Happy new year?

I have a bit of a break from blogging over Christmas and New Year, but I thought I would make a post to wish everyone a happy new year and review the past year of blogs.

Except I will leave that for another day as we are reminded every day on the news that it is not a happy new year for some, particularly in Gaza and Israel at the present time.

So, instead, here are two related thoughts.

Firstly, please don't send formula to Gaza! We have this every time there is an emergency. People collect formula to send. We had to remind people at the time of the Asian Tsunami in 2004 that this is harmful in both the short and long term.

In the short term, donated formula is rarely distributed properly. Some mothers end up using it, thinking it is necessary rather than breastfeeding. They and those caring for orphans or separated children usually find donated milk is labelled in a language they don't understand.

In fact, if formula is labelled in the wrong language it is actually illegal to export it from the UK, including as a donation. We had to resort to invoking the law in the case of the Tsunami. See:
http://www.babymilkaction.org/press/press13jan05.html

All the same, formula found its way to places like Sri Lanka. The Health Minister of Sri Lanka is quoted in a briefing paper from the Emergency Nutrition Network (of which we are members), released to raise awareness of the dangers of formula to Gaza.

This is what the Health Minister had to say:

---quote begins
Although Sri Lanka is a country with a high exclusive breastfeeding rate, there was a myth among mothers about the inability to produce enough breastmilk when under stress. A major problem was the distribution of infant formula and feeding bottles by donors and non-governmental organisations (NGOs), without the appropriate controls, to breastfeeding mothers. Donors acted emotionally withoutany scientific basis, disregarding the dangers of artificial feeding in disasters. Additionally the mass media was very keen on feeding babies so made a public appeal to supply artificial milk and feeding bottles. The Ministry of Health faced many challenges to ensure that breastfeeding mothers continued to do so and did not swap to unsustainable and potentially dangerous infant formula.

Statement from the Sri Lankan Ministry of Health after the 2004 Indian Ocean Tsunami
---quote ends

You can download the briefing at:
http://www.ennonline.net/pool/files/ife/ife-media-flyer-final(1).pdf

Long-term effects can be devastating and last a decade. After the Armenian earthquake in 1988, breastfeeding rates fell from 64% to 20%. My colleague, Susanna Harutyunyan was interviewed in the Armenia Weekly about this and said: "During the early 1990s Armenia was provided with infant formula as humanitarian aid, and the availability of free infant formula was one of the most obvious reasons for the dramatic decrease in breastfeeding."

You can listen to an interview I conducted with Susanna at the International Baby Food Action Network (IBFAN) Europen meeting in 2006 in our broadcasts section:
http://www.babymilkaction.org/ram/ibfaneurope06.html

At the time of the Kosovo crisis when many refugees moved into Albania, our partners there in the IBFAN set up baby friendly corners. Mothers experiencing problems with lactation were helped to relactate. Babies that needed to be bottle fed, where fed in a separate area with locally sourced formula, labelled in the correct language, and prepared hygienically.

The Emergency Nutrition Network has training manuals for field staff working in emergency situations, which can be found at:
http://www.ennonline.net/

Please support the Emergency Nutrition Network, or if you want to send a donation that will go to humanitarian relief efforts in Gaza, you might like to send them to UNRWA (UN Relief and Works Agency for Palestine Refugees in the Near East). See:
http://www.un.org/unrwa/emergency/donation/emergency_activities.html

Secondly, I don't want to discuss the politics of what is happening in Gaza here, but I don't think think wishing peace and security for all should be contentious. The Avaaz campaign is calling for action from the international community to help achieve that. You can find out more and sign the petition if you wish at:
http://www.avaaz.org/en/gaza_time_for_peace/

Study day on Infant and Young Child Feeding in Emergencies

We work with the Emergency Nutrition Network to help ensure that responses to natural disasters and other emergency situations are appropriate when it comes to infant feeding.

Those of you directly involved in this area may be interested in the following study day in June at the Institute of Child Health, for which I am posting the announcement here:

---
BREASTFEEDING: PRACTICE AND POLICY COURSE 2008
Infant and young child feeding in emergencies (IFE)

Wednesday 25th June

Marie McGrath, Felicity Savage, Marko Kerac,

One purpose of the day is to introduce to policy makers and programme managers concerned with infant and young child feeding, the operational issues and special needs of populations in emergency situations. Another purpose will be to increase understanding among emergency relief workers about the practicalities of infant feeding in these settings. The day will also share how the work on IFE has developed, locate IFE in humanitarian initiatives and give practical pointers on where to locate key resources, materials and contacts on IFE.

The day will take as its starting point the Operational Guidance on IFE for Emergency Relief Staff and Programme Managers, and will cover the importance of the issue, policy, co-ordination, assessment, technical interventions and training needs in emergencies. Special infant feeding issues will also be addressed in the morning session, such as artificial feeding, and a collaborative effort to review and improve the management of infants with acute malnutrition. In the afternoon, participants will be asked to think through and discuss how to approach specific situations presented in the form of scenarios with reference to the Operational Guidance on IFE.

10 .00 Introduction and Overview of infant and young child feeding in emergencies
Operational Guidance and reference materials
11.00 Break

11.30 Special feeding challenges –
- Artificial feeding in emergencies
- Managing acute malnutrition in young infants (*MAMI Project)
12.30 Lunch

1.30 Working groups: questions on typical scenarios

2.30 Plenary discussion on the answers to scenario questions

1600 End

The Emergency Nutrition Network (ENN) will participate in the day as a representative of the IFE Core Group, an international interagency concerned with policy guidance and capacity building on IFE.

*The MAMI Project is an ENN led project to review the management of acute malnutrition in infants, in collaboration with the Centre for International Health and Development (CIHD), and Action Contre la Faim (ACF).
For further information on the work of ENN and the MAMI project, visit www.ennonline.net


Fee £75 including sandwich lunch

If you are interested please contact info@ichevents.com

Infants surviving on breastmilk in China earthquake

Just a quick mention here today of a link someone sent me with a couple of breastfeeding stories from the China earthquake. The heartbreaking story of a trapped mother who managed to sustain her baby through breastfeeding, though she died herself. And a police woman who has been acting as a wet nurse to some of the orphaned children. See:
http://newpaper.asia1.com.sg/news/story/0,4136,165248,00.html

While obviously some infants will be in need of formula, relief agencies do not want you or the companies to send this. It is far better for it to be sourced locally, as I wrote yesterday.

Instead send money.

Don't send formula to Burma or China

Disaster relief agencies have made it clear that they do not welcome donations of infant formula when responding to emergencies such as the cyclone in Burma and the earthquake in China.

To often donated formula is distributed without care and undermines breastfeeding. In addition labels are often in the wrong language. For those infants that do need to be formula fed it is far better for agencies to source formula locally and distribute it in a carefully targeted way.

So please don't send donations of formula. It is far better to send money.

If you are in the UK or other countries in the European Union it is actually illegal to export formula with labels in the wrong language.

We have worked closely with the Emergency Nutrition Network. See its website for appropriate responses at:
http://www.ennonline.net/ife/generalpublic/default.aspx

Formula donations causing diarrhoea in emergency situations

The press release below, from the UNICEF East Asia website, reminds us of the need for care in providing help to mothers and infants in emergency situations. Find the original at:
http://www.unicef.org/eapro/media_7973.html

You can find resources for planning an appropriate response to emergency situations via my blog:
http://boycottnestle.blogspot.com/2007/10/babies-in-emergencies.html

Call to action to stop the use of breastmilk substitutes in emergencies

Jakarta, March 20th, 2008 - The lives of babies and young children are being put at risk by the inappropriate use of breastmilk substitutes, particularly in emergency situations, says a coalition of more than 100 nutrition and emergency experts.

“The protection, promotion and support of infant and young children feeding in emergencies is inadequate. Inappropriate use of breastmilk substitutes in emergencies, often received as unsolicited donations, endangers the lives of infants and young children,” says the coalition.

102 representatives from the UN, international NGOs, and Government from 16 countries gathered together in Bali 10th – 13th March at a meeting organized by the Emergency Nutrition Network. At the end of the 3 day meeting, a strongly worded statement was released with a call to action to prevent the continued use of breastmilk substitutes in emergencies and to improve the support of infant and young child feeding in emergencies in general.

“The issue of nutrition in emergencies, particularly for babies and young children, is of paramount importance …and one that need serious attention,” says Dr Gianfranco Rotigliano, UNICEF Representative to Indonesia. “We …..know that a decline in breastfeeding indicates an increase in the use of formula milk, which, even if used correctly, is inferior to breastmilk.”

In emergency situations when clean water and opportunities to clean feeding bottles are often lacking, the risks associated with artificial feeding are particularly high. There is a common mis-conception that families in emergencies need infant formula and powdered milk. Authorities in emergencies often see unsolicited donations of such products flooding the affected area.

“Systems are urgently needed to prevent and control such donations in order to protect the lives of young children. And the public and the well intentioned donors need to be informed that such products are not needed or wanted during emergencies,” says the coalition.

Presenters at the meeting emphasized the fact that improving infant and young child feeding during emergencies is one of the most effective ways of reducing death rates and preventing malnutrition.

In 2006 after the Yogyakarta earthquake, UNICEF, UNFPA, the local Department of Health, the University of Gadjah Mada and other partners conducted a survey. It began 21 days after the earthquake and found that some 70 per cent of households with children had received baby milk donations.

The survey revealed that infant formula donations had contributed to a two-fold increase in formula consumption among children under-two and, consequently, a six-fold increase in rates of diarrhoea among these children. Diarrhoea is the second biggest killer of children in developing countries after acute respiratory tract infections.

This was one of the first surveys to document the extent and scale of infant formula donations and its impact on feeding practices and illness rates.

“We know through decades of medical research that breastfeeding children up to the age of two years, or even longer, gives them the optimum opportunity for growth, development and good health. In the first six months of life, it is the only food and drink a baby needs,” says Dr .Rotigliano.

*****************************************************
For further information contact:
Kirsty McIvor, Communication Officer, UNICEF
+ 62 21570 5816 ext 298/+62 8121052631

Protecting babies in emergencies: The role of the public

Our partners in the International Baby Food Action Network (IBFAN) in Switzerland have been working on this guide with the Emergency Nutrition Network.
http://www.ennonline.net/ife/generalpublic/default.aspx

Here's the introduction:

---

Every year, natural and man-made disasters and emergencies affect hundreds of thousands of people. Whenever there is an emergency, we think of the children who have been affected and want to do something to help them. In particular, those of us who are parents imagine ourselves in the emergency and envisage the desperation of struggling to care for a baby or young child under such circumstances.

We give generously to appeals to help children affected by disasters. However, the sort of aid that will assist babies and young children is of a very specific type. It is very important to make sure that our donations help children and do not harm them and to ensure that governments and aid agencies do the same.

This guide has been prepared by the IFE Core Group and collaborators to help you understand the important role of the general public in protecting and supporting infants and young children caught up in crisis worldwide. Focusing on infant and young child feeding, this guide includes a description of what happens on the ground in emergencies, works to dispel some myths surrounding infant feeding in emergencies and most importantly, details on what you can do to help. Sample letters are included to get you started. We welcome feedback on what you think of this guide, and how you have used it.
---

You can read the sections on line or download the full guide as a pdf.
http://www.ennonline.net/ife/generalpublic/default.aspx

For past blog entries on infant feeding in emergencies in places such as Peru, Iraq and the UK, see the 'Past blogs by topic links' to 'HIV and emergencies'.

Emergencies in Iraq and Peru

We have received reports of free formula being distributed in Iraq and have raised this with the UK authorities and partners. News just in is that UNICEF is calling for the Government of Iraq to take action by enforcing the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant World Health Assembly Resolutions. The experiences in Iraq and during the Asian tsunami of 2004 show why donating formula to Peru, hit by an earthquake this week, is the wrong way of trying to help.

The Code and Resolutions aim to protect and promote breastfeeding and to ensure the safe use of breastmilk substitutes if these are necessary.

In a UNICEF press release Roger Wright, UNICEF’s Representative for Iraq, called on Iraq’s government to reinforce national compliance with the International Code on Marketing of Breastmilk Substitutes. He also urged Iraq’s communities to give new mothers special care and support to help them breastfeed successfully. “Exclusive breastfeeding is the single most powerful means of protecting the health of Iraqi babies during this time of crisis,” he said.

See:
http://www.unicef.org.uk/press/news_detail_full_story.asp?news_id=1008

According to UNICEF, free formula is being distributed to all infants as food rations as part of Iraq's Public Distribution System (PDS).

---UNICEF press release extract

Dr. Nidhal, Manager of the Breastfeeding Programme for Iraq’s Ministry of Health, noted that Iraq’s rate of exclusive breastfeeding was worryingly low, at just 25 per cent for infants under six months. The free distribution of infant formula through the PDS is a negative factor in contributing to these low rates, discouraging the traditional and much better exclusive breastfeeding.

“Breast milk is the best possible nourishment for children and contains everything they need to be healthy for the first six months,” she said. “It protects against diarrhoea from contaminated water, and also provides vital antibodies against pneumonia and other illnesses that could affect many Iraqi children during infancy. Mothers must not risk any other food or additional water for their young babies.”

---extract ends

The situation for mothers and babies in particular is very difficult in Iraq. According to UNICEF about one in 10 children under five in Iraq are underweight and one in five are short for their age, this report states:
http://www.irinnews.org/Report.aspx?ReportId=70509
Baby Milk Action and our partners in the International Baby Food Action Network (IBFAN) have long worked as part of the Emergency Nutrition Network on raising awareness of appropriate infant feeding support in emergency situations.

During the response to the asian tsunami at the end of 2004 we had to resort to warning the public in the UK that they were breaking the law if they sent free formula to the region as labels would not be in the appropriate language. It is far better for any required formula to be sourced locally so the instructions are in the correct language and distribution can be appropriate and accompanied by training. See:
http://www.babymilkaction.org/press/press13jan05.html

However, in an Indian survey in Pondicherry it was found that infant formula was distributed by Non-Governmental Organisations (NGOs) indiscriminantly and: "The occurrence of diarrhea was three times higher among children who were fed with free breast milk substitutes (BMS) than in those who were not fed with the same."

Our IBFAN partners, the Breastfeeding Protection Network of India (BPNI) reviewed this and other studies at its national convention in December 2005. The proceedings can be downloaded by clicking here:
http://www.bpni.org/Report/infant-feeding-emergency-situation.pdf

A survey on the response to the tsunami in Tamil Nedu, where Nestlé formula was routinely distributed by NGOs, found that "64% NGOs, 76% social workers, 32% paramedical staff and 87% victims" were unaware of the importance of breastfeeding in emergency situations.

The importance of promoting the benefits of breastfeeding before an emergency and enforcing the International Code and Resolutions (implemented comprehensively in India as the Infant Milk Substitutes Act) was stressed.

Also important is training of field workers on supporting mothers who may experience difficulties with breastfeeding due to stress and, in extreme cases, their own poor diet (though undernourished mothers are able to breastfeed). The Emergency Nutrition Network produces training modules for field workers.

IBFAN has a guide for the public, warning not to send donations of formula. With the tragic situation in Peru, which has just been hit by an earthquake, we are making our banner advertisement to this live to help to stop a bad situation being made worse by well-meaning people sending formula. See:
http://www.ibfan.org/site2005/Pages/article.php?art_id=335&iui=1

Feel free to copy the banner to your site, with the above link:

We have worked closely with organisations such as Save the Children and Oxfam in the past. Both are responding to the Peruvian earthquake and have good operational guidance to make sure interventions are appropriate. Oxfam reports that 150,000 people are affected and so the effort to provide assistance will be considerable. You can donate following the links to the organisations.

Advice on infant feeding during the UK floods

Thousands of people have been affected by flooding in the UK. In one county 340,000 people have lost their water supply. More rain is expected this weekend, which may lead to further problems.

The Food Standards Agency has posted advice on its website for carers who are feeding infants with infant formula:
http://www.food.gov.uk/news/newsarchive/2007/jul/flooding

This states:

---Quote begins

If your drinking water supply is either interrupted or contaminated by the flooding and you need to prepare formula feed for a baby, it is important to be careful with the water you use. Here are some tips on preparing formula safely.

• Ideally use water from a bowser (a water tank provided by water companies), or bottled water, brought to a ‘rolling’ boil and left covered to cool for no more than half an hour, then follow the manufacturer’s instructions on making up the feed. The use of unboiled bowser water should be avoided.

• Use cooled boiled water or bottled water for cooling the feed once it has been made up.

• Ready-to-feed liquid formula could be used instead.

• If there is no electricity or gas to allow boiling and you don’t have ready-to-feed liquid formula available, bottled water (table, spring or mineral water) can be used without boiling to prepare baby feeds, but the prepared feed should then be used immediately.

• Some bottled water labelled as 'natural mineral water' may have high levels of sodium. When buying bottles of natural mineral water, look at the label and check that the figure for sodium or 'Na' is not higher than 200mg a litre. If it is, then try to use another water. If no other water is available, then use this water for as short a time as possible.

----Quote ends

In past emergency situations affecting other countries, we have had to warn people not to send donations of formula as this is not wanted by people on the ground and can do more harm than good. For those that do need formula it is better if this is purchased locally so labels are in the correct language and distributed appropriately and with necessary instructions to minimise risks.

Whether overseas or in the UK, it is important for field workers who will be advising carers familiarise themselves with the materials produced by the Emergency Nutrition Network. These can be accessed at:
http://www.ennonline.net/ife/

We have received an article from Sarah Saunby, a Baby Milk Action Area Contact in Sheffield. Sarah is also a Registered Breastfeeding Supporter with the Breastfeeding Network, which provides support to mothers.

I am included the article below. If you would like to reproduce this in any form, please contact me for permission.

---Article by Sarah Saunby

Infant Feeding in Emergencies – is it relevant in the UK?

Late last night I eagerly watched the news to see the scenes of devastation, due to flooding, in my home town of Sheffield. Sheffield is well known for being built on 7 hills, which naturally means we have a lot of valleys and rivers. These valleys and rivers took the brunt of a months’ rainfall falling in 24 hours. Local rivers were unable to cope with the volume of water, bursting their banks and subsequently flooding many roads, buildings and houses, causing severe disruption.

As I watched, my thoughts went out to all those affected by the flooding. I felt lucky to be living at the top of a hill and that the worst I had to cope with was a few clothes to dry, when the children returned home from school. My sister’s basement had flooded and both her and my parent’s home were left without electricity. Things were also not so good for those, left stranded at work. Rescue RAF helicopters were called in to the area to help winch over 100 people, including a woman and her baby, to safety.

So what’s this got to do with breastfeeding?

Well SKY news and BBC news 24 reported late yesterday that 35,000 homes were left without power and some 250 homes had been evacuated. Sheffield Hallam Arena was providing emergency accomodation, as were local nightclubs, leisure centres, schools and various other places. I then began to wonder how many babies would have been amongst those evacuated or left in a home without power. How are those babies being fed, I wonder?

When we think about Infant Feeding in Emergencies (IFE), it’s generally associated with some crisis in developing countries; a tornado, earthquake, tsunami or displacement due to conflict or fighting. The UK shouldn’t really need to give much consideration to the WHO and IBFAN publications on IFE, which give guidance (Ref. 1, 2) because things like this just don’t happen in the UK.

So when I heard the following day that in South Yorkshire alone 14,000 people remained evacuated from their homes and that 86,000 homes had disrupted power supplies with 32,000 homes being completely without power I wondered what systems, if any, do we have in place to protect vulnerable babies in these situtations in the UK? When it does become a reality it must be worth highlighting that In emergencies, children under five are more likely to become ill and die from malnutrition and disease than anyone else. In general, the younger they are, the more vulnerable they are. Inappropriate feeding increases their risks (Ref: 3).

Irrespective of any emergency, artificially fed infants already constitute a risk group (Ref: 4) and should receive special attention from the health and social welfare system, so situations like this really emphasise the importance of breastfeeding. Without wishing to add to any mother’s distress I think it is valid to ask how parents of formula feeding infants, are coping with this situation? Babies continue to need feeding. In these emergency shelters and when there is no power supply - how easy is it to maintain safety guidelines set out by the Food Standards Agency, Department of Health and infant formula manufacturers for preparing infant formula? Such as mixing powdered formula with water at 70 degrees centigrade (the temperature necessary to kill harmful pathogens) (Ref: 5, 6) and cleaning and sterilising bottles and teats. A recent report in The Guardian newspaper highlighted the acute risks that formula feeding presents to infants where there aren't the resources to safely support it (Ref: 7). Whilst anecdotally it is discussed that we don’t have the same problems as in developing countries, the current situation across South Yorkshire and other areas of the country show that occasionally we do (Ref: 8).

In a BBC Radio Sheffield interview, one man described how he was woken in the middle of the night by emergency crews who told him he and his family had 5 minutes to get ready and leave their home. This must have been an incredibly frightening experience, especially for those families with young babies and children. For a breastfeeding mother, so long as the mother and baby are kept together, the baby’s food needs are pretty much catered for, plus the baby will have additional protection from the new environment she / he is faced with, via mum’s antibodies. Breastmilk is known to contain anti-infective properties which provide protection against illnesses and reduce the severity of those that occur (Ref: 9). In a room full of strangers and unfamiliar bugs / germs, this will be very reassuring. But for those mothers artificially feeding, how must they have felt to have to leave their homes so suddenly without any necessary equipment or means to feed their infant? Their babies will not have any additional protection by any antibodies made by mum and are already at risk due to the pathogens already present in up to 14% of tins of infant formula (Ref: 10, 11, 12, 13).

If local authorities and other agencies are donating supplies of food; which includes infant formula milk are they following the UK Law (Ref: 14) WHO and UNICEF code and resolutions and IBFAN guidelines (Ref: 15) in ensuring breastfeeding is protected and not undermined by emergency relief efforts and distribution of breastmilk substitutes? Are those aid workers / staff aware that such guidelines even exist? Any appeals being made on behalf of victims should be for money rather than donations. Many health workers and parents are not aware that infant formula is not even a sterile product to start with (Ref: 16).

Is this covered as part of the ‘major incident’ preparations? Is the importance of keeping a mother and her infant together understood and training given in assisting mothers with relactation, if necessary? Breastfeeding is the safest method of feeding infants. Those women who are feeding both breastmilk and infant formula should be encouraged to breastfeed exclusively and be informed and educated about how supply and demand process of milk production works, if they have concerned about their breastmilk supply.

In situations where the infant is around 6 months and the mother is thinking of weaning, then consideration should be given as to whether it would be safer to continue exclusively breastfeeding, for a while, particularly if the necessary means to wean safely are not available.

Do health workers and other aid agencies have knowledge to inform breastfeeding mothers that stress has no effect on the milk-making hormone (prolactin), but it can have a temporary effect on the hormone which makes the milk flow out of the breast (oxytocin)? The temporary stoppage of this reflex is a useful biological mechanism to stop milk being ejected from the breast at difficult moments. The oxytocin reflex is sensitive: it can stop temporarily, but it resumes quickly. So lots of skin-to-skin contact and continued suckling is important. The skin-to-skin also can help the baby feel secure and limit the damage of the emotional traumas of stressful situations (Ref: 17). The breastfeeding hormones help many women feel calmer in stressful situations. Women should be given additional information about where they can get help with breastfeeding (regardless of current method of feeding).

For those babies being formula fed, is advice given to parents, that it could be safer to cup feed? (Ref: 18). Cups are safer than bottles as they can be cleaned easier. Bottles and teats have intricate parts and need to be thoroughly clean, an important consideration when little or no mains water is available and the kitchen is not big enough for safe handling and preparation to cope with many different babies’ equipment. Kitchen areas may have already been contaminated with debris from the river and also from burst sewage systems. For babies and young children, who’s immune systems are still maturing and may not be fully developed until around 6 years this becomes a real concern (Ref: 19). Health workers should be aware that, at an already difficult time of cleaning up their homes and having to look after small babies and children, people may not have time or necessary resources to be so thorough.

Mothers using powdered formula should be informed that the ready to feed cartons of infant formula may pose less of a risk than powdered feed, during this time, particularly where the clean water supply has been affected. Bottled waters (mineral, spring and table) may be unsuitable to mix with powdered feeds (Ref: 20). This is because the solute levels (sodium, nitrate, sulphate and fluoride) may not be suitable levels for the infant’s system to cope with. In circumstances where people are left without mains, drinking water supply or any bowser water bottled water may be the only option. The advice given by the Food Standards Agency and Health Protection Agency is that in circumstances where the power supply is affected then bottled water can be used unboiled. Prepared feeds should be used immediately (Ref: 21, 22). Whilst boiling water may kill off some bacteria and parasites it does not remove chemical contaminants (Ref: 23). Repeated boiling may actually lead to further concentrating of certain chemicals as the water is boiled off.

If it is felt that the that Infant Feeding in Emergencies guidelines are not that relevant in this country then it’s really time to think again. My feeling is that this highlights just how important it is in the UK as well as the rest of the world and I would urge the Government and other agencies to ensure systems are in place to protect this vulnerable group at such a difficult time.

One real concern is for those people in disadvantaged groups and who are already experiencing inequalities in health. They are likely to be the most affected in these circumstances as they are more likely to have health problems, have lower incomes (ready-to-feed cartons of formula are usually more expensive than powdered formula), less likely to be able to afford house insurance (to replace any damaged items such as sterilisers, bottles and teats), and may be less likely to have their own transport to collect water from depots.

Sarah Saunby
Sheffield Area Contact, Baby Milk Action & BfN Registered Breastfeeding Supporter.

References

1. http://www.ibfan.org/site2005/Pages/article.php?art_id=335&iui=1
IBFAN Infant feeding in emergencies, 2000

2. http://www.euro.who.int/document/e56303.pdf
WHO Infant feeding in emergencies; a guide for mothers, 1997

3. http://www.ennonline.net/pool/files/ife/module1-manual.pdf
Infant Feeding in Emergencies, Module 1;for emergency relief staff WHO, UNICEF, LINKAGES, IBFAN, ENN, 2001

4. http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/gs_iycf.pdf
WHO/ UNICEF Global Strategy on Infant and Young Child Feeding, 2003

5. http://www.food.gov.uk/news/newsarchive/2006/dec/infantform
Food Standards Agency Revised guidance on powdered infant formula, 2006

6. http://www.food.gov.uk/multimedia/pdfs/formulaguidance.pdf
Food Standards Agency / Department of Health Guidelines for Health Professionals on safe preparation, storage and handling of powdered infant formula

7. http://www.guardian.co.uk/comment/story/0,,2090780,00.html
The Guardian Formula milk is even more deadly in disaster zones, by Marie McGrath, Wednesday May 30th, 2007

8. http://news.bbc.co.uk/1/hi/uk/6239828.stm
BBC News Floods force thousands from homes Tuesday, 26 June 2007

9. http://www.waba.org.my/wbw/wbw05/actionfolder.pdf

10. http://www.cfsan.fda.gov/~dms/inf-ltr3.html
Health Professionals Letter on Enterobacter sakazakii Infections Associated With Use of Powdered (Dry) Infant Formulas in Neonatal Intensive Care Units, U. S. Food and Drug Administration, April 11 2002 Ref: Muytjens HL, Roelofs-Willemse H, Jaspar GHJ.

11. http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1740-8709.2004.00008.x?cookieSet=1
Iversen, C., & Forsythe, SJ. 2004 Isolation of Enterobacter sakazakii and other Enterobacteriaceae from powdered infant formula milk and related products. Food Microbiology as cited in New Scientist 5 June 2004.

12. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=266435&blobtype=pdf
Quality of powdered substitutes for breast milk with regard to members of the family Enterobacteriacae. J Clin Microbiol 1988;26:743-746.

13. http://www.cababstractsplus.org/google/abstract.asp?AcNo=20043165927
Iversen, C., & Forsythe, SJ. 2004 Isolation of Enterobacter sakazakii and other Enterobacteriaceae from powdered infant formula milk and related products. Food Microbiology as cited in New Scientist 5 June 2004.

14. http://www.opsi.gov.uk/si/si1995/Uksi_19950077_en_1.htm
The Infant Formula and Follow-on Formula Regulations 1995; Statutory Instrument 1995 No. 77

15. http://www.ibfan.org/site2005/Pages/article.php?art_id=51&iui=1
The WHO / UNICEF International Code of Marketing of Breastmilk Substitutes and Subsequent WHA Resolutions

16. http://www.food.gov.uk/multimedia/pdfs/powderinfantform.pdf
COI and FSA Powdered Infant Formula Qualitative Research Final Report Coi Ref: 272546 (Define ref: 1547) April 2006

17. http://www.euro.who.int/document/e56303.pdf
WHO Infant feeding in emergencies; a guide for mothers, 1997

18. http://www.euro.who.int/document/e56303.pdf
WHO Infant feeding in emergencies; a guide for mothers, 1997

19. http://www.kathydettwyler.org/detwean.html
Katherine Dettwyler, PhD A Natural Age of Weaning

20. http://www.babymilkaction.org/pages/bwater.html
Baby Milk Action Briefing Paper, Bottled water and infant feeding, June 1998

21. http://www.hpa.org.uk/flooding/health_advice.pdf
Health Protection Agency, Health Advice Following Flooding

22. http://www.food.gov.uk/news/newsarchive/2007/jul/flooding
Food Standards Agency, Food Safety advice for people affected by flooding, Tuesday 24th July 2007

23. http://www.bt.cdc.gov/disasters/foodwater.asp
Centres for Disease Control and Prevention, Keep Food and Water Safe after a Natural Disaster or Power Outage

A little knowledge can be dangerous

A rather sad and tragic story today. A Yale student working in a poor community in Rwanda found a mother infected with HIV breastfeeding her 4-month-old child and so sent word home for money and bought a cow so the child can be fed cow's milk instead.

Sad because the student knew of the risk of transmission of HIV through breastfeeding and thought what she was doing would help, but didn't investigate the risk factors and didn't know or ignored the recommendations of the World Health Organisation. Tragic because the infants are more likely to contract HIV and to succumb to other possibly fatal infections.

The article reporting this states: "Marie's HIV-infected mother, too poor to buy formula or animal milk, was breast-feeding the infant, putting her at substantial risk for contracting the virus, with the likelihood rising once she reached 6 months."

I posted a comment to try to direct people to expert sources of information:

---
It is unfortunate that this article and the advice given contradicts the recommendations of the World Health Organisation and the research on risks of transmission of HIV. See:
http://www.babymilkaction.org/resources/yqsanswered/yqacodehiv.html

The mother was in fact following the recommendation of WHO, if she was exclusively breastfeeding. Introducing other substances, such as cow's milk, increases the risk of HIV transmission. Infants who are not breastfed are at far greater risk of dying from other illnesses as they are denied the protective factors of breastmilk.

New research from South Africa found that infants of HIV-infected infants living in poor conditions are more likely to survive if exclusively breastfed for the first six months. See:
http://www.babymilkaction.org/update/update39.html#cs

Field workers can obtain expert training and information on supporting mothers and infants in difficult circumstances at:
http://www.ennonline.net/
---

The WHO position has recently been strengthened and adopted as a UN Consensus Statement following the results of a major study from South Africa. It states:
http://www.who.int/child-adolescent-
health/New_Publications/NUTRITION/consensus_statement.pdf

---
Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time.... Breastfeeding mothers of infants and young children who are known to be HIV-infected should be strongly encouraged to continue breastfeeding.... Governments should ensure that the package of interventions referenced above, as well as the conditions described in current guidance, are available before any distribution of free commercial infant formula is considered.
---

Possibly cow's milk could have a role after the period of exclusive breastfeeding as rapid cessation when introducing other foods is recommended to minimise the period of mixed feeding, but should not be a replacement for breastfeeding. As Marie McGrath of the Emergency Nutrition Network comments on the article cow's milk has "high sodium and protein, inadequate micronutrients" and in practice its introduction may lead to mixed feeding as well as increased risk of other infections.

Another comment refers to the South Africa study we reference in our newsletter (link above) and states:

---
Remember: not all infants that are breastfed by HIV+ mothers get HIV; the risk of getting HIV decreases with exclusive breastfeeding; breastmilk protects against infections, take away that and increase the number of infective agents that are fed to the child through the cows milk, feeding method, etc and the likely hood of that child becoming ill and possibly dying are raised enormously - depending on the situation, much more than the risk of getting HIV. It is this because of this high risk of morbidity and mortality from not being breastfed in places where providing infant formula (and other breast-milk substitutes, such as cows milk) is not affordable, feasible, acceptable, sustainable and safe (places like rural Rwanda) that the guidelines have come down so heavily on the side of exclusive breastfeeding.

It is wonderful that she managed to fund raise but perhaps it could have been used to teach local community health workers and others how to counsel women to exclusively breastfeed - studies in S.Africa and else where clearly show that quality counselling can improve exclusive breastfeeding rates and therefore reduce HIV transmission.
---

For more on the South Africa study (the Coovardia study, published in the Lancet) see:
http://boycottnestle.blogspot.com/2007/06/bob-geldof-on-hiv-at-g8.html

Bob Geldof on HIV at the G8

The G8 meeting of the world's richest Western nations, plus Russia, broke up today. After the promises of action on climate change and in support of Africa made at the previous G8 meeting two years ago, to applause from veteran campaigner Bob Geldof, we have been brought down to earth with a bump. There has been much back-tracking and weasel words from the G8 to try to cover the fact that action and aid promised will be much less than first suggested.

This time Bob has not been taken in and called the communique issued at the end of the meeting a rude word, which probably was bleeped out by much of the world's media. Thoroughly deserved it was too.

As George Monbiot wrote earlier this week, while the rich-country governments profess to care, they will not take action if it conflicts with their own financial interests. And will take action to promote their financial interests, the example of US pressure on the Philippines government to scrap its new baby food marketing regulations being used to illustrate the point. See:
http://boycottnestle.blogspot.com/2007/06/wyeths-assault-on-law-and-logic-in.html

Bob was asked on BBC television's 'Newsnight' programme what the scaling back in promised aid would mean to Africa in practical terms. He cited children who had been going to school, who would no longer be able to do so.

And then he said this: "A child who picked up aids from its mothers breast. Chances of life, minimal..... No more medicines so you die."

It is a valid point that if the Global Fund for Aids does not receive its promised funding, people who need drugs will suffer. But invoking breastfeeding as the cause of a child picking up Aids is ill informed and ultimately a dangerous message to send.

Yes, there is a risk of transmission through breastfeeding. However, if current UN health guidance is followed by a mother in conditions of poverty the risk of transmission is not only relatively small (at 4% in a new study), her child will be more likely to survive other illnesses than a child given formula, even free formula.

The best people to listen to on this issue are people on the ground in Africa. The International Baby Food Action Network (IBFAN) has had African partners for 25 years and recently the coordinating office has posted an overview of HIV and infant feeding to the IBFAN website:
www.ibfan.org

You will find lots of other valuable information from people who are experts in their fields and at the sharp end of infant feeding issues in their countries.

You can find the specific document from IBFAN Africa on HIV and infant feeding at:
http://www.ibfan.org/site2005/Pages/article.php?iui=1&art_id=485&articulo_id=895

As with everything IBFAN does it is evidence and science based. Here is an extract:

---Quote begins
Recent research by Coovardia H.M[4] (Lancet Vol. 369 March 2007) has made very valuable findings for Africa and the developing world. The researchers from the Africa Centre for Health and Population Studies have found out that there is only a 4% risk of postnatal transmission of HIV to infants who are exclusively breastfed from 6 weeks to 6 months of age. The researchers are now calling for the United Nations Guidelines to be changed to promote exclusive breastfeeding for mothers in developing countries. This study has serious implications for resource poor countries where over 60% of populations live below the poverty line. According to the study, infants who receive supplements such as commercial formula or cow’s milk were two times as likely to be infected as infants who were solely breastfed, while those given solids in addition to breastmilk were 11 times more likely to be infected than those who exclusively breastfed.

The study that involved around 2700 babies born between 2001 and 2005 further found that the death rate by 3 months of age for babies who were exclusively breastfed was less than half that of infants who received formula milk alone. Over 15% of babies whose HIV positive mothers did not breastfeed them died by 3 months compared to only 6% of the babies whose mothers breastfed them exclusively.
---quote ends

So it is critically important that the message of the importance of exclusive breastfeeding is not lost or distorted in sound bites about children becoming infected at their mother's breast. The UN has indeed strengthened its language in a new consensus statement, as we reported in Update 39:

---From UN Consensus Statement
“Exclusive breastfeeding is recommended for HIV-infected women for the first 6 months of life unless replacement feeding is acceptable, feasible, affordable, sustainable and safe for them and their infants before that time.... Breastfeeding mothers of infants and young children who are known to be HIV-infected should be strongly encouraged to continue breastfeeding.... Governments should ensure that the package of interventions referenced above, as well as the conditions described in current guidance, are available before any distribution of free commercial infant formula is considered.”
---Quote ends

Breastfeeding saves lives in poor conditions, even for those infants whose mothers are infected with HIV.

Even before the reduced risks of exclusive breastfeeding were properly researched and the practice recommended, it was true that more infants were infected with HIV in utero than through breastfeeding (a risk that anti retro viral drugs can reduce).

But lets not let these facts distract from the starkness of the absolute figures cited above.

6% of the babies who were exclusively breastfed in the Coovardia study died by 3 months. 15% of those who were formula-fed had died by 3 months. Every death is a tragedy.

For comparison, in the UK the infant mortality rate is about 5 per 1,000 live births. Or, to put it another way, 0.5% have died by one year of age.

Considering the population as a whole, infant mortality rates in Africa are far higher than in the rich world. I've just turned up a figure of 92 infant deaths per 1,000 live births for Malawi where I used to work, nearly 20 times the UK rate.

The bigger killer is poverty and I believe Bob Geldof is right to blast rich-country leaders for their lack of action, particularly when so many of their citizens and tax payers have called for action. Particularly when so much of the wealth of rich countries comes through abuse of power over poorer countries.

It is great that he is heard by the world's media (beeps aside), but I hope for greater clarity in future when touching on mother-to-child transmission of HIV, please Bob.

Infant feeding in emergencies in the news

Two articles today deal with the difficult subject of infant feeding in emergencies. One, in The Guardian, picks up on the paper’s recent investigation of Nestlé’s marketing in Bangladesh and stresses that the marketing requirements Nestlé should be abiding by are even more important in emergency situations. The trouble is that when an emergency hits the headlines, shortly afterwards formula hits the refugee camps. Sometimes distributed without thought, with labels in the wrong language, to any family with a baby. In situations where safe water and hygienic conditions are likely to be in short supply, the protection given by breastfeeding is even more important.

The Emergency Nutrition Network brings together experienced field workers to share and disseminate best practice. Marie McGrath, co-director of the Emergency Nutrition Network, and IFE Core Group coordinator and author of the article in today’s Guardian, recalls a recent example showing the importance of supporting breastfeeding. For the full article see:
http://www.guardian.co.uk/comment/story/0,,2090780,00.html

---Quote begins
Moorhead [author of the article on Nestlé in Bangaldesh] - in her description of a ward in the "diarrhoea hospital" in Dhaka, where most patients are babies and "not one is crying: they are all much too weak for that" - very clearly showed the acute risks that formula feeding presents to infants where there aren't the resources to safely support it. Put these infants in the face of a humanitarian disaster and the risks multiply. This was highlighted most blatantly in an outbreak of diarrhoea among artificially fed infants in Botswana in 2006, due to contaminated water supplies. Babies who were not breastfed were 50 times more likely to be hospitalised with diarrhoea, and seven times more likely to die, than babies who were breastfed.
---quote ends

She also recalls that in the Kosovo crisis, UNICEF gathered 27 tonnes of breastmilk substitutes.

While UNICEF was trying to stop the indiscriminate distribution of formula in refugee camps, we were working to try to stop well-meaning people filling trucks with formula to send. Our partners in the International Baby Food Action Network (IBFAN) went into action in other countries.

The International Baby Food Action Network (IBFAN – Baby Milk Action is the UK member) forms part of the ENN Infant Feeding in Emergencies core group. This has produced training modules for agencies so that mistakes of the past are not repeated, while what works to save lives is. You can find out more at:
http://www.ennonline.net/ife/

IBFAN’s Infant Feeding in Emergencies (IFE) working group has information here:
http://www.ibfan.org/site2005/Pages/article.php?art_id=367&iui=1

Our IBFAN partners in Albania worked in the refugee camps supporting mothers with breastfeeding – some needing assistance in re-lactating after the stress of fleeing their homes, perhaps having left men folk behind.

They also worked to ensure formula was correctly prepared for those infants who needed it. At one of our regional meetings where we evaluated the experience, we heard how someone - agency or company or well-meaning members of the public - distributed formula indiscriminately in the camp, leaving a tin of formula outside each tent where there was a child. There was no discussion as to whether it was needed or how it should be prepared. The labels were in the wrong language.

We knew the same would happen when the tsunami hit Indonesia and other countries on the Indian Ocean on Boxing Day 2004. We immediately made our briefing on infant feeding in emergencies live, and put up the banner advertisement we have ready for such times:

Next time there is an emergency, drop it onto your site or blog if appropriate, with a link to:
http://www.ibfan.org/site2005/Pages/article.php?art_id=335&iui=1

We contacted people and the media when we heard of appeals for formula. But the voice of experience is not always appreciated. People want to do something and in a culture where bottle-feeding is seen by many as the same or almost the same as breastfeeding, sending formula seems a caring thing to do.

We finally invoked the fact that it was illegal under UK law against exporting formula with labels in the wrong language. See:
http://www.babymilkaction.org/press/press13jan05.html

Still formula gets through. Marie McGrath recalls that some of the donations during the Kosovo crisis were huge, suggesting a commercial source. In past emergencies there has been a definite commercial link.

Flooding a country with formula in an emergency can have an impact for years - a disaster for the population and big profits for baby food companies. When I interviewed our IBFAN partner from Armenia in 2006, she recalled that breastfeeding rates there had only recently recovered to the levels before the Armenian earthquake of 1988. Donations of formula coming from rich nations had undermined breastfeeding to the point that only 20% of infants were predominantly breastfed at 4 months (that is breastfed exclusively or fed breastmilk with water, tea or juice). You can listen to the interview, included alongside those with other IBFANers, here:
http://www.babymilkaction.org/ram/ibfaneurope06.html

You can find a written interview about the Armenian experience here:
http://www.hairenik.com/armenianweekly/april_may_2002/society002.html

The interviewer in the Armenian Weekly raises questions over the risk of HIV through breastfeeding. This brings me to the second article of today. This is an article based on a report on BBC television breakfast news. It is by Kate Silverton who travelled to Lesotho with UNICEF. Here is a quote. The full article is at:
http://news.bbc.co.uk/1/hi/programmes/breakfast/6692619.stm

---Quote begins
If [Lesotho] is to survive it needs to find a way of creating a new generation that is born free of HIV and UNICEF is supporting a government campaign that aims to do just that.

It wants everyone in the country to be tested for the virus, and has committed the drugs for treatment should they test positive.

It's also actively promoting a programme that teaches HIV positive mothers how to avoid passing on the virus to their children.

The risk of passing on the virus can fall from 35% to just 2% if a mother follows a few simple steps.

If she takes the right drugs during pregnancy and after birth and exclusively breastfeeds for six months, her child is likely to be born HIV free.

It sounds incredibly simple - and goes against local customs where young infants are given a mix of traditional food as well as breast milk - but new research from the World Health Organisation has found that breast milk can actually protect the child from the virus.

The feeding has to be exclusive however because anything other than breast milk can serve as an irritant in the gut and allow the virus to pass through.
---quote ends

In the HIV emergency the baby food marketing requirements are also critically important. We have exposed in the past how companies have exploited HIV to try to have regulations over turned.

It is great this information is finally finding its way into the mainstream news.

I even had the opportunity to post a comment on the Guardian article addressing Nestlé’s untrue comments about its marketing activities, rectifying somewhat the situation I described on Monday. See:
http://boycottnestle.blogspot.com/2007/05/having-last-word.html

Three newspaper articles and an IBFAN newsletter

Several things going on at the moment.

Firstly, our leafleting at the Nestlé Book Prize was picked up by an international news agency and sent out in English, French and Arabic.

You can read it here:
http://www.destinationsante.com/en_depeche.php?id_rubrique=26&id_article=20218&cat=1

There's a picture of our team of leafleters. There on the left is Sarah, our new Office Manager, next to Patti, Policy Director.

Second bit of news was a report on the US Food and Drug Administration finding Nestlé infant formula in the US had lower than permitted minimum levels of Phosphorous and Calcium. Included a reference to the boycott with: "The group is already one of the most boycotted food firms in the world because of allegations that it unfairly pushed its infant formula onto women in the developing world, discouraging them to breast feed." See:
http://www.fda.gov/foi/warning_letters/g6152d.htm

You can see the FDA warning letter on-line. It shows Calcium levels are about 10% down on what Nestlé shows on the labels, Phosphorous about 20%. See
http://www.fda.gov/foi/warning_letters/g6152d.htm

A third article of note was in the UK Daily Telegraph. It concerns HIV and the risks of transmission through breastfeeding. The headline is "HIV positive and forced by poverty to breastfeed." It says things like: "Ajabu is HIV positive but has deliberately not been told that breastfeeding is highly infectious and that, in effect, she risks passing on a death sentence every time she raises her children to her breast." See:
http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2006/12/16/wmala16.xml

The World Health Assembly position, as I have explained in a past blog entry, is : "when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-positive women is recommended; otherwise, exclusive breastfeeding is recommended during the first months of life; and that those who choose other options should be encouraged to use them free from commercial influences."
See http://boycottnestle.blogspot.com/2006/10/but-sometimes-journalists-get-it-wrong.html

This sensationalist 'death sentence' journalism is not only at odds with the reality, it is potentially very damaging to health if taken seriously. The fact is that the vast majority of infants born to HIV infected mothers do not get infected. While no-one should minimise the impact on the 15% of infants who are infected through breastfeeding, it needs to be put in context of the risk assessment recommended by the World Health Assembly. As UNICEF has pointed out, in the first 20 years of the HIV pandemic, perhaps 1.7 million infants have been infected with HIV through breastfeeding, but 30 million have died as a result of not being breastfed.

More recently evidence is emerging of the impact of promoting formula as the solution to mother-to-child transmission. Remember Nestlé set up a Nutrition Institute for southern Africa in 2001 with just that stated purpose. Botswana is one country where Nestlé provides formula to a government scheme. We have exposed the idealising leaflets that go with the Pelargon formula in the past. They suggest the formula helps to prevent diarrhoea, whereas formula-fed infants are more likely to die as a result of diarrhoea than breastfed infants. See
http://www.babymilkaction.org/CEM/compjune03.html

A study in Botswana evaluating different approaches to infant feeding by HIV-infected mothers evaluated child survival, not just HIV transmission. It concludes:

---
Breastfeeding with zidovudine prophylaxis was not as effective as formula feeding in preventing postnatal HIV transmission, but was associated with a lower mortality rate at 7 months. Both strategies had comparable HIV-free survival at 18 months. These results demonstrate the risk of formula feeding to infants in sub-Saharan Africa, and the need for studies of alternative strategies.
---

In other words, because infants die from the risks of artificial feeding, the strategies about balance out over 18 months from the point of view of child survival. Prior to this: "Cumulative infant mortality at 7 months was significantly higher for the formula-fed group than for the breastfed plus zidovudine group." To use the wording of the Telegraph journalist, putting a bottle in a babies mouth was more likely to be a death sentence during this period.

At 18 months the mortality rate amongst the formula-fed group was 10.7% and 8.7% in the breastfed group. HIV infection was 6% in the formula-fed group (infants being infected in utero or during birth) and 9.5% in the breastfed group.

You can find the paper on PubMed

There was a flaw with the study however. The breastfed group were not exclusively breastfed, there was also mixed feeding. Other studies suggest that mixed feeding is the most dangerous scenario and so this would have made breastfeeding look worse than if exclusively-breastfed infants alone had been considered (Coutsoudis A. Influence of infant feeding patterns on early mother-to-child transmission of HIV-1 in Durban, South Africa. Ann N Y Acad Sci. 918: 136-144, 2000). So if the message about exclusive breastfeeding was effectively spread in conditions where artificial feeding is life threatening we should see less HIV-transmission and far better survival rates.

If you want greater insight into the complexities of this issue, an understanding of why the World Health Assembly policy is as it is and why sensationalist and ill-informed articles like that in the Telegraph are so unhelpful to child health you need to look behond the catchy headlines. For example, see the Spring/Summer 2006 newsletter from INFACT Canada. This reports on the Botswana study and a recent HIV conference. Click here to download the pdf

...but sometimes journalists get it wrong

As I said last time, we like journalists. They give the baby food issue coverage in a variety of ways.

But sometimes things can go a little awry. An example came up last Friday, which prompted me to write these two pieces. It began with an article in a Canadian news magazine which I forwarded to the Nestlé boycott yahoo discussion group. It explained how Nestlé was found giving away "free Baby Einstein and Disney DVDs, free rice-cereal samples, free infant formula samples, and a send-away card for a free diaper bag, a baby-magazine subscription, and more formula" at a baby care exhibition in Canada. This was contrasted with the difficulty the breastfeeding support groups, without any freebies on offer, had in enticing mothers to come to their meetings. Our Canadian partner, INFACT Canada, was mentioned in the article, though the name of the Director was given incorrectly. And there was a strange comment in the article, apparently coming from an official report, saying that a third of mothers could not breastfeed for health reasons. Knowing that virtually all mothers breastfeed in countries where there is support for breastfeeding and company promotion has been stopped I went looking for the original report (we are quite pernickety about such things). This showed there was a misunderstanding of the findings. Some mothers reported lack of milk and obviously experienced genuine difficulties, but not because there was a medical problem making breastfeeding impossible. The report concluded: "The relatively low percentage of Canadian mothers whose breastfeeding practices matched the current recommendations is a challenge for public health. The sharp drop in breastfeeding within a few weeks of leaving hospital suggests a lack of reinforcement in the family or community. A number of studies have called on health care professionals to provide consistent, clear information about breastfeeding and support throughout pregnancy, childbirth and the postpartum period." Without support mothers with difficulties find it hard to overcome them and are preyed on by the baby food companies with their 'carelines', advice websites and free gifts. Clearly it is not only some mothers who believe they cannot produce milk - there are journalists too. Perhaps because of their own bad experience or that of a friend or neighbour.

My worst memory of a journalist getting the wrong end of the stick came when I briefed the health correspondent of a national daily newspaper on the advice on infant feeding for mothers who might be infected with HIV. I referred to the recommendations the World Health Assembly adopted after much research and debate. This sets the policy of the World Health Organisation (WHO). The recommendation is: "when replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-positive women is recommended; otherwise, exclusive breastfeeding is recommended during the first months of life; and that those who choose other options should be encouraged to use them free from commercial influences." I won't go into all the reasons for this advice here (see below), but I explained them to the journalist. The article he wrote was along the lines of Baby Milk Action has this strange proposal, but WHO is unconvinced and experts argue 'exclusive breastfeeding is impractical in Africa, where few women produce enough breast milk to sustain a baby.'

The newspaper later printed letters from experts pointing out the errors in the article. But Baby Milk Action's telephone calls were not answered and our letter explaining that we had set out WHO policy, not invented our own proposals as the article suggested, was not published.

As you can see, it still rankles when I think of it. But the point is to learn from experience. I very quickly added a page on HIV to the Baby Milk Action website with quotes from the relevant World Health Assembly documents and linked to them. Now I can refer journalists there. In fact, the site is a treasure trove full of such gems. See the Your Questions Answered section for some of the key ones.

Another top tip is if you are going to be quoted, ask the journalist to wait for this to be sent in writing if there is time. When it is on the radio, however, that's another story...