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.

Global evidence of persistent violations of the International Code of Marketing of Breastmilk Substitutes: A systematic scoping review

This scoping review systematically examined the published research evidence on the nature and extent of exposure to The International Code of Marketing of Breastmilk Substitutes violations from 1981 to August 2021. Of a total of 657 items, 153 studies were retained in the review from at least 95 countries. Studies reported a broad range of marketing violations, including increased use of marketing via digital platforms, which targeted mothers and families, health workers, and the general public. The evidence showed the use of misleading and inaccurate labeling and health and nutrition claims in breach of the Code. Findings confirm that violations of the Code have not ceased, and calls for renewed attention from the World Health Assembly and national governments are urgently needed in order to protect the health of children and their mothers.

Becker, G. E.Zambrano, P.Ching, C.Cashin, J.Burns, A.Policarpo, E.Datu-Sanguyo, J., & Mathisen, R. (2022). Global evidence of persistent violations of the International Code of Marketing of Breast-milk Substitutes: A systematic scoping reviewMaternal & Child Nutrition18S3):e13335. https://doi.org/10.1111/mcn.13335

National implementation of the International Code: Status Report 202

This report provides updated information on the status of implementation of the International Code of Marketing of Breastmilk Substitutes (BMS) and subsequent relevant World Health
Assembly (WHA) resolutions and presents the legal status of the Code, including the extent to which the provisions have been incorporated in national legal measures. The report examines how legal measures enacted in the past five years differ from earlier measures. It also identifies provisions specifically pertaining to the digital marketing of breastmilk substitutes (BMS).

View the report by the World Health Organization and UNICEF here. 

Conflicts of interest are harming maternal and child health: time for scientific journals to end relationships with manufacturers of breastmilk substitutes

Forty years after the World Health Assembly adopted the International Code of Marketing of Breastmilk Substitutes (the Code), inappropriate marketing of breastmilk substitutes persists and puts infants and young children at risk of malnutrition, illness and death. This report explores how the formula industry  uses ‘medical marketing’ strategies to influence scientists and health professionals as to the purported benefit of breastmilk substitutes and calls for all scientific journals and publishers to stop accepting funding from manufacturers and distributors.

Pereira-Kotze C, Jeffery B, Badham J, et al. Conflicts of interest are harming maternal and child health: time for scientific journals to end relationships with manufacturers of breast-milk substitutes. BMJ Global Health 2022;7:e008002. doi:10.1136/bmjgh-2021-008002

Effective regulatory frameworks for ending inappropriate marketing of breast-milk substitutes and foods for infants and young children in the WHO European Region (2022)

This policy brief shares step-by-step guidance on strengthening implementation of the Code and provides a regulatory framework to put an end to unethical marketing practices. It is intended to guide WHO European Region Member States in safeguarding parents and caregivers from promotion of breastmilk substitutes‎ by reviewing current implementation of The International Code of Marketing of Breastmilk Substitutes (the Code) and subsequent resolutions by the World Health Assembly, as well as the 2016 WHO Guidance on ending the inappropriate promotion of foods for infants and young children. Read more and download the brief on our website.

WHO/Europe Nutrition, 2022. 

Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry and public health resistance in the Philippines

This paper examines the Philippines as a case study to understand the battle for national Code implementation, with particular attention on political strategies used by the baby food industry to shape the country’s ‘first-food system’.  Findings indicate a decline in breastfeeding in the Philippines in the mid-twentieth century associated with intensive breastmilk substitutes (BMS) marketing via health systems and consumer advertising. The Philippines illustrates the continuing battle for worldwide Code implementation, and in particular, how the baby food industry uses and adapts its market and political practices to promote and sustain breastmilk substitutes.

Baker, P., Zambrano, P., Mathisen, R. et al. Breastfeeding, first-food systems and corporate power: a case study on the market and political practices of the transnational baby food industry and public health resistance in the Philippines. Global Health 17125 (2021). https://doi.org/10.1186/s12992-021-00774-5

Allergy societies and the formula industry

From the early years, the formula industry aligned itself with allergists and other trusted sources of infant feeding information, leading to widespread inappropriate guidance for infant feeding and false promotion of special health-promoting properties of formula. Hydrolysed formula has been inappropriately recommended for allergy prevention for over 30 years and there is excessive consumption of specialised formula in some regions due to milk allergy overdiagnosis. Formal analysis of allergy societies’ relationships with formula companies has not yet been undertaken, but it is likely that most societies and many conferences and educational activities are sponsored by formula companies. This article discusses the World Allergy Organization’s alignment with the formula industry and calls on them to follow WHO guidance, protect the patients that their members serve and stop accepting funding from formula companies.

Boyle, RJShamji, MHAllergy societies and the formula industryClin Exp Allergy2021511260– 1261. https://doi.org/10.1111/cea.14017

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. 

Older research 

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

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

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

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

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

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

https://changingmarkets.org/portfolio/milking-it

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

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 

Find out more about First Steps Nutrition

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

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 

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

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.

Related research and further reading