Implementing and Monitoring the International Code of Marketing of Breast-milk Substitutes in New Zealand

Code of Practice for Health Workers - Online version

Context
The Code of Practice for Health Workers (Health Workers’ Code) is based on the International Code and has been developed by the Ministry of Health after consultation with the health sector. It recommends best practice for health workers only, so does not apply to other groups such as formula companies.

The Health Workers’ Code replaces Infant Feeding Guidelines for New Zealand Health Workers (Ministry of Health 1997).

Relevant professional bodies and employer organisations are expected to support health workers to uphold the principles and aims of the Health Workers’ Code and their responsibilities under it by developing policies and practices and providing ongoing training.

Breastfeeding forms a unique biological and emotional basis for the health of both mother and child and is the best and safest way to feed infants (see Appendix 1). Breast milk is the ideal food for infants, and meets all an infant’s nutritional and fluid requirements for up to the first six months of life, and most of the nutritional and fluid requirements from around six months to one year of age.

When breast milk is not available, infants must be given an appropriate infant formula until they are one year old. Infant formula can be used for up to 12 months of age. Unmodified cow’s milk is not recommended as the primary drink before the age of one year, because it can lead to anaemia from poor iron absorption and gastrointestinal bleeding. This can be made worse if iron-containing complementary foods are not given from six months of age (Ministry of Health 2000).

For more information about infant nutrition, see Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0-2): A background paper) (www.moh.govt.nz/nutrition).

Purpose
The Health Workers’ Code has the same aim as the International Code. That is to contribute to the provision of safe and adequate nutrition for infants by:

protecting and promoting breastfeeding
ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Specifically, the Health Workers’ Code wants health workers to:

protect, promote and support breastfeeding, giving clear, consistent and accurate information about the importance of breastfeeding and the health consequences of not breastfeeding
encourage mothers and families before the birth of their infant to make an informed decision on the feeding method they will use
help mothers and families to prevent and resolve the most common problems that cause mothers to stop breastfeeding
meet their obligation to give detailed information and advice to parents, caregivers and families of breastfed and formula-fed infants on infant feeding
ensure the appropriate and safe preparation, usage and storage of formula when necessary
be aware of the complaints processes for use when they are confronted with potential breaches of the codes.

Scope
The Health Workers’ Code is based on Ministry policy from Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2): A background paper, and the International Code, and includes all types of formula for infants 0-12 months.¹ Therefore, it differs from the INC Code of Practice which applies to infant formula only.²

Health care providers should develop policies in their organisation on the use of formula, formula samples, gifts from formula companies, product information, and feeding bottles and teats. Policies should include how to promote, protect and support breastfeeding in difficult circumstances, for example, hospitalisation of infant and/or mother or a natural disaster. The policies should be based on Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2): A background paper, the spirit and intent of the International Code, the Health Workers’ Code, the Baby Friendly Hospital Initiative, and the Baby Friendly Community Initiative. Health care providers, including pharmacists, need to be aware of these documents and initiatives and accept responsibility for ensuring staff implement them in the workplace.

Note that the term health worker applies to a person working for a health care provider, including a voluntary, unpaid worker and anyone providing information to pregnant women and mothers. A health practitioner is a subset of this wider group, and is defined as a practitioner of a particular health profession who is registered with, and overseen by an authority, for example, a dietitian, doctor, nurse, pharmacist (see the Glossary for Code of Practice for Health Workers on page 25 of Implementing and Monitoring the International Code of Marketing of Breast-milk Substitutes in New Zealand: The Code in New Zealand).

Articles of the Code of Practice for Health Workers

1. Health workers must protect, promote and support breastfeeding.

1.1 The Ministry expects health workers to protect, promote and support breastfeeding and be familiar with their responsibilities under the Health Workers’ Code, and other Ministry policies and strategies, for example, the Baby Friendly Hospital Initiative, the Baby Friendly Community Initiative and the Well Child Framework.

1.2 Health workers play an essential role in guiding feeding practices. They do this by encouraging and facilitating breastfeeding and providing objective and consistent advice to mothers and families about the superior value of breastfeeding.

2. Health workers should enable mothers to make an informed decision about infant feeding.

2.1 Health workers should give accurate, objective and consistent information and educational material on breastfeeding and formula feeding, and should discuss the benefits and problems associated with the different methods of feeding so parents can make an informed decision.

2.2 Health workers should be aware of individual circumstances, and apply best clinical practice for those circumstances to ensure appropriate health care and safe and adequate nutrition for all infants. For example, although virtually all women can breastfeed, some mothers decide not to breastfeed their infants, are unable to breastfeed, or try to breastfeed without success. In some medical situations, establishing breastfeeding is more difficult than others. In such cases specialist lactation services may be required. If the mother is unable to establish breastfeeding, an appropriate infant formula should be provided for the baby or donor milk if available and acceptable to the mother. If used, donor milk must meet the required standards for safe collection and storage.

2.3 Antenatally, information on appropriate infant nutrition should always be presented in the context of breastfeeding as the biological norm and as an unparalleled way of feeding an infant. Pregnant women should also be told that if they want to formula feed then information is available. Any instructions in the use of infant formula should be undertaken one to one with the woman concerned and not in a class setting.

2.4 Mothers who do not breastfeed their infants should receive the same attention from health workers and the health care system since not breastfeeding is associated with increased risks to the health of infants and mothers.

3. Health workers must assist mothers and families to breastfeed.

3.1 Health workers should be knowledgeable about breastfeeding and breastfeeding management, skilled in helping mothers and able to access further information and support as required. Even though it is a natural act, breastfeeding is also a learned behaviour. Virtually all mothers can breastfeed provided they have accurate information and support within their families and communities and from the health care system.

3.2 Health workers need to work with women in a way that increases women’s confidence in their ability to breastfeed. Health workers must not undermine breastfeeding by creating negative perceptions and behaviour towards breastfeeding.

3.3 Health workers should help to prevent or resolve the most common problems that cause mothers to stop breastfeeding.

3.4 Health workers should acknowledge the important role of skilled and knowledgeable peer supporters and peer support groups, refer mothers to them and work in collaboration with these groups in the community.

3.5 Health workers should, where appropriate, provide mothers with information about sterilising bottles and storing expressed breast milk. Information should not imply or create a belief that bottle feeding is equivalent or superior to breastfeeding. Mothers should be informed that there is a cup method of feeding expressed breast milk.

4. Health workers must ensure appropriate use of formula when necessary.

4.1 Only health workers should demonstrate to mothers or family members how to prepare and use formula. Family members who need to use formula require instruction and information on the preparation and safe storage of formula, feeding techniques and types of formula available.

4.2 Health workers who cannot provide a family with information about formula feeding must refer the family to another health service provider who can provide the information.

4.3 Health workers should strengthen the health and nutrition education of these mothers and their family members in order to foster preparation for the initiation and maintenance of breastfeeding of any future infants born, whatever the previous feeding experience. These mothers should be referred to community-based breastfeeding support groups antenatally
for future births.

4.4 Health workers should not promote a specific brand of formula, or be involved in the promotion of products used for infant feeding.

5. All information prepared by health workers on formula feeding should explain the benefits of breastfeeding, and the costs and health hazards of the unnecessary or improper use of formula.

5.1 Information 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 the following points.

The benefits and superiority of breastfeeding.
Maternal nutrition, and the preparation for and maintenance of breastfeeding.
The negative effect on breastfeeding of introducing partial formula feeding.
The difficulty of reversing the decision not to breastfeed.
Where needed, the proper use of formula. When such material contains information about the use of formula, the information should include the social and financial implications of formula use; the health hazards of inappropriate foods or feeding methods; and, in particular, the health hazards of the unnecessary or improper use of formula.

5.2 Information and educational materials should not use pictures or text that may idealise the use of formula.

5.3 All materials used to provide information should be objective and consistent with current knowledge.

5.4 For a list of information and support providers and resources available nationally, see Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0–2): A background paper.

6. Health workers must be aware of the key principles in the New Zealand Infant Formula Marketers’ Association (INC) Code of Practice for the Marketing of Infant Formula.

6.1 The key principles are provided on page 19 of Implementing and Monitoring the International Code of Marketing of Breast-milk Substitutes in New Zealand: The Code in New Zealand.

6.2 A health worker may contact a formula company for scientific and factual product information.

6.3 Health workers may meet individually or collectively with formula company representatives to be informed about company products.

6.4 For general information on infant feeding, health workers should consult Food and Nutrition Guidelines for Healthy Infants and Toddlers (Aged 0-2): A background paper.

7. Health workers should not accept samples from formula companies.

7.1 Health workers should not accept samples of formula, equipment or utensils for their preparations or use except when necessary for the purpose of professional evaluation and research at an institutional level. They may be used for educating parents who have decided to use formula, in the correct preparation of formula, while not promoting a specific brand of formula (see 4.4).

7.2 Health workers should not give samples of formula to pregnant women, mothers of infants, or members of their families.

8. Health workers should not accept gifts from formula companies.

8.1 Health workers or members of their family should not accept financial or material inducements to promote products.

8.2 Health workers should disclose to the institution to which they are affiliated, any contribution made to him or her on his or her behalf for fellowships, study tours, research grants, attendance at professional conferences or the like. Health workers should ensure that financial support does not create conflict of interest.

9. Health care facilities should not promote formula products in their facilities.

9.1 A health care provider environment should not display items provided by companies such as formula, bottles, teats, posters, growth charts, calendars or formula preparation charts.

9.2 Health workers may ask for materials such as pamphlets, posters and booklets and equipment from manufacturers and distributors, providing the material is restricted to scientific and factual matters. Such material should not imply or create a belief that bottle feeding is equivalent or superior to breastfeeding.

9.3 All infant formula information and educational material prepared by manufacturers and distributors, whether written, audio or visual, must be consistent with the INC Code of Practice. Such materials may bear the donating company’s name or logo, but should not refer to the product brand name, with the exception of product information brochures for health practitioners and advertisements in medical publications, and should be distributed only through (ie, within) the health care system.

9.4 Only mothers and families who have decided to use formula may be given information relating to formula products on discharge.

10. Formula products should not be donated to health care facilities.

10.1 Health care facilities may purchase formula at wholesale prices in accordance with the principles of the Baby Friendly Hospital Initiative and the Baby Friendly Community Initiative, through the normal procurement channels, and not through free or subsidised supplies.

10.2 Organisations and institutions should not accept donated supplies of formula from manufacturers or distributors. In the case of a natural disaster or similar situation donated supplies may be given but only if infants are medically required to be fed or are already fed on formula. The supply must be continued as long as the special circumstances continue and must not be used as a sales inducement.

Footnotes
1 Includes infant formula and follow-on formula.
2 Follow-on formula is not marketed as a breast milk substitute in New Zealand.

Page last updated: 2 July 2009