Global Health Leaders Call for End to Formula Company Sponsorship

Letter to The Lancet highlights ‘aggressive marketing’ by manufacturers of commercial milk formula

International Lactation Consultant Association® (ILCA®) partnered with five global and regional healthcare professional associations (HCPAs), including midwives, neonatal nurses, breastfeeding medicine specialists, and paediatricians to draft a letter that was published in The Lancet on 9 March that calls for an end to sponsorship by companies which manufacture commercial milk formula. This call to action comes in recognition of the harm such sponsorship causes to the health of infants and their mothers worldwide.

The letter, of which ILCA Board President Iona Macnab, BA(Hons), LLB, IBCLC, served as corresponding author of, points out that in 2016, the World Health Assembly (WHA) had passed a Resolution and the World Health Organisation (WHO) had issued guidance stating that HCPAs should not allow such companies to sponsor meetings of health professionals and scientific meetings, on the grounds that such events are marketing activities which create a conflict of interest among health professionals. The authors state that “Sponsorship of educational events influences many activities, including research and prescribing behaviour, even when healthcare professionals do not recognise this influence.”

Macnab and others say, “we pledge to support and assist our member associations to end sponsorship from companies that market breastmilk substitutes through training, advocacy for policy development and implementation, information dissemination, and monitoring.”

The letter follows many recommendations from WHA, WHO, UNICEF and other global organisations over the years in an attempt to control the marketing by commercial milk formula companies, which make false claims about the benefit of artificial feeding over breastfeeding. The health benefits of breastfeeding in all countries are well proven and current marketing practices are damaging to the health of infants by making it appear that formula fed infants are as healthy as breastfed babies – which is demonstrably false.

The new initiative being taken by global health leaders in this Lancet letter is supported by WHO and will be followed by further actions by the leaders (none of whose organisations accept formula company sponsorship) to bring their experience to bear on associations which still take such funding and are exposed to conflict of interest as a result.

About the issue: Marketing to parents and health professionals by commercial milk formula companies (also known as manufacturers of breastmilk substitutes) has been a major problem in global health for decades, and led to the launch of the International Code of Marketing of Breastmilk Substitutes (the Code) in 1981 which established minimum requirements for regulation of marketing of commercial milk formula, later expanded by subsequent WHA resolutions. Unfortunately there have been many violations of the Code by companies over the which was described fully in a recent Lancet series in 2023. Commercial milk formula company sponsorship of educational meetings for paediatric societies and other healthcare professional associations has become the norm, with a 2019 WHO survey finding that 60% of 114 paediatric associations received such sponsorship.

Letters published in the Correspondence section represent the views of the authors and not necessarily the views of The Lancet journals. Letters to the Editor are not normally externally peer reviewed. 

Challenges and Opportunities in the Global Lactation Consultant Profession: A Summary and Invitation for Discussion

by Lisa Mandell, MBA, IBCLC, Global Advocacy Adviser, ILCA

On 13 August, I was honored to moderate the opening plenary session at the ILCA 2023 Annual Conference, which took place in Las Vegas, Nevada, USA. It was truly delightful to work with a varied group of expert panelists, which included:

  • Nadrah Arifin, Physician and Lactation Consultant (Malaysia)
  • Paulina Erices, MS, IBCLC (USA; originally from Chile)
  • Egondu Onuoha, MS, RDN, IBCLC (USA; originally from Nigeria)
  • Daiva Sniukaite, MA, IBCLC (Lithuania)

The session commenced with a brief outline of just some of the advocacy work that ILCA is engaged with on the global stage, followed by introductions from the panelists. I then shared a startling statistic: Globally, there are about 35,700 IBCLCs; of this, approximately 19,000 are in the United States, leaving only 16,000 IBCLCs in the rest of the world. Many countries have no IBCLCs at all, or very few. In comparison, there are approximately 28 million nurses and 1.9 million midwives, worldwide.

Given these relatively small numbers, the panel discussed how IBCLCs can most effectively impact breastfeeding/chestfeeding. Much of the discussion centered around working with and training peer counselors, removing barriers and partnering with other health care providers, and how IBCLCs can work to coordinate support, which in turn will hopefully increase the numbers of IBCLCs.

Another part of the discussion focused on providing culturally sensitive or responsive care. Agreeing that this is a critical skill, the panelists discussed the need for intentional learning in this area, availability of lactation care providers who come from different cultures, and the importance of being able to provide alternative solutions when one solution isn’t readily accepted in a culture.

A major challenge shared by all panelists was the lack of recognition of the IBCLC – legal or professional recognition allowing providers to work, as well as recognition by other health care providers. The panelists shared their varied experiences working on this issue. This is an important area for ILCA’s advocacy efforts and we look forward to working at the global level and with national associations to address this.

During the session, we also discussed some of the outside influences, such as the lack of regulation of marketing of commercial milk formula and maternity protections, both of which influence breastfeeding. This pointed to the need for more IBCLCs, improved training programs, emphasizing the value and importance of breastmilk and maternal/child health, addressing disparities, and increasing data collection on breastfeeding to be better able to advocate for policy changes.

Our final topic of discussion was how we can best work together with other IBCLCs, ILCA members, peer supporters, health care providers, etc. The key themes of discussion were collaboration, inclusivity, and connection.

Continue the Conversation

As ILCA’s Global Advocacy Adviser, I encourage you to share your thoughts by submitting a comment (click on the though bubble icon below). Consider the following questions: What challenges are you currently facing that were not addressed during the session? Of the challenges addressed, which are ones you don’t face or perhaps haven’t thought of? What other opportunities can you suggest?

Report on WHO’s Global Congress on the Implementation of the International Code of Marketing of Breast-milk Substitutes (the Code)

by Lisa Mandell, MBA, IBCLC, Global Advocacy Adviser, ILCA

As the Global Advocacy Adviser for International Lactation Consultant Association® (ILCA®), I had the honor and privilege of attending the Global Congress on the Implementation of the International Code of Marketing of Breast-milk Substitutes in Geneva, Switzerland, 20-22 June 2023, on behalf of our association. This informative and inspiring meeting was attended by more than 400 delegates from over 100 countries, all of whom gathered to learn more about,  develop plans for, and make commitments to the implementation of the Code.

The Purpose of the Congress

The Code has been shown to improve breastfeeding rates, yet many countries have not enacted legislation (or have weak legislation). The Congress served as an opportunity to increase the knowledge and understanding of the Code, help develop national roadmaps for implementation or improvements of the Code, and develop regional networks to continue support for work on the Code.

Summary of the Congress

The Congress opened with a presentation by Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. Dr. Tedros explained that the Code helps protect health, nutrition, and development in the first years of life, and cited that rates of exclusive breastfeeding are 20% higher in countries with legislation substantially aligned with the Code than in those without. He identified that the original concerns that prompted development of the Code were contamination of water used for formula in poor areas, but now, increased research and understanding of health impacts shows the importance of the Code in both low- and high-income countries, but that legislation has mostly been very limited in high income countries. He identified that the Code is a core obligation of countries and exclaimed that now is the time to end exploitative marketing, which is what the Code aims to do.

A series of other high-level speakers brought up many important points:

  • Half of the world’s children are not exclusively breastfed
  • Sophisticated marketing of commercial milk formula is impacting breastfeeding rates
  • We must recognize and uphold the right of every child to good nutrition and of every family to accurate information and support
  • Structural discrimination and racism impact the right to health, creating health inequities
  • Commercial determinants of health are important factors to understand
  • There is an important need for paid maternity leave, access to safe, clean, private places to express milk, and listening to women
  • Breastfeeding thrives with skilled support

Of particular interest, Clare Patton from the School of Law at the University of Leeds spoke about breastfeeding in a human rights framework. She explained that the Convention on the Rights of the Child (CRC, article 24) and the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW, article 34) identify breastfeeding rights. She said breastfeeding should be recognized as a standalone human right, and further explained that human rights laws apply to states (countries), that the state has the duty to educate, protect citizens, and enact legislation such as the Code. The commercial milk formula industry has no responsibility to protect, promote, or support breastfeeding; rather, their responsibility is to NOT market commercial milk formula.

Katie Pereira Kotze from First Steps Nutrition Trust clarified the scope of the conflict between public health and industry by contrasting a WHO video on social media that had 10,000 views and a video from a commercial milk formula company that had over 500,000 views. She also contrasted WHO’s entire annual budget of $3.3 billion vs. the $55 billion market for commercial milk formula.

Jeanette McCulloch from the Global Breastfeeding Collective offered guidance on advocacy around the Code and reviewed the importance of establishing a strategic group including influencers, enforcers, and experts, determining concrete actions you want the target of your efforts to take, and building a network of allies. She emphasized that efforts supporting Code legislation are not about restraining individual feeding choices (and the importance of making that clear). She quoted Loretta Ross with this advice: “Don’t confuse problematic allies with your enemy.”

Marion Nestle, professor emerita, New York University, spoke compellingly about the conflicts of interest in many industries, and how industries work hard to lobby government officials, sponsor research, and hide their influence. Phillip Baker of Deakin University cited the incredible $55 million spent just on lobbying for the commercial milk formula industry in the United States over a 12-year period and identified the fundamental conflict of interest between the baby food industry and public health. He reviewed strategies for countering industry influence.

Kathy Shats from UNICEF, David Clark, legal consultant formerly with UNICEF, and Fatmata Fatima Sesay from UNICEF provided lots of information on understanding the Code. Kathy later identified steps to take in pursuing Code legislation, starting with establishing baseline measurements on breastfeeding rates, companies operating in the country, current marketing practices, and more. Next, reviewing existing laws, including in other industries, and evaluating their effectiveness and how they are being monitored and enforced. Additionally, considering financing mechanisms, and what to include in legislation vs. regulations. David later presented information on ensuring effective legal enforcement. Kate Robertson from WHO provided detailed information on how to draft legislation that does not trigger concerns about restraint of trade, and how to address those concerns if they do arise. Marcus Stalhofer from WHO provided further information on monitoring and enforcement provisions, and how to strengthen them.

Elizabeth Zehner from Helen Keller International reviewed the many resources on the Code, most of which are available on the Global Breastfeeding Collective Toolkit. She and others highlighted several new resources:

  • What I Should Know About ‘the Code’: A guide to implementation, compliance and identifying violations
  • Clarification on Sponsorship of Health Professional and Scientific Meetings by Companies that Market Foods for Infants and Young Children
  • Protecting Infant and Young Child Nutrition from Industry Interference and Conflicts of Interest

Speakers also reviewed the findings of these recent important publications:

In addition, there were several presentations from countries and from non-governmental organizations (NGOs) sharing inspiring examples of how they overcame resistance to implement or strengthen legislation on the Code. Of particular interest to me was a speaker from Timor Leste who spoke about the importance of positioning nutrition as “politics neutral.”

On the first day of the Congress, a panel of mothers was included to help illustrate the importance of Code legislation. The mothers spoke about their experiences of having their infant feeding choices impacted my manipulative marketing. One mother said “I wish breastfeeding support would be marketed as much as formula.”

Perhaps the most important work of the Congress occurred in breakout work sessions, where country delegations from a region gathered to work on understanding their Code legislation (or lack thereof), and what they can do to move forward, culminating with commitments for actions to take. I was a facilitator for the North America and Caribbean Region and was delighted to work with fellow facilitators from UNICEF and the dedicated groups of people from Canada, United States, Antigua and Barbuda, Barbados, Guyana, Haiti, Jamaica, St. Kitts and Nevis, and Trinidad and Tobago. In total, over one hundred countries’ commitments were shared visually and select countries highlighted their commitments verbally. Additionally, the countries provided information on how they might continue to work together in regional networks to continue to advance work on the Code.

Next Steps and What You Can Do

The real determination of success of this Congress will be in seeing countries fulfilling these commitments and moving forward with enacting new legislation or strengthening existing legislation. This work will depend on much support from beyond governments, including from those working with breastfeeding families. I was thrilled to see at least 20 IBCLCs in attendance at the Congress and was able to gather 15 of them together for a photo! It is important to have IBCLCs at the table when policies related to infant and young child feeding are being determined, and it is exciting to see IBCLCs in health ministries and other positions. Look for more information and opportunities to become involved and advocate for the Code in your country.

A Recap of the USA Launch of the Lancet Series on Breastfeeding

by Lisa Mandell, MBA, IBCLC and Tova Ovits, BA, IBCLC

The USA launch of the Lancet Series on Breastfeeding took place 18 April 2023 in New York, New York, USA, and was attended by representatives of the International Lactation Consultant Association® (ILCA®), including Tova Ovits, BA, IBCLC, secretary of the ILCA Board of Directors, and Lisa Mandell, MBA, IBCLC, ILCA’s Global Advocacy Adviser. ILCA Executive Director Jenn Kasowicz, MA, attended the launch virtually. Ellen Chetwynd, PhD, MPH, BSN, IBCLC, the Editor-in-Chief of the Journal of Human Lactation, was also in attendance.

The purpose of ILCA’s representation at the launch was to gain insight into how the important information within the papers was being presented in the United States, and to have the opportunity to speak with other breastfeeding supporters and to advocate for skilled lactation care.

Introductory speakers Victor Aguayo, PhD, Director of Nutrition and Child Development at UNICEF, Fatmata Fatima Sesay, Nutrition Specialist in Infant Feeding at UNICEF, and moderator Nina Martin, editor and reporter for Reveal/Center for Investigative Reporting, opened the launch, collectively stating that the enablement of breastfeeding is a collective societal responsibility, not the responsibility of individual families, and set the stage for what the findings of the Lancet series mean for breastfeeding in the United States.

While 83% of birthing parents in the US initiate breastfeeding, only 24.9% of babies are being exclusively breastfed at six months of age, supporting the recurring theme that there is greater need for systems of support, including paid family leave and skilled breastfeeding support.

From the Series Authors’ Perspective

Rafael Pérez-Escamilla, PhD, professor at the Yale School of Public Health, explained that the phrase “commercial milk formula” (CMF) was used in the series rather than “breastmilk substitute” to highlight the artificial, processed nature of formula. The word “substitute” implies that formula is equivalent to human milk despite it being so different.

He discussed how commercial milk formula companies and marketers influence beliefs, values, and practices, especially by reframing normal baby behaviors (fussing, crying, spitting up) and creating opportunities that position formula as the solution. He also highlighted case studies from four countries which illustrated how investments in breastfeeding over the past decade has improved exclusive breastfeeding rates in those countries.

Cecília Tomori, PhD, Associate Professor and Director of Global Public Health and Community Health at the Johns Hopkins School of Nursing, identified that marketing of commercial milk formula has a powerful system of influence that is multifaceted, sophisticated, and well-resourced, especially with digital marketing that sells peace-of-mind while undermining parental self-efficacy. This type of product marketing differs from others as it has lifelong effects on the health, development, and rights of children.

She also shared that the WHO International Code of Marketing of Breast-milk Substitutes is oftentimes blocked, reinterpreted, circumvented, and ignored, and that the Codex Alimentarius is manipulated to establish weak standards that become a ceiling for CMF marketing regulation, instead of the minimum. Tomori emphasized that criticism of the industry’s marketing practices is not a criticism of parents’ decisions on how to feed their babies, further stating that the system targets individuals, families, society, businesses, government, and politicians to shape decisions that increase shareholder profits but at great cost. 

Katheryn Russ, PhD, Professor and Chair of Economics at the University of California – Davis, explained how the commercial milk formula industry is highly concentrated, with six highly profitable companies representing the majority of worldwide sales and provided examples of how the industry has worked to impact public policy and trade policy in the US. Inadequate paid leave makes it harder to breastfeed, and other policies make it difficult to pump milk at places of employment.

The authors also identified how racism in the US has resulted in inequities in Black and Brown communities, including breastfeeding support. 

Key Messages from the Series

  • Breastfeeding success is a collective responsibility that depends on multifaceted policy and societal responses and is not the sole responsibility of individuals.
  • Infant behaviors, such as sleep and crying, have normal trajectories like learning to walk or speak and can be misinterpreted as hunger or reframed as ‘abnormal’ to promote artificial solutions.
  • Commercial milk formula marketing influences our beliefs, values, and practices. It has changed the infant-feeding ecosystem and its extent and power has not been fully appreciated by most in health, civil society, and government.
  • There are many constraints for individuals who want to breastfeed. It is the responsibility of governments to implement structural interventions and policies to support breastfeeding and mitigate negative, undermining influences.

Additionally, the series speakers spoke about specific implications of the global Lancet series in the United States, and the many challenges facing implementation of the recommendations. Among the many important points they made, the following were most notable.  

  • The US voted against adoption of the International Code of Marketing of Breastmilk Substitutes in 1981 and has continued to undermine the Code and subsequent World Health Assembly (WHA) resolutions.
  • Lax privacy laws in the US allow for targeted digital marketing of CMFs and the lack of Code legislation results in rampant formula marketing of all kinds.
  • US trade policy positions undermine attempts of other countries to regulate inappropriate marketing of CMFs.
  • According to the Organization for Economic Cooperation and Development, the US is the only country out of 41 that lacks mandated paid parental leave.
  • Systemic inequities in the US result in Black and Hispanic parents being significantly less likely than white parents to meet their breastfeeding goals. These same inequities influence Native and Indigenous families, but data is lacking. Racism is a key driver of these inequities.
  • Many factors, including climate change, emergencies, water safety issues, formula contamination, racism, and more, result in a vulnerable first-food system in the US and contribute to an infant feeding crisis.
  • There is extensive influence on health professionals in the US through sponsorship of conferences, associations, and research by CMF manufacturers (in violation of WHA 69.9).
  • Health professionals in the US receive insufficient lactation training.
  • The Baby Friendly Hospital Initiative (BFHI) has been a huge success in the US, with over a million births (almost 28% of all births) taking place in 590 BFHI-designated facilities.
  • BFHI in the US still needs more investment, especially in facilities that serve communities that have not been reached, including many that serve Black and Brown communities.
  • The 2022 White House National Strategy on Hunger, Nutrition, and Health recommends expanding breastfeeding support and counseling for mothers (p. 26) and recognizes some of the societal problems that need to be addressed.

Panelist Perspectives of US-Specific Issues

Sekeita Lewis-Johnson, DNP, FNP-BC, IBCLC, from the US Breastfeeding Committee’s Board of Directors, spoke about the need for greater breastfeeding support due to the coercion to give formula, lack of access to care, and lack of informed choice. She identified the important work needed to correct policy failures and to prevent them from happening again, the need for infrastructure to deal with emergencies, and the importance of centering policy decisions on the lived experience of Black and Brown families.

Ruth Petersen, MD, MPH, Director of CDC’s Division of Nutrition, Physical Activity, and Obesity, identified that although there have been improvements in breastfeeding initiation, racial disparities remain and that 60% of breastfeeding parents don’t meet their breastfeeding goals. The CDC now has county-level data that can help evaluate disparities and help local advocates focus on areas that need more support.

Stacy Davis, MPH, IBCLC, the Health Equity and Community Partnerships Manager for the National Women, Infant and Children (WIC) Association, spoke about the lack of societal support and the different needs in rural areas in accessing support. She identified that WIC is working to train staff as registered dieticians (RDs) and International Board Certified Lactation Consultants (IBCLCs) so they are more reflective of the communities they serve.

Lori Feldman-Winter, MD, MPH, Professor of Pediatrics at Cooper Medical School of Rowan University, identified the huge gap in physician education on breastfeeding as an important issue, with 55% of recent graduates reporting no training. She also discussed the lack of accountability and collaboration with other healthcare providers as well as short visits in clinical settings as contributing factors. Prenatal opportunities to discuss how to breastfeed, not just why, help increase breastfeeding initiation rates.

Camie Goldhammer, MSW, LICSW, IBCLC (Sisseton-Wahpeton Oyaté), clinical social worker and lactation consultant, founder of several organizations, and a devoted leader for Indigenous families, discussed the significant lack of diversity of IBCLCs and how breastfeeding is a traditional cultural practice. She emphasized the importance of increasing access to high-quality lactation support, especially with more peer counselors.

Tina Sherman, Senior Campaign Director for Maternal Justice at MomsRising, highlighted several achievements: the passage of the PUMP Act, Pregnant Workers Fairness Act, and the postpartum Medicaid extension. She shared that she would like to see more accomplishments in the areas of paid leave, affordable childcare, and having every parent go home with their baby.

ILCA’s Participation

As the only international association representing skilled lactation consultants, ILCA continues to support and actively participate in important advocacy-related efforts such as the Lancet Series on Breastfeeding. At the conclusion of the presentation, ILCA’s Advocacy Adviser Lisa Mandell thanked the Lancet authors and panelists, recognized the number of IBCLCs on the panel and in the audience, and asked how lactation professionals can help improve coordination of lactation care after hospital discharge.

Lori Feldman-Winter suggested that lactation consultants collaborate with and participate in dialogue with pediatricians about such cases. Sekeita Lewis-Johnson emphasized the importance of respect for the different roles of care providers, as well as the importance of dismantling the hierarchies prevalent in the healthcare field. 

What You Can Do

ILCA invites and encourages you to read the important information presented in the 2023 Lancet Series on Breastfeeding, and consider how you can use this information to advocate for improved policies and support in your community. You can also watch a recording of the USA Lancet Series on Breastfeeding launch, available in English and Spanish, here.

A Sneak Peek at the ILCA 2023 Annual Conference: Q&A with the Chair of the Conference Program Task Force

International Lactation Consultant Association® (ILCA®) recently sat down with Hannah Rice, MPH, IBCLC, Chair of the 2023 Conference Program Task Force (CPTF) for a behind-the-scenes look at program-planning for the ILCA 2023 Annual Conference, taking place 13-15 August 2023 at the Hilton Lake Las Vegas Resort and Spa in Las Vegas, Nevada, USA.

With a number of innovative and thought-provoking sessions planned for this year, we wanted to give the lactation community a sneak peek of just some of what can be expected at this year’s conference before full session details are made available in May. Read the Q&A to learn about Hannah’s role, gain insight into some of this year’s session topics, what she is most excited about, and why this year’s conference is one not to miss!

Q&A with Hannah Rice, MPH, IBCL

Q: Please share a bit about your professional background and what brought you to ILCA.
A: My academic and professional background is in education and public health. I received my MPH in Global Health at UNC Gillings School of Global Public Health, where I attended the Mary Rose Tully Training Initiative to become a lactation consultant. I now work at Duke University as an IBCLC in pediatric outpatient services. I was drawn to ILCA as it provided me the opportunity to combine my passion for education, research, and lactation care. I love being a part of this collaborative and supportive community of lactation professionals!

Q: What excited you about the opportunity to serve on the Conference Program Task Force?
A: I truly believe that it is our duty as lactation professionals to continually learn and grow in our practice. The ILCA Annual Conference is an exciting opportunity to stay informed on cutting-edge research to better support families and communities in their breastfeeding goals. It is an honor to be part of the CPTF team.

Q: Abstract submission numbers are higher this year than they have been the past two years; as your team reviewed the submissions, what were some of the big/recurring themes you saw across all submissions?
A: There were a lot of great submissions sent in this year! One of the particularly exciting aspects of the many submissions we received were the new and innovative perspectives on common challenges we face in the lactation field. Many of the authors presented novel approaches to understanding and practicing key elements of lactation care.

Q: What did the CPTF look for when reviewing submissions for concurrent sessions?
A: With so many great submissions, it was difficult to select only a few for the concurrent sessions. The CPTF focused on identifying submissions with strong evidence-based research and content that was inclusive of our diverse ILCA community.

Q: Without giving away too much, is there any accepted content that you are excited about this year? 
A: I am most excited about the wide range of topics that are covered in this year’s sessions. There will be speakers addressing policy, research, programmatic, clinical, and advocacy topics, providing interdisciplinary perspectives on key issues in the lactation field. Some of the highlights will be presentations on postpartum mood disorders, microbiota, and equity in lactation training and practice.

Q: Why should someone attend this year’s Annual Conference?
A: This is a special year as we can finally join together again and learn with one another in person. What is also really great is that anyone who registers for the in-person conference will get access to all the virtual and recorded sessions as well. This means more opportunities to access the interesting and exciting content from our speakers.

Learn More

Visit the ILCA 2023 Annual Conference website for event details. Additional information will be posted online as it becomes available.

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A Recap of the 2023 Lancet Series

by Lisa Mandell, ILCA Global Advocacy Advisor and Zoe Faulkner, ILCA Board of Directors

The Lancet published a powerful 2023 Series on Breastfeeding during an in-person event held 8 February 2023 in London, United Kingdom.

International Lactation Consultant Association® (ILCA®) Board Member Zoe Faulkner, who is also Chair of Lactation Consultants of Great Britain, attended the in-person launch and shared, “It was a real privilege to be in person at an event that was being live-streamed internationally. There was an incredible atmosphere in the room, with a sense of hope and excitement that these papers may play a part in enabling positive change.”

During the Series’ Q&A portion, she asked if now was the time to also focus attention on the workforce that is so vital to counseling and supporting breastfeeding families.

“It appears that the lack of understanding of the importance of breastfeeding for public health is also reflected in a lack of understanding of the infant feeding workforce, inclusive of the knowledge, skills, and the range of roles that provide the support services that mothers and lactating individuals need. This workforce is inclusive of peer supporters, breastfeeding counselors, International Board Certified Lactation Consultants, midwives, and health visitors such as community public health nurses – all of whom collectively play a role in providing vital support.”

The 2023 Lancet Series on Breastfeeding builds on the 2016 Lancet Series on Breastfeeding and explores how the value of breastfeeding is undervalued and underinvested in by governments and public health, and how the vulnerabilities of women and children are exploited by the Commercial Milk Formula industry. The three-paper series is structured around the following themes, as outlined at the launch:

  1. How baby behaviors, such as sleep and crying, are misunderstood and misconstrued to undermine breastfeeding, but multi-sectoral interventions can protect the extensive health impacts of breastfeeding
    • Unsettled infant behaviors such as crying, fussiness, posseting/spitting up, and short night-time sleep duration are common and normal
    • These behaviors often result in parents changing from breastfeeding to commercial milk formula (CMF) or from one CMF to another or to a specialized CMF that claims (without evidence) to resolve the issue
  2. How the formula marketing ‘playbook’ targets parents, health professionals, and politicians, and undermines the health and rights of children and mothers
    • CMF sales worldwide have grown from $1.5 billion USD in 1978 to $55.6 billion USD in 2018 (a 3,700% increase in 41 years)
    • Health professionals are targeted by CMF companies due to their capacity to encourage sales
    • CMF companies are large and powerful. The four largest companies together generated $187 billion USD in revenue in 2022These four CMF companies employed more than 535,000 people globally in 2018, which is greater than the entire health workforce of South Africa, Zimbabwe and Lesotho combined
    • “CMF marketing impinges on the human rights of women and children, harms their health, and adversely affects society”
  3. How power imbalances and political and economic structures determine feeding practices, women’s rights, and health outcomes
    • Breastfeeding and breastmilk are not included in most countries’ gross domestic product (GDP), so improving breastfeeding rates does not impact GDP, while increasing CMF sales does
    • The monetary value of the milk produced by breastfeeding women globally is estimated to be about $3.6 trillion USD
    • Unpaid care work, including breastfeeding, is primarily performed by women; not including the value of this unpaid care work shifts policy priorities away from it and exacerbates gender inequities
    • The CMF industry exacerbates economic disparities and health inequalities; the harms associated with CMF concentrate in low and middle income countries, while the shareholders of CMF companies who increase their wealth through increased CMF sales are almost exclusively in high-income countries

A number of critical points were made throughout the series, with the following quotes being especially relevant to the role of lactation consultants and International Board Certified Lactation Consultants (IBCLCs):

“…universal access to improved breastfeeding-supportive maternity care, evidence-based breastfeeding counselling, and public and health worker education are crucial for preventing common early lactation problems, avoiding attempts to address common behaviors of infant development by introducing CMFs, and helping mothers improve their breastmilk production and self-efficacy.”

“Skilled counselling and support should be provided prenatally and post-partum to all mothers to prevent and address self-reported insufficient milk and avert the introduction of prelacteal feeds or CMF early on…”

“Health professionals, mothers, families, and communities must be provided with better educational support and skill development, free from commercial influence…”

Key Takeaway

“Breastfeeding success is a collective responsibility that depends on multifaceted policy and societal responses. Fact-based information on feeding infants and young children that is free from commercial influence is a human right that must be made available to all.”

What You Can Do

The Series offers excellent, well-researched support for any policy decisions related to breastfeeding and supporting new families, and highlights the importance of regulation and the legal protections governments can and should provide. ILCA encourages all involved in infant and young child feeding to read these papers, amplify the messages, and act on the recommendations they provide. Lactation consultants, especially IBCLCs, should be part of every solution, from providing training for health professionals, helping to make policy decisions, and providing care to breastfeeding families.

ILCA is committed to providing the latest, quality education free from commercial influence, and upholds the WHO International Code of Marketing of Breast-milk Substitutes and subsequent resolutions. ILCA strives to support and empower all lactation consultants and IBCLCs to advocate locally, nationally, and globally for breastfeeding and for the policies that promote, protect and support breastfeeding.

The USA launch of the 2023 Lancet Series on Breastfeeding will be held on 18 April in New York, NY. Learn more about it and register for the livestream here.

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ILCA Participates in WHO Meetings Pertaining to HCPA Sponsorships

by Lisa Mandell, Global Advocacy Adviser, ILCA

In November of 2022, I participated in a series of virtual meetings organized by World Health Organization (WHO) that addressed sponsorships from the baby food industry. Attended by a number of national and international healthcare professional associations (HCPAs), these meetings were an important step in the long process of realizing the goals of the International Code of Marketing of Breastmilk Substitutes (Code), and all subsequent, relevant WHA resolutions.

During the meetings, the case was made for why it is critical to end such sponsorships, and several speakers presented their successes in doing so. Attendees participated in breakout group discussions aimed at identifying reasons for accepting sponsorships, key obstacles to moving forward, and opportunities and next steps.

Associations such as Royal Australasian College of Physicians (RACP), Indian Academy of Pediatrics (IAP), and the British Medical Journal (BMJ) highlighted how they ended such sponsorships. The BMJ ended advertising from formula companies as a result of commissioning an article by Chris van Tulleken in 2018 on “Overdiagnosis and Industry Influence: How Cow’s Milk Protein Allergy is Extending the Reach of Infant Formula Manufacturers.” This article identified that prescriptions for specialized commercial milk formulas for infants with cow’s milk protein allergy (CMPA) increased by nearly 500% over a ten year period, from 2006 to 2016, while there is no epidemiological data to support such a large increase in prevalence of CMPA, and suggesting an industry-driven overdiagnosis. When physicians get their information about CMPA from formula manufacturers and their research, they are subject to the bias of the commercial entity. 

ILCA has been a leader in refusing sponsorship from companies who do not meet their obligations under the Code. ILCA’s International Code Committee critically reviews all applications for sponsorship, and works with companies to understand their obligations. This recent meeting was an opportunity to share that expertise with other associations, as well as ILCA’s continued work and diligence in this area. ILCA is also a member of the planning committee for a Global Congress on Implementation of the International Code of Marketing of Breastmilk Substitutes being convened by WHO and UNICEF in June 2023.

Stay tuned for more information on ending sponsorship by HCPAs, and increasing implementation and monitoring of the Code – and especially what YOU can do to help.

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What is Codex, and Why is it Important?

You’re a lactation professional working with families to help solve breastfeeding/chestfeeding problems. Why should you care about something called the Codex Alimentarius Commission?

Your focus may be to help families reach their breastfeeding/chestfeeding goals. Think about some of the things that get in the way of that – poor information and advice from other health professionals and from families and friends, physiological challenges, and most certainly easy availability and heavy promotion of breastmilk substitutes. When breastmilk substitutes need to be used, you want to be sure that they meet basic standards, and that they are not labeled and marketed in such a way as to further discourage breastfeeding. That’s where international food standards come in, and the Codex Alimentarius Commission (Codex) is the global body that sets those standards.

The Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) are the parent bodies of the Codex Alimentarius Commission. The members of Codex are member countries, with 188 member countries plus the European Union. Non-governmental organizations (NGOs) can apply for observer status with Codex and participate in meetings, offering expert opinion and information. ILCA is officially recognized as an observer for Codex, and has been participating and contributing to these meetings for 16 years; Maryse Arendt has been the primary spokesperson for ILCA at these meetings, and Lisa Mandell, ILCA’s Global Advocacy Adviser, joined her this year.

Codex has more than 15 different committees that work in specific areas. The one that sets standards for infant formulas, follow up formulas, and growing up milks is the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). This committee usually meets once a year. The committee did not meet in 2020 due to the pandemic; they met this year virtually, and ILCA was there to represent you and your concerns on this important world stage.

The work of Codex and its committees is long-term and follows a complex process. It is often influenced more by trade issues than public health, frequently involves controversies and compromises, and eventually results in food standards that are adopted by the member countries. This year’s virtual meeting of CCNFSDU occurred during the last week of November 2021, and we are excited to report on some positive decisions made at this meeting.

Three standards are currently being developed by CCNFSDU:

— a revision of the standard for follow up formula (FUF) for older infants (defined as 6-12 months)

— a standard for growing up milk (GUM), identified by Codex as drink or product for young children with added nutrients, or drink for young children (defined as 12-36 months)

— a standard for ready-to-use therapeutic foods (RUTF), which are provided to children 6-59 months with severe acute malnutrition

In the community of lactation care providers and breastfeeding supporters, many of us are frustrated just by the existence of FUFs and GUMs. These products were developed by industry as a way to get around the International Code of Marketing of Breastmilk Substitutes (the Code). Regular infant formula is adequate for the first year, with no need for a special formula for 6-12 months; and growing up milks are highly-processed food products that are not needed at all; both FUF and GUM are considered breastmilk substitutes by WHO.

However, these products exist, and as such it is important to set standards for them. One of the biggest issues for ILCA and others concerned about protecting breastfeeding was about sweet taste of the product and  whether flavourings could be included in FUF and GUM. The concern about use of sweet taste and flavourings is that these products replace the liquid part of a diet and are considered breastmilk substitutes; allowing flavourings could cause infants and children to develop a preference for sweet taste, which could have a negative impact on food choices and lifelong health; it could also cause infants and children, and their caregivers, to prefer these products and increase their use. ILCA strongly supported not allowing flavourings in either product. Country delegations have the first chance to comment on any issue, and all countries who spoke supported no flavourings in FUF. At least 13 country delegations spoke for no flavourings in either FUF or GUM, and 7 countries supported allowing flavourings for GUM, stating that it was not a breastmilk substitute (BMS), that these older children (12-36 months) are already exposed to a wide variety of other foods and flavors; and that flavourings should not impact sweet taste. The Chair concluded that no flavourings would be allowed in FUF. Much more discussion occurred, with more countries stating either their support or disagreement with allowing flavourings in GUM. Delegates from WHO and UNICEF stated clearly that these products for children aged 12-36 months are breastmilk substitutes, and are considered not necessary in the diet; they opposed allowing flavourings. The Chair suggested a compromise solution for GUM, allowing flavourings but adding a footnote that national and/or regional authorities may restrict or prohibit the use of the listed flavourings.

WIN: No flavourings allowed in FUF 

Partial WIN: Flavourings allowed in GUM, but countries may restrict or prohibit use of flavourings.

Another big concern of ILCA and others at this meeting was the definition to be used for “growing up milk,” for ages 12-36 months. The previous meeting ended with the following definition: “Drink/product for young children with added nutrients or Drink for young children means a product manufactured for use as a liquid part of the diversified diet of young children [which may contribute to the nutritional needs of young children].” In considerable discussion on whether these products should be defined as breastmilk substitutes, a compromise was to include the following footnote: “In some countries these products are regulated as breast-milk substitutes.” This was despite WHO guidance, adopted by the World Health Assembly (WHA), that all FUF and GUM should be considered breastmilk substitutes.  The text in brackets above was left to be discussed at this meeting. The arguments against including this text are that it does not need to be included; and that the World Health Assembly has agreed that these products are unnecessary and including this text suggests that these products can play an important role in the diets of young children, which they do not. Considerable discussion among countries and observers, including some objections to including “with added nutrients” in the name options, resulted in a decision to delete the bracketed text. Additional discussion over the name options led to a decision to offer four name possibilities from which countries can choose one: drink for young children with added nutrients, product for young children with added nutrients, drink for young children, or product for young children.

WIN: Definition of GUM will NOT include the phrase “which may contribute to the nutritional needs of young children”

Another important agenda item at this meeting was finalizing the preamble for Ready-to-use Therapeutic Foods (RUTF), for children aged 6-59 months suffering severe acute malnutrition (SAM). The preamble to a standard sets the stage for what the standard covers. Thanks to the suggestion of a representative from UNICEF, and with the support of country delegations, ILCA, and other observers, it was agreed to add to the preamble the following clause, identifying that interventions for SAM should occur: “within an appropriately designed programme that promotes continuation of breastfeeding, appropriate transition to nutritious family food and psycho-social support for recovery.” Additionally, the adopted preamble concludes that use of RUTF “does not preclude other dietary options including the use of locally based foods. RUTF is not for general retail sale.”

WIN: Preamble for RUTF will stress the importance of programmes to support continued breastfeeding. Additionally, RUTF is not for general retail sale and thus cannot be promoted.

The CCNFSDU meeting covered many other topics (composition of FUF and GUM, nutrient reference values for children, and much more). The next meeting of CCNFSDU (tentatively planned for early 2023) will include finalizing the preambles for FUF and GUM, which we hope will clearly reference the Code. This is important work that ultimately serves to protect consumers. For our population of families with infants and young children, the contributions of ILCA representatives, along with the important voices of other observer organizations and many country delegations, will help to protect and support breastfeeding, and infant and child health.

For more information on Codex and other Codex committees, see:

Arendt, M. (2021). Advocacy at Work During the Codex Committee on Food Labelling Meeting. Journal of Human Lactation, 089033442110570. https://doi.org/10.1177/08903344211057083

Arendt, M. (2018). Codex Alimentarius: What Has It To Do With Me? Journal of Human Lactation, 089033441879465. https://doi.org/10.1177/0890334418794658

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Become an Oxytocin Expert, and Earn CERPs: New free independent study module dives deep into groundbreaking study connecting lactation outcomes with postpartum hormone levels


You know that oxytocin and prolactin are critical to lactation outcomes.

But how direct is the relationship?

If you knew a parents’ oxytocin and prolactin levels following birth, could you make predictions about how soon their milk would come in, their baby’s milk transfer, or even their baby’s weight gain?

This is the question Elise Erickson, PhD, CNM, and colleagues wanted to answer with their 2020 pilot study published in the Journal of Human Lactation.

And Erickson et al wanted to go one step further.

They wanted to know whether it was possible to connect certain parental variables with hormone profiles postpartum.

Do aspects of labor, age, and BMI predict levels of hormones postpartum?

If they could answer that, they might be able to provide a new way to identify parents at risk for struggling with lactation, for earlier and more effective help. 

Their study is the first to attempt to define the relationship between hormone levels postpartum and breastfeeding measures, as well as between hormone profiles and aspects of labor.

Now, you have the opportunity to look closely at the results of the study while earning CERPs in a new Independent Study Module through ILCA (members only)!

Want a sneak preview of some of the key findings?

  • Older participants had moderately higher levels of oxytocin postpartum than younger participants.
  • Participants with higher body mass index scores when they gave birth had moderately lower oxytocin levels.
  • Participants with shortest labors had higher oxytocin postpartum, while those with longer active labors had lower oxytocin.  
  • Participants who received synthetic oxytocin during labor had a different hormone profile during a feeding than those who did not. They showed an increase in the hormone vasopressin during a 20-minute feeding, while in those who did not receive synthetic oxytocin, vasopressin dropped during the feeding. This is important because vasopressin may bind to oxytocin receptor sites, causing “cross talk” and weakened oxytocin response.
  • Babies born to parents with higher oxytocin lost less weight post-birth than those born to parents with lower oxytocin.
  • Babies born to parents with higher vasopressin post-birth lost more weight than those born to those with lower vasopressin.

How might these findings affect the way you practice?

If you are a member, you can dive deeper and learn more with ILCA’s Independent Study Module. Register for free today.

Interested in earning CERPs to study a different topic? Check out all of ILCA’s free educational content at our Knowledge Center

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New Tools for Implementing Lactation Counselling Programs


“Skilled breastfeeding counselling meant that breastfeeding could remain a choice for me and my baby.” 

“Having skilled breastfeeding counselling completely changed my mental state. It was transformative.”

“Without it, I probably would have just given up and never breastfed ever again.”

These are direct quotes from parents, shared in a new video released during the webinar Building Better Breastfeeding Counselling Programmes: New tools for implementation.

As a lactation professional, you know the importance of skilled lactation care to families.

However, you also know that access to care is far from guaranteed. In some countries, there are no or very few International Board Certified Lactation Consultants® (IBCLCs®) available. In other areas, IBCLCs may be practicing, but existing policies do not support a full range of options for families.

How can we as IBCLCs support the creation of more and better skilled breastfeeding counselling programs? IBCLCs are critical to ensuring improved options, by advocating for high-quality care, training others, and helping to implement programs where IBCLCs are a critical part of the warm chain of support. 

The recent webinar from the Global Breastfeeding Collective (GBC), including ILCA, WHO and UNICEF was created to update you on new tools and resources to increase access to high quality breastfeeding counselling programs. Recordings of the event are available in five languages (Arabic, English, French, Russian, and Spanish).

Implementation Guidance on Counselling Women to Improve Breastfeeding Practices

In 2018, WHO released its ground-breaking guideline, “Counselling of Women to Improve Breastfeeding Practices.”

The 2018 guideline represented a paradigm shift in thinking about breastfeeding counselling, explains Laurence M. Grummer-Strawn, MPA, MA, PhD the unit head of the Food and Nutrition Actions in Health Systems unit at WHO. 

Key recommendations of the 2018 guideline include counselling for all pregnant women and mothers of young children during both the antenatal and postnatal period; at least six contacts, ideally face-to-face; and offering counselling that anticipates and addresses key challenges.

Now, there is new guidance available on how to carry out these important guidelines.

In chapter format, the document describes the stages of breastfeeding counselling program implementation and includes case studies from around the globe.

From gathering initial data to providing services to designing, implementing, and monitoring a skilled breastfeeding counselling training program—as well as evaluating, advocating, and sustaining it—this document provides a wealth of applicable advice. 

Find the document in the Global Breastfeeding Collective’s Breastfeeding Advocacy Toolkit here.

Infant and Young Child Feeding Counselling: Training Course

Now available: the second edition of a curriculum that “aims to address the practices that address childhood malnutrition as well as those that lead to the accumulation of excessive weight,” according to Dr. Ma del Carmen Casanovas Vargas, MPH.

Tied to the WHO Child Nutrition Standards, this curriculum covers breastfeeding, advanced breastfeeding, complementary feeling, growth assessment, and HIV and infant feeding.

With modules for each area and eight clinical practice sessions, it combines lecture with hands-on learning, with the goal of giving health care workers basic counselling skills so they can help mothers and caregivers more effectively.

The curriculum also includes materials for course directors, course trainers, and participants, such as manuals, handouts, and counselling cards with guides for use.

The curriculum is designed for lay counselors, community health workers, primary healthcare nurses and physicians, pediatricians, nutritionists, and many other professionals.

No prior knowledge of infant feeding is assumed, and guidance is given for adapting it to your own setting.

“We hope that [this course] will be useful for different countries and different regions, considering the wide type of uses we are expecting for it,” Cassanova notes.

Find the document in the Global Breastfeeding Collective’s Breastfeeding Advocacy Toolkit here.

Operational Guidance: Breastfeeding Counselling in Emergencies

The newly released document “Breastfeeding Counselling in Emergencies: Operational Guidance” offers pragmatic guidance on how to apply the 2018 WHO Counselling of Women to Improve Breastfeeding Guideline specifically in emergency settings.

“When systems are disrupted, breastfeeding continues to offer nutrition and hydration, comfort and connection, and protects babies from infectious disease … yet just when it’s needed the most, good breastfeeding practices are often eroded and undermined by misinformation, formula donations, and other Code violations,” notes Isabelle Modigell, Lead Researcher of the Operational Guidance.

Parents need “urgent reassurance and skilled support so they can continue to nurture and nourish … their babies under difficult circumstances,” Modigell continues.

Skilled breastfeeding counselling can make a critical difference during emergencies, but real-world guidance is needed to operationalize effective support.

“When there are hundreds affected, how to reach them all?” Modigell says. “How do we provide six sessions of counselling, when they are constantly changing locations to escape violence? Do we continue to provide face-to-face care, even during an infectious disease outbreak?”

The IFE Core Group conducted a desk review of 80 papers and case studies and conducted interviews with key informants around the world.

“We explored the successes, challenges, gaps, required resources, compromises, and adaptations for implementing counselling interventions in emergency settings, guided by an expert peer review group,” Modigell says.

The end result is Implementation Guidance: Breastfeeding Counselling in Emergencies.

The document “elaborates on several recommendations,” providing “challenges, solutions, adaptations, and compromises.”  

For example, Modigell says, one of the WHO guidelines recommends that all pregnant parents and parents of children under two receive skilled BF counselling.

But this is not always possible in an emergency, when needs tend to rise and systems are overwhelmed.

“So a compromise is to prioritize particular groups, through rapid triage and screening,” Modigell explains.

The new guidance contains specific suggestions on who to prioritize—sick and malnourished infants, for example.

“Despite the perceived difficulty … experiences have shown that it is possible to establish or reestablish breastfeeding counselling services and even to improve breastfeeding practices, even in the midst of a crisis,” Modigell shared. “This guidance will tell you how to do it!”

Find the document in the Global Breastfeeding Collective’s Breastfeeding Advocacy Toolkit here.

Advocacy Brief: The Role of Midwives and Nurses in Protecting, Promoting, and Supporting Breastfeeding

Nurses and midwives are “key health providers who care for women and children before and during pregnancy and birth, and throughout early childhood.”

A new advocacy brief by the Global Breastfeeding Collective highlights the role of nurses and midwives in protecting, promoting, and supporting breastfeeding.

To produce the document, authors first conducted a survey to gather the experiences of nurses, neonatal nurses, and midwives in the area of breastfeeding.

“Why is this important?” asks Carole Kenner, PhD, RN, FAAN, FNAP, ANEF, the Chief Executive Officer, Council of International Neonatal Nurses, Inc., who worked on the document.

Kenner’s answer: Nurses and midwives must be empowered to provide skilled breastfeeding support because we know that when breastfeeding mothers and infants are not supported, there is an increase in mortality rates and childhood infections, cognitive development is compromised, and rates of lifelong illnesses increase in both mothers and children.

“All midwives and nurses, including neonatal nurses, must endorse the importance of breastfeeding and be competent in providing support as well as protect mothers and newborns from barriers to breastfeeding,” Kenner adds.

This new tool provides a key opportunity to advocate for this reality.

“We’re asking all of you to join us in this call of action,” says Theresa Shaver, USAID, GHSI-III contractor.

“Please invest in midwives. We need to fully integrate critical competencies, funds to develop a comprehensive specialized training for midwives, nurses, and neonatal nurses, and to fully integrate quality and respectful maternal and newborn care. We need to establish and enforce legislation to protect breastfeeding.”

“And most importantly, we need time,” she continues, urging professionals to advocate in their settings for the allocation of “adequate staffing levels so there is time to dedicate to breastfeeding and supporting women and their babies.”

This is an ideal tool if you are in a position to “strengthen the leadership role of midwives and nurses at a national, local, and facility level,” she concludes.

Find the document in the Global Breastfeeding Collective’s Breastfeeding Advocacy Toolkit here.

Case Studies Compendium

See the development of skilled breastfeeding counselling programs in action with the newly released Case Studies Compendium.  

“Last year, the Global Breastfeeding Collective released an advocacy brief on skilled breastfeeding counselling, which outlined seven key actions stakeholders, donors, and governments can take to improve access to skilled breastfeeding counselling,” explains Lesley Oot, MPH, an Associate Director of Alive & Thrive.

“In support of the call to action, the GBC worked with authors around the world to document case studies of how individual countries, programs and initiatives have successfully answered this call to action, with practical guidance and lessons learned that others can use to duplicate their successes,” she continues.

The result is a compendium of eight case studies.

Geographically diverse, these case studies represent a robust set of examples that are applicable around the globe.

To conclude the webinar, four of the case study authors share their stories about supporting skilled breastfeeding counselling with videos and interactive sessions.

Watch the webinar to learn from and be inspired by stories from eight countries (four in each webinar), highlighting work with government agencies, peer support groups, university midwifery training programs, and hospitals in implementing BFHI. 

Coming soon! When available, you will be able to find the document in the Global Breastfeeding Collective’s Breastfeeding Advocacy Toolkit here.

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