Breast milk substitutes, long decried by global health specialists, are making new inroads into the markets of poor countries during the COVID-19 pandemic – including through new and more effective modes of digital marketing.

Guidelines for distributing and donating such substitutes to households facing hunger and malnourishment due to the economic fallout of COVID-19 lockdowns, are urgently needed, a number of member states told members of the World Health Assembly (WHA) meeting in a virtual session on maternal and child nutrition on Tuesday.

Nearly a dozen countries, including Kenya, Zambia and the United States, drew attention to the need for WHO and other global health organizations to address the marketing, distribution and recommendations for breast milk substitutes in a more uniform manner.

“Inappropriate promotional foods for infants and young children has been a big challenge in the fight against malnutrition in countries such as Zambia, particularly with the many advances in marketing strategies using various technologies,” said the country’s representative to the WHA.

Digital marketing makes it difficult for countries to ensure that mothers are not unduly targeted by ads promoting substitutes, further complicating authorities’ ability to control the reach of manufacturers.

“Zambia, for instance, despite recording a decline in most childhood forms of malnutrition has experienced a decline in infants exclusively breastfed in their first six months from 73% in 2013, to 17% in 2018.

“At the same time, the country has seen an increase in nutrition-related non-communicable diseases, which could in part, be attributable to inappropriate feeding of infants and young children as a result of advertising.”

The Zambian representative said that clear guidelines are needed on how to address donations of breast milk supplements during the COVID-19 pandemic.

WHO says countries should monitor the marketing of such substitutes, which often undermine breastfeeding and normalise artificial feeding, more strictly.

The recommendation is part of a draft WHO report on the comprehensive implementation plan on maternal, infant and young child nutrition.

The draft report states: “The widespread use of digital marketing strategies for the promotion of breastmilk substitutes is a cause of growing concern.

“Modern marketing methods that were still unknown when the International Code for Marketing Breastmilk Substitutes was first adopted, are now used regularly to reach young women and their families with messages that normalize artificial feeding and undermine breastfeeding.”

It also said: “Tactics such as industry-sponsored online social groups, individually-targeted Facebook advertisements, paid blogs and vlogs, online magazines, and discounted Internet sales are used increasingly.”

Missing the WHO Targets

The report finds that an estimated 41% of infants aged under 6 months were exclusively breastfed, based on the latest survey estimates for 2013-2018. The World Health Assembly has set a target to increase this global rate to at least 50% of nursing infants by 2025.

48 countries have exclusive breastfeeding rates higher than 50%, while 51 countries have rates below it. Of 73 countries with sufficient data to estimate current trends, 34 are on track to reach the proposed target by 2025. 16 countries present insufficient progress, while 23 either present no improvement or are worsening.

The draft report also said: “WHO Guidance on ending the inappropriate promotion of foods for infants and young children recommends that companies marketing foods … should not sponsor meetings for health professionals. Despite that guidance, 38% of national paediatric associations continue to receive funding for their conferences from the manufacturers of breastmilk substitutes.”

A US representative asked the WHO Secretariat to provide clarity on its data collection, however. She said that transparency is important in preparing a comprehensive report to understand the scope and impact of digital marketing strategies which may not be in accordance with the International Code for marketing of breast milk substitutes.

“In the interest of good governance, it is important to ensure that the Secretariat clearly defines the scope and resources necessary to provide a comprehensive report and member state guidelines,” the representative stated.

Global Perception Versus Local Reality

While stressing their support for WHO’s Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition: Biennial Report, a sharp contrast existed between the issues raised by developing countries compared with their developed counterparts. While developed countries suggested that their local laws have provisions to deal with the various issues mentioned in the report, developing countries stressed the need for WHO to further increase its support for member countries.

In its submission, Israel described the issue of maternal, infant and young child nutrition as crucial to global health. It then pledged its support to WHO which it also commended the various policy documents and guidelines that the global health authority had put forward regarding the COVID-19 pandemic.

Kenya – one of two African countries that commented – localised the burdens of nutrition especially for their citizens. Kenya’s representative said the country has been making “difficult progress” in promoting maternal infant and young child nutrition. While describing the country’s breast milk substitute act of 2012, the country’s spokesperson said the government has been able to secure legislative provisions for breastfeeding-friendliness at the workplace in Kenya.

“There is also the development of national guidelines for healthy diets and physical activity. In addition, we have integrated food and nutrition content in our current school curriculum,” the spokesperson stated.

But in spite of the progress made, several challenges remain and they have been exacerbated by the COVID-19 pandemic in Kenya, disproportionately affecting young children and older persons.

“We therefore invite WHO to support member states to monitor and document the impact of COVID-19 on food security, nutrition status and to develop measures to mitigate the negative impact on nutrition,” the representative said.

“We also note with concern the findings that in the absence of a substantial scaleup, it is likely that the 2025 targets will not be met,” the UK said. “This is now even more of a challenge. Given the direct, indirect impacts of COVID-19, the Japan 2021 Nutritions for Growth Summit will come at a critical time.”

The United Kingdom urged the WHO Secretariat to promote engagement between WHO country offices and member state governments to support them to use published commitment guidelines to develop concrete policy and financial commitments that can catalyze progress towards the global nutrition targets.

Image Credits: WHO, WHO / UNICEF Global Breastfeeding Collective, WHO / UNICEF Global Breastfeeding Collective, WHO.