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LETTERS: Magda Sachs and Andrée Bronner Monitoring marketing of infant formula feeds BMJ 2003; 326: 984 [Full text]

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International Code : The burden of compliance rests with manufacturers

Víctor M. Aguayo   (3 May 2003)

Why diverse prices of infant formula in Europe never seems harmonised?

Maurizio Bonati   (3 June 2003)

Well said!

Tracy Hayden   (15 March 2004)

International Code : The burden of compliance rests with manufacturers 3 May 2003
Víctor M. Aguayo, Regional Nutrition and Child Survival Advisor for Africa B.P. E-1557. Bamako, Mali. Send response to journal: Re: International Code : The burden of compliance rests with manufacturers	International Code of Marketing of Breastmilk Substitutes: The burden of compliance rests with manufacturers EDITOR_ This is in response to the letter from Mrs Andrée Bronner, Secretary General of the International Association of Infant Food Manufacturers (“Manufacturers encourage transparent and official monitoring of WHO code“; BMJ 2003; 326:984; 3 May). Three points of clarification: 1. The study “Monitoring compliance with the International Code of Marketing of Breastmilk Substitutes in West Africa: multisite cross sectional survey in Togo and Burkina Faso” (BMJ 2003; 326: 113-114; January 18, 2003) was carried out by a team of independent researchers in coordination with national health authorities in Togo and Burkina Faso. It is false, as Mrs Bronner claims, that the study was led by a representative of the International Baby Feeding Action Network. The research team submitted a report (in French) with the findings of the survey to national health authorities, to whom the research team was accountable, immediately upon completion of data collection and analysis. 2. The International Code and relevant WHA (World Health Assembly) resolutions cover all breastmilk substitutes; follow-up milks and commercially processed baby foods fall within the scope of the International Code if they are marketed or represented as a partial or total replacement for breast-feeding. WHA Resolution 49.15 urges “to ensure that complementary foods not be marketed for or used in ways that undermine exclusive and sustained breastfeeding”. In Burkina Faso and Togo, some manufacturers recommend the use of commercially processed baby foods at an inappropriate age (3-4 months). This contravenes both WHO’s international recommendations and national infant feeding policies of both countries that recommend that mothers and caregivers be encouraged to breastfeed their infants exclusively for six months. 3. It light of repeated reporting of Code violations both in industrialized and developing countries, it is difficult to agree with Mrs Bronner that all member companies of the International Association of Infant Food Manufacturers “are committed to the health and well-being of infants and young children” and that they all “support the aims and principles of the WHO code” (the correct name is International Code of Marketing of Breastmilk Substitutes). Although it is reasonable to expect that national governments must oversee monitoring and enforcement of the International Code, the burden of compliance with the International Code rests with manufacturers themselves. Competing interests:   None declared
Why diverse prices of infant formula in Europe never seems harmonised? 3 June 2003
Maurizio Bonati, Head, Laboratory for Mother and Child Health "Mario Negri" Research Institute, Via Eritrea 62, 20157 Milan, Italy Send response to journal: Re: Why diverse prices of infant formula in Europe never seems harmonised?	The benefits of breast-milk over artificial formula are unquestionable, and the matter is of interest to more than 3 million European new-borns and families/year, but the efforts to promote, protect and monitoring breast-feeding are, again, minute compared to the marketing actions.1 In March 2000 the Italian Competition Authority imposed a penalty of 3 million euros to six of the major infant formula manufacturers (present not only in Italy) because they had agreed on fixed prices in order to avoid competition and to share the market.2 Three years ago it was documented that artificial formula milk price differentials in EU were high, in particular in Italy.3 To evaluate the present situation, a similar assessment was repeated and implemented. On a single day, the same product (one of the best-selling powdered starting formulas in Italy), and package size (900 g), as the one used for the comparison three years before, was bought in pharmacies in Italy (Milan), France (Paris), Spain (Barcelona), United Kingdom (London) and Germany (Bonn). The distressing findings were the same. The price ranged from €16.38 (Bonn) to €34.00 (Milan), with small differences between France, Spain, United Kingdom and Germany, but with a large difference between these countries and Italy. No correlation was observed between formula price and the price of a controlled product (a well-selling car in Europe was chosen as an example), income, inflation, annual births, or rate of breastfed children (table). Cost of reference infant milk formula and of reference car, income, inflation rate, annual birth, and breastfed children, in four European countries Cost Formula (€/g) Cost Car* (€) GNI per head† (€ HICP‡ Annual no. of births° (thousands Children exclusively breastfed at 4 months§ (%) Italy 0.0377 14 333 20 010 2.2 511 37 Spain 0.0196 14 570 14 960 3.0 360 44 France 0.0189 13 731 23 670 1.7 732 15 United Kingdom 0.0186 14 075 24 500 0.8 668 28 Germany 0.0182 14 570 25 050 1.8 718 33 *Price after tax of the same basic model; source European Commission on car prices. †Gross National Income; source World Bank. ‡Harmonised Index of Consumer Prices for food, as percentage change on corresponding month of previous year; source EUROSTAT. °Source UNICEF. §Source WHO Regional Office for Europe. The price differencials are still substantial and unacceptable inside a “common community”. In Italy breast-milk substitutes are listed in the National Compendia as drugs and parapharmaceutical products and are sold prevalently in pharmacies, compared to other EU countries, where they are sold also in other shops. Italian consumers are therefore led to believe that these are health goods and that, like drugs, they are regulated and monitored by the health authority. Medical professionals, however, could also help support breast-feeding and limit extreme overpricing. In fact, formula companies are continuing to offer economic support to medical paediatric and obstetric societies, fund meetings and journals (too often of questionable scientific value), give gadgets, and donate medical instrumentation. All these actions affect the price of formula significantly and their costs fall on the families. Thus, if something is moving in the drug field concerning direct and indirect conflicts of interest, and evaluation of information, it doesn’t involve the relationship between scientific societies, medical professionals, and the formula industry.4 Because of the impotence, or incapacity to take steps to regulate such inequality at a national level, only EU initiatives could possibly be effective. The breast-milk-substitute business, compared to other important market segments such as drugs or cars, can only be of secondary importance for harmonisation and transparency across EU countries. However, taking into account the large number of interested families, that the differences of prices are to add to the lack of a national policy on feeding infants (situation common to other countries, i.e. UK)5, and that the EU, and the common market, is expanding the situations such as the Italian one are likely to become more common. 1. Waterston T, Tumwine J. Monitoring the marketing of infant formula feeds. BMJ 2003; 326: 113-4. 2. Provvedimento n. 8087 (1328) Latte artificiale per neonato, 2 marzo 2000. (http://www.agcm.it/index.htm) 3. Bonati M. Why such diverse prices of infant formula in Europe? Lancet 2000; 355: 321-2. 4. Tamburlini G, Marolla L, Bonati M. Italian paediatric association has launched code on competing interests. BMJ 2000; 320: 382 5. Sachs M. WHO’s global strategy is tool to protect breast feeding and child health. BMJ 2003; 326:984. Competing interests:   None declared
Well said! 15 March 2004
Tracy Hayden, Nursing mummy! Cm3 5ZS Send response to journal: Re: Well said!	I totally agree. I'm often reporting breeches of the pathetic UK legislation on infant formula promotion. However trading standards do nothing! They don't seem to realise the effect this promotion has. They need to enforce the laws we have already and hopefully one day comply to the international code. It seems to me formula promotion is the start of a lifetime of junk food advertising aimed at children! Follow on milk says "not intended to replace breastfeeding" which makes no sense to me because any milk type drink aimed at the under 2's to me is replacing a breastfeed, what is it intended for exactly then? Competing interests: None declared