BREASTFEEDING is the gold standard in infant feeding as it confers protection against illnesses and helps forge a strong bond between mother and child. The first approach to feeding infants should be mother's milk. Indeed, breast milk should be the sole source of nourishment for an infant up to six months of age.

Despite this, the Ministry of Health (MOH) has highlighted that the proportion of mothers who continue breastfeeding up to six months is low. The MOH, professional bodies and non-governmental organisations (NGOs) have all made efforts to promote breastfeeding.

As another effort to protect, support and promote breastfeeding practices in the country, MOH first formulated a Code of Ethics for Infant Formula Products in 1979. A revised version of the Code was launched on August 1, 2008 and was renamed: Code of Ethics for the Marketing of Infant Foods and Related Products. Through this Column, I would like to highlight some sections of this Code to all relevant stakeholders. We should all do our bit to promote breastfeeding.

The need for a Code of Ethics

The MOH revealed that exclusive breastfeeding (babies given only mother's milk and nothing else) for up to six months is only at a dismal rate of 14.5%.

There are of course many reasons for this. They include ignorance of the value of breast milk, lack of support from family members, returning to work soon after delivery, and even lack of support from health workers.

Relevant to the context of this write-up, MOH has identified that yet another reason is the availability of commercial infant foods that are portrayed to be as good as, if not better, than breast milk. Mothers may be exposed to attractive commercial information on infant feeding and may be inclined to mix-feed. This reduces the infant's suckling at the breast, which in turn diminishes breast milk supply and leads to cessation of breastfeeding.

Companies are said to have employed a wide range of marketing strategies to reach mothers and infants, including use of the mass media, retail outlets, healthcare staff and facilities and professional bodies as the medium through which promotional messages are carried through to the public.

Basically, the Code is a set of guidelines to control competitive promotion and advertising of commercial infant products which may undermine mothers' ability and intent to breastfeed.

Ultimately, the Code aims to uphold the supremacy of breast milk by protecting, promoting and supporting breastfeeding. It also aims to ensure proper use, when required, of infant formulas and related products and complementary foods.

Components of the Code

This revised Code now uses the term "designated products". These include infant formula, follow-up formula, special dietary or medical formulas, feeding bottles, teats and pacifiers and any other product represented or marketed for feeding infants up to the age of six months.

This Code covers the basic principles of marketing and product information of designated products and complementary foods in Malaysia. It provides guidelines on ethical practices for two main groups, namely:

1. Manufacturers and distributors of designated products and complementary foods; and

2. Health professionals and health personnel in the healthcare system.

The Code has listed 17 items which manufacturers and distributors of designated products are required to adhere to. Milk companies are required to observe professional and marketing ethics and established rules of conduct in all contacts within the healthcare system, retail outlets, child care centres and the community.

The main thrust of the Code is that manufacturers and distributors should not market, promote, or advertise designated products in such a way as to challenge or undermine the supremacy of breast milk. Designated products should not compete with breast milk in any way.

Towards this end, the Code has stipulated that milk companies should not provide samples, supplies or gifts of designated products; provide any educational or promotional material pertaining to maternal and child care and infant and young child feeding to pregnant women, parents of infants and young children and members of their families for the purpose of promoting designated products; display designated products in public events including trade shows, conferences, seminars, exhibitions or any other similar forums; conduct any activity that involves infants, and young children, pregnant women and mothers of infants and young children for the purpose of promoting designated products

Health professionals and health personnel are urged to subscribe to and abide by this Code, observe professional ethics and established rules of conduct.

The Code has provided 14 action points to be undertaken by health staff. Several of these points relate to ethical relationship with manufacturers and distributors of designated products. In this regard, health professionals should:

• not accept any sponsorship or any incentive in cash or in kind from manufacturers and distributors.
  
  
• neither request nor receive samples, gifts or supplies of designated products for themselves or for redistribution to pregnant women, parents of infants and young children and members of their families.
  
  
• not be involved in any manner in any activity that involves the promotion of designated products.

For mothers who are unable or choose not to breastfeed their babies, health professionals should give all the necessary instructions for the safe and appropriate use of designated products. This should include clear explanation of the consequences of inappropriate use of designated products, the financial implications of their use and the negative effects of pacifier use on babies.

Vetting of information

The MOH requires that all information materials and labels of designated products (except feeding bottles, teats and pacifiers) and complementary foods must be submitted to the Vetting Committee for prior approval. The format for submitting such applications has been clearly spelt out.

Approval codes shall be provided and the codes must be clearly indicated on the approved materials.

This Code has provided detailed requirements for the labelling of the different types of infant formulas for infants.

In relation to breastfeeding and the Code, specific prohibitions should be noted. Labels of infant and follow-up formulas should not:

• display any claim of superiority or similarity of the product to breast milk;
  
  
• include words, graphics or pictures to indicate grading, quality or superiority or any other similar meaning;
  
  
• use the term "humanised" or "maternalised" or similar terms.
  
  
• use any picture, graphic, word or statement which may idealise formula feeding. Pictures or graphics of infants and parts of infants or any other persons are not allowed.
  
  
• be used as a medium for promoting another product.

At the same time, the Code has highlighted that labels of such formulas must clearly display the following statements:

• "before deciding to use this product, seek the advice of a health professional"
  
  
• "breast milk is the best food for infants"
  
  
• "infant formula is not the only food for infants over six months of age" (for infant formulas)
  
  
• "follow-up formula is not the only food for infants over six months of age" (for follow-up formulas)

Materials and labels for complementary foods

Manufacturers and distributors may advertise and promote complementary foods to the public provided that all materials relating to complementary foods including advertisements and labels should contain the following statements:

• Not to be given to infants below six months of age, unless advised by a health professional
  
  
• For optimal health of infants, breastfeeding should be continued till two years of age in addition to providing them with complementary foods

In addition to the above, labels of complementary foods should not use pictures or graphics of infants less than six months old.

Ethical and practical issues

Breast milk is the best food for infants; no one disputes this. I believe no infant formula company disputes this. I really hope no milk company even attempt to say their product is comparable with mother's milk. There is simply no comparison.

All parties involved should do their part in promoting breastfeeding. This should not be left only to MOH and health professionals. Family members, relatives, friends, colleagues; all can play a positive role.

By simply not discouraging a woman who is contemplating to breastfeed is already a great help. Work places, shopping malls, hospitals too all can contribute to raising the opportunities for breastfeeding. The media is a powerful tool; it can certainly continue to play an effective role in promoting breastfeeding to the masses.

Manufacturers of infant formulas should also contribute to promoting breastfeeding. You might ask why would a milk company promote breastfeeding? Wouldn't that jeopardise the sales of his products?

I would say there are many good reasons a milk company may want to do that. I am told by a manufacturer that he is keen to chip in but he may be looked upon suspiciously. On the other hand, a health worker may not be keen to work with a milk company to promote breastfeeding because he doubts its real motives.

I feel there is room for give and take and compromises so that breastfeeding promotions can be even bigger and more effective than before.

Do infant formulas and foods for young children contribute positively to child nutrition? Most certainly. Even the most ardent champion of breast milk would agree with that. What is being disputed is the way infant foods are being promoted. It is said that they are being unethically promoted such that they undermine breastfeeding practices. That should not be tolerated; most certainly.

I applaud the efforts of health workers and NGOs in promoting breastfeeding. I understand their eagerness in policing the Code of Ethics. I would however urge for better communications between the milk industry and the relevant MOH officials.

I do not believe that emotional approaches on either side is going to benefit the infants. It would certainly be more beneficial for all to adopt a consultational rather than confrontational approach.

NutriScene is a fortnightly column by Dr Tee E Siong, who pens his thoughts as a nutritionist with over 30 years of experience in the research and public health arena. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice.

Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care.

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