Session 4

1. Discuss the effect of marketing on infant feeding

practices

2. Outline the key points of International Code of

Marketing of Breast-milk Substitutes.

3. Describe actions health workers can take to

protect families from marketing of breast-milk

substitutes.

4. Outline the care needed with donations of breast-

milk substitutes in emergency situations.

5. Discuss how to respond to marketing practices.

Federal legislation gives women the right to breastfeed on federal property if they have a right to be there.

2010 Health Care Reform Act amended Fair Labor Standards Act requiring employers of >50 employees to provide “reasonable break time” to express milk for a child up to 1 yr.

Break time does not have to be paid. Employer must provide space that is private

and not a bathroom.

State legislation varies state by state, issues addressed include: Breastfeeding in public Employment and workplace issues Jury duty Custody and visitation rights

At the time of publication of this 4th edition, marketing of breast-milk substitutes has not been addressed in any legislation in the United States.

The National Conference of State Legislatures reports on current legislative information (see resource list).

Some cities and communities have regulated protection, e.g. NYC public hospitals no longer are allowed to distribute formula company discharge bags.

Adopted by the World Health Assembly (WHA) in 1981. Calls for all governments to regulate marketing

practices that promote artificial feeding (formula and other breastmilk substitutes) as well as feeding devices such as bottles and nipples.

To date, no legal action has been taken to implement this Code in the United States.

However, the Baby-Friendly Hospital Initiative standards include Code compliance in Baby-Friendly designated facilities.

Protect, promote and support breastfeeding.

Ensure that breast-milk substitutes (BMS) are used properly when they are

necessary. Provide adequate information about infant

feeding. Prohibit the advertising or any other form

of promotion of BMS.

Product labels must clearly state the superiority of breastfeeding, the need for the advice of a health care worker, and a warning about health hazards. They may show no pictures of babies, or other pictures or text idealizing the use of infant formula.

Advertising of breast-milk substitutes to the public is not permitted under the Code.

Companies can provide necessary information to health workers on the ingredients and use of their products. This information must be scientific and factual, not marketing materials.

This product information should not be given to mothers.

91% of U.S. hospitals give formula advertising materials and free samples of formula to new mothers, even if they are breastfeeding (Merewood et al., 2010) Formula for use in hospitals is commonly provided

at no cost to the hospital. Formula company diaper bags are given as gifts to

mothers on discharge to home. Hospital supplies and patient educational materials

with company proprietary logos are purchased or provided free of charge to hospitals.

Advertising materials used in hospitals and clinics may include: Notepads and pens Calendars and write-on boards for patient

rooms Crib cards and measuring tapes Conversion charts, growth charts Hospital badge holders and lanyards for staff

Staff and managers are often naïve about company marketing practices.

“Gifts” are accepted and used without awareness of Code violations or ethical issues involved.

Mothers were less likely to achieve exclusive breastfeeding goals if supplemental feeding were given in the hospital; 70% intended to vs. 50% actually doing so at 1 wk (DeClercq et al., 2009).

Removal of formula and coupons from discharge bags is not sufficient – the bags are printed with proprietary logos.

Hospital PR departments might prefer to advertise the hospital with their own version of a discharge bag.

Educational materials may need to be reinvented, and may be cheaper to produce in-house than purchase from a commercial vendor whose logo and product information is on the materials.

Check vendor policies/hospital ethics statements to be sure that they are applying to formula companies/other commercial entities.

Remove posters that advertise formula, teas, juices or baby cereal, as well as any that advertise bottles and teats and refuse any new posters.

Refuse to accept free gifts from companies. Refuse to allow free samples, gifts, or leaflets to be given to mothers. Eliminate antenatal group teaching of formula preparation to pregnant

women, particularly if company staff provides the teaching. Do individual private teaching of formula use if a baby has a need for it. Report breaches of the Code (and/or local laws) to the appropriate

authorities. Accept only product information from companies for their own

information that is scientific and factual, not marketing materials.

Emergencies can happen anywhere at any time with little warning (e.g. Hurricane Katrina). Disasters can be natural or man-made.

In emergencies, infants and young children are particularly vulnerable to malnutrition, illness and death. Deaths in infants < 1 yr may rise 12%-53% from

normal rates for the region (WABA, 2009). In 2005 during Niger’s food crisis, up to 95% of

children admitted to hospital for therapeutic feeding were under 2 yrs. (WABA, 2009).

Following the 2006 Indonesia earthquake,, donated formula was distributed to children under 2, even if breastfeeding. Among those who received infant formula donations, diarrhea prevalence doubled (12% to 25%).

Aid organizations are usually unaware of the hazards of infant formula.

Formula companies are very aware of the marketing power of getting their donated products into a region.

The press publishes horror stories of children who are dehydrated or malnourished

The public rushes to send emergency foods, usually powdered infant formula

PIF is the LEAST safe alternative Breastmilk and breastfeeding are the best If formula is used it should be ready-to-feed and

not require any mixing or diluting

Lack of consistent availability High risk of contamination Errors in preparation No clean, safe water for reconstitution No means of sterilizing bottles, teats,

formula No electricity or refrigeration for

preservation

Infants and children often get sick and die when exposed to contamination through water, dirty feeding implements, unsterile formulas.

Formula use by a breastfeeding mother decreases her milk supply and hastens the return of fertility.

When mother gets pregnant again, her infants are in double jeopardy for malnutrition, due to greater demands on limited nutritional resources.

The cleanest safest food for infants in an emergency situation is human milk Readily available, no supplies need to be shipped in Nutritionally ideal – prevents malnutrition Keeps infant hydrated Act of suckling and skin to skin contact may prevent

hypothermia Protective against infectious diseases Absence of vectors that can cause disease:

contaminated water, dirty bottles/teats, lack of refrigeration

Aid workers should encourage and support continued exclusive breastfeeding.

Discourage introduction of formula to breastfed infants or children.

For breastfeeding mothers, provide appropriate support.

If mother initially chose not to breastfeed, encourage and support relactation efforts.

For mothers and babies who are separated, can use donor milk from an HIV-negative woman or a milk bank.

Last option is ready-to-feed formula.

Providing breastfeeding support training for relief workers

Keeping families together in safe areas that provide security, water, counseling, and food

Providing mothers priority access to food for the family Assisting new mothers who deliver in emergencies to

breastfeed: within 1 hr of birth exclusively for 6 months and to continue for at least a year

If breastfeeding is not a possibility, using only ready-to-feed formula

Assessing, coordinating, and monitoring infant feeding resources before and during disasters (AAP, 2007)