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What is Codex, and Why is it Important?

You’re a lactation professional working with families to help solve breastfeeding/chestfeeding problems. Why should you care about something called the Codex Alimentarius Commission?

Your focus may be to help families reach their breastfeeding/chestfeeding goals. Think about some of the things that get in the way of that – poor information and advice from other health professionals and from families and friends, physiological challenges, and most certainly easy availability and heavy promotion of breastmilk substitutes. When breastmilk substitutes need to be used, you want to be sure that they meet basic standards, and that they are not labeled and marketed in such a way as to further discourage breastfeeding. That’s where international food standards come in, and the Codex Alimentarius Commission (Codex) is the global body that sets those standards.

The Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) are the parent bodies of the Codex Alimentarius Commission. The members of Codex are member countries, with 188 member countries plus the European Union. Non-governmental organizations (NGOs) can apply for observer status with Codex and participate in meetings, offering expert opinion and information. ILCA is officially recognized as an observer for Codex, and has been participating and contributing to these meetings for 16 years; Maryse Arendt has been the primary spokesperson for ILCA at these meetings, and Lisa Mandell, ILCA’s Global Advocacy Adviser, joined her this year.

Codex has more than 15 different committees that work in specific areas. The one that sets standards for infant formulas, follow up formulas, and growing up milks is the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). This committee usually meets once a year. The committee did not meet in 2020 due to the pandemic; they met this year virtually, and ILCA was there to represent you and your concerns on this important world stage.

The work of Codex and its committees is long-term and follows a complex process. It is often influenced more by trade issues than public health, frequently involves controversies and compromises, and eventually results in food standards that are adopted by the member countries. This year’s virtual meeting of CCNFSDU occurred during the last week of November 2021, and we are excited to report on some positive decisions made at this meeting.

Three standards are currently being developed by CCNFSDU:

— a revision of the standard for follow up formula (FUF) for older infants (defined as 6-12 months)

— a standard for growing up milk (GUM), identified by Codex as drink or product for young children with added nutrients, or drink for young children (defined as 12-36 months)

— a standard for ready-to-use therapeutic foods (RUTF), which are provided to children 6-59 months with severe acute malnutrition

In the community of lactation care providers and breastfeeding supporters, many of us are frustrated just by the existence of FUFs and GUMs. These products were developed by industry as a way to get around the International Code of Marketing of Breastmilk Substitutes (the Code). Regular infant formula is adequate for the first year, with no need for a special formula for 6-12 months; and growing up milks are highly-processed food products that are not needed at all; both FUF and GUM are considered breastmilk substitutes by WHO.

However, these products exist, and as such it is important to set standards for them. One of the biggest issues for ILCA and others concerned about protecting breastfeeding was about sweet taste of the product and  whether flavourings could be included in FUF and GUM. The concern about use of sweet taste and flavourings is that these products replace the liquid part of a diet and are considered breastmilk substitutes; allowing flavourings could cause infants and children to develop a preference for sweet taste, which could have a negative impact on food choices and lifelong health; it could also cause infants and children, and their caregivers, to prefer these products and increase their use. ILCA strongly supported not allowing flavourings in either product. Country delegations have the first chance to comment on any issue, and all countries who spoke supported no flavourings in FUF. At least 13 country delegations spoke for no flavourings in either FUF or GUM, and 7 countries supported allowing flavourings for GUM, stating that it was not a breastmilk substitute (BMS), that these older children (12-36 months) are already exposed to a wide variety of other foods and flavors; and that flavourings should not impact sweet taste. The Chair concluded that no flavourings would be allowed in FUF. Much more discussion occurred, with more countries stating either their support or disagreement with allowing flavourings in GUM. Delegates from WHO and UNICEF stated clearly that these products for children aged 12-36 months are breastmilk substitutes, and are considered not necessary in the diet; they opposed allowing flavourings. The Chair suggested a compromise solution for GUM, allowing flavourings but adding a footnote that national and/or regional authorities may restrict or prohibit the use of the listed flavourings.

WIN: No flavourings allowed in FUF 

Partial WIN: Flavourings allowed in GUM, but countries may restrict or prohibit use of flavourings.

Another big concern of ILCA and others at this meeting was the definition to be used for “growing up milk,” for ages 12-36 months. The previous meeting ended with the following definition: “Drink/product for young children with added nutrients or Drink for young children means a product manufactured for use as a liquid part of the diversified diet of young children [which may contribute to the nutritional needs of young children].” In considerable discussion on whether these products should be defined as breastmilk substitutes, a compromise was to include the following footnote: “In some countries these products are regulated as breast-milk substitutes.” This was despite WHO guidance, adopted by the World Health Assembly (WHA), that all FUF and GUM should be considered breastmilk substitutes.  The text in brackets above was left to be discussed at this meeting. The arguments against including this text are that it does not need to be included; and that the World Health Assembly has agreed that these products are unnecessary and including this text suggests that these products can play an important role in the diets of young children, which they do not. Considerable discussion among countries and observers, including some objections to including “with added nutrients” in the name options, resulted in a decision to delete the bracketed text. Additional discussion over the name options led to a decision to offer four name possibilities from which countries can choose one: drink for young children with added nutrients, product for young children with added nutrients, drink for young children, or product for young children.

WIN: Definition of GUM will NOT include the phrase “which may contribute to the nutritional needs of young children”

Another important agenda item at this meeting was finalizing the preamble for Ready-to-use Therapeutic Foods (RUTF), for children aged 6-59 months suffering severe acute malnutrition (SAM). The preamble to a standard sets the stage for what the standard covers. Thanks to the suggestion of a representative from UNICEF, and with the support of country delegations, ILCA, and other observers, it was agreed to add to the preamble the following clause, identifying that interventions for SAM should occur: “within an appropriately designed programme that promotes continuation of breastfeeding, appropriate transition to nutritious family food and psycho-social support for recovery.” Additionally, the adopted preamble concludes that use of RUTF “does not preclude other dietary options including the use of locally based foods. RUTF is not for general retail sale.”

WIN: Preamble for RUTF will stress the importance of programmes to support continued breastfeeding. Additionally, RUTF is not for general retail sale and thus cannot be promoted.

The CCNFSDU meeting covered many other topics (composition of FUF and GUM, nutrient reference values for children, and much more). The next meeting of CCNFSDU (tentatively planned for early 2023) will include finalizing the preambles for FUF and GUM, which we hope will clearly reference the Code. This is important work that ultimately serves to protect consumers. For our population of families with infants and young children, the contributions of ILCA representatives, along with the important voices of other observer organizations and many country delegations, will help to protect and support breastfeeding, and infant and child health.

For more information on Codex and other Codex committees, see:

Arendt, M. (2021). Advocacy at Work During the Codex Committee on Food Labelling Meeting. Journal of Human Lactation, 089033442110570. https://doi.org/10.1177/08903344211057083

Arendt, M. (2018). Codex Alimentarius: What Has It To Do With Me? Journal of Human Lactation, 089033441879465. https://doi.org/10.1177/0890334418794658

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Six Tips For Preparing To Breastfeed

Your baby has not yet arrived, but you know you plan to breast- or chestfeed. What are the best ways to prepare? Below, International Board Certified Lactation Consultants® (IBCLCs®) share six top tips on how to get ready for the journey ahead. Taking these steps now will maximize your chances of meeting your breastfeeding goals.

Spend time with someone who is breastfeeding.

There is no substitute for seeing the process up close and personal before your baby arrives. “Go and see and be around other nursing mothers,” advises Roxanna Farnsworth, IBCLC. Look in your circle of friends and family for parents with nursing babies who may be willing to share their experience. Or, seek out a local mother-to-mother breastfeeding group—they welcome pregnant and prospective parents, and you will see lots of babies breastfeeding.

Know what normal looks like.

Misconceptions about infant feeding and sleep are common. If you expect your baby to sleep long stretches and eat every three hours, you may panic when he or she does not conform to this idea. You may worry that your baby is not getting enough milk or that there is some other problem. Healthy newborn babies nurse a lot, and unpredictably. It is important to know what to expect. “Focus on learning about what normal newborn breastfeeding behaviors are!” says Lynette Beard, IBCLC. “They are very different from that beautiful five-month-old you may have seen breastfeeding.”

Engage your partner.

Research shows that the messages we get from those close to us dramatically impact our confidence in our ability to breastfeed. If you have a partner, take the time before your baby arrives to seek their support. “Talk to your partner about what breastfeeding means to you and what you think might be helpful from them (and not),” suggests Farnsworth. “Often the partner (if one is involved) says or does things that hurt the breastfeeding person without realizing it. In my class, we practice how the partner can share and show love by asking what the mom needs in the moment (versus giving advice or dismissive comments).”

Learn the basics.

While birth classes may be your major focus leading up to your baby’s arrival, set aside some time to educate yourself about breastfeeding. Gaining knowledge will boost your confidence. “My advice? Take a prenatal breastfeeding class and set up a prenatal consult with an IBCLC if you can,” Bryna Sampey, IBCLC, says. One key skill to learn: hand expression. “Learn and practice hand expression so you can get good at it by the time you need it,” Sampey adds. “It is really beneficial.”

Protect the first hours.

Once your baby is in your arms, plan for breastfeeding to be your only priority for the first hours of life. As tempting as it is to invite friends and family to hold and admire the new arrival, this is a critical time for privacy. “Ask about your hospital or birth center’s policy on skin-to-skin and the hours [immediately] after birth,” recommends Chasta Carson Hite, IBCLC. “Plan for uninterrupted skin-to-skin and breastfeeding for a minimum of one to two hours or longer if needed. Prepare your family that you will be limiting visitors during this time.”

Set up support.

Most importantly, have your lactation support team in place before you need them. Locate the names and phone numbers of local support group leaders and IBCLCs, and keep this information handy. “Having contact information of a lactation consultant and breastfeeding support in your community [will] support your personal breastfeeding goals, so you can have your best experience possible,” says Angie Hilliard, IBCLC. Preparing and educating yourself is key, but knowing you are not alone on this journey is the best peace of mind.

Find an IBCLC to help with your questions about lactation and employment or your other breastfeeding questions.

An International Board Certified Lactation Consultant® (IBCLC®) is a healthcare professional who specializes in the clinical management of breastfeeding. 

An IBCLC can reassure you when breastfeeding and lactation are going well, and provide information and support to help prevent and manage common concerns. Learn more and find an IBCLC in your community here.

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