Marketing infant nutrition: getting it right

In 1966, Dr. Derrick Jelliffe, Director of the Caribbean Food and Nutrition Institute, published a brochure called ‘Child Nutrition in Developing Countries’, which warned about the dangers of bottle-feeding in “traditional and semi-sophisticated populations.”

In 1969, he voiced his concerns at a meeting of the United Nations Protein Advisory Group (PAG). However, another group of health experts maintained that infant formula was a much-needed product and that we should see infant mortality within the context of wider socio-economic problems.

In 1972, another PAG meeting addressed infant formula marketing. In a statement, PAG outlined the responsibilities of governments, pediatricians and the infant formula industry.

PAG asked manufacturers to stress the importance of breastfeeding in employee training, to avoid discouraging breastfeeding, to develop standard directions for the preparation of commercial formulas and to use product labels and literature to encourage better hygiene in infant food preparations.

The manufacturers were criticized for rolling out marketing strategies suitable for developed countries without adapting them to the context of low- and middle-income countries. For example, samples were distributed to mothers; promotional campaigns were implemented in stores; and, products were advertised like any other product (i.e. on billboards). The manufacturers at that time did not provide the necessary instructions for a safe use of the infant formula, which may have led to negative public health outcomes in places with poor sanitary conditions and lack of access to clean water.

Following studies and reports from international organizations, Nestlé revised its marketing and promotional activities. By 1972, we had prohibited contact between Nestlé employees and mothers in hospital maternity wards in most countries and banned direct infant formula sampling for new mothers.

On a systematic basis, we also began to include a statement on the superiority of breastfeeding on the labels of all infant formula products sold in developing countries.

In 1973, The New Internationalist published 'The Baby Food Tragedy,' an interview with two child nutritionists that sparked a public debate over breast-milk substitute (BMS) marketing.

However, the controversy did not boil over until 1974, when the British organization War on Want published the pamphlet, 'The Baby Killer,' which was widely distributed and translated, notably in German by the student organization Arbeitsgruppe Dritte Welt (Third World Working Group) with a title as provocative as 'Nestlé Kills Babies.'

Nestlé reacted by suing Arbeitsgruppe Dritte Welt for libel and won the court case in 1976. While such a course of action may seem severe in today's climate, at the time, the private sector did not really engage with outside organizations on societal issues.

In 1974, the World Health Organization (WHO) published its first Declaration on Infant Nutrition and Breastfeeding Protection during the 27th World Health Assembly.

Nestlé revises marketing practices

During this period, Nestlé reviewed its marketing practices in developing countries. In 1974 and 1975, we revised our educational and informational materials to strengthen the emphasis on the importance of breastfeeding, and to remove advertising or promotional material.

Also in 1975, we created the International Council of Infant Food Industries (ICIFI) with seven other infant formula manufacturers. Members adopted a code of ethics to guide their marketing and advertising practices.

By 1976, we had begun phasing out mass media advertising of infant formula. By the end of the year, we had withdrawn it in all developing countries.

However, the controversy continued. Dana Raphael, Director of the Human Lactation Center of Connecticut, was one of the first scientists to hold infant formula manufacturers responsible for high infant mortality rates in developing countries.

But in 1976, after a two-year study on infant feeding in 11 different cultural settings worldwide, Raphael found that a decline in breastfeeding was not a major cause of high infant mortality rates. Crucially, Raphael's study showed that mixed feeding was common – infants were breastfed but also given other, inappropriate foods (e.g. water, juices and cow's milk) from a very early age.

In 1979, a two-year WHO/UNICEF collaborative study on breastfeeding revealed the same pattern.

The first Nestlé boycott

In July 1977, the newly formed Infant Formula Action Coalition (INFACT) began a consumer boycott against Nestlé, demanding an end to infant formula promotion.

They also lobbied US Senator Edward Kennedy, chair of the Sub-Committee on Health and Scientific Research of the Committee of Human Resources, to hold public hearings on the infant formula issue.

These took place in 1978, and afterwards Senator Kennedy met with industry representatives, including Nestlé, to decide next steps. At the request of the ICIFI, and with a support letter from Nestlé, Senator Kennedy asked WHO to sponsor a conference on the issue to develop an international recommendation for marketing infant formula in developing countries.

In 1979, Nestlé developed internal guidelines to limit advertising and sales promotions, curb free samples and supplies, spell out the content of informational materials and end all financial incentives for health professionals to sell infant formula.

In the same year, a study by WHO and UNICEF recommended the development of an International Code of Marketing of Breast-milk Substitutes and The International Nestlé Boycott Committee (INBC) and International Baby Food Action Network (IBFAN) were formed.

The WHO International Code of Marketing of Breast-milk Substitutes (the Code or the WHO Code), was adopted at the 34th World Health Assembly in 1981 as a public recommendation to UN member states.

This was the chosen option, supported by the desire for consensus in a context of tensions between industry and NGOs. At the same time, the initiators of the Code had to cope with the threat of rejection by some member states wishing to protect their commercial interests against binding rules.

The Code is not a convention (legally binding treaty) or regulation but it calls on governments to implement its recommended rules, through their local legal and social frameworks.

Since this is a voluntary framework, this has led to a complex and non-uniform regulatory environment worldwide. In 2018, 35 countries have legislated to implement the full provision of the original 1981 WHO Code, while 49 have no legal measures in place. These different mechanisms for implementation of the Code results in different yardsticks being used. This is one of the main challenges for the implementation of the Code across the distribution channels and for the international manufacturers that operate in different countries.

What the WHO Code covers

The Code identifies breast milk as the ideal food for healthy growth and development of babies. It also recognizes a legitimate market for breast-milk substitutes intended for babies who are not breastfed. It states that these products should be made available through commercial and non-commercial distribution channels but should not be marketed in any way that could undermine breastfeeding.

The Code asks member states to implement a set of rules on the following:

• Information and education on products
• Relationships with general public and mothers
• Relationships with healthcare systems and health workers
• Managing employees of distributors and manufacturers
• Product labelling
• Product quality
• Implementing and monitoring the Code

The Code also recognizes that manufacturers and distributors of breast-milk substitutes have an important and constructive role to play in promoting the aim of the Code and ensuring its proper implementation.

The World Health Assembly Resolutions on the WHO Code

Since the WHO Code was adopted in 1981, several subsequent World Health Assembly (WHA) resolutions have completed the initial rules on the marketing of breast-milk substitutes, attempting to clarify the notion of appropriate marketing and products marketed as suitable for the replacement of breast milk.

Most WHA resolutions have the same legal status as the WHO Code – they are recommendations for member states and are not legally binding. This created a complex set of recommendations that makes it uneasy to know exactly what rules are applying, and their whole implementation relies on the member states.

Nestlé implements the WHO Code

In 1982, shortly after the WHO Code was adopted, Nestlé publicly released its first version of the Policy and Procedures implementing the WHO Code. These policies are Nestlé’s public and transparent commitment to implement the Code.

Since then, the Policy and Procedures (which we continually update) have been mandatory for all Nestlé employees and any third party acting with our authorization.

The Policy and Procedures have been expressing our recognition that the WHO Code is an important instrument to protect infant health, particularly in countries with poor sanitary, economic and social conditions.

They show, for each article of the WHO Code, how Nestlé practically applies the rules in its daily sales and marketing activities. Over time we have structured these rules into a WHO Code Management system that now includes specific compliance mechanisms on topics such as display of products at point of sale, the relationship with distributors and retailers, and training sessions for the healthcare professionals.

Also in 1982, we set up an independent audit commission, the Nestlé Infant Formula Audit Commission (chaired by former US Secretary of State and Senator Edmund Muskie) with responsibility for ensuring that our field offices complied with the Code provisions and Nestlé’s own instructions.

After talks with Nestlé, WHO, UNICEF and the Muskie Commission, INFACT suspended the boycott in a press conference in Washington, on October 4, 1984.

In 1988, activists attempted to re-launch a boycott, but this received little attention. The boycott was subsequently taken over by IBFAN and Baby Milk Action (BMA).

In 1989, Nestlé published a ‘Plan of Action for Infant and Young Child Feeding’ where we committed to end all free and low-priced supplies of infant formula in developing countries, except for those infants (a limited number) who really needed it.

In 1991, the Muskie Commission decided it had fulfilled its mandate and dissolved itself. That same year, the Association of Infant Formula Manufacturers (IFM) agreed to cooperate to end donations of infant formula to hospitals in developing countries by the end of 1992. However, stopping free supply of infant formula was a long journey because many hospitals were willing to receive these products for free.

In 1994, the WHA Resolution 47.5 reiterated earlier calls in 1986, 1990 and 1992 to end free or low-cost supplies.

After progressive reduction of donations, Nestlé stopped providing healthcare facilities with free supply of infant formula in most parts of the world (to strictly limit exceptions, especially for cases of emergency or natural disaster). However, although Nestlé completely stopped donations in the middle of the following decade, currently this is not a practice that has been given up by all manufacturers.

During the 1990s, fierce criticism of the infant formula industry continued. In 1992, The Church of England Synod announced the boycott of Nescafé which ended in 1994. In 1993, UNICEF released unilateral papers and positions against the industry to exclude it from talks.

In 1994, the International Baby Food Action Network (IBFAN) published a report entitled ‘Breaking the Rules’ (which has been republished in subsequent years) on alleged WHO Code violations by manufacturers. This report is published every three years and reports detected instances of non-compliance initiated and implemented by all breast-milk substitute manufacturers over that period. Nestlé carefully investigated these criticisms when they applied to us and we implemented corrective actions whenever it was necessary. Today, we still apply the same strictness in reviewing the allegations from IBFAN and other stakeholders: we systematically publish our responses on our website.

In 2001, the World Health Assembly adopted Resolution 54.2, stating that exclusive breastfeeding should be recommended for the first six months of life. The same year Nestlé released a Charter with Do’s & Don’ts on the marketing of breast-milk substitutes and introduced the Nestlé Ombudsman system.

The charter includes the following rules that are still applied today in countries with high levels of malnutrition and child mortality. They are also reflected in our current Policy and Procedures:

• No free supplies of infant formula to hospitals.
• Infant Formula/Follow-on formula (IFFO) sales and marketing staff are not allowed to seek direct contact with mothers.
• No free samples of infant formula to mothers.
• No incentives to healthcare professionals for the purpose of promoting infant formula.
• No incentives to its staff based on infant formula sales.

In 2002, Nestlé voluntarily decided to change its infant cereal packaging to recommend it from 6 months of age (rather than 4) in line with the WHA recommendation, even though this was not law.

The same year the WHA resolution 55.25 was adopted, endorsing the Global Strategy on Infant and Young Child Feeding. It ‘describes essential interventions to protect, promote and support appropriate infant and young child feeding […] to improve – through optimal feeding – the nutritional status, growth and development, health, and thus the survival of infants and young children.’ This is a fundamental document that acknowledges breast-milk substitutes such as infant formula as the suitable feeding option when infants cannot or should not be breastfed. It also confirmed that manufacturers should conform to the Code, subsequent relevant Health Assembly resolutions, and national measures that have been adopted to give effect to both.

In 2004, we refined our internal instructions on the WHO Code compliance and implemented a global management system to ensure compliance with the Code across our operations. This included the Nestlé Policy and Instructions, a Nestlé WHO Code Management System, an internal ombudsman procedure and internal and external audits. In 2006, the European Commission adopted the Directive on Infant Formula and Follow-on Formula that Nestlé implemented in its marketing practices in the whole European Union.

FTSE4Good is a set of socially responsible indices from FTSE, the global index group, created in 2001. They are designed to establish a measure of companies classed as socially responsible to aid investors.

In 2011, following a consultation that included investors, companies and NGOs (including Save the Children and UNICEF UK) FTSE4Good decided to develop FTSE4Good inclusion criteria for breast-milk substitutes (BMS) marketing.

Nestlé is proud to have been the first BMS manufacturer included in the FTSE4Good Index (from March 2011) and we’ve consistently met its 104 rigorous criteria (monitored by PwC) for the responsible marketing of breast-milk substitutes since 2011.

To date, Nestlé is one of only three BMS manufacturers that are part of the index.

Senior Nestlé managers are accountable for the compliance with the FTSE4Good criteria. These are reflected in our corporate policy and translated into our WHO Code Management System.

Meeting the FTSE4Good BMS criteria led to a significant change in our approach to WHO Code Compliance. It widened the scope of products covered by restricted marketing and defined the geographic areas where this applies more accurately, as the table below shows.

FTSE4Good defines ‘higher risk’ countries according to the following UNICEF measures:

• A mortality rate of more than 10 per 1000 in children under five.
• More than 2% acute malnutrition (moderate and severe wasting) in children under five.

We apply the FTSE4Good BMS Index criteria in all these countries, which represent 80% of the countries in the world.

The FTSE4Good BMS Index aims to protect vulnerable populations from inappropriate marketing practices that could deter mothers from breastfeeding in countries facing the highest infant mortality rates due to malnutrition. Over time, FTSE intends to bring on board ‘lower-risk’ countries – where Nestlé already follows national laws – and require companies within FTSE4Good to apply this higher risk policy in all countries.

Nestlé’s compliance approach respects the sovereignty of member states, is based on local laws and applies FTSE4Good principles:

• Nestlé must follow the WHO Code as implemented by national governments everywhere in the world.
• The Nestle Policy and Procedures for the Implementation of the WHO International Code of Marketing of Breast-milk Substitutes must apply when it is stricter than the national regulations in higher-risk countries (152).
• As a minimum in higher-risk countries, Nestlé does not promote infant or follow-on formulas for children under 12 months of age.

We support these principles and FTSE4Good's efforts to move towards better Code compliance. We commit to work with all stakeholders (governments, CSOs, industry, health professionals and academics, etc) to bring about this objective.

Nestlé’s global commitment to support breastfeeding

Nestlé has made a public commitment to support breastfeeding and protect it by implementing industry-leading policies in support of our corporate purpose to enhance the quality of life and contribute to a healthier future. We track our achievements each year and publish the results in our Creating Shared Value progress report.

The FTSE4Good BMS Index and the creation of the Access to Nutrition BMS sub-index in 2015 have ushered in a new era of commitment and transparency.

We have also implemented an external grievance mechanism, Tell Us, that enables anyone to report instances of non-compliance with this policy, through our websites across the world or by phone.

In 2016, the Bill and Melinda Gates Foundation, through the Meridian Institute, has engaged with various stakeholders to explore new approaches for improving company practices on the marketing of breast-milk substitutes. Through a series of dialogues, all the participating stakeholders have agreed to work towards a shared goal of optimum nutrition and health for all infants, young children and mothers around the world, with the ambition for the industry to achieve full Code Compliance by 2030.

Recently, despite the long-lasting lack of consensus in the dialogue between the industry and civil organizations, a common end goal-initiated unity amongst stakeholders: the optimal nutrition for mothers and babies and full Code compliance to the WHO Code and subsequent relevant resolutions.

Nestlé shares this goal and is part of these dialogues. We’re keen to work closely with civil organizations, governments and industry to help achieve this.

Even though there has been some progress towards achieving the Sustainable Development Goals, changes are not happening fast enough: malnutrition in all its forms is still a global emergency affecting more than 1 in 3 people worldwide.

Therefore, concerted and coordinated action from policymakers, civil society organizations and business is needed to address the complex challenge of ending malnutrition. This can only be achieved by a multi-stakeholder approach, where all players act together towards unified objectives.

As of 2020, only 25 countries have regulations which are substantially aligned with the Code, and no country has fully implemented it. On June 25, 2020, the WHO, UNICEF and eight civil society organizations published a Call to Action, inviting all manufacturers of breast milk substitutes (BMS) to make a public commitment to and achieve full compliance with the International Code of Marketing of Breast milk Substitutes and subsequent relevant resolutions to help ensure optimal breastfeeding and healthy diets for infants and young children.

On December 4, 2020 Nestlé sent its final response to the Call to Action's signatories.

Nestlé welcomes the Call to Action as a significant milestone in the implementation of the WHO Code and subsequent relevant resolutions. Nestlé also thanked the signatories for the role that they and other civil society organizations have played in advancing infant and maternal nutrition over the past decades.

In its response, Nestlé has made a unilateral commitment to strengthen further its marketing of breast milk substitutes policy. In addition, Nestlé has committed to work with the signatories to drive efforts to bring the majority of industry to a common level of performance on the promotion of formula for babies aged 0-12 globally.

The full Nestlé response is accessible on the CtA website.

Download the Nestlé Action Plan (pdf, 150Kb) to implement our commitments to the Call to Action

More information is also available on Ask Nestlé.