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!