Local Policy

FORWARD

There is no doubt that breast feeding benefits mother, child and society at large. This was primarily the reason for a working party to study the issue of breastfeeding at a national level.

In fact in 1996 a working group composed of health professionals from primary health care, health promotion, maternal care as well as breast feeding counsellors, started designing a policy statement on the issue of breast feeding in Malta. This was done in an effort to encourage more mothers to experience one of nature’s gifts which unfortunately has been threatened during the last half of the twentieth century,

This document is the result of an in-depth study into the reasons many mothers find breast feeding a challenge. It also outlines the health services required to empower mothers with knowledge and support whilst it serves as a tool for all health care professionals to enable them to protect and promote breastfeeding through the course of their daily work.

Our national breast feeding policy expands on the significance of breast feeding which had been mentioned in an earlier health document, Health Vision 2000 (1995). Our dedication towards the health of future generations of newborns, lies in our responsibility to preserve breast feeding as the mainstay of infant nutrition,

(signed)

Hon. Dr L. Deguara

Minister of Health

Valletta                                                                                                                           April, 2000

ACKNOWLEDGMENTS

The Health Promotion Department would like to thank the following persons for their assistance in completing this document:-

Dr. R. Busuttil                  Director General                                        Health Division

Ms. M. Abela                    Manager Midwifery Services                    Karin Grech

                                                                                                             (Hospital)

Ms. H. Borg                      Breastfeeding Counsellor                           Association of

                                                                                                              Breastfeeding

                                                                                                              Counsellors

1.0              Introduction

The Innocenti Declaration of 1987 appeals to many governments all over the world to support, protect and promote breast feeding.  This decision has been further strengthened by the nations participating in the World Conference on Nutrition (1992).  For these reasons the Health Division needs a policy on breast feeding which it can implement on a national level through its six departments.  In fact the rationale for formulating and implementing a breast feeding policy lies in the following considerations:-

·        Benefits to the health of the infant and mother.

·        Benefits to the mother-infant relationship.

·        Economic benefits.

·        Malta’s low level of breast feeding which is the lowest in Europe, alongside Ireland.

The following table shows the % rates of breast feeding mothers at the time of discharge from hospital:

(source: Health Information Department)

·        A mother’s right to make an informed choice about the method she chooses to feed her infant.

1.1       Goal

            To re-establish and reinforce a breast feeding culture.

1.2              Aim

To formulate a local breast feeding policy that will be implemented in various settings within the health system, workplace and community.

1.3              Objectives

·        To increase the percentage of mothers practicing exclusive breast feeding when leaving the hospital

·        To enable mothers to exclusively breast feed their infants for the first six months of life

·        To ensure the protection and promotion of breast feeding in the community.

1.4              Issues for Implementation

·        Enact legislation controlling the marketing of breast milk substitutes

·        Enforce a breast feeding policy in maternity hospitals based on the principles of the Baby Friendly Hospital Initiative (BFHI) (Appendix 3)

·        Establish a breast feeding policy at a community level including the role of mother-to-mother support groups

·        Train health care professionals in the promotion and management of breast feeding

·        Develop strategies for the promotion and support of breast feeding in the community

·        Set targets, implement and monitor this policy

1.5              Priority Target Areas involved in policy Implementation

Maternity Hospitals

-         Neonatal and Paediatric Intensive Care Unit

-         Paediatric Wards

-         Ante-natal Classes and Clinics

-         Labour Ward

-         Post-Natal Ward

Primary Health Care

-         Health Centres and Immunisation Schemes

-         Community Midwives (MMDNA) Scheme

Mother-to-Mother Voluntary Support Groups (CANA Group)

Health Promotion Department

-         Strategic capaigns in the various settings namely schools, workplace and localities in the community

Training of Health Care Professionals

-         Doctors

-         Community Pharmacists

-         Midwives and MMDNA workers

-         Nurses

-         Voluntary groups

2.0       Promotion Breast feeding in Maternity Hospitals & Units –

            Baby Friendly Hospital Initiative

Establishing a breast feeding culture in the maternity hospitals is the first step in promoting community care policies that may support a woman’s decision to breast feed and continue once she has left the hospital.

In 1991 at the International Paediatric Association Conference, WHO and UNICEF launched the Baby Friendly Hospital Initiative (BFHI) with the following goals:-

·        To enable mothers to make an informed choice about how to feed their newborns.

·        To support exclusive breast feeding for the first 6 months of life.

·        To ensure the cessation of free and low cost infant formula supplies to hospitals.

·        To include, possible at a later stage and where needed, other mother and infant health care issues.

All hospitals that house maternity wards are invited to participate in the BFHI.  The ‘Ten Steps for Successful Breast feeding’ (Appendix 3) provide the basis and minimum requirement for hospitals that wish to be designated as baby friendly.

Anecdotal reports to midwives indicate that most mothers have already decided on their method of feeding before delivery.  In fact the mother’s wish is included in the baby’s notes.  Therefore hospital activity should be primarily oriented to support the mother’s chosen feeding practice.  However this might be an opportunity to influence the feeding decision of some mothers who might still be doubtful as to whether they should breast feed or bottle feed.

Consequently  those mothers who have selectively chosen breast feeding, should be given support by knowledgeable hospital staff that can make this a successful experience.

Recommendations

2.1              A Breast feeding Policy

The breast feeding policy at Karen Grech Hospital conforms with the BFHI.  This needs to be routinely circulated to staff and strictly enforced.

2.2              Hospital Staff

Even though breast feeding is partly instinctive, it is an acquired experience.  In fact, successful breast feeding depends on what the mother learns and is highly dependent on skilled teaching and support that she receives during her short stay in hospital.

It is therefore recommended that health care professionals working in the Maternity Department are well prepared to encourage, support and advise mothers on the successful management of breast feeding for at least the first 6 months of the infant’s life.

It is recommended that hospital personnel, especially midwives, are sufficiently skilled in the practical management of breast feeding problems.  This advice should be provided within the context of positive and supportive attitude from the staff.

All the staff should be thoroughly familiar with the breast feeding policy within the maternity wards.

2.3              Hospital Routine

The following points should be considered:-

a)                  Skin-to-skin contact should be encouraged as early as possible and initiation of breast feeding should follow within the first half hour of life.  Many studies have shown that mothers who commence breast feeding early rather than late enjoy a longer duration of breast feeding.  Therefore hospital staff should facilitate and support the mother to initiate skin-to-skin contact immediately following a normal delivery, and breast feeding be initiated within the first hour of birth or so.

b)                  Rooming-in of the child with the mother facilitates the continuation of breast feeding.  This should be encouraged by the staff and be established as the norm.  However where the mother objects or feels too tired, her requests should be respected.

c)                  Breast feeding is only successful when the baby is fed on demand i.e. the frequency and duration of the feed is determined by the baby.

This is usually every 2-3 hours thereby ensuring successful breast feeding.  Many health workers and mothers need guidance and reassurance that this is the most appropriate way to feed the child.  The frequency of feeds will vary according to the baby’s needs.  Night feeds should be encouraged since these help to maintain the prolactin level which is released in larger amounts during the night.

It is recommended that mothers are instructed to recognize cues from the baby when feeding is required.  Some babies will feed from both breasts and therefore both should be offered even if the second breast is not required.  Correct latching of the baby onto the breast along with frequent feeds will prevent sore or cracked nipples and breast engorgement.

d)         Supplementing breast feeding with either water, glucose or artificial milk is a common malpractice amongst Maltese mothers.  This very often happens when the mother feels uncertain whether her baby is getting enough milk solely from breast feeding.  Such misconceptions are a result of doubts arising following comments from health care professionals, neighbours, family and friends.  It is therefore recommended that:-

·        Within the maternity wing no supplementary feeds should be given unless medically indicated (this is very rare, arising in <1% of cases)

·        To avoid nipple confusion, the use of artificial teats and soothers should be discouraged within maternity wards until breast feeding is well established.

·        Correct positioning of the baby on the breast should be ensured from the first feed since this is the best way to prevent sore nipples.

e)         Expressing milk is a convenient method for the mother to maintain breast feeding if she is temporarily separated from her baby.  Expressed milk is preferably fed to the baby by cup or spoon.

f)                    Promotion of Infant Feeding Products including the donation of free samples and literature of infant formulas to hospitals and maternity wards is prohibited by the International Code of Marketing of Breast milk Substitutes (appendix 2).  In fact there should be no such distribution in other public health care facilities like health centres and clinics.

g)                  Successful maintenance of breast feeding once the mother is discharged from hospital, depends on the support the mother receives at home.  It is very common for the mother to encounter difficulties with breast feeding when she goes back home.  Currently the community midwives visit the mothers on postnatal visits three times over a period of ten days.  They offer assistance to the mother but it is recommended that other services are in operation so that the mother can fall back on these for support, counselling and advice.

Before mothers are discharged, it is recommended that they are given contact telephone numbers of members from the Association of Breastfeeding Counsellors (ABC).  This organization may offer hands-on advice either by phone or home visits on a 24 hour basis.

h)                  Caesarian Deliveries

Those mothers who deliver by Caesarian section should be given continuous assistance especially during the first 2-3 days postpartum.  These mothers should be offered safe pain relief medication that would not require them to stop breast feeding.

i)                    Special Care & Premature Babies

All mothers whose baby needs any kind of special care should be informed of how important breast milk is to these babies.  It should be stressed that:

a)                  Breast milk helps protect against infection and necrotizing enterocolitis, chest and urinary infections.  All of these are serious threats to premature babies.

b)                  Mothers should be advised on:

i)          Initiating and milk supply

ii)                   Expressing and storage of breastmilk

iii)                 Maintenance of lactation

iv)                 Self care e.g. adequate nutrition and rest

v)                  Correct positioning and latching-on when baby is ready to feed from the breast.

Mothers should be shown how to initiate milk supply, express milk and store it properly.  Mothers also need to help and support in latching the baby to the breast when the infant is ready to do so.

3.0       Promoting Breast Feeding at Community Care Level

All mothers-to-be and those who have delivered should find adequate support for breast feeding.  In Malta ante-natal contact is well established with midwives who run ante-natal courses.  Following discharge of mother and child from the post-natal ward, the mother has a total of three visits from an MMDNDA community midwife over a span of ten days. These visits are not sufficiently utilised for the establishment of breast feeding.  One of the objectives of these visits should be the protection and support of breast feeding.

Recommendations

3.1              Ante-Natal Period

Throughout pregnancy mothers-to-be are very sensitive to any health messages concerning the well-being of their baby.  In fact many mothers decide on the choice of infant feeding during the ant-natal period.  This provides an excellent opportunity for health professionals (obstetricians, pharmacists, nurses) who come into contact with the mother to reinforce the message that breast milk is best for mother and infant.  At this stage information may be obtained from Parent Craft classes, Association of Breastfeeding Counsellors (ABC) and the Health Promotion Department.

3.2              Post-Natal Period

The few days following discharge from hospital are crucial.  They determine the success or failure in breast feeding.  It is therefore crucial that the mother is aware of who can help her when problems arise with breast feeding.  The following services could prove useful in helping mothers:-

a)      A 24 hour help line is available through the Labour Ward, Postnatal Ward, Midwifery/Nursing Staff and the ABC.

b)      Mothers are given proper advice and support during their brief stay in the Postnatal Ward.  A positive attitude by the staff helps to dispel any fears.

c)      On discharge from hospital, mothers are given a list of contact persons available as need be.

d)      The health care staff within the health centres is informed of the breast feeding policy of the hospital and refer the mother to the above post-natal services.

e)      The Well-Baby Clinic needs to evolve in a way that it will foster the maintenance of breast feeding.

f)        The health centres should ensure the protection and promotion of breast feeding.  On no account should a mother encountering difficulties with breast feeding be advised by any of the staff to switch to bottle-feeding before an attempt is made to tackle the problem.  When difficulties arise proper referral should be made.

3.3              Mother-to-Mother Support Groups

In Europe, the concept of mothers helping and motivating other mothers originally developed in Norway where throughout the years it has proved a successful and resourceful strategy in the promotion of breast feeding.  Currently in Malta such a support group working in the community is the Association of Breastfeeding Counsellors run by Cana.  This team of women is devoted to the protection and promotion of breast feeding.  Amongst the various services that the organizers offer, is a help line service.  In fact those who seek their help are more likely to succeed in breast feeding over the first four months.

Recommendations

a)                  The team should work in close liaison with hospital maternity services.

b)                  The staff at the health centre should refer mothers to the support group for follow up.

c)                  The support group may advise the Health Division of any necessary changes which might encourage more mothers to breast feed.

d)                  The Health Division should assist and support this group in any possible manner

4.0              Training Health Professionals

Health professionals who are directly involved with mothers and infants, such as paediatricians, obstetricians, GPs, nurses, midwives, lactation counsellors and  hospital administrators, have the responsibility to promote and encourage the Health Division’s policy that breast milk is the most satisfactory nutrition for infants.

Many of these health professionals come in contact with mothers during the antenatal, intrapartum and post-natal period  These contacts should provide opportunities for the promotion of breast feeding.  It is therefore essential that such professionals are appropriately trained for this role.  Such training should form an integral part of the respective curricula at the Institute of Health Care and the Medial Schools.  Such training should be further enhanced by a comprehensive programme of continuing professional development.  The adequacy of training and the heightened awareness of health professionals is considered to be a critical success factor for the establishment of successful breast feeding.

4.1       Recommendations

At Undergraduate Level

The ten steps for successful breast feeding (Appendix 3) should form the basis of an education programme for nurses, midwives and medical personnel.  The curriculum should also include:-

1.                  physiology of and rationale for breast feeding.

2.                  effective management of lactation.

3.                  familiarization with the Code on Breast Milk Substitutes (Appendix 2).

4.                  baby-friendly hospital initiative (BFHI).

The Medical School and Institute of Health Care should be the two institutions from which health care professionals emerge with the necessary knowledge and positive attitudes regarding breast feeding.  Professional organizations should be encouraged to get involved in the breast feeding issue and act as advocates in the pursuit of a breast feeding culture.

In-Service Training

Nurses, midwives and medical personnel caring for the pregnant women, mothers and infants in maternity hospitals and units as well as in the community, require training in the skills necessary to promote and facilitate successful breast feeding.

These should include communications and counselling skills, training sessions and workshops.

5.0              Promoting Breast feeding In the Wider Community

The decision taken by a mother on the feeding methods suitable for her child depends on may factors such as:-

·        attitudes prevailing in the wider society.

·        attitudes of the more immediate network of family and friends e.g. grandmother, neighbours, colleagues at work.

·        socio-cultural variables associated with the female physiology and sexuality.

·        the attitude of the baby’s father.

·        possible embarrassment felt by the mother because of the need for privacy.

5.1       Recommendations

Community

No discrimination should be made against breast feeding in public places, e.g. restaurants, shopping areas and banks.

Education about breast feeding should not be solely directed at women but must also address the whole community.  The media has a significant role to play in this context so as to promote and support a positive image of breast feeding, thereby portraying it as the norm.

Schools

To ensure that women are less apprehensive about breast feeding it is essential to increase female self-confidence and awareness on the basic physiology of the breast.  This could be a component of a “social and health education programme” in primary and secondary schools, with the objective of promoting from an early age the value of breast feeding.  In fact, health education and life-skills curricula should foster a positive body image with the eventual result that both males and females are comfortable with the idea of breast feeding.  Schools that have joined the European Network of Health Promoting Schools could be amongst the first to implement projects focusing on increasing awareness of breast feeding.

Workplace

Women’s needs in today’s world must be balanced between the family and work outside the home.  Therefore from a practical aspect, maternity leave entitlement and work-place facilities should encourage breast feeding.  As structural support this would relate to partial/full maternity leave, entitlement to paternity leave, nursing breaks and workplace facilities for expressing and storing milk.  Such initiatives as creche facilities and lactation breaks should be promoted by the health sector.

6.0              Targets

6.1       Long Term

An increased initiation rate of breast feeding on discharge from hospital to at least 90% of babies.  An increased proportion of infants still breast fed at 4 months of age to at least 80%.

6.2              Medium Term

·        Establish a breast feeding policy in the maternity hospital by 2000.

·        Health care centres to identify a breast feeding resource person by 2001.

·        The Health Division to include provisions for the designation of a national breast feeding resource centre starting at Lm 1,000 and increasing by Lm 500 annually.

·        To incorporate the recommendations on professional training (Section 4.0) in all Health Promotion/Public Health courses by 2002.

·        With eventual EU membership review EU directive on maternity leave and therefore extend to at least 16 weeks.

·        The Health Education programme in primary and secondary schools to contain a breast feeding component by the year 2001 as recommended in this policy document.

·        To make available workplace creche facilities and lactation breaks within the health sector by 2005.  This is to be followed by similar provisions in the public and private sector.

·        The Health Information Department is to establish a system of monitoring breast feeding rates following discharge from hospital at 15 days, 2 months, 8 months and at 1 year by 2003.

·        To establish a Code Monitoring Committee which will be the body responsible for ensuring that the International Code of breast Milk Substitutes is adhered to.

6.3              Policy Implementation

The Health Promotion Department will disseminate the policy to relevant organizations including:-

            Maternity hospitals and units

            Departments within the Health Division

            IHC and Medical School Course Co-ordinators

            Faculties of Higher Education

            Education Ministry

            Health Ministry

            Finance Ministry

            Department for the advancement of Women

            Employment Agencies

            Media – TV and Radio Stations

            Baby Food Importers and Agents

            Health Centres

            Voluntary Women’s Organization

            Workers’ Unions

            College of Family Doctors

            Chamber of Pharmacists

            Parishes

            Ta’ Cana Movement

            Professional organizations aligned to health

7.0              References

A National Breast feeding Policy for Ireland-Department of Health, July 1994

Baby Friendly hospital Initiative WHO/UNICEF – Part 1 European Action Plan (January 1993); Part 2 Hospital Level Implementation (August 1992)

Declaration of the International Conference on Nutrition, Rome, 1992

Protecting Infant Health – IBFAN June 1993

Innocenti Declaration 1990

APPENDIX 1

Breast Feeding Policy for Maternity Hospitals

Advise on the management of breast feeding is to be given during antenatal classes where breast feeding is to be actively promoted.  Women attending such classes are also to be instructed on the importance of breast examination.

The baby should be put to the breast at least within an hour after birth, unless there is a contraindication.  At this time the baby is alert, has a good sucking reflex and this feed, which may last only a few minutes, boosts the confidence of the mother who at this time has a natural instinct to feed her baby.

Staff should provide every support to breast-feeding mothers.  Mothers should be actively encouraged to breast feed and every effort should be made to boost their confidence.  Given the appropriate support, only a few mothers will not be able to breast feed.

Staff should ensure that the baby is well positioned to achieve good nipple attachment.  This will not only ensure that the baby gets the maximum nourishment from the mik/colostrum in the breast but will also enhance further milk production and prevent nipples from getting sore.

Babies should be fed on demand.  There may be a great variation in the frequency at which babies demand a feed particularly in the early days.  Babies should feed at one breast for as long as they wish in order to gain the high calorie “hind milk”.  The other breast may be offered when the first has been emptied.  There should be no strict timing or strict limitation of feeding times, but in general, feeds should not be given more frequently than every two or three hours and should not last for more than 30 minutes.

Care should be taken that each feed is adequate to prevent undue wakefulness:  If feeds are widely spaced i.e. more than five hours during the day, hypoglycaemia way result.

Complementary feeding should be avoided if sucking is adequate.  In exclusively breast-fed babies, the gut flora inhibits the growth of pathogens.  This can be adversely altered even with one artificial feed.  Artificial feeding results in lack of breast stimulation which results in less milk production.

If  the mother has any doubt about the amount of milk the baby is having, she can be reassured by weighing the by to measure the weight gain.  Normally a healthy baby regains the birth weight within 7 to 15 days from birth.

On discharge, mothers should be given a list of breast feeding counsellors who they can contact if they have any problem.

APPENDIX 2

International Code of Marketing of Breast-milk Substitutes

Preamble

The Member States of the World Health Organization:

AFFIRMING  the right of every child and every pregnant and lactating woman to be adequately nourished as a means of attaining and maintaining health;

RECOGNIZING  that infant malnutrition is part of the wider problems of lack of education, poverty and social injustice;

RECOGNIZING  that the health of infants and young children cannot be isolated from the health and nutrition of women, their socioeconomic status and their roles as mothers;

CONSCIOUS  that breast feeding is an unequaled way of providing ideal food for the healthy growth and development of infants; that it forms a unique biological and emotional basis for the health of both mother and child; that the anti-infective properties of breast-milk help to protect infants against disease; and that there is an important relationship between breast feeding and child-spacing;

RECOGNIZING  that the encouragement and protection of breast feeding is an important part of the health, nutrition and other social measures required to promote healthy growth and development of infants and young children; and that breast feeding is an important aspect of primary health care;

CONSIDERING  that when mothers do not breast feed, or only do so partially, there is a legitimate market for infant formula and for suitable ingredients from which to prepare it; through commercial or non-commercial distribution systems; and that they should not be marketed or distributed in ways that may interfere with the protection and promotion of breast feeding;

CONVINCED  that it is important for infants to receive appropriate complementary foods, usually when the infant reaches four to six months of age and that and that every effort should be made to use locally available foods; and convinced, nevertheless that such complementary foods should not be used as breast milk substitutes;

APPRECIATING  that there are a number of social and economic factors affecting breast feeding and that, accordingly, governments should develop social support systems to protect, facilitate and encourage it and that they should create an environment that fosters breast feeding, provides appropriate family and community support, and protects mothers from factors that inhibit breast feeding;

AFFIRMING  that health care systems and the health professionals and other health workers serving in them, have an essential role to play in guiding infant feeding practices, encouraging and facilitating breast feeding, and providing objective and consistent advice to mothers and families about the superior value of breastfeeding, or, where needed, on the proper use of infant formula, whether manufactured industrially or home-prepared;

AFFIRMING  further that educational systems and other social services should be involved in the protection and promotion of breast feeding, and in the appropriate use of complementary foods;

AWARE  that families, communities, women’s organizations and other non governmental organizations have a special role to play in the protection and promotion of breast feeding and in ensuring that support needed by pregnant women and mothers of infants and young children, whether breast feeding or not;

AFFIRMING  the need for governments, organizations of the United nations system, non-governmental organizations, experts in various related disciplines, consumer groups and industry to co-operate in activities aimed at the improvement of maternal, infant and young child health and nutrition;

RECOGNIZING  that governments should undertake a variety of health, nutrition and other social measures to promote healthy growth and development of infants and young children, and that this Code concerns only one aspect of these measures;

CONSIDERING  that manufacturers and distributors of breast milk substitutes have an important and constructive role to play in relation to breast feeding, and in the promotion of the aim of this Code and its proper implementation;

AFFIRMING  that governments are called upon to take action appropriate to their social and legislative framework and their overall development objectives to give effect to the principles and aim of this Code, including the enactment of legislation, regulations, or other suitable measures;

BELIEVING  that, in the light of the foregoing considerations, and in view of the vulnerability of infants in the early months of life and the risks involved in inappropriate feeding practices, including the unnecessary and improper use of breast milk substitutes, the marketing of breast milk substitutes requires special treatment, which makes usual marketing practices unsuitable for these products;

THEREFORE 

The Member States hereby agree the following articles which are recommended as a basis for action.

Article 1:  Aim of the Code

The aim of this code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast feeding, and by ensuring the proper use of  breast milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Article 2:  Scope of the Code

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

Article 3:  Definitions

For the purposes of this Code:

Breast-milk substitute means any food being marketed or otherwise represented as a partial or total replacement for breast-milk, whether or not suitable for that purpose.

Complementary food means any food, whether manufactured or locally prepared, suitable as a complement to breast-milk or to infant formula, when either becomes insufficient to satisfy the nutritional 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 sale as a normal retail unit, including wrappers.

Distributor means a person, corporation or any other entity in the public or private sector engaged in the business (whether directly or indirectly) of marketing at the wholesale or retail level a product within the scope of this Code.  A “primary distributor|” is a manufacturer’s sale agent, representative, national distributor or broker.

Health Care System means governmental, non-governmental or private institutions or organizations engaged, directly or indirectly, in health care for mothers, infants and pregnant women; and nurseries or child-care institutions.  It also includes health workers in private practice.  For the purposes of this Code the health care system does not include pharmacies or other established sales outlets.

Health worker means a person working in a component of such a health care system, whether professional or non-professional, including voluntary, unpaid workers.

Infant formula means a breast-milk substitute formulated industrially in accordance with applicable Codex Alimentarius standards, to satisfy the normal nutritional requirement of infant up to/or between four and six months of age, and adapted to their physiological characteristics.  Infant formula may also be prepared at home, in which case it is described as “home prepared”

Label means any tag, brand mark, pictorial or other descriptive matter, written, printed, stenciled, marked, embossed or impressed on, or attached to, a container (see above) of any products within the scope of this Code.

Manufacturer means a corporation or other entity in the public or private sector engaged in the businessor function (whether directly or through an agent or through an entity controlled by or under contract with it) of manufacturing a product within the scope of this Code.

Marketing means product promotion, distribution, selling, advertising, product public relations, and information services

Marketing personnel means any persons whose functions involve the marketing of a product or products coming within the scope of this Code.

Samples means single or small quantities of a product provided without cost.

Supplies means quantities of a product provided for use over an extended period, free or at a low price, for social purposes including those provided to families in need.

Article 4:  Information and Education

4.1       Governments should have the responsibility to ensure that objective

and consistent information is provided on infant and young child feeding for use by families and those involved in the field of infant and young nutrition. This responsibility should cover either the planning, provision, design and dissemination of information, or their control.

4.2       Informational and educational materials, whether written, audio or

visual, dealing with the feeding of infants and intended to reach pregnant women and mothers of infants and young children, should include clear information on all the following points:

a)                  the benefits and superiority of breast feeding

b)                  maternal nutrition, and the preparation for and maintenance of breast-feeding;

c)                  the negative effect on breast-feeding when introducing partial bottle-feeding;

d)                  the difficulty of reversing the decision not to breast-feed; and

e)                  where needed, the proper use of infant formula, whether manufactured industrially or home-prepared.

When such material contains information about the use of infant formula, they should include the social and financial implications of its use; the health hazards on inappropriate foods or feeding methods; and, in particular, the health hazards of unnecessary or improper use of infant formula and other breast-milk substitutes.  Such materials should not use any pictures or text which may idealize the use of breast-milk substitutes.

4.3       Donations of informational or educational equipment or materials by

manufacturers or distributors should be made only at the request and with the written approval of the appropriate government authority or within guidelines given by governments for this purpose.  Such equipment or materials may bear the donating company’s name or logo, but should not refer to a proprietary product that is within the scope of this Code, and should be distributed only through the health care system.

Article 5:  The general Public and Mothers

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

5.2              Manufacturers and distributors should not provide, directly or indirectly, to pregnant women, mothers or members of their families, samples of products within the scope of this Code.

5.3              In conformity with paragraphs 1 and 2 of this Article, there should be no point-of-sale advertising, giving of samples or any other promotion device to induce sales directly to the consumer at the retail level, such as special displays, discount coupons, premiums, special sales, loss-leaders and tie-in sales, for products within the scope of this Code.  This provision should not restrict the establishment of pricing policies and practitioners intended to provide products at lower prices on a long-term basis

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

5.5              Marketing personnel, in their business capacity, should not seek direct or indirect contact of any kind with pregnant women or with mothers of infants and young children.

Article 6:  Health care systems

6.1              The health authorities in Member states should take appropriate measures to encourage and protect breast-feeding and promote the principles of this Code, and should give appropriate information and advice to health workers in regard to 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 promoting infant formula or other products within the scope of this Code.  This Code does not, however, preclude the dissemination of information to health professionals as provided in Article 7.2.

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

6.4              The use by the health care system of “professional services representatives”, “mothercraft nurses” or similar personnel, provided or paid for by manufacturers or distributors, should not be permitted.

6.5              Feeding with infant formula, whether manufactured or home prepared, should be demonstrated only by health workers, or other community workers if necessary and only to the mothers or family members who need to use it;

6.6              Donations or low-price sales to institutions or organization of supplies of infant formula or other products within the scope of this Code, whether for use in the institution or for distribution outside them, may be made.  Such supplies should only be used or distributed for use outside the institutions, this should be done only by the institutions or organizations concerned.  Such donations or low-price sales should not be used by manufacturers or distributors as a sales inducement.

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

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

Article 7:  Health Worker

7.1              Health workers should encourage and protect beast-feeding; and those who are concerned in particular with material and infant nutrition should make themselves familiar with their responsibilities under this Code, including the information specified in Article 4.2.

7.2              Information provided by manufacturers and distributors to health professionals regarding products within the scope of this Code should be restricted to scientific and factual matters, and such information should not imply or create a belief that bottle-feeding is equivalent or superior to breast-feeding.  It should also include the information specified in Article 4.2.

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

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

7.5           Manufacturers and distributors of products within the scope of this Code should disclose to the institution to which a recipient health worker is affiliated any contribution made to him or on his behalf for fellowship, study tours, research grants, attendance at professional conference, or the like.  Similar disclosures should be made by the recipient.

Article 8:  Persons employed by manufacturers and distributors

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

8.2              Personnel employed in marketing products within the scope of this Code should not, as part of their job responsibilities, perform educational functions in relation to pregnant women or mothers of infants and young children.  This should not be understood as preventing such personnel from being used for other functions by the health care system at the request and with the written approval of the appropriate authority of the government concerned.

Article 9:  Labelling

9.1              Labels should be designed to provide the necessary information about the appropriate use of the product, and so as not to discourage breast-feeding.

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

a)                  The words “Important Notice” or their equivalent;

b)                  A statement of the superiority of breastfeeding;

c)                  A statement that the produce should be used only on the advice of a health worker as to the need for its use and the proper method of use;

d)                  Instructions for appropriate preparation and a warning against the health hazards of inappropriate preparation.

Neither the container nor the label should have pictures of infants, nor should they have other pictures or text which may idealize the use of infant formula.  They may, however, have graphics for easy identification of the product as a breast-milk substitute and for illustration methods of preparation.  The terms “humanized”, “materialized” or similar terms should not be used.  Inserts giving additional information about the product and its proper use, subject to the above conditions, may be in