Infant Feeding Practices: Observations from Macedonia and Kosovo
As a result of concerns expressed about the usage of infant formula and a need for more information regarding weaning practices during and after the conflict in Kosovo, Action Against Hunger-UK began to examine infant feeding practices in the area and found that some aspects of infant feeding were extremely poor. Furthermore, the emergency had led to a situation where some of these poor practices were likely to be exacerbated. At the same time, the crisis provided an opportunity for AAH-UK to collaborate with WHO and UNICEF in strengthening health structures in order to improve infant feeding. This article was written by Laura Phelps and Caroline Wilkinson. Laura and Caroline have worked for AAH-UK in Kosovo as nutritionist and nutrition co-ordinator since June 1999.
Poor breast-feeding and infant feeding practices are well known to have adverse consequences for the health and nutritional status of children, which in turn have consequences for the development of the child both physically and mentally. An increase in morbidity in turn impacts heavily on public health expenditure.
Inappropriate infant feeding practices in the Balkans have been observed for some years. Although Kosovo is generally recognised as a breast feeding society, the rate of exclusive breast-feeding pre-emergency was extremely low and the introduction of complementary fluids and foodstuffs was common within the first 2 months of life1. These poor practices were recently confirmed by the infant feeding surveys undertaken in Macedonia in June of 19992 and July of 1999 in Kosovo3.
In 1997 the UNICEF MICS1 survey showed that only 12.2% of children were breast-fed exclusively until 4 months. More recently the combined Nutritional Anthropometric, Child Health and Food Security Survey in 1998 showed that 25.6% of breast feeding mothers did not continue feeding past 3 months4. During the recent Kosovo crisis a survey in the Macedonia refugee camps found that 23% of infants under 4 months received neither breast milk nor a suitable breast milk substitute5.
Following the influx of breast milk substitutes during the crisis, WHO led an information finding consultation in Macedonia6. Findings showed that there was little clear documentation about the infant formula that was imported into the country during the conflict and the supply of infant formula grossly outweighed the need. This document reports that infant formula was given on request to mothers who self presented to health workers, often in the absence of breast-feeding counselling or lactation support.
Prior to the conflict a reported 76.8% of children breast fed for more than 3 weeks4 while post conflict 71.5% were reported to breast feed for more than 3 weeks3. It should be noted that both of theses figures reflect mixed not exclusive breast feeding.
It appears that the following factors have had the greatest effect on breast feeding and weaning practices in the Kosovar population:
- Many mothers (44.3%), cited insufficient milk as the reason for cessation of breast feeding4 prior to and during the conflict.
- There has been very little support from health professionals, whether national or international, and very minimal breast-feeding counselling immediately after birth. Furthermore the active promotion of re-lactation and support to mothers with difficulties in breast feeding has been very limited.
The influx of humanitarian aid to the region and the absence of co-ordinated control of breast milk substitutes, meant that infant formula and specialised baby foods were handled directly by humanitarian organisations who in many cases lacked the technical knowledge about their correct use. The donation of powdered milks, and also to a certain extent locallyprocured pre-prepared complementary foods has led to the distribution of these products during and post crisis in the camps and through the health units in Kosovo. Donated powered milks and complementary foods were distributed without being properly targeted and without appropriate labelling in Albanian or another suitable language. The use of all types of foods for infants, (including cows' milk and pre-prepared weaning foods) within the refugee population has been uncontrolled and untargeted.
A recent survey7 assessed infant feeding practices following the return of refugees to Kosovo in July 1999 (standard 30 x 30 cluster sampling). The methodology involved retrospective questioning of mothers of children between 6-18 months of age, and key informant discussions. All mothers (total of 922) were questioned on breast feeding practices while only 219 mothers were questioned on weaning practices. The following are some of the key findings from this study.
Twenty-five percent of women do not start to breast feed until 24 hours or more after birth. Late introduction to the breast has implications for breast feeding success, low colostrum intake and bonding between mother and child. Interestingly there appears to be a trend towards stopping breast feeding earlier in younger children; of the 18 month olds only 16.7% had stopped at 6 months or before, compared with 23.6% of the infants that were 6 months old at the time of the survey. Key informant discussions confirmed that younger women are breast feeding for a shorter length of time than their mothers did, although the reasons for this were not established.
Twenty-four percent of infants aged 12 months or under received infant formula (no pre-war baseline data), 25.5% of their mothers were unable to read the instructions. Fifteen percent of infants received both breast milk and infant formula. Following donations by humanitarian organisations and multinational companies, national doctors and food distribution agencies (both national and international) were seen to be prescribing/donating infant formula for mothers who report problems breast feeding, many without counselling or lactation support. A continued supply was not always assured so the family either had to purchase this expensive product or swap it for an accessible alternative. The options available are far from ideal as, six month's supply of infant formula is equal to an average family's bread expenditure for 6 weeks8. Key informant discussions suggest that if the mothers could not afford to continue with formula that they changed to diluted cows' milk with added sugar. In cases where there was an adequate supply of formula, often mothers did not have the knowledge or facilities for hygienic preparation. Both practices may potentially result in an increased incidence of diarrhoea due to either unclean water/preparation facilities or due to an immature infant gut. Diarrhoea is a significant problem in Kosovo, confirmed by WHO weekly epidemiological bulletins which report that up to a third of children aged 5 years or under are presenting with watery diarrhoea.
Sixty-eight percent of infants drink cows' milk on a daily basis before 6 months of age. The number of cows killed during the conflict (62%) negatively affected the availability of milk. Children under the age of 2 years, were prioritised for receipt of cows' milk when in short supply.
Frequency of breast feeds may be compromised when other feeds, such as cows' milk, is given, resulting in a reduced supply of breast milk to the child. Introduction of cow's milk before 4-6 months has implications for renal damage as it has an osmolar load greater than the excretory capacity of their immature kidneys (although, a third of the mothers did dilute the milk). More importantly, cows' milk is probably a significant contributor to the high incidence of diarrhoea reported in young infants, as a result of early introduction to an undeveloped gut. It appears from the key informant discussions that cows' milk is seen as a good substitute for breast milk at any age. Another problem with cows' milk is the low iron content, which make it a poor weaning food, especially if taken in large volumes when it could displace other foodstuffs.
The International Code of marketing of Breastmilk substitutes
In 1979, WHO and UNICEF organised an international meeting on infant and young child nutrition. One of the recommendations made was that there should be an international code of marketing of infant formula and other products used as breastmilk substitutes. Member states of WHO and other groups/individuals who had attended the 1979 meeting, including representatives of the infant food industry, were then involved in a consultative process which culminated in the production of the International Code. This Code was endorsed by the World Health Assembly in 1981 in a Resolution which stressed that the Code is a "minimum requirement" to be enacted "in its entirety" by all countries.
The Code sets out the responsibilities of the infant food industry, health workers, national governments and concerned organisations in relation to the marketing of breastmilk substitutes, feeding bottles and teats as well as information regarding the use of these products. Since 1981, subsequent WHA Resolutions have been passed which aim to strengthen and clarify the Code. These Resolutions have the same status as the Code itself and should be read with it.
The most important parts of the Code, which relate to infant feeding in emergencies, are:
"The aim of this Code 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 Scope The Code applies to any product which is marketed or otherwise represented as a partial or total replacement for breastmilk, and to feeding bottles and teats. Only certain products are suitable as breastmilk substitutes, but many other unsuitable products (such as baby cereals, baby drinks and follow-on formulas) fall under the scope of the Code when they are marketed inappropriately.
No advertising of above products to the public.
No free samples to mothers, their families or health care workers.
Health care facilities
No promotion of products i.e. no product displays, posters or distribution of promotional materials. No use of mothercraft nurses or similar company-paid personnel. No free or low-cost supplies.
Health care workers
No gifts or samples to health care workers. Product information must be factual and scientific.
No free or low-cost supplies of breastmilk substitutes to maternity wards and hospitals. (The 1994 Resolution states that they should not be in any part of the health care system).
Governments have the responsibility to ensure that "objective and consistent information is provided on infant and young child feeding". Such information should never promote or idealise the use of breastmilk substitutes and should include specified points. It should also explain the benefits and superiority of breastfeeding and the costs and hazards associated with artificial feeding. Manufacturers should provide only scientific and factual information to health workers and should never seek contact with mothers.
Product labels must clearly state the superiority of breastfeeding, the need for the advice of a health worker and a warning about health hazards. No pictures of infants, or other pictures idealising the use of infant formula.
Unsuitable products, such as sweetened condensed milk, should not be promoted for infants. All products should be of high quality and take account of the climatic and storage conditions of the country where they are used. Manufacturers and distributors should comply with the Code INDEPENDENTLY of government action to implement it. NGOs have a responsibility to report any violations to governments and to manufacturers.
Excerpt from "Infant Feeding Report in Emergencies, policy, strategy and practice, May 1999 (Available from the ENN)
Ninety-five percent of infants have had tea introduced by the age of 12 months. Tea is commonly given from the age of 2-3 months old in bottles with sugar added. The poly-phenol content of tea contributes to the inhibition of iron absorption; an even more serious problem when the overall diet of a majority of children aged 6-12 months would appear to contain insufficient iron. This needs further investigation and will be included in the next survey, planned for November/December 1999.
Sugar added contributes to the development of dental caries at a very young age. Tea should not normally be given until at least 2 years of age for these reasons, but 90% of infants under 1 year receive tea on a daily basis. Tea does not appear to be given for health reasons, although it is advocated by the Kosovar doctors for both treatment of diarrhoea, and as a night time drink in two major hospitals in Kosovo.
Biscuits and cakes
By 6 months 78.6% of infants were eating biscuits, 92% of these on a daily basis, and 7.5% on a weekly basis. A majority of infants in Kosovo are weaned onto biscuits and cows' milk, which may or may not be mixed with extra sugar. The biscuits available are nutritionally poor and provide inadequate vitamins and minerals. In addition, this product is often started at 3-6 months and as a wheat-containing product this is too early for introduction. The infant's intestine is not sufficiently developed until 6-8 months to deal with the protein type, and the child may have problems digesting the wheat, which can result in diarrhoea. Kosovar doctors/nurses and hospitals both directly and indirectly support biscuits by recommending them or giving them to children during their in-patient stay.
Fruit and Vegetables:
Generally the intake of both fruit and vegetables is very low (43% of infants 6-18 months, 66% on a daily basis) and not in line with complementary food guidelines. It is recommended that fruit and vegetables should be introduced at 4-6 months as the initial complementary food, especially as they provide important vitamin C, which helps in the absorption of iron. Most of the mothers in the key informant discussions stated that they felt fruit was a good weaning food for infants, but the cost was prohibitive, especially in this time of food insecurity. However, it must be noted that vegetables would be just as beneficial to the child and it would seem that some vegetables (potatoes, cabbage) are available to even the poorest families5.
On a broader level, the results of the Food Security Survey5 indicate that the differences between a meal now and what was classed as a 'normal' meal preconflict is primarily a reduction in meat followed by fresh vegetables and milk. Fruits, cheese and yoghurt were the next most commonly mentioned items to be reduced in the diet. This is an especially worrying trend for the winter-time as the diet in the winter months is known to be less diverse than the summer diet and access to these foods is likely to be even more problematic this winter. Micro nutrient intakes are a particular concern in light of the results of the infant feeding survey and the practices previously discussed.
Complementary Feeding practices Kosovo-wide generally do not follow internationally accepted recommendations. They are potentially contributing to the reported high incidence of diarrhoea and iron deficiency anaemia in children under 18 months of age. These practices could, however, be significantly improved upon over time through a widespread information programme.
The issue of exclusive breast feeding appears to be an educational one, as the introduction of tea, cows' milk and biscuits to children under 6 months has reportedly only occurred in the last 20 years, and has occurred in response to marketing, availability and inappropriate health advice. Kosovo is such a child orientated society that when mothers and health professionals are able to make an informed decision then in our limited experience, their practices change. The dissemination of this information to health professionals and throughout the community will be a lengthy process, but the initial stages are promising.
It is essential that breast-feeding is pro-actively supported and fully endorsed by international organisations working in the emergency and postemergency stage. However it must be recognised that there are situations where breast-feeding is not an option, and where safe alternatives need to be facilitated. Accurate preparation of infant formula is essential for correct usage. This is dependent on clear instructions in the appropriate language and adequate resources within the household to ensure good hygiene.
For the use of complementary foods, however, there are times when humanitarian organisations are left in a dilemma. The question remains, when targeting and monitoring of food distributions cannot be carried out but it is clear that families have limited or no access to appropriate complementary foods for infants - provide commercial infant foods and risk potential misuse or deny the population in question these products?
Broad untargeted distributions are inevitable, but they require a quick response in terms of advice and practical suggestions to minimise potential damage to the infant population, both in the short term health of the child and longer term orientation of practices in the population. Action Against Hunger-UK are currently working in collaboration with UNICEF, UNHCR and WHO to disseminate clear policy guidelines for breast milk substitutes in Kosovo, which became law from November 1st 19999. For imported goods we suggest that they are labelled in the appropriate language, with specific information about their use. This labelling also offers the opportunity for a health promotion message to target this potentially vulnerable group.
The nutrition programme for Action Against Hunger- UK, in the coming year will include breast feeding / infant feeding education from the tertiary to primary health care structures in 15 municipalities throughout Kosovo. This will be a co-ordinated programme with UNICEF in line with the Baby Friendly Initiative at the tertiary level and a community based approach utilising the 'train the trainer' model and linking in with women's group initiatives at the secondary and primary health care level.
- Breast feeding: How to support success, Copenhagen, WHO Regional Office for Europe, 1996
- Infant Feeding in Emergencies: A guide for mothers. WHO Regional Office for Europe, revised 1997.
- Ten successful steps to breast feeding; Infant feeding in Emergencies, Nutrition Unit, Copenhagen, WHO Regional Office for Europe, revised 1997.
- Re-Lactation: Review of experience and recommendations for practice, WHO Department of Child and Adolescent Health Development, 1997
- Infant Feeding in Emergencies: Policy, Strategy and Practice. Report of the Ad Hoc Group on Infant Feeding in Emergencies, May 1999.
For further information please contact Laura Phelps or Caroline Wilkinson, at firstname.lastname@example.org or email@example.com Or contact Frances Mason, Nutrition and Food Security Advisor, Action Against Hunger-UK on Tel: 0171 831 5858, or firstname.lastname@example.org
1UNICEF Multiple Indicator Cluster Survey. Federal Republic of Yugoslavia, Institute of Public Health of Serbia and Montenegro (Belgrade 1997)
2UNHCR, Action Against Hunger, Macedonian IMCH, UNICEF (June 1999) Nutrition and Health Survey of Kosovar Refugees in camps in Macedonia
3Action Against Hunger-UK, (July 1999) Infant Feeding and Weaning Practices in Kosovo, Federal Republic of Yugoslavia
4Action Against Hunger, Mercy Corps International, UNICEF (December 1998) Nutritional Anthropometric, Child Health and Food Security Survey. Kosovo, FR Yugoslavia.
5UNHCR, Action Against Hunger, Macedonian IMCH, UNICEF (June 1999) Nutrition and Health Survey of Kosovar Refugees in camps in Macedonia.
6Forsyth.V., WHO consultant, (July 1999) Report of the WHO infant feeding consultancy to the Former Yugoslav Republic of Macedonia and Albania.
7Action Against Hunger, Anthropometric Nutritional & Infant Feeding and Weaning Survey, Kosovo 15-27th July 1999
8Calculated from the average costs of 6 popular Infant Formulas at urban prices and compared to figures taken from the Action Against Hunger, Food Security Survey, Kosovo 12-26th July 1999
9Breast milk substitutes are products that replace breast milk up to the age of 6 months and includes infant formula and specialised feeding products.
Taken from Field Exchange Issue 8, November 1999