Complying with the WHO Code in Low Supply–Informed Care

There is arguably no text more foundational to the work of International Board-Certified Lactation Consultants than the International Code of Marketing of Breastmilk Substitutes, adopted by member states of the World Health Organization in 1981. It’s so fundamental to global infant feeding that the public health community often refers to it as simply “the Code.”

IBCLCs have an ethical responsibility to comply with the WHO Code. It’s part of our Standards of Practice and Code of Professional Conduct. And healthcare workers in countries that have legally adopted the Code, or at organizations that require Code adherence, must also follow its provisions. The WHO Code was written in an effort to protect breastfeeding around the world, particularly in low- and middle-income countries where the formula industry’s unscrupulous forays had well-documented, tragic consequences widely publicized in the 1970s (Rollins et al., 2023). If you happen to have time, the 2023 deep dive from The Lancet on formula marketing is a fascinating but disturbing read.

In creating a resource for families with low supply, we have realized that complying with the WHO Code while serving our particular population is far from simple. This site is for people who want to breast/chestfeed, but who are not able to make a full supply. So by definition they need to use supplementation in the form of donor milk or formula. Others with low supply go on to exclusively formula feed. We believe parents should not have to listen to messaging that demonizes formula, which members of our support group report can worsen the considerable psychological turmoil that often accompanies low supply. To be clear, the Code itself does not recommend such messaging, though it can be misinterpreted.

So why is it important for us to learn about the WHO Code? We deserve to know that when we are being counseled, or when we are reading educational materials, information might be coming through a filter of WHO Code compliance. This is not a bad thing, and as we explained before, we believe it is important. But policies aimed at protecting babies and breastfeeding can exacerbate the feelings of inadequacy and sometimes the trauma that members of the low supply community experience, and we have the right to understand the context of the guidance we receive.

In service of providing that well deserved information to the low supply readers of this site and the professionals who support them, we present a few passages of the WHO Code, along with our thoughts on how the Code is relevant to low supply families.

First, the scope of the Code, as defined in Article 2, is of particular note to the low supply population:

The code applies to the marketing, and practices related thereto, of the following products: breast-milk substitutes, including infant formula; other milk products, foods and beverages, including bottle-fed complementary foods, when marketed or otherwise represented to be suitable, with or without modification, for use as a partial or total replacement of breast-milk; feeding bottles and teats. It also applies to their quality and availability, and to information concerning their use (World Health Organization, 1981).

Now let’s look at how that scope relates to people with low milk supply.

It affects what IBCLCs—along with healthcare workers in WHO Code–compliant countries and organizations—can say about formula.

How is this relevant to the guidance low supply parents receive? When IBCLCs talk about formula, we need to take care not promote any particular brand. Further, Article 5.1 states that “There should be no advertising or other form of promotion to the general public of products within the scope of this Code.” Article 5.3 states that “Manufacturers and distributors should not use indirect means to promote products within the scope of this Code.” And finally, Article 7.3 states that “Health workers should not be used by manufacturers or distributors of products within the scope of this Code to promote such products” (World Health Organization, 1981). Professionals bound by the Code need to tread carefully when discussing formula.

That said, the Code does not preclude us from talking about brands with individual families (Brooks, 2024), or from providing unbiased and evidence-based education about formula. Baby Formula Expert, for example, is an informative resource by a Certified Lactation Counselor and researcher of human milk who educates parents, presumably often ones with low supply, while complying with the WHO Code, as far as we can tell. When donor milk is not used due to access or parental choice, low supply families rely on formula, and we see in our group that a lot of us have questions about it. If we ask those questions of an IBCLC who is fulfilling their ethical obligations, we should understand that they may phrase their response in a particular way to avoid any possible perception of bias toward or promotion of one company.

It means there are certain messages IBCLCs and other healthcare organizations are required to convey in educational materials, such as this site.

Article 4.2 of the Code uses language about breastmilk and formula that might be upsetting to some low supply parents who are grieving not being able to exclusively breastfeed, but its content is important:

Informational and educational materials, whether written, audio, or visual, dealing with the feeding of infants and intended to reach pregnant women and mothers of infants and young children, should include clear information on all the following points: (a) the benefits and superiority of breast-feeding; (b) maternal nutrition, and the preparation of and maintenance of breast-feeding; (c) the negative effect on breast-feeding of introducing partial bottle-feeding; (d) the difficulty of reversing the decision not to breast-feed; and (e) where needed, the proper use of infant formula, whether manufactured industrially or home-prepared. When such materials contain information about the use of infant formula, they should include the social and financial implications of its use; the health hazards of inappropriate foods or feeding methods; and, in particular, the health hazards of unnecessary or improper use of infant formula and other breast-milk substitutes. Such materials should not use any pictures or text which may idealize the use of breast-milk substitutes (World Health Organization, 1981).

How is this relevant to people with low supply? We have made a point of covering these subjects throughout this site, and below this article we provide additional resources for the topics that we haven’t written about or linked to elsewhere. If it seems like we’re talking a lot about the benefits of breastmilk over formula when breastmilk is available, this passage is one reason why. Such information can feel like a knife in the wound of families with low supply, since many of us had every intention of exclusively breastfeeding, and found out that we would not be able to in upsetting conditions, sometimes after undergoing weeks or more of emotionally and physically draining triple feeding—and all of this during a period of our lives when we already would have been at our most vulnerable, even without the compounding factors of low milk supply. By complying with the WHO Code, we try to ensure that the education on this site will not be misinterpreted, especially by people who are capable of making a full milk supply. Other educational materials you access may do the same, though it’s possible they won’t have a low supply–informed approach to their messaging.

It limits how we can talk about particular bottles and pumps.

As you can see above, the Code also extends to infant bottles and teats (or nipples). Some consider this aspect of the Code an artifact of earlier times, before the adoption of electric breast pumps in well-resourced settings. This part of the Code is why lactation consultants may be cautious about promoting many pump brands, since they often manufacture bottles as well. While it may not be totally clear in the text above, WHO guidance equates product promotion with brand promotion in subsequent publications (World Health Organization, 2023). However, Article 1 (“Aim of the Code”) is relevant to this discussion:

The aim of this Code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution (World Health Organization, 1981).

In this light, the marketing of bottles and teats is a violation of the Code only when it undermines the protection and promotion of breastfeeding, and we can extend this logic to pump companies that make bottles and teats but do not manufacture or market breastmilk substitutes. IBCLC and lawyer Liz Brooks discussed this interpretation in a recent presentation on the Code (Brooks, 2024). And in an interview, Certified Breastfeeding Specialist and lawyer Allison Porter also interpreted the WHO Code as not applying to bottles and teats when they are used for expressed milk (Porter, 2022).

This commentary from legal experts in the lactation community exists because interpreting the WHO Code is not always simple. Every IBCLC may have a more liberal or more conservative reading of the Code, and parents deserve to be aware of this variation in opinions when seeking out guidance on bottles and pumps from lactation consultants.

Further, many people now choose to breastfeed by pumping, sometimes exclusively, and they often rely on bottles to breastfeed their babies. (Because pumping is breastfeeding!) Although in some circumstances pumping can pose risks to the breastfeeding relationship (Eglash and Edelstein, 2025), in the low supply community, a lot of us end up exclusively pumping because our babies will not latch, which can happen when breastmilk production does not meet the baby’s physiological needs. Others use pumps as part of a triple feeding strategy to increase milk production. For many people with low supply, pumping becomes the only way we can breastfeed our babies, or a method through which we attempt to give them more of our milk. By our reading, to educate about pumping and bottles is an extension of the protection of breastfeeding outlined in the Code.

It limits when and how we are allowed to depict formula feeding.

Article 6.5 states:

Feeding with infant formula, whether manufactured or home-prepared, should be demonstrated only by health workers, or other community workers if necessary; and only to the mothers or family members who need to use it; and the information given should include a clear explanation of the hazards of improper use (World Health Organization, 1981).

What does this mean for low supply parents? Though many of us rely on formula and combo feeding for our babies’ survival and we might appreciate seeing pictures of infants being fed formula, such images will not appear on this site. But the Code does not prevent us from educating about bottle use (Brooks, 2017), especially when such education is in the spirit of the “protection and promotion of breastfeeding” as explained in Article 1—which bottle feeding very much can do, particularly for parents who are not physiologically capable of making a full milk supply. And the demonstration of bottle use for the feeding of expressed breastmilk is not limited by the Code. If you see a picture of a baby being bottle-fed on this site, we are posting it with full awareness of the Code’s recommendations about formula and bottle feeding.

The WHO Code was not designed for the low supply community. That is probably OK. It is there to protect the world population of babies from the formula industry’s predatory marketing practices. But if you are reading all this and wishing that the international community could acknowledge our struggles too, we hear you. In their 2025 article on primary low milk supply, Whelan et al. wrote, “The condition is not listed among conditions that are deemed by the WHO and UNICEF as acceptable medical reasons for the use of breastmilk substitutes.” We as lactation consultants must do our best to comply with the WHO Code. But we also cannot forget about how it affects the low supply community, and we should be aware that there are ways to follow the Code while also being mindful of the specific needs of parents who cannot make a full milk supply. By promoting awareness and a different paradigm for screening and treating patients, the Low Supply Lactation Project, along with some of the organizations and voices listed on our resources page, aims to help low supply families feel more supported, even when they are not the focus of this particular foundational text on breastfeeding. 

 

References

International Lactation Consultant Association. (2013). Standards of practice for International Board Certified Lactation Consultants (4th ed.). https://ilca.org/wp-content/uploads/2021/05/Standards-of-Practice-for-International-Board-Certified-Lactation-Consultants-newlogo.pdf

IBCLC Commission. (2023). Code of professional conduct for IBCLCs. https://ibclc-commission.org/ibclc-information/code-of-professional-conduct-for-ibclcs/

Rollins, N., Piwoz, E., Baker, P., Kingston, G., Mabaso, K. M., McCoy, D., Neves, P. A. R., Pérez-Escamilla, R., Richter, L., Russ, K., Sen, G., Tomori, C., Victora, C. G., Zambrano, P., & Hastings, G. (2023). Marketing of commercial milk formula: A system to capture parents, communities, science, and policy. The Lancet, 401(10375), 486–502. https://doi.org/10.1016/S0140-6736(22)01931-6

World Health Organization. (1981). International Code of Marketing of Breast-Milk Substitutes. World Health Organization. https://www.who.int/publications/i/item/9241541601

Brooks, E. C. (2024). The International [WHO] Code in everyday practice: Real life scenarios [Conference session]. Breastfeeding Conferences. Retrieved December 24, 2025, from https://www.breastfeedingconferences.com.au/about/The-International-WHO-Code-in-Everyday-Practice-Real-Life-Scenarios

World Health Organization. (2023). Guidance on regulatory measures aimed at restricting digital marketing of breast-milk substitutes. World Health Organization. https://www.who.int/publications/i/item/9789240084490

Porter, A. (2022). Deeper dive into the WHO code: Theory and application. Paperless Lactation. https://learn.paperlesslactation.com/course/deeper-dive-into-the-who-code-theory-and-application

Eglash, A., & Edelstein, L. (2025). Pumping trends in the USA and how parental diet affects milk quality [Audio podcast episode]. Breastfeeding Medicine Podcast. https://lacted.org/podcasts/pumping-trends-in-the-usa-and-how-parental-diet-affects-milk-quality

Brooks, E. C. (2017). Lions, and bottles, and teats, oh my! Clinical Lactation, 8(2), 48–52. https://doi.org/10.1891/2158-0782.8.2.48

Whelan, C., O’Brien, D., & Hyde, A. (2025). Breastfeeding with primary low milk supply: A phenomenological exploration of mothers’ lived experiences of postnatal breastfeeding support. International Breastfeeding Journal, 20, Article 7. https://doi.org/10.1186/s13006-025-00699-4

Resources to learn about topics covered by the WHO Code

We have discussed many of these subjects elsewhere, but here are some more sites where you can learn about breastfeeding and formula. Article 4.2 requires us to provide education on these topics.

For more insight on the Code, many lactation consultants turn to IBCLC and lawyer Liz Brooks. Her article Lions, Bottles, and Teats, Oh My! (cited above) is a useful resource for practitioners to understand her interpretation of how the Code relates to bottles and teats, and her continuing education course The International [Who] Code in Everyday Practice: Real Life Scenarios is extremely detailed and informative. This is particularly important to the Low Supply Lactation Project because low supply families so often need education about bottles. If we broaden our interpretation of what we can educate about without fear of violating the WHO Code—for example, by mentioning paced bottle feeding in a prenatal class—we can help preserve the breastfeeding relationship of parents who may later need to introduce medically indicated supplementation but do not have access to timely, competent, one-on-one lactation counseling at the moment of initial supplementation. A thoughtful interpretation of the Code will allow more IBCLCs to help more families with primary or chronic low supply. 

The Lancet Series on Breastfeeding from 2023 is a great place to start learning about the socioeconomic impact of formula use. On this page there is a useful infographic that summarizes findings from the report, and the series itself is illuminating. It also covers many of the other topics mentioned in Article 4.2. The landmark 2016 Lancet Series on Breastfeeding goes into even more detail on the benefits of breastfeeding for the lactating parent and the child. 

This article by IBCLC and DrPh Margaret Salty discusses the research on requirements for maternal food and water intake during lactation.

Here is information from the US CDC on Food Or Drinks to Avoid or Limit in babies and young children.

We also liked this article from the American Academy of Pediatrics about choking hazards (including foods) for young children.

In this article the American Academy of Pediatrics discusses why babies who do not meet their nutritional needs through breastmilk need formula instead of cow’s milk.

Here the US FDA explains why it is important to handle and prepare formula safely.

Please see our resources pages and the articles throughout the site for more low supply–informed and WHO Code–compliant lactation education.