WORLD HEALTH ORGANIZATION FIFTY-THIRD WORLD HEALTH ASSEMBLY Provisional agenda item 12.4 A53/INF.DOC./2 8 May 2000
Infant and young child nutrition Technical consultation on infant and young child feeding Submitted to the Health Assembly for information
FORGING A NEW VISION 1. Improved infant and young child nutrition is central to human development, and so contributes significantly to poverty reduction. Each major form of malnutrition – for example intrauterine growth retardation, deficiency of iodine, vitamin A or iron, and protein-energy malnutrition – dwarfs most other diseases on a global scale; and the young are almost always the first to suffer and the worst affected.1 Inappropriate feeding is responsible for at least one-third of the malnutrition, and a large part of the “silent” morbidity and mortality, in children under five years of age. Given the singular impact that food – and its adequate, safe and timely provision – has on survival, health, growth, development and well-being in the early years, WHO has long supported its Member States in their efforts to improve feeding practices on behalf of infants and young children. 2. Over the past two decades WHO and its international partners have promoted universal implementation of some key approaches. The Baby-friendly Hospital Initiative and the International Code of Marketing of Breast-milk Substitutes, for instance, have not only succeeded as frameworks for ensuring that both health services and marketing practices contribute to good nutrition, they have also effectively raised awareness of the specific nutritional needs of the very young and how these needs should be met. The success of WHO’s approach to the integrated management of childhood illness is due, in part, to the explicit inclusion of appropriate feeding as both a preventive and curative measure. Meanwhile, the WHO multicentre growth reference study, which is under way in six countries, will establish the optimal growth of breastfed infants as the normative model and provide a strong advocacy tool for promoting the right of all children to achieve their full genetic potential. 3. Despite the progress of the past two decades, WHO recognizes that much more needs to be done, nationally and internationally, to encourage appropriate feeding practices for infants and young children. Priority actions include: • promoting exclusive breastfeeding (only an estimated 35% of infants are exclusively breastfed between 0 and 4 months of age);
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See document A53/7.
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• ensuring timely, appropriate and safe complementary feeding while breastfeeding continues (frequently, other foods are introduced too early or too late and infants are weaned too early); • reinforcing policies that support breastfeeding by working women (such as increasing the proportion of women covered by ILO standards and other measures); • taking steps to prevent premature interruption of exclusive breastfeeding and, as appropriate, to avoid artificial feeding from becoming the norm or to reverse the decline in prevalence and duration of breastfeeding (steps that include appropriate marketing of infant foods, consistent with the principles and aim of the International Code, minimizing the negative impact of globalization on feeding patterns, and improving public education and training of health workers); • overcoming the threat to healthy nutrition posed by difficult circumstances such as HIV/AIDS and major emergencies (meeting these children’s nutritional needs in ways that are appropriate to their specific circumstances). 4. Much has been accomplished since the first international meeting on this topic in 1979.1 The combined scientific and epidemiological evidence, and the programmatic experience accumulated over the past two decades, provide a solid technical platform on which to base continuing concerted national and international action.
LAYING THE FOUNDATION 5. As one step in identifying future priorities and accelerating progress, WHO convened, in collaboration with UNICEF, a technical consultation on infant and young child feeding (Geneva, 13 to 17 March 2000). Its objectives were: • to assess the strengths and weaknesses of current feeding policies and practices; • to identify barriers to implementation of policies; • to review key interventions as a first step to identifying feasible and effective ways forward; and • to contribute to the development of a comprehensive draft strategy that, when adopted, will guide Member States and the international community in the years to come. 6. Participants were invited in their individual capacity on the basis of their technical expertise in strategy and programme development. Also taking part were staff from WHO headquarters and regional advisers in nutrition; UNICEF headquarters and regional staff; and representatives from ILO, UNAIDS, UNHCR and the ACC Subcommittee on Nutrition. 7. Participants in the consultation explored the implications of nine programmatic themes for a comprehensive global strategy and plan of action for infant and young child feeding: • measuring trends and progress in infant-feeding practices; 1
See document WHA33/1980/REC/1, Annex 6.
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• increasing rates of exclusive breastfeeding; • improving complementary feeding; • strengthening and expanding the Baby-friendly Hospital Initiative; • integrating support throughout the health care system for appropriate feeding practices; • identifying effective models for community support of breastfeeding women; • promoting policies and practices to support breastfeeding in the workplace; • strengthening implementation of the International Code of Marketing of Breast-milk Substitutes; and • understanding the impact of globalization on infant feeding. 8. Cross-cutting issues that were significant for the discussion themes were also examined, including an overall human rights perspective,1 the nutritional status of women, protein-energy malnutrition, micronutrient malnutrition, growth and development, maternal and child morbidity and mortality, HIV and infant feeding, and feeding during emergencies.
A NEW GLOBAL STRATEGY AND PLAN OF ACTION 9. Following this preparatory and consultative process, a draft strategy and plan of action are now being prepared for critical review by Member States and other interested parties (see paragraph 13 below); they will identify priorities, action areas and operational targets – for governments, international organizations and civil society – to improve the feeding of infants and young children. The strategy currently has three main objectives: • to improve the survival, health, nutritional status, and growth and development of infants and young children through optimal feeding. Ensuring the survival, health and nutrition of women, in their own right and in the context of their role as mothers, is fundamental to attaining this objective; • to guide government policy and action – and related support provided by the international community – for protecting, promoting and supporting optimal feeding practices for infants and young children; • to enable mothers, families and caregivers in all circumstances to make – and implement – informed choices about optimal feeding practices for infants and young children.
1 Especially as defined in the Convention on the Rights of the Child (the child’s right to nutritious food and adequate feeding) and in the Convention on the Elimination of All Forms of Discrimination against Women (on the social significance of maternity).
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10. Building on past achievements, the draft strategy will reaffirm commitment to existing goals, including attainment of the operational targets of the Innocenti Declaration,1 continued implementation of the Baby-friendly Hospital Initiative and achievement of the aim of the International Code of Marketing of Breast-milk Substitutes. It will also emphasize the three following priority areas. (a) Exclusive breastfeeding. Existing initiatives need to be strengthened, and new approaches developed, in order to protect, promote and support exclusive breastfeeding.2 The dual challenge for governments is to play a strong advocacy role and to enact policies and develop programmes that reinforce family and community support for breastfeeding mothers, including that provided by mother-to-mother support groups the world over. This support includes ensuring that “baby-friendly” principles are applied wherever mothers give birth and that the Initiative’s high standards are maintained through careful monitoring, promoting adoption of effective measures – including legislation – to give effect to the International Code of Marketing of Breast-milk Substitutes, and protecting the maternity rights, including breastfeeding, for women at work. (b) Complementary feeding. Timely, safe and adequate complementary feeding, with continued breastfeeding, needs to be made a priority of global nutrition. Indeed, the continued high frequence of growth faltering in many parts of the world suggests that complementary feeding practices remain inadequate for substantial numbers of children. More needs to be done to improve feeding practices based on locally available and affordable foods, to develop guidelines and indicators of appropriate nutritional outcomes, and to expand the content and availability of objective and consistent informational and educational materials for health workers, mothers and families. Action-oriented research is also needed to identify causes and remedies for growth faltering. (c) Feeding in difficult circumstances. Caring for populations during emergencies remains a major global humanitarian priority. The best hope for averting the disability and death that are so common among infants and young children in such circumstances is to ensure that they are adequately cared for and fed. However, meeting the nutritional needs of infants and young children during, for instance, natural disasters, famine and civil unrest, in refugee settings, in the presence of HIV/AIDS, or when they are already severely malnourished, is a particularly complex and demanding task. New approaches are required both to meet the needs of this especially vulnerable population group and to cope with the growing scale, variety and frequency of emergencies around the world that threaten their nutritional status. 11. In this context it is crucial to define, in operational terms, where responsibilities lie for improving infant and young child feeding practices, and to determine how the resources needed to meet these responsibilities can be mobilized. For example, for governments, these responsibilities cover areas such as public information and education, pre-service education and training for health 1 The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (1990) has four operational targets for all countries: appointment of an authoritative national breastfeeding coordinator and multisectoral committee; ensuring all maternity facilities are “baby-friendly”; action taken to give effect to the principles and aim of the International Code of Marketing of Breast-milk Substitutes; and legislation enacted to protect breastfeeding rights of working women.
The WHO Multicentre Growth Reference Study (see document A53/7, Annex), is expected to contribute to improved understanding of the age range during which breast milk alone is sufficient to meet the healthy infant’s nutritional requirements for growth and development. In addition, WHO is conducting a systematic review of the relevant scientific literature, for the period after the report (1995) of the WHO Expert Committee on Physical Status, in the context of the development of a new global strategy and plan of action for infant and young child feeding.
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workers, programme monitoring and evaluation, and action-oriented research. For international organizations, they include establishing standards and guidelines, strengthening national capabilities through technical support, and monitoring progress using global data banks and appropriate indicators.
THE WAY FORWARD 12. Successful international strategic instruments, whatever their purpose, all share common features: they are carefully prepared, they benefit from indispensable coalition building, and they enjoy a sense of ownership – among governments as much as among their citizen-beneficiaries. Successful formulation and implementation of a new strategy for infant and young child feeding thus depend on: • a bottom-up approach, whereby countries and their citizens “own” a strategy, because they are involved, from the outset, both in tailoring it to their specific needs, and in adopting and implementing coherent policies across sectors to give effect to it in ways that are consistent with their specific circumstances; • support and positive participation, from their unique perspective of all the main actors – governments and civil society together – in its development and implementation; • consensus across the international community, with the endorsement of WHO’s governing bodies, for a new global strategy and plan of action; and • international advocacy and support, grounded in the best available scientific and epidemiological evidence, that will facilitate the strategy’s energetic implementation by all concerned. 13. Based on these principles and inputs provided during the technical consultation, WHO is proceeding with the development of a draft global strategy and plan of action for infant and young child feeding. It will organize regional consultations during the last quarter of 2000 and the first quarter of 2001, starting in South-East Asia and Eastern Mediterranean regions. Selected Member States will be asked to contribute by assessing the suitability and expected effectiveness of the draft strategy and plan of action. The drafts will be revised in the light of comments and circulated for information and feedback to Member States and other interested parties. Finally, the Director-General will submit the results of this process to the Executive Board at its 109th session (January 2002) and to the Fifty-fifth World Health Assembly (May 2002).
CONCLUSION 14. With its focus on fundamental issues relating to the feeding of infants and young children and critical examination of ways of dealing with them, the technical consultation has contributed significantly to a step-wise process leading to the formulation and adoption of a new consensus-driven global strategy. Mindful of the crucial linkages between an effective strategy and a lasting reduction in malnutrition, poverty and deprivation, WHO and its international partners are building on this foundation to develop a technically sound and politically feasible approach that governments and civil society everywhere will be ready to accept, adapt and apply. = = =
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