Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694819519141.pdf (Australia)
Submission no.
307 AUTHORISED: 17/4/07 QUEENSLAND HEALTH SUBMISSION To the Australian Parliament House of Representatives Standing Committee on Health and Ageing INQUIRY INTO BREASTFEEDING Queensland Health Submission - Inquiry into breastfeeding INQUIRY INTO BREASTFEEDING QUEENSLAND HEALTH SUBMISSION INTRODUCTION Queensland Health welcomes the opportunity to provide the following submission in response to the Australian Parliament House of Representatives Standing Committee on Health and Ageing Inquiry into Breastfeeding on the following terms of reference.
• The extent of the health benefits of breastfeeding; • Evaluate the impact of marketing of breast milk substitutes on breastfeeding rates and, in particular, in disadvantaged, Aboriginal and Torres Strait Islander and remote communities; • The potential short and long term impact on the health of Australians of increasing the rate of breastfeeding; Initiatives to encourage breastfeeding; • • Examine the effectiveness of current measures to promote breastfeeding; and • The impact of breastfeeding on the sustainability of Australia's health system.
The Queensland Health submission on the Inquiry into Breastfeeding has been written by the Public Health Nutritionists from the Health Promotion Unit of the Population Health Branch in consultation with the public health and community nutrition Early Life Priority Area Action Plan Reference Group and the Child and Young People's Health Unit.

The submission has been approved by the Chief Health Officer of Queensland Health.
RECOMMENDATIONS The Queensland Health submission recommends that the Commonwealth Government: 1.

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Establish a national committee with representation from all State and Territory Governments to coordinate a strategic approach to promoting and supporting breastfeeding in Australia; Review the Marketing in Australia of Infant Formula: Manufacturers and Importers (MAIF) Agreement to capture all elements of the WHO Code; Fund and mandate the Baby Friendly Hospital Initiative (BFHI) in all Australian maternity hospitals; and Establish a national monitoring system based on the principles and standard indicators outlined in Towards a national system for monitoring breastfeeding in Australia (Commonwealth Department of Health and Ageing, 2001).
Queensland Health Submission - Inquiry into breastfeeding RESPONSE TO SPECIFIC ISSUES IDENTIFIED IN THE TERMS OF REFERENCE OF THE INQUIRY INTO BREASTFEEDING 1.

THE EXTENT OF THE HEALTH BENEFITS OF BREASTFEEDING Breastfeeding is the physiological norm for feeding infants and scientific evidence supports the view that breastfeeding is superior to feeding infants with breast milk substitutes.
Breast milk contains all the nutrients needed for healthy physical and cognitive growth and development until six months of age (NHMRC, 2003).
Research has shown that breastfeeding not only enhances the infant's immune system but also reduces the risks or severity of a range of preventable illnesses and chronic diseases throughout the life cycle, including: - physiological reflux - pyloric stenosis - gastrointestinal tract infections and diseases - necrotising enterocolitis in premature infants - inflammatory bowel disease - coeliac disease - respiratory illness - asthma - otitis media - bacteria meningitis - atopic dermatitis (eczema) among infants with a family history of atopy - urinary tract infection - some childhood cancers - dental caries development in infancy and childhood - obesity - diabetes - some risk factors for cardiovascular disease in adulthood.
(References NHMRC, 2003; QH, 2003; WHO, 2006).

The psychological benefits of breastfeeding should not be overlooked.

Evidence suggests that breastfeeding is an important factor in the bonding between mother and infant which can infer secure infant emotional attachment (QH, 2003) and decrease maternal depression (Mezzacappa, 2004).

Breastfeeding has also associated with higher childhood intelligence (NHMRC, 2003).

Breastfeeding has proven health benefits for the mother too.
These include: - increased fertility control - increased likelihood of postpartum weight loss - assisting involution of the uterus - reduced risk of developing breast cancer - reduced risk of developing ovarian cancer - reduced risk of developing type 2 diabetes in mothers with a history of gestational diabetes.
(Reference QH, 2003; WHO, 2006) Queensland Health Submission - Inquiry into breastfeeding Conclusion Queensland Health (QH) believes all Australian Jurisdictions should work together to improve the healthy growth and development of infants and children by promoting and supporting the WHO and NHMRC recommendations of exclusive breastfeeding for the first six months of life, the introduction of appropriate solid food around six months of age and continued breastfeeding for at least twelve months (QH, 2003; WHO, 2002 ; NHMRC, 2003).
The association between optimal infant nutrition and improved health outcomes for both infant and mother makes the promotion and support of breastfeeding and the appropriate introduction of solid food one of the most important primary prevention measures available.

QH supports further research into better understanding the health benefits of breastfeeding, particularly the association with the prevention of overweight, obesity and chronic disease in adulthood.
References: National Health and Medical Research Council (2003) Dietary Guidelines for Children and Adolescents in Australia, Commonwealth of Australia: Canberra Queensland Health (2003) Optimal Infant Nutrition: Evidence-Based Guidelines 2003-2008, Queensland Health, Brisbane.

World Health Organisation (2006) The International Code of Marketing of Breast- Milk Substitutes: Frequently Asked Questions, WHO, Geneva.

Mezzacappa ES.

Breastfeeding and maternal stress response and health.
Nutr Rev 2004; 62(7 p t l ): 261-268.

World Health Organisation (2002) Infant and Young Child Nutrition: Global Strategy on Infant and Young Child Feeding, WHO, Fifty-fifth World Health Assembly, April.

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EVALUATE THE IMPACT OF MARKETING OF BREAST MILK SUBSTITUTES ON BREASTFEEDING RATES AND, IN PARTICULAR, IN DISADVANTAGED, ABORIGINAL AND TORRES STRAIT ISLANDER AND REMOTE COMMUNITIES.
The WHO International Code for the Marketing of Breast milk Substitutes (WHO Code) is a set of recommendations to regulate the marketing of breast milk substitutes, feeding bottles and teats.

The Code aims to contribute "to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, 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."
The code advocates that babies be breastfed and that breast milk substitutes should be available when needed, but not be promoted.

Queensland Health Submission - Inquiry into breastfeeding Australia voted to adopt the WHO Code at the 34th session of the World Health Assembly in 1981.

Governments of Member States decide on the legislation, regulations and/or other suitable measures to give effect to the Code ie what, if any, actions they would take in response to a violation of the Code.
As not all of the Code is legislated in Australia, industry self-regulation in accordance with the Code is encouraged by the Government.

The Marketing in Australia of Infant Formula: Manufacturers and Importers (MAIF) Agreement was voluntarily signed in 1992 by the larger infant formula manufacturers in Australia.

The MAIF Agreement covers the marketing of infant formulas, but does not include follow-on ("toddler") milk formulas, other breast milk substitutes, feeding bottles and teats.
Retailers of infant formula are also excluded from the MAIF Agreement, which is where the majority of consumer complaints lie (DOHA 2004).

Whilst the Advisory Panel on the Marketing in Australia of Infant Formula (APMAIF) was established to monitor compliance with and advise the Government on the MAIF Agreement, the MAIF Agreement is not legally binding.

While Queensland Health endorses the WHO Code and the MAIF Agreement, it would like to see legislation strengthened to enforce all of the WHO Code.
Important aspects of the WHO Code not currently covered by the MAIF Agreement include follow-on ("toddler") milk formulas targeting children over 12 months of age, the supply of free and subsidised supplies of breast milk substitutes in the health care system, guidelines for the marketing of bottles and teats, and a code of marketing for retailers including pharmacies and supermarkets.

Queensland Health would also like the MAIF Agreement to be mandatory for all infant formula companies.
The marketing of follow-on milk formula is not consistent with the WHO and NHMRC recommendations to encourage breastfeeding beyond 12 months of age and does not encourage child progressing to regular family foods, which includes cows milk, from 12 months.

These expensive products have the potential to reduce breastfeeding duration in addition to misleading parents to believe that such products are superior to normal family foods, which may result in unnecessary expenditure and financial burden.
Aboriginal and Torres Strait Islander and remote communities Queensland Health believes that in Aboriginal and Torres Strait Islander communities, correct information regarding breast milk substitutes should be provided to families.

The inappropriate marketing of breast milk substitutes in these communities is sometimes accompanied by misinformation, making the promotion of these products highly 'successful' and commonly used.
Anecdotal evidence from health practitioners in Queensland and the Northern Territory suggests the regular use of alternate breast milk substitutes to infant formula in Aboriginal and Torres Strait Islander communities.

This includes cow's milk and soft drink via infant bottles in infants less than 12 months of age and highlights the need for additional strategies to promote breastfeeding and regulate the WHO code in its entirety in these communities.
Queensland Health Submission - Inquiry into breastfeeding References: World Health Organisation (1981) International Code for the Marketing of Breast milk Substitutes, World Health Organisation, Geneva World Health Organisation (2006) The International Code of Marketing of Breast- Milk Substitutes: Frequently Asked Questions, WHO, Geneva.
Australian Government Department of Health and Ageing (2004) Annual Report of the Advisory Panel on the Marketing in Australia of Infant Formula: July 2002 - June 2003, APMAIF, Canberra.

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THE POTENTIAL SHORT AND LONG TERM IMPACT ON THE HEALTH OF AUSTRALIANS OF INCREASING THE RATE OF BREASTFEEDING A number of leading health problems in Australia have been identified as being potentially prevented by breastfeeding.
Among these are gastrointestinal illnesses, respiratory illnesses, asthma, SIDS and some cancers.

More importantly the health burden of chronic diseases such as diabetes, heart disease and obesity and the potential health gain-cost savings at a population level through improving breastfeeding rates can not be ignored.

NHMRC has set breastfeeding objectives of an initiation rate in excess of 90% and 80% for breastfeeding at six months.
There is currently no national coordinated monitoring of breastfeeding rates in Australia which makes it difficult to ascertain the impact of breastfeeding on health.

A review of all the state and territory perinatal forms reveal that data collection around breastfeeding is inconsistent, with some states and territories not monitoring at all.

Recent studies in a number of states confirm that rates in Australia continue to struggle to meet NHMRC recommendations.
In the Infant and Child Nutrition in Queensland 2003 survey (Qld Health, 2005) breastfeeding initiation rate was 91.8% but there was a sharp fall in the first month after birth, followed by a steady decline.

By six months of age, just over half of infants were receiving any breast milk and by twelve months this had dropped to around one third.

Similar rates were recorded in the 2003-04 data from the NSW Population Health Survey and the 2002-04 data from the Perth Infant Feeding Study.
More alarming is the data from the 2003 Queensland survey on infant formula consumption and the introduction of solid food.

Regular consumption of infant formula was commenced before four weeks of age in 23% of children, with 70% of children ever given infant formula regularly (ie at least once a day).

Regular consumption of solid foods commenced before four months of age (after 4 months was recommended at the time) in 18% of children.
NHMRC recommend that infants be exclusively breastfed for the first six months.

Queensland Health Submission - Inquiry into breastfeeding If the NHMRC infant feeding recommendations were achieved, this would be expected to lead to significant positive short and long term impacts on the health of all Australians, as outlined above.

Improvements in population breastfeeding practices regarding duration and exclusivity to date have been small.
More coordinated strategies including a national monitoring and surveillance system with standard indicators of breastfeeding is recommended and long overdue (Webb et al, 2001).

References: Binns C and Graham K (2005) Project report of the Perth Infant Feeding Study Mark II (2002 - 2204) for the Australian Government Department of Health and Ageing, Australian Government Department of Health and Ageing, Canberra.
Queensland Health: Gabriel R, Pollard G, Suleman G, Coyne T and Vidgen H (2003) Infant and child nutrition in Queensland, Queensland Health, Brisbane.

Webb K, Marks G, Lund-Adams M, Rutishauser IHE and Abraham B (2001) Towards a national system for monitoring breastfeeding in Australia, Australian Government Department of Health and Ageing, Canberra.

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INITIATIVES TO ENCOURAGE BREASTFEEDING The results from the Infant and Child Nutrition in Queensland 2003 survey (QH 2005) may give an insight into identifying potential interventions to encourage breastfeeding.

Maternal prenatal intention to breastfeed was consistently the strongest association found with actual breastfeeding practice in this survey.
Mothers who had decided before giving birth to breastfeed were nearly 19 times more likely to initiate breastfeeding, nearly 5 times more likely to breastfeed for six months and 13 times more likely to breastfeed for 12 months than mothers who had not made that decision prior to the birth.

When only demographic variables were examined, mothers with a higher education level were more likely to initiate breastfeeding.
Older mothers (over 30 years) were more likely to initiate breastfeeding and more likely to continue breastfeeding than younger mothers.

The provision of information regarding post-discharge feeding support and advice was positively associated with breastfeeding to six months.

This simple practice which could have significant impact on the median duration of breastfeeding requires good quality information to be consistently provided.
Families and friends were identified as major sources of breastfeeding advice.

Other studies have identified the father's support for breastfeeding as important (Scott and Binns, 1998).

This highlights the need to include the wider community in any education programs.

The supportive role of community health workers and the Queensland Health Submission - Inquiry into breastfeeding Australian Breastfeeding Association (ABA) in assisting and increasing the duration of breastfeeding was also acknowledged.
Mothers who experience problems with breastfeeding had some of the lowest mean durations of breastfeeding.

The prevention and successful management of breastfeeding problems is vital to increasing breastfeeding duration.

The high usage of infant formula from an early age and the early introduction of solids in the survey, highlight the need to address these influential factors on breastfeeding rates and duration.

At an individual level, interventions to encourage breastfeeding need to start prenatally.
Early postnatal support regarding breastfeeding management including practical skills and problem shooting is essential to increasing breastfeeding duration.

This should include both peer and professional support.

The hospital environment has been identified as an important factor in supporting breastfeeding.
The Baby Friendly Hospital Initiative (BFHI) which is an international project developed jointly by WHO and UNICEF aims to educate and support mothers through the provision of well trained staff and an environment conducive to breastfeeding.

This includes following the WHO Code to prevent the marketing and usage of breast milk substitutes, bottles and teats.

Increasing breastfeeding duration involves addressing the home environment.
Breastfeeding and parenting skills in addition to wider community supports that make breastfeeding acceptable outside the home are required.

This includes access to public breastfeeding facilities and breastfeeding friendly venues.

Social marketing such as the joint ABA and Queensland Health campaign targeting breastfeeding duration is an activity aimed at the wider community.

Work commitments were also identified in the Queensland study as a factor affecting breastfeeding duration.
Public workplace policies and environments should be created to establish and continue breastfeeding.

Queensland Health has a Work and Breastfeeding Policy ((QH, 2006).

Conditions around maternity leave should also address to support the successful establishment of breastfeeding.

In addition to national coordinated monitoring, creating a supportive social and physical environment as well as improving individual knowledge and skills are the fundamental keys to improving breastfeeding rates and duration.
Initiatives reflect those previously captured in the National Breastfeeding Strategy 1996 - 2001 (DOHA, 2001).

Ongoing coordination and commitment to promoting and supporting breastfeeding is essential.

References: Australian Government Department of Health and Ageing (2001) National Breastfeeding Strategy Summary Report, DOHA, Canberra.
Queensland Health Submission - Inquiry into breastfeeding Queensland Health: Gabriel R, Pollard G, Suleman G, Coyne T and Vidgen H (2005) Infant and child nutrition in Queensland, Queensland Health, Brisbane.

Queensland Health (2006) Work and Breastfeeding Policy, Queensland Health, Brisbane (http://www.health.qld.gov.au/industrial re!ations/Masters/SECT2/Irm2 5 22 accessed 27 Feb 2007) UNICEF.

Baby-Friendly Hospital Initiative and programme manual.

Geneva, 1992.

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Geneva, 1992.

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EXAMINE THE EFFECTIVENESS OF CURRENT MEASURES TO PROMOTE BREASTFEEDING Evidence around the effectiveness of current measures should be based on sound evaluation of project work.

Published literature on successful interventions to promote breastfeeding is limited.

While Queensland Health acknowledges the health benefits of breastfeeding and supports initiatives that aim to increase duration and rates, much of the work to date is yet to be fully evaluated.
The multistrategic work plan reflects the difficulty in assessing direct breastfeeding outcomes.
Current breastfeeding initiatives within Queensland Health include: Optimal Infant Nutrition: Evidence-Based Guidelines 2003 - 2008: This multistrategic plan aims to improve the healthy growth and development of infant and children by promoting and supporting the WHO and NHMRC infant feeding recommendations of exclusive breastfeeding for the first six months of life, the introduction of appropriate solid food around six months of age and continued breastfeeding for at least twelve months.
The plan identifies priority population groups in addition to outlining partnerships and key actions required to influence the provision of optimal infant nutrition.

The guidelines aim to achieve by 2008: - breastfeeding rates at discharge from hospital of at least 90%, - exclusive breastfeeding at 3 months of at least 60%, and - exclusive breastfeeding at six months of at least 50%.
Work and Breastfeeding Policy: Queensland health supports staff wishing to continue breastfeeding on returning to work by: - allowing paid lactation breaks of up to 1 hour per day - providing facilities suitable for breastfeeding or expressing milk - providing supportive management to assist the needs of both the staff and their work commitments.
Baby Friendly Hospital Initiative (BFHI): The Baby Friendly Hospital Initiative (BFHI) is an international project developed and launched jointly by WHO and UNICEF in 1991.

It aims to educate and support mothers through the provision of an environment conducive to breastfeeding.
Queensland Health Submission - Inquiry into breastfeeding Implementation of the "Ten Steps to Successful Breastfeeding" includes the provision of a breastfeeding policy, suitably trained staff and supporting the recommendations of the MAIF Agreement.

There are currently 58 BFHI accredited hospitals in Australia and 8 within Queensland.

Queensland Health is currently developing strategies to market and streamline the accreditation process to assist institutions to become and remain accredited.
This includes the recent revision of the state perinatal form for 2007/08 to incorporate infant feeding information that captures BFHI reporting requirements.

Personal Health Record: The personal health record is given to each mother who births in Queensland.

It provides information on developmental milestones, growth standards and immunisation.

In 2005 the Child Health Information booklet was added to this publication.
It includes information on successful breastfeeding, managing breastfeeding problems along with details of breastfeeding support agencies.

To date the booklet has been warmly received and has been translated into fact sheet form in five different languages on the Queensland Health website.

Growing Strong Growing Strong is a series of resources aimed at supporting health workers to better engage with Aboriginal and Torres Strait Islander mothers and families.
Evaluation has demonstrated that the training and resources improve the health workers' confidence and knowledge.

Resources target low literacy clients.

They provide information on healthy eating during the antenatal period and the early years, in addition to addressing breastfeeding and management of common problems.

Evaluation of Growing Strong in 2005 found that the resource was widely used Queensland Health in addition to a number of other States and Territories.
The format and information included in the resource was found to be conducive to the education of the Aboriginal and Torres Strait Islander target group.

Social marketing The recent expansion of social marketing within the health sector to influence social awareness to encourage healthy behaviour reflects the growing weight of evidence supporting this strategy.
Queensland Health has commissioned the services of the Australian Breastfeeding Association (ABA) to develop messages around improving the duration and rates of breastfeeding in Queensland.

The media campaign developed to promote increased duration of breastfeeding in 2006 has since been considered for use in Western Australia.

References: Queensland Health (2003) Optimal Infant Nutrition: Evidence-Based Guidelines 2003-2008, Queensland Health, Brisbane.
(http://www.health.qld.gov.au/publications/childhealth/Optimal_InfantNutrition.pdf accessed 27 Feb 2007) Queensland Health Submission - Inquiry into breastfeeding 10 Queensland Health (2006) Work and Breastfeeding Policy, Queensland Health, Brisbane (http://www.health.qld.gov.au/industrial relations/Masters/SECT2/Irm2 5 22 accessed 27 Feb 2007) Queensland Health (2006) Growing Strong: Feeding You and Your Baby Evaluation Report 2006, Queensland Health, Brisbane.
(http://www.health.qld.gov.aU/phs/Documents/shpu/31524.pdf accessed 27 Feb 2007) 6.

THE IMPACT OF BREASTFEEDING ON THE SUSTAINABILITY OF AUSTRALIA'S HEALTH SYSTEM Breastfeeding will have a significant impact on the sustainability of Australia's health system in direct and indirect ways.

In addition to direct health benefit, improved nutrition through breastfeeding brings major economic and social benefits.
Improving breastfeeding rates would have a positive impact on the long term sustainability of Australia's health system by providing protection against obesity, serious infant infections and a range of chronic disease for both infants and mothers.

Queensland Health Submission - Inquiry into breastfeeding 11