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Maternal and Child Health. 2018 Sep 8;  p.Promoting exclusive breastfeeding (EBF) is a highly feasible and cost-effective means of improving child health. Regulating the marketing of breastmilk substitutes is critical to protecting EBF. In 1981, the World Health Assembly adopted the World Health Organization International Code of Marketing of Breastmilk Substitutes (the Code), prohibiting the unethical advertising and promotion of breastmilk substitutes. This comparative study aimed to (a) explore the relationships among Code enforcement and legislation, infant formula sales, and EBF in India, Vietnam, and China; (b) identify best practices for Code operationalization; and (c) identify pathways by which Code implementation may influence EBF. We conducted secondary descriptive analysis of available national-level data and seven high level key informant interviews. Findings indicate that the implementation of the Code is a necessary but insufficient step alone to improve breastfeeding outcomes. Other enabling factors, such as adequate maternity leave, training on breastfeeding for health professionals, health systems strengthening through the Baby Friendly Hospital Initiative, and breastfeeding counselling for mothers, are needed. Several infant formula industry strategies with strong conflict of interest were identified as harmful to EBF. Transitioning breastfeeding programmes from donor-led to government-owned is essential for long-term sustainability of Code implementation and enforcement. We conclude that the relationships among the Code, infant formula sales, and EBF in India, Vietnam, and China are dependent on countries' engagement with implementation strategies and the presence of other enabling factors.
Maternal and Child Nutrition. 2017 Aug 10; 1-3.Written by the WHO/UNICEF NetCode author group, the comment focuses on the need to protect families from promotion of breast-milk substitutes and highlights new WHO Guidance on Ending Inappropriate Promotion of Foods for Infants and Young Children. The World Health Assembly welcomed this Guidance in 2016 and has called on all countries to adopt and implement the Guidance recommendations. NetCode, the Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and Subsequent Relevant World Health Assembly Resolutions, is led by the World Health Organization and the United Nations Children's Fund. NetCode members include the International Baby Food Action Network, World Alliance for Breastfeeding Action, Helen Keller International, Save the Children, and the WHO Collaborating Center at Metropol University. The comment frames the issue as a human rights issue for women and children, as articulated by a statement from the United Nations Office of the High Commissioner for Human Rights.
Marketing of breast-milk substitutes: National implementation of the international code. Status report 2016.
Geneva, Switzerland, WHO, 2016.  p.This report provides updated information on the status of implementing the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly resolutions (“the Code”) in and by countries. It presents the legal status of the Code, including -- where such information is available -- to what extent Code provisions have been incorporated in national legal measures. The report also provides information on the efforts made by countries to monitor and enforce the Code through the establishment of formal mechanisms. Its findings and subsequent recommendations aim to improve the understanding of how countries are implementing the Code, what challenges they face in doing so, and where the focus must be on further efforts to assist them in more effective Code implementation.
Country implementation of the International Code of Marketing of Breast-Milk Substitutes: status report 2011.
Geneva, Switzerland, WHO, 2013.  p.Globally, breastfeeding has the potential to prevent 220 000 deaths among children under five each year. WHO recommends that all infants should be exclusively breastfed for the first six months of life, but actual practice is low (38%). The implementation and enforcement of International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly Resolutions (the Code) are critical for an environment that supports proper infant and young child feeding and for the attainment of Millennium Development Goal 4 (reduce child mortality). This report summarizes the progress countries have made in implementing the Code. It is based on data received from WHO Member States between 2008 and 2010 and on information for 2011 from UNICEF. WHO recognizes ongoing progress being made in various countries since 2011, in terms of passing laws, strengthening existing laws or improving monitoring mechanisms. Updates will be included on an ongoing basis in the WHO Global database on the Implementation of Nutrition Action (GINA). In addition, WHO will publish status reports periodically.
[Geneva, Switzerland], World Health Organization [WHO], 2006. 9 p.The purpose of this paper is to examine the nutritional aspects of feeding home-modified milk. This paper focuses only on non-breastfed children aged 0 to 6 months with no access to infant formula. Feeding older non-breastfed infants is described in another WHO document. Other problems, including the risk of dilution error when modifying the milk, the risk of bacterial contamination, and the risk that it will cause occult bleeding in the gut if not adequately boiled are acknowledged, but will not be discussed here. (excerpt)
Lancet. 2007 May 26; 369(9575):1773.A recent briefing paper by the charity Save the Children UK, and an investigation by the Guardian newspaper, highlight that inappropriate activities surrounding baby-milk formula marketing and promotion cannot be resigned to the pages of history. 25 years on from the introduction of the WHO International Code of Marketing Breast Milk Substitutes, food companies persist in their dubious practices, but in a more subtle manner than in their aggressive activities of 30 years ago. Most importantly, such practices are still responsible for the deaths of thousands of children. In 1970s, an international campaign against the food giant Nestle was responsible for eliciting such collective outrage that it led to one of the biggest public boycotts in corporate history. Subsequent international pressure resulted in the WHO code, which not only covers the marketing of infant formula, but also other commodities if promoted as partial or total breastmilk replacements. (excerpt)
Geneva, Switzerland, WHO, 2006. 11 p.The Code is a set of recommendations to regulate the marketing of breast-milk substitutes, feeding bottles and teats. The Code was formulated in response to the realization that poor infant feeding practices were negatively affecting the growth, health and development of children, and were a major cause of mortality in infants and young children. Poor infant feeding practices therefore were a serious obstacle to social and economic development. The 34th session of the World Health Assembly (WHA) adopted the International Code of Marketing of Breast-milk Substitutes in 1981 as a minimum requirement to protect and promote appropriate infant and young child feeding. 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. If babies are not breastfed, for whatever reason, the Code also advocates that they be fed safely on the best available nutritional alternative. Breast-milk substitutes should be available when needed, but not be promoted. The Code was adopted through a WHA resolution and represents an expression of the collective will of governments to ensure the protection and promotion of optimal feeding for infants and young children. (excerpt)
BMJ. British Medical Journal. 2007 Mar 10; 334(7592):487-488.Recently, the World Health Organization updated its recommendations of 2000 on infant feeding in the context of HIV. At that time, data had just been published quantifying the risk of infection through breast feeding so avoiding breast feeding was acknowledged as the only effective way of avoiding transmission. WHO had also just published a meta-analysis of the mortality risks of not breast feeding, but in non-HIV infected populations. Considerations of these data resulted in the statement that, "When replacement feeding is acceptable, feasible, affordable, sustainable and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended." Since the 2000 recommendations, the main emphasis of most national programmes aimed at preventing mother to child transmission of HIV has been to avert transmission of HIV in young infants. The most difficult challenge has been how to make breast feeding safer in communities with a high prevalence of HIV where breast feeding is the traditional mode of feeding. Remarkably, the dilemma of infant feeding and HIV has split scientific communities and programme managers into opposing camps. Even with the risk of HIV transmission, some maintain that breast feeding may still be the best option for many mothers infected with HIV because of its anti-infective and nutritional advantages. Others promote commercial infant formula, arguing that the risks of diarrhoea and malnutrition associated with formula feeding are lower in most urban communities, or that the risks of not breast feeding may not be as great for infants born to mothers infected with HIV who, to prevent transmission, choose to give formula milk from birth; it has been suggested that this active decision making and motivation may result in safer preparation and use of formula milk. (excerpt)
Lancet. 2006 Nov 25; 368(9550):1868-1869.Exclusive breastfeeding for 6 months is the normal way to feed all infants. The new WHO growth reference released in April, 2006, is based on breastfed infants under optimum conditions. The sample is highly selected for the factors likely to promote growth in breastfed infants, and less than 10% of those initially surveyed were included in the final study. Most mothers and health professionals are concerned about their infants' growth, particularly for the first 6 months. If they believe their infants are not growing adequately, they are more likely to introduce supplementary foods, including "top-ups" with infant formula or even switching to formula completely. "Insufficient milk" is the most common reason for the early cessation of breastfeeding and mothers often self-diagnose this on the basis of perceived slower growth. (excerpt)
Are WHO/UNAIDS/UNICEF-recommended replacement milks for infants of HIV-infected mothers appropriate in the South African context?
Bulletin of the World Health Organization. 2004 Mar; 82(3):164-171.Little is known about the nutritional adequacy and feasibility of breastmilk replacement options recommended by WHO/ UNAIDS/UNICEF. The study aim was to explore suitability of the 2001 feeding recommendations for infants of HIV-infected mothers for a rural region in KwaZulu Natal, South Africa specifically with respect to adequacy of micronutrients and essential fatty acids, cost, and preparation times of replacement milks. Nutritional adequacy, cost, and preparation time of home-prepared replacement milks containing powdered full cream milk (PM) and fresh full cream milk (FM) and different micronutrient supplements (2 g UNICEF micronutrient sachet, government supplement routinely available in district public health clinics, and best available liquid paediatric supplement found in local pharmacies) were compared. Costs of locally available ingredients for replacement milk were used to calculate monthly costs for infants aged one, three, and six months. Total monthly costs of ingredients of commercial and home-prepared replacement milks were compared with each other and the average monthly income of domestic or shop workers. Time needed to prepare one feed of replacement milk was simulated. When mixed with water, sugar, and each micronutrient supplement, PM and FM provided <50% of estimated required amounts for vitamins E and C, folic acid, iodine, and selenium and <75% for zinc and pantothenic acid. PM and FM made with UNICEF micronutrient sachets provided 30% adequate intake for niacin. FM prepared with any micronutrient supplement provided no more than 32% vitamin D. All PMs provided more than adequate amounts of vitamin D. Compared with the commercial formula, PM and FM provided 8–60% of vitamins A, E, and C, folic acid, manganese, zinc, and iodine. Preparations of PM and FM provided 11% minimum recommended linoleic acid and 67% minimum recommended a-linolenic acid per 450 ml mixture. It took 21–25 minutes to optimally prepare 120 ml of replacement feed from PM or commercial infant formula and 30–35 minutes for the fresh milk preparation. PM or FM cost approximately 20% of monthly income averaged over the first six months of life; commercial formula cost approximately 32%. No home-prepared replacement milks in South Africa meet all estimated micronutrient and essential fatty acid requirements of infants aged <6 months. Commercial infant formula is the only replacement milk that meets all nutritional needs. Revisions of WHO/UNAIDS/UNICEF HIV and infant feeding course replacement milk options are needed. If replacement milks are to provide total nutrition, preparations should include vegetable oils, such as soybean oil, as a source of linoleic and a-linolenic acids, and additional vitamins and minerals. (author's)
Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomized trial. [Comparaison de l'efficacité d'une nourriture solide prête à l'emploi et d'un régime liquide à base de lait, en vue du rétablissement d'enfants souffrant de malnutrition grave : un essai randomisé]
American Journal of Clinical Nutrition. 2003 Aug; 78(2):302-307.Background: The World Health Organization recommends a liquid, milk-based diet (F100) during the rehabilitation phase of the treatment of severe malnutrition. A dry, solid, ready-to-use food (RTUF) that can be eaten without adding water has been proposed to eliminate the risk of bacterial contamination from added water. The efficacies of RTUF and F100 have not been compared. Objective: The objective was to compare the efficacy of RTUF and F100 in promoting weight gain in malnourished children. Design: In an open-labeled, randomized trial, 70 severely malnourished Senegalese children aged 6–36 mo were randomly allocated to receive 3 meals containing either F100 (n = 35) or RTUF (n = 35) in addition to the local diet. The data from 30 children in each group were analyzed. Results: The mean (± SD) daily energy intake in the RTUF group was 808 ± 280 (95% CI: 703.8, 912.9) kJ·kg body wt-1·d-1, and that in the F100 group was 573 ± 201 (95% CI: 497.9, 648.7) kJ·kg body wt-1·d-1 (P < 0.001). The average weight gains in the RTUF and F100 groups were 15.6 (95% CI: 13.4, 17.8) and 10.1 (95% CI: 8.7, 11.4) g·kg body wt-1·d-1, respectively (P < 0.001). The difference in weight gain was greater in the most wasted children (P < 0.05). The average duration of rehabilitation was 17.3 (95% CI: 15.6, 19.0) d in the F100 group and was 13.4 (95% CI: 12.1, 14.7) d in the RTUF group (P < 0.001). Conclusions: This study indicated that RTUF can be used efficiently for the rehabilitation of severely malnourished children. (author's)
UNICEF and baby food manufacturers. UNICEF continues to base its actions and programmes on the best interests of the child [letter]
BMJ. British Medical Journal. 2000 Oct 14; 321(7266):960.This article presents the response of Carol Bellamy, executive director of the UN International Children's Emergency Fund (UNICEF), to the article by Yamey about the alliances UNICEF is seeking to form with manufacturers of infant formula that do not comply with the international code of marketing of breast milk substitutes. Bellamy confirms that UNICEF will continue to refuse donations from manufacturers of infant formula whose marketing practices violate this code and subsequent World Health Assembly resolutions. It is noted that there has been considerable discussion within the organization regarding this issue. This emerged when UNICEF participated in discussions with five large pharmaceutical companies on the possibility of obtaining various drugs to fight HIV/AIDS at discounted prices on behalf of developing countries. One of these companies is widely viewed as violating the code. This has been misinterpreted as a sign that UNICEF is weakening its support for breast-feeding and the code. However, Bellamy indicates that UNICEF believes that in the face of AIDS, their support for breast-feeding must be strengthened, not diminished. At the same time, UNICEF will uphold its support of the code and will continue to call violators of the code to account publicly.
BMJ. British Medical Journal. 2000 Jul 15; 321(7254):132.UN International Children's Emergency Fund (UNICEF) is about to form partnerships with companies that produce infant formula and that do not comply with the international code of marketing of breast milk substitutes, it was claimed this week. Two UNICEF employees have resigned in protest, and others are expected to tender their resignations. A document written by a UNICEF employee, who does not wish to be named, states that “decisions have been taken at UNICEF's top level to make alliances with pharmaceutical companies... which market their breast milk substitutes in disregard [of the code]”. UNICEF has previously refused to accept funding from the baby food industry, and it has supported breast-feeding advocacy groups in the developing world. A new partnership with industry would add to the growing concern among infant feeding specialists that international health agencies, including the WHO, are going too far in their dealings with the private sector. The International Baby Food Network commented: “There is a need for UNICEF to protect its status as a truly independent advocate for human rights and health for all, and to ensure that its policies, research priorities, and direction are not unduly influenced.” On 4 July, Carol Bellamy, executive director of UNICEF sent a memorandum to all UNICEF representatives, managers, and directors, which stated that UNICEF will “engage in dialogue with the private sector when it is clear that such an endeavor can contribute to the best interests of the child.” Michael Latham, professor of international nutrition at Cornell University in New York, said: “Carol Bellamy does not seem willing to state that UNICEF will not form partnerships with, nor accept funds from, corporations that violate the code.” (full text)
BMJ. British Medical Journal. 2000 May 20; 320(7246):1362.International specialists in infant feeding expressed concern that the policy of WHO of establishing partnerships with private industry has gone too far, with the result that debate about the infant food industry's role in marketing breast milk substitutes is being stifled. Specialists, who want the WHO to recommend exclusive breast-feeding to babies up to 6 months, claim that at a recent joint meeting on infant feeding they were prevented from discussing the issue. In addition, some papers intended for the meeting were edited so that they were less critical to the infant food industry. Although 20 of the 28 consultants signed a statement saying that scientific evidence was now sufficient to warrant changing of the current WHO recommendation on the introduction of complementary feeding from age 4-6 months to about 6 months, no discussion was allowed. In response, a spokesman for the WHO stated that the current recommendation of WHO on the duration of exclusive breast-feeding was excluded in the discussion because of the WHO’s research that is under way in this connection. As far as the alleged censorship of the background papers is concerned, he explained that WHO documents have to conform to a high standard of scientific objectivity and balance. Lastly, WHO cited that the food industry continues to play an important and constructive role in relation to infant feeding.
Protecting breast feeding from breast milk substitutes. Royal college supports promotion of breast feeding [letter]
BMJ. British Medical Journal. 1998 Oct 3; 317(7163):949-50.The Royal College of Paediatrics and Child Health suggested interventions to increase the number of women who breast feed their babies in its report to the Acheson inquiry on poverty and health. The UN Children's Fund (UNICEF) had a stand, which offered information on its 1991 initiative promoting breast feeding, at the trade exhibition of the college's annual general meeting in 1998. Members and fellows gave unequivocal support to a policy statement which encouraged exclusive breast feeding for the first 4-6 months of an infant's life followed by breast feeding accompanied by weaning food for as long as the mother wished. However, Costello and Sachdev, in discussing attempts by manufacturers of infant formula to seek "endorsement by association" or "passivity towards their products," chastised the Royal College for not joining an interagency group on breast feeding and for accepting research funds from infant formula manufacturers. The College did not join the interagency group because of concerns regarding the proposed research methodology. The College will accept no more research funds or donations from infant formula manufacturers until the recommendations and report of its ethics committee regarding breast milk substitute marketing, which were requested by the 1997 annual general meeting, are finished in late 1998.
Protecting breast feeding from breast milk substitutes. Royal college supports promotion of breast feeding. Authors reply [letter]
BMJ. British Medical Journal. 1998 Oct 3; 317(7163):950.Jacobs (of the Infant and Dietetic Foods Association) and Bronner (of the International Association of Infant Food Manufacturers) object to a peer-reviewed interagency study of widespread violations of the international code of the World Health Organization (WHO) regarding marketing of breast milk substitutes. They say that the study has been severely criticized, but provide no published peer-reviewed references in support of this. They say that the code does not apply to follow-on formulas, but the code specifically states that it applies to any product marketed to replace breast milk, partially or totally. They seek to avoid honoring the code by citing local regulations. Although not all components of the code are established in national legislation in many countries, the industry agreed to abide by the code when it was written in 1981. Marcovitch et al. state that the Royal College of Paediatrics and Child Health will support breast feeding with stronger measures and that they will not accept donations from formula manufacturers until receipt of a report from their ethics committee. However, they refused to join the interagency study because of concerns about research methodology. If the college fully supported the code, it should have joined the study and corrected the research methodology. The college research unit commenting on the methodology is funded by Nestle, which represents a conflict of interests.
[Consensus declaration on the World Health Organization [WHO] / UNICEF consultation on HIV transmission and breast feeding] Declaration de consensus a l'issue de la consultation OMS / UNICEF sur la transmission du VIH et l'allaitement au sein.
IMBONEZAMURYANGO / FAMILLE SANTE DEVELOPPEMENT. 1992 Dec; (25):18-9.In 1992, WHO and UNICEF held a Conference on HIV Transmission and Breast Feeding to review available information on the risk of HIV transmission via breast milk and to formulate recommendations on breast feeding. In all populations, regardless of the HIV infection rate, one must continue to defend, promote, and protect breast feeding. Where infection and malnutrition are the main causes of death among newborns, the risk of death linked to these infections is especially high among newborns who are not breast fed. Under conditions where the infant is less likely to contract HIV infection by breast milk than die of other causes, it is best to breast feed. If women under these conditions have access to other infant feeding methods, it is necessary to offer them the option of an HIV test while respecting confidentiality. When infectious diseases are not the main causes of death, HIV infected pregnant woman should be advised to use breast milk substitutes. Pregnant women of unknown HIV status should be advised to undergo an HIV test before delivery. Pressure from manufacturers should not influence HIV infected mothers in their choice of artificial feeding, as stated in the International Code on the Commercialization of Breast Milk Substitutes. HIV-related counseling should aim to help HIV infected adults address infant feeding methods, the risk of HIV transmission to children if the woman becomes pregnant, and the risk of HIV transmission at the time of sexual relations and via blood. All HIV positive adults who wish to avoid pregnancy should use family planning services and information. In all countries, the first priority to prevent vertical HIV transmission is prevention of HIV infection in women of reproductive age. Women must be taught how to protect themselves from HIV infection. Society must grant them the means to easily procure condoms and assure prevention and treatment of sexually transmitted diseases.
Breastfeeding management and promotion in a baby-friendly hospital: an 18-hour course for maternity staff.
New York, New York, UNICEF, 1993 Jan. , vii, 127,  p.The Baby Friendly Hospital Initiative seeks to promote exclusive breast feeding in the first 4-6 months of life, followed by supplemental feeding up to two years of age or beyond. To assist hospitals in making the policy changes necessary for achieving this goal, an 18-hour course for physicians, midwives, nurses, and other maternity staff was devised. The curriculum was designed to impart the knowledge required to implement the 10 steps to successful breast feeding: 1) develop a written breast feeding policy, 2) train all health care staff in skills needed for policy implementation, 3) inform all pregnant women about the benefits and management of breast feeding, 4) help mothers initiate breast feeding within 30 minutes of delivery, 5) show mothers how to breast feed and maintain lactation when separated from their infant, 6) give newborns no food or drink other than breast milk unless medically necessary, 7) allow mothers and infants to remain together in the hospital, 8) encourage demand feeding, 9) provide no pacifiers, and 10) promote the establishment of breast feeding support groups. In addition to the 14 lessons that comprise this manual, the course includes three hours of clinical experience.
MOTHERS AND CHILDREN. 1992; 11(3):6-7.The International Baby Food Action Network (IBFAN) is a coalition of over 40 citizen groups in 70 countries. IBFAN monitors the progress worldwide of the implementation of the International Code of Marketing of Breastmilk Substitutes. The Code is intended to regulate the advertising and promotional techniques used to sell infant formula. The 1991 IBFAN report shows that 75 countries have taken some action to implement the International Code. During 1992, the IBFAN Code Documentation Center in Malaysia conducted 2 training courses to help countries draft legislation to implement and monitor compliance with the International Code. In April, government officials from 19 Asian and African countries attended the first course in Malaysia; the second course was conducted in Spanish in Guatemala and attended by officials from 15 Latin American and Caribbean countries. The resource people included representatives from NGOs in Africa, Asia, Latin America, Europe and North America with experience in Code implementation and monitoring at the national level. The main purpose of each course was to train government officials to use the International Code as a starting point for national legislation to protect breastfeeding. Participants reviewed recent information on lactation management, the advantages of breastfeeding, current trends in breastfeeding and the marketing practices of infant formula manufacturers. The participants studied the terminology contained in the International Code and terminology used by infant formula manufacturers to include breastmilk supplements such as follow-on formulas and cereal-based baby foods. Relevant World Health Assembly resolutions such as the one adopted in 1986 on the need to ban free and low-cost supplies to hospitals were examined. The legal aspects of the current Baby Friendly Hospital Initiative (BFHI) and the progress in the 12 BFHI test countries concerning the elimination of supplies were also examined. International Labor Organization conventions on maternity legislation also need to be implemented to support breastfeeding.