Digital Marketing Tactics, Non‐Compliance With the International Code of Marketing of Breastmilk Substitutes and Legal Breaches of Code‐Based Legislation by the Commercial Milk Formula Industry in Central America and the Caribbean

ABSTRACT

Digital marketing has become the dominant channel for the promotion of commercial milk formula (CMF), accounting for most consumer exposure in many settings. This study characterized the digital CMF marketing landscape in Guatemala, Panama, and the Dominican Republic, identified prevalent promotional tactics, and assessed non‐compliance with the International Code of Marketing of Breastmilk Substitutes (the Code) and breaches of national Code‐based legislation. We applied the World Health Organization's CLICK monitoring framework, including mapping the digital ecosystem and analyzing active marketing campaigns. From November 2023 to May 2024, we manually monitored CMF brand websites and official social media accounts to document promotional practices and assess Code non‐compliance and legal breaches. A total of 355 digital advertisements were identified, with growing‐up milks accounting for 98.3% of promoted products. On average, each advertisement employed 13 marketing tactics and contained 7.5 instances of Code non‐compliance. Overall, 2 797 instances of Code non‐compliance were documented, of which 1 480 constituted legal breaches in Guatemala, 2 189 in Panama, and 2 160 in the Dominican Republic. The most frequent breaches involved labeling requirements. Major regulatory gaps were identified, particularly regarding growing‐up milks, cross‐promotion strategies, and health and nutritional claims. These findings reveal a highly sophisticated and insufficiently regulated digital marketing environment for CMF in Central America and the Caribbean, underscoring the need to strengthen and update Code‐based legislation to explicitly address digital environments.

Summary

• Digital platforms are the dominant channel for commercial milk formula marketing in Guatemala, Panama, and the Dominican Republic, enabling sustained exposure of caregivers to promotional content.

• Growing‐up milks accounted for nearly all advertised products and were central to cross‐promotion strategies that exploit gaps in Code‐based legislation.

• Non‐compliance with the International Code of Marketing of Breastmilk Substitutes was widespread, with individual advertisements combining multiple marketing tactics and repeated instances of non‐compliance.

• Existing national legislation does not adequately regulate digital marketing practices, underscoring the need to strengthen Code‐based laws to protect breastfeeding in digital food environments.

1. Introduction

The promotion of commercial milk formula (CMF) has long been recognized as a major threat to optimal breastfeeding practices (Piwoz and Huffman 2015). Despite decades of advocacy and the adoption of the International Code of Marketing of Breast‐milk Substitutes (the Code) by the World Health Assembly (WHA) on national legislations, CMF industry continues to deploy aggressive promotional tactics that undermine breastfeeding, particularly in low‐ and middle‐income countries (Piwoz and Huffman 2015; Becker et al. 2022).

In recent years, digital platforms have emerged as a central channel for the promotion of CMF (Jones et al. 2022; Becker et al. 2022). Digital marketing has become the predominant promotional channel in regions such as Europe and Asia, with some countries reporting that over 80% of exposure to CMF advertisements occurs online (Jones et al. 2022). Latin America is not the exception; Mexico and Argentina have reported a great parent's exposure to digital marketing (Hernández‐Cordero et al. 2022; Demonte et al. 2024; Unar‐Munguía et al. 2022). Most recently, digital marketing has been associated with negative influence on breastfeeding intention, initiation and exclusive duration (Hernández‐Cordero et al. 2022; Unar‐Munguía et al. 2022).

Despite this shift, digital environments remain largely under‐monitored and unregulated (Jones et al. 2022; Becker et al. 2022; World Health Organization 2023). The digital environment and sophisticated tactics allow companies to reach parents with unprecedented personalization and frequency (Jones et al. 2022). These digital marketing tactics often blur the lines between information and promotion, making it difficult for families to take infant feeding decisions and distinguish commercial content from evidence‐based health advice.

Although nearly all Central American and Caribbean countries (except for Belize) have incorporated provisions of the Code into national legislation for breastfeeding protection (Gobierno de Guatemala 1983, 1987; Gobierno de la República Dominicana 1995, 2018; Gobierno de Panamá 1995, 2012), these regulatory frameworks have not yet been adapted to the rapidly evolving digital environments. While some countries have begun to document examples of digital promotions in their monitoring reports, existing systems remain primarily focused on traditional channels such as health facilities, mass media, and retail outlets (supermarkets and pharmacies) (Ministerio de Salud Pública y Asistencia Social MSPAS, Organización Panamericana de la Salud OPS, Organización Mundial de la Salud, Región de las Américas OMS/AMRO, International Baby Food Action Network IBFAN, Instituto de Nutrición de Centroamérica y Panamá INCAP 2018; Ministerio de Salud de Panamá, OPS, INCAP 2019; Ministerio de Salud Pública República Dominicana, Programa Nacional de Lactancia Materna, INCAP 2021). This leaves a significant oversight gap in the digital food environment, where marketing practices are increasingly concentrated. This regulatory blind spot enables continued breaches of legally Code‐based national measures designed to protect breastfeeding. To address this gap, we conducted a multi‐country study to characterize the digital marketing landscape and identify the most prevalent tactics used by CMF industry in Central America and the Caribbean. Additionally, we aimed to assess the extent of non‐compliance with the Code and the occurrence of legal breaches, providing evidence to strengthen enforcement efforts and to advance the protection of children's rights to adequate feeding, as well as the rights of parents and caregivers to accurate information.

2. Methodology

We applied the CLICK monitoring framework developed by the World Health Organization (World Health Organization Regional Office for Europe 2018). The CLICK framework has been adapted to evaluate digital marketing practices of the CMF. For this study, two steps of the framework were used: (1) comprehending the digital ecosystem and (2) analyzing the landscape of campaigns (World Health Organization Regional Office for Europe 2018).

First, we identified the top CMF products and the main digital platforms used in Central America and the Caribbean. We identified leading companies and brands in the infant formula market through store visits (including supermarkets and pharmacies) in areas representing diverse socioeconomic strata, as well as through reviews of commercial websites in Guatemala, Panama, and the Dominican Republic. This process allowed us to map the market presence of major industry actors across the region. To validate our selection, we cross‐referenced our findings with the most recent national reports on compliance with the Code, confirming which companies had been previously flagged for market dominance and regulatory scrutiny (Ministerio de Salud Pública y Asistencia Social MSPAS, Organización Panamericana de la Salud OPS, Organización Mundial de la Salud, Región de las Américas OMS/AMRO, International Baby Food Action Network IBFAN, Instituto de Nutrición de Centroamérica y Panamá INCAP 2018; Ministerio de Salud Pública República Dominicana, Programa Nacional de Lactancia Materna, INCAP 2021; Ministerio de Salud de Panamá, OPS, INCAP 2019). We identified the most used digital platforms through data from the We Are Social and Meltwater reports (We are Social, Meltwater 2024), which provided 2023 country‐level insights on social media usage in Guatemala, Panama, and the Dominican Republic. Based on this analysis, the most frequently used platforms across the three countries were Instagram, TikTok, Facebook, and YouTube (We are Social, Meltwater 2024).

Second, we manually monitored CMF posts and promotions published on the websites and social media feeds of the leading companies and brands, including Facebook pages, YouTube channels, and Instagram accounts. The objective was to document the most frequently used marketing tactics to which parents and caregivers are exposed, and to quantify non‐compliance with the Code and breaches of Code‐based legislation in Guatemala (Gobierno de Guatemala 1983, 1987), Panama (Gobierno de Panamá 1995, 2012), and the Dominican Republic (Gobierno de la República Dominicana 1995, 2018). Monitoring covered a 6‐month period preceding data collection, from November 2023 to May 2024. All identified advertisements were captured and archived for detailed analysis of marketing tactics and legal breaches.

To systematically analyze the digital marketing tactics used by companies that promote CMF and complementary feeding and toddler products, we developed a classification scheme organized into eight digital tactic types, each encompassing a set of specific promotional practices. These include: (1) content and publication tactics, (2) product‐based tactics, (3) audience targeting tactics, (4) distribution and optimization tactics, (5) tactics to generate engagement and brand loyalty, (6) messaging and narrative tactics, (7) visual and media format tactics, and (8) tactics aimed at generating validation and credibility. This typology enables the grouping of diverse promotional approaches employed in digital environments and facilitates cross‐country and cross‐brand comparisons. It also supports the identification of recurring patterns and aggressive promotional practices (Table 1).

Table 1.

Digital tactics for promoting commercial milk formula and complementary feeding and toddler products.

Tactic type	Tactics	Example
Content and publication tactics	Informative post and educational articles	“Discover some tips that will help your child's development”
	Product preparation and usage tutorials	“How to prepare Babina Plus for your little one?”
	Testimonials from parents and consumer experiences	“Because girls grow up with Nido1+ lactose‐free, which helps strengthen bones and muscles”
Product‐based tactics	Infant formulas (0‐6 m)	Formula for ages 0–6 months. “What nutrients does your baby need to grow?
	Follow‐up formulas (6‐12 m)	Formula for ages 6–12 months. “Enfamil Complete 2 is the product children need during the second stage of feeding”
	Growing‐up formulas (12‐36 m)	Formula for ages 1–3 years. “Have you ever wondered if all milks are the same? Learn more about NIDO's specialized system”
	Complementary feeding and toddler products (6+ m)	Products introduced as a complement to breastfeeding or infant formula from 6 to 36 months. “This vacation is ideal for your child to try new flavors. Prepare a smoothie with Pediasure.”
Audience targeting tactics	Psychographic targeting (parents, health professionals)	“Your little one grows fast and that brings a lot of questions. Join NutriciaClub”. (parent's targeting)
	Lifecycle stage targeting (pregnancy, breastfeeding complementary feeding)	“A balanced diet from the beginning of pregnancy through breastfeeding is key for both mom and baby.”
Distribution and optimization tactics (platform and distribution channels and ad targeting and optimization techniques)	Social media	“Signs of weaning: Has your baby started this process? Tell us in the comments.” (Instagram post)
	Website advertising	“Available at” (link redirects to purchase points for the product).
	Geotargeting and cross‐border marketing	“Get ready for fun! Buy your HEINZ baby food pack and scan the QR code. Valid in Central America.”
	Time‐based optimization	Ads are shown at times when the audience is most receptive, outside of their daily routines, to increase effectiveness. (Facebook post)
Engagement, conversion, and loyalty tactics	Promotions and incentives (discounts, giveaways, gifts)	“If you already purchased RD$900 or more of NIDO, swipe to see the 2 ways to participate and be one of the 100 winners.”
	Click‐to‐chat marketing and direct purchase links	One button offers more information “Learn more here” and another allows you to “Chat with a nutritionist.”
	Links to support networks like mom clubs or discussion forums	“NutriciaClub, our online community with over 100,000 moms. Sign up and swipe up to visit nutriciaclub. com.”
	Loyalty programs or subscription	“Save with Abox — now is their time to grow! Register your purchase receipts and redeem them for free Pediasure.”
	Cross‐promotion within the same product line	Related products such as formulas and baby cereals are promoted together to encourage combined purchase.
Messaging and narrative tactics	Emotional messaging (love, connection, ideal parenthood)	“You evolve as a mom, Similac3 evolves with science.”
	Child growth and development	“More than a job, it's a privilege to watch them grow.” “Support them with the benefits of Enfagrow: MFGM and DHA.”
	Nutritional or health claims	“We're the only ones on the market with BPL1.”
	Addressing pain points (crying, sleep, digestion)	“During the first 1,000 days of life, a baby's tummy is very delicate and sensitive, which can lead to digestive discomfort.”
	Promotional messaging (drives purchasing)	“The best always comes with more—enjoy our 2‐for‐1 promo.”
Visual and media format tactics	Images of families and mothers with babies	A mother, father, and child are shown doing fun activities, with the formula product present in this family context
	Representation of children under two years	Child under two featured in the ad: “Is it normal that my son pushes food out with his tongue?”
	Short‐form videos and reels	Eye‐catching short video content: “Your child needs nutrients every day. Enfagrow is the only one with *MFGM and DHA to support development.”
	Interactive content (polls, stories, Q&A)	“Is this the right choice?” “Will it work?” These are some questions first‐time moms ask. What's the one you always ask? Write it here. #Similac #You'reDoingGreat #TipsForMom
Validation and credibility tactics	Endorsements by health professionals or associations; quality seals and certifications	“#1 recommended by pediatricians”
	Validation by influencers and brand ambassadors	Influencer or content creator shows and validates use of the product

Note: This typology groups digital marketing into eight digital tactic types, each representing a set of specific tactics used to promote commercial milk formula and related products in digital environments.

Data collection and coding were conducted by two trained research assistants. Both were responsible for identifying and documenting advertisements, classifying marketing tactics, and assessing non‐compliance with the Code and breaches of national legislation. Data was reviewed on a weekly basis to ensure consistency and quality control. In cases of discrepancies in the classification of tactics or in the assessment of non‐compliance or legal breaches, these were discussed and resolved in consultation with the principal investigator. We documented all observations using an electronic instrument. This instrument was specifically developed for the study and included relevant provisions of the Code and its subsequent WHA resolutions, as well as the corresponding articles of national Code‐based legislation in Guatemala, Panama, and the Dominican Republic. The instrument was designed to assess non‐compliance and legal breaches across five analytical domains: (1) scope, (2) monitoring and enforcement, (3) information and educational materials on infant and young child feeding, (4) promotion to the general public, and (5) labelling (World Health Organization 1981). We excluded articles related to promotion in health care facilities and engagement with health workers, as these were outside the scope of digital monitoring.

To analyze non‐compliance with the Code and breaches of existing Code‐based legal measures, we followed a two‐step approach. First, we assessed the alignment of each country's Code‐based legislation with the provisions of the Code and subsequent WHA resolutions to identify gaps in legal coverage. Second, we verified non‐compliance with each relevant Code provision and WHA resolution, and breaches of each article of the national Code‐based laws within the five analytical domains described before.

2.1. Ethics

All data collection followed protocols that were approved by the Institutional Review Boards of the Institute of Nutrition of Central America and Panama (INCAP). The descriptive analysis is presented by digital tactics and brands of CMF. All descriptive analyses were conducted using R software.

3. Results

3.1. Digital Early Food Environment: Leading Companies and Brands of Commercial Milk Formula in Central America and the Caribbean

We found that three multinational companies Nestlé (NAN and Nido), Abbott (Similac), and Mead Johnson/Reckitt (Enfamil and Enfagrow) dominate the digital infant formula marketing landscape across Central America and the Caribbean. Other companies, such as Friso (Guatemala), Nutricia (Panama), and Arla and Grupo Hochdorf (Dominican Republic) showed a more country‐specific advertising presence.

The most frequently advertised brands were Babina (25.6%), followed by Nutribén (15.5%), Nutrilon (14.6%), and Nido (11.0%) (Table 2). Most of the promoted products were growing‐up milks (98.3%), followed by infant formulas (3.4%) and follow‐up formulas (1.7%). Regarding digital platforms, Instagram was the most frequently used (50.4%), followed by a combination of Instagram and Facebook (26.5%), and Facebook alone (17.7%). In terms of the life stage targeted by advertising, the continued breastfeeding period was the primary focus (84.5%) (Table 3).

Table 2.

Monitored digital advertisements by commercial milk formula company and brand in Guatemala, Panama, and the Dominican Republic, Nov 2023–May 2024.

Company	Brand	Product	Number of monitored digital advertisements n = 355 n (%)
Abbott	Similac	Similac 3 Similac Total Comfort 2	37 (10.4)
Grupo Hochdorf	Babina	Babina plus	91 (25.6)
Mead Johnson/Reckitt	Enfamil	Enfamil premium promental 1	1 (0.3)
	Enfagrow	Enfagrow premium promental 3	38 (10.7)
Nestlé	Nido	Nido crecimiento 1+ Nido deslactosada 1+	39 (11.0)
	NAN	NAN optipro 3 NAN expertpro 3	12 (3.4)
Nutribén	Nutribén	Nutriben crecimiento pro+ 3 Nutriben Inova 3	55 (15.5)
Nutricia	Nutrilon	Nutrilon premium+ 3	52 (14.6)
	Bebelac	Bebelac Gold 3	30 (8.5)

Table 3.

Profile of digital advertisements for commercial milk formula products in Guatemala, Panama, and the Dominican Republic, Nov 2023–May 2024.

	All n = 355 n (%)	Guatemala n = 18 n (%)	Panama n = 92 n (%)	Dominican Republic n = 174 n (%)	Central America n = 53 n (%)	Central America and the Caribbean n = 18 n (%)
Product typea
Growing‐up formulas (12–36 m)	349 (95.1)	18 (100.0)	88 (95.7)	173 (99.4)	52 (98.1)	18 (100.0)
Infant formulas (0–6 m)	12 (3.3)	0 (0.0)	4 (4.3)	3 (1.7)	5 (9.4)	0 (0.0)
Follow‐up formulas (6–12 m)	6 (1.6)	0 (0.0)	0 (0.0)	2 (1.1)	4 (7.5)	0 (0.0)
Digital platform used
Instagram	179 (50.4)	9 (50.0)	52 (56.5)	104 (59.8)	6 (11.3)	8 (44.4)
Instagram & Facebook	94 (26.5)	0 (0.0)	0 (0.0)	55 (31.6)	37 (69.8)	2 (11.1)
Facebook	63 (17.7)	2 (11.1)	37 (40.2)	12 (6.9)	6 (11.3)	6 (33.3)
Website	16 (4.5)	7 (38.9)	3 (3.3)	1 (0.6)	4 (7.5)	1 (5.6)
YouTube	3 (0.8)	0 (0.0)	0 (0.0)	2 (1.1)	0 (0.0)	1 (5.6)
Life stage
Continued breastfeeding	300 (84.5)	15 (83.3)	69 (75)	156 (89.7)	48 (90.6)	12 (66.7)
Complementary feeding	22 (6.2)	2 (11.1)	5 (5.4)	9 (5.2)	3 (5.7)	3 (16.7)
Exclusive breastfeeding	15 (4.2)	1 (5.6)	8 (8.7)	4 (2.3)	1 (1.9)	1 (5.6)
Pregnancy	9 (2.5)	0 (0.0)	9 (9.8)	0 (0.0)	0 (0.0)	0 (0.0)
Continued breastfeeding & complementary feeding	6 (1.7)	0 (0.0)	0 (0.0)	4 (2.3)	1 (1.9)	1 (5.6)
Pregnancy & breastfeeding	3 (0.8)	0 (0.0)	1 (1.1)	1 (0.6)	0 (0.0)	1 (5.6)
Tactics per advertisement (mean ± SD)	13.0 ± 1.9	13.7 ± 2.0	13.3 ± 2.3	12.3 ± 1.5	13.9 ± 1.9	14.7 ± 1.5
Non‐compliance with the Code (mean ± SD)	7.5 ± 2.7	8.5 ± 2.3	6.6 ± 2.9	7.9 ± 2.2	7.3 ± 2.8	6.9 ± 3.6
Legal breaches per ad (mean ± SD)b	6.2 ± 2.5b	4.2 ± 1.7	6.1 ± 2.5	6.1 ± 2.5

^a 12 advertisements included more than one product type, increasing the total count in this category.

^b To estimate the total number of legal violations, only the provisions formally adopted into national legislation were considered.

3.2. Digital Marketing Tactics Used by the Commercial Milk Formula Industry in Central America and the Caribbean

The most frequently observed tactics were those based on narrative and advertising messaging (25.4%). These sought to build emotional connections with parents and caregivers, the use of nutritional and health claims, and address pain points and critical situations (e.g. colic, sleep, digestion). These were followed by distribution and optimization tactics (18.8%) designed to expand reach across digital platforms, particularly social media. Target audience segmentation strategies (15.4%) were also prevalent, tailoring messages to specific profiles, primarily parents but also health professionals. Additionally, companies used visual and format‐based strategies (14.8%), including short videos and reels to enhance visibility and engagement in competitive digital spaces. In contrast, less commonly used tactics included engagement and loyalty tactics (7.7%) like promotions, giveaways, and validation and credibility strategies such as endorsements by health professionals or influencers (1.0%) (Table 4).

Table 4.

Tactics most frequently used to promote commercial infant formulas during media monitoring in Guatemala, Panama, and the Dominican Republic, November 2023–May 2024.

	All = 4612 n (%)
Messaging and narrative tactics	1170 (25.4)
Emotional messaging (love, connection, ideal parenthood)	347 (7.5)
Child growth and development	295 (6.4)
Promotional messaging (drives purchasing)	290 (6.3)
Nutritional or health claims	184 (4.0)
Addressing pain points (crying, sleep, digestion)	54 (1.2)
Distribution and optimization tactics	869 (18.8)
Platforms and distribution channels
Social media	340 (7.4)
Website advertising	15 (0.3)
Ad targeting and optimization techniques
Geotargeting	355 (7.7)
Time‐based optimization	88 (1.9)
Cross‐border marketing	71 (1.5)
Audience targeting tactics	710 (15.4)
Lifecycle stage targeting	355 (7.7)
Psychographic targeting	355 (7.7)
Visual and media format tactics	681 (14.8)
Images of families and mothers with babies	291 (6.3)
Interactive content (polls, stories, Q&A)	220 (4.8)
Short‐form videos and reels	115 (2.5)
Representation of children under two years	55 (1.2)
Content and publication tactics	415 (9.0)
Informative post and educational articles	349 (7.6)
Testimonials from parents and consumer experiences	50 (1.1)
Product preparation and usage tutorials	16 (0.3)
Product‐based tactics	367 (8.0)
Growing‐up formulas	349 (7.6)
Infant formulas	12 (0.3)
Follow‐up formulas	6 (0.1)
Engagement, conversion, and loyalty tactics	354 (7.7)
Cross‐promotion within the same product line	164 (3.6)
Click‐to‐chat marketing and direct purchase links	112 (2.4)
Links to support networks like mom clubs or discussion forums	57 (1.2)
Promotions and incentives (discounts, giveaways, gifts)	19 (0.5)
Loyalty programs or subscription	2 (0.0)
Validation and credibility tactics	46 (1.0)
Endorsements by health professionals or associations; quality seals and certifications	33 (0.7)
Validation by influencers and brand ambassadors	13 (0.3)

Note: Bold represents the total of the category.

On average, 13.0 ± 1.9 marketing tactics were identified by advertisement, highlighting the density and complexity of digital promotions. Regional brand pages targeting both Central America and the Dominican Republic employed the most intensive tactics, averaging 14.7 ± 1.4 strategies per post. When assessing non‐compliance with the Code and its subsequent WHA resolutions, we found an average of 7.5 ± 2.7 instances of non‐compliance per advertisement. Promotions targeting Guatemala (8.5 ± 2.3) and the Dominican Republic (7.9 ± 2.2) exhibited the highest levels of Code non‐compliance (Table 3).

When disaggregating marketing tactics by company, several patterns emerged. Babina and Nutricia most frequently used narrative‐driven messaging. All companies primarily relied on social media platforms as part of their dissemination and optimization strategies. Abbott and Mead Johnson engaged in regional (cross‐border) marketing through shared regional pages, while Abbott, Nestlé, and Nutricia applied time‐based optimization to increase visibility. In terms of engagement and loyalty strategies, Nutricia led in the use of click‐to‐chat tools, whereas Nestlé frequently offered promotions such as discounts, sweepstakes, and giveaways. Lastly, Mead Johnson and Nestlé used validation and credibility strategies by leveraging endorsements from health professionals and employing influencer marketing and brand ambassadors, respectively (Table 5).

Table 5.

Tactics most frequently used by commercial infant formula companies during media monitoring in Guatemala, Panama, and the Dominican Republic, November 2023–May 2024.

	Abbott n = 535 n (%)	Mead Johnson n = 520 n (%)	Nestlé n = 710 n (%)	Nutribén n = 670 n (%)	Nutricia n = 1079 n (%)	Babina n = 1098 n (%)
Messaging and narrative tactics	131 (24.5)	122 (23.5)	171 (24.1)	193 (28.8)	259 (24.0)	294 (26.8)
Emotional messaging (love, connection, ideal parenthood)	37 (6.9)	37 (7.1)	50 (7.0)	53 (7.9)	81 (7.5)	89 (8.1)
Child growth and development	30 (5.6)	37 (7.1)	40 (5.6)	50 (7.5)	65 (6.0)	73 (6.6)
Nutritional or health claims	31 (5.8)	20 (3.8)	29 (4.1)	33 (4.9)	39 (3.6)	32 (2.9)
Addressing pain points (crying, sleep, digestion)	9 (1.7)	0 (0.0)	18 (2.5)	9 (1.3)	9 (0.8)	9 (0.8)
Promotional messaging (drives purchasing)	24 (4.5)	28 (5.4)	34 (4.8)	48 (7.2)	65 (6.0)	91 (8.3)
Distribution and optimization tactics	123 (23.0)	123 (23.7)	126 (17.7)	112 (16.7)	202 (18.7)	183 (16.7)
Platforms and distribution channels
Social media	29 (5.4)	35 (6.7)	48 (6.8)	55 (8.2)	81 (7.5)	91 (8.3)
Website advertising	8 (1.5)	4 (0.8)	3 (0.4)	0 (0.0)	1 (0.1)	0 (0.0)
Ad targeting and optimization techniques
Geotargeting	37 (6.9)	39 (7.5)	51 (7.2)	55 (8.2)	82 (7.6)	91 (8.3)
Cross‐border marketing	28 (5.2)	37 (7.1)	6 (0.8)	0 (0.0)	0 (0.0)	0 (0.0)
Time‐based optimization	21 (3.9)	8 (1.5)	18 (2.5)	2 (0.3)	38 (3.5)	1 (0.1)
Audience targeting tactics	74 (13.8)	78 (15.0)	102 (14.4)	110 (16.4)	164 (15.2)	182 (16.6)
Psychographic targeting	37 (6.9)	39 (7.5)	51 (7.2)	55 (8.2)	82 (7.6)	91 (8.3)
Lifecycle stage targeting	37 (6.9)	39 (7.5)	51 (7.2)	55 (8.2)	82 (7.6)	91 (8.3)
Visual and media format tactics	98 (18.3)	62 (11.9)	118 (16.6)	99 (14.8)	138 (12.8)	166 (15.1)
Images of families and mothers with babies	33 (6.2)	28 (5.4)	41 (5.8)	45 (6.7)	70 (6.5)	74 (6.7)
Representation of children under two years	21 (3.9)	7 (1.3)	9 (1.3)	10 (1.5)	7 (0.6)	1 (0.1)
Short‐form videos and reels	18 (3.4)	17 (3.3)	30 (4.2)	0 (0.0)	48 (4.4)	2 (0.2)
Interactive content (polls, stories, Q&A)	26 (4.9)	10 (1.9)	38 (5.4)	44 (6.6)	13 (1.2)	89 (8.1)
Content and publication tactics	48 (9.0)	46 (8.8)	66 (9.3)	56 (8.4)	95 (8.8)	104 (9.5)
Informative post and educational articles	37 (6.9)	39 (7.5)	45 (6.3)	55 (8.2)	82 (7.6)	91 (8.3)
Product preparation and usage tutorials	1 (0.2)	1 (0.2)	1 (0.1)	0 (0.0)	5 (0.5)	8 (0.7)
Testimonials from parents and consumer experiences	10 (1.9)	6 (1.2)	20 (2.8)	1 (0.1)	8 (0.7)	5 (0.5)
Product‐based tactics	41 (7.7)	43 (8.3)	51 (7.2)	59 (8.8)	82 (7.6)	91 (8.3)
Starter formulas	3 (0.6)	3 (0.6)	1 (0.1)	3 (0.4)	2 (0.2)	0 (0.0)
Follow‐up formulas	2 (0.4)	2 (0.4)	0 (0.0)	2 (0.3)	0 (0.0)	0 (0.0)
Growing‐up formulas	36 (6.7)	38 (7.3)	50 (7.0)	54 (8.1)	80 (7.4)	91 (8.3)
Engagement, conversion, and loyalty tactics	19 (3.5)	26 (5.0)	60 (8.4)	41 (6.1)	133 (12.3)	75 (6.8)
Cross‐promotion within the same product line	12 (2.2)	10 (1.9)	24 (3.4)	30 (4.5)	25 (2.3)	63 (5.7)
Promotions and incentives (discounts, giveaways, gifts)	1 (0.2)	0 (0.0)	15 (2.1)	1 (0.1)	2 (0.2)	0 (0.0)
Click‐to‐chat marketing and direct purchase links	5 (0.9)	13 (2.5)	17 (2.4)	10 (1.5)	55 (5.1)	12 (1.1)
Links to support networks like mom clubs or discussion forums	1 (0.2)	1 (0.2)	4 (0.6)	0 (0.0)	51 (4.7)	0 (0.0)
Loyalty programs or subscription	0 (0.0)	2 (0.4)	0 (0.0)	0 (0.0)	0 (0.0)	0 (0.0)
Validation and credibility tactics	1 (0.2)	20 (3.8)	16 (2.3)	0 (0.0)	6 (0.6)	3 (0.3)
Endorsements by health professionals or associations; quality seals and certifications	1 (0.2)	19 (3.7)	7 (1.0)	0 (0.0)	6 (0.6)	0 (0.0)
Validation by influencers and brand ambassadors	0 (0.0)	1 (0.2)	9 (1.3)	0 (0.0)	0 (0.0)	3 (0.3)

Note: Bold represents the total of the category.

3.3. Non‐Compliance With the International Code of Marketing of Breastmilk Substitutes in the Promotion of Commercial Infant Formula Products

Between November 2023 and May 2024, we identified a total of 355 online advertisements for CMF products, accounting for 2797 instances of non‐compliance with the Code. On average, 7.5 ± 2.7 instances of non‐compliance were found per advertisement (Table 3).

The most frequent type of non‐compliance was related to the labelling provision of the Code (73.3%), including omissions of the recommended age for product introduction, the use of text and imagery that idealized CMF consumption, and messaging portraying these products as superior or equivalent to breast milk. These practices were closely aligned with the most prevalent digital marketing tactics identified in our study, particularly those centered on narrative and emotional messaging strategies, which are designed to build trust, evoke care, and offer solutions to common parenting challenges. These emotionally charged and persuasive messages reinforce misleading perceptions about the necessity or benefits of CMF over breastfeeding.

The second most frequent category of non‐compliance (7.5%) involved misuse of informational and educational materials on IYCF, specifically through the omission of statements on the negative consequences of not breastfeeding or introducing partial bottle feeding. The third most prevalent category (7.2%) included promotional content disguised as educational materials, and direct promotion to the public, including digital invitations for parents to join support groups, access one‐on‐one chats, or engage with brand communities. These tactics, native to digital platforms, blur the boundaries between education and promotion, exploiting features such as personalized chat tools, embedded links, and interactive formats in ways traditional media cannot. Additional instances of non‐compliance involved failure to adhere to WHA resolutions and subsequent guidance, including the widespread use of cross‐promotion across formula stages, a tactic used to bypass restrictions by maintaining consistent packaging and branding. Endorsements by health professionals and the use of their credentials to bolster marketing credibility were also observed, along with frequent use of health and nutrition claims, such as promises of immune support, cognitive development, or digestive comfort (Table 6).

Table 6.

Number and type of instances of non‐compliance with the International Code of Marketing of Breastmilk Substitutes in the promotion of commercial infant formula products in Guatemala, Panama and Dominican Republic.

Article of the Code	Provision of the Code	Violation type	Total number of violations n = 2797 n (%)	Tactics examples used that violate the Code
Labelling	9.2 Labelling		2051 (73.3)
	The recommended age for introduction of the product	Omission of the recommended text	301 (14.7)	N/A
	Prohibition of pictures that may idealize the use of infant formula on label of infant formula products	Use of prohibited pictures	296 (14.4)	Visual and media format tactics (images of families) Messaging and narrative tactics (emotional messaging)
	Prohibited information: messages that recommend or promote bottle feeding	Use of prohibited messages	272 (13.3)	N/A
	Prohibited content: images or text that discourages breastfeeding or compares to breast milk	Use of prohibited images or text	267 (13.0)	Visual and media format tactics (child under two featured in the ad) Messaging and narrative tactics (nutritional or health claims)
	A statement on using only on the advice of a health worker	Omission of the statement on seeking advice of a health worker	250 (12.2)	N/A
		Omission of the statement on using only on the advice of a health worker	225 (11.0)	N/A
	A statement on superiority of breastfeeding	Omission of the statement	226 (11.0)	N/A
	The words “Important Notice”	Omission of the words	214 (10.4)	N/A
Informational/educational materials on IYCF	4.2 Information and education		210 (7.5)
	A message of: the negative effect on breastfeeding of introducing partial bottle‐feeding	Omission of the message	210 (100.0)	N/A
Promotion to general public	5.3, 5.4, 5.5 The general public and mothers		200 (7.2)
	Prohibition of contact with mothers	Use of an invitation/link to contact	134 (67.0)	Engagement, conversion, and loyalty tactics (click‐to‐chat marketing)
		Use of invitations to virtual support groups or baby clubs	33 (16.5)	Engagement, conversion, and loyalty tactics (links to support networks)
	Prohibition of promotional devices at point of sale	Use of promotion or discounts	20 (10.0)	Engagement, conversion, and loyalty tactics (promotions and incentives)
	Prohibition of gifts to pregnant women and mothers	Use of gifts to pregnant women and mothers	13 (6.5)	Engagement, conversion, and loyalty tactics (promotions and incentives)
WHA 58.32 Infant and young child nutrition	Prohibition of nutritional and health claims	Use of prohibited claims	143 (5.1)	Messaging and narrative tactics (nutritional or health claims)
A69/7 Add.1 Guidance on ending the inappropriate promotion of foods for infants and young children	Recommendations 5 & 6		193 (6.9)
	Overall prohibition of advertising	Use of cross‐promotion	164 (85.0)	Messaging and narrative tactics (cross‐promotion)
	Prohibited content: professional endorsements	Use of prohibited content	29 (15.0)	Validation and credibility tactics (professional endorsements)

Note: Bold represents the total of the category.

At the brand level, labelling‐related non‐compliance consistently represented more than 70% of all instances. The companies responsible for the highest number of instances of non‐compliance were Babina, Nutricia, and Nestlé. Babina stood out for consistently omitting the required “Important Notice” on breastfeeding and using imagery that may undermine breastfeeding. Babina and Nestlé also engaged heavily in cross‐promotion across different product stages. Nutricia and Nestlé were notable for leveraging personalized digital marketing tools, including click‐to‐chat links, exclusive clubs, and promotional offers aimed at building brand loyalty. Even among companies with fewer overall instances such as Nutribén, Abbott, and Mead Johnson non‐compliant practices persisted, including omission of the age of introduction and unauthorized use of health‐related claims (Table 7).

Table 7.

Number and type of non‐compliance with the International Code of Marketing of Breastmilk Substitutes by commercial infant formula companies in Guatemala, Panama and Dominican Republic.

Article of the Code	Provision of the Code	Violation type	Abbott n = 285 (%)	Babina n = 843 (%)	Mead Johnson n = 283 (%)	Nutribén n = 426 (%)	Nutricia n = 553 (%)	Nestlé n = 407 (%)
Labelling	9.2 Labelling		215 (75.4)	687 (81.5)	205 (72.4)	314 (73.7)	366 (66.2)	264 (64.9)
	The recommended age for introduction of the product	Omission of the recommended text	31 (10.9)	84 (10.0)	38 (13.4)	27 (6.3)	77 (13.9)	44 (10.8)
	Prohibition of pictures that may idealize the use of infant formula on label of infant formula products	Use of prohibited pictures	30 (10.5)	88 (10.4)	29 (10.2)	41 (9.6)	61 (11.0)	47 (11.5)
	Prohibited information: messages that recommend or promote bottle feeding	Use of prohibited messages	27 (9.5)	87 (10.3)	27 (9.5)	38 (8.9)	59 (10.7)	34 (8.4)
	Prohibited content: images or text that discourages breastfeeding or compares to breast milk	Use of prohibited images or text	25 (8.8)	88 (10.4)	28 (9.9)	39 (9.2)	59 (10.7)	28 (6.9)
	A statement on using only on the advice of a health worker	Omission of the statement on seeking advice of a health worker	27 (9.5)	85 (10.1)	16 (5.7)	43 (10.1)	39 (7.1)	40 (9.8)
		Omission of the statement on using only on the advice of a health worker	28 (9.8)	80 (9.5)	16 (5.7)	42 (9.9)	19 (3.4)	40 (9.8)
	A statement on superiority of breastfeeding	Omission of the statement	23 (8.1)	85 (10.1)	23 (8.1)	38 (8.9)	39 (7.1)	18 (4.4)
	The words “Important Notice”	Omission of the words	24 (8.4)	90 (10.7)	28 (9.9)	46 (10.8)	13 (2.4)	13 (3.2)
Informational/educational materials on IYCF	4.2 Information and education		24 (8.4)	67 (7.9)	16 (5.7)	41 (9.6)	31 (5.6)	31 (7.6)
	A message of: the negative effect on breastfeeding of introducing partial bottle‐feeding	Omission of the message	24 (8.4)	67 (7.9)	16 (5.7)	41 (9.6)	31 (5.6)	31 (7.6)
Promotion to general public	5.3, 5.4, 5.5 The general public and mothers		9 (3.1)	17 (2.0)	18 (6.4)	11 (2.6)	94 (17.0)	51 (12.5)
	Prohibition of contact with mothers	Use of an invitation/link to contact	7 (2.5)	14 (1.7)	14 (4.9)	9 (2.1)	64 (11.6)	26 (6.4)
		Use of invitations to virtual support groups or baby clubs	2 (0.7)	0 (0.0)	2 (0.7)	0 (0.0)	25 (4.5)	4 (1.0)
	Prohibition of promotional devices at point of sale	Use of promotion or discounts	0 (0.0)	2 (0.2)	2 (0.7)	1 (0.2)	0 (0.0)	15 (3.7)
	Prohibition of gifts to pregnant women and mothers	Use of gifts to pregnant women and mothers	0 (0.0)	1 (0.1)	0 (0.0)	1 (0.2)	5 (0.9)	6 (1.5)
WHA 58.32 Infant and young child nutrition	Prohibition of nutritional and health claims	Use of prohibited claims	25 (8.8)	9 (1.1)	17 (6.0)	29 (6.8)	33 (6.0)	30 (7.4)
A69/7 Add.1 Guidance on ending the inappropriate promotion of foods for infants and young children	Recommendations 5 & 6		12 (4.2)	63 (7.5)	27 (9.5)	31 (7.2)	29 (5.2)	31 (7.6)
	Overall prohibition of advertising	Use of cross‐promotion	12 (4.2)	63 (7.5)	10 (3.5)	30 (7.0)	25 (4.5)	24 (5.9)
	Prohibited content: professional endorsements	Use of prohibited content	0 (0.0)	0 (0.0)	17 (6.0)	1 (0.2)	4 (0.7)	7 (1.7)

Note: Bold represents the total of the category.

3.4. Breaches of Code‐Based Legislation in Guatemala, Panama, and the Dominican Republic in the Promotion of Commercial Milk Formula

Despite widespread non‐compliance with the Code, not all documented practices constituted legal breaches under national Code‐based legislation in Guatemala, Panama, and the Dominican Republic. Of the 2797 documented instances of non‐compliance with the Code, just 1480 were classified as legal breaches in Guatemala, 2 189 in Panama, and 2160 in the Dominican Republic. In Guatemala, 47.1% of instances of non‐compliance were not covered by current legislation, reflecting the country's partial incorporation of the Code. Similarly, 21.7% and 22.8% of the documented instances in Panama and the Dominican Republic, respectively, fell outside the scope of existing legal provisions (Table 8 and Figure 1).

Table 8.

Number and type of legal breaches under Code‐based legislation by article in Guatemala, Panama and Dominican Republic.

Article of the Code	Provision of the Code	Violation type	Guatemala Law 66‐83 and governmental agreement 841‐87 n = 1480 (100%) n (%)	Panama Law 50 and Executive Decree 1457 of 2012 and 513 of 2013 n = 2189 (100%) n (%)	Dominican Republic Law 8‐95 and Decree No. 142‐18 n = 2160 (100%) (%)
Labelling	9.2 Labelling		1061 (71.9)	1750 (79.9)	1750 (81.0)
	The recommended age for introduction of the product	Omission of the recommended text	Non regulated	Non regulated	Non regulated
	Prohibition of pictures that may idealize the use of infant formula on label of infant formula products	Use of prohibited pictures	296 (20.0) Agreement Art. 12	296 (13.5) Law Art. 22.2 & Decree Art. 29	296 (13.7) Decree Art. 12
	Prohibited information: messages that recommend or promote bottle feeding	Use of prohibited messages	272 (18.4) Agreement Art. 12	272 (12.4) Decree Art. 25	272 (12.6) Ley Art. 17
	Prohibited content: images or text that discourages breastfeeding or compares to breast milk	Use of prohibited images or text	267 (18.0) Law Art.13	267 (12.2) Law Art. 22.2 & Decree Art. 29	267 (12.4) Law Art. 17
	A statement on using only on the advice of a health worker	Omission of the statement on seeking advice of a health worker	Non regulated	250 (11.4) Law Art. 22.2 & Decree Art. 29	250 (11.6) Law Art. 17
		Omission of the statement on using only on the advice of a health worker	Non regulated	225 (10.3) Law Art. 22.2 & Decree Art. 29	225 (10.4) Law Art. 17
	A statement on superiority of breastfeeding	Omission of the statement	226 (15.3) Agreement Art. 5 & 11	226 (10.3) Law Art. 24	226 (10.5) Law Art. 7 & 17
	The words “Important Notice”	Omission of the words	Non regulated	214 (9.8) Law Art. 22.2	214 (9.9) Law Art. 17
Informational/educational materials on IYCF	4.2 Information and education		210 (14.2)	210 (9.6)	210 (9.7)
	A message of: the negative effect on breastfeeding of introducing partial bottle‐feeding	Omission of the message	210 (14.2) Law Art. 3	210 (9.6) Law Art. 14 & Decree Art. 19	210 (9.7) Law Art. 7
Promotion to general public	5.3, 5.4, 5.5 The general public and mothers		180 (12.2)	200 (9.1)	200 (9.1)
	Prohibition of contact with mothers	Use of an invitation/link to contact	134 (9.1) Law Art. 7 & Agreement Art. 8	134 (6.1) Law Art.14.4 & Decree Art. 20	134 (6.2) Law Art. 11 incise E
		Use of invitations to virtual support groups or baby clubs	33 (2.2) Law Art. 7 & Agreement Art. 8	33 (1.5) Law Art.14.4 & Decree Art. 20	33 (1.5) Law Art. 11 incise E
	Prohibition of promotional devices at point of sale	Use of promotion or discounts	Non regulated	20 (0.9) Law Art. 17.3 & Decree Art. 24.3	20 (0.9) Law Art. 11 incise C
	Prohibition of gifts to pregnant women and mothers	Use of gifts to pregnant women and mothers	13 (0.9) Law Art. 5	13 (0.6) Law Art. 17.4 & Decree Art. 24.4	13 (0.6) Law Art. 11 incise C
WHA 58.32 Infant and young child nutrition	Prohibition of nutritional and health claims	Use of prohibited claims	Non regulated	Non regulated	Non regulated
A69/7 Add.1 Guidance on ending the inappropriate promotion of foods for infants and young children	Recommendations 5 & 6		29 (2.0)	29 (1.3)	0 (0.0)
	Overall prohibition of advertising	Use of cross‐promotion	Non regulated	Non regulated	Non regulated
	Prohibited content: professional endorsements	Use of prohibited content	29 (2.0) Agreement Art. 5	29 (1.3) Decree Art. 29.6	Non regulated

Figure 1.

Non‐compliance with the Code and breaches of national legislation by CMF industry.

The most frequent legal breaches across all three countries were related to labelling requirements. This included content that idealized CMF use, undermined breastfeeding, or portrayed formula as superior or equivalent to breastmilk, as well as the omission of mandatory warnings such as the recommendation to consult a health professional and the “Important Notice” on the superiority of breastfeeding. These gaps are particularly concerning in digital formats, where short, visual, and fast‐paced messaging increases the risk of misleading or incomplete information (Table 8).

Breaches involving informational and educational materials were also common, particularly the failure to include warnings about the potential negative impact of partial bottle feeding on breastfeeding. In addition, companies frequently employed direct‐to‐public promotional tactics, including invitations to brand‐affiliated clubs or online groups and embedded links for chat or customer service.

4. Discussion

The monitoring of the digital first food environment reveals an active and sophisticated promotional ecosystem. A total of 355 digital advertisements using more than 4000 digital tactics were identified on platforms such as Instagram, Facebook, YouTube, and official brand websites. These strategies frequently appealed to emotions, used trending visual formats, and segmented content according to audience characteristics facilitating precise and persuasive targeting. While effective for engagement, this level of sophistication poses substantial challenges for oversight, particularly in fast‐paced digital environments where tactics are difficult to detect, trace, and sanction under current Code‐based legislation.

On average each digital advertisement employed 13 marketing tactics and demonstrated 7.5 instances of non‐compliance with the Code. The most frequent forms of non‐compliance were related to labelling, including the omission of the appropriate age for product introduction, the use of idealized imagery, and messaging that portrayed CMF as superior to breastfeeding. These findings suggest that the most prevalent tactics, especially those relying on narrative and emotional appeals, are not only persuasive but also commonly non‐compliant.

Many of these tactics mirror those used in traditional media, such as idealized portrayals of CMF use and promotional discounts. However, the digital environment enables novel approaches that present new regulatory challenges (Jones et al. 2022). These include the use of click‐to‐chat tools, interactive features, algorithmic targeting, and mobile apps to communicate directly with parents in real‐time. Moreover, digital platforms allow companies to deploy cross‐border marketing (Jones et al. 2022) enabling campaigns to simultaneously target audiences in multiple countries with minimal regulatory friction.

Beyond non‐compliance with the Code, we identified 2160, 2189 legal breaches under national Code‐based legislation in Panama and the Dominican Republic, respectively, and 1480 in Guatemala. The most common legal breaches were related to labelling requirements such as omitting mandatory warnings, failing to indicate the recommended age of introduction, and using imagery or claims that idealize CMF or undermine breastfeeding. Our findings are consistent with a study conducted in Vietnam, which aimed to quantify the extent and nature of digital breaches of national legislation by CMF marketing. That study similarly found that the most common breaches involved promotion to the public and violations of labelling provisions (Backholer et al. 2025).

A significant proportion of the instances of non‐compliance with the Code identified in this study were not considered illegal under national laws due to substantial gaps in regulatory coverage. For example, growing‐up milks, which represented most CMF advertisements, are not regulated under existing legislation in Guatemala (Gobierno de Guatemala 1983, 1987) or the Dominican Republic (Gobierno de la República Dominicana 1995, 2018) and in Panama are only regulated up to 24 months of age, leaving products marketed for children aged 24–36 months (Gobierno de Panamá 1995, 2012) outside the scope of the law. A recent systematic scoping review found that while advertisements for infant formulas have been decreasing, promotions for growing‐up milks have increased in recent years (Becker et al. 2022). This pattern suggests that national legislation, even if incomplete, does have an effect (Topothai et al. 2024) as most countries regulate infant formula but not growing‐up milks (Topothai et al. 2024; Becker et al. 2022). The CMF industry appears to be capitalizing on this gap. Nutritional and health claims are also widely used but remain largely unregulated. Furthermore, existing legal frameworks do not address key features of the digital ecosystem, including influencer marketing, algorithm‐driven promotions, personalized advertising, and cross‐promotion across formula stages. These blind spots in regulation allow companies to operate with limited accountability (Becker et al. 2022). A comparison between the provisions of the Code and existing national legislation highlights consistent gaps across countries. While core provisions related to labelling and promotion are partially reflected in national laws, key areas such as the scope of products covered, the regulation of claims, and the oversight of digital marketing practices remain insufficiently addressed. These inconsistencies limit the ability of governments to effectively identify, classify, and sanction non‐compliant practices in the digital food environment. Moreover, even when legal provisions exist, enforcement remains challenging due to limited and inconsistent monitoring systems, unclear institutional mandates, weak coordination among government agencies, and insufficient sanctioning mechanisms. The dynamic, personalized, and cross‐border nature of online l marketing further compounds these enforcement challenges (World Health Organization 2023).

Taken together, our findings underscore the urgent need to update and strengthen national legal frameworks to align them with the full scope of the Code and subsequent WHA resolutions. In particular, the digital food environment requires a more comprehensive regulatory approach that not only prohibits inappropriate marketing practices but also mandates the inclusion of key information. This includes clearly visible statements on the risks associated with CMF use, minimum recommended age for introduction, the superiority of breastfeeding, and details on nutritional quality, even within short‐form digital content. Regulation in digital spaces should go beyond prohibitions to also require transparency and empower caregivers to make informed decisions. Effective monitoring and enforcement in digital environments also require coordination among institutions beyond Ministries of Health, including communication regulators, consumer protection agencies, competition authorities, and digital platforms themselves. Clearly defining institutional roles and enforcement responsibilities is essential to address the complexity and cross‐border nature of digital marketing practices.

This study has several limitations. First, the monitoring was limited to brand‐managed digital platforms such as social media accounts and official websites, which may have excluded other relevant digital marketing channels. For example, we did not include marketing strategies distributed via email, mobile apps, or e‐commerce platforms such as online pharmacies and supermarkets, channels that are increasingly leveraged by the CMF industry. Second, the monitoring period was limited to 6 months, potentially missing seasonal or event‐based campaigns. Third, most platforms did not provide timestamps for posts, limiting our ability to assess posting patterns (e.g., whether ads are timed for evenings or weekends). Despite these constraints, our study offers a replicable, scalable monitoring framework for digital environments and provides novel insights into both non‐compliance with the Code and legal breaches under national legislation.

Our findings carry key policy implications for protecting breastfeeding and safeguarding the first food system. First, countries should urgently revise and expand national legislation to fully incorporate all Code provisions and WHA resolutions, explicitly covering all products intended for children under 36 months, nutritional and health claims, and all communication channels, including digital. Second, enforcement mechanisms must be strengthened. This includes defining sanctions, clarifying mandates across government institutions, and building capacity among regulatory bodies. Third, investments are needed in real‐time digital surveillance tools to detect non‐compliant marketing practices. Notably, countries like Vietnam, Mexico, and Argentina have begun deploying artificial intelligence driven monitoring systems to detect CMF ads and analyze content automatically (Topothai et al. 2024; Backholer et al. 2025; Fundación SANAR 2025). These tools can greatly enhance the reach and speed of monitoring efforts. Fourth, it is essential to foster coordinated action between health authorities, communication regulators, consumer protection agencies, competition authorities, civil society organizations, and digital platforms. This collaborative approach can help detect and prevent covert or unauthorized marketing strategies, while narrowing the gap between the Code's provisions and national binding laws. Strengthening the technical, human, and legal capacity of regulatory institutions is critical to ensure effective enforcement across all applicable legal frameworks. This includes the development of digital monitoring protocols, improved legal responses, and the establishment of safe and ethical digital food environments for children and families. Fifth, governments and regional bodies should establish cooperation mechanisms to address cross‐border digital marketing strategies (Franco‐Lares et al. 2023). This may include harmonizing legal frameworks between countries in the region, implementing shared digital monitoring systems for content targeting multinational audiences, and formalizing inter‐institutional agreements to exchange alerts, evidence, and enforcement actions.

In conclusion, the digital marketing landscape for CMF in Central America and the Caribbean is increasingly sophisticated, aggressive, and non‐compliant. Our findings highlight the urgent need to adapt regulatory frameworks, enforcement mechanisms, and monitoring systems to protect breastfeeding, safeguard the first food system, and ensure safe and ethical digital environments for parents and children.

Author Contributions

The authors' responsibilities were as follows: M.M. conceived and designed the study and secured funding; L.A. and B.P. collected and curated the data; B.P., L.A., and M.M. performed the data analysis; M.M. drafted the original manuscript; M.M., B.P., L.A., and J.R.D.L. interpreted the findings, critically revised the manuscript, and approved the final version. MM is the guarantor and takes primary responsibility for the final content.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.