Research on Marketing and the Code

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These studies explore issues around the marketing of infant formula which come under the umbrella of the International Code of Marketing of Breastmilk Substitutes (the Code). See our dedicated resource page for more information on the Code and further reading.

Costs of infant formula, follow-on formula and milks marketed as foods for special medical purposes available over the counter in the UK

This report by First Steps Nutrition Trust summarises current data available on the costs of infant formula, follow-on formula and infant milks marketed as foods for special medical purposes marketed over the counter in the UK. The costs of products are given at purchase and have been calculated per 100ml, and per week for a 2-3 month old baby, so that costs can be compared.

First Steps Nutrition Trust: Costs of infant formula, follow-on formula and milks marketed as foods for special medical purposes available over the counter in the UK. August 2021.

Advocacy brief: nutrition for growth year of action: nine SMART breastfeeding pledges

This advocacy brief is organized into two separate papers. The first half acts as a standalone briefing that highlights the importance of the Nutrition for Growth (N4G) Year of Action, positions breastfeeding within its universal health coverage pillar and organizes the SMART breastfeeding recommendations into their corresponding N4G commitment types. The latter half provides the rationale for each of the pledges and signposts towards helpful resources, including official guidance notes and case studies, to support country implementation.

World Health Organization 2021 – License: CC BY-NC-SA 3.0 IGO. ISBN9789240030947

Rates and time trends in the consumption of breastmilk, formula, and animal milk by children younger than 2 years from 2000 to 2019: analysis of 113 countries

This time-series analysis combines cross-sectional data from low-, middle- and high-income countries to assess consumption trends in breastmilk, formula, and animal milk by children younger than two years from 2000 to 2019. Increases in breastfeeding rates at six months were found in various regions and income groups, whilst formula consumption increased in upper-middle-income countries. In order to achieve the global target of 70% exclusive breastfeeding by 2030, breastfeeding rates must increase and renewed efforts are needed to counteract declining trends in low-income societies, including strict enforcement of the International Code of Marketing of Breastmilk Substitutes and to halt the marketing and sale of infant formula.

Neves, P., et al. Rates and time trends in the consumption of breastmilk, formula, and animal milk by children younger than 2 years from 2000 to 2019: analysis of 113 countries.2021. World Health Organization. Licensee Elsevier. DOI: https://doi.org/10.1016/S2352-4642(21)00163-2

The history and the future of the Code: A four-part series by David Clark

In a four-part series for Alive and Thrive, UNICEF’s former legal specialist for 25 years, David Clark, discusses the history and future of the International Code of Marketing of Breast-milk Substitutes. During his tenure at UNICEF, David was instrumental in assisting more than 60 countries to draft legislation to implement the Code and subsequent resolutions of the World Health Assembly.

Read more on the Baby Friendly blog and visit Alive and Thrive’s website. 

Marketing of infant milk in the UK: what do parents see and believe?

Findings from an online survey of 1307 UK mothers with a baby 0 – 12 months revealed that nearly 100% of mothers reported seeing a wide range of adverts for infant milks, with 75% of respondents describing them as ’emotive’ and younger mothers more likely to view them favourably. Mothers who already used infant milks were more inclined to perceive the adverts as clear, scientific and helpful, whilst mothers who did not use infant milks expressed anger at the misleading messaging.

Brown, A., Jones, S., Evans, E. 2020. Marketing of Infant Milk in the UK: What do Parents See and Believe? Commissioned by First Steps Nutrition Trust. 

Globalization, first-foods systems transformations and corporate power: a synthesis of literature and data on the market and political practices of the transnational baby food industry

Global milk formula sales grew from ~US$1.5 billion in 1978 to US$55.6 billion in 2019, raising concerns for breastfeeding, child and maternal health and the implementation of the Code. This paper uses a theoretically guided synthesis review method to understand the integrated market and political strategies used by the baby food industry to shape ‘first-foods systems’ and thereby drive global infant formula consumption.

Baker, P., Russ, K., Kang, M. et al. Globalization, first-foods systems transformations and corporate power: a synthesis of literature and data on the market and political practices of the transnational baby food industry. Global Health 17, 58 (2021). https://doi.org/10.1186/s12992-021-00708-1

Spotlight on lobbying: Baseline benchmark of major breastmilk substitute manufacturers’ lobbying policies, management systems and disclosure

Lobbying by breastmilk substitute manufacturers is a driving force behind why many countries have not yet adopted the entirety of the Code. This report puts a spotlight on lobbying by evaluating the policies and practices of the nine largest breastmilk substitute manufacturers, which account for 54% of a global market, and highlighting how companies can commit to responsible lobbying.

Access to Nutrition Initiative. Spotlight on Lobbying. May 2021. 

Advertising of Human Milk Substitutes in United Kingdom Healthcare Professional Publications: An Observational Study

This cross-observational study calls into question widespread advertising of human milk substitutes which are targeted at UK healthcare professionals. A total of 32 such advertisements were identified, none of which were deemed to be compliant with the International Code of Marketing of Breastmilk Substitutes (the Code) or the UK Formula and Follow-on Formula Regulations. Authors call for urgent adherence to international and local regulations in order to reduce efforts which undermine the protection of breastfeeding.

Hickman N, Morgan S, Crawley H, Kerac M. Advertising of Human Milk Substitutes in United Kingdom Healthcare Professional Publications: An Observational Study. Journal of Human Lactation. May 2021. doi:10.1177/08903344211018161

First‐food systems transformations and the ultra‐processing of infant and young child diets: The determinants, dynamics and consequences of the global rise in commercial milk formula consumption

This study describes trends in global formula sales volumes in 77 countries from 2005 to 2019 in order to understand how first‐food systems (those that provision foods for children aged 0–36 months) explain the global transition to higher formula diets. Results highlight how the marketing and promotion of breastmilk substitutes undermines breastfeeding and harms child and maternal health in all country contexts.

Baker, P., Santos, T. et al. First‐food systems transformations and the ultra‐processing of infant and young child diets: The determinants, dynamics and consequences of the global rise in commercial milk formula consumption. https://doi.org/10.1111/mcn.13097

Selling second best: how infant formula marketing works

The study was comprised of a mix of secondary analysis of business databases and qualitative interviews with marketing practitioners, including some of whom had previously worked in formula marketing, to address and attempt to explain the widespread marketing of formula milk. Conclusions found that powerful emotional techniques are used to sell parents a product that is inferior to breast milk and there is urgent need to strengthen regulation.

Hastings, G., Angus, K., Eadie, D. et al. Selling second best: how infant formula marketing works. Global Health 16, 77 (2020). https://doi.org/10.1186/s12992-020-00597-w

Danone Nutricia: Why do they want to be your partner?

This evidence-based report published in January 2020 helps NGOs, charities, health professionals and advocacy groups to better understand why breastmilk substitute companies attempt to partner with organisations working with pregnant women, infants and children and how these partnerships can negatively affect care for mothers and babies

Baby Feeding Law Group UK. Danone Nutricia: Why do they want to be your partner? (2020)

Based on science? Revisiting Nestlé’s infant milk products and claims, 2019

This report investigates Nestlé, as the world market leader for infant milk products for babies under 12 months old. It revisits findings from previous reports (Busting the myth of science-based formula, 2018 & Milking it: How Milk Formula Companies are Putting Profits Before Science, 2017 – see write up below). The current report finds that, despite Nestlé committing to making three changes to its global infant formula ranges (removing sucrose and vanilla compounds from all its products for babies aged under 12 months, and removing contradictory nutritional advice on sucrose and vanilla flavourings), it has so far failed to fulfil two out of these three commitments, with only the promise to remove sucrose being fulfilled at the time of publication of the report.

Researchers also found that Nestlé continues to draw comparisons between its products and human milk (a practice coming under the scope of the Code); and practises price premiumisation between different countries and markets. For more detail, see our news post on the report.

The Changing Markets Foundation and SumOfUs (2019). Based on science? Revisiting Nestlé’s infant milk products and claims. 

Infant formula advertising in medical journals: a cross-sectional study (and struggle to publish)

Researchers in this study hand-searched high-impact paediatric and general medical journals published between 2003 and 2012 to quantify the prevalence of breastmilk substitute (BMS) advertising. Although uncommon overall, in this study period BMS advertising was carried by leading clinical journals and, in particular, two leading child health journals, Archives of Diseases in Childhood (ADC) and ADC Fetal and Neonatal edition. Adverts also appeared in the British Medical Journal (BMJ), which had the highest print circulation in the UK (BMJ Group, 2013). The authors recommend that journals do not carry BMS adverts, arguing that there are many other opportunities for health professionals in the UK to access independent and comparative information about BMS products. Interestingly, the authors struggled to publish their findings, with the paper initially being rejected by two journals carrying the most advertisements.

Morgan, S, Waterston, T, and Kerac, M (2018). Infant formula advertising in medical journals: a cross-sectional study (and struggle to publish). Field Exchange. https://www.ennonline.net/fex/58/infantformulaadvertising

WHO, IBFAN and UNICEF’s joint report, Marketing of breast-milk substitutes: national implementation of the international code, status report 2018 looks at the extent to which countries have incorporated the Code into their national laws. Although some countries have made progress since the last status report in 2016, the authors highlight that too few countries have robust measures in place to tackle inappropriate marketing of breastmilk substitutes.

http://apps.who.int/iris/handle/10665/272649

Don’t push it: Why the formula industry must clean up its act

Save the Children’s cross-sector report highlights how misleading and inaccurate marketing of breastmilk substitutes is putting babies’ lives at risk by undermining breastfeeding and preventing families from receiving clear, evidence based information about infant feeding.

https://resourcecentre.savethechildren.net/library/dont-push-it-why-formula-milk-industry-must-clean-its-act (March 2018)

Breaking the rules, Stretching the rules 2017

IBFAN-ICDC’s 11th global monitoring report is a compilation of marketing practices from around the world that violate the International Code over the past 3 years. Collected from IBFAN’s regional and country groups and volunteers, it contains almost 800 legally-vetted entries on 28 companies from 79 countries.

https://www.ibfan-icdc.org/ibfan-icdc-launches-its-11th-global-monitoring-report-breaking-the-rules-stretching-the-rules-2017/

Milking it: How Milk Formula Companies are Putting Profits Before Science

This report from the Changing Markets Foundation investigates the products of four formula milk companies across 14 global markets. It finds wide disparities in price across different markets, and concludes that increasing product differentiation is not science-based, but instead informed by careful research into consumer preferences, guided by a desire to increase profits. https://changingmarkets.org/portfolio/milking-it/ (October 2017)

Long chain polyunsaturated fatty acid (LCPUFA) supplementation in infants born at term

Some formula milk companies have begun supplementing their products with LPCUFA; this review explored the marketing claim that such supplementation supports term infants’ development. The authors found that full-term babies fed formula milk supplemented with LCPUFA did not have better outcomes than were reported for full-term babies fed formula milk without LCPUFA.

Jasani, B, et al (2017). Long chain polyunsaturated fatty acid supplementation in infants born at term, Cochrane Database of Systematic Reviews, DOI: 10.1002/14651858.CD000376.pub4

New Review of Breastmilk Substitutes Advertising Launched 

First Steps Nutrition Trust has published “‘Scientific and factual?’ A review of breastmilk substitutes advertising to healthcare professionals.” The document examines the evidence given to support advertising claims about formula milk, revealing a worryingly common use of misleading and unscientific information contrary to international, EU and national regulations over formula milk advertising.

The review points out that there is “no mechanism to challenge whether adverts are in fact ‘scientific and factual’ in their content and presentation. Manufacturers of breastmilk substitutes advertise their products to healthcare professionals in magazines, through company representatives’ information, healthcare professional websites, at study days and via helplines. Many of the claims made by manufacturersare, however, not accepted by scientific bodies, the evidence may be weak or non-existent and it may relate to a product other than that being advertised. We believe that this misleads healthcare professionals.

This is an insightful and essential read for any health professional working on infant feeding, demonstrating the need fto be extremely vigilant before accepting any claims.

Read the review of breastmilk substitutes advertising

Find out more about First Steps Nutrition

The impact of marketing of breast-milk substitutes on WHO-recommended breastfeeding practices 

This study describes sales and marketing of breast-milk substitutes and their influence on World Health Organization-recommended breastfeeding behaviours, focusing on low- and middle-income countries.

Global sales of breast-milk substitutes reached US$40 billion in 2013. Growth in sales exceeds 10% annually in many low- and middle-income countries, while it is close to stagnant in high-income countries. Breast-milk substitutes are marketed directly to consumers via mass media and print advertisements and indirectly via incentives, free supplies, and promotions to and through health workers and facilities, retailers, and policy makers. Internet marketing via company web sites and social media is on the rise. Marketing influences social norms by making formula use seem to be extensive, modern, and comparable to or better than breast milk. Clear evidence of a negative impact is found when breast-milk substitutes are provided for free in maternity facilities and when they are promoted by health workers and in the media. Influences through other channels are plausible, but rigorous studies are lacking. Marketing remains widespread even in countries that have adopted the International Code of Marketing of Breast-milk Substitutes to restrict such activities.

The authors conclude that adopting stricter regulatory frameworks coupled with independent, quantitative monitoring and compliance enforcement are needed to counter the impacts of formula marketing globally.

Piwoz, E.G. & Huffman, S.L. (2015). The Impact of Marketing of Breast-Milk Substitutes on WHO-Recommended Breastfeeding Practices. Food and nutrition bulletin, doi: 10.1177/0379572115602174.

Enforcing the code for better promotion of exclusive breastfeeding 

This study explored the implementation challenges regarding the Code.
The authors recommend establishing national breastfeeding committees with authority to improve regulations, investigate violations, and enforce the laws. They stress that managers of multinational companies must be held accountable for international violations, and international legislative enforcement needs to be established.

Barennes, H., Slesak, G., Goyet, S., Aaron, P., Srour, LM. (2015) Enforcing the International Code of Marketing of Breast-milk Substitutes for Better Promotion of Exclusive Breastfeeding: Can Lessons Be Learned? Journal of Human Lactation, doi:10.1177/0890334415607816

Advertisements of follow-on formula and their perception by pregnant women and mothers in Italy 

Findings highlighted in this study:

  • Qualitative study, interviewing mothers about magazine advertisements for follow-on formula
  • Ambiguity of advertisements meant that the follow-on formula was confused with infant (first) formula
  • A majority of women thought that the products advertised were to be used from birth

Cattaneo et al (2014). Advertisements of follow-on formula and their perception by pregnant women and mothers in Italy. Archives of disease in childhood, doi:10.1136/archdischild-2014-306996.

Unicef UK Baby Friendly Initiative Supports Call for Adherence to International Code of Marketing Breastmilk Substitutes 

9 April 2013

Unicef UK Baby Friendly Initiative today urged supporters to join the call for formula milk companies to change their marketing techniques, as outlined in the recent Save the Children report ‘Superfood for Babies’.

Since the International Code of Marketing of Breastmilk Substitutes (the Code) was adopted by the World Health Assembly in 1981, Unicef has worked with national governments to make the Code part of national law, and to date more than 100 countries have done so, at least in part. Unicef has also promoted the adoption of the principles of the Code in health-care facilities across the world through the Baby Friendly Initiative.

Despite the Code now being over 30 years old, aggressive marketing practices from the formula milk industry continue to be reported (as highlighted by the recent Save the Children report and ongoing work of groups such as IBFAN). Such practices can influence a mother’s decision not to breastfeed, with the subsequent impact on child health.

To find out more about Save the Children’s action on breastmilk substitutes, click here.

Unicef UK’s  Guide for health workers to working within the International Code of Marketing of Breastmilk Substitutes provides health professionals with guidance on all the forms of professional interactions with the formula milk industry from using their materials to attendance at study days to accepting accepting money in the form of grants or research funding.

The importance of breastfeeding in tackling malnutrition in developing countries was underscored in the UNICEF UK report The right ingredients: the need to invest in child nutrition, launched on Mother’s Day, which highlights the potential of exclusive breastfeeding to dramatically reduce child deaths. To find out more about the report, click here.

New Report Calls for Global Action to Support Breastfeeding 

18 February 2013

Save The Children has today launched a new report calling for more support for breastfeeding and action to prevent formula companies using damaging marketing practices.

The report, Superfood for Babies, estimates more than 800,000 deaths could be prevented each year if babies were given breastmilk in the first hour of life. It highlights four major barriers to breastfeeding:

Community and cultural pressures: In many cases a mother may not be free to make her own choice about how she feeds her baby. Education and awareness of the benefits of breastfeeding are instrumental in helping to change views.

The health worker shortage: Currently, one third of babies are born without a skilled attendant present at birth. Resources are needed to improve this.

Lack of maternity legislation: Maternity leave, pay and workplace provision for breastfeeding are all key factors needed to support mothers to continue to breastfeed.

The big business barrier: Formula milk companies use marketing practices and target healthcare workers in ways that threaten lives and violate the International Code of Marketing of Breastmilk Substitutes. These practices can lead to infant formula being used unnecessarily and improperly, ultimately putting children at risk. Changes in company policy and stronger legislation are required to restrict these activities.

The report calls for action on all these issues, and particularly calls on the UK to use its presidency of the G8 this year to secure funding for breastfeeding programmes as part of plans to tackle malnutrition.

You can read the full report here.

Circumventing the WHO Code? An Observational Study 

This study compares the formula milk advertisements appearing in parenting magazines in four countries – the USA and Canada where there are no restrictions on formula advertising, the UK where formula milk advertising is prohibited but advertising for follow-on formula is not and Australia where both formula milk and follow-on formula milk advertising is prohibited.

The authors found that promotion of formula products or brands occurred in all the magazines, however the type of product advertised differed. Follow-on formula advertisements occurred most frequently in the UK and toddler milk advertisements in Australia.

The authors conclude that bans on the advertising of some infant formula products do not reduce the advertising of infant formula per se, and that products such as follow-on formula are presented in ways that encourage consumers to associate the claims made in them with a group of products (a product line) that includes infant formula, reducing the effectiveness of any advertising restrictions.

Unicef UK comment – This study demonstrates that comprehensive and complete legislation is required to implement the International Code of Marketing of Breastmilk Substitutes if such legislation is to be effective.

Click here to read the report ‘A weak formula for legislation’.

Berry NJ, Jones SC, Iverson D, et al. Circumventing the WHO Code? An observational study. Arch Dis Child (2011). doi:10.1136/adc.2010.202051

Related research and further reading