To the authors’ best knowledge, this is the first peer-reviewed study that monitored Code violations specific to CMF donations during an earthquake relief effort. The authors collected and reviewed a total of 40 reports on CMF and feeding equipment donations and Code violations collected within a month after the initial Türkiye-Syria Earthquake in February 2023.

We identified three main types of violation of the OG-IFE and the Code:

1)

NGOs/public agencies and civil society seeking donations of milk products and milk feeding equipment,

2)

CMF, complementary foods, other milk products, or feeding equipment in emergencies being included in a general or blanket distribution, and.

3)

Inappropriate promotions of CMF. These reports comprised of social media postings and news reports, with the majority of them being incidences of individuals, humanitarian organizations, and government agencies seeking or accepting donations.

Local and international NGOs/public agencies and civil society seeking donations of milk products and milk feeding equipment

Although the Code probits the use of free and subsidized infant formula in healthcare systems and recognizes their adverse consequences to breastfeeding (WHA39.28, 43.3, 45.35), specific recommendations for infant feeding in emergencies were only issued in 1994 (WHA47.5) andcalling for extreme caution when planning for the protection and support of breastfeeding, and clarify that the use of donated supplies of CMF should only be done following a strict criteria. In 2000, WHO issued the Guiding principles for feeding infants and young children and clarified that “Offers of well-meant but ill-advised large-scale donations of “baby foods” and feeding bottles should be refused” and also emphasized that “Planners and managers of emergency relief operations should resist superficially attractive quick-fix “solutions” that can result in widespread, unnecessary and potentially harmful distribution of infant formula and other prepared foods that are used as breastmilk substitutes” [71]. In 2010 the WHA63.23 endorsed the OG-IFE, which prohibits the donation or acceptance of BMS, other milkproducts or feeding equipment (including bottles, teats and breast pumps) in emergencies. The same resolution also urges Member States to ensure their emergency preparedness plan follow the OG-IFE on IYCF-E practices. Donation appeals made by local and international NGOs and civil societies were in non-compliance to the OG-IFE article 5.28 and 6.1. Many of the organizations and agencies documented in this paper were based in higher income countries like the United Kingdom, the United States or Canada, countries where national emergency preparedness policies do not include any or all the basic components of the OG-IFE [26, 56, 57]. For example, the U.S. and U.K. both scored zero on World Breastfeeding Trends Initiative (WBTi) indicator 9: Infant and Young Child Feeding during Emergencies, reflecting the absence of appropriate policies and programs in place to ensure that mothers, infants, and young children receive adequate protection and support for appropriate feeding during emergencies [26, 56, 57]. The absence of national IYCF-E preparedness and response plans in donor countries leave the responsibility of implementing recommendations listed in OG-IFE on NGOs, public agencies and civil societies, that typically have no obligations to integrate IYCF-E strategies in their internal policies. Under current Turkish legislation, donations of equipment or services by CMF companies are neither prohibited nor is there a clear policy regarding the actions required to minimize the risk of artificial feeding in emergency settings. As Türkiye’s national emergency response plan is led by a third-party agency, the Red Crescent, instead of appointing specific personnel or a government department as the main coordinator, the implementation of OG-IFE is subject to the Red Crescent’s interpretation of the document and their internal standards.

The Code and its subsequent WHA resolutions serve as a comprehensive international policy framework and aim to protect public health by preventing the harmful and exploitative marketing of CMF safeguarding the well-being of women, parents, children, and the health system [9]. However, for it to have a significant impact, it must be translated into national policies and laws and rigorously enforced. Recent research highlights the need to address industry interference in policymaking and regulation at national and international levels [24, 54].

CMF, complementary foods, other milk products, or feeding equipment in emergencies being included in a general or blanket distribution

The three Turkish humanitarian organizations involved in possibly distributing CMF and feeding equipment indiscriminately in earthquake-affected areas did not appear to have IYCF-E experts on their local team, nor did they follow any protocols for the needs assessment as prescribed by OG-IFE and UNICEF. These actions are in non-compliance with OG-IFE article 6.25 and in violation of WHA47.5 and 63.23. Although Türkiye has legislations that cover some provisions of the Code with defined sanctions for violations, measures that ensure Code compliance are not included [25]. Incidences like this reflect a lack of a national robust mechanism for the coordination and monitoring of disaster response agencies’ activities and a responsible body to enforce compliance with the OG-IFE and the Code. On 21 February 2023, in an official document from OCHA, IFRC reported baby formula shortages in all affected provinces in Türkiye [17]. The same document projected 24,000 expected births in the affected area in March, 2023 [17]. CMF products and feeding bottles had remained in high demand in the months after the initial emergency relief effort, protracting the need for a comprehensive package of IYCF support in full compliance with the OG-IFE to safeguard the health and well-being of the mothers and their breastfed and non-breastfed infants.

Save the Children’s response to an EN-NET forum post reporting their blanket distribution of baby food, milk, and bottles, in Malatya and Antep was a positive case of rapid response to take corrective action [44, 58]. The organization “immediately ceased distribution and informed response team of appropriate ways to support infant and young child feeding” and posted a response on the forum reiterating the organization’s position on prioritizing support for exclusive breastfeeding during emergencies [59].

Inappropriate promotions of CMF

Article 5 of the Code and subsequent WHA Resolutions (WHA58.32 [2005] and WHA63.23 [2010]) prohibit advertising or promotion of CMF or any foods or feeding equipment under its scope to the public. Our study found that Danone, together with its subsidiaries Aptamil and Bebelac violated the aforementioned articles by offering free online classes with a focus on infant feeding in disasters, using the heightened public attention towards the earthquake to maximize reach on social media. The promotional material of these classes was posted on popular social media websites in an easily shareable format [54]. Company-sponsored medical professionals and scientists were highlighted in these posts to foster a sense of impartiality and authority [54].

In past humanitarian emergencies and in the context of the 2023 earthquake in Türkiye, Danone, Nestlé, Weebaby and Philips utilized digital platforms to advertise their partnerships with NGOs or government agencies to help legitimize their promotional tactics as charitable giving, rather than marketing schemes [27, 64, 65]. CMF companies took full advantage of the rapid evolution of social media and the lag in digital marketing regulations by turning social media users who shared these posts into their unwitting promoters.

Similar exploitative marketing practices observed during emergencies, including the COVID-19 pandemic, were highlighted in the 2023 Lancet Series on Breastfeeding, underscoring the need for countries to allocate resources for effective implementation and enforcement of the Code [60, 61, 63]. Coherent legal measures must be established to protect breastfeeding and promote infants’ health in emergency situations. CMF companies employ highly effective marketing tactics that undermine caretakers’ confidence in breastfeeding, pathologize normal infant development behaviors, and commodify infant feeding practices. Major CMF companies like Danone and Nestlé are still the main offenders of the rules and regulations as identified by WHO [27, 28].

Other findings

The Code article 6.6 and WHA resolutions 39.28, 43.3, 45.34, 47.5 prohibit not only the supplies of donated but also discounted infant formula to the healthcare system. Although CMF companies identified in this study provided large quantities of CMF and feeding equipment to local or international disaster relief agencies, they did not report whether these supplies were donated or sold at discounted rates. Their social media posts detailing their close collaboration with the Turkish Red Crescent (Kızılay), government agencies, and disaster relief IYCF coordination authorities and the quantity of CMF product is distributed require further scrutiny. International CMF companies with better logistical organization and substantially more financial resources than aid agencies pose further challenges in preventing the influx of unregulated CMF products during a time of acute needs [70].

Online content created by individuals not in collaboration with CMF companies that inadvertently displays CMF products remains a grey area in terms of various marketing approaches prohibited by the Code. These contents reflect a lack of awareness of appropriate infant feeding practices and support in emergency contexts among the general public and public health professionals. At the same time, the spread of misinformation online may further encourage the inappropriate donation of CMF from well-meaning individuals.

There is a pressing need to strengthen the policy and regulatory framework to support the implementation of OG-IFE. Past research concerns have been raised about the lack of monitoring and penalizing non-compliance [13, 66,67,68]. A systematic literature review by Mudiyanselage et al. further identified the regulation of infant formula/CMF provisions as a facilitator of appropriate IYCF in natural disaster context [69]. OG-IFE builds on the Code as a basis for some of its recommendations. Without proper integration into the local policy framework, the OG-IFE may be treated as an afterthought, lacking adequate monitoring and penalties for non-compliance. The critical nature of emergencies starkly contrasts with the nebulous state of OG-IFE implementation, underscoring the need for a comprehensive and coherent document that can provide clear mandates, enforceable regulations, and robust monitoring mechanisms for infant feeding in emergency situations. National governments and international NGOs should lead the way in pushing and advocating for the adoption of the OG-IFE, the Code and other relevant instruments in appropriate national policies, plans and guidance that can subsequently be constructed as legal and regulatory measures in line with the country priorities.

As of 2022, 144 out of 194 Member States of WHO have incorporated certain provisions of the Code into their national regulations [60]. However, only 32 countries adopted all the Code’s provisions [60]. Limited progress has been made in areas such as prohibiting gifts and incentives from CMF companies to healthcare workers, restricting sponsorship of health-professionals association meetings, and implementing digital promotion restrictions [60,61,62]. Inadequate funding and a lack of meaningful penalties for non-compliance further undermine national monitoring and enforcement mechanisms [60,61,62]. To ensure compliance, it is necessary to move beyond voluntary measures and introduce legislative actions and regulations based on the full set of provisions of the Code.

IYCF-E settings require a multidisciplinary approach, involving nutrition, pediatric medicine, logistics, and emergency preparedness and other sectors [67, 69]. Similar to infant formula management in healthcare facilities, clear standards, guidelines, and best practices should be harmonized and adopted by regulatory bodies overseeing infant formula procurement and management. Specialized staff trained in pediatric nutrition and lactation consulting should be involved at every stage to minimize the risk of artificial feeding [69]. In earthquake settings, where destruction of infrastructure is likely to occur, specialists can identify context-specific clean water and sanitation risks such as CMF donation or the use of powdered infant formula instead of ready-to-use infant formula.

Efforts should be made to professionalize IYCF-E, aligning it with UNICEF’s procurement guidance and treatment protocols for malnutrition [22]. Specialized expertise is necessary for streamlined standard practices in procurement, storage, and distribution. Emergency responders and health professionals must adhere to the principles of doing no harm and minimize the potential harm caused by improper handling of CMF on infants and their caretakers. Additionally, each earthquake-prone country should develop a preparedness plan for infant and young child feeding, particularly for children dependent on CMF, as they are most vulnerable during emergencies that disrupt their feeding routine.

Limitations

Because of the rapidly unfolding and ongoing nature of the relief efforts and our data collection methods (major social media platforms and Google search), the instances reported here are not exhaustive, and it is difficult to ascertain the true extent of Code violations. Furthermore, social media posts or reports from north-western Syria were insufficiently captured due to language barriers, which limited the search terms inputs and possibly contributed to accessing the right platforms. Nonetheless, the main types of violations we report here are likely representative of the occurrences of Code violations in earthquake affected areas of Türkiye at the time of writing.

The objective of the study is to capture non-adherence to OG-IFE and violations of the Code articles most pertinent to donations in emergency settings. Language barriers, time constraints, and the absence of a system in place to collect and monitor Code violations rendered monitoring the full breadth of Code violations difficult. Code violations pertaining to conflict of interest and nutrition and health claims were not fully captured and analyzed with limited access to native Turkish speakers to provide accurate translations. Therefore, only the most relevant Code articles adopted by Türkiye and subsequent WHA resolutions related to OG-IFE were included as a part of the framework analysis.