The need for the International Code, Breastfeeding Protection: milks marketed for older infants and young children The need for the International Code, WHA Resolutions and WHA resolutions 69.9 IBFAN briefing FUFs

The International Code and WHA resolutions: WHY IMPORTANT for FUFs A unique instrument to address the aggressive marketing by the infant formula and the infant and young child foods industries that undermines breastfeeding. Hello everyone.   My name is Elisabeth Sterken, I am a nutritonist by profession and have been working as a specialist in IYCF for 30 years by now and the importance of the International Code and resolutions has always been a key focus for my work. 2. What I want to accomplish for our Code session is --- IBFAN briefing FUFs

Why important? Suboptimum breastfeeding accounts for an estimated 800,000 deaths in children under five annually, Only 38 per cent of 0-5 month olds in the low and medium income countries are exclusively breastfed. The Lancet’s Series on Maternal and Child Undernutrition, 2016 IBFAN briefing FUFs

Optimal infant and young child feeding Adapted from F Optimal infant and young child feeding Adapted from F. Savage King and A. Burgess Nutrition for Developing Countries

Energy from Breastmilk during 6-24 months of age WHO (2009). Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals.

Breastmilk is vital source of nutrients during 12–23 months WHO (2009). Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals.

Continued Breastfeeding Matters! Fulfills substantial part of energy and nutrient needs Vital during illness, can help prevent dehydration and provides nutrients required for recovery Provides disease protection – could prevent half of all deaths during the 12–23 month period Environmental friendly From the First hour of life. UNICEF, 2016

Continued Breastfeeding Matters! Across all income levels, higher performance in intelligence tests among children and adolescents leading to improved educational attainment, increased long-term earnings and better productivity – with those children breastfed longer than 12 months benefiting most from these gains. Longer periods of breastfeeding may reduce a child’s risk of overweight and obesity. Continued breastfeeding is also important for mothers; for every 12 months of breastfeeding in their lifetime, there is a 6 per cent reduction in the risk of breast cancer. From the First hour of life. UNICEF, 2016

GHG Emissions from Milk Formula IBFAN Asia, 2015

Global status of IYCF practices From the First hour of life. UNICEF, 2016

Breastfeeding at 20-23 months of age From the First hour of life. UNICEF, 2016

Key provisions in national legal measures on the Code (out of 114 countries with legal measures in place)

Trends in sales of FUF Relevance of Regulating Marketing Source: Euromonitor

S. NO. Nomenclature used by companies for different formula products for age group > 6 months – 36 months (13 countries) 1 Follow – up formula 2 Follow-up formula - Complementary food 3 Follow-up formula powder for older infants 4 Premium nutritional milk supplement with probiotics 5 Milk Drink 6 Older baby and toddler nutrition 7 Toddler milk 8 Growing –up Milk 9 Milk formula for 1 to 2 years children 10 Milk powder for young children 11 Milk for young children 12 Premium junior follow-up formula 13 Growing up formula in powder form with iron 14 Growing up milk based on cow’s milk for toddlers – with iron 15 Nutritional milk powder 16 Growing-up formula

South Africa – Formula for Young Children Sri Lanka – Milk Formula for 1-2 year old Children

Preamble Since infant formula can continue to be used beyond 6 months, these products are not necessary. The production, distribution, sale and use of follow-up formula for older infants and [name of product] for young children should only be permitted if it is be consistent with national health and nutrition policies and relevant national/regional legislation. The marketing of these products and these products should not discourage breastfeeding and must be in accordance with  take into account, [as appropriate,] the recommendations made in the International Code of Marketing of Breast-milk Substitutes (1981), and the Global Strategy for Infant and Young Child Feeding, relevant WHO guidelines and policies,  as well as relevant World Health Assembly (WHA) resolutions, including the WHA resolution 69.9 (2016) and its accompanying WHO Guidance on Ending the Inappropriate Marketing of Foods for Infants and Young Children. 

Scope This section of the Standard applies to Follow-up Formula for Older Infants, as defined in Section 2.1, in liquid or powdered form. 1.2 This section of the Standard contains compositional, quality, safety, information for use, warnings against needless and inappropriate use, labelling and analytical requirements for Follow-up Formula for Older Infants. 1.3 Only products that comply with the criteria laid down in the provisions of this section of this Standard [should / shall] be presented as] Follow-up Formula for Older Infants  

Add 1.4 Add: 1.4 IBFAN does not agree with the deletion of provision 1.4 in the Scope. The scope must remind Regulatory Authorities of the safeguards contained in the over-arching Preamble if they are to ensure that the WHO recommendations underpin the marketing and labelling of each product category.

3.1.2 3.1.2 The nutritional safety and adequacy of follow-up formula for older infants must be scientifically demonstrated, through relevant convincing scientific evidence or the comparable level of evidence under the GRADE classification, to support growth and development of older infants.

Optional ingredients IBFAN is opposed to the addition of optional ingredients and suggest that 3.2 is replaced with the following text: The addition of optional ingredients may have adverse effects on child health and should not be permitted. The addition of ingredients and/or nutrients that have not been proven to be essential to the growth and development of an older infant and a young child may be an added chemical burden. Competent national and/or regional authorities wishing to alter the list of essential ingredients listed under 3.2.4 to 3.2.6, must ensure that the ingredients are evaluated and demonstrated as safe and nutritional useful by relevant convincing scientific evidence or the comparable level of evidence under the GRADE classification.

Labelling 9.5.1 Reconstitution of powdered product no less than 70 degrees; 9.5.3 There should be no preparation instructions showing bottles. Graphics should only illustrate cup feeding. 9.6.1 (b) Breastfeeding is the normal and healthy way to feed your baby. When your baby is not breastfed she is likely to be sick more often. Exclusive breastfeeding is recommended from 0- 6 months of age, with continued breastfeeding along with appropriate complementary foods to two years of age or beyond.

Cross branding 9.6.4 Products targeting babies 6 to 36 months shall not be cross branded with other infant formula or infant food products

Claims 9.6.6 The use of nutrition, health and convenience claims are prohibited.