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Abstract Background The International Code of Marketing of Breast-milk Substitutes, or ‘the Code,’ sets standards to regulate marketing of commercial milk formula (CMF) to protect breastfeeding. World Health Organization member states are advised to legislate the Code into national law, but understanding of its implementation outcomes is limited. This systematic review aimed to examine implementation outcomes in countries implementing the Code as national law. Methods We systematically searched five academic databases in September 2022 for articles published in English from 1982 to 2022. We double-screened titles/abstracts and then full texts for eligible articles reporting implementation outcomes of the Code in 144 eligible countries. We used the Mixed Methods Appraisal Tool for quality assessment and synthesized data thematically. We applied the Proctor et al. framework to guide synthesis of implementation outcomes, organizing our findings according to its taxonomy. Results We included 60 eligible articles of the 12,075 screened, spanning 28 countries. Fifty-seven articles focused on legal compliance, 5 on acceptability, and 1 on feasibility. Compliance was assessed across multiple sources, including mothers, health workers, media, points of sale, and product labels. Maternal exposure to CMF promotion remained widespread, with reports of mothers receiving free samples and coupons, and encountering media advertisements. Compliance of health workers varied across countries, with many reporting contact with CMF companies despite legal prohibitions. Public hospitals generally showed better adherence to the national law than private ones. While implementing the Code as national law effectively regulated the promotion of CMF for infants aged 0–12 months in public settings and in the media, it remains insufficient in addressing the promotion of unregulated products like growing-up milk, which are often marketed through emerging strategies such as cross-promotion and digital advertising. Point-of-sales compliance was inconsistent, with many countries reporting non-compliant price-related promotions. Conclusion To enhance legal compliance, robust monitoring and reporting systems are necessary. Utilizing technology-assisted solutions for monitoring compliance can be an option for countries with limited human resources. Adequate training for health workers and communication strategies targeting shop managers about national law are also essential in enhancing their acceptability and compliance.

Abstract Background On 6 February 2023, an Mw 7.8 earthquake struck southern and central Türkiye and north-western Syria, affecting the lives of 4.6 and 2.5 million children, respectively. In such crises, infants who are dependent on commercial milk formula (CMF) face increased vulnerability to diseases and malnutrition as safe preparation of CMF becomes difficult and sometimes impossible. The Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE) provides guidance on protecting and supporting recommended infant and young child feeding and minimizing the risks that come with CMF feeding. In addition, the International Code of Marketing of Breastmilk Substitutes (the Code) ensures adequate nutrition for infants by protecting and promoting breastfeeding and ensuring the proper usage of CMF. This study aims to document violations of the Code and the OG-IFE during the earthquake relief efforts to help strengthen infant and young child feeding emergency responses and inform future disaster relief policies. Methods Data was collected from 6 February to 10 March 2023 through Internet sources. Social media, news websites, and the Emergency Nutrition Network forum were used for data collection. Turkish content was translated into English for analysis, with a focus on donation-related information and Code violations related to baby food and infant feeding. Results A total of 40 reports on CMF, complementary food, and feeding equipment donations were collected. Three main types of violations of the OG-IFE and the Code were identified, with the majority of them being incidences of individuals, humanitarian organizations, and government agencies seeking or accepting donations. Infant formula companies continued to violate the Code by donating large quantities of CMF and feeding equipment to the Turkish Red Crescent, government agencies, and disaster relief infant and young child feeding (IYCF) coordination authorities. Conclusions These incidents reflected a systematic violation of the Code and non-compliance with the OG-IFE. Globally accepted IYCF standards and recommendations were not consistently followed due to fragmented early responses. There is a critical need to step up efforts to ensure appropriate and safe IYCF practice protecting and supporting breastfed and non-breastfed infants in emergencies.

Background: The International Code of Marketing of Breast-milk Substitutes, or 'the Code,' sets standards to regulate marketing of commercial milk formula (CMF) to protect breastfeeding. World Health Organization member states are advised to legislate the Code into national law, but understanding of its implementation outcomes is limited. This systematic review aimed to examine implementation outcomes in countries implementing the Code as national law. Methods: We systematically searched five academic databases in September 2022 for articles published in English from 1982 to 2022. We double-screened titles/abstracts and then full texts for eligible articles reporting implementation outcomes of the Code in 144 eligible countries. We used the Mixed Methods Appraisal Tool for quality assessment and synthesized data thematically. We applied the Proctor et al. framework to guide synthesis of implementation outcomes, organizing our findings according to its taxonomy. Results: We included 60 eligible articles of the 12,075 screened, spanning 28 countries. Fifty-seven articles focused on legal compliance, 5 on acceptability, and 1 on feasibility. Compliance was assessed across multiple sources, including mothers, health workers, media, points of sale, and product labels. Maternal exposure to CMF promotion remained widespread, with reports of mothers receiving free samples and coupons, and encountering media advertisements. Compliance of health workers varied across countries, with many reporting contact with CMF companies despite legal prohibitions. Public hospitals generally showed better adherence to the national law than private ones. While implementing the Code as national law effectively regulated the promotion of CMF for infants aged 0–12 months in public settings and in the media, it remains insufficient in addressing the promotion of unregulated products like growing-up milk, which are often marketed through emerging strategies such as cross-promotion and digital advertising. Point-of-sales compliance was inconsistent, with many countries reporting non-compliant price-related promotions. Conclusion: To enhance legal compliance, robust monitoring and reporting systems are necessary. Utilizing technology-assisted solutions for monitoring compliance can be an option for countries with limited human resources. Adequate training for health workers and communication strategies targeting shop managers about national law are also essential in enhancing their acceptability and compliance. [ABSTRACT FROM AUTHOR]

Background: On 6 February 2023, an Mw 7.8 earthquake struck southern and central Türkiye and north-western Syria, affecting the lives of 4.6 and 2.5 million children, respectively. In such crises, infants who are dependent on commercial milk formula (CMF) face increased vulnerability to diseases and malnutrition as safe preparation of CMF becomes difficult and sometimes impossible. The Operational Guidance on Infant and Young Child Feeding in Emergencies (OG-IFE) provides guidance on protecting and supporting recommended infant and young child feeding and minimizing the risks that come with CMF feeding. In addition, the International Code of Marketing of Breastmilk Substitutes (the Code) ensures adequate nutrition for infants by protecting and promoting breastfeeding and ensuring the proper usage of CMF. This study aims to document violations of the Code and the OG-IFE during the earthquake relief efforts to help strengthen infant and young child feeding emergency responses and inform future disaster relief policies. Methods: Data was collected from 6 February to 10 March 2023 through Internet sources. Social media, news websites, and the Emergency Nutrition Network forum were used for data collection. Turkish content was translated into English for analysis, with a focus on donation-related information and Code violations related to baby food and infant feeding. Results: A total of 40 reports on CMF, complementary food, and feeding equipment donations were collected. Three main types of violations of the OG-IFE and the Code were identified, with the majority of them being incidences of individuals, humanitarian organizations, and government agencies seeking or accepting donations. Infant formula companies continued to violate the Code by donating large quantities of CMF and feeding equipment to the Turkish Red Crescent, government agencies, and disaster relief infant and young child feeding (IYCF) coordination authorities. Conclusions: These incidents reflected a systematic violation of the Code and non-compliance with the OG-IFE. Globally accepted IYCF standards and recommendations were not consistently followed due to fragmented early responses. There is a critical need to step up efforts to ensure appropriate and safe IYCF practice protecting and supporting breastfed and non-breastfed infants in emergencies. [ABSTRACT FROM AUTHOR]

Abstract Background The exploitative marketing of commercial milk formula (CMF) reduces breastfeeding, and harms child and maternal health globally. Yet forty years after the International Code of Marketing of Breast-Milk Substitutes (The Code) was adopted by WHO member states, many countries are still to fully implement its provisions into national law. Furthermore, despite The Code, worldwide CMF markets have markedly expanded. In this paper, we adopt Brazil as a case study to understand the power of the baby food industry’s marketing and corporate political activity, and how this influences the country’s ‘first-food system’ in ways that promote and sustain CMF consumption. Methods We used a case study design, drawing data from from documents and key informant interviews (N = 10). Results Breastfeeding rates plummeted in Brazil to a historic low in the 1970s. A resurgence in breastfeeding from the mid-1980s onwards reflected strengthening political commitment for a national policy framework and breastfeeding protection law, resulting in-turn, from collective actions by breastfeeding coalitions, advocates, and mothers. Yet more recently, improvements in breastfeeding have plateaued in Brazil, while the industry grew CMF sales in Brazil by 750% between 2006 and 20. As regulations tightened, the industry has more aggressively promoted CMF for older infants and young children, as well as specialised formulas. The baby food industry is empowered through association with powerful industry groups, and employs lobbyists with good access to policymakers. The industry has captured the pediatric profession in Brazil through its long-standing association with the Brazilian Society of Pediatrics. Conclusion Brazil illustrates how the baby food industry uses marketing and political activity to promote and sustain CMF markets, to the detriment of breastfeeding. Our results demonstrate that this industry requires much greater scrutiny by regulators.

The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0–12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross‐promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest. Key message: Mothers' and health professionals' exposure to commercial milk formula (CMF) promotion was still widespread in Singapore even after the new CMF restriction was implemented in 2019.Digital marketing, distribution of free samples of milk for toddlers and mothers, dubious premium health and nutrition claims, and sponsorship from CMF industries were common tactics found in this study.Updating CMF restrictions to align with the Code, including restricting CMF marketed for toddler milk, prohibiting cross‐promotion, and disallowing sponsorship from CMF industries, together with an effective enforcement system, may facilitate better control of unethical CMF promotions in Singapore. [ABSTRACT FROM AUTHOR]

Abstract The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0–12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross‐promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest.

IntroductionBreastfeeding (BF) is considered an essential component of optimal care for child health and development. In the past two decades, global data have shown improvements in some, but not all, BF indicators. Despite these positive changes sales and per capita intake of commercial milk formula (CMF) have increased globally. The CMF industry invests millions of dollars in marketing, which targets families and healthcare professionals (HCP). In Mexico, more than half of the mothers (53%) who feed their infants with CMF chose their Brand on the recommendation of HCP. Understanding the reasons behind the current recommendations for the use of CMF by HCP is important for the design of BF interventions. The primary objective of this study was to explore Mexican HCP' beliefs, attitudes, perceptions, and practices about early infant feeding practices, and reasons for recommending CMF. The secondary objective was to explore pregnant women and mother's perceptions of the infant feeding recommendations they received from HCP, and of the factors that influenced their infant feeding decisions.MethodsThe study was based on a secondary qualitative data analysis of a WHO/UNICEF multi-country study. We analyzed focus group discussions (FGDs) and in-depth interviews (IDIs) from Mexico. Data were collected through convenience sampling in Mexico City and Guadalajara. HCP (n = 34) analysis was based on IDIs, and pregnant women or mothers of children 0-18 months (n = 74) on FGDs and IDIs.ResultsThrough a thematic analysis, we identified the socioecology of BF and triangulated HCP and women's accounts. HCP, pregnant women, and mothers recognized that several factors might have influenced their infant feeding decisions including healthcare facilities' policies and maternal work conditions. Although HCP believed that BF is the best way to feed newborns and young children, they routinely recommended CMF. On the other hand, pregnant women and mothers had a strong belief that BF is the best way to feed their babies. However, when women sought support from HCP, the latter often recommended switching to CMF.DiscussionThis study highlights the discordance between HCP perceptions and mothers' experiences of HCP recommendations about infant feeding. Our findings support a national call for policy actions.

ObjectivesThis study examines the status of implementation of the International Code of Marketing of Breast-milk Substitutes of eight countries in the South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), and describes the sales value and volume of commercial milk formula (CMF) marketed as breastmilk substitutes (BMS) and baby food in four countries (Bangladesh, India, Pakistan, and Sri Lanka).DesignA mix of descriptive methods is used to assess national status of Code implementation, including a desk review of the 2022 WHO/UNICEF/IBFAN Code Status Report, systematic content analysis of national Code measures, and insights generated from the participation of key government and UNICEF/WHO actors in a regional workshop that aimed to identify each country’s barriers, gaps, and the status of Code implementation. Data on the sales value and volume of CMF and baby food between 2007 to 2021 and with the prediction to 2026 in Bangladesh, India, Pakistan, and Sri Lanka were obtained from Global Data.FindingsThere are major gaps in Code implementation in countries even with legal measures considered substantially aligned with the Code, such as the inadequate age range of CMF covered in the scope, insufficient safeguards against conflicts of interest in the health system, lack of warning of risks of intrinsic contamination of powdered milk formula, and an absence of effective monitoring and enforcement mechanisms. Data on CMF sales shows health facilities and pharmacies sustain the highest sales. Lower sales volume of infant formula (including special formula), compared to other CMF such as follow-up formula and growing-up milk, has been observed in three of the four countries (Bangladesh, India, and Sri Lanka). Overall, GUM, followed by baby cereals, accounted for a large portion of CMF and baby foods sales in the same three countries.Recommended actions include(1) Closing the gaps between national measures and the Code, (2) Ensuring effective monitoring and enforcement mechanisms, (3) Strengthening conflicts of interest safeguards in the health system, (4) Tackling digital marketing, and (5) Galvanizing political support and support from in-country public health and women’s rights jurist networks.

Breastfeeding has unique benefits for the child and the mother, and its decline may be one of the most significant mass phenomena in infant feeding. While there are several causes, standing out among them is the marketing practices of commercial milk formula (CMF) and commercial complementary foods (CCF). This descriptive cross-sectional study was conducted using qualitative and quantitative methodology, between August 2018 and August 2020. Regarding the promotion, advertising and labeling of CMF and CCF, none of the companies in Argentina at the time complied with the International Code of Marketing of Breast-milk Substitutes or the related laws in force in the country. The multiple forms of violation found emphasize the need to establish and strengthen monitoring and enforcement mechanisms to curb abuses by the CMF and CCF industry in Argentina, safeguarding the rights of mothers, families, and their newborns. Likewise, the Government must lead the political process and adapt its regulatory framework in terms of transparency and conflict of interest, as well as generate comprehensive and intersectoral public policies on the protection of breastfeeding.

Women’s contributions to food production and food security are often overlooked, thus perpetuating inequitable and unsustainable globalized commercial food systems. Women’s role as producers in the first-food system, breastfeeding, is largely invisible and underfunded, encouraging the production and consumption of environmentally unsustainable commercial milk formula (CMF). This policy brief highlights opportunities for including and funding interventions enabling breastfeeding under carbon offset schemes such as the United Nations Clean Development Mechanism (CDM). A Green Feeding Tool is being developed to account for the national carbon and water footprints of CMF. The tool will help ensure that women’s contributions to a sustainable first-food system are not ignored by the CDM and other mechanisms funding greenhouse gas emissions reductions.

The Philippine Milk Code was enacted in 1986 to protect breastfeeding and reduce inappropriate marketing of breastmilk substitutes (BMS). The Philippine Milk Code is categorized as “substantially aligned” with the International Code of Marketing of Breast-milk Substitutes (“the Code”), but its provisions are assessed as relatively weak in prohibiting promotion to the general public. The extent to which violations of the Philippine Milk Code persist in traditional media platforms and in the digital space has not been systematically explored. This study employed a cross-sectional multimedia audit to examine the marketing and promotion of products under the scope of the Code, as well as those regulated by the Philippine Milk Code. Through a media monitoring conducted from March to September 2018, a total of 430 unique television (n = 32), printed (n = 87) and online (n = 311) promotional materials were identified. A coding tool was used to analyze the content, including the marketing elements used in the materials. Our findings show that commercial milk formula (CMF) for children ≥36 months old was the most promoted type of product (n = 251); and staging of events (n = 211), provision of special discounts or financial inducements (n = 115) and the use of taglines (n = 112) were the most used marketing elements. Promotion of CMF for children

Current international infant and young child (IYC) feeding recommendations consider nutrition and health but not environmental impacts. Only a handful of countries have dietary guidelines that provide quantitative recommendations for food groups of environmental concern. This study aimed to perform a narrative review of the environmental impacts of commercial milk formula compared with breastfeeding and to analyze the degree to which current country-specific IYC feeding recommendations are aligned with sustainable dietary targets. A mixed-methods review was conducted, including the following: 1) a narrative review of the environmental impact of commercial milk formula compared with breastfeeding and 2) a comparison of recommended intake of meats and dairy for children IYC based on country-specific dietary guidelines compared with the EAT-Lancet Commission dietary targets (ELCT) for children 24 mo or older and adults and if the ELCT should be adjusted for the energy needs of IYC. Formula feeding has a greater environmental impact (∼48% higher carbon footprint) than exclusive breastfeeding. Available country-specific dietary guidelines for meat and dairy products in children IYC are, in general, at or below the upper limits of the ELCT recommended ranges for older children and adults but are in most cases above the upper limit when adjusting for the energy needs of IYC. Exclusive breastfeeding should be protected and promoted not only as the healthier but also as the most sustainable alternative. Available complementary dietary feeding recommendations of nonprocessed meat and dairy fall below current ELCT for older children and adults. Given that IYC require a more nutrient-dense diet than older children and adults and considering the small quantities they consume, we recommend using the unadjusted ELCT as reference for IYC feeding while specific international consumption recommendations are developed for this age group., Competing Interests: Conflict of interest The authors report no conflicts of interest., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Breastfeeding rates in Vietnam, and globally, remain suboptimal. A major contributor to this is the aggressive marketing of commercial milk formulas (CMF), mainly through online media. The Vietnamese Government has implemented legal measures to limit CMF marketing, but these have been difficult to enforce, because of complex online environments. We aimed to quantify the extent and nature of online violations and contradictions in various Vietnamese laws related CMF marketing over 12 months in 2022. Using a cross-sectional study design, we used an artificial intelligence-enabled virtual violations detector (VIVID) to monitor official websites and social media pages of 25 breastmilk substitute (BMS) merchandise and distributors, every day for 12 months in 2022. Data were summarised descriptively. We detected more than 3000 online advertisements that violated or contradicted the intent of Vietnamese laws, involving almost 7000 violations of various articles within these laws (average 9.5 violations per day). More than 700 detections were related to CMF products being registered as "supplementary foods" or similar, thereby circumventing Vietnamese CMF marketing laws, because they are not registered as "BMS products. We demonstrate the need to strengthen the design, monitoring and enforcement of existing Vietnamese laws to eliminate mothers" exposure to the exploitative digital marketing of CMF. By turning a highly resource-intensive task into one that is, automated requiring substantially less resources, our study represents the most comprehensive in Vietnam and internationally on the extent and nature of the online marketing of BMS. VIVID can be applied worldwide to hold industry accountable for the inappropriate marketing of CMF., (© 2024 The Authors. Maternal & Child Nutrition published by John Wiley & Sons Ltd.)

Introduction: Breastfeeding (BF) is considered an essential component of optimal care for child health and development. In the past two decades, global data have shown improvements in some, but not all, BF indicators. Despite these positive changes sales and per capita intake of commercial milk formula (CMF) have increased globally. The CMF industry invests millions of dollars in marketing, which targets families and healthcare professionals (HCP). In Mexico, more than half of the mothers (53%) who feed their infants with CMF chose their Brand on the recommendation of HCP. Understanding the reasons behind the current recommendations for the use of CMF by HCP is important for the design of BF interventions. The primary objective of this study was to explore Mexican HCP' beliefs, attitudes, perceptions, and practices about early infant feeding practices, and reasons for recommending CMF. The secondary objective was to explore pregnant women and mother's perceptions of the infant feeding recommendations they received from HCP, and of the factors that influenced their infant feeding decisions., Methods: The study was based on a secondary qualitative data analysis of a WHO/UNICEF multi-country study. We analyzed focus group discussions (FGDs) and in-depth interviews (IDIs) from Mexico. Data were collected through convenience sampling in Mexico City and Guadalajara. HCP (n = 34) analysis was based on IDIs, and pregnant women or mothers of children 0-18 months ( n = 74) on FGDs and IDIs., Results: Through a thematic analysis, we identified the socioecology of BF and triangulated HCP and women's accounts. HCP, pregnant women, and mothers recognized that several factors might have influenced their infant feeding decisions including healthcare facilities' policies and maternal work conditions. Although HCP believed that BF is the best way to feed newborns and young children, they routinely recommended CMF. On the other hand, pregnant women and mothers had a strong belief that BF is the best way to feed their babies. However, when women sought support from HCP, the latter often recommended switching to CMF., Discussion: This study highlights the discordance between HCP perceptions and mothers' experiences of HCP recommendations about infant feeding. Our findings support a national call for policy actions., Competing Interests: Some HCP reported that they have not had contact with representatives of CMF, but mainly because it is not allowed by the rules of their Institutions, especially those working in public healthcare facilities. However, despite these regulations some HCP were approached by CMF companies and received funding to attend scientific conferences. Among the different types of HCP participating in this study, pediatricians were approached the most by CMF companies. “.. Yes, they [company representatives] live at the pediatrician's, they're there every day…” (In-Depth-Interview- Obstetrician/Gynecologist, Private health care facility).“... Yes, they give us samples, but only for their specialized formulas. Like I mentioned, they don't leave samples for stages 1 and 2. It's just for their specialized formulas. And sometimes they'll give us pens, or towels, small things [...] Yes, yes. They do invite us [to scientific conferences] [...] Well, yes, for example, there's one they organize themselves, a “summit,” that's what they call it, so it's the company's “summit” and they give us conferences on breast milk, on protein allergies, lactose intolerance... These are scientific topics. They pay for the lodging and travel expenses, and we go to the conference [...] Yes, yes [attendance to the conference]...” (In-Depth-Interview- Pediatrician, Private health care facility).HCP participating in the study did not identify receiving funds or gifts from CMF companies as a conflict of interest. Therefore, they did not avoid relationships with the companies in their practice or in their research. “... Well, sponsorship is good, having investigation [research] resources is always good, as long as they have ethical guidelines [...] That the research is based on the truth…“ (In-Depth-Interview- Pediatrician, public health care facility).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Hernández-Cordero, Vilar-Compte, Tomori, Lara-Mejía, Rovelo-Velázquez, Hayes and Pérez-Escamilla.)

Objectives: This study examines the status of implementation of the International Code of Marketing of Breast-milk Substitutes of eight countries in the South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka), and describes the sales value and volume of commercial milk formula (CMF) marketed as breastmilk substitutes (BMS) and baby food in four countries (Bangladesh, India, Pakistan, and Sri Lanka)., Design: A mix of descriptive methods is used to assess national status of Code implementation, including a desk review of the 2022 WHO/UNICEF/IBFAN Code Status Report, systematic content analysis of national Code measures, and insights generated from the participation of key government and UNICEF/WHO actors in a regional workshop that aimed to identify each country's barriers, gaps, and the status of Code implementation. Data on the sales value and volume of CMF and baby food between 2007 to 2021 and with the prediction to 2026 in Bangladesh, India, Pakistan, and Sri Lanka were obtained from Global Data., Findings: There are major gaps in Code implementation in countries even with legal measures considered substantially aligned with the Code, such as the inadequate age range of CMF covered in the scope, insufficient safeguards against conflicts of interest in the health system, lack of warning of risks of intrinsic contamination of powdered milk formula, and an absence of effective monitoring and enforcement mechanisms. Data on CMF sales shows health facilities and pharmacies sustain the highest sales. Lower sales volume of infant formula (including special formula), compared to other CMF such as follow-up formula and growing-up milk, has been observed in three of the four countries (Bangladesh, India, and Sri Lanka). Overall, GUM, followed by baby cereals, accounted for a large portion of CMF and baby foods sales in the same three countries., Recommended Actions Include: (1) Closing the gaps between national measures and the Code, (2) Ensuring effective monitoring and enforcement mechanisms, (3) Strengthening conflicts of interest safeguards in the health system, (4) Tackling digital marketing, and (5) Galvanizing political support and support from in-country public health and women's rights jurist networks., Competing Interests: 4.1.8.Conflicts of interest within the health system and government, such as industry sponsorship of health programs and industry’s participation in policymaking and monitoring, can impede the adoption of strong laws and proper enforcement. This study reveals two main problems. Firstly, for some countries, their law specifies that financial or material inducements are not allowed only if they are used for promoting products covered in the law. This creates situations where financial or materials inducements could arguably be allowed so long as they are not explicitly specified with a purpose to promote designated products. Secondly, the definition of conflicts of interest may not be clear, allowing room for companies to establish ambiguous ‘partnerships’ or ‘corporate social responsibility’ campaigns that are fraught with conflicts of interest. The 2016 WHO Guidance reinforces with clearer conflicts of interest safeguards within the health systems.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Ching, Sethi, Nguyen, Murira, Shats, Rowel, Ahmed, Dorji, Chakma, Haag, Singh, Khatoon, Bukhari, Aminee, Ghosh, Forissier, Kappos, Zambrano and Khan.)

The Philippine Milk Code was enacted in 1986 to protect breastfeeding and reduce inappropriate marketing of breastmilk substitutes (BMS). The Philippine Milk Code is categorized as "substantially aligned" with the International Code of Marketing of Breast-milk Substitutes ("the Code"), but its provisions are assessed as relatively weak in prohibiting promotion to the general public. The extent to which violations of the Philippine Milk Code persist in traditional media platforms and in the digital space has not been systematically explored. This study employed a cross-sectional multimedia audit to examine the marketing and promotion of products under the scope of the Code, as well as those regulated by the Philippine Milk Code. Through a media monitoring conducted from March to September 2018, a total of 430 unique television ( n = 32), printed ( n = 87) and online ( n = 311) promotional materials were identified. A coding tool was used to analyze the content, including the marketing elements used in the materials. Our findings show that commercial milk formula (CMF) for children ≥36 months old was the most promoted type of product ( n = 251); and staging of events ( n = 211), provision of special discounts or financial inducements ( n = 115) and the use of taglines ( n = 112) were the most used marketing elements. Promotion of CMF for children <36 months old was uncommon, which supports the conclusion that there is broad compliance with the Philippine Milk Code in terms of the types of products promoted. However, analysis of marketing elements reveals that the CMF industry circumvents the Philippine Milk Code through the use of false and misleading health and nutrition claims, emotionally manipulative language in promotional materials, and cross-promotion. The findings indicate gaps in enforcement and regulatory measures that require urgent attention., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Capili, Datu-Sanguyo, Mogol-Sales, Zambrano, Nguyen, Cashin and Mathisen.)

The aim of the present study was to evaluate the cariogenicity of cows', human and infant formula milks, supplemented or not with fluoride, in rats. Sixty female Wistar rats were desalivated and infected with Streptococcus sobrinus 6715.Animals were divided into six groups: group 1, sterilised deionised distilled water (SDW; negative control); group 2, 5 % sucrose added to SDW (positive control); group 3, human milk; group 4, cows' milk; group 5, Ninho® formula reconstituted with SDW; group 6, Ninho® formula reconstituted with 10 parts per million F and SDW. At day 21 the animals were killed and their jaws removed to quantify total cultivable microbiota, Strep. sobrinus and dental caries. The concentration of carbohydrate and fluoride in the milks was analysed. The Kruskal–Wallis test (α = 5 %) was used to analyse the data. The caries score by the milk formula was as high as that provoked by sucrose. Regarding smooth-surface caries, human milk was statistically more cariogenic than cows' milk, which did not differ from the SDW and the Ninho® with fluoride (P>0·05). Groups 2–6 showed higher Strep. sobrinus counts when compared with the negative control group (P < 0·05) but no statistically significant difference was found among them (P>0·05). HPLC analysis showed that infant formula had 9·3 % sucrose and 3·6 % reducing sugars. The infant formula should be considered cariogenic due to the sugars found in it, but fluoride supplementation reduced its cariogenic effect. The human milk was more cariogenic than the cows' milk but not as much as the formula milk. [ABSTRACT FROM PUBLISHER]

Food systems are increasingly being understood as driving various health and ecological crises and their transformation is recognised as a key opportunity for planetary health. First-food systems represent an underexplored aspect of this transformation. Despite breastfeeding representing the optimal source of infant nutrition, use of commercial milk formula (CMF) is high and growing rapidly. In this review, we examine the impact of CMF use on planetary health, considering in particular its effects on climate change, water use and pollution and the consequences of these effects for human health. Milk is the main ingredient in the production of CMF, making the role of the dairy sector a key area of attention. We find that CMF use has twice the carbon footprint of breastfeeding, while 1 kg of CMF has a blue water footprint of 699 L; CMF has a significant and harmful environmental impact. Facilitation and protection of breastfeeding represents a key part of developing sustainable first-food systems and has huge potential benefits for maternal and child health.