REPORT ON THE REGIONAL SCIENTIFIC WORKING GROUP ON BREASTFEEDING NICOSIA, CYPRUS 26 - 30 January 1981 The views expressed in this Report do not necessarily reflect the official policy of the World Health Organization TABLE OF CONTENTS 1.1 RECENT ADVANCES IN KNOWLEDGE CONCERNING BREASTFEEDING 5 1.2 RECENT DEVELOPMENTS IN PROGRAMMES TO PROMOTE AND PROTECT 8 BREASTFEEDING 2. MVLEW OY THE !3MASTYEEULNG SITUATLON IN 'lXE REGION 13 3. PROPOS.ALS FOK KLSEARCH CONCERNING THC PREVA1.ESCL AN11 nI'HATTON l)r '!RI:A$II:FI:I)TUC ANn ASSOI'TATFn FACTORS 4. PROMOTIONAL AND EDUCATIONAL ACTIVITIES FOR THE PUBLIC ON 22 BREASTFEEDING 5. THE TRAINING OF HEALTH WORKERS CONCERNING BREASTFEEDING 25 6. THE PROPOSED CODE OF MARKETTNG OF BREAST-MT1.K SITRSTTT1TTF.S 28 7. THE ROLE OF WOMEN'S ORGANIZATIONS IN THE SUPPORT OF BREASTFEEDING 29 8. MATERNITY OR "LACTATION" LFAVE 9. LEARNING MATERIALS ON BREASTFEEDING RECOMMENDATIONS 40 ANNEXES I. OPENING ADDRESS OF H.E. THE MINISTER OF HEALTH, MR G. TOMBAZOS !i. MESSAGE FROM DR A.H. TABA, DIRECTOR WHO EASTERN MEDITERRANEAN REGION 111. TiiE TEXTS OF WORLD HEALTH ASSEMBLY RESOLUTIONS 27.43 of 1974, 31.17 "1 1978 arid 33.32 "1 1980 1V DRAFT INTERNATIONAI. CODE OF MARKETING OF BREAST-MILK SUBSTITUTES AS SUBMITTED TC: Ti!i: WHO EXECUTIVE BOARD IN JANUARY 1981; IN ITS RECOMMENMTION FORM. (WHO DOCUMENT EB 67/20 PAGES 14 THROUGH 21) V. LIST OF PARTICIPANTS Ever since infant formulas manufactured industrially became available on a large scale early this century as substitutes for breast-milk, it is probably true that most doctors have nevertheless believed that breastfeeding was the method of feeding more likely to result in an infant's hsalthv growth. While some paediatricians deplored more emphatically than others the decline in breastfeeding, the belief also came to be widely held that really there was little difference between breast-milk and infant formulas, and that it did not much matter by which of the two methods an infant was nourished. However, scientific knowledge about the composition of human milk and its anti-infective properties has been expanding at an accelerating pace in the last twenty years. It has now come to be realised that, as H.E. the Minister of Health of Iyprus atates in his opening address to tho meeting (Anncx I): "Breastfeeding in an unequalled way of providing the ideal food for the healthy and harmonious physical and psychosocial development of infants". It is a unique biological substance with biochemical and immunological characteristics far beyond the capacity of modern science and industrial technology to replicate. With this realimtion, and accom- panying other changes in life st,yle, there has come a marked revival of interest in breastfeeding in Europe, North America and Australasia. As the Regional Director points out in his intmduotory massage (Annex 2), it is with some eurprise, as well as satisfaction, that we have seen an actual well-documented increase in the percentage of muthers breastfeeding in those regiuns. The view that breastfeeding was a "lost cause", that the slide towards bottle feeding was unavoidable and irreversible, has been shown to be wrong. However, the view that it did not much matter whether an infant was bottle fed or breastfed rarely prevailed among physicians and nurses in the developing countries except tnosa wno, in private urban pracuce anb uncnznlcingly accepting rorelgn rasnlon, were riot in touch with reality. All who served the ordinary people of developing countries were daily oonfronted with the evidence of the dreadful effects which could result from illiterate mothers in unhygienic surroundings bottle feeding their infants. The common contamination of We feeds, made worse by the absence of the specific anti- infective factors of breast-milk, produced frequent episodes of diarrhoea1 disease. If the child did not die in one such attack, the over-dilution of feeds owing to poverty and ignorance would combine with the consequences of recurrent diarrhoea to produce severe and often fatal protein-energy malnutrition. It is no wonder that Cicely Williams, the pioneer and doyenne of tropical paediatrics, entitled an address she gave in Malaya in 1940 on this subject, "Milk and Murder", or that H.C.Trowel1, co-author with D.B. Jelliffe of "Diseases of Children in the Tropics and Sub-tropics", said in 1946 that In rural Africa one ml@t as well wrltt! an infant its death certi- ficate as write a prescription to bottle-feed it. In our Eastern Mediterranean Region, Professor Jam1 Harfouche in her contri- bution (pages 13 - 16 ) summarizes well the present situation as regards breast- feeding, and explains why those dealing with child health view this state of affairs with concern and apprehension. Her views are based on what must surely be the most comprehensive review of infant feeding practices ever made in this part of the world, which was undertaken by her for WHO/EMRO in 1980, covering all published and * many unpublished reports from all countries of the Region. AS Professor Harfouohe shows, there is in the Region a peculiarly mixed situation. We have a few industrialized or wealthy countries where breastfeeding has probably reached the lowest point it will ever reach, its nadir so to speak,, and the trend henceforth will be one of increase in breastfeeding, the speed of the trend back to breastfeeding probably depending much on the future efforts of the health professions. At the other end of the spectrum, we certainly have rural areas and populations where to a large extent the traditional mode of breastfeeding for two or more years still prevails almost undisturbed. Nomads in Central Asia and North-East Africa come to mind as examples, as well as some remote agricultur- alists or pastoralists, but it becomes harder to name such traditional groups. A great variety of patterns of breaatfeeding between these two, the nadir and the traditional, occurs over most of our Region. The bottle has penetrated even small vLllages to a much greater extent than is usually realized, even for feeding soft drinks, diluted animal milk or cereal paps. As Professor Harfouche points out, perhaps the most worrying problem which alarms the greatest number of national health authorities is cessation of breastfeeding at a veSy early age (under three months) followed by bottle-feeding undertaken by mothers who are illiterate or semi- literate and do not understand how 'to bottle-feed either in correct proportions or in a hygienic manner, having little idea that diarrhoea is caused by the ingestion of pathogenic organisms in contaminated reeds. This is largely reSpOnSiDle ror tne * This review on breastfeedingin the Eastern Mediterranean Region is to be published soon in the WHO/EMRO Technical Publication Series, and its draft version was made available to each of the participants in the meeting. change in the epidemiology of severe protein-enerw malnutrition from the kwashiorkor- type or mara~rmsof fairly late onset (e.g. 9 - 18 months), to the type of infantile - maraemus affecting infants under six months which has such a wide prevalence at present in many countries, e.g. Libya, Iraq, the Gulf Area, and parts of Yemen Arab Republic, as well as in urban areas throughout most of the Region. This type of infantile marasmus is often combined with recurrent diarrhoea and often comes to the notice of health workers during an acute episode. Indeed, in some cities the prevalence of this diarrhoea/malnutritim syndrome and incidence of acute episodes is auch as to occupy at certain seasons a large proportion, even half or more, of all available paediatric bed spaoe, Problems such as these Led in 1974 to the adoption of World Health Aosernbly Resolution 27.43 whioh called for action on the part of WHO and its Member States to promote and protect breastfeeding; and in 1978 and 1980 to the further Resolutions 31.47 and 33.32, again strongly supporting breaetfeeding and the latter Resolution spelling out in detail a programne of actions which the Assembly requested to be under- taken by the Director-General, The texts of all three Resolutions will be found in Annex 3. Following on these Resolutions, each Reglonal Office of Wm) has begun a series of activities to promote and protect breastfeeding. The Eastern Mediterranean's activities have included among others, (1) a letter of advice to the Governments of the Region in 1976 concerning the marketing of breast-milk substitutes; (2) some seminars or parts of sednars at national or sub-national levels devoted to the subject; (3) the extensive distribution throughout the Region of several hundred (in one uase, several thousand) copiea of each of five books or booklets which deal either exclusively or in large part with breastfeecling; (4) the inclusion 0% four of these publicstions in its Arabic Language Programme; (5) the translation, in cooperation with UNICEF, of the WHO Booklet into Urdu, Persian and Pushtu besides Arabic; (6) the drafting, as mentioned above, of the propoeed Technical Publication on breastfeeding in this Region. Now, the Regional Office has convened this Scientific Working Group comprising in Y the win persons of experience from the Region, in order to advise the Regional Director on a programme of action for the years 1981-1983, the remaining half of the period + covered by the WHO Sixth General Program of Work. me main components of the programme of action were envisaged as coming under the seven headings specified in items 3 to 9 of the Agenda, whioh was as follows: * List of participants can be found in Annex 5 1. Review recent advances in knowledge about breastfeeding and recent developments in programmes concerning breastfeeding in the world in general. 2.