The threat posed by social media to exclusive breastfeeding in Cambodia

• There has been an exponential rise in the use of digital marketing strategies to promote commercial milk formula products, which can erode supportive breastfeeding norms, beliefs and practices. 
• The Government of Cambodia is working to strengthen the implementation of the International Code of Marketing of Breastmilk substitutes (the "Code"), including updating legal provisions to prevent the promotion of commercial milk formula products through social media platforms. 
• Further effective enforcement of the Code will require increased funding, increased political will on, and increased coordination of, the enforcement of the Code regulations, and addressing bottlenecks relating to institutional human resources to support Code monitoring.

In 2005, the Government of Cambodia adopted many provisions of the International Code of Marketing of Breastmilk Substitutes (the "Code"). To support implementation of the Code, in 2007 a Joint Prakas1 was adopted by four line ministries: the Ministry of Health, the Ministry of Information, the Ministry of Commerce and the Ministry of Industry. Improved internet access and increasing social media use have driven an exponential rise in the use of digital marketing strategies to promote commercial milk formula products in Cambodia. However, the Code, as it is currently implemented in Cambodia, only prohibits the marketing of commercial milk formula products "at the points of sale, in hospitals or health centres or any other places", and does not explicitly cover digital marketing strategies.  

The report by World Vision International titled Under Social Media Influence: Digital Marketing of Breastmilk Substitutes in Cambodia identified that commercial milk formula product advertisements target pregnant women and mothers by using personal data on social media platforms, by using social media influencers to promote various commercial milk formula products (often paired with a health professional to add credibility), and by hosting online support channels for advice on childcare and feeding while promoting commercial milk formula products. The report also found that digital advertisements encourage the use of commercial milk formula products through making emotional appeals (e.g., showing images of idealised family relationships among happy families, or of mothers and children), by offering discounts, sales or free samples, and through the cross-promotion of commercial milk formula products with milk products for pregnant women. 

A major concern is that the marketing tactics of commercial milk formula companies not only increase sales of commercial milk formula but also erode supportive breastfeeding norms, beliefs and practices. Cambodia’s Demographic and Health Surveys have found that the percentage of Cambodian children who are exclusively breastfed for the first six months of life has decreased from 74% in 2010 to 51% in 2021. Uncontrolled marketing of commercial milk formula on digital platforms can cause Cambodian mothers to believe that commercial milk formula is superior to breastmilk. In urban areas, formula feeding is perceived to be a sign of modernisation. There is also a perception that mothers who give birth via caesarean section cannot breastfeed. Furthermore, an increasing number of maternity clinics in urban areas do not promote breastfeeding due to their engagement with commercial milk formula companies.  

In addition to the lack of provisions to prevent digital marketing of commercial milk formula products, there are several loopholes in the implementation of the Code in Cambodia, including the following: 

• The absence of strict regulations on the promotion of infant and young child feeding products. 
• A lack of provisions to prevent the distribution of sample products, equipment and materials to health facilities by manufacturers and distributors of commercial milk formula products. 
• A lack of provisions to prevent sponsorship of events and scholarships by manufacturers and distributors of commercial milk formula products. 
• The absence of a ban on nutrition and health claims being made about infant and young child feeding products.
• A lack of warning messages on labels regarding the early introduction of commercial milk formula and its risks.  

To address these gaps, in June 2022, the Ministry of Health initiated an update (yet to be fully endorsed) to the Joint Prakas. The key amendments include the following: 

• Limiting the promotion and supply of commercial milk formula in health facilities. 
• Expanding the targeted age groups from children aged 24 months to children aged zero to 36 months.  
• Preventing false and misleading health and nutrition claims being made by commercial milk formula companies. 
• Preventing advertisements and promotions being made through social media platforms. 
• Enacting strict penalties for manufacturers and distributors who undermine breastfeeding while promoting their products.  

Efforts are under way to help support the Government of Cambodia in this area. Alive & Thrive Cambodia has trained healthcare providers on breastfeeding and lactation counselling and have incorporated the Code’s legal provisions within the Early Essential Newborn Care Quality Improvement Guideline (2022) and the Maternal and Child Health Nutrition Score Card tool. Helen Keller International has oriented healthcare staff on the Code and has pioneered some early work to improve monitoring and enforcement mechanisms. World Vision International Cambodia has piloted (2021) an online reporting tool that can be used to capture violations of the Code (including in retail stores and health facilities, as well as on social media). This tool has the option to share screenshots and links to online platforms that violate the Code and has been found to be effective in reducing paperwork associated with tracking violations. Discussions are under way with the Ministry of Health on using this tool as an official government reporting system. 

To ensure infant and young child feeding is protected in Cambodia there is a need for intensified efforts and political will. Further effective enforcement will require continuing improvements to a specific budget allocation by the Ministry of Health to support the monitoring of the Code, increasing political will and coordinating the enforcement of the Code regulations, and addressing bottlenecks relating to institutional human resources and capacity to support Code monitoring. It is critical that the momentum of the successes achieved so far is not lost, and that the commitment of a greater range of organisations and government ministries to protecting breastfeeding and promoting the responsible marketing of commercial milk formula in Cambodia is encouraged.