Letters

Marketing of breast milk substitutes

BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7154.350 (Published 01 August 1998) Cite this as: BMJ 1998;317:350

Infant food manufacturers hope code will be implemented properly

  1. Sarah Jacobs, Executive secretary,
  2. Andrée Bronner, Secretary general
  1. Infant and Dietetic Foods Association, London WC2B 5JJ
  2. International Association of Infant Food Manufacturers, 75001 Paris, France
  3. Unit for Health Services Research and International Cooperation, Istituto per l'Infanzia, Via dell'Istria 65/1, 34100 Trieste, Ital
  4. Mayday University Hospital, Thornton Heath, Surrey CR7 7YE
  5. University Hospital of Lewisham, London SE13 6LH

    EDITOR—It is disappointing that the BMJ should give such prominence to Taylor's paper1as it is based on a report of the Interagency Group on Breastfeeding Monitoring that was first published 15 months ago. The paper is no more than a reworked presentation of less than 30% of the original document, some of which had already been reported in the journal.2

    The timing is also disappointing in view of the announcement by the World Health Organisation in January 1998 that it is to hold consultations on infant feeding, including an initiative to identify, examine, and overcome the main obstacles to implementing the international code of marketing of breast milk substitutes in all countries. The infant food industry is happy to work with the WHO and others, but in the past the Interagency Group on Breastfeeding Monitoring has refused to meet with us and has repeatedly refused to provide the information that would allow companies to investigate the alleged contraventions.

    Taylor concludes that the survey methods used in this study were successful in detecting violations of the international code and recommends that the methodology should be used in future monitoring. Yet the protocol, results, and conclusions have been severely criticised for using arbitrary definitions (J Rey, personal communication) and flawed methodology.3 We also take issue with many of the alleged violations that relate to foods not covered by the code, such as follow-on formulas (weaning milks) and weaning foods. Local regulations and codes are also ignored, even though the code states that countries should develop their own controls as appropriate to their own requirements.

    In its January 1998 report to its executive board the WHO “urges that national measures adopted to give effect to the International Code include: clear definitions, which are communicated to and understood by all parties; transparent monitoring and reporting procedures to determine whether alleged violations contravene national measures; and a monitoring authority established under government responsibility.” The infant food industry fully supports this recommendation and the current consultation process, which we trust will lead to proper implementation of the code by all countries, with effective, transparent and impartial monitoring of the code under government supervision.

    References

    Italy has initiatives regarding compliance with international code

    1. Susanna Centuori, Research fellow,
    2. Adriano Cattaneo, Epidemiologist,
    3. Riccardo Davanzo, Neonatologist,
    4. Tea Burmaz, Research student,
    5. Del Menuela Santo, Resident in paediatrics
    1. Infant and Dietetic Foods Association, London WC2B 5JJ
    2. International Association of Infant Food Manufacturers, 75001 Paris, France
    3. Unit for Health Services Research and International Cooperation, Istituto per l'Infanzia, Via dell'Istria 65/1, 34100 Trieste, Ital
    4. Mayday University Hospital, Thornton Heath, Surrey CR7 7YE
    5. University Hospital of Lewisham, London SE13 6LH

      EDITOR—Manufacturers of infant food violate the international code for the marketing of breast milk substitutes in many countries. 4 5 The code is meant to regulate the practices of governments and companies, but disciplines also the behaviour of health workers. Under article 7, companies should not offer “financial or material inducements to promote products” and health workers should not accept such inducements, and this statement was reinforced by the World Health Assembly in 1996. 

      Italy has a law based on the International Code and European Union directives. The prevalence of breast feeding, not well defined and probably including any breast feeding, was about 67% at 1 month and 31% at 6 months of age in 1994,6 well below the WHO recommendations for exclusive breast feeding. At discharge from hospital, 68% of mothers are given free samples of formula.

      A large survey, Paediatric Education Breastfeeding Research (funded by the European Union in 1995 to assess knowledge, attitudes, and practices of paediatricians on breast feeding), included in its long questionnaire this item: “Do you think it is correct for paediatricians to accept financial support from companies for research or clinical activities?” A total of 842 questionnaires were given out in 1996 at the annual congress of the Societé Italiana di Pediatria. We received 406 completed questionnaires (48%); 319 responders (38%) answered that question. The table shows the results.

      Opinion of Italian paediatricians about financial support from baby food companies

      View this table:

      This represents the opinion of paediatricians who attend an annual congress, answer questionnaires, are interested in breast feeding, and know that there is an international code. In addition, the question (which we were not allowed to modify, as it was part of a multinational study) addressed only financial support for research or clinical activities; other types of financial support, such as participation in congresses, were not included. About two thirds of the responders were hospital paediatricians; they may be more likely than community paediatricians to know the code as the law has applied mostly in hospitals since 1995. The real level of awareness about the codeand the attitude towards financial support from companies may be worse among paediatricians. To tackle this problem, the Associazione Culturale Pediatri, another association of paediatricians, is developing an internal code that will regulate the relation of individual associates and groups who apply for or are offered financial support from companies. The association will also update annually a list of companies with documented violations of the international code.

      Acknowledgments

      We thank Luis Ruiz, co-ordinator of PEBR, for the permission to publish these preliminary results

      References

      Manufacturers have sponsored healthcare journals

      1. Maxwell Asante, Senior registrar,
      2. Kathleen Asante, Midwife
      1. Infant and Dietetic Foods Association, London WC2B 5JJ
      2. International Association of Infant Food Manufacturers, 75001 Paris, France
      3. Unit for Health Services Research and International Cooperation, Istituto per l'Infanzia, Via dell'Istria 65/1, 34100 Trieste, Ital
      4. Mayday University Hospital, Thornton Heath, Surrey CR7 7YE
      5. University Hospital of Lewisham, London SE13 6LH

        EDITOR—Breast milk substitutes remain a major cause of childhood morbidity and mortality in both low and high income countries. 7 8 As Taylor points out,9 widespread breaching of the international code of marketing breast milk substitutes10 has prompted cautions about covert endorsements by healthcare professionals of such products.11 We are therefore concerned that sponsorship of a recent index supplement for the 1997 volume of the British Journal of Midwifery by a company that manufactures breast milk substitutes could be misconstrued as an overt endorsement of such products by healthcare organisations. This practice may in the long term be counterproductive for health education on breast feeding.

        References

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