Minutes after Keo Somaly gave birth to her first son, a female representative from

the France Bébé company was in the room to suggest her brand of infant

formula for the baby.

Staff in the private Sophear Maternity clinic were quick to tell the new mother that

the small amount of milk she produced and her sore nipples meant that breast milk

substitute was necessary. They provided the first tin free, but now the family spends

$36 a month on infant milk products, while their 11 month-old baby has been in and

out of hospital with fever and diarrhoea.

Six months after a draft law on the marketing of infant foods was submitted to the

Ministry of Health (MoH), little has been done to curb the unethical promotion of

breast milk substitutes in Cambodia, say NGO health workers.

In a country where 13.5 per cent of children will die before the age of five, Cambodia's

traditional high breast-feeding rates have been considered a rare strength in infant

health and one that needs to be protected, says Mark Thomson, communications officer

with UNICEF.

Breast milk is considered the best available source of nutrients for children, but

experts say the growing use of powdered milk substitutes in Cambodia increases the

risk of diarrhoea from unsafe water and unsanitary feeding practices. Poverty and

poor education also play a part, leading some mothers to over-dilute the powdered

formula or use condensed milk in the belief it is better for their baby than breast

milk.

"The consequence of not getting the breast milk is the child isn't getting the

nutrients which he or she needs to fight things like acute respiratory infections,

to fight the effects of diarrhoea, so it's really a two-pronged evil," says

Thomson.

A series of articles on child survival published in The Lancet in 2003 concluded

that "infants aged 0-5 months who are not breastfed have a significantly greater

risk of dying from diarrhoea and pneumonia compared to infants who are exclusively

breastfed."

This lack of nutrition is particularly crucial soon after a baby is born when the

mother's enriched first milk, or colostrum, gives what is in effect a natural vaccination

against disease. Only 24 per cent of Cambodian babies are breastfed within their

first day of life, according to the Cambodian Demographic Health Survey 2000 (CDHS).

While 96 per cent of Cambodian mothers breastfeed, only two per cent breastfeed exclusively

for the baby's first six months, which is the recommendation from doctors, says the

CDHS.

The National Pediatric Hospital in Phnom Penh has seen the rates of infant sickness

and mortality increase in recent years as more mothers return to work in garment

factories a month after giving birth, leaving relatives to feed their babies with

milk substitutes, says Dr Chhin Lan, an infant nutrition expert at UNICEF.

Doctors and health officials say the reasons behind this move away from breast milk

include the increased availability of alternatives, a reluctance to breastfeed while

working in offices or markets and the belief that infant formula is more nutritional

than breast milk.

This belief is strengthened by product advertising, say a range of nutrition experts.

The draft law to regulate the promotion of infant foods was written in 2001 by a

working group made up of the World Health Organization, UNICEF, Helen Keller International

and the Ministry of Health's National Nutrition Program and Communicable Diseases

Control departments. Representatives from the working party say Nestlé, one

of the three major suppliers of infant formula in Cambodia, asked to join the group

but was refused.

After two years of international feedback and refining, the working group eventually

produced a document similar to the International Code of Marketing of Breastmilk

Substitutes adopted by the World Health Authority in 1981 as the "minimum requirement"

to protect infant health. To date, only seven countries - Switzerland, the Philippines,

Zimbabwe, Malaysia, Singapore, Australia and New Zealand - have set up formal monitoring

bodies to enforce the code.

If the law is passed, the Cambodian Ministry of Health would be responsible for its

implementation with breaches attracting fines of up to 10 million riel and three

months in prison.

When the draft legislation was submitted to the Ministry of Health in July 2003,

they showed "strong support" and forwarded it to the MoH legal department,

but there has been little progress in the political vacuum that has followed last

year's election. Health Minister Hong Sun Huot requested that Professor Koum Kanal,

director of the National Maternity and Child Health Hospital, answer questions about

the progress of the regulations, but repeated efforts by the Post to speak to Kanal

by phone and in person were to no avail.

Women's Minister Mu Sochua is a strong supporter of breastfeeding and says she was

appalled at what happened to Keo Somaly, whose husband is Sochua's driver.

"To me I see it as a crime," says Sochua. "Especially for a poor country

like Cambodia, there's no way you can afford to promote formula because it is so

dangerous."

Sochua says unethical marketing of infant formula is widespread in private clinics

and in some state hospitals throughout the nation, and that the MoH is not doing

enough to promote a natural approach. Although she hadn't read the proposed breastfeeding

legislation, she questions the legal approach.

"I'm sure the law will say you can only market this to certain mothers with

certain problems but who will monitor that?" asks Sochua.

"The Ministry of Health should discourage [the use of infant formula] so totally

by having a huge campaign...for natural milk [and] breastfeeding."

That education role has been taken up in part by the BBC World Service Trust, which

will launch a wide-ranging education program in March tackling child and maternal

health as well as HIV issues. Giselle Portenier, the head of projects in Cambodia,

said their research found companies continued to breach internationally accepted

marketing standards and as such were an important part of the solution.

"We really want to work with the baby formula companies," said Portenier.

"This is all about saving children's lives and if we can get the baby food companies

to help us we've done a great job."

Nestlé, one of the main targets of criticism from advocacy groups such as

the International Baby Food Network (IBFN), has distributed its products in Cambodia

since 1998 and says it welcomes stronger legislation on marketing breast milk substitutes.

"We need this law," said Bertrand Sigwalt, the general manager of Nestlé

in Cambodia, saying the lack of a legal framework makes it more difficult to do business

in the country.

Sigwalt said all his staff received training about the ethical promotion of their

products and that Nestlé's company policy on marketing was stricter than the

internationally accepted World Health Authority document.

Nestlé's policy on implementing the 1981 WHA code states that "where

the national implementation is weaker than our own internal rules, we implement our

instructions."

Nestlé is the only brand that labels its under-six month formula tins with

Khmer language warnings and instructions. Of the two most popular products, Dumex

carries a detachable Khmer label under the lid of the can, while France Bébé

formula only has instructions in English and Chinese.

The Cambodian representative for France Bébé, Bou Maly, declined to

comment. Questions put to Abbot Laboratories, the maker of Dumex infant formula,

via their Phnom Penh business manager Avinash Kulkarni a month ago have not been

answered.