Nutrition magazine issue 2 may 2006

Issue theme Breastfeeding Issue 2 May 2006 Viewpoint Give breastfeeding a chance 4 Ghana Seeing is believing 5 Thailand Challenging industry 8 Ethiopia Time for breastfeeding 10 A family affair 12 Kenya, DRC and Indonesia Surviving emergencies 14 Vietnam Pressure of work 16 What would you do? The condensed milk baby 17 Research Resources Pullout poster Editorial team Lourdes Fidalgo (guest editor) Carmel Dolan, Kerry Selvester, Fiona Watson The themes of coming issues of nutrition will be: • Iron deficiency anaemia • Growth monitoring and promotion Subscribe to receive your own FREE copies of nutrition. Go to www.nutritioninternational.org.uk and click on SUBSCRIBE. Contribute by sharing your own experiences, both successful and unsuccessful. We will provide writing and editing support if needed. Send articles of up to 1,000 words, with photos or illustrations: by post 7 Winterbrook Road, London SE24 9HZ by email contributionsnutritioninternational.org.uk Letters and emails to the editors are also welcome. Please write editorsnutritioninternational.org.uk Statistics on children under five provided at the start of each of the countrybased articles in this issue use the following definitions. • Underweight refers to weightforage less than minus two standard deviations below the median of the reference population. This results from wasting or stunting or a combination of both. • Wasting refers to weightforheight less than minus two standard deviations below the median of the reference population. Wasting, or thinness, develops as a result of recent rapid weight loss or a failure to gain weight. • Stunting refers to heightforage less than minus two standard deviations below the median of the reference population. Stunting, or shortness, develops over a long period of time. Front cover: A mother and her child at the entrance to their home in Ethiopia Save the Children UK Venetia Dearden 2005 The nutrition symbol is derived from the three key areas essential to nutrition: food, health and care. Out of each of these, seeds of ideas and experience disperse. WHO Global Strategy for Infant and Young Child Feeding 2003 www.who.intnutritionpublicationsinfantfeedingen The global strategy builds on past and continuing achievements in particular the Baby Friendly Hospital Initiative (1991), the International Code of Marketing of Breastmilk Substitutes (1981) and the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding (1990). Governments need to achieve the following targets: 1 To develop, implement, monitor and evaluate a comprehensive policy on infant and young child feeding, in the context of national policies and programmes for nutrition, child and reproductive health, and poverty reduction. 2 To ensure that the health and other relevant sectors protect, promote and support exclusive breastfeeding for six months and continued breastfeeding up to two years of age or beyond, while providing women access to the support they require – in the family, community and workplace – to achieve this goal. 3 To promote timely, adequate, safe and appropriate complementary feeding with continued breastfeeding. 4 To provide guidance on feeding infants and young children in exceptionally difficult circumstances, and on the related support required by mothers, families and other caregivers. 5 To consider what new legislation or other suitable measures may be required, as part of a comprehensive policy on infant and young child feeding, to give effect to the principles and aim of the International Code of Marketing of Breastmilk Substitutes and to subsequent relevant Health Assembly resolutions. Acronyms BCC Behaviour change and communication BFHI Baby Friendly Hospital Initiative EBF Exclusive breastfeeding FAO Food and Agriculture Organisation GIFS Global Initiative for Father Support HIV Human immunodeficiency virus IBFAN International Baby Food Action Network IYCF Infant and young child feeding MDG Millennium Development Goal NGO Nongovernmental organization UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund USAID United States Agency for International Development WABA World Alliance for Breastfeeding Action WFP World Food Programme WHO World Health Organisation To receive your own FREE copies of nutrition, subscribe online at: www.nutritioninternational.org.uk Issue 2 May 2006 N U T R I T I O N 3 N U T R I T I O N Issue 2 May 2006 Securing children’s future Lourdes Fidalgo Senior nutritionist ANSA, Mozambique Welcome to the second issue of nutrition, in which we we focus on breastfeeding, the best start for children. Looking at the articles in this issue, it is clear that a critical area for action is for a strong health sector position that provides positive messages and leads by example in terms of good breastfeeding practice. This needs to be coupled with a policy environment that allows families to opt for breastfeeding. Families and communities are the key providers of care to a mother and her newborn child and counselling and education should work with all providers to achieve positive behaviour change for good breastfeeding practice. In Viewpoint, Annelies Allain points out that we are still far from having adequate monitoring and compliance to the International Code for Breastmilk Substitutes. Although 76 countries have legislation based on the Code, only 32 countries are fully implementing the legislation. The article from Thailand by Yupayong Hangchaovanich illustrates how even in a country where the Ministry of Health adopted the Code in 1984, compliance with the Code is still a big challenge. IBFAN believe that countries need to move beyond the Code and towards legal measures with sanctions that enable mothers to breastfeed. Options for enabling mothers to stay at home to breastfeed are highlighted in Tayech Yimer’s article from Ethiopia, stressing the particular needs of poorer women. This theme is also taken up in the article by Trinh Hong Son from Vietnam, where exclusive breastfeeding is still a big challenge as women make up a significant proportion of both the formal and informal labour market. In this context, the passing of laws in the areas of maternity leave protection and the Code are seen as an essential part of any breastfeeding campaign. The problem case from Laos poignantly shows the real life constraints to good breastfeeding practice; hard physical work of women, often away from the home, cultural beliefs and readily available breast milk substitutes. However, in the article based on work in Ghana, Joan Shubert and Luann Martin give us hope that breastfeeding practices can be improved in a relatively short period through partnership, training, behaviour change communication and support to the whole family. The article describes the practical steps taken by a national programme. The article by Kerry Selvester and Okechukwu Aniche indicates the importance of involving all influential members of the family, with particular emphasis on the role of fathers. For decades, the main responsibility for child health has been given to mothers, and the influence of other members has been ignored. This has led to less successful breastfeeding promotion programmes. Examples are given of men’s involvement in Nigeria, Bolivia, Ghana and Sweden. The challenge to protect and promote breastfeeding is also met by CAREsponsored projects in Kenya, the Democratic Republic of Congo and Indonesia, where counselling on breastfeeding was seen as an essential part of emergency interventions. Emergencies present a threat to breastfeeding and specific measures were taken to ensure that good practice could be maintained. Readers wanting to improve their emergency interventions please see the Resources page where there are details regarding training in infant feeding in emergencies. We have not included a specific article on breastfeeding and HIV in this issue, as it was discussed in Balancing the risks in Issue 1, which focused on nutrition and HIVAIDS. A wide range of research on breastfeeding is being carried out at present, namely in the areas linked to the physiology of breastfeeding, breastfeeding and HIV, the benefits of breastfeeding in reducing morbidity and mortality and the economic impact of breastfeeding. This research will support the design of policies and guidelines as well as answer some of the practical concerns of implementers. The magazine includes a selection of resources, with technical reviews, guidelines, course materials and training courses available. Please use this information to improve the implementation of your own activities. Our main objective is to provide an opportunity to those working in the development field, to share practical experiences of implementing nutrition activities. We have been pleased to hear from our readers after the publication of Issue 1, both in print and on the web (www.nutritioninternational.org.uk) and we look forward to future letters and articles contributed for future issues. Enjoy the second issue of nutrition. Please be encouraged to share your experiences of the challenges and successes of community nutrition initiatives. 2 0 0 6 4 Issue 2 May 2 0 0 6 N U T R I T I O N Viewpoint Give breastfeeding a chance May 2006 marked the 25th birthday of the International Code1 at the World Health Assembly. The Code has served as a reminder to governments and health workers and policy makers of the lifesaving benefits of breastfeeding. Some believe that it has been overtaken by different or more urgent health interventions such as the battle to reduce HIV infection or the need to vaccinate as many children as possible. Yet The Lancet in a series of articles in 2003 identified breastfeeding as the single most effective intervention to prevent child mortality and morbidity. It is often forgotten that breastfeeding provides longterm protection and that colostrum is the first and the most important vaccination in a child’s life. A recent study in Ghana on neonatal deaths calculates that if mothers start breastfeeding within one hour of birth, almost one million neonates could be saved.2 The same study shows that babies that were fed only breast milk were four times less likely to die than those who were also given cows’ milk or solids. Cows’ milk is made for calves whose body weight has to increase rapidly after birth as opposed to human babies who only grow half as quickly but whose brains experience the fastest development during the first three months. If we think of a baby’s growth this way, it becomes quite clear that human milk is very special. How did people turn to formulas based on cows’ milk? More and more mothers started bottle feeding thinking it was the same thing or believing it was better. One of the most powerful factors behind this has been the promotion of artificial feeding. By 1965, only 25 per cent of babies in the richest countries were breastfed. And the same pattern started in developing countries with disastrous results. WHO and UNICEF realised they had to stop the drift to bottle feeding and, with others, developed the International Code (see box for summary). Governments were asked to make laws to reduce or eliminate commercial promotion. Many have done so, but not enough. Some are not convinced while others think of breastfeeding as so natural that it needs no protection. Mothers ended up being confused and losing the confidence and support that they need to breastfeed. Although formula makers know that formula cannot match the real thing, they keep this information in the small print and aim marketing at convincing consumers that the latest formula is better than ever. The Code, if fully implemented, will remove advertising for breast milk substitutes, free gifts etc and babies worldwide will get a chance for the best start in life. Breast milk substitutes may then be used for those rare cases of medical need where they can save lives. Companies spend millions to get their share of an estimated US20 billion market and find ways to get around the Code. One thing, however, is clear: where a country has a strong national law, properly implemented and enforced, Code compliance improves. This should spur more governments to implement the Code at the national level. Some 76 countries have made the Code into national legislation, 32 in full, the others partially. Monitoring and compliance however, are far behind the ideal. Twenty five years of studying effective protection of breastfeeding has taught IBFAN that legal measures with sanctions are the only real means to give breastfeeding a chance. All nations, big or small, poor or rich, can act to enable mothers to give children the best start and the best future. Summary of the International Code • No advertising of breast milk substitutes, feeding bottles teats. • No free samples to mothers. • No promotion in healthcare facilities, including no free or lowcost formula. • No company personnel to contact mothers. • No gifts or personal samples to health workers. Health workers should never pass samples on to mothers. • No pictures of infants or words idealising artificial feeding, on the labels of products. • Information to health workers should be scientific and factual. • Information on artificial feeding should explain the benefits and superiority of breastfeeding and the dangers associated with artificial feeding. Annelies Allain Director The International Code Documentation Centre, IBFAN, Malaysia 1 The International Code of Marketing of Breastmilk Substitutes was adopted by the World Health Assembly on 21 May 1981, as a nonbinding public health recommendation. 2 Delayed breastfeeding initiation increases risk of neonatal mortality. Edmond KM et al. Pediatrics 117; 380–386; 2006. N U T R I T I O N 5 Issue 2 May 2 0 0 6 Seeing is believing Mobilizing community support for breastfeeding in Ghana Children under five in 1998 Underweight 25% Wasting 10% Stunting 26% UNICEF Global database on child malnutrition “The yellow milk is God’s way of welcoming your baby into the world” Counselling card message Breastfeeding practices can be improved over a relatively short period and on a large scale through partnerships, training, behaviour change communication (BCC), and support. The Ghana Health Service and the USAIDfunded LINKAGES Project,1 jointly implemented a national programme to improve the nutritional status of Ghanaian children by promoting early initiation of breastfeeding, exclusive breastfeeding for the first six months of life, and timely and adequate complementary feeding. Nearly all mothers start breastfeeding in Ghana. Commonly though, initiation of breastfeeding is delayed, water and other liquids are introduced early, while semisolid foods are introduced late. The three northern regions of Ghana, where 16 per cent of the population live, have the highest rates of malnutrition and are the most remote, sparsely populated regions in the country. More than twothirds of the women in these regions have never been to school. The majority are engaged in agricultural activities. The programme, begun in nine northern districts in 2000, used existing networks and communitybased approaches. Programme partners included UNICEF and their local government counterparts, radio announcers from three local stations, and 10 international and local nongovernmental organizations. The partners were involved in a variety of activities such as child survival, community development, mothers’ clubs, microcredit, water and sanitation, growth promotion, food distribution, and mobile clinics. Programme interventions included training and BCC through radio programmes, print media, interpersonal counselling, community events, and mothertomother support groups. By 2004, the programme reached all 24 districts in the northern regions plus seven districts in four other regions. Surveys to measure progress were conducted every year and the three indicators used were exclusive breastfeeding, timely initiation of breastfeeding, and timely complementary feeding. All rates were higher at the last survey in 2003 (see graph). Infant feeding practices in programme areas in Ghana Nearly all mothers breastfeed in Ghana, but infant feeding practices are sometimes inappropriate. A largescale behaviour change and communication project has been successful in changing practices. N U T R I T I O N 6 Issue 2 May 2 0 0 6 Messages, materials, and media From the beginning, the partners were actively engaged in the planning process, including initial research, a twoweek message and materials production workshop, pretesting of materials, and a sixday followup workshop to refine the messages and establish the strategic direction for the programme. The research provided insights into deeply ingrained beliefs. For example, giving water early was the norm and some mothers discarded colostrum because they were told it was ‘dirty.’ “In the beginning it was terrible promoting exclusive breastfeeding” reported a mother support leader from the Upper East Region. “Mothersinlaw and husbands would ask, ‘When you were born, were you not given water? How can you not give this child water? Do you want to kill him?’” Resistance to exclusive breastfeeding started to break down when people saw that babies of ‘early adopters’ of exclusive breastfeeding were healthier than those who received water: seeing was believing. The project developed a set of counselling cards with culturally appropriate messages for pregnant women and mothers, and another set for grandmothers and traditional birth attendants. Messages for fathers were placed on posters, Tshirts, and calendars. The following are examples of messages focused on specific behaviours for priority audiences: • Mothers, put your baby to the breast immediately after delivery to ensure a healthy beginning for both you and your child. This will help reduce bleeding and protect your child from infection. The yellow milk is God’s way of welcoming your baby into the world. • Fathers, a wise father encourages exclusive breastfeeding so his baby grows up to be strong, healthy, and intelligent. Give your wife the time she needs to breastfeed your baby. • Grandmothers, breast milk has everything your grandchild needs through six months of age to satisfy and quench hunger and thirst. Consistent messages were communicated through the media and interpersonal communication. The close working relationship with local radio broadcasters resulted in entertaining and technically accurate programmes that appealed to listeners. Some radio programmes broadcast songs and interviews with mothers that had been recorded during training exercises in the communities. Over four years, approximately 500 radio broadcasts were made. The programmes, broadcast in English and eight local languages, used a variety of formats such as radio callin shows, quiz programmes, dramatic comedies, panel discussions, and interviews with traditional chiefs and community leaders, both male and female. Mothertomother support groups Women’s groups, including microenterprise and credit groups, Red Cross mothers’ clubs, and breastfeeding support groups, served as another avenue for breastfeeding promotion and support (see example in box below). Red Cross mothers’ club in the village of Deega, Ghana Twice a month a group of 20 mothers gather to sing, discuss a health topic, and share their experiences. They are mainly farmers, most of whom are illiterate. Some are cowives and share the same husband. The youngest person in the circle is twomonthold Amsha; the club’s second ‘experimental’ child because she is only the second one to be exclusively breastfed. The leader of the group (Amsha’s grandmother) came back from a Red Cross training telling club members that children up to the age of six months need only breast milk and that the tradition of giving water to young infants leads to illness. Club members started hearing the same new message on the radio and at the antenatal clinic, child welfare clinic and hospital. At first many in Deega doubted that a child could survive without water. Amsha’s grandfather was one of the sceptics. When he saw that the first exclusively breastfed child was healthy, his resistance broke down, especially when he realized that the family could save money by not having to buy drugs to treat a sick child. Frequent, unhurried feeding Position well Fathers’ support Breastfeed exclusively Women’s group Counselling cards N U T R I T I O N 7 Issue 2 May 2 0 0 6 Joan W Schubert Academy for Educational Development Country coordinator, LINKAGES Ghana office 1999–2003 Luann H Martin Academy for Educational Development Information development specialist, LINKAGES For further information on the LINKAGES Project www.linkagesproject.org. Ghanaian woman breastfeeding Joan W Schubert Another mothers’ support group composed songs warning “Only foolish women do not exclusively breastfeed. They run from clinic to herbalist to treat their child’s diarrhoea.” Group members visited women after childbirth, offering their support and encouragement and inviting new mothers to their meeting. The project provided training to the partners in mothertomother support group methodology for breastfeeding and complementary feeding. The partners then conveyed their information and skills to women’s group leaders. The project also organized annual exchange visits for group leaders. The visits included message reviews, technical updates, planning for world breastfeeding week, and songs, dances, and dramas on breastfeeding. At one of the exchange visits, Gaston Bozie, who at the time was the Regional Health Educator and Chairman of the Upper East Red Cross, said “I used to like getting large groups of women together and talking to them about health. I was sceptical of mothertomother support groups, but now I see their value. It doesn’t mean that health talks and health education will end. But when you’re participating in mothertomother support groups, remember: no standing, no lectures, no knowing it all. These groups are for sharing information.” World breastfeeding week During the annual world breastfeeding week, the radio campaigns intensified. Community activities provided an opportunity for celebration, advocacy, community mobilization, and recognition of community health volunteers. Activities during the week included parades and community festivals featuring skits, original songs, drumming and dancing, poems by schoolchildren, testimonies by mothers, and speeches by dignitaries. These festivals frequently received television coverage. Lessons learned The experience of community mobilization in Ghana showed the importance of engaging a diverse set of partners and a variety of forums to keep the partners involved and motivated. Annual monitoring of programme progress also served to motivate partners. When the programme ended, the partners had print materials and skills in BCC and mothertomother support methodologies. Close working relationships had been forged with the radio journalists and stations who, due to popular demand, continued to broadcast extensively on infant and young child feeding issues. The materials and approaches developed through the programme are currently being adapted for promotion of infant and young child feeding in southern Ghana. All the activities played a role in helping create a positive environment for breastfeeding. Alongside the communitybased programme, LINKAGES supported advocacy activities, training for health staff, assessments of babyfriendly hospitals, and revision of the curricula of all medical and paramedical training institutions in the country to ensure that they adequately addressed breastfeeding. Experience shows that a comprehensive programme that engages partners and focuses on these aspects – communitybased promotion and support, health services, and policies – fosters longterm sustainability of results. 1 The LINKAGES Project is funded by USAID and managed by AED under the terms of grant HRNA0097 0000700. The opinions expressed are those of the authors and do not necessarily reflect the views of USAID or AED. Information on Similac product Brain Development Develops visual and mental ability, promotes learning • DHA and ARA • high omega 3, 6, 9 • taurine and choline • high iron Bone Development Improves bone strength and a healthy body • no palmitic oil • high calcium and potassium • high vitamin C and D Immunity Development Supports immunity • nucleotides 72 mgl • high zinc N U T R I T I O N 8 Issue 2 May 2 0 0 6 Challenging industry Opposing misleading advertisements in Thailand Children under five in 1995 Underweight 18% Wasting 5% Stunting 13% UNICEF Global database on child malnutrition All photographs by the author Many mothers in Thailand are abandoning natural breastfeeding in favour of cows’ milk formula products. This is the effect of advertisements claiming that products rich in docosahexaenioic acid (DHA) and arachidonic acid (AA or ARA) are important for a baby’s mental development. Thai powdered milk manufacturers started fortifying their products with DHA and AA four years ago and have been conducting an intensive advertising campaign. The box below illustrates some of the claims made about these products. There are worrying signs that the campaign has been successful. A poll1 carried out in February 2006 of 733 Bangkok mothers with infants under one year of age found that almost half had seen advertisements for DHA and AA powdered milk products. Of these, 65 per cent said they were convinced of the health benefits to their infants. The claims wildly exaggerate the value of DHA and AA. “Actually, the most important factors in brain development are genes and breast milk” notes Dr Werapong Chatranont, a paediatrician.2 DHA and AA can help brain development, but both nutrients are found naturally only in human breast milk. Manufacturers therefore add linoleic acid and linolenic fatty acids to the milk, which the infant’s body can turn into DHA and AA. It is not known what harm this may do in the long run. Implementing the Code in Thailand The Ministry of Public Health (MoPH) adopted the first Code of Marketing of Breastmilk Substitutes in 1984. It was revised in 1995 and renamed the Thailand Code of Marketing of Foods for Infants and Young Children and Related Products. The new Code and a Memorandum of Understanding (MOU) for its implementation was signed by the MoPH and a number of companies. A 1992 agreement stated that “the Royal Thai Government and Trade Association of Breast milk Substitutes and Related Products have agreed to cease all free and lowcost supplies of infant formula to ALL hospitals in Thailand from February 1992.” Code compliance is voluntary, however, though Thailand does have a national law concerning food advertising. The Food and Drug Administration (FDA) is responsible for monitoring food labels 2006 Thai mothers are being told that their babies’ mental development can be promoted through the use of formula milks. Campaigners are working to oppose advertising of baby milk formula and promote a renewed culture of breastfeeding in Thailand. N U T R I T I O N 9 Issue 2 May 2 0 0 6 Yupayong Hangchaovanich Vice Chairperson of Thai Breastfeeding Center For further information yupayong_hyahoo.com Example of an advertisement for medical practitioners and advertisements while the MoPH is responsible for monitoring information distributed within the health care system. Weakening the Code In 1997, the MoPH signed an MOU with four baby food companies, which limited the applicability of the voluntary Code to products for babies less than a year old. The MOU lapsed after a year but following representations by more baby food companies, another MOU was prepared in 2001 that reversed the position taken by the 1995 Code. This contravened the World Health Assembly Resolutions 39.28 (1986), 45.34 (1992) and 47.5 (1994) by allowing free supplies of milk formula to children over one year of age. Breaking the Code Four surveys carried out on Code compliance show that code breaking is common. 1 In 1992, a survey by the Consumer Protection Association of Thailand found extensive evidence of free and lowcost baby formula supplies to hospitals. 2 In 1995, IBFAN surveyed four regions of the country and found violations within health facilities and outside the healthcare system. 3 In 1997, the Interagency Group on Breastfeeding Monitoring carried out a fourcountry study and Thailand was found to have the largest number of health facilities receiving free samples. 4 In 2003, the MoPH and Thai Breastfeeding Alliance surveyed 84 hospitals and clinics. A significant portion of the hospitals (84 per cent) were part of the Baby Friendly Hospital Initiative (BFHI). Around 80 per cent of the hospitals and clinics received free supplies from baby milk companies, most commonly unsolicited. Almost all of the advertising material was not approved by the FDA. Of 700 mothers with babies under six months, half only breastfed. A third of the mothers who used formula reported that they used a specific brand of formula based on a health worker’s recommendation. Mothers reported that they had received free samples, gifts and company materials from health workers in the hospitals and clinics. Opposing advertising In 2004, the FDA took steps to improve compliance with new regulations, as follows. • Advertising food for infants and young children is prohibited, including infant and followup formula and complementary foods with the exception of advertisements in medical journals. • Advertisements should not claim that the product is better, equivalent or similar to mother’s milk. They should not encourage feeding babies or children with manufactured food products. • Pictures portraying babies or small children in advertisements is prohibited. • Advertisements should include statements to the effect that a mother’s milk is the best food for her baby. As a result of training given to health care workers on the Code, baby milk donations and advertisements to BFHs have now ceased. However, one barrier to change is that many milk company representatives are friends with the doctors and nurses. A plan of action on the Code was developed in 2005 by the MoPH. This includes: 1 Training of Code watchers to report incidents of violation. 2 Approval by the FDA of all baby milk company materials before distribution. 3 Meeting between the MoPH and companies to announce the policy and the measures that will be taken when violations occur. 4 Strengthening BFHI through appointing a reassessment team at the regional level. Thailand has the opportunity to emulate countries that have banned powdered milk advertisements for infants and children. This will protect the fragile physiology and underdeveloped immune systems of young babies from becoming prey to products bolstered by suspect claims. This would lead to a new era of breastfeeding culture in Thailand. Free sample gift bag given to new mothers, containing a tin of formula and brochures. Mothers reported that they had received free samples and gifts from health workers in hospitals and clinics. 1 ABAC poll. 8–16 February 2006. 2 Report of a meeting convened by the Thai Breastfeeding Center in cooperation with the Thai Health Promotion Fund Organization. Bangkok, 21 February 2006. N U T R I T I O N 10 Issue 2 May 2 0 0 6 Time for breastfeeding Supporting mothers to stay home and breastfeed in Ethiopia Ethiopia is one of the poorest countries in the world. The majority (80 per cent) of the population lives on less than US2 a day while recurring drought, famine and epidemics have caused countless deaths over the years. Malnutrition is also high and around half of all underfives are stunted. Save the Children United Kingdom (SC UK) is working in Gubalafto woreda, North Wollo Zone in Amhara Region on a project that aims to reduce dependency on external assistance and improve the resiliency of chronically foodinsecure households. This article describes research undertaken by SC UK in Gubalafto. The research aimed to assess the causes of chronic malnutrition in children aged 0–24 months. A total of 1,471 children were selected for weighing and measuring and their carers were asked to complete detailed questionnaires. Extensive focus group discussions were conducted (carers were divided by wealth group and educational status). Breastfeeding pattern was found to be the most important determinant of malnutrition in babies under six months. Babies who were not exclusively breastfed were five times more likely to be malnourished than those who were. The rate of breastfeeding is high in Gubalafto (almost 90 per cent of women interviewed were breastfeeding their children at age six months) but exclusive breastfeeding begins to decline after two months. It is also common practice for women to give rancid butter and sugar to their children in the first few days of life. Hence only 60–70 per cent are exclusively breastfeeding by the time their baby is five months old (see graph). The rate of exclusive breastfeeding by child’s age Mothers’ time Exclusive breastfeeding depends not only on a mother knowing that exclusive breastfeeding is best, but also on her ability to spend enough time with her child to provide sufficient breast milk. The survey found that among women with children under six months, those who spent more than two hours a day away from their babies were significantly less likely to exclusively breastfeed than those who spent less time away from home. Focus group discussions revealed that, postpartum (after delivering a child), women from poorer groups have to leave their home to undertake various activities earlier than betteroff Children under five in 2000 Underweight 47% Wasting 11% Stunting 52% UNICEF Global database on child malnutrition Babies who were not exclusively breastfed were five times more likely to be malnourished than those who were. Exclusive breastfeeding protects babies from malnutrition. Yet in Ethiopia, it is the poorest mothers who face the most constraints in being able to exclusively breastfeed. Can supporting them to stay at home longer improve exclusive breastfeeding rates? N U T R I T I O N 11 Issue 2 May 2 0 0 6 women and for longer periods in order to obtain food and income to look after their families (see table). This means that poorer women are less likely to be able to exclusively breastfeed. In many cultures, women stay at home for 40 days after delivery and other family members support them. In Gubalafto, poor mothers have to go to fetch water prior to the 40 days. Betteroff women do not undertake farm work with an infant of less than six months, but women from poorer households start to work on the farm after about three months. Thus poor women have to leave their children at a young age. When a mother has to leave her child in the house, someone else has to look after him. Normally this will be the grandmother or a teenage child. But the best person to look after an infant who needs to be breastfed is his mother. If the mother is away for a long time she cannot breastfeed, unless she has expressed milk before leaving (a practice that is unheard of in Gubalafto). To improve exclusive breastfeeding rates and decrease inappropriate feeding practices, ways need to be found to keep poor women at home for longer postpartum. Supporting mothers to stay at home Wealth, or rather poverty, is an overriding factor in the development of malnutrition that has to be addressed in order to improve the situation of young children. Every effort must be made to improve the food and cash income of poorer groups in the community, either through income generating activities or social support mechanisms. Women from all wealth groups should be enabled to spend at least the first six months of their child’s life at home with their child in order to be able to exclusively breastfeed. Different methods to encourage women to stay at home during this critical period need to be considered. One idea is to provide women with the cash or food equivalent of their earnings outside the house, so that they do not have to leave the house for long periods of time (more than two hours per day). Alternatively, women could be encouraged to take part in income generating activity that they can undertake at home so that they do not have to leave their children. Through the current project, SC UK is working to: 1 Promote wealth in poor households in the project area through food and income activities, such as goat loans. 2 Lobby the government to allow lactating women who are eligible for employment generation schemes (Food for Work) to be paid to attend health and nutrition education lessons instead of being forced to do physical labour. This represents a major breakthrough with the Government of Ethiopia. So far, there has been no documented impact of the programme, but it is continuing and a final evaluation is planned. Ethiopian mothers and children Save the Children UK Boris Heger 2005 Tayech Yimer Nutritionist Save the Children UK Ethiopia Office For further information tayech.yscuk.org.et Numbers of days postpartum after which women leave their homes to undertake certain activities Betteroff Medium poor Fetch water Go to market Do farm work 40 days 140 days 180 days 30 days 90 days 120 days Poorer women are less likely to be able to exclusively breastfeed N U T R I T I O N 12 Issue 2 May 2 0 0 6 In many societies, breastfeeding is regarded as a woman’s business. As the example in the box illustrates, even educated men may have very oldfashioned views about breastfeeding. Recognition that a supportive family is an essential part of good breastfeeding practice has led some organizations to focus on behaviour change that targets men and other family members with influence as well as women. Drawing men into the breastfeeding debate is a challenge in communities as far apart as Bolivia, Ghana and Sweden. In each of these countries different methods have been used to encourage men to support breastfeeding proactively. Involving men in breastfeeding In Ghana, a LINKAGESled campaign appealed to men’s sense of responsibility and pride, with the theme of ‘Breastfeeding: A wise family choice’ which included posters aimed specifically at fathers. In Bolivia, LINKAGES found that the majority of health promoters were male and that over half of all births were attended by family members including fathers. Behaviour change work concentrated on improving the men’s understanding of the importance of immediately starting breastfeeding, relieving women of domestic duties so they have time to breastfeed and becoming involved in complementary feeding of older infants. Messages were passed through the male health promoters during family visits on Sundays when fathers were present and through radio and TV promotion. All images and messages stressed the importance of A family affair Strengthening fathers’ support for breastfeeding worldwide Counselling cards from Bolivia LINKAGES Bolivia Nigerian men’s views on breastfeeding A selected sample of 25 Nigerian men who have attended higher institution in Lagos were asked for their views on breastfeeding. The men were 25 to 45 years old and 13 were married, while 12 were single. All knew that breastfeeding is good for a child’s health but seven did not agree that men have a role to play in breastfeeding. Only five mentioned that men should provide nutritious food and support to their wives. Only one mentioned that men should provide a stressfree environment to a breastfeeding woman. Okechukwu Aniche, who conducted the survey especially for this article, comments: ”My general assessment is that only one fifth of the men sampled really know what breastfeeding is all about. Some even declined from partaking in my questionnaire (as they think that breastfeeding is exclusively a mother’s affair) and wondered why a man like me would be involved in such a survey. It is a true reflection of our society. I am residing in Lagos where educated men are found. But the majority still believe that men have no role to play in breastfeeding. This lack of interest is linked to African beliefs and also to our policy formulators and implementers. Most employers still find it difficult to grant the required maternity leave and some even disallow newly employed females from getting pregnant within the probation period.” A man helping his wife to put the baby on the breast immediately after birth. Support for child care during breastfeeding All family members need to be involved in the care of the newborn infant. In particular, fathers need to actively support good breastfeeding practice. Some organizations therefore target men and other influential family members, as well as women. N U T R I T I O N 13 Issue 2 May 2 0 0 6 the role of fathers in supporting the women in good breastfeeding practice. In Sweden the project Pappagrupperna (‘Dads for Real’) targets firsttime fathers, offering six counselling sessions (one before the birth of the child and five after the birth) to: • focus on the child’s interest • increase gender equality within the home • strengthen relationships in the family • support fathers to be active parents. There are a number of key issues for family support initiatives around the world, namely: • increasing awareness of the demands of breastfeeding, focusing on physiological, emotional and time management issues • enhancing understanding of good breastfeeding practice, including the importance of exclusive breastfeeding • lobbying for a supportive legislative environment. Men need to be aware that mothers need blocks of time to sit and breastfeed. Women often feed ‘on the run’ if they work outside the home, or have many domestic tasks such as collecting water, child care and food preparation. This affects the quality of the feed. Reorganisation of family activities and sharing of responsibilities for domestic chores are needed to provide time for breastfeeding. Creating a supportive environment for the mother has a physiological effect on the quality of breastfeeding. The hormone oxytocin is produced during the feed and ensures milk flow. Oxytocin is often referred to as a “love hormone” as it is associated with good feelings, thinking lovingly, and being confident. A poor oxytocin reflex reduces milk flow and results from being worried or afraid, pain or if the mother feels embarrassed. Fathers can help to provide a stressfree environment for breastfeeding. Finally, there is increasing recognition that good breastfeeding practice requires a national legislative framework that is supportive of family rights. The fight for maternity and paternity leave, breastfeeding time allowance or provision of workplace crèche facilities are issues raised in various countries where women in the formal sector are denied the right to breastfeed their infants due to employment policy. The Swedish fathers support project, Pappagrupperna, lobbies for increased takeup of paternity leave and equal sharing of child care and support. Currently Swedish men take 19 per cent of the parental leave allocation (almost double the amount taken in 1995) and the group would like to see this increase. Conclusions In order to ensure that all babies are given a healthy start to life, the message is to involve all adult carers. Whether your interest is in promotion of good breastfeeding practice at the household level, greater equality for women in the workplace, or improved fathering skills, communication and information is the key to success. Useful contacts • Global Initiative for Father Support (GIFS) Ray Maseko rmasekorealnet.co.sz Arun Kumar Thakur arun_thakurrediffmail.com or go to: www.waba.org.myfathersindex.html • LINKAGES www.linkagesproject.org • Pappagrupperna www.pappagrupperna.se Kerry Selvester Senior nutritionist, ANSA Mozambique Okechukwu Aniche Department of Chemical Engineering, University of Lagos, Nigeria For further information ansatvcabo.co.mz Take time to optimize the nutritional value of each feed Foremilk • Secreted at the beginning of a feed • Contains more proteins, vitamins and minerals Hind milk • Secreted at the end of a feed • Contains more fat and helps baby gain weight Support for good nutrition during breastfeeding Counselling card from Ethiopia LINKAGES Ethiopia Fathers can help to provide a stressfree environment for breastfeeding N U T R I T I O N 14 Issue 2 May 2 0 0 6 Surviving emergencies Support for breastfeeding in Kenya, the Democratic Republic of Congo and Indonesia Emergencies (droughts, floods, wars, famines) cause terrible hardship and can have lasting impacts on breastfeeding. For example, WFP and UNICEF carried out a rapid assessment of the food and nutrition situation following the earthquake that struck the northern part of Pakistan in October 2005 killing over 80,000 people. The assessment found a decrease in overall breastfeeding rates of 20 per cent among children under 24 months.1 One of five priority actions in the WHO Global Strategy for Infant and Young Child Feeding (IYCF), is support in exceptionally difficult circumstances, including emergencies. CARE, an international NGO, is therefore building institutional capacity to address IYCF and care in emergency situations (IYCFE) by including special training in breastfeeding counselling as part of a more comprehensive programme. The risks to breastfeeding in emergencies There are many risks to breastfeeding during emergencies. The uncontrolled distribution of breast milk substitutes may unintentionally create dependence. During a field visit to the tsunamiaffected areas of Aceh nine months after the event, CARE staff observed that infant formula had been given to new mothers by midwives as a ‘precaution’ in the event that the mother experienced breastfeeding problems.2 There are a number of myths, misconceptions and halftruths that suggest that breastfeeding is particularly vulnerable in difficult circumstances. • Stress can affect a woman’s ability to breastfeed or the quality of her breast milk. • Tired and malnourished mothers cannot produce enough milk. • If a mother breastfeeds while ill, she will transfer the sickness to her infant. • Once breastfeeding has stopped, it cannot be reestablished. • A mother who must leave her infant with other caregivers for extended periods (to farm, obtain food or gather wild foods, water or firewood in insecure environments) cannot continue to breastfeed her baby. Just as damaging is the belief that since “all women breastfeed” no special assistance is required, and that infants under six months of age are protected from malnutrition. These beliefs have resulted in the distribution of infant formula and inappropriate milk products during some emergencies. There have also been failures to: • include young infants in anthropometric surveys and IYCF practices in emergency assessments • implement special interventions designed to protect, promote and support breastfeeding • integrate breastfeeding protection and support into therapeutic care of malnourished infants • address the special needs of mothers who have been raped or who suffer from depression, stress, poor diet or malnutrition, all factors that may impact either their perception of their ability to breastfeed or their willingness to do so. Children under five Underweight Kenya 20% DRC 31% Indonesia 26% Wasting Kenya 6% DRC 13% Stunting Kenya 31% DRC 38% Years of data: Kenya 2003, DRC 2003, Ind 2002 No data on wasting and stunting for Indonesia UNICEF Global database on child malnutrition “Now I have wonderful new knowledge. I am going to teach my daughters. As refugees, we are poor people – the only thing we will carry back to Somalia with us is our new knowledge.” Somali elder refugee and women’s leader 1 Kenya 2 Democratic Republic of Congo 3 Indonesia Breastfeeding is at particular risk of disruption in emergencies. Training on breastfeeding counselling has been carried out in three different emergency contexts. The focus is on clinical practice sessions where participants have a chance to work directly with mothers. 1 2 15 Issue 2 May 2 0 0 6 The CARE Infant and Young Child Feeding Initiative CARE has a broad, threepart strategy: • capacitybuilding of staff and partners • contributing to global learning • actively supporting interagency efforts to develop common guidance. This article describes innovative CARE IYCFE activities in three emergency settings. In the Dadaab camps for Somali refugees in northeastern Kenya, CARE, GTZ and UNHCR are implementing a comprehensive programme through both the community development and health care delivery systems. Initial inservice training is reinforced by ante and postnatal counselling schemes and communications strategies to encourage behaviour change. In three districts of foodinsecure and floodprone West Timor, Indonesia and on tsunamiaffected Simeulue Island off the northwest coast of Sumatra, CARE and the Ministry of Health are working to protect and support breastfeeding during the rehabilitation of malnourished infants. This includes guidance on ‘supplementary suckling’, a method of giving milk supplements to an infant who is unwilling to suckle at a breast that is not producing milk. The infant draws a milk supplement through a tube while suckling at the breast, which stimulates the mother’s own breast milk production. In Maniema Province of the Democratic Republic of Congo (DRC), a postconflict setting, CARE is integrating breastfeeding support into reproductive health activities. The focus is on LAM (the Lactational Amenorrhoea Method), which supports improved breastfeeding as a family planning method. Building breastfeeding counselling and communication skills CARE is building the counselling capacity of staff and partners who work directly with mothers (using an adapted version of the WHOUNICEF breastfeeding counselling course and modules 1 and 2 of Infant feeding in emergencies – see Resources page). The distinguishing feature is the emphasis on developing counselling skills during four clinical practice sessions in which participants have practical, handson experience with mothers and babies. They learn by observing and talking with mothers experiencing different challenges: for example, a mother with a low birth weight infant, twins, or a breast problem. By the end of the twoweek Training of Trainers, there is team of up to eight qualified trainers, and up to 24 participants are trained as breastfeeding counsellors. Both male and female participants have been enthusiastic. As a Kenyan Somali male nurse noted“It is important that we involve men to help fathers understand the importance of breastfeeding. They are the individuals who have been negative in the past… We must communicate what we have learned to other men.” After the training, additional activities are undertaken to support behaviour change among mothers and families, the community, service providers and programme managers. A joint UNHCRWFP evaluation recently concluded that the training in Dadaab was “at a very manageable and reasonable cost … Even health workers with years of experience found the training extremely informative … They now have practical tools to support good breastfeeding practices.” 3 Joan Jennings Child Health Team Leader, CARE Anne Njuguna IYCF Coordinator, Dadaab Camps, CARE Kenya For further information care_iycfecare.org 1 Field Exchange, Issue 27, April 2006. 2 Report of observations by Endang Widiastuti, CARE International Indonesia and Mary S Lung’aho, CARE Initiative for IYCFE Aceh, September 2005. 3 Addressing high malnutrition rates in protracted situations: The nutrition and food security situation in selected refugee camps in Kenya. A Joint UNHCR and WFP Mission 17 November to 2 December 2005 Clinical practice session in a Dadaab camp Mary S Lung’aho 2005 “We no longer wait three days before putting a newborn baby to the breast.” TBA in Dagahaley Camp, Dadaab 3 N U T R I T I O N 16 Issue 2 May 2 0 0 6 Pressure of work Exclusive breastfeeding in Vietnam It is difficult to create a balance; encouraging breastfeeding and promoting high incomeearning potential for women. Baby milk formula on sale in Hanoi NutritionWorks 2004 Most Vietnamese children under one year old are breastfed, but a recent survey found that only 12 per cent of infants under six months are exclusively breastfed and 39 per cent of mothers give food as well as breast milk in the first week of an infant’s life.1 Nearly a quarter of babies are bottlefed. Pressure of work A number of factors have been identified that explain the current pattern of breastfeeding. Firstly, the survey found that mothers who have to go back to work before the infant is six months of age are 14 times more likely not to exclusively breastfeed than mothers who stay at home for longer. By Government law, maternity leave lasts until the infant is four months of age. The majority of women, however, who are selfemployed (those involved in farming, handicrafts, small business etc) are forced to go back to work soon after giving birth to sustain their livelihoods. Women employees of private companies may lose their job if they stay at home too long after giving birth. They will not receive bonuses whilst on maternity leave and they feel the pressure to return to work early in order to get promotion and a higher salary. Policy makers have found it difficult to create a balance between the two benefits; encouraging breastfeeding and promoting high incomeearning potential for women. Confidence to breastfeed Maternal confidence in having enough breast milk is another important factor. A study has shown that mothers are not confident in their capacity to breastfeed and do not understand the importance of breastfeeding.2 Furthermore, decisions regarding breastfeeding within the family depend a lot on the opinion of family members and the community. The baby food industry which promotes its products on television and which shows healthy looking babies on milk substitute product labels, exerts a negative influence on attitudes towards breastfeeding. Moving forward The Baby Friendly Hospital Initiative (BFHI) was started in Vietnam in 1993 and, so far, 53 out of 80 hospitals have been awarded BFH status. A new Government Decree in February 2006 on the marketing and use of formula and nutrition products for infants and young children illustrates the Government’s commitment to the protection and promotion of breastfeeding. The Ministry of Health and other agencies have a duty to promote BFH nationwide and to advocate for babyfriendly work places for lactating mothers, such as breastfeeding rooms at the office or factory and breastfeeding time (at least one hour per day). Although mothers in Vietnam face many challenges, we must seize the opportunity to promote breastfeeding. Children have the right to be optimally fed and cared for in order to reach their individual potential for growth and development in later life. 1 The situation of maternal and child nutrition 1994–2004. NIN and GSO. 2005. 2 Report on assessment of breastfeeding policy. Promotion and practice in Vietnam. Gupta et al. NINUNICEF. Hanoi. 2004. Children under five in 2003 Underweight 28% Wasting 7% Stunting 32% UNICEF Global database on child malnutrition Trinh Hong Son National Institute of Nutrition, Hanoi, Vietnam For further information viendinhduonghn.vnn.vn Only one in 12 babies under six months are exclusively breastfed in Vietnam. Mothers face work pressures and lack the confidence to breastfeed. 17 N U T R I T I O N Issue 2 May 2006 What would you do? Your chance to share and tackle reallife cases This baby (shown with his grandmother) is five months old and lives in a remote village in Nong district of Savannakhet Province in southern Laos. Conditions are poor in the village. Water is fetched from a well, there are no latrines or electricity and houses are made of bamboo. He is a member of the Lao Theung ethnic group, who make up about 20 per cent of the population of Laos. The women in the village are largely responsible for subsistence farming; growing rice in slashandburn plots deep in the forests near to the border with Vietnam. When the rice runs out, the women collect forest products: vegetables, fruits, roots and insects to eat, bamboo, dyes and barks to make medicine to sell. Women work extremely hard and are away from the home for up to ten hours a day in the heavy work seasons. Cultural practices among the Lao Theung are strong. Men and women have particular roles prescribed by tradition. Women give birth alone in the forest. Although breastfeeding is initiated immediately, women are expected to go back to work in the fields within one to two weeks (as early as three days in some cases). They believe that the babies should not be carried to the rice plots by mothers as it is too hot and the risk of malaria is too great. Rather, babies remain in the villages, cared for by their fathers, grandparents or older siblings. Babies as young as one week of age are fed premasticated sticky rice with water when their mothers are away, and breastfed when their mothers are home. There is a widespread belief that breast milk is not enough for babies: “How can a baby survive on breast milk alone?” The father of this baby is the Village Health Volunteer. He knows all about the importance of breastfeeding and passes on his knowledge in group and individual education sessions in the village. His baby is strikingly larger than the other babies in the village. When asked how he managed to have such a healthy looking baby, he said that as culture dictates that his wife must work in the fields all day, it was not possible to breastfeed the boy. Instead, knowing the importance of milk, he had bought condensed milk from the local market and had fed it to the baby from birth using a cup with a teat attached. What can be done in a community with such strong beliefs to promote exclusive breastfeeding? Condensed milk being sold in local shop NutritionWorks 2006 The condensed milk baby In each issue of nutrition a problem case will be presented. We invite readers to write in with their suggestions of how to deal with the case. The best answers will be published. These are all reallife cases. If you have your own examples of problem cases that you would like to share, please do send them to the editors. 18 Issue 2 May 2 0 0 6 N U T R I T I O N Exclusive breastfeeding Exclusive breastfeeding for six months is optimal for the health of mother and baby. The old saying “breast is best” has been with us for many years, but the new millennium has seen greater emphasis on exclusive breastfeeding (EBF), where babies receive no other foods or fluids except breast milk (including expressed breast milk or from a wet nurse), vitamins or medicines. In 2002, WHO and UNICEF extended the recommended duration of EBF from four to six months, to six months (see box 1). The main reason for the change was evidence that most babies under six months don’t need more nutrients than can be provided by EBF, and that giving additional solids doesn’t improve growth but does increase the risk of infections. These recommendations have not been universally wellreceived. Some commentators argue that the greater risk of infections is only relevant to developing countries. But a sick baby puts a great strain on a family whether they live in Nairobi or New York. A recent study in the USA compared infants who received EBF for four months with those receiving EBF for six months. It found that the extra couple of months of EBF halved the risk of ear infections, and quartered the risk of pneumonia.1 It is not that mothers ‘should’ breastfeed exclusively for six months, rather, that for the optimal health of mother and baby, there is no need to do anything else. When revising the recommendation, WHO did caution that there was insufficient evidence to rule out some concerns about EBF in mothers with low iron status (medicinal iron drops might be required) and among severely malnourished mothers. But in practice, this doesn’t mean malnourished mothers should start feeding other foods before six months. Studies have found that when breastfed babies are given solids before six months, they take less breast milk, so that unless the foods given are more nutrientdense than breast milk, there is little net nutritional gain.2 Severely malnourished mothers are unlikely to have the resources to feed their babies more nutrientdense solids. WHO concluded that “in all circumstances, these risks must be weighed against the benefits provided by exclusive breastfeeding, especially the potential reduction in morbidity and mortality”. In 2005, the influential American Academy of Pediatrics (AAP) updated its policy statement on breastfeeding.3 The AAP stated that EBF is the ideal model against which all alternative feeding methods should be compared. The evidence in terms of the health costs of not being breastfed is summarised below. The health costs of not being breastfed There is evidence that not breastfeeding increases the frequency and severity of infections in babies, and increases their risk of some chronic conditions later in life. There are also health risks for mothers who do not breastfeed. For the baby: There is strong evidence that not breastfeeding increases the frequency and severity of a wide range of infections in babies including: • diarrhoea • respiratory tract infections • bacterial meningitis, bacteremia • otitis media • urinary tract infection • late onset sepsis in preterm infants. Evidence also suggests that nonbreastfed babies are at increased risk of developing the following conditions, as a child or adult. • autoimmune diseases such as type I and type 2 diabetes • lymphoma, leukemia, Hodgkin’s disease and inflammatory bowel disease • overweight, obesity, hypercholesterolemia • asthma They may also have slightly lower performance in cognitive development tests. 1 WHO Global strategy for infant and young child feeding “As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.” Highlights of past and current research projects into breastfeeding Research 19 N U T R I T I O N Issue 2 May 2006 For the mother: There is strong evidence that mothers who do not breastfeed have: • increased postpartum bleeding and slower recovery from childbirth • earlier return of fertility • increased risk of breast and ovarian cancer. Evidence also suggests that non breastfeeding mothers may have: • slower postpartum weight loss • increased risk of hip fracture and osteoporosis in postmenopausal period. A recent study suggests that women who have breastfed have a lower risk of developing type 2 diabetes.4 Breastfeeding and HIV transmission The risk of HIV transmission from mother to baby during the first six months of breastfeeding is only around five per cent. HIV can be transmitted by breastfeeding, but most babies who are breastfed by HIVinfected mothers do not become infected. The average risk of infection from mother to child during breastfeeding is 10–20 per cent. This assumes that breastfeeding is prolonged for 18 months to two years. The shorter the duration of breastfeeding, the lower the risk. The risk of transmission during the first six months of breastfeeding, is around five per cent (1 in 20 risk).5 The risk of transmission when breastfeeding is exclusive is likely to be even lower. In areas where infant mortality due to infectious diseases is generally high, there is a tradeoff between preventing transmission of HIV by not breastfeeding but exposing the baby to risk of death from other infections (see Issue 1 of nutrition). Breastfeeding and the new growth curves WHO has released new growth curves based on the growth of breastfed rather than formulafed babies. Two significant events have occurred since the recommendation to increase EBF to six months. Firstly, FAO has published revised estimates of human energy (kilocalorie) requirements.6 For infants over six months, the requirements are around 15 per cent lower than FAO’s 1985 figures which are widely used in text books. Secondly, WHO’s new Breastfed Growth Curves were released in April 2006 (see www.who.intchildgrowth). These growth curves confirm that breastfed babies have a different growth pattern from formulafed babies. They grow faster in the early months, then slow down, so that by 12 months of age, breastfed babies are leaner, weighing about half a kilogram less than formulafed babies. This has huge implications for the global obesity epidemic and the growing awareness that ov