/sites/assets/Assets/Article%20Images/baby_bottle.jpg?Width=970&Height=405

​The guide to best practices in infant and childhood nutrition

The World Health Organization (WHO) advocates exclusive breastfeeding for the first six months of an infant's life as it provides all the energy and nutrients needed for growth, development and protection against infectious and chronic diseases. According to the 2001 Breastfeeding Survey, although 95% of mothers in Singapore initiated breastfeeding, less than 21% sustained this practice exclusively for six months.
 
To guide the marketing practices of the Infant Food Industry as well as protect and promote the practice of breastfeeding in Singapore, the Ministry of Health (MOH) established the Sale of Infant Foods Ethics Committee, Singapore (SIFECS) in 1979. This Committee formulated and implemented the 'Code of Ethics on the Sale of Infant Foods in Singapore'. Since 1981, this Code has undergone three revisions to keep up with the changing marketing practices in the Infant Food Industry and consumer needs.
 
This Code has served as a useful working document for all who are involved in the promotion of childhood nutrition, and the marketing and distribution of breast milk substitutes in Singapore.It provides guidelines on the appropriate marketing and distribution of breast milk substitutes.
 
With the establishment of the Health Promotion Board (HPB) in 2001, the administration of the SIFECS was transferred from MOH to HPB. HPB will continue to support the SIFECS to promote breastfeeding and to safeguard ethical standards amongst the Infant Food Industry and the healthcare professionals.
 
Under the able Chairmanship of Prof. Ho Lai Yun, I am confident that Members of the SIFECS will continue to work together to promote and implement the third edition of the Code.
 
Lam Pin Woon
Chief Executive Officer
Health Promotion Board

Introduction

The contention of the Code of Ethics on the Sale of Infant Foods in Singapore is that breastfeeding is an unequalled way of supporting the healthy growth and development of infants. It affirms that the success of breastfeeding lies in public education. The healthcare system also plays an essential role in facilitating breastfeeding, and in ensuring that its workers or members are equipped with the necessary knowledge and skills to advise and guide mothers in breastfeeding practices.
 
The Code also recognises that there is a legitimate market for infant formula, which is scientifically formulated to provide an alternative, if breastfeeding is not possible. However, the sale and distribution of infant formulas should be carried out in such a way as to avoid competing with breast milk. Therefore, marketing of infant formulas, requires special attention which makes the usual marketing practices unsuitable for these products.
 
In 1981, the 34th World Health Assembly adopted the World Health Organization (WHO) International Code of Marketing of Breast Milk Substitutes. The aims and the principles of the WHO Code were supported by a majority of countries, including Singapore. At that time, Singapore had already adopted its own Code since 1979. As both Codes work towards achieving similar objectives, Singapore decided to continue with the implementation of its own Code, adjusting it to suit the local development situation.
 
The Members of the SIFECS are well aware of the art and science of human milk feeding, as well as the current local and global trends and challenges in breastfeeding. The current list of Members is in Appendix 1. The Code is regularly reviewed and updated so that it is in line with the World Health Assembly Resolutions.
 
The representatives from the Infant Food Industry participated actively in the revision of the Code. They will continue to ensure its successful implementation and monitoring. They have agreed to subscribe to and operate within the Code, and to submit their promotional, educational and product use instructional materials to be approved by the Vetting Committee of the SIFECS. This speaks very highly of the professionalism of the Infant Food Industry representatives. It behooves all healthcare professionals to work even harder to see that our infants receive their birthright i.e. that they are provided with human milk for as long as possible.


1. Definition of Terms

For the purposes of the Code of Ethics on the Sale of Infant Foods in Singapore, frequently used terminologies are defined in Appendix 2 below.

2. Aim of the Code

The aim of the Code is to contribute to the provision of safe and optimum nutrition for infants, by protecting and promoting the practice of breastfeeding, through the provision of guidelines to guide the marketing and distributing practices of breast milk substitutes in Singapore.

3. Scope of the Code

The Code applies to the promotion, marketing and distribution practices of all breast milk substitutes as defined in Appendix 2 (below), when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breast milk. It also applies to information concerning the use of these products such as bottles and teats.

4. Informational and Education Materials

4.1 The Infant Food Industry must ensure that informational and education materials provided on infant feeding are objective and consistent with guidelines of the Health Promotion Board.

4.2 Informational and education materials, whether printed, online, audio or visual, dealing with the feeding of infants must not contain any pictures or text which idealise the use of breast milk substitutes. Terms such as 'humanised', 'maternalised' or similar terms must not be used in the materials. Materials must not compare infant milk formula to breast milk or imply that infant milk formula is equivalent or superior to breast milk (e.g. using statements like 'closer to breast milk').

4.3 The materials must carry the term 'Important Notice', under which, the following information must be printed in letters, not less than 1.5 millimetres in height:

 Breast milk is the best for babies. The World Health Organisation recommends exclusive breastfeeding for the first six months of life. Unnecessary introduction of bottle feeding or other food and drinks will have a negative impact on breastfeeding. After six months of age, infants should receive age-appropriate foods while breastfeeding continues for up to two years of age or beyond. Consult your doctor before deciding to use infant formula or if you have difficulty breastfeeding.

4.4 All nutrient claims on breast milk substitutes must be evidencebased and not supersede breast milk. The Code recognises the need for continuous research by the Infant Food Industry to reduce the gaps in knowledge of the Industry's products.

4.5 Company personnel must not distribute education and product use print materials on breast milk substitutes within the scope of the Code. These materials can only be distributed through healthcare professionals. Company personnel can contact healthcare professionals to provide scientific and factual information on breast milk substitutes. Copies of the cited references should accompany the product information leaflets.

4.6 All materials for distribution may bear the company's name or logo, but must not contain specific information on the company's proprietary products. Product names or logos will only be allowed on materials specific to the products. Pack shots in print materials will be limited to products specific to the content of the materials. Materials for distribution must not discourage breastfeeding or in any way imply that the products are equivalent or superior to breast milk.

4.7 All informational and education materials on breast milk substitutes, within the scope of the Code, must be approved by the Vetting Committee of the SIFECS. These materials include overseas publications which are intended for use in Singapore. All approved publications must carry a SIFECS code number issued by HPB.

4.8 Manufacturers and distributors of all follow-on formulas and weaning food are strongly encouraged to include the phrase 'After 6 months' on their materials or cans. This is in line with WHO s recommendation that newborn infants are to be breastfed exclusively for the first six months after birth.

4.9 Changes in a can's packaging must only be communicated to healthcare professionals through a printed brochure approved by the Vetting Committee of the SIFECS.

5. Infant Food Industry Practices


5.1 Company personnel must not, as part of their job responsibilities, provide advice or any type of educational services for pregnant women or parents of infants and young children. All advice on the use of breast milk substitutes can only be given by doctors, nutritionists/dietitians, nurses, voluntary consumers' group and breastfeeding specialists. Company personnel are to be excluded from speaking at, or organising public education events and/or parental counselling sessions on infant feeding. This includes doctors, nurses and nutritionists/dietitians in the company s employment.

5.2 The Infant Food Industry is not allowed to provide or fund mothercraft or similar services (see Appendix 2 for listing of mothercraft-type services). Mothers requesting for mothercraft-type services must be referred to polyclinics, hospitals, paediatric clinics or the Singapore Breastfeeding Mothers' Support Group.

5.3 Sales and marketing personnel in the Infant Food Industry responsible for marketing and promoting breast milk substitutes, within the scope of the Code, must not have their sales incentive schemes tied to the volume of sales of these products. No financial inducements (e.g. special discounts for other medical and paramedical items by the companies) are allowed to be offered to hospitals, clinics and retail pharmacies to promote products within the scope of the Code.

5.4 Sponsors, organisers and all those involved in medical events/workshops/congressional meetings and symposiums may distribute detail aids for infant formulas. However, they are not allowed to display infant formulas including special feeds, cans (filled or empty) and banners depicting pictures of infant formulas at these events. Approved detail aids with pictures of infant formula may be distributed to healthcare professionals. Distributors of these detail aids are encouraged to remind healthcare professionals that the detail aids are for their information only and should not be distributed or displayed to the public.

5.5 The Infant Food Industry may sponsor medical events such as health talks and public forums only with the relevant professional bodies and societies as the main organisers. Industry members cannot be the main organisers, nor can they speak at these events, regardless of the content. They must also not employ or pay speakers to conduct such talks. The speakers at the medical events (refers to professional/ scientific) should be approved by professional societies. Experts affiliated with the Infant Food Industry should not speak at public events. Brand names and logos of companies within the Infant Food Industry should not be featured in the presentation slides nor mentioned at these talks. Holding talks at the clinics of general practitioners and specialists are considered a violation of the Code.

5.6 Infant formulas must NOT be sold online. The Infant Food Industry should discourage retailers and other third parties from selling their infant formulas online or offer delivery services. Infant formulas sold at supermarkets must not have 'point of sale' materials such as shelf-talkers or be in a blockstack display. Infant formulas must only be displayed within the allocated/normal shelf space. It is the responsibility of the companies to inform the distributors, supermarkets and the retailers of the existence and the contents of the Code, as well as to advise and remind them on the appropriate ways of displaying and marketing the infant formulas, as defined in the Code. Companies must not publish promotional materials for products within the scope of the Code on the internet, nor should they send promotional e-mails to existing or potential customers with the aim of marketing their products. The restriction on distribution of materials online for informational and marketing purposes applies even if the intended recipients of such materials are healthcare professionals. The Industry must not provide any financial inducement towards the purchase of their products online or via any other electronic channel.

5.7 The only information that companies, clinical staff and third parties (e.g. websites) may obtain from the parents and consumers is the 'Estimated Month of Delivery', and the request for this information should be marked optional. All other personal information about mothers or infants must not be actively solicited including Year of Delivery and 'Child's Date of Birth'. This restriction applies to those involved in the production, distribution and marketing of both antenatal and infant formulas. Third party companies soliciting information for promotional, membership or marketing purposes should be discouraged from engaging in such solicitation.

 The Infant Food Industry must be sensitive to the possibility of the inappropriate use of this information when an unfortunate or unforeseen event happens to the family, such as a serious medical condition or the death of the infant.

5.8 Ready-to-Feed (RTF) infant formulas must only be used in hospital wards and must not be offered for sale to the public. Manufacturers and distributors should submit any requests for RTF formula for other uses to SIFECS which will be reviewed on a case-by-case basis.

5.9 The Infant Food Industry must not give discounts on the bulk purchase of infant formulas or provide any financial or material inducement, directly or indirectly, that would encourage such bulk purchases. This restriction applies to all sales channels including retail, institutional and online channels.

5.10 The Infant Food Industry may sponsor healthcare professionals' attendance and participation in symposiums, congressional meetings and other medical/healthcare or education programmes that the Industry organises. However, the sponsorship should be limited to meals and registration fees. If the event is held overseas, then the sponsorship may also apply to travel and accommodation. This sponsorship should be limited only to the invited healthcare professional and not be extended to accompanying persons.

6. Milk Supplies to Hospitals

6.1 In keeping with the recommendations of baby-friendly hospitals, hospitals will have to bear the responsibility of providing adequate facilities and an environment that is conducive to parent-infant bonding and the successful establishment of breastfeeding.

 Hospitals with maternity service should employ professional and dedicated staff who are qualified and trained in breastfeeding to educate parents on the preferred and proper methods of infant feeding during antenatal classes as well as in the post-partum period. After discharge, mothers should continue to have easy access to follow-up care, as well as consultancy services on breastfeeding.

6.2 Breastfeeding is the preferred method of feeding in hospitals. In instances where the mother is unable to breast feed, or the infant is unable to breast feed, the use of infant formula must be decided by medical staff based on the infant s and mother s clinical condition. The same recommendation will apply to staff working in antenatal and prenatal clinics.

6.3 Bottles of pre-prepared milk should be treated as medications and should not be distributed and left on baby cots as a routine. Hospital staff should ensure that bottles of infant formula are kept in storage, out of sight of parents and visitors, to avoid the implication that anything other than breastfeeding is the preferred method of feeding in the hospital. Partial breastfeeding should be discouraged as this can be a deterrent to a successful lactation.

6.4 Donations of infant formulas or other products within the scope of the Code, by the Infant Food Industry may not be made to hospitals, with the exception of ready-to-feed (RTF) infant formula for pre-term infants. Hospitals should be responsible in ensuring that the amounts of available samples are kept to a minimum to reduce the likelihood of over-distribution.

6.5 Medical and nursing staff must not order the infant formula (including ready-to-feed infant formula. Also see section 5.8) from the Infant Food Industry directly from the ward. All ward orders for infant formulas must be communicated to the hospital food service or the dietetic department for arrangements of delivery and distribution of milk supplies to the nurseries.

6.6 Staff will also ensure that bottles of infant formula are kept in storage, out of sight of parents and visitors to avoid imparting a misguided impression of the preferred method of feeding in the hospital.

6.7 Only healthcare professionals such as doctors and stateregistered nurses are entitled to order infant formula and at a special pricing; including those in private practice. However, the specially priced formula must not be resold at a higher price so as to make a profit.

6.8 Discharge Packs usually given out by hospitals must not contain any products within the scope of the Code. Mothers who are breastfeeding may perceive the provision of samples of infant formula at discharge as a tacit discouragement to breastfeeding and an endorsement to formula use

7. Product Samples

7.1 Company personnel must not distribute samples and retail packs of breast milk substitutes within the scope of the Code to pregnant women, mothers or members of their families or healthcare professionals. Home deliveries of product samples, infant formulas, infant food related products or any other products within the scope of the Code or any gifts of equipment or utensils which may promote the use of breast milk substitutes are not allowed.

7.2 The Infant Food Industry must not distribute samples of infant formula, whether old or new, to all clinics, both public and private. The restriction also applies to distributing samples to doctors.

8. Product Advertisement and Promotion

8.1 Direct advertising (including advertisements on the internet) of products, within the scope of the Code, to the general public is prohibited, except when the advertisements are approved by the Vetting Committee of the SIFECS and/or targeted at healthcare professionals. Advertisements and promotional materials must not compare infant milk formula to breast milk or imply that any infant food product is equivalent or superior to breast milk e.g., "closer to breast milk".

8.2 The Infant Food Industry cannot organise point-of-sale promotions to induce sales at the retail level. These include distribution of samples or any other promotional materials, special displays, shelf labelling, price-off offers, discount coupons, premiums such as hampers and gift packs, and tie-in sales for products within the scope of the Code.

8.3 The Infant Food Industry must not be associated in any manner with Baby Shows for products within the scope of the Code. It follows that there will be no co-organising of events with any healthcare professional bodies or societies. The Infant Food Industry must not solicit for contacts with pregnant women or mothers of infants and young children.

8.4 Products within the scope of the Code, as well as samples, pamphlets and posters depicting the different brands of products, must not be sold or displayed at polyclinics, maternity wards, specialist clinics and general practitioners premises.

8.5 The Infant Food Industry can mention certain nutrients on their websites and also link to peer-reviewed scientific references (with links to the full paper). However, the websites must not provide links to the products, use terms like 'smart', 'intelligent' and 'intellectual potential' or other such terms that imply or create a belief that the products are equivalent or superior to breastfeeding. This article comes under the Food Regulation Laws of the Agri-Food and Veterinary Authority of Singapore (AVA). Violation of this article will entail necessary action by AVA.

8.6 The Infant Food Industry must not publish promotional materials on products within the scope of the Code on the internet, or send promotional e-mails to existing or potential customers with the aim of marketing their products. The Industry must not provide any financial inducement towards the purchase of their products online or via any other electronic channels.

9. Labels

9.1 Labelling of products within the scope of the Code must not be designed in a manner that would imply that the products are superior to breast milk. Labelling must meet the regulations under the Sale of Food Act.

9.2 Can inserts or any form of can attachments (e.g. stickers, shelf-talkers) are not allowed for products within the scope of the Code. All product information and its use should appear on labels as part of the can.

9.3 Can labels can only provide information on the appropriate use of the product. They are not allowed to carry instructions or illustrations which encourage progression to follow-on formulas, or interfere with the protection and promotion of breastfeeding. Violation of this article will entail immediate removal of the product off the shelf without a grace period.

9.4 Can labels must carry the term 'Important Notice', under which, the following information must be printed in letters, not less than 1.5 millimetres in height:

Breast milk is the best for babies. The World Health Organisation recommends exclusive breastfeeding for the first six months of life. Unnecessary introduction of bottle feeding or other food and drinks will have a negative impact on breastfeeding. After six months of age, infants should receive age-appropriate foods while breastfeeding continues for up to two years of age or beyond. Consult your doctor before deciding to use infant formula or if you have difficulty breastfeeding.

Kindly submit your labels to HPB_SIFECS@hpb.gov.sg for vetting by the SIFECS Committee.​


10. Implementation and Monitoring

10.1 Adherence to the Code is obligatory on the entire Infant Food Industry operating in Singapore, regardless of whether the companies are signatories of the SIFECS. Companies of the Infant Food Industry are responsible for monitoring their marketing practices in order to ensure that they follow the guiding principles and aims of the Code. This will be supervised by the SIFECS.

 The Infant Food Industry must not only communicate the details of the Code to their company personnel, but also to the retailers, wholesalers and distributors.

10.2 Professional groups, institutions and individuals are also obligated to observe the Code and draw attention to activities that are incompatible with or are infringing on the guiding principles and aims of the Code, so that appropriate actions can be taken.

10.3 The successful implementation and monitoring of the Code calls for cooperation from all the following sectors: the Infant Food Industry, retailers, wholesalers and distributors, hospitals, medical and other allied healthcare professionals and government authorities. These sectors must be proactive in the promotion and implementation of the Code. In particular, institutions responsible for the education and training of healthcare professionals should incorporate the Code into their curricula in order to ensure awareness of its contents.

Appendix 1

Lists of committee members 2016 - 2018

​Chairman​ Prof Ho Lai Yun
​Main Committee MembersA/Prof Daniel Goh Yam Thiam
Head of  Paediatrics
National University Hospital, Yong Loo Lin School of Medicine, National University of Singapore

Dr Chua Mei Chien
​Head, Special Care Unit 
Senior Consultant, Dept of Neonatology
KK Women's and Children's Hospital

Ms Cynthia Pang
Assistant Director, Nursing
KK Women's and Children's Hospital

Ms Alderline Wong
Counsellor
Breastfeeding Mothers Support  Group

Dr Thowfique Ibrahim
Senior Consultant
KK Hospital Perinatal Society of Singapore 

Hoirul Hafiidz Bin Maksom
Assistant Vice President, Hospital Administration
Gleneagles Hospital 

Ms Natalie Goh
Dietician
Singapore Nutrition & Dietetics Association

Ms Shirley Tay Poh Ching​
Director, Nursing
Mount Alvernia Hospital

Mae Mah
Deputy Director, Operations Administration
Thomson Medical Pte Ltd

Dr Natalie Chua
OG Consultant
SOG Heng Clinic for Women

Dr Yvonne Ng
Senior Consultant, Dept of Neonatology
National University Hospital

Dr Varsha Atul Shah
Honorary Treasurer
College of Paediatrics & Child Health, Singapore
Senior Consultant, Dept of Neonatal & Development Medicine
Singapore General Hospital 

Ms Lilian Yew
Chief Nurse
Raffles Hospital

Ms Mythili Pandi
Breastfeeding Mothers' Support Group
​Advisory MemberMs Tan Yi Ling
Senior Manager
Agri-Food & Veterinary Authority

Industry Members

​Abbott Laboratories (S) Pte Ltd​​Nestle Nutrition Singapore
​Danone Dumex ELN Spore Pte Ltd​​Orient Europharma Pte Ltd
​FrieslandCampina (Singapore) Pte Ltd​Mead Johnson Nutritionals
​​Wyeth Nutrition (Spore) Pte Ltd​

Appendix 2: Definition of Commonly Used Terms​

BREAST MILK SUBSTITUTES refer to any food marketed or otherwise represented as a partial or total replacement for breast milk, whether or not suitable for that purpose. These include:
  • Infant formulas (for infants from birth to six months of age)
  • Complementary food such as cereals, juices, water and other baby food (for infant after 6 months of age).
 
COMPANY PERSONNEL refers to any persons (including doctors and nutritionists/dietitians) employed by companies manufacturing, distributing and marketing products within the scope of this Code.
 
COMPLEMENTARY FOOD refers to any food, whether manufactured or prepared, suitable as a complement to breast milk or to infant formula, when either becomes insuffi cient to meet the nutritional requirements of the infant. Complementary food is also referred to as 'weaning food' or 'breast milk supplement'.
 
INFANT FORMULA refers to breast milk substitutes scientifically formulated to satisfy the nutritional requirements of infants up to six months of age. This term includes special formula products available over the counter.
 
MOTHERCRAFT SERVICES refer to the employment by the Infant Food Industry of nurses, midwives or related personnel to advise and assist mothers on infant feeding and infant care.
 
Different forms of related services will come under the umbrella of mothercraft. These include:

  • Parentcraft services or home care programme
  • Hotlines / helplines
  • Soliciting of mothers
  • Baby clubs
  • Newsletters
  • Talks on infant care
  • Websites
  • As determined by the Vetting Committee of the SIFECS 
This definition applies especially to products and activities within the scope of the Code.