Samples” means single or small quantities of a productprovided without cost.

“Supplies” means quantities of a product provided for useover an extended period, free or at a lowprice, for social purposes, including thoseprovided to families in need.

Infant Feeding 35

WHO Code Article 4 – Information andEducation

4.1 Governments should have the responsibility to ensure that objective and consistentinformation is provided on infant and young child feeding for use by familiesand those involved in the field of infant and young child nutrition. Thisresponsibility should cover either the planning, provision, design anddissemination of information, or their control.

4.2 Informational and educational materials, whether written, audio, or visual, dealingwith the feeding of infants and intended to reach pregnant women and mothersof infants and young children, should include clear information on the followingpoints:

• the benefits and superiority of breastfeeding;

• maternal nutrition, and the preparation for and maintenance of breastfeeding;

• the negative effect on breastfeeding of introducing partial bottle feeding;

• the difficulty of reversing the decision not to breastfeed;

• where needed, the proper use of infant formula, whether manufacturedindustrially or home prepared. When such materials contain information aboutthe use of infant formula, they should include the social and financialimplications of their use; the health hazards of inappropriate foods or feedingmethods; and in particular, the health hazards of unnecessary or improperuse of infant formula and other breast-milk substitutes. Such materials shouldnot use any pictures or text which may idealise the use of breast-milksubstitutes.

4.3 Donations of informational or educational equipment or materials bymanufacturers or distributors should be made only at the request and with thewritten approval of the appropriate government authority or within guidelinesgiven by governments for this purpose. Such equipment or materials may bearthe donating company’s name or logo, but should not refer to a proprietaryproduct that is within the scope of this Code, and should be distributed onlythrough the health care systems.

Guidelines36

WHO Code Article 5 – The general publicand mothers

5.1 There should be no advertising or other form of promotion to the general publicof products within the scope of this Code.

5.2 Manufacturers and distributors should not provide, directly or indirectly, topregnant women, mothers or members of their families, samples of productswithin the scope of this Code.

5.3 In conformity with paragraphs one and two of this Article, there should be nopoint-of-sale advertising, giving of samples, or any other promotion device toinduce sales directly to the consumer at the retail level, such as special displays,discount coupons, premiums, special sales, loss-leaders and tie-in sales, forproducts within the scope of this Code. This provision should not restrict theestablishment of pricing policies and practices intended to provide products atlower prices on a long-term basis.

5.4 Manufacturers and distributors should not distribute to pregnant women ormothers of infants and young children any gifts of articles or utensils which maypromote the use of breast-milk substitutes or bottle-feeding.

5.5 Marketing personnel, in their business capacity, should not seek direct or indirectcontact of any kind with pregnant women or with mothers of infants and youngchildren.

Infant Feeding 37

WHO Code Article 6 – Health Care Systems

6.1 The health authorities in Member States should take appropriate measures toencourage and protect breastfeeding and promote the principles of this Code,and should give appropriate information and advice to health workers in regardto their responsibilities, including the information specified in Article 4.2.

6.2 No facility of a health care system should be used for the purpose of promotinginfant formula or other products within the scope of this Code. This Code doesnot, however, preclude the dissemination of information to health professionalsas provided in Article 7.2.

6.3 Facilities of health care systems should not be used for the display of productswithin the scope of this Code, for placards or posters concerning such products,or for the distribution of material provided by a manufacturer or distributor otherthan that specified in Article 4.3.

6.4 The use by the health care system of ‘professional service representatives’,‘mothercraft nurses’, or ‘similar personnel’, provided or paid for by manufacturersor distributors should not be permitted.

6.5 Feeding with infant formula, whether manufactured or home prepared, shouldbe demonstrated only by health workers, or other community workers if necessary;and only to the mothers or family members who need to use it; and the informationgiven should include a clear explanation of the hazards of improper use.

6.6 Donations or low-price sales to institutions or organisations of supplies of infantformula or other products within the scope of this Code, whether for use ininstitutions or for distributions outside them, may be made. Such supplies shouldonly be used or distributed for infants who have to be fed on breast-milksubstitutes. If these supplies are distributed for use outside the institutions, thisshould be done only by the institutions or organisations concerned. Such donationsor low-price sales should not be used by manufacturers or distributors as a salesinducement.

6.7 Where donated supplies of infant formula or other products within the scope ofthis Code are distributed outside an institution, the institution or organisationshould take steps to ensure that supplies can be continued as long as the infantconcerned need them. Donors, as well as institutions or organisations concerned,should bear in mind this responsibility.

6.8 Equipment and materials, in addition to those referred to in Article 4.3, donatedto a health care system may bear a company’s name or logo, but should not referto any proprietary product within the scope of the Code.

(WHA resolution 39.28 passed in May 1986, urges member states ‘to ensure that thesmall amounts of breast-milk substitutes needed for the minority of infants who requirethem in maternity wards and hospitals are made through the normal procurementchannels and not through free or subsidised supplies’.)

Guidelines38

WHO Code Article 7 – Health Workers

7.1 Health workers should encourage and protect breastfeeding; and those who areconcerned in particular with maternal and infant nutrition should makethemselves familiar with their responsibilities under this Code, including theinformation specified in Article 4.2.

7.2 Information provided by manufacturers and distributors to health professionalsregarding products within the scope of this Code should be restricted to scientificand factual matters, and such information should not imply or create a belief thatbottle-feeding is equivalent or superior to breastfeeding. It should also includethe information specified in Article 4.2.

7.3 No financial or material inducements to promote products within the scope ofthis Code should be offered by manufacturers or distributors to health workersor members of their families, nor should these be accepted by health workers ormembers of their families.

7.4 Samples of infant formula or other products within the scope of this Code, or ofequipment or utensils for their preparation or use, should not be provided tohealth workers except when necessary for the purpose of professional evaluationor research at the institutional level. Health workers should not give samples ofinfant formula to pregnant women, mothers of infants and young children, ormembers of their families.

7.5 Manufacturers and distributors of products within the scope of this Code shoulddisclose to the institution to which a recipient health worker is affiliated anycontribution made to him or on his behalf for fellowships, study tours, researchgrants, attendance at professional conferences, or the like. Similar disclosuresshould be made by the recipient.

Infant Feeding 39

WHO Code Article 8 – Persons employedby manufacturers and distributors

8.1 In systems of sales incentives for marketing personnel, the volume of sales ofproducts within the scope of this Code, should not be included in the calculationof bonuses, nor should quotas be set specifically for sales of these products. Thisshould not be understood to prevent the payment of bonuses based on the overallsales by a company of other products marketed by it.

8.2 Personnel employed in marketing products within the scope of this Code shouldnot, as part of their job responsibilities, perform educational functions in relationto pregnant women or mothers of infants and young children. This should not beunderstood as preventing such personnel from being used for other functions bythe health care systems at the request and with the written approval of theappropriate authority of the government concerned.

Guidelines40

WHO Code Article 9 – Labelling

9.1 Labels should be designed to provide the necessary information about theappropriate use of the product, and so as not to discourage breastfeeding.

9.2 Manufacturers and distributors of infant formula should ensure that eachcontainer has a clear, conspicuous, and easily readable and understandablemessage printed on it, or on a label which cannot readily become separated fromit, in an appropriate language, which includes all the following points:

• the words ‘Important Notice’ or their equivalent

• a statement of the superiority of breastfeeding

• a statement that the product should be used only on the advice of a healthworker as to the need for its use and the proper method of use

• instructions for appropriate preparation, and a warning against the healthhazards of inappropriate preparation. Neither the container nor the labelshould have pictures of infants nor should they have other pictures or textwhich may idealise the use of infant formula. They may however have graphicsfor easy identification of the product as a breast-milk substitute and forillustrating methods of preparation. The terms “humanised”, “maternalised”,or similar terms should not be used. Inserts subject to the above conditions,may be included in the package or retail unit. When labels give instructionsfor modifying a product into infant formula, the above should apply.

9.3 Food products within the scope of this Code, marketed for infant feeding, whichdo not meet the requirements of an infant formula, but which can be modified todo so, should carry on the label a warning that the unmodified product shouldnot be the sole source of nourishment of an infant. Since sweetened condensedmilk is not suitable for infant feeding, nor for use as a main ingredient of infantformula, its label should not contain purported instructions on how to modify itfor that purpose.

9.4 The label of food products within the scope of this Code should also state all thefollowing points:

• the ingredients used

• the composition /analysis of the product

• the storage conditions required

• the batch number and the date before which the product is to be consumed,taking into account the climatic and storage conditions of the countryconcerned.

Infant Feeding 41

WHO Code Article 10 – Quality

10.1 The quality of the products is an essential element for the protection of the healthof infants and therefore should be of a high recognised standard.

10.2 Food products within the scope of this Code should, when sold or otherwisedistributed, meet the applicable standards recommended by the CodexAlimentarius Commission and also the Codex Code of Hygienic Practice for Foodsfor Infants and Children.

Guidelines42

WHO Code Article 11 – Implementationand Monitoring

11.1 Governments should take action to give effect to the principles and aim of theCode, as appropriate to their social and legislative framework, including theadoption of national legislation, regulations or other suitable measures. For thispurpose, governments should seek, when necessary, co-operation of WHO,UNICEF and other agencies of the United Nations system. National policies andmeasures, including laws and regulations, which are adopted to give effect to theprinciples and aim of this Code should be publicly stated, and should apply onthe same basis to all those involved in the manufacture and marketing of productswithin the scope of this Code.

11.2 Monitoring the application of this Code lies with governments acting individually,and collectively through the World Health Organization as provided inparagraphs six and seven of this Article. The manufacturers and distributors ofproducts within the scope of this Code, and appropriate non-governmentalorganisations, professional groups, and consumer organisations shouldcollaborate with governments to this end.

11.3 Independently of any other measures taken for implementation of this Code,manufacturers and distributors of products within the scope of this Code shouldregard themselves as responsible for monitoring their marketing practicesaccording to the principles and aim of this Code, and for taking steps to ensurethat their conduct at every level conforms to them.

11.4 Non-governmental organisations, professional groups, institutions andindividuals concerned should have the responsibility of drawing the attention ofmanufacturers or distributors to activities which are incompatible with theprinciples and aim of this Code, so that appropriate action can be taken. Theappropriate governmental authority should also be informed.

11.5 Manufacturers and primary distributors of products within the scope of this Codeshould apprise each member of their marketing personnel of the Code and oftheir responsibilities under it.

11.6 In accordance with Article 62 of the Constitution of the World Health Organization,Member States should communicate annually to the Director-General informationon action taken to give effect to the principles and aim of this Code.

11.7 The Director-General shall report in even years to the World Health Assemblyon the status of the implementation of the Code; and shall on request, providetechnical support to Member States preparing national legislation or regulations,or taking other appropriate measures in implementation and furtherance of theprinciples and aim of this Code.

Infant Feeding 43

Appendix 3

World Health Assembly Resolutions

The following appendix has been taken directly from the WHA resolutions and has not beenfurther edited by the publisher.

Excerpt from the Forty-Seventh World Health Assembly 9 May1994

2. Urges Member States to take the following measures:

(1) to promote sound infant and young child nutrition, in keeping with theircommitment to the World Declaration and Plan of Action for Nutrition,through coherent effective intersectoral action, including:

(a) increasing awareness among health personnel, non-governmentalorganisations, communities and the general public of the importanceof breast-feeding and its superiority to any other infant feedingmethod;

(b) supporting mothers in their choice to breast-feed by removingobstacles and preventing interference that they may face in healthservices, the workplace, or the community;

(c) ensuring that all health personnel concerned are trained inappropriate infant and young child feeding practices, including theapplication of the principles laid down in the joint WHO/UNICEFstatement on breast-feeding and the role of maternity services;

(d) fostering appropriate complementary feeding practices from the ageof about six months, emphasising continued breast-feeding andfrequent feeding with safe and adequate amounts of local foods;

(2) to ensure that there are no donations of free or subsidised supplies of breast-milk substitutes and other products covered by the International Code ofMarketing of Breast-milk Substitutes in any part of the health care system;

(3) to exercise extreme caution when planning, implementing or supportingemergency relief operations, by protecting, promoting and supportingbreast-feeding for infants, and ensuring that donated supplies of breast-milk substitutes or other products covered by the scope of the InternationalCode are given only if all the following conditions apply:

Guidelines44

(a) infants have to be fed on breast-milk substitutes, as outlined in theguidelines concerning the main health and socioeconomiccircumstances in which infants have to be fed on breast-milksubstitutes;

(b) the supply is continued for as long as the infants concerned need it;

(c) the supply is not used as a sales inducement;

(4) to inform the labour sector, and employers’ and workers’ organizations,about the multiple benefits of breast-feeding for infants and mothers, andthe implications for maternity protection in the workplace;

Excerpt from the Forty-Ninth World Health Assembly 25 May 1996

3. Urges Member States to take the following measures:

(1) to ensure that complementary foods are not marketed for or used in waysthat undermine exclusive and sustained breast-feeding;

(2) to ensure that the financial support for professionals working in infantand young child health does not create conflicts of interest, especially withregard to the WHO/UNICEF Baby Friendly Hospital Initiative;

(3) to ensure that monitoring the application of the International Code andsubsequent relevant resolutions is carried out in a transparent, independentmanner, free from commercial influence.

(4) to ensure that the appropriate measures are taken including healthinformation and education in the context of primary health care, toencourage breast-feeding;

(5) to ensure that the practices and procedures of their health care systems areconsistent with the principles and aims of the International Code ofMarketing of Breast-Milk Substitutes;

(6) to provide the Director-General with complete and detailed informationon the implementation of the Code;

Infant Feeding 45

Appendix 4

A History of the World HealthOrganization International Code ofMarketing of Breast-Milk Substitutes

The artificial food industry began in the mid 19th century. However, it was not until themid 20th century that infant formula became widely used and commercial promotionof bottle feeding was recognised as a major factor contributing to the decline ofbreastfeeding (Baumslag 1989). It became clear that usual product marketing practiceswere undesirable for infant feeding in view of the vulnerability of infants in the earlymonths of life and due to the risks of inappropriate feeding practices, including the useof substitutes for breast-milk (WHO 1981). Now that researchers in the 1990s understandthe short and long term health implications for mothers and infants of not breastfeeding(Cunningham et al 1991, Howie et al 1990, Dewey et al 1995), the need for a collaborativeapproach to protect, promote and support breastfeeding is essential if a breastfeedingculture is to be reinstated.

In 1970 the United Nations Protein-Calorie Advisory Group (PAG) began raising concernabout industry marketing practices. Two years later in 1972, the InternationalOrganisation of Consumers Unions (IOCU), a group dedicated to the protection andpromotion of consumer rights through information, research and education activities,submitted a draft code of practice on the advertising of infant foods to the CodexAlimentarius Commission.

In 1975 a number of infant formula companies joined to become the International Councilof Infant Food Industries (ICIFI). In 1977 the Infant Formula Action Coalition launcheda boycott of Nestle products. This spread throughout the United States of America,Canada, Australia, New Zealand, and later other countries, to become one of the mostpowerful consumer actions in history (Marmet 1993).

In 1979 a joint WHO/UNICEF meeting on infant and young child feeding was convenedin Geneva. The 150 participants included representatives of governments, the UnitedNations system and technical agencies, non-governmental organisations, the infant foodindustry, and scientists working in the field. The themes and the resulting statementand recommendations of this working group, agreed upon by consensus, were to:

• encourage and support breastfeeding

• promote and support appropriate weaning practices

• strengthen information, education, communication and training

• develop support for improved health and social status of women in relation to infantand young child feeding

Guidelines46

• monitor the appropriate marketing and distribution of breast-milk substitutes (WHO1981).

Despite the general agreement to the principles of the 1979 WHO/UNICEF meeting,several industry companies in 1980 retracted their pledge of support of therecommendations.

The International Baby Food Action Network (IBFAN), a coalition of voluntaryorganisations, was founded in 1979 to promote breastfeeding and to eliminateirresponsible marketing of artificial infant foods, feeding bottles and teats, and therebyimprove child health and nutrition. The network has over 140 groups in 74 countries.

In May 1981 the World Health Assembly (WHA), of which New Zealand is a memberstate, approved and adopted the final version of the WHO International Code ofMarketing of Breast-milk Substitutes (WHO 1981). The Code, comprising eleven Articles,was a compromise from its inception and its main targets were governments, infantformula manufacturers and health workers. Of the 122 votes cast on the Code resolution(WHA 34.22) 118 were in favour, including New Zealand, three abstained, and the UnitedStates of America was the lone vote against adoption. The USA has now revised itsopposition to the WHO International Code.

‘The aim of the WHO Code is to contribute to the provision of safe and adequate nutritionfor infants, by the protection and promotion of breast-feeding, and by ensuring theproper use of breast-milk substitutes, when these are necessary, on the basis of adequateinformation and through appropriate marketing and distribution’ (WHO 1981). TheCode recognises that there is a legitimate market for infant formula for mothers who donot breastfeed or for those who partially breastfeed.

New Zealand adopted the Code nationally on 13 April 1983 in its entirety, but ‘throughconsensus and discussion rather than through legislation’. A committee was establishedto monitor the WHO Code. The committee’s tasks included making recommendationsbased on the application of the Code in practice, and reporting alleged breaches of theCode to the Minister of Health. The committee was finally disbanded in 1991. The PublicHealth Commission (PHC) took over the monitoring role and sought to increaseeducation and promotion of the intent of the WHO Code.

In 1985 IBFAN set up the International Code Documentation Centre (ICDC) in Penangto specifically monitor Code implementation measures worldwide and to provide aresource for those seeking Code information and skills training. More recently ICDCco-ordinated a large monitoring exercise in 59 countries resulting in the publicationState of the Code by Country (IBFAN 1996).

Other significant worldwide moves have occurred to accelerate the protection andpromotion of breastfeeding and increase awareness of the critical role that health servicesplay in promoting breastfeeding, such as the 1989 Joint WHO/UNICEF Statement,Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Services.

In 1989 the General Assembly of the United Nations adopted the resolutions of theConvention on the Rights of the Child seeking to ensure the health of children. At thatmeeting, the late UNICEF Executive Director James P. Grant, speaking of the plight of

Infant Feeding 47

all children internationally, cited breastfeeding as part of the ‘revolution for children’and said that ‘more than a million children’s lives a year could be saved by effectivebreastfeeding’.

The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (WHO/UNICEF 1990), is a set of international standards for breastfeeding and was adopted bypolicy makers from 32 governments and 10 United Nations and other agencies on 1August 1990. The operational targets of the Innocenti Declaration for all Governmentsby the year 1995 are to have:

• appointed a national breastfeeding co-ordinator and established a multisectoralnational breastfeeding committee

• ensured that every facility providing maternity services practices all ten of the TenSteps to Successful Breastfeeding (see reference to step nine in text underRecommendations for Promotion and Support of Breastfeeding in Health CareSystems)

• taken action to give effect to the principles and aim of all Articles of the InternationalCode of Marketing of Breast-milk Substitutes and subsequent relevant World HealthAssembly resolutions

• enacted legislation protecting the breastfeeding rights of working women andestablished means for its enforcement.

The formation of a new global alliance in 1991, the World Alliance for BreastfeedingAction (WABA), was the result of a UNICEF-sponsored meeting for non-governmentalorganisations (NGOs). The WABA umbrella is working toward the goals of the InnocentiDeclaration and to this end launched the Baby-Friendly Hospital Initiative (BFHI) on 1August 1992 on the anniversary of the signing of the Innocenti Declaration (WABA1992). The emphasis of the BFHI was on worldwide implementation of the Ten Steps toSuccessful Breastfeeding and the cessation of free and low cost infant formula by industryin all maternal and infant health areas. Since the BFHI launch there has been a differenttheme, 1 - 7 August each year, during what has become known as ‘World BreastfeedingWeek’.

Throughout the years efforts to support breastfeeding women and specifically protectbreastfeeding have continued on other levels in New Zealand through the dedicationand action of many voluntary groups including: La Leche League New Zealand, ParentsCentres New Zealand, Royal New Zealand Plunket Society, Whangai U andBreastfeeding Action Alliance (1986), now defunct. Professional groups, including theNew Zealand College of Midwives (Inc) (1990), the Royal New Zealand Plunket Societyand the New Zealand Lactation Consultants Association (1991), actively support womenwho breastfeed.

The WHO Code remains a recommended minimum set of standards about responsiblemarketing. The ICDC lists 63 countries as having enacted legislation or other legalmeasures on some or all provisions of the Code (IBFAN 1996). New Zealand haslegislation in the Food Regulations 1984 which specifies the composition and labellingrequirements for infant and follow-on formula. Infant formulas that meet therequirements of the Australia Food Standards Code may be sold in New Zealand.

Guidelines48

The PHC worked toward advancement of the Code through public consultation anddistributed a discussion document in September 1994 (Hinson 1994). Over 70 submissionswere received from the health sector, health-related associations, manufacturers andmarketers, media organisations, consumer groups, universities, and individuals.Guidelines for a New Zealand interpretation of the Code were developed following thediscussion document responses (PHC 1995d).

When the PHC was disestablished, the management and responsibility for the Codewere transferred from the PHC back to the Ministry of Health on 1 July 1995. The Codeis now being implemented through the development of the health worker guidelinesand industry self-regulatory codes of practice.

Infant Feeding: Guidelines for New Zealand Health Workers, together with the NZIFMAself-regulatory code of practice, provide a New Zealand interpretation of the WHOCode. Together they will serve to express the aim of the WHO Code and establish afoundation for additional activities to protect and promote breastfeeding.

Infant Feeding 49

Appendix 5

Consumer Information Services

community health worker Telephone the local CHE.

district midwife Telephone the local CHE.

domiciliary midwife Look in the yellow pages under ‘midwives’ or in thewhite pages, under the front section ‘hospitals andurgent pharmacies’ or ‘m’ for midwife. Contact the localCrown health enterprise (CHE) maternity servicesdepartment.

La Leche League A nationwide voluntary organisation which offersexpertise and support for breastfeeding. NationalOffice, PO Box 13 383, Wellington 4.

For local assistance refer to the local telephone directory.

lactation consultants Telephone the local CHE.

medical practitioner Listed at the front of the telephone book under‘registered medical practitioners’.

new mothers’ support groups Refer to the Plunket nurse, practice nurse, or generalpractitioner.

Parents Centre: A nationwide voluntary organisation which offerseducation in birthing and parenting, support to parents,and aims to improve community attitudes and facilities.Many Parents Centres offer breastfeeding support.There are 62 centres in New Zealand. For local supportrefer to the local telephone directory under ‘P’.

Plunket nurse National Office, PO Box 1480, Dunedin. Plunketline toll-free number 0800 10 10 67. Plunket has 32 area officesnationwide and lactation consultants are available aspart of the team. For local assistance refer to the localtelephone directory.

practice nurse Practices with medical practitioner.

public health nurse Telephone the local CHE Public Health Service.

Te Kohanga Reo Listed in the local telephone directory.

Tipu Ora Listed in the telephone directory.

Guidelines50

CHE Authorised Provider Network

Lynette SouthwickThe Resource UnitGround Fl Maunu HouseMaunu RoadBox 742WhangareiPhone 09 430 4101 x 3551Fax 09 430 4124

Joyce SmithPublic Health Promotion9 Huron StreetPrivate Bag 93 502Takapuna 9Phone 09 489 3580Fax 09 489 3560

Kristi CalderPublic Health Promotion22 Moselle PlaceP O Box 21 949HendersonPhone 09 836 6370Fax 09 836 6295

Jim Callaghan/Tina HansenPublic Health Promotion615 New North RoadKingslandBox 41 200St Lukes, Auckland 3Phone 09 815 6204Fax 09 815 2594

Lynda HarfordFamily HealthFloor 2 Leyton HouseLeyton WayBox 76 123Manukau CityPhone 09 262 1855Fax 09 262 1880

Fred BirchCommunity HealthPembroke StreetBox 505HamiltonPhone 07 839 8969Fax 07 839 3897

Sharleen IrwinHealth Development75 Elizabeth StreetP O Box 2121TaurangaPhone 07 571 8975Fax 07 578 5485

Sandy WateneHealth Development UnitEastbay HealthStewart StBox 241WhakatanePhone 07 307 8734 Fax 07 307 8992

Caroline TauteHealth Development Unit49 Pukuatua StP O Box 1858RotoruaPhone 07 349 3520Fax 07 346 0105

Sharon Johnstone/A ShawPublic Health UnitTairawhiti Health CareCnr Bright St/Childers RdBox 119GisbornePhone 06 867 9119Fax 06 867 8414

Michael JohnsonHealth Promotion UnitBarrett BuildingPrivate Bag 2016New PlymouthPhone 06 753 7799Fax 06 753 7788

Judi StanleyHealth Promotion Unit14 Herscell StNapierPhone 06 834 1812Fax 05 834 1894

Jeanette HagueGood Health WanganuiBox 64539-41 Drews AveWanganuiPhone 06 345 5527Fax 06 345 8776

Sally ReedPublic Health Unit68 Queen StBox 1942Palmerston NorthPhone 06 358 1055Fax 06 350 1106

Simon DennisPublic Health Service191-205 Thorndon QuayBox 2468WellingtonPhone 04 473 4965Fax 04 473 4972

Infant Feeding 51

Fiona BaudinetHealth Information CentreHutt HospitalPrivate Bag 31 907Lower HuttPhone 04 566 6999Fax 04 570 4404

Lana PurcellPublic Health ServiceFl3 Housing CorpBuildingWalton Leigh AveBox 50 063PoriruaPhone 04 237 5549Fax 04 237 9131

Carol PetersChoice Health107 Chapel StreetPrivate Box 58MastertonPhone 06 378 9029Fax 06 378 2393

Kathy TatlockCommunity Health36 Franklin StreetBox 647NelsonPhone 03 546 1537Fax 03 546 1542

Diane PollockCommunity Health UnitBox 46Wairau HospitalBlenheimPhone 03 577 1914Fax 03 578 9517

Gaye LindleyCommunity HealthServiceCoast Health CareBox 387GreymouthPhone 03 768 2799Fax 03 768 2793

Julie Stapleton/Sue BurgessThe Pamphlet Place76 Chester Street East Box 1475ChristchurchPhone 03 364 7844Fax 03 379 6125

Jackie GirvenChild & FamilyCrown Public Health11 Elizabeth StAshburtonPhone 03 308 7447Fax 03 308 8783

Janet McIver Public Health ServiceTimaru Hospital Queen StBox 510TimaruPhone 03 688 6019Fax 03 688 6015

Inga NielsonHealth PromotionPublic Health Service154 Hanover StDunedinPhone 03 474 7737Fax 03 474 7631

Leanne MilnesSouthern Public HealthServices62 Dee StreetBox 1364InvercargillPhone 03 214 2375Fax 03 214 2410

Guidelines52

Appendix 6

Submissions Received on the DraftGuidelines

Submission Made By:

Advertising Agencies Association Of New Zealand

Advertising Standards Authority Inc

Advisory Panel on the Marketing in Australia of Infant Formula (APMAIF)

Anchor Products Limited

Annandale, Marcia

Association of New Zealand Advertisers Inc

Auckland Womens Health Council

Bevin, Tui; Lactation Consultant

Bradfield, Orma; Otago Polytechnic

Breastfeeding Connection

Bruce, J M

Campbell, Bobbi; Aoraki Polytechnic

Canterbury Enhanced Breastfeeding Alliance

Cosgrove, Bette; La Leche League New Zealand

Department of Nursing and Midwifery, Massey University

Department of Paediatrics, University of Auckland

Devereux, Anne

Dignam, D; Department of Nursing and Midwifery, Massey University

Fallow, Chrissy

Family and Public Health Service, Taranaki Healthcare

Federation of Womens Health Councils Aotearoa New Zealand

Franklin, Sylvia; Lactation Consultant

Gordon, Rosemary

Gorinski, Beverley

Gorrell, Jane; Child Health Nurse, Te Whanau O Waipareira Trust

Greig, Elizabeth

Hall, E M

Health Waikato

Infant Feeding 53

Jensen, Julian; University of Otago

La Leche League New Zealand

La Leche League New Zealand (LLLNZ) Area IV

Lewn, Del; Burwood Hospital

Manager Maternity Services, Nelson Hospital

Maternity Services Consumer Council

McNeill, Sally; Otago Polytechnic

MidCentral Health

Ministry of Womens Affairs

National Council of Women of New Zealand Inc

New Zealand College of Midwives (Inc), Canterbury/West Coast Region

New Zealand College of Midwives (Inc), Auckland Region

New Zealand Dairy Board

New Zealand Dairy Foods Ltd

New Zealand Dietetic Association (Inc)

New Zealand General Practitioners Association

New Zealand Lactation Consultants Association

New Zealand Nutrition Foundation

Norton, Anne; Lactation Consultant & Plunket Nurse, Plunket Society

Nutricia Australasia

Parents Centres New Zealand

Pharmacy Guild of New Zealand

Public Health Service Nutrition Team, Healthcare Otago

Public Health Service, Healthlink South

Public Health Service, Hutt Valley Health Corporation Ltd

Public Health Services, Health South Canterbury

Royal New Zealand Plunket Society

Ryan, Kath; School of Pharmacy, University of Otago

School of Pharmacy, University of Otago

The National Heart Foundation of New Zealand

The Samoan Womens Council in Christchurch

Upper Hutt Midwives

Warder, Trish

Weber, Janet

Wickham, Jane; Lactation Consultant, Lakeland Health

Womens Health, Health Waikato

World Health Organization

Young, Ngaire