Issue 28 / 23 July 2018

BREASTFEEDING needs all the protection, promotion and support it can get. Yet these three words were at the centre of a breastfeeding resolution fiasco earlier this year. At the World Health Assembly in May, the United States made deliberate attempts to dilute a resolution on breastfeeding and specifically sought to remove the wording that countries should “protect, promote and support” breastfeeding. The US threatened the original sponsor of the resolution, Ecuador, with trade sanctions and military aid withdrawal if the resolution passed unchanged. Fortunately, Russia stepped up to sponsor the resolution and it passed largely unscathed.

The actions of the US have outraged the health sector, reminding us of the risks of corporate interference in public health guidelines, policies and programs. Media and commentators around the world have expressed surprise at these actions, yet formula manufacturers have been active in aggressively marketing the substitution of mothers’ milk with commercial alternatives for many years.

Rates of breastfeeding in Australia and internationally are low. The Australian National Infant Feeding Survey in 2010 found that while over 90% of women initiate breastfeeding, only 15% exclusively breastfeed their babies to 5 months. In low income and middle income countries, less than 40% of infants under 6 months are exclusively breastfed. In high income countries, there is a significant gap in breastfeeding patterns between the rich and poor; breastfeeding rates show a clear gradient with higher initiation and duration in higher income brackets. Australian guidelines recommend that babies are exclusively breastfed to around 6 months of age when solids are introduced and breastfeeding continued until the age of 12 months and beyond, if both mother and infant wish. We recognise that there are certain circumstances when breastfeeding is not possible, and the safe use of infant formula is essential. Establishing and continuing breastfeeding may be challenging for many mothers and babies. New mothers deserve encouragement and support to feed their babies. However, the evidence is clear: breastfeeding is a far superior option on a number of fronts and should be strongly promoted as such. Unfortunately, marketing strategies used by the formula industry can weaken and distort this message.

Breastfeeding provides children with the best start in life and is a key contributor to improved infant and maternal health outcomes. Authors of the recent Lancet series conducted meta-analyses that indicated that breastfeeding provides children with protection against infections and malocclusion, increases in intelligence and likely reductions in overweight and diabetes. For nursing mothers, there were benefits in terms of protection against breast cancer and potential protection against ovarian cancer and type 2 diabetes. Breastfeeding can also help with family planning with improved birth spacing. The benefits for children in low and middle income countries are significant. Diarrhoeal diseases and lung infections are among the major causes of death in children under 5 years of age. Improving breastfeeding rates could nearly halve diarrhoeal episodes and cut respiratory infections by a third. Breastfeeding also has economic benefits, achieved not only through health care cost reductions and lives saved but also through the benefits of improved cognitive development leading to greater economic productivity. Internationally, if all infants under 6 months of age were exclusively breastfed, we could prevent 823 000 annual deaths in children under 5 years and an estimated US$302 billion annually in economic losses from cognitive deficits.

The pervasive marketing and availability of infant formula is a critical factor in lagging breastfeeding rates. Big Formula operates in the same playground as Big Tobacco. The aggressive tactics employed by the infant formula industry to promote their products and expand their markets mirror those used by the tobacco industry. These tactics include:

  • interfering with political and legislative processes;
  • overstating the economic importance of the industry;
  • manipulating public opinion to improve their appearance;
  • engineering support through “expert” front groups;
  • discrediting evidence-based science; and
  • intimidating governments with legal action.

The Hong Kong Infant and Young Child Nutrition Association (HKIYCNA) appears to be a society of health professionals and claims to “improve the nutritional wellbeing of infants and young children in Hong Kong”. Yet, HKIYCNA is a front group for six baby food companies – Abbott, Danone, FrieslandCampina, Mead Johnson, Nestle and Wyeth – and has openly lobbied in opposition of the code on marketing of breast milk substitutes.

Big Formula follows Big Tobacco playbook - Featured Image

Credit: Lisa Amir. Infant formula advertising in Vietnam, Ho Chi Minh City, 2016

With infant formula sales plateauing in high income countries, we can expect to see increased lobbying efforts specifically targeting low and middle income countries, which have been identified by infant formula producers as key growth markets. Yet again, Big Formula is following in the footsteps of Big Tobacco. Tobacco marketing has been reported to be substantially higher in low and middle income countries, and the infant formula industry will not be far behind. Research has shown that the marketing of breast milk substitutes has a deleterious impact on the breastfeeding practices recommended by the World Health Organization. Marketing in low and middle income countries is less regulated than in high income countries and infant formulas are directly marketed to consumers via the mass media and print advertisements; with the use of internet marketing and social media on the rise.

Free samples, incentives and benefits are provided to health workers and services to promote infant formula products. Misleading and even false health claims have been used by the infant formula industry with attempts to portray formula as “more modern” and “even better” than breast milk. The billboard advertisement shown above suggests improved cognition with their product “360° brain plus”. Earlier this year, Nestle came under fire for violating breast milk substitute marketing guidelines with products in Hong Kong and Spain advertised as having an “identical structure” to breast milk and “inspired by human milk”.

The recent events at the World Health Assembly reveal the depth and extent of interference that the infant formula industry is willing to take to protect their $70 billion industry. Any health commitments which may limit their ability to indiscriminately promote their products will be challenged. Women and their families deserve better.

One approach may be to view breastfeeding through a food security lens. Food security for infants and young children relies on high rates of breastfeeding. Political attention and policy coordination may be strengthened by viewing breastfeeding within a food security framework. A right-to-health approach demands that women are given the best opportunity to breastfeed without the undue influence of the industry. Governments need to ensure responsible advertising of infant formula, challenge countervailing narratives from the industry, address globalised supply changes for breast milk substitutes and have effective legislation in place to reprimand unacceptable behaviour. Workplaces need to have supportive policies and practices that enable women to return to work and continue breastfeeding. Women need to be supported at all levels of society with structures in place and a culture that enables them to breastfeed anywhere, anytime.

World Breastfeeding Week is celebrated in the first week of August; and this year’s slogan is “Foundation for life”. Let’s take this opportunity to provide babies and their mothers with a supportive breastfeeding environment which indeed enables them to provide a foundation for lifelong good health and wellbeing.

Dr Alyce Wilson is an aspiring public health physician with a background in public health nutrition. She works in research and international development in maternal, child health and nutrition and lectures medical students on nutrition.

Dr Mariam Tokhi is a GP and global public health researcher focusing on women’s and children’s Health. She works in community medicine in north-west Melbourne.

Associate Professor Lisa Amir is a GP and lactation consultant. She works in breastfeeding medicine at the Royal Women’s Hospital in Melbourne and in private practice. She is a Principal Research Fellow at the Judith Lumley Centre, La Trobe University, Australia.


The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.

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9 thoughts on “Big Formula follows Big Tobacco playbook

  1. Sue Ieraci says:

    The Lancet 2016 meta-analysis involves significant issues with data collection. In contrast to the direct data collection in the PROBIT study, the authors in the Lancet review state that “For all high-income countries with 50 000 or more annual births, we did systematic reviews of published studies and the grey literature and contacted local researchers or public health practitioners when data from a particular country were not available or when there was ambiguity (appendix pp 13–17). Information about breastfeeding from national samples was not available from many countries. Although 27 out of 35 countries had some information about breastfeeding at a national level, response rates were often in the 50–70% range, indicators were rarely standardised, and recall periods tended to be long. We used administrative or other data when surveys were not available. If necessary, we estimated the proportion of infants breastfed at 12 months on the basis of information
    available for breastfeeding at 6 months and vice versa.”

    Also: ” Information about early initiation or exclusive or continued breastfeeding at 2 years was not available for most high-income countries.”

    The authors applied the “lives saved tool” to calculate the theoretical number of lives that might be saved by breastfeeding. This is problematic, as it is not known what percentage of infectious deaths are among breast-fed children. In Australia, infectious deaths in infancy are, thankfully, vanishingly small. Our infant mortality rate is 3 per 1000 live births (ABS data) – from all causes. Neonatal infectious mortality is almost always confined to infection from birth organisms, such as acquired from prematurely ruptured membranes.

    So, the proposal from the Lancet paper, that “The scaling up of breastfeeding to a near universal level could prevent 823 000 annual deaths in children younger than 5 years” does not appear to apply to wealthy countries like ours. This is confirmed by the authors’ statement that “In terms of child morbidity, overwhelming evidence
    exists from 66 diff erent analyses, mostly from LMICs and including three randomised controlled trials, that breastfeeding protects against diarrhoea and respiratory
    infections” (LMICs = low to middle income countries).

    Ironically, the paper confirms that the nations with the highest breastfeeding rates have the highest infant mortality.

  2. Joy Anderson says:

    Readers casting doubt over the importance of breastfeeding in Australia and other developed countries may be interested in this article from the Lancet in 2016:

  3. Sue Ieraci says:

    The authors are correct to call out unethical marketing practices, and particularly the marketing of infant formula in impoverished communities – where lack of clean water and poverty can lead to infection and dilution. What the article misses, however, is the contrast in wealthy societies like ours, where the differences in outcomes from different types of infant feeding are much smaller.

    I had always accepted the “Breast is Best” message until I read the actual studies of infant feeding outcomes in developed societies, such as the PROBIT studies. Essentially, six months of exclusive breast feeding led to a small reduction in the number of respiratory and gastro illnesses in the first year. It is notable that exposure is a major influences on infant infections – such as cigarette smoke in the home, or the presence or other siblings or child care contacts.

    Also, contemporary breastfeeding rates in Australia have essentially doubled since the 1970s, when rates fell below 50%. Obesity rates have risen despite a major increase in breastfeeding prevalence. A secondary analysis of PROBIT data, published in JAMA Pediatrics last year, showed that “A randomized intervention that increased the duration and exclusivity of breastfeeding was not associated with lowered adolescent obesity risk or BP. On the contrary, the prevalence of overweight/obesity was higher in the intervention arm”. Proposed effects on cognitive function are also questionable as it has not been possible to separate breastfeeding rates from other characteristics of the parents.

    Babies can become significantly dehydrated when families are scared of supplementing with formula, fearing it may disadvantage their child. It’s in this context that I now understand the “Fed is Best” message. Also, as other commenters have mentioned, the proposed benefits of breastfeeding for mothers must be balanced against disadvantages such as anxiety and guilt.

    While I don’t question the sincerity or motivation of the authors, it’s important that Australian clinicians are able to share valid evidence with families. In Australia (in contrast to impoverished communities), the nature of infant feeding makes little difference to infant health. In particular, in contrast to tobacco, infant formula nourishes babies – it doesn’t harm them.

  4. Anonymous says:

    Agree with #5.
    In fact the pressure on mothers to breastfeed (“everyone can do it”) leads to its own version of performance anxiety when it turns out everyone can’t. This anxiety itself physiologically leads to failure to let-down, and a downward spiral to complete failure.

  5. Anonymous says:

    Very surprised to see some of the broad statements in this article:

    1) “Breastfeeding can also help with family planning with improved birth spacing” – it is exactly this myth ‘you can’t get pregnant while breastfeeding’ that has caused a lot of unwanted/unplanned births.

    2) “Marketing in low and middle income countries is less regulated than in high income countries” – there should be a full stop at the end of this sentence. It’s not specific to formula, marketing and other things have less regulations generally.

    3) “Australian guidelines recommend that babies are exclusively breastfed to around 6 months of age when solids are introduced” – as stated in another comment this is out of date and allergy specialists worldwide advise introducing solids at 4 months.

    4) Yes there is an issue if formula is marketed as the ‘same as’ or ‘better than’ breastmilk. But what is wrong with “inspired by human milk”? What else should it be inspired by? Cheese?

    As a husband with a wife who suffered from PND, formula was a lifesaver for us. Fed was best in our case. Please don’t add to the guilt and stress for new mothers with sensationalist headings comparing formula and tobacco companies.

  6. Sarah says:

    Interesting article. Breast is best – except when it isn’t. The pressure to breastfeed is immense in NZ. I was told my baby would die of SUDI, be obese, have a lower IQ and develop diabetes if I gave him formula. So I persisted, with support (read pressure) from the hospital, my midwife, Plunket nurse and lactation consultants. They assured me ‘everyone can breastfeed’ and that I ‘need to try harder’. My baby screamed and cried for 20hrs a day. He couldn’t sleep because I was starving him. Thankfully my GP caught on but I still did not want to give him formula out of fear for his health and being stigmatised. My GP asked me to come back every week to weigh him, as I insisted on exclusively breastfeeding. His weight dropped week by week. Finally my GP said: “Your baby is starving and dehydrated. He needs formula – it is not poison”. What an amazing difference within a day, I breastfed my boy then he guzzled a bottle. He was content, actually slept and for the first time I enjoyed my baby.

    To ‘protect, promote and support’ breastfeeding can go too far. Articles like this (comparing formula to tabacco companies?) are so extreme. The WHO guidelines, from which NZ/Aus breastfeeding legislation and policies are based, appeal to the lowest common denominator. They found, particularly in Asian countries, women weren’t breastfeeding as it wasn’t ‘trendy’. They were in poverty but spending money on formula unnecessarily. Also the theory of exclusively breastfeeding (virgin gut) until 6 months has been debunked. Latest research shows common allergens should be introduced between 4-6 months, to help avoid developing these allergies later in life. At least this was the advice from several GPs, our paediatrician, allergy specialist and two dieticians here in NZ.

    My boy was being monitored because he was tracking small – not obese ironically. He has also been ‘marked’ as gifted and will undergo testing at 2yo – so his IQ isn’t affected. I only recently learned I was formula fed too, and I’m doing pretty well. Spoke to my German friend and cousin in France, they say there is no pressure either way in Europe. Their health practitioners encourage what is best for mum, taking into account both physical and mental health. This seems a sensible approach for developed countries.

    NZ hospitals/midwives/antenatal classes do not give out free samples. In fact they were ‘not allowed’ to talk to us about formula. When you visit a formula producers website, you need to click “accept” that formula is bad to proceed. At the hospital I was given ‘breast is best’ brochures and had to sign a waiver to get formula for my daughter. Ironically, I received ZERO information when Drs had to perform a spinal tap on her. I had to Google the risks of puncturing my baby’s spinal canal, but I received glossy brochures on the risks of using formula. It would be interesting to see a study between the link of PND and pressure to breastfeed, especially for first time mums. Is this something you would consider to balance out this article?

    Sent from my iPhone

  7. John Barr says:

    The only really surprising thing here is the fact that media and commentators were surprised at the lengths to which Big Business will go to make money, be it Tobacco, Agri, Food and especially Pharma.
    The Big Pharma companies are regularly fined millions, nay billions of dollars for fraudulent marketing.

  8. Anonymous says:

    I breastfed my daughter until she was 2.5 years old with the first 6 month of only having consumed breast milk-and when I returned to work when she was 12 months old in a health facility, there was no way I could express my breast milk due to workload demands despite having policies in place. She missed out on daytime breastmilk and kept me up all night feeding.

    However with that experience, when I found out I was pregnant with twins, I thought I could meet the challenge. However, there was no support from MFMs, Ob-Gyns, Lactation Consultants, midwives, to properly learn to feed. The babies became dehydrated and lost >10% weight and the Paediatrician recommended formula and kept the babies hospitalised. Then after a mammoth effort to breast feed the babies and reduce “top ups” of formula, at my GP review the doctor said there was no way I could breast feed twins and the Child and Maternal Health Nurse said they needed more formula top ups and recommended a brand- and initially said she would help to reduce the formula top ups but NEVER returned.

    None of the health professionals cared to help me, despite strong intentions and willingness to breastfeed. There was zilch information on reducing top ups of formula once started mix feeding. The only person who enabled me to continue to breastfeed was my mother in law. She was on the ground helping. She deserves a medal.

  9. Joy Johnston says:

    Protection, promotion and support of any precious *thing* demands continuing and continuous action and strategies. Each generation needs to take it up as their own. Thankyou for keeping the interests of the ‘innocenti’ in the sight of this professional community.

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