The Australian Feeding Infants and Toddlers Study (OzFITS) 2021: Study Design, Methods and Sample Description

(1) Background: Caregiver feeding practices during the first two years of a child’s life influence nutrition, growth, and development, as well as long term taste preferences and dietary patterns. Suboptimal feeding practices lead to poorer health outcomes, such as obesity, that persist into adulthood. Although the importance of early life nutrition is well-established, there are no Australia-wide surveys of dietary intakes of children under two years of age. The 2021 Australian Feeding Infants and Toddlers Study (OzFITS) aims to fill this gap. This paper describes the methods and study sample of OzFITS 2021. (2) Methods: OzFITS 2021 is a cross-sectional study of children aged 0 to 23.9 months of age and their caregiver across Australia. Data were collected between April 2020 and April 2021. A telephone-based survey was completed with a caregiver to obtain information on child and caregiver characteristics and feeding practices. For exclusively breastfed infants, the number of breastfeeds in a 24 h period was reported. Dietary intakes for mixed fed children were estimated using a one-day food record, with 30% of caregivers completing a second food record on a non-consecutive day. (3) Results: We enrolled 1140 caregiver and child dyads. Of those eligible to complete a food record, 853 (87%) completed the food record. Compared to the Australian population, caregivers were more likely to be university-educated (>75%), married or in a de facto relationship (94%), and have a household income >$100,000/y (60%). (4) Conclusions: OzFITS 2021 is the first national study to examine food and nutrient intake in Australian children aged under 2 years. The study will provide information on breastfeeding rates and duration, use of breast milk substitutes, and timing of solid food introduction. Dietary intake data will allow the comparison of core food groups and discretionary food intake to Australian guidelines and estimate the prevalence of inadequate intake of key nutrients, like iron. Healthcare practitioners and policymakers can use the study findings as a source of evidence to inform the next iteration of infant feeding guidelines.

The Politics of Regulating Foods for Infants and Young Children: A Case Study on the Framing and Contestation of Codex Standard-Setting Processes on Breast-Milk Substitutes

Background: Breastfeeding is important for the health and development of the child, and for maternal health, in all country contexts. However, global sales of breast-milk substitutes (BMS), including infant, follow-up and toddler formulas, have ‘boomed’ in recent decades. This raises the importance of international food standards established by the Codex Alimentarius Commission (Codex) on the safety, composition and labelling of BMS. Such standards appear to be strongly contested by governments, industry and civil society groups, yet few studies have investigated the politics of Codex standard-setting processes. The aim of this paper is to understand who participates in decision-making, and how actors frame and contest proposals to revise the Codex Standard on Follow-up Formula (FUF). Methods: We adopted a case study design involving two steps. First, we enumerated government, industry, civil society, and international organization stakeholders participating in standard-setting processes of the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). Second, we conducted a framing analysis of stakeholder inputs during the FUF standard revision in CCNFSDU meetings. Publicly available online meeting reports (2015-2019) were retrieved, analyzed using a theoretical framework, and organized thematically. Results: High-income country (HIC) delegates greatly outnumbered those from other country income categories. Industry representation was higher compared with other observer categories Member state delegations included more industry representation than civil society representation, and were occasionally the only member state delegates. Industry stakeholders framed arguments in terms of trade implications, science, and flexible standards. Civil society groups used public health, science, and pro-breastfeeding frames. Conclusion: Codex BMS standard-setting procedures are dominated by HICs and industry groups. Limited representation of civil society, and of middle- and low-income countries, suggest actions are needed to substantially increase support for their involvement at Codex. Such representation may help to counteract power asymmetries and commercial influences on food standards for infants and young children.

IS ANYBODY KEEPING THE CODE IN BULGARIA? A STUDY TO EXPLORE LOCAL PARENTS' AWARENESS REGARDING THE INTERNATIONAL CODE FOR THE MARKETING OF BREAST-MILK SUBSTITUTES.

This paper reviews Bulgarian parents’ awareness concerning the existence of the WHO Code for the marketing of breast-milk substitutes and how it can help them optimize their breastfeeding journey. Frequently occurring problems and breaches of the Code in Bulgaria are discussed, and their context explained. We focus on parental attitudes and investigate whether they acknowledge the significant necessity for a Code-compliant prenatal education and postnatal care. We also explore their viewpoints on the implementation of the Code and maximizing compliance with it on a local level. The research findings are presented graphically, and we present tendencies showcased by respondents’ opinions they have expressed in the survey. OBJECTIVES: Purposes of this research are: (1) to explore parents’ awareness about the WHO Code and their encounter with local prenatal classes in this regard (2) to assess their viewpoints on implementing the Code and if they see it as a significant step towards an optimal breastfeeding experience. METHODS: The methods we applied include an online-based cross-sectional semi-quantitative questionnaire with closed-ended and open-ended questions, aiming to explore parents’ current knowledge and viewpoints in regard to the Code and its implementation in Bulgaria. The research has been carried out via social media, and it samples parents from a local parent peer support group. Acquired data from closed-ended questions is presented, demonstrating percentages and tendencies. RESULTS: A total of 463 respondents are included CONCLUSION: It is a common practice in Bulgaria for prenatal classes not to comply with the WHO Code. Disregarding recommendations and evidence-based medicine, both some experts and companies under the scope of the Code breach its main points. Code-compliant prenatal education is practically almost non-existent with the lack of midwife-led care and classes, predominantly in the private sector, where they are almost entirely, sponsored by those companies. Nearly all parents included in this survey are more than willing and motivated to have access to Code-compliant prenatal education and postnatal care. The lack of such leaves almost no choice for Bulgarian parents actually to have access to code-compliant education and care. This inevitably influences their decision making, attitudes and behavior, potentially leading to lower breastfeeding rates and suboptimal breastfeeding satisfaction and success. Adequate measures must be reinforced to ensure implementation and proper legislation, providing monitoring and enforcement, protecting parents and their babies when they are most vulnerable.

What Hinders Twin Mothers From Breastfeeding - A Qualitative Study of Chinese Women

Objective To explore the difficulties of twin mothers in breastfeeding and the factors that promote breastfeeding, so as to develop interventions to improve the breastfeeding rate of twin mothers. Methods Semi-structured interviews were used to interview women with twin pregnancy experience. Results We found that twin pregnancy itself was an obstacle to breastfeeding. Lack of breastfeeding knowledge guidance, separation of mother and newborns, poor maternal and child health conditions and the convenience of breast milk substitutes also hindered the implementation of breastfeeding for women with twin pregnancy. On the other hand, the emotional support of family members, proper breastfeeding guidance, sufficient breast milk production and economic pressure were the main factors that promote the breastfeeding of women with twin pregnancy. Conclusion To promote the breastfeeding of women with twin pregnancy needs the support of family, society and policy. Breastfeeding education should be extended to prenatal care and the primary caregiver of the new mother, and timely guidance should be provided after delivery to achieve satisfactory breast milk production.

Implementation of two policies to extend maternity leave and further restrict marketing of breast milk substitutes in Vietnam: a qualitative study

Policy research can reveal gaps and opportunities to enhance policy impact and implementation. In this study, we use a theoretically informed qualitative approach to investigate the implementation of two policies to promote breastfeeding in Vietnam. We conducted semi-structured interviews with national and local policy stakeholders (n = 26) in 2017. Interviews were audio-recorded, transcribed verbatim and then translated to English by certified translators. Transcript data were analysed using an integrated conceptual framework of policy implementation. Respondents identified several positive outcomes resulting from implementation of an extended maternity leave policy (Labour Code No. 10/2012/QH13) and further restrictions on marketing of breast milk substitutes (Decree No. 100/2014/ND-CP). Decree No. 100, in particular, was said to have reduced advertising of breast milk substitutes in mass media outlets and healthcare settings. Key implementation actors were national-level bureaucratic actors, local organizations and international partners. Findings reveal the importance of policy precedence and a broader set of policies to promote the rights of women and children to support implementation. Other facilitators were involvement from national-level implementing agencies and healthcare personnel and strength of government relationships and coordination with non-governmental and international organizations. Implementation challenges included insufficient funding, limited training to report violations, a cumbersome reporting process and pervasive misinformation about breast milk and breast milk substitutes. Limited reach for women employed in the informal labour sector and in rural communities was said to be a compatibility issue for the extended maternity leave policy in addition to the lack of impact on non-parental guardians and caretakers. Recommendations to improve policy implementation include designating a role for international organizations in supporting implementation, expanding maternity protections for all working women, building local-level policy knowledge to support enforcement, simplifying Decree No. 100 violation reporting processes and continuing to invest in interventions to facilitate a supportive policy environment in Vietnam.

Breastmilk or infant formula? Content analysis of infant feeding advice on breastmilk substitute manufacturer websites

Objective: To evaluate messages about infant feeding on breastmilk substitute (BMS) manufacturer websites directed at US caregivers and compare information and portrayals of breast-feeding/breastmilk with that of infant formula (IF) feeding. Design: We conducted a content analysis of US BMS companies’ websites. A codebook was created through an iterative process to identify messages and images about breast-feeding/breastmilk and IF feeding, including benefits or issues associated with each, and direct-to-consumer marketing practices that could discourage breast-feeding. Setting: Data were collected in 2019–2020 and analysed in 2020–2021 for US websites of five IF manufacturers. Participants: The websites of Similac, Enfamil and Gerber, which collectively represent approximately 98 % of the US IF market, and two US organic brands, Earth’s Best and Happy Baby. Results: Websites contained more messages about breast-feeding/breastmilk than IF but were significantly more likely to mention benefits to baby of IF (44 %) than breast-feeding/breastmilk (<26 %), including significantly more statements that IF provides brain, neural and gastrointestinal benefits; 40 % of breast-feeding/breastmilk content was dedicated to breast-feeding problems (e.g. sore nipples). Twice as many screenshots compared IF brands favourably to breastmilk than as superior to other brands. Certain companies displayed images indicating ease of IF feeding and difficulty of breast-feeding. Conclusions: Substantial messaging on BMS manufacturer websites encouraged IF feeding and discouraged breast-feeding. Health professionals should discourage their patients from visiting these websites and the US government should regulate misleading claims. Companies should refrain from providing breast-feeding advice and align their US marketing with the International Code of Marketing of Breast-milk Substitutes.

Evidence of Violations of the International Code of Marketing of Breast-Milk Substitutes since the Adoption by the World Health Assembly in 1981: A Systematic Scoping Review Protocol

This is the protocol for a scoping review that aims to systematically explore and summarise the published evidence of violations of the International Code of Marketing of Breast-milk Substitutes (the Code) and subsequent World Health Assembly Resolutions globally. The planned scoping review will seek to identify what research has been conducted on the topic, examine the geographic spread and nature of violations, and summarise knowledge gaps. The Code was adopted in 1981 by the World Health Assembly to protect infant health, in particular from aggressive and inappropriate marketing of breastmilk substitutes including formula and related products. Non-compliance with the Code or violations are described in reports, however, no existing systematic review of the global research appears to have been conducted that encompasses the varied disciplines including health, economics, and gender. The review will inform international and national decision-makers on the nature of violations and potentially highlight the need for new modalities to regulate this marketing. The proposed scoping review will use the six-step process of Arksey and O’Malley which includes defining the research question; identifying the relevant literature; selecting studies; charting the data; collating, summarising and reporting the findings; and will include a consultative group.

What You Don’t Know About the Codex Can Hurt You: How Trade Policy Trumps Global Health Governance in Infant and Young Child Nutrition

Background: International food standards set by the Codex Alimentarius Commission (CAC), have become more prominent in international trade politics, since being referenced by various World Trade Organization (WTO) agreements. The new standing of the CAC imposes limits on domestic public health regulation. We show this includes implementation of the World Health Organization (WHO) International Code of Marketing of Breast-milk Substitutes. Methods: Using trade in commercial milk formulas (CMF) as a case study, we collected detailed data on interventions across various WTO bodies between 1995 and 2019. We used language from these interventions to guide data collection on member state and observer positions during the CAC review of the Codex Standard for Follow-up Formula (CSFUF), and during CAC discussions on the relevance of WHO policies and guidelines. Results: Exporting member states made 245 interventions regarding CMFs at the WTO, many citing deviations from standards set by the CAC. These did not occur in formal disputes, but in WTO Committee and Accession processes, toward many countries. In Thailand, complaints are linked to weakened regulation. Exporters also sought to narrow the CSFUF at the CAC in a way that is at odds with recommendations in the International Code. Tensions are growing more broadly within the CAC regarding relevance of WHO recommendations. Countries coordinated during WTO committee processes to advocate for reapportioning core WHO funding to the CAC and in order to further influence standard-setting. Conclusion: The commercial interests of the baby food industry are magnifying inconsistencies between health guidelines set by the WHO, standard-setting at the CAC, and functions of the WTO. This poses serious concerns for countries’ abilities to regulate in the interests of public health, in this case to protect breastfeeding and its benefits for the health of infants, children and mothers.

Implementation of the Code of Marketing of Breast-Milk Substitutes in Vietnam: Marketing Practices by the Industry and Perceptions of Caregivers and Health Workers

Background: The promotion of breastmilk substitutes (BMS) is an important barrier to successful breastfeeding. Objective: To examine the enactment and implementation of the Code of Marketing of Breast-Milk Substitutes (the Code) in Vietnam with a focus on marketing practices by the baby food industry and perceptions of caregivers, health workers, and policy makers. Methods: From May to July 2020, we conducted a mixed-method, cross-sectional study including a survey of 268 pregnant women and 726 mothers of infants aged 0–11 months and in-depth interviews with a subset of interviewed women (n = 39), policy makers, media executives, and health workers (n = 31). Results: In the previous 30 days, two mothers (out of 726) participating in the quantitative survey reported that health workers had recommended BMS, at private hospitals in both cases. In-depth interviews with health workers showed that hospitals have internal procedures to prevent the promotion of BMS by health workers. However, companies employed representatives to promote products not covered under the Code (e.g., commercial milk formula for pregnant women) at antenatal care visits and by gaining contact information from women and using this information to promote BMS outside the hospital, often on social media. In the 30 days preceding the survey, one-fifth of pregnant women were exposed to promotions of commercial milk formula for pregnant women and 7.1% to promotions of BMS. Among mothers of infants, 7.3% and 10.7% of respondents with infants aged 0–5 and 6–11 months, respectively, were exposed to some form of BMS promotion in the past 30 days. Around the time of birth, parents commonly brought BMS to maternity facilities (52.5%) or purchased it nearby (35.4%). Conclusions: Although Vietnam has a strong regulatory environment for the protection, promotion, and support of breastfeeding, there are implementation, monitoring, and enforcement gaps. Stronger enforcement of national policies to regulate the presence of BMS industry representatives in health facilities—both public and private—and the promotion of BMS products on digital platforms are needed.