The superiority of breastfeeding in ensuring physical and psychosocial health and well-being of mother and child as well as the important impacts of early nutrition on long-term health are widely recognised. In addition to clear short-term health benefits such as protection from gastrointestinal and middle-ear infections in children, breastfeeding has also been shown to be protective against obesity and development of non-communicable diseases in adulthood.1,2,3,4 A systematic review conducted by the World Health Organization (“WHO”) reaffirmed the long-term benefits of breastfeeding, including the significant improvement in performance of intelligence test.5 On top of that, studies have also shown that breastfeeding could protect against premenopausal breast cancer in mothers. The benefits of breastfeeding are shown to be proportional to its duration and exclusiveness.
Suboptimal breastfeeding practices incur considerable economic loss and preventable infant deaths even in developed countries with good sanitation and standard of care. An economic study of the United States (“US”) revealed that if 90% of US families comply with exclusive breastfeeding for 6 months as recommended by Healthy People 2010, it would save $13 billion/year and prevent an excess of 911 deaths.6 Another study of the United Kingdom also showed that even moderate increase in breastfeeding rate (i.e. 100% of babies breastfed at hospital discharge and 65% of women exclusively breastfeeding at 4 months) would be translated into cost savings for the health service of £27 million and tens of thousands of fewer hospital admissions and consultations by the general practitioners.7
WHO has made a global public health recommendation that infants should be exclusively breastfed for the first 6 months of life to achieve optimal growth, development and health and thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to 2 years of age or beyond.8
The creation of an environment that protects, promotes and supports breastfeeding requires a systemic approach, which includes enabling parents to make informed decisions on infant feeding free from commercial influence, ensuring policies and practices of maternal-and-child-health facilities are supportive of breastfeeding, and building family-friendly social policies and community services. To protect breastfeeding from being undermined by inappropriate commercial practices, the WHO developed and adopted the International Code of Marketing of Breastmilk Substitutes (“International Code”) in 1981 to empower mothers to make fully informed decisions on infant feeding free from commercial influences and to recommend restrictions on marketing practices of breastmilk substitutes so that breastfeeding can thrive and risks arising from feeding by formula milk can be minimised. Subsequent World Health Assembly (“WHA”) resolutions have been passed to clarify and update certain provisions of the International Code to align it with scientific advances and evolving marketing strategies.
In July 2013, a WHO statement entitled “Information concerning the use and marketing of follow-up formula” (“2013 WHO Statement”) was published to specifically address the issue of marketing of follow-up formula. 9 The 2013 WHO Statement remarked that “a number of studies strongly suggest a direct correlation between marketing strategies for follow-up formula and perception and subsequent use of these products as breastmilk substitutes.” The 2013 WHO Statement maintained that “follow-up formula is unnecessary and unsuitable when used as a breastmilk replacement from six months of age onwards”. It concluded that “if follow-up formula is marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement for breastmilk, it is covered by the Code. In addition, where follow-up formula is otherwise represented in a manner which results in such product being perceived or used as a partial or total replacement for breastmilk, such product also falls within the scope of the Code.”
In May 2016, WHO issued the “Guidance on ending the inappropriate promotion of foods for infants and young children” (“2016 WHO Guidance”).10 The 2016 WHO Guidance recommended that “products that function as breast-milk substitutes should not be promoted. A breast-milk substitute should be understood to include any milk, in either liquid or powdered form, that are specifically marketed for feeding infant and young children up to age of 3 years (including follow-up formula and growing-up milks). It should be clear that the implementation of the International Code and subsequent relevant WHA resolutions covers all these products”. On 28 May 2016, the sixty-ninth WHA urged all member states to implement the International Code and WHO recommendations on marketing of foods to children.
The Government of the Hong Kong Special Administrative Region (“the Government”) has all along endeavoured to protect, promote and support optimal feeding of infants and young children. In February 2010, the Steering Committee on Prevention & Control of Non-Communicable Diseases (“Steering Committee”), chaired by the Secretary for Food and Health, endorsed the proposal of the Working Group on Diet and Physical Activities (“the Working Group”) to develop and implement a code of marketing of breastmilk substitutes. The Working Group was set up under the Steering Committee to promote healthy diet and physical activity in Hong Kong. The proposal to develop a code of marketing of breastmilk substitutes is part of the action plan recommended by the Working Group and was made in response to the aggressive marketing of formula milk in Hong Kong, which is considered one of the contributing factors to the low breastfeeding rates in the local community.
In June 2010, the Department of Health set up the Taskforce on Hong Kong Code of Marketing of Breastmilk Substitutes (“the Taskforce”) to develop a code of marketing of breastmilk substitutes for Hong Kong. Membership of the Taskforce comprises representatives from community organisations, professional bodies, academia, and Government bureau and departments.
In drafting the code for Hong Kong, the Taskforce has referred to the International Code and the relevant subsequent WHA resolutions. In addition, the Taskforce also considered the potential impacts of local marketing practices on parental attitudes and practices of feeding infants and young children. The Taskforce also held three meetings with representatives of six multinational formula milk companies to listen to their views. The Taskforce subsequently submitted a draft of the Hong Kong Code of Marketing and Quality of Formula Milk and Related Products, and Food Products for Infants & Young Children (“the 2012 draft HK Code”) to the Government for public consultation, which was conducted from 26 October 2012 to 28 February 2013. The results of the public consultation on the 2012 draft HK Code and the way forward were reported to the Legislative Council Panel on Health Services on 21 July 2014.
Taking into account the findings from the public consultation, comments expressed thereafter, the legislation enacted in 2014 regarding requirements on nutritional composition of infant formulae and nutrition labelling of infant formulae, follow-up formula products and prepackaged foods for infants and young children under the age of 36 months, and the issuance of the 2016 WHO Guidance, the code for Hong Kong has now been finalized and is entitled as “the Hong Kong Code of Marketing of Formula Milk and Related Products, and Food Products for Infants & Young Children” (“the HK Code”).
The HK Code is voluntary in nature and aims to contribute to the provision of safe and adequate nutrition for infants and young children without interfering with the sale of products for infant-and-young-child feeding. The Government, in collaboration with non-governmental organisations, professional groups and consumer organisations concerned, will evaluate the overall effectiveness of the HK Code. Individual members of the trade are encouraged to make reference to the principles and aim of the HK Code in formulating its own marketing practices independently.
The practices of feeding infants and young children are affected by a multitude of socio-economic, cultural and environmental factors. The implementation of the HK Code is just part of the effort to attain optimal infant-and-young-child feeding practices. Ongoing and concerted actions by the Government and various sectors of the community are necessary for the purpose of protecting and promoting breastfeeding and hence optimal infant-and-young-child feeding. In April 2014, the Committee on Promotion of Breastfeeding was set up by the Food and Health Bureau to provide advice on strategies and action plans to further protect, promote and support breastfeeding in Hong Kong and to oversee their effective implementation, as well as to evaluate the overall effectiveness of the HK Code after it has been promulgated. In addition, various measures have been implemented in phases to strengthen professional support for breastfeeding in healthcare facilities (e.g. through implementing the Baby-Friendly Hospital Initiative); to strengthen the publicity and education on breastfeeding, including the promotion of HK Code; to support working mothers to sustain breastfeeding by encouraging the community to adopt breastfeeding friendly workplace policy; to promote and support breastfeeding in public places through promotion of breastfeeding friendly premises and provision of babycare facilities; and to strengthen the surveillance on local breastfeeding.
This Code is named as the Hong Kong Code of Marketing of Formula Milk and Related Products, and Food Products for Infants & Young Children.
The aim of this Code is to contribute to the provision of safe and adequate nutrition for infants and young children, by－
This Code covers the marketing practices of designated products as defined in Article 3. It also applies to the information on the use of designated products.
means any form of advertising intended for the general public which is published by any means including, but not limited to, the following –
means feeding liquid or semi-solid food from a bottle with a nipple.
means a name given by the manufacturer to a product or range of products.
means breastfeeding of infants and young children, including nutrition of breastmilk.
means any food suitable or represented as suitable as an addition to breastmilk or formula milk for infants of or above the age of 6 months and young children of or below the age of 24 months.
means the transition from exclusive breastfeeding to eating family foods, which typically covers the period from 6 to 24 months of age, even though breastfeeding may continue to 2 years of age and beyond.
includes every kind of box, bottle, tin, carton, package or wrapping enclosing an article or substance, but does not include an outer cover or wrapping superimposed for the purpose of consignment or delivery.
means the Department of Health of the Government of the Hong Kong Special Administrative Region.
means a person, corporation or other entity engaged in the sale, whether wholesale or retail, of any designated product.
means infant formula, follow-up formula and formula for special medical purposes for infants and young children.
means feeding by formula milk of infants and young children, including nutrition of formula milk.
means a product that –
means any feeding bottles and teats for infants and young children.
means any public or private institution or organisation or practice engaged directly or indirectly in the provision of health care or child care, including day-care centre, nursery, or other infants-and-young-children care facility.
means a health worker with a professional degree, diploma or licence, such as a medical practitioner, nurse, midwife, dietitian, nutritionist, clinical psychologist or such other person as may be specified by the Department of Health for the purposes of this Code.
means a person providing or who are in training to provide health care services in a health care facility, whether professional or non-professional, including voluntary unpaid worker.
means a person not more than 12 months of age.
means any tag, mark, pictorial or other descriptive matter, written, printed, stenciled, marked, embossed, attached or otherwise appearing on a container of a designated product.
in relation to a designated product, includes any word, particulars, trade mark, brand name, pictorial matter or symbol relating to the designated product and appearing on the packaging of the designated product or on any document, notice, label, ring or collar accompanying the designated product.
means an emblem, picture or symbol by means of which a company or a product is identified.
means a person, corporation or other entity engaged in the business of manufacturing a designated product whether directly, through an agent, or through a person controlled by or under an agreement with it.
means product promotion, distribution, selling and advertising, product public relations and information services and “market” will be construed accordingly.
means any representation of a designated product either by photograph or graphic illustration.
means any prepackaged food that, according to its descriptions or instructions for use, is intended for consumption by persons of any age under 36 months (even if it is also claimed in the descriptions or instructions, if applicable, to be suitable for consumption by persons of any age from 36 months onwards), but does not include any infant formula or follow-up formula.
means to employ any method of directly or indirectly encouraging a person to purchase or use a designated product.
means any sale outlet or premises including, but not limited to, pharmacies, shops and supermarkets.
means a single or small quantities of a designated product provided without cost.
means any sign which is capable of distinguishing the goods or services of one trader from those of others and may consist of words (including personal names), indications, designs, letters, characters, numerals, figurative elements, colours, sounds, smells, the shape of the goods or their packaging or any combination of such signs.
means persons of any age from more than 12 months to under 36 months.
4.1.1 Except as allowed under Article 4.1.2, a manufacturer or distributor should not himself or herself, or by any other person on his or her behalf –
4.1.2 Provided that the materials to be distributed do not contain the name, brand name, packshot, logo and / or trade mark of a formula milk and formula milk related product (except the name and logo of the manufacturer or distributor), or refer to such product in any other manner, a manufacturer or distributor may (a) distribute to the public informational or educational materials on breastfeeding and formula milk feeding prepared by the Department of Health, and (b) reproduce all or parts of the materials mentioned in (a) for distribution to the public if there is no alteration of the content of the materials, and the Department of Health is acknowledged in the reproduced materials as the source of the information.
4.2.1 A manufacturer or distributor of formula milk and formula milk related product may provide information on specific brands of formula milk and formula milk related product via electronic (e.g. websites, emails) or physical means (e.g. hotlines, at the premises of retailers or at health care facilities) upon request provided that such information –
4.2.2 The information referred to in Article 4.2.1 may include the name, address and telephone hotline of the manufacturer or distributor.
4.3.1 A manufacturer or distributor may produce, donate or distribute informational or educational materials, or sponsor or perform educational activities on matters related to infants and young children other than breastfeeding and formula milk feeding, provided that –
4.4.1 Informational and educational materials produced or distributed by parties other than manufacturers and distributors, whether written, audio or visual, which refer to infants-and-young-children feeding and nutrition and are intended to reach the general public, expectant parents or parents of children under the age of 36 months should –
4.5.1 Notification of pre-order service for formula milk provided by any parties should –
5.1 A manufacturer or distributor should not himself or herself, or by any other person initiated by or on his or her behalf, carry out any promotional activities involving formula milk and formula milk related products. Such promotional activities include but are not limited to –
5.2 A manufacturer or distributor may promote prepackaged food for infants and young children, provided that the promotional practice –
5.3 A manufacturer or distributor should not himself or herself, or by any other person on his or her behalf –
for the purpose of promoting designated products.
6.1 A manufacturer or distributor should not himself or herself, or by any other person on his or her behalf –
7.1.1 Health workers should encourage and protect breastfeeding and those health workers who are engaged in particular with maternal and infant nutrition should make themselves familiar with their responsibilities under this Code, including the matters specified in Article 4.4.1 (e).
7.1.2 Health workers engaged in maternal and child health may demonstrate the use of infant formula or formula for special medical purposes for infants and young children to parents when it is considered necessary and, where demonstration of the use of infant formula is considered necessary, should give a clear explanation of the risks of the use of infant formula as well as the information specified in Article 4.4.1 (e) (iii) (A) to (H) during the demonstration.
7.2.1 Manufacturers or distributors may provide designated products to health workers or health care facilities only for the purpose of professional evaluation or research at the institutional level.
7.2.2 Notwithstanding Article 4, manufacturers or distributors may give any materials about a designated product to health workers if such materials –
7.3.1 A manufacturer or distributor should not himself or herself, or by any other person on his or her behalf offer or give any gift or benefit to health workers or to associations of health workers engaged in maternal and child health, except as allowed under Articles 7.3.2 and 7.3.3.
7.3.2 Subject to review, if any, to be carried out after this Code takes effect, a manufacturer or distributor should not himself or herself, or by any other person on his or her behalf offer health worker or associations of health workers funding for organising or participating in continuing education activities related to maternal and child health, unless the following requirements are satisfied –
7.3.3 Health workers and associations of health workers should only accept or receive research grants from manufacturers and distributors if, where the manufacturers and distributors have an interest in the subject matter of the research, the grants and any relationships, financial or not, with the manufacturers or distributors are disclosed in the printed materials publishing the result of the research.
8.1.1 The label affixed to a designated product should not –
8.1.2 The particulars required under Articles 8.2.1, 8.3.1 and 8.4.1 should appear in both English and Chinese if both languages are used in the labelling or marking of the designated product.
8.1.3 The label must be legible.
8.2.1 The container of formula milk or the label affixed thereto should satisfy the following requirements –
8.3.1 The container of prepackaged food for infants and young children or the label affixed to these products should indicate in a clear, conspicuous and legible manner the following particulars –
8.4.1 In addition to the relevant legal requirements stipulated in Toys and Children’s Products Safety Ordinance (Cap. 424) and the Consumer Goods Safety Ordinance (Cap. 456), the container or package of a formula milk related products or the label affixed thereto should indicate in a clear, conspicuous and legible manner the following particulars –
8.4.2 Formula milk related product should display the information required to be shown under the labeling requirements in Article 8.4.1 on the container or in a product insert.
8.5.1 Article 8.2.1 does not apply to formula for special medical purposes for infants and young children provided that the product is marked or labelled with –
8.5.2 Article 8.2.1 does not apply to infant formula or follow-up formula packed in a container that has a total surface area of less than 250 cm2.
8.5.3 Article 8.3.1 (b) does not apply to prepackaged food for infants and young children packed in a container that has a total surface area of less than 100 cm2.
9.1 Manufacturers and distributors are encouraged to regard themselves as responsible for monitoring their marketing practices according to the principles and aim of this Code, and for taking steps to ensure that their conduct at every level conforms to them.
9.2 Non-governmental organisations, professional groups, institutions and individuals concerned are invited to draw the attention of manufacturers and distributors to activities which do not follow the principles and aim of this Code.
9.3 Manufacturers and distributors, non-governmental organisations, professional groups, and consumer organisations are invited to collaborate with the Government to evaluate the overall effectiveness of this Code.
9.4 The evaluation plan is illustrated at Annex I.
|1. Title of the Code||
This Code is named as the Hong Kong Code of Marketing of Formula Milk and Related Products, and Food Products for Infants & Young Children (“the HK Code”).
|2. Aim and Scope||
The HK Code aims to contribute to the provision of safe and adequate nutrition for infants and young children by protecting breastfeeding and ensuring the proper use of designated products, on the basis of adequate and unbiased information and through appropriate marketing.
The HK Code applies to the following designated products for infants and young children under 36 months old:
Terms used in the HK Code are defined.
|4. Information and Education (to the general public, expectant parents and parents)||
Information and education provided by manufacturers or distributors (M&Ds)
M&Ds of designated products should not perform / sponsor educational activities nor produce and distribute informational / educational materials on breastfeeding and formula milk feeding.
Nevertheless, M&Ds may:
provided that such materials do not contain the name, brand name, packshot, logo and / or trade mark of any formula milk and formula milk related product.
Provision of product information by M&Ds
M&Ds should only provide product information about formula milk, feeding bottles and teats upon request, via electronic (e.g. websites, emails) or physical means (e.g. hotlines, at the premises of retailers or at health care facilities). The information provided should be factual and correct and does not undermine or discourage breastfeeding.
Notification of pre-order service for formula milk provided by any parties should only contain essential information pertaining to the operation of order and delivery.
Information and education provided by other parties
Parties other than M&Ds may produce or distribute informational / educational materials on infant-and-young- child feeding and nutrition, provided that such materials:
|5. Promotion to the Public||
M&Ds should not carry out promotional activities involving formula milk, and formula milk related products. Such activities include but are not limited to advertising, using special displays, and offering prizes or gifts such as free samples.
M&Ds may promote prepackaged food for infants and young children, provided that the promotional activity does not:
M&Ds should not seek directly or indirectly personal details of infants, young children, expectant parents or parents of children under the age of 36 months; or inviting their participation in activities including baby shows and mother craft activities, for the purpose of promoting designated products.
|6. Promotion in Health Care Facility||
M&Ds of designated products should not:
|7. Information and Promotion to Health Workers||
Informational materials about products provided by M&Ds should be limited to scientific and factual matters.
M&Ds may provide designated products to health workers only for the purpose of professional evaluation or research at the institutional level.
Sponsorship of Continuing Medical Education Activities:
The container or label of a designated product should not:
Product labels of formula milk, feeding bottles and teats should clearly state breastfeeding as the norm of infant feeding. Product labels of formula milk should also clearly state the need for the advice of a health professional before the use of formula milk and the health hazards of its use.
|9. Implementation and Evaluation||
M&Ds themselves are responsible for monitoring their marketing practices according to the principles and aim of the HK Code.
Non-governmental organisations, professional groups, institutions and individuals concerned are invited to draw the attention of M&Ds to activities which do not follow the principles and aim of the HK Code.
All parties are invited to collaborate with the Government to evaluate the overall effectiveness of the HK Code.
Surveys will be conducted from time to time to evaluate the overall trends in marketing practices of designated products. Feedback and suggestions from members of the public will also be collated and analysed. The overall effectiveness of the HK Code will be reported to the Committee on Promotion of Breastfeeding, which will further advise the Government on the future strategies and actions to promote and protect breastfeeding and infant-and-young-child nutrition.
Food and Health Bureau
Department of Health