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British Medical Journal: Paediatricians criticise college survey on links with formula milk firms

BMJ 2016; 354 doi: (Published 17 August 2016)

Cite this as: BMJ 2016;354:i4555

Paediatricians campaigning for their royal college to sever its links with infant formula milk manufacturers have criticised the wording of the college’s survey of members.

Delegates at the annual general meeting of the Royal College of Paediatrics and Child Health in April voted in favour of a motion urging it to “decline any commercial transactions or any other kind of funding or support” from all companies that market and manufacture breast milk substitutes.1

The college discussed the motion at its July council meeting and agreed to survey its members on the issue. The survey was sent to members in August.

Those campaigning for the college to change its policy say, however, that the wording of the survey is confusing and that college members “lack the background information necessary to understand the complexity of the issues” and have written their own briefing for members.2

The survey is split into six sections covering general donations; attribution and branding; advertising; conference stands; events with company involvement; specific educational projects; and specific research projects. There are three questions in each section.

Charlotte Wright, professor of community child health at the University of Glasgow and one of the members campaigning for the change in the policy, told The BMJ that she had no objection to the college surveying its members given that the numbers who voted at the annual general meeting were so small—66 delegates supported the motion and 53 were against it.

She added, “The college is expecting people to fill the survey in without any background information about what the college’s current position is and how much income they get from formula manufacturers.”

Each section of the survey begins with a question on due diligence—for example, “RCPCH should accept funding after due diligence has been completed and assured.”

Wright said that this implied that if a formula company abided by ethical codes then “it was okay to take money from them.”

However, the World Health Organization has recently tightened up its code on the marketing of breast milk substitutes, and in May the World Health Assembly recommended that health professional associations and non-governmental organisations should not “accept gifts or incentives from such companies … or allow such companies to sponsor meetings of health professionals and scientific meetings.”3

Wright said, “This implies that it doesn’t matter if companies are adhering to this or that code. They make formula milk and that’s the top and bottom of it.”

The college survey offers the option of only accepting funding related to specialist milk products. Almost all of the companies making these products, however, derive most of their profits from breast milk substitute products marketed to parents of healthy children, said the campaigners.

The consultation with members closes on 6 September and will be discussed by the college’s executive committee two days later. The committee will then make a recommendation to council for its next meeting on 27 October.

In a statement the college said that it wanted to get the views of members “on the basis of their personal expertise, without undue influence or prompting.”

“The consultation aims to assist in reaching a decision on any changes to the existing [college] code on interactions with industry and ensure that the college’s approach to this issue commands as much support as possible from its members. For this reason, it was felt that a single yes or no question was not the best way of capturing the range of opinions held by members,” it said.



  1. Gulland A. Royal college told to stop taking money from infant formula milk firms. BMJ 2016;353:i2459. doi:10.1136/bmj.i2459pmid:27125784.FREE Full Text
  2. British Association for Child and Adolescent Public Health. Briefing paper for RCPCH members responding to the survey on sponsorship by formula manufacturers. 2016.
  3. World Health Organization. Maternal, infant and young child nutrition: guidance on ending the inappropriate promotion of foods for infants and young children. 2016.


Ref 2. Briefing paper for RCPCH members responding to the survey on sponsorship by formula milk manufacturers

A group of College members proposed the motion recently passed at the AGM arguing that the College should in future decline all kinds of funding from formula milk manufacturers (FMMs). This briefing paper sets out the evidence and policies that led them to take this position.

For the first time in May 2016, the World Health Assembly[ii] recommended that:

“…health professional associations and non-governmental organizations should not:

  • accept gifts or incentives from such (FMM) companies;
  • allow such companies to sponsor meetings of health professionals and scientific meetings”.


Which companies are we concerned about? This guidance applies to companies who make and market breast milk substitutes (BMS), feeding bottles or teats for healthy infants anywhere in the world, even if the specific funding refers to one of their specialist BMS products. It also applies to indirect funding from trusts or organizations that are funded by companies marketing BMS. Of course, this does not prohibit use of specialist BMS products for recognised medical indications[iv]. Whilst individuals may need to work with FMMs to undertake research on specialist formulas, it is vital to maintain the College’s independent status by avoiding this source of income and the resulting institutional conflict of interest.

What are the key arguments in favour of this approach?

  • Around 80% of UK mothers start breastfeeding, but the rate drops away sharply after birth and we now have one of the lowest continued breastfeeding rates in the world. This is strongly associated with the use of ‘supplementary’ formula feeding, which displaces breastmilk and inhibits breastmilk production, increasing the risk of early cessation of breast feeding 13-24 fold.
  • There are significant health consequences within the UK. A recent Lancet series summarised 28 systematic reviews and meta-analyses and found that in high-income countries, even after fully allowing for socioeconomic confounding, the impact of not breast feeding on child morbidity and mortality is substantial, while the impact on maternal health is actually higher than in resource poor settings.
  • The question is not whether individual formula manufacturers are behaving ‘ethically’. All FMMs have a responsibility to their shareholders to maximise sales of a product that by its very nature displaces breastmilk. While FMMs also produce therapeutic products, the great majority of their profits come from products marketed to parents of healthy children and this market is growing rapidly worldwide
  • The College ended formula milk funding for core activities about fifteen years ago, after the previous AGM vote on this topic, but recently this policy has been reversed. The College now accepts core funding from Mead Johnson, a major producer of formula milk worldwide, accepted a research grant from an unnamed manufacturer and has also been in discussions with both Nestle and Danone.
  • Unlike other potential donors, this income is not charitable giving. Rather, it allows FMMs to portray their products as safe and scientific by associating themselves with paediatricians.
  • Institutional conflict of interest is manifest when a strategic or financial influence has the potential to undermine that institution’s collective purpose. We suggest that a financial relationship with FMMs has potential to create bias within the institution that threatens public trust in the College as an independent source of guidance upon infant and young child feeding. This therefore is a probity issue.
  • This income is at most no more than 1% of the College turnover, so is not necessary for the College to function.
  • This is not about a mother’s right to choose how she feeds her baby; it is about her right to access unbiased information on which to base that choice. We can easily afford not to have the money; we cannot afford the loss of reputation.



Charlotte Wright

Tony Waterston

Anthony Williams

Delan Devakumar

Rosie Kyeremateng







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