BMJ 2018;362:k3577 doi: 10.1136/bmj.k3577 (Published 23 August 2018)

The resurgent influence of big formula
Education on infant feeding must not be left to industry
Natalie S Shenker
Human Milk Foundation


In May, word spread from the World Health Assembly of
remarkable developments around an apparently
non-controversial World Health Organization resolution to
support breastfeeding. The Trump administration had opposed
the motion and threatened the proposer country, Ecuador, with
a suspension of trade and military support.1 Ultimately, the
motion was proposed by Russia and accepted by the assembly,
but the behaviour of the US caused ripples of surprise and
concern throughout the global public health community.
Increased lobbying from infant formula manufacturers may
underlie the US’s new hard line approach.2 The formula industry
is anticipated to turn over about $70bn (£55bn; €61bn) next
year,3 and $60m has been spent lobbying the US government
alone in the last decade.4 The formula industry has other links
to US power—one of the companies tasked with separating
children from immigrant parents at the US-Mexico border shares
two board members with a formula company.5 6
The 2016 Lancet Breastfeeding Series estimated that over 820
000 babies’ lives could be saved annually worldwide by
increased breastfeeding rates.7 Mothers benefit too—recent
meta-analyses have shown marked risk reductions for triple
negative breast cancer, ovarian cancer, and endometrial cancer
in a duration dependent manner, along with apparent protection
from a range of autoimmune and chronic diseases.8 9 In the
European Union, over 90% of infants receive formula milk at
some stage in their first year.7 The increasing use of infant
formula in low and middle income countries has coincided with
a slowing of the rise in infant and maternal mortality.7 Events
at the World Health Assembly suggest a new level of Trumpian
disregard for maternal and infant wellbeing that should be
resisted in the strongest terms.
Human milk is not simply a food. It is a vastly complex biofluid,
containing thousands of components, many unique,
individualised to each baby and environment.10 Lactation
developed as an evolutionary strategy before placentation,
primarily to protect the immunocompromised neonate.11 Recent
findings provide new mechanistic explanations for the wide
ranging health protections of breastfeeding to both mother and
infant. Human milk drives the development of a diverse gut
microbiome and healthy gut epithelium, which underpin normal
metabolic, immune, and neurological development.12 Recent
work indicates that perturbations in gut immune “sensing”
mechanisms after early cessation of breastfeeding may
contribute to the risk of acute lymphoblastic leukaemia.13
Doctors have great potential to influence behaviour, and yet
training in lactation support is almost entirely absent from
undergraduate or postgraduate paediatric training programmes,
and attitudes can be influenced by difficult personal
experiences.14 Normal neonatal behaviour (cluster feeding,
frequent waking to feed) may not be understood, and
breastfeeding can be hard to establish; in specific circumstances,
breastfeeding is impossible.
Instead, formula companies have invested heavily in medical,
nursing, and dietetic education and online tools for parents,15
including the dissemination of diagnostic criteria and tools for
non-IgE mediated cow milk protein allergy or intolerance.
Breastfeeding mothers who think their child has this allergy or
intolerance may think that their own milk is harming their infant,
with a consequent effect on breastfeeding and increased
prescribing of specialised low allergy formula milks (which are
processed to remove allergenic epitopes). Sales of these formulas
exceeded £59.9m in 2016 in England and Wales alone.16
Leadership against industry educational initiatives has been
hampered by the continued acceptance of formula sponsorship
by professional bodies such as the Royal College of Paediatrics
and Child Health and by close associations between industry
and professional allergy, gastroenterology, and nutrition
organisations, which WHO and the assembly continue to
advocate against.17 Without strong institutions at the heart of
medicine, the provision of unbiased medical education is
questionable. There is a global imperative to create fully
independent infant feeding curriculums and resources for
medical students and doctors.3 18
There are causes for optimism, with new grassroots
organisations using social media to offer globally accessible
resources. In the UK, the GP Infant Feeding Network (www.
gpifn.org.uk) has provided evidence based unbiased information
for doctors working in primary care since 2016, inspiring a
recently formed Hospital Doctor Infant Feeding Network.
The Scottish government’s 2017-18 breastfeeding programme
highlighted the positive impact of fully adopting Unicef’s evidence based UK Baby Friendly Initiative in each neonatal
unit and maternity hospital19; six month breastfeeding rates have
already improved by more than 10%,20 and milk bank services
are expanding. Appropriate use of screened donor milk in
neonatal units, where it is primarily used to prevent necrotising
enterocolitis in extreme preterm infants,21 can also encourage
breastfeeding22 23—could this be a tool to support more new
The time to act on infant feeding is now, with investment in
independent medical educational programmes, medical advocacy
for training in Unicef’s initiative, and up-to-date information
on prescribing, underpinned by research to fill in knowledge
gaps. The 2016 UK National Maternity Review found that 90%
of mothers stop breastfeeding before they have met their goals.24
Doctors need to advocate breastfeeding, so another generation
of mothers and babies are not failed.

Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following: NS is the director of the Hearts Milk Bank, a non-profit organisation providing screened donated human milk. She has non-commercial links with several national and international initiatives, including Unicef UK and the Chicago Human Capital and Economic Opportunity Global
Working Group, which have paid expenses for lectures. She is an honorary research associate at Imperial College London and a visiting lecturer at the University of Hertfordshire.

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