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R E P O R T

R E P O R TON MONITORING OF THE FEEDING

PRACTICES OF INFANTS AND YOUNGCHILDREN IN ALBANIA

REPORT ON MONITORING OF FEEDING PRACTICES

The Project is implementedby: Albanian Group for theProtection of Breastfeeding,IBFAN member

AKNOWLEDGMENTS

2/ REPORT ON MONITORING OF FEEDING PRACTICES

The Project is implementedby: Albanian Group for theProtection of Breastfeeding,IBFAN member

Grup of monitors:Yllka ManoVjollca KoroshiYllka PoçiDylbere SkenderajIrjeta KamboFlora BufiLiri DomiLida BoshkuShyqyrie DemaMarika ShoreFillareti OsmaniDesantila TahirajDrita DemiriSuzana GjevoriJerina KeliPetraq AlkanjariAna KoxhakuDorina VeroTatjana HasaniNexhat BunguriManjola ShporiDrita LacejTeuta SokoliZamira Vllahu

The Project is implemented by:Albanian Group for the Protectionof Breastfeeding, IBFAN member

Partners:Reproductive Health SectorStatistic’s SectorMinistry of Health

Supported by:UNICEF- office,Tirana, Albania

Graphic design:Studio Adridesign

Printed by:Albdesign

AKNOWLEDGMENTS

The project “Report on Monitoring of the Feeding Practicesof Infants and Young Children in Albania” was carried out incoordination and partnership between the Albanian Group forProtection of Breastfeeding, Ministry of Health and the UNICEFoffice in Tirana.

This project was drafted in coherence with the long termstrategy of the Ministry of Health, more specifically based onthe objectives set forth on mother and child health. Since 1998,the same partner organizations have started their cooperationon the First Monitoring Project which was naturally continuedsuccessfully in the latest project. This process started with draftingof questionnaires, training and briefing of the monitors, followedby the process of collection of data in districts, data entry andelaboration to finalize into the results and writing of the FinalReport.

Hereby, we would like to thank the entire group of peoplethat carried out successfully the process of monitoring of infantand young child feeding practices in Albania:

Dr. Nedime Ceka, Sector Chief of the Reproductive Healthat the Ministry of Health who gave institutional support to theproject, training of monitors, elaboration of data and other inputsfor the final report; Dr. Donika Beba, specialist of same RHSector, who contributed greatly in training of the monitors; alldata entry clerks of Statistics Sector at Ministry of Health whocarefully inputed all the data of the survey and Lysien Shkurti,specialist in Statistics who supported the data entry process bycontinuous training and assistance to the clerks, as well as finalelaboration of them to produce the results of the monitoringproject.

The fully and continuous support of Dr.Petrit Vasili, Directorof Primary Health Care at the Ministry of Health, assured completeinstitutional support to the implementation of the project.

Special thanks go to the members of the Albanian Group forProtection of Breastfeeding, Dr Edlira Shara and Dr EditLlagami, who worked with dedication through the entire spanof the project.

This project would have not been successfully completedwithout the dedication and hard work of the monitors in thedistrics that carried out the survey and collection of data.

The Final Report of the project was drafted and completedbased upon recommendations and inputs of all members of theworking team.

Special thanks go to Dr. Marjana Bukli and the local officeof UNICEF in Albania that has assisted the project through theentire process of monitoring, implementation of this project andwriting of the Final Report.

Finally, to Dr. Mirela Dibra, Pediatrician and Coordinatorof the Albanian Group for Protection of Breastfeeding goes themerit and thanks to have inspired and given the ideas adoptedinto the monitoring project and the survey methodology, aswell as the overall coordination of the project, drafting of thepreliminary reports and writing of the Final Report.


TABLE OF CONTENTS

/3REPORT ON MONITORING OF FEEDING PRACTICES

TABLE OF CONTENTS

PreambleWhy breastfeeding?The situation in Albania and in the worldInternational Code of Marketing of Breastmilk SubstitutesAlbanian LegislationWhy we monitor?Monitoring in Albania.

1. Feeding practices of infants and young children from 0-2 yearsof age in our country.

2. Promotion of breastmilk substitutes through the healthcaresystem

3. Targeting mothers4. Selling points5. Labelling6. The story doesn’t end here7. Conclusions and recommendations

Appendices1a. WHO/UNICEF International Code of Marketing of Breast Milk

Substitutes, EU directives1b. World Health Assembly Resolutions following the

International Code2. Order of Health Minister, No 163, May 28, 19983. Albanian Legislation: Law on Promotion and Protection of

Breastfeeding, September 19994. Order of Health Minister, No. 157; Minister’s Guidelines for

establishment of Baby Friendly Units, No.1262/1, April 9, 2002.5. Statistical Data on Breastfeeding in Albania.6. 10 Steps for Sucessful Breastfeeding7. Monitoring Map8. IMR in years. IMR’s structure in Albania9. Breastfeeding Indicators. Definitions10. Breastfeeding Indicators Forms11. Monitoring Forms (based on the Standart International Forms

of IBFAN, applied for our national Law).12. Definitions of Breastfeeding Categories13. Table 1. Criteria of Infant’s Inclusion in Feeding Categories.14. Bibliography


“Marketing practices thatundermine breastfeeding arepotentially dangerouswhenever they appear: indeveloping countries, WHOevaluate that 1,5 millionchildren dye each yearbecause they are notbreastfeeding in anappropriate manner”.

Executive Director ofUNICEF-it, Carol Bellamy.

“Malnutrition has beenresponsible, directly orindirectly, for 60% of the 10.9million deaths annuallyamong children under five.Well over two-thirds of thesedeaths, which are oftenassociated with inappropriatefeeding practices, occurduring the first year of life…Because poor feedingpractices are a major threat tosocial and economicdevelopment, they are amongthe most serious obstacles toattaining and maintaininghealth that face this agegroup”.Global Strategy on Infant andYoung Child Feeding in May2002.

ALL MOTHERS SHOULD BE ABLE TOBREASTFEED AND ALL INFANTSSHOULD BENEFIT FROM IT


“Marketing practices thatundermine breastfeeding arepotentially dangerouswhenever they appear: indeveloping countries, WHOevaluate that 1,5 millionchildren dye each yearbecause they are notbreastfeeding in anappropriate manner”.

Executive Director ofUNICEF-it, Carol Bellamy.

“Malnutrition has beenresponsible, directly orindirectly, for 60% of the 10.9million deaths annuallyamong children under five.Well over two-thirds of thesedeaths, which are oftenassociated with inappropriatefeeding practices, occurduring the first year of life…Because poor feedingpractices are a major threat tosocial and economicdevelopment, they are amongthe most serious obstacles toattaining and maintaininghealth that face this agegroup”.Global Strategy on Infant andYoung Child Feeding in May2002.

ALL MOTHERS SHOULD BE ABLE TOBREASTFEED AND ALL INFANTSSHOULD BENEFIT FROM IT

Endi’s first breastfed immediately afer delivery at the maternity

Endi by the sixth month, exlusively breastfed.

Imagine that the world had invented a new “dream product”to feed and immunise everyone born on Earth. Imagine also that itwas available everywhere, required no storage or delivery - andhelped mothers to plan their families and reduce the risk of cancer.

Then imagine that the world refused to use it.

At the end of a century of unprecedented discovery andinvention, even as scientists discover the origins of life itself, thisscenario is not, alas, a fiction. The “dream product” is breastmilk,available to us all at birth, and yet we are not using it.


THE SITUATION INALBANIA AND IN THEWORLD

It has been estimated thatimproved breastfeedingpractices could save some 1.5million children a year. Yet fewof the 129 million babies borneach year receive optimalbreastfeeding and some are notbreastfed at all. Early cessationof breastfeeding in favor ofcommercial breastmilksubstitutes, needlesssupplementation, and poorlytimed complementary practicesare still too common.Professional and commercialinfluences combine todiscourage breastfeeding, as docontinued gaps in maternitylegislation.During the 1990s, substantialimprovements were made inexclusive breastfeeding for thefirst four months of life, withrates increasing by nearly onethird in the developing world.Timely complementary feeding(at 6 to 9 months) has improvedat a more modest rate, with thelevels increasing from 41% to50% between 1989 and 1999. Theproportion of infants stillbreastfeeding at one and twoyears of age increased onlyslightly.The highest levels of timelycomplementary feeding andcontinued breastfeeding are inthe least developed countries.It should be noted that, despitethis substantial overallimprovement, fewer than halfof all infants are now beingexclusively breastfed for up tofour months, and only abouthalf are receivingcomplementary foods in atimely manner. Although globallevels of continuedbreastfeeding are relativelyhigh at one year of age (80%),only around half of infants arestill breastfeeding at two yearsof age. Thus, the currentbreastfeeding patterns are stillfar from the recommendedlevels.

WHY BREASTFEEDING?


THE SITUATION INALBANIA AND IN THEWORLD

It has been estimated thatimproved breastfeedingpractices could save some 1.5million children a year. Yet fewof the 129 million babies borneach year receive optimalbreastfeeding and some are notbreastfed at all. Early cessationof breastfeeding in favor ofcommercial breastmilksubstitutes, needlesssupplementation, and poorlytimed complementary practicesare still too common.Professional and commercialinfluences combine todiscourage breastfeeding, as docontinued gaps in maternitylegislation.During the 1990s, substantialimprovements were made inexclusive breastfeeding for thefirst four months of life, withrates increasing by nearly onethird in the developing world.Timely complementary feeding(at 6 to 9 months) has improvedat a more modest rate, with thelevels increasing from 41% to50% between 1989 and 1999. Theproportion of infants stillbreastfeeding at one and twoyears of age increased onlyslightly.The highest levels of timelycomplementary feeding andcontinued breastfeeding are inthe least developed countries.It should be noted that, despitethis substantial overallimprovement, fewer than halfof all infants are now beingexclusively breastfed for up tofour months, and only abouthalf are receivingcomplementary foods in atimely manner. Although globallevels of continuedbreastfeeding are relativelyhigh at one year of age (80%),only around half of infants arestill breastfeeding at two yearsof age. Thus, the currentbreastfeeding patterns are stillfar from the recommendedlevels.

WHY BREASTFEEDING?

The last recommendations made by WHO, (World HealthOrganisation, May 2001), based on the last research data, suggestthat optimal breastfeeding practices include exclusivebreastfeeding, (breastmilk with no other foods or liquids) for aboutthe first six months of life, followed by breastmilk andcomplementary foods, (solid or semi-solid foods) from about sixmonths of age on, and continued breastfeeding for up to at leasttwo years of age while receiving complementary foods.

Breastmilk alone is the ideal nourishment for infants for aboutthe first six months of life, combining the three fundamentals ofsound nutrition – food, health and care. Breastmilk alone containsall the nutrients, antibodies, hormones and antioxidants an infantneeds to thrive.

It protects babies from diarrhea and acute respiratory infections,acute otitis and atopic dermatitis, stimulates their immune systemsand response to vaccination and, according to some studies conferscognitive benefits as well.

From 6-12 months it fulfills 50% of nutritional needs, and from12-24 months it continues to fulfill 1/3 of them. Breastmilk quantityincreases as the feeding frequency increases; it decreases if formulaor other products, including water is introduced.

Continued breastfeeding to two years, accompanied byappropriate complementary feeding, maintains good nutritionalstatus and continues to help prevent diarrhea.

The mother herself benefits: breastfeeding is proven to reducethe risk from ovarian and pre-menopausal breast cancer, it playsan important role in birth spacing, help reduction ofpostmenopausal hip fractures and create a special emotionalbonding between the mother and her baby.

It is safe, clean and available in just the amount the baby needs.Breastfeeding is also associated with significant economical andenvironmental benefits.


Ushqyerja me gji gjategjashte muajve


Ushqyerja me gji gjategjashte muajve

According to the data of the First Monitoring Project, carriedout during 1998 by Albanian Group for the Protection ofBreastfeeding, (hereinafter referred to as AGPB), in closecollaboration with the Reproductive Health Sector at MOH andUNICEF, despite a great number of the mothers that initiatedbreastfeeding at the maternity, (94% according to our study), a lowpercentage exclusively breastfed or still breastfeed in the followingmonths.

The data of our survey shows that soon after discharge fromthe maternity, the incidence of exclusive breastfeeding decreasedby 15 % by the end of first month. (First month, Tip 1)

By the second month the percentage remained approximatelythe same, taking into account that the percentage of predominantbreastfeeding increases (Tip 2). The tendency for early introductionof non-nutritious liquids was evident, while giving up theadvantages of exclusive breastfeeding.

Gradual increase of artificial feeding started by this month (Tip6). Another alarming data was that, while the incidence of exclusiveand predominant breastfeeding decreased obviously during the3rd and 4th month of age, cow’s milk was widely used as its substitute(Tip 4). The factors that explain that phenomenon are low incomeand the tradition of feeding with cow’s milk - based foods.

Taking into account the latest data on the nutritional andenergetic content of cow’s milk, it’s worthy to underline that itsearly introduction leads to the future major problems in terms ofpublic health: the over dilution and improper preparation of cow’smilk formulas and cereal mixtures, leads to the increase ofmalnutrition rates, iron deficiencies anemia, high morbidity rateof diarrhea and respiratory diseases, followed by high infantmortality rate.

(Appendix 8: IMR in years. The structure of IMR in Albania).

Following the figures month by month, exclusive breastfeedingresulted in continuous decrease, with only 1/3 of infants exclusivelybreastfeed by the end of the fourth month, 17% by the end of thefifth month and only 11% by the end of sixth month.

Infant formulas (Tip 3), were used as a supplement to breastmilkduring the first three months of age with gradual increase of 2,5%per month , while in the second three months of age its use droppedquickly, in favor of cow’s milk being used as a supplementary food.This fact is related to the high cost of formulas and the fact that in3-6 months, daily intakes are higher and more formula isconsumed.

Most of the Albanian families can’t afford the use of formula,which takes 50- 70% of the average monthly stipend of a member ofthe family.


International Code (IC)

The International Codewas adopted by theWorld Health Assemblyon 1981, as a set of rulesto protect breast feedingfrom unethicalmarketing practices.Relevant resolution hasbeen adopted since than.The purpose of the Codeis to protect women’sright to decide how tofeed her infant based oncomplete and accurateinformationuninfluenced by theindustry, which pretendsto care about health, butin reality making profitis its only priority. Thepreamble of the ICexplains that themarketing of breastmilksubstitutes requiresspecial treatment, whichmakes usual marketingpractices unsuitable forthese products.The Code, which you canfind as a full text atAnnex 1a, prohibits anyadvertisement, directand indirect promotionof any breastmilksubstitute, or any otherproduct covered by thescope of the Code.The Code applies toinfant formula, feedingbottles and teats as wellother breast milksubstitutes. Breast milksubstitutes are definedin the Code as “any foodbeing marketed orotherwise represented asa partial or total

Why infants are not properly and long enoughbreastfed?


International Code (IC)

The International Codewas adopted by theWorld Health Assemblyon 1981, as a set of rulesto protect breast feedingfrom unethicalmarketing practices.Relevant resolution hasbeen adopted since than.The purpose of the Codeis to protect women’sright to decide how tofeed her infant based oncomplete and accurateinformationuninfluenced by theindustry, which pretendsto care about health, butin reality making profitis its only priority. Thepreamble of the ICexplains that themarketing of breastmilksubstitutes requiresspecial treatment, whichmakes usual marketingpractices unsuitable forthese products.The Code, which you canfind as a full text atAnnex 1a, prohibits anyadvertisement, directand indirect promotionof any breastmilksubstitute, or any otherproduct covered by thescope of the Code.The Code applies toinfant formula, feedingbottles and teats as wellother breast milksubstitutes. Breast milksubstitutes are definedin the Code as “any foodbeing marketed orotherwise represented asa partial or total

Why infants are not properly and long enoughbreastfed?

The answer to the question is not simple, and the presumedcauses could be grouped in 3 parts:

Ø The first group of reasons are related to the role of womenin the economical and social development of the community: themore the women are part of a nucleus family vs. a larger traditionalfamily, or in an environment where she works vs. just being athome or doing work in the field, the more difficult is for her tocarry on breastfeeding. In addition to this, their health educationknowledge is also poor and they have very little information ontheirselves.

Ø A second group is related to the actual organization of thehealthcare system: the modern healthcare system tries “to produce”health, by way of organizing the hospitals and maternities in orderto arrive at the best management of their resources both humanand equipments, rather than pay respect to the naturalrequirements of the delivery process as well as to the perinatalcare. That is why it used to be that infants were taken appart fromtheir mothers into separated compartments immediately after birth,(many times far away from the place where their mothers stay).This brought to reccomending glucose water solutions and formulamilk as the most practical way for the staff of the maternities tofeed the children instead of bringing them to the mother andbreastfeed.

The Baby Friendly Hospital Initiative, (10 Steps to SuccessfulBreastfeeding, Appendix 6) aims at building a friendly andsupportive environment to promote early and best breastfeedingpractices, in the maternities. In our country only two maternitieshave been certified as Baby Friendly hospitals, one in Lezha with1450 births annually – certified in 1998 and the other one is in Fierwith 3100 births annually – certified in 2000. The Maternity nr 1 inTirana has received a certificate of commitment, as it fulfills only 6out of 10 Steps.

The Maternities in Korca and Kruja have already begun theprocess of implementation of the Ten Steps. Rooming-in is appliedin most of the maternity units in our country, but still there is a lotof work to be done towards improving other practices, like earlystart of breastfeeding at the delivery room and skin to skin contact.

Ø A third group of reasons includes the commercial pressureof the companies that produce infant formulas. Data on themonitoring of marketing practices for all breastmilk substituteproducts will be given in more details in special chapters of thisReport.


replacement for breastmilk”. Thus it is not onlythe nature of the productitself but also the way inwhich it is marketed orrepresented. Whencompanies promote foodsfor infants younger than6 months, they are ineffect marketing thesefoods to replace breastmilk. The same argumentapplies for follow upformulas and milks forolder children becausethey replace the part ofthe diet that is bestfulfilled by breastmilk.

Since the InternationalCode was adopted byWHA in 1981, theAssembly has respondedto problems that havebecome apparent frommonitoring of marketingpractices covered underthe Code. The examplesthat stand out include theresolutions thatresponded to the problemof free supplies (1986,1994, 1996), theresolution declaring thatfollow-up formula is notnecessary (1986) and theresolution calling forcaution over industrysponsorship of healthprofessionals (1996).In 1996, the Assemblyurged member states to“ensure thatcomplementary foods arenot marketed for or used

ALBANIAN LEGISLATION

LAW ON PROMOTION AND PROTECTION OFBREASTFEEDING


replacement for breastmilk”. Thus it is not onlythe nature of the productitself but also the way inwhich it is marketed orrepresented. Whencompanies promote foodsfor infants younger than6 months, they are ineffect marketing thesefoods to replace breastmilk. The same argumentapplies for follow upformulas and milks forolder children becausethey replace the part ofthe diet that is bestfulfilled by breastmilk.

Since the InternationalCode was adopted byWHA in 1981, theAssembly has respondedto problems that havebecome apparent frommonitoring of marketingpractices covered underthe Code. The examplesthat stand out include theresolutions thatresponded to the problemof free supplies (1986,1994, 1996), theresolution declaring thatfollow-up formula is notnecessary (1986) and theresolution calling forcaution over industrysponsorship of healthprofessionals (1996).In 1996, the Assemblyurged member states to“ensure thatcomplementary foods arenot marketed for or used

ALBANIAN LEGISLATION

LAW ON PROMOTION AND PROTECTION OFBREASTFEEDING

The protection of the health of infants and young childrenhas always been and remains a priority of the health policies.Protection and promotion of breastfeeding as the best way offeeding the infants is one of the strategies of the Ministry of Healthfor decreasing maternal and infant’s morbidity and mortality aswell.

Albania, as one of the Member States at WHA in 1981, votedin favor of the International Code. But still in 1997 nothing wasdone towards adoption a legislation framework based on theInternational Code.

Frequent violations of the International Code occurred, (seechapter: “Why we monitor?”). UNICEF, health workers andlawyers trained in the international training courses on theInternational Code, organized by ICDC and UNICEF, begunworking towards this aim.

The instability of the political life and other urgent prioritiesfor the fulfillment of the existing legislative gaps were the mainconstraints influencing that process. International Code andadvocacy materials were translated by Albanian Group forProtection of Breastfeeding in 1997.

UNICEF office played a leading role on the process of Law’simplementation. Model Law of ICDC (International CodeDocumentation Center) was translated and presented to therelevant structures at the Ministry of Health. Albanian Group forthe Protection of Breastfeeding took over the responsibility ofspeeding up the process and the monitoring of the marketingpractices of breastmilk substitutes.

The implementation of the Monitoring Project in 1998 playedan important role in this process. The collection anddocumentation of the Code violations, as well as the conclusionsof the Report on Monitoring of Feeding Practices of Infants andYoung children in Albania helped the process of the Law’sadoption.

On May 28, 1998, The Order No. 163 of the Minister of Healthwas released, aiming at protecting the health of mother and child,ensuring the proper feeding, breastfeeding, and the avoiding ofthe speculations with breastmilk substitutes. It stresses the needfor the protection, promotion and support of breastfeeding,propaganda on it’s advantages, the adoption of a written policybased on the 10 Steps, and it requires from every healthcarefacility that deals with mother and children health, to stop usingbottle and teats and pacifiers, especially at the neonatologywards, and to put an end to the acceptance of free and low costsupplies of breastmilk substitutes; direct and indirect promotionof breastmilk substitutes. (Appendix 2).


The aim of this Law is to contribute towards ensuring safeand proper feeding for children, through protection andpromotion of breastfeeding, as well as ensuring the right use ofbreastmilk substitutes, when they are necessary, based on properinformation and proper marketing and distribution.

in ways that undermineexclusive and sustainedbreastfeeding.”Even though the 1996WHA resolution urgedmember states to foster“appropriatecomplementary feedingpractices from the age ofabout six months,” somedisagreement persistedover the optimal periodof exclusivebreastfeeding.

The 54th World HealthAssembly (WHA) thatmet in Geneva in May2001 adopted resolution54.2 on infant feeding,which urges memberstates “to strengthenactivities and developnew approaches toprotect, promote andsupport exclusivebreastfeeding for sixmonths as a global publichealth recommendation”.The adoption followed ameeting of experts inGeneva in March 2001,which concluded that,based on scientificevidence a full sixmonths of exclusivebreastfeeding is optimaland emphasized steps tobe taken to maximize theproportion of exclusivelybreastfed at six months.The steps includeproviding adequatesocial and nutritionalsupport to lactatingwomen.


Thanks to the commitment of the core group of people whoworked on the draft, this process ended up on September 1999,with the adoption by the Albanian Parliament of the Law onPromotion and Protection of Breastfeeding (Appendix 3). The lawwas based on the legal provisions of IC.

The law filled an important legal gap, fulfilling the obligationtaken over by Albanian government (when voted in favour of theInternational Code at the World Health Assembly) to implementthe Code at national level.

The aim of this Law is to contribute towards ensuring safeand proper feeding for children, through protection andpromotion of breastfeeding, as well as ensuring the right use ofbreastmilk substitutes, when they are necessary, based on properinformation and proper marketing and distribution.

This Law regulates marketing and the practices related thereto,of the products of breastmilk substitutes, including industrial milkand other milk products; when they are marketed or representedas suitable, with or without modifications, for use as partial ortotal substitute of breastmilk. The relationships of producers anddistributors of these products with the health care institutions, aswell as the responsibilities of health workers are covered by thisLaw.

The Law is composed of 15 Articles and is divided in fourchapters: Definitions, restrictions related to the labelling of infantformula and follow up formula, the duties and respossibilities ofthe health care system, and the last chapter on “VIOLATIONS”

The State Sanitary Inspectorate is legally responsible to enforcethe law and monitor related practices. For violations of the law,different degrees of fines are applicable. The Law is published onOctober 27, 1999 in the Official Paper. Immediately after the Lawwas passed, we have started working to make it applicable. Firstthe Law was explained and promoted through the Directors ofPublic Health in the districts, Clinical chiefs of the neonatologyunits as well as the Sanitary Inspectors who are directly responsiblefor its implementation and monitoring of practices.

Further on by the assistance of the IC expert Mrs. Ellen Sokol,acting as an UNICEF - Tirana consultant, a workshop was held onJune 6, 2000, yielding an Action Plan to follow and monitorimplementation of the Law on Promotion and Protection ofBreastfeeding.

In all training sessions with health personnel held in theframework of the UNICEF program of Breastfeeding in Albania,promotion and protection of breastfeeding has been a keycomponent. Additionaly, basic knowledge on marketing andadvertising of milk formula companies, as well as a detaileddescription of the Law and deriving responsibilities for thehealthcare staff has been explained to them.

Another very important activity was the Regional Workshoporganized by UNICEF and MoH on February 23, 2001 in theMaternity Hospital of Fier. This hospital is certified as “BabyFriendly Hospital”.

in ways that undermineexclusive and sustainedbreastfeeding.”Even though the 1996WHA resolution urgedmember states to foster“appropriatecomplementary feedingpractices from the age ofabout six months,” somedisagreement persistedover the optimal periodof exclusivebreastfeeding.

The 54th World HealthAssembly (WHA) thatmet in Geneva in May2001 adopted resolution54.2 on infant feeding,which urges memberstates “to strengthenactivities and developnew approaches toprotect, promote andsupport exclusivebreastfeeding for sixmonths as a global publichealth recommendation”.The adoption followed ameeting of experts inGeneva in March 2001,which concluded that,based on scientificevidence a full sixmonths of exclusivebreastfeeding is optimaland emphasized steps tobe taken to maximize theproportion of exclusivelybreastfed at six months.The steps includeproviding adequatesocial and nutritionalsupport to lactatingwomen.


Why do we monitor?

The last monitoring report ofIBFAN in 2001 has indicatedcontinuous and systematicviolations of the IC in allcountries. The last Resolutionof WHO Assembly(Resolution 54.2) on May 18,2001 reads:

Conscious that despite thefact that the InternationalCode of Marketing ofBreastmilk Substitutes andrelevant, subsequent HealthAssembly resolutions statethat there should be noadvertising or other forms ofpromotion of products withinits scope, new moderncommunication methods,including electronic means,are currently increasinglybeing used to promote suchproducts... mindful that 2001marks the twentiethanniversary of the adoptionof the International Code ofMarketing of BreastmilkSubstitutes, and that theadoption of the presentresolution provides anopportunity to reinforce theInternational Code’sfundamental role inprotecting, promoting andsupporting breastfeeding... tostrengthen nationalmechanisms to ensure global

MONITORING IN ALBANIA


Why do we monitor?

The last monitoring report ofIBFAN in 2001 has indicatedcontinuous and systematicviolations of the IC in allcountries. The last Resolutionof WHO Assembly(Resolution 54.2) on May 18,2001 reads:

Conscious that despite thefact that the InternationalCode of Marketing ofBreastmilk Substitutes andrelevant, subsequent HealthAssembly resolutions statethat there should be noadvertising or other forms ofpromotion of products withinits scope, new moderncommunication methods,including electronic means,are currently increasinglybeing used to promote suchproducts... mindful that 2001marks the twentiethanniversary of the adoptionof the International Code ofMarketing of BreastmilkSubstitutes, and that theadoption of the presentresolution provides anopportunity to reinforce theInternational Code’sfundamental role inprotecting, promoting andsupporting breastfeeding... tostrengthen nationalmechanisms to ensure global

This workshop aimed to share and spread around in all otherSouth-South East regions of Albania the experience and lessonslearned in this Maternity; to make a preliminary evaluation of allsteps that each of other hospitals that participated was able tofulfill and to establish which obstacles and ways should beoverpassed and undertaken in order to assist them obtaining thesame title. The following districts were involved in this process:Berati, Elbasani, Gjirokastra, Durres, Korça, Lushnja, Pogradeci, Vlora,Skrapar, Saranda, Tepelena, Permet, each of them with threerepresentatives including the chief of obstetrics, neonatology andthe head nurse of the obstetrics and gynecology service.

Based on the conclusions and reccomendations of the aboveworkshop, on April 6, 2001, the Minister of Health issued the OrderNr 157, applicable to all healthcare institutions that offer services tothe mother and child, (mother and child consultory, maternities andpediatric hospitals), ordering complete support towards the initiativeof transforming them into “Baby Friendly Health Institutions”, whichhelp and protect breastfeeding. This was followed and completed bythe Minister of Health guidelines Nr 1262/1 on 9.04. 2002 for thecreation of Baby Friendly Services. (Appendix 4)

The legal framework that protects mother and child health issupplemented by the Law on the payed maternity leave for themothers, which gives them one year time to take care of the child,thus offering optimal support to complete breasfeeding of the child.In addition the Order Nr 185 of the MC (Minister’s Council) date3.05.2002 “Supplementary changes of the order nr 397 date20.05.1996 of the MC – on “Special protection of pregnant womenand motherhood”, which sets forth the rules for payed breaks ofwork in order to allow working mothers to breastfeed their children,not less than 20 minutes for each 3 consecutive hours of work.Nevertheles, last years many young mothers, under the pressureof loosing their work, (especially those working in the privatesector), quit their payed leave and restart working. This seems tobe a growing tendency and could become a prominent problem inthe near future, taking into account at the same time that more andmore young mothers have to work.

MONITORING IN ALBANIA

Our national survey is part of the international exercisedeveloped by IBFAN, the Third International Code MonitoringProject (IMP III), aimed to monitor compliance with the InternationalCode (IC). The training of national coordinators for the III EuropeanMonitoring Project of the IC took place in Sofia, on June 2000.National Coordinators were trained on IC provisions, how to detectviolations of the IC, how to start planning for a national monitoringproject, how to use SIM Forms (Standart IBFAN Monitoring Forms),how to use the SIM database.

This training was organized by WEMOS Foundation, (a DutchNGO), and GIFA (Geneva Infant Feeding Association). Theparticipation of two Albanian representatives was made possibleby UNICEF-Tirana office funding.

Soon after this training, we have begun the preparations toestablish our national monitoring project. Luckily enough to havedone a previous monitoring during 1998, we found it easier to


organize the second one, as we still had contacts with our monitorsin the districts, and part of the materials ready for the training. Weadopted SIM Forms, (Standart IBFAN Monitoring Forms) accordingto our National Law, (Law on Promotion and Protection ofBreastfeeding). In close collaboration with Reproductive HealthSector, we selected the districts in which the monitoring was goingto happen. We kept the core group of the monitoring of the FirstMonitoring Project, and we used some of the monitors asfacilitators in the training. Close links were established with theStatistics Sector at the MOH, which is considered as a partner inthis project.

11 districts were involved in the monitoring process: Berati,Gjirokastra, Lushnja, Shkodra, Peshkopia and Kukes (MonitoringMap at Appendix 7). Monitoring was performed from 24 persons,6 of them in Tirana, 3 in Durres, 2 in Korce, 3 in Elbasan, 1 in Berat,1 in Lushnje, 2 in Fier, 1 in Kukes, 1 in Peshkopi, 3 in Shkoder and1 in Gjirokaster.The districts involved in the study covered roughly all the countryareas, by the geographical point of view, the data were collected frombig cities as well as smaller ones, but with bigger number of deliveries, inorder to reach a big sample size.

A two days training was done in Tirana. All the monitors receivedtraining, during the first day they were trained on topics related toprotection and promotion of breastfeeding, on marketing practices ofbreastmilk substitutes, international and national legislative frameworkon breastfeeding protection, how to monitor, how to detect, evaluateand report a violation and on the responsibilities of health workersaccording to the Law. During the second day they were trained in tounderstand the content and value of each indicator, the methodology ofcollecting data, on interview techniques with mothers and how to fill inthe questionnaires. A Plan of Action was set up and division of theduties between monitors coming from bigger cities was done.Monitoring process was done during a 5 th months period, from December200-May 2001.Each monitor interviewed 50 mothers, monitored the practices of 2 healthcare facilities (maternity hospital/pediatric hospital/ and a childcounseling center/private clinic/ church clinic), three points of sale(supermarket, food store, drug store), 5 labels of infant formula/follow-up formula and complementary foods. Promotional materials of thecompanies and written and audio-visual media were monitored as well.Monitoring questionnaires are tested in 9 countries of the world, anddata entry was done according to a standard database, unified fordifferent countries.

Births by district Nr of births/yearBERAT 2147DURRES 2847ELBASAN 4077FIER 2977GJIROKASTER 854KORÇE 1980KUÇOVE 407 KUKES 1859LUSHNJE 2455SHKODER 3170TIRANE 9019TOTAL 31792


compliance with theInternational Code ofMarketing of BreastmilkSubstitutes and subsequentrelevant Health Assemblyresolutions, with regard tolabelling as well as all formsof advertising, andcommercial promotion in alltypes of media... to informthe general public onprogress in implementing theCode and subsequentrelevant Health Assemblyresolutions.

Around the year 1990,Albania receivedhumanitarian aids for thefirst time, which parts weretins of infant formula too.This was the first contact ofAlbania with this product,after many years of lackingof locally produced formula.It was in that period of timethat such paradoxeshappened, as donation of thetins of infant formula to thepupils and teachers ofelementary and secondaryschools. Meanwhile, the firstviolations appeared:promotion to the State TV,main newspapers, free and lowcost supplies, promotionwithin the health care system.Those donations put theinstitutions in a state ofdependency on this kind ofproductions and they broughtout the mode of their use.Soon the companiesestablished their market, andapplied their marketingmethods. Although Albaniais a small country, you canfind here the representativesand the distributors of almostall the multinationals: Hipp,Nestle, Nutricia/Cow&Gate,Wyeth, Danone, Bledina,Humana, HEINZ, Plasmon,Jothis etc. etc.During these years the numberof the companies who enteredto the market increased, and

Feeding Practices of Infants and YoungChildren in Albania, (1-2 years old)

• EXCLUSIVE BREASTFEEDING• PREDOMINANT BREASTFEEDING• TIMELY COMPLEMENTARY FEEDING• CONTINUED BREASTFEEDING AT ONE AND TWO YEARS OF AGE• BOTTLE FEEDING

THE AIM

SUBJECT OF THE STUDY


compliance with theInternational Code ofMarketing of BreastmilkSubstitutes and subsequentrelevant Health Assemblyresolutions, with regard tolabelling as well as all formsof advertising, andcommercial promotion in alltypes of media... to informthe general public onprogress in implementing theCode and subsequentrelevant Health Assemblyresolutions.

Around the year 1990,Albania receivedhumanitarian aids for thefirst time, which parts weretins of infant formula too.This was the first contact ofAlbania with this product,after many years of lackingof locally produced formula.It was in that period of timethat such paradoxeshappened, as donation of thetins of infant formula to thepupils and teachers ofelementary and secondaryschools. Meanwhile, the firstviolations appeared:promotion to the State TV,main newspapers, free and lowcost supplies, promotionwithin the health care system.Those donations put theinstitutions in a state ofdependency on this kind ofproductions and they broughtout the mode of their use.Soon the companiesestablished their market, andapplied their marketingmethods. Although Albaniais a small country, you canfind here the representativesand the distributors of almostall the multinationals: Hipp,Nestle, Nutricia/Cow&Gate,Wyeth, Danone, Bledina,Humana, HEINZ, Plasmon,Jothis etc. etc.During these years the numberof the companies who enteredto the market increased, and

Feeding Practices of Infants and YoungChildren in Albania, (1-2 years old)

One of the main objectives of this study was to perform a survey onfeeding practices of infants and young children in our country, basedon WHO’s indicators and WHO’s recommendations on exclusivebreastfeeding during the first six months of life, followed by introductionof complementary feeding (solids or semi-solids) from the 6th month on,and continuation of breastfeeding in the second year of life and beyond.The definitions of breastfeeding indicators and the specific methodologyof their measurement is reached at a wide consensus meeting of WHOexperts on 1991.The indicators measure these feeding categories:

• EXCLUSIVE BREASTFEEDING• PREDOMINANT BREASTFEEDING• TIMELY COMPLEMENTARY FEEDING• CONTINUED BREASTFEEDING AT ONE AND TWO YEARS OF AGE• BOTTLE FEEDING

These indicators help to assess breastfeeding practices andevaluate the progress of promotional programmes, are limited innumber, relatively easy to measure and interpret, and operationallyuseful. The focus of indicators is on intra-country comparison,although the degree of comparability between countries is also ofinterest.

THE AIM

Although the benefits of breastfeeding in terms of child survivalare well known, changes in child mortality are difficult to measureand cannot easily be attributed to specific interventions. Attitudestowards breastfeeding, awareness of the importance ofbreastfeeding, and support to enable mothers to breastfeed are allimportant outcomes of promotional activities in healthprogrammes, but they may also be difficult to measure and/orinterpret and may not reflect actual practice.

We measured some other indicators apart from thosedescribed above.

You can find at Annex 9 the definitions of breastfeedingcategories used in this report (all of which apply to the 24-hoursperiod preceding the enquiry).

The criteria for including the infants within the abovementioned cathegories, that are used for developing of theindicators are sumarised at the Table at Appendix 13.

SUBJECT OF THE STUDY

The material of the study were infants and children youngerthat 2 years old.

The total number of children that were included in the studywas 1204


the marketing methods becamemore sophisticated. Widedistribution of educationaland promotional materialsbegun, counseling phone lineswere offered by thecompanies’ doctor, companyrepresentatives visitedhospitals and maternities,where gifts and educationalmaterials were given to healthworkers, midwifes of thehealth centers distributedHIPP envelope for youngmothers (they wererecompensed with 50 leks foreach envelope).Baby foods industry hassponsored the pediatricconferences as well,distributing their educationalmaterials (leaflets) for healthworkers and has organizeddisplays of its products.The birth rate in Albania isvery high, which make a veryinteresting market for thebaby food industry.As infant formulas are morerecognized and sold, follow upformulas and other baby foodproducts constitute a smallpart of the market, as theirprices are very high, and thetradition of feeding infantswith cow’s milk, yogurts andhome-prepared solid foods isstill in place.During the period of economicgrowth, the marketing of theseproducts was increased andthe number of the distributorsalso, associated with theincrease of aggressive andunethical marketing practices.Breastmilk substitutes in ourcountry are marketing inpharmacies, as well as insupermarkets and groceries ordry good stores. Unlike inmajor towns, in other parts ofthe country, infant formulasare mainly marketed inpharmacies, and are oftencalled by parents “pharmacymilk”.

METHODOLOGY FOR MEASURING INDICATORS


the marketing methods becamemore sophisticated. Widedistribution of educationaland promotional materialsbegun, counseling phone lineswere offered by thecompanies’ doctor, companyrepresentatives visitedhospitals and maternities,where gifts and educationalmaterials were given to healthworkers, midwifes of thehealth centers distributedHIPP envelope for youngmothers (they wererecompensed with 50 leks foreach envelope).Baby foods industry hassponsored the pediatricconferences as well,distributing their educationalmaterials (leaflets) for healthworkers and has organizeddisplays of its products.The birth rate in Albania isvery high, which make a veryinteresting market for thebaby food industry.As infant formulas are morerecognized and sold, follow upformulas and other baby foodproducts constitute a smallpart of the market, as theirprices are very high, and thetradition of feeding infantswith cow’s milk, yogurts andhome-prepared solid foods isstill in place.During the period of economicgrowth, the marketing of theseproducts was increased andthe number of the distributorsalso, associated with theincrease of aggressive andunethical marketing practices.Breastmilk substitutes in ourcountry are marketing inpharmacies, as well as insupermarkets and groceries ordry good stores. Unlike inmajor towns, in other parts ofthe country, infant formulasare mainly marketed inpharmacies, and are oftencalled by parents “pharmacymilk”.

Graph. 1/1Distribution of studied cases according to their age-group.

METHODOLOGY FOR MEASURING INDICATORS

The breastfeeding indicators derived from interviews at thehousehold level are measured using a household surveymethodology. These indicators are based on all live children lessthan 24 months of age (not yet having had their second birthday).Deceased children are not included.

The indicators will be based on current status data, i.e., the currentage of the child and other information for the 24 hours precedingthe survey, rather than on retrospective data; mothers were notbeen asked when they stopped or started particular feedingpractices, which are questions that tend to produce a heaping ofdata at certain ages. The 24-hour recall period for feeding practiceswas selected because it has been widely used and foundappropriate in surveys of dietary intake.

Since it is the mother’s behaviour vis-à-vis her child(ren) that isof interest, it is recommended that the estimates be based on allchildren born in a given time period, rather than including onlythe last-born child. If only last-born children would be included inthe sample, the findings may be biased, and the bias may not beequal in all countries or among all population subgroups. Lastbirths are not a representative sample of all births.

In addition, last births are spread out over an unspecified period.The sample of children for whom the indicator is calculated shouldalways refer to all children born during a specified time period inorder to be representative of a population of children.

A questionnaire of interviewing the mothers was elaborated,based on the model-questionnaire of WHO for data collection.

Infants 0-6 months 353Infants 6-12 months 362Infants 0-12 months 715Children12-18 mths 290Children 18-24 mths 188Children 12-24 mths 418Children 0-24 mths: 1193

11 children of age 24-30 months were excluded from the studyof breastfeeding indicators.


SELECTION OF AGEGOUPS FOR MEASURINGBREASTFEEDING INDICA-TORS IN RELATION TOAGE-BASED FEEDINGRECOMMENDATIOMNS

Taking into consideration theRecommendations of WHAon Infants and YoungChildren Feeding, May 2001,(Appendix 1b), we did thefollowing interpretations:

- “All infants should be fedexclusively on breastmilkfrom birth to 6 months ofage”:

the inference of thisstatement is that 100% ofinfants up to exact age 6months (<180 days) should beexclusively breastfed.

- In order to meet theirnutritional requirements,complementary foods shouldbe introduced to the majorityof infants during atransitional period lasting 2months, (that is during theseventh and eighth months oflife). Thus, nearly all infantsolder than exact age 6 monthsshould be receivingcomplementary foods inaddition to breastmilk.

- Children should bebreastfed for at least one yearand preferably for up to 2years of age or beyond.

Taking into account the abovefeeding recommendationsand the limitations of typicalhousehold surveys in terms ofsample size, the meetingdecided that, for the purposeof measuring indicators, fourage groups should be used,and that, for the sake ofsimplicity, the four age groupsshould be of equal duration,i.e.,4 months each. Thesegroups are defined below:

Database and elaboration of the data

GENERAL OVERVIEW

INFORMATION TECHNOLOGY


SELECTION OF AGEGOUPS FOR MEASURINGBREASTFEEDING INDICA-TORS IN RELATION TOAGE-BASED FEEDINGRECOMMENDATIOMNS

Taking into consideration theRecommendations of WHAon Infants and YoungChildren Feeding, May 2001,(Appendix 1b), we did thefollowing interpretations:

- “All infants should be fedexclusively on breastmilkfrom birth to 6 months ofage”:

the inference of thisstatement is that 100% ofinfants up to exact age 6months (<180 days) should beexclusively breastfed.

- In order to meet theirnutritional requirements,complementary foods shouldbe introduced to the majorityof infants during atransitional period lasting 2months, (that is during theseventh and eighth months oflife). Thus, nearly all infantsolder than exact age 6 monthsshould be receivingcomplementary foods inaddition to breastmilk.

- Children should bebreastfed for at least one yearand preferably for up to 2years of age or beyond.

Taking into account the abovefeeding recommendationsand the limitations of typicalhousehold surveys in terms ofsample size, the meetingdecided that, for the purposeof measuring indicators, fourage groups should be used,and that, for the sake ofsimplicity, the four age groupsshould be of equal duration,i.e.,4 months each. Thesegroups are defined below:

All persons that collected the data (monitors) received trainingto understand the content and value of each indicator, themethodology of collecting the data, interview techniques withmothers and how to fill in the questionnaires.

Database and elaboration of the data

GENERAL OVERVIEW

Following collection of all completed questionnaires the workwas organized to complete data input into an electronic archive(Database), in order to allow further elaboration and productionof statistics and reports. A software application was used to createdata entry forms, customized to the questionnaire format.

In an integrated way, the data entry process was combinedwith correction and update software application to checkaccuracy of data entry. Once the database was complete and dataentry ended, the programs to elaborate the data and final reportformats were setted up to satisfy the necessary requirements offinal use of the collected information. Search and printing formswere setted up in consultation with working group and theproduced reports are represented at the final report.

INFORMATION TECHNOLOGY

Customized programs based on data entry and elaborationforms were used to complete the Information System required forthe study.

The program was built with the tool CENTURA and the databaseused was programmed with SQL Base version 6.1. The InformationTechnology specialist at the Ministry of Health and two operatorsworked to set up the system and complete Data Entry.


-EXCLUSIVEBREASTFEEDING andPREDOMINANTBREASTFEEDING aremeasured in infants up toexact age 4 months (120 days).

-TIMELYCOMPLEMENTARYFEEDING is measured ininfants older than exact age 6months but less than exact age10 months (180-299 days).

-CONTINUEDBREASTFEEDING ismeasured twice, in childrenone year old, and in childrennearing the end of theirsecond year of life - that is, agegroups older than exact age 12months but less than exact age16 months, and older thanexact age 20 months but lessthan exact age 24 months.

TIMELY FIRST-SUCKLING RATE

Out of 788 infants age 0-12months, only 342 (43,4% tetyre) have startedbreastfeeding within the first24 hours of life. The graphwhich illustrates early start ofbreastfeeding according toeach district, indicates that inthe Materntity of Fieri, 99% ofborned babies are placed atbreast within the first hour oflife, followed by the Maternityof Tirana with 65%, Korcawith 47%, Elbasani with 45%,Lushnja with 41%, Durresiwith 32% and Shkodra with14%. In the maternities inKukes, Berat and Gjirokastra,none of the newborns areplaced at breast within thefirst hour of life.

Results and Discussion


-EXCLUSIVEBREASTFEEDING andPREDOMINANTBREASTFEEDING aremeasured in infants up toexact age 4 months (120 days).

-TIMELYCOMPLEMENTARYFEEDING is measured ininfants older than exact age 6months but less than exact age10 months (180-299 days).

-CONTINUEDBREASTFEEDING ismeasured twice, in childrenone year old, and in childrennearing the end of theirsecond year of life - that is, agegroups older than exact age 12months but less than exact age16 months, and older thanexact age 20 months but lessthan exact age 24 months.

TIMELY FIRST-SUCKLING RATE

Out of 788 infants age 0-12months, only 342 (43,4% tetyre) have startedbreastfeeding within the first24 hours of life. The graphwhich illustrates early start ofbreastfeeding according toeach district, indicates that inthe Materntity of Fieri, 99% ofborned babies are placed atbreast within the first hour oflife, followed by the Maternityof Tirana with 65%, Korcawith 47%, Elbasani with 45%,Lushnja with 41%, Durresiwith 32% and Shkodra with14%. In the maternities inKukes, Berat and Gjirokastra,none of the newborns areplaced at breast within thefirst hour of life.

Results and Discussion

From 1135 interviewed mothers, 101 (9%), had universityeducation, whereas 1034, (91%) had only secondary schooleducation.

Graphic 1- Degree of education of interviewed mothers67,7% of all mothers were unemployed, whereas 32,2%

employed. More specifically the percentage of employment variesin different districts as follows: Gjirokastra: 61%, Korca: 60%,Tirana: 35%, Durresi: 31%, Elbasani:27% etj.

Graphic 2. Degree of employment of interviewed mothers


ROOMING- IN RATEOut of the 1134 babies, only 614(54,14%) of them have been placedin the same room with the motherduring their stay in the maternityhospitals. According to districts,89% of mothers that have deliveredin the maternity of Tirana, haveshared the room with their baby,80% of mothers in Fier, 77% inElbasan, 63% in Korce, 60% inDurres, 48% in Lushnje, 4% inBerat and only 1% in Shkoder. Noneof the mothers that delivered theirbabies in Gjirokaster, Kucova andKukes, shared the room with theirbabies.The mothers that didn’t share theroom with their babies during the24 hours, (day and night) havereported that the average time ofstay with their babies was 6,72hours. Among the main reasons ofnot staying with their babies themothers report most frequentlydifficulties to move due to thestructure and internal rules of thematernities in 66.5%. 10% of themsay they are forbitten to see theirbabies; 24% are not allowed due tothe internal rules of the maternityand their clinical practice; 18% saythe baby stays in a separate room;9% indicate lack of appropriateconditions; 0.5% complain of a coldenvironment; 2% indicate that thereis not enough space and 3% thatdue to the rehabilitation of thematernity hospitals they couldn’tshare the room with the babies.

The second block of reasons (27%)relates to health issues, out ofwhich (5%) related to the health ofthe mother, 11% with the baby, andanother 11% are due to C-sectiondelivery. Only 1.5% of the reasonsare due to psychological barriers ofthe mother or wrong information;fear from asphyxia (1%) or lack ofdesire (0.5%). In 5% of the cases themother gives no reason whyrooming-in is not applied.

Graph. 6 shows the incidence ofexclusive breastfeeding for eachmonth until the end of the first yearof life. As you can see, in the firstmonth the exclusive breastfeedingis as high as 69%, but drops into56% in the second month andremains stable through the thirdmonth, but drops down again inthe following 4th month of life into39% and continues to do so downto 23% in the 6th month. After thismonth supplementary foods areadded into the diet and exclusivebreastfeeding is rarely the case,only 2.4%.


ROOMING- IN RATEOut of the 1134 babies, only 614(54,14%) of them have been placedin the same room with the motherduring their stay in the maternityhospitals. According to districts,89% of mothers that have deliveredin the maternity of Tirana, haveshared the room with their baby,80% of mothers in Fier, 77% inElbasan, 63% in Korce, 60% inDurres, 48% in Lushnje, 4% inBerat and only 1% in Shkoder. Noneof the mothers that delivered theirbabies in Gjirokaster, Kucova andKukes, shared the room with theirbabies.The mothers that didn’t share theroom with their babies during the24 hours, (day and night) havereported that the average time ofstay with their babies was 6,72hours. Among the main reasons ofnot staying with their babies themothers report most frequentlydifficulties to move due to thestructure and internal rules of thematernities in 66.5%. 10% of themsay they are forbitten to see theirbabies; 24% are not allowed due tothe internal rules of the maternityand their clinical practice; 18% saythe baby stays in a separate room;9% indicate lack of appropriateconditions; 0.5% complain of a coldenvironment; 2% indicate that thereis not enough space and 3% thatdue to the rehabilitation of thematernity hospitals they couldn’tshare the room with the babies.

The second block of reasons (27%)relates to health issues, out ofwhich (5%) related to the health ofthe mother, 11% with the baby, andanother 11% are due to C-sectiondelivery. Only 1.5% of the reasonsare due to psychological barriers ofthe mother or wrong information;fear from asphyxia (1%) or lack ofdesire (0.5%). In 5% of the cases themother gives no reason whyrooming-in is not applied.

Graph. 6 shows the incidence ofexclusive breastfeeding for eachmonth until the end of the first yearof life. As you can see, in the firstmonth the exclusive breastfeedingis as high as 69%, but drops into56% in the second month andremains stable through the thirdmonth, but drops down again inthe following 4th month of life into39% and continues to do so downto 23% in the 6th month. After thismonth supplementary foods areadded into the diet and exclusivebreastfeeding is rarely the case,only 2.4%.

Graphic 4- Rooming-in Rate according to districts

Graphic 5: Main reasons of separation of mother from thebaby at the maternity.

Exclusive breasfeeding rate at 4 th month is calculated 52,4%.

Exclusive breasfeeding at 6th month is calculated 43,6%.

Graphic 6.Exclusive Breastfeeding according to the months


Graph. 7. In this graph. are giventhe % of breastfeeding (infants whobreastfeed, regardless of the type)according to the age groups ofinfants in the study, starting in thefirst month through 2 years of age.It is observed that 90% of all infantsare breastfed during the first 6months, whereas only 70% continuebreastfeeding through the secondhalf of the first year. Approximately35% of children continue to receivebreast milk through their first 6month of the 2nd year of life, butthere is a sharp fall down to 9.4% inthe second half of the same year.

Graph. 8 Tendencies of startingnon-nutritive liquids (water,glucose water, herbal teas) andfruit juices in addition to breastmilk.In the first month 19% of babiesstart to receive non nutritiveliquids, in the second months 36%of them (it’s here that fruit juicesare started too), in the fourthmonth 53%, to add up to 64% inthe fifth month, and 93% in thesixth month, after which allchildren receive non nutritiveliquids and fruit juices.

Graph. 9The cow’s milk has a tendency tobe added to the diet of breastfedbabies even in the first fourmonths of life. 29% of studiedinfants received cow’s milk at theage of 5 months. 48% of childrenreceived cow’s milk or other foodprepared with it, during their 6thmonth of life and 80% of themduring the second half of the firstyear of life.

In graph 10 is given the % ofcow’s milk in the diet of each agegroup, starting the first month oflife through the end of the firstyear. It is clear that cow’s milkand other food prepared with itare widely used (up to 70%)inthe 2nd half of the first year of life.


Graphic 7 Graph. 7. In this graph. are giventhe % of breastfeeding (infants whobreastfeed, regardless of the type)according to the age groups ofinfants in the study, starting in thefirst month through 2 years of age.It is observed that 90% of all infantsare breastfed during the first 6months, whereas only 70% continuebreastfeeding through the secondhalf of the first year. Approximately35% of children continue to receivebreast milk through their first 6month of the 2nd year of life, butthere is a sharp fall down to 9.4% inthe second half of the same year.

Graphic 8.

Graphic 9

Graphic 10

Graph. 8 Tendencies of startingnon-nutritive liquids (water,glucose water, herbal teas) andfruit juices in addition to breastmilk.In the first month 19% of babiesstart to receive non nutritiveliquids, in the second months 36%of them (it’s here that fruit juicesare started too), in the fourthmonth 53%, to add up to 64% inthe fifth month, and 93% in thesixth month, after which allchildren receive non nutritiveliquids and fruit juices.

Graph. 9The cow’s milk has a tendency tobe added to the diet of breastfedbabies even in the first fourmonths of life. 29% of studiedinfants received cow’s milk at theage of 5 months. 48% of childrenreceived cow’s milk or other foodprepared with it, during their 6th

month of life and 80% of themduring the second half of the firstyear of life.

In graph 10 is given the % ofcow’s milk in the diet of each agegroup, starting the first month oflife through the end of the firstyear. It is clear that cow’s milkand other food prepared with itare widely used (up to 70%)inthe 2nd half of the first year of life.


Graph 12 shows mixedfeeding, with breast milk andsolids or semi-solids duringthe first 2 years of life. 13% ofchildren start to takesupplementary food in the fifthmonth, 29% in the 6 th monthand 61% in the 7 th month.There is a sharp increase oftheir use in the 8 th month up to81% and goes almost 90% inremaining months through thefirst year of life. Following allchildren receive solid foods intheir diet during their 2nd yearof life.

Graph. 13 represent use ofadditional vitamins inbreastfed infants. In thequestionnaire it is notspecified what type ofvitamine is given, but most ofthe monitors report large useof vitamine D by drops p.os.and other vitamins, whichmainly is prescribed by theirfamily doctor along withantibiotics in case of disease.

Graph.14 It is clear in thegraph that bay the end of thefirst year of life 54% of thechildren continue tobreastfeed, whereas bay theend of the second year only7.8% of them do so.

Graph 11 shows the use ofinfant formulas during thefirst year of life. Their use islow, varying from 10-20%.


Graphic 12

Graphic 13

Timely complementary feeding rate at 6-9 months is calculatedto be 80%CONTINUED BREASTFEEDING RATE (1 YEAR) is 54%CONTINUED BREASTFEEDING RATE (2 YEARS) is 7,8%Graphic 14

Graph 12 shows mixedfeeding, with breast milk andsolids or semi-solids duringthe first 2 years of life. 13% ofchildren start to takesupplementary food in the fifthmonth, 29% in the 6 th monthand 61% in the 7 th month.There is a sharp increase oftheir use in the 8 th month up to81% and goes almost 90% inremaining months through thefirst year of life. Following allchildren receive solid foods intheir diet during their 2nd yearof life.

Graph. 13 represent use ofadditional vitamins inbreastfed infants. In thequestionnaire it is notspecified what type ofvitamine is given, but most ofthe monitors report large useof vitamine D by drops p.os.and other vitamins, whichmainly is prescribed by theirfamily doctor along withantibiotics in case of disease.

Graph.14 It is clear in thegraph that bay the end of thefirst year of life 54% of thechildren continue tobreastfeed, whereas bay theend of the second year only7.8% of them do so.

Graphic 11Graph 11 shows the use ofinfant formulas during thefirst year of life. Their use islow, varying from 10-20%.


Graph 15From the total number ofstudied children (1135children), it was observed that30% of them are bottle-fedduring their first year of life.

Graph 16 shows variations ofbottle feeding in various agegroups.

In graph 17 the abovevariations are given fordifferent districts. The highestvalue is reached inShkoder(54%), followed byGjirokastra (35%) and Fieri34%, Durresi and Lushnja30%, Tirana and Korca 27%.

Graph. 18 Pacifier’s use rate41% of the children were usingpacifiers, (121 out of 1135children).


Graph 19 summarizes all various forms of nutrition, indicating month tomonth the observed tendencies.

In our cohort children exclusivebreastfeeding during the first monthwas in average 70%, falls to 55% on 2nd

month, in order to remain stable duringthe 3rd month, but falls again in the 4th

month into 40%. In the 5th month only30% of children are breastfed exclu-sively, and 20% in the 6th month.

Over 80% of children that we havestudied result have been breastfed in thefirst 10 month of their life, or over 60%during the first year of life. It has beenobserved a tendency to start early

feeding of children that breastfeed, withsolid and semi-solid foods, but suchtendency is embraced only by 10% of thestudied group. Even use of formula milkremains similarly low at 10-20%.

There is a major change starting afterthe 4th month, because over 30% preferto start complementary foods. More thanhalf of the children receive such foods,to add up to 70% and 80% the coming 7th

and 8th month. Such tendency remainsunchanged through the 11th month andtops 90% by the end of the first year.


Discussion of the results

EDUCATION DEGREE AND WORKINGSTATUS OF MOTHERS

TIMELY FIRST SUCKLING RATE ANDROOMING-IN RATE

EXCLUSIVE BREASTFEEDING

BREASFEEDING RATE

COW’S MILK

FORMULA USE


Discussion of the results

EDUCATION DEGREE AND WORKINGSTATUS OF MOTHERS

The average of mothers included at the studywith high school degree reaches 91%.Unemployment rate among mothers was really high,up to 67,7%.

TIMELY FIRST SUCKLING RATE ANDROOMING-IN RATE

Only 43,4% have started suckling at thematernity during the first hour following delivery.There is a clear difference among the maternities inFier, Tirane and Korce where the staff has receivedadequate training (18 hours module), compared tothe maternities in Shkodra, Kukes, Berat andGjirokastra, where this index is very low, (14% inShkoder), or it’s not applicable at all, – which is thecase for the other three cities.

The rooming-in rate remains low, only 54% ofthe children have shared the room with theirmothers during the 24hours of the day, (includingdaylight and night). This rate is higher in theMaternities of Fier, Tirana, Elbasani and Korca, butrooming-in practices are not applicable at all inGjirokaster, Kucove and Kukes.

The result of 89% in the maternity of Tirana it’squite satisfactory, if taken into account the largenumber of deliveries by C-section in this maternity,due to the fact that rooming-in for the first daysfollowing the surgery is not applied. On the otherhand, remains much left to be done in the othermaternities to improve the practice of rooming–in.The mothers who do not stay all the time with theirbabies during the 24hours have reported andaverage time of stay of 6.72 hours. The main reportedreason for not fully applying rooming-in was thestructure of the maternities and their functioning.This leads to the need of motivating the Directoratesof these maternities to undertake the necessarychanges in the structure and daily practices. Havingin hand a powerful tool, the Order nr.157 of theMoH and the the Guidelines that supports itsimplementation, all of us should take concrete stepsin putting it into practice.

EXCLUSIVE BREASTFEEDINGExclusive breastfeeding rate at the 4th month

reaches 52%, (same to the international average),which indicates that more than half of the childrenthat participated into the study were fed exclusivelywith breast milk for their first 4 months of life,whereas only 44% up to the 6 th month. Taking intoaccount the priorities of breastfeeding in the first 6months of life, especially in our case, it is veryimportant to insist in working in this direction,changing the mentality of mothers, but also the

practice and belifs of the healthcare staff, in orderto avoid useless supplementations with nutritiveand non nutritive liquids, as well as othercomplementary foods. Although mothers startexclusive breasfeeding upon recommendations andin consultation with the maternity staff, yet thisindex remains only 69%, indicating that mothersquit very fast in front of first week difficulties ofbaby’s nutrition and at the same time they start (in19% of cases), to give them herbal teas or otherliquids. During the 2nd and the 3rd month the rateremains stable at 56%, which indicates that almosthalf of the children have missed their chance toexclusively breastfeed and benefit from the prioritiesof it. In the 2nd month 36% of the children werestarted other liquids, and it is indicated as the timewhen mothers begin to prepare and give fruit juicesto the children, sometimes this happens uponrecommendation of the healthcare staff. In the 4th

month the rate goes down to 39%, i.e. over 60% ofthe mothers have started their children oncomplementary foods, out of which 53% are nonnutritive and nutritive liquids. Only 23% of themothers continue exclusive breastfeeding by the 6 th

month of age.

BREASFEEDING RATEThe collected data on breastfeeding rate,

(children that are breastfed regardless how), accordingto the age group of studied children in the firstmonth of their life, up to 2 years, indicate that onthe first 6 months, approximately 90% of them arebreastfed, whereas 70% continue even the secondhalf of the first year to do so. By the end of the firstyear of life 54% of children continure to receivebreast milk, but only 7.8% of them continue to do soby the end of the second year. This phenomenon isrelated to the wrong belief of the mothers, who notrarely are misinformed by the healthcare staff, thatin the second year of life the breast milk providesno added value for the child.

COW’S MILKThere is a tendency to start cow’s milk as

complementary to breastmilk since the 4 th month oflife. 29% of children in the study were found toreceive cow’s milk in their 5th month of life. Thispercentage increases up to 48% on the 6th monthfor the food prepared with cow’s milk, and adds upto 70% in the second 6 months of first year.

FORMULA USEActual use of infant formula remains low, (10-

20%) mainly due to their high price, which isunaffordable for the budget of the Albanian familiesand obviously the more traditional use of cow’s milk.


COMPLEMENTARY FOOD

USE OF FEEDING BOTTLES

CONCLUSIONS


COMPLEMENTARY FOODThere is a tendency to start complementary food

(semi-solid or solid) durig the first four months, butthis happens in no more than 10% of children. In thefollowing months this tendency becomes strongerand reaches 30% in the 5 th month. More than half ofchildren receive complementary food in the 6t h

month, 70% in the 7 th month, and more thans 80% inthe 8 th month, it remains at the same level up to the11th month and adds up to 90% at the end of the firstyear. The start of complementary foods at theappropriate time (6-9m) is 80% (internationalaverage 49%). Although this index is at satisfactorylevels, we should aim at assuring both quantitativeand qualitative food after the 6 th month, safe for thechild’s health and most preferably home made.

USE OF FEEDING BOTTLESDuring the first year 30% of children are fed by

bottles, which puts them at the risks constituted bythis way of feeding. The highest percentage of useit’s observed in the cities of Shkoder, Gjirokaster,where bottlefeeding starts at the maternities. Themothers are quite attracted by the images of healthychildren with bottles in their hands, as well as otherindustrialized food that could be prepared and fedto the child by using the feeding bottle. (see photosin pg 28,29).

CONCLUSIONSThe breastfeeding situation in our country has

improved significantly compared to the resultsprovided by the First Monitoring Project. It is clearthat there is a major change in between the citieswhere an intervention was made in providingtraining to the healthcare staff through the 18 hourstraining module, and other cities where thisintervention is missing.

The supportive practices to breastfeeding in thematernities: early start of breastfeeding within thefirst hour of life, complete application of rooming-in,for 24 hours (day and night), provision of supportiveinformation to the mother by the healthcare staffduring their stay in the maternity, practical help tobetter positioning of the child on mother’s breast,have been proven to be the basis for a good start inbreastfeeding and successful continuation of it lateron. This is why it becomes emergent to intervene inall maternities and apply the 10 Steps of the “BabyFriendly Hospital Initiative” as the golden standartof the care for the neonate and assurance ofbreastfeeding in the maternity. Nothing could justifylack or incomplete application of rooming-in, whichbring to arbitrary separation of the mother from thechild in the maternities.

It is obvious that the healthcare staff has beensensibilized on the priorities of exclusivebreastfeeding in the first 6 months, which is alsoreflected in improvements of its rate compared to

previous studies. Nevertheles, much remains to bedone in supporting the mothers in the first month,during which they face the major challenges infeeding their child and jump into giving them non-nutritive liquids or useless complementary foods.The 4th month seems to be a crucial moment, too,because this is the time when most of mothers startthinking about starting complementary foods totheir children. Building the belief among healthprofessionals through continuous training,updating them on the latest scientific andprofessional debate on the priorities of exclusivebreastfeeding in the first 6 months of life, stressingthe vital importance and its impact on the health ofthe child and application especially in the realityof our country, as well as making mothers trust thispriorities and apply breastfeeding should representthe pillars of future intervention and work to bedone. Actually more than half of the children in thestudy do not receive breasmilk in their 2nd year oflife. This is believed to be the reality in the cities,because in the countryside breastfeeding continueslonger. Such issue, is another hot topic upon whichthe health professionals and the mothers themselvesshould be sensibilized in order to increase rates ofcontinuation of breastfeeding in the 2nd year of life,alongside to providing for all calories as well asproteins, lipids and most importantly Vitamin C,other vitamins and antibodies which are readilyprovided through mother’s milk. It is reallyimportant to start complementary food on the righttime, amount and quality after the 6th months oflife, most preferably home made, in addition tocontinuing breastfeeding through the 2nd year of lifeand further on.

Feeding infants with bottles, along withproblems generated from this practice havecontinued to grow in our country. Marketing ofindustrialized food that could be provided throughfeeding bottles, their labels with attractive imagesof healthy children, the false image of the symbolmother in good economic conditions whobottlefeeds her child, employment of the mother andpremature termination of payed maternity leave, aswell as wrong practices imported from theexperiences abroad in immigration, are the mainfactors contributing to the increasing usage of thebottle, jeopardizing breastfeeding. Instead, any childthat needs complementary food should be given itby by spoon and not by the feeding bottle.

In conclusion, collection of data based onindicators of WHO and setting up of thebreastfeeding database, gives us a clear picture ofthe situation in our country and sets the ground forcomparative studies in the future, evaluation of theimpact of the programs or various interventions onthe health of the mother and child and helps inguiding the work in this area.


ARTICLE 4

For a manufacturer, or aseller is prohibited,advertising and promotion ofany designated product inarticle 2, including specialvisual presentation ondisplays, special sales,premiums, advertising fordiscount, discount on specialconditions, or gifts and theirpromotion in a health carefacility in state or privatehealth system.

ARTICLE 5

A manufacturer or any otherperson on his behalf and anyseller shall not:

a. sell to a health state orprivate facility thedesignated products definedon article 2, lower thanpublished price

b. donate or distribute withina health care facility,equipment or offer services,and promotion materialswhich are referred, orpromote the use of adesignated product definedon article 2 point ç of thislaw, excluded that caseswhen these products aredefined as humanitarydonations.

c. offer benefit, gifts,contributions, to the healthworkers engaged in maternaland child health

d. sponsor activities, whichare related to the health ofmother and children, apartfrom their form ofpresentations, excludedthose activities which have ascientific character only.

2. PROMOTION OF BREASTMILKSUBSTITUTES THROUGH THEHEALTHCARE SYSTEM


ARTICLE 4

For a manufacturer, or aseller is prohibited,advertising and promotion ofany designated product inarticle 2, including specialvisual presentation ondisplays, special sales,premiums, advertising fordiscount, discount on specialconditions, or gifts and theirpromotion in a health carefacility in state or privatehealth system.

ARTICLE 5

A manufacturer or any otherperson on his behalf and anyseller shall not:

a. sell to a health state orprivate facility thedesignated products definedon article 2, lower thanpublished price

b. donate or distribute withina health care facility,equipment or offer services,and promotion materialswhich are referred, orpromote the use of adesignated product definedon article 2 point ç of thislaw, excluded that caseswhen these products aredefined as humanitarydonations.

c. offer benefit, gifts,contributions, to the healthworkers engaged in maternaland child health

d. sponsor activities, whichare related to the health ofmother and children, apartfrom their form ofpresentations, excludedthose activities which have ascientific character only.

Distributed by the community of Sant-Egidio in Kukes.

2. PROMOTION OF BREASTMILKSUBSTITUTES THROUGH THEHEALTHCARE SYSTEM

34 health units were included in the monitoring activities.10 of them were maternity clinics, 6 pediatric clinics and therest of 18 units were primary healthcare centers and motherand child counselling centers.

20 % (2) of the maternities were “Baby FriendlyHospitals”. No promotional material produced by thecompanies, donations or free samples to mothers (exceptone case) were found. Breast milk substitutes were usedonly in the cases that had medical indications. Limitedprocurement of breast milk substitutes was done same asfor other food or drugs.

The only case of violation was in Kukes, where theCommunity of Saint Egidio was distributing HIPP productsfor infants, (HIPP Friscmilchbrei). The distribution wasconducted through the pediatrician of the hospital and thenurses of the mother and child consultory, but only for theinfants with malnutrition or with other problems, onmonthly bases (1-2 cans once a month, accompanied withinstruction to use them only 1-2 times per day to supplementbreastfeeding or other food). We posse the questions: “Isthis the best way of helping the children? Who is makingthe evaluation and on which criteria?, How could be avoidedthat normal breasfed babies are not affected? Is it enoughfood to really supplement the diet of the babies, for aslong as they need it?”

Same practice was reported in Shkodra. 2 years ago thesame organization, distributed HIPP infant formula in allmother and child consultories in this city. It looks that this


ARTICLE 6

A health worker engaged inmaternal and child healthshall not:

a. accept any gift,contribution, or benefit froma manufacturer, distributor,or any other person on hisbehalf

b. accept or distributesamples of designatedproducts to any person

c. promote the use ofdesignated products onarticle 2 point ç, excludedvery special cases whereexist an absolute indicationfor their use, and in that casemust give a clearexplanation of their hazards.

ARTICLE 10

Heads of health care facilitiesand national and local healthauthorities shall takemeasures to encourage andprotect breastfeeding and toinform the public about thegreat negative effects of otheralternative feedings

HEALTH OR PROFIT? THE ETERNAL DILEMANewborns babies need breastfeeding to ensure ideal feeding, best immunisation

status and optimal bonding with their mothers.But, for each exclusively breastfed child for six months, the industry doesn’t take

the profit of 450 USD.It is calculated that, in the annual value of industrialised foods for children, the

ammount of the profit taken from the use of recommended foods of the grup-age4-6 months reaches 1 billion USD.


ARTICLE 6

A health worker engaged inmaternal and child healthshall not:

a. accept any gift,contribution, or benefit froma manufacturer, distributor,or any other person on hisbehalf

b. accept or distributesamples of designatedproducts to any person

c. promote the use ofdesignated products onarticle 2 point ç, excludedvery special cases whereexist an absolute indicationfor their use, and in that casemust give a clearexplanation of their hazards.

ARTICLE 10

Heads of health care facilitiesand national and local healthauthorities shall takemeasures to encourage andprotect breastfeeding and toinform the public about thegreat negative effects of otheralternative feedings

Poster of HIPP in Berat.

The tin of Frisolac, found at Durres maternity.

HEALTH OR PROFIT? THE ETERNAL DILEMANewborns babies need breastfeeding to ensure ideal feeding, best immunisation

status and optimal bonding with their mothers.But, for each exclusively breastfed child for six months, the industry doesn’t take

the profit of 450 USD.It is calculated that, in the annual value of industrialised foods for children, the

ammount of the profit taken from the use of recommended foods of the grup-age4-6 months reaches 1 billion USD.

practice is over by now, andaccording to our reports it hasbeen going on for limited timeas part of a study on anemia andmalnutrition in children. Thepediatric clinics buy infant’sfood same as other i tems,whereas mother and childconsultories and privat clinicsdon’t buy at all such items.

The monitors didn’t detectany tendency in the hospital clinics to promote or stimulateselling of these products, but noticed large use ofpromotional materials at in the counseling centers anddoctor’s offices in privare practice. A variety of old posters,calendars, wall-clocks with the logo or name of thecompanies was seen in these places. Commercial promotionwas observed in 50% of health units.

The company that used such promotion is HIPP.In the district of Durres the monitor could find a can of

Frisolac formula milk in a mother that had a C-section delivery.The mother herself has bought it, based on recommendationof the doctor.

Sporadicreports ofpurchase of infantformulas by themother were givenin the maternity ofShkodra and at thePediatric Hospitalin Durres. As longas for the rest ofthe milk, it hasbeen procuredthrough thenormal channels(mostly wholemilk from “Ajka”company).


3. TARGETING MOTHERS


NUMICODerives from the fusion of

NUTRICIA, MILUPA andCow &Gate (the latest one isnot much marketed in ourcountry and in Italy)

-multinational company offood for infants, the secondlargest after Nesstle

- 33 branches in equalnumber of countries and 65distributors in various cou-ntries.

Annual turnover for theyear 2000 was 2300 millionsof Euro (376 million grossprofits), 923 millions only infoods for infants; employs10’000 workers in 45 establi-shments.

Main offices:Rokkeveenseweg 49, 2712PJ Zoetermeer, Hollande

Tel.: 0031 79 353 9000,Fax.: 0031 79 353 9620,

Website:www.numico.com or

www.nutricia.com

Main products: Milumil,Aptamil, Nutrilon, Conformil,Omneo, Nektarmil, Babypiu,Neosoya, Som, Pregomin,HN25, cereals, biscuits, soups,teas, fruit juices, powdered orhomogenized products.

3. TARGETING MOTHERS

A total of 615 mothers that had a child under six months of agewere interviewed.

Graph 20.

From the total of 615 mothers, 140 (22,7%) were found to useformula milk and other industrialized food such as various liquids,cereals, tea and mixed fruit juices etc.

Graph. 21:

The most frequent brands of formulas are: FRISOLAC, HIPP,FRANCE LAIT and BEBELAC.

Graph. 22

The most frequent reason for a mother to make the choice of abrand of infant formula was the suggestion of a healthcare staff,(in 41% of the cases, 11% was suggestion of a nurse), in 24% ofcases the suggestion came from the relatives, 14 % of mothers chosethe brand based on their previous experience and only in 2.14 % ofthe cases this decision has come due to advertising of theproducing company.


HUMANApresent in the alimentary

sector with the brands HU-MANA and MILTE

Main Offices:Bielefelder Strasse 66,

32046 Gerford, GjermaniTel.: 0049 5221 1810,

Fax.: 0049 5221 181300,Website:

www.humana.de andwww.humana.it

Annual turnover in Italy: 78billions of Italian Lireta in1998. The main products are:Humana, Sinelac, Miltina,Colimil, Disanal, Sedastip,cereals and other food pro-ducts to stop breastfeeding. Inaddition to this has commer-cialized the water “Amorosa”and the products of “Der-mana” and “Linea blue” forthe neonate (cologne, powder,bath foam, oils etc… which areadvertised together to infantformula and other productsthat aim at stopping breast-feeding).

70% of mothers answered for other reasons, except for thosementioned in questionary. 9% of reasons are those related todoctor’s or relative’s reccomendation and 7% from the personalexperiences. Only 2% of those are answered that they areinfluenced by the advertisment to make the choice of the brand.

NESTLEit is the largest multinational company in the alimentary

sector and at the same time the largest Swiss industry.

Main Offices:Avenue Nestle 55, PO Box: 353,

CH 1800 Vevey, Zvicer;Tel.: 0041 21 924 2111, Fax.: 0041 21 924 2813;

Website: www.nestle.com

Factories in the world: over 450 in 100 different countriesand employs 230’000 workers.

Annual turnover: approximately 50 billion USD, with 3billion USD gross profits. Their products are: approximately1200, practically sold all over the globe. The principal brandnames in the sector of infant food are: Nestle and Guigoz. Mainproduct of infant food are: Alsoy, Alfare, AL 110, Nolac, Arobon,Nidex, Latte mio, Primi Passi, Cerelac, different cereals etc.

Graph 23.The most frequent brand of industrialized infant food.

The most frequent brands of industrialised infants foods are:PLASMON, HIPP, NOYNOY, FRUTOCREMA, CEREALI dheBLEDINA.

Graph. 24


4. SELLING POINTS


HEINZmultinational company of

food products that sells closeto 10 billion USD annually. Itcontrols around 50 companies(44’700 workers) employed in200 countries and produce5000 different products.

Among the most famousbrand names are: Heinz,Weight Watchers, Farley’s, TheBudget Gourmet, john West.

In Italy is present with thebrands: Plasmon, Dieterba,Nipiol and Bi-Aglut.

Main Offices:PO Box 57, Pittsburgh,

Pennsylvania 15230-0057,U.S.A.Website:

www.heinz-baby.com

Their main products forearly childhood are: Primigi-orni, Vivena, Nipiolac, Alidiar,Transilat, Late David, cereals,biscuits, small cheese, fruitjuice, tea, medicinal herbal tea,powder and homogenizedfood.

Advertisment in public Korca city.

Plasmon’s food for babies reccomme-nded from the fourth month of life. Thelabel contains the baby picture.Poster of HIPP, in one drug store in Korca.

4. SELLING POINTS

50 selling points (20 shops and 30 pharmacies) in 11 cities inAlbania were visited. In 25 of them, especially pharmacies,promotional materials of various companies were found. Thecompanies that most frequently use this way of reaching out tothe customers were: HIPP, HUMANA, NOYNOY, NESTLE,CHICCO, NUK. In the table below it is indicated more specificallyhow each company advertises for their products which isincluded in the Law.

Type of advertising Nr of selling points %Posters 24 48%Special displays 39 78%Use of gifts 0Reduction in price 1 2%Promotional leafletdistributionto mothers 10 20%Ties in sale 0Plastic bags withthe logo and nameof the company 0

Drug stores play a special role. As the main selling point forinfant food and other food products they should educate theconsumers on the health risks of these products, as well as how tobetter use them. Instead, the pharmacies are being used to promotecommercially breast milk substitutes.

This is more obvious in the big cities where it is sold the bulk ofthese products. In smaller cities the pharmacists report that only alimited number of people could afford to buy and use infant formulamilk for the first few months of the child, and even less to buy otherinfant food products.

One selling point in Tirana “Baby Dream”, offered 20%reduction in price for supplementary infant food of HIPP. Therewas no reduction in price for the infant formula or the follow upformula milk.


ARTICLE 7A manufacturer, distributor orseller shall not offer for sale orsell infant formulas, unlessthe container, or label shallnot have the following words:“ Breastmilk is the ideal foodfor healthy growing anddevelopment of children.Before you decide to modify,or substitute the breast milkconsult your doctor.”

ARTICLE 8A manufacturer, distributor, orseller shall not offer for sale,or sell follow -up formulas,a. unless the container, orlabel shall not have thefollowing words:“Breastmilk is the ideal foodfor healthy growing anddevelopment of children.ATTENTION ! this productshall be used for infants up tosix months. Before you decideto modify, or substitute thebreast milk consult yourdoctor.”b. the label promote artificialfeeding

5. LABELS

LABELS OF THE INFANT FORMULAS


ARTICLE 7A manufacturer, distributor orseller shall not offer for sale orsell infant formulas, unlessthe container, or label shallnot have the following words:“ Breastmilk is the ideal foodfor healthy growing anddevelopment of children.Before you decide to modify,or substitute the breast milkconsult your doctor.”

ARTICLE 8A manufacturer, distributor, orseller shall not offer for sale,or sell follow -up formulas,a. unless the container, orlabel shall not have thefollowing words:“Breastmilk is the ideal foodfor healthy growing anddevelopment of children.ATTENTION ! this productshall be used for infants up tosix months. Before you decideto modify, or substitute thebreast milk consult yourdoctor.”b. the label promote artificialfeeding

Similar labelsbetween infantformula andfollow-upformula.

5. LABELS

LABELS OF THE INFANT FORMULAS

During the monitoring process all brands of infant formulasthat were found at the selling points or at mother’s home wereanalysed. Almost all companies violate the rules by disegninglabels that have attractive images or text messages that couldinfluence mothers to decide quit breastfeeding and switch to thebottle feeding.

The most frequent labelling violations are as follows:

* “Important Note” is missing (NOYNOY)* doesn’t state that breast milk is superior, or it’s written only

in foreing language, not in Albanian (all product’s labels);

* there is no clear note or statement to warn health risks ofimproper preparation of the milk (FRANCE LAIT 1), as well as thefact that such products should be used only after consulting ahealth professional.

* some companies advertise use of feeding bottles, such as,(Plasmon PRIMIGIORNI, Hipp Frischmilchbrei, Herbal tea Hipp,France Lait, NAN 1), which have a very clear picture of such bottlesin their labels.

* the labels contain photos or text which indicates that theirproduct is ideal to infant nutrition, thus putting breastfeeding onthe shade.

*PLASMON (PRIMIGIORNI) it’s being advertised as enrichedwith vitamins (+vit). “Ecological Oasis PLASMON: giving yourbaby the best and safest milk!”

*SMA White “A milk for hungrier babies” . The label containstwo feeding bottles. It hasn’t been forgotten to write down to thelabel: “…cow’s milk shouldn’t be used as main milk during the firstyear. Your baby can grow up with SMA’s family infant formula andfollow-up formula”IMPORTANT NOTE comes after that sentence only: “Breastfeeding isbest. SMA White intends to replace breastmilk when mothers aren’tbreastfeeding”

*Frisolac H Contains idyllic photos.France-Lait “What do you have to know: Breastfeeding is

preferable, but if the mother can’t breastfed or have little milk, shecan use FRANCE-LAIT.”

Hipp 1, PreHipp: Contains idyllic photosHUMANA PREThe label contains idyllic pictures, inside a nest with the mother

embrasing her two littles into her safety. Inside of the can there is aleaflet, which unfortunately for the Albanian mothers is written inGerman. German language is not common among Albanians. Inthis leaflet it is higly reccommended the feeding bottle (obviouslyonly HUMANA brand) as well as other products of the lineHumana, infant formula Humana 1, Humana 1 (baby fit) (?) which


Plasmon 1, infantformula. Thefeeding bottle isshown at thelabel.

Plasmon 2,follow-upformula. Similarlabels with infantformula (feedingbottle)

Plasmon ricecream. A pictureof a healthy babyis shown at thelabel.

Humana Pre,acompanyingadvertisment ofother products atthe label.

is advertised as a proven food that reduces gastro-esophagealreflux. It has not been forgotten to advertise the Humana Water forbabies. The Important Note on priority of breastfeeding is there,but immediately below it is placed the coupon to be filled bymothers with their data (address, age of child). Following it givesthe mother the telephone number of Humana Parent’s Club.

* The telephone number of the company’s doctor or theirconselling service is given by:

SMA WhiteHIPP Frischmilchbrei: Gives the telephone number of HIPP

Service for ParentsHUMANA PRE

* Violation of suggested age of starting the product, whichnegatively influences breastfeeding practices.

HIPP Frischmilchbrei starting the second week of life.Herbal Tea HIPP, it has been suggested to start from the

first week (nothing is said on the risk of interfeering withbreastfeeding, they are reccommended as “easily absorbed”,“against coughing” and having “a calming effect on the baby”).

* Advertisment of accompanying products of the samecompany line.

HIPP Frischmilchbrei: The label contains advertising of infantfood that starts on 4 th and 6 th months of age.

HUMANA PRE: In the label it has been advertised : Humanawater, follow up formula Humana 2, complementary food Humanafrom 4th month containing 13 vitamins and iodine.

LABELS OF COMPLEMENTARY FOODSThe producing and distribution companies of infant

complementary foods do not respect the Law. Most of them playboth roles, producer’s and distributor’s. We have noticed thefollowing violations:

* Idyllic pictures of bottle feeding: (PLASMON)* Labels contain logo of the company (HIPP, NOYNOY)* Recommended age to use it’s less than six months-most

commonly 1-4 months (HIPP – BABY MEAL, HIPP – TEA,PLASMON).

LABELS OF FEEDING BOTTLES AND TEATSThe companies producers and distributors of the

feeding bottles and teats don’t respect the Law. Their labelscontain the following violations:

* Inclusion of idyllic images discourage breastfeedingand encourage bottle feeding (pictures of very nice andhealthy babies) – NUK, CAMERA, CHICCO);

* Posters displaying healthy babies at points of sale* Car’s stickers with the company name and logo.

EDUCATION AND INFORMATION MATERIALSOF THE COMPANIES

During the monitoring process we have analyzed thepromotional materials of the companies, which falls underthe scope of the Law.

The majority of the materials was found in private


HIPP LEAFLET


Baby’s picture and feeding bottle. Theage of initiation is not determined (itsays first months).

Plasmon, baby’s picture. Age of initiation isfour months.

Special display.

Frisocrem, baby’s picture.Age of initiation is four months.

pharmacies (PLASMON, NOYNOY, HIPP). The companies werefound to violate the Article 11 of the Law:

* There is no clear indication of the negative effects of bottlefeeding over breastfeeding (PLASMON, HIPP).

* They do not inform either on difficulties of continuingbreastfeeding after the infant has started to bottlefeed, e shishe,nor the cost the family has to bear from choosing to bottlefeed theirbaby (PLASMON, HIPP).

* The majority of the promotional materials addressing thepublic contain the logo of the company (PLASMON, HIPP).

* They reccommend the introduction of complementary foodsfrom the 4’th month.

HIPP LEAFLET

Breastfeeding benefits are mentioned at the leaflet. There is asentence saying “ Doctors recommend breastfeeding during firstmonths”, but it’s not clear about how many months. Exclusivebreastfeeding is recommended for allergic babies only. Fornormal babies the idea of complementing breastfeeding withPreHiPP is obvious: “HiPP Pre is extremely adequate ascomplementary to breastfeeding, when the baby needs it… HiPP1 is a milk that satisfy your baby’s hunger, from the first bottle.HiPP 2, as follow-up of HiPP 1 after the 4rth month, is perfectfor the age of the baby when “normal” food is being introduced”.All of these messages are subtle ways of products promotion,undermine breastfeeding and its continuity.

If you have a look at HiPP Feeding Guide, you can notice thesymbol of breastfeeding mother till the 6-7th month. From the 8 th

month it appears only the feeding bottle symbol or cup-feedingsymbol. There is no more need for breastfeeding, - HiPP says so!!!

There is a telephone number of counseling line of HIPPMother’s Services in the leaflet. After the second month of agethe teas has been suggested as compliant and tolerated by thegastro intestinal tract of the infant. (Comment: they have solelya major drawback, because decrease apetite of the child anddeprives them from the regular breastfeeding, which is not onlythe most fit for the infant digestive tract, but also contains allthe nutrient and calories needed to the child to grow).

Although the age of introducing complementary foods is 4months, there is one product which could be started the 2n d

week which the mixture of milk and rice flour.It is recommended that over 12 weeks of age the mothers

could start feeding infants with vegetable and fruit purees, over3 months of age homogenizated meat and other menu containingveal meat, over 4-5 months various purees.


ARTSANAA big company that pro-duces

sanitary products in the field ofinfant feeding (teats/nipples)with the brand name Chicco;controls also the brand Prenatal,and combines its pro-ducts withwholesale products of Neobaby.

It is present in Europe, NorthAmerica and Latin America. In2000 they had an annualturnover of 1 billion Euro. It has15 producing points in Europeand an indefinite number ofthem are spread all overcountries with low incomegeneration, mainly in South-East Asia, employing over 5500workers.

In 1998 the company drafteda Code of Conduct in respect ofthe rights of its employees(minor’s work, forced labor,health and social insurance,trade union rights) applicablenot only to Artsana establi-shments but also their externalfurnishing partners. Thiscompany though, didn’t me-ntion anything for the con-sumer’s rights in their Code. Indifference with other companiesthat produce breast milksubstitutes they do not mentionto have signed the IC of WHO.

Main Offices:Via Mentana 31, 22100

Como,Tel.: 031 382111, Fax: 031

382400,Website: www.artsana.comand www.chicco.com or

www.chicco.it

Main products are: an infinite(and useless) variety of teats/nipples and accessories for milkpreservation and bottle-feeding,not only for milk but also forother infant food, as well asother products for the develop-ment and safety of the child.

Humana leaflet in German.

Plasmon’s leaflet.

HIPP’s leaflet.


6. THE STORY DOESN’T END HERE


6. THE STORY DOESN’T END HERE

MILUPA and HIPP advertising in public and private TV

During the year 2001, MILUPA advertised its products at public and privet televisions, during thepeak hours. In response to that advertising, National Conference of Albanian Pediatrics Association, heldon November 2001, approved and issued a Statement in the name of all pediatricians of the country,against MILUPA advertisement, considering it as a violation of the Law on Promotion and Protection ofBreastfeeding, approved by Albanian Parliament on September 1999. (The Statement is placed next page).

HiPP promoted its products at public and private televisions as well.

CHILDREN’S FAIROn June 2002, children’s fair was opened in Tirana. HiPP, PLASMON, CHICCO and JOTIS had their

special displays at the fair. Flagrant violations of the Law were noticed.(look at the pictures below).


DEKLARATE


CONCLUSIONS AND RECCOMMENDATION TO IMPROVE THESITUATION OF BREASTFEEDING


CONCLUSIONS AND RECCOMMENDATION TO IMPROVE THESITUATION OF BREASTFEEDING

To improve access and care concerningbreastfeeding management in the motherand child services.

Breastfeeding should continue to be thenatural and preferred method of feedinginfants.

To draft a national strategy and policyon breastfeeding based in scientificarguments, data from monitoring surveys,as well as best practices. This policy shouldbecome part of the national strategy for thedefence of mother and child health.

To identify and apply best practices andpolicies related to breasfeeding, in the entirehealthcare system concerning mother andchild.

To make sure that any healthcareinstitution that offers services to the motherand child, applies best and most up to datepractices of breastfeeding, thusimplementing “Baby Friendly HospitalInitiative”.

To educate and train all healthcare staffthat works directly with the mother andchild in management of breastfeeding andcounseling, through combining this twoimportant elements in a standart trainingmanual, based in the 40 hours course ofWHO.

To assure that all mothers have access tosupport services of breastfeeding in thematernities and their communities.Activation of structures such as supportgroups for mothers would provide muchuseful help in this direction.

To continuously monitor the situation ofbreastfeeding in our country, and unify thedata collection system from the entirehealthcare network.

A standard questionnaire should be

drafted to collect all data from thematernities and consultory services ofmother and child in the entire country.

To inform and assure support of allhealth professionals for exclusivebreasfeeding in the first 6 months of life,help and support the mothers to recognizeits priorities and apply it.

It is really important to startcomplementary food on the right time,amount and quality after the 6th months oflife, most preferably home made, in additionto continuing breastfeeding through the 2nd

year of life and beyond.

To sensibilize the media in order topromote and support breasfeeding throughadvertising positive and stimulating imagesfor the mothers and quit advertisingartificial milk formulas.

To reduce the negative influence of thenon ethical marketing of the breastmilksubstitutes on the breastfeeding practices.

To continue the fully implementation ofthe Law on Promotion and Protection ofBreastfeeding through provision of sublegalacts.

To set up a regular reporting system ofthe sanitary inspectors on violations of theLaw; continuous monitoring of the violationof the Law and their publication. To informall health professionals for their legalobligations, as well as the larger public,NGOs, the business community etc.

To raise awareness of the employers ofboth private and public enterprises, on therights of the employed women thatbreastfeed their children.

To educate the general public andespecially women on their rights as mothersthat work and breastfeed their children.


Appendix 1a

THE INTERNATIONAL CODE OF MARKETING OF BREASTMILKSUBSTITUTES


Appendix 1a

THE INTERNATIONAL CODE OF MARKETING OF BREASTMILKSUBSTITUTES

PreambleThe Member States of the World Health

Organisation:

Affirming the right of every child and everypregnant and lactating woman to be adequatelynourished as a means of attaining and maintaininghealth;

Recognising that infant malnutrition is part of thewider problems of lack of education, poverty, and socialinjustice;

Recognising that the health of infants and youngchildren cannot be isolated from the health and nutritionof women, their socio-economic status and their rolesas mothers;

Conscious that breastfeeding is an unequalled wayof providing ideal food for the healthy growth anddevelopment of infants; that it forms a unique biologicaland emotional basis for the health of both mother andchild; that the anti-infective properties of breast milkhelp to protect infants against disease; and that there isan important relationship between breastfeeding andchild spacing;

Recognising that the encouragement and protectionof breastfeeding is an important part of the health,nutrition and other social measures required to promotehealthy growth and development of infants and youngchildren; and that breastfeeding is an important aspectof primary health care;

Considering that when mothers do not breastfeed,or only do so partially, there is a legitimate market forinfant formula and for suitable ingredients from whichto prepare it; that all these products should accordinglybe made accessible to those who need them throughcommercial or noncommercial distribution systems;and that they should not be marketed or distributed inways that may interfere with the protection andpromotion of breastfeeding;

Recognising further that inappropriate feedingpractices lead to infant malnutrition, morbidity andmortality in all countries, and that improper practicesin the marketing of breastmilk substitutes and relatedproducts can contribute to these major public healthproblems;

Convinced that it is important for infants to receiveappropriate complementary foods, usually when theinfant reaches four to six months of age, and that everyeffort should be made to use locally available foods;and convinced, nevertheless, that such complementaryfoods should not be used as breastmilk substitutes;

Appreciating that there are a number of social andeconomic factors affecting breastfeeding, and that,accordingly, governments should develop socialsupport systems to protect, facilitate and encourage it,and that they should create an environment that fostersbreastfeeding, provides appropriate family andcommunity support, and protects mothers from factorsthat inhibit breastfeeding;

Affirming that health care systems, and the healthprofessionals and other health workers serving in them,have an essential role to play in guiding infant feedingpractices, encouraging and facilitating breastfeeding, andproviding objective and consistent advice to mothersand families about the superior value of breastfeeding,or, where needed, on the proper use of infant formula,whether manufactured industrially or home prepared;

Affirming further that educational systems and othersocial services should be involved in the protection andpromotion of breastfeeding, and in the appropriate useof complementary foods;

Aware that families, communities, women’sorganisations and other nongovernmental organisa-tions have a special role to play in the protection andpromotion of breastfeeding and in ensuring the supportneeded by pregnant women and mothers of infantsand young children, whether breastfeeding or not;

Affirming the need for governments, organisationsof the United Nations system, nongovernmentalorganisations, experts in various related disciplines,consumer groups and industry to cooperate in activitiesaimed at the improvement of maternal, infant and youngchild health and nutrition;

Recognising that governments should undertake avariety of health, nutrition and other social measuresto promote healthy growth and development of infantsand young children, and that this Code concerns onlyone aspect of these measures;

Considering that manufacturers and distributors ofbreastmilk substitutes have an important andconstructive role to play in relation to infant feeding,and in the promotion of the aim of this Code and itsproper implementation;

Affirming that governments are called upon to takeaction appropriate to their social and legislativeframework and their overall development objectivesto give effect to the principles and aim of this Code,including the enactment of legislation, regulations orother suitable measures;

Believing that, in the light of the foregoingconsiderations, and in view of the vulnerability of infantsin the early months of life and the risks involved ininappropriate feeding practices, including theunnecessary and improper use of breastmilk substitutes,the marketing of breastmilk substitutes requires specialtreatment, which makes usual marketing practicesunsuitable for these products;

THEREFORE:The Member States hereby agree the following

articles which are recommended as a basis for action.

Article 1. Aim of the Code

The aim of this Code is to contribute to the provisionof safe and adequate nutrition for infants, by theprotection and promotion of breastfeeding, and by


ensuring the proper use of breastmilk substitutes, whenthese are necessary, on the basis of adequateinformation and through appropriate marketing anddistribution.

Article 2. Scope of the Code

The Code applies to the marketing, and practicesrelated thereto, of the following products: breastmilksubstitutes, including infant formula; other milk products,foods and beverages, including bottle-fed compleme-ntary foods, when marketed or otherwise representedto be suitable, with or without modification, for use as apartial or total replacement of breast-milk; feeding bottlesand teats. It also applies to their quality and availability,and to information concerning their use.

Article 3. Definitions

For the purposes of this Code:“Breastmilk substitute” means any food being

marketed or otherwise represented as a partial or totalreplacement for breast milk, whether or not suitablefor that purpose.

“Complementary food” means any food, whethermanufactured or locally prepared, suitable as acomplement to breast milk or to infant formula, wheneither becomes insufficient to satisfy the nutritionalrequirements of the infant. Such food is also commonlycalled “weaning food” or “breastmilk supplement”.

“Container” means any form of packaging ofproducts for sale as a normal retail unit, includingwrappers.

“Distributor” means a person, corporation or anyother entity in the public or private sector engaged inthe business (whether directly or indirectly) ofmarketing at the wholesale or retail level a productwithin the scope of this Code. A “primary distributor”is a manufacturer’s sales agent, representative, nationaldistributor or broker.

“Health care system” means governmental,nongovernmental or private institutions ororganisations engaged, directly or indirectly, in healthcare for mothers, infants and pregnant women; andnurseries or childcare institutions. It also includes healthworkers in private practice. For the purposes of thisCode, the health care system does not includepharmacies or other established sales outlets.

“Health worker” means a person working in acomponent of such a health care system, whetherprofessional or nonprofessional, including voluntary,unpaid workers.

“Infant formula” means a breastmilk substituteformulated industrially in accordance with applicableCodex Alimentarius standards, to satisfy the normalnutritional requirements of infants up to between fourand six months of age, and adapted to their physiologicalcharacteristics. Infant formula may also be prepared athome, in which case it is described as “home prepared”.

“Label” means any tag, brand, mark, pictorial orother descriptive matter, written, printed, stencilled,marked, embossed or impressed on, or attached to, acontainer (see above) of any products within the scopeof this Code.

“Manufacturer” means a corporation or other entityin the public or private sector engaged in the business orfunction (whether directly or through an agent or throughan entity controlled by or under contract with it) ofmanufacturing a product within the scope of this Code.

“Marketing ” means product promotion,distribution, selling, advertising, product publicrelations, and information services.

“Marketing personnel” means any persons whosefunctions involve the marketing of a product orproducts coming within the scope of this Code.

“Samples” means single or small quantities of aproduct provided without cost.

“Supplies” means quantities of a product providedfor use over an extended period, free or at a low price,for social purposes, including those provided to familiesin need.

Article 4. Information and education4.1 Governments should have the responsibility to

ensure that objective and consistent information isprovided on infant and young child feeding for use byfamilies and those involved in the field of infant andyoung child nutrition. This responsibility should covereither the planning, provision, design and disseminationof information, or their control.

4.2 Informational and educational materials, whetherwritten, audio, or visual, dealing with the feeding ofinfants and intended to reach pregnant women andmothers of infants and young children, should includeclear information on all the following points:

1. the benefits and superiority of breastfeeding;2. maternal nutrition, and the preparation for and

maintenance of breastfeeding;3. the negative effect on breastfeeding of introducing

partial bottle feeding;4. the difficulty of reversing the decision not to

breastfeed; and5. where needed, the proper use of infant formula,

whether manufactured industrially or home prepared.When such materials contain information about the

use of infant formula, they should include the socialand financial implications of its use; the health hazardsof inappropriate foods or feeding methods; and, inparticular, the health hazards of unnecessary orimproper use of infant formula and other breastmilksubstitutes. Such materials should not use any picturesor text which may idealise the use of breastmilksubstitutes.

4.3 Donations of informational or educationalequipment or materials by manufacturers ordistributors should be made only at the request andwith the written approval of the appropriategovernment authority or within guidelines given bygovernments for this purpose. Such equipment ormaterials may bear the donating company’s name orlogo, but should not refer to a proprietary product thatis within the scope of this Code, and should bedistributed only through the health care system.

Article 5. The general public and mothers5.1 There should be no advertising or other form of

promotion to the general public of products within thescope of this Code.


5.2 Manufacturers and distributors should notprovide, directly or indirectly, to pregnant women,mothers or members of their families, samples ofproducts within the scope of this Code.

5.3 In conformity with paragraphs 1 and 2 of thisArticle, there should be no point-of-sale advertising,giving of samples, or any other promotion device toinduce sales directly to the consumer at the retail level,such as special displays, discount coupons, premiums,special sales, loss leaders and tie-in sales, for productswithin the scope of this Code. This provision shouldnot restrict the establishment of pricing policies andpractices intended to provide products at lower priceson a long-term basis.

5.4 Manufacturers and distributors should notdistribute to pregnant women or mothers of infantsand young children any gifts of articles or utensils whichmay promote the use of breastmilk substitutes or bottlefeeding.

5.5 Marketing personnel, in their business capacity,should not seek direct or indirect contact of any kindwith pregnant women or with mothers of infants andyoung children.

Article 6. Health care systems6.1 The health authorities in Member States should

take appropriate measures to encourage and protectbreastfeeding and promote the principles of this Code,and should give appropriate information and advice tohealth workers in regard to their responsibilities,including the information specified in Article 4.2.

6.2 No facility of a health care system should beused for the purpose of promoting infant formula orother products within the scope of this Code. This Codedoes not, however, preclude the dissemination ofinformation to health professionals as provided inArticle 7.2.

6.3 Facilities of health care systems should not beused for the display of products within the scope of thisCode, for placards or posters concerning such products,or for the distribution of material provided by amanufacturer or distributor other than that specified inArticle 4.

6.4 The use by the health care system of “professionalservice representatives”, “mothercraft nurses” orsimilar personnel, provided or paid for bymanufacturers or distributors, should not be permitted.

6.5 Feeding with infant formula, whethermanufactured or home prepared, should bedemonstrated only by health workers, or othercommunity workers if necessary; and only to themothers or family members who need to use it; andthe information given should include a clear explanationof the hazards of improper use.

6.6 Donations or low-price sales to institutions ororganisations of supplies of infant formula or otherproducts within the scope of this Code, whether for usein the institutions or for distribution outside them, maybe made. Such supplies should only be used ordistributed for infants who have to be fed on breastmilksubstitutes. If these supplies are distributed for useoutside the institutions, this should be done only by theinstitutions or organisations concerned. Such donationsor low-price sales should not be used by manufacturers

or distributors as a sales inducement.6.7 Where donated supplies of infant formula or

other products within the scope of this Code aredistributed outside an institution, the institution ororganisation should take steps to ensure that suppliescan be continued as long as the infants concerned needthem. Donors, as well as institutions or organisationsconcerned, should bear in mind this responsibility.

6.8 Equipment and materials, in addition to thosereferred to in Article 4.3, donated to a health care systemmay bear a company’s name or logo, but should notrefer to any proprietary product within the scope ofthis Code.

Article 7. Health workers7.1 Health workers should encourage and protect

breastfeeding; and those who are concerned in particularwith maternal and infant nutrition should makethemselves familiar with their responsibilities under thisCode, including the information specified in Article 4.2.

7.2 Information provided by manufacturers anddistributors to health professionals regarding productswithin the scope of this Code should be restricted toscientific and factual matters, and such informationshould not imply or create a belief that bottle feeding isequivalent or superior to breastfeeding. It should alsoinclude the information specified in Article 4.2.

7.3 No financial or material inducements to promoteproducts within the scope of this Code should be offeredby manufacturers or distributors to health workers ormembers of their families, nor should these be acceptedby health workers or members of their families.

7.4 Samples of infant formula or other productswithin the scope of this Code., or of equipment orutensils for their preparation or use, should not beprovided to health workers except when necessary forthe purpose of professional evaluation or research atthe institutional level. Health workers should not givesamples of infant formula to pregnant women, mothersof infants and young children, or members of theirfamilies.

7.5 Manufacturers and distributors of productswithin the scope of this Code should disclose to theinstitution to which a recipient health worker is affiliatedany contribution made to him or on his behalf forfellowships, study tours, research grants, attendance atprofessional conferences, or the like. Similar disclosuresshould be made by the recipient.

Article 8. Persons employed by manufacturersand distributors

8.1 In systems of sales incentives for marketingpersonnel, the volume of sales of products within thescope of this Code should not be included in thecalculation of bonuses, nor should quotas be setspecifically for sales of these products. This should notbe understood to prevent the payment of bonusesbased on the overall sales by a company of otherproducts marketed by it.

8.2 Personnel employed in marketing productswithin the scope of this Code should not, as part oftheir job responsibilities, perform educational functionsin relation to pregnant women or mothers of infantsand young children. This should not be understood as


preventing such personnel from being used for otherfunctions by the health care system at the request andwith the written approval of the appropriate authorityof the government concerned.

Article 9. Labelling9.1 Labels should be designed to provide the

necessary information about the appropriate use of theproduct, and so as not to discourage breastfeeding.

9.2 Manufacturers and distributors of infant formulashould ensure that each container has a clear,conspicuous, and easily readable and understandablemessage printed on it, or on a label which cannot readilybecome separated from it, in an appropriate language,which includes all the following points:

1. the words “Important Notice” or their equivalent;2. a statement of the superiority of breastfeeding;3. a statement that the product should be used only

on the advice of a health worker as to the need for itsuse and the proper method of use;

4. instructions for appropriate preparation, and awarning against the health hazards of inappropriatepreparation.

Neither the container nor the label should havepictures of infants, nor should they have other picturesor text which may idealise the use of infant formula.They may, however, have graphics for easyidentification of the product as a breastmilk substituteand for illustrating methods of preparation. The terms“humanised”, “maternalised” or similar terms shouldnot be used. Inserts giving additional information aboutthe product and its proper use, subject to the aboveconditions, may be included in the package or retailunit. When labels give instructions for modifying aproduct into infant formula, the above should apply.

9.3 Food products within the scope of this Code,marketed for infant feeding, which do not meet all therequirements of an infant formula, but which can bemodified to do so, Should carry on the label a warningthat the unmodified product should not be the solesource of nourishment of an infant. Since sweetenedcondensed milk is not Suitable for infant feeding, norfor use as a main ingredient of infant formula, its labelshould not contain purported instructions on how tomodify it for that purpose.

9.4 The label of food products within the scope ofthis Code should also state all the following points:

1. the ingredients used;2. the composition/analysis of the product;2. the storage conditions required; and3. the batch number and the date before which the

product is to be consumed, taking into account theclimatic and storage conditions of the countryconcerned.

Article 10. Quality10.1 The quality of products is an essential element

for the protection of the health of infants and thereforeshould be of a high recognised standard.

10.2 Food products within the scope of this Codeshould, when sold or otherwise distributed, meetapplicable standards recommended by the CodexAlimentarius Commission and also the Codex Code ofHygienic Practice for Foods for Infants and Children.

Article 11. Implementation and monitoring11.1 Governments should take action to give effect

to the principles and aim of this Code, as appropriate totheir social and legislative framework, including theadoption of national legislation, regulations or othersuitable measures. For this purpose, governmentsshould seek, when necessary, the cooperation of WHO,UNICEF and other agencies of the United Nationssystem. National policies and measures, including lawsand regulations, which are adopted to give effect to theprinciples and aim of this Code should be publicly stated,and should apply on the same basis to all those involvedin the manufacture and marketing of products withinthe scope of this Code.

11.2 Monitoring the application of this Code lies withgovernments acting individually, and collectivelythrough the World Health Organisation as provided inparagraphs 6 and 7 of this Article. The manufacturersand distributors of products within the scope of thisCode, and appropriate nongovernmental organisations,professional groups, and consumer organisationsshould collaborate with governments to this end.

11.3 Independently of any other measures taken forimplementation of this Code, manufacturers anddistributors of products within the scope of this Codeshould regard themselves as responsible for monitoringtheir marketing practices according to the principlesand aim of this Code, and for taking steps to ensurethat their conduct at every level conforms to them.

11.4 Nongovernmental organisations, professionalgroups, institutions, and individuals concerned shouldhave the responsibility of drawing the attention ofmanufacturers or distributors to activities which areincompatible with the principles and aim of this Code,so that appropriate action can be taken. The appropriategovernmental authority should also be informed.

11.5 Manufacturers and primary distributors ofproducts within the scope of this Code should appriseeach member of their marketing personnel of the Codeand of their responsibilities under it.

11.6 In accordance with Article 62 of the Constitutionof the World Health Organisation, Member States shallcommunicate annually to the Director Generalinformation on action taken to give effect to theprinciples and aim of this Code.

11.7 The Director General shall report in even yearsto the World Health Assembly on the status ofimplementation of the Code; and shall, on request,provide technical support to Member States preparingnational legislation or regulations, or taking otherappropriate measures in implementation andfurtherance of the principles and aim of this Code.


Appendix 1b

WORLD HEALTH ORGANIZATION

The Fifty-Fourth Assembly of Health. Agenda item 13.1, 18 MAY 2001.INFANT AND YOUNG CHILD FEEDING

The Fifty-Fourth World Assembly of Health WHA54.2


Recalling resolutions WHA33.32 , WHA34.22,WHA35.26, WHA37.30, WHA39.28, WHA41.11,WHA43.3 , WHA45.34, WHA46.7, WHA47.5 andWHA49.15 on infant and young child nutrition,appropriate feeding practices and related questions;

Deeply concerned to improve infant and young childnutrition and to alleviate all forms of malnutrition inthe world, because more than one-third of under-fivechildren are still malnourished - whether stunted,wasted, or deficient in iodine, vitamin A, iron or othermicronutrients - and because malnutrition stillcontributes to nearly half of the 10.5 million deaths eachyear among preschool children worldwide;

Deeply alarmed that malnutrition of infants andyoung children remains one of the most severe globalpublic health problems, at once a major cause andconsequence of poverty, deprivation, food insecurityand social inequality, and that malnutrition is a causenot only of increased vulnerability to infection and otherdiseases, including growth retardation, but also ofintellectual, mental, social and developmental handicap,and of increased risk of disease throughout childhood,adolescence and adult life;

Recognizing the right of everyone to have access tosafe and nutritious food, consistent with the right toadequate food and the fundamental right of everyoneto be free from hunger, and that every effort should bemade with a view to achieving progressively the fullrealization of this right;

Acknowledging the need for all sectors of society -including governments, civil society, health professionalassociations, nongovernmental organizations,commercial enterprises and international bodies - tocontribute to improved nutrition for infants and youngchildren by using every possible means at their disposal,especially by fostering optimal feeding practices,incorporating a comprehensive multisectoral, holisticand strategic approach;

Noting the guidance of the Convention on the Rightsof the Child, in particular Article 24, which recognizes,inter alia, the need for access to and availability of bothsupport and information concerning the use of basicknowledge of child health and nutrition, and theadvantages of breastfeeding for all segments of society,in particular parents and children;

Conscious that despite the fact that the InternationalCode of Marketing of Breastmilk Substitutes andrelevant, subsequent Health Assembly resolutions statethat there should be no advertising or other forms ofpromotion of products within its scope, new moderncommunication methods, including electronic means,are currently increasingly being used to promote such

products; and conscious of the need for the CodexAlimentarius Commission to take the InternationalCode and subsequent relevant Health Assemblyresolutions into consideration in dealing with healthclaims in the development of food standards andguidelines;

Mindful that 2001 marks the twentieth anniversaryof the adoption of the International Code of Marketingof Breastmilk Substitutes, and that the adoption of thepresent resolution provides an opportunity to reinforcethe International Code’s fundamental role in protecting,promoting and supporting breastfeeding;

Recognizing that there is a sound scientific basis forpolicy decisions to reinforce activities of Member Statesand those of WHO; for proposing new and innovativeapproaches to monitoring growth and improvingnutrition; for promoting improved breastfeeding andcomplementary feeding practices, and sound culture-specific counselling; for improving the nutritional statusof women of reproductive age, especially during andafter pregnancy; for alleviating all forms ofmalnutrition; and for providing guidance on feedingpractices for infants of mothers who are HIV-positive;

Noting the need for effective systems for assessingthe magnitude and geographical distribution of all formsof malnutrition, together with their consequences andcontributing factors, and of foodborne diseases; andfor monitoring food security;

Welcoming the efforts made by WHO, in closecollaboration with UNICEF and other internationalpartners, to develop a comprehensive global strategyfor infant and young child feeding, and to use the ACCSub-Committee on Nutrition as an interagency forumfor coordination and exchange of information in thisconnection;

1. THANKS the Director-General for the progressreport on the development of a new global strategy forinfant and young child feeding;

2. URGES Member States:(1) to recognize the right of everyone to have access

to safe and nutritious food, consistent with the right toadequate food and the fundamental right of everyoneto be free from hunger, and that every effort should bemade with a view to achieving progressively the fullrealization of this right and to call on all sectors of societyto cooperate in efforts to improve the nutrition ofinfants and young children;

(2) to take necessary measures as States Partieseffectively to implement the Convention on the Rightsof the Child, in order to ensure every child’s right tothe highest attainable standard of health and health care;

(3) to set up or strengthen inter institutional andintersectorial discussion forums with all stakeholders

Appendix 1b

WORLD HEALTH ORGANIZATION

The Fifty-Fourth Assembly of Health. Agenda item 13.1, 18 MAY 2001.INFANT AND YOUNG CHILD FEEDING

The Fifty-Fourth World Assembly of Health WHA54.2


in order to reach national consensus on strategies andpolicies including reinforcing, in collaboration with ILO,policies that support breastfeeding by working women,in order substantially to improve infant and young childfeeding and to develop participatory mechanisms forestablishing and implementing specific nutritionprogrammes and projects aimed at new initiatives andinnovative approaches;

(4) to strengthen activities and develop newapproaches to protect, promote and support exclusivebreastfeeding for six months as a global public healthrecommendation, taking into account the findings ofthe WHO expert consultation on optimal duration ofexclusive breastfeeding, (note 1) and to provide safeand appropriate complementary foods, with continuedbreastfeeding for up to two years of age or beyond,emphasizing channels of social dissemination of theseconcepts in order to lead communities to adhere to thesepractices;

(5) to support the Baby-friendly Hospital Initiativeand to create mechanisms, including regulations,legislation or other measures, designed, directly andindirectly, to support periodic reassessment of hospitals,and to ensure maintenance of standards and theInitiative’s long-term sustainability and credibility;

(6) to improve complementary foods and feedingpractices by ensuring sound and culture-specificnutrition counselling to mothers of young children,recommending the widest possible use of indigenousnutrient-rich foodstuffs; and to give priority to thedevelopment and dissemination of guidelines onnutrition of children under two years of age, to thetraining of health workers and community leaders onthis subject, and to the integration of these messagesinto strategies for health and nutrition information,education and communication;

(7) to strengthen monitoring of growth andimprovement of nutrition, focusing on community-based strategies, and to strive to ensure that allmalnourished children, whether in a community orhospital setting, are correctly diagnosed and treated;

(8) to develop, implement or strengthen sustainablemeasures including, where appropriate, legislativemeasures, aimed at reducing all forms of malnutritionin young children and women of reproductive age,especially iron, vitamin A and iodine deficiencies,through a combination of strategies that includesupplementation, food fortification and dietdiversification, through recommended feeding practicesthat are culture-specific and based on local foods, aswell as through other community-based approaches;

(9) to strengthen national mechanisms to ensureglobal compliance with the International Code ofMarketing of Breastmilk Substitutes and subsequentrelevant Health Assembly resolutions, with regard tolabelling as well as all forms of advertising, andcommercial promotion in all types of media, toencourage the Codex Alimentarius Commission to takethe International Code and relevant subsequent HealthAssembly resolutions into consideration in developingits standards and guidelines; and to inform the generalpublic on progress in implementing the Code andsubsequent relevant Health Assembly resolutions;

(10) to recognize and assess the available scientificevidence on the balance of risk of HIV transmission

through breastfeeding compared with the risk of notbreastfeeding, and the need for independent researchin this connection; to strive to ensure adequate nutritionof infants of HIV-positive mothers; to increaseaccessibility to voluntary and confidential counsellingand testing so as to facilitate the provision of informationand informed decision-making; and to recognize thatwhen replacement feeding is acceptable, feasible,affordable, sustainable and safe, avoidance of allbreastfeeding by HIV-positive women isrecommended; otherwise, exclusive breastfeeding isrecommended during the first months of life; and thatthose who choose other options should be encouragedto use them free from commercial influences;

(11) to take all necessary measures to protect allwomen from the risk of HIV infection, especially duringpregnancy and lactation;

(12) to strengthen their information systems,together with their epidemiological surveillancesystems, in order to assess the magnitude andgeographical distribution of malnutrition, in all itsforms, and foodborne disease;

3. REQUESTS the Director-General:(1) to give, greater emphasis to infant and young

child nutrition, in view of WHO’s leadership in publichealth, consistent with and guided by the Conventionon the Rights of the Child and other relevant humanrights instruments, in partnership with ILO, FAO,UNICEF, UNFPA and other competent organizationsboth within and outside the United Nations system;

(2) to foster, with all relevant sectors of society, aconstructive and transparent dialogue in order tomonitor progress towards implementation of theInternational Code of Marketing of BreastmilkSubstitutes and subsequent relevant Health Assemblyresolutions, in an independent manner and free fromcommercial influence, and to provide support toMember States in their efforts to monitorimplementation of the Code;

(3) to provide support to Member States in theidentification, implementation and evaluation ofinnovative approaches to improving infant and youngchild feeding, emphasizing exclusive breastfeeding forsix months as a global public health recommendation,taking into account the findings of the WHO expertconsultation on optimal duration of exclusivebreastfeeding (note 1), the provision of safe andappropriate complementary foods, with continuedbreastfeeding up to two years of age or beyond, andcommunity-based and cross-sector activities;

(4) to continue the step-by-step country- and region-based approach to developing the new global strategyon infant and young child feeding, and to involve theinternational health and development community, inparticular UNICEF, and other stakeholders asappropriate;

(5) to encourage and support further independentresearch on HIV transmission through breastfeedingand other measures to improve the nutritional statusof mothers and children already affected by HIV/AIDS;

(6) to submit the global strategy for considerationto the Executive Board at its 109th session in January2002 and to the Fifty-fifth World Health Assembly (May2002).


REPUBLIC OF ALBANIA PARLIAMENT

LAW

Nr 8528, Date 23.09.1999

FOR

PROMOTION AND PROTECTION OFBREASTFEEDING

Based on articles 78 and 83 point 1 of the Constitutionof Republic of Albania, with the proposal of MinistersCouncil, the

ASSEMBLY OF REPUBLIC OF ALBANIA

DECIDED

ARTICLE 1This law, had the scope to promote and protect

breastfeeding and regulate the marketing of breastmilksubstitutes, with the scope to ensure a healthy nutritionfor children.

ARTICLE 2For the purposes of this Law, the definitions below

means:a)“Advertising” means to make any representation

by any means whatsoever for the purpose of promotingand sale, or consuming of products for substitution ofbreast milk

b)“ Complementary food” means, any food suitable,as an addition to breastmilk, infant formula, or follow-up formula

c)“ Container” means any form of packaging of adesignated product for sale as a retail unit, includingwrappers, according the article 3 (15) of the Law forNutrition, No. 7941, approved on 31.5.1995.

ç)“Designated product” means:-infant formula; means any animal or vegetable-based

milk, or a product similar to it formulated industrially,which is market for the nutrition of infants and frombirth during the first six months.

-follow-up formula; means any animal or vegetable-based milk, or a product similar to it formulatedindustrially, which is market for the nutrition of infantsafter six months of age .

-any other product, which is sold for nutrition ofinfants and young children

Appendix 2 - Order No 163

Appendix 3


d)“Infant ” means a child from birth to the age of 12months

dh)“Young child” means a child from the age of 12months up to the age of three years

RESTRICTIONS

ARTICLE 3No person shall not produce, distribute, sell, stock,

exhibit for sale any designated product defined on article2, that

-are not registered in accordance with the nationallegislation

-have reached their expiration date-are not in its original container

ARTICLE 4For a manufacturer, or a seller is prohibited,

advertising and promotion of any designated productin article 2, including special visual presentation ondisplays, special sales, premiums, advertising fordiscount, discount on special conditions, or gifts andtheir promotion in a health care facility in state or privatehealth system.

ARTICLE 5A manufacturer or any other person on his behalf

and any seller shall not:a. sell to a health state or private facility the

designated products defined on article 2, lower thanpublished price

b. donate or distribute within a health care facility,equipment or offer services, and promotion materialswhich are referred, or promote the use of a designatedproduct defined on article 2 point ç of this law, excludedthat cases when these products are defined ashumanitary donations.

c. offer benefit, gifts, contributions, to the healthworkers engaged in maternal and child health

d. sponsor activities, which are related with thehealth of mother and children, apart from their form ofpresentations, excluded those activities which had onlya scientific character.

ARTICLE 6A health worker engaged in maternal and child

health shall not:a. accept any gift, contribution, or benefit from a

manufacturer, distributor, or any other person on hisbehalf

b. accept or distribute samples of designatedproducts to any person

c. promote the use of designated products on article2 point ç, excluded very special cases where exist anabsolute indication for their use, and in that case mustgive a clear explanation of their hazards.

Prohibitions related to labels infant formulas

ARTICLE 7A manufacturer, distributor or seller shall not offer

for sale or sell infant formulas, unless the container, orlabel shall not have the following words:

“Breastmilk is the ideal food for healthy growingand development of children. Before you decide to

modify, or substitute the breast milk consult yourdoctor.”

ARTICLE 8A manufacturer, distributor, or seller shall not offer

for sale, or sell follow -up formulas,a. unless the container, or label shall not have the

following words:“Breastmilk is the ideal food for healthy growing

and development of children. ATTENTION ! thisproduct shall be used for infants up to six months.Before you decide to modify, or substitute the breastmilk consult your doctor.”

b. the label promote artificial feeding

ARTICLE 9A manufacturer, distributor, or seller shall not offer

for sale or sell skimmed or condensed milk, in powderor liquid form as breastmilk substitutes.

The container of this products must contain thefollowing words:

“This product should not be used to feed infants”

Health System responsibilities

ARTICLE 10Heads of health care facilities and national and local

health authorities shall take measures to encourage andprotect breastfeeding and to inform the public aboutthe great negative effects of other alternative feedings

ARTICLE 11Information materials, or with the scope for

promotion and education shall be obligatory approvedby the Ministry of health, through it competentstructures, or authorised by the Ministry of Health.

ARTICLE 12The Ministry of Health is responsible for the

implementation of this law.The State Health inspectoriate should be responsible

for control and implementation of this law

PENALTIES

ARTICLE 13The contravention of this Law, when they did not

consists a penalty act, areadministrative contravention’s and will be punished

with penalty as below:a) For contravention of article 3 of this law, penalty

on amount 50 thousand till 100 thousand lek (albaniancurrency: 1 lek=1. 340 USD), or with suspension of anylicense for production and /or import

b) For contravention of article 4 of this law, penaltyon amount 25 thousand till 50 thousand lek

c) For contravention of article 5 of this law, theamount of penalty is from 5 thousand till 75 thousandlek

ç) For contravention of article 6 of this law, penaltyon amount 40 thousand till 10 thousand lek and in caseof repetition suspension from their job

d) For contravention of articles 7 8 and 9 of this law,penalty on amount 50 thousand till 100 thousand lek


For contravention of article 9, in case of repetition isproposed the suspension of license

The complaints against the penalties of District‘ sInspectors could be appealed to the Chief SanitaryInspector of Districts, and the decisions of SanitaryInspectors of Republic could be appealed to the Headof Sanitary Inspectors of Republic

Complain against the decisions of penalties shouldbe done according the procedures of the Law Nr 7697,date 7. 4. 1993 “ For administrative Penalties” with thechanges and fulfilment done after

ARTICLE 14The Ministry of Health is responsible for fulfilling

the sublaw acts regarding the responsibilities for usingthe designed products defined by this law, and theproblems related with the promotion and education ofhealth facilities.

This law shall come into force after 15 days ofpublishing in Official Journal.

HEAD OF THE ASSEMBLYSkender GJINUSHI

Urdheri 157 dhe udhezimiREPUBLIKA E SHQIPERISE

MINISTRIA E SHENDETESISEKABINETIBulevardi

“Bajram Curri” Tirana, ALBANIA,Tel/FAX +355 4 329437

Nr. 157, Prot. Tirane 09/04/2002

URDHERNr. 157, Dt. 09/04/2002

U R DH E R O J

Te gjitha sherbimet shendetesore qe ofrojne kujdesper nenen dhe femijen (konsultoret e gruas dhe femi-jes, maternitetet dhe repartet pediatrike te:

1. Mbeshtesin inisiativen per t’u bere “Sherbimeshendetesore mike te femijes” qe perkrahin dhembeshtesin ushqyerjen me gji.

2. Personeli shendetesor qe punon ne ketoinstitucione te njihet me politiken e hartuar nga OBSH/UNICEF lidhur me 10 hapat per nje ushqyerje tesukseshme me gji.

3. Drejtuesit e institucioneve te mesiperme tehartojne nje plan konkret veprimi sipas çdo hapi teparaqitur ne kete politike, duke percaktuar nevojatdhe kerkesat per implementimin e kesaj inisiative.

4. Materniteti i Lezhes dhe Materniteti Fier, te ciletkane marre çertifikaten nderkombetare te UNICEF/OBSH, si “spitale mik te femijes” do te jene aktualishtdy qendra reference per te treguar zbatimin praktik tekesaj politike.

5. Drejtoria e Kujdesit Shendetesor Paresor,Drejtoria Spitalore, Drejtoria Ekonomike ne Ministrinee Shendetesise dhe Drejtorite e Shendetit Publik nerrethe se bashku me specialistet qe ato kane, te marrinmenjehere te gjitha masat e duhura per venien nezbatim te ketij urdheri.

MINISTRILeonard SOLIS

REPUBLIKA E SHQIPERISEMINISTRIA E SHENDETESISE

KABINETI

Bulevardi “Bajram Curri” Tirana, ALBANIA,Tel/FAX +355 4 364671

Nr. 1262/1 Prot. Tirane, 09/04/2002

UDHEZIMPER KRIJIMIN “SHERBIMEVE MIK TE

FEMIJES”

Ne mbeshtetje te ligjit nr 8528 “ Per nxitjen dhe

mbrotjtjen e te ushqyerit me gji”, dhe ne veçanti tenenit 10 te ketij ligji

UDHEZOJ

Çdo institucion shendetesor qe ofron kujdes pernenen dhe te porsalindurin duhet te mbroje dhembeshtese inisiativen e OBSH/UNICEF per krijimin e“sherbimit mik te femijes” qe mbron dhe nxit ushqyerjenme gji. Per kete ai duhet:

1. Te kete te hartuar nje politike per mbrojtjen eushqyerjes me gji qe t’i komunikohet dhe te njihet ngai gjithe stafi i kujdesit shendetesor ne rreth.

Kjo politike duhet te permbledhe veprimet qeduhen ndermarre per te arritur kete inisiative dhetregon menyren si do te realizohen, duhet te jete e

afishuar ne te gjitha keto institucione. Ne te duhet teperfshihen:

a)*10 hapat per ushqyerjen e sukseseshme me gji

b)*Nje rregullore, ose urdher, te institucionit qendalon pranimin e mostrave falas, apo me çmim me teulet te zevendesuesve te qumeshtit te gjirit, shishevedhe biberonave

2. Te trajnoje te gjithe stafin shendetesor me aftesitee nevojeshme per te zbatuar kete politike

Fushat e trajnimit duhet te perfshijnea-perparesite e ushqyerjes me gjib-rreziqet e ushqyerjes artificialec-mekanizmat e laktacionit dhe thithjesd-si te ndihmohen nenat te fillojne dhe mbajne

Appendix 4


ushqyerjen me gjie-si te vleresojme ushqyerjen me gji dhe te zgjidhen

veshtiresite gjate ushqyerjes me gjif-praktikat e ushqyerjes me gji

3. Te informoje te gjitha grate shtatzena rrethperparesive dhe menyrave te ushqyerjes me gji

Edukimi antenatal shendetesor i gruas shtatzeneduhet te permbaje:

a-perparesite e ushqyerjes me gjib-fillimin e hershem te ushqyerjes me gjic-rendesine e rooming-ind-rendesine e ushqyerjes me gji sipas kerkesese-si te sigurohet prodhimi i mjaftueshem i

qumeshtitf-teknikat e pozicionimit dhe kapjes se gjiritg-rendesia e ushqyerjes ekskluzive me gjih-rreziqet e ushqyerjes artificiale dhe perdorimit

te shisheve dhe biberonave

4. Te ndihmoje nenat te fillojne ushqyerjen me gjibrenda ½ ore mbas lindjes

Per kete insitucioni duhet te :a-mbaje nenen dhe foshnjen bashke gjate gjithe 24

oreshit qe ajo ndodhet e shtruar ne institucionb-vendose foshnjen ne gjirin e nenes brenda 30

minuta-1 ore pas lindjes

5. T’u tregoje nenave si te ushqejne me gji dhe si tembajne laktacionin edhe ne se ato duhet te ndahen ngafoshnjat.

Ne keto institucione duhet te nxitet ushqyerja sipaskerkeses se femijes, sa here qe ai te doje dhe kur tedoje.

Gjate ndarjes se foshnjes nga nena duhet tevazhdohet zbrazja gjirit per te ruajtur aftesine eprodhimit te qumeshtit te gjirit.

6. Te mos u jape te porsalindurve asnje ushqim apoleng tjeter perveç qumeshtit te gjirit, perjashtuar rastekur qumeshti i gjirit ka kunderindikacion mjeksor.

Çdo ushqim apo leng tjeter i dhene se bashku mequmeshtin e gjirit per te porsalindurin eshte ipanevojshem si dhe do te pengoje ushqyerjen me gji,duke pakesuar prodhimin e qumeshtit.

Ne perputhje me rekomandimet e OBSH, arsyetmjeksore per dhenien e shtesave me ushqime te huajaapo solucione per te porsalindurin jane shume te paktadhe konkretisht:

a-foshnjet me peshe shume te ulet (< 1500 gr, osefoshnje te porsalindura me papjekuri te thelle, mehypoglicemi te mundshme, ose qe kerkojne terapi perhypoglicemi, dhe nuk permirsohen duke shtuarushqyerjen me gji, ose nga dhenia e qumeshtit te gjirit.

b-nena ka semundje amtare te rende (psikoze,eklampsia, ose gjendje shoku)

c-femije me çrregullime metabolike te lindura(galaktosemia, phenylketonuria)

d-femije me crregullime akute te humbjes se ujit,p.sh.gjate fototerapise per ikter, ne se rritja e ushqyeriesme gji nuk mund te permirsoje hidratimin

e-femije nenat e te cileve jane duke marremedikamente qe jane te kunderindikuar kur ushqehen

me gji, (medikamentet citostatike, medikamentetradioaktive, medikamentet anti-tiroidike e te tjera sipropilthiouracili.)

7. Te praktikoje qendrimin e nenes ne foshnjen sebashku ne 24 ore (rooming –in)

Ky qendrim eshte i rendesishem sepse:-pakson kostot e institucionit-kerkon pajisje minimale-nuk kerkon personel shtese-pakson infeksionet tek i porsalinduri-ndihmon ne fillimin dhe mbajtjen e ushqyerjes me

gji-lehteson lidhjen nene-femije

8. Te nxite ushqyerjen me gji sipas kerkeses sefoshnjes

Ushqyerja me gji sipas kerkeses se foshnjesndihmon ne:

-kalimin e hershem te mekoniumit-pakeson ne maksimum humbjen ne peshe-vendoset me heret ardhja e qumeshtit te gjirit-foshnja ka me pak ikter9. Te mos u japi\e ushqim me shishe me biberona,

ose te mos u perdore biberona qetesues foshnjeve qeushqehen me gji

Perdorimi i shisheve dhe biberonave krijonpengese ne ushqyerjen me gji. Ne vend te biberonaveartificiale, alternativa per t’u perdorur per ushqyerjene foshnjave duhet te jene:

filxhanilugapikatoreshiringa

10. Te nxite krijimin e grupeve te mbeshtetjes seushqyerjes me gji dhe te referoje nenat aty, kur atodalin nga spitali apo klinika.

Mbeshtetja e nenave per te mbajtur ushqyerjen megji mund te perfshije:

a-kontrollin e hereshem postnatalb-vizitat ne shtepic-thirrjet ne telefond-klinikat e sherbimit ambulator (konsultoret nene-

femije)e-grupet e mbeshtetjes se nenave qe kane ushqyer

femije me gji.11. Ky udhezim hyn ne fuqi menjehere

MINISTRILeonard SOLIS


·


THE INCIDENCE OF BREASTFEEDING IN ALBANIA

These data are available from the statistics of Ministry of Health:

Breastfed children according to age groups:

Years 1994 1995 19960-4 month 55,7% 56,5% 63,4%4-6 month 10% 10,1% 10,6%Over 6-12 month 9,8% 11,7% 13,2%

· That percentage is calculated by dividing the number of children according to age groups with thetotal birth number of the year. (Source: Department of Statistics, Ministry of Health).

Appendix 5

Appendix 6

10 STEPS FOR SUCCESSFUL BREASTFEEDING

Every facility providing maternity services and care for newborn infants should:1. Have a written breastfeeding policy that is routinely communicated to all health care staff.2. Train all health care staff in skills necessary to implement this policy.3. Inform all pregnant women about benefits and management of breastfeeding4. Help mothers to initiate breastfeeding within half-hour of birth.5. Show mothers how to breastfed, and how to maintain lactation even if they should be

separated from their infants.6. Give newborn infants no food or drink other than breastmilk, unless medically indicated.7. Practice rooming-in - allow mothers and infants to remain together –24 hours a day.8. Encourage feeding on demand.9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.10. Foster the establishment of breastfeeding support groups and refer mothers to them on

discharge from the hospital or clinic.


Appendix 7

DISTRICTS INVOLVED IN THE STUDY

SHKODRA

TIRANADURRES

LUSHNJA

FIER BERATI

GJIROKASTER

KORÇA

ELBASANI

PESHKOPI

KUKES


THE STRUCTURE OF INFANT MORTALITY RATE IN ALBANIA

Appendix 8

Appendix 9DEFINITION OF KEY INDICATORSThe key indicators are defined and explained below. A

summary list of the indicators is presented in Annex 3.

EXCLUSIVE BREASTFEEDING RATEProportion of infants less than 4 months of age who

were exclusively breastfed:

Infants <4 months (120 days) of agewho were exclusively breastfed in the last 24 hours=————————————————————Infants <4 months (120days) of age

Explanatory notes:All infants should be fed exclusively on breastmilk from

birth to 4-6 months of age. The exact age at whichcomplementary feeding should be introduced will vary fromchild to child; however, implicit in the recommendation ofthe 4-6 months range is that all infants less than exact age 4

months (120 days) should be exclusively breastfed.Individual infants 120 days or older should be receivingcomplementary foods in addition to breastmilk if theirgrowth on exclusive breastfeeding starts to falter.

This indicator includes breastfeeding from a wet nurseand feeding on expressed breastmilk. It was, however,thought simpler to retain the term “exclusive breastfeeding”rather than the more precise but cumbersome term “fedexclusively on breastmilk”.

Using a 24 -hour recall period may cause the proportionof exclusively breastfed infants to be slightly overestimated,since some infants who are given other liquids irregularlymay not have received them in the 24 hours before thesurvey.

Although this rate may be low, at least initially, anincrease in the proportion of exclusively breastfed infantswill be the goal of many programmes, and thus it is desirableto have an indicator that measures the change.


PREDOMINANT BREASTFEEDING RATEProportion of infants less than 4 months of age who are

predominantly breastfed:

Infants <4 months (120days) of ageWho were predominantly breastfed in the last 24 hours= ————————————————————Infants <4 months (120 days) of age

Explanatory notes:As the proportion of infants exclusively breastfed may

be very low, the intent of this indicator is to identify infantswhose predominant source of nourishment is breastmilk,but who also receive other fluids. (For the definition of“predominant breastfeeding” see section 2 and Table 1.)

TIMELY COMPLEMENTARYFEEDING RATEProportion of infants 6-9 months of age who are receiving

breastmilk and complementary foods:Infants 6-9 months (180-299days) of age who received

complementaryfoods in addition to breastmilk in the last 24 hours= ————————————————————Infants 6-9 months (180-299 days) of age

Explanatory notes:Solid and/or semi-solid complementary (weaning) foods

should normally be introduced from 4-6 months of age.Thus, after exact age 6 months almost all infants should bereceiving complementary food in addition to breastmilk.As well as being introduced at the right time, complementaryfoods should be appropriate and adequate in terms of infantnutrient requirements.

All infants who are breastfed and are receiving solid/semi-solid foods are included in the numerator of thisindicator, regardless of whether or not they also receivebreastmilk substitutes. This latter practice is notrecommended, unless medically indicated. Because ofdifficulties associated with measuring the notions of“appropriateness” and “adequacy” where complementaryfoods are concerned, they are not included as part of thisindicator. However, if a programme has a policy statementrecommending certain complementary foods as appropriateor adequate, an optional or additional indicator couldincorporate the recommended foods into the definition.

CONTINUED BREASTFEEDINGRATE (1YEAR)Proportion of children 12-15 months of age who are

breastfed:Children 12-15 months of age who were breastfed in thelast 24 hours= ————————————————————Children 12-15 months of age

CONTINUED BREASTFEEDING RATE(2 YEARS)Proportion of children 20-23 months of age who are

breastfed:

Children 20-23 months of age who were breastfed in thelast 24 hours= ————————————————————Children 20-23 months of age

Explanatory notes:Some programmes promote breastfeeding “for one or

longer”. However, the Innocenti Declaration states thatchildren should continue to be breastfed while receivingappropriate complementary food “for up to two years orbeyond”. Thus it is useful to have indicators that measurethe proportion of children who are still breastfed at 1 or 2years of age.

To be consistent with the first, second and thirdindicators proposed, the latter indicators are also mesuredusing 4-month age groups. The continued breastfeeding rate(1 year) gives an indication of breastfeeding beyond oneyear, and the continued breastfeeding rate (2 years) gives anindication of breastfeeding practices towards the end of thesecond year of life.

BOTTLE-FEEDING RATEProportion of infants less than 12 months of age who are

receiving any food or drink from a bottle:

Children <12 months(<366 days) of age who were bottle-fed in the last 24 hours= ————————————————————Children <12 months (<366 days) of age

Explanatory notes:In addition to monitoring recommended feeding

practices, many country programmes are interested in bottle-feeding rates because of the interference of bottle-feedingwith optimal breastfeeding practices and the associationbetween bottle-feeding and increased diarrhoeal diseasemorbidity and mortality. Included in the numerator of thisindicator are infants less than 12 months of age (366 days)who received any food or drink from a bottle with a nipple/teat in the last 24 hours, regardless of whether or not theinfant was breastfed. An optional, related indicator thatmight be useful for some programmes would be the bottle-feeding rate for infants less than 6 months of age.

OPTIONAL ADDITIONAL INDICATORSConsidering the need to limit the number of indicators

and quantity of data to be collected to a minimum, theconsensus of the participants at the meeting was that thesix key indicators described above are the most useful forprogramme assessment and evaluation. However,recognising that some programmes may wish to measureadditional indicators, the participants recommended thefollowing option: ever breastfed rate, timely first-sucklingrate, median duration of breastfeeding, and exclusivebreastfeeding rate by mothers. These are defined below.

EVER BREASTFED RATEProportion of infants less than 12 months of age who

were ever breastfed:Infants <12 months of age who were ever breastfed= ————————————————————————Infants < 12 months of age

TIMELY FIRST-SUCKLING RATEProportion of infants less than 12 months of age who

first sucked within one hour of birth:

Infants <12 months of age who first suckled within onehour of birth= ————————————————————————Infants < 12 months of age


Appendix 10-11


Appendix 12

DEFINITIONS OF BREASTFEEDING CATEGORIES

The definitions of breastfeeding categories used inthis report (all of which apply to the 24-hours periodpreceding the enquiry) are as follows:

-EXCLUSIVE BREASTFEEDING: the infant hasreceived only breastmilk from his/her mother or a wetnurse, or expressed breastmilk, and no other liquids orsolids with the exception of drops or syrups consistingof vitamins, mineral supplements or medicins.

-PREDOMINANT BREASTFEEDING: the infant’spredominant source of nourishment has been breastmilk.However, the infant may also have received water andwater-based drinks (sweetened and flavoured water ,teas,infusions, etc.);fruit juice ;Oral Rehydration Salts (ORS)solution ;drop and syrup forms of vitamins, mineral andmedicines; and ritual fluids (in limited quantities).With theexception of fruit juice and sugar-water, no food-basedfluid is allowed under this definition.

-EXCLUSIVE BREASTFEEDING AND PREDO-MINANT BREASTFEEDING together constitute FULLBREASTFEEDING

-BREASTFEEDING: the child has receivedbreastmilk (direct from the breast or expressed).

-COMPLEMENTARY FEEDING: the child hasreceived both breastmilk and solid (semi-solid) food.

-BOTTLE-FEEDING: the child has received liquidor semi-solid food from a bottle with a nipple/teat.

Although bottle-feeding is not strictly a“breastfeeding” categori, it was considered essential toinclude it among the key indicators because of its impacton breastfeeding. The objective is to measure theprevalence of this mode of feeding, irrespective of thecontent of the feed –e.g., infants receiving breastmilk ina bottle are also included here.

The breastfeeding categories described aboveareessencially the same as those described in “Schema forthe development of breastfeeding definitions” adoptedby IGAB (Interagency Group for Action on Breast-feeding) in 1988 and published in Studies in FamilyPlanning, 21:226-230’1990, by M. Labbok and K.Krasovek. The differences are: (1) a change in termi-nology from “almost exclusive” to “predominant”; (2)the acceptance of certain of drops or syrups in thecategory “exclusive breastfeeding”; and (3) theacceptance of certain liquids and ritual fluids, in limitedamounts, in the category “predominant breastfeeding”.

Appendix 13

TABLE: CRITERIA FOR INCLUSION IN INFANT FEEDING CATEGORIES


BIBLIOGRAFI

1. Contemporary patterns of breastfeeding. Report on theWHO Collaborative study on Breastfeeding. 1981(221 pages).

2. Energy and protein requirements. Report of a Joint/FAO/WHO/UNU Expert Consultation. WHOTechnical Report Series, No. 724. 1985 (206 pages).

3. The growth chart. A tool for use in infant and child healthcare. 1986 (33 pages).

4. Beghin, I., Cap, M. & Dujardin, B. A guide to nutritionalassessment. 1988 (80 pages).

5. Guidelines for training community health workers innutrition . Second edition 1986 (121 pages)

6. James, W.P.T. et al. Healthy nutrition. Preventingnutrition- related diseses in Europe, 1988 (150 pages)

7. Measuring change in nutritional status. Guidelines forassesing the nutritional impact of supplementary feedingprogrammes for vulnerable groups. 1983 (101 pages).

8. Minor and trace elements in breastmilk. Report of a JointWHO/IAEA Collaborative Study. 1989 (171 pages).

9. Mason, J.B. et al. Nutritional Surveillance. 1984 (194pages).

10. DeMaeyer, E. et al. Preventing and controlling irondeficiency anaemia through primary health care. A guidefor health administrators and programme managers. 1989(58 pages).

11. Protecting, promoting and supporting breastfeeding. Thespecial role of maternity services. A Joint WHO/UNICEF Statement 1989 (32 pages).

12. The quantity and quality of breastmilk. Report on theWHO Collaborative Study on Breastfeeding. 1985(148 pages).

13. Weaning-from breast milk to family food. A guide forhealth and community workers. 1988 (36 pages).

14. Lawrence, R.A. Breastfeeding: A guide for the medicalproffesion . Sant Louis: C.V. Mosby Co. 1989.

15. Renfrew, M.J., Fisher, C. & Arms, S. Bestfeeding:getting breastfeeding right for you. Berkley, California:Celestial Arts, 1990.

16. Minchin, M.K. Breastfeeding matters: what we need toknow about infant feeding. Melbourne: AlmaPublications, 1989.

17. Jensen, R.G. & Neville, M.C. Human lactation: milkcomponents and methodologies. New York: PlenumPress, 1986.

18. Goldman, A.S., Atkinson, S. A. & Hanson, L.A. (ed.).Human lactation: effects on the recipient infant. NewYork: Plenum Press, 1987.

19. Howell, R.R., Morriss, F.H. & Pickering, L.K. Humanmilk in infant nutrition and health. Springfield: C.C.Thomas, 1986.

20. Jelliffe, D.B. & Jelliffe, E.F.P. Human milk in the modernworld. Oxford: Oxford University Press, 1978.

21. Hanson l. The immunology of the neonate. Berlin:Springer Verlag, 1988.

22. Tsang, R.C. & Nichols, B.L. Nutrition during infancy.Sant Louis: C.V. Mosby Co., 1988.

23. Jelliffe, D.B. & Jelliffe, E.F.P. Programmes to promotebreastfeeding. Oxford: Oxford University Press, 1988.

24. Protecting children health- A guide for health workers tothe International Code of Marketing of BreastmilkSubstitutes. ICDC - Penang, 1997.

25. International Code of Marketing of Breastmilk Substitutes

- WHA, 1981.26. Uvnas-Moberg, Eriksson: Breastfeeding:

physiological, endocrine and behavioral adaptationscaused by oxytocin and local neurogenic activity inthe nipple and mammary gland.: Acta Paediatrica,1996 May, 85(5):525-30

27. Newcomb PA, Storer BE, Longnecker MP, et al.Lactation and a reduced risk of premenopausalbreast cancer. N Engl J Med. 1994;330:81-87

28. Freudenheim, J. et al. 1994 “Exposure to breast milkin infancy and the risk of breast cancer”. Epidemiology5:324-331

29. Horwood and Fergusson, “Breastfeeding and LaterCognitive and Academic Outcomes”, Jan 1998Pediatrics Vol. 101, No. 1

30. Wang YS, Wu SY. The effect of exclusivebreastfeeding on development and incidence ofinfection in infants. J Hum Lactation . 1996; 12:27-30

31. Koutras, A.K., “Fecal Secretory ImmunoglobulinA in Breast Milk vs. Formula Feeding in EarlyInfancy”. J. Ped Gastro Nutr 1989.

32. Dewey KG, Heinig MJ, Nommwen LA. Maternalweight-loss patterns during prolonged lactation. AmJ Clin Nutr 1993;58:162-166

33. Virtanen et al: “Diet, Cow’s milk protein antibodiesand the risk of IDDM in Finnish children.”Childhood Diabetes in Finland Study Group.Diabetologia, Apr 1994, 37(4):381-7

34. Mayer, EJ, Hamman RF, Gay EC, et al. “Reducedrisk of IDDM among breast-fed children”. Diabetes,1988;37:1625-1632

35. Virtanen SM, Rasanen L, Aro A, et al. “Infant feedingin Finnish children <7 yr of age with newlydiagnosed IDDM”. Diabetes Care, 1991;14:415-417

36. Gerstein HC. “Cow’s milk exposure and type 1diabetes mellitus”. Diabetes Care. 1994;17:13-19

37. Borch-Johnson, K., et al., “Relation betweenbreastfeeding and incidence of insulin-dependentdiabetes mellitus”. Lancet 2:1083-86 (1984)

38. Lucas A, Brooke OG, Morley R, et al. “Early diet ofpreterm infants and development of allergic aratopic disease: randomized prospective study”. BrMed J. 1990:300:837-840

39. Halken S, Host A, Hansen LG, et al. “Effect of anallergy prevention programme on incidence ofatopic symptoms in infancy”. Ann Allergy .1992;47:545-553

40. Saarinen UM, Kajossari M. “Breastfeeding asprophylaxis against atopic disease: prospectivefollow-up study until 17 years old.” Lancet .1995;346:1065-1069

41. Aniansson G, Alm B, Andersson B, et al. “Aprospective cohort study on breast-feeding and otitismedia in Swedish infants”. Pediatr Infect Dis J. 1994;13:183-188

42. Kovar MG, Serdula MK, Marks JS, et al. “Review ofthe epidemiologic evidence for an associationbetween infant feeding and infant health.” Pediatrics.1984:74:S615-S638

43. Saarinen UM. “Prolonged Breast Feeding asprophylaxis for recurrent otitis media.” Acta PaediatrScand. 1982;71:567-571


44. Ford RPK, Taylor BJ, Mitchell EA, et al.“Breastfeeding and the risk of sudden infant deathsyndrome. Int J. Epidemiol. 1993;22:885-890

45. Mitchell EA, Taylor BJ, Ford RPK, et al. “Fourmodifiable and other major risk factors for cot death:the New Zealand Study”. J Paediatr Child Health.1992;28:S3-S8

46. Kovar MG, Serdula MK, Marks JS, et al. “Review ofthe epidemiologic evidence for an associationbetween infant feeding and infant health.” Pediatrics.1984:74:S615-S638

47. Dewey KG, Heinig MJ, Nommsen-Rivers LA.Differences in morbidity between breast-fed.“Differences in morbidity between breast-fed andformula-fed infants.” Pediatr. 1995;126:696-702

48. Howie PW, Forsyth JS, Ogston SA, et al. “Protectiveeffect of breast feeding against infection.” Br Med J.1990;300:11-16

49. Popkin BM, Adair L, Akin JS, et al. “Breast-feedingand diarrheal morbidity.” Pediatrics. 1990;86:874-882

50. Beaudry M, Dufour R, Marcoux S. “Relation Betweeninfant feeding and infections during the first sixmonths of life.” J Pediatr. 1995; 126:191-197

51. Frank Al, Taber LH, Glezen WP, et al. “Breast-feeding and respiratory virus infection.” Pediatrics1982;70:239-245

52. Wright AI, Holberg DJ, Martinez FD, et al. “ Breastfeeding and lower respiratory tract illness in thefirst year of life.” Br Med J. 1989;299:935-949

53. Chen Y. “Synergistic effect of passive smoking andartificial feeding on hospitalization for respiratoryillness in early childhood.” Chest. 1989;95:1004-1007

54. Wright AL, Holberg CH, Taussig LM, et al.

“Relationship of infant feeding to recurrentwheezing at age 6 years.” Arch Pediatr Adolesc Med.1995;149:758-763

55. Preliminary data from U. of North Carolina/DukeUniversity researchers indicates breastfed childrenwere only 40% as likely to develop JA. “Mother’sMilk: An Ounce of Prevention?” Arthritis Today May-June 1994

56. “An Exploratory Study of Environmental and Medi-cal Factors Potentially Related to Childhood Can-cer.” Medical & Pediatric Oncology, 1991; 19(2):115-21

57. Birch E, et al. “Breastfeeding and optimal visualdevelopment.” J Pediatr Ophthalmol Strabismus1993;30:33-8

58. “The role of universal distribution of vitamin Acapsules in combatting vitamin A deficiency inBangladesh.: Am J Epidemiol 1995; 142(8): 843-55

59. Han-Zoric, M., “Antibody responses to parenteraland oral vaccines are impaired by conventional andlow protein formulas as compared tobreastfeeding.” Acta Paediatr Scand 1990; 79:1137-42

60. Convert RF, Barman N, Comanico RS, et al. “Priorenteral nutrition with human milk protects againstintestinal perforation in infants who developnecrotizing enterocolitis.” Pediatr Res. 1995; 37:305A.

61. Van Den Bogaard, C. “Relationship Between BreastFeeding in Early Childhood and Morbidity in ageneral Population.” Fan Med, 1991; 23:510-515

62. Baumgartner, C.,”Psychomotor and SocialDevelopment of Breast Fed and Bottle Fed babiesDuring their First year of Life”.

63. Kaiser Permanente: Internal research to determinebenefits of sponsoring an official lactation program)

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