Even though scientific evidence has proved that exclusive breastfeeding is best for infants, some baby milk formula companies continue to use questionable methods to create demand for their products, writes Elsabé Brits in Spotlight.
The issue was recently highlighted in a series of articles in The Lancet explaining the economic and political power of the dominant formula companies and the alleged public policy failures resulting in millions of women not breastfeeding as recommended.
The authors said this has a negative impact on infants and their development.
The World Health Organisation recommends breastfeeding for six months for optimal health and growth of infants, but in many countries, this not a common practice.
‘Poor science’
One common reason women introduce formula is that they misinterpret unsettled baby behaviour, especially disrupted sleep and persistent crying in the first few months, as signs that their breast milk is insufficient.
“Commercial milk formula marketing portrays breastfeeding, and thereby women’s bodies, as inherently difficult, unreliable and inconvenient,” according to the series.
“CMF (commercial breastfeeding) marketing allows for public health messaging to further promote its products, for example … suggesting that CMF is necessary after six months because breast milk alone is insufficient. This false message undermines women’s confidence …and their ability to make informed decisions about continued breastfeeding,” the series reports.
Professor Linda Richer from the Centre of Excellence for Human Development at Wits University and a co-author of The Lancet papers, said: “The formula milk industry uses poor science to suggest, with little supporting evidence, that their products are solutions to common infant health and developmental challenges.
“Adverts claim specialised formulas help with colic, prolong night-time sleep, and even encourage superior intelligence – but studies show no benefit of these product ingredients on academic performance or long-term cognition.
“These techniques violate the 1981 WHO International Code of Marketing of Breast Milk Substitutes, to which countries agree that labels should not idealise the use of formula, nor exploit poor science to create an untrue story to sell more product.”
The review of 153 studies for The Lancet Series details how marketing practices in violation of the Code have continued in nearly 100 countries – including South Africa – and worldwide since its (voluntary) adoption more than 40 years ago.
In 2012, South Africa published regulations relating to foodstuffs for infants and young children to implement the Code into law.
Mota Mota, head of external communications at Nestlé East and Southern Africa, said Nestlé “supports the WHO’s recommendation of exclusive breastfeeding for the first six months, followed by the introduction of adequate nutritious complementary foods along with sustained breastfeeding up to two years of age and beyond”.
“We do not promote formula for infants 0-6 months,” he said. “In 163 countries, most of which have high rates of malnutrition, we apply a stricter policy and do not promote formula for infants aged 0-12 months.”
In the series, the authors said industry lobby groups resisted some of the legal and regulatory changes that took almost nine years to implement.
Naazneen Khan, dietician and chairperson of lobby group the Infant Feeding Association, said they are unaware of a nine-year delay. “It is unclear which part or parts of the regulations the authors deem IFA to have unduly influenced. Legislation in South Africa now prohibits marketing, advertisements, sponsorships, donations, and a variety of activities relating to the designated products – all of which IFA and its members adhere to.”
Khan calls The Lancet series “general in nature and not specific to South Africa”. “We urge a careful reading of the text of the three articles and an assessment of the supporting footnotes, as not all statements are universally applicable or applicable to South Africa and/or members of the IFA. The IFA always and will continue to support the establishment of exclusive breastfeeding for the first six months of life,” she said.
‘Confidence undermined’
According to the series and based on follow-up interviews, expectant mothers are often told that if they don’t eat well, it may affect the baby. The mother’s confidence in her own body to produce breast milk is undermined, the authors said, with normal infant behaviour being “problematised” and formula being offered as the solution.
One real-life label indicates that “relief from these infant behaviours can be accomplished within 24 hours and brain development enhanced at the same time”. The words gentle, sensitive, soothe, and comfort appear frequently to reassure parents, and terms such as premium appeal to emotional values, strengthen these associations.
The most pervasive suggestions is that milk formula will encourage superior intelligence. Yet intervention studies and systematic reviews show no benefit of the ingredients added to these products on academic performance or long-term cognition.
The science of breast milk
Dr Helen Mulol from the University of Pretoria’s Research Centre for Maternal, Foetal, Newborn, and Child Health Care Strategies, undertook a study some years ago to determine the breast milk output volumes and maternal body composition objectively at five different time points in the first year of the infant’s life.
She told Spotlight how this was done. The mother is given a 30mL dose of deuterium oxide, also known as heavy water, which is a stable isotope of water. It is safe for mother and baby in the low levels given and is not radioactive.
It acts almost identically to water in the body, mixing with the water in the mother’s body. A saliva sample is taken from mother and baby before the dose is given to the mother and then on days 1, 2, 3, 4, 13 and 14 after the dose was given.
If the baby is breastfeeding, the milk will contain some deuterium, which can then be measured in the infant’s saliva. These saliva samples are measured for deuterium content by an analytical chemistry method and the levels entered into a spreadsheet, which compares the results to model curves.
The main output of the method is the breast milk intake, but the method also shows whether the infant is receiving something else in addition to breast milk (such as water, tea, juice, or formula) or whether the infant is exclusively breastfed.
The results were clear. The infants who were breastfed exclusively were leaner. “So, the results showed that early infant feeding practices affected the body composition of the infant. Given the worldwide trends towards obesity even in child populations, it shows the importance of early infant feeding on later outcomes,” said Mulol.
At birth, breast milk is also known as colostrum. It is produced in very small quantities, but the baby’s stomach is also small. The colour is different from later breast milk and is a yellow/orange shade, packed with nutrients, vitamins and minerals as well as antibodies to protect the newborn from any diseases or infections from the birthing process.
Colostrum is also thought to line the baby’s gut, which prevents the passage of pathogens. Without this, the gut can be inflamed and enable infections. This partly explains why exclusively breastfed babies have fewer infections.
After the first few days, the composition of the milk changes to a more “milky” colour. The volume the baby can ingest also increases now.
Breast milk contains proteins, sugars, vitamins, and minerals, as well as antibodies to protect the baby against infections. It changes daily according to what the mother eats and the composition changes according to the infant’s age so the composition of the milk given to the baby at one month will be different from that at six months.
Research has shown that even in hot climates, it is unnecessary to give the baby extra water as breast milk is sufficient, packed with maternal antibodies protecting against illnesses, and many other components which act like probiotics, encouraging the growth of healthy gut bacteria. For example, exclusively breastfed infants have a predominance of the beneficial Bifidobacteria, and the establishment of healthy gut microbiota has been shown to affect not just the early infant feeding period but also into childhood and adulthood.
“Although the manufacturers would like us to believe formula is almost the same as breast milk, it is not,” said Mulol.
Although breastfeeding is common for most women in South Africa, exclusive breastfeeding is not. The latest SA Demographic and Health Survey from 2016, which collected data on infant feeding practices, reported that breastfeeding rates decreased from about 80% at 0-1 months to about 73% at 4-5 months and about 59% at 6-8 months.
Exclusive breastfeeding rates were 44% at 0-1 months, decreasing to 24% at 4-5 months. Any exclusive breastfeeding six months was 32% in South Africa.
Many mothers reported giving water and complementary foods in addition to breast milk. Often this is due to perceptions of the baby being thirsty or that there is insufficient breast milk.
The Lancet Series
Unveiling the predatory tactics of the formula milk industry (Open access)
Breastfeeding: crucially important, but increasingly challenged in a market-driven world
Marketing of commercial milk formula: a system to capture parents, communities, science, and policy
Spotlight article – Major study turns spotlight on formula milk industry (Creative Commons Licence)
See more from MedicalBrief archives:
Most baby formula health claims not science-backed – global analysis
Reports by experts slam ‘underhand, exploitative’ milk formula marketing
US federal probe into baby formula company
Health professionals targeted by formula milk companies to push products