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Draft Guidelines for the Marketing of Ready to Use Supplemental Foods for Children

In the absence of guidelines to govern the marketing of ready to use supplemental foods (RUSFs), members of the UNSCN NGO/CSO constituency drafted a guidance to specifically address this in 2010. The basis and content of the draft guidance were shared on en-net (www.en-net.org.uk) in April 2011 to seek further opinion and an open invitation to make substantial comment in Field Exchange was issued. Two comments were submitted to the ENN that are included here, along with a response to both from Ted Greiner on behalf of the draft guidance signatories. We appreciate that the issues raised below are the 'tip of the iceberg', and that there are many more stakeholders that will have a position. We hope, however, that the constructive exchange of opinion that is shared here will kick start a process that will result in authoritative guidance for practitioners as well as for the private sector. We welcome further contributions from our readers on this issue, both to Field Exchange and on en-net (www.en-net.org.uk) (eds)

Context and source of draft guidelines

Draft Guidelines for the Marketing of Ready to Use Supplemental Foods for Children have been developed over a period of two years by members of the United Nations System Standing Committee on Nutrition (SCN) NGO/CSO constituency with assistance from others. This process included a series of meetings held on the occasion of the 2009 International Conference on Nutrition in Bangkok.

Ready to use supplemental foods (RUSFs) are receiving increasing attention by agencies working to alleviate problems of malnutrition. One reason for this is the fact that water does not need to be added to these foods, reducing their risk of contamination. However, the potential benefit may not be as great as expected. Due to their low water content and high renal solute load, RUSFs actually increase the child's need for safe water compared to diets based on foods cooked with water, where heating automatically eliminates its pathogens, at least when the food is consumed soon after cooking.

RUSFs should represent only a small proportion of any child's diet and be used for a relatively short period of time to provide some missing nutrients. Indeed, the very need for RUSFs in a given location should be seen by governments and donors as an indication that nutritious foods are likely to be out of reach of many families, and also that breastfeeding patterns are likely not to be optimal. Thus, in such situations, the provision of RUSFs should not be a stand-alone approach but combined with measures to protect and support breastfeeding, complementary feeding and household food security.

We do not believe that RUSFs for children should be marketed to the general public. Nor do we believe that either these foods or Ready to Use Therapeutic Foods (RUTFs) should be used in programs for prevention, rather than treatment, of malnutrition. However, commercial marketing of these foods is already being studied and discussed by manufacturers and other interested parties. It is therefore necessary to take steps to prevent the kind of unethical marketing that has been widespread for breast milk substitutes. While RUSF may not be intended by manufacturers to replace breastmilk, we know that there are risks of them being marketed and widely used in ways that do displace breast milk.

We propose that UN agencies with mandates to generate international normative guidelines to achieve good nutrition and health for infants and children, in particular Codex Alimentarius, continue the process of refining and obtaining widespread agreement on food marketing guidelines.

The following members of the drafting group have consented to the use of their names as supporters of these guidelines: Hanifa Bachou, Geoffrey Cannon, Wenche Barth Eide, Alke Friedrichs, Catherine Geissler, Ted Greiner, Irmgard Jordan, Silvia Kaufmann, George Kent, Peggy Koniz-Booher, Harriet Kuhnlein, Michael Krawinkel, Michael Latham, Irene Lausberg, Pamela Morrison, Chris Mulford, Veronika Scherbaum, Claudio Schuftan, and Carol Williams.

Ted Greiner, Chair
Non-governmental Organisation/Civil Society Organisation Constituency United Nations System Standing Committee on Nutrition
October 27, 2010

DRAFT Guidelines for the Marketing of Ready-to-Use Supplemental Foods for Children October 27, 2010

Article 1. Aim of the Guidelines

The aim of these Guidelines is to contribute to the optimal nutrition for infants and young children, in part by the protection and support of breastfeeding, and safe, timely and nutritionally adequate complementary feeding and by ensuring the proper use of Ready to Use Supplemental Foods (RUSFs), when these are necessary, and by eliminating inappropriate marketing and distribution methods. These Guidelines are written as an adjunct to the existing International Code of Marketing of Breast-milk Substitutes and relevant WHA resolutionsa, and also the Global Strategy for Infant and Young Child Feedingb.

Article 2. Scope of the Guidelines

These Guidelines apply to the provision, use, marketing, and practices related thereto, of RUSFs. They also apply to Ready-to-Use Therapeutic Foods (RUTFs) whenever they are used for any purpose other than the treatment of severe acute malnutrition (SAM) under competent, independent medical supervision. They also apply to RUSF's quality and availability, and to information concerning their use. These guidelines may be seen as an adjunct to any developed within the Codex Alimentarius system to standardise the ingredients, labelling, and processing methods used in the manufacture of these products.

These guidelines do not cover non-foodbased micro- or multi-nutrient powders used as home fortificants. They also do not cover complementary foods as defined below.

Article 3. Definitions

Ready to Use Supplemental Foods (RUSFs) are foods that are fortified with micronutrients as a remedy for malnutrition and can be consumed without cooking or the addition of water. They include:

They possess qualities that allow their distribution and use in low-income settings at ambient temperatures even in hot climates without undue loss of nutrients. They are fortified such that a substantial proportion of the child's requirements of a wide range of nutrients are provided from eating a relatively small quantity. Unlike RUTFs, RUSFs are not specifically designed for use in treatment of severe acute malnutrition (SAM).

Complementary foods, whether based on customary family foods or commercially manufactured complementary foods tend to be bulkier than RUSFs. Although they may sometimes be fortified, they usually supply a smaller amount of fewer nutrients in a single meal. Many complementary foods need to be cooked.

Unlike complementary foods, RUSFs are not a necessary part of the diet of older infants and young children. Where perceived or used as a breast-milk substitute, they should be covered under the existing International Code of Marketing for Breast-Milk Substitutes and subsequent relevant WHA Resolutions.

Other definitions applicable to these Guidelines are identical with those in the International Code of Marketing of Breastmilk Substitutes.

Article 4. Information and education

4.1 Governments have the responsibility to ensure that objective and consistent information on infant and young child feeding, particularly breastfeeding, is provided to families and those involved in the field of infant and young child nutrition. This responsibility should cover the planning, provision, design and dissemination of information, or its control.

4.2 Informational and educational materials, whether written, audio, or visual, dealing with the feeding of infants and intended to reach pregnant women and mothers of infants and young children, should include clear information on all the following points: (a) the importance of early initiation and exclusive breastfeeding for the first six months of life and the importance of maintaining breastfeeding, usually up to and beyond 24 months; (b) the importance of providing adequate complementary foods to children beginning at 6 months of age; and (c) where needed, the proper use of Ready to Use Foods. When such materials contain information about the use of RUSFs, they should include the financial implications of its use and the fact that the nutrients contained in RUSFs can be obtained from natural foods. Such materials should not use any pictures or text which may idealize the use of RUSFs. RUSFs should not be promoted based on their eliminating the need for clean water for older infants and young children. To the contrary, the specific requirement for additional safe water (boiled or treated) should be noted in all instructions.

4.3 Any RUSFs needed for the small number of infants and young children likely to require them in health care facilities should be made available through the normal procurement channels and not through free or subsidised supplies from manufacturers or their agents.

4.4 All actors dealing with RUSFs should avoid implying that their use should be the norm or should in any way replace recommended patterns of breastfeeding and complementary feeding.

Article 5. The general public and mothers

5.1 There should be no advertising or other form of promotion to the general public of RUSFs.

5.2 Manufacturers and distributors should not provide samples of RUSFs, directly or indirectly, to pregnant women, mothers or members of their families.

5.3 In conformity with paragraphs 1 and 2 of this Article, there should be no point-ofsale advertising, giving of samples, or any other promotion device to induce 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 RUSFs. This provision should not restrict the establishment of pricing policies and practices intended to provide products at lower prices on a longterm basis.

5.4 Manufacturers and distributors should not distribute to pregnant women or mothers of infants and young children or their families, any gifts of articles or utensils which may promote the use of RUSFs.

5.5 Marketing personnel, in their business capacity, should not seek direct or indirect contact of any kind with pregnant women or with mothers, parents and caregivers of infants and young children.

Article 6. Health care systems

6.1 Health authorities should take appropriate measures to support and protect breastfeeding and promote these Guidelines, and should give appropriate information and advice to health workers in regard to their responsibilities, including the information specified in Article 4.2.

6.2 No facility of a health care system should be used for the purpose of promoting RUSFs. These Guidelines do not, however, preclude the dissemination of information to health professionals as provided in Article 7.2.

6.3 Facilities of health care systems should not be used for the display of RUSFs, for placards or posters concerning such products, or for the distribution of material provided by a manufacturer or distributor.

6.4 The use by the health care system of 'professional service representatives', 'mothercraft nurses' or similar personnel, provided or paid for by manufacturers or distributors, should not be permitted.

6.5 Feeding with RUSFs should be demonstrated only by independent health workers, or other community workers if necessary and not by commercial representatives or others working directly or indirectly for companies producing a RUSF. The demonstration should only be to the mothers or family members of children who these health workers deem need to use these foods.

6.6 Donations or temporary low-price sales to health care institutions of supplies or samples of RUSFs, may not be made by manufacturers or their agents.

6.7 Health authorities are advised to exert utmost care in allowing any funding for any purposes from commercial enterprises, including ensuring that conflicts of interest and unintentional 'endorsement by association' are avoided. Financial support for health professionals working for infant health should not create a conflict of interest.

6.8 There should be no infant or young child food industry involvement in infant nutrition programme implementation or policy formulation.

Article 7. Health workers

7.1 Health workers should be fully trained to support and protect early, exclusive and sustained breastfeeding and adequate complementary feeding; and those who are concerned in particular with maternal and infant nutrition should make themselves familiar with their responsibilities under these Guidelines, including the information specified in Article 4.2.

7.2 Information provided by manufacturers and distributors to health professionals regarding RUSFs should be restricted to scientific and factual matters and such information should not imply or create a belief that RUSF or any other food is equivalent or superior to breastfeeding. It should also include the information specified in Article 4.2.

7.3 No financial or material inducements to promote RUSFs should be offered by manufacturers or distributors to health workers or members of their families, nor should these be accepted by health workers or members of their families.

7.4 Samples of RUSF, or of equipment or utensils for their preparation or use, should not be provided by manufacturers or their agents to health workers except when necessary for the purpose of professional evaluation or research at the institutional level. RUSF should be used in a well thought out program designed to meet specific needs only for as long as those needs exist and thus health workers should not give samples of RUSF to pregnant women, mothers of infants and young children, or members of their families.

7.5 Manufacturers and distributors of RUSF should disclose to the institution to which a recipient health worker is affiliated any contribution made to him or on his behalf for fellowships, study tours, research grants, attendance at professional conferences, or the like. Similar disclosures should be made by the recipient.

Article 8. Manufacturers and Distributors and persons they employ

8.1 In systems of sales incentives for marketing personnel, the volume of sales of RUSFs should not be included in the calculation of bonuses, nor should quotas be set specifically for sales of these products. This should not be understood to prevent the payment of bonuses based on the overall sales by a company of other products marketed by it.

8.2 Personnel employed in marketing of RUSF should not, as part of their job responsibilities, perform educational functions in relation to pregnant women or mothers of infants and young children.

Article 9. Labelling

9.1 Labels should be designed to provide the necessary information about the appropriate use of the product, and so as not to discourage breastfeeding or the use of traditional complementary foods.

9.2 Manufacturers and distributors of RUSFs should ensure that all packaging has a clear, conspicuous, and easily readable and understandable message printed on it, or on a label which cannot readily become separated from it, in an appropriate local language, which includes all the following points: (a) the words "Important Notice" or their equivalent; (b) a statement of the importance of breastfeeding exclusively up to six months and then continuing breastfeeding with appropriate complementary foods up to and beyond two years; (c) a statement that the product should be used only on the advice of a health worker as to the need for its use and the proper method of use. Where packages are too small, the information can be printed on a separate page attached to the package.

Neither the container nor the label should have pictures of infants, nor should they have other pictures, text or claims which may idealize the use of RUSFs or encourage use too early or inappropriate use. They may, however, have graphics for easy identification of the product as a Ready to Use Food and for illustrating methods of use. Inserts giving additional information about the product and its proper use, subject to the above conditions, may be included in the package or retail unit. Additional labelling requirements may be made in accordance with the legislation of the country in which the product is distributed.

The labelling of all RUSF products shall meet the applicable standards of the Codex Alimentarius Commission.

9.3 RUSFs which do not fully meet all the nutritional requirements of an older infant or young child should carry on the label a warning that the unmodified product should not be their sole source of nourishment.

9.4 The label of RUSFs should also state all the following points: (a) the ingredients used; (b) the composition/analysis of the product; (c) the storage conditions required; and (d) the batch number and the date before which the product is to be consumed, taking into account the climatic and storage conditions of the country concerned.

9.5 RUSF products should not make idealized claims or nutrition and health claims as stated in WHA Resolution 63:1:4 except where specifically provided for, in relevant Codex Alimentarius standards or national legislation.

Article 10. Quality

10.1 The quality of products is an essential element for the protection of the health of infants and therefore should be of a high recognized standard.

10.2 RUSFs should, when sold or otherwise distributed, meet applicable standards recommended by the Alimentarius Commission and also the Guidelines of Hygienic Practice for Foods for Infants and Children.

Article 11. Implementation and monitoring

11.1 Governments should take action to give effect to the provisions of these Guidelines, as appropriate to their social and legislative framework, including the adoption of national legislation, regulations or other suitable measures. National policies and measures, including laws and regulations, which are adopted accordingly, should be publicly stated, and should apply on the same basis to all those involved in the manufacture and distribution of RUSFs.

11.2 Responsibility for monitoring the application of these Guidelines lies with governments acting individually and collectively. The manufacturers and distributors of RUSFs, and appropriate nongovernmental organizations, professional groups, and consumer organizations should collaborate with governments to this end.

11.3 Independently of any other measures taken for implementation of these Guidelines, manufacturers and all distributors of RUSFs should regard themselves as responsible for monitoring their marketing practices according to the principles, aims and provisions of these Guidelines and the International Code and subsequent relevant WHA resolutions, and for taking steps to ensure that their conduct at every level conforms to them.

11.4 Nongovernmental organisations, professional groups, institutions and individuals concerned should have the responsibility of drawing the attention of manufacturers or distributors to activities which are incompatible with the principles, aims, and provisions of these Guidelines, so that appropriate action can be taken. The appropriate governmental authority should also be informed.

11.5 Manufacturers and primary distributors of RUSFs should apprise each member of their marketing personnel of the Guidelines and of their responsibilities under it.

Comment from Arimond et al

The Draft Guidelines for the Marketing of Ready-to-Use Supplemental Foods for Children aim to contribute to optimal nutrition for infants and young children. We share that aim, but do not agree with some of the implications of the Draft Guidelines.

We agree that public health practitioners and others need guidance to avoid confusion about appropriate uses for a number of newer products.

We believe that ideally, such guidance should be developed by international health authorities, using a transparent, inclusive, and evidence-based process.

We also strongly agree that support, protection and promotion of optimal breastfeeding are urgent and continuing public health priorities in both emergency and non-emergency contexts. Further, we support policies and programmatic efforts that aim to diversify diets using locally available nutrient-dense foods.

We diverge from the authors of the Draft Guidelines on several issues around the role and potential benefits of low-dose lipid-based nutrient supplements (LNS) used for home fortification of infant diets.

'Low-dose LNS' provide a relatively low dose of energy (calories) but a full range of vitamins, minerals, and essential fatty acids, many of which are often deficient in infant diets. The Draft Guidelines state that the nutrients in LNS "can be obtained from natural foods", but even with diverse diets including animal-source foods it is difficult to meet some micronutrient needs, particularly for infants 6-11 months of age.1 For this reason, fortified products have been developed for this age group. Such products are commonly given in many developed countries, where they have contributed to reductions in the prevalence of iron deficiency during infancy.

We note that the Draft Guidelines do not suggest regulation of marketing for cerealbased complementary foods, whether fortified or not. They also do not suggest regulation of marketing of many snacks commonly purchased for infants, even by poor families. In effect, and without offering evidence, the Draft Guidelines single out LNS as uniquely dangerous to infant diets.

To date there is no evidence that low-dose LNS are harmful to breastfeeding compared to cereal-based fortified complementary foods; there is evidence for no impact on breastfeeding. 2,3,4,5 There is no basis for regulating LNS differently from cereal-based complementary foods or, indeed, the many snack foods and other foods marketed for children. Regulation of health and nutrition claims for all foods and home fortificants can and should be addressed. The other key issue not covered by the Draft Guidelines is the potential benefit of consumption of LNS. Several studies have suggested benefits related to linear growth and infant development.6,7,8,9

However, unlike the situation with RUTF used in treatment of acute malnutrition, the evidence base for the benefits of LNS is thin and evolving. We and others are currently working to answer a number of questions about LNS, including:

Until these questions are resolved, use of LNS in programmes should be governed by considerations such as cost, accessibility, and acceptability. Programmes that deliver LNS can and should be designed to include strong promotion, support and protection of breastfeeding, and context-specific activities to support dietary diversification.10

As for marketing outside of programmatic channels, singling out LNS for regulation as indicated in the Draft Guidelines would be likely to stifle private sector investment, which in turn would have implications for supplies not only to retail markets, but also to programmes. This would reduce opportunities for lowincome households to find affordable means to enrich the diets of infants currently consuming unfortified, nutrient-poor porridges and snacks.

While we have focused on our differences here, we would like to affirm that they are greatly outnumbered by our areas of agreement and common ground. We look forward to continued dialogue.

Mary Arimond and Kathryn Dewey, Programme in Community and International Nutrition, University of California, Davis

André Briend, Department of International Health, University of Tampere, Finland

Comment from IBFAN

IBFAN (International Baby Food Action Network) contributed to the development of the Draft Guidelines for the Marketing of Ready-to-Use Supplemental Foods for Children and supports the safeguards contained. However, because they are limited in scope, IBFAN was not a signatory. We feel strongly that the scope should be wider to include all fortified complementary food products for older infants and young children. This is in conformity with World Health Assembly Resolution 63.23 (2010) which calls for an end to the inappropriate promotion of foods for infants and young children. The narrow scope introduces the risk of industry disregarding its responsibility for full compliance with WHA Resolution 63.23.

Breastfeeding support together with nutrition education and counselling on the best way to prepare family foods as complementary foods, free from commercial influence, can both prevent malnutrition and promote optimal growth and development. A central value of human relationships and cultures is a family's skill to feed itself and include its younger members in food sharing11. Thus while IBFAN accepts that the fortification of foods in certain situations may be useful, inappropriate marketing of fortified complementary foods may undermine 6 months of exclusive breastfeeding and sustained breastfeeding for 2 years or beyond, recommended by WHO. It may also have a detrimental impact on the availability and use of culturally suitable and sustainable family foods. The current practice of promoting such foods to 'prevent malnutrition', dressed up as an act of Corporate Social Responsibility, is particularly questionable.

We advocate that governments regulate the marketing of fortified foods and that all promotional health and nutrition claims on all foods for infants and young children be forbidden. Promotional claims, even if accompanied by messages promoting breastfeeding, can distort parents' perceptions of the nutritional value of products. Labels should always carry full and frank information about ingredients. IBFAN is working to this end at the Codex Alimentarius and other international fora.

We take this opportunity to express our concern about the Guidelines prepared by GAIN entitled 'Using the Code of Marketing of Breastmilk Substitutes to Guide the Marketing of Complementary Foods to Protect Optimal Infant feeding Practices12', shared during the ennet discussion around the draft guidance13. These were prepared in March 2010, before the May 2010 WHA Resolution (63.23). The GAIN guidelines do not adequately address inappropriate marketing such as promotional claims and baby pictures. In fact, the examples given in the GAIN guidelines (on pages 28 and 29) are typical promotional claims: "Yummy cereal aids in your baby's healthy growth and development" and "Super supplement."

Finally, IBFAN is working on guidelines for the marketing of fortified complementary foods. These aim to protect optimal and sustainable infant and young child nutrition and we plan to make them available on the IBFAN website in late 2011.

Patti Rundall,
Policy Director, Baby Milk Action

Elisabeth Sterken,
Director INFACT Canada, Regional Coordinator North America

Arun Gupta,
BPNI, Regional Coordinator, IBFAN Asia

Joyce Chanetsa,
Regional Coordinator, IBFAN AFRICA

Marta Trejos,
Regional Coordinator, Latin America

Lida Lhotska,
Regional Coordinator, IBFAN Europe

Rebecca Norton,
IBFAN GIFA

Annelies Allain,
Director ICDC

Maryse Arendt,
Initiativ Liewesenfank

Response

We are pleased to receive comments from Arimond et al who have done such important research related to infant health, including on LNS, and from IBFAN with their longstanding experience in Code implementation. Arimond et al state that health and nutrition claims for all foods and home fortificants should be regulated - a much broader issue than the one our guidelines dealt with, but something we very much agree with. Indeed, without free reign to make health and nutritional claims about their products, we suspect that promotional expenses for RUSFs would hardly pay off. We also agree that "ideally, such guidance should be developed by international health authorities, using a transparent, inclusive, and evidence-based process." Indeed, it is our hope that the publications of these draft guidelines by Field Exchange will encourage WHO, which has already expressed interest in the guidelines, to itself take up work on this. Below are some specific responses to their commentary:

1. IBFAN believes that the scope of the guidelines should be expanded to include fortified complementary foods and Arimond et al further assume that the authors of the RUSF Guidelines (which they rightly assume would include LNS) are singling out RUSFs as "uniquely dangerous" because the marketing of snacks and complementary foods are not included in the scope of these guidelines. That is not the case.

To the contrary, we would support any efforts to regulate inappropriate marketing of those products as food for infants. However, those foods have been in existence for a long time - there has been plenty of time to achieve this. Snacks would be exceedingly difficult to define in such guidelines. The most effective approach would thus probably be, as India and some other countries have done, simply banning all advertising and other marketing approaches of any foods for children under two years of age, for example. Then, of course, RUSFs would be included and no separate guidelines would be needed.

Complementary foods are by definition aimed at infants and young children. They have been inappropriately marketed for well over a century. WHO noted already over a decade ago that "when perceived or used as breast-milk substitutes" (as they often are, particularly in countries where they are commonly overdiluted and fed by bottle), a national government could include them by brand name in local laws governing the marketing of breast milk substitutes. In addition, guidelines for the marketing of complementary foods have in fact already been developed for GAIN14. Adding them to the RUSF guidelines would have thus been somewhat duplicative, as well as greatly increasing the complexity of obtaining widespread agreement on them. We are pleased to note that IBFAN will be issuing guidelines for fortified complementary foods in the near future.

We have been particularly motivated by the fact that RUSFs are new products and not yet marketed commercially in most countries. For once, would it not be wise to regulate the marketing of products aimed at infants BEFORE abuses are documented, the mass media sensationalises it, and local jobs and vested interests are created based on perhaps inappropriate marketing and use of these products?

2. The guidelines are hardly the place to review the literature on the benefits of LNS, something we do not dispute. Infant formula is also beneficial in its place. The very idea of regulating the marketing of infant formula was controversial originally but the need for it is almost universally agreed on nowadays. In stating their support for the protection of breastfeeding, we would assume that this includes Arimond et al?

3. When efforts to regulate the marketing of infant formula began, that industry made dire predictions about the impact of said regulation on a wide range of business and economic factors, none of which came to pass. Indeed, the infant formula market continues growing rapidly, especially in emerging markets15. Its growth in the poorest markets probably has been delayed, as more ethical marketing strategies avoided damaging the breastfeeding culture in these countries. But all these marketing regulations have done, and all the regulation of marketing of RUSFs would aim to do, is to level the playing field at a higher level of ethics. Otherwise, the companies with the dirtiest marketing strategies are likely to be the ones that make the most money. Larger companies like Nestle have often said that by adopting more ethical marketing approaches they have lost market share in many countries but nowadays they say they welcome regulation that levels the playing field.

We would like to point out that, in reviewing experience implementing the International Code in 1991, WHO found that those countries which did not outlaw advertising, but rather attempted to restrict it to some kind of "acceptable" wording, regretted doing so. It simply proved to be too difficult, contentious, time-consuming and expensive to engage the private sector in endless discussions and negotiations about exactly what wording was acceptable and what wording was not.

4. It is indeed likely, as Arimond et al imply, that in the short run, widespread commercial sales of RUSFs would generate economies of scale that would in turn make programmatic use of the products lower in cost. But without marketing guidelines in place, is it not likely that much of these sales would be harmful? For example excessive hyping of these products would likely encourage consumers who cannot afford them to buy quantities too small to be beneficial for health, yet large enough to reduce how much money they have available to spend on their normal diets? We have often seen this kind of harm being done for example when nutritionists too strongly promote the use of expensive animal foods in low-income settings. Would it really be so risky to slow down the commercial growth of these products by restricting them to ethical marketing approaches?

It is just such a narrowness of focus (in this case, accepting potentially harmful private sector approaches to benefit public sector use of the product), the well-known "magic bullet" approach, that those working more broadly with public health object to, as they so often see the harmful side effects.

5. I agree with Arimond et al that we share much common ground, and look forward to their continued engagement with us. They do not discuss details of the wording of the guidelines, which is intentionally quite strong. But we hope that they will do so, and that reasonable compromises can be reached which nevertheless achieve the objectives of banning unethical marketing practices. Those who know the history of the Code of Marketing of Breast-milk Substitutes will recall that strong pressure from Ted Kennedy was required to get WHO to work on that Code. We hope we can arrive at an agreed position that will allow Arimond et al to join us in encouraging WHO to shoulder its responsibility in developing and promoting the use of such guidelines. If this can include fortified complementary foods, so much the better. In the meantime, we hope that this attention to the existing draft guidelines from ENN and Field Exchange will assist in spreading awareness of the need to avoid marketing of RUSFs to the general public.

Ted Greiner, Professor,
Department of Food and Nutrition, Hanyang University, Seoul Korea
On behalf of the signatories of the draft Guidelines

Detailed comments on the draft guidance are welcome and can be sent directly to Ted Greiner at tedgreiner@yahoo.com

Show footnotes

ahttp://www.who.int/nutrition/publications/code_english.pdf

bhttp://www.who.int/nutrition/publications/infantfeeding/9241562218/en/index.html

1WHO/PAHO. Guiding principles for complementary feeding of the breastfed child. Washington, DC, Pan American Health Organization, 2003.

2Galpin L, et al. Breast milk intake is not reduced more by the introduction of energy dense complementary food than by typical infant porridge. J Nutr. 2007 Jul;137(7):1828-33.

3Flax VL, et al. Feeding patterns of underweight children in rural Malawi given supplementary fortified spread at home. Matern Child Nutr. 2008 Jan;4(1):65-73.

4Flax VL, et al. Feeding patterns and behaviors during home supplementation of underweight Malawian children with lipid-based nutrient supplements or corn-soy blend. Appetite. 2010 Jun;54(3):504-11. Epub 2010 Feb 11.

5Owino VO, et al. Breast-milk intake of 9-10-mo-old rural infants given a ready-to-use complementary food in South Kivu, Democratic Republic of Congo. Am J Clin Nutr. 2011 Mar 30. [Epub ahead of print]

6Adu-Afarwuah S, et al. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr 2007;86:412-20.

7Adu-Afarwuah S, et al. Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana. Am J Clin Nutr. 2008 Apr;87(4):929-38.

8Phuka JC, et al. Complementary feeding with fortified spread and incidence of severe stunting in 6- to 18-monthold rural Malawians. Arch Pediatr Adolesc Med. 2008 Jul;162(7):619-26.

9Phuka JC, et al. Postintervention growth of Malawian children who received 12-mo dietary complementation with a lipidbased nutrient supplement or maize-soy flour. Am J Clin Nutr. 2009 Jan;89(1):382-90. Epub 2008 Dec 3.

10Paul KH et al. Complementary feeding messages that target cultural barriers enhance both the use of lipid-based nutrient supplements and underlying feeding practices to improve infant diets in rural Zimbabwe. Matern Child Nutr. Article first published online: 4 Aug 2010.

11:What is complementary feeding? A philosophical reflection to help a policy process. Discussion paper developed for the International Baby Food Action Network, by Gabrielle Palmer, September 2009. http://www.ibfan.org/Gay_Palmer.html

12Available at http://www.ennonline.net/resources/769

13View at http://www.en-net.org.uk/question/409.aspx

14Available at http://www.ennonline.net/resources/769

15http://www.ubicconsulting.com/template/fs/documents/Nutraceuticals/Ingredients-in-the-world-infant-formulamarket.pdf

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A paper and recently summarised editorial1,2 Violations of the International Code of Marketing of Breastmilk Substitutes have been previously reported in Field Exchange3. A...

FEX: Use of LNS to improve food rations in emergencies

WFP/Alejandro Chicheri, Nicaragua, 2007 Summary of review1 A recent review focuses on the potential role of lipid-based nutrient supplements (LNS)' in meeting the nutritional...

FEX: Letter on relevance of IFE guidelines in developed countries, by Sarah Saunby

Recently, ENN was party to an exchange of questions and discussion between field staff and 'experts' relating to decisions on the use of readymade therapeutic products versus...

FEX: Action to improve infant and young child feeding in nutrition and child health programmes

A mother prepares porridge from soy-fortified bulgur in Guatemala Proceedings of meeting1 Over 50 researchers, programme implementers, infant feeding experts and...

en-net: RUTF FDA Approved

Is Plumpy Nut RUTF approved by FDA? Can anyone forward me the link.

Thanks Judy Canahuati. Really it was a new question for me, i don't know how much is this...

FEX: Artificial feeding in emergencies: experiences from the ongoing Syrian crisis

By Suzanne Mboya Suzanne Mboya is a consultant nutritionist. In 2014 she completed a sixth month mission supporting the Syrian crisis IYCF-E response through a partnership...

FEX: Infant Feeding in Emergencies: Recurring Challenges

Published Report By Marie McGrath The importance of infant feeding in emergencies has been highlighted during recent emergencies in countries such as Iraq and Bosnia, where...

FEX: ENN/GIFA project

Summary of presentation1 The Core Group2, composed of UNICEF, UNHCR, WFP, WHO, ENN and GIFA/IBFAN have developed and disseminated module 13 on Infant Feeding in Emergencies....

FEX: Infant Feeding in Emergencies - the challenges

To the uninitiated, Infant Feeding in Emergencies (IFE) may seem like a pretty innocuous topic which gets a lot of media coverage when crises occur. The fact is that there is a...

FEX: Evaluation of use of IFE training materials

By Chloe Angood Chloe has a Bachelors degree and a Masters degree in Development Studies, with an emphasis on HIV/AIDS, nutrition and agriculture. Following 3 years as a...

FEX: Violations of the International Code of Marketing of Breast-milk Substitutes: Indonesia context

Research snapshot1 Information and promotional materials produced by breast-milk substitute (BMS) companies and the distribution of free samples of BMS have a well understood...

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Reference this page

Draft Guidelines for the Marketing of Ready to Use Supplemental Foods for Children. Field Exchange 41, August 2011. p47. www.ennonline.net/fex/41/draft