POSITION PAPER OF THE INFANT AND PEDIATRIC NUTRITION ASSOCIATION OF THE PHILIPPINES (IPNAP) IPNAP strives to be a key contributor in promoting the health and well-being of infants and young children, thereby helping to eradicate malnutrition and to reduce infant mortality in the Philippines. - The IPNAP Vision
Malnutrition is a serious problem, globally and locally. The World Health Organization (WHO) estimates that malnutrition is directly or indirectly responsible for at least 35% of deaths of children less than five years of age. In the Philippines, over 30% of children in the country are malnourished. The WHO reports that inappropriate infant and young child feeding practices are associated with malnutrition, and the infant and child nutrition industry has come together to be part of the solution. In the Philippines, the industry is represented by the Infant and Pediatric Nutrition Association of the Philippines (IPNAP) whose members include Abbott, Fonterra, Mead Johnson, Nestle and Wyeth. These five companies from New Zealand, Switzerland, and the United States formed IPNAP in 2008 to promote responsible business practices and ethics among its members, coordinate the industrys approach to combating the myriad issues surrounding inadequate infant nutrition and to underline these companies commitment to the Philippines. IPNAP helps to promote and improve the nutrition and well-being of Filipinos by providing nutritious and safe food products that meet the highest standards of food safety and quality. IPNAP also supports multi-sectoral efforts to improve infant nutrition, in line with the Philippine Government and its agencies, the medical profession, international and local non-governmental organizations and the general public.
December 2010 Manila, Philippines
INFANT AND CHILD NUTRITION PROGRAMS AND POLICIES IN THE PHILIPPINES Key messages: 1. IPNAP and its members are committed to solving the problem of malnutrition through improved infant and young child feeding practices. All IPNAP members believe that breastmilk is best for infants.
IPNAP supports the international policies of the WHO and global UNICEF that promotes exclusive breastfeeding for the first 6 months and appropriate complementary feeding from 6 months onward up to 2 years. In support of breastfeeding and in adherence with international standards and locals regulations, IPNAP members have not advertised infant formula 0-6 months since 1986 and 6-12 months since 2007.
2. IPNAP supports public-private partnerships for the development of programs and dissemination of information on infant and young child nutrition.
IPNAP members participate in government-approved feeding programs to assist lower income families with malnourishment issues.
IPNAP members are prepared to increase their donations of young child nutritional food products for feeding purposes in cooperation with the Philippine government, including during emergencies.
IPNAP believes that the industry, the government and NGOs should work together to educate and through improved policy provide help to mothers so that they can continue the breastfeeding initiated at the birth of the infant.
IPNAP believes parents and caregivers should be properly informed with evidence-based advice on optimal feeding practices.
3. IPNAP members products are developed through the most rigorous scientific
method. All nutritional claims are scientifically substantiated.
IPNAP member companies employ nutrition experts and food technologists, and are advised by external nutritionists, pediatricians and scientists.
Maintaining the very highest standards of food quality and safety is a core value of every IPNAP member company. Specific and very strict hygiene and quality management procedures are implemented and continuously improved.
Infant formulas a breastmilk substitute formulated for infants up to 6 months of age are developed according to national legislation and standards set by international bodies such as the FAO/WHO Codex Alimentarius Commission. No other breast-milk substitute is as nutritious as infant formula.
Follow-on milk and growing-up milk which is different from infant formula and developed for infant 6 months onwards and 1 year onwards respectively provide nutrition for the healthy development of infants and young children.
4. The two primary reasons mothers stop breastfeeding are inadequate milk flow (34.5%) and working outside the home (25.5%). Contrary to speculation, advertising does not factor in to their decision to stop breastfeeding.
This is supported by the 2008 National Nutrition Survey conducted by the Food and Nutrition Research Institute of the Department of Science and Technology. The survey also showed that advertising influence had a negligible effect (1.3%) on the mothers decision on the kind of milk to give her child. The single biggest factor was affordability (40.3%). IPNAP believes that industry, the government and NGOs should work together to develop and implement policies and programs that would address these issues, and IPNAP expresses its full support for the Rooming-in and Breastfeeding Act.
5. Excessive legislation that goes beyond international standards may be harmful to the more important interest of the welfare of children and achievement of the UN MDGs.
Based on the erroneous premise that aggressive industry promotion of infant formula is directly responsible for low breastfeeding rates in the Philippines and, by association, malnutrition, these policies proceed to over-regulate the industry beyond international standards.
6. IPNAP members significantly contribute to the Philippine economy, operating several manufacturing plants and also exporting, employing more than 5,000 Filipinos directly, paying more than PhP 17 billion in taxes, procuring over PhP 30 billion in local goods and services, and investing nearly PhP 100 million a year in corporate social responsibility programs aligned with the Millenium Development Goals. In recent years, several IPNAP members have shifted global call center and other business process operations to the Philippines, resulting in more new jobs.
I. BACKGROUND Childhood malnutrition is a serious problem in the Philippines, where over 30% of children nationwide are malnourished. A National Nutrition Survey conducted by the Food and Nutrition Research Institute (FNRI) of the Department of Science and Technology (DOST) showed there was a significant increase in the proportion of children aged 0-5 years who were underweight and under height when comparing data from 2005 to 2008. In a recent workshop conducted by the World Bank in Indonesia, it was reported that the Philippines faces serious under-nutrition in children under five, with alarmingly high prevalence rates well above 20% - and many babies begin life already malnourished, weighing in at less than 2,500 grams at time of birth. The Philippines is likewise behind in accomplishing the United Nations Millenium Development Goals (MDG) with respect to eradicating extreme poverty and hunger (Goal #1), reducing child mortality (Goal #4) and improving maternal health (Goal #5). The Department of Health (DOH) reported that the infant mortality rate is at 25 per 1,000 live births more than twice the MDG goal of 11 per 1,000 live births with 54,058 infant deaths per year. The outlook is far from encouraging, and these studies suggest the situation may be getting worse. Together with other contributing factors such as lack of education, poverty, and social injustice, the World Health Organization (WHO) estimates that: Malnutrition in children is related to inappropriate infant and young child feeding practices. Only 35% of infants less than 6 months of age are exclusively breastfed and complementary feeding practices are far from optimal. Improvement of breastfeeding practices could save annually the lives of about one million children. Complementary feeding along with continual breastfeeding for up to two years or beyond could save the lives of another half a million children.
- WHO website report on the World Health Assembly (WHA), May 2010 These strategies have been echoed for the past 30 years, with WHO and global UNICEF recommendations calling for a comprehensive, multi-sectoral, evidence-based approach to improving infant and young child nutrition, a strategy that is widely accepted by the international community of developed and developing nations. International guidelines and regulations to address malnutrition and improve infant and young child feeding have also been in place since the 1980s. Globally, the promotion of infant nutrition and corresponding regulation of the infant and child nutrition industry is guided by the International Code of Marketing of Breast-milk Substitutes (ICMBS) and applicable provisions of the Codex Alimentarius, together with the aforementioned international policies of the WHO and UNICEF. These policies are further explained in Annex I. The member states of the WHO, in drafting the ICMBS, recognized that breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants, and that breastfeeding is an important aspect of primary health care. 1 At the same time, they acknowledged that:
1. There is a legitimate market for infant formula; 2. It is important for infants to receive appropriate complementary foods at 6 months of age; and 3. Inappropriate feeding practices lead to infant malnutrition, morbidity and mortality in all countries.2 This calls for a responsible dissemination of information through health workers and other appropriate means, and requires that health workers have access to evidence-based, factual information, and must be made fully aware that infant formula produced according to national standards and international guidelines is the only safe and fully-nutritious alternative to breastfeeding. It is their responsibility to assess the individual circumstances of mother and child, and in cases where first age formula should be fed, they must be prepared to instruct users in proper preparation, handling and storage. It is within this framework that IPNAP and its members operate. In addressing the issue of infant and childhood malnutrition, IPNAP and its members believe that breastmilk is best for infants, and supports exclusive breastfeeding up to 6 months. Additionally, in a country like the Philippines where over 30% of the children are still malnourished, IPNAP believes it has a responsibility to promote and encourage appropriate complementary feeding, and the consumption of products with higher nutritional benefits, versus less nutritious alternatives.
II. CHALLENGES IN IMPROVING INFANT AND CHILD NUTRITION1 2
IPNAP and its member companies work within the parameters of Philippine laws and regulations in the industrys approach to improving infant and child nutrition. Currently, the primary law regulating the industry is Executive Order No. 51 3, more commonly known as the Milk Code. Signed into law in 1986 by then President Corazon Aquino, the Milk Code substantially reproduces the provisions of the ICMBS, requires that products be developed in accordance with the Codex Alimentarius, and adopts the same international policy of promoting breast-feeding while recognizing the need to inform the public about proper use of breast-milk substitutes and related products. The Milk Code and other relevant laws and regulations are further explained in Annex II. The Philippines was one of the first countries to substantially adopt the International Code of Marketing of Breastmilk Substitutes (ICMBS) more than twenty years ago and continues to have one of the strictest regulatory environments for the industry in Asia. While several Asian countries have adopted the ICMBS by law in similar manner as the Philippines, most have not. According to International Baby Food Action Network (IBFAN), countries in Asia that have adopted all or most of the provisions are India, Maldives, Nepal, the Philippines and Sri Lanka. Countries which have many of the provisions are Bangladesh, Cambodia, Indonesia, Kyrgyzstan, Mongolia, Pakistan, Tajikistan, and Vietnam. Countries which have only a few provisions are China, Israel and Laos. Those countries which have adopted a voluntary code are Bhutan and Malaysia. Finally, countries that have adopted only some provisions voluntarily include Afghanistan, Brunei, Japan, South Korea, Singapore, Taiwan and Thailand.
IPNAP members adhere to the Milk Code and other stringent national, regional and global standards and laws to ensure the highest levels of quality and safety demanded of one of the most strictly regulated industries in the world. On Safety With the ultimate goal of protecting infants health, the member companies of IPNAP employ nutrition experts and food technologists, and are advised by external nutritionists, pediatricians and scientists. Today the industry is able to produce formulas and complementary food that incorporate and benefit from scientific advances. Infant formulas will never be equivalent to breast milk, but they are an important complement that families use and can if consumed appropriately and correctly contribute to important nutrition and health outcomes for the child, particularly when breast milk is not available. When prepared according to manufacturers instructions, no other breast-milk substitute is as safe and nutritious as commercial infant formula.3
National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplement and Other Related Products.
Quality and safety criteria are communicated by labeling products with culturally appropriate instructions in the local language on proper preparation and handling of infant formulas. To ensure that illiterate mothers are clearly informed about how to correctly prepare infant formula, all labels carry simple descriptive pictures. Because no other breast-milk substitute is as safe, infant formula plays a crucial public health role in fulfilling the nutritional needs of babies whose mothers cannot or choose not to breastfeed. In times of calamity, UN agencies engaged in emergency relief operations provide affected families with generic infant formula manufactured and packaged in accordance with Codex Alimentarius standards as well as ready to use infant formula (RUIF).
On Responsible Advertising The Milk Code and its Revised Implementing Rules and Regulations (RIRR) require approval of an Inter-Agency Committee (IAC) for advertising, promotion or marketing activities for infant formula (0-6 months), breast-milk substitutes, and bottle-fed complementary food. IPNAP member companies comply with this and submit to the IAC all advertising, promotions, marketing materials and activities for approval, including sponsorships and support for medical and scientific meetings. Product labels include proper Important Messages and Warnings on the superiority of breastfeeding, use of the product upon advice of a health worker, instructions for appropriate preparation, and health warnings on improper use of infant formula. Contrary to allegations of heavy advertising, IPNAP members have not advertised their infant formula (0-6 months) since the enactment of the Milk Code in 1986 and in compliance with the WHO ICMBS. Furthermore, IPNAP member companies ceased advertising their bottle-fed products intended for infants 6-12 months of age in the Philippines since the issuance of the RIRR in 2007. And since 2007, the IAC has not approved any advertisement of such products intended for infants and young children 0 36 months of age. For these reasons, none of the IPNAP member companies are among the largest advertisers of milk products in the Philippines. Moreover, their expenditures are nowhere near estimates that are occasionally reported in the Philippine media. Based on this erroneous premise of aggressive advertising, recent efforts have been made to introduce excessive legislation that goes beyond international standards and may be harmful to the more important interest of the welfare of children and achievement of the UN MDGs.
Unfortunately, the issue of infant nutrition has become a somewhat controversial topic in the Philippines leading to a number of wildly erroneous claims being made about the industry that IPNAP represents. In turn, this has led to several potentially counterproductive policies and regulations being implemented or proposed to be so. Based on the erroneous premise that aggressive industry promotion of infant formula is directly responsible for low breastfeeding rates in the Philippines and, by association, malnutrition, these policies proceed to over-regulate the industry and beyond international standards. These local policies include: 1. House Bill No. 3396 (HB 3396) This bill has been introduced in this 15th Congress, and it expands the definition of infant formula, from the internationally accepted bracket of up to six (6) months to include products that continue to meet part of an infants nutritional requirements after the first six (6) months. The proposal has no upper age limit and significantly changes the internationally accepted definition for infant formula. The bill also proposes that all milk products including but not limited to those intended for pregnant women and/or nursing mothers be covered by an advertising ban, effectively regulating food products that are not within the purview of the ICMBS and international policy. 2. Senate Bill No. 2469 (SB 2469) This bill has also been introduced in this 15 th Congress and contains the same expanded definition of infant formula and a similar policy of over-regulation of products not otherwise covered by the ICMBS as that found in HB 3396 . 3. Department of Health (DOH) Guidelines for Physicians on Breastfeeding (2010) before a mother is allowed to bottle-feed, the Guidelines require her to sign an Information Sheet that she has been informed by the attending health personnel of the advantages of breastfeeding. However, the annexed "Information Sheet" provides inaccurate, misleading, and inflammatory statements against formula feeding or any choice other than breastfeeding. This goes against the objective of proper, holistic infant nutrition when a mother - through improper and misleading information - is led to believe she only has two options: breastfeed or compromise your childs health. These regulatory proposals unfortunately arise from a misappreciation of the definition of infant formula and a misunderstanding of the industrys advertising practices. Infant formula properly refers to a breastmilk substitute formulated industrially in accordance with applicable Codex Alimenterius standards, to satisfy the normal nutritional requirements of infants up to between four to six months of age, and adapted to their physiological characteristics.4 Products intended for infants older than 6 months are not infant formula and are properly classified as follow-on milk (for babies 6 months onwards) and growing-up milk (for children 1 year onwards), neither of which should be considered as breast milk substitutes considering that follow-on milk and growing-up milk are correctly intended to supplement the solid food diet, but not breast milk. With respect to advertising, IPNAP underscores the explanation in the preceding section, in that its member companies:4
Section 4(h), E.O. 51.
1. do not and have not advertised infant formula (0-6 months) since 1986 in keeping with the WHO ICMBS and its local adaptation in EO 51; 2. have not been advertising its bottle-fed products intended for infants 6-12 months of age in the Philippines since 2007; and 3. in the past 3 years has not been allowed by the IAC to advertise products intended for infants and young children 0 36 months of age. On evidence of other factors affecting breastfeeding rates In spite of these existing stringent advertising regulations and voluntary advertising withdrawal by IPNAP member companies, breastfeeding rates are not as high as expected. Therefore it is necessary to take a more evidence-based approach to pinpoint the root cause of the problem. To this end, the National Nutrition Survey (NNS) conducted in 2008 by the Department of Science and Technology and its Food and Nutrition Research Institute provides valuable insights. The NNS showed exclusive breastfeeding rates of 45.6% for infants less than two months old and 48% for infants between 2-3 months old. Exclusive breastfeeding rates tapered down to 15.4% for infants 4-5 months old and zero for infants 6-7 months old. The NNS also found that the main reasons mothers stopped breastfeeding were: inadequate milk flow (34.5%), working outside home (25.5%), another pregnancy (9.1%), child refused (7.8%), mother was ill (7.6%), cracked nipple (5.4%), child old enough for weaning (2.8%), child abandoned (1.5%), others (2.9% percent), advised by health personnel/relatives/friends (0.5%) and child not gaining weight (0.1%). Nowhere was it mentioned that milk formula or milk formula advertising was the reason mothers decided to stop breastfeeding. With respect to factors influencing the mothers decision on the kind of milk to give their child, the NNS showed that affordability was the single largest reason at 40.3%, while nutrition was a far second at 13.9%. Advertising influence had a negligible effect, with benefits shown by media garnering a mere 1.3%, and to make child intelligent only 2.2%. In the Philippines, the rate for exclusive breastfeeding in the first six month (34%) has not changed for at least five years despite strong efforts to encourage breastfeeding and the absence of advertising of infant formula. However, the data for mothers who have breastfed their babies at some time in the first six months is 88%. Several conclusions may be gleaned from the results of the survey: 1. Exclusive breastfeeding rates in the first 3 months of life are relatively high. 2. The two primary reasons for declining breastfeeding rates after the 3 rd month appear
to be inadequate milk flow and need to return to work on the part of the mother. 3. Advertising plays no role in the decision to stop breastfeeding. Neither does it significantly influence the mother to choose one kind of milk over another. 4. Nutrition is not a very important criterion when mothers select the kind of milk to give their child. From the foregoing, it is clear that there is an obvious need to educate mothers on the benefits of breastfeeding and proper infant nutrition. The figures also suggest that addressing the problem of working mothers (through lactation stations) and providing support for mothers with milk flow issues (possibly through more milk banks) will do more to improve breastfeeding rates than over-regulation of the industry can. With the limited resources of the government, efforts are best geared toward addressing these direct causes rather than targeting an issue (advertising) that will have little or insignificant effect on improving infant and child nutrition. Notably, and in contrast to the congressional proposals discussed earlier, other bills introduced in this 15th Congress have taken a more holistic approach to addressing the issue of malnutrition by balancing the need for industry regulation in accordance with the ICMBS together with increased efforts to promote the benefits of breastfeeding and educate mothers on proper infant nutrition. In particular, House Bills No. 3525, 3527, 3537, as well as Senate Bill No. 2606, encourage extended breastfeeding, support lactation facilities to address the problem of mothers returning to work, require the dissemination of consistent and objective information on infant and young child nutrition, and responsibly regulate the industry by prohibiting advertisements of infant formula products intended for the crucial period of 0-6 months old.
On the effect of severe restrictions in the Philippines and other countries The fact that nutritional value is not given great emphasis by mothers is also disturbing. Severely restricting the flow of information about product quality through excessive regulation can only make the problem worse. In the Philippines, uninformed mothers have been known to use less nutritious alternatives in feeding their infants, such as rice water, unmodified powdered milk, and even soft drinks and fruit juices, which lack the same nutrients as breastmilk and infant formula. Research studies conducted in countries with extensive marketing restrictions have shown that, when mothers do not exclusively breastfeed, they are often feeding nutritionally inadequate substitutes to younger infants, rather than infant formula. Thus, while efforts to strengthen understanding of the benefits of exclusive breastfeeding are important, the evidence suggests that limitations on infant food marketing have not had any positive influence on feeding decisions and there may have been an adverse affect from limitations on the availability of factual information.
The evidence shows that mothers and caregivers are feeding their infants aged 0-6 months nutritionally inadequate substitutes that adversely affect health. This is done at the expense of either exclusive breastfeeding or the use of infant formula manufactured according to national standards and international guidelines. This result, found in countries with extensive marketing codes, demonstrates that restrictive and expanded Codes do not lead to better nutrition. In Brazil, researchers found that for infants 0-6 months the majority of mothers offered primarily homemade foods (fruit juice, pap or gruel, water with or without sugar, and tea).5 Research in Ghana shows that infants are given homemade foods and condensed milks, and that currently, infant formula may not contribute as much to the supplementary feeding of infants in Ghana within the first two to three months of life.6 Another study covering 20 developing countries found that in 16 countries infant formula was the least reported of all fluids given by mothers to 0-6 month olds. Milk, water, other liquids and solid foods were the leading substitutes for breastfeeding. In 11 of the 16 countries, less than 10% of mothers reported use of infant formula at all.7 Both the Ghana study8 and the one undertaken in Brazil9 indicate that a need to work and the circumstances surrounding their working conditions are the most significant factors in limiting a womans ability to breastfeed. In the Brazil study, doctors stated that the recommendation to use industrialized breast milk substitute infant formulas prior to the sixth month of age of babies is made as a result of requests and complaints from mothers themselves due to the need to work (87%), the belief that breast milk is insufficient and therefore babies cry (65%), and refusal to breastfeed due to fear of esthetic problems (47%).105
Denise Cavallini Cyrillo, Flavia Mori Sarti, Elizabeth Mercier Querido Farina, Jose Alonso Mazzon, Two Decades of the Brazilian Standard for Marketing of Baby Food: are there reasons to celebrate?, Pan American Journal of Public Health, 2009, pg. 136.6
Goski Alabi, Joshua Alabi, Isabella Sagoe Moses, Effects Of The Law On the Marketing of Infant Foods in Ghana, International Business & Economics Research Journal, June 2007, pg. 73.7
Bernadette Marriott, Larry Campbell, Erica Hirsch, David Wilson, Preliminary Data from Demographic and Health Surveys on Infant Feeding in 20 Developing Countries, The Journal of Nutrition Supplement, 2007, pg. 520S.8
Goski Alabi, Joshua Alabi, Isabella Sagoe Moses, Effects Of The Law On the Marketing of Infant Foods in Ghana, International Business & Economics Research Journal, June 2007, pgs. 63, 71, and 73.9
Denise Cavallini Cyrillo, Flavia Mori Sarti, Elizabeth Mercier Querido Farina, Jose Alonso Mazzon, Two Decades of the Brazilian Standard for Marketing of Baby Food: are there reasons to celebrate? Pan American Journal of Public Health, 2009, pgs. 136, 137, and 139.10
Denise Cavallini Cyrillo, Flavia Mori Sarti, Elizabeth Mercier Querido Farina, Jose Alonso Mazzon, Two Decades of the Brazilian Standard for Marketing of Baby Food: are there reasons to celebrate? Pan American Journal of Public Health, 2009, pg. 137.
Again, while the results may lead to different conclusions, in no case do the statistical results show that marketing, advertising or promotional activities are a major factor in the decision to breastfeed or not. Given the lack of direct evidence linking the Milk Code to increased rates of breastfeeding and/or continued breastfeeding, extension of the Milk Code to cover complementary feeding, as proposed in HB 7022, would not address the real causes of poor feeding behavior and would divert attention from interventions that could make a real difference in addressing malnutrition.
On the need for a multi-sectoral approach IPNAP supports WHO and UNICEF global policy recommendations that call for a comprehensive, multi-sectoral, evidence-based approach to improving infant and young child nutrition. Since IPNAP believes breast-milk is best for infants, IPNAP supports programs that allow mothers to optimize infant nutrition even when outside their homes. One broadly accepted reason that the numbers of women who exclusively breastfeed their children drops off so dramatically after two months is simply because the mother must return to work. IPNAP believes that industry, the government and responsible NGOs should work together to develop and implement policies that would make it easier for mothers to continue breastfeeding once they return from maternity leave and to help mothers working in informal jobs that do not even allow maternity leave. In practice this would mean including lactation stations in offices, factories and other places of work, as the new Expanded Breastfeeding Act of 2010 (Republic Act 10028) requires. IPNAP members have set an example in this regard by providing sufficient and proper lactation stations at our facilities. In some countries, the government itself institutes programs to improve infant and child nutrition. In the United States for example, the US federal government provides infant formula to 8 million persons under the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). In addition to nutritious foods, the WIC program also provides nutrition counseling and referrals to health care and social services for infants and children up to age five. Notably, since the U.S. voted against the ICMBS, infant formula and young child nutrition products are not as heavily regulated there as in the Philippines and elsewhere. Young children products are promoted without requiring prior government approval. The bottom line is that focusing solely on prohibiting advertising and informationdissemination activities that seek to educate mothers on appropriate infant feeding a component that, according to the NNS, does not even significantly factor in to the decision not to breastfeed will not solve the problem of malnutrition and may even exacerbate it.
IV. CORPORATE SOCIAL RESPONSIBILITY OF IPNAP As explained above, all IPNAP member companies are committed to the development of multi-sectoral efforts designed to improve infant nutrition in the Philippines.
There have been many examples of successful cooperation programs between IPNAP member companies and government agencies in dealing with malnutrition, school dropout rates, metabolic disorders, and other health issues, and IPNAPs commitment includes both substantial monetary contributions and the sharing of employees time and expertise. For example, IPNAP member companies work with various arms of the Philippines Government including the Department of Education, the Department of Social Welfare and Development, and the Department of Health to develop and implement programs that concretely improve the quality of life for disadvantaged children. In one case this means providing monetary support to ensure at-risk children can remain in secondary education; in another a member firm dispenses free nutritional products to malnourished children which are provided in specialized feeding centers, while parents are also given educational assistance in proper nutrition, healthy food preparation, cooking and basic financial planning. Additionally, IPNAP member firms sponsor continuing educational programs for doctors and medical technicians about proper breastfeeding practices and the use of infant formula. In total, the industry invested almost PhP 100 million in its CSR programs in 2009. Since 1986, with the adoption of the Milk Code, its RIRR and the DOH Administrative Order, IPNAP members have been forced to abandon a number of projects that were positively contributing to the educational and nutritional development of the people of the Philippines. One member company, for example, had to dramatically reduce its financial commitment to improving the knowledge of healthcare professionals through sponsorship of Continuing Medical Education as it could have been perceived to have conflicted with the new DOH regulations.
V. ECONOMIC CONTRIBUTION The five member companies of IPNAP contribute significantly to the Philippine economy through their investments in manufacturing, call centers/BPO, technology transfer, logistics, and distribution. They are important investors, employers, taxpayers, and purchasers of local goods and services. These companies, committed to the development of the country, have been contributing to that development for nearly a century. IPNAP member firms have been in the Philippines for a total of 284 years or an average of 57 years each. The oldest (Nestle) began operations in 1911 and the most recent (Fonterra) in 1995. Their collective contribution to the Philippine economy consists of: (a) investments of more than US$400 million including three manufacturing plants; (b) direct employment of more than 5,100 persons, (c) considerable indirect employment through local procurement of goods and services of more than PhP 30 billion annually, (d) public revenue payments of over PhP 17 billion annually for payroll, corporate, VAT, local and import taxes and fees, and (e) global outsourcing into the Philippines of customer relations and business processing services. The industry welcomes the statements of President Aquino that his administration 13
will assure a level playing field for investors and policy stability. This should mean that, at the least, the Department of Health and the Congress will take sufficient time to fully understand the vital role of the industry in promoting infant and young child nutrition, consulting routinely with industry stakeholders on implementation of the Milk Code and malnutrition programs. At the most, it will mean recognizing that the industry complies with rules adopted by the Philippines in 1986 and that new restrictions are not only unnecessary but my be harmful to the more important interest of the welfare of children and achievement of the UN Millennium Development Goals. IPNAP is fully committed to the public private partnership policy of the Aquino Administration. The Philippine Government has allowed the development of a dynamic and competitive market for nutrition products. The infant and child nutrition sectors are particularly so with dozens of brands offering a wide range of choices to consumers. This high level of competition has resulted in the products in the Philippines being at the low end of the pricing of such products in Asian countries. Though the rises in infant formula prices that have occurred have drawn criticism in the Philippine press, IPNAP members have endeavored to limit price rises. Through the last two years, IPNAP members have incurred increased costs due to a number of significant inflationary pressures, unfavorable exchange rates, compliance with more restrictive legal requirements, and the near continual rise in the price of raw milk. Most of this has been absorbed. Though some would claim that infant nutrition companies have raised prices in the past in order to pay for excessive advertising campaigns is manifestly not the case. As explained above, IPNAP members have for some years eliminated advertising of products for infants below the age of 12 months, and have greatly reduced their total advertising spending.
VI. CONCLUSIONS The Philippines is still a long way from achieving the UN Millenium Development Goals on poverty and health, and is struggling to eradicate or at least significantly reduce childhood malnutrition. To this end, IPNAP member companies products make a major contribution to fighting malnutrition in the Philippines and elsewhere, especially after 6 months when exclusive breast milk feeding is no longer adequate for the nutritional needs of an infant. While certainly not the equivalent of natural breast milk, they are the best that modern science can produce, are rigorously tested, and are designed to enhance and improve the health of infants and young children. IPNAP members products are scientifically proven and manufactured to meet international standards and approved by the Department of Health and its Food and Drug Administration. The products are completely safe when prepared in accordance with the manufacturers instructions. When mothers cannot or choose not to breastfeed, these products are among the best complimentary foods to natural breast milk. Choosing a method for infant or young child feeding is ultimately the parents
decision. However, in making this decision, parents should rely on the advice of physicians, nutritionists, and other health professionals who are extensively trained in this area and that will take into account the unique nutritional needs of each individual. Unfortunately, as shown by the most recent Philippine Government surveys, restrictions on the scientifically proven nutritional products of IPNAP member firms have hindered rather than helped the goal of reducing infant and child malnutrition. Disagreements over the interpretation of the ICMBS have also contributed to the dilemma. In an article by JS Forsythe, he observes that "[t]he controversy that has bedeviled the (ICMBS) for 30 years is almost entirely limited to matters of interpretation and compliance. However, because these issues have been so protracted it has led to an atmosphere of mistrust that has now become embedded between key agencies. Moreover, there has been considerable debate on how healthcare workers, including paediatricians, should relate to milk formula companies. It is, therefore, timely to reflect on the vision of those who initiated the code and to embrace the original spirit of the code which is that participation and cooperation are essential if activities aimed at the improvement of maternal, infant and child nutrition are to be successful. To enable this to happen, it is proposed that measures are taken to replace current hostilities with effective national and international governance."11 IPNAP ultimately believes that promoting a culture of breastfeeding coupled with objective and consistent information dissemination on optimal and appropriate complementary feeding practices for infants and young children - given their specific circumstances will drastically improve infant and young child nutrition by enabling mothers to make an educated choice on nutritious feeding methods and products for their children. IPNAP and its member companies remain committed to these goals and will continue to be a dedicated and active partner with the Philippine Government, playing a constructive role in upholding international standards for infant and child nutrition. ANNEX I
International Regulation of the Infant and Young Child Nutrition Industry Globally, the promotion of infant nutrition and corresponding regulation of the industry is guided by the International Code of Marketing of Breast-milk Substitutes (ICMBS), applicable provisions of the Codex Alimentarius, and international policies of the WHO and UNICEF.11
International code of marketing of breast-milk substitutesthree decades later time for hostilities to be replaced by effective national and international governance", by JS Forsyth, Archives of Disease in Childhood. The article describes the Code, the history of its creation, and goes into details about the problems linked with its implementation and monitoring.
1. International Code of Marketing of Breast-milk Substitutes (ICMBS)
Adopted in 1981 by the World Health Assembly, it aims to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.12 The ICMBS regulates infant formula for infants up to between four to six months of age.13
2. Codex Alimentarius
Provides internationally recognized standards, codes of practice, guidelines and other recommendations relating to food production, food safety, and consumer protection, including providing guidance on the nutritional and technical aspects of the production of formulated supplementary food for older infants and young children.
3. Global Strategy for Infant and Young Child Feeding (GSIYF)
Jointly developed by the WHO and UNICEF in 2003, the GSIYF recognized that [a]ppropriate complementary feeding depends on accurate information and skilled support from the family, community and health care system. Inadequate knowledge about appropriate foods and feeding practices is often a greater determinant of malnutrition than the lack of food.14
Annex II Current Philippine Laws, Rules and Regulations affecting Infant Nutrition 1. Executive Order No. 51 (1986)
National Code of Marketing of Breastmilk Substitutes, Breastmilk Supplement and Other Related Products, more commonly known as the Philippine Milk Code. Almost a verbatim reproduction of the International Code of Marketing of Breastmilk Substitutes adopted by the World Health Assembly. Contributes to the provision of safe and adequate nutrition for infants by protecting and promoting breastfeeding and ensuring proper use of breast-milk substitutes and breast-milk supplements when necessary, on the basis of adequate information and through appropriate marketing and distribution.
Article 1, ICMBS. Article 3, ICMBS. 14 Article 14, GSIYF.
Requires approval of an Inter-Agency Committee (IAC) for advertising, promotion or marketing activities for infant formula (0-6 months), breast-milk substitutes, and complementary food within the scope of the Milk Code. The IAC is composed of the Department of Health, Department of Trade and Industry, Department of Justice and Department of Social Welfare and Development
2. Revised Implementing Rules and Regulations of Executive Order No. 51 (2006)
Challenged before the Supreme Court of the Philippines for going beyond the scope of Executive Order No. 51, resulting in the nullification of provisions that absolutely prohibited advertising, promotions, marketing, or sponsorships of infant formula, breast-milk substitutes and other related products. IPNAP complies with these rules and submits to the IAC all advertising, promotions, marketing materials and activities for its approval, including sponsorships and support for medical and scientific meetings. IPNAP also complies with the requirement that labels include proper Important Messages and Warnings on the superiority of breastfeeding, use of the product upon advice of a health worker, instructions for appropriate preparation, and health warnings on improper use of infant formula.
3. Rooming-in and Breastfeeding Act (2010)
Expanded Breastfeeding Promotion Act of 2009 (the law was approved on March 16, 2010). Adopts rooming-in as a national policy to encourage, protect and support the practice of breastfeeding and provides specific measures that would present opportunities for mothers to continue expressing their milk and/or breastfeeding their infant or young child. Provides tax incentives for private health and non-health establishments, where expenses incurred in complying with the Act shall be deductible expenses for income tax purposes up to twice the actual amount incurred. Mandates all health and non-health facilities, establishments or institutions to establish lactation stations and take measures to prevent any direct or indirect form of promotion, marketing, and/or sales of infant formula and/or breastmilk substitutes within the lactation stations, or in any event or circumstances which may be conducive to the same. The Department of Health is likewise mandated to produce and make available
relevant information and programs on maternal nutrition and proper nourishment in preparation for successful and sustainable breastfeeding, which should be disseminated to all city, municipal and barangay health centers.
Provides continuing education and training of health workers and health institutions on lactation management and stipulates that information materials shall be given to all health workers involved in maternal and infant care health institutions. Provides for the integration of breastfeeding education in the curricula.
4. Department of Health (DOH) Guidelines for Physicians on Breastfeeding (2010)
Issued on May 14, 2010 by the DOH to guide physicians in promoting, protecting and supporting breastfeeding. An Information Sheet annexed to the guidelines portrays formula milk as dangerous and even toxic. It fails to qualify that formula milk is produced in accordance with the standards set in the Codex Alimentarius as mandated by the WHO Global Strategy for Infant and Young Child Feeding. Many of the items in the Information Sheet that are presented as factual and scientific are not evidenced-based and are misleading, inaccurate and speculative. The statements are alarmist and one sided, and do not provide unbiased information from which mothers can make an informed decision.