International expert meeting on the donation and use of human milk: Brief report.

Where a mother's own milk is not available or is insufficient, donor human milk (DHM) processed by a human milk bank (HMB) is the recommended next best alternative. HMBs exist in over 65 countries. However, most countries have yet to establish national policies or programmes that support the provision of DHM. In July 2019, a group of international experts in fields relevant to human milk banking gathered at a meeting organised by the Institute of Biomedical Ethics, University of Zurich, and co-sponsored by the World Health Organisation. Prompted by the growing interest globally in creating and sustaining HMBs and addressing current safety and ethical concerns and standards, the aims of the meeting were to define knowledge gaps, determine the need for and scope of global guidelines and provide recommendations on steps that need to be taken at the international level. Following wide-ranging discussions that included the integration of milk banks into health care systems, strategy and policy, quality and safety, the use of DHM and associated ethical considerations, the overall conclusion of the meeting was that in the absence of global recommendations on the implementation, operation and regulation of HMBs, evidence-based guidance is urgently needed.

Food pattern modeling to inform global guidance on complementary feeding of infants.

Nutrient needs are difficult to meet during infancy due to high nutrient requirements and the small quantities of food consumed. Guidelines to support food choice decisions are critical to promoting optimal infant health, growth and development and food pattern modeling can be used to inform guideline development. We employed the Optifood modeling system to determine if unfortified complementary foods could meet 13 nutrient targets for breastfed infants (6-11 months), and to describe food patterns that met, or came as close as possible to meeting targets. We also examined the impacts of eliminating food groups, increasing starchy staple foods or adding sentinel unhealthy foods. We collated a global food list from dietary studies in 37 countries and used this list to develop nutrient values for a set of 35 food subgroups. We analyzed infant dietary intakes from studies in eight countries to inform maximum quantities and frequencies of consumption for these subgroups in weekly food patterns. We found that unfortified foods could meet targets for most infants for 12 nutrients, but not for iron. For the smallest and youngest infants, with the lowest energy intakes, there were additional deficits for minerals. Best-case food patterns that met targets or came as close as possible to meeting targets included ample amounts of diverse vegetables, diverse plant- and animal-source protein foods, small amounts of whole grain foods and dairy and no refined grains or added fats or sugar. There were nutrient deficits if animal-source foods or vegetables were eliminated or if unhealthy foods were included.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress.

Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0-36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.

Digital Marketing of Breast-Milk Substitutes: a Systematic Scoping Review.

PURPOSE OF REVIEW: Globally, too few children are breastfed as recommended. Commercial promotion of breast-milk substitutes (BMS) is one factor undermining breastfeeding globally. Although the International Code of Marketing of BMS prohibits all forms of marketing, promotion has been observed in digital environments. We aimed to understand the scope and impact of digital marketing for the promotion of BMS. RECENT FINDINGS: BMS are promoted strategically and in an integrated fashion across multiple digital channels (social media, manufacturer websites, online retailers, blogs, mobile apps and digital streaming services). Traditional marketing strategies like gifts, discounts and coupons are also disseminated digitally. Data mining, real-time direct-to-consumer advertising and partnering with peer-group social media influencers are additional avenues. Exposure to digital marketing is common. Research on the impact of digital marketing is scarce, but its negative impact on breastfeeding intention and initiation has been documented. Case reports from marketing industry press corroborate academic evidence by highlighting the benefits of digital marketing to BMS companies in recruiting new users and increasing sales. To protect and promote breastfeeding, coordinated global action and strengthened national measures will be needed to implement, monitor and enforce the International Code in a digital context. Further action could include voluntary restrictions on BMS marketing by social media platforms and greater use of government-led data and health privacy regulation.

Developing global guidance on human milk banking.

Donor human milk is recommended by the World Health Organization both for its advantageous nutritional and biological properties when mother's own milk is not available and for its recognized support for lactation and breastfeeding when used appropriately. An increasing number of human milk banks are being established around the world, especially in low- and middle-income countries, to facilitate the collection, processing and distribution of donor human milk. In contrast to other medical products of human origin, however, there are no minimum quality, safety and ethical standards for donor human milk and no coordinating global body to inform national policies. We present the key issues impeding progress in human milk banking, including the lack of clear definitions or registries of products; issues around regulation, quality and safety; and ethical concerns about commercialization and potential exploitation of women. Recognizing that progress in human milk banking is limited by a lack of comparable evidence, we recommend further research in this field to fill the knowledge gaps and provide evidence-based guidance. We also highlight the need for optimal support for mothers to provide their own breastmilk and establish breastfeeding as soon as and wherever possible after birth.

Lorsque la mère est dans l'impossibilité d'allaiter, l'Organisation mondiale de la Santé recommande d'opter pour le lait humain provenant de donneuses, tant pour ses propriétés nutritionnelles et biologiques que pour la contribution avérée qu'il apporte à la lactation et à l'allaitement quand il est utilisé à bon escient. Un nombre croissant de banques de lait humain s'établissent dans le monde entier, en particulier dans les pays à faible et moyen revenu, afin de faciliter la collecte, le traitement et la distribution de lait humain provenant de donneuses. Cependant, contrairement à d'autres produits médicaux d'origine humaine, il n'existe aucune norme minimale de qualité, de sécurité et d'éthique en la matière, et aucun organe de coordination global n'a été créé pour guider les politiques nationales. Dans le présent document, nous évoquons les principaux obstacles à la progression des banques de lait humain, notamment l'absence de définition claire ou de registre de produits; les problèmes relatifs à la réglementation, la qualité et la sécurité; ainsi que les questions éthiques entourant la commercialisation et l'exploitation potentielle des femmes. Jugeant cette progression limitée par le manque de données comparables, nous encourageons à mener d'autres recherches dans ce domaine pour combler les lacunes et fournir des orientations fondées sur des preuves. Nous soulignons également la nécessité d'offrir un soutien optimal aux mères afin qu'elles puissent produire leur propre lait et allaiter autant que possible immédiatement après la naissance.

La Organización Mundial de la Salud recomienda la leche humana donada tanto por sus ventajosas propiedades nutricionales y biológicas cuando no se dispone de la propia leche materna como por su reconocido apoyo a la lactancia y al amamantamiento cuando se utiliza de manera adecuada. Cada vez se crean más bancos de leche humana en todo el mundo, sobre todo en los países de ingresos bajos y medios, para facilitar la recogida, el procesamiento y la distribución de leche humana donada. Sin embargo, a diferencia de lo que ocurre con otros productos médicos de origen humano, no existen estándares mínimos de calidad, seguridad y ética para la leche humana donada ni un organismo mundial de coordinación que sirva de base a las políticas nacionales. En este documento se exponen los principales problemas que impiden el progreso de los bancos de leche humana, como la falta de definiciones claras o de registros de productos; los problemas relacionados con la regulación, la calidad y la seguridad; y las preocupaciones éticas sobre la comercialización y la posible explotación de las mujeres. Dado que el progreso de los bancos de leche humana se ve limitado por la falta de evidencias comparables, se recomienda seguir investigando en este campo para compensar los vacíos de conocimiento y proporcionar una guía asistencial. Asimismo, se destaca la necesidad de apoyar al máximo a las madres para que se provean de su propia leche materna y establezcan la lactancia materna tan pronto y siempre que sea posible después del nacimiento.

Complementary feeding of infants and young children 6 to 23 months of age.

Complementary feeding, when foods are introduced to complement a milk-based diet, generally occurs between 6 and 23 months of age. It is a critical period for both physical and cognitive development. During this period, the growth rate of the brain is one of the fastest during the life span and, consequently, the timing, dose, and duration of exposure to specific nutrients can result in both positive and negative effects. Complementary feeding is more than ensuring an adequate intake of nutrients; it also is about avoiding excess intakes of calories, salt, sugars, and unhealthy fats. Meals are cultural and social events where young children observe, imitate, learn about foods to like or dislike, and form lifelong eating habits and practices. Meals are also when a child learns to touch foods and connect food tastes to how foods look and feel. Ideally, complementary feeding is responsive and promotes child autonomy, but it can also be used to manage behavior problems or overly indulge a child, resulting in long-term consequences for nutrition and health. Therefore, in addition to what a child is fed, attention to how a child is fed is also important. In this review, 12 topics relevant for updating global guidance on complementary feeding were identified: age of introduction of complementary foods; continued breastfeeding; responsive feeding; safe preparation and storage of complementary foods; food textures, flavors, and acceptance; energy and meal and snack frequency; fats, protein, and carbohydrates; dietary diversity; milks other than breast milk; fluid needs; unhealthy foods and beverages; and use of vitamin and mineral supplements or supplementary foods.

Measuring coverage of infant and young child feeding counselling interventions: A framework and empirical considerations for survey question design.

Most countries implement nutrition counselling interventions as part of programmes to support breastfeeding and complementary feeding. However, data to track coverage of counselling interventions are rarely available. As a result, little is known about the coverage of counselling on infant and young child feeding (IYCF). Survey-based data collection systems generally collect data on IYCF practices but do not collect data on coverage of interventions to support IYCF, and those surveys that do collect this information do not do so consistently. We present a framework to guide the design of survey questions to measure IYCF counselling coverage. We provide examples of how large-scale surveys for programme evaluation and national monitoring have included survey questions to address these data gaps. Our review suggests that elements relevant to designing survey questions to capture coverage of counselling interventions include timing of contact, target behaviour and message content, place of contact, type of service provider, frequency of contact and mode of intervention. Application of this framework may help strengthen harmonized measurement of IYCF counselling coverage to enable better tracking of programme investments, document progress in scaling up nutrition services and allow for cross-country comparisons. Thus, improving measurement of counselling coverage may lead to improved reach of programmes to support optimal IYCF practices.

David Clark: Defender of Human Rights and Breastfeeding.

On September 10, I had the pleasure of interviewing my friend and colleague David Lawson Clark, the legal advisor for infant and young child nutrition and expert on the International Code of Marketing of Breast-milk Substitutes at UNICEF. A native of Scotland, David began his career as an attorney with the Scottish Development Agency and subsequently worked for the United Nations Interregional Crime and Justice Research Institute in Rome, Italy. Since 1995, David has assisted more than 60 countries in drafting legislation to implement the International Code of Marketing of Breastmilk Substitutes and has been instrumental in bringing a human rights-based approach to the protection, promotion, and support of breastfeeding. He has contributed to the development of international policy guidelines in the area of HIV and infant feeding and infant feeding in emergencies, and has provided guidance on issues around international trade agreements and intellectual property rights. David has written and contributed to many articles and publications on health and nutrition policy, developed courses and training materials on the implementation of the International Code and maternity protection, and has facilitated numerous workshops on the issue. (LGS refers to Dr. Laurence Grummer-Strawn and DC are the verbatim responses of David Clark).

Dynamics of the double burden of malnutrition and the changing nutrition reality.

The double burden of malnutrition (DBM), defined as the simultaneous manifestation of both undernutrition and overweight and obesity, affects most low-income and middle-income countries (LMICs). This Series paper describes the dynamics of the DBM in LMICs and how it differs by socioeconomic level. This Series paper shows that the DBM has increased in the poorest LMICs, mainly due to overweight and obesity increases. Indonesia is the largest country with a severe DBM, but many other Asian and sub-Saharan African countries also face this problem. We also discuss that overweight increases are mainly due to very rapid changes in the food system, particularly the availability of cheap ultra-processed food and beverages in LMICs, and major reductions in physical activity at work, transportation, home, and even leisure due to introductions of activity-saving technologies. Understanding that the lowest income LMICs face severe levels of the DBM and that the major direct cause is rapid increases in overweight allows identifying selected crucial drivers and possible options for addressing the DBM at all levels.

Sponsorship of national and regional professional paediatrics associations by companies that make breast-milk substitutes: evidence from a review of official websites.

OBJECTIVES: Professional paediatrics associations play an important role in promoting the highest standard of care for women and children. Education and guidelines must be made in the best interests of patients. Given the importance of breastfeeding for the health, development and survival of infants, children and mothers, paediatric associations have a particular responsibility to avoid conflicts of interest with companies that manufacture breast-milk substitutes (BMSs). The objective of this study was to investigate the extent to which national and regional paediatric associations are sponsored by BMS companies. METHODS: Data were collected on national paediatric associations based on online searches of websites and Facebook pages. Sites were examined for evidence of financial sponsorship by the BMS industry, including funding of journals, newsletters or other publications, conferences and events, scholarships, fellowship, grants and awards. Payment for services, such as exhibitor space at conferences or events and paid advertisements in publications, was also noted. RESULTS: Overall, 68 (60%) of the 114 paediatric associations with a website or Facebook account documented receiving financial support from BMS companies. Sponsorship, particularly of conferences or other events, was the most common type of financial support. The prevalence of conference sponsorship is highest in Europe and the Americas, where about half of the associations have BMS company-sponsored conferences. Thirty-one associations (27%) indicated that they received funding from BMS companies as payment for advertisements or exhibitor space. Only 18 associations (16%) have conflict of interest policies, guidelines, or criteria posted online. CONCLUSION: Despite the well-documented importance of breastfeeding and the widespread recognition that commercial influences can shape the behaviours of healthcare professionals, national and regional paediatric associations commonly accept funding from companies that manufacture and distribute BMS. Paediatric associations should function without the influence of commercial interests.

Violations of the International Code of Marketing of Breast-milk Substitutes in Mexico.

This study estimated the prevalence of violations of the International Code of Marketing of Breast-milk Substitutes (BMS) and subsequent resolutions of the World Health Assembly (Code) at health facilities, points of sale (POS), and on BMS labelling and media in Mexico. We carried out a cross-sectional survey among 693 mothers with children aged less than 24 months and 48 health providers at public and private health facilities in two states of Mexico. Observational assessment at 20 POS and the health facilities was conducted as well as an analysis of labels on BMS products for sale. Women attending public and private health facilities reported receiving free BMS samples in the previous 6 months (11.1%), and about 80% reported seeing BMS promotion in the mass media. Health providers reported contact with BMS manufacturer representatives in the previous 6 months (15.5%), and only 41.6% of the health providers had knowledge of the Code. BMS promotions were identified at nearly all POS. Analysis of 190 BMS labels showed that 30% included pictures/text idealizing the use of BMS, and all labels incorporated health and nutrition claims. Violations of the Code are prevalent within the health services, POS, and labelling of BMS products. The high percentage of health providers with no knowledge of the Code calls for action at national level to better disseminate and comply with the Code. A transparent, free from commercial influence, and continual monitoring system for Code compliance is needed, including a follow-up component on sanctions for contraventions of the Code.

The magnitude and distribution of iron deficiency using serum/plasma ferritin among preschool children and non-pregnant women: a multi-country analysis.

Background: In 2004, World Health Organization (WHO) recommended the use of serum ferritin as a primary indicator of iron deficiency. However, there was limited data on the magnitude and distribution of iron deficiency based on ferritin. Objective: To describe the prevalence of iron deficiency as measured by serum/plasma ferritin in different regions of the world and its relationship with demographic and health indicators. Methods: Data from the Biomarkers Reflecting Inflammation and Nutrition Determinants of Anemia and the WHO Vitamin and Mineral Nutrition Information System Micronutrients Database were used for this analysis. Unadjusted and inflammation-adjusted low ferritin prevalence were calculated for both databases. The prevalence of low ferritin among preschool children and non-pregnant women was examined according to its relationship with national gross domestic product (GDP), infant mortality rate (IMR), and anemia rate. Results: In children, the median inflammation-adjusted prevalence of low ferritin was 35.3% (1st and 3rd quartiles: 17.5% and 48.1%). In non-pregnant women, the median inflammation-adjusted prevalence of low ferritin was 28.4% (1st and 3rd quartiles: 21.4% and 42.0%). For both children and women, the correlation between the prevalence of low ferritin and GDP, IMR, or anemia was consistently stronger using inflammation-adjusted prevalences than when using unadjusted prevalences. Conclusions: The quartile values of low ferritin prevalence for children and non-pregnant women could be used to define the severity of ferritin as a public health problem.

Emerging issues in complementary feeding: Global aspects.

The complementary feeding period (6-24 months) is a window of opportunity for preventing stunting, wasting, overweight, and obesity and for improving long-term development and health. Because WHO published its guiding principles for complementary feeding in 2003, new knowledge and evidence have been generated in the area of child feeding. The aim of this paper is to highlight some of the emerging issues in complementary feeding and potential implications on the guidelines revision. Evidence on the effect of the quality and quantity of protein and fat intake on child growth during the complementary feeding period is summarized. The increased availability of sugar-containing beverages and unhealthy snack foods and its negative effect on young child's diet is described. Negative effects of nonresponsive feeding and force feeding are also discussed, although few scientific studies have addressed these issues. There are several emerging research areas that are likely to provide a better understanding of how complementary feeding influences growth, development, and health. These include the effect of the young child's diet on body composition, gastrointestinal microbiota, and environmental enteric dysfunction. However, at present, findings from these research areas are not likely to influence guidelines. Several emerging issues will be relevant to address when complementary feeding guidelines will be updated. With the increasing prevalence of obesity globally, it is important that guidelines on complementary feeding address both prevention of undernutrition and prevention of overweight, obesity, and noncommunicable diseases later in life.

New World Health Organization guidance helps protect breastfeeding as a human right.

Written by the WHO/UNICEF NetCode author group, the comment focuses on the need to protect families from promotion of breast-milk substitutes and highlights new WHO Guidance on Ending Inappropriate Promotion of Foods for Infants and Young Children. The World Health Assembly welcomed this Guidance in 2016 and has called on all countries to adopt and implement the Guidance recommendations. NetCode, the Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and Subsequent Relevant World Health Assembly Resolutions, is led by the World Health Organization and the United Nations Children's Fund. NetCode members include the International Baby Food Action Network, World Alliance for Breastfeeding Action, Helen Keller International, Save the Children, and the WHO Collaborating Center at Metropol University. The comment frames the issue as a human rights issue for women and children, as articulated by a statement from the United Nations Office of the High Commissioner for Human Rights.

Is Erythrocyte Protoporphyrin a Better Single Screening Test for Iron Deficiency Compared to Hemoglobin or Mean Cell Volume in Children and Women?

Hemoglobin (Hb), mean cell volume (MCV), and erythrocyte protoporphyrin (EP) are commonly used to screen for iron deficiency (ID), but systematic evaluation of the sensitivity and specificity of these tests is limited. The objective of this study is to determine the sensitivity and specificity of Hb, MCV, and EP measurements in screening for ID in preschool children, non-pregnant women 15-49 years of age, and pregnant women. Data from the National Health and Nutrition Examination Surveys (NHANES) (NHANES 2003-2006: n = 861, children three to five years of age; n = 3112, non-pregnant women 15 to 49 years of age. NHANES 1999-2006: n = 1150, pregnant women) were examined for this purpose. Children or women with blood lead ≥10 µg/dL or C-reactive protein (CRP) >5.0 mg/L were excluded. ID was defined as total body iron stores <0 mg/kg body weight, calculated from the ratio of soluble transferrin receptor (sTfR) to serum ferritin (SF). The receiver operating characteristic (ROC) curve was used to characterize the sensitivity and specificity of Hb, MCV, and EP measurements in screening for ID. In detecting ID in children three to five years of age, EP (Area under the Curve (AUC) 0.80) was superior to Hb (AUC 0.62) (p < 0.01) but not statistically different from MCV (AUC 0.73). In women, EP and Hb were comparable (non-pregnant AUC 0.86 and 0.84, respectively; pregnant 0.77 and 0.74, respectively), and both were better than MCV (non-pregnant AUC 0.80; pregnant 0.70) (p < 0.01). We concluded that the sensitivity and specificity of EP in screening for ID were consistently superior to or at least as effective as those of Hb and MCV in each population examined. For children three to five years of age, EP screening for ID was significantly better than Hb and similar to MCV. For both non-pregnant and pregnant women, the performance of EP and Hb were comparable; both were significantly superior to MCV.