Do Global Infant Feeding Policies Respect the United Nations Principles on the Rights of Children and Families?

Abstract

Background

Under the terms of the United Nations Convention on the Rights of the Child (UNCRC), governments are now required to enable all children to fulfil their full potential with the key principles being non-discrimination, the right to life and development, the best interests of the child, and the right to be heard. A recent statement by UNICEF indicated that implementation of the principles of the UNCRC provide a pathway for WHO, WHA, and UNICEF global infant feeding policy documents to be introduced into domestic law. But these documents are not recent and have not been updated, and they represent high levels of non-compliance. Moreover, do they actually comply with the principles set out in the UNCRC?

Summary

Global decisions on infant feeding are being made by organisations who are distant from family circumstances and primarily reflect the views of WHO/UNICEF and activist groups. Evidence of dismissal of public consultation is discriminatory, and an unwillingness to manage differences of opinion is a denial of the right to be heard.

Key Message

National governments can serve the best interests of the child through sovereign rights, national responsibility and accountability, and development of national infant feeding policies that reflect UNCRC principles.

Plain Language Summary

The United Nations Convention on the Rights of the Child (UNCRC) which was adopted by the United Nations on the 20 November 1989 has its origins in the 1948 Universal Declaration of Human Rights which proclaimed that childhood is entitled to special care and assistance. Under the terms of the UNCRC, governments are now required to meet children’s basic needs and to enable them to fulfil their full potential. This paper focuses on global policies for infant nutrition and how these relate to the principles contained within the UNCRC. This is important as all countries that ratified the UN Convention are being encouraged to enact these infant feeding policies into domestic law. However, infant feeding is a highly contentious area of public health. Many of the issues referred to in this review could be prevented through appropriate consultation, partnership working and independent governance. From a parent perspective, global decisions are being made by organisations and individuals who are distant from their life circumstances. Parents do not understand why infant feeding policy does not reflect local living circumstances or why WHO persists with a global one-size-fits-all infant feeding policy when it clearly does not fit with global socioeconomic diversity? It is concluded that the principles endorsed by UNCRC are clearly aimed at national governments and this should continue to be the primary focus. It is important that the credibility of the UNCRC principles are not undermined by the ratification of infant feeding policies that do not effectively serve the health needs of the population and fail to serve the rights of infants and their families.

Introduction

The United Nations Convention on the Rights of the Child (UNCRC) which was adopted by the United Nations (UN) on the November 20, 1989, has its origins in the 1948 Universal Declaration of Human Rights which proclaimed that childhood is entitled to special care and assistance [1, 2]. Under the terms of the UNCRC, governments are now required to meet the basic needs of all children and to enable them to fulfil their full potential. All countries that ratified the UNCRC are bound by international law to implement the principles set out in the convention and for progress to be monitored by the Committee on the Rights of the Child (CRC).

The Rights of the Child

The key principles that underpin the implementation of children’s rights are non-discrimination, the right to life and development, the best interests of the child, and the right to be heard [1]. The convention provides a legally binding framework that outlines the rights of children across various aspects of life, including health, education, protection from abuse, and participation in decision-making.

The document consists of 54 articles and specific reference to infant feeding is made in Article 24 with the statement that “all segments of society, (…) are supported in the use of basic knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental sanitation and the prevention of accidents” [1]. The family is referred to as “the fundamental group of society and the natural environment for the growth and well-being of all its members and particularly children.” This statement is especially relevant when addressing issues on infant feeding where the rights of parents are integral to the rights of the infant.

The Committee on the Rights of the Child produce “General Comments” on any issue relating to children to which it believes the State parties should devote more attention. As of September 2023, the UN Convention Committee has adopted 26 General Comments. Despite not being legally binding, the General Comments are considered authoritative interpretations of the UNCRC, and national governments are expected to take them into account when implementing the Convention (Table 1). It is also noted in Article 45 of the Convention that the UN Convention Committee may invite specialized agencies, the United Nations Children’s Fund (UNICEF) and other competent bodies to provide expert advice on the implementation of the Convention in areas falling within the scope of their respective mandates [1]. In 2013, the Committee through their General Comment No 15 [3] included text on children’s right to health and referenced the International Code on Marketing of Breastmilk Substitutes (the Code) [4], the Global Strategy for Infant and Young Child Feeding [5] and relevant subsequent World Health Assembly (WHA) resolutions [6].

Table 1.

Key global directives relating to the Rights of the Child

1	United Nations Universal Declaration of Human Rights (1948)
2	United Nations Convention on the Rights of the Child (1989) – 54 Articles
3	The Committee on the Rights of the Child – 18 independent experts that monitor implementation of the Convention on the Rights of the Child
4	The Committee makes “General Comments” on any issue relating to children to which it believes the State parties should devote more attention. As of September 2023, the UN Convention Committee on the Rights of the Child has adopted 26 General Comments
5	In 2013, General Comment No 15; para 44, made specific reference to infant nutrition and current WHO/WHA/UNICEF global policies and indicated that internationally agreed standards concerning children’s right to health, should be introduced into domestic law
6	General Comments are not legally binding but considered authoritative interpretations of the UNCRC which national governments should appraise when implementing the Convention

More recently, UNICEF stated that with reference to the 2013 General Comment No. 15 [3], the 1981 Code should now be considered the “original” Code and the term “The Code” should be an umbrella term that includes the “original” Code, the 2003 WHO Global Strategy for Infant and Young Child Feeding and subsequent WHA resolutions [7]. The intent of this UNICEF statement appears to be to use the principles of the UNCRC to provide a pathway for the World Health Organisation (WHO), WHA, and UNICEF infant feeding policy documents to be introduced into domestic law. The concern with this initiative is that these documents are not recent and have not been updated, there are high levels of non-compliance, and to determine if they are fit for purpose as health policy, legislative instruments or examples of compatibility with the principles set out in the UNCRC, they need to be formally reviewed before being presented as evidence in a court of law. Infant feeding policymaking is a highly contested environment and there are interrelated factors that may negatively impact on the legal rights of infants and their parents.

Activism and Pragmatism

The establishment of the Global Breastfeeding Collective in 2017 by WHO and UNICEF has created divisions within the parental population with the Collective predominantly being populated by activist groups who have been invited to join on the understanding that they are committed to WHO and UNICEF policies and recommendations [8]. This is a “dream ticket” for these organisations as it allows their voice to be heard at one step below the WHA decision making body. As a consequence, global infant feeding policy primarily reflects the views of WHO/UNICEF and activist groups.

Special interest and activist groups do have a role to play in raising standards and ensuring that parents are adequately supported on aspects of infant and young-child feeding. However, it should also be recognized that all stakeholders need to have a clear understanding of their function within the multidisciplinary approach to infant feeding. The Code has articles on the role of industry, health services, health professionals and parents, but there are no articles on the roles and responsibilities of WHO, WHA, UNICEF, and activist groups [4]. In effect, the Code has separated the activists from the pragmatists with the former assuming an activist agenda and leadership role. Breastfeeding compliance statistics indicate that policy objectives directed by WHO and breastfeeding activist groups have limited support from the general population and this is indicative of the majority of parents choosing to adopt approaches that they believe are more sensitive to their family needs [9]. In general, the wider parental population is less idealistic, more pragmatic and their indifference to the activist agenda should not be ignored.

In 2023, a Congress was arranged by WHO and UNICEF to review the implementation of the 1981 International Code and the delegates were “selected” and “vetted” by WHO and UNICEF to ensure that they did not have a conflict of interest, especially with industry, and subsequently some delegates were disinvited [10]. It is noted that a key campaigning and activist group had thirty representatives at the meeting [11], and the introductory talk was delivered by the Director-General of WHO [10]. The filtering of opinion not only diminishes the quality and relevance of discussion it is also a breach of the rights of those who were not included and not heard. Parents are key stakeholders, and they need to be more closely involved with each of the stakeholders if they are going to be in a position to understand the issues and make the best decisions for their children.

Consultation and Evidence

Stakeholder communication with the target audience provides access to additional knowledge, experience, and skills that will not only help develop or implement the policy but will also form the foundation for future working relationships. The 2023 WHO Guideline for Complementary Feeding was heavily criticised in a joint publication from several health related societies and a key concern was the lack of consultation [12, 13]. The WHO response to this concern was that “The societies (…) object to the fact that the guidelines were not subject to an open consultation process before publication. Public comment is not a usual practice for WHO guidelines and poses significant challenges for managing conflicts of interest, particularly on guidelines with implications for the sale of commercial products” [14]. This dismissal of the need for public consultation is discriminatory and appears to reflect a failure or unwillingness to manage differences of opinion. It is noted in the WHO Handbook for Guideline Development 2nd ed. 2014, that “Standard guidelines usually take between 9 and 24 months to complete, depending on their scope, and should be prepared after wide consultation on their need, scope and rationale” [15].

In the 2003 Global Strategy for Infant and Young Child Nutrition, WHO recommended that infants should be breastfed for 2 years or beyond [5]. In 2016, WHO recommended that all milk products marketed for children up to the age of 3 years should be understood to be a breastmilk substitute [16]. In 2023, a systematic review that was commissioned by WHO as part of the complementary feeding guideline, reported that there were no significant additional health benefits for the infant or for the mother from breastfeeding beyond 12 months [12]. This conclusion was also reached by the Scientific Advisory Committee for Nutrition that advises the United Kingdom government [17]. However, despite this confirmatory evidence the WHO Complementary Feeding Guideline reaffirmed the view that breastfeeding for 2 years or beyond is a strong WHO recommendation and this was despite their acknowledgment that the evidence was graded as very low certainty [12]. Do governments and therefore parents act in accordance with WHO assertions or should they choose the scientific evidence? In this debate where is the governance perspective? Does the WHO complementary feeding document meet the UNCRC principles? Or does it reflect self-interest and lack of transparency?

In the complementary feeding document WHO also recommended that infants may be commenced on cow’s milk at 6 months, despite well documented health concerns relating to the introduction of cow’s milk in the first year of life. They supported their view by claiming that infant formulas are “expensive and not necessary” [14], having previously published a statement that infant formulas are “goods that are not in the best interest of maternal and child health” [18]. For an infant that is dependent upon infant formula, the product is lifesaving and in those circumstances availability of infant formula is clearly in the best interest of the child’s survival and future health. This would be strongly defended in a court of law.

Governance and Trust

Many of the issues referred to in this review could be prevented through appropriate consultation, partnership working, and independent governance. From a parent perspective, global decisions are being made by organisations and individuals who are distant from their life circumstances. They do not understand why infant feeding policy does not reflect and respond to the diversity of need worldwide. Or why does WHO persist with a global one-size-fits-all infant feeding policy when it clearly does not fit with global socioeconomic diversity? The health benefits of clean water, sanitation, food supplies, healthcare and other related factors are obvious, and for an infant feeding policy to be compliant it needs to be sensitive to the changing health needs of the target population.

The “original” Code clearly states that there is a legitimate market for infant formula, but it should not be marketed or distributed in ways that may interfere with the protection and promotion of breastfeeding [4]. The issue is therefore not that infant formula has no role to play in infant feeding but the marketing of these products needs to be independently regulated, and it is the failure to resolve this fundamental logistic issue over the last 40 years that has created so much dysfunction and mistrust between industry and WHO, with the crossfire impacting on parents and their health professionals.

To restore trust in this vitally important area of public health, an option is that national governments take greater responsibility for their own infant feeding policy. Governments are able to consult with their national policymakers, health professionals, food industry representatives and parents and this degree of collaboration will provide clarity of ownership, responsibility, and accountability. This contrasts with global policy which is distant from national stakeholders, health personnel, and parents and consequently, the approach lacks sensitivity, collective ownership, and direct accountability. WHO is primarily an advisory organisation, available to assist Governments, upon request in strengthening health services [19]. It does not have sovereign rights at a national level and consequently they have promulgated their views and objectives through other UN institutions including the WHA and the UN Convention Committee in order to legitimise their policies. The principles endorsed by UNCRC are clearly aimed at national governments, and this should continue to be the primary focus [1]; it is important that the credibility of these principles is not undermined by UNCRC ratifying associated global policies that do not effectively serve the health needs of the population and fail to serve the rights of infants and their families.

Conclusion

Infant feeding remains a contentious issue. The UNCRC is an essential document for ensuring that parents and their children are protected and supported. Current global infant feeding policy documents do not meet the principles or the spirit of UNCRC and therefore do not merit legislative status. An independent review is urgently required. With there now being a deep seated mistrust between infant feeding stakeholders, a new approach should recognise that trust is not only a fundamental principle for change, but it is also a fundamental right for infants and their parents [20].

Conflict of Interest Statement

In relation to research interests, S.F. has received grants from governments, national research funding organizations, charitable organizations and industry, and has received honoraria and expenses for presenting research findings at conferences in UK and abroad. Following his retirement from his clinical post, he undertook consultancy work for DSM an international company that manufactures nutrient ingredients, and he specifically advised on fatty acids. Within the last 3 years, S.F. has received an honorarium from Danone for participation in discussions on governance and regulation of marketing of infant formulas.

Funding Sources

There are no funding sources related to this article.

Author Contributions

S.F. is the sole author of this article and is responsible for the content.

Funding Statement

There are no funding sources related to this article.