International Code of Marketing of Breast-milk Substitutes 

International Code  

Marketing of Breast Milk Substitutes  

Frequently asked questions 

2017 update

WHO/NMH/NHD/17.1  

© World Health Organization, 2017  

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International Code of Marketing of Breast-milk Substitutes 

Frequently asked questions 

2017 update 

Many people who have heard about the International Code of Marketing of Breast-milk Substitutes have expressed an interest in learning more about it. 

This booklet provides detailed, easy-to-read information on specific topics related to the Code. It is intended for policymakers, health workers, and other interested parties, as well as the general public.

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1. WHAT IS THE INTERNATIONAL CODE OF MARKETING OF BREAST-MILK SUBSTITUTES? 

The Code is a set of recommendations aimed at regulating the marketing of breast-milk substitutes, baby bottles, and teats. The objective of the Code is to curb the aggressive and improper marketing of breast-milk substitutes. In 1981,1 the 34th World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes as a minimum requirement to protect and promote the adequate feeding of infants and young children. 

The Code aims to "provide infants with safe and adequate nutrition, protecting and promoting breastfeeding and ensuring the proper use of breast milk substitutes, when necessary, based on adequate information and through appropriate marketing and distribution methods" (Article 1). 

The Code advocates breastfeeding for infants. If breastfeeding is not possible, the Code also advocates feeding infants safely with the best available nutritional alternative. Breastmilk substitutes should be available when needed, but should not be promoted. 

The Code is an expression of the collective will of governments to ensure the protection and promotion of optimal nutrition for infants and young children.  

  

1Resolution WHA34.22 (1981).

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1. WHAT DOES THE WHO CURRENTLY RECOMMEND?  

TO FEED INFANTS AND YOUNG CHILDREN? 

For infants to achieve optimal growth, development, and health, the WHO recommends initiating breastfeeding within the first hour of life and continuing it as the sole form of feeding for the next six months; from that point on, it is recommended to continue breastfeeding until at least two years of age, appropriately supplemented with other safe foods. 

Most women who wish to do so can feed their babies exclusively with breast milk from birth. This practice is recommended for all children except when the mother or baby has certain health problems, for example, when the mother is undergoing treatment with radioactive substances.2 Breastfeeding  

Exclusive breastfeeding as often and for as long as the baby wants increases milk production. 

1. WHY IS BREASTFEEDING IMPORTANT?  

Breastfeeding is unmatched as a way to provide ideal nutrition for infants. Breast milk is safe, clean, and contains antibodies that help protect them against many common childhood illnesses. 

The protection, promotion, and support of breastfeeding are among the most effective interventions for improving child survival. Increasing breastfeeding to near-universal levels could save more than 820,000 lives annually.3 In addition, increasing breastfeeding rates could prevent almost half of all deaths among children under five. 

  

2WHO/UNICEF. Breastfeeding counseling: training course. WHO/CDR/93.4, Geneva, World Health Organization, 1993, http://www.who.int/child-adolescent-health/publications/NUTRITION/BFC.htm 

3Victora CG, Bahl R, Barros A et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effects. Lancet. 2016; 387:475-490.

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diarrheal diseases and one-third of respiratory infections in children in low- and middle-income countries. Children who are breastfed are less likely to be overweight or obese and are less likely to develop diabetes later in life. 

Women who breastfeed also have a lower risk of developing breast and ovarian cancer. Based on current breastfeeding rates, it is estimated that around 20,000 breast cancer deaths could be prevented, and this figure could double if rates improve.4 In addition, breastfeeding delays the time when women become fertile again after giving birth and reduces the risk of postpartum hemorrhage. 

In addition to the risks associated with lacking the protective qualities of breast milk, breast milk substitutes, and especially baby bottles, carry a high risk of contamination that can cause potentially fatal infections in young children. Infant formula is not sterile and may contain germs that cause deadly diseases. Artificial feeding is expensive and requires safe drinking water. In addition, the mother or caregiver must be able to read and follow the preparation instructions, and the family home must have a minimum level of general hygiene, conditions that are not met in many homes around the world. 

Beyond the health benefits, breastfeeding has economic advantages. Interventions aimed at increasing this practice are cost-effective, and the benefits obtained justify the costs incurred, which are low compared to those of curative interventions. Studies conducted in Brazil, China, the United Kingdom, and the United States of America have shown that increasing exclusive breastfeeding rates in infants under 6 months of age significantly reduces the costs of treating 

  

4Ibid.

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Common childhood illnesses such as pneumonia, diarrheal diseases, and asthma.5 

Breastfed children perform better on intelligence tests. It is estimated that the decline in intellectual capacity in children who were not breastfed resulted in economic losses of more than US$300 billion in 2012, a figure equivalent to 0.49% of global gross national income.  

1. WHY IS THE CODE IMPORTANT?  

The Code is one of the most essential elements for establishing general conditions that enable mothers, based on impartial information and free from commercial influences, to make the best decisions about feeding their children and receive the full support they need.  

The improper marketing of food products that compete with breastfeeding often negatively affects a mother's decision to breastfeed her infant optimally. 

Given the particular vulnerability of infants and the risks inherent in inappropriate feeding practices, standard marketing practices are not appropriate for these products. 

1. Has the code been updated since 1981? 

There is only one version of the Code. However, since 1981, the World Health Assembly has adopted a series of resolutions relating to the  

  

5Ibid.

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marketing and distribution of breast milk substitutes and which clarify or expand on aspects covered in the Code.6 For example: 

∙ Resolution WHA39.28 clarifies that maternity wards should purchase these substitutes through normal distribution channels and should not receive free or subsidized supplies from companies. 

∙ Resolution WHA49.15 urges Member States to ensure that complementary foods are not marketed in a way that undermines exclusive and continued breastfeeding; 

∙ Resolution WHA54.2 updated the recommendation to maintain exclusive breastfeeding for up to 6 months instead of for 4 to 6 months. 

∙ Resolution WHA58.32 urges Member States to ensure that no nutrition and health claims are made in relation to breast-milk substitutes. 

The 2016 resolution on eliminating the inappropriate promotion of foods for infants and young children (WHA69.9) urges Member States, manufacturers and distributors, health professionals, and the media to implement new WHO recommendations that clarify certain aspects of the Code: 

∙ it is clarified that the Code applies to "complementary preparations" and "growing-up milks," and that these products should not be promoted; 

∙ It is recommended that messages used in complementary food preparations always include a reference to the need to continue breastfeeding until the age of 2 and the importance of not introducing complementary foods before 6 months. 

∙ It is recommended that the design and labeling of products that are not breast milk substitutes be differentiated from those used for the latter in order to avoid cross-promotion. 

  

6World Health Assembly Resolutions 33.32, 34.22, 35.26, 37.30, 39.28, 41.11, 43.3, 45.34, 46.7,  47.5, 49.15, 54.2, 55.25, 58.32, 59.11, 59.21, 61.20, 63.23, 65.6, and 69.9.

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∙ it is stated that donations to health systems (including health workers and health professional associations) by companies that market foods for infants and young children represent a conflict of interest and are not 

allow; 

∙ It is recommended that companies marketing foods for infants and young children be prohibited from sponsoring scientific or healthcare professional meetings. 

The Code and subsequent relevant resolutions of the World Health Assembly should be considered together for their interpretation and incorporation into national measures.  

1. IS THE CODE STILL RELEVANT 35 YEARS AFTER ITS APPROVAL? 

The importance and relevance of the Code remain the same as when it was adopted in 1981, if not greater. The World Health Assembly has reiterated the importance of the Code on numerous occasions over the past 35 years. Most recently, in 2016, the Assembly urged Member States to continue to implement the Code. 

Despite continued clear emphasis on the importance of breastfeeding, global sales of breast milk substitutes continue to grow rapidly: in 2014, they reached US$44.8 billion, and this figure is expected to increase to US$70.6 billion by 2019.7 

Several studies showing the prevalence of the improper marketing of breast-milk substitutes have demonstrated that this practice persists in many countries and continues to undermine efforts to improve breastfeeding rates. 

  

7Victora CG, Bahl R, Barros A et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016; 387:491-504.

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Marketing practices increasingly transcend traditional venues such as stores and health centers. Social media and websites about pregnancy and motherhood, which are becoming increasingly numerous and popular, are often new, unregulated outlets that manufacturers and distributors exploit to market their products. 

The promotion of breast milk substitutes for older children is also increasing. These products, which include follow-on and growing-up milks, reduce the rates of continued breastfeeding of children up to two years of age or even older. Because the packaging and promotional materials for these products are often similar to those for infant formula, some mothers may feed them to their babies under six months of age.8 

Despite the continuing threat posed by inappropriate marketing practices to efforts to improve rates of exclusive and continued breastfeeding, few countries have adopted comprehensive legal measures to regulate these practices. In 2014, only 39 of the 194 WHO Member States had enacted legislation that fully reflected the Code and subsequent relevant World Health Assembly resolutions. In addition, very few countries have operational mechanisms in place to monitor and enforce laws and regulations related to 

  

8Scientific Advisory Committee on Nutrition, United Kingdom, Infant Feeding Survey 2005: A commentary on infant feeding practices in the UK, position statement by the Scientific Advisory Committee on Nutrition, 2008. 

Nina J Berry, Sandra Jones, Don Iverson, It’s all formula to me: women’s understandings of toddler milk ads, Breastfeeding Review, Vol. 18 No. 1, 2010. 

Sobel H. et al. Is unimpeded marketing for breast milk substitutes responsible for the decline in breastfeeding in the Philippines? An exploratory survey and focus group analysis. Social Sciences & Medicine 2011; 73: 1445-1448. 

Mintzes B. Regulation of formula advertising in the Philippines and promotion and protection of breastfeeding: A commentary on Sobel, Iellamo, Raya, Padilla, Olivé, and Nyunt-U. Social Sciences & Medicine 2011; 73: 1449-1451.

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two with the Code.9 Much remains to be done to end the improper marketing of breast-milk substitutes. 

1. WHAT ARE THE PRODUCTS COVERED?  

FOR THE CODE? 

The Code applies to the marketing of the following products and practices related to marketing: 

∙ breast milk substitutes, including infant formula. This should include any dairy product (or product that can be used as a milk substitute) that is specifically marketed for feeding infants and children up to 3 years of age, including follow-on formula and growing-up milk;10 

∙ other foods and beverages (e.g., juices, teas, and waters) that are promoted as suitable for feeding infants during the first 6 months of life when exclusive breastfeeding is recommended; 

∙ Baby bottles and nipples.  

1. WHAT IS COVERED  

FOR THE CODE? 

The Code establishes detailed provisions on the following matters:  

1. information and education on infant feeding; 2. promotion of breast-milk substitutes and related products to the general public and to mothers; 

  

9WHO, UNICEF, IBFAN. Marketing of breast-milk substitutes: Implementation of the International Code. Status report, 2016, Geneva, 2016 

10 WHO. Guidance on ending the inappropriate promotion of foods for infants and young children, Geneva, 2016.

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3. promotion of breast milk substitutes and related products to health workers and in health facilities; 4. labeling and quality of breast milk substitutes and related products; and 
4. implementation and monitoring of the Code. 
5. WHAT DOES THE CODE SAY ABOUT INFORMATION AND EDUCATION ON INFANT FEEDING? 

The Code and subsequent relevant resolutions of the World Health Assembly call on governments to ensure that objective and consistent information on infant and young child feeding is provided to families and others responsible for their nutrition. 

Information and educational materials should clearly state the advantages and superiority of breastfeeding, as well as the social and financial implications of using infant formula, the health risks of artificial feeding, and instructions for the proper use of infant formula.  

1. WHAT ARE THE LIMITATIONS ESTABLISHED IN THE CODE ON THE PROMOTION OF BREAST MILK SUBSTITUTES TO MOTHERS?  

AND TO THE GENERAL PUBLIC? 

The Code explicitly states that advertising or other forms of promotion to the general public should not be used, including advertising through media such as television, magazines, billboards, websites, and social media.

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In addition, manufacturers and distributors of breast-milk substitutes must not provide samples of their products to pregnant women, mothers, or members of their families. Promotion through other means, such as presentations, is also prohibited. 

special offers, discount coupons, price reductions, and special sales. In addition, marketing company staff should not attempt to maintain direct or indirect contact with pregnant women or mothers, or provide them with advice, either in retail stores or through social media. 

1. DOES THE CODE RESTRICT ACTIVITIES?  

PROMOTIONAL ACTIVITIES CARRIED OUT IN HEALTH CENTERS OR TARGETED AT HEALTH WORKERS? 

Yes. The Code and subsequent relevant resolutions of the World Health Assembly stipulate that all promotion of breast-milk substitutes, bottles, and teats in health services should be completely prohibited. 

Furthermore, no health facility is permitted to make free or subsidized donations of breast-milk substitutes or other products, or to give gifts or samples to health workers. Medical facilities that care for infants for whom breastfeeding is contraindicated should also not accept free or discounted supplies or samples of such products. Resolution WHA39.28 clearly stated that infant formula that may be needed by infants for medical reasons should be purchased through normal channels. 

The information provided by manufacturers and distributors to healthcare professionals about products should be limited to scientific and objective data.

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1. WHAT DOES THE CODE SAY ABOUT THE LABELING AND QUALITY OF BREAST MILK SUBSTITUTES?  

Product labels should not feature images of infants or other images that may idealize the use of breast milk substitutes. 

Information on artificial feeding, including that on labels, should explain the advantages of breastfeeding and the costs and risks that may arise from unnecessary or incorrect use of infant formula and other breast milk substitutes. 

Products that are not suitable for feeding infants, such as sweetened condensed milk, should also not be promoted.  

1. WHAT MEASURES ARE REQUIRED TO IMPLEMENT THE CODE?  

The Code requires that appropriate measures be taken to give effect to its principles and objectives, including the adoption of national laws and regulations or other relevant measures. All measures must be made public. Since the Code is a minimum requirement, governments may take additional measures—possibly stricter than those set out in the Code—and make them legally binding. 

binding. 

The most effective measure for regulating the improper marketing of breast-milk substitutes and other products covered by the Code is to have comprehensive and enforceable legislation covering all provisions. 

provisions of the Code and subsequent relevant resolutions of the World Health Assembly.

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1. WHO SHOULD BE RESPONSIBLE FOR ENFORCING THE CODE?  

Governments should take the necessary steps to give effect to the Code, taking into account subsequent resolutions of the World Health Assembly. In the resolution adopting the Code, the World Health Assembly urged Member States 

brothers to incorporate it into laws, regulations, or other appropriate instruments at the national level. 

While governments must take responsibility for adopting measures to implement the International Code, food manufacturers and distributors, health professionals, non-governmental organizations, and consumer associations must also play their respective roles. 

Non-governmental organizations, professional associations (including health professionals), and other relevant actors have the responsibility to hold manufacturers and distributors of breastmilk substitutes accountable for actions that violate the Code. In addition, they should report detected violations to the relevant government agencies. 

Manufacturers and distributors of breast-milk substitutes must comply with the Code "regardless of any other measures adopted for its implementation." This means that even if governments have not fully incorporated the Code into national legislation, manufacturers and distributors must comply with it. 

1. IS ENFORCEMENT OF THE CODE ENOUGH TO IMPROVE INFANT AND CHILD NUTRITION?  

No. Additional measures are needed to promote optimal feeding practices for infants and young children. The Promotion Initiative

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Breastfeeding,11 led by WHO and UNICEF, aims to increase global commitment to this practice. In addition to achieving full implementation of the Code through strong legal measures, the Initiative's Call to Action12 calls on governments, donors, and development partners to take the following actions: 

∙ increase funding for initiatives to promote breastfeeding; 

∙ Enact better policies for family leave and breastfeeding in the workplace. 

∙ improve the quality of maternity services, especially for sick and vulnerable newborns; 

∙ Increase access to specialized breastfeeding counseling. 

∙ Strengthen community networks that protect, promote, and support breastfeeding. 

∙ create monitoring systems to track the progress of policies, programs, and funding. 

The points mentioned above are recommended within the framework of the Second International Conference on Nutrition (ICN2)13 and its relevant recommendations. 

1. HOW SHOULD COMPLIANCE WITH NATIONAL MEASURES BE ENFORCED? 

Incorporating the provisions of the Code into national legislation is not sufficient. It is necessary to ensure proper enforcement of the legislation to guarantee that these provisions are complied with.  

  

11 WHO, UNICEF. Breastfeeding Advocacy Initiative, Geneva, 2015. 

12 UNICEF. Breastfeeding Advocacy Initiative, A call for Action. New York, 2016. 

13 FAO, WHO. ICN2 2014/3 Corr.1, Framework for Action. Rome, 2014.

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in practice and that the achievements made are not undermined. This monitoring also provides information on the quality of the legislation, including its possible shortcomings and gaps.  

Monitoring mechanisms must be transparent, independent, and free from commercial influence, and must cover labeling and all forms of advertising and commercial promotion in all media. The responsible bodies must have the authority to impose appropriate sanctions in accordance with existing legal systems.  

1. WHO SHOULD BE RESPONSIBLE FOR MONITORING THE IMPLEMENTATION OF THE INTERNATIONAL CODE? 

The primary responsibility for monitoring the implementation of the Code rests with governments. Monitoring is most effective when this responsibility is shared among the main government agencies involved in the different stages of product marketing. National legislation on the Code should indicate which  

government agencies carry out surveillance and how it should be conducted.  

Manufacturers and distributors of breast-milk substitutes should monitor their own marketing practices at all levels. Similarly, health professionals and health officials should take responsibility for monitoring practices in health facilities to ensure that products are not marketed on their premises. 

NGO, institutions, and individuals can draw the attention of manufacturers and distributors to activities that are inconsistent with the Code and inform their governments so that action can be taken. 

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1. WHAT IS THE WHO DOING TO HELP COUNTRIES IMPLEMENT THE CODE AND MONITOR COMPLIANCE? 

In 2014, WHO and UNICEF created a global monitoring and support network for the implementation of the International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly Resolutions (Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast-milk Substitutes and Subsequent relevant World Health Assembly Resolutions, NetCode). 

In the NetCode network, the efforts of civil society organizations, universities, and certain countries are combined to establish standards for monitoring the Code. This network has also developed a monitoring protocol consisting of two main components: ongoing monitoring to detect and investigate alleged violations of the Code and existing national measures and to take appropriate action, and periodic evaluation to verify the level of compliance with national measures and the Code and to identify gaps and issues that need to be addressed through policy and legislative measures. WHO is working with several countries to implement this monitoring protocol. 

In addition, the NetCode network provides countries with additional information on the implementation of the Code within the framework of the Codex Alimentarius Commission, on certain issues relating to international trade and the Code, and on the application of international human rights standards for the monitoring and enforcement of the Code. 

1. HOW IS THE CODE APPLIED IN THE CONTEXT OF HIV INFECTION? 

The Code applies in all countries, regardless of what is established in national policies on infant feeding.

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whose mothers are infected with HIV. Implementation of the code is essential to prevent a decline in breastfeeding rates. Decisions regarding infant feeding should be based on impartial information, and mothers who decide not to breastfeed should have access to a reliable and sustainable source of infant formula or other similar products so that they can always feed their children adequately. The Code does not restrict the availability of breast-milk substitutes to mothers who make an informed choice to use them. 

In countries where social and environmental circumstances are unsafe or do not fully guarantee the availability of substitute foods, the WHO recommends that HIV-infected mothers breastfeed their babies for at least 12 months and continue to do so until at least 24 months and beyond. 

In countries where regulations require HIV-infected mothers to completely avoid breastfeeding, the promotion of breast milk substitutes in general continues to be inappropriate. Governments, social security agencies, and  

Health centers can provide them to HIV-positive mothers. However, these products must be obtained through normal purchasing channels, and not through donations from manufacturers (WHA39.28 (1986). 

1. HOW IS THE CODE APPLIED IN COMPLEX EMERGENCY SITUATIONS?  

The International Code and relevant resolutions of the World Health Assembly are important in all situations to protect infants and their caregivers from improper marketing practices for breast-milk substitutes. The Code prohibits advertising and other forms of promotion of infant formula, breast-milk substitutes, and other breast-milk substitutes.

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formulas for infants and other breast milk substitutes, as well as baby bottles and nipples. 

In emergency situations, the Code is particularly important for controlling the donation and distribution of these products. In such circumstances, there are always infants who cannot be breastfed, such as those who have been separated from their mothers, those whose mothers are ill or have died, and those who were not breastfed before the emergency situation arose. When sources of breast milk are not available, these infants must be fed with substitutes. Another necessary measure is to convince mothers of infants under 6 months of age who were feeding their babies with both their milk and substitutes before the emergency that they should opt for exclusive breastfeeding. 

The Code protects infants who are fed artificial products because it stipulates that the labels of these products must include the necessary warnings and instructions for their safe preparation and use. Furthermore, in accordance with paragraph 6.5, only health workers and community workers may demonstrate infant formula preparation, and they should only do so for mothers who need it. Furthermore, the information provided must include a clear explanation of the risks that may arise from the incorrect use of these products. 

1. IS THE CODE COMPATIBLE WITH INTERNATIONAL HUMAN RIGHTS INSTRUMENTS? 

The Code was not adopted as a legally binding document, but rather as a set of recommendations. However, its implementation is often considered a fundamental measure of the right to health, as stipulated in several international human rights treaties that establish legal obligations for countries.

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The United Nations Convention on the Rights of the Child is the most comprehensive international human rights framework in this regard. Numerous articles of the Convention promote the achievement of the Code's objectives, in particular the right of the child to enjoy the highest possible standard of health through, among other goals, the reduction of infant mortality and the promotion of breastfeeding. 

tender. 

The United Nations Committee on the Rights of the Child, a body composed of independent experts that monitors governments' compliance with the provisions of the Convention on the Rights of the Child, has explicitly recognized that  

The application of the Code is an appropriate measure for governments to fulfill their obligation to ensure the full realization of children's right to health and health care (Article 24). 

The Committee has recommended that certain governments enact laws to implement the Code or to strengthen and support the implementation of existing legislation as an appropriate measure to implement the Convention.

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For further information, please contact: 

Department of Nutrition for Health and Development (NHD) World Health Organization 

20 Appia Avenue 

1211 Geneva 27 

Switzerland 

Fax: +4122 791 41 56  

Email: nutrition@who.int