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 representatives of WHO and UNICEF headquarters departments and regional offices gathered in Geneva in October 2008, to discuss how to fill the gap between the progress that has been made in defining principles for appropriate feeding for infants and young children from 6 to 23 months and translating these into specific policies and programmes.

Participants recognised that there are not enough examples of well-documented, largescale programmes that have successfully improved feeding practices in children 6-23 months of age and resulted in improved health outcomes. Therefore, there are important weaknesses in the evidence base for effective actions. Nevertheless, the evidence is strong to support the following conclusions:

The context

• Recommendations for optimal infant and young child feeding include that infants should be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health, and thereafter, they should receive nutritionally adequate and safe complementary foods while breast feeding continues up to 2 years or beyond.
• The Global Strategy for Infant and Young Child Feeding, endorsed by WHO Member States and the UNICEF Executive Board in 2002, provides the overall framework for actions needed to protect, promote and support appropriate feeding practices in infants and young children 0-23 months of age.
• The Planning Guide that accompanies the Global Strategy is intended to assist country teams to develop national plans of action to improve child nutrition. The Guide outlines what needs to be done to protect, promote and support breastfeeding. However, it should be updated to give further clarity on what is needed to strengthen complemen tary foods and feeding practices in children 6-23 months of age.
• Acknowledging the critical contribution of continued breastfeeding to child nutrition, the meeting focused mostly on evidencebased and feasible options to improve the quality of complementary foods and on caregivers' practices to enhance their intake.

Effective interventions

• Appropriate nutrition in children 6-23 months of age requires interventions across the life span, from pregnancy into the first 2 years of life. They include support for maternal nutrition², early initiation of breastfeeding, exclusive breastfeeding for 6 months, and the introduction of adequate complementary foods at 6 months with continued breastfeeding for 2 years of age or beyond. Influencing appropriate feeding practices is as critical as influencing avail ability and use of adequate foods.
• Quality counselling of mothers and caregivers, and appropriate behavioural change communication to other family and community decisionmakers, are essential for improving infant and young child feeding practices. They should be at the centre of any strategy to improve infant and young child nutrition.
• Similarly, strategies should maximise the utilisation of locally produced foods in any given setting, and consider the promotion of additional products only if they can fill a critical gap in nutrients in an acceptable, feasible, affordable, sustainable and safe way, as a complement to continued breastfeeding and the local diet, not as a replacement.
• Where locally available foods alone will not satisfy nutritional requirements, various types of products offer promise. They may include centrally produced fortified foods, micronutrient powders, and lipid-based nutrient supplements. Further research and carefully monitored applications at scale are needed to generate more evidence on which product is best for which circumstance, how best to promote their correct utilisation, and their contribution to improving nutritional, developmental and health status in different circumstances.

Effective programme design and delivery

What is the role of industrially produced products in complementary feeding?

• Effective programming should be based on sound information about the setting. It should follow a systematic approach that includes a situation assessment, formative research to identify locally appropriate feeding recommendations and solutions to barriers, development and pre-testing of a limited set of key messages that promote do-able actions, and dissemination of the messages through multiple channels and contacts, including individual counselling and behaviour change communication directed at the wider social environment and key decision-makers. Effective programming should also consider how to create demand among different stakeholders (politicians, health care providers and parents) for good child nutrition to enhance programme uptake.
• A variety of tools are available to support the listed steps in programme design, implementation, evaluation, and research, but there is need for a more detailed framework and user-friendly toolkit to guide assessment, prioritisation and planning of inter ventions for the age group 6-23 months. New methods, such as linear programming and ProPAN, should be built into such a toolkit.
• To strengthen the evidence base for effective interventions and programmes, especially for improving feeding in children 6-23 months of age, there is an urgent need for large-scale effectiveness studies and well welldesigned evaluations that also include measures of cost. In addition, a standard set of criteria on design, documentation and evaluation of programmes is needed to facilitate comparisons of process, impact and costs. Although the focus should be on effectiveness studies, efficacy research is needed as well to answer key questions.
• To promote production and utilisation of food supplements or fortified complementary foods in settings where they are needed, collaboration with the private sector is usually necessary. There is a need for standards for product formulation which may require collaboration with the private sector. Any collaboration however needs to be carried out in such a way that conflicts of interest are minimised and those that can not be avoided are adequately dealt with. The efforts must benefit public health and be compliant with the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions (the Code).

¹Strengthening action to improve feeding of infants and young children 6-23 months of age in nutrition and child health programmes. Geneva, 6-9 October 2008. WHO, UNICEF. Report of Proceedings. Available from WHO website or direct link: http://whqlibdoc.who.int/publications/2008/9789241597890_eng.pdf

²Although not addressed at this meeting, other practices, such as delayed umbilical cord clamping to enhance newborn body iron stores and micronutrient supplementation and nutrition during pregnancy, are also very important for young child nutrition.