The International Code of Marketing of Breastmilk Substitutes

The article by Nelson, Chan and Yu1‘Breast milk substitutes in Hong Kong’ highlights the difficulties with the implementation of the International Code of Marketing of Breastmilk Substitutes (the Code). The Code was adopted by the World Health Assembly (WHA) in 1981. Although WHA recommendations are generally not binding, they ‘carry moral or political weight, as they constitute the judgement on a health issue of the collective membership of the highest international body in the field of health2.’ Implementation of the International Code and Resolutions is recognized as an obligation under the Convention of the Rights of the Child. Australia was one of the first of 191 member countries of the WHA to endorse the Code. Hong Kong is signatory to the Code but, as documented by Nelson and colleagues, compliance in Hong Kong remains poor. See related article, p 350. The aim of the 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 breast milk substitutes on the basis of adequate information and through appropriate marketing and distribution. The Code is broad in its scope and applies to the availability and marketing of products used as partial or total replacement of breast milk, and the bottles and teats required for their use. The Code recognizes that governments are responsible for the provision of information on infant feeding but forbids reference to proprietary products. It also states that information must not idealize the use of breast milk substitutes and specified warnings must be included. The Code bans companies from seeking contact with pregnant women and mothers. Companies must only provide health care workers with scientific and factual information. Companies may not provide free samples unless for professional evaluation or institutional research. If company funding is accepted, it must be declared and there must not be a conflict of interests. Inducements to promote products are banned. Company personnel may not be paid on a commission basis for sales of products within the scope of the Code, nor may they be involved in training mothers or pregnant women. Composition and labelling of products should meet the relevant standards adopted by the FAO/WHO Codex Alimentarius. Warnings and clear instructions must be included, idealizing text or pictures are forbidden and text must be in the appropriate language. The Code states that governments should implement, monitor and report progress to WHO. More detailed explanation of the Code is available on the International Baby Food Action Network (IBFAN) website (http://www.ibfan.org). IBFAN is a coalition of public interest groups in 90 developing and industrialized nations working for better child health and nutrition through the promotion of breastfeeding and eliminating irresponsible marketing of infant feeds, bottles and teats. Internationally 24 countries (including India, Phillipines, Brazil, Tannzania, Albania) have legislated Code implementation. Most of the countries of the European Union have legislation that encompasses some but not all of the provisions of the Code. Australia is one of 23 countries that have implemented the Code as a voluntary measure or National Health Policy. The United States of America whilst signatory has taken no action. Hong Kong has adopted some provisions of the Code and industry has agreed to comply. The Australian Government has legislated for the testing, manufacture and content of infant formula. However it has chosen to implement those aspects of the Code that apply to the marketing of infant formula through an agreement authorized under the Trade Practices Act 1974. The Marketing in Australia of Infant Formulas: Manufacturers and Importers (MAIF) Agreement 1992 was made between the Commonwealth Government and members of the Infant Formula Manufacturers Association of Australia. This is a voluntary agreement but when properly monitored, may be as effective as legislation. As such, the Advisory Panel on the Marketing in Australia of Infant Formula (APMAIF) was appointed in 1992 and exists as a non-statutory body reporting to the Minister for Health and Ageing. The aims of APMAIF include assessing complaints regarding the marketing in Australia of infant formulas, and providing advice to the Commonwealth Minister for Health and Ageing, on the operation of the agreement. The annual report of APMAIF is available on the Australian Department of Health and Ageing website3. The Royal Australasian College of Physicians (Division of Paediatrics and Child Health) supports the Code and MAIF Agreement4. Most paediatricians would be familiar with the Code as implemented via the Baby Friendly Hospital Initiative and be aware of the cost implications.