Breastfeeding is critical to maternal and child health and survival, and the benefits persist until later in life. Inappropriate marketing of breastmilk substitutes (BMS), feeding bottles, and teats threatens the enabling environment of breastfeeding, and exacerbates child mortality, morbidity, and malnutrition, especially in the context of COVID-19. These tactics also violate the International Code of Marketing of Breast-Milk Substitutes. This study identified marketing tactics of BMS companies since the start of the COVID-19 pandemic by reviewing promotional materials and activities from 9 companies in 14 countries, and the official Code reporting data from the Philippines. Eight qualitative themes emerged that indicate companies are capitalizing on fear related to COVID-19 by using health claims and misinformation about breastfeeding. Other promotional tactics such as donations and services were used to harness the public sentiment of hope and solidarity. Past studies show that these tactics are not new, but the pandemic has provided a new entry point, helped along by the unprecedented boom in digital marketing. There was a sharp increase of reported violations in the Philippines since the pandemic: 291 during the first months of the outbreak compared with 70 in all of 2019, corroborating the thematic findings. A lack of public awareness about the harm of donations and inadequate Code implementation and enforcement have exacerbated these problems. Proposed immediate action includes using monitoring findings to inform World Health Assembly (WHA) actions, targeted enforcement, and addressing misinformation about breastfeeding in the context of COVID-19. Longer-term action includes holding social media platforms accountable, raising public awareness on the Code, and mobilizing community monitoring.

The influence of marketing on infant and young child feeding and health is well recognized, and an International Code was adopted by the World Health Assembly (WHA) in 1981 to reduce inappropriate marketing and protect breastfeeding. Yet the marketing and influencing continue. This scoping review systematically examined the published research evidence on the nature and extent of exposure to International Code violations from 1981 to August 2021. We used several search strategies involving multi-language databases, organization websites, citation tracking, and expert consultation, to find research items meeting our inclusion criteria. We evaluated 657 items and retained 153 studies from at least 95 countries in the review. The majority of the studies (n = 113) documenting exposure to inappropriate marketing were published since 2010. Studies reported a broad range of marketing violations targeting mothers and families, health workers, and the general public. Marketing via digital platforms and brand extension has become more frequent. The evidence shows the use of misleading and inaccurate labeling and health and nutrition claims in breach of the Code. Our review confirms that violations of the Code have not ceased and calls for renewed attention from the WHA and national governments to protect the health of children and their mothers.

Commercial milk formula for pregnant women (CMF-PW) is an expensive, ultra-processed food with a high concentration of sugar, the consumption of which may be linked to negative health outcomes. However, CMF-PWs are promoted as beneficial for pregnant women and lactating mothers as well as their children. To date, little is known about the factors associated with the use of CMF-PW among pregnant women. We performed this analysis to examine the association between the use of CMF-PW and related beliefs and norms among pregnant women in Vietnam. We interviewed 268 pregnant women in their second and third trimesters from two provinces and one municipality representing diverse communities in Vietnam. Multinomial (polytomous) logistic regression, structural equation modeling (SEM), and propensity score matching (PSM) analysis were used to examine associations between beliefs and social norms related to CMF-PW and reported consumption, characterized as occasional, recent, and never during the current pregnancy. Overall, 64.6% of pregnant women reported using CMF-PW during the current pregnancy and 34.7% consumed CMF-PW on the day prior to the interview. Strong beliefs that CMF-PW will make a child smart and healthy (53.7%) and the perception that use of CMF-PW is common (70.9%) were associated with increased use on the previous day (beliefs: aOR: 3.56; 95% Confidence Interval (95% CI): 1.65, 7.71; p < 0.01 and social norms aOR: 2.29; 95% CI: 1.13, 4.66; p < 0.05). SEM and PSM analyses confirmed these findings for both occasional and regular CMF-PW use. Results are consistent with observations of CMF-PW product labels and marketing tactics in Vietnam. The prevalent use of CMF-PW in Vietnam is associated with the belief that these products make children smart and healthy and the perceived social norm that most mothers use these products, which mirrors marketing messages and approaches employed by the CMF industry.

This is the protocol for a scoping review that aims to systematically explore and summarise the published evidence of violations of the International Code of Marketing of Breast-milk Substitutes (the Code) and subsequent World Health Assembly Resolutions globally. The planned scoping review will seek to identify what research has been conducted on the topic, examine the geographic spread and nature of violations, and summarise knowledge gaps. The Code was adopted in 1981 by the World Health Assembly to protect infant health, in particular from aggressive and inappropriate marketing of breastmilk substitutes including formula and related products. Non-compliance with the Code or violations are described in reports, however, no existing systematic review of the global research appears to have been conducted that encompasses the varied disciplines including health, economics, and gender. The review will inform international and national decision-makers on the nature of violations and potentially highlight the need for new modalities to regulate this marketing. The proposed scoping review will use the six-step process of Arksey and O’Malley which includes defining the research question; identifying the relevant literature; selecting studies; charting the data; collating, summarising and reporting the findings; and will include a consultative group.

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