Karen has asked some excellent questions and I will see if I can shed
some light on some her concerns. The WHO Code is a compromise document
that can be vague and open to interpretation. In the US, the National
Alliance for Breastfeeding Advocacy (NABA) is the IBFAN group that
monitors the Code and reports on it through its publications, Selling
out Mothers and Babies and Still Selling out Mothers and Babies. Many
other countries have IBFAN organizations such as INFACT Canada in
Canada and Baby Milk Action in the UK. The International Code
Documentation Center (ICDC) in Penang is Code central and the
repository of Code issues. It is all of these organizations that
interpret the Code.

Evenflo is meeting its obligations under the Code. I have spent a year
and a half working with Evenflo in consultation with INFACT Canada and
ICDC on helping Evenflo meet its obligations under the Code. The Code
provides guidelines on how formula, feeding bottles, and artificial
nipples are marketed. It does not prohibit their sale and use. Bottles
and nipples are permitted to be sold and pictures of these items are
permitted on websites as long as the text does not idealize their use.
You will notice a pack shot on the Evenflo website of all of the
bottles and nipples (items covered under the Code). This is permitted.
You will also notice that the only information about these items is
factual. Evenflo does not market bottles and nipples directly to the
consumer. It has no print ads or printed materials about its feeding
bottles and nipples that are distributed to mothers. All of its
packaging meets Code specifications with no pictures of feeding
bottles/nipples and language that is only factual.

Your question about Medela and how it can be a violator with only a
picture on its website is not a complete look at the situation. NABA
has received examples of Code violations by Medela in print ads in
American Baby Magazine and in materials given directly to mothers.
Packaging of pumps and feeding bottles contain pictures of these items
with language that idealizes their use. These are all Code violations.

The Code is interested in how formula and bottles/nipples are marketed.
If a baby needs formula, the Code does not prohibit its use. If a baby
needs to be fed breastmilk with a bottle, it does not prohibit this
either. The Code is continually updated with the resolutions that are
added to it every 2 years or so.

There are no judgements or spear-throwing here. ICDC, INFACT Canada,
Baby Milk Action, NABA, and all of the other IBFAN groups are doing
their best to interpret the Code. Use of bottles and artificial nipples
when necessary is not the issue, it is how these products are marketed
that the Code addresses.

Marsha Walker, RN, IBCLC
Weston, MA


Date: Mon, 23 Feb 2009 07:21:11 -0800
From: Karen Querna <[log in to unmask]>
Subject: Re: LACTNET Digest - 22 Feb 2009 - Special issue (#2009-191)

WHO Code-and violators
I would like to people to especially those in the United States, ask
what the WHO code means and how and who should interpret it. I
struggle with how Evenfloe can be code compliant (visit their web
site) and how another company that has only a bottle with a nipple on
it is a violater. The CODE states "such materials should not use any
pictures or text which may idealize the use of breastmilk
substitutes." What does the word "idealize" really mean?
One definition of idealize is: to consider or represent (something) as
ideal or more nearly perfect than is true. Collins Essential English
Dictionary 2nd Edition 2006 (c) HarperCollins Publishers 2004, 2006

The code also unfortunately does not address the feeding of expressed
human milk and related products needed when a mother in unable to
exclusively breastfeed or chooses not to. In the United States the
breastfeeding dyad of 2008 has different expectations and needs
compared to those of 1981. Even the CDC defines breastfeeding at the
breast or receiving breastmilk.

The Academy of Breasfeeding Medicine even states in its
Supplementation Protocol:
"When supplemental feedings are needed, one of the following
techniques may be used: a supplemental nursing device at breast, cup
feeding, spoon or dropper feeding, finger-feeding, or bottle feeding.
There is little evidence about the safety or efficacy of most
alternative feeding methods and their effect on breastfeeding;"

In 1981 WHO and UNICEF made the final recommendations:

to continue efforts to promote breast-feeding as well as sound
supplementary feeding and weaning practices as a prerequisite to
healthy child growth and development;

to intensify activities in the field of health education, training and
information on infant and young child feeding;
the marketing of breast-milk substitutes and weaning foods must be
viewed within the framework of the problems of infant and young child
feeding as a whole;

the aim of the code should be to contribute to the provision of safe
and adequate nutrition of infants and young children, and in
particular to promote breast-feeding and ensure, on the basis of
adequate information, the proper use of breast-milk substitutes,

if necessary=85
products should meet international standards of quality and
presentation=85and their labels should clearly inform the public of the
superiority of breastfeeding."

The Executive Board of the WHO recommended the Code as we know it
today in 1981 and realized in 1981 that it "might be desirable or even
necessary to revise the code at an early date in the light of the
experience obtained in the implementation of its various provisions.
This has not happened since 1981.

I feel the WHO Code needs to be updated and before we continue to
judge and throw spears at LCs and corporations I invite you to really
think about the process that is used to determine compliancy and ask
for the CODE to be updated.

Karen Querna, RN, BSN, IBCLC, RLC
Spokane, WA USA

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