Annelies Allain: Pioneer of the International Code of Marketing of Breastmilk Substitutes.

Annelies Allain has been at the forefront of global efforts to support and promote breastfeeding for more than 30 years. Her accomplishments continue to affect all of us who work with breastfeeding families. Born in the Netherlands in 1945, Annelies Allain-van Elk received a scholarship and completed a BA from the University of Minnesota, Duluth, USA. Back in Europe, she obtained a BA in French language and literature (University of Geneva, Switzerland) as well as a translator's diploma. After 4 years working in West Africa and visits to South America, she returned to Geneva to obtain an MA in development studies. She is fluent in English, French, and Dutch and has working knowledge of Spanish, Portuguese, Italian, and German. Ms. Allain was a co-founder of IBFAN (1979) and the coordinator of IBFAN Europe (1980-1984). In 1984, she moved to Penang, Malaysia, and IBFAN work soon took over as a full-time job. She was instrumental in developing the Code Documentation Centre (1985) and by 1991 it became a foundation (ICDC) registered in the Netherlands. Subsequently, the Centre has trained over 2,000 officials from 148 countries about the International Code, making it the world's top International Code implementation institution. Among her many other education and advocacy activities, Ms. Allain was a co-founder of WABA (1990) and for many years has been a consultant with UNICEF and WHO's Western Pacific Regional Office on International Code implementation and monitoring. In this interview she provides a firsthand account of how most of the major global breastfeeding protection efforts influencing our current situation came into being. (This is a verbatim interview: MA = Maryse Arendt; AA = Annelies Allain.).

The History of Infant Formula: Quality, Safety, and Standard Methods.

Food-related laws and regulations have existed since ancient times. Egyptian scrolls prescribed the labeling needed for certain foods. In ancient Athens, beer and wines were inspected for purity and soundness, and the Romans had a well-organized state food control system to protect consumers from fraud or bad produce. In Europe during the Middle Ages, individual countries passed laws concerning the quality and safety of eggs, sausages, cheese, beer, wine, and bread; some of these laws still exist today. But more modern dietary guidelines and food regulations have their origins in the latter half of the 19th century when the first general food laws were adopted and basic food control systems were implemented to monitor compliance. Around this time, science and food chemistry began to provide the tools to determine "purity" of food based primarily on chemical composition and to determine whether it had been adulterated in any way. Since the key chemical components of mammalian milk were first understood, infant formulas have steadily advanced in complexity as manufacturers attempt to close the compositional gap with human breast milk. To verify these compositional innovations and ensure product quality and safety, infant formula has become one of the most regulated foods in the world. The present paper examines the historical development of nutritional alternatives to breastfeeding, focusing on efforts undertaken to ensure the quality and safety from antiquity to present day. The impact of commercial infant formulas on global regulations is addressed, along with the resulting need for harmonized, fit-for-purpose, voluntary consensus standard methods.

Feeding the feeble: steps towards nourishing preterm infants.

This paper describes historic steps in feeding techniques and knowledge on the nutritional needs of premature infants. Devices to overcome weak sucking and swallowing were developed from 1851 to 1920, including tube feeding by gavage, medicine droppers and pipettes, feeding bottles with an air inlet, and beaked spoons for nasal feeding. Indwelling nastrogastric tubes were in use from 1951. For alleged safety concerns in the 1950s, postnatal feeding was postponed until a week of starvation was reached, and studies showed an association with neurological handicaps. The premature infant's elevated need for energy, protein, and minerals has been established since 1919. However, these remained controversial, and nutritional practices continued to lag behind theoretical knowledge. Concentrated formula was developed in the 1940s, parenteral supplementation in the 1960s, and human milk fortifiers in the 1970s. In the 1990s, necrotizing enterocolitis was found to be more frequent in infants who were fed formula than in those who were fed human milk. Recently, probiotics were shown to reduce the risk of necrotizing enterocolitis. Nevertheless, compared with other aspects of neonatal medicine, there is still remarkably little evidence on how to feed preterm infants.

Historic records on the commercial production of infant formula.

Industrialized food production first appeared in 1856, pioneered by Borden in the USA, Liebig in Germany, Nestlé in Switzerland, and Mellin in the UK. Their products differed remarkably and deviated from human and cow's milk, and physicians discussed the importance of minute variations in protein, fat and carbohydrates. Proprietary formulas were free of bacteria, and the companies prospered with mass production, international marketing and aggressive advertising. From 1932 on, medical societies restricted advertising to the laity. In 1939 Williams in Singapore and in 1970 Jelliffe in Jamaica suspected that commercial formula may be increasing infant mortality in the Third World. Breastfeeding continued to decline during the early 20th century, falling in 1970 below 10% in the USA. The Swiss 'Third World Group' and the US 'Infant Formula Action Coalition' linked infant mortality and industry marketing in the Third World. The controversy of 1970-1984 led to the WHO Code, which regulated the advertising and marketing of baby food. This was one of several public health statements contributing to the resurgence of breastfeeding.

Technical inventions that enabled artificial infant feeding.

Artificial feeding of infants, called hand-feeding, was unsafe well into the 19th century. This paper aims to identify technical innovations which made artificial feeding less dangerous. In rapid succession from 1844 to 1886, the vulcanization of rubber, production of rubber teats, cooling machines for large-scale ice production, techniques for milk pasteurization, evaporation and condensation, and packing in closed tins were invented or initiated. Remarkably, most of these inventions preceded the discovery of pathogenic bacteria. The producers of proprietary infant formula made immediate use of these innovations, whereas in the private household artificial feeding remained highly dangerous - mostly because of ignorance about bacteria and hygiene, and partly because the equipment for safe storage, transport, preparation and application of baby food was lacking.

Pap, gruel, and panada: early approaches to artificial infant feeding.

This paper collects information on artificial infant feeding published before 1860, the year when commercial formula became available. We have extensive artifactual evidence of thousands of feeding vessels since the Bronze Age. Special museum collections can be found in London, Paris, Cologne, Fécamp, Toronto, New Mexico, and elsewhere. The literature on the use of animal milk for infant feeding begins with Soranus in the 2nd century CE. Literature evidence from the very first printed books in the 15th century proves that physicians, surgeons, midwives, and the laity were aware of the opportunities and risks of artificial infant feeding. Most 17th to 19th century books on infant care contained detailed recipes for one or several of the following infant foods: pap, a semisolid food made of flour or bread crumbs cooked in water with or without milk; gruel, a thin porridge resulting from boiling cereal in water or milk, and panada, a preparation of various cereals or bread cooked in broth. During the 18th century, the published opinion on artificial feeding evolved from health concerns to a moral ideology. This view ignored the social and economic pressures which forced many mothers to forego or shorten breast-feeding. Bottle-feeding has been common practice throughout history.

Milk demystified by chemistry.

This article traces the decline of milk from a heavenly elixir to a tradeable food. Early cultures regarded milk not as a simple nutrient, but a living fluid. Heroes and gods were believed to have been nurtured by animals after being abandoned. Character traits were assumed to be transmitted by milk; infantile diseases were attributed to "bad milk", whereas "good milk" was used as a remedy. With chemical methods developed at the end of the 18th century, it became known that human milk was higher in sugar and lower in protein than cow's milk. During the 19th century, "scientific" feeding emerged that meant modifying cow's milk to imitate the proportion of nutrients in human milk. In Boston from 1893, Rotch initiated the "percentage" method, requiring a physician's prescription. In Paris from 1894, Budin sterilized bottled infant milk. In Berlin in 1898, Rubner measured oxygen and energy uptake by calorimetry, prompting feeding by calories, and Czerny introduced regulated feeding by the clock. These activities ignored the emotional dimension of infant nutrition and the anti-infective properties of human milk. They may have also enhanced the decline in breastfeeding, which reached an all-time low in 1971. Milk's demystification made artificial nutrition safer, but paved the way for commercially produced infant formula.

Innovations in infant milk feeding: from the past to the future.

Innovation is important for life science and economy, but the value of innovation for public health depends on its impact on promoting health. Breastfeeding is not innovative but evolved slowly over 250-300 million years, yet its total benefits are not surpassed by more innovative ways of infant feeding. Until the 19th century, infants fed inadequate breast milk substitutes suffered from high mortality. In 1865 a major improvement was von Liebig's 'soup for infants', the first breast milk substitute based on chemical human milk analysis, soon followed by commercial applications. Other early innovations include whey protein-dominant formula, addition of specific carbohydrates to promote bifidobacteria ('prebiotic') and of live bacteria ('probiotic'), predecessors of apparently recent innovations. Opportunities for innovations exist since many outcomes in formula-fed infants do not match those in breastfed populations. Of concern, expected economic benefits through innovations may override scientific arguments. Business and marketing desires must be counterbalanced by independent pediatric and scientific evaluation. Developing innovations with relevant outcome effects is complex, costly and cannot be expected to occur every few years. Cooperation between academic investigators, small and medium enterprises with high innovative potential, and large industries promotes progress and should be facilitated, e.g. by public research funding.

The role of pediatricians as innovators in pediatric nutrition.

Innovation is about making changes. When it comes to health care, innovations, though they may be something 'new', may not be beneficial if not demonstrated to be an improvement over what is current practice. Innovations in pediatric nutrition sometimes fall into this category. The establishment of safe water and milk supplies at the end of the 19th and beginning of the 20th centuries is viewed as one of the greatest advances in preventative medicine and truly was an 'innovation', with its dramatic impact on infant mortality. Other innovations in pediatric nutrition included the development of the caloric method of infant feeding which led to the large-scale adoption of a single infant formula. This required cooperation with industry and ultimately led to the development of life-saving specialty formulas for various disease states including inborn errors of metabolism. Over the last 50 years there have been further modifications of term infant formula that have included taurine, carnitine, nucleotides, whey proteins, PUFAs including decosahexenoic acid (DHA) and arachidonic acid, probiotics, and prebiotics. Many of these additions are of questionable benefit and are questioned as true innovations. Though the addition of novel nutrients to infant formula has been an area of great interest, more basic research (including randomized controlled trial) is needed to determine many pediatric nutrient requirements including the lower and upper limits of nutrients added to infant formula. Such research could be facilitated by institutions such as the US National Institute of Child Health whose establishment in 1962 was a significant 'innovation' as it led to advances in pediatric nutritional research. Much more research is needed to determine basic pediatric nutritional requirements and pediatricians should strive for such true innovations.

The history of infant nutrition.

OBJECTIVE: To retrace the history of infant nutrition with the objective of better understanding breastfeeding. SOURCES OF DATA: Bibliographic searches were run on MEDLINE, LILACS, SciELO, and the Internet. Encyclopedias, scientific textbooks and books for the general public, in addition to literature, art and history, were also used. Texts on child care from several different periods were consulted, in addition to the history of medicine and recent scientific articles on infant nutrition. SUMMARY OF THE FINDINGS: During the preindustrial period, customs varied little and the likelihood of survival was linked to breastfeeding or its substitution by a wetnurse's milk. Where this was not possible, infants were given animal milk, pre-chewed foods or paps that were poor in nutrients and contaminated, which caused high mortality rates. There was nothing that could successfully substitute breastfeeding and the survival of the species was dependent on breastfeeding. Once the industrial revolution had started, women who had been accustomed to breastfeeding went to work in factories, stimulating the search for alternative infant nutrition. Consumption of animal milk and formulae (diluted, flour-based, powdered milk) and premature introduction of complementary foods compromised children's health. The feminist movement and the contraceptive pill caused a fall in birth rates. Manufacturers in search of profits developed modified formulae and invested in advertising. Society reacted with breastfeeding support movements. CONCLUSIONS: Nowadays, the advantages of breastmilk are recognized and exclusive breastfeeding is recommended up to 6 months, to be supplemented with other foods from this age on and continued until at least 2 years of age. Infant nutrition, whether natural or artificial, has always been determined and conditioned by the social value attributed to breastfeeding.

Alimentos utilizados ao longo da história para nutrir lactentes: [revisão] / The history of infant nutrition: [review]

OBJETIVO: Resgatar a história da alimentação infantil, com o intuito de compreender a prática da amamentação. FONTES DOS DADOS: O levantamento bibliográfico foi realizado nas bases MEDLINE, LILACS e SciELO, Internet, enciclopédias, livros científicos e leigos, literatura, arte e história. Foram consultados textos sobre os cuidados com lactentes em diferentes épocas, a história da Medicina, e artigos científicos recentes sobre nutrição infantil. SÍNTESE DOS DADOS: Durante o período pré-industrial, os costumes pouco variaram, e a chance de sobrevivência estava relacionada ao aleitamento materno ou à sua substituição pelo leite de uma ama. Caso isso não fosse possível, os lactentes recebiam leite animal, alimentos pré-mastigados ou papas pobres em nutrientes e contaminadas, que determinavam altos índices de mortalidade. Nada podia substituir a amamentação com sucesso, e dela dependia a sobrevivência da espécie. Com a Revolução Industrial, as mulheres, que costumavam amamentar, foram trabalhar nas fábricas, motivando a busca de alternativas para nutrir os lactentes. O consumo de leite animal e fórmulas (diluídas, farinhas, leite em pó), bem como a introdução precoce de alimentos comprometeram a saúde das crianças. O movimento feminista e a pílula anticoncepcional determinaram queda da natalidade. As fábricas, visando o lucro, desenvolveram fórmulas modificadas e investiram em propaganda. A sociedade reagiu com um movimento de incentivo ao aleitamento. CONCLUSÕES: Atualmente, reconhecem-se as vantagens do leite materno, e recomenda-se aleitamento exclusivo até os 6 meses, complementado com outros alimentos a partir dessa idade até pelo menos os 2 anos. A alimentação infantil, natural ou artificial, sempre foi determinada e condicionada pelo valor social atribuído à amamentação.

OBJECTIVE: To retrace the history of infant nutrition with the objective of better understanding breastfeeding. SOURCES: Bibliographic searches were run on MEDLINE, LILACS, SciELO, and the Internet. Encyclopedias, scientific textbooks and books for the general public, in addition to literature, art and history, were also used. Texts on child care from several different periods were consulted, in addition to the history of medicine and recent scientific articles on infant nutrition. SUMMARY OF THE FINDINGS: During the preindustrial period, customs varied little and the likelihood of survival was linked to breastfeeding or its substitution by a wetnurse's milk. Where this was not possible, infants were given animal milk, pre-chewed foods or paps that were poor in nutrients and contaminated, which caused high mortality rates. There was nothing that could successfully substitute breastfeeding and the survival of the species was dependent on breastfeeding. Once the industrial revolution had started, women who had been accustomed to breastfeeding went to work in factories, stimulating the search for alternative infant nutrition. Consumption of animal milk and formulae (diluted, flour-based, powdered milk) and premature introduction of complementary foods compromised children's health. The feminist movement and the contraceptive pill caused a fall in birth rates. Manufacturers in search of profits developed modified formulae and invested in advertising. Society reacted with breastfeeding support movements. CONCLUSIONS: Nowadays, the advantages of breastmilk are recognized and exclusive breastfeeding is recommended up to 6 months, to be supplemented with other foods from this age on and continued until at least 2 years of age. Infant nutrition, whether natural or artificial, has always been determined and conditioned by the social value attributed to breastfeeding.

The role of basic nutritional research in pediatric liver disease: An historical perspective.

The advent of liver transplantation for end-stage liver disease (ESLD) in children has necessitated a major rethink in the preoperative preparation and management from simple palliative care to active directed intervention. This is particularly evident in the approach to the nutritional care of these patients with the historical understanding of the nutritional pertubations in ESLD being described from a single pediatric liver transplant center. ESLD in children is a hypermetabolic process adversely affecting nutritional status, metabolic, and non-metabolic body compartments. There is a complex dynamic process affecting metabolic activity within the metabolically active body cell mass, as well as lipid oxidation during fasting and at rest, with other factors operating in conjunction with daily activities. We have proposed that immediately ingested nutrients are a more important source of energy in patients with ESLD than in healthy children, among whom energy may be stored in various body compartments.

From breast to bottle: a history of modern infant feeding.

In the early twentieth century, mothers began to turn towards scientific infant-feeding formulae as an alternative to breastfeeding their babies. This is strange because the benefits of breastfeeding were widely recognised. The extraordinary rise of the formula feed therefore demands a special explanation, one that includes an appreciation of key changes in public health, the emergence of paediatrics as a profession, commercial interests and advances in the sciences of bacteriology and nutrition. All these factors conspired to propel the formula feed to the fore.