More than 30 years have passed since the introduction of the International Code of marketing of breast milk substitutes, but around the globe, most countries still have limited sets of laws that implement it.
This policy framework was adopted by the assembly of the World Health Organisation (WHO) in 1981 to promote breastfeeding and prevent aggressive marketing practices of infant formula. However, the marketing of breast milk substitutes remains an important one, totalling US$ 45 billion worldwide (about £31 billion).
A recent report published by the organisation - in cooperation with UNICEF and the International Baby Food Action Network - reveals that between the 194 countries surveyed, important differences remain.
Around 135 countries already implement some form of legislation relating to part of the code, which is an improvement from 103 countries in 2011. However, only 39 have laws that enact all provisions of the code, mostly in low and medium income countries.
This means practices such as advertising of breast milk substitutes, gifts to health workers and distribution of free samples are still common place in many parts of the world, so women are on many occasions not encouraged to breastfeed. Many brands also still make nutritional health claims idealising infant formula or lack clear instructions on how to use the product.
What does the WHO recommend?
The WHO recommends babies should be fed nothing but breast milk during their first six months. Then, breastfeeding can be pursued, alongside other nutrients, up to two years and beyond. These guidelines are based on years of scientific literature showing that breast milk is optimal for children's development and that it protects them against infections and other diseases.
However, nearly two out of three infants around the world are not exclusively breastfed for the recommended 6 months. This rate has not moved in two decades and the WHO is concerned that promoting breast milk substitutes will lead to more and more women turning away from breastfeeding.
"The code is important to make sure the information that women receive is adequate. It is crucial they are not given biased and inappropriate information and are not swayed by conflicts of interest from the business world which can lead them to question the quality of their own milk", WHO's Dr Laurence Grummer-Strawn, told IBTimes UK. "We need to fight the message that breastfeeding is difficult and not modern, because it is in fact the best nutrient for the baby's health and it has benefits for mothers as well."
To achieve this, the report says all forms of promotion of substitutes, including advertising, gifts to health workers and distribution of free samples should be banned. It asks that labels also include clear instructions on how to use the product, and carry messages about the superiority of breastfeeding over formula and the risks of not breastfeeding.
What is the problem with substitutes?
It is impossible to artificially reproduce breast milk perfectly as it is a very complex liquid, containing thousands of molecules.
In terms of nutrients and fats, it is the optimal food for babies' development, but this nutritive aspect of breast milk can more or less be reproduced by the industry. The problem is re-creating the milk's anti-infective and protective properties. Indeed, breast milk contains many antibodies, anti-bacterial proteins and hormones from the immune system - known as cytokines - that are difficult to include in infant formula.
"From a technical point of view it is complicated to add these molecules in. And if we were able to reproduce some of them in infant formula, it would be financially costly. Legally, it is also problematic because adding antibodies could potentially mean considering infant formula as a medicine, which would have to go through clinical tests. Few businesses would want that", Thierry Hennet, from the Institute of Physiology at the University of Zurich, told IBTimes UK.
Some extra products are added to infant formula and advertised as providing health benefits but for Hennet, this is often not based on scientific evidence. Though they are not dangerous, some of these added products are simply not useful for the baby's development and well-being.
Why six months and more?
While the health benefits of breast milk for infants and their mothers are undeniable, the question of how long mothers should really breastfeed for is still open. Beyond the debate about breast milk substitutes' marketing, the question is whether women should really breastfeed exclusively for as much as six months.
"WHO's arguments are solid in the sense there is strong scientific evidence - especially in low-income countries where water quality and medical support is not good - that breastfeeding radically diminished the risk of infectious disease and ensuing infant mortality. But this is less the case in high- income countries," says Hennet.
"Other problem, the protective effects of breast milk get diluted in time, because the quantity of antibodies diminishes over time. At the end of the first month for example, the milk contains only between 1-10% of the antibodies present in the liquid at birth. The baby's gastric acidity also evolves in a way that makes protection factors in the milk less effective. Of course, breast milk is still more protective than formula, and it remains an optimal nutrient, but this does raise the question of whether six months is really necessary".
What will implementing the code change?
Experts agree that in the end, it is up to women to make the decision whether to breastfeed or not. "Often, stigma plays a large part in women's decision to breastfeed or not, whether she is pushed to do so or deterred, and this is not helpful at all", says Grummer-Strawn.
The WHO believes implementing the code will create a better environment for women to make this choice. It will encourage health workers to give them more care and support.
"Today, many women do not breastfeed because of socio-economic barriers. They may not be able to conciliate it with their career, have no place at work to express milk or find it painful because no health professional has offered adequate counselling. The code is critical to build cultural support for breastfeeding. Giving everyone access to unbiased information is the first step in removing these barriers", concludes Grummer-Strawn.