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Bottled water and infant feeding

June 1998

A Baby Milk Action briefing. Paper copies are available. Contact us for further details.


Contents


Introduction

Breastfeeding is the best start in life for a child. The Word Health Organisation (WHO) estimates that one and a half million infants die each year because they are not breastfed. However, despite the proven benefits of breastfeeding, women throughout the world are under pressure to use artificial milks as a result of the unethical marketing practices of the baby food industry. In 1981 the World Health Assembly adopted the International Code of Marketing of Breast-milk Substitutes, to ensure that babies, carers and health workers were protected from commercial pressure to favour artificial feeding. Subsequent Resolutions have been adopted since to address new marketing strategies and scientific knowledge and to resolve questions of interpretation.

Monitoring by Baby Milk Action and our partners in the International Baby Food Action Network (IBFAN) shows that companies continue to promote artificial infant feeding in violation of the International Code and Resolutions. A further worrying development has now come to our attention. Baby milk companies are producing and marketing bottled water for the preparation of infant formula. Bottled water is also promoted as a water drink for infants.

In this paper we look at the implications for health, existing controls on bottled water and the marketing activities of the companies involved. Finally, we examine the reality of infant feeding in Pakistan, a country targeted as a test market for this promotional strategy by one company.

 

An advertisement for Valvert bottled water in a Russian parenting magazine is used to promote artificial infant feeding. The baby's bottle appears to contain infant formula and the text says, "...be careful with the quality of his feed... we recommend mineral water which is ecologically pure. It is good for the baby's organs. It is natural..."

Valvert is owned by Nestlé, the company which controls about 40% of the world baby milk market. When asked to stop promoting artificial infant feeding in this way Nestlé said in December 1997, "...in view of our support for breastfeeding [sic], we have decided that in future we will not make references to bottles and formula in materials produced."

Yet the same advertisement was still appearing in Russia in April 1998.



The need to protect breastfeeding

WHO recommends that breastfeeding be promoted as one of the most important measures for preventing diarrhoea, which takes the lives of 2.2 million children yearly and leaves millions more underweight, mentally and physically stunted and immunosuppresse (Ref. 1). There is conclusive evidence that breastfeeding confers significant protection against illness and death associated with diarrhoea. This is not only because it removes the risk of unsafe water, but because breastmilk is a living substance containing the mother's antibodies and immuno-globulins. A study carried out in Brazil (Ref.2) found that infants who did not receive any breastmilk were at 14.2 times the risk of death from diarrhoea compared with infants who did not receive artificial milk. It was also found that supplementation with tea, water or juice increased the risk of death resulting from diarrhoea.

The International Code of Marketing of Breastmilk Substitutes regards any product that is promoted to substitute that part of the infant and young child's diet that would normally be made up of breastmilk as a breastmilk substitute. The World Health Assembly recommends that additional foods are not introduced until about 6 months of age (Resolution WHA47.5). Hence, any substance promoted for use before 6 months is substituting for breastmilk. It is recommended by WHO and UNICEF that breastfeeding continues into the second year of life and beyond and so products promoted for use during this period as replacements for breastmilk also come within the scope of the International Code.

"The Code applies to ...beverages ...when marketed or otherwise represented to be suitable , with or without modification, for use as a partial or total replacement of breastmilk" Article 2, International Code "

There should be no advertising or other form of promotion to the general public of products within the scope of the code” Article 5.1, International Code


Bottled water - a suitable solution?

Is bottled water a suitable way to tackle the problem of diarrhoea? There are several reasons to doubt it:

* marketing of bottled water for infants is being conducted in violation of the International Code and Resolutions in ways that undermine breastfeeding, suggesting that this is an attempt to by-pass these restrictions.

* bottled water is an added unnecessary expense for those mothers who struggle to buy infant formula once pursuaded not to breastfeed.

* supporting breastfeeding and safe, local water supplies is better for health and the environment.

* supplementary feeding with bottled water may be detrimental to health.


Health risks to infants fed with commercial bottled drinking water

In 1993 two infants were admitted to a hospital in Wisconsin and treated for seizures associated with low sodium levels caused by excessive water intoxication(Ref. 3).

In the first case, a 55-day-old infant suffered epileptic fits as a result of low sodium levels in her blood. Furthermore, the infant also experienced respiratory depression. The infant had been fed with infant formula supplemented with bottled water. The mother reported using bottled water as a supplement because the product was inexpensive and because she interpreted the labelling to indicate that the product had been produced specifically for infants and contained nutrients adequate for use as a feeding supplement.

In the second case, a 56-day-old infant was admitted to hospital following an apparent brief seizure. Again, the seizure was diagnosed as a result of low sodium levels. In this case, the mother had used bottled water to supplement feedings of soy based formula. Once again, the mother indicated that she believed the bottle label depicted a product specifically made for infants.

Diarrhoea is the greatest killer of infants worldwide(Ref. 4) and requires Oral Rehydration Treatment to replace lost fluid and minerals. The promotion of bottled water as suitable for infants may encourage parents to use this product to rehydrate their children so increasing the risk of low sodium related seizures.

Too high a concentration of minerals may also put infants at risk. In a 1994 report, Weaning and the Weaning Diet, the UK Department of Health states that (Ref. 5):

"Excessive sodium intake is undesirable especially in infancy."

"High nitrate content of water is one of the causes of methaemoglobinaemia in infants. Where the concentration exceeds 50 milligrams per litre (as nitrate ion) water undertakers [providers] are obliged to inform the health authorities and professions in the affected area. Water with a concentration of nitrate greater than 100 milligrams per litre is not suitable for infant feeding."

"High concentrations of nitrate and sulphur are present in some natural mineral waters. High sulphate levels of 400 - 500 milligrams per litre may be purgative [cause excessive bowel movements] especially in children."

"Natural mineral waters may contain varying amounts of fluoride and those with high levels are unsuitable as part of an infant's diet or for making up dried foods or drinks because of the risk of fluorosis of the tooth enamel."


UK Legislation covering water

Although there is no binding legislation relating to the composition and use of bottled water, the Department of Health has indicated that (Ref.5):

"Bottled waters, other than those labelled 'natural mineral water', are expected to conform to essentially the same standards as the public water supply and they are therefore suitable for giving to infants or for preparing feeds. As with tap water, bottled waters should be boiled and cooled before using to make up infant formula feeds."

" 'Natural mineral water' is covered by less comprehensive regulations than tap water and may contain higher concentrations of solutes such as nitrate, sodium, fluoride and sulphate which might lead to solute overload if these waters are given to young infants."

The tap water that we drink every day contains only chloride and flouride - all minerals are removed during the treatment process. However, with mineral water the composition is unchanged - extra minerals are neither added nor removed from it.

In guidelines sent to health authorities (Ref.6), the Department of Health recommends:

"Check the label and avoid using water in bottles labelled 'natural mineral water' - they are not required to meet all the standards for tapwater and other bottled waters."

Concentrations greater than those given in the box should be avoided for infant feeding according to the Department of Health guidelines (Ref. 6):

 

Maximum mineral concentrations for drinking water (UK Department of Health)

Sodium 200 milligrams per litre (mg/l)

Nitrate 100 mg/l (best below 50 mg/l)

Nitrite 3 mg/l

Sulphate 500 mg/l


Other Legislation

The Food and Drug Administration (FDA) in the U.S.A. has published a "final rule" governing regulations on bottled water, including mineral water. The regulations require accurate labelling of bottled waters marketed for infants. Any product labelled "sterile" must be processed to meet the FDA's requirements for commercial sterility. If the water is not sterile, the labelling should indicate this. In this instance it should only be used in the preparation of infant formula as directed by a Doctor or according to infant formula preparation instructions.

In U.S.A. the FDA has recommended to the International Water Association that the labels of bottled water products should indicate clearly their contents and appropriate uses and that they should not be used in lieu of infant formula.

Within the European Community, there are currently no standards governing sterilization of bottled water.


Companies promoting bottled water

Saint Mungo's

As part of Gleneagles Spring Waters Company, Saint Mungo's have recently introduced onto the UK market a pure spring water for babies - "All's Well". The drink is marketed for babies and infants from 4 months upwards and is packaged in a ready-to-feed bottle. The label on the product asserts that it is "Ready to Serve No Need To Boil". A spokesperson for Gleneagles stated that they use a "purity protection process" to kill bacteria. However, the labelling not only contravenes the UK Department of Health recommendation that all bottled water should be boiled, it also contravenes the recommendation of the World Health Assembly that no additional foods should be introduced until about 6 months of age.

Humana

Humana produces infant formula in Germany and is now producing "baby water" which they claim is suitable for preparing infant formula. Currently their product is only being marketed in Germany, but the company suggests that (Ref. 7), "our water would be suitable for Third World Countries" but "the transport is too expensive."

Milupa

Milupa, a subsidiary of Nutricia (which also owns Cow&Gate), markets a tablewater for use in the preparation of infant formula, drinks and teas for children. Currently this water is only distributed in Germany, and Milupa say that they have no plans to distribute the water in the Third World. Milupa also states its opinion that water does not fall with the WHO Code as it is not a breastmilk substitute (Ref.8) - even when promoted for use in making up formula!

Nestlé

An article in the London newspaper, the Evening Standard (Ref. 9), on 12 September 1997, suggested that Nestlé plans to introduce a new brand of mineral water with a "lower than average mineral content" designed for babies. According to the report, another mineral water is being developed as a "hush-hush" project for distribution in the Third World. The report does not acknowledge the risk of supplementary feeding with water, the added expense for families persuaded to use bottled water for infant feeding or the environmental impact of bottling and transporting water instead of developing local supplies. On the contrary, the paper presents the secret project as a way to counter the international Nestlé boycott, "which" it reports, "began in 1977 because poor families were putting babies at risk by over-diluting the powder, using polluted water or not sterilising equipment. Its new products could help to solve this problem."

Since 1992, Nestle has been buying up bottled water companies, and now controls over 10% of the world market. Perrier, the Nestle bottled water subsidiary is present in more than 120 countries. It owns over 50 brands, including:

Buxton, Perrier, Vittell, Ashbourne, Contrex and Valvert

A German magazine article on 21 November 1997 suggests that Dr. Kalscheuer, Chief Executive Officer of Perrier (Nestlé) is hoping to develop the Asian market (Ref. 10). It suggests that in 1998 Pakistan will be a test market for Nestlé's mineral water. Nestlé has already opened bottled water factories in China and the Philippines.

Nestlé's Valvert water has been used to promote artificial infant feeding in a number of countries, including Côte d'Ivoire and Russia (see page 4). Baby Milk Action featured Nestlé's advertisement in Russia in the October 1997 Campaign for Ethical Marketing action sheet. In December 1997 Nestlé promised to stop promoting artificial infant feeding through its marketing of bottled water, yet stated that, "Thanks to its low mineral content Valvert is suitable for use with infants and this fact will be mentioned where appropriate." As the discussion on health explains, supplementary feeding with water may lead to seizures due to low sodium levels.

Water promoted in this way comes within the scope of the International Code, but Nestlé claims that it does not.

Nestlé was still using the advertisement shown on page 4 months after it promised to end this promotional method.

Worldwide sales of Nestle water (in millions of litres).

Worldwide Total 7000

U.S.A /Canada 2600

France 1960

Italy 980

Germany 630

Rest of Europe 560

Asia 70

Rest of World 210

Professor Jean Rey, a member of the Nestlé Perrier Vittel Water Institute, is an influential member of the Codex Alimentarius Commission, which sets international food standards under the UN system. Until recently he was also a member of the European Commission's Scientific Committee for Food, which advises on food standards. (He resigned from this position after his links with Nestlé were exposed amidst the controversy surrounding his public support for Nestlé when it was claimed he spoke as an "independent expert.")

Other companies

The latest monitoring report of the International Baby Food Action Network (IBFAN), called Breaking the Rules, Stretching the Rules 1998, reports promotion of artificial infant feeding through the marketing of water by other companies: Font Vella in Colombia and Spain, National in Malaysia and Gulfa in Pakistan.


Country Case Study - Pakistan

Pakistan continues to provide an ever-promising market for the promotional and sales tactics of multinational corporations. It has a population of 140.5 million with 5.5 million babies born every year.

The artificial baby food industry is strongly represented. This can be judged by the fact that Nestlé's infant formula Lactogen 1 appears at number 66 in the list of best-selling products in Pakistan, with sales worth Rs 67 million in 1995 (Ref.11). Now it is reported that Nestlé plans to use Pakistan as a test market for its mineral water.

Pakistan is a poor country. In 1994 its GNP / Capita was only US$430, as compared to US$18,340 in the United Kingdom (Ref.12). Even more disturbing is the fact that 60% of the population in Pakistan earns less than the average per capita income. All the same, the baby food industry is making headway as it attempts to expand its market in Pakistan.

A monitoring report, the Feeding Fiasco, was published by the Network of Association for Rational use of Medication in Pakistan in March 1998 and is available from Baby Milk Action (£5.00 plus 50 pence postage and packing in the UK). The report states:

"But the reality is that in Pakistan today, the breastfeeding culture is a dying one. Bottle-feeding is being accepted as the rule, rather than the exception. Mothers unnecessarily 'supplement' their own milk with other milks, water and foods before it is nutritionally required by the baby."

Breastfeeding in Pakistan (Ref.12)

16% of children exclusively breastfed to 3 months

56% of mothers still breastfeeding at 20-23 months

 

Although Pakistan was one of the countries that recommended the adoption of the World Health Assembly Code in 1981, it has not been properly implemented as a result of political and economic constraints on the government and powerful commercial interests.

Pressure exerted by Nestlé resulted in breastmilk substitutes being removed from a list of products which could only be sold in pharmacies. Today these products are sold in groceries and at street markets.

Costs

According to a report in the newsletter (Ref. 13) of the Network of Association for Rational use of Medication in Pakistan, the cost of Pakistan’s imports of milk powder and baby food doubled during the first 10 months of the 1995-1996 financial year compared with the previous one.

Pakistan imported 9,500 tonnes of baby foods at a cost of US$ 43.5 million between July 1995 and April 1996. According to the report, this upsurge coincides with new aggressive marketing tactics from Nestlé.

But what about the cost to the average household?

According to the report Feeding Fiasco the average cost of infant formula for feeding a baby from birth to six months in Pakistan is Rs 1,480 per month - this equals the average monthly income in Pakistan and is for milk powder only. It did not include bottles, teats, fuel, or labour time. The obsenity of Nestlé's plan to launch mineral water in Pakistan to reduce the risks associated with using unsafe water for mixing formula can now be appreciated. It is not for the health of infants - mothers are better advised to breastfeed - it is to make additional profit and will increase the financial burden on families.

A further problem is the low status of women in general - the outcome is a bias which heavily favours males, particularly in access to education. Female literacy is only 24% as compared to male literacy of 50%12 . Consequently, poverty and ignorance result in poor women being particularly susceptible to the marketing practices of baby milk companies which aim to undermine breastfeeding, and susceptible to harmful information which convinces them that that they are "unable" to breastfeed for reasons like - not enough milk, poor quality milk etc.

Also worrying is a growing culture amongst the middle classes which views breastfeeding in public as "shameful". Although poor women in rural areas continue to breastfeed in public, they are also susceptible to this view. Marketing is one way of speeding up this process.

Infant mortality is high at 95 per 1000 live births, compared with 6 per 1000 in the UK (Ref. 12). Hundreds of thousands of children die each year in Pakistan as a result of diarrhoeal dehydration. Many of these deaths could be avoided through the promotion of breastfeeding.

The marketing of mineral water in Pakistan will not solve the problem of diarrhoeal deaths and infant malnutrition. It will merely be an inducement for many to climb further into the poverty trap, whilst enriching multinational corporations.

* It fails to solve the complicated and costly process of sterilizing bottles and teats.

* It fails to solve the time-consuming task of preparing formula in a country where most women already face a heavy burden of domestic duties.

* It fails to solve the problems of low female literacy which can result in malnourishment of the infant if formula fed.

* It increases the overall cost of artificial infant feeding.

* It encourages supplementation with water, which may put infant at risk. If supplementation becomes part of the infant feeding culture those unable to afford bottled water may resort to using other supplies of water which pose an even greater hazard to health.


Conclusion

The promotion of bottled water for infant feeding may undermine breastfeeding, poses risks to health and has an adverse impact on family finances and the environment.

The promotion of bottled water is not an appropriate way to reduce the risks to infant health posed by artificial infant feeding - bottled water has to be boiled like any other supply of water and its mineral content may not be appropriate. In addition, encouraging supplementation with water may lead to seiéures due to reduced sodium levels. It makes far more sense to support schemes to provide safe water and adequate sanitation while supporting, promoting and protecting breastfeeding. The cost to consumers of a safe community supply of water is usually significantly less than bottled water.

There are worrying indications that at least one baby food company is attempting to develop the market for bottled water for infant feeding in developing countries and elsewhere in the pursuit of profit and to counter criticism of its marketing of infant formula.

Non-Governmental Organisations (NGO's), health professionals, UN bodies and governments should be alert to the marketing of bottled water. It should be made clear to companies that when bottled water is promoted for use with infants it comes within the scope of the International Code and the subsequent, relevant Resolutions of the World Health Assembly.


References

1. Khan. AH. The sanitation gap: Development's deadly menace, The Progress of Nations, 1997. UNICEF New York, pp 5-9. back

2. Victora CG et al. Infant feeding and deaths due to diarrhoea, American Journal of Epidemiology, 129(5): 1032-1039.back

3. Bruce RC, Kliegman RM. Hyponatraemic seizures among infants fed with commercial bottled drinking water - Wisonsin 1993. Morbidity and Mortality Weekly Report, 43(35), 9 Sept 1994, pp 641-643.back

4. United Nations Children's Fund (UNICEF). Re-slicing the cause-of-death pie, The Progress of Nations, 1997. UNICEF New York, pp 28, attributes 19% of under-5 deaths to diarrhoea.back

5. Department of Health, Report on Health and Social Subjects 45, Weaning and the Weaning Diet, HMSO, London, 1994.back

6. Communication from Dr. Michael Waring, Senior Medical Officer, Environmental Pollutants Unit, Department of Health.back

7. Communication from Humana Export Department, 29 October 1997.back

8. Communication from Milupa Corporate Affairs Manager, 20 October 1997.back

9. Evening Standard (London), page 40, 12 September 1997.back

10. Lebensmittelzeitung, 21 November 1997. back

11. The Network of Association for Rational Use of Medication in Pakistan, The Baby and the Beast, Feeding Fiasco, The Network, March 1998, page 16-21. back

12. UNICEF. Tables, State of the World's Children, 1997. UNICEF New York, page 80-86.back

13. The Network of Association for Rational Use of Medication in Pakistan, Baby Milk Boom, The Network's Newsletter, March 1996, page 13. back

 


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