The WHO Code on the Marketing of Breastmilk Substitutes

by Stephanie Murray

It’s the week of WHO Code’s 39th birthday and a great opportunity to heighten awareness of “the Code” to all organisations and individuals that are passionate about infant and young child feeding.  ALCI, as part of its goals, supports the full implementation of the International Code of Marketing Breastmilk Substitutes and subsequent resolutions of the World Health Assembly.

 

 

What is it?

The Code comprises of the original WHO/UNICEF International Code of Marketing of Breastmilk Substitutes adopted in 1981 and all updates to this, in the form of resolutions https://www.who.int/nutrition/publications/code_english.pdf These are made every two years or so to strengthen and clarify the code at the World Health Assembly.  The Code is an internationally agreed code of practice, designed to protect breastfeeding by preventing unscrupulous marketing and claims about breastmilk substitutes. This incorporates infant formulas, follow-on formulas and any other food or drink, feeding bottles and teats along with setting standards for the labelling and quality of products. As of April 2018, 136 out of 194 countries had some form of legal measure in place covering all, many or few provisions of the Code. Irish affiliation and laws are found here  http://bflgireland.ie/irish-laws/

 

What does it mean to me as me as an IBCLC-private/Hospital?

The IBCLE’s Code of Professional Practice states that a crucial part of an IBCLC’s duty is to protect the public health of mothers and children and therefore adherence to the principles and aim of the WHO Code and subsequent relevant documents of the World Health Assembly is vital. Also, ILCA, the professional organisation of an IBCLC endorses all divisions of the WHO Code and encourages all members to do same. The HSE- National Breastfeeding Strategy Committee approves and recommends  the Who Code as per their fact sheet for health professionals https://www.hse.ie/file-library/the-who-code-of-marketing-of-breast-milk-substitutes.pdf.

 

The main points in the Code for healthcare workers both professionals and volunteers to adhere to are:

 

  • no advertising of breast-milk substitutes and other related products to the public: this can relate to advising on products such as pumps, nipple creams etc with clients and promoting companies that adhere to the code is preferred practice. Important also not to recommend any particular brand of formula to the formula feeding mother.
  • no free samples to mothers or their families: Again, here be mindful of the companies we as health carers obtain feeding accessory products from and provide families with such as nipple shields/creams, latch aids etc. Also included here would be to involved with events such as baby fairs that supply mothers and their families with loads of free samples.
  • no promotion of products, i.e. no product displays, posters, calendars, or distribution of promotional materials. This encourages brand recognition and a means of gaining media exposure and what better way than to get a well-respected person endorsing or being photographed with your product or logo. Individuals sharing information online or on social media in relation to products within the scope of the code is also a violation. It is very difficult to keep up to date with all companies that are code compliant as this is ever changing as companies merge and acquire subsidiaries. it is important to be aware that companies that maybe code compliant but owned by a code violating company that they are to be considered the same of the parent company. A heightened awareness prior to sharing information online is advised.
  • no donations of free or subsidised supplies of breast-milk substitutes or related products in any part of the health care system.
  • no company-paid personnel to contact or to advise mothers: This can relate to a healthcare worker being asked to speak at an event for mothers that is sponsored by a company that violates the who code.
  • no gifts or personal samples to health workers: This includes attending events and having dinner provided, research funded, conferences paid and invites or any personal gain. In cases where an event or some part of an event is sponsored by an entity not meeting its obligations under the International Code, the IBCLC/healthcare worker may refuse to attend that event; attend, but not those portions sponsored by this entity; or waive a speaker fee, but acknowledge to attendees this disassociation.
  • no pictures of infants, or other pictures or text idealising artificial feeding, on the labels of products
  • information to health workers should only be scientific and factual: Healthcare workers should be able to identify research that could indicate bias or a conflict of interest. The Code permits educational activities as long as no affiliation to companies with a return of interest is involved, they are scientific and factual
  • information on artificial feeding should explain the importance of breastfeeding, the health hazards associated with artificial feeding and the costs of using artificial feeding
  • all products should be of a high quality, and unsuitable products, such as sweetened condensed milk, should not be promoted for babies.

 

It is important to note that companies can be associated with products that are under the scope of the WHO Code but as long as there is no marketing of them then no violation has occurred. Mothers who decide to use infant formula should be given one-to-one or small group instruction on the safe preparation on formula feeds in the postnatal period. Also, to note that any product covered under the International Code may be sold when medically indicated and an IBCLC/healthcare worker should explain the clinical use, the required duration of the use and the risks of the products.

 

The WHO Code states that non-governmental organisations, professional groups, institutions and individuals should monitor for Code violations and report violations.  If you suspect you have come across a Code violation you should bring this to the attention of

 

An in-store Code violation, you might like to bring it to the attention of management as a first port of call. If this is unsuccessful you should contact the FSAI.  FSAI is the body tasked with implementing and enforcing EU and national food law only. Report a Code violation via the FSAI online complaints form here. You can also inform IBFAN Ireland, you can contact by email at IBFANIreland@gmail.com .Also you can choose to inform The Baby Feeding Law Group Ireland  by email at bflgireland@gmail.com.   The Advertising Standard authority of Ireland (ASAI) accepts violations relating to radio, tv or internet.

 

Breastfeeding Support during the COVID-19 Restrictions

Since the introduction of COVID-19 restrictions and social distancing measures, everyone providing breastfeeding support in Ireland, from hospital IBCLCs to voluntary breastfeeding supporters, has had to make significant changes to how they help breastfeeding parents . Many have had to switch from doing  face-to-face support to doing virtual antenatal and postnatal breastfeeding support.

 

Regina Keogh, IBCLC, Midlands Regional Hospital Mullingar

Hospital staff have cancelled face-to-face antenatal breastfeeding classes and many are now doing them online via a range of different platforms. Some record the classes and provide them to parents via a link, while others are doing interactive live classes. Staff provide breastfeeding support as normal during the mother’s hospital stay, albeit while wearing PPE. Midwives and IBCLCs are trying to provide care from a distance wherever possible. They will demonstrate using a doll and breast wherever possible to avoid going closer.  Efforts are being made to minimise the mother’s postnatal stay in the hospital, and discharged, staff will continue to provide support over the phone. One of the biggest challenges in the maternity hospital system in Ireland has been how to safely facilitate parent visits and breastfeeding for babies in the NICU and SCBU. At the moment, parents are limited to one 15-minute visit per day, but ongoing discussions around this continue.

 

Stephanie Murray, Antenatal Educator Wexford University Hospital

 

Public health nurses, who normally do a couple of home visits to a mother after she has been discharged from hospital, have made a number of changes to how they work. They are doing phone consults where possible. And if they need to do a home visit, they will wear PPE and do a risk assessment to ensure there is no one in the home with symptoms of COVID-19. They will advise that only the mother and baby be in the room, try to maintain social distancing and keep the visit under 15 minutes (some will set an alarm to go off 15 minutes after the visit starts). For parents who prefer not to have anyone in their home, the PHNs will also offer clinic visits and apply the same precautions. The Dublin North Central PHNs have set up a mothers’ peer-to-peer WhatsApp group and they have found it to be invaluable. None of the PHNs are in the group themselves, but they have a couple of mothers who are admins and will add mothers when provided with their phone numbers by the PHNs.

 

The HSE is in the process of rolling out a new telehealth platform which will enable HSE staff to offer secure video consults to people, including mothers seeking breastfeeding support. In the meantime, HSE IBCLCs are continuing to provide breastfeeding support online 10am – 3pm, Monday to Friday, via www.mychild.ie.

 

Regina Kincaid, IBCLC in Private Practice

IBCLCs in private practice are unable to do home or clinic visits while the restrictions are in place, so most have switched to providing online video consultations using platforms such as Zoom, IntakeQ, Skype and WhatsApp video. The consensus among the private practice IBCLCs is that these video consultations can be effective in providing breastfeeding support, and that they help to promote breastefeding self-efficacy. However, they have limitations and most IBCLCs tend to find them more tiring than face-to-face consultations.

 

Voluntary breastfeeding supporters are continuing to provide breastfeeding support over the phone, and they are all currently running their breastfeeding support groups virtually using Zoom. Apparently, these groups are proving just as popular as the face-to-face support groups.