International Lactation Consultant Association

Independent Study Module

The International Code of Marketing

of Breastmilk Substitutes:
What It Means for Mothers
and Babies Worldwide
Helen C. Armstrong, MAT, IBCLC
and Ellen Sokol, JD

2001. International Lactation Consultant Association

(BLANK PAGE)

Preface
Breastfeeding is about caring, about sharing, and
about action.

tive through the World Alliance for Breastfeeding Action

(WABA). WABA works in close liaison with UNICEF
and the WHO/UNICEF Baby-Friendly Hospital Initiative (BFHI). It acts through a range of support actions
covering information, research, training on health care
practices, and women and work issues. It fosters the
culture of breastfeeding. WABA links mother support
groups and serves as a catalyst for popular mobilization
actions through World Breastfeeding Week (WBW), held
each year in August. Most importantly, in conjunction
with IBFANs Code Documentation Centre, it also helps
to support initiatives to ensure code implementation at
the national level, monitoring, and compliance.

The first food for the child is more than just that. It is
life protecting. It is love. It is natural. It is the right of
the child to have it and the right of the mother to be
supported to give it.
A mother-unfriendly environment and a market
system hungry for profits began a process of subversion
of this most special bond between mother and child. It
has taken decades of struggle to fight this subversion.
In 1981, the world community acting through the World
Health Organization (WHO) adopted a universal code to
protect, promote, and support breastfeeding. The
International Code of Marketing of Breastmilk Substitutes provided a global framework of accountability, for
governments, business enterprises, professionals, and
community organizations. Specialized breastfeeding
organizations, including the International Lactation
Consultant Association (ILCA), have given the Code
their full support.

The International Code of Marketing needs to be

monitored continuously. It needs to be understood and
even strengthened to cover a host of post-Code marketing practices that continue to subvert the culture of
breastfeeding. ILCA members have the particular skills
and opportunities to participate in this global effort.
We have to be continuously vigilant if the Code is to
become a reality in communities and to help mothers
and children everywhere. This special publication by
Helen Armstrong and Ellen Sokol will help each of us to
make that happen.

Today, thousands of groups throughout the world are

acting to make this code a reality in their countries and
in their communities. The work of groups like the
International Baby Food Action Network (IBFAN), La
Leche League, and ILCA have recently been strengthened by the creation of a world-wide coordinated initia-

Anwar Fazal, Chairperson

World Alliance for Breastfeeding Action (WABA)
Penang, Malaysia

Introduction
The International Code of Marketing of Breastmilk
Substitutes and discussions of it were first presented to
readers of the Journal of Human Lactation in each of
four issues during 1988 and 1989. In February 1988, the
ILCA Board of Directors endorsed the International
Code, and since then the association had endeavored to
familiarize its membership and other JHL readers with
the conditions of the Code. With a clear understanding
of the Codes implications for mothers and infants
worldwide, health professionals and decision-makers
will hopefully endorse and promote its implementation.

We urge all readers to use the International Code as a

benchmark to evaluate practices in their own institutions and places of business. Implementation of the
International Code is necessary throughout the world,
in developing and developed countries alike. It is our
hope that after reviewing the International Code and its
accompanying discussions, the reader will understand
its significance and work toward it implementation. Our
common goal is a return to a global breastfeeding
culture; implementation of the Code is a necessary step
toward that end.

The International Code continues to have great significance, especially within the context of the global WHO/
UNICEF Baby Friendly Hospital Initiative. The four
original articles are presented here in a single document
for convenience of referral and review. Revisions have
been made to incorporate issues and activities that have
arisen since the articles were first published. The
appendix includes an unabridged copy of the International Code.

Linda Kutner, BSN, IBCLC

President (1992-1994), ILCA

The International Code of Marketing of Breastmilk Substitutes:

What It Means for Mothers and Babies World-wide1
Helen C. Armstrong, MAT, IBCLC and Ellen Sokol, JD2
Beginning with the September, 1988 and ending with the June, 1989 issues of JHL, the following information was published to assist readers to
understand the implications of the International Code of Marketing of Breastmilk Substitutes, first adopted by the World Health Assembly in
1981. In order to provide readers with this information in a single document, these four articles are reprinted here as revised in 1994 and again
with this publication. The International Code may be found in the Appendix, on pages 30-34.

Part 1: The Code Preamble and Articles 1 and 2

The following years saw increasing public attention to
the issue, including press and media coverage, professional discussions, a US Senate subcommittee hearing
and a boycott against the worlds largest baby milk
manufacturer. In Europe and North America, activist
groups increased public awareness of the link between
declining breastfeeding rates and high levels of child
illness, malnutrition, and death. Similar groups developed in non-industrialized countries where imported
baby foods were having a lethal impact on infant
health.8

Development of the International Code

The harmful effects of the use of breastmilk substitutes
first attracted public attention and concern in the early
1970s. In 1973, The New Internationalist, a British
magazine, published a cover story based on interviews
with two pediatricians with long experience in developing countries.3 It was becoming clear that babies deprived of mothers milk were becoming ill and dying far
more often than those exclusively breastfed. Since then,
the evidence has continued to mount.

One response of the baby food companies to the mounting publicity was to form a council called the International Council of Infant Food Industries (ICIFI). The
eight initial members included Cow & Gate, Dumex,
Meiji, Morinaga, Nestl, Snow Brand, Wakado and
Wyeth. ICIFI drafted a Code of Ethics which it publicized widely to show the world it was responding to the
problem.9 The ICIFI Code of Ethics, however, sanctioned
most of the existing marketing practices, provided that
breastfeeding was mentioned as the first choice for
infant nutrition.

A well-known 1987 study in Brazil demonstrated that

infants who were not breastfed in the first year of life
were fourteen times more likely to die of diarrhoeal
infection (22 times in the first two months) than exclusively breastfed infants and 3.6 times more likely to die
of a respiratory infection. Even partial formula feeding
to supplement breastfeeding greatly augments the risks
to infant health. Formula supplements for breastfeeding
babies more than quadrupled the risk of diarrhoea in
the first year.4
The benefits of breastfeeding are certainly not confined
to the developing world. Even in affluent countries,
under the best conditions, a bottle-fed baby is five times
more likely than a breastfed baby to get a digestivetract infection.5

Advertising continued to create an artificial need for

baby food products. In 1979, the World Health Organization (WHO) and United Nations Childrens Fund
(UNICEF) convened a joint international meeting of
health professionals, government representatives, UN
agency delegates, public interest and consumer groups,
and members of the infant food industry. This joint
meeting recommended that there should be an international code to regulate the marketing of infant formula
and other products used as breastmilk substitutes
which could be observed by all manufacturers. After
drafting, discussions, and negotiations among all
parties, the International Code of Marketing of
Breastmilk Substitutes was presented to the WHA in
May 1981 and approved by a vote of 118-1.

The story in The New Internationalist was followed by

the development agency War on Wants publication of
The Baby Killer 6, which exposed the role of advertising
and promotion of breastmilk substitutes in the decline
of breastfeeding and increased infant malnutrition.
Marketing of breastmilk substitutes was widely considered one major contributor to the trend away from
breastfeeding.
In 1974, at its annual meeting, the World Health
Assembly (WHA) resolved that governments should
review sales promotion activities and introduce
appropriate remedial measures, including advertisement codes and legislation where necessary.7

The lone negative vote was cast by the United States

delegates, who contended that regulations on the
marketing of baby foods interfered with free enterprise.
No other western democracy shared this view, nor did
5

common denominator, a step on the way, rather than

the terminus of our efforts.14

many Americans. Dr. Stephen Joseph, subsequently

Health Commissioner for New York City, was one US
official who resigned in protest at the Reagan
Administrations refusal to endorse the Code. Subsequently, both the Senate and the House of Representatives approved resolutions expressing dismay over the
U.S. vote.10 In 1994, the United States voted for the first
time in favor of a World Health Assembly resolution on
infant and young child feeding, (Resolution 47.5). The
resolution reaffirmed support for the International Code
and the subsequent relevant resolutions, meaning that
the United States finally joined in supporting the Code
and resolutions that endorse it.

Many countries have used the International Code as a

springboard to stricter or more detailed laws, regulations, or other measures. For example, the Indian
regulation on infant milk substitutes has labeling
requirements that are stricter than those in the International Code. The Kenya Code augments the International Code by forbidding any suggestions that
breastmilk may be insufficient, and by requiring the
same product information to be printed in both English
and Kiswahili (previously, the Kiswahili information
had been less accurate and complete). In Guatemala,
informational material about infant nutrition may not
include images of health professionals or any indication
that a particular product is recommended by the health
authorities. The Tanzania regulations on the marketing
of breastmilk substitutes apply to a broader array of
products than does the International Code.

A Minimum Universal Requirement

The 118 nations supporting the International Code
recommended that its provisions be strengthened, but
not weakened.11 As stated by one delegate, This is only
the minimum that is required. Every country is free to
improve it as it sees fit.12

In the early years following adoption of the Code, some

countries such as Canada, Germany and Hong Kong
allowed the baby food industry to self-regulate with
industry codes. Consumer advocates likened this to
allowing foxes to design the chicken coop.15 Fortunately,
few, if any governments still accept industry codes on
marketing of breastmilk substitutes.

The Code is intended to apply throughout the world.

Nowhere does it exempt industrialized countries,
educated urban communities, wealthy families babies,
or any other group from the aim of protection and
promotion of breastfeeding. It establishes a universal
set of standards for responsible marketing.

Some governments, such as Australia, Malaysia and

South Africa, have chosen to implement the International Code by means of a voluntary national code,
which is somewhere between a law and an industry
code. A voluntary code is an agreement worked out
among government, industry, consumer groups and
other non-governmental organizations. Voluntary codes
have had some effect in controlling some types of
inappropriate marketing practices, but, in the end,
success depends on the will of the industry. Few, if any,
sanctions can be imposed for non-compliance. Voluntary
codes with monitoring and enforcement procedures have
had a greater effect than those that rely on self-policing.

There can be no doubt that there is a need for regulation of the

marketing of infant food I would like to underline that it is
not possible in this question to apply for a double set of
standards one for industrialized countries and another for
the Third World.13

Code Implementation
The WHA is not a law-making body; its decisions do not
override national sovereignty. It was the intention of the
World Health Assembly that each nation incorporate
the International Code into its own system of governance. In some countries, legislation is required. In
others, administrative regulations or an executive order
may be sufficient to give a national code the force of law.

Any national measure, voluntary or legal, is only as

strong as the community or government agencies which
monitor compliance, publicize deviations, and impose
sanctions. International cooperation reinforces national
monitoring, as products or promotional materials
banned in one country often reappear elsewhere in the
same multinational companys marketing area. There is
much to be done not only to encourage passage of strong
national laws or other measures, but to ensure their
firm observance in all countries.

The final text of the Code was agreed to as a compromise among differing interests. The initial text was
prepared by WHO and UNICEF after much consultation with the varying interests including experts,
government delegations, non-governmental organizations (NGOs) and industry (mainly ICIFI, the organization formed in the 70s). The Code went through four
drafts and each was circulated to the different parties
for comment. The text that became the International
Code is thus weaker than the ideal and some articles
and definitions are open to interpretation. It was and is,
however, a necessary first step. In 1981 a Swedish
delegate stated, The present text of the Code can, in
our opinion, only be regarded as a temporary lowest

The Aim of the Code (Article 1)

Focus on Marketing. The Code Preamble specifies that
there is a legitimate market for infant formula. Article 1
elaborates the aim, one part of which is ensuring the
6

formulas or deuxime ge milks are strongly promoted

for babies from four or five months onward without
regard to the continued protection and promotion of
breastfeeding. Some marketing copy offers a fine-print
disclaimer, Not intended as a breastmilk substitute,
but then stipulates that in addition to a diet of complementary foods, the baby should take 720-960 ml (26-34
oz.) of the milk product daily, an amount which would
probably preclude continued intake of substantial
amounts of breastmilk.

proper use of breastmilk substitutes, when these are

necessary, on the basis of adequate information and
through appropriate marketing and distribution. The
Code clearly intends to correct unnecessary use of
breastmilk substitutes, inadequate information, and
inappropriate marketing and distribution.
Misunderstanding of the aim of the Code is frequently
encountered. The Code does not eliminate the commercial availability of bottles or baby food. Nor does the
Code deny freedom of choice. A woman who has been
misled into giving up breastfeeding no longer has a
choice. The Code preserves freedom of choice by limiting
commercially motivated interference with breastfeeding
that may abbreviate or terminate the mothers
breastfeeding option.

A pediatric ward that admits a breastfeeding child of

whatever age but forbids the mother to stay with her
child denies protection to breastfeeding. A supplemental
food program that provides extra food to the lactating
mother only for six months or twelve months, despite
evidence that she is still breastfeeding, also embodies a
cut-off point for protection and promotion.

The Code seeks controls for marketing practices, defined in Article 3 as product promotion, distribution,
selling, advertising, product public relations, and
information services. Distribution includes providing
samples and supplies to individuals, hospitals, and
community nutrition programs.

Lactation consultants may find it instructive to study

leaflets on infant feeding available from whatever
source. Although such materials may contain sound
information on breastfeeding initiation, they may
exclude completely any allusion to breastfeeding the
child who can sit up, crawl, or walk. A manufacturers
emphasis on breastfeeding in the newborn period builds
credibility for the company as an advisor on infant
feeding. But the same leaflet, by omitting discussion of
later stages, may prepare the mother to abandon
breastfeeding in a few weeks. By implication or omission, most manufacturers and many government
publications violate the aim of the Code to protect and
promote breastfeeding with no time limit.

Protection and Promotion. The Code also seeks to

protect and promote breastfeeding. These terms can be
defined as follows:
Protection: safeguarding breastfeeding practices
which already exist;
Promotion: actively encouraging improvement in
breastfeeding rates, durations, and effectiveness.
Preventing the erosion of helpful practices, such as virtually universal breastfeeding initiation or long duration, is
protection. In many developing countries, protection must
be a major focus of health education and public policy.

Scope of the Code (Article 2)

The International Code covers more than infant formula. Article 3 defines infant formula as an industrially
prepared breastmilk substitute meeting certain international standards of composition and safety,17 and specially adapted to meet the nutritional needs of infants
up to four to six months of age. Infant formula is the
most common breastmilk substitute, especially for the
newborn. The term includes special formulas such as
those intended for premature and low-birth-weight
babies; soy-based formula and formula marketed as
hypoallergenic.

To urge more women to breastfeed, or to encourage

longer periods of exclusive breastfeeding, is promotion.
In many industrialized countries and in most urban
areas world-wide, active promotion of improved
breastfeeding patterns is essential. Whoever endorses
the aim of the Code is making a commitment to work
toward optimal child feeding, not just to reinforce
existing patterns, if they are not ideal for infant health.
No Time Limit. No provision of the Code stipulates a time
limit to the protection and promotion of breastfeeding.
Encouragement should not be intense initially and then
vanish after a few weeks, six months, or a year. This is of
particular importance in those societies including the majority of the worlds families, where breastfeeding past
twelve months is still the norm.16

Breastmilk substitutes are defined far more broadly, as

any food being marketed or otherwise represented as a
partial or total replacement for breastmilk, whether or
not suitable for that purpose. This definition can
include follow-up milks, sugar or fruit drinks, commercially processed baby foods and packaged baby cereals
depending on how they are marketed or represented.
Apple juice sold in a jar ready to have a teat screwed on
is being represented as a breastmilk substitute. As a
rule of thumb, any product represented as suitable for
feeding infants under 6 months and any milk targeted

Promotion of milk foods, fruit drinks, cereal foods, and

other additions to the babys diet contravenes the aim of
the Code unless continued substantial breastfeeding is
encouraged. Many milk products such as follow-up
7

for babies or toddlers is marketed as a breastmilk

substitute. Such products are being represented as
suitable to replace that part of the diet that is best
fulfilled by breastmilk.

The Code also covers feeding bottles and teats (rubber

or silicon nipples). Unlike some manufacturers of baby
foods, many companies making these feeding devices
have not yet begun to protect or promote breastfeeding.19 They consistently violate the aim of the Code by
using all possible marketing strategies to create an
artificial need for their products. A recent advertisement
appearing in a US parenting magazine claims No other
system is more sanitary or more convenient to use. Now
feeding your baby is easier than ever.20 Breast pump
companies may also violate the code by promoting these
items. One company claims in its leaflet that its patented nipple is medically proven to eliminate nipple
confusion in most nursing babies.21

The scope of the Code also includes other milk products, foods and beverages, including bottle-fed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for
use as partial or total replacement of breastmilk. In
many countries, putting cereal mixtures into bottles is a
long tradition. These are bottle-fed complementary
foods. Rice flakes, wheat flour, cornstarch powders, and
bottle biscuits to be dissolved in liquid are widely
promoted. Instructions on such products recommend
mixing with water, cow milk, or formula, but not
breastmilk.

The influence of commercial interests on the thinking of

health professionals and on the cultures they live in is
dramatized by the common assumption among todays
medical workers at every level that the only alternative
to direct breastfeeding is a feeding bottle. Even if
expressed breastmilk is used, it is commonly given by
bottle, a technique inherently dangerous wherever
home conditions preclude safe sterilization at every
feed. This technique also risks the development of
nipple confusion in parents and infants alike.22 If
infants are left to bottle-feed themselves, they will be at
increased the risk for otitis media and dental caries.23

In disregard of the Codes wording, many manufacturers of infant foods have taken the position that the Code
applies only to infant formula. Following passage of the
Code formula manufacturers shifted much of their
marketing emphasis to other products which they claim
are not breastmilk substitutes and hence fall outside of
the Codes marketing restrictions. The promotion of
follow-up formula is the most obvious example of this
practice.
Beginning soon after passage of the Code, nearly every
infant formula manufacturer developed a formula or
milk for babies of four, five, six months or older even
though the some of the same companies had previously
marketed full-year formulas, and continue to do so in
the USA. Manufacturers and distributors advertise and
promote these products in much the same way as they
used to promote infant formula. Moreover, in a number
of cases, the brand name and label of the follow-up milk
closely resemble those of the infant formula. Thus,
although product promotion for infant formula has
decreased in nearly all countries, manufacturers
achieve similar sales results from the promotion of
follow-up milks.

Hospitals can function without recourse to feeding

bottles,24 UN agencies recommend it when mothers
decide not to breastfeed25 and relief organizations have
long emphasized that feeding bottles should not be used
even for very young motherless infants.26 Yet health
workers have so internalized commercial promotion of
bottles that they may forget all other options. Although
the Code Preamble recognizes the legitimate role of
breastmilk substitutes, it admits no irreplaceable role
for the bottle-and-teat feeding technique.
Lactation consultants are encouraged to consider the
aim and the scope of the Code in relation to the community where they work. What does application of the aim
entail? From what quarters can either support or
resistance be anticipated? What products within its
scope are in use? The lactation consultant is challenged
to consider: What does this Code mean for me, for my
colleagues, and for the mothers we serve?

It is interesting to note that in 1986, the World Health

Assembly stated that the practice being introduced in
some countries of providing infants with specially
formulated milks (so-called follow-up milks) is not
necessary.18

Part 2
Articles 4 and 527
the Child, which, since it came into force in 1990, has
been ratified by 191 countries. Unlike the International
Code, the Convention is binding on countries that have
ratified it. Article 24 of the Convention provides that
governments should ensure that all segments of
society, in particular parents and children, are informed, have access to education and are supported in
the use of basic knowledge of the advantages of
breastfeeding.31

Introduction
When parents need information about infant feeding,
very often what is most readily available emanates from
a commercial source. Sometimes the company sponsorship of a widely distributed, free, and attractive resource or website is clear; at other times, parents may
not realize that the information comes from a company
with an interest in baby feeding products. Government
agencies or private organizations can put out excellent
infant feeding information, such as the Zimbabwe
booklet Baby Feeding28 or the German booklet Stillen29.
Too often, however, the booklet must be purchased, or
funds supporting free distribution are reduced or
withdrawn, the item goes out of stock, and commercial
publications continue to be used.

Few governments fulfill this responsibility, leaving it up

to individuals or institutions throughout the health care
system. While some governments have in place requirements or prohibitions regarding information materials,
few, if any, forbid infant feeding information produced
by the infant food industry. Unfortunately, although the
majority of infant food manufacturers state that they
endorse the Code, their educational material usually
diverges markedly from it. If a company chooses to
distribute booklets, charts, or audio-visual materials, or
maintain an internet site, it does so as part of an overall
marketing strategy. This motivation may skew the
information given. In addition, manufacturing staff
share culturally accepted misinformation, and transmit
it without assessing its scientific accuracy.

In many nations, virtually no non-commercial information on breastfeeding is freely distributed. Companyproduced or sponsored information spans the globe.
Booklets or advertisements written in the United States
or Europe may be found in Western Samoa, Abidjan or
Mbabane, Rio de Janeiro or Singapore. Such general
dispersal, especially if alternative sources of information are lacking, calls for world-wide agreement on what
the essential messages should be.

Recognizing the dangers, the Code specifies a minimum

of information which should be included, but does not
exclude additional consistent information, thus respecting the principle of free speech. Article 4.1 of the International Code requires consultation with public health
authorities to ensure appropriate messages. Article 4.2
mandates the inclusion of clear information on a number of points about breastfeeding. Quoting the Code in
fine print cannot substitute for compliance. Nor can
written materials about bottle-feeding products be
excluded from Code provisions by the simple disclaimer,
Not intended to replace breastmilk.

A recent study in the US adds to the evidence showing

that the use of materials produced by baby milk companies has an adverse effect on breastfeeding. The authors
of the study concluded that although breastfeeding
initiation and long-term duration were not affected,
exposure to formula promotion materials increased
significantly breastfeeding cessation in the first two
weeks.30
Many countries already have some degree of government supervision of information and advertising for
cigarettes, alcohol, over-the-counter and prescription
drugs. The Code extends this governmental responsibility to breastmilk substitutes, bottles and teats as their
inappropriate use may also affect health adversely.

Code provisions apply to every leaflet. A manufacturer

cannot say, Well, we discussed the benefits of
breastfeeding in our general booklet, so in these instructions for formula feeding, we do not need to repeat
ourselves. Under the Code, the same minimum set of
messages is to be presented in every informative item
distributed to the public or mothers. There are special
extra rules to follow if formula use is discussed, such as
an explanation of the financial implications (meaning
the costs to the family) and the hazards that use of such
artificial baby milks represents. Have JHL readers yet
encountered any manufacturers information that levels
with parents on the costs of one years supply of
breastmilk substitutes, sterilizing procedures, and
possible additional health care costs?

Information and Education (Article 4)

Article 4 of the International Code outlines requirements for information, a global common ground for
parent education. According to Article 4.1, governments
have the responsibility to ensure objective and consistent information is provided on infant and young child
feeding for use by families and those involved in the
field of infant and young child nutrition. This responsibility was reinforced in the Convention on the Rights of

cols. Commercial information typically omits any hint that

all decisions not to breastfeed a baby when he or she is
hungry, starting from birth, have a cumulative effect which
does become difficult to reverse.

Common Deficiencies
Most commercially sponsored leaflets, charts, phone
advisory services and other information materials fail to
fulfill Code requirements in some way. But booklets
from non-commercial sources also may be inadequate.
Nor does a government imprint provide an absolute
guarantee of Code compliance.

Another deficiency of many booklets is their narrow

focus on the start of breastfeeding, without the required
information on how to maintain it through the infants
first year. Commercial interests usually do not tell
mothers how to go on, despite the Code standard, since
profits depend upon a transition to use of other baby
feeding products during the first twelve months.

Readers can assess what is available to the families

they serve for compliance with the minimum standards
listed in Article 4.2. They will notice shortcomings in
materials that give cursory attention to Code requirements but omit much information that parents need. A
hypothetical example illustrates the point:

It is difficult to find company produced information

materials that promote exclusive breastfeeding for
about 6 months or continued breastfeeding for even one
year, let alone the 2 years and beyond recommended
in the Innocenti Declaration. Many of the company
information booklets state that supplementing
breastmilk with a commercial infant formula, fed by
bottle, will be necessary at some stage.

Breastmilk is best for your baby. If you choose to use an

alternative, Yummilac closely resembles human milk. It has all
the protein, energy, vitamins, and minerals which baby needs
for healthy growth. And to make sure your precious baby gets
all he deserves, we add taurine for brain development, iron for
strong blood, extra vitamin C You see, the specialists who
prepare Yummilac know it is for the most important person in
the world your new baby.

Often the materials devote more text space to the topic

of bottle feeding than to breastfeeding. In 1997, Abbott
Ross was distributing several different infant care
booklets in Western Samoa. Two were devoted entirely
to bottle feeding.36 A third, on the topic of parenthood,
begins with a section on feeding and how to decide
between bottle feeding and breastfeeding.37 Incidentally,
these booklets were obviously intended for the North
American market as they include a US telephone
number for joining the Abbott-Ross sponsored baby club.
In addition, although the parenting booklet was produced in 1991, it was still being distributed in 1997.

Wording like this may superficially fulfill the Code

stipulation regarding the superiority of breastfeeding.
Yet by giving glowing specifics about the artificial
product, while omitting them about breastmilk, it
damns breastfeeding with faint praise.32 Article 4.2
disapproves such text, which serves to idealize the use
of breastmilk substitutes. Similarly, text comparing
formula to breastfeeding does not impart the superiority
of breastfeeding. A Nestl booklet distributed in the late
1990s in the Philippines states There is no need to be
anxious about bottle feeding since modern science has
made infant formulas as similar to human milk as
possible.33
The negative effect at any stage of adding bottle feeds to
breastfeeding is especially likely to be downplayed or
omitted:
Q: My 2-month-old wont take a bottle.
A: Try these tricks Leave the room Let someone help
Try a nipple that resembles the shape of a real areola and
nipple34

Another booklet that was given to mothers in a health

care facility states,
If you wait until you and your baby have had at least 2 to 4
weeks of successful breastfeeding, supplemental feeding
shouldnt interfere with the establishment of your breastmilk
supply.35

Most information never mentions the difficulty of reversing the decision not to breastfeed, nor does it point out
that this is a feed-by-feed decision. A standard delay in
starting to breastfeed of perhaps 24 hours amounts to at
least eight decisions not to breastfeed made sometimes
by the mother but probably more often by nursery proto-

Unlike this real picture of two mothers, commerciallysponsored information romanticizes bottle-feeding and does
not depict the more distant mothering style which it may
encourage. Photo credit: UNICEF photo by Bernard Wolff.

10

Unfortunately, the Code does not control the giving of

outright inaccuracy about the usual course of lactation,
misinformation which will reduce both the milk supply
and the confidence of a mother with a normally enthusiastic nursling. Mead Johnson was distributing information in the Philippines in 1997 counseling mothers to
avoid nursing baby in bed especially at night when one
may fall asleep. This statement is followed by a list of
reasons why breastfeeding might fail and a full page on
formula feeding.38 Lactation consultants, pediatric
associations, and government health agencies are
justified in challenging the distribution of such inaccurate information.

Another company that markets both pumps and feeding

bottles mentions nipple confusion but then advises,
After the first few weeks, giving him a bottle of expressed
breastmilk periodically, when it is convenient for both of you, is
all you need to do.41

Donations Only Upon Request

Article 4.3 forbids donations of educational materials
from manufacturers unless they are specifically requested, with government approval, and distributed
only through the health care system (not, for instance,
through schools or community nutrition programs).
They may not bear any brand names or pictures of
products. And, of course, if they mention infant feeding
at all, they should observe the standards of Article 4.2.
Article 4.3 aims to keep dissemination of educational
materials within the same health care system which
must deal with their potential health consequences.

Illustrations that idealize the use of breastmilk substitutes fail to abide by Article 4.2. We all recognize the
characteristic aspect of the habitually bottle-fed infant
turned away from the mother while sucking, in
minimal body contact, looking anywhere but at her face
(as in the photograph on page 10). Yet this very common
pose is not shown in commercial illustrations. Instead,
although the text may allude to the closeness of
breastfeeding, adjoining pictures will suggest the closest
bonding between mother (and perhaps father) and
bottle-fed baby; breastfeeding pictures typically omit
the father, cut off the mothers head, or show lack of
eye-to-eye contact.

No Promotion to the General Public

and Mothers (Article 5)
Article 5 is aimed at stopping promotion that reaches
everyone such as mass-media advertising and promotion in places where infant feeding products are sold
including pharmacies, supermarkets and road-side
kiosks. Article 5.1 is a model of clarity. Advertising and
promotion of bottles, teats, breastmilk substitutes or
any other product within the scope of the Code is not
allowed. Promotion is a broad term that encompasses
all means of encouraging the sale of a product. It
includes not only advertising and retail level discounts,
gifts and samples, but also sponsored public relations
activities such as radio or TV programs, baby shows,
health fairs, internet websites and other strategies to
bring products to public notice.

Breast Pump Information

Breast pumps are not covered by the Code, but bottles
and teats are. Here, as in many other areas, there is a
fine line between information and promotion of a
particular artificial feeding device. Breast pump instructions which state that expressed milk may be fed
by gavage tube, dropper, nursing supplementer, spoon,
cup, special feeder, or bottle give a fair range of options.
But a pump advertisement which idealizes use of a
bottle and mentions no other way to feed expressed milk
is promoting products within the scope of the Code.

Why ban promotion? Because it creates a tendency to

use artificial milks unnecessarily, or even a belief that
they are essential. Their use correlates everywhere with
increased infant morbidity, and in many countries, with
greater infant mortality.

Baby will feed happily from the soft, wide, breast-like nipple
because combining breast and bottle feeding is easy with
Avent.39

Since pump information deals with the feeding of

infants, it should comply with all requirements of
Article 4.2. In particular, it should discuss the superiority of breastfeeding (not just breastmilk), and the
negative effect on breastfeeding of introducing partial
bottle-feeding. Some pump advertising reads like a
strong sell for casual mother-baby separation:

It is vital to understand that absence of advertising does

not mean that formula will become unavailable. Many
widely used products are not promoted to the public.
Vegetables, string, notebook paper (or exercise books),
pencils, T-shirts and matches come to mind. These
common items are sold almost everywhere in the world,
and most people can afford them, thanks in part to the
absence of advertising costs. Families that need infant
formulas or bottles can still buy them if advertising and
public promotion are eliminated; possibly, the products
may even become less expensive.

whether youre dashing off for the weekend or holding an

impromptu supper party for friends, the last thing you want to
worry about is feeding a truly versatile range of equipment
from nipple shields and breast pumps (express your milk in
advance and freeze it for a special occasion) to the new shaped
feeder and teat which gives your baby the next best thing to
breastfeeding.40

11

After the International Code was passed, most companies stopped advertising infant formula in what they
refer to as developing countries. In the mid-1990s,
most members of the European Union passed laws on
the marketing of infant and follow-up formulae. The
European laws are based on a Directive of the Commission of the European Union which is weaker in some
ways than the International Code. The Directive, for
example, allows advertising of infant formula and
follow-up formula in publications specializing in baby
care and scientific publications. Many countries in
Europe included this clause in their national law
leading to the situation in which companies are allowed
to advertise these products in parenting magazines but
not in more general publications.

A Ban on Free Samples, Gifts and

Other Tactics
Article 5 also bans the distribution of samples of products within the scope of the Code as well as other
promotional tactics at the retail level such as coupons
and discounts on products. The article also prohibits the
distribution of free gifts of articles or utensils which
may promote the use of breastmilk substitutes or bottlefeeding (Article 5.4).
Does termination of samples work a hardship on low
income families? On the contrary, it is in their best
interest. If a mother cannot afford to buy her babys first
500 gm. tin of a breastmilk substitute, how then can she
afford to purchase the approximately 39 additional tins
needed to feed her baby adequately during its first six
months? In low income families particularly, having to
buy baby milk and chemicals or fuel for sterilization may
lead to nutritional deprivation of the other children and
the mother.44 In 1998 in Slovakia, buying enough formula
for a 3-month-old baby took 50% of the minimum wage
and 26% in Poland.45 UNAIDS calculates that a years
supply of infant milk in Pakistan requires 31% of a years
urban minimum wage, in Brazil 22% and in Kenya 84%.46

Although the Code has never been implemented by the

United States government, for some years the major
American manufacturers of infant formula adhered to
their own voluntary agreement not to advertise directly
to the public. The agreement was, of course, in their
own best interest as they had each developed extensive
marketing channels through direct contacts with
pediatricians and other parts of the health care system.
When Nestl entered the US market for infant formula
through its purchase of Carnation and begin direct
advertising to the public in the late 1980s, however, the
voluntary agreement not to advertise collapsed.

In countries of rapid population growth and limited access to family planning services, the low income mother
helped with a sample of formula or a feeding bottle may
conceive earlier due to diminished prolactin levels, and
have yet another mouth to feed too soon. Professor Roger
Short has dramatized this problem by stating that anyone who gives a woman a tin of formula should also be
responsible for giving her a tin of condoms.47

This failure to abide by one of pillars of the International Code in the United States has international
implications, particularly since the advent of the
Internet. Companies have developed or supported
websites devoted to marketing their infant food products, often under the guise of providing breastfeeding
and other infant feeding information. Mead Johnson, for
example, has a website advertising home delivery of
Enfamil infant formula. Nestles website lists and
describes its lines of infant and follow-up formulae.
Wyeth Nutrition also actively advertises formula that it
manufactures for various chain stores.42 This direct
advertising is of course available to anyone with access
to the Internet anywhere in the world, including the
many countries where the Code is law.

Article 5.5 precludes direct contact with mothers by

company marketing personnel. This should eliminate
the free phone numbers maintained by manufacturers
to dispense advice to mothers. Companies also should
not urge mothers to write for advice, nor provide clinic
talks through milk nurses. An advisory number
maintained by a breastfeeding support group, a community nutrition service, or a hospital is all right. But an
advisory number funded by a company that produces
breastmilk substitutes, bottle-fed juices, or other
products under the Code, is not.

It is also important to note that some multinational

companies commitment to the Code is limited to developing countries and to infant formula. Most companies
have begun or never stopped advertising other infant
feeding products such as follow up formula and other
infant foods promoted for the very early months. In the
Philippines, Wyeth and Mead Johnson use full-page
newspaper advertisements to push their follow-up
formula brands.43 Follow-up formula is also advertised
on placards on public buses.

What can the individual lactation consultant do about

information which violates the provisions of Articles 4 and
5? Some have challenged distribution of commercial leaflets in their work setting and sought a budget allocation
allowing the purchase of more objective material. Others
have selected from the range only those few items which
are in full compliance with the Code.
Still others have pursued national or state legislation or
regulations that will emphasize to all commercial
sources that Code provisions on information reaching
the public must be observed scrupulously.
12

Part 3
Articles 6, 7 and 8
Encroachment of Commercial Messages
Imagine a hospital respiratory diseases unit which displays
cigarette company logos. It offers leaflets written by tobacco
companies with fragmentary and misleading information about
respiration, and gives every patient a sample packet of reduced
nicotine cigarettes. The lung specialist has just returned from a
professional conference titled Promoting Pneumonic Progress,
about reducing tars in smoke, sponsored by a cigarette
manufacturing firm. He has just received a Tobacco Foundation
research grant to compare the health of Puffums Perfects
smokers with the health of people who smoke other brands (but
not with the health of non-smokers).

Routine violations of Code provisions may be built into

health care settings. Companies view the health care
system and health workers as the most direct avenue to
mothers and babies and health workers as the best
authority to recommend new products. A recruitment ad
placed in a Malaysian newspaper by a major manufacturer of infant formula describes the job of nutritional
representative as to promote, sell, educate and create
demand for the usage of the companys products
through regular and aggressive coverage of all heath
care professionals.50

The unit distributes handsome booklets provided free by a

tobacco company, titled Healthy Breathing. They first praise
getting off to a good start by breathing plain air, but then
when ordinary breathing becomes inconvenient, or the person
has become ready for something more, Puffums Perfects are
closest to Natures own freshness, specially formulated by
leading experts in air modification. New improved Puffums
Perfects, now better than ever before. Puffums Perfects - when
plain breathing just isnt quite enough.

It is exclusive and continued breastfeeding that are

most threatened. It has been manufacturers strategy to
promote breastfeeding when possible at the start
while representing formula as the only alternative or as
an eventual necessity. Underlying every breast is best
statement are the messages that breastmilk needs to be
supplemented, that follow-up formula is necessary at
four or six months implying that breastfeeding
should stop, that working women need formula, that
fathers cannot bond with their infants unless they take
part in early feeding and that early feeding of herbal
drinks, biscuits, bottled water and/or other packaged
infant foods are common and necessary.

Can we give this scenario the laugh it deserves, and yet

continue to accept in our health care settings parallel practices
lessening the health of babies?

Lactation consultants and breastfeeding counselors are

health workers as defined by Code Article 3: persons
working in any part of a health care system, whether
professional or not. The health care system includes
institutions, private practices and offices (health care
facilities), and voluntary organizations working directly
or indirectly in health care. Like other health care
workers, LCs may be unwittingly disregarding Code
provisions which apply to their work.

Years of exposure to literature with an oversimplified

breast or bottle dichotomy has so affected the thinking
of many health workers and parents that they fail to
consider any other options. In one recent survey of US
pediatricians attitudes and practices regarding
breastfeeding, only 65% recommend exclusive
breastfeeding in the first month and only 61% recommend breastfeeding to continue for one year. Another
finding was that the majority of those surveyed agree or
are neutral regarding the statement that breastfeeding
and formula feeding are equally acceptable methods of
infant feeding.51

Articles 6 and 7 are aimed at keeping commercial messages about infant feeding out of the health care system.
The Innocenti Declaration, adopted in 1990 states that as
a global goal for optimal maternal health and child health
and nutrition, all women should be enabled to practice
exclusive breastfeeding and that after the period of
exclusive breastfeeding, all children should continue to
be breastfed, while receiving appropriate and adequate
complementary foods, for up to two years of age and
beyond.48 The Declaration goes on to state that attainment of this goal requires, in many countries, the reinforcement of a breastfeeding culture and its vigorous
defense against incursions of a bottle-feeding culture.

Health workers still engaging in customary activities,

which may be stipulated in their nursing protocols and
reinforced by manufacturer-funded research and free
literature for medical workers, are simply out of touch.
Articles 6 and 7 give a series of nos, not to be unduly
critical, but to help nations, institutions, and individual
health workers halt intrusion of misinformation and
commercial promotion into both their practices and
their patterns of thinking about infant feeding.

The Baby Friendly Hospital Initiative (BFHI), which promotes adoption of the evidence-based Ten Steps to Successful Breastfeeding and the elimination of free supplies
of baby food products, seeks to change hospital practices
that are harmful to breastfeeding and in so doing, promote
a breastfeeding culture.49 The International Code is synergistic with the BFHI and is aimed at protecting breastfeeding from inappropriate marketing practices.
13

the Wyeth formula S-26 is associated with a particular

cartoon baby which at one time appeared on the product
label. This particular image appears on a multitude of
items displayed in health care facilities in Argentina
along with the Wyeth name.54

Health Care Systems (Article 6)

The intention of Article 6 is to make breastfeeding, not
bottle feeding of formula, the norm in every health care
facility.52 The first provision of Article 6 spells out the
obligation of health authorities to promote and protect
breastfeeding and to inform health workers about their
responsibilities under the Code. The rest of Article 6
covers the activities that should not take place within
the health care system. Products within the scope of the
Code should not be promoted within a health care
facility (with the caveat that the dissemination of
information to health professionals is not precluded)
(6.2). There should be no display of products or posters
or charts mentioning such products (6.3). No formula
company materials should be distributed other than
information permitted by Article 4.3 (with no reference
to a proprietary product).

Health workers concerned about breastfeeding and the

Code should not accept or distribute such items because
they also serve to promote infant feeding products. Why
else would companies spend money to produce such items?

Gifts and Free Samples

Samples and gifts are popular means of product promotion and are thus also prohibited by the broad prohibition of the use of a health care facility for promotion.
Article 3 defines a sample as a single or small quantity of a product provided without cost. A number of
studies undertaken in the 1980s and early 1990s
demonstrate the adverse effect of infant formula
samples on the duration of breastfeeding.55

Article 6 also prohibits the use of mothercraft nurses or

other personnel paid for by manufacturers or distributors in a health care facility (6.4). Only health workers
may demonstrate how to use infant formula and only to
family members who need such information, with a
clear explanation of the hazards (6.5). A physician or
other health worker giving private instruction in
artificial feeding can, of course, recommend a brand and
give any needed specifics about its preparation. However, formula and bottle labels, for which the Code
stipulates minimum requirements in Article 9, should
always be adequate in themselves to permit intelligent
use of the product. Finally, equipment and materials
that are donated to a health care system should not
refer to any product brand name (6.8).

Health professionals involved in developing the Code

urged that all such distributions should be ended. Looking ahead a bit, Article 7 consequently stipulates that
health workers should not give product samples or bottles
to mothers or their families (7.4). It will be recalled that
Article 5 also prohibits the practice of sampling by manufacturers and distributors. (See p.11).
LCs will be well aware that in many countries this
provision is not observed. Samples, particularly in
hospital discharge packs, are still common. A study by
the Interagency Group on Breastfeeding Monitoring
(IGBM) found that in Bangkok in 1997, 97 out of 370
mothers interviewed (26%) reported receiving a free
sample of a breastmilk substitute, feeding bottle or teat.
The study states that most of the samples were reported to have come from a health facility; this suggests
that samples given to facilities were passed on to
mothers, whether or not that was the intention of the
company donating the samples.56

What does this mean in practice? Leaflets, baby care booklets, growth records, posters, cot cards, development
charts, films, videotapes, prescription pads, and all other
items seen by mothers may not mention or depict any
particular product within the scope of the Code. Printed
information on infant feeding may be distributed, so long
as it includes all points stipulated in Article 4.2 (see pp.
9-11) and does not mention brand names.

The distribution of discharge packs containing infant

formula samples and literature advertising formula or
other promotional items also falls within the prohibition
of Article 6.2 as well as Article 5 which prohibits manufacturers and distributors from distributing gifts that
may promote the use of breastmilk substitutes or bottle
feeding. Even discharge packs specifically aimed at the
breastfeeding mother often contain prohibited items.

Many companies try to get around the prohibitions of Article 6 by distributing posters, calendars and a whole array of other items that depict babies, breastfeeding mothers or images associated with babies such as toys and baby
animals along with their company name. Because no particular product is ever mentioned, companies claim that
these items do not violate the Code.
A recent trend reported by the International Code
Documentation Centre in the 1998 Breaking the Rules53
is the marketing technique of associating products with
symbols, colors and slogans, a tactic that has long been
popular for cigarette advertisements. These associations
become known to health workers and mothers so that
companies achieve the effect of advertising without ever
mentioning a brand name. For example, in Argentina,

In 2000, Mead Johnson was distributing a breastfeeding

bag in US hospitals containing 4 packets of formula
powder, each enough to make a 4-ounce feed; a one-page
pamphlet entitled A Formula made for You; a booklet
advertising home delivery of Enfamil infant formula
and an enrollment form for Enfamil Formula Beginnings which entitles the applicant to receive a wealth of
14

information at home. The company was conducting an

in-service training for health workers specifically about
its breastfeeding bag, which they encourage heath
workers to distribute to mothers. To encourage attendance of this training, the company was offering a
sweepstakes with a chance to win a trip to the 2001
Grammy awards in Hollywood.

and free supplies were never available in the poorest

countries such as Nepal and Burkina Faso. Yet in the
US and Canada some companies have been reported to
have payed enormous sums of money to individual
hospitals for the privilege of being the sole supplier of
free breastmilk substitutes.
In 1985, so many questions were raised about the
availability of free supplies in hospitals that WHO
convened an expert meeting to define the term infants
who have to be fed on breastmilk substitutes. The
Report of the meeting stated that routine availability of
breastmilk substitutes in maternity wards and hospitals was not only unnecessary but potentially dangerous
and should not be permitted since the number of infants
who need them is so small.57

Free or Reduced-Cost Supplies

(Articles 6.6 and 6.7)
When the Code was being developed, manufacturers
made an urgent plea to be permitted to continue providing case lots of formula to institutions. They contended
that a considerable number of babies for one reason or
another needed breastmilk substitutes following birth,
and that despite the costs to themselves, supplies of
formula were given out of a spirit of generosity to hardpressed institutions. They also insisted on their wish to
supply free formula to orphanages, emergency feeding
centers, and the like.

These conclusions were incorporated into a resolution of

the World Health Assembly, adopted by consensus
including all industrialized member nations, in May
1986. The relevant passage urges member states
to ensure that the small amounts of breastmilk substitutes
needed for the minority of infants who require them in
maternity wards and hospitals are made available through the
normal procurement channels and not through free or subsidized supplies.58

Health workers involved in the joint Code drafting

process agreed that perhaps supplies programs had
some value. However, they felt that any direct distribution of supplies, for instance to mothers of twins, or to
mothers who are health workers and thus likely to
influence others, was risky.

Despite this internationally agreed upon statement,

supplies donated or sold at low cost to hospitals persisted in developing nations as well as in many industrialized countries.

Articles 6.6 and 6.7 of the Code represent the ensuing

compromise:

In 1991 the UNICEF Executive Board adopted a resolution calling for the end of free supplies by the end of
1992. This resolution was echoed by the WHA in 1992.
Still not satisfied with progress, the 1994 World Health
Assembly adopted a resolution urging member states
to ensure that there are no donations of free or subsidized supplies of breastmilk substitutes and other
products covered by the International Code in any part
of the health care system.59 Between 1992 and 1995
many countries issued directives or circulars forbidding
health care facilities to accept free supplies.

Donations allowed, but only for babies that have to

be fed on breastmilk substitutes (6.6)
Supplies are not to be used by manufacturers or
distributors as a sales inducement (6.6)
Supplies are to be continued for as long as the infant
needs them (6.7)
Experience subsequent to the adoption of the Code in
1981 proved that the supplies clause provided an
enormous loophole. There was no definition of which
babies had to be fed on breastmilk substitutes nor was
there any guidance regarding the duration of need.
Donations of large quantities of infant formula and
other infant feeding products became routine in hospitals around the world. Because the majority of health
workers were poorly trained in breastfeeding management, the supplies led to the routine use of pre-lacteal
and supplementary feeds which undermined the establishment of breastfeeding.

Health workers should be aware of the rules governing

free supplies in their countries and educate themselves
about how their own facilities obtain the products that
are used. The Code does not ban the use of breastmilk
substitutes in health care facilities, but they must be
purchased just like any other medical or food supply.
The health service, or social welfare department it
liaises with, must ensure that the mother will have a
supply of formula for as long as her infant needs it
that is at least 6 months, requiring 20 kg (44 lbs) of the
powdered product.

From the large amounts that companies have been

willing to spend to give away their products, it is
obvious that giving free supplies to hospitals has been a
successful marketing technique. Donations to orphanages or for individual abandoned babies have been rare

The knowledge that Human-Immunodeficiency Virus

(HIV) may be transmitted from mother to child during
breastfeeding does not change these principles. Many
governments are considering ways to make alternative
15

feeding options available to HIV-positive mothers who

have decided not to breastfeed. It is vital for infant
health that such options do not lead to a spill-over of
artificial feeding to infants of HIV-negative mothers. If
hospitals and health centers have to buy formula, as
they usually buy drugs and food, this should ensure
that it is provided in a carefully controlled way, and not
wasted or misused.60

lated in Article 4.2. Furthermore, the information

should not imply or create a belief that bottle feeding is
equivalent or superior to breastfeeding.
Few manufacturers comply. Both illustrations and
wording of most promotion to medical professionals
romanticize artificial feeding, and suggest it is very
similar to breastfeeding. Promotion provokes doubt
about the wisdom or feasibility of breastfeeding and
stirs up fears through biased presentation of data.

It is vital to understand that use of products within the

scope of the Code is not curtailed. Only their promotion
is to be stopped. A hospital which feeds patients bread
does not also display posters for the brand or distribute
publicity flyers for it. Bread is available as needed, but
never promoted to patients. Infant formula, another
foodstuff for patients, should be used in the same way.

Typically it also omits essential information on the

superiority of breastmilk immunologically as well as
nutritionally. Health professionals hear from the manufacturers about the importance of nutrients such as
lactoferrin, docosahexaenoic acid (DHA) and secretory
IgA only when they succeed in adding them to commercial products. When Snow Brand, a Japanese manufacturer of infant formula, succeeded in adding taurine, a
substance abundant in breastmilk, to its milk products,
they gave it all kinds of publicity and even created a
new product called Snow Brand T1 (for taurine-enriched). But so long as valuable elements are available
only in breastmilk, they will receive no publicity.

Bottles, formulas, and informative booklets without brand

endorsements can continue to be available when required
in the case-by-case judgment of health workers and
parents. Their right to make decisions is unimpaired. The
Article 6 ban on promotion within the health care system
aims to protect that right, keeping it free of distortion by
explicit or subliminal commercial messages.

Section 7.1 charges health workers to protect and

promote breastfeeding and to familiarize themselves
with the information required by Article 4.2. Lactation
consultants are already fully conversant with most of it.
However, they may not be able to explain the social and
financial implications of using breastmilk substitutes.

Promotion to health personnel often leaves out virtually

all of the information required by Article 4.2. Some
manufacturers simply reprint portions of the text of
Article 4.2 in place of complying with it, like a driver
who expects to drive as fast as he pleases, so long as he
has jotted down the speed limit on a notepad. Often,
some of the required information can found at the
bottom of the page, but in minuscule letters that can be
read only with the aid of a magnifying glass.

We should be prepared to tell both parents and policy

makers the actual cost of buying other milks and foods
in adequate quantities for two years replacement of
breastmilk, along with the equipment, water, fuel,
chemicals, and time needed for correct preparation. We
can calculate the likely costs in additional health care
and in parental time away from employment for the
non-breastfed child. In countries where baby feeding
products are imported, costs in foreign exchange become
an added burden for the economy.

It is common for companies to compare their formula

favorably with breastmilk in advertisements and
literature to health professionals. Such text violates
Article 7s prohibition of creating a belief that bottle
feeding is equivalent to breastfeeding. Detailing material for Nestles Nan infant formula in Pakistan in 1997
compares the product to human milk stating that it is
virtually the same as breastmilk, same as breastmilk
like breastmilk and mirrors the constituents of
breastmilk.62

Morbidity studies as well as studies on health care costs

that result from formula feeding help to dramatize the
hidden financial implications.61 Perhaps the costs are
borne by families, perhaps by a government program-but
for every decision not to breastfeed, someone has to pay.
Article 7.1 urges us to know who pays, and how much.

Readers are invited to consider to what extent the

following examples from professional journals conform
to Article 7.2s mandate that product information to
health professionals be restricted to matters that
scientific and factual:

Health Workers (Article 7)

One advertisement for Wyeths store brand formulas,

appearing in several medical journals, pictures a
pyramid of formula cans surmounted by a cute baby
clutching a bottle. The text states, The best news for
parents today is these less expensive formulas. Free
samples to doctors and a toll-free information line for
parents are offered.63

Scientific and Factual Information Only

(Article 7.2)
Under Article 7.2, product information to health professionals must be restricted to scientific and factual
matters, and must contain all the information stipu16

has been interpreted by formula companies to allow the

practice of giving all kinds of so-called gifts to doctors,
nurses and other health workers ranging from text
books and stethoscopes for medical students to leatherbound diaries to pens, pencil holders, prescription pads
and wall calendars. Nestles internal marketing instructions issued after the Code was adopted lists personal
gifts such as chocolates and key-rings as no longer
appropriate, yet includes a whole list of items of professional utility as permitted.69

A Nestle advertisement also shows a cute baby and

claims that the combination of a feeding bottle and
Good Start formula, both illustrated, helps keep babies
and parents content. The tag line is bringing out the
very best in babies.64
Neither of these advertisements includes the information required by Article 7.2. Other manufacturers
promotion, to be seen in many journals for health
professionals, except where editors and sponsoring
associations have adopted specific Code-inspired policies, shows similar examples of violation of the Codes
minimum universal requirements. A bottle-fed electrolyte replenisher for babies is advertised as a nippleready part of simple solutions for happy babies. An
information line for parents and a consumer website are
publicized by this formula manufacturer for these apple
and grape flavored drinks for infants.65

Also appropriately classed as gifts are medical books

and substantial workshop reports published by companies. Frequently these are not sold by ordinary medical
bookstores. They are available primarily as free gifts
from manufacturers representatives to selected health
professionals. The doctor who requests a copy commits
himself to further contact with formula company
personnel and products.
Companies have become more and more creative in
what they offer to health professionals. In the Philippines, Mead Johnson was offering doctors a Club Med
Privilege Card touted as available only to doctors and
providing a years membership to Club Med with credit
card privileges.70

Gifts and Samples (Articles 7.3 And 7.4)

Article 7 places only mild restrictions on the relationship between manufacturers and health workers. The
compromises achieved during the development of the
Code allow the baby food industry to make contacts
with health workers by providing literature, equipment,
research, samples, travel funds and other assistance to
individuals and institutions.

A study published in the Journal of the American

Medical Association explains how gifts, even if not
expressly given as an inducement may influence professional decisions:

Commercial practices of this nature have strongly

influenced health care workers in developed and developing countries. Most health workers are accustomed to
reading company advertisements in their journals;
accepting company sponsorship of their conferences;
receiving donated equipment in their institutions and
free professional books for themselves; and attending
workshops given by doctors who are paid by the baby
food industry. Such industry presence has a purpose as
was well articulated back in 1980:

whenever a physician accepts a gift from a drug company, an

implicit relationship is established between the physician and
the company or representative. Inherent in the relationship is
an obligation to respond to the gift.71

While most health professionals scoff at the idea that

they might be influenced by gifts, they also know that
companies are motivated by profit. No drug company
gives away its shareholders money in an act of disinterested generosity.72 One author suggests that the
acceptance of gifts in virtually any form violates fundamental duties of the physician of non-malfeasance,
fidelity, justice and self-improvement.73

Abbott Topics, Abbotts medical magazine, is mailed four times a

year to some 150,000 readers, including doctors, interns,
medical students, and hospital personnel. Its objective: to gain
physician goodwill In effect, we are striving to make the
physician a low-pressure salesman of Abbott.66

Moreover, most routine gifts from infant formula

companies serve as advertisements either for specific
products, for a particular line of products or for the
company name. Companies give out pens, pencil holders, calendars, growth charts, prescription pads and a
plethora of other items imprinted with company or
brand names and logos. These are often displayed in
plain view of parents and pregnant women in clinics
and maternity and pediatric wards. Minor gifts showered by retail persons on individual health personnel,
while ostensibly to generate goodwill and information,
also serve to keep the name of the company in constant
view and play a critical role in molding opinion and
influencing decisions.74

In 1988, a Philippine pediatrician remarked, Its not

the detailing per se that captures the doctors. Its the
ride home, the ticket to Manila, buying a book. It
creates a relationship and a debt of gratitude.67 More
recently, a former medical delegate for Nestles Pakistan subsidiary described how his job required him to
record incentives to doctors so that he could later use
them to pressure the doctor into prescribing more
Nestle products.68
Under Article 7.3, health workers should neither be
offered nor accept any financial or material inducements to promote products within the scope of the Code.
The inclusion of the word inducement in Article 7.3
17

Money talks. The Codes mild disclosure requirements,

even when sometimes observed, are inadequate to
protect health workers from influences which in the
long run are likely to vitiate their objectivity. Conflict of
interest has been defined as a set of conditions in
which professional judgment concerning a primary
interest (such as patients welfare or the validity of
research) tends to be unduly influenced by a secondary
interest (such as financial gain).78 An editorial in the
British Medical Journal recently looked into the question of conflict of interest:

Article 7.4 prohibits manufacturers and distributors

from giving samples of products within the scope of the
Code to health workers with the exception of samples
necessary for professional evaluation or research at the
institutional level. While these exceptions would seem
to be quite limited, world-wide monitoring has continued to show that providing product samples to health
professionals is a widespread and regular practice. The
1997 study by the Interagency Group on Breastfeeding
Monitoring (IGBM) of marketing practices in South
Africa, Poland, Bangladesh and Thailand showed that
across the four cities, from 3 out of 40 (8%) to 20 out of
40 (50%) health facilities had received free samples
which were not being used for research or professional
evaluation.75 As noted above, the samples end up being
given out to mothers.

Several studies have shown that financial benefit will make doctors more likely to refer patients for tests, operations, or hospital
admission, or to ask that drugs be stocked by a hospital pharmacy.
Now we are beginning to have data on the effects of conflict of interest on publications. Original papers published in journal supplements sponsored by pharmaceutical companies are inferior to those
published in the parent journal. Reviews that acknowledge sponsorship by the pharmaceutical or tobacco industry are more likely
to draw conclusions that are favorable to the industry.79

Funding (Article 7.5)

In 1988, an Indian Pediatrician described how manufacturers were strengthening their hold on the health care
system by nurturing the young undergraduate medical
student and by supporting the older pediatricians for
their so-called academic pursuits.

Consider the example of the funding of universitylinked institutes such as the Institute of Pediatric
Nutrition at Harvard University (USA), which is
sponsored by Abbott/Ross.80 The head of this institute
contended in his 1994 parenting book:

Currently, Nestl is giving huge amounts of money to the

Indian Academy of Paediatrics for conducting a quiz program
for the undergraduate students in 108 medical colleges of India.
These students are given free travel by Nestl and are put in
posh hotels. They are tempted to win prizes up to Rupees
16,000 (more than US $1000). For senior pediatricians, the
company has been holding Nestl Nutrition Workshops in
different parts of the world. The entire expenditure for the visit
abroad is met by Nestl. But most important, the company has
made the health system an addict to artificial feeding.76

The choice about whether to breastfeed or to bottle-feed comes

down to personal preference babies thrive with either method
of feeding.81

Reputable scientists who attend industry-funded workshops may not realize that literature selectively published
from their presentations may become a point of entry for
company representatives into the offices and the minds of
medical colleagues. It greatly benefits companies to be
able to publish over their logos technical information
about lactation, building their credibility as being in favor
of breastfeeding, and associating names of recognized
authorities on infant feeding with particular commercial
products. Formula company aid for doctors events
discussing breastfeeding is therefore always ready.

Indias passage of a law in 1992 on the marketing of

breastmilk substitutes as well as policy changes within
the Indian Academy of Paediatrics has put an end to
many of these practices there.
Article 7.5 recognizes the problem of some medical
professionals dependence on companies. It does not
prohibit contributions to health workers for fellowships, study tours, research grants, attendance at
conferences or the like (Article 7.5). It merely stipulates that donors and recipients should be open about
the source of such funds. Those who attend conferences
through formula manufacturers aid are to report to
their superiors. A survey in Italy on the financing of
continuing medical education of pediatricians in the
Naples area during 1998 showed that of 136 pediatricians interviewed (17% of the total), 120 (88%) reported
that their travel or hotel expenses, or both, had been
paid fully by the baby food industry; and 60 pediatricians had received medical or computer equipment for
their office.77 Lactation consultants also have been
offered such aid by companies that distribute feeding
bottles, teats and pacifiers, which has no explicit price
tag but contains an implicit hint of future cooperation.

By allowing companies to continue promotion to health

professionals, the Code leaves them vulnerable to what
the late Dr. Derrick Jelliffe called manipulation by
assistance. Lactation consultants will need to consider
if they too have experienced some of these ostensibly
helpful but insidious strategies.
Article 7.5 does not preclude acceptance of such funding by
professionals. Nevertheless, reflection on its implications is
appropriate. Beginning in the late 1980s more and more
organizations have been rethinking their position on this
issue. In 1987, an international group of doctors developed
a declaration of support for breastfeeding. Signatories under all ordinary circumstances [will] not accept personal
funding from an infant food company for purposes such as
travel, research, or equipment.82 Since its original publication, thousands of physicians from many countries have
signed the Declaration at professional meetings.
18

At the 1992 International Pediatric Association (IPA)

Congress, James Grant, then Executive Director of
UNICEF, called on the IPA to seriously debate the
impact of accepting financial support from infant
formula manufacturers on your ability to lead a movement for a massive return to breastfeeding.83

the code and will continue its long-standing support for

breastfeeding programs worldwide.88

Persons Employed in Marketing (Article 8)

The volume of sales of bottles and of bottle-feeding
products of any sort should not serve as the basis for
commissions or bonuses to company representatives. If
the manufacturer is complying with the Code, the
representatives job is not at stake when use of formula
and bottles decreases. Since no major manufacturer
relies upon baby milk as its sole product, if the health
care system market shrinks, sales people can be deployed into other areas. Knowing this, the LC can
maintain a friendly relationship with representatives
who visit the hospital, even as she consistently refuses
to accept their free supplies and literature.

The 8th Asian Congress of Pediatrics, February 1994,

was hosted by the Indian Academy of Pediatrics. The
Congress organizing committee rejected all formula
company funding, hundreds of thousands of dollars.
They also took steps to distance any displays of
breastmilk substitutes from the scientific sessions.
This principled action draws on their years of discussion, and on the teachings of Gandhi and Vivekananda.
In 1996, the World Health Assembly expressed concern
that health institutions and ministries may be subject
to subtle pressure to accept support for professional
training in infant and child health. The Assembly
resolution urged Member States to ensure that the
financial support for professionals working in infant
and young child health does not create conflicts of
interest.84

For LCs, a more important provision of 8.2 states that if

someone is marketing bottles, teats, formulas, or other
bottle-fed foods, they should not be educating mothers
of babies and young children. Marketing as defined by
Code Article 3 includes promotion, distribution, advertising, and product public relations, not just selling.
This provision would prevent an LC who distributes
publicity leaflets, for example, on a specific type of
rubber teat, nipple feeder or breastmilk feeding
bottle with any form of nipple from advising mothers.
By agreeing to promote specific products, the LC places
herself in the category of those employed in marketing
products within the scope of the Code.

Following this action, the Executive Board of the Indian

Academy of Pediatrics decided that it should not accept
sponsorship in any form from companies under the purview of the Indian law on the marketing of breastmilk
substitutes. In 1997, the General Body of IAP passed a
resolution not to take support in any form from the manufacturers of infant formulas and feeding bottles and from
any company involved directly or indirectly with the manufacture or sale of such products.

La Leche League International, the Nursing Mothers

Association of Australia, and a number of other
breastfeeding support groups have endorsed the International Code in its entirety. The International Board of
Lactation Consultant Examiners has adopted a new
Principle 24 to guide IBCLCs.

Pediatric associations in Pakistan and Brasilia Brazil

have passed similar resolutions. In 1999, The Royal
College of Paediatrics and Child Health of the UK voted
73% in favor of continuing to accept sponsorship from
baby food manufacturers but recommended that clear
criteria for should be developed for ethical sponsorship.85 The Italian Pediatric association launched an
initiative to develop a code on competing interests. The
code is based on the principles of the code of the International Pharmaceutical Manufacturers Association
and the International Code of Marketing of Breastmilk
substitutes.86

IBCLCs must adhere to those provisions of the International

Code of Marketing of Breastmilk Substitutes which pertain to
health workers.89

Some groups, however, may not yet realize that as

organizations involved indirectly in providing health
care, they are included in the Codes definition of the
health care system. LCs may find this distinction not
observed in local breastfeeding mothers groups, where
publicity for particular products is still distributed.

In 1999, the International Society for Research on

Human Milk and Lactation (ISRHML), broke with
years of commercial sponsorship and held its 9th annual
professional conference with funding only from noncommercial sources.87

As LCs and health workers wishing to comply with the

Code, we must be careful neither to endorse nor to
undertake other promotional activities for any specific
bottles, teats, breastmilk substitutes, or any other
bottle-fed foods or drinks. Used well, the Code articles
on health care systems and health workers can be our
allies in ensuring that our facilities build health, not
commercial profits.

In late 2000, Carol Bellamy, UNICEF Executive Director confirmed that UNICEF does not accept donations
from manufacturers of infant formula whose marketing
practices violate this code and subsequent World Health
Assembly resolutions. UNICEF stands firmly behind
19

Part 4
Articles 9, 10 and 11
Discussion of the final sections of the Code may give a
dizzying sense of dissonance, for what the Code says
and how it has been reinterpreted by baby food industry
representatives differ. In addition, a noticeable gap
exists between what the companies say they do and
what they actually do. Matters are further complicated
by many peoples eagerness to shift responsibility from
themselves by blaming the mother, as in the following
examples:

tic mother-baby images; they have added mention that

breastmilk is best. Even simple requirements, however,
may be disregarded when the silence of health professionals appears to sanction traditional labels While the
International Code does not require full information
mentioning the needed elements which formulas lack,
an honest label might well read:
Deficient in lactoferrin, lysozyme, leucocytes, immunoglobulins,
L.bifidus growth factor, and all other protective elements found
in mothers milk. Use of this baby milk increases your childs
risk of gastroenteritis, acute respiratory infections, and
allergies. Because the formula lacks the balance of long chain
fatty acids found in breastmilk, it may not encourage optimal
visual and brain development.

She didnt breastfeed even though we told her she must.

Shes too nervous, too young, too insecure.
She didnt read the fine print of our instructions.
She didnt boil the bottle for ten minutes six times a day.

USA cigarette warnings model what honesty about

infant formulas might require. In the current climate
where optimal health of babies is not the overriding
consideration, however, protective factors are not likely
to be mentioned on formula labels unless it is in the
companies best interest. Companies publicize such
factors only when they succeed in adding them as new
ingredients to their infant formulae, yet without stating
that they have always been available in breastmilk.
What the International Code asks for is relatively mild
some brief objective information on labels and the
elimination of tempting pictures and text.

She didnt boil the water.

She over-diluted the milk.
She doesnt care for her child properly.
She is too ignorant to do what we say.
She is too poor.

Baby food manufacturers and health professionals alike

still chant this litany when it may serve to let them off
the hook. The International Code of Marketing of
Breastmilk Substitutes embodies a more equitable
perspective. The Code in its entirety emphasizes the
specific responsibilities of international organizations,
national governments, manufacturers and distributors,
and health professionals collectively. The Code arose
from a recognition that when baby milk is promoted
anywhere in the world, the mother is not solely responsible for ensuing allergies, illnesses, malnutrition, and
death; nor is any single nurse or midwife. The child
who dies of breastmilk deprivation represents a multiple failure.

Figure 1. Infant Formula Label Checklist

(Article 9.2)
The information on an infant formula label must be:
clear and conspicuous
easily readable and understandable
in an appropriate language

Yet some manufacturers deny such responsibility. Asked

in 1978 if they took any steps to prevent the use of their
formula wherever water was impure or families were
impoverished, one company representative replied:
We cant have that responsibility. We cant have that
responsibility. Ten years later, they sang the same
refrain: Nous ne sommes pas responsables du fait que
lallaitement maternel soit remplac, dans certains
rgions, par des substituts que nous fabriquons.
(We are not responsible for the fact that, in some
regions, breastfeeding is replaced by substitutes which
we manufacture.)90

The information must include words such as:

Important Notice
a statement of superiority of breastfeeding
instruction to use product only on advice of health worker
specific instructions on appropriate preparation
(graphics are allowed)
warning against hazards of wrong preparation
The label may not include:
picture of a baby
pictures or text idealizing the use of formula

Labeling (Article 9)

terms like humanized or maternalized

Of all the elements addressed by the Code, labeling

appears to have improved more since 1981 than any
other. In much of the world, labels have dropped roman20

Most countries have laws stating what must appear as

well as what may not appear on labels of all types of
food products. Such laws are generally aimed at insuring that labels give information about the products
ingredients and composition and that they do not
present false claims about the products. The labeling
requirements in Article 9 of the International Code are
meant to complement such laws. The main object of the
labeling section of the Code is to make sure that labels
do not discourage breastfeeding and that they provide
the information that is necessary for appropriate use of
products within the scope of the Code.

Another common and harmful labeling deficiency is the

use of comparisons with mothers milk. Nearly all infant
formula labels include a short phrase such as breast is
best, yet do not adequately convey the superiority of
breastfeeding. Take the example of the label on Ross
Pediatrics Similac concentrated liquid sold in the USA.
The fine print states breast milk is best for babies, but
the large text on the front of the label states Closer
Than Ever to Mothers Milk as well as the phrases 1st
Choice of Doctors and excellent nutrition for babies.
In addition, many labels continue to use text or images
that idealize formula feeding. After the Code was
adopted, most companies removed pictures of babies or
mother/baby images from their labels. Yet, today we find
that such images have been replaced with others which
can equally be described as idealizing. The next time
you see packages of formula on the shop shelves consider the effect of images such as a teddy bear holding a
blanket and a pillow (Ross Similac), Peter Rabbit being
bottle fed on his mothers lap (Mead Johnsons Enfamil)
or a feeding bottle surrounded by flowers and a bear
(Nutricia, various brands).

The first provision of Article 9 applies to all products

within the scope, which includes feeding bottles and
teats. Article 9.1 states that Labels should be designed
to provide the necessary information about the appropriate use of the products, and so as not to discourage
breastfeeding.
It would seem evident that to provide necessary information, the label should be written in a language that
can be understood by those who are expected to buy the
product. Article 9.2 requires that the labels for infant
formula should be written in an appropriate language.
Some national legislation such as those in Sri Lanka,
Zimbabwe and Kenya requires that labels be written in
multiple languages. A number of companies fail to
comply with these requirements.

Figure 2. Label Requirements for all Products

Under Scope of Code (Articles 9.1, 9.3, 9.4)
Label may not:
discourage breastfeeding

Some labels still contain discouraging text implying

that breastfeeding is difficult and may be impossible or
insufficient. For example, a label of Milupa Aptamil sold
in Mauritius uses the phrase Quand lallaitement nest
pas possible. (When breastfeeding is not possible).
Similarly, the label of Bonna (by Wyeth) infant formula
in the Philippines reads Bonna is intended to replace
or supplement breastmilk when breastfeeding is not
possible or is insufficient.

Label must have:

a warning against the use of unsuitable unmodified product
as the only nourishment for baby
list of ingredients used
nutritive analysis
storage conditions
batch number and expiry date
(frequently embossed into bottom)

The labels for all infant formula packages, which

necessarily include soy, lactose-free, hypoallergenic and
formula for premature babies, must be in accordance
with Article 9.2. Those requirements are set forth in
Figure 1. Infant formula as well as any other food
product falling within the scope of the Code must also
comply with the requirements of articles 9.3 and 9.4
(see Figure 2).

Implementation (Article 11)

Implementation, referred to but not defined in the Code
itself, means giving effect to the International Code.
This means making the Code into a law or a set of
regulations with the force of law, or other suitable
governmental measures. The World Health Assembly
cannot itself promulgate laws, but it recommends the
Code as a minimum requirement for stronger action by
each nation. At the institutional or individual level,
implementation means putting in place guidelines,
complying or monitoring compliance with the Code.

For the most part, companies seem to be complying with

these requirements for the labels of infant formula, but
there are some glaring exceptions. For one, many
companies do not seem to find it important to include
the obligatory warnings. A 1998 survey showed that
various brands of formula in 20 of 31 countries did not
include a warning against the health hazards of inappropriate preparation.91

Countries are to transform the International Code into

measures that are appropriate to their own social and
legislative frameworks. If your country has taken no
steps since 1981 to implement the Code, it may be time
21

In Europe, nearly all of the members of the European

Union have enacted laws to implement the European
Community Directive on Infant Formulae and Followup Formulae (1991). Yet about one-half of those countries laws allow advertising in baby care magazines and
samples of follow up formulae.

to ask why. This mandate applies to all countries, not

just those where breastmilk deprivation is most lethal,
or those that are considered developing, and its enactment is consistent with freedom of choice.

Government Reporting
Some other countries such as Australia, South Africa,
Sweden, Malaysia and New Zealand have developed
voluntary codes in cooperation with the infant food
industry. In some countries this arrangement may work,
but it really depends on the commitment of the body in
charge, monitoring and taking action upon violations. In
Australia, the voluntary agreement sets up an advisory
panel to accept and review complaints about violations.
The inclusion on the panel of a member from the baby
food industry, however, means that it is not fully independent of the sector it is meant to monitor. The panel
has made decisions unfavorable to industry, but action
has decreased since its inception. The Code in Sweden
seems to have kept marketing of formula to a minimum,
although there is still wide-spread marketing of the
popular vlling, a gruel for older infants.

Every government in the World Health Organization

(WHO) is expected to report annually on how it is implementing the Code (Article 11.6). According to WHO, by
the end of 1999, 160 Member States (84% of members)
had reported to WHO on action taken to give effect, in
whole or in part, to the International Code.92 Optimistic
as this may sound, it does not, however, mean that the
Code has been implemented in a majority of countries.
Actions reported to WHO range from the issuance of
memoranda to health workers with copies of the Code;
holding of meetings to discuss the Code; establishment of
working groups to determine how best to implement the
Code; negotiation of voluntary agreements with the infant
food industry and requests to WHO for technical assistance to actually putting in place laws, regulations,
decrees or ministerial resolutions.

In many countries voluntary codes do not measure up to

the requirements of the International Code. They allow
existing marketing strategies to continue and incorporate loopholes. Yet once agreed to, a voluntary code may
supersede International Code provisions in that country.
Understandably, companies push for voluntary codes
with provisions as weak as possible.

To get a better idea of exactly what countries were doing

to implement the Code, the International Baby Food
Action Network (IBFAN) established the International
Code Documentation Centre (ICDC) and began in 1986
to research and keep track of Code implementation at
the national level. According to ICDC, by the end of
2000, only 24 countries had adopted a law to implement
all of the provisions of the International Code. Another
31 had adopted many of the Codes provisions as law.
Twenty-three countries had developed voluntary measures to implement the Code. Of the 191 countries
studied, 113 have not yet adopted a legally enforceable
or voluntary measure to implement the Code.93

What About Popular Implementation?

Professional organizations and health institutions can
implement Code provisions without waiting for a
government to act. ILCA is one professional organization that has chosen to implement the Code in all of its
activities. Nursing Mothers Association of Australia also
has done so.

It is disturbing that Code implementation has been

weak or non-existent in the countries that are home to
the majority of the manufacturers and distributors of
breastmilk substitutes. Neither the United States nor
Canada have implemented the Code. The Blueprint for
Action on Breastfeeding launched by US Surgeon
General in 2001, includes only three sentences alluding
to the Code without stating that it should be followed or
applied in the USA.94 The United States uses such
guarantees as the freedom of speech and certain commercial freedoms as an excuse for failing to implement
the International Code. Most democratic countries,
however, set limits on marketing of products potentially
detrimental to health, such as tobacco, alcohol, weapons
and medications.95 The issue in the USA is not freedom
of speech, but the degree of lobbying power enjoyed by
the formula companies in Washington.

Individuals can follow the Code. A former ILCA Board

member works in a hospital where commercial leaflets
and discharge samples of formula are customary. But
her colleagues know that she will not distribute them.
Instead she gives out breastfeeding information from
non-commercial sources. Hundreds of breastfeeding
counselors and health workers in developing countries
do likewise. IBCLCs now can cite Principle 24 of the
IBLCE Ethical Code if they find themselves under
pressure to contravene the International Code.
Any health worker who chooses to contravene the Code
should be aware at the very least that she is making a
choice. If she feels constrained to make that choice by
conditions at her workplace, then the next question is
how to change those conditions.

22

Bangladesh, Costa Rica, Australia and India are examples of countries that have instituted official monitoring mechanisms which have exposed violations and
made companies stop several prohibited practices. In
many countries, whether or not a formal monitoring
mechanism exists, individuals or groups monitor, and
through exposure of Code violations, have been able to
pressure companies to change some practices.

What About the Lactation

Consultants Workplace?
A lactation consultant who personally endorses and
adheres to the Code in settings where commercial
influence is deeply embedded is bound to anger some
colleagues and superiors. Many doctors, nurses, and
administrators have never given care totally free from
implicit commercial ties. The idea may be breathtakingly new, and accordingly frightening. Learning to stop
depending on free company leaflets and supplies of
formula, and to manage without gifts and personal or
research funding derived from profits on baby foods, is
inevitably a slow process. It is not unlike weaning.
People vary in how soon and how readily they outgrow a
dependence, but such growth can occur.

For example, when a group complained to the Sale of

Infant Food Ethics Committee, Singapore (SIFECS)
about Nestls Baby World Club which targets pregnant
women in Singapore, the Singapore committee responded with a letter stating that such clubs are explicitly prohibited by the Singapore Code.99
Over the years, even before the Code was adopted,
monitoring has been a major activity of the groups that
make up the International Baby Food Action Network
(IBFAN). IBFAN coordinates global surveys every 2-3
years that look into the marketing practices of companies in selected countries. The results are published in
two reports: The State of the Code by Company and
Breaking the Rules. National NGOs also produce
reports showing what is happening at the national level.

An LC who wishes to implement the Code at her workplace may have a rough road ahead, depending on the
degree of profit-motivated activity which has been
permitted to encroach upon medical care. Publications
such as Protecting Infant Health may aid in re-educating colleagues about the internationally agreed upon
standards represented by the Code.96 It is not difficult to
document that exclusive use of breastmilk can dramatically cut overall costs to a health system, including its
pediatric services. Films such as Becoming Baby
Friendly: one hospitals experience97 and the reports of
national breastfeeding authorities can be helpful even
in industrialized settings. The Breastfeeding Committee
for Canada has compiled an annotated bibliography of
studies measuring various cost savings that result from
breastfeeding.98

In 1997, for example, the Association for Rational Use of

Medication in Pakistan (the Network) organized and
conducted a survey in 33 cities and towns throughout
Pakistan. The results were published in the report
Feeding Fiasco100 which was described by officials in
Pakistan as an eye opener and revealing a disturbing
situation.101 Such a reaction indicates that monitoring
is necessary to bring the issue to public attention.

To consult about actions, and perhaps be safer from

retaliation while winning over skeptical colleagues,
each LC needs the support of an ILCA affiliate or a
Code implementation group. In the long run, although
each persons own effort is important, private or local
solutions are no substitute for binding national measures. Enforceable national standards can be achieved
only when people coalesce to work toward them.

The UK organization, Baby Milk Action (BMA), carries

out the Campaign for Ethical Marketing. Every month,
BMA produces an action sheet highlighting a number of
examples of marketing malpractice by baby food companies. These and companies responses are posted on
BMAs website.102
Infant food companies have consistently ignored or
attempted to discredit the results of such citizen monitoring. Such claims led the General Synod of the Church
of England to commission an independent international
monitoring study in 1997. A coalition of NGOs, academic institutions and churches was formed in the UK
to carry out the task. The coalition, the Interagency
Group on Breastfeeding Monitoring (IGBM) did a study
designed to measure the prevalence of Code violations
in the major cities of Poland, Bangladesh, Thailand and
South Africa.

Monitoring A Responsibility for All

Monitoring compliance is essential to make the Code
effective. Monitoring the Code involves setting up
systems whereby Code violations may be noted, witnessed, documented and reported. Under Article 11.1,
monitoring application of the Code is the responsibility
of governments. Manufacturers and distributors, nongovernmental organizations and professional groups
should collaborate with governments to this end
(Article 11.1).

The study concluded that the research proves that many

companies are taking action which violates the Code, and
in a systematic rather than one-off manner.103 The research coordinator for the study stated that:

Not many governments have fulfilled this responsibility,

but a few stand out as examples. Guatemala,

23

The frequency of the violations occurring in four major cities

shows that 16 years after the World Health Assembly adopted
the code, its requirements are still unmet. There is little to
suggest that the situation would be different in many other
countries; the code is not enforced in its entirety under current
legislation in the United Kingdom and Europe. There is little
hope that breast feeding will be protected from commercial
pressure as envisioned by the World Health Assembly unless
there is a commitment to enforce and monitor the code
nationally.104

its 1999 report of this exercise, Nestl claimed that the

report includes official responses from 54 governments
(or designated monitoring bodies) that verify Nestl
compliance with the [International Code] as applied in
their countries.107
The Nestl report was met with criticism because of the
way the so-called monitoring process was carried out.
Rather than asking for results of monitoring, Nestl
wrote to each country asking whether, in an individual
officials judgment, Nestl was in compliance with the
applicable national measure. Only six of the statements
in the report refer to monitoring or something similar
conducted by the authority providing the statement.
This exercise was obviously intended more to serve the
companys image than to monitor compliance with the
Code.108

The industry, through their trade association, the

International Association of Infant Food Manufacturers
(IFM) criticized the studys conclusions as not supported
by the evidence gathered and stated that the methodology was critically flawed. UNICEF commented:
It is both unfortunate and ill-advised that the International
Association of Infant Food Manufacturers saw fit to ignore the
findings, and to reject the report .It is also noteworthy that
the findings of IBFAN, in its regular monitoring activities, are
clearly vindicated by this report [UNICEF] proposes that
IBFAN be given renewed encouragement to continue monitoring compliance with the International Code. UNICEF views
this as an issue of great consequence It speaks , quite simply,
to child survival and development.105

Figure 3. Members of IFM

(as of January 2000)109

Failure of Self-monitoring by
Manufacturers
Article 11.3 states that manufacturers should monitor
their own compliance and ensure that their conduct at
every level conforms to the International Code. The
IFM is a trade organization of baby milk companies
including some of the worlds largest corporations (see
Figure 3).
Regarding the Code, IFM states that its members
strictly respect national legislation, regulations and
other government measures in all countries where
action has been taken. In those developing countries
where no such measures have been adopted, IFM
endorses the aim and principles of the WHO Code
unequivocally, and has undertaken many positive
activities to empower women to make informed
choices.106 In developed countries with no measures to
implement the Code, members have made no particular
undertaking. This may explain why in Japan, Canada
and the United States, deleterious practices contrary to
Code provisions still predominate.

Bldina SA (Danone Group)

France

Cofranlait

France

Friesland Nutrition

Netherlands

Gerber Products

USA

Hipp

Germany

HJ Heinz

Italy

International Nutrition Co

Denmark

Meiji Milk Products

Japan

Morinaga Milk Industry

Japan

Nestle

Switzerland

New Zealand Dairy Board

New Zealand

Royal Numico

Netherlands

Semper Foods

Sweden

Snow Brand Milk Products

Japan

Wyeth-Ayerst International

USA

Not all major manufacturers belong to this organization, and

there is no equivalent grouping of feeding bottle companies.

One reason for the discrepancy between claims of compliance by manufacturers and distributors and critical
monitoring reports is the difference in Code interpretations. In addition to their claim that the Code applies only
in developing countries, many also claim that it applies
only to standard infant formula.110 When confronted with
violations such as those involving the promotion of a
specialized formula, follow-up formula, or a juice or cereal
marketed for 3 month-old babies, many companies claim
these fall outside the scope of the Code. The wording of
the Code, however, is unambiguous on both issues it
applies in all countries and to all products represented to
replace, in full or in part, breastmilk.

At the 1998 World Health Assembly, the WHO Director

of Family and Reproductive Health stated that the
Infant-food industry needs to be proactive and more
responsible to monitor its own marketing practices and
respond promptly to correct all the violations that are
reported. In response to this call for action, Nestl
instituted what it termed a code monitoring process. In

24

Some companies have also taken the position that WHA

Resolutions adopted after the Code do not alter the
application of the Code. In 1994, World Health Assembly
adopted WHA Resolution 47.5 urging Member States to
foster appropriate complementary feeding from the age
of about six months. WHA Resolution 49.15 (1996) urged
Member States to ensure that complementary foods are
not marketed for or used in ways that undermine exclusive and sustained breastfeeding. Yet Boots (now Knoll)
distributes in Pakistan health facilities, a booklet which
includes the following text:

Many countries have monitoring groups of their own.

Some of these groups also work toward adoption of
enforceable laws. An IBFAN coordinating office can put
you in touch with a nearby working group if you request. ILCA state or regional affiliates may also choose
Code implementation and monitoring as a common
effort. Your identity will be safeguarded by any of the
voluntary organizations listed below:
National Alliance for Breastfeeding Action (NABA)
Research, Education and Legal Fund
254 Conant Rd
Weston, MA 02493-1756 USA
Marshalact@aol.com
www.hometown.aol.com/marshalact/naba/home.html

The age for stopping breastfeeding cannot be fixed as the same

for every child. In normal conditions three, four months is an
appropriate age, when the child weighs 7.5 kg (15 lbs).111

The booklet contains none of the information required

in Article 4.2 of the Code. In the USA, telephone information services of the Gerber and Beech Nut companies
advocate that their baby foods be started before the age
of six months112, despite the recommendation of the
American Academy of Pediatrics recommendation of six
months of exclusive breastfeeding.113

International Code Documentation Center

PO Box 19
10700 Penang MALAYSIA
ibfanpg@tm.net.my
IBFAN Europe c/o GIFA
BP 157
1211 Geneva 19
SWITZERLAND
info@gifa.org

A resolution adopted by the World Health Assembly in

2001 should put to rest any remaining disagreement
regarding a global definition for the optimal period of
exclusive breastfeeding. Resolution 54.2 urges member
states to support exclusive breastfeeding for six months
as a global public health recommendation. The WHA
resolution makes specific reference to the findings of a
March 2001 WHO Technical Consultation on the duration of exclusive breastfeeding.114

WEMOS (for European violations)

Postbus 1693
Amsterdam
NETHERLANDS
wemos@wemos.nl
Baby Milk Action
23 St Andrews St, 2d Floor
Cambridge CB2 3AX
UK
babymilkacti@gn.apc.org
www.babymilkaction.org

Monitoring Is a Key
Health workers and consumer groups are specifically
given the privilege of monitoring by Article 11.4. Monitoring is effective only if it is detailed, shared with
others, and published. A quiet letter to an offending
local distributor may clear up a single violation, but it
leaves the company free to carry on the same practice
down the street, across municipal, state, and/or provincial boundaries, or across an ocean.

IBFAN Africa
PO Box 781
Mbabane Swaziland
ibfanswd@realnet.co.sz
IBFAN Afrique
01 BP 1776
Ouagadougou
BURKINA FASO
ibfanfan@fasonet.bf

Health workers often are best placed to notice Code

violations. In countries with a legal Code, the first step
is to report to the government authority charged with
enforcement. In countries lacking legal measures or
effective enforcement mechanisms, violations should be
reported to the head of the institution, or if an advertisement is involved, in a letter to the editor.

IBFAN Latin America

c/o CEFEMINA
Apartado 5355
1000 San Jose, Costa Rica
cefemina@sol.racsa.com.or

Dont stop there. Send a copy of your letter to the state or

national Ministry of Health and to regional or international monitoring groups. Ideally, full reports go to everyone simultaneously (thanks to the photocopier and e-mail),
thereby making action more probable. Always include the
date and place where the violation occurred, which Code
article it contravenes, and all other specifics.
25

Avoid being drawn into advising manufacturers on how

to improve their marketing or their leaflets. This
common tactic for stilling voices of opposition to marketing of breastmilk substitutes encourages you to cooperate and be quiet, but allows the company to suppress
whatever you write, or to associate it with formula
promotion. Some of the worlds best breastfeeding
specialists have had such bitter experiences.

Reporting to Manufacturers
If it is not important to maintain your anonymity, write
to the manufacturers, as suggested in Article 11.4,
bearing in mind that their complaint staff may be
closely linked to their marketing structures. Manufacturers have been known to reveal the identity of an
informant to those in her area with whom they have
existing ties. Retaliatory action is a tradition in some
cultural settings, including the most modern hospitals;
readers may wish to consider if it is politic to report to
manufacturers. The address is:

According to IFM, complaints are forwarded to the

company concerned for investigation. If the practice
complained of is found to be justified, corrective action
is instituted without delay. IFM issues an annual
summary (without names of products or companies)
available on request from the IFM secretariat.

IFM
194, rue de Rivoli
F-75001 Paris FRANCE

All this sounds like a lot of work. It is. Changing entrenched customs is neither simple nor quick. But what
is the alternative? To allow parents to be misled or even
trapped, for lack of protective policies, into accepting
second-rate feeding for their babies. Shall we acquiesce
in the commercialization of infant feeding by people to
whom babies are a key market for profitable products-or
shall we act?

Manufacturers may press for more details than you feel

free to give, and attack you if you do not provide them.
Stand firm. It is their responsibility under Article 11 to
monitor their own operations closely. Their salaried
marketing staff should track down violations, once
alerted to a problem by your brief report. You need not
be co-opted into performing for any company a role that
its own field representatives are paid to fulfill.

26

References
1.*

This material first appeared as follows: JHL 4:137-42, 1988;

JHL 4:194-99, 1988; JHL 5:46-52, 1989; and JHL 5:103-11,
1989.

2.**

Helen Armstrong, IBCLC, was formerly Training Coordinator

for IBFAN Africa. From 1992 to 2000, she was a full time
consultant to UNICEF New York on infant feeding and care.
Ellen Sokol is the former Legal Advisor to the International
Code Documentation Centre, Penang, Malaysia. She is now a
consultant on issues concerning the International Code.

17.

These standards, primarily related to food quality and labeling,

are developed by the International Codex Alimentarius
Commission, which is not the same as the International Code of
Marketing. Products in full compliance with the former are
often marketed in violation of the latter.

18.

World Health Assembly Resolution 39.28, Geneva, 1986.

19.

International Baby Food Action Network, Breaking the Rules,

Stretching the Rules 1998 and State of the Code by Company
1998, Penang: IBFAN, 1998.

3.

Geach H, The Baby Food Tragedy, The New Internationalist,

August 1973.

20.

Playtex Easy-Feed Drop-Ins Nurser, advertisement, Parents

magazine, USA, January 2001.

4.

Victora C, Smith P, Baughan J, Evidence for Protection by

Breastfeeding against Infant Deaths from Infectious Diseases,
Lancet, 1987, 2:317-22.

21.

White River Concepts, 1999, Breastfeeding Success Products

leaflet for parents. The company did not respond to written and
verbal requests for medical proof of this claim.

5.

Howie PW et al, Protection of Breastfeeding against Infection,

British Medical Journal, 1990, 300:11-16.

22.

Armstrong HC, Adult nipple confusion: a commerciogenic

problem, J Hum Lact, 1996, 3:179-81.

6.

Muller M, The Baby Killer, London: War on Want, March 1974,

2d ed. May 1975.

23.

Walker M, A fresh look at the risks of artificial feeding, J

Hum Lact 1993, 2:97-107.

7.

World Health Assembly Resolution 27.43, Geneva 1974.

24.

8.

For more detailed discussions of the publicity and public

activism that this issue provoked see Chetley A, The Politics of
Baby Foods: Successful Challenges to an International Marketing Strategy, London: Frances Pinter, 1986; Palmer G, The
Politics of Breastfeeding, London: Pandora Press, 1993 (2d ed.);
Allain A, IBFAN on the Cutting Edge, Penang: IBFAN, 1991
(rev. ed) (originally published in Development Dialogue, the
journal of the Dag Hammarskjld Foundation, 1980:2); Sokol E,
The Code Handbook: A Guide to Implementing the International
Code of Marketing of Breastmilk Substitutes, Penang: IBFAN,
1997; International Baby Food Action Network, History of the
Campaign, Action Pack, IBFAN/Gifa, Geneva; Baumslag N,
Milk, Money and Madness: The Culture and Politics of
Breastfeeding, Westport Connecticut: Bergin & Garvey, 1995.

Armstrong H, Feeding low birthweight babies, J Hum Lact

1987, 3:34-37; Lang S, Lawrence CJ, Orme RL, Cup feeding: an
alternative method of infant feeding, Arch Dis Ch, 1994,
71:365-9.

25.

WHO, UNICEF, UNAIDS, HIV and Infant Feeding Counselling:

a Training Course, Geneva: WHO/FCH/CAH/00.3, 2000.

26.

Ad Hoc Group on Infant Feeding in Emergencies, Infant

Feeding in Emergencies: Policy, Strategy, Practice, Dublin:
Emergency Nutrition Network, 1999; World Health Organization, Management of Severe Malnutrition: a Manual for
Physicians and other Senior Health Workers, Geneva: WHO,
1999; World Health Organization, Infant feeding in Emergencies: a Guide for Mothers, Copenhagen: WHO/EURO (undated
pamphlet EU/ICP/LVNG010208); United Nations High
Commissioner for Refugees, Handbook for Emergencies,
UNHCR (undated).

27.*

Article 3 of the Code contains definitions which are mentioned

in this text where relevant.

9.

International Council of Infant Food Industries, Code of Ethics

and Professional Standards for Advertising, Product Information, Advisory Service for Breastmilk Substitutes, Zurich: ICIFI,
1975, (amended 1976).

10.

Palmer G, The Politics of Breastfeeding, London: Pandora

Press, 1993, (2d ed.) p.252.

28.

Zimbabwe Ministry of Health, Baby Feeding, Harare: Government of Zimbabwe, 1981, entire booklet.

11.

World Health Assembly Resolutions 34.22 and 35.26, Geneva

1981 and 1982.

29.

Arbeitsgemainschaft Freier Stillgruppen, Stillen, Wrzburg:

AFS, 1995.

12.

Dr. F. Oldfield, Representative of The Gambia, WHA Executive

Board,1981.

30.

13.

A. Nilsen, Minister of Health and Social Affairs, Norway, WHA

1981.

Howard et al, Prenatal advertising and its effect on

breastfeeding patterns, Obstetrics and Gynecology, 2000,
95(2):296-303.

31.

Convention on the Rights of the Child, Article 24.2(e).

14.

Alsen S., National Board of Health and Welfare, Sweden, WHA,

1981.

32.

15.

Allain A, International Organization of Consumers Unions

(IOCU, now known as Consumers International), quoting Action
for Corporate Accountability in an unpublished presentation to
WHA Committee, 1988.

Auerbach KG, Beyond the issue of ccuracy: evaluating patient

education materials for breastfeeding mothers, J Hum Lact,
1988, 4: 108-10.

33.

Nestle, Motherhood, a Special Post-natal Experience (booklet

distributed in the Philippines).

34.

Sears W, Answers from Dr. Sears: Moving from Breast to

Bottle, Parenting, September 2000.

35.

Ross Laboratories, Supplemental Feeding. What Breastfeeding

Mothers Ask, Columbus, Ohio: Ross, 1990, p. 3.

36.

Abbott Ross, Supplementary Feeding, May 1, 1996; Increase

your Infant Formula IQ, Oct 1, 1993.

37.

Abbott Ross, Becoming a Parent, 1991.

38.

Mead Johnson, Baby Book.

39.

Avent America advertisement in Baby Talk, October 1994.

16.

Manaseki-Holland S, Global breastfeeding data: sources,

prevalence, trends and association with global programs, Draft
paper for WHO/UNICEF Technical Consultation on Infant and
Young Child Feeding, Geneva, March 2000 (Figures in this
paper estimated breastfeeding at 12-15 months to prevail in
90% of sub-Saharan Africa, 80% of Asia and over 60% of Latin
America/Caribbean and North Africa/Near East.) UNICEF,
State of the Worlds Children 2001, New York: UNICEF
(prevalence of breastfeeding at 20-23 months: sub-Saharan
Africa 52%, South Asia 66%, World 51%).

27

40.

Nursery Ltd: Advertisement in British parents magazines,

1987.

41.

Medela, Breastfeeding Information Guide, USA:1998.

42.

Http://www.storebrandformulas.com/

43.

International Baby Food Action Network, Breaking the Rules,

Stretching the Rules 1998 and State of the Code by Company
1998, Penang: IBFAN, 1998, p29.

44.

Readers are encouraged to view the slide show, Malnutrition in

an urban environment, which links bottle-feeding, malnutrition in older children, and close child spacing; by Mercedes
Solon and Ann Burgess, 24 slides and script. [Teaching Aids at
Low Cost (TALC), item 177, PO Box 49, St. Albans, Herts, AL1
4AX, UK], revised 1998.

45.

World Alliance for Breastfeeding Action, Breastfeeding, The best

investment for life, (World Breastfeeding Week 1998 Action
Folder), Penang: WABA, 1998.

46.

WHO, UNAIDS, UNICEF, HIV and Infant Feeding: a guide for

health care managers and supervisors, Geneva: UNAIDS, 1998,
p.30.

47.

Short, RV, Unpublished presentation at the International

Lactation Conference, Melbourne, Australia (15 August 1988).

48.

The Innocenti Declaration was adopted in August 1990 in

Innocenti Italy by the participants at the WHO/UNICEF policy
makers meeting on Breastfeeding in the 1990s: A Global
Initiative.

49.

WHO/UNICEF, Joint Statement: Protecting, Promoting and

Supporting Breastfeeding: The special role of maternity services,
1989; WHO/CHD, Evidence for the 10 Steps to Successful
Breastfeeding, Geneva: WHO/CHD/98.9, 1998.

50.

International Baby Food Action Network, Breaking the Rules,

Stretching the Rules, 1998, Penang: IBFAN Penang: iii (citing
September 1997 Advertisement by Wyeth)

51.

Schanler R, OConner K, Lawrence R, Pediatricians Practices

and Attitudes Regarding Breastfeeding Promotion, Pediatrics,
1999, 103:e35.

52.

This discussion draws heavily on Protecting Infant Health: A

Health Workers Guide to the International Code of Marketing of
Breastmilk Substitutes, 9th Edition, Penang: IBFAN, 1999.
Editions are available in Arabic, Chinese, Egyptian Arabic,
English, French, German, Indonesian, Korean, Peruvian
Spanish, Portuguese, Spanish, Thai, Czech, Georgian,
Lithuanian, Bulgarian and Armenian.

57.

Report of a joint WHO/UNICEF Consultation Concerning

Infants who have to be fed on breastmilk substitutes, Geneva:
WHO, April, 1986 (WHO/MCH/NUT/ 86.1). A background paper
by M. Behar (MCH/NUT 85.1) serves as the basis of Health
factors which may interfere with breastfeeding, Chapter 3 in
Akr, ed, Infant Feeding: The Physiological Basis, Bull WHO
67 (Suppl):41-51, 1989. This document is also available from the
ILCA Publications Department.

58.

World Health Assembly Resolution 39.28, Geneva, May 1986.

59.

World Health Assembly Resolution 47.5, Geneva, May 1994.

60.

UNAIDS, Making breastmilk substitutes available to infants of

mothers living with HIV. HIV and Infant Feeding: guidelines for
decision makers, Geneva: UNAIDS 98.3, 1998.

61.

See Ball, TM, Wright, AL, Health care costs of formula feeding
in the first year of life, Pediatrics, 1999, 103:870-876; WHO
Collaborative Study Team on the Role of Breastfeeding in
Prevention of Infant Mortality, Effect of breastfeeding on infant
and child mortality due to infectious diseases in less developed
countries: a pooled analysis, Lancet, 2000, 355:451-55. See also
Risks of Artificial Feeding, Compilation by Dr. Jack Newman,
Revised May 2000 (available on the web at
www.infactcanada.ca);

62.

The Network, Feeding Fiasco: pushing commercial infant foods

in Pakistan, Islamabad 1998: 52.

63.

Wyeth Nutritionals, advertisements in J Ped Health Care,

2000,14(5):15A-16A and in Pediatric Annals, 2001,30(1):14-15.

64.

Nestle, advertisement in Pediatric Nursing, 2000, 26(1):12.

65.

Gerber, advertisements in Pediatric Health Care, 2000, 14(2):6-7

and J Ped Nursing, 2000, 15 (5): inside cover.

66.

Direct Mail and Mail Order Handbook, 1981, quoted in

A Dangerous Trend, Breast is Best: From Policy to Practice.
Geneva, London and Minneapolis, IBFAN 1992.

67.

Salmon CL, Clement D, Eds: Still Breaking the Rules, Minneapolis: Action for Corporate Accountability/IBFAN, 1988; p. 8.

68.

The Network, Association for Rational Use of Medication in

Pakistan, Milking Profits, How Nestle puts sales ahead of infant
health, Islamabad 1999:p.9.

69.

Nestle, WHO International Code of Marketing of Breastmilk

Substitutes, Instructions to all Companies of the Nestl Group
and to Agents and Distributors who Market Infant Formula
under Trade Marks owned by Nestle, 1982, updated 1996, Vevey:
Annex 4.

53.

International Code Documentation Centre, Breaking the Rules,

Stretching the Rules, 1998, Penang: IBFAN Penang: 8-9.

70.

Letter to doctors from President and General Manager of Mead

Johnson, Philippines, 1997.

54.

Ibid, p.8.

71.

55.

Bergevin Y, Dougherty C, Kramer MS, Do infant formula

samples shorten the duration of breastfeeding? Lancet, 1983, I:
1148-1151; Dungy C et al, Effect of discharge samples on
duration of breastfeeding, Pediatrics, 1992, 90:233-237; Evans
CJ, Lyons NB, Killien MG, The effect of infant formula samples
on breastfeeding practice, J Obstet Gynecol Neonatal Nurs,
1986, 15:401-405; Feinstein et al, Factors related to early
termination of breastfeeding in an urban population, Pediatrics, 1986, 78:210-215; Frank DA et al, Commercial discharge
packs and breastfeeding counselling: effects on infant feeding
practices in a randomized trial, Pediatrics, 1987, 80:845-854.

Chren M, Landefeld CS and Thomas HM, Doctors, Drug

Companies and Gifts, J Amer Med Assoc, 1989, 262:3448.

72.

Ibid p.3449.

73.

Margolis, L, The ethics of accepting gifts from pharmaceutical

companies Pediatrics, 1991, 88(6):1233-37.

74.

Administrative Petition to United States Food and Drug

Administration, Lulac et al v. Secretary of Health, June 17,
1981.

75.

Taylor, A, Violations of the International Code of Marketing of

Breastmilk Substitutes: prevalence in four countries, British
Med J, 1998, 316:1117.

76.

Anand RK: Press statement, Washington, DC, October 1988.

56.

Taylor, A, Violations of the International Code of Marketing of

Breastmilk Substitutes: prevalence in four countries, British
Medical Journal 1998, 316:1117-1122.

28

77.

Pisacane, A, Letter to Editor, Brit Med J, 2000, 321:959.

78.

Thompson DF, Understanding financial conflicts of interest,

N Engl J Med, 1993, 329:573-576.

79.

Editorial, Beyond conflict of interest Transparency is the key

Brit Med J 1998, 317:291-292.

80.

Womens International Public Health Network Newsletter,

1995, 18(6).

81.

Kleinman RE, Jellinek MD, Let them eat cake the case against
controlling what your children eat. Villard Press: 1994.

82.

Doctors declaration for breastfeeding, Ind Med Assoc News

21:9-11,1987.

83.

Address by James P. Grant, Executive Director, UNICEF to the

Twentieth International Congress of Paediatrics, Rio de
Janeiro, September 7, 1992.

84.

World Health Assembly Resolution 49.15, 1996.

85.

Royal College of Paediatrics and Child Health, Commercial

Sponsorship in the Royal College of Paediatrics and Child
Health, London:1999.

86.

Tamburlini et al, Letter to Brit Med J, 2000, 320:382 (5

February).

87.

Koletzke B, Michaelsenk F, Hernell O, Short and long term

effects of breastfeeding on child health, New York: Kluwer/
Plenum, 2000.

88.

Bellamy, C, Unicef and baby food manufacturers. Unicef

continues to base its actions and programs on the best interests
of the child Letter to Brit Med J, 2000, 321:960, 14 October.

89.

Scott J, Code of Ethics Changes, The IBCLICK, July 2000: 3(1).

90.

Nestl spokesman: Senate subcommittee hearings chaired by

Senator Ted Kennedy (MA), May 1978, and Nestl spokesman:
media show 24 Heures, October 5, 1988. Quoted in Vers un
Dveloppement Solidaire, 97, December 1988.

91.

International Baby Food Action Network, Breaking the Rules,

Stretching the Rules 1998, Penang: IBFAN Penang, p.41.

92.

World Health Organization Executive Board, Implementation of

Resolutions and Decisions. Report by the Secretariat. Document
EB/105/36, part IV. Geneva 2000, paras 12 & 13.

93.

101.

The Network, Feeding Fiasco: pushing commercial infant foods

in Pakistan, Islamabad: The Network, 1998: Statements by Dr.
Mubbashar Riaz Sheikh, Deputy Director General Health,
Federal Ministry of Health, Pakistan and Urban Jonsson,
Regional Deputy Director UNICEF, Regional Office for South
Asia.

102.

www.babymilkaction.org/pages/campaign.html

103.

Interagency Group on Breastfeeding Monitoring, Cracking the

Code, London: IGBM, 1997, p.1.

104.

Taylor, A, Violations of the International Code of Marketing of

Breastmilk Substitutes: prevalence in four countries, British
Med J, 1998, 316:1122.

105.

UNICEF Geneva, 14th January 1997.

106.

International Association of Infant Food Manufacturers

website, www.ifm.net.

107.

Nestl, Nestl Implementation of the WHO Code, Report to the

Director General, World Health Organization, July 1999,
Executive Summary,.

108.

For a full analysis of the Nestl report, see Baby Milk Action,
Dont Judge a Book by its Cover The truth behind Nestls
book: Nestl implementation of the WHO Code - Official
Responses of Governments, December 1999. Available on the
World Wide Web at www.babymilkaction.org/pages/jbc.html.
Paper copies of this briefing paper can be ordered from Baby
Milk Action. See also International Baby Food Action Network
(IBFAN) and The Geneva Infant Feeding Association (GIFA),
Nestl Implementation of the WHO Code (International Code
of Marketing of Breastmilk Substitutes): Does The Nestl
Report Comply with The International Code? A Legal Evaluation of The Nestl Report, Geneva: IBFAN/GIFA, April 2000.

109.

IFM Website, www.babymilk.com/ifm-net/memdirect.html

110.

For example Nestls Instructions for the Implementation of the

WHO International Code of Marketing of Breastmilk Substitutes
(updated July 1996) - a manual for companies of the Nestl
Group and its agents and distributors (hereinafter Nestl
Instructions), states:

30 of these countries have measures in draft form and the

others had either adopted only a few of the Codes provisions or
were still studying how to proceed. Very few have taken no
action at all. (Communication with International Code Documentation Centre, February 2001).

These Instructions apply to the marketing of infant formula

i.e. infant formulae which are suitable for use as the sole source
of nutrition for a baby during the first 4 to 6 months of life (See
Art. 10.2).

94.

US Department of Health and Human Services, HHS Blueprint

for Action on Breastfeeding, Washington: DHHS, 2000

95.

See WHO: Report of the Director General to the 45th World

Health Assembly. Geneva: WHO, 1992. WHO A45/28. Paras
120-123 (discussing health implications of advertising
breastmilk substitutes directly to the public).

Note: The following Nestl products are not covered by the

Code: Follow-up formulae*, Sweetened Condensed Milk,
Evaporated Milk, Skimmed Milk; UHT Milk, Full Cream
Powdered Milk, Cereal Foods, Growing Up Milks and Sterilized
Meat, Vegetable and Fruit preparations for babies.

96.

International Baby Food Action Network, Protecting Infant

Health: A Health Workers Guide to the International Code of
Marketing of Breastmilk Substitutes, 9th Edition, Penang:
IBFAN, 1999.

* except follow-up formulae which have the same brand name

as starter formula, (e.g. Nan 1 and Nan 2) and which are
subject to the same marketing restrictions as starter formula.

97.

UNICEF, Breastfeeding Compilation II [videotapes] 1999, New

York: UNICEF and US Committee for Unicef. Available through
national UNICEF offices or committees or from UNICEF, 3 UN
Plaza, New York, NY 10017 USA.

98.

Breastfeeding Committee for Canada, Cost Savings from

Breastfeeding, June 1999 (available from INFACT Canada
website: www.infactcanada.ca)

99.

Baby Milk Action, Campaign for Ethical Marketing Action

Sheet, Dec 2000/Jan 2001, Cambridge: Baby Milk Action
(quoting letter from SIFECS, 8 January 2001),

100.

The Network, Feeding Fiasco: pushing commercial infant foods

in Pakistan, Islamabad: The Network, 1998.

29

111.

Boots Pharmaceutical (Knoll), Your Childs Growth: first year

with Farex, p.9, (booklet in Urdu, quoted in The Network,
Feeding Fiasco: pushing commercial infant foods in Pakistan,
Islamabad 1998:35.

112.

Beechnut telephone advisory service, 1 800 Beechnut and

booklets, Beech Nut Naturals, Solid Advice: a guide to feeding
your baby and Beech Nut Naturals, Dietary Guidelines for
Babies, Beech-Nut Nutrition Corporation, 1999; Gerber
telephone advisory service, 1-800 4 Gerber and booklet, Feeding
Your Baby, Gerber Products Co, Fremont MI 1998.

113.

American Academy of Pediatrics Work Group on Breastfeeding,

Breastfeeding and the use of human milk, Pediatrics 1997,
100(6):1035-39.

114.

World Health Organization, Expert Consultation on the

Optimal Duration of Exclusive Breastfeeding, Conclusions and
Recommendations, A54/INF.DOC./4, Geneva 2001.

APPENDIX 1
The International Code of Marketing of Breastmilk Substitutes
Preamble
The Member States of the World Health Organization:

convinced, nevertheless, that such complementary foods

should not be used as breastmilk substitutes;

AFFIRMING the right of every child and every lactating woman to be adequately nourished as a means of
attaining and maintaining health;

APPRECIATING that there are a number of social and

economic factors affecting breastfeeding, and that,
accordingly, governments should develop social support
systems to protect, facilitate and encourage it, and that
they should create an environment that fosters
breastfeeding, provides appropriate family and community support, and protects mothers from factors that
inhibit breastfeeding;

RECOGNIZING that infant malnutrition is part of the

wider problems of lack of education, poverty and social
injustice;
RECOGNIZING that the health of infants and young
children cannot be isolated from the health and nutrition of women, their socioeconomic status and their
roles as mothers;

AFFIRMING that health care systems, and the health

professionals and other health workers serving in them,
have an essential role to play in guiding infant feeding
practices, encouraging and facilitating breastfeeding,
and providing objective and consistent advice to mothers and families about the superior value of
breastfeeding, or where needed, on the proper use of
infant formula, whether manufactured industrially or
home-prepared;

CONSCIOUS that breastfeeding is an unequalled way

of providing ideal food for the healthy growth and
development of infants; that it forms a unique biological
and emotional basis for the health of both mother and
child; that the anti-infective properties of breast milk
help to protect infants against disease; and that there is
an important relationship between breastfeeding and
childspacing;

AFFIRMING further that educational systems and

other social services should be involved in the protection
and promotion of breastfeeding, and in the appropriate
use of complementary foods;

RECOGNIZING that the encouragement and protection

of breastfeeding is an important part of the health,
nutrition and other social measures required to promote
healthy growth and development of infants and young
children; and that breastfeeding is an important aspect
of primary health care;

AWARE that families, communities, womens organizations and other nongovernmental organizations have a
special role to play in the protection and promotion of
breastfeeding and in ensuring the support needed by
pregnant women and mothers of infants and young
children, whether breastfeeding or not;

CONSIDERING that when mothers do not breastfeed,

or only do so partially, there is a legitimate market for
infant formula and for suitable ingredients from which
to prepare it; that all these products should accordingly
be made accessible to those who need them through
commercial or non-commercial distribution systems;
and that they should not be marketed or distributed in
ways that interfere with the protection and promotion of
breastfeeding;

AFFIRMING the need for governments, organizations

of the United Nations system, nongovernmental organizations, experts in various related disciplines, consumer
groups and industry to cooperate in activities aimed at
the improvement of maternal, infant and young child
health and nutrition;

RECOGNIZING further that inappropriate infant

feeding practices lead to infant malnutrition, morbidity
and mortality in all countries, and that improper
practices in the marketing of breastmilk substitutes and
related products can contribute to these major public
health problems;

RECOGNIZING that governments should undertake a

variety of health, nutrition and other social measures to
promote healthy growth and development of infants and
young children, and that this Code concerns only one
aspect of these measures;
CONSIDERING that manufacturers and distributors of
breastmilk substitutes have an important and constructive role to play in relation to breastfeeding, and in the
promotion of the aim of this Code and its proper implementation;

CONVINCED that it is important for infants to receive

appropriate complementary foods, usually when the
infant reaches four to six months of age, and that every
effort should be made to use locally available foods; and
30

Container means any form of packaging of products for

sale as a normal retail unit, including wrappers.

AFFIRMING that governments are called upon to take

action appropriate to their social and legislative framework and their overall development objectives to give
effect to the principles and aim of this Code, including
the enactment of legislation, regulations or other
suitable measures;

Distributor means a person, corporation or any other

entity in the public or private sector engaged in the
business (whether directly or indirectly) of marketing
at the wholesale or retail level a product within the
scope of this Code. A primary distributor is a
manufacturers sales agent, representative, national
distributor or broker.

BELIEVING that, in the light of the foregoing considerations, and in view of the vulnerability of infants in the
early months of life and the risks involved in inappropriate feeding practices, including the unnecessary and
improper use of breastmilk substitutes, the marketing
of breastmilk substitutes requires special treatment,
which makes usual marketing practices unsuitable for
these products;

Health care system means governmental, nongovernmental or private institutions or organizations engaged,
directly or indirectly, in health care for mothers, infants
and pregnant women; and nurseries or child-care
institutions. It also includes health workers in private
practice. For the purposes of this Code, the health care
system does not include pharmacies or other established
sales outlets.

THEREFORE: The Member States hereby agree [to] the

following articles which are recommended as a basis for
action.

Health care worker means a person working in a component of such a health care system, whether professional
or non-professional, including voluntary, unpaid workers.

Article 1: Aim of the Code

The aim of this Code is 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 breastmilk substitutes, when these are
necessary, on the basis of adequate information and
through appropriate marketing and distribution.

Infant formula means a breastmilk substitute formulated industrially in accordance with applicable Codex
Alimentarius standards, to satisfy the normal nutritional requirements of infants up to between four and
six months of age, and adapted to their physiological
characteristics. Infant formula may also be prepared at
home, in which case it is described as home-prepared.

Article 2: Scope of the Code

The Code applies to the marketing, and practices related
thereto, of the following products: breastmilk substitutes,
including infant formula; other milk products, foods and
beverages, including bottle-fed complementary foods,
when marketed or otherwise represented to be suitable,
with or without modification, for use as a partial or total
replacement of breastmilk; feeding bottles and teats. It
also applies to their quality and availability, and to
information concerning their use.

Label means any tag, brand, mark, pictorial or other descriptive matter, written, printed, stencilled, marked,
embossed crimpressed on, or attached to, a container (see
above) of any products within the scope of this Code.

Article 3: Definitions
For the purposes of this Code:

Marketing means product promotion, distribution,

selling, advertising, product public relations, and
information services.

Breastmilk substitute means any food being marketed or

otherwise represented as a partial or total replacement
for breastmilk, whether or not suitable for that purpose.

Marketing personnel means any persons whose functions involve the marketing of a product or products
coming within the scope of this Code.

Complementary food means any food, whether manufactured or locally prepared, suitable as a complement to
breastmilk or to infant formula, when either becomes
insufficient to satisfy the nutritional requirements of
the infant. Such food is also commonly called weaning
food or breastmilk supplement.

Samples means single or small quantities of a product

provided without cost.

Manufacturer means a corporation or other entity in the

public or private sector engaged in the business or function (whether directly or through an agent or through an
entity controlled by or under contract with it) of manufacturing a product within the scope of this Code.

Supplies means quantities of a product provided for use

over an extended period, free or at a low price, for social
purposes, including those provided to families in need.

31

Article 4: Information and Education

within the scope of this Code. This provision should not

restrict the establishment of pricing policies and practices intended to provide products at lower prices on a
long-term basis.

4.1 Governments should have the responsibility to

ensure that objective and consistent information is
provided on infant and young child feeding for use by
families and those involved in the field of infant and
young child nutrition. This responsibility should cover
either the planning, provision, design and dissemination of information, or their control.

5.4 Manufacturers and distributors should not distribute

to pregnant women or mothers of infants and young children any gifts of articles or utensils which may promote
the use of breastmilk substitutes or bottle-feeding.

4.2 Informational and educational materials, whether

written, audio or visual, dealing with the feeding of
infants intended to reach pregnant women and mothers
of infants and young children, should include clear
information on all the following points: (a) the benefits
and superiority of breastfeeding; (b) maternal nutrition,
and the preparation for and maintenance of
breastfeeding; (c) the negative effect on breastfeeding of
introducing partial bottle-feeding; (d) the difficulty of
reversing the decision not to breastfeed; and, (e) where
needed, the proper use of infant formula, whether
manufactured industrially or home-prepared. When
such materials contain information about the use of
infant formula, they should include the social and
financial implications of its use; the health hazards of
inappropriate foods or feeding methods; and, in particular, the health hazards of unnecessary or improper use
of infant formula and other breastmilk substitutes.

5.5 Marketing personnel, in their business capacity,

should not seek direct or indirect contact of any kind
with pregnant women or with mothers of infants and
young children.

Article 6: Health Care Systems

6.1 The health authorities in Member States should
take appropriate measures to encourage and protect
breastfeeding and promote the principles of this Code,
and should give appropriate information and advice to
health workers in regard to their responsibilities,
including the information specified in Article 4.2.
6.2 No facility of a health care system should be used for
the purpose of promoting infant formula or other
products within the scope of this Code. This Code does
not, however, preclude the dissemination of information
to health professionals as provided in Article 7.2.

Such materials should not use any pictures or text

which may idealize the use of breastmilk substitutes.

6.3 Facilities of health care systems should not be used

for the display of products within the scope of this Code,
for placards or posters concerning such products, or for
the distribution of material provided by a manufacturer
or distributor other than that specified in Article 4.3.

4.3 Donations of informational or educational equipment

or materials by manufacturers or distributors should be
made only at the request and with the written approval of
the appropriate government authority or within guidelines given by governments for this purpose. Such equipment or materials may bear the donating companys
name or logo, but should not refer to a proprietary product that is within the scope of this Code, and should be
distributed only through the health care system.

6.4 The use by the health care system of professional

service representatives, mothercraft nurses or similar
personnel, provided or paid for by manufacturers or
distributors, should not be permitted.
6.5 Feeding with infant formula, whether manufactured
or home-prepared, should be demonstrated only by
health workers, or other community workers if necessary; and only to the mothers or family members who
need to use it; and the information given should include
a clear explanation of the hazards of improper use.

Article 5: The General Public and Mothers

5.1 There should be no advertising or other form of
promotion to the general public of products within the
scope of this Code.
5.2 Manufacturers and distributors should not provide,
directly or indirectly, to pregnant women, mothers or
members of their families, samples of products within
the scope of this Code.

6.6 Donations or low-price sales to institutions or

organizations of supplies of infant formula or other
products within the scope of this Code, whether for use
in the institution or for distribution outside them, may
be made. Such supplies should only be used or distributed for infants who have to be fed on breastmilk
substitutes. If these supplies are distributed for use
outside these institutions, this should be done only by
the institutions or organizations concerned. Such
donations or low-priced sales should not be used by
manufacturers or distributors as a sales inducement.

5.3 In conformity with paragraphs 1 and 2 of this

Article, there should be no point-of-sale advertising,
giving of samples, or any other promotion device to
induce sales directly to the consumer at the retail level,
such as special displays, discount coupons, premiums,
special sales, loss-leaders and tie-in sales, for products
32

6.7 Where donated supplies of infant formula or other

products within the scope of this Code are distributed
outside an institution, the institution or organization
should take steps to ensure that supplies can be continued as long as the infants concerned need them. Donors,
as well as institutions or organizations concerned,
should bear in mind this responsibility.

nuses, nor should quotas be set specifically for sales of

these products. This should not be understood to prevent the payment of bonuses based on the overall sales
by a company of other products marketed by it.
8.2 Personnel employed in marketing products within
the scope of this Code should not, as part of their job
responsibilities, perform educational functions in
relation to pregnant women or mothers of infants and
young children. This should not be understood as
preventing such personnel from being used for other
functions by the health care system at the request and
with the written approval of the appropriate authority
of the government concerned.

6.8 Equipment and materials, in addition to those referred

to in Article 4.3, donated to a health care system may bear
a companys name or logo, but should not refer to any proprietary product within the scope of this Code.

Article 7: Health Workers

7.1 Health workers should encourage and protect
breastfeeding; and those who are concerned in particular
with maternal and infant nutrition should make themselves familiar with their responsibilities under this Code,
including the information specified in Article 4.2.

Article 9: Labelling

7.2 Information provided by manufacturers and distributors to health professionals regarding products
within the scope of this Code should be restricted to
scientific and factual matters, and such information
should not imply or create a belief that bottle feeding is
equivalent or superior to breastfeeding. It should also
include the information specified in Article 4.2.

9.2 Manufacturers and distributors of infant formula

should ensure that each container has a clear, conspicuous, and easily readable and understandable message
printed on it, or on a label which cannot readily become
separated from it, in an appropriate language, which
includes all the following points: a) the words Important Notice or their equivalent; b) a statement of the
superiority of breastfeeding; c) a statement that the
product should be used only on the advice of a health
worker as to the need for its use and the proper method
of use; d) instructions for appropriate preparation, and
a warning against the health hazards of inappropriate
preparation.

9.1 Labels should be designed to provide the necessary

information about the appropriate use of the product,
and so as not to discourage breastfeeding.

7.3 No financial or material inducements to promote

products within the scope of this Code should be offered
by manufacturers or distributors to health workers or
members of their families, nor should these be accepted
by health workers or members of their families.
7.4 Samples of infant formula or other products within
the scope of this Code, or of equipment or utensils for
their preparation or use, should not be provided to
health workers except when necessary for the purpose
of professional evaluation or research at the institutional level. Health workers should not give samples of
infant formula to pregnant women, mothers of infants
and young children, or members of their families.

Neither the container nor the label should have pictures

of infants, nor should they have other pictures or text
which may idealize the use of infant formula. They may,
however, have graphics for easy identification of the
product as a breastmilk substitute and for illustrating
methods of preparation. The terms humanized,
maternalized or similar terms should not be used.
Inserts giving additional information about the product
and its proper use, subject to the above conditions, may
be included in the package or retail unit. When labels
give instructions for modifying a product into infant
formula, the above should apply.

7.5 Manufacturers and distributors of products within

the scope of this Code should disclose to the institution
to which a recipient health worker is affiliated any
contribution made to him or on his behalf for fellowships, study tours, research grants, attendance at
professional conferences, or the like. Similar disclosures
should be made by the recipient.

9.3 Food products within the scope of this Code, marketed for infant feeding, which do not meet all the
requirements of an infant formula, but which can be
modified to do so, should carry on the label a warning
that the unmodified product should not be the sole
source of nourishment of an infant. Since sweetened
condensed milk is not suitable for infant feeding, nor for
use as a main ingredient of infant formula, its label
should not contain purported instructions on how to
modify it for that purpose.

Article 8: Persons Employed by Manufacturers

and Distributors
8.1 In systems of sales incentives for sales personnel,
the volume of sales of products within the scope of this
Code should not be included in the calculation of bo33

9.4 The label of food products within the scope of this

Code should also state all the following points: a) the
ingredients used; b) the composition/analysis of the
product; c) the storage conditions required; and, d) the
batch number and the date before which the product is
to be consumed, taking into account the climatic and
storage conditions of the country concerned.

paragraphs 6 and 7 of this Article. The manufacturers

and distributors of products within the scope of this
Code, and appropriate nongovernmental organizations,
professional groups, and consumer organizations should
collaborate with governments to this end.
11.3 Independently of any other measures taken for
implementation of this Code, manufacturers and
distributors of products within the scope of this Code
should regard themselves as responsible for monitoring
their marketing practices according to the principles
and aim of this Code, and for taking steps to ensure
that their conduct at every level conforms to them.

Article 10: Quality

10.1 The quality of products is an essential element for
the protection of the health of infants and therefore
should be of a high recognized standard.

11.4 Nongovernmental organizations, professional

groups, institutions and individuals concerned should
have the responsibility of drawing the attention of
manufacturers or distributors to activities which are
incompatible with the principles and aim of this Code,
so that appropriate action can be taken. The appropriate governmental authority should also be informed.

10.2 Food products within the scope of this Code should,

when sold or otherwise distributed, meet applicable
standards recommended by the Codex Alimentarius
Commission and also the Codex Code of Hygienic
Practice for Foods for Infants and Children.

Article 11: Implementation and Monitoring

11.5 Manufacturers and primary distributors of products within the scope of this Code should apprise each
member of their marketing personnel of the Code and of
their responsibilities under it.

11.1 Governments should take action to give effect to

the principles and aim of this Code, as appropriate to
their social and legislative framework, including the
adoption of national legislation, regulations or other
suitable measures. For this purpose, governments
should seek, when necessary, the cooperation of WHO,
UNICEF and other agencies of the United Nations
system. National policies and measures, including laws
and regulations, which are adopted to give effect to the
principles and aim of this Code should be publicly
stated, and should apply on the same basis to all those
involved in the manufacture and marketing of products
within the scope of this Code.

11.6 In accordance with Article 62 of the Constitution of

the World Health Organization, Member States shall
communicate annually to the Director-General information on action taken to give effect to the principles and
aim of this Code.
11.7 The Director-General shall report in even years to
the World Health Assembly on the status of implementation of the Code; and shall, on request, provide technical support to Member States preparing national
legislation or regulations, or taking other appropriate
measures in implementation and furtherance of the
principles and aim of this Code.

11.2 Monitoring the application of this Code lies with

governments acting individually, and collectively
through the World Health Organization as provided in

34

APPENDIX 2
Selected Resolutions of the World Health Assembly
(3) to make the fullest use of all concerned parties health professional bodies, nongovernmental organizations, consumer organizations, manufacturers
and distributors - generally, in protecting and
promoting breastfeeding and, specifically, in implementing the Code and monitoring its implementation and compliance with its provisions;

WHA Resolution 39.28 (1986)

The Thirty-ninth World Health Assembly, Recalling
resolutions WHA27.43, WHA31.47, WHA33.32,
WHA34.22, WHA35.26 and WHA37.30 which dealt with
infant and young child feeding;
Having considered the progress and evaluation report by
the Director-General on infant and young child nutrition;1

(4) to seek the cooperation of manufacturers and distributors of products within the scope of Article 2 of the
Code, in providing all information considered necessary for monitoring the implementation of the Code;

Recognizing that the implementation of the International Code of Marketing of Breastmilk Substitutes is
an important contribution to healthy infant and young
child feeding in all countries;

(5) to provide the Director-General with complete and

detailed information on the implementation of the
Code;

Aware that today, five years after the adoption of the

International Code, many Member States have made
substantial efforts to implement it, but that many
products unsuitable for infant feeding are nonetheless
being promoted and used for this purpose; and that
sustained and concerted efforts will therefore continue
to be necessary to achieve full implementation of and
compliance with the International Code as well as the
cessation of the marketing of unsuitable products and
the improper promotion of breastmilk substitutes;

(6) to ensure that the small amounts of breastmilk

substitutes needed for the minority of infants who
require them in maternity wards are made available
through the normal procurement channels and not
through free or subsidized supplies;
3. REQUESTS the Director-General:
(1) to propose a simplified and standardized form for
use by Member States to facilitate the monitoring
and evaluation by them of their implementation of
the Code and reporting thereon to WHO, as well as
the preparation by WHO of a consolidated report
covering each of the articles of the Code;

Noting with great satisfaction the guidelines concerning

the main health and socioeconomic circumstances in
which infants have to be fed on breastmilk substitutes,2
in the context of Article 6, paragraph 6, of the International Code;

(2) to specifically direct the attention of Member States

and other interested parties to the following:

Noting further the statement in the guidelines, paragraph 47:

Since the large majority of infants born in maternity
wards and hospitals are full term, they require no
nourishment other than colostrum during their first 2448 hours of life - the amount of time often spent by a
mother and her infant in such an institutional setting.

(a) any food or drink given before complementary

feeding is nutritionally required may interfere
with the initiation or maintenance of
breastfeeding and therefore should neither be
promoted nor encouraged for use by infants
during this period;

Only small quantities of breastmilk substitutes are

ordinarily required to meet the needs of a minority of
infants in these facilities, and they should only be
available in ways that do not interfere with the protection and promotion of breastfeeding for the majority;

(b) the practice being introduced in some countries of

providing infants with specially formulated milks
(so-called follow-up milks) is not necessary.
16 May 1986

1. ENDORSES the report of the Director-General;1

2. URGES Member States:

References
(1) to implement the Code if they have not yet done so;
(2) to ensure that the practices and procedures of their
health care systems are consistent with the principles and aim of the International Code;
35

1.

Document WHA39/1986/REC/1, or Document A39/8

2.

Document WHA39/1986/REC/1, or Document A39/8 Add.1

(2) to ensure that there are no donations of free or

subsidized supplies of breastmilk substitutes and
other products covered by the International Code of
Marketing of Breastmilk Substitutes in any part of
the health care system;

WHA Resolution 47.5 (1994)

Infant and Young Child Nutrition
The Forty-seventh World Health Assembly, Having
considered the report by the Director-General on infant
and young child nutrition;

(3) to exercise extreme caution when planning, implementing or supporting emergency relief operations,
by protecting, promoting and supporting
breastfeeding for infants, and ensuring that donated
supplies of breastmilk substitutes or other products
covered by the scope of the International Code be
given only if all the following conditions apply:

Recalling resolutions WHA33.32, WHA34.22,

WHA35.26, WHA37.30, WHA39.28, WHA41.11,
WHA43.3, WHA45.34 and WHA46.7 concerning infant
and young child nutrition, appropriate feeding practices
and related questions;

(a) infants have to be fed on breastmilk substitutes,

as outlined in the guidelines concerning the
main health and socioeconomic circumstances in
which infants have to be fed on breastmilk
substitutes;3

Reaffirming its support for all these resolutions and

reiterating the recommendations to Member States
contained therein;
Bearing in mind the superiority of breastmilk as the
biological norm for nourishing infants, and that a
deviation from this norm is associated with increased
risks to the health of infants and mothers;

(b) the supply is continued for as long as the infants

concerned need it;
(c) the supply is not used as a sales inducement;

1. THANKS the Director-General for his report;

(4) to inform the labor sector, and employers and workers organizations, about the multiple benefits of
breastfeeding for infants and mothers, and the implications for maternity protection in the workplace;

2. URGES Member States to take the following measures:

(1) to promote sound infant and young child nutrition,
in keeping with their commitment to the World
Declaration for Nutrition,1 through coherent effective intersectoral action, including:

3. REQUESTS the Director-General:

(1) to use his good offices for cooperation with all
parties concerned in giving effect to this and related
resolutions of the Health Assembly in their entirety;

(a) increasing awareness among health personnel,

nongovernmental organizations, communities
and the general public of the importance of
breastfeeding and its superiority to any other
infant feeding method;

(2) to complete development of a comprehensive global

approach and program of action to strengthen
national capacities for improving infant and young
child feeding practices; including the development of
methods and criteria for national assessment of
breastfeeding trends and practices;

(b) supporting mothers in their choice to breastfeed

by removing obstacles and preventing interference that they may face in health services, the
workplace, or the community;

(3) to support Member States, at their request, in monitoring infant and young child feeding practices and
trends in health facilities and households, in keeping
with new standard breastfeeding indicators;

(c) ensuring that all health personnel concerned

are trained in appropriate infant and young
child feeding practices, including the application
of the principles laid down in the joint WHO/
UNICEF statement on breastfeeding and the
role of maternity services;2

(4) to urge Member States to initiate the Baby-friendly

Hospital Initiative and to support them, at their
request, in implementing this Initiative, particularly in their efforts to improve educational curricula and in-service training for all health and
administrative personnel concerned;

(d) fostering appropriate complementary feeding

practices from the age of about six months,
emphasizing continued breastfeeding and
frequent feeding with safe and adequate
amounts of local foods;

36

(5) to increase and strengthen support to Member

States, at their request, in giving effect to the
principles and aim of the International Code and all
relevant resolutions, and to advise Member States
on a framework which they may use in monitoring
their application, as appropriate to national circumstances;

WHA Resolution 49.15 (1996)

(6) to develop, in consultation with other concerned

parties and as part of WHOs normative function,
guiding principles for the use in emergency situations of breastmilk substitutes or other products
covered by the International Code which the competent authorities in Member States may use, in the
light of national circumstances, to ensure the
optimal infant-feeding conditions;

Recalling resolutions WHA33.32, WHA34.22,

WHA39.28 and WHA45.34 among others concerning
infant and young child nutrition, appropriate feeding
practices and other related questions;

Infant and Young Child Nutrition

The Forty-Ninth World Health Assembly, having considered the summary of the report by the Director-General
on infant feeding and young child nutrition;

Recalling and reaffirming the provisions of resolution

WHA 47.5 concerning infant and young child nutrition,
including the emphasis on fostering appropriate complementary feeding practices;

(7) to complete, in cooperation with selected research

institutions, collection of revised reference data and
the preparation of guidelines for their use and
interpretation, for assessing the growth of breastfed
infants;

Concerned that health institutions and ministries may

be subject to subtle pressure to accept, inappropriately,
financial or other support for professional training in
infant and child health;

(8) to seek additional technical and financial resources

for intensifying WHOs support to Member States in
infant feeding and in the implementation of the
International Code and subsequent relevant resolutions.

Noting the increasing interest in monitoring the application of the International Code of Marketing of
Breastmilk Substitutes and subsequent relevant Health
Assembly resolutions;
1. THANKS the Director-General for his report;

9 May 1994

1.

World Declaration and Plan of Action for Nutrition. FAO/WHO,

International Conference on Nutrition, Rome, December 1992.

2. STRESSES the continued need to implement the

International Code of Marketing of Breastmilk
Substitutes, subsequent relevant resolutions of the
Health Assembly, the Innocenti Declaration, and the
World Declaration and Plan of Action for Nutrition;

2.

Protecting, promoting and supporting breastfeeding: the special

role of maternity services. A joint WHO/UNICEF statement.
Geneva, World Health Organization, 1989.

3. URGES Member States to take the following measures:

3.

Document WHA39/1986/REC/1,Annex 6, part 2.

References:

(1) to ensure that complementary foods are not marketed for or used in ways that undermine exclusive
and sustained breastfeeding;
(2) to ensure that the financial support for professionals working in infant and young child health does
not create conflicts of interest, especially with
regard to the WHO/UNICEF Baby Friendly Hospital Initiative;
(3) to ensure that monitoring the application of the
International Code and subsequent relevant resolutions is carried out in a transparent, independent
manner, free from commercial influence;
(4) to ensure that the appropriate measures are taken
including health information and education in the
context of primary health care, to encourage
breastfeeding;

37

(5) to ensure that the practices and procedures of their

health care systems are consistent with the principles and aims of the International Code of Marketing of Breastmilk Substitutes;

WHA RESOLUTION 54.2

Infant and young child nutrition
The Fifty-fourth World Health Assembly, Recalling
resolutions WHA33.32, WHA34.22, WHA35.26,
WHA37.30, WHA39.28, WHA41.11, WHA43.3,
WHA45.34, WHA46.7, WHA47.5 and WHA49.15 on
infant and young child nutrition, appropriate feeding
practices and related questions;

(6) to provide the Director-General with complete and

detailed information on the implementation of the
Code;
4. REQUESTS the Director-General to disseminate, as
soon as possible, to Member States document WHO/
NUT/96.4 (currently in preparation) on the guiding
principles for feeding infants and young children
during emergencies.

Deeply concerned to improve infant and young child

nutrition and to alleviate all forms of malnutrition in
the world, because more than one-third of under-five
children are still malnourished - whether stunted,
wasted, or deficient in iodine, vitamin A, iron or other
micronutrients - and because malnutrition still contributes to nearly half of the 10.5 million deaths each year
among preschool children worldwide;

25 May 1996

Deeply alarmed that malnutrition of infants and young

children remains one of the most severe global public
health problems, at once a major cause and consequence
of poverty, deprivation, food insecurity and social
inequality, and that malnutrition is a cause not only of
increased vulnerability to infection and other diseases,
including growth retardation, but also of intellectual,
mental, social and developmental handicap, and of
increased risk of disease throughout childhood, adolescence and adult life;
Recognizing the right of everyone to have access to safe
and nutritious food, consistent with the right to adequate food and the fundamental right of everyone to be
free from hunger, and that every effort should be made
with a view to achieving progressively the full realization of this right;
Acknowledging the need for all sectors of society including governments, civil society, health professional
associations, nongovernmental organizations, commercial enterprises and international bodies - to contribute
to improved nutrition for infants and young children by
using every possible means at their disposal, especially
by fostering optimal feeding practices, incorporating a
comprehensive multisectoral, holistic and strategic
approach;
Noting the guidance of the Convention on the Rights of
the Child, in particular Article 24, which recognizes,
inter alia, the need for access to and availability of both
support and information concerning the use of basic
knowledge of child health and nutrition, and the advantages of breastfeeding for all segments of society, in
particular parents and children;

38

Conscious that despite the fact that the International

Code of Marketing of Breastmilk Substitutes and
relevant, subsequent Health Assembly resolutions state
that there should be no advertising or other forms of
promotion of products within its scope, new modern
communication methods, including electronic means,
are currently increasingly being used to promote such
products; and conscious of the need for the Codex
Alimentarius Commission to take the International
Code and subsequent relevant Health Assembly resolutions into consideration in dealing with health claims in
the development of food standards and guidelines;

(2)

to take necessary measures as States Parties

effectively to implement the Convention on the
Rights of the Child, in order to ensure every childs
right to the highest attainable standard of health
and health care;

(3)

Mindful that 2001 marks the twentieth anniversary of

the adoption of the International Code of Marketing of
Breastmilk Substitutes, and that the adoption of the
present resolution provides an opportunity to reinforce
the International Codes fundamental role in protecting,
promoting and supporting breastfeeding;

to set up or strengthen interinstitutional and

intersectoral discussion forums with all stakeholders in order to reach national consensus on strategies and policies including reinforcing, in collaboration with ILO, policies that support
breastfeeding by working women, in order substantially to improve infant and young child
feeding and to develop participatory mechanisms
for establishing and implementing specific nutrition programmes and projects aimed at new
initiatives and innovative approaches;

(4)

Recognizing that there is a sound scientific basis for

policy decisions to reinforce activities of Member States
and those of WHO; for proposing new and innovative
approaches to monitoring growth and improving nutrition; for promoting improved breastfeeding and complementary feeding practices, and sound culture-specific
counselling; for improving the nutritional status of
women of reproductive age, especially during and after
pregnancy; for alleviating all forms of malnutrition; and
for providing guidance on feeding practices for infants of
mothers who are HIV-positive;

to strengthen activities and develop new approaches to protect, promote and support exclusive
breastfeeding for six months as a global public
health recommendation, taking into account the
findings of the WHO expert consultation on
optimal duration of exclusive breastfeeding, (note
1) and to provide safe and appropriate complementary foods, with continued breastfeeding for up to
two years of age or beyond, emphasizing channels
of social dissemination of these concepts in order to
lead communities to adhere to these practices;

(5)

to support the Baby-friendly Hospital Initiative

and to create mechanisms, including regulations,
legislation or other measures, designed, directly
and indirectly, to support periodic reassessment of
hospitals, and to ensure maintenance of standards
and the Initiatives long-term sustainability and
credibility;

(6)

to improve complementary foods and feeding

practices by ensuring sound and culture-specific
nutrition counselling to mothers of young children,
recommending the widest possible use of indigenous nutrient-rich foodstuffs; and to give priority
to the development and dissemination of guidelines on nutrition of children under two years of
age, to the training of health workers and community leaders on this subject, and to the integration
of these messages into strategies for health and
nutrition information, education and communication;

(7)

to strengthen monitoring of growth and improvement of nutrition, focusing on community-based

strategies, and to strive to ensure that all malnourished children, whether in a community or
hospital setting, are correctly diagnosed and
treated;

Noting the need for effective systems for assessing the

magnitude and geographical distribution of all forms of
malnutrition, together with their consequences and
contributing factors, and of foodborne diseases; and for
monitoring food security;
Welcoming the efforts made by WHO, in close collaboration with UNICEF and other international partners, to
develop a comprehensive global strategy for infant and
young child feeding, and to use the ACC Sub-Committee
on Nutrition as an interagency forum for coordination
and exchange of information in this connection;
1. THANKS the Director-General for the progress
report on the development of a new global strategy
for infant and young child feeding;
2. URGES Member States:
(1)

to recognize the right of everyone to have access to

safe and nutritious food, consistent with the right
to adequate food and the fundamental right of
everyone to be free from hunger, and that every
effort should be made with a view to achieving
progressively the full realization of this right and
to call on all sectors of society to cooperate in
efforts to improve the nutrition of infants and
young children;
39

(8)

to develop, implement or strengthen sustainable

measures including, where appropriate, legislative
measures, aimed at reducing all forms of malnutrition in young children and women of reproductive
age, especially iron, vitamin A and iodine deficiencies, through a combination of strategies that
include supplementation, food fortification and
diet diversification, through recommended feeding
practices that are culture-specific and based on
local foods, as well as through other communitybased approaches;

3. REQUESTS the Director-General:

(1)

to give, greater emphasis to infant and young child

nutrition, in view of WHOs leadership in public
health, consistent with and guided by the Convention on the Rights of the Child and other relevant
human rights instruments, in partnership with
ILO, FAO, UNICEF, UNFPA and other competent
organizations both within and outside the United
Nations system;

(2)

to foster, with all relevant sectors of society, a

constructive and transparent dialogue in order to
monitor progress towards implementation of the
International Code of Marketing of Breastmilk
Substitutes and subsequent relevant Health
Assembly resolutions, in an independent manner
and free from commercial influence, and to provide
support to Member States in their efforts to
monitor implementation of the Code;

(3)

to provide support to Member States in the identification, implementation and evaluation of innovative approaches to improving infant and young
child feeding, emphasizing exclusive breastfeeding
for six months as a global public health recommendation, taking into account the findings of the
WHO expert consultation on optimal duration of
exclusive breastfeeding (note 1), the provision of
safe and appropriate complementary foods, with
continued breastfeeding up to two years of age or
beyond, and community-based and cross-sector
activities;

(4)

to continue the step-by-step country- and regionbased approach to developing the new global
strategy on infant and young child feeding, and to
involve the international health and development
community, in particular UNICEF, and other
stakeholders as appropriate;

(5)

(11) to take all necessary measures to protect all

women from the risk of HIV infection, especially
during pregnancy and lactation;

to encourage and support further independent

research on HIV transmission through
breastfeeding and other measures to improve the
nutritional status of mothers and children already
affected by HIV/AIDS;

(6)

(12) to strengthen their information systems, together

with their epidemiological surveillance systems, in
order to assess the magnitude and geographical
distribution of malnutrition, in all its forms, and
foodborne disease;

to submit the global strategy for consideration to

the Executive Board at its 109th session in January 2002 and to the Fifty-fifth World Health
Assembly (May 2002).

References

(9)

to strengthen national mechanisms to ensure

global compliance with the International Code of
Marketing of Breastmilk Substitutes and subsequent relevant Health Assembly resolutions, with
regard to labelling as well as all forms of advertising, and commercial promotion in all types of
media, to encourage the Codex Alimentarius
Commission to take the International Code and
relevant subsequent Health Assembly resolutions
into consideration in developing its standards and
guidelines; and to inform the general public on
progress in implementing the Code and subsequent relevant Health Assembly resolutions;

(10) to recognize and assess the available scientific

evidence on the balance of risk of HIV transmission through breastfeeding compared with the risk
of not breastfeeding, and the need for independent
research in this connection; to strive to ensure
adequate nutrition of infants of HIV-positive
mothers; to increase accessibility to voluntary and
confidential counselling and testing so as to
facilitate the provision of information and informed decision-making; and to recognize that
when replacement feeding is acceptable, feasible,
affordable, sustainable and safe, avoidance of all
breastfeeding by HIV-positive women is recommended; otherwise, exclusive breastfeeding is
recommended during the first months of life; and
that those who choose other options should be
encouraged to use them free from commercial
influences;

1.

40

As formulated in the conclusions and recommendations of the

expert consultation (Geneva, 28 to 30 March 2001) that
completed the systematic review of the optimal duration of
exclusive breastfeeding (see document A54/INF.DOC./4).

APPENDIX 3
Further Reading and Relevant Websites
Readings:

Websites:

Allain A, IBFAN on the Cutting Edge, Penang: IBFAN,

1991 (rev. ed) (originally published in Development
Dialogue, the journal of the Dag Hammarskjld Foundation, 1980:2). Available from the International Code
Documentation Centre, P.O. Box 19, 10700 Penang,
Malaysia, ibfanpg@tm.net.my.

Action pour lAllaitment, France

web.superb.net/apastras
Arbeitsgemeinschaft Freier Stillgruppen, Germany
www.stillen.org
Baby Milk Action, Great Britain
www.babymilkaction.org

Baumslag N, Milk, Money and Madness: The Culture

and Politics of Breastfeeding, Westport Connecticut:
Bergin.& Garvey, 1995.

Breastfeeding Promotion Network of India (BPNI)

www.bpni.org

Chetley, A., The Politics of Baby Foods: Successful

Challenges to an International Marketing Strategy,
London: Frances Pinter, 1986.

Cefemina, Costa Rica

www.cefemina.or.cr

International Baby Food Action Network, Protecting

Infant Health: A Health Workers Guide to the International Code of Marketing of Breastmilk Substitutes, 9th
Edition, Penang: IBFAN, 1999. Available in numerous
languages from any IBFAN regional coordinating
center. (See addresses on page 25)

Hungarian Association for Breastfeeding

www.c3hu/~hab
INFACT, Canada
www.infactcanada.ca
Information pour lAllaitment, France
www.perso.wanadoo.fr/ipa

International Baby Food Action Network, History of

the Campaign, Action Pack, IBFAN/Gifa, Geneva.
Available from IBFAN/Gifa, BP 157, 1211 Geneva 19,
SWITZERLAND, info@gifa.org.

Interagency Group on Breastfeeding Monitoring (IGBM)

www.oneworld.org/unicef/igbm.htm

Minchin M, Breastfeeding Matters: What we need to

know about infant feeding, Australia: Alma Publications
and George Allen & Unwin, 1985.

International Baby Food Action Network (IBFAN)

IBFAN Argentina
IBFAN Brazil Coordinating Office
www.ibfan.org
www.yabiru.fmed.uba.ar/nspba/ibfarg
www.ibfan.org.br

Palmer, Gay, The Politics of Breastfeeding, London:

Pandora Press, 1993, p.252 (2d ed.)
Shubber S, International Code of Marketing of
Breastmilk Substitutes, Kluwer Law International,
1999.

IBFAN Latin America y el Caribe

www.yabiru.fmed.uba.ar/ibfan

Sokol E and Allain A, Complying with the Code? A

Manufacturers and Distributors Guide to the Code,
Penang, IBFAN 1998. Available from the International
Code Documentation Centre, P.O. Box 19, 10700
Penang, Malaysia, ibfanpg@tm.net.my.

International Lactation Consultant Association

www.ilca.org

Sokol, E., The Code Handbook, A Guide to Implementing

the International Code of Marketing of Breastmilk
Substitutes, Penang: IBFAN, 1997. Available in English,
French Spanish and Portuguese from the International
Code Documentation Centre, P.O. Box 19, 10700
Penang, Malaysia, ibfanpg@tm.net.my.

LACMAT, Argentina
www.fmed.uba.ar/mspba/ibfarg

La Leche League
www.lalecheleague.org

Nestl
www.babymilk.nestle.com
Nordic Working Group for International Breastfeeding

41

Issues (NAFIA)
www.nordet.se/nafia/welcome.html

WEMOS, Netherlands
www.wemos.org

Origem, Brazil
bbs.elogica.com.br/aleitamento

World Health Organization

www.who.int

Ted Greiners Breastfeeding Website

www.geocities.com/HotSprings/Spa/3156

Breastfeeding advocacy page

www.promom.org/features/articles/bfpage.htm

The Breastfeeding Advocacy Page

www.clark.net/pub/activist/bfpage/bfpage.html

National Alliance for Breastfeeding Action

www.members.aol.com/marshalact/naba

UNICEF
www.unicef.org

World Alliance for Breastfeeding Action (WABA)

www.waba.org.br/

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