Formula milk: why WHO has taken a hard stance on sponsorship

Dear Editor

The failure of the International Code of Marketing of Breastmilk Substitutes to resolve industry violations has ignited a blame culture that has led to widespread dysfunctional behaviour across the key infant feeding stakeholders [1], as illustrated in the above BMJ article. It is therefore evident that after 40 years the concept of the Code needs to be reviewed.

First, it should be acknowledged that the purpose of the Code is to prevent inappropriate marketing and promotion of infant formulas by industry [2] and therefore for resolution to be achieved there needs to be an acceptance that the issue is primarily a breach of trading standards by industry. A key action should therefore be to agree trading standards for the infant formula industry and for these standards to be managed and regulated by trading authorities [3]. The detail of the new approach to preventing industry violations should be set out in a revised International Code of Marketing of Breastmilk Substitutes. The new regulatory system should have global reach using modern day digital technologies and should be developed with the objective that all products and their related texts and advertising materials should be fully evaluated and registered before entering the open market. All data will be held on-line and regulated by a specialist trading authority, and with the in-market product having digital codes this will allow monitoring groups, policymakers, national authorities and consumers to gain access to the registered evaluation data to confirm authenticity. If violation is detected, trading standards authorities will be able to issue sanctions on the relevant manufacturer and/or retailer.

Second, to prevent misunderstandings in relation to the role of health professionals involved in infant feeding practice and how this may require contact with industry, it is important that this is addressed through infant feeding standards that are developed and evidenced within the context of all other aspects of infant feeding policy. Discussions need to ensure that infants who do not receive breastmilk and infants who may require a specialised formula for an underlying medical condition receive the best possible nutritional care. Moreover, the consistent finding from many surveys of mothers worldwide, that approximately 5-15% of mothers believe that they were not able to produce enough breastmilk for their infant, should not be ignored [4]. Currently we know more about lactation in a cow than we do for a female human being [5]. Dairy research has clearly demonstrated that there are both environmental and genetic factors associated with variation in milk production. There is now some emerging human data identifying genetic factors relating to prolactin and prolactin receptor sites and further information is awaited [6]. In the meantime the assumption that every woman is able to adequately breastfeed their infant for 2 years or beyond should be treated with caution.

Third, governance and regulation need to be independent from the policymaking process. If WHO are responsible for setting global policy it is inappropriate that they should assume regulatory and judicial functions, as they will have an inherent conflict of interest. Independent regulatory and governance systems need to be in place. To ensure that industry behaviour is compliant with the revised Code, it is suggested that Codex Alimentarius, which is part of the United Nations family, and is affiliated with the World Trade Organisation, and also has responsibility for protecting consumer health and ensuring fair practices in the food trade [7], could have overall responsibility for overseeing the monitoring of the infant formula industry by trading standards authorities. The practice of health professionals, both clinical and professional, should be monitored and investigated by current or revised health regulatory systems.

References
1. Forsyth S: International code of marketing of breast-milk substitutes -- three decades later time for hostilities to be replaced by effective national and international governance. Arch Dis Child 2010;95:769-70.
2. World Health Organisation. International Code of Marketing of Breastmilk Substitutes. 1981. https://www.who.int/nutrition/publications/code_english.pdf
3. Forsyth S. Marketing of breastmilk substitutes revisited: New ideas for an old problem. In: Koletzko B, Bhutta ZA, Dhansay MA, Makrides M, Orsi M, Cai W, Duggan CP (eds): Pediatric Nutrition in Practice. 3rd Edition. World Rev Nutr Diet. Basel, Karger, 2021, vol 124, pp 1–6 (DOI: 10.1159/000516724).
4. Shere H, Weijer L, Dashnow H, et al. Chronic lactation insufficiency is a public health issue Breastfeed Med 2021; 16: 933–934. Commentary on ‘We need patient-centered research in breastfeeding medicine’ by Stuebe. Breastfeeding Medicine 16, 349–50. DOI: 10.1089/bfm.2021.0202.
5. Boss M, Gardner H, Hartmann P. Normal human lactation: closing the gap. F1000 Research 7F1000 Faculty Reviews 8019. 2018.
6. Lee S, Kelleher SL Biological underpinnings of breastfeeding challenges: the role of genetics, diet, and environment on lactation physiology. American Journal of Physiology Endocrinology and Metabolism 2016; 311: E405–22. DOI:10.1152/ ajpendo.00495.2015.
7. Food and Agriculture Organization of the United Nations and World Health Organization. Codex Alimentarius. Understanding Codex. 2016. http://large.stanford.edu/courses/2017/ph241/kim-k2/docs/fao-2016.pdf