The infant formula industry is once again in the spotlight, after several pressure groups have independently criticised the marketing practices of baby milk suppliers, who spend more than US$7bn on promoting their products.

The Changing Markets Foundation has accused Nestle of inconsistency in its marketing messages in different countries, and criticised some of the claims it makes for certain infant formula products. Meanwhile, the Save the Children charity has accused the six leading manufacturers worldwide – Nestle, Danone, Mead Johnson (now part of Reckitt Benckiser), Abbott, Kraft Heinz and FrieslandCampina – of using aggressive marketing techniques to undermine breastfeeding.

The marketing of infant formula is a contentious issue. Although there are some situations where it is not possible for a baby to be breastfed, the vast majority of mothers can breastfeed. The World Health Organisation (WHO) recommends that babies should be exclusively breastfed for the first six months of their lives, with continued breastfeeding alongside age-appropriate solid foods for two years or beyond.

The reality, however, is that breastfeeding rates are far below this level, whether in developed markets or in the developing world. In 2015, just 22.3% of babies in the US were exclusively breastfed up to six months, while in Thailand the figure was even lower at 12.3% (2012).

While there are a number of factors at play here – the convenience of bottle feeding, social unacceptability of breastfeeding in public, the rising number of working mothers – there can be no doubt that the promotion of infant formula is a major factor in the low levels of breastfeeding across the globe.

To try to counter this, the WHO introduced the International Code of Marketing of Breast-Milk Substitutes in 1981. This lays out guidelines which emphasise the superiority of breast milk and propose a ban on direct advertising to parents, as well as bans on free samples, coupons and other promotions, and aim to regulate the relationship between infant formula manufacturers and health care professionals.

However, in 2016 – 35 years after the Code was first introduced – a joint report by the WHO, United Nations Children’s Fund (UNICEF) and the International Baby Food Action Network (IBFAN) found that few countries were fully implementing it. Of the 194 countries covered in the report, only 39 largely comply with the Code (up from 37 in 2011), although a further 96 have some legal measures, up from 66 five years earlier. All WHO member states have committed to achieving a 50% exclusive breastfeeding rate at six months by 2025, but few appear likely to meet this target.

In addition to the failure to fully enshrine the principles of the International Code of Marketing of Breast-Milk Substitutes into law, governments are lax in funding breastfeeding promotion, monitoring breastfeeding rates and enforcing those aspects of the Code that have been enacted. If they are to stand any chance of even approaching the 2025 breastfeeding target, governments are going to have to change their priorities and get tough with the baby milks companies, rather than leaving the work to non-governmental organisations, charities and pressure groups.

If they don’t, it will be hard to blame the manufacturers for promotional activities that breach the spirit of the Code, even if arguably complying with the letter of it. Infant formula production involves costly ingredients, high standards of manufacturing practice, heavy investment in research and development, and a consumer base that is constantly changing, meaning that brand loyalty has to be constantly built.