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Considerations in developing lipid-based nutrient supplements for prevention of undernutrition: experience from the International Lipid-Based nutrient supplements (iLiNS) Project.
Maternal and Child Nutrition. 2015 Dec; 11(Suppl 4):31-61.The International Lipid-Based Nutrient Supplements (iLiNS) Project began in 2009 with the goal of contributing to the evidence base regarding the potential of lipid-based nutrient supplements (LNS) to prevent undernutrition in vulnerable populations. The first project objective was the development of acceptable LNS products for infants 6-24 months and for pregnant and lactating women, for use in studies in three countries (Burkina Faso, Ghana and Malawi). This paper shares the rationale for a series of decisions in supplement formulation and design, including those related to ration size, ingredients, nutrient content, safety and quality, and packaging. Most iLiNS supplements have a daily ration size of 20 g and are intended for home fortification of local diets. For infants, this ration size is designed to avoid displacement of breast milk and to allow for dietary diversity including any locally available and accessible nutrient-dense foods. Selection of ingredients depends on acceptability of flavour, micronutrient, anti-nutrient and essential fatty acid contents. The nutrient content of LNS designed to prevent undernutrition reflects the likelihood that in many resource-poor settings, diets of the most nutritionally vulnerable individuals (infants, young children, and pregnant and lactating women) are likely to be deficient in multiple micronutrients and, possibly, in essential fatty acids. During ingredient procurement and LNS production, safety and quality control procedures are required to prevent contamination with toxins or pathogens and to ensure that the product remains stable and palatable over time. Packaging design decisions must include consideration of product protection, stability, convenience and portion control.
Indian National Code for Protection and Promotion of Breast-feeding. [Resolution No. 18-11/81-NT dated 19 Dec 1983].
Indian Pediatrics. 1984 Mar; 21(3):259-64.The objective of the Indian National Code for Protection and Promotion of Breastfeeding is to contribute to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and by ensuring the proper use of breast milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution. The Code applies to the marketing and practices related thereto, of the following products: breast milk substitutes, including infant formula; other milk products, foods, and beverages, including bottle fed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breast milk; and feeding bottles and teats. It also applies to their quality and availability and to information about their use. Article 4 of the Code maintains that the government shall ensure that objective and consistent information is provided on infant and young child feeding for use by families and those involved in the field of infant and young child nutrition. This responsibility shall cover the planning, provision, design, and dissemination of information and their control. Informational and educational materials, whether, audio, or visual, should include clear information on the following: the benefits and superiority of breastfeeding; maternal nutrition and preparation for the maintenance of breastfeeding; the negative effect on breastfeeding of introducing partial bottle feeding; the difficulty of reversing the decision not to breastfeed; and where needed, the proper use of infant formula. According to the Code, there shall be no advertising or other form of promotion to the general public of products within the scope of the Code. Manufacturers and distributors should not provide, directly or indirectly, to anybody, samples of products within the scope of this Code. Other provisions of the Code include: health authorities should take appropriate measures to encourage and protect breastfeeding and promote the principles of the Code; health workers should encourage and protect breastfeeding; in systems of sales incentives for marketing personnel, the volume of sales of products within the scope of this Code should not be included in the calculation of bonuses, nor should quotas be set specifically for sales of these products; labels should be designed to provide the necessary information about the appropriate use of the product so as not to discourage breastfeeding; the quality of products is an essential element for the protection of the health of infants and should be of a high recognized standard; and the government shall give effect to the principles and objective of the Code through legislation and other appropriate measures.
[Recommendations for marketing of infant foods] Recommandations pour la commercialisation des aliments de l'enfance.
Archives Francaises de Pediatrie. 1980 Jun; 6(37):415-6.Frequency of breast feeding has decreased in most European countries; this decrease is due partly to the lack of knowledge of the importance of breast feeding on the part of young mothers and also of nursing personnel, but it is especially due to the excessive promotion of infant formula on the part of the industry. This promotion is carried out even in maternity hospitals through distribution of pamphlets and brochures to mothers, and through radio and television commercials, and through the liberal distribution of free samples. Several international organizations have already acted to limit the publicity in favor of maternal milk substitutes. A document, elaborated by the French Pediatric Association, and approved in 1979 by the European Society of Pediatric Gastroenterology, makes several recommendations to encourage breast feeding and limit bottle feeding. The major recommendations are: 1) publicity in favor of maternal milk substitutes must never be addressed directly to the public, but it must be filtered through information given by the medical and paramedical profession; 2) all labeling of maternal milk substitutes must clearly state that maternal milk is the ideal infant food until at least 3 months of life; 3) breast feeding must occupy the 1st place in all brochures on infant feeding directed to the public; 4) distribution of free samples to families and hospitals must stop; and 4) no reduced prices are admissable even for the sale of products to clinics, hospitals, and maternity hospitals.
[Infant food labels: some aspects of marketing practices in Brazil] Rotulos de alimentos infantis: alguns aspectos das praticas de marketing no Brasil.
REVISTA DE NUTRICAO DA PUCCAMP. 1997 Jul-Dec; 10(2):127-35.A monitoring study of the Brazilian Code of Marketing of Breast Milk Substitutes was carried out during 1995-96 with the objective of verifying the compliance of companies with the Code with regard to labeling and packaging their products. In 32 cities of 13 states a total of 125 products were analyzed (feeding bottles, teats, pacifiers, infant food, formula, and liquid milk). The following rules were found to have been violated: 1) prohibition of pictures of babies idealizing bottle feeding and questioning the ability of the mother to breast-feed; 2) the requirement of stating the superiority of mother's milk over formula and the use of formula only if directed by the physician or nutritionist; 3) the requirement not to use skim milk, semi-skim milk, or whole milk as the sole source of nutrition for the infant; 4) the requirement that the labeling should state the continuation of breast-feeding after the introduction of formula; 5) the requirement that for feeding bottles, teats, and pacifiers the labeling should not contain expressions that suggest connection to the maternal breast and that the breast-fed infant had no need for feeding bottles and teats. In comparison to previous evaluations using the same methodology, a certain degree of compliance was ascertained. However, several products lacked adequate labels, particularly feeding bottles and pacifiers. The rules dealing with warning require a review on account of poor visibility. Furthermore, routine monitoring procedures are needed to assist the authorities in promoting breast-feeding over commercial breast-feeding substitutes.
Lancet. 1992 Oct 17; 340(8825):962-3.[The Indian] parliament has passed the Infant Milk Substitutes, Feeding Bottles and Infant Foods (Regulation of Production, Supply and Distribution) Bill, which, when it comes into force, will severely restrict the advertising and promotion of these baby products. Essentially the bill incorporates the contents of the International Baby Food code adopted by the World Health Assembly in 1981, but expands its scope to include infant foods--i.e., foods being marketed "as a complement to mother's milk to meet the growing nutritional needs of the infant after the age of 4 months". Apart from disallowing the advertising of these products, the bill prohibits the distribution of free samples and the offer of other inducements for promoting them. Donations of infant-milk substitutes and bottles may be made only to orphanages. The law also lays down stringent conditions for the labeling of baby foods and categorically bans the use of pictures of an infant or a woman or both, or the use of words such as "humanized" or "maternalized" in the information printed on the containers. All information material on the product must promote breastfeeding and stress the "financial and social implications" of using infant formulas and baby bottles. Further, manufacturers are forbidden from offering inducements to or fixing salaries of employees on the basis of volume of sales. Offenses under this act may be punishable by imprisonment for up to 3 years or a fine of up to Rs 500. Not surprisingly, baby-food manufacturers opposed the bill tooth and nail and succeeded in stalling it for a considerable time. There is, after all, a huge and growing market at stake. According to a Voluntary Health Association of India estimate, the market for baby foods, worth nearly Rs 7200 million (approximately 180 million pounds)--almost entirely shared between Amul, the manufacturing unit of a highly successful and pathbreaking Indian milk cooperative venture, and Nestle--is growing at 6%/year. The bill has had a long and interrupted passage. A diluted version was 1st introduced in Parliament in 1986, when it was passed by the Upper House but lapsed with the dissolution of the Lower House. The current version of the bill was introduced in January; again it lapsed with the dissolution of the House and was reintroduced in May. Institutions such as the Indian Academy of Pediatrics, the Consumer Guidance Society of India, and the Voluntary Health Association of India have endorsed the bill and have played a leading role in having it enacted in parliament. The question now is whether the law can be implemented successfully. The problems are many. For one, the law makes food inspectors appointed under the food Adulteration Act responsible for taking cognizance of any offenses under it. The already overworked and often corrupt inspection staff is hardly likely to take the new task seriously. Secondly, the bill makes illegal the use of the health system or its employees for the promotion or advertising of these baby products, which implies the existence of an agency that will monitor or at least keep watch over the functioning of the health system. There is no such agency and the proliferating private sector in health care is largely unregulated. And thirdly, there is the other side of the coin--restricting the promotion of baby food must be accompanied by creation of conditions that enable the vast majority of poor women to breastfeed. Such a task in a country where most women are forced to work in the unorganized sector would be colossal. (full text)
In: Bond JT, Filer LJ Jr, Leveille GA, Thomson AM, Weil WB Jr, ed. Infant and child feeding. New York, Academic Press, 1981. 441-5.Government regulations concerning the food supply in general regulate infant food as well. The 2 principal organizations issuing regulations that impact on infant food and with responsibility for inspecting and assuring quality and wholesomeness in food supply are the FDA (Food and Drug Administration), and the Food Safety and Quality Service in the Dept. of Agriculture. Neither the FDA nor the Dept. of Agriculture has the authority to seize food which fails to meet standards; the removal of a product from the market is largely a voluntary action by the food industry, unless there is a court order by the Dept. of Justice. The Dept. of Agriculture, however, can refuse to let meat and poultry leave a processing plant if the food is found deficient. The option called Nutrition Labeling is available but not compulsory to the food processing industry. Nutrition Labeling would include service size, the caloric, proteic fat and carbohydrate content of the serving size, and information about vitamins and minerals. Nutrition manuals for the consumer have been published by several government offices, and often contain conflicting advice. The federal government is currently spending 160 million dollars on nutrition research and the National Institutes of Health are spending 107 million dollars. General principles for the labeling of infant food are now in final regulation form; for example, percentages of contents must be declared. Some of the proposals still under consideration regard the setting of an appropriate level for manganese in infant food, and of upper limits for vitamins A and D.
Infant and young child nutrition, including the nutritional value and safety of products specifically intended for infant and young child feeding and the status of compliance with and implementation of the International Code of Marketing of Breast-milk Substitutes: report by the Director-General.
Geneva, Switzerland, WHO, March 1983. 39 p.This report to the Health Assembly is presented in 3 parts: Part I--a summary of the present global nutritional situation with particular reference to infants and young children--is based on an initial reading of the results of national surveillance and monitoring activities in over 50 countries. Part II has been prepared in accordance with resolution WHA34.23 which requested the Director-General to report to the Assembly on steps taken to assess the changes that occur with time and under various climatic conditions in the quality, nutritional value and safety of products specifically intended for infant and young child feeding. Part III, in accordance with resolution WHA34.22, summarizes information provided by Member States on action being taken to give effect to the International Code of Marketing of Breast-milk Substitutes. It should be read in conjunction with section VI of the Director-General's progress report which informed the 35th World Health Assembly of action taken by WHO and its Member States in the field of infant and young child feeding. In light of the information on the implementation of the Code contained in these 2 reports, and in the absence of any suggestions from Member States for change, the Director-General considers that it would be premature, at this time, to propose any revision of the text of the Code, either its form or content. The Health Assembly's attention will be drawn, in future biennial progress reports on infant and young child feeding, to any development which may have a bearing on the International Code, in accordance with its Article 11.7 and resolution WHA33.32.