Formula labeling violations to the WHO Code: a quantitative and qualitative analysis

BACKGROUND: The WHO Code on Marketing of Breastmilk Substitutes is intended to be adopted as a minimum requirement by all governments and aims to protect infant health by preventing inappropriate marketing of breastmilk substitutes. Labels need to have correct and clear dispositions since they frequently are the only source of vital information for consumers regarding the content of the product and its uses. OBJECTIVE: The purpose of this study was to determine violations to the provisions of the International Code Article 9 regarding infant formula labeling existing in Puerto Rico. Methods: A quantitative and qualitative evaluation of 34 labels of infant formula was done. Instrument 4-A of the IBFAN Monitoring Project (IMPIII) and the Standard IBFAN Monitoring (SIM) was utilized. This instrument included 14 criteria that identified violations to the International Code of Breastmilk Substitutes on labeling. Descriptive analysis was used for all variables. The 34 labels evaluated represent 77.3% of infant formula labels of the four companies which market them in the island. RESULTS: All the labels (100%) that were evaluated were found to violate the Code in one or more of its dispositions. Most striking violations include: a statement that breastfeeding is best is lacking in 73.5%, as well as a statement that the product should be used only on the advice of a health worker. None of the labels are written in Spanish, the local language. Text which may idealize the use of infant formula or discourage breastfeeding is present in 97.1% of the samples, and the same percentage has a photo or picture idealizing the use of infant formula. CONCLUSIONS: It is vital to produce legislation that implants the WHO Code in Puerto Rico in order to regulate indiscriminate marketing practices and their subsequent ill effects on children's health and breastfeeding practices.

Puerto Rican health teachers: attitudes towards breastfeeding.

OBJECTIVE: The purpose of the study was to identify attitudes towards breastfeeding and support for breastfeeding in public in a group of health teachers in the Department of Education. METHOD: The study design was correlational descriptive. A self-administered questionnaire was used (Cronbach's alpha = 0.83) for 125 health teachers. Descriptive and inferential statistics (chi square and t test) were used for data analysis. RESULTS: 89.6% were women, 47.1% had 39 years of age or less, 76.4% were married, the median of years in the profession was 12.5. Only 8.8% had breastfed exclusively, 46.1% used artificial feedings exclusively, and 45.1% combined artificial milk and breast milk. A moderate/negative attitude towards breastfeeding was shown by 53.1%. 60.3% stated they agreed or totally agreed that in order to breastfeed the mother must follow a specific diet, 36.0% agreed or totally agreed that breast milk should alternate with artificial milk, and 100% of participants do not support breastfeeding in public. No significant difference was found in the attitude scale towards breastfeeding and the gender, the age, years in the profession, and the type of milk given their children. CONCLUSIONS: We must train teachers in the Department of Education, on a priority basis, in the field of human lactation in view of their importance for health promotion.

Profile of calls to a breastfeeding clinic information and help telephone line.

Breastfeeding mothers need orientation and help in order to succeed with breastfeeding. Lack of support from health professionals and societal barriers result in a median duration of breastfeeding in Puerto Rico of only 3 weeks. A telephone warm line at our breastfeeding clinic tries to provide some much-needed support and orientation. The purpose of this study was to determine the principal reasons for calls to the warm line and the action taken by the counselor. Five hundred and thirty three calls were received in a 4-month period. They were handled by certified lactation educators who gathered demographic and feeding information from the mother and registered the action taken. Descriptive analysis was used with crosstabs tables and multi-response analysis; chi-square test was used to establish the association between variables. 78.7% of callers were breastfeeding fully, while 21.3% were breastfeeding partially or formula feeding, 62.8% of the babies were 2 months old or less. 68.8% of the calls originated in the metropolitan San Juan area. The source of the referral was family/friend in 64.2% of calls, while only 9.8% of the callers were referred by a physician, 3.0% by hospital personnel and 2.0% by other health care providers. Significant differences between full breastfeeders and partial or artificial feeders were found in calls related to position (p = 0.01), engorgement (p = 0.04), breast refusal (p = 0.001), product information (p = 0.02), medications (p = 0.009), breastmilk management and storage (p = 0.001), and relactation (p = 0.02). Actions taken by the counselor included orientation, referral to breastfeeding specialist physician and referral to breastfeeding support groups or classes. Results indicate that more active promotion of referral to breastfeeding support groups or classes is warranted since this action was taken in only 14.5% of fully breastfeeding mothers and 12.6% of partial breastfeeding or formula users. Promotion of the warm line among physicians, hospitals and other health care professionals is also needed.

Reliability and validity of a breastfeeding attitudes instrument for nursing staff.

An instrument was designed and validated with the purpose of identifying attitudes towards breastfeeding among nursing professionals. The preliminary instrument contained 19 items which were submitted to experts in the field of human lactation and breastfeeding for content validity. The construct validity was measured through factor analysis and matrix correlation. Four factors were identified in the analysis. Overall internal consistency of the instrument was 0.83, with a subscale's range fluctuating from 0.64 to 0.73. The instrument is valid and reliable, and it is the first of its nature in Puerto Rico.

[Ethical aspects of human lactation and breastfeeding]. / Aspectos éticos en la promoción de la lactancia humana y el amamantamiento.

Breastfeeding has experienced a surge in Puerto Rico thanks to the efforts of many women, as well as governmental, non-governmental and private organizations. Among the aspects which can affect the initiation, establishment and maintenance of successful breastfeeding one finds potential ethical conflicts among health professionals as well as the financial interests of the companies which produce and market artificial milks. These companies dedicate great marketing efforts and enormous sums of money in the sale of their products, in detriment of breastfeeding. The profit motive of these companies is in open contradiction to public health and to breastfeeding promotion. The international community has carried out efforts for more than two decades in the creation of structures which protect the rights of women and their children to ideal nutrition practices, free from commercial pressures, through breastfeeding. Possible ethical conflicts related to the new industry of breastfeeding paraphernalia are discussed, especially when these are marketed exclusively for profit. Recommendations are presented for health professionals in order for them to be able to face and respond to the unethical strategies practiced by the manufacturers of artificial milks in utilizing these professionals for legitimating and marketing their products.

The management of labor and delivery and its implications for breastfeeding.

The main professional organizations of obstetrical and pediatric care providers in the United States and Puerto Rico have issued official position papers in favor of breastfeeding. Routine labor and delivery practices, however, constitute frequent barriers for the initiation, type and duration of breastfeeding. Many of these practices, moreover, lack the scientific basis to justify their routine use. We analyze in this article some of the most common obstetrical practices and their impact on breastfeeding.

[Breast feeding in Puerto Rico: traditional patterns, national trends and future strategies]. / La lactancia materna en Puerto Rico: patrones tradicionales, tendencias nacionales y estrategias para el futuro.

The Puerto Rican society has gone through profound transformations during the past 50 years. Industrialization and the incorporation of women into the labor force have been accompanied by medicalization of the reproductive process and a progressive reduction in the prevalence of breastfeeding as the cultural norm for nutrition of infants. The data base for 1990 places Puerto Rico significantly below Latin America and the United States in the percentage of breastfed infants. The authors report their experience in the promotion of breastfeeding during the last 5 years. The principal negative factors which hinder the beginning and maintenance of successful breastfeeding are of a social nature. The orientation of physicians towards technology underrates the benefits of breastfeeding. The marketing strategies of the corporations which manufacture artificial milk continuously violate the International Code for Marketing of Breast Milk Substitutes and disfigure the community's perception on the benefits of breastfeeding. The lack of social and legal support for the breastfeeding working mother frequently prevents her from carrying out successful breastfeeding for the recommended period of time. Strategies are presented for the overturn of the existent barriers which have reduced breastfeeding in Puerto Rico to the present precarious levels.