The Mumsnet parenting website invited their followers to post questions to be answered by Mike Brady, Campaigns and Networking Coordinator at Baby Milk Action in December 2010, and the moderators selected the following as representative.
Edited versions of these answers have been posted on the Mumsnet site (there is a word limit on the answers) – full answers are given here with links to supporting information.
It is interesting to look at the discussion on Mumsnet – it ran to over 300 posts in a heated discussion, but stopped abruptly when links to the actual answers were posted, with the comment: “Nooooooo! Please, no more of this thread!!!!!!”
It shows how difficult it is for us to break through the misconceptions some people have of our work to explain we are protecting breastfeeding AND protecting babies fed on formula.
what drives you to carry on campaigning?
what has been the single most positive/encouraging change you have seen during your campaign?
Sometimes I wish I could pack it in and do something less stressful (perhaps making the part-time job I do to make ends meet full-time), but a combination of necessity and progress keeps me going – plus the truly inspiring people I meet.
Strategically the most encouraging change has been the progress in bringing the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant Resolutions of the World Health Assembly into legislation – and seeing how breastfeeding rates have been recovering in some of the countries where this has been achieved. It continues to be a long, hard slog, but, with our partners, we are winning, country-by-country. The campaign defending strengthened regulations in the Philippines in 2006/2007 was particularly satisfying, given we were successful despite the best efforts of some of the world’s most powerful companies – and the US Chamber of Commerce.
There have been many other victories, big and small, so it is difficult to choose any particular one. In the UK, it was great to pick up some powdered infant formula in the supermarket earlier this year to find labels now warn that it is not sterile. We are still working for companies to bring their instructions fully into line with the Department of Health guidance on how to reduce the risks from possible contamination with harmful bacteria, but at least this important information is there as a direct result of our campaigning. This work was prompted by a 5-day-old baby dying in Belgium as a result of being fed Nestlé formula contaminated with Enterobacter Sakazakii. The parents sued Nestlé and the hospital for failing to warn them powdered formula is not sterile, but they lost the case on the grounds that they should have already have known about the risks – but people don’t know.
Internationally, having worked in Malawi, one of the poorest countries in the world, I was particularly pleased when we forced Nestlé to translate its formula labels into the national language after it had resisted this for years on the grounds of ‘cost restraints’ – but disappointed to see on a personal visit last year (2009) that Nestlé has now added colourful logos claiming the formula ‘protects’ babies. Although we haven’t stopped that yet, we have already prompted Nestlé to crack down on point-of-sale displays. I was absolutely disgusted to find a big end-of-aisle display in a rural trading area, a breach of the marketing requirements and the height of irresponsibility.
What drives me to carry on is knowing that we are helping to save the lives and reduce the suffering of the most vulnerable people on the planet – newborn babies. With your help.
Bottlefeeding mums perceive Baby Milk Action to be anti formula. Whilst this may not be the case, that perception will affect the credibility of anything you say. Does your organisation need a makeover?
Do bottle-feeding mums perceive Baby Milk Action as anti-formula? Perhaps, if they are unfamiliar with our work or take what others say we are about at face value.
I’m not sure what we need to do by way of a makeover when our site and materials explicitly state that we are not anti-formula and our slogan is, ‘Protecting breastfeeding – Protecting babies fed on formula’.
I have seen the industry suggest we are anti-formula and Nestlé has also falsely told people that we are trying to stop formula being sold, which is untrue – amongst other things we are trying to make it cheaper for mothers and carers who use it. Formula has amongst the highest mark-ups on the supermarket shelves. I don’t have evidence that it happens in the UK, but elsewhere, notably Italy, major formula companies have been found operating illegally to keep prices artificially high. Our partners in the International Baby Food Action Network (IBFAN) in Italy took action on this and the companies were fined.
Formula in the UK covers a wide price range. This is not because the more expensive formula is better than the cheaper formula, it has much more to do with how the company is placing its product in the market and how much its spends on advertising and promotion. The most expensive formula, Danone’s Aptamil, is heavily advertised and promoted. Danone even offers grants of £1,000 to midwives, linked to the name of the Aptamil formula brand.
I asked the Advertising Standards Authority (ASA) to investigate whether Aptamil really is the ‘best’ formula when this claim appeared in an advertisement for the follow-on milk, as well as a claim used about the added ingredient, Immunofortis. The ASA found the company could not prove its claims and warned the company not to repeat them.
It makes me very sad when I see parents repeating the misleading claims about a brand – doing the company’s advertising job for it – particularly when this leads to parents paying out more money than they need to. I will talk more about the health claims companies use in another answer.
There is a lot of other work Baby Milk Action does to protect babies fed on formula, from campaigning for levels of pesticides in formula to be reduced, to campaigning for improved composition and labelling.
So I’m not so sure that we need a makeover, more that we need to find ways to persuade people to look at what we actually do and say. Being invited to answer these questions is a great opportunity and I hope to make the most of it.
Do you work with schools to raise awareness of issues around the formula industry? Do you think it might be useful to educate future parents at an early age about the pros/cons of formula/BFing?
Also, just wanted to say thank you for standing up to the big corporations. Shame our politicians don’t have the balls to.
Infant feeding is something that is covered in the school curriculum – and information about the World Health Assembly marketing requirements was added to this after one of our directors raised it with a previous government. But we are not health educators ourselves so, other than our new educational resource on infant formula (see another answer), our focus is on how companies market breastmilk substitutes.
We do have materials for schools and the Nestlé boycott plays a key role in interesting students. I’ll use this question as a peg to talk about that a bit.
I was able to take part in debates with Nestlé executives in several schools between 2001 and 2004, but as Nestlé lost whenever there was a vote and students got even more behind the boycott afterwards, Nestlé finally decided not to take part anymore.
There are also some pieces of theatre that I’ve written about on my blog that are a way for young people to relate the issues to their friends and colleagues. Often we hear of students running a campaign at their school as a result of the Nestlé Box-Tops for Education scheme. In Nestlé’s scheme teachers are basically recruited to promote its breakfast cereal – the majority of which is high in salt and sugar (Shredded Wheat is the exception used in its PR gumph) in return for books, if students bring in box tops. Schools that have decided not to support the scheme have then explained why to all parents, so spreading the word about the issue and the boycott. So Nestlé PR expenditure boomerangs back to spread the word about the boycott!
We worked with a development education organisation a while ago to produce a school education pack on issues about understanding public relations, from corporations and campaigning organisations, which is still available as free downloads on our site. This includes analysing the famous picture of a mother in Pakistan with a breastfed son and bottle-fed daughter, though the pack is not specifically on infant feeding issues.
My question is this: if there is one message you would like the 18-21 year old mums / dads of the future to receive about breastfeeding, what would it be?
I’ve just been working on a project where I’ve interviewed health experts from various professional bodies and mother support groups that are member of the Baby Feeding Law Group (BFLG). Baby Milk Action set this up ten years ago to campaign for the UK baby food laws to be brought into line with international standards. This project is about infant formula rather than breastfeeding, but there was a very interesting point made by several people, which I think is important to make more widely known, particularly in a country like the UK where a quarter of babies are put on formula from birth and breastfeeding rates decline quickly.
The point is: every drop counts, every feed counts, every day counts when it comes to breastfeeding. So continue breastfeeding as long as is right for you and your baby.
Everyone on Mumsnet probably already knows the World Health Organisation and Department of Health recommends exclusively breastfeeding for 6 months and then to continue to breastfeed while introducing complementary foods. Sometimes that is described as the ‘optimum’, but really the evidence is that it’s the feeding regime that fits with the way we have evolved as a species. Human babies are born at an earlier stage of development than other mammals and breastfeeding is important for continuing development, particularly of the digestive, immune and neurological systems. Replacing breastmilk with other foods, even foods based on cow’s milk, has an impact, as shown by studies looking at large populations of infants, children and adults.
The one message that I would like all 18 – 21 mums and dads of the future to understand is that any period of breastfeeding will help a child’s development and the impact is not totally undone if formula is introduced at some point. We really need to take the heat out of the breastfeeding v. formula argument that blows up too often, because it drives people into one camp or the other. It seems some people think that the choice is between breastfeeding exclusively for 6 months, or exclusively using formula instead. Even if using formula, some feeds can still be breastfeeding as long as a mother and baby wants – being aware, of course, that introducing feeding bottles interferes with lactation and reduces a mother’s milk supply.
Mixed feeding is not recommended over exclusive breastfeeding because it reduces lactation and increases the risk of infection (a particularly serious concern where a mother is infected with HIV) and other illnesses. However, I think it is a shame to throw the baby out with the bath water, if people who do use formula mistakenly understand this to mean they must automatically stop breastfeeding.
The first feeds of colostrum provide protection to the newborn child. Later feeds are important for other aspects of development. So every drop counts, every feed counts, every day counts.
I would like to ask Mike how Baby Milk Action can explain that concern about formula is not the same as judging mothers who use it.
Maybe an idea to respond to this one !
We need to be clear what is meant by ‘concern about formula’.
This is what we say on our website about our work to protect babies fed on formula:
“Breastmilk substitutes are legitimate products for when a child is not breastfed and does not have access to expressed or donor breastmilk. Companies should comply with composition and labelling requirements and other Code requirements to reduce risks – independently of government measures. Parents have a right to accurate, independent information.
“Baby Milk Action is not anti-baby milk. Our work protects all mothers and infants from irresponsible marketing.”
I don’t know if that is sufficient, particularly given the question 2, where I’ve explained in greater detail some of the ways our work does protect babies fed on formula.
But perhaps I should say something about ‘judging mothers’.
I have argued in the past that no mother should be made to feel guilty about how she decides to feed her child – and some people have taken issue with me about this, sometimes arguing, for example, that we make mothers (and everybody else, for that matter) feel guilty about smoking, so why not try to dissuade use of formula with similar tactics?
My short answer is I don’t think it does nobody any good – except, perhaps, making some breastfeeding advocates feel superior. In my view, mothers use formula either because they weighed up a whole host of factors and made the decision they thought was right for them and their baby, or because they were misinformed and thought formula is the same as breastfeeding (or even better than breastfeeding given some promotional claims and sensationalist media articles) and so it wasn’t an issue.
We don’t know all that is going on in a mother’s life to shape her decision. A mother can know more than any of us about the health issues and still have good reason to use formula. I have met many mothers who were fully intending to breastfeed and could not. Maybe because of drug contra-indications (and sadly doctors display a lot of ignorance on this point, sometimes telling mothers to stop breastfeeding when there is no medical need. It is best to contact breastfeeding experts if told a drug is contra-indicated).
Maybe a mother is using formula because breastfeeding just wouldn’t go right, no matter how bloody and painful she got.
Maybe it is because of personal circumstances.
Who does it help to load guilt on top of these things?
I’ve recently had people contact me about the picture of David Cameron bottle-feeding his daughter. “What am I going to do about it?” I have been asked. Well, nothing. Firstly, why assume it is formula, not expressed breastmilk in the bottle? Secondly, even if it is formula, we don’t know the reasons for the decision. Thirdly, and most importantly from our point of view, it is not promoting a brand (as his opposite number, Ed Miliband, did on the television news, which was naive, at best). I object to feeding bottles being used as shorthand for babies on signs for changing rooms and the like, but that doesn’t mean they should be airbrushed out of existence.
While I don’t think we should try to make mothers feel guilty for using formula, we should be not coy about speaking the truth about formula – and I hope to talk elsewhere about claims made about formula by companies and how bogus they are.
If we are ‘concerned about infant formula’, as the question puts it, then why the concern? Baby Milk Action’s concern is that formula should be as good as it can be, sold at a fair price, have correct instructions on how to reconstitute it and be marketed appropriately. By appropriate marketing, we mean in accordance with the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant Resolutions of the World Health Assembly. That’s standards agreed by the world’s health ministries, not something Baby Milk Action pulled out of thin air.
What’s the aim of the Code? This:
The aim of this Code is to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.
In every talk I give on the Code and Resolutions, I stress that it is not just about protecting breastfeeding, it is about, ‘ensuring the proper use of breastmilk substitutes, when these are necessary’.
Every mother should, therefore, be able to support the Code and Resolutions and our work supporting these measures and I wish it were so.
Along with other posters, I too am uncomfortable with this discussion. I’m afraid that BMA and it’s followers really do appear to be anti formula, and to me that is unacceptable.
I am not sure if politically it is wise for Mumsnet to host a chat with an organisation which holds such one sided views. Of course they say they support both types of infant feeding, but a glance at their site would suggest otherwise.
Suffice to say I won’t be posting a question.
Incidentally, why is a man fronting this campaign. Surely there are many women who would be better placed to do so?
I was very pleased for the invitation to answer questions and will gladly respond directly to anyone who wishes to contact me via our website – subject to my workload. I hope people do find these answers useful.
Baby Milk Action’s focus is ‘protection’. We work for products to be marketed appropriately as I have explained in my answers to questions 2 and 5 and that is to protect both breastfeeding and babies fed on formula.
The protection we have achieved for mothers and carers who use formula is real and it is a bit disappointing to have our hard work in this area dismissed with a ‘glance’ at our website. However, I have learned to take comfort from knowing that we are helping mothers and babies, however they feed, whether we get thanked for it or not.
For example, if it was not for the work we have done with our partners at the European Union, the Codex Alimentarius Commission and elsewhere, the limits on the levels of pesticides in formula would be higher than currently permitted, inappropriate ingredients would be more common and marketing even more bogus and aggressive.
To take a for instance: Nestlé has tried several times to break into the UK market. The last time it did so was by launching a product called Nan HA, which is promoted as hypoallergenic. Nestlé was stopped from calling it ‘hypoallergenic’ in the United States and Canada after parents fed it to babies with cow’s milk allergy when it is unsuitable for this purpose – babies have suffered anaphylactic shock as a result. Hypoallergenic is a health claim and should not be used. We raised concerns about this when Nestlé launched the product in the UK and Nestlé was required by the Department of Health to add warning stickers to lids saying it should not be fed to babies with a known cow’s milk allergy. Health workers generally advise that allergic babies who are not being breastfed should use a fully hydrolysed formula. Soya formula can be used, but only on medical advice, due to other concerns about the safety of soya formula.
Now, people can be as cynical about Baby Milk Action as they like, but that piece of work to ensure that babies who needed it received fully hydrolysed formula or soya formula rather than Nestlé’s unsuitable product was not anti-formula. It was focused on what is always our primary focus: the well being of babies and the right of their mothers, carers and health workers to accurate information.
Although we are not a mother support group, we have an infant feeding section on the Baby Feeding Law Group website with links to reliable sources of information – and seeing as the companies are not reliable sources, a presentation by myself with information helpful for choosing a formula and reconstituting it correctly. We have now produced a professional film with an educational film company for health workers and parents who are intending to formula feed.
Regarding your question, there are no doubt many women who could do a better job than I, but when I was interviewed for the job back in 1996 I was considered to be the best candidate for the job. Gender was obviously not a defining requirement. My colleague, Patti Rundall, our Policy Director, is a woman and she is extremely able and knowledgeable. Indeed, it is Patti who argues on behalf of mothers and babies at the European Commission and Codex Alimentarius for improvements to the safety and composition of formula.
Question 1: Mike how did you get involved with BMA?
Question 2: What practical actions can MNers do to support BMA and are there any tasks which MNers could volunteer to help out with?
Question 3: How can we launch an effective campaign to ensure HCPs know/understand and communicate the safe methods of preparing formula?
Q 1: I worked in Malawi, Africa, for 4 years in the 1990s. Two years as a science teacher and two years as a district engineer for the Ministry of Health. This was through the organisation Voluntary Service Overseas, though I was employed by the Malawi Government on a local salary.
When I came back to the UK in 1996, Baby Milk Action was advertising for a Campaigns and Networking Coordinator on an initial 6-month contract. I knew a little about the campaign because of the boycott and some of the reality of infant feeding in Malawi. At my hospital, I raised money from UNICEF to build a nutrition shelter and as part of the contract we were asked for our hospital breastfeeding policy. I asked the District Health Officer (DHO) about this and in addition to the policy, he said the DHOs had turned down a donation of formula from a company because of the devastating impact that such donations can have on a breastfeeding culture.
I wasn’t sure what to make of the job, but took it and later accepted a renewal of contract. Then I attended an international meeting in 1997 where I met paediatricians from the former Soviet Union to train them on the International Code and Resolutions. They explained how the baby food companies had gone into their countries after the fall of communism and were doing all the things the Code said they should not. When I came back I started our Campaign for Ethical Marketing action sheets to empower people to write to company executives about specific cases of malpractice. One of the first exposés, was Nestlé advertising infant formula on television and trams in Armenia, and we very quickly we got this stopped. So I saw in a very real way how people around the world need help in forcing the baby food companies to meet their obligations, and how we in the rich world have the power to help them. Incidentally, I recorded an interview with the paediatrician from Armenia about 10 years later when breastfeeding rates had recovered markedly (Armenia also had a problem after being flooded by free supplies of formula after an earthquake). This can be heard on our website.
Knowing we are making a real impact in saving lives and preventing avoidable suffering is why I’ve stayed with Baby Milk Action all these years.
Q 2. Practical things: Join our email alert list if you have not done so already, then you will receive information about campaigns, events and developments. We ask the public to send messages to companies that are violating the Code and Resolutions, and in the context of the UK to report violations to us, Trading Standards and the Advertising Standards Authority. The best way to do this is via the Baby Feeding Law Group website.
We currently have an email campaign calling on Nestlé to stop its latest baby milk marketing scam. It is claiming its formula ‘protects’ babies and is ‘The new “Gold Standard” in infant nutrition’. Nestlé responds to pressure. Although it is still defending its claims at the moment, in its latest letter to me it has admitted that ingredients it bases its marketing campaign on, such as DHA and ARA Long Chain Polyunsaturated Fatty Acids, have no proven benefit when added to infant formula, a totally different environment to breastmilk. [Update: Our campaign was a success and Nestlé finally agreed to drop this promotional claim]
The Nestlé boycott is a very effective way to raise the issue of inappropriate marketing of breastmilk substitutes, keep it in the media spotlight and put pressure on Nestlé, the largest and most aggressive of the companies. Danone, now the second biggest, is likely to be the target of a similar campaign, as I’ll explain in the answer to another question.
We have various resources available in our online Virtual Shop, which help to fund the campaign and are a useful source of information on infant feeding and holding corporations to account. Of course, there is a mass of free information as well.
We also welcome people to join Baby Milk Action as members. Members receive our newsletter and Year Report and elect the Board of Directors at our Annual General Meeting.
Over half of our income comes from membership fees, donations and merchandise sales. The rest comes from development organisations (such as Oxfam and Save the Children) and charitable trusts.
Q 3. Educating Health Care Professionals: The newest addition to our resources is the DVD, Infant Formula Explained, which consists of a film for health workers and a film for parents who are intending to use formula. This is available for health facilities to use under an annual license. It explains the different types of formula on the market and how to reconstitute powdered formula in line with World Health Organisation and Department of Health guidance.
As I mention above, powdered formula in the UK does now warn on labels that it is not sterile, though the instructions still need some attention. This came about following our submissions on behalf of the Baby Feeding Law Group to the Government consultation on the Infant Formula and Follow-on Formula Regulations. The Guidance Notes that accompany the Regulations stipulate the information that should be included on labels.
Companies do not give this information in most other countries – the Philippines is one that does, following a successful international campaign we ran with international partners to defend new regulations there in 2006-07, which came under attack not only from the pharmaceutical industry, but the US Camber of Commerce (and Nestlé tried to have the heads of UNICEF and WHO removed for supporting the regulations).
In 2007 I did spot monitoring of the formula company telephone ‘carelines’ and found their information for parents on how to prepare and store formula was generally totally wrong, even though the problem of intrinsic contamination of powdered infant formula with salmonella and enterobacter sakazakii has been known about since the 1950s and came to prominence in 2003 with the deaths of babies in Europe (Belgium and France) linked to such contamination.
My question is what you would suggest to a mother who does not want to use formula but still requires, for whatever reason, milk to supplement her own?
We do not give advice to mothers, other than in line with international recommendations.
If a mother is breastfeeding a child under 6 months of age and believes this is insufficient for her child, the first step should be to check this out to see if it really is the case and, if so, if she can change how she is breastfeeding to increase supply.
If she is wanting to supplement and not use formula, then there may be an option of breastmilk from a donor milk bank. This is generally intended for premature babies, who may be fed on it for a day or just a few days while a mother’s milk comes in, or she recovers from surgery, which may occur in the case of premature birth.
Milk banks may have milk available for older babies, but it is unusual. Baby Milk Action helped support a family in Brazil that had triplets with income from a postcard with a picture that I took. Rozanilda was breastfeeding the triplets and did so exclusively for two and a half months. After that, more milk was needed and pasteurised donor milk was provided from the local milk bank. Other foods were introduced from about 5 months.
The Global Strategy for Infant of Young Child Feeding states: “For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.”
I am aware of internet sites which link mothers. These are most active in the United States and Canada. There are risks with feeding unpasteurised or unscreened milk from a stranger found through the internet (and risks in meeting strangers in general through the internet, for that matter). I was discussing this with an advisor the other day, and we really need to see some clear statement and guidance from our health professional bodies for anyone who is planning to go this route. A statement has been made by our partners in Infact Canada – click here.
UPDATE: This interesting article by Karleen Gribble on peer-to-peer milk sharing has since been brought to my attention, which responds to warnings from the American Academy of Pediatrics and Health Canada and refers to information on ‘managing and minimising risks associated with peer-to-peer milk sharing’.
La Leche League’s statement on milk sharing can be found by clicking here. It includes the following:
The World Health Organisation says that if a mother’s own milk is not available then the next best thing is the milk of another woman and in some circumstances this will be life saving. When LLL receives enquiries about wet/cross nursing we mention various important points which a mother should take into consideration.
• The woman who will be breastfeeding her baby should have medical checks for various infectious agent.
• She should not drink alcohol, or consume large amounts of caffeinated or artificially sweetened beverages.
• When cross nursing, her own baby should be close in age to the baby to be nursed, healthy, gaining weight and free from infection.
• Cross nursing may be done on a more casual basis between friends or sisters, but again the health implications need to be considered.
I’ve come across some health care professionals who aren’t as clued up on breastfeeding as what they are on formula feeding. It seems that the information is so readily available to those who want to find it, do you think there is any way of correcting the inbalance that seems to exist in some quarters?
I would suggest that these health care professionals are not that clued up about formula feeding either as they will probably have received the information they have about formula from company reps. Remember, Baby Milk Action and others have won various cases at the Advertising Standards Authority (ASA) against the formula companies for making untrue claims about their products in advertisements. The information health workers receive is actually unregulated, because when we have reported misleading advertising to the ASA, it has refused to investigate, on the grounds health workers are more expert than they are.
Regarding breastfeeding, it is surprising how little information there is about breastfeeding on medical courses, which is one obvious place where this needs to be addressed.
The UNICEF Baby Friendly Hospital Initiative, the only UNICEF programme that operates in rich and poor countries, is improving the situation in hospitals, with staff training on the 10 steps for successful breastfeeding, and with programmes in the community. The 10 steps include prohibiting company promotion. Mothers who do intend to use formula should be shown how to reconstitute this by a healthcare professional.
As company reps. are limited to providing information on products to a designated person in a Baby Friendly Hospital, they try to entice staff off site with gifts, meals and the promise of giving them valuable information. Then they provide promotional materials with misleading claims about their products.
So health workers are well advised to look to independent sources of information. In some Primary Care Trusts, a multidisciplinary committee has responsibility for vetting company materials and providing any new information that is required about formula to health workers. This is a good model to follow, in my view.
Mike Brady My question is, how can the marketing of formula properly be controlled in the UK when the only apparent organisation to control it, the ASA, is a toothless waste of time. As it stands, if an advert is found to breach the regulations (such as the big-cup advert) the company is simply told to stop running it. Often they don’t (I’ve seen this advert since its banning despite C&G telling me they were not running it again) and even if it isn’t run again there’s no requirement for retraction so viewers simply assumed it’s run its course.
The Infant Formula and Follow-on Formula Regulations 2007 (adopted separately in England and Wales, Scotland and Northern Ireland) are a bit of a hopeless compromise, because the last Government was not prepared to stand up to the European Commission.
Basically, our law comes from a Commission Directive. When this was updated the last Government did actually ask for various things from the International Code and Resolutions to be included, but were not very successful, for various reasons. Unfortunately, they decided not to rock the boat and approved the Directive, telling us they would do more nationally. When it came to introducing legislation, however, they said they could do no more than the Directive, or they might be taken to the European Court by the Commission. As all expert bodies had called for the Government to do more, from the Baby Feeding Law Group members to the Government’s own Scientific Advisory Committee on Nutrition, and Trading Standards, the Government said they would conduct a review of the law and if that showed the law wasn’t working effectively, they would then have a strong case to face up to the Commission.
Well, the review came out in March 2010 and said ‘steps’ needed to be taken to address the failings in the law. Since then, we’ve had an election and the coalition government has come in. The new Minister of Health has said he will respond to this review. We are reminding him of this undertaking. The Liberal Democrats made a pledge (along with the Green Party) to us during the election promising to work and vote for implementation of the Code and Resolutions in the UK – we are reminding them of this.
An argument we are using is that simplifying the law by applying the prohibition on infant formula advertising to follow-on formula, in line with the International Code, makes it easier all round – Trading Standards specifically said the double standard caused them unnecessary work.
Follow-on formulas were introduced by the companies to try to get around the ban on advertising of products in the scope of the International Code on the false premise that they are not breastmilk substitutes. As long ago as 1986 the World Health Assembly said these are unnecessary products. Although they are promoted as having more iron and other minerals, a child, whether breastfed or formula fed, should receive the extra nutrients required from complementary foods introduced after 6 months. Providing excess minerals through follow-on formula is a waste of money.
So supporting our campaign to have the review recommendations implemented is one way to help improve the situation.
The ASA could do more than it does. It takes a very narrow view of company responsibilities under the Advertising Code. Adverts are supposed to be ‘legal, decent, honest and truthful’. Even though the UK law is narrow, the International Code says that companies should ensure their practices at every level are in accordance with its provisions independently of government measures. Therefore, ‘decent, honest and truthful’ advertising should be in line with the Code and Resolutions. I’ve not been able to convince the ASA of this logic as yet – but then it is funded by the advertising industry.
Hey Mike I have two questions:
1. Why do you think our food safety authorities don’t test and approve formula? Surely it should be regulated so it doesn’t contain such harmful things; bisphenol-A, aluminum, enterobacter sakazakii and salmonella enterica.
2. A lot of people are unaware of the risks of using formula so cant make an informed decision when deciding how to feed their babies. Do you think formula should be labeled with the health risks like tobacco boxes are?
Q 1. There are composition requirements for formula and we work actively to improve these at the Codex Alimentarius Commission, European Union, the Food Standards Agency and elsewhere. We also joined in the successful campaign opposing the UK coalition government plan to scrap the Food Standards Agency.
Formulas sold on the UK market have all ingredients that are known to be beneficial and necessary for babies. Some companies add extra ingredients and make health claims about them, but these claims do not stand up to scrutiny. Some claims even violate our weak UK law and have been stopped (such as the Immunofortis claim on Aptamil infant formula, the Heinz Nurture claim about prebiotics and all companies who claimed their formula was ‘closer to breastmilk’).
The exception is goat’s milk infant formula, which is illegal and should not be on sale.
In the consultation on revising the Infant Formula and Follow-on Formula Regulations, we asked for a pre-approval procedure for when novel ingredients are added to formula. Unfortunately, the last Government listened to the industry instead of health experts.
The way it stands, companies can add new ingredients to formula without having to prove need or efficacy. General food safety standards apply, but these do not require any independent assessment.
This is a very serious concern. Most formula companies have added Long Chain Polyunsaturated Fatty Acids (LCPs) to formula and suggest these are important for brain and eye development. This is a bogus claim – although LCPs in breastmilk are known to be important, and supplements to premature babies may have benefits (and also risks), there is no evidence of benefit from adding synthesised LCPs to the totally different environment of formula. On our site we link to information from the Cochrane Library which has reviewed the science and concluded there is ‘no proven benefit’.
Please don’t attack me or Baby Milk Action for saying these optional ingredients, which some parents pay over the odds for, are of ‘no proven benefit’ – it is the assessment of independent experts reviewing the science, and people have a right to know they are being misled by formula companies.
In effect, a mass uncontrolled experiment is being conducted on the population at large and the results showing the benefits – and risks – of these unproven ingredients will appear in time. There are some alarm bells starting to ring about possible risks with LCPs in formula.
In a study published in February 2010 premature infants fed with formula supplemented with LCPs were followed. The study concluded: “Girls born preterm and randomised to LCPUFA-supplemented formula showed increased weight, adiposity and BP [Blood Pressure] at 9–11 years, which might have adverse consequences for later health. No effects were seen in boys. Long-term follow-up of other LCPUFA supplementation trials is required to further investigate this finding.’
The US Food and Drug Administration has recorded reports from parents whose babies have had adverse reactions to formula with LCPs – including problems with breathing.
In the US, parents who use formula are concerned that it is increasingly difficult to find formula without LCPs as companies are all adding them for marketing purposes (indeed, on our site I have analysed how back in the 1990s industry analysts predicted companies would add them, even if there was no benefit, to imply their formula is ‘closer to breastmilk’).
So, yes, I very much agree there should be pre-approval involving studies conducted in the public interest, not just by formula companies. If an ingredient is found to reduce the shortcomings of formula, then it should be added to all products (unless there is a possibility of an adverse reaction in some infants). These ingredients should not be used for promotional purposes, and if there is the possibility of some babies reacting badly to them, there should be a warning about this.
Q 2. Health risks labelling: Warnings are important, but I think there is also a pressing need to get rid of health CLAIMS on formula. Danone’s claim that Aptamil ‘builds the immune system’ has now gone from the infant formula, but you still see it on the follow-on milk, because of the double standard in our formula regulations.
There are required health warnings, but these are undermined by more colourful and prominent claims. I imagine some people think the warning is there because of the ‘breastfeeding lobby’ and that claims about benefits from the formula must be true otherwise they wouldn’t be allowed. In reality, regulations are often lacking or ineffective and you cannot be confident a health claim is true.
Brazil has done much more to implement the International Code and Resolutions – in fact, no food for babies up to three years of age can be advertised. As a result of this and better breastfeeding support, median breastfeeding duration has increased from 3 months in the early 1980s to over 10 months today. You don’t seen Nestlé’s ‘protect’ logo in Brazil, because there the Code is enforced (such logos and claims are prohibited by Article 9.2 of the International Code).
When the Brazilian regulations were last updated to keep pace with marketing strategies, a ‘Ministry of Health Warning’ was added to formula and whole milks (feeding with whole milks is a serious concern in Brazil, which I’ll talk about later). The text and its size were stipulated in the law. Whether this language was particularly effective, I’m not sure, but the industry hated it and has repeatedly tried to have it removed or toned down. Now it says, ‘Ministry of Health Information’, so they have made a little progress.
My view is we should treat formula for what it is: a nutritional medicine. Get rid of the polar bears and bright colours, free gifts and baby clubs, and have it available for those who need it, but without the hype.
Interestingly, a few years ago Baby Milk Action had the job of helping to design a label for infant formula being used by UNICEF in test projects in Africa for HIV interventions. Because of the risk of HIV transmission through breastfeeding, they trialled an intervention providing mothers infected with HIV who wanted to formula feed with enough to do so exclusively. We were consulted to make the instructions as clear as possible. All the same, the trials were soon halted because it was found that in poor conditions the risk to children’s health from formula feeding was greater than the risk of HIV transmission from breastfeeding. This in part led to the HIV and infant feeding recommendation of exclusive breastfeeding if formula feeding is particularly dangerous (studies have shown that exclusive breastfeeding has no greater risk of transmitting HIV than exclusive formula feeding – it is mixed feeding that carries the risks).
Powdered formula is impossible to make and store in a sterile manner, and therefore liquid formula is theoretically ‘safer’ in terms of potential hazardous contents.
Why, then, is there no concentrated sterile liquid formula product available on the market which can be diluted with cooled boiled water to provide a safer drink for babies.
Are current liquid sterilization/pasteurisation etc. techniques effective enough to allow a bottle of concentrated liquid formula to be kept in a fridge and used safely for a number of days? Are any formula companies looking into such a product or would it not be viable?
This is an interesting question. We’ve worked a lot on how to reduce risks from possible intrinsic contamination of powdered formula. Concentrated sterile formula is available in the US, at least, for diluting in the ratio 1:1. So volume wise, it is not a great convenience. It is a little cheaper than ready-to-feed, but more expensive than powder. The big concern in the US is the risk of it being fed concentrated, which overloads the child’s organs with minerals.
I’ve been filming reconstituting powdered formula with a couple of mothers in recent weeks for our Infant Formula Explained DVD. Though it is a bit of a pain to have to cool the bottle after it has been reconstituted with water above 70 deg. C (to kill any bacteria), it is not much more inconvenient than mixing up a bottle is anyway. Unused formula should be discarded after use, but prepared bottles can be kept in the back of the fridge, at a temperature no higher than 5 deg. C, for up to 24 hours, for later warming. For the film, we have followed the guidance available on the World Health Organisation website.
Do you think that the other baby milk companies that also violate the marketing code are relieved that the singular focus of the campaign on Nestle takes the heat off them? Is there any competition amongst baby milk companies to be recognised and seen as the most ethical in marketing, or do they all keep their heads down to stay out of the way of bad publicity?
If you visit our website, you find reports and campaigns on other companies. Danone is an increasing problem since it took over the NUMICO companies: Nutricia, Milupa (which includes the Aptamil brand) and Cow and Gate.
We look to the Breaking the Rules reports produced by our partners in the International Baby Food Action Network (IBFAN), led by the International Code Documentation Centre (ICDC) in Penang, Malaysia.
Nestlé systematically violates the International Code and Resolutions, more so than any other company in terms of volume and the provisions it breaks, which is why it is targeted with the boycott. According to industry analysts Nestlé currently controls about 29% of the global baby food market.
Danone has jumped to 15% market share and in the last monitoring report in 2007 the combined violations of it and its new companies rivalled Nestlé. However, as Danone had only just bought the companies, we contacted the management and asked them to sort out the marketing practices of their new companies. Unlike Nestlé’s dismissive response, Danone executives promised a ‘root-and-branch review’, and we gave them credit for this.
However, a new monitoring report has just been produced and, if anything, Danone’s ‘review’ has made things worse, not better. Executives have promised to send me a report on what they changed, but we have to go by what is actually happening on the ground, rather than what companies claim they are doing and, on that basis, the time is coming to up the pressure on Danone. So we will be contacting executives to say we want to see changes within 6 months or we will call for a consumer campaign.
Danone’s consolidation in the market does not mean Nestlé has improved – indeed, it is Danone trying to compete with Nestlé, the market leader, that is driving down standards.
Laws, of course, are the way to create a level playing field. In this area we find Nestlé is the biggest obstacle when it comes to bringing the Code and Resolutions into independently monitored and enforced legislation. I won’t go into it here, but we are also working for improved regulations at an international level for when national laws are missing or ineffective (anyone interested should look at our work on the UN Global Compact and the OECD Guidelines for Multinational Enterprises).
Some companies do wish to be seen as better than others. A US bottle and teat company has worked with our partners because it wanted to be Code compliant and changed its labelling and removed promotion from its website.
We have no problem with pointing out to companies where they need to change.
Do you think the boycott of nestle is having an impact. I haven’t brought nestle products for 10 years but sometimes wonder if its worth it as they are such a huge company – not sure if little old me makes much of dent (not that I’ll stop the boycott)..
From everyone who has made a dent, we have collectively sculpted Nestlé into the most boycotted company in the UK by far and one of the four most boycotted companies on the planet – according to independent analysts GMI.
I find people tell me one of two things: either they are surprised how many people know about the boycott, or the opposite.
The boycott is an effective tool for getting this issue into the media and raised elsewhere. It was instrumental in defending the regulations that the Philippines was trying to introduce in 2006/2007. It was our way to interest people in the situation in the Philippines. Nestlé marketed its formula with the claim it contains ‘brain building blocks’, implying it make children more intelligent. At the same time, we exposed marketing malpractice by all the main companies who were misbehaving. Do not underestimate the importance of action here in the UK. We asked people to send messages of solidarity to campaigners in the Philippines and some of these ended up on the front page of the main national newspaper – when editors are concerned about pressure from companies and may be scared to run stories, being able to report on something happening internationally is a way to speak out. This successfully negated the pressure from the industry lobby on the media, the President and the Supreme Court.
We are in regular communication with Nestlé, which is a bit of a thankless task because the executives who write to us make statements that might sound good but do not stand up to scrutiny. For the few years when Nestlé agreed to debate with us in public, principally at universities and schools, we were able to expose its dishonesty before the audience – and so Nestlé kept losing the debates and subsequent votes on the boycott. Now Nestlé refuses to speak if we are even present in the room. When you communicate with Nestlé executives directly, you realise how entrenched the profits-first, do-as-they-like management culture is – and it stretches across all business activities, not just formula. We set up the Nestlé Critics website to link people in to other campaigns which are trying to stop human rights and environmental abuses.
What makes Nestlé take notice is a hit to its profits and public image. Our job is to increase the pressure and exposure to force movement – which has happened time and again. We will eventually stop the ‘protect’ logos we are calling on Nestlé to remove from its formula labels. But the executives try all they can to divert criticism and have a big budget to link their name with good causes, so people look on them favourably.
Nestlé has also tried to improve its image by launching a Fairtrade KitKat. This involves just 1% of the cocoa Nestlé purchases. At the same time, it has failed to deliver on a promise made in 2001 to stop child slavery in its cocoa supply chain within 5 years (by 2006). Campaigners in the US have taken Nestlé to court on behalf of children who were trafficked to farms supplying the company. There are also concerns over the source of palm oil in Nestlé products and the destruction of Indonesian rainforests to produce it. This was targeted in a Greenpeace campaign this year and Nestlé has said it will change its suppliers of palm oil – within 5 years.
The more people who boycott Nestlé and tell the people who run the company, the more influence we have. So it would be great if everyone who reads this goes to our site and clicks on the email Nestlé link.
Hi Mike – How can I get across to people that it is important to boycott Nestle – my sons school seem to think it is something that happens abroad and nothing to do with us.
I think I’ve answered this one above in terms of how our action here has an impact.
Practically, we have leaflets, credit-card sized boycott lists, Nestlé – No thanks cards, posters and so on. There are various DVDs that could be shown in school. It may also be possible for us to arrange a speaker to come in, or we can help with a presentation.
We do also offer to come to debate the issues with Nestlé and this has happened in a few schools, but Nestlé now refuses to take part. It is still worth asking, however. They may surprise us.
I live overseas. Nestle is ubiquitous – in the way that, oh I don’t know, bread, is in the UK. Any hints for boycotting things here?
The main focus of the boycott is Nescafé coffee, its flagship product (though it depends on which country you are in). So that is the easy way – find an alternative coffee, tell Nestlé you are boycotting and spread the word to your friends and colleagues. We produce various materials to help with this.
With other products, I would be very surprised if there are not alternatives for confectionery, cereals etc. or whatever processed food you are looking to buy.
If you are somewhere where Nestlé brands are used, that is an opportunity to raise the issue, if you feel comfortable doing so. If not, leave a leaflet or card behind!
We are launching a new campaign shortly, called Nestlé – Good Grief ! (Nestlé has the slogan, Good Food, Good Life, and we want people to think of what is not so good about its business activities). So watch out for resources to promote the Nestlé – Good Grief ! message. It would be great if it becomes something people say automatically when Nestlé products appear.
Hi Mike – How can I get across to people that it is important to boycott Nestle – my sons school seem to think it is something that happens abroad and nothing to do with us.
There’s a mix-up with the questions, as this appears above.
FORMULA IN 3RD WORLD COUNTRIES
Do you think the use of formula in developed countries is over demonized in order to protest against it’s use in 3rd world countries?
Can you see how this alienates many parents and do you think a different approach would be more beneficial?
These are very interesting questions, that need a bit of unpacking – thank you for asking.
Firstly, is ‘the use of formula’ over demonized in developed countries? Well, I’ve seen there is a Facebook group called, “It’s baby formula – NOT POISON”, which I think shows us that some feel it is.
Of course, formula is the opposite of poison, it is a nutritional medicine that is better than the other alternatives if a mother’s milk or safe donor milk is not available.
Do those who feel formula has been demonised think this has happened because of the situation in conditions of poverty? Conditions where babies fed on formula are not only more likely to become sick than breastfed babies, but more likely to die? Possibly, and pictures such as the famous one of a mother with twins in Pakistan are upsetting (I’ll talk about that more elsewhere).
However, in my experience talking with mothers and carers, those who are angry about the way formula is sometimes talked about are angry because of what is said about it in the context of developed countries. This anger is fuelled by certain sections of the media that report infant feeding stories through the prism of the ‘bottle feeding v. breastfeeding’ debate, and love to highlight studies or comments that challenge the ‘breast is best’ message.
I vividly remember a friend saying that even seeing the ‘breastfeeding is best for babies’ message on formula labels was like a knife through her heart, because she had wanted to breastfeed, but her child was not taking her milk. She didn’t want reminding breastfeeding was better than formula, she wanted to be told the formula was just as good.
But formula is not just as good as breastfeeding, from a health point of view.
Should we cover up that truth?
I think we need to treat parents and carers like grown ups and let them make decisions based on accurate information. I won’t go through the health issues here, partly because I may be attacked simply for relaying information from expert health bodies who are unequivocal that babies who are not breastfed are more at risk of short and long-term illness and sub-optimum development. These are scientific facts, not Baby Milk Action’s opinion.
But the difference in both the short and long term health outcomes is real. The National Health Service spends millions of pounds treating extra cases of illness attributed to babies not being breastfed. The problem in developing countries is sometimes seen as just due to poor water or hygiene, but the more critical issue is denying babies the protective effect of breastfeeding – when they become sick, as they are more likely to do, they may die without the benefit of the treatment babies have access to in the UK.
While babies in the rich world are unlikely to die, and anecdotes can be cited of healthy formula-fed babies and sickly breastfed babies, short and long-term health differences appear in studies of large groups of breastfed and formula-fed people. Although there is overlap, people fed on formula, as a group, have poorer health outcomes than those who were breastfed.
Being objective about the risks of formula is important and mothers should be supported and encouraged to breastfeed. But for the mothers and carers who use formula, Baby Milk Action is working to ensure clear, accurate, unbiased information about formula is available to stop parents being misled and ripped off by companies hyping their formula as the ‘best’.
We aim to highlight key facts that people who use formula – a nutritional medicine, remember – need to know:
oIf using formula, price is as good a reason as any for choosing a brand – more expensive formula is not ‘better’ than other brands.
oAll brands of infant formula on the market must comply with composition requirements and so contain what is known to be necessary for babies. Optional ingredients are not compulsory simply because they have no proven benefit.
oGoat’s milk should not be used (it is illegal to sell it).
oSoya milk should only be used on medical advice.
oYou can switch brands to see if your child seems to like one more than another if you like (they do taste different, if you fancy giving them a go).
oIf using formula, it is best to use the whey-based milk for use from birth for the first 12 months, until normal cow’s milk can be used.
oMilks for so-called hungrier babies are not only unnecessary, there is no sound evidence to show that their casein base is more satisfying to babies.
oFollow-on milks are unnecessary and were introduced to try to get around the restrictions on advertising infant formula – any additional iron, protein or other nutrients a child requires will be amply supplied by a normal weaning diet from 6 months of age.
oSo-called Good-night milks should be avoided – there is no evidence that they help babies to sleep and a baby’s teeth should be cleaned after being fed with them, which will wake the baby up!
And, as I’ve said at greater length above, every drop of breastmilk counts, every feed counts, so don’t believe that formula feeding has to be exclusive (unless HIV is an issue, when mixed feeding is the most dangerous approach).
Two other points, when these ‘breastfeeding v. bottle feeding’ stories break in the media challenging the ‘breast is best’ message, we look into them to see if they have substance – and without exception, they do not. Sometimes there is a formula company connection, sometimes it is a journalist putting a spin on a story because they know it will attract attention, sometimes even a scientist is speaking outside their area of expertise to draw attention to other research. There are case studies examined on our website.
Secondly, it is best to look at independent information on formula, rather than company websites (UNICEF and mother support groups such as the NCT have information for mothers who use formula).
If you do look at company information, pay close attention, because they are very sneaky, particularly in countries where there are some regulations, even if weak. For example, look at what companies say about LCPs (which I’ve talked about elsewhere). They say these are in breastmilk and are thought to have benefits. They want the reader to make the jump to thinking formula with LCPs also has benefits – but the evidence to date shows that formula with LCPs is no better than formula without LCPs.
With other ingredients over which claims are made, it is sometimes necessary to look at the research in depth. We and others have asked the Advertising Standards Authority to do so on a number of occasions and they have found various claims cannot be substantiated, such as the claim that ‘prebiotics’ in formula build the immune system. Prebiotics are properly called oligosaccharides. Formulas contain a handful of synthesised oligosaccharides, whereas breastmilk contains over a hundred.
So the sad fact is that the claims that give some people comfort about using formula, are either not what they appear or are outright dishonest.
Unfortunately when we point this out, Baby Milk Action is sometimes attacked for ‘demonising’ formula, when those who deserve to be criticised are the companies that knowingly and deliberately mislead to increase their sales and profits.
I am interested in inappropriate formula feeding during disasters and the aftermath, such as Haiti.
How do we ensure that aid money we give is not used to provide formula and thereby increase the suffering or babies and children at such a difficult point of their lives?
Is formula safe only in countries with good water supply, good standard of living, hygiene etc?
Baby Milk Action set up an ad hoc committee with the UK development agencies in the 1990s to address the issue of infant feeding in emergencies. There had been some devastating situations, such as the Armenian earthquake in 1988, where breastfeeding rates fell from 64% to 20% after the country was flooded with free supplies. The ad hoc committee drafted policy guidelines, which have since been introduced by the development agencies. The Emergency Nutrition Network was part of this initiative and has developed training modules for field staff and also has information for members of the public.
The basic advice to the public is it is better to send money than formula. Any formula is best acquired locally where it should be labelled in the correct language. On that point, thinking of the Asian Tsunami, we had earlier campaigned to defend regulations requiring labelling in three national languages in Sri Lanka when this was being opposed by Nestlé (despite Nestlé using 3 languages in its home country of Switzerland).
Our partners in Albania had first-hand experience during the Kosovo crisis and I have had the privilege of working with them as they spread information about this. They set up infant feeding sections in refugee camps, where mothers who needed help with breastfeeding received this. Some needed help in relactating after the stress of fleeing the war. For orphans and other babies requiring formulas, our partners provided training for carers on how to reconstitute formula as safely as possible and obtained this locally, with instructions in the correct language. At the same time they reported that less responsible organisations were going round and simply dropping tins outside tents where there were babies. Baby Milk Action had to invoke the law prohibiting export of formula without labels in the correct language to stop well-meaning people loading up trucks with formula to drive to the region.
Regarding ‘safety’ of formula, it is a nutritional medicine and should be treated with appropriate respect, which includes understanding its limitations. It is not a living substance, it does not contain the same constituents as breastmilk, those it does contain are not necessarily absorbed or used in the same way as those in breastmilk and babies fed on it are more at risk of short and long-term illness. Powdered formula is not sterile and may contain harmful bacteria and so must be used in accordance with WHO guidance to reduce risks.
There are additional risks where water is unsafe. Not only is the child denied the protection provided by breastmilk, it may be exposed directly to infection through the feed. The big killer, however, is lack of treatment when babies get sick. In the UK, the illness is treated. In poor conditions it may be too late.
As I understand it from “UNICEF stats www.childinfo.org/breastfeeding_infantfeeding.html etc..the majority of babies in the developing world who are not exclusively breastfed are not given other milk or given formula, but water or complimentary foods traditional in that community such as maize meal porridge.
So the challenge of enabling more women to exlusively breast feed for longer and save the lives of 140 million children a year is not simply one of breastmilk vs formula (or of poor people vs big corporates) it is also about challenging some of the traditional practices handed down from Grandmas etc…
So the question is, do you think that there is any hope, that a company such a Nestle could be a force for good. They have has so much marketing expertise, scientific research and global reach, and an interest in selling products to children and families throughout their lives – do you think there is any hope that they might become a force for good in promoting sound nutrition, from breastfeeding to eventual weening and beyond. Do you see any sign of companies doing this?
I’m not sure that you have interpreted the information on the UNICEF site correctly. This is what UNICEF states on that site:
“It has been estimated that optimal breastfeeding of children under two years of age has the potential to prevent 1.4 million deaths in children under five in the developing world annually. Yet early cessation of breastfeeding in favour of commercial breast milk substitutes, needless supplementation and poorly timed introduction of solid, semi-solid and soft foods, often of poor quality, are far too common.”
WHO and the Lancet published the Child Survival series looking at interventions that could most effectively prevent under-5 deaths and breastfeeding came out top, potentially preventing 13% of under-5 deaths in the 42 countries where most occur. Appropriate introduction of complementary foods could prevent a further 6%. These interventions could save more lives than universal provision of safe water, adequate sanitation and vaccination.
Commercial breastmilk substitutes are not the only problem, as you say. Water, teas and juices are sometimes introduced to needlessly supplement breastfeeding during the first 6 months. Sometimes inappropriate milks are used. We have campaigned for a long time calling on Nestlé, the market leader, to stop promoting its powdered whole milk in the infant feeding sections of pharmacies and supermarkets, but it continues to defend this practice, even though it knows mothers who cannot afford formula may buy the whole milk along the shelf, which is typically a third of the price.
Nestlé was criticised in the British Medical Journal in 2008 for marketing its Bear Brand whole milks and coffee creamers with a logo showing a mother bear holding a baby in the breastfeeding position. Evidence showed some parents were using it as a breastmilk substitute (illiteracy can be an issue, which makes such logos the height of irresponsibility). Nestlé has said it will change its logo, but this hasn’t yet worked through to the market place.
Promotion of artificial milks, more generally, undermines belief in breastfeeding. UNICEF Philippines produced a film in 2007 showing how promotion of milks for older babies with claims about added LCPs building brain and eye development (bogus claims as I’ve explained elsewhere) has led to the belief amongst some that breastfed babies aren’t so intelligent.
As UNICEF has said in the past: “Marketing practices that undermine breastfeeding are potentially hazardous wherever they are pursued: in the developing world, WHO estimates that some 1.5 million children die each year because they are not adequately breastfed. These facts are not in dispute.”
Certainly it is true that harmful traditional practices and use of other substances need to be challenged. But I disagree that the ‘expertise’ of Nestlé should be called on to assist in this – other than improving conditions for their own staff, in line with International Labour Organisation Conventions (the issue of maternity rights is another area where Baby Milk Action and our partners have worked).
Where we have seen Nestlé and other companies involved in breastfeeding promotion it has, at the very least, been used to try to divert criticism, but has also been used to undermine breastfeeding by the images selected, the language used etc. This has been documented in the Breaking the Rules reports by our IBFAN partners.
Nestlé and other companies can be of most use by stopping the harm they do, but they refuse to do so and have to be forced by laws or consumer campaigns. Companies dismiss the vast majority of reports of violations of the marketing standards. Nestlé has rejected our four-point plan aimed at saving infant lives and ultimately ending the boycott. Danone promised us it would conduct a ‘root-and-branch’ review when it took over other companies to become the second biggest in the global market, but the evidence shows things have got worse, not better.
Until these companies act on their obligations as required by Article 11.3 of the International Code of Marketing of Breastmilk Substitutes, it is a mistake to even think of involving them in breastfeeding promotion programmes – indeed, the World Health Assembly has adopted Resolutions saying that conflicts of interest should be avoided in this area.
There is a reason to be hopeful, however. Over 60 countries have regulations of some sort. Countries such as Brazil and India have implemented the Code and Resolutions fully in legislation and banned the promotion of breastmilk substitutes and baby foods. The fact that companies can comply when forced to do so demonstrates that we are not asking them to do something that is impossible. They simply don’t want to comply because they know that breastfeeding rates increase, which means less sales for them.
Again, look to the evidence. Independent industry analysts Euromonitor said in 2008: “There are significant international variations in the regulations governing the marketing of milk formula, which are reflected in sales differences across countries.”
And: “The industry is fighting a rearguard action against regulation on a country-by-country basis.”
We need to defend the regulations for the benefit of all babies, whether breastfed or fed on formula.
I have seen that there was a discussion about the famous ‘twins’ picture used on a postcard sold by Baby Milk Action.
This image has been around a while. It originally appeared in the United Nations Standing Committee on Nutrition (SCN) newsletter, May 1991.
The image raises many questions. So much so, we included it in an education pack which encourages students to think about the use of images, not just take them at face value. See the exercise ‘Every Picture Tells a Story’ in the ‘Seeing through the Spin’ pack, which can be downloaded at:
The background to the picture is a photographer working for UNICEF (United Nations Children’s Fund) was visiting the Children’s Hospital in Islamabad, Pakistan and was introduced to the mother, whose daughter was very sick. I think it is a shame that we don’t know the name of the mother or have contact with her, but perhaps she didn’t want her name to be used.
She had her son with her, who was in good health. The son was breastfed, but the daughter had been cared for by her grandmother on the understanding the mother would not be able to breastfeed both babies. The daughter had become sick through the classic cycle of diarrhoea and malnutrition that can result from unsafe bottle feeding and actually died the day after the picture was taken. Having learned that the lack of breastfeeding was the reason attributed for her daughter’s illness, the mother wanted others to know of the risks and posed for the picture. Sometimes people criticise the photograph for being posed, as if it would only be valid if the mother had been found sitting with the children in that position and photographed surreptitiously. It was taken to illustrate the mother’s story, with her consent.
So it graphically shows the different health outcomes of babies fed differently in otherwise similar living conditions. Controlled trials assigning babies to be either breastfed or bottle fed are unethical, but this is effectively what happened in this case due to the decisions of the family. In the original report, another point is drawn from the picture and story – the son was kept with the mother and it was the daughter who had to go to a relative, which was interpreted as gender bias – the SCN story had the title, ‘The lesser child’.
For me there is another aspect to this picture that has played on my mind: why was the daughter kept from breastfeeding even after she became ill? Why didn’t a health worker explain that the mother would be able to give at least some breastmilk and protection to both children and that mothers can usually fully breastfeed twins?
We can’t know the reasons in this specific case, but we do know that increased risk of illness is not automatically associated with lack of breastfeeding by parents and health workers, or even company representatives.
A few years ago I had the privilege of working with Syed Aamir Raza who had worked for Nestlé in Pakistan as a Medical Delegate. His job was to promote formula to health workers and had the tools and training to do so as effectively as possible, including a fund for paying bribes to doctors, and ways to get approval for larger items, such as air conditioners, from senior executives for what they designated AAA doctors having a lot of influence on prescribing practices.
Aamir eventually blew the whistle on Nestlé. What prompted his action was a doctor he was visiting, one who did not accept bribes, was called away for a medical emergency. When he returned, Aamir asked what had happened and was told a baby of a few months had just died. Aamir asked why and the doctor said, ‘Because of people like you.’
Aamir had to walk past the grieving family as he left the hospital and handed in his notice to Nestlé the same week and went on to expose Nestlé’s practices, suffering greatly for doing so.
I have spoken with Aamir at length and he said that Medical Delegates had been told how wonderful Nestlé formula was – even though they were trained to rattle off ‘breastfeeding is best for babies’ in their pitch – and it came as a shock for him to learn of the health implications. He had no idea that babies fed on the formula were more likely to become sick than breastfed babies, and, in conditions of poverty, more likely to die. To quote the World Health Organisation, “infants who are not breastfed in the first month of life may be as much as 25 times more likely to die than infants who are exclusively breastfed.”
I also met Dr. Diamond, the doctor who had opened Aamir’s eyes, and asked him why doctors were so willing to accept gifts, hospitality and outright bribes from companies and prescribe formula when they saw the health impact. Dr. Diamond said that not all health workers realise the health impact and he only really became aware of the protection afforded by breastfeeding and risks of formula feeding after attending a specific training course.
The image of the twins graphically illustrates the protection provided by breastfeeding and the risks from formula under these conditions and we have to be grateful to the mother for wanting to provide this warning.