Breastmilk Has No Substitute protecting breastfeeding and enforcing the code in cambodia

As the breastmilk substitutes (BMS) industry uses increasingly aggressive and unethical marketing around the world, infant formula usage has risen sharply in Cambodia, undermining breastfeeding practices.

The 2014 Cambodia Demographic and Health Survey revealed that the rate of exclusive breastfeeding during infants’ first six months fell from 74% in 2010 to 65% in 2014 – at a significant cost to the babies, mothers, and health and economic systems in the country.

Alive & Thrive’s Cost of Not Breastfeeding tool found that every year in Cambodia, optimal breastfeeding practices can prevent over 1,000 child deaths and save above USD $539 million.

The Cambodian government translated the International Code of Marketing of Breastmilk Substitutes (the Code) into national legislation. The Sub-Decree on Marketing of Products for Infant and Young Child Feeding (Sub-Decree 133) was passed 2005.

Sub-Decree 133 is classified by WHO, UNICEF and IFBAN as “Moderately Aligned with the Code”, setting a foundation to protect infants and young children under two from the misleading and inappropriate promotion of infant formula and other BMS.

In this photo, four-month-old baby is fed with formula milk by her grandmother while her mom is away for work.

However, a study to assess the promotion and consumption of commercial products for infants and young children in Phnom Penh revealed that 86% of mothers reported observing commercial promotions for BMS, 19.0% reported observing infant and young child food product brands or logos on health facility equipment, and 18.4% reported receiving a recommendation from a health professional to use BMS.

These data are clear signs that companies are violating the Code and creating conflicts of interest in the health system. Actions like these risk babies’ health and undermine their parents’ right to accurate information about infant feeding.

A recent study by Alive & Thrive reveals the industry is now using the COVID-19 pandemic to capitalize on families’ fears and sell their products.

BMS companies gave many products away for free before the pandemic, and continue to do so as a standard marketing tactic. This "giveaway" is conducted in a shop in Cambodia by the corporation Bibere.

The enforcement of Sub-Decree 133 became a hot topic in Cambodia last July, when at least 17 families in Cambodia complained to the Ministry of Health that their infants’ health were adversely affected after having been fed with Nutrilatt formula milk powder. The infants were hospitalized due to severe iron deficiency and anemia.

Acting on the complaints, the Cambodian Directorate-General of the Competition and Fraud Repression Department (Ministry of Commerce) conducted an investigation of these products and found that the formula contained only a fraction of the iron and zinc required by law - putting babies' health at serious risk with a grave Code violation.

In this photo, The General Department of Consumer Protection, Competition, and Fraud Repression (CCF) officials inspect supermarkets, pharmacies, and stores to confiscate Nutrilatt formula in Tbong Khmum province. Photo Credit: Phnom Penh Post.

The Ministry of Commerce ordered Nutrilatt to halt the sale of products in Cambodia. CCF, with the support of Helen Keller International (HKI), UNICEF and Alive & Thrive continued testing 60 other formula milk brands, revealing that many exaggerated the amounts of iron and zinc their products contained. Out of the 60 BMS brands tested, one in five brands had low levels of iron compared to what they advertised on their labels, while one in ten brands had exaggerated the levels of zinc on their labels. This photo shows brands going through a blind test with black ink, revealing their levels of iron and zinc.

Subsequently, CCF convened a meeting with BMS companies to urge the recall of those products that put babies’ health in immediate and grave danger.

In this photo, CCF staff prepare and register products before spraying them with black ink for the blind iron and zinc test.

CCF disseminated the lab results to BMS companies, and called a separate meeting with the companies who had committed violations, which focused on recall of dangerous and unqualified products from the market.

In the wake of unethical marketing of BMS companies and the Nutrilatt scandal, it was clear that stronger legislation and regulation around harmful BMS marketing practices and BMS quality was needed.

Advocating for stronger child health protections, HKI, UNICEF, WHO and Alive & Thrive submitted a joint statement to the Ministry of Health recommending the amendment of Sub-Decree 133.

The scope of the law was extended to regulate the marketing of products for children up to 36 months of age; closing loopholes that allow BMS companies to engage with health workers; monitoring and enforcing the Code on social media; and increasing penalties for violators.

Simultaneously, together with HKI, A&T is working to improve on-going monitoring of Sub-Decree 133 through capacity building for Point-of-Sale monitoring for CCF staff at provincial level.

These inspectors are trained to use checklists to identify Code violations by shop owners, which were then recorded for further enforcment.

More than 100 inspectors, from each of Cambodia’s 25 provinces, were trained to monitor Code violations. Training included visits to shops, where inspectors used checklists to identify violations of the Code.

To facilitate Code monitoring in health facilities, A&T supported the integration of Sub-Decree 133 into early essential newborn care assessment checklists that are used in 15 provincial referral hospitals and two district referral hospitals.

Alive & Thrive’s work to support the enforcement of BMS regulations earned an official letter of appreciation from CCF and Cambodia's Ministry of Commerce.

Alive & Thrive and partners, including HKI, UNICEF, and WHO, are actively involving in efforts to ensure that the national code and supportive policies are fully implemented and enforced to support breastfeeding - protecting our most vulnerable lives.

We must enforce the BMS Code to #ProtectBreastfeeding and put #BabiesBeforeProfits.

The Alive & Thrive initiative, managed by FHI Solutions, is funded by the Bill & Melinda Gates Foundation, Irish Aid, and other donors.

Photo Credit: Giacomo Pirozzi | Alive & Thrive

Pries, A. M. (2016b). Pervasive promotion of breastmilk substitutes in Phnom Penh, Cambodia, and high usage by mothers for infant and young child feeding. Maternal & Child Nutrition, 12(Suppl 2), 38–51. https://doi.org/10.1111/mcn.12271

Created By
Mackenzie Mayo


Alive & Thrive