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Promoting, Protecting and Supporting Breastfeeding
in Hong Kong
Dr. Shirley LEUNG MBBS(HK); FRCP(Glasg); FHKAM(Paed); FFPH(UK)
Family & Elderly Health Services, Department of Health
7 May 2012
Outline
The superiority of Breastfeeding & the risks of not breastfeeding
The status of breastfeeding in Hong Kong
Promoting, protecting, & supporting breastfeeding: a systemic approach
Tackling the aggressive marketing of formula milk – the Hong Kong Code of Marketing of Breastmilk Substitutes
The responsibilities of HC professionals in promoting, protecting and supporting breastfeeding
The Superiority of Breastfeeding &
The Risk of NOT Breastfeeding
Breast Milk is a Living Tissue Non-nutrient components
Passive immunity
Cells: lymphocytes; macrophages
Specific immunity: IgA
Nonspecific immunity: lysozyme, complement, etc
Growth factors
Facilitators of nutrient assimilation
Lactoferrin; bile salt-stimulated lipase, etc
Nutrient components
Energy, proteins, fats, vitamins, minerals – optimum quality & quantity
Infant Formula Legally defined as a product which by itself meets
the nutritional requirements of normal healthy infant in the first 4 to 6 months of life
Manufacture of IF changes the composition of cow’s milk, e.g.
Protein & Electrolyte contents ↓; Ca : P ratio altered;
addition of lactose; addition of vegetable oils; reduce saturated fat; addition of minerals & vitamins (to simulate BM, but can never be the same as BM)
Contamination can occur at various stages: manufacture; storage; reconstitution; etc.
Risks of Infections
The risk of FM feeding is inherent
In many industrialised countries with quality sanitation and medical treatments, most babies can withstand the risks of deaths resulting from artificial feeding, but still suffer excessive related diseases and ill health
Infant who do not breastfeed are nearly 5x more
likely to be hospitalized in their 1st year due to diarrhoea & respiratory illnesses
(Paricio Talayero. Full breastfeeding & hospitalization as a result of infections in the 1st year of
life. Pediatrics 118, e92-299,2006.)
Early Nutrition Programming
Research evidence from observational studies & RCTs reveals early nutrition (from conception to early years) has profound effect on adult health
Brain development (IQ)
Risks of chronic diseases (e.g. diabetes, coronary heart disease and hypertension)
Risks of Not Breastfeeding
For the Child: Increase risk of infections
Diarrhoea
Respiratory infections
Ear infections
Lower intelligence
Increased risk of chronic diseases
Allergy
Obesity
Hypertension
For the Mother:
Increased risk of
Breast cancer
Ovarian cancer
Optimal Infant & Young Child Feeding E
nerg
y I
nta
ke
The Status of Breastfeeding in Hong Kong
Percentages of Newborns Ever Breastfed on Discharge from Hospitals, 1981-2010
Source: regular reports from all maternity units in public and private hospitals in Hong Kong.
10%
0
10
20
30
40
50
60
70
80
90
Per
cen
tage
Year
79.9%
Percentage of Surveyed Babies with Exclusive Breastfeeding for over 4-6 months, 1997-2010
Source: FHS, DH
0
2
4
6
8
10
12
14
16
19971998199920002001 20022004 200620082010
6 5.85
8.39.2
12.4 11.5
13.512.7
14.8
Percen
tage
Year of birth of surveyed babies
The majority of mothers who have initiated cannot establish breastfeeding…
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Ever BF 1-month 2-month 4-month
Rat
e (
%)
BF (of all forms) rate
Exclusive BF
Reasons for Stopping Breastfeeding
87%
Promoting, Protecting & Supporting Breastfeeding in Hong Kong: A Systemic Approach
Public perception & acceptance
Marketing
of
Formula Milk
Babycare Facilities
Support in the workplace
Maternity Leaves
Health Care
Facilities
Health Care
Professionals
Mother
& Baby
NGOs
A Systemic Approach to Promoting,
Protecting and Supporting Breastfeeding
Tackling the Aggressive Marketing of Formula Milk: The Hong Kong Code of Marketing of Breastmilk Substitutes
Strategic Framework for Prevention & Control of NCD: Action Plan to Promote
Healthy Diet and Physical Activity Participation
One of the actions: to develop and implement the Hong Kong Code of Marketing of Breastmilk Substitutes, in view of: Breastfeeding ‘s short & long-term impacts on child
& population health
Rising prevalence of overweight & obesity among children
Aggressive marketing of Formula Milk in Hong Kong
The Hong Kong Code Of Marketing Of Breastmilk Substitutes
Aim
To contribute to the provision of safe and adequate nutrition for infants and young children by
protecting breastfeeding
ensuring the proper use of breastmilk substitutes
Through ensuring
adequate and unbiased information, and
appropriate marketing Does not interfere with sales
The Taskforce
Set-up in June, 2010
To develop and promulgate the Hong Kong Code of Marketing of Breastmilk Substitutes
Multi-disciplinary membership drawn from: Relevant Government Bureaux and Departments;
Statutory Bodies (e.g. Consumer Council)
Public & private health care system
Relevant professional Colleges & Societies (Obstetric & Gynecology, Paediatrics, Family Medicine, Nursing, Nutrition, Dietitian)
Non-government organizations
Marketing professionals
The Overarching Principles
Conflicting rights
Children’s rights: to food & nutrition; to achieve the highest attainable standard of health
Consumers’ rights: to access unbiased information
Trade’s rights: to freedom of expression
The rights of children (the vulnerable) and consumers, rather than those of the trade (the almighty) should be protected, especially in matters of public health
The Considerations
Minimum requirements
International Code of Marketing of Breastmilk Substitutes (WHO, 1981)
Subsequent WHA resolutions
Local situation
Marketing practices of manufacturers and distributors
Possible impacts on the perceptions and feeding practices of parents and dietary pattern of their children
The International Code of Marketing of Breastmilk Substitutes (WHO, 1981)
The International Code of Marketing of Breastmilk Substitutes (1981)
Adopted, as a recommendation, at the 34th World Health Assembly (WHA) in 1981
A total of 11 Articles Relevant resolutions in subsequent WHAs (1982,
1984, 1986, 1988, 1990, 1992, 1994, 1996, 2001, 2002, 2005, 2006, 2008, 2010)
Full Code can be accessed from the website:
http://www.ibfan.org/issue-international_code.html
The Articles
Article No.
1 - 3 Aims, Scope and Definitions
4 Information and Education (for general public & mothers)
5 Promotion to the Public
6 Promotion in Health Care Facilities
7 Promotion to Health Workers
8 Manufacturers and Distributors
9 Labeling
10 Quality standards
11 Implementation and Monitoring
A Summary (1)
No advertising or other forms of promotion to the general public
No point-of-sale advertising, giving of samples, or any other promotion device to induce sales directly to the consumer at the retail level.
Do not provide, directly or indirectly, to pregnant women, mothers or members of their families, samples of breast-milk substitutes.
Do not distribute to pregnant women or mothers of infants and young children any gifts of articles or utensils which may promote the use of breast-milk substitutes or bottle-feeding.
A Summary (2)
Do not provide any samples of infant formula or other products to health workers, except when necessary for the purpose of professional evaluation or research at the institutional level.
Neither the container nor the label should have pictures of infants, nor should they have other pictures or text which may idealise the use of infant formula.
Governments should take action to give effect to the principles and aim of the WHO Code, as appropriate to their social and legislative framework, including the adoption of national legislation, regulations or other suitable measures.
Subsequent WHA resolutions: In response to scientific advances & evolving marketing practices
Relevant WHA Resolutions
1986 - WHA 39.28
“Any food or drink given before complementary feeding …. should neither be promoted nor encouraged for use by infants during this period
“the practice of providing infants with follow-up milks is not necessary”
Relevant WHA Resolutions 2002 - WHA 55.25
Endorsed Global Strategy for Infant and Young Child Feeding (WHO / UNICEF) “Infants should be exclusively breastfed for the first 6
months to achieve optimal growth, development and health; thereafter receive nutritionally adequate & safe complementary foods; while breastfeeding continues for up to 2 years of age or beyond”
2010 - WHA 63.26 End to all forms of inappropriate promotion of foods for
infants and young children and that nutrition and health claims should not be permitted on these foods
State of the Code in 196 countries (Source: State of Code 2009, IBFAN)
1. Law (30) • Enacted legislation encompassing all / nearly all provisions • Philippine
2. Many provisions law (33) • Enacted legislation encompassing many of the provisions • UK, France, Germany, Norway, Denmark, China
3. Few provision law (42) • Enacted legislation / regulation encompass only fews of the provisions
4. Voluntary Code / policy measure (17) • Gov’t adopt all / most provisions thro voluntary code, policy, guidelines
• Malaysia, Australia 5. Some provisions voluntary or policy (5)
• Gov’t adopt some provisions thro voluntary code, policy, guidelines
• Japan, Taiwan, Singapore, Korea 6. Measures drafted, waiting final approval (22) 7. Being studied (10)
• A gov’t committee is studying how best to implement the Code
8. No action /No information (14) • USA
Marketing Practices of Manufacturers & Distributors
Local Situation
Branding
The “Follow-up” formulae carry the same / similar brand name as the infant formula. Advertising the “FU” formulae cleverly promote the infant formula as well.
…On Televisions
…Transport System
Advertisement on
Buses
Advertisement at MTR Platforms & on Trains
Advertisement at MTR Platforms
…At Points Of Sale
Promotion at Drug Stores
Promotion at Supermarkets
…Direct Promotion To Mothers
Mother-Baby Clubs
Mother-Baby Club Activities
Mother-Baby Club Newsletters
Free Samples & Gifts for Mothers
…Through Health Professionals
Providing (misleading) information
Sponsoring CME activities in grand settings & providing sumptuous
meals
overseas travelling & hotel expenses
Giving gifts / stationeries / samples
Promotion to Health Professionals
Information for Health Professionals
Promotion Materials in Medical Journals
Promotion Materials in Medical Journals
Promotion Materials in Medical Journals
Free Gifts & Samples
Nutrition & Health Claims
Composition of Infant Formula
Infant formulas* are generally very similar to each other in composition
Manufacturers have to adhere to the international or national standards (referenced from breastmilk)
e.g. Codex Alimentarius (WHO); Infant Formula Directive, European Commission
usually comprise a list of nutrients with reference ranges
essential nutrients (e.g. energy, fat, proteins, mineral & vitamins)
optional nutrients (e.g. DHA , taurine, nucleotides)
Common Nutrient Additives to FM: The Health Claims
DHA &AA: “幫助嬰兒建立良好視力及促進腦部發展的重要脂肪酸” ; DHA含量全港最高係 6至12個月,腦細胞會攝取儲存大量DHA”
Prebiotics oligosaccharides : “BB 便秘,可以食有益生纖維嘅奶粉,增加腸道益菌,減少便秘,唔怕熱氣,有助有助腸道健康,增强抵抗力”
Probiotics: “有助腸道健康,增強抵抗力。”
Taurine: “牛磺酸對腦部發展和維持視網膜功能十分重要。”
Nucleotides : “核苷酸是免疫系統發展的重要元素。”
Carotene: “胡蘿蔔素有助促進免疫系統功能。”
Lutein : “抗氧化營養素,對發育眼睛很重要。”
Choline : “是支持腦部成長的重要營養素。”
Feeding Formula A to
a child……
Nutrient x will produce
physiological function y,
thus resulting in better health
+
Nutrient x (in
breastmilk)
performs
physiological
function y,
which results
in better
health
A Quantum Leap of Faith!
Formula A is fortified
with nutrient x
Formula A is fortified
with nutrient x
The Missing Link…….
Formula milk(FM) with composition similar to breastmilk (BM) does not make FM equal to BM because:
the bioavailability and metabolic effect of the same nutrients of similar contents in BM and FM are often different
Moreover…Whereas the nutritional composition of BM may be more amenable to simulation by FM, its immunological function may not
Approach to Evaluating the Adequacy of Infant Formula Composition
To compare infants fed FM with exclusively breastfed infants in terms of
Physiological outcome (e.g. growth patterns)
Biochemical outcome (e.g. plasma markers)
Functional outcome (e.g. immune response)
Conclusions on the suitability and safety of nutrient contents
in infant formula cannot be simply based on its similarity to human milk composition
(Global Standard for the Composition of Infant Formula: Recommendations of an ESPGHAN Coordinated International Expert Group. 2005)
Example: Long Chain Polyunsaturated Fatty Acids
Docosahexaenoic acid, DHA (Omega-3 fatty acids) &
Arachidonic acid, AA / ARA (Omega-6 fatty acids)
Breastmilk is rich in DHA and AA Powerful regulators of metabolism, major components of
structural lipids in retina and central nervous system Regarded as conditionally essential for newborns
(especially preterm babies) because of reduced production capacity to cater for the rapid brain and retina development
Added as optional ingredients in formula milk with the anticipated benefits on visual and intellectual
development in term and preterm infants.
Scientific Substantiation of Claims
European Food Safety Authority, 2009 http://www.efsa.europa.eu/cs/Satellite
1. “DHA contributes to the visual development
of infants (at 12 months of age)” (casual relationship established) provided that the formula bearing the claim should contain at least 0.3% of the total fatty acids as DHA (13 RCTs published between 1996 & 2007)
[Note: No benefit compared to breastfed group]
1. “insufficient evidence to establish a cause and effect relationship between intake of formula supplemented with DHA and the contribution to normal brain development in infants and young children from birth to three years of age”
Scientific Substantiation of Claims
Long chain polyunsaturated fatty acid supplementation in infants born at term
Karen Simmer1,*, Sanjay K Patole2, Shripada C Rao3 (Cockrane Review published Online: 7 DEC 2011)
“Majority of the RCTS have not shown beneficial effects of LCPUFA supplementation on the neurodevelopmental outcomes of term infants. The beneficial effects on visual acuity have not been consistently demonstrated. Routine supplementation of term infant milk formula with LCPUFA can not be recommended”
(meta-analysis of 15 RCTs published between 1995 & 2010)
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000376.pub3/pdf/standard
Local Situation
Possible Impact Of These Marketing Practices On
Parents’ Perceptions & Feeding Practices
&
Children’s Dietary Pattern
Survey of Infant and Young Child Feeding in Hong Kong (2010)
Key findings
Imbalanced dietary pattern
Overdependence on formula milk (especially in children 12 – 24 months)
Low vegetable and fruit intakes and high meat consumption
Children who drank more milk generally consumed a smaller amount of grains, vegetables and fruits
A significant proportion of parents have misconceptions about milk
“Milk is indispensable for the growth and development of a child”
0
20
40
60
80
100
120
12m 18m 24m 48m
94 88.1 84.9 71.4
Agree/Strongly agree
Disagree/Strongly disagree
%
%
%
%
%
%
%
“Milk should still be a major part of the diet of a child”
0%
20%
40%
60%
80%
100%
12m 18m 24m 48m
59.2 42.4
26.8 14.1
Agree/Strongly agree
Disagree/Strongly disagree
“A child must drink milk to obtain adequate calcium”
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
12m 18m 24m 48m
66.1 63.2 54.9 51.6
Agree/Strongly agree
Disagree/Strongly disagree
“Follow-up Formula contains nutrient additives that promote children’s brain development, which
cannot be found in other foods”
0%
20%
40%
60%
80%
100%
12m 18m 24m 48m
54.8 53.5 55.5 51
成長配方奶粉(大仔奶粉)含有添加的營養份能促進腦部發展,是其
他食物沒有的。
Agree/Strongly agree
Disagree/Strongly disagree
The HK Code
Likely to be much broader in scope than the International Code (1981)
Draft completed by Q2, 2012
Communication and Consultation: Q3, 2012
Implementation: 2013
Health Care System
& Healthcare Professionals
in Promoting, Protecting & Supporting
Breastfeeding
Creating a Supportive Environment for BF in the Health Care System
Building a “Mother & baby friendly” environment
Maternity units of hospitals HA implemented its Breastfeeding Promotion Policy in
December, 2010
All HA hospitals have ceased accepting free donations of infant and follow-on formula from 2010 onwards
Plans to facilitate its maternity units to fully comply with the “Tens Steps”
The private hospitals are following the HA example
Maternal & child health facilities “Seven Point Plan”: being implemented in DH
MCHCs of DH fully comply with the Code
Healthcare Professionals Clinical responsibilities of healthcare
professionals (Obstetricians, Paediatricians,
Family Doctors; Midwives & Nurses; Dietitians)
To facilitate mothers to make informed choices on infant feeding
To support mothers to initiate & maintain BF
To manage lactation problems
In supporting HC professionals to do so….
Hong Kong Code
A self-learning kit on Breastfeeding for medical & other HC practitioners, & other resources
Self-learning Kit on Breastfeeding
http://www.fhs.gov.hk/BFseminar2011/form/rferhpform.doc
Other Education Resources
THANK YOU!
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