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. 1998 Aug 1;317(7154):350.

Marketing of breast milk substitutes

Infant food manufacturers hope code will be implemented properly

Sarah Jacobs 1,2, Andrée Bronner 1,2
PMCID: PMC1113643  PMID: 9685294

Editor—It is disappointing that the BMJ should give such prominence to Taylor’s paper1 as 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

  • 1.Taylor A. Violations of the international code of marketing of breast milk substitutes: prevalence in four countries. BMJ. 1998;316:1117–1119. doi: 10.1136/bmj.316.7138.1117. . (11 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Wise J. Baby milk companies accused of breaching marketing code. BMJ. 1997;314:167. [PMC free article] [PubMed] [Google Scholar]
  • 3.Rothman J. Monitoring, compliance and surveys. Marketing and Research Today 1998 May.
BMJ. 1998 Aug 1;317(7154):350.

Italy has initiatives regarding compliance with international code

Susanna Centuori 1, Adriano Cattaneo 1, Riccardo Davanzo 1, Tea Burmaz 1, Menuela Del Santo 1

Editor—Manufacturers of infant food violate the international code for the marketing of breast milk substitutes in many countries.1-1,1-2 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 1994,1-3 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 Società Italiana di Pediatria. We received 406 completed questionnaires (48%); 319 responders (38%) answered that question. The table shows the results.

Table.

Opinion of Italian paediatricians about financial support from baby food companies

Answer No (%) of paediatricans (n=319)
Accept financial support:
 Unconditionally 42 (13)
 From companies complying with international code 211 (66)
Refuse financial support:
 Because there is no way to control the compliance of companies with international code 12 (4)
 On moral grounds 37 (12)
Uncertain 17 (5)
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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 code and 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.

Footnotes

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

References

  • 1-1.Taylor A. Violations of the international code of marketing of breast milk substitutes: prevalence in four countries. BMJ. 1998;316:1117–1119. doi: 10.1136/bmj.316.7138.1117. . (11 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-2.Costello A, Sachdev HS. Protecting breast feeding from breast milk substitutes: the WHO code is widely violated and needs monitoring and supporting. BMJ. 1998;316:1103–1104. doi: 10.1136/bmj.316.7138.1103. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 1-3.Conti Nibali S, Castorina N, Pizzimenti G, Salomone L, Siracusano MF. La pratica dell’allattamento al seno in Italia. Medico e Bambino. 1998;17(1):25–29. [Google Scholar]
BMJ. 1998 Aug 1;317(7154):350.

Manufacturers have sponsored healthcare journals

Maxwell Asante 1,2, Kathleen Asante 1,2

Editor—Breast milk substitutes remain a major cause of childhood morbidity and mortality in both low and high income countries.2-1,2-2 As Taylor points out,2-3 widespread breaching of the international code of marketing breast milk substitutes2-4 has prompted cautions about covert endorsements by healthcare professionals of such products.2-5 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

  • 2-1.Golding J, Emmett P, Rogers I. Breast feeding and infant mortality. Early Human Development. 1997;49(suppl):S143–S155. doi: 10.1016/s0378-3782(97)00060-1. [DOI] [PubMed] [Google Scholar]
  • 2-2.Wilson A, Forsyth J, Greene S, Irvine L, Hau C, Howie P. Relationship of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ. 1998;316:21–25. doi: 10.1136/bmj.316.7124.21. . (3 January.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-3.Taylor A. Monitoring the international code of marketing of breast milk substitutes: an epidemiological study in four countries. BMJ. 1998;316:1117–1122. doi: 10.1136/bmj.316.7138.1117. . (11 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2-4.WHO. International code of marketing breast milk substitutes. Geneva: WHO; 1981. [PubMed] [Google Scholar]
  • 2-5.Costello A, Sachdev H. Protecting breast feeding from breast milk substitutes. BMJ. 1998;316:1103. doi: 10.1136/bmj.316.7138.1103. . (11 April.) [DOI] [PMC free article] [PubMed] [Google Scholar]

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