Tragedies of Infant Formula and Sub-optimal Breastfeeding

Tragedies of Infant Formula and

Sub-optimal Breastfeeding

Published by

Bangladesh Paediatric Association

Plot # 7/3C, Barabag, Section # 2

Mirpur, Dhaka-1216

e-mail: [email protected]

Web: www.bpabd.org

M Q-K Talukder

Nazneen Akhter Banu

Khurshid Talukder

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First Published : April 2014

Child Nutrition and IYCF sub-Committee Printed at

Asian Colour Printing

BANGLADESH PAEDIATRIC ASSOCIATION
130, DIT Extension Road, Fakirerpool

2014 Dhaka-1000, Bangladesh

 CHILD NUTRITION AND IYCF SUB-COMMITTEE
Tragedies of Infant Formula and
OF

Sub-optimal Breastfeeding BANGLADESH PAEDIATRIC ASSOCIATION (BPA)

Chairman : Professor M Q-K Talukder

Vice Chairperson : Professor Soofia Khatoon
Secretary : Dr. Khurshid Talukder
EDITORS Members : Professor M R Khan
Dr M Q-K Talukder
Professor Hosne Ara Begum
MBBS (Dak), DIP.NUTR (Lond), DCH (Glasg) Professor A S M Bazlul Karim
MRCP (UK) FCPS(BD) FRCP(Edin) PhD (Edin) Professor M A K Azad Chowdhury
Dr Nazneen Akhter Banu
Professor Nazmun Nahar
MBBS (Dak) FCPS (BD) Professor Ekhlasur Rahman
Professor Shafiqur Rahman
Professor Shahida Akhter
Dr Khurshid Talukder
MBBS(Dak) DCH (Glasg) MRCP(UK)
Professor Abid Hossain Mollah
Professor Abdul Hannan
Professor Mesbah Uddin Ahmed
Professor Chowdhury Habibur Rasul
Dr. Nazneen Akhter Banu

Child Nutrition and IYCF sub-Committee

BANGLADESH PAEDIATRIC ASSOCIATION

2014
Foreword Foreword

I am pleased that Bangladesh Paediatric Association is publishing this

The publication on 'Tragedies of Infant Formula and sub-optimal breast
important document on the Tragedies of Infant Formula and Sub-optimal
feeding' by the Bangladesh Paediatric Association reminds us how
breastfeeding. The booklet is authored by Paeditricians who are involved
unnecessarily children are still dying because of improper breastfeeding and
clinically in the management of children with severe acute malnutrition
complementary feeding practices. In the last 3 decades Paediatricians in
(SAM) and in the protection, promotion and support of Infant and Young
the country have worked hard with the Ministry of Health and Family
Child Feeding (IYCF) Practices. The illustrated cases are the real life
Welfare, UN agencies and other stake holders to curb the violation of the
situation where due to wrong feeding practices, these unfortunate new born,
international and the national breast milk substitute (BMS) code.
infants and children have either died or became the victims of morbidities
Unfortunately the milk companies unabatedly ignored the essence of the with various illnesses and poor quality of life. One of the causes of these

code which is aimed to save children's lives and instead lured the SAM cases is the intake of dilute and contaminated infant formula which

professionals and policy makers to violate the code. As a result mothers understandably happened as a result of aggressive marketing of breast milk

have opted for formula feeding the consequences of which are illustrated in substitutes by the milk companies in the country.

the tale of 27 unfortunate children in this booklet. Morality and justice dictate
Obstetricians are primarily involved in the management of infant feeding
that this man-made plight of our children with severe acute malnutrition sooner after the birth of a baby. Mothers should be counseled on proper

(SAM) be stopped. breastfeeding practices. We should make sure that the new born is on

breastfeeding within 1 hour of birth. This early initiation of breastfeeding will

I agree with the authors that the country now has knowledgeable and skilled
help the establishment of exclusive successful lactation.
human resources to scale up proper breastfeeding and complementary

feeding practices. The Ministry of Health and Family Welfare (MOHFW) can, I also strongly recommend that all Obstetricians and other medical professionals

know and put into practice the new law titled 'The Breast Milk Substitutes, Infant
through the recently launched National Nutrition Services (NNS) develop
Foods, Complementary Infant foods Manufactured commercially and the
mother support groups to help mothers to establish successful breastfeeding
Accessories Related thereto (Regulation of Marketing) Act, 2013'.
and complementary feeding. At the same time the new strong BMS law

needs strict implementation with the collaboration of all stakeholders. And finally I urge the OGSB to join hands with the BPA in their advocacy

work with the MOHFW to promote appropriate IYCF promotion on two

This publication should help not only Bangladesh but other countries which
important government public health platforms. The first is the postnatal visit
also plan to prevent SAM and other forms of malnutrition through
within 24 hours of birth - now a part of the job description of every FWA and
programme implementation of correct Infant and Young Child Feeding
female HA - which research has shown can prevent faulty positioning and
(IYCF) practices. attachment climbing exponentially by 7 days of age. And the second is the

EPI, where over 93% of mothers are bringing their babies to Health

Assistants before 6 months of age and 80% at 16-18 months of age for

immunization. These are both excellent opportunities to promote exclusive

breastfeeding in infants less than 6 month of age and a minimum acceptable

Professor (Dr.) M R Khan
diet in 6-23 month old.
Paediatrician and National Professor

I wish a wider readership and effective application of this publication.

Professor (Dr.) Shahla Khatun

Obstetrician and Gynaecologist

National Professor
Comments Publisher's Note

The evidence collected on effects of feeding breastmilk substitute and failure The Bangladesh Paediatric Association (BPA) has, throughout its history, been

to promote, protect and support of breastfeeding appropriate complementary intimately associated with the struggle for the promotion, protection and

feeding is eye opening to all parents and health professionals of Bangladesh. support of breastfeeding in this country. And thus the BPA, above all, feels the

This work by the Bangladesh Pediatric Association is highly commendable. pain of that struggle as it confronts the latest infant and young child feeding

This work by three members of both the BPA and the board of Trustees (BOT) (IYCF) figures from the 2012 Food Security and Nutrition Surveillance Project

of the BBF is highly commended. Children die 14 times more with formula (FSNSP) report1. This comprehensive and nationally representative study

feeding compared to exclusive breastfeeding. Bangladesh Breastfeeding shows that exclusive breastfeeding rate under six months of age has become

Foundation shares the comments and reinforces the implementation of New stagnant at 45%, that 1st hour breastfeeding is also static at 48%, that

BMS Law, 2013 of Bangladesh to minimize the use of Breastfeeding prelacteal feeding continues in half our newborns, that infant formula feeding

Substitute and save the children of Bangladesh as well as to ensure their and bottlefeeding are both on the rise and that just over a third of 6-23 month

healthy life. old babies are fed a minimum acceptable diet2 (MAD). Is it, thus, any wonder

that the same report tells us that under 5 wasting (WHZ<-2) is 11%, stunting

(HAZ<-2) 38% and underweight (WAZ<-2) 34% - intolerable figures for a

country congratulating itself on its rapid progress to middle income country

status.

Dr. S K Roy This booklet is therefore a timely reminder from BPA's Child Nutrition and
Chairperson
IYCF Sub-committee that the fight for establishing good IYCF practices is not
Bangladesh Breastfeeding Foundation
over. The National Nutrition Service of the MOHFW has started an extensive

programme of training front line government health workers to promote and

support mothers in their IYCF practices. Where these workers will actually

access the 8 million or so mothers with under two children to counsel them is,

however, unclear.

There have been suggestions from a number of quarters that the EPI

programme, accessed by over 93% of mothers before 6 months and by about

80% at 16-18 months, is the ideal opportunity to support mothers in their effort

to follow recommended IYCF practices. The EPI is the government's flagship

public health programme and there needs to be a new level of advocacy to

policymakers and EPI managers to allow IYCF promotion to be grafted on to

this most successful platform. The Executive Committee of the BPA is

committed to this advocacy and we urge our members to persevere with

dedication in the day-to-day struggle for IYCF, wherever they may be. This will

mean that extra minute of counselling with the bottle feeding mother of an

infant with diarrhoea on the ward round or appointing lactation nurses in our

workplace would do justice to the vulnerable who have come to us for help.

The other role of the BPA in this struggle is our advocacy for the new BMS

Code that has been strengthened in 2013 to provide a law, which will

transform the regulation of marketing of these dangerous products in our

country. The new law covers not only infant formula but also processed foods

targeted to all young children under 5 and thus will prevent the terrible
exploitation of this vulnerable population by commercial food companies. The Tragedies of Infant Formula and
BPA's advocacy role for this Law will be important because the law now warns Sub-optimal Breastfeeding
of serious consequences for all health professionals if they take gifts or any
form of support for attending meetings or educational courses from the
producers of these products. Our members need to be made aware of this
new changed environment, especially with regard to meeting funding, so that
we actively shun association with these companies. CONTENTS

● Preface 01
● Acknowledgements 02
Prof. Md. Ruhul Amin Prof. Mohammod Shahidullah
● Tale of 27 unfortunate malnourished children 03
President Secretary General An urgent call to action 30
Bangladesh Paediatric Association (BPA) Bangladesh Paediatric Association (BPA)
●

1. Released in March 2014 by the Bangladesh Bureau of Statistics, Helen Keller International and
the James P Grant School of Public Health of the BRAC Institute of Global Health.
2. A child between 6-23 months of age is said to have a minimum acceptable diet (MAD) when, in
the previous 24 hours, in addition to breastmilk, they've been fed
a. from at least four of WHO defined seven food groups (1. Eggs 2. Vitamin A rich fruit and
vegetables 3. Legumes 4. Dairy 5. Other fruit and vegetables 6. Flesh foods and 7.
Starches)
a. at least twice a day for 6-8 month olds and at least three times a day for 9-23 month olds
Preface Acknowledgements
This small book focuses on the disastrous consequences of powder milk

feeding mostly in the name of infant formula instead of breastfeeding. Detailed

histories of illness of these children are not described but without exception
The editors acknowledge the contribution and help of the following

these unfortunate children were fed dilute infant formula or other forms of colleagues in the compilation of this document. Special thanks to

powder milk and in a few cases dilute cow 's milk. those who supplied the clinical photographs.

Search of literature shows that globally infant feeding practices had never

been right. In particular since the 1860s cow's milk in powder form began to

be produced in Germany. Henri Nestle produced powder milk in 1867. By Professor Md. Ruhul Amin

1890, 29 brands of powder milk were marketed in Europe. Instead of

Professor Mohammod Shahidullah
breastmilk, infants were fed water reconstituted whole powder milk in bottles.

In England the infant mortality rate was around 200 per 1,000 live births at the Professor Chowdhury Ali Kawsar
beginning of the 20th century. The major contributing factors of this high infant

mortality were very poor breastfeeding rates and improper feeding practices.
Professor Hosne Ara Begum

During the second world war in 1939 Cicely Williams, a British Pediatrician, Professor A R M Luthful Kabir

gave a lecture at the Singapore Rotary club meeting where she said "If your
Professor Soofia Khatoon
lives were embittered as mine is, by seeing day after day this massacre of the

innocents by unsuitable feeding, then I believe you would feel as I do that Professor M A K Azad Chowdhury
misguided propaganda on infant feeding should be punished as the most

criminal form of sedition, and that those deaths should be regarded as Professor Abid Hossain Mollah

murder." What Cicely Williams observed 70 years ago is still happening in

Professor Syeda Afroza
Bangladesh today. About 200 children under 5 years of age are dying every

day from malnutrition as an ultimate consequence of infant formula feeding Professor Shahida Akhter
instead of proper breastfeeding. This is most unfortunate during a time when

knowledge, skill and resources are available to meet the recommendations of

Professor Shafi Ahmed

the universal Infant and Young Child Feeding (IYCF) practices. These
Dr. S K Roy
recommendations are i) to initiate breastfeeding within one hour of birth; ii) to

breastfeed exclusively for 6 months; iii) to begin home based complementary Dr. Wahida Khanam
food from 6 months and iv) to continue breastfeeding for 2 years and beyond.
Dr. Nazma Begum
Basically two actions are required to successfully breastfeed the child. Firstly,

the mother should be helped to initiate breastfeeding soon after the child is Dr. Iffat Ara Shamsad

born. This should be done within one hour of birth. Secondly, no infant formula
Dr. Aditi Sarker
or any form of powder milk should be given to the newborn and infant. In this

regard, we should adhere to the 2013 Bangladesh Breastmilk Substitute Dr. Shonjoy
(BMS) law. Exclusive breastfeeding rates have increased from a stagnant

42% in the previous decade to 64% according to the 2011 Bangladesh

Dr. Shumon

Demographic Health Service data. This is very encouraging and there are
Dr. Shehrin Kabir
indications that this should rise to over 90% very soon if current stakeholder

commitments and efforts continue. Ms. Khurshid Jahan

The cases described in this booklet have been arranged by age of the

unfortunate children described. This will provide insight into the consequences

of wrong feeding practices from the newborn to 3 years of age.

 Case-2: Severe wasting from feeding with dilute formula.
Tale of 27 Unfortunate Malnourished

Children

Case-1: The consequence of not breastfeeding at 1

month of age.

An one month male infant presented with failure to gain weight and

diarrhoea. His father was a day laborer. The baby was bottle fed with
A 1 month 19 day old boy, was delivered by LUCS at Khanpur sadar
powdered rice since birth. He was suffering from Severe Acute
hospital, Narayanganj. Mother said that the baby did not get breast
Malnutrition (SAM) with acute watery diarrhoea.
milk after her delivery so they introduced dilute infant formula since

birth. The baby has signs of severe wasting.

03 04
 Case-4: What does the future hold for this child?
Case-3: Tragic death of twins from severe acute

malnutrition, pneumonia and sepsis.

A 3 month old male child, weighing 2 kg presented with several

episodes of loose motion & failure to thrive. Child was fed dilute

formula milk along with breast milk upto 2 months. Then mother gave

rice powder along with formula milk. Daily energy deficit was 150

Kcal. Mother was a house wife and father a rickshaw puller. Monthly

income of the family was 5000 Taka. He was admitted into hospital

and diagnosed as SAM with dermatoses, severe anaemia and acute

watery diarrhoea.

Twins with birth weight 800 and 650 g more than doubled to 1.7 kg

by 3 months of age on exclusive breastfeeding. Then formula feeding

was started and the babies died of pneumonia and sepsis.

05 06
Case-5: Brothers with malnutrition from bottle feeding Case-6: Consequences of an infant whose breastfeeding
dilute powder milk. was stopped and fed dilute infant formula.

Case-6: A 4 month old boy weighing 4 kg was diagnosed as SAM with

bronchopneumonia. Father was a day laborer, mother housewife.

Monthly income 7000 taka. Baby was exclusively breastfed for 28

A 3 month old boy was admitted with SAM along with his 13 month
days only. Then dilute infant formula was given, breastfeeding
old brother. Bottle feeding, dilute powder milk, no breast feeding,
discontinued. Baby was fighting for his life at Mitford Hospital at the
poor family, faulty feeding practices were the underlying cause of
time of reporting.
malnutrition in these siblings.

07 08
Case-7: Blindness in an infant at 4 months of age. Case-8: This infant suffers malnutrition as he was bottle
fed with powder milk.

Case-8: This 4 months old girl is suffering from SAM. Father had left
her after delivery as he wanted a boy. Mother started to work at
This infant was never breastfed. He was given rice gruel, dilute infant
someones house. Baby was cared for by her maternal grandmother.
formula and cow's milk. Baby became blind by 4 months from
She was fed dilute infant formula in a bottle with a teat.
xerophthalmia (Vitamin A deficiency).

09 10
Case-9: Powder milk and bottle: infant killer.
Case-10: What should we do with these killer powder

milk and bottles?

A boy of 5 months weighing 3.8 kg was diagnosed as SAM (Oedematous

Malnutrition) with bronchopneumonia. Father is a day laborer with

A 5 month old male infant weighing 4.5 kg was admitted with
monthly income of 3000 taka. Boy was never exclusively breastfed. He
oedema, peeling of skin and reluctance to feed. Father was a day

laborer. He was never exclusively breasfed and was fed with dilute was fed with dilute formula in bottle. At the time of taking photograph,

infant formula in bottle. He was diagnosed as oedematous baby was receiving treatment in the hospital. See on the bed side locker,

malnutrition with septicaemia. The baby died. infant formula tin and the bottle that were brought by mother.

11 12
Case-11: Wrong feeding practice made the infant lifeless Case-12: SAM following dilute formula feeding.

with malnutrition.

This girl of 6 months presented with oedema and progressive pallor.

A 5 month old boy weighs 6.1 kg having puffy face, edema of both Father is unemployed. Mother is a garments worker. Baby was fed with

legs and dermatitis. He was exclusively breastfed for one and half dilute infant formula. She was admitted to Dhaka Medical College

months only, then rice powder with dilute cow's milk added. Mother is Hospital where she was diagnosed as SAM (oedematous malnutrition)

a day labourer, father left them when the mother was pregnant. with nutritional anemia (severe pallor) and bronchopneumonia.

13 14
Case-13: What a tragedy of a 7 month old with SAM ! Case-14: Maid in a home lured to use infant formula as a

result SAM in an infant.

A 8½ mo old female infant weighing 6.7 kg presented with swelling of

whole body. Mother was a maid in a house where the landlady feeds

her 3 month old baby with infant formula. Inspired with that, this

mother started formula. She fed the baby dilute milk. Baby was in a

A 7 month old boy with oedematous malnutrition (Kwashiorkor). It private hospital for 12 days and the bill was 3650 taka. Family was

was the result of feeding dilute infant formula. able to pay 1400 taka only.

15 16
Case-15: Another infant dies from SAM. Case-16: No powder milk, I need home cooked complementary

food.

A boy of 10 months weighing 3.75 kg presented with progressive loss

A 10 month old girl weighing 4.5 kg presented with cough and failure to
of weight, fever and cough. Father was a day laborer, monthly income
gain weight. Father was a rickshaw puller. She was exclusively breastfed
4000 taka. Baby was exclusively breastfed for 6 months. Then diluted
for 1 month. Then dilute infant formula was given. She was diagnosed as
infant formula in 1:3 dilution was given and was not given home
Severe Acute Malnutrition (SAM) with bronchopneumonia. After admission
based complementary food. He was diagnosed as Severe Acute
she suddenly developed subcutaneous emphysema (arrow) & severe
Malnutrition (SAM) with broncho-pneumonia. Baby was receiving
respiratory distress. X ray showed pneumatocoele and pneumo-
treatment in hospital at the time of reporting.
mediastinum (arrow). The child died.

17 18
Case-17: Total injustice from improper feeding. Case-18: Why does this child have SAM?

An 11 month old boy, weight 4.9kg, length 63cm, MUAC 115 mm. A boy of 1 year weighing 5 kg presented with loose motion and

Mother initiated breastfeeding after birth, he was exclusively swelling of whole body with peeling of skin. Mother was a Maid and

breastfed for only 1 month and then dilute infant formula milk added. father a rickshaw puller. He was fed with dilute formula since birth.

Complementary feeding started with occasional rice and suzi, no Complementary feeding was not given. He was diagnosed as SAM

animal foods were given. He was diagnosed as Severe Acute (Oedematous Malnutrition) with acute watery Diarrhoea. Boy

Malnutrition with severe anemia. recovered with treatment at hospital.

19 20
 Case-20: Swollen cheeks and malnutrition.
Case-19: Powder milk fed with a soft drink bottle.

1 year old with severe malnutrition with swollen cheeks . Baby is fed

dilute infant formula with occasional plain rice.

A 12 month old girl weighs 4 kg. She was fed formula and dilute

cow's milk. Mother fed the baby with an empty soft drink bottle. The

infant developed Severe Acute Malnutrition and several episodes of

diarrhoea.

21 22
Case-21: SAM from chronic insufficient food. Case-22: A helpless child with SAM.

A 16 month old female child weighing 8.2 kg presented with swelling

of whole body. She was diagnosed as SAM (oedematous

malnutrition) with bronchopneumonia. Skin changes of kwashiorkor is

obvious. Her father was unemployed and mother was a primary

school teacher. Upto the age of 40 days, she was on breastfeeding,

then dilute milk formula was added. She was given 400 g pack of

milk powder in the first month and then 2 packs of 400 g in next

month. Full cream milk was started in dilute form. Since 6 months, A 16 month old helpless boy with severe wasting and skin ulceration.

she was on mashed rice only and occasional khichuri (rice and pulse Faulty feeding and dilute powder milk feeding were the causes of

only). malnutrition.

23 24
Case-23: 18 month old child weighting 3.5 kg ! Case-23: Powder milk, SAM and blindness.

A 2 year old boy weighing 6 kg presented with failure to gain weight

An 18 month old boy weighing 3.5 kg was diagnosed as SAM with and inability to see in the dark. Mother was a maid, father
bronchopneumonia. His father was a rickshaw puller. The baby was unemployed. He was exclusively breastfed for 2 months. Then dilute
only breastfed for 10 months. Then dilute formula, cow's milk and
infant formula, dilute cow's milk and subsequently rice with dilute dal
rice powder with occasional khichuri was given. He was severely
was given. Bitot's spot was found in the right sclera and conjunctivitis
wasted and severely stunted. Child recovered with treatment.
in the left. He was diagnosed as SAM with xerophthamia.

25 26
Case-25: SAM is an everyday event in this country. Case-26: As though he does not have any wish to live.

A 3 year 2 month old male child presented with weight loss, oedema

and dermatosis. This was his 3rd admission in the last 5 months. His

father was a truck helper. He was given breast milk up to the age of 3

months and later dilute milk formula along with breast feeding. Family

food was given from one year of age. He was severely underweight (wt

6.8 kg, Z-sore-6.9), severely stunted (ht. 77 cm, Z- score -5.1) and

severely wasted (Z-score-5.6). Gastric lavage showed AFB. He was

Another 2 year old boy at Dhaka Medical College Hospital diagnosed diagnosed as SAM (Oedematous malnutrition), with dermatosis and
as oedematous malnutrition with dermatosis (Kwashiorkor). The child disseminated tuberculosis. He was discharged after 3 weeks with anti
was fed with dilute powder milk. TB therapy.

27 28
Case-27: Powder milk, improper complementary feeding An urgent call to action

SAM and xerophthalmia.

The tragedies that have befallen the children described in this booklet

are man made. Ignorance and apathy must be forsaken at all levels.

The Ministry of Health and Family Welfare (MOHFW) should prioritise

investment in the promotion, protection and support of recommended

IYCF practices which, as a preventive measure, will save lives, promote

health, improve nutrition and contribute to prevent non-communicable

chronic diseases. It is heartening that the Government has passed a

new law in Parliament in September 2013 entitled 'Breastmilk

Substitutes, Child Foods, Complementary Foods manufactured

commercially and the accessories related thereto'. A strict

implementation of this law will undoubtedly increase exclusive

breastfeeding rates and facilitate proper complementary feeding. As a

result the present nutritional status will improve. Severely malnourished

children should be managed with relactation and homemade energy

dense foods. Any recommendation for the use of ready to use

therapeutic food (RUTF) will go against the BMS act and will be subject

to legal action.

Paediatricians and Obstetricians, as a priority, should help to establish

and maintain all newborns, infants and young children on proper

breastfeeding. At the same time Paediatricians should manage severely

malnourished children with relactation and home made energy dense

foods. The health care providers in the community must be trained to

relactate and demonstrate energy dense food preparation at home for

the management of severe acute malnutrition. There should be zero

tolerance for conflicts of interest in child nutrition.

The present trend of commercial approaches to child nutrition is

unfortunate and regrettable for all children in the world. UN, bilateral and

donor agencies' endorsements on use of commercial products has done

untold damage to global child nutrition. These products will be a

deterrent to child nutrition and should be a non-starter. The roles of UN

agencies are critical not only to identify countries health issues but also

to discuss with the Government, professionals and relevant stakeholders

to address the problems. National and international NGOs should

carefully complement Government Health and Nutrition programmes

rather than embarking on any innovative measures.

A boy (31/2 years age) with xerophthalmia (Vitamin A deficiency) at

Dhaka Medical College Hospital. He was fed dilute formula and Prevention of malnutrition must be the key approach and this is possible

cow's milk earlier, then dilute tinned complementary food and in all our countries through the full implementation of the WHO/UNICEF

occasional plain rice. He had severe wasting, severe stunting and recommended global IYCF strategy.

corneal ulceration.

29 30