Intended for healthcare professionals


Monitoring the marketing of infant formula feeds

BMJ 2003; 326 doi: (Published 18 January 2003) Cite this as: BMJ 2003;326:113

Manufacturers of breast milk substitutes violate the WHO code—again

  1. Tony Waterston (a.j.r.waterston{at}, consultant paediatrician,
  2. James Tumwine, associate professor of paediatrics and child health
  1. Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
  2. Makerere Medical School, PO Box 7072, Kampala, Uganda

    Papers p 127

    Breast feeding is one of the most cost effective interventions to improve health and prevent illness in early childhood. Protection of breast feeding from commercial exploitation should be among the highest priorities for the international community, yet violations of the World Health Organization's code of marketing of breast milk substitutes have been seen regularly, despite companies' expressed intentions to conform.13 The study by Aguayo et al in west Africa in this issue (p 127) provides further evidence that many manufacturers fly in the face of the code by providing free samples, giving donations to health workers, and contravening standards for labelling.4

    How reliable is the methodology of the study? The selection of health centres to be monitored was either random or complete. The number of mothers interviewed was modest: 105 compared with 1582 in the 1998 study,2 and, surprisingly, more health workers than mothers were interviewed. None the less, many of the figures are comparable to the study by Taylor, although the frequency of violations is rather lower in this research.

    It is particularly disturbing that in Togo, 85% of health workers had never heard of the WHO code and none had participated in training, whereas in Burkina Faso, 40% worked in a “baby friendly” facility but only 17% had participated in training. This indicates a failure of the training and accreditation systems in these facilities.

    Three essential issues arise from this study. Firstly, how should we monitor compliance of the code effectively to reduce the continuing violations? As Carol Bellamy, executive director of Unicef, said in welcoming the report that led to Taylor's paper: “The question now becomes: how do we proceed when all the evidence suggests that, despite the protestations of good faith by the breast milk substitute manufacturers, many continue to view the international code as a covenant more to be honoured in the breach than in the substance?”5 Currently three international models of monitoring exist: the WHO Common Review and Evaluation Framework (WHO/NUT/96.2), the International Baby Food Action Network (IBFAN) Monitoring Forms Manual (email ibfanpg{at}, and the Interagency Group on Breastfeeding Monitoring (IGBM) protocol currently in draft ( The third has the advantage of assessing compliance with both the international code and national legislation and describes clearly the sampling method used. Endorsement of a protocol such as this by the international community would advance the enforcement of the code by all member states as well as individual manufacturers.

    Secondly, how should we train health workers about the protection and support of breast feeding? The potential benefits of the Unicef baby friendly initiative of accrediting health facilities are considerable and now evidence based.6 There are also indications that the initiative has led to an arrest in the worldwide decline in breast feeding.7 Training of health workers is an essential prerequisite to reducing the harmful effects of health services, but pretraining should be carried out systematically and periodically so that new workers are included, and there should be an emphasis on the development of advocacy skills. 8 9

    Thirdly, how should we combine support for breast feeding with a recognition of the risk of maternally transmitted HIV infection. It should be made absolutely clear that in most poor countries afflicted by AIDS the risk of bottle feeding is higher than the risk of mother to infant transmission of HIV infection. This fact needs to be continually reiterated to decision makers as otherwise manufacturers of breast milk substitutes will capitalise on HIV infection as a reason for promoting free samples of their formula.10 It is extraordinary that the Wall Street Journal painted the baby food manufacturers as heroes poised to save African children from certain death because of their offer to donate free formula to HIV infected mothers.11 The WHO recommends avoidance of breast feeding by HIV infected mothers only if replacement feeding is feasible, safe, sustainable, and affordable—otherwise exclusive breast feeding is recommended during the first six months of life.12 Non-infected women must be given access to credible information, quality care, and support, in order to empower them to make informed decisions regarding feeding of their infant.13

    Governments should accept promotion and protection of breast feeding as a critical area for improving child health. The WHO code is central to ensuring this protection, but a better way of monitoring and enforcing its application in both industrialised and low income countries must be identified.


    • Competing interests TW is a professional adviser to Baby Milk Action, which campaigns on protecting breast feeding from commercial exploitation. JT has no competing interests.


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