Global evidence of persistent violations of the International Code of Marketing of Breast-milk Substitutes: A systematic scoping review

The influence of marketing on infant and young child feeding and health is well recognized, and an International Code was adopted by the World Health Assembly (WHA) in 1981 to reduce inappropriate marketing and protect breastfeeding. Yet the marketing and influencing continue. This scoping review systematically examined the published research evidence on the nature and extent of exposure to International Code violations from 1981 to August 2021. We used several search strategies involving multi‐language databases, organization websites, citation tracking, and expert consultation, to find research items meeting our inclusion criteria. We evaluated 657 items and retained 153 studies from at least 95 countries in the review. The majority of the studies (n = 113) documenting exposure to inappropriate marketing were published since 2010. Studies reported a broad range of marketing violations targeting mothers and families, health workers, and the general public. Marketing via digital platforms and brand extension has become more frequent. The evidence shows the use of misleading and inaccurate labeling and health and nutrition claims in breach of the Code. Our review confirms that violations of the Code have not ceased and calls for renewed attention from the WHA and national governments to protect the health of children and their mothers.

Exposure to inappropriate marketing continues across the world in health systems, public spaces, points of sale, media, emergency programs, and direct to mothers.

Studies have documented the emergence of products and marketing practices designed to circumvent the Code.

Labeling and health and nutrition claims were found that were misleading, inaccurate, and in breach of the Code.

Evidence of marketing through social media and other digital platforms has increased over time.

Future research, guidance, and policies would benefit from an accessible central repository of comprehensive and comparable measurement tools and evidence.

Assessment of Bottle-Feeding Practices in Kassala, Eastern Sudan: A Community-Based Study

BACKGROUND

The World Health Organization encourages exclusive breastfeeding up to six months and avoidance of bottle-feeding. There are few published research articles on the practice of bottle-feeding and associated factors in Sudan.

AIM

The study aimed to assess the usage and factors associated with bottle-feeding practices during the first six months of life among mothers with children aged between 6 and 24 months in Kassala, Eastern Sudan.

METHODS

A community-based cross-sectional study was conducted from July to September 2017. A structured questionnaire was used to collect relevant data from interviewed mothers.

RESULTS

A total of 242 mother-child pairs participated in the study. The mean (standard deviation) of maternal age and children's age was 27.13 (5.73) years and 12.2 (6.7) months, respectively. From the total, 96/242 (39.7%) used bottle-feeding for their children in the first six months of life. In multivariable analysis, urban residence (Adjusted Odds Ratio [AOR] 1.96, 95% Confidence Interval [CI] (1.06, 3.63), not receiving breastfeeding education (AOR 1.92, 95% CI 1.07, 3.45) and child hospitalization (AOR 1.83, 95% CI 1.02, 3.28) were significantly associated with bottle-feeding.

CONCLUSION

There was a high usage of bottle-feeding and it was found to be associated with child hospitalisation. To avoid bottle-feeding, urgent actions are required to support and educate mothers regarding breastfeeding with special attention to urban-residence ones.

Undernutrition, obesity and governance: a unified framework for upholding the right to food

This paper addresses the need for conceptual and analytic clarity on nutrition governance, an essential underpinning of more effective approaches for undernutrition, the 'single greatest constraint to global development' and obesity, which already accounts for 4% of the world's disease burden and is growing rapidly. The governance of nutrition, which is essential to designing and implementing policies to realise the right to food, is among the most important and most defining duties of society. But research and action on nutrition governance are hampered by the absence of conceptual rigour, even as the continuing very high burden of undernutrition and the rapid rise in obesity highlight the need for such structures. The breadth of nutrition itself suggests that governance is both needed and sure to be complicated. This analysis explores the reasons attention has come to governance in development policy making, and why it has focused on nutrition governance in particular. It then assesses how the concept of nutrition governance has been used, finding that it has become increasingly prominent in scholarship on poor nutritional outcomes, but remains weakly specified and is invoked by different authors to mean different things. Undernutrition analysts have stressed coordination problems and structural issues related to the general functioning of government. Those studying obesity have emphasised international trade policies, regulatory issues and corporate behaviour. This paper argues that the lack of a clear, operational definition of governance is a serious obstacle to conceptualising and solving major problems in nutrition. To address this need, it develops a unified definition of nutrition governance consisting of three principles: accountability, participation and responsiveness. These are justified with reference to the social contract that defines modern nations and identifies citizens as the ultimate source of national power and legitimacy. A unified framework is then employed to explore solutions to nutrition governance problems.

Enforcing the International Code of Marketing of Breast-milk Substitutes for Better Promotion of Exclusive Breastfeeding: Can Lessons Be Learned?

Exclusive breastfeeding, one of the best natural resources, needs protection and promotion. The International Code of Marketing of Breast-milk Substitutes (the Code), which aims to prevent the undermining of breastfeeding by formula advertising, faces implementation challenges. We reviewed frequently overlooked challenges and obstacles that the Code is facing worldwide, but particularly in Southeast Asia. Drawing lessons from various countries where we work, and following the example of successful public health interventions, we discussed legislation, enforcement, and experiences that are needed to successfully implement the Code. Successful holistic approaches that have strengthened the Code need to be scaled up. Community-based actions and peer-to-peer promotions have proved successful. Legislation without stringent enforcement and sufficient penalties is ineffective. The public needs education about the benefits and ways and means to support breastfeeding. It is crucial to combine strong political commitment and leadership with strict national regulations, definitions, and enforcement. National breastfeeding committees, with the authority to improve regulations, investigate violations, and enforce the laws, must be established. Systematic monitoring and reporting are needed to identify companies, individuals, intermediaries, and practices that infringe on the Code. Penalizing violators is crucial. Managers of multinational companies must be held accountable for international violations, and international legislative enforcement needs to be established. Further measures should include improved regulations to protect the breastfeeding mother: large-scale education campaigns; strong penalties for Code violators; exclusion of the formula industry from nutrition, education, and policy roles; supportive legal networks; and independent research of interventions supporting breastfeeding.

Implementation of international code of marketing breast-milk substitutes in China

BACKGROUND

Breastmilk is the best source of nourishment for infants and young children, and breastfeeding is one of the most effective ways to ensure child health and survival. In May 1981, the World Health Assembly adopted the International Code of Marketing Breast-Milk Substitutes. Since then several subsequent resolutions have been adopted by the World Health Assembly, which both update and clarify the articles within the International Code (herein after the term "Code" refers to both the International Code and all subsequent resolutions). The Code is designed to regulate "inappropriate sales promotion" of breastmilk substitutes and instructs signatory governments to ensure the implementation of its aims through legislation. The Chinese Regulations of the Code were adopted by six government sectors in 1995. However, challenges in promotion, protection, and support of breastfeeding remain. This study aimed to monitor the implementation of the Code in China.

SUBJECTS AND METHODS

Six cities were selected with considerable geographic coverage. In each city three hospitals and six stores were surveyed. The International Baby Food Action Network Interview Form was adapted, and direct observations were made. Research assistants administered the questionnaires to a random sample of mothers of infants under 6 months old who were in the outpatient department of the hospitals. In total, 291 mothers of infants, 35 stores, 17 hospitals, and 26 companies were surveyed.

RESULTS

From the whole sample of 291 mothers, the proportion who reported exclusively breastfeeding their infant was 30.9%; 69.1% of mothers reported feeding their infant with commercially available formula. Regarding violations of the Code, 40.2% of the mothers reported receiving free formula samples. Of these, 76.1% received the free samples in or near hospitals. Among the stores surveyed, 45.7% were found promoting products in a way that violates the Code. Also, 69.0% of the labeling on the formula products did not comply with the regulations set out in the Code.

CONCLUSIONS

As the social and economic developments continue, the interactions of more and more factors curb further success in breastfeeding. Support from all sectors of the society is needed in order to create a social environment to enable the promotion of breastfeeding, in addition to the efforts already made by the healthcare system.

Compliance with the International Code of Marketing of breast-milk substitutes: an observational study of pediatricians' waiting rooms

Abstract The importance of breastmilk as a primary preventative intervention is widely known and understood by most healthcare providers. The actions or non-actions that heathcare providers take toward promoting and supporting breastfeeding families make a difference in the success and duration of breastfeeding. Recognizing this relationship, the World Health Organization developed the International Code of Marketing of Breast-milk Substitutes (the Code), which defines best practices in breastfeeding promotion, including physicians' offices. The pediatric practices' waiting rooms are often a family's first experience with pediatric care. The specific aims of this study were to describe (1) Code compliance, (2) the demographic factors affecting the Code compliance, and (3) the amount and type of breastfeeding-supportive materials available in the pediatricians' waiting rooms. An observational cross-sectional design was used to collect data from 163 (82%) of the pediatric practices in Maricopa County, Arizona. None of the 100 waiting rooms that had any materials displayed (61%) was found to be completely Code compliant, with 81 of the offices having formula-promotional materials readily available. Waiting rooms in higher income areas offered more non-Code-compliant materials and gifts. Breastfeeding support information and materials were lacking in all but 18 (18%) offices. A positive relationship (t97=-2.31, p=0.02) occurred between the presence of breastfeeding educational materials and higher income areas. We were able to uncover some practice-related patterns that impact families and potentially undermine breastfeeding success. To move current practices toward breastfeeding-friendly physicians' offices, change is needed.