First foods in a packaged world: Results from the COMMIT consortium to protect young child diets in Southeast Asia.

Although commercially produced complementary foods (CPCFs) are increasingly sold throughout Southeast Asia, concerns have been raised about CPCFs nutritional quality, labelling practices and the strength and scope of national CPCF regulations. The Consortium for Improving Complementary Foods in Southeast Asia (COMMIT), composed of UN agencies and civil society organizations, was formed to assess the nutrient gap in the diets of young children and the consumer, product and policy landscapes for CPCFs in seven Southeast Asian countries. Results from a nutrient gap assessment indicate that the diets of children aged 6-23 months are suboptimal and deficient in micronutrients. A consumer survey revealed that caretakers commonly use CPCFs, are conscious of the importance of nutrition and are influenced by label claims. Results from a CPCF benchmarking showed that many products sold in Southeast Asia contained added sugar or sweeteners, had a high total sugar and/or high sodium content and that no CPCF product adhered to all recommended labelling practices. Further, a legal review of national binding legal measures relevant to CPCFs showed minimal alignment with available global guidance. Urgent actions are necessary to strengthen national regulations related to CPCF nutrient composition and labelling practices. To speed progress, COMMIT developed a compendium of existing standards and global guidance to help countries align their national regulations with CPCF composition, labelling and production recommendations. Advocacy to garner public support for new or improved CPCF regulations, as well as strong government monitoring and enforcement of regulations, is crucial to support efforts to safeguard and improve the diets of older infants and young children in Southeast Asia.

Nutrient profiles of commercially produced complementary foods available in Cambodia, Indonesia and the Philippines.

OBJECTIVE: To assess the nutritional suitability of commercially produced complementary foods (CPCF) marketed in three South-East Asian contexts. DESIGN: Based on label information declared on the products, nutrient composition and content of CPCF were assessed against the WHO Europe nutrient profile model (NPM). The proportion of CPCF that would require a 'high sugar' warning was also determined. SETTING: Khsach Kandal district, Cambodia; Bandung City, Indonesia; and National Capital Region, Philippines. PARTICIPANTS: CPCF products purchased in Cambodia (n 68) and Philippines (n 211) in 2020, and Indonesia (n 211) in 2017. RESULTS: Only 4·4 % of products in Cambodia, 10·0 % of products in Indonesia and 37·0 % of products in the Philippines fully complied with relevant WHO Europe NPM nutrient composition requirements. Sixteen per cent of CPCF in Cambodia, 27·0 % in Indonesia and 58·8 % in the Philippines contained total sugar content levels that would require a 'high sugar' warning. CONCLUSIONS: Most of the analysed CPCF were not nutritionally suitable to be promoted for older infants and young children based on their nutrient profiles, with many containing high levels of sugar and sodium. Therefore, it is crucial to introduce new policies, regulations and standards to limit the promotion of inappropriate CPCF in the South-East Asia region.

Sugar content and nutrient content claims of growing-up milks in Indonesia.

'Growing-up milks' (GUMs)-breast-milk substitutes targeted for young children (aged 12-36 months)-are commonly consumed in Indonesia. The World Health Assembly has stated that GUMs are not necessary for proper growth and development, and recently, the American Academy of Pediatrics declared that such products are not recommended for young children due to their common use of sweeteners. To contribute to the evidence base on the composition of GUMs and their appropriateness for young child diets, this cross-sectional study documented the declared sugar content and presence of nutrient content claims of 99 GUMs newly launched in Indonesia between January 2017 and May 2019. Sugar content was evaluated against the draft 2018 Codex Alimentarius Standard for Follow-Up Formula guidance on sugar content and the United Kingdom Food Standard Agency's front-of-pack (UK FSA FOP) colour coding system for sugar. Almost all (97%) GUMs contained one or more added sugars. None of the products were fully compliant with all three sugar content recommendations in the draft Codex standard. Seventy-one per cent of GUMs were determined to have high sugar content according to the UK FSA FOP system. Nutrient content claims were found on 97% of GUMs. Median total sugar content was 7.3 g per 100 ml, similar to sugar content levels in sugar-sweetened beverages. Many GUMs available in Indonesia claim to offer nutritional benefits; however, the current levels of sugar content in GUMs are a serious concern and are inappropriate for inclusion in the diets of young children.

Breastfeeding and breastmilk substitute use and feeding motivations among mothers in Bandung City, Indonesia.

Suboptimal breastfeeding is common in Indonesia, with only half of infants 0-5 months of age exclusively breastfed and feeding of breastmilk substitutes (BMS) highly prevalent among infants and toddlers. Various factors influence these feeding practices, including social norms, limited health system support and BMS manufacturer marketing practices. This cross-sectional survey aimed to identify the prevalence of breastfeeding and BMS feeding among children aged 0-35 months, explore socio-demographic characteristics and motivating factors associated with these feeding behaviours and identify the prevalence of mothers' exposure to BMS promotions. Indonesian mothers of children <3 years of age (n = 595) were interviewed in Bandung City health facilities using structured questionnaires. Although all children were ever breastfed, half of children across all age groups received BMS in the previous day. Maternal employment outside the home and insufficient breastmilk production were associated with BMS use. The most important motivational factors for feeding BMS were perceived benefits for growth, intelligence and immunity. Despite Indonesian legislation restricting some BMS marketing, 93% of mothers reported observing a BMS promotion outside the health system, with television, social media and newspapers as the most common sources. Half of mothers (43%) reported observing a BMS promotion within the health system, and half (46%) reported receiving recommendations from health workers to use BMS. Such high prevalence of BMS marketing may be influencing caregivers' feeding choices; stronger national legislation and implementation of laws are needed to ensure mothers' ability to make feeding choices free from manufacturer influence.

High proportions of children under 3 years of age consume commercially produced snack foods and sugar-sweetened beverages in Bandung City, Indonesia.

Child undernutrition continues to be a national concern in Indonesia, whereas childhood overweight/obesity rises. Economic development has led to wide availability of highly processed foods and beverages, with growing evidence that children are consuming commercial snack products during the critical complementary feeding period. This study assessed the prevalence and patterns of consumption of commercially produced snack foods and sugar-sweetened beverages among Indonesian children. A cross-sectional survey was conducted with 495 mothers of children aged 6-35 months living in Bandung City, Indonesia. Among all children, 81.6% consumed a commercial snack food and 40.0% consumed a sugar-sweetened beverage in the day preceding the interview. At 6-11 months, 46.5% of children consumed a snack food and 2.0% consumed a sugar-sweetened beverage. Snack foods were consumed 3 or more times a day by 60.0% of children 24-35 months of age. Sweet biscuits and savory snacks were the most commonly consumed snack foods; sweetened milks and sweetened teas were the most common beverages. Maternal education, child age, and consumption of a commercially produced complementary food were associated with snack food consumption. Factors associated with sugar-sweetened beverage consumption were child age and consumption of a commercially produced complementary food or breastmilk substitute. These findings reflect a high presence of processed, high-sugar/salt commercial snack products in the diets of children 6-35 months. National attention should focus on interventions to reduce reliance on processed snack products and increase consumption of nutrient-rich, locally available foods during the complementary feeding period.

Perceptions of commercial snack food and beverages for infant and young child feeding: A mixed-methods study among caregivers in Kathmandu Valley, Nepal.

Ensuring nutritious complementary feeding is vital for child nutrition. Prior research in Kathmandu Valley found high consumption rates of commercially produced snack foods among young children, which are often energy-dense/nutrient poor. This mixed-methods study was conducted to elicit Nepali caregivers' perceptions of commercial snack foods and beverages and factors influencing their use for young child feeding. Seven facilitated focus group discussions (FGD) were conducted with Kathmandu Valley caregivers of children 12-23 months, and a survey of 745 primary caregivers of children 12-23 months of age was then conducted. During the FGD, caregivers reported commonly providing commercial food and beverage products to their children as snacks, and 98.6% of caregivers participating in the survey reported feeding their child such a food in the previous week. Because of processing and packaging, snack foods were not trusted by many FGD participants and considered as "junk foods" and not healthy for children. However, commercial snack foods were consistently ranked highly on convenience, both because of minimal preparation and ease of feeding; 48.5% of all surveyed caregivers reported providing a snack food because of convenience. Other family members' diets or provision of snack foods as treats also influenced children's consumption of these snack foods and beverages. This study indicates that caregivers of young children prefer snack options that are nutrient rich; however, this may conflict with preferences for foods that require minimal preparation and are appealing to young children. Such findings carry programmatic implications for interventions aiming to address children's diet quality in urban Nepal.

Predictors of breast milk substitute feeding among newborns in delivery facilities in urban Cambodia and Nepal.

Introducing breast milk substitutes (BMS) in the first days after birth can increase infant morbidity and reduce duration and exclusivity of breastfeeding. This study assessed determinants of BMS feeding among newborns in delivery facilities in Phnom Penh, Cambodia, and Kathmandu Valley, Nepal. Cross-sectional surveys were conducted among mothers upon discharge from health facilities after delivery: 304 mothers in Kathmandu Valley and 306 mothers in Phnom Penh participated. On the basis of a conceptual framework for prelacteal feeding, multivariable logistic regression was used to identify factors associated with BMS feeding prior to facility discharge. In both Phnom Penh and Kathmandu Valley, feeds of BMS were reported by over half of mothers (56.9% and 55.9%, respectively). Receiving a health professional's recommendation to use BMS increased the odds of BMS feeding in both Kathmandu Valley and Phnom Penh (odds ratio: 24.87; confidence interval [6.05, 102.29]; odds ratio: 2.42; CI [1.20, 4.91], respectively). In Kathmandu Valley, recommendations from friends/family and caesarean delivery were also associated with BMS use among mothers. Early initiation of breastfeeding and higher parity were protective against the use of BMS in Kathmandu Valley. Breastfeeding support from a health professional lowered the odds of BMS feeding among newborns. Exposure to BMS promotions outside the health system was prevalent in Phnom Penh (84.6%) and Kathmandu Valley (27.0%) but was not associated with BMS feeds among newborns. Establishment of successful breastfeeding should be prioritized before discharging mothers from delivery facilities, and health professionals should be equipped to support and encourage breastfeeding among all new mothers.

Prevalence, duration, and content of television advertisements for breast milk substitutes and commercially produced complementary foods in Phnom Penh, Cambodia and Dakar, Senegal.

Promotion of breast milk substitutes (BMS) and inappropriate marketing of commercially produced complementary foods (CPCF), including through television, can negatively influence infant and young child feeding. The World Health Organization International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions prohibit such advertising and require manufacturers and distributors to comply with its provisions; however, such regulations at national level may vary. Advertisements require Ministry of Health approval in Cambodia but are not regulated in Senegal. Television stations were monitored for 13 months in Phnom Penh and for 3 months in Dakar to assess advertisements for BMS and CPCF. Ten television channels (out of 16) in Phnom Penh and four (out of 20) in Dakar aired advertisements for BMS. Three and five channels, respectively, aired advertisements for CPCF. All BMS advertised in Phnom Penh were for children over 1 year of age. BMS products for children 6+ months of age and 1+ years of age were advertised in Dakar. Average air time for BMS advertisements was 189.5 min per month in Phnom Penh and 29.7 min in Dakar. Air time for CPCF advertisements averaged 3.2 min per month and 13.6 min, respectively. Fewer than half of BMS advertisements and three quarters of CPCF advertisements explicitly stated an age of use for products. Nutrition and health claims were common across BMS advertisements. This study illustrates the need to adopt, regulate, monitor, and enforce legislation prohibiting BMS promotion, as well as to implement regulations to prevent inappropriate promotion of CPCF.

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.

Consumption of commercially produced snack foods and sugar-sweetened beverages during the complementary feeding period in four African and Asian urban contexts.

The availability and consumption of commercially produced foods and beverages have increased across low-income and middle-income countries. This cross-sectional survey assessed consumption of commercially produced foods and beverages among children 6-23 months of age, and mothers' exposure to promotions for these products. Health facility-based interviews were conducted among 218 randomly sampled mothers utilizing child health services in Dakar, Senegal; 229 in Dar es Salaam, Tanzania; 228 in Kathmandu Valley, Nepal; and 222 in Phnom Penh, Cambodia. In the day prior to the interview, 58.7% of 6-23-month-olds in Dakar, 23.1% in Dar es Salaam, 74.1% in Kathmandu Valley, and 55.0% in Phnom Penh had consumed a commercially produced snack food. In the previous week, the majority of children in Dakar (79.8%), Kathmandu Valley (91.2%), and Phnom Penh (80.6%) had consumed such products. Consumption of commercially produced sugar-sweetened beverages was noted among 32.0% of Phnom Penh, 29.8% of Dakar, 23.1% of Dar es Salaam, and 16.2% of Kathmandu Valley children. Maternal education was negatively associated with commercial snack food consumption in Dakar and Kathmandu Valley. Children of Phnom Penh mothers in the lowest wealth tercile were 1.5 times more likely to consume commercial snack food products, compared to wealthier mothers. These snack consumption patterns during the critical complementary feeding period demand attention; such products are often high in added sugars and salt, making them inappropriate for infants and young children.

Cross-sectional survey shows that follow-up formula and growing-up milks are labelled similarly to infant formula in four low and middle income countries.

This cross-sectional survey assessed the characteristics of labels of follow-up formula (FUF) and growing-up milk (GUM) compared with infant formula (IF), including cross-promotion practices between FUF/GUM and IF manufactured by the same company, sold in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania. All products were imported. A wide recommended age/age range for introduction was provided by manufacturers across all sites, with products with an age recommendation of 0-6 months being most prevalent in three sites, representing over a third of all products. Various age categories (e.g. 1, 1+ and Stage 1) commonly appeared on labels. A number of descriptive names (e.g. infant formula and milk formula) per category of age of introduction were used with some appearing across more than one category. Images of feeding bottles were found on most labels across all age categories, but prevalence decreased with older age categories. The majority of FUF/GUM manufactured by IF companies across all sites displayed at least one example of cross-promotion with one or more of the company's IF: two-thirds or more contained similar colour schemes/designs and similar brand names; 20-85% had similar slogans/mascots/symbols. A wide and potentially confusing range of ages/categories of introduction and descriptive names were found, and cross-promotion with IF was common on FUF/GUM labels. Global guidance from normative bodies forms the basis of most low and middle income countries policies and should provide specific guidance to prohibit cross-promotion between FUF/GUM and IF, and all three categories should be classified as breastmilk substitutes.

Promotion and prelacteal feeding of breastmilk substitutes among mothers in Kathmandu Valley, Nepal.

UNLABELLED: In 1992, Nepal passed the Mother's Milk Substitutes (Control of Sale and Distribution) Act in order to regulate the sale, distribution and promotion of substitutes for breastmilk within Nepal, in an effort to protect and promote breastfeeding. Helen Keller International, in collaboration with Nepal's Ministry of Health and Population's Child Health Division, implemented a study to assess mothers' exposure to promotions for and utilization of breastmilk substitutes in Kathmandu Valley, Nepal. A health facility-based, cross-sectional survey was conducted among 304 mothers being discharged after delivery. Prelacteal feeding of breastmilk substitutes is prevalent (55.9% of mothers, n = 170). Reported recommendations during antenatal checks and after delivery from health professionals to use breastmilk substitutes were prevalent, occurring among 47.4% (n = 144) of mothers; rates of these recommendations were significantly higher for mothers that delivered in private health facilities, as compared with public (67.7% vs. 38.0%, P < 0.001). Mothers that received a recommendation to use a breastmilk substitute from a health worker were 16.7 times more likely to provide a prelacteal feed of a breastmilk substitute, as compared with mothers that did not receive a recommendation (P < 0.001). Few mothers reported observation of commercial advertisements for breastmilk substitutes inside a health facility (reported by 3.6% of mothers). No mothers reported receiving a sample of a breastmilk substitute, bottle or teat from a health professional. More information is needed to determine why there is such a high rate of health worker recommendations for breastmilk substitute use in the first few days after delivery. KEY MESSAGES: While utilization of breastmilk substitutes is low among mothers of young children in Nepal, prelacteal feeding of breastmilk substitutes is highly prevalent in Kathmandu Valley. Reported recommendations from health professionals to use breastmilk substitutes are common (over 40%) and are associated with prelacteal feeding among Nepal mothers included in this study. Provision of lactation management training to health workers and monitoring their practices regularly could strengthen breastfeeding counselling, aid in reducing high rates of prelacteal feeding and contribute to improved infant feeding practices.

Pervasive promotion of breastmilk substitutes in Phnom Penh, Cambodia, and high usage by mothers for infant and young child feeding.

UNLABELLED: In 2005, Cambodia passed the Sub-Decree on Marketing of Products for Infant and Young Child Feeding (no. 133) to regulate promotion of commercial infant and young child food products, including breastmilk substitutes. Helen Keller International assessed mothers' exposure to commercial promotions for breastmilk substitutes and use of these products through a cross-sectional survey among 294 mothers of children less than 24 months of age. Eighty-six per cent of mothers reported observing commercial promotions for breastmilk substitutes, 19.0% reported observing infant and young child food product brands/logos on health facility equipment and 18.4% reported receiving a recommendation from a health professional to use a breastmilk substitute. Consumption of breastmilk substitutes was high, occurring among 43.1% of children 0-5 months and 29.3% of children 6-23 months of age. Findings also indicated a need to improve breastfeeding practices among Phnom Penh mothers. Only 36.1% of infants 0-5 months of age were exclusively breastfed, and 12.5% of children 20-23 months of age were still breastfed. Children that received a breastmilk substitute as a prelacteal feed were 3.9 times more likely to be currently consuming a breastmilk substitute than those who did not. Despite restriction of commercial promotions for breastmilk substitutes without government approval, occurrence of promotions is high and use is common among Phnom Penh mothers. In a country with high rates of child malnutrition and pervasive promotions in spite of restrictive national law, full implementation of Cambodia's Sub-Decree 133 is necessary, as are policies and interventions to support exclusive and continued breastfeeding. KEY MESSAGES: Despite prohibition without specific approval by the national government, companies are pervasively promoting breast-milk substitutes in Phnom Penh, particularly on television and at points of sale. Strengthened implementation and enforcement of Cambodia's subdecree 133 are needed to better regulate promotion in order to protect breastfeeding for the nutrition and health of infants and young children in Cambodia. Mothers who used a breast-milk substitute as a prelacteal feed were 3.9 times more likely to currently feed this same child a breast-milk substitute, as compared with mothers who did not provide breast-milk substitute as a prelacteal feed. Supporting breastfeeding among mothers after delivery is critical to establish and sustain optimal breastfeeding practices. Use of breast-milk substitutes is also very common among mothers of children under 2 years of age in Phnom Penh. We recommend promoting exclusive and continued breastfeeding as beneficial to children's health and development, and supporting policy and workplace environments that enable breastfeeding up to and beyond 24 months of age.

High use of commercial food products among infants and young children and promotions for these products in Cambodia.

Despite national improvements in child survival, 40% of Cambodian children less than 5 years of age are stunted. Commercially produced complementary foods could be nutritionally beneficial for young children in Cambodia if fortified and of optimal nutrient composition. However, other nutrient-poor commercially produced snack foods may be detrimental to young child feeding by displacing consumption of other nutritious foods. This study assessed consumption of commercial food products among infants and young children and their mothers' exposure to promotions for these products. A cross-sectional survey was conducted among 294 mothers of children less than 24 months of age living in Phnom Penh. Of children 6-23 months of age, 55.0% consumed a commercially produced snack food product on the prior day, and 80.6% had consumed one in the prior week. Only 12 (5.4%) children 6-23 months of age had consumed a commercially produced complementary food. Almost all mothers (96.9%) had observed a promotion for a commercially produced snack food product, and 29.3% reported observation of a promotion for a commercial complementary food. Only one-third (32.9%) of children 6-23 months of age achieved a minimum acceptable diet. Findings indicate that there is a need to improve infant and young child feeding practices among children less than 24 months of age living in Phnom Penh. Nutritious options should be promoted, and consumption of unhealthy commercially produced snack food products should be discouraged.

High consumption of commercial food products among children less than 24 months of age and product promotion in Kathmandu Valley, Nepal.

Commercially produced complementary foods can help improve nutritional status of young children if they are appropriately fortified and of optimal nutrient composition. However, other commercially produced snack food products may be nutritionally detrimental, potentially increasing consumption of foods high in salt or sugar and displacing consumption of other more nutritious options. Helen Keller International, in collaboration with the Nepal government, implemented a study to assess mothers' utilization of commercial food products for child feeding and exposure to commercial promotions for these products. A cross-sectional survey was conducted among 309 mothers of children less than 24 months of age across 15 health facilities. Utilization of breastmilk substitutes was low, having been consumed by 6.2% of children 0-5 months of age and 7.5% of children 6-23 months of age. Approximately one-fourth (24.6%) of children 6-23 months age had consumed a commercially produced complementary food in the prior day. Twenty-eight percent of mothers reported observing a promotion for breastmilk substitutes, and 20.1% reported promotions for commercially produced complementary foods. Consumption of commercially produced snack food products was high at 74.1% of children 6-23 months. Promotions for these same commercially produced snack food products were highly prevalent in Kathmandu Valley, reported by 85.4% of mothers. In order to improve diets during the complementary feeding period, development of national standards for complementary food products is recommended. Nutritious snack options should be promoted for the complementary feeding period; consumption of commercially produced snack food products high in sugar and salt and low in nutrients should be discouraged.

Infant and young child feeding practices among children under 2 years of age and maternal exposure to infant and young child feeding messages and promotions in Dar es Salaam, Tanzania.

There are limited data describing infant and young child feeding practices (IYCF) in urban Tanzania. This study assessed the types of foods consumed by children under 2 years of age and maternal exposure to promotions of these foods in Dar es Salaam, Tanzania. A cross-sectional survey was conducted among 305 mothers of children less than 24 months of age who attended child health services in October and November, 2014. Among infants less than 6 months of age, rates of exclusive breastfeeding were low (40.8%) and a high proportion (38.2%) received semi-solid foods. Continued breastfeeding among 20-23-month-olds was only 33.3%. Consumption of breastmilk substitutes was not prevalent, and only 3.9% of infants less than 6 months of age and 4.8% of 6-23 month-olds were fed formula. Among 6-23-month-olds, only 38.4% consumed a minimum acceptable diet (using a modified definition). The homemade complementary foods consumed by the majority of 6-23-month-olds (85.2%) were cereal-dominated and infrequently contained micronutrient-rich ingredients. Only 3.1% of 6-23-month-olds consumed commercially produced infant cereal on the day preceding the interview. In contrast, commercially produced snack foods were consumed by 23.1% of 6-23-month-olds. Maternal exposure to commercial promotions of breastmilk substitutes and commercially produced complementary foods was low (10.5% and 1.0%, respectively), while exposure to promotions of commercially produced snack foods was high (45.9%). Strategies are needed to improve IYCF practices, particularly with regard to exclusive and continued breastfeeding, increased dietary diversity and consumption of micronutrient-rich foods, and avoidance of feeding commercially produced snack foods.

Promotion and consumption of commercially produced foods among children: situation analysis in an urban setting in Senegal.

This study assessed the promotion of commercially produced foods and consumption of these products by children less than 24 months of age in Dakar Department, Senegal. Interviews with 293 mothers of children attending child health clinics assessed maternal exposure to promotion and maternal recall of foods consumed by the child on the preceding day. Promotion of breastmilk substitutes and commercially produced complementary foods outside health facilities was common with 41.0% and 37.2% of mothers, respectively, reporting product promotions since the birth of their youngest child. Promotion of commercially produced snack food products was more prevalent, observed by 93.5% of mothers. While all mothers reported having breastfed their child, only 20.8% of mothers breastfed their newborn within the first hour after delivery, and 44.7% fed pre-lacteal feeds in the first 3 days after delivery. Of children 6-23 months of age, 20.2% had consumed a breastmilk substitute; 49.1% ate a commercially produced complementary food, and 58.7% ate a commercially produced snack food product on the previous day. There is a need to stop the promotion of breastmilk substitutes, including infant formula, follow-up formula, and growing-up milks. More stringent regulations and enforcement could help to eliminate such promotion to the public through the media and in stores. Promotion of commercial snack foods is concerning, given the high rates of consumption of such foods by children under the age of 2 years. Efforts are needed to determine how best to reduce such promotion and encourage replacement of these products with more nutritious foods.

Assessment of corporate compliance with guidance and regulations on labels of commercially produced complementary foods sold in Cambodia, Nepal, Senegal and Tanzania.

National legislation and global guidance address labelling of complementary foods to ensure that labels support optimal infant and young child feeding practices. This cross-sectional study assessed the labels of commercially produced complementary foods (CPCF) sold in Phnom Penh (n = 70), Cambodia; Kathmandu Valley (n = 22), Nepal; Dakar Department (n = 84), Senegal; and Dar es Salaam (n = 26), Tanzania. Between 3.6% and 30% of products did not provide any age recommendation and 8.6-20.2% of products, from all sites, recommended an age of introduction of <6 months. Few CPCF products provided a daily ration (0.0-8.6%) and 14.5-55.6% of those that did exceeded the daily energy recommendation for complementary foods for a breastfed child from 6 to 8.9 months of age. Only 3.6-27.3% of labels provided accurate and complete messages in the required language encouraging exclusive breastfeeding, and almost none (0.0-2.9%) provided accurate and complete messages regarding the appropriate introduction of complementary foods together with continued breastfeeding. Between 34.3% and 70.2% of CPCF manufacturers also produced breastmilk substitutes and 41.7-78.0% of relevant CPCF products cross-promoted their breastmilk substitutes products. Labelling practices of CPCF included in this study do not fully comply with international guidance on their promotion and selected aspects of national legislation, and there is a need for more detailed normative guidance on certain promotion practices in order to protect and promote optimal infant and young child feeding.

Point-of-sale promotion of breastmilk substitutes and commercially produced complementary foods in Cambodia, Nepal, Senegal and Tanzania.

UNLABELLED: In order to assess the prevalence of point-of-sale promotions of infant and young child feeding products in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania, approximately 30 retail stores per site, 121 in total, were visited. Promotional activity for breastmilk substitutes (BMS) and commercially produced complementary foods in each site were recorded. Point-of-sale promotion of BMS occurred in approximately one-third of sampled stores in Phnom Penh and Dakar Department but in 3.2% and 6.7% of stores in Kathmandu Valley and Dar es Salaam, respectively. Promotion of commercially produced complementary foods was highly prevalent in Dakar Department with half of stores having at least one promotion, while promotions for these products occurred in 10% or less of stores in the other three sites. While promotion of BMS in stores is legal in Senegal, it is prohibited in Cambodia without prior permission of the Ministry of Health/Ministry of Information and prohibited in both Nepal and Tanzania. Strengthening legislation in Senegal and enforcing regulations in Cambodia could help to prevent such promotion that can negatively affect breastfeeding practices. KEY MESSAGES: Even in countries such as Cambodia, Nepal and Tanzania where point-of-sale promotion is restricted, promotions of BMS were observed (in nearly one-third of stores in Phnom Penh and less than 10% in Dar es Salaam and Kathmandu). Limited promotion of commercially produced complementary foods was evident (less than 10% of stores had a promotion for such foods), except in Dakar Department, where promotions were found in half of stores. Efforts are needed to strengthen monitoring, regulation and enforcement of restrictions on the promotion of BMS. Manufacturers and distributors should take responsibility for compliance with national regulations and global policies pertaining to the promotion of breastmilk substitutes.