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Aggressive marketing of formula and other milks reduces breastfeeding rates
Commercial promotion of breastmilk substitutes seeks to undermine women’s confidence in their ability to breastfeed. The multi-million dollar marketing budgets of baby foods company compete aggresively with breastfeeding and cancel out all efforts of breastfeeding promotion. Global sales of baby foods climbed to USD58 billion in 2014 (Euromonitor) and if current marketing trends continue, are expected to reach USD70.6 billion in 2019 (Lancet). The baby food industry is the fastest growing food sector with powerful economic force that creates an uneven playing field for other players in infant and young child feeding. 
 
The decline in breastfeeding increases infant malnutrition
The impact of promotion is a decline in breastfeeding rates. Associated with this decline, and corresponding increase in formula-feeding, is an increase in malnutrition, morbidity and mortality among infants and young children, in developed and developing countries. Decades of research confirm the link between infants being fed formula or baby milks and increased risk of infant illness and death.
  • The odds of death in the first six months were 21 % lower for breastfed infants compared with formula-fed infants. (Ip et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Apr.)
  • A controlled study by the National Health Strategy found children fed artificial milk for at least three months were 12-31% more likely to suffer serious chronic illness. (National Health Strategy (Australia) (1992). Enough to make you sick. Canberra, Department of Health, Housing and Community Services.)
  • Infants who received powdered milk were at 4.2 times increased risk of death from diarrhea compared with infants who did not receive artificial milk. (Victora et al. Infant feeding and deaths due to diarrhea. A case-control study. American journal of Epidemiology (1989), 129,5.)
  • Excess Health Risks (%) Associated with Not Breastfeeding
    Acute ear infection (otitis media) - 100%
    Diarrhea and vomiting (gastrointestinal infection) - 178%
    Hospitalization for lower respiratory tract diseases in the first year - 257%
    (Office of the Surgeon General (US); Centers for Disease Control and Prevention (US); Office on Women's Health (US). The Surgeon General's Call to Action to Support Breastfeeding. Rockville (MD): Office of the Surgeon General (US); 2011.

Recent findings continue to support the case for breastfeeding
On 29 January 2016, the Lancet Breastfeeding Series was launched. The Series evaluated global breastfeeding levels, trends and inequalities, in addition to the short and long term consequences for both mother and child and underscores the importance of policy interventions to increase and sustain breastfeeding levels. Estimates published in the new Series reveal that

  • Increasing breastfeeding to near-universal levels could save more than 800 000 lives every year, the majority being children under 6 months. 
  • Nearly half of all diarrhoeal diseases and one-third of all respiratory infections in children in low- and middle-income countries could be prevented with increased rates of breastfeeding.
  • Children who are breastfeed perform better in intelligence tests, are less likely to be overweight or obese, and less prone to diabetes later in life.
  • Mothers who breastfeed also reduce their risk of developing breast and ovarian cancers. At current breastfeeding rates, an estimated 20 000 deaths from breast cancer are prevented and an additional 20 000 could be saved if rates improved.
  • The new Series presents a strong economic case for investing in promoting and protecting breastfeeding worldwide.Global economic losses from lower cognition associated with not breastfeeding reached more than US$ 300 billion in 2012, equivalent to 0.49% of the world’s gross national income. Boosting breastfeeding rates for infants below 6 months of age to 90% in Brazil, China, and the United States of America, and to 45% in the United Kingdom would cut treatment costs of common childhood illnesses, such as pneumonia, diarrhoea and asthma, and save healthcare systems at least US$ 2.45 billion in the United States, US$ 29.5 million in the United Kingdom, US$ 223.6 million in China, and US$ 6.0 million in Brazil.
 
Implementing the Code protects breastfeeding
By adopting the International Code and subsequent resolutions into law, governments have reduced blatant and visible forms of advertising and sampling of products. However, more subtle forms of commercial promotion still continue, especially in online and web-based promotions. In countries without Code-based laws and enforcement, baby milk advertising, promotions, free samples to mothers and the health care sector and event sponsorship remain unchecked. The impact on breastfeeding rates is devastating.

The Code

Aim of the Code
Adopted by the World Health Assembly (WHA) in 1981, the International Code of Marketing of Breastmilk Substitutes aims to contribute to the provision of safe and adequate nutrition for infants by the protection and promotion of breastfeeding and the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.
 
Scope of the Code
The Code applies to all products that are marketed or otherwise represented as a partial or total replacement for breastmilk.  It is aligned with WHO infant feeding recommendations of exclusive breastfeeding for the first six months, at which time complementary foods can be introduced, with breastfeeding continuing for two years or beyond.  Breastmilk substitutes include foods and beverages, such as
  • infant formula
  • follow-on milks
  • growing-up milks and other milk products
  • cereals, vegetable mixes, baby juices and teas, when these products are marketed or otherwise represented for use before six months.
The Code also applies to feeding bottles and teats.
 
The Code and subsequent resolutions contain the following provisions

Advertising: No advertising of above products to the public. No nutrition or health claims on products.

Samples: No free samples to mothers, their families or health care workers.

Health care facilities: No promotion of products, i.e. no product displays, posters, calendars or distribution of promotional materials. No use of mothercraft nurses or similar company-paid personnel.

Health care workers: No gifts or samples to health care workers. Financial support and incentives should not create conflicts of interest.

Supplies: No free or low-cost supplies of breastmilk substitutes to any part of the health care system.

Information: Information and educational materials must explain the benefits of breastfeeding, the health hazards associated with bottle feeding and the costs of using infant formula. Product information for health professionals must be factual and scientific.

Labels: Product labels must clearly state the superiority of breastfeeding, the need for the advice of a health worker and a warning about health hazards. No pictures of infants, other pictures, or text idealising the use of infant formula. Labels must contain a warning that powdered infant formula may contain pathogenic microorganisms and must be prepared and used appropriately.

Quality: Unsuitable products, such as sweetened condensed milk, should not be promoted for babies. All products should be of a high quality (Codex Alimentarius standards) and take account of the climatic and storage conditions of the country where they are used.

Marketing Practices that Violate the Code

Manufacturers pay lip service to breastfeeding, but actually promote infant formula, follow-on milks, and other baby foods with one aim in mind—to increase product sales. The most common marketing activities that violate the Code are promotions directly to mothers and promotions through the health care system.

Direct promotion to mothers

Advertising and other forms of promotion to the public are banned under Article 5 of the Code. This includes

  • Advertising on tv, the internet, in shopping malls, newspapers, magazines, and at baby shows
  • Free samples, gifts, and competition prizes
  • Discounts and in store promotions
  • Sponsored baby clubs, parenting clubs, and "expert advice”
  • "Educational" pamphlets and brochures on infant feeding
  • Posters in shops, hospitals and pharmacies, brand names and logos on equipment, pens, pads etc.

To get around these restrictions, companies promote growing-up milks (targeting children 1 -2 years old) to the public, which have the same brand name and logo as their infant formulas. Manufacturers claim that these promotions do not violate the Code, because they say growing-up milks are not breastmilk substitutes.

However, doctors and WHO recommend that children benefit from breastfeeding until two years of age or longer, making milk products promoted for infants under two years a breastmilk substitute and subject to Code provisions.

Seeking direct and indirect contact with pregnant women and mothers of infants and young children (defined as children up to three years of age) is also prohibited by the Code. Yet most companies operate telephone and email Carelines and advice websites, and offer baby clubs targeting pregnant women and mothers. Through these channels, the companies offer free products, gifts and other product incentive schemes.

Promotion through the healthcare system and professionals

Promotion to health workers is banned by the International Code Articles 6 and 7, any information provided must be limited to scientific and factual matters. In 1996 the World Health Assembly adopted Resolution WHA49.15 and in 2005, Resolution 58.32, which call for Member States to adopt measures to ensure that financial support for health programmes and health workers does not cause conflicts of interest.

The Code also bans the following promotional activities:

  • Free product samples for mothers at obstetric, paediatric, and maternity clinics, and in hospitals
  • Donations of formula or feeding bottles to hospitals
  • Gifts for health workers, for their own use or to give to mothers

WHA resolutions warn against potential conflicts of interest involving

  • Sponsorship of health professionals to events, conferences, and their professional associations
  • Sponsorship of infant health research
  • Sponsored mothercare classes by company personnel

Free supplies were banned in all parts of the health care system in 1994 by the WHA Resolution WHA47.5. Despite the ban, companies try to use free supplies (formula or bottles), as an effective means of promoting their products. When a hospital uses free supplies to bottle feed a newborn, the mother’s ability to produce milk is impeded.

Companies that belong to the International Association of Infant food Manufacturers (IFM) pledged as far back as 1991 to work towards the goal of ending free and low-cost supplies. Yet ICDC's Breaking the Rules, Stretching the Rules monitoring reports show that this promotional strategy remains common. Donations of follow-up formula and complementary foods have also been taking place.