Pediatric Nutrition in Practice

106 Kler  Gupta  Thakur

code represents the development of an interna-
tional consensus. The code also covers ethical
considerations and regulations for the market-
ing of feeding bottles and teats. Even after 3 de-
cades of implementation of the code there are
continuing issues of implementation, monitor-
ing and compliance, which predominantly re-
flect weak governance [5].

Violations of the Code

Since 1981, when the code was formulated, nu-
merous violations have been reported both from
the developing and the developed world. In devel-
oping nations, multistage, random sampling of
pregnant mothers and mothers of infants less
than 6 months old was carried out in 4 cities
(Dhaka, Durban, Bangkok and Warsaw) with dis-
appointing results: 26% of mothers in Bangkok
received free samples of breast milk substitutes
from companies [6]. Many violations were re-
ported in Uganda in a survey of mothers and
health workers. In 2008, 70% of 427 health profes-
sionals in Pakistan were unaware of their own
breastfeeding laws, and 80% unaware of the code;
12% had received sponsorship from pharmaceu-
tical companies for training sessions or atten-
dance at conferences [7]. In countries with weak
regulations, sales of formula were noticed to be
higher. Differences were seen, for example, be-
tween the Philippines and India. In India, where
advertising is strictly controlled by the Infant
Milk Substitutes Act [8] , breastfeeding rates are
46% at 5 months of age. In contrast, the Philip-
pines, with much weaker regulations, have 3
times lower breastfeeding rates [9]. In the devel-
oped world, marketing tends to be more subtle
than in developing countries [10]. Among the in-
dustrialized nations, the lowest breastfeeding
rates (7% at 4 months) were seen in the UK, where
companies spend 10 times more on advertising
than the Department of Health spends on pro-
moting breastfeeding. Interestingly, 20% of moth-

ers in the UK who were weaning their babies at

4–6 months of age thought formula was better

and more nutritious than breast milk.

Monitoring the Code

Information provided by monitoring helps the

WHO, UNICEF, governments and nongovern-

mental organizations to imply the code and moni-

tor violations. The reports on violations demon-

strate the need for transparent, independent and

effective controls in the marketing of baby food

and bottles. Governments should ensure a consis-

tent strategy of monitoring, involving investiga-

tion, observation and recording of information.

The basics of monitoring include: familiarization

with the main points of the International Code and

with national measures; obtaining information on

the breast milk substitutes locally used; recording

details about the company and brand names and

the hospitals/clinics where infant formula is used;

description of posters, displays, etc.; and reporting

of violations to the appropriate body.

It is now recognized that voluntary initiatives

alone are inadequate for implementation of the

International Code of Marketing of Breast-Milk

Substitutes. Health professionals and breastfeed-

ing organizations call for enforcement of stricter

rules. Under the international code, information

provided by the manufacturers should not imply

or create a belief that bottle feeding is equivalent

or superior to breastfeeding.

Impact on Mortality and Morbidity

In developing countries, numerous studies have

reported an increased mortality and morbidity

with the use of breast milk substitutes. A recent

meta-analysis showed excess risk of diarrhea mor-

tality in nonbreastfed babies in comparison with

exclusive breastfeeding among infants 0–5 months

of age (relative risk: 10.52) and with any breast-

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 104–108

DOI: 10.1159/000360326