Infant formula companies have “pathologised” normal baby behaviour to promote their products, and there should be “an international, legal treaty” to prevent their marketing,  according to health experts.

In addition, political lobbying by milk formula companies to influence public policy should be sharply curtailed. 

These are some of the suggestions contained in a three-part series published in The Lancet on Wednesday morning.

Fewer than half of all babies are breastfed as recommended by the World Health Organization (WHO), as formula milk companies “exploit parents’ emotions and manipulate scientific information to generate sales at the expense of the health and rights of families, women, and children,” argue the authors.

“The sale of commercial milk formula is a multi-billion-dollar industry which uses political lobbying alongside a sophisticated and highly effective marketing playbook to turn the care and concern of parents and caregivers into a business opportunity. It is time for this to end,” says series co-author, Professor Nigel Rollins from WHO’s Department of Maternal, Newborn, Child and Adolescent Health.

Exploiting mothers’ insecurities

The series exposes how the commercial milk formula (CMF) industry portrays normal baby behaviour –  including crying, fussiness, vomiting and poor night-time sleep – as “pathological” problems. They “exploit mothers’ insecurities about their milk and their ability to satisfy and calm their baby” – and offer CMF as a solution, adds the series.

The damning exposé comes over 40 years after the World Health Assembly adopted the voluntary International Code of Marketing of Breast-milk Substitutes in 1981 to reign in the infant formula industry – which has been powerless to stop marketing manipulation.

In fact, sales of milk formula grew 37-fold between 1978 and 2019 – from $1∙5 billion to $55∙6 billion annually.

Political lobbying

Nestlé (Switzerland), Danone (France), Reckitt (UK), Abbott (US), Friesland Campina (Netherlands), and Feihe (China) dominate today’s global market, and use tactics similar to those of the tobacco, alcohol, and ultra-processed food industries.

“The ability of CMF corporations to expand and sustain their marketing practices worldwide is only possible because of their large investments in corporate political activities aimed at fostering policy, regulatory, and knowledge environments conducive to such marketing,” argues the series.

Between 2007 and 2018, the big six manufacturers spent $184∙2 million on lobbying the US government, which went on to oppose marketing regulations in Hong Kong, Thailand, Malaysia, and Indonesia, and in the World Trade Organization, and through direct bilateral engagements with governments seeking to implement national breastfeeding protection laws.

Unsubstantiated claims

Specialised formula is being sold as “comfort milks” for hungry babies, for colic, allergies, and to enhance sleep –  claims that are scientifically unsubstantiated.

These “comfort milks” can contain prebiotics, hydrolysed proteins, xanthan gum, or low lactose, but there are no clinical trials to back claims that they can provide relief for infant discomfort.

”Hypoallergenic milks” are “increasingly playing a key role in the growth strategy of major manufacturers, fuelled by a rising awareness about allergies and food intolerance among parents”, according to the report.

The companies also make unsubstantiated inferences that milk formula can “enhance brain development and improve intelligence”, using terms such as “brain, neuro, and intelligence quotient” written in large font on their products.

Undermining breastfeeding

There are huge health advantages to breastfeeding. Mothers transmit elements of their microbiota to their children through breastmilk, and these bacteria live in the babies’ gut and help fight disease, digest food, and regulate the child’s evolving immune system

Breastfeeding also releases oxytocin, prolactin, and other metabolites that “foster mother–child bonding and reduce physiological stress for both”,  while hormones in breastmilk stimulate babies’ appetite and sleep development.  

“Not breastfeeding increases the risk of infant and young child mortality, infections and malocclusion, and potentially obesity and diabetes,” notes the report.

For mothers, it reduces breast cancer and potentially ovarian cancer and type 2 diabetes.

Yet breastfeeding is portrayed in CMF marketing as generic, outmoded, and even “anti-feminist”, while formula milk marketing links it to “upward mobility, modernity, and later with women’s liberation”. 

“The idea that breastfeeding is anti-work and anti-feminist is repeated in popular blogs, media, and academic publications, especially in high-income countries,” argue researchers.

By undermining breastfeeding and fostering dependency on commercial supply chains, CMF marketing undermines infant and young child food security in the context of major disruptions to supply chains (such was seen in the US during COVID-19).

Pitches to health professionals

“Similar to pharmaceutical companies, the CMF industry sponsors professional organisations and their conferences, meetings, and training, and posts adverts and publishes sponsored articles in scientific journals,” the series notes.

Their influence is widespread. A review of paediatric association websites and Facebook accounts, found that 60% documented receiving financial support from CMF companies.

Pitches to health professionals are presented as the sharing of scientific information or professional training, creating an image of the formula milk company as an “objective and respectable adviser”. 

“For the company to provide support materials, sponsor attendance at scientific meetings, and fund conferences and other needs therefore seem natural and acceptable. These activities are presented as professional collaborations rather than inducements,” it notes.

The series also detailed the environmental harms associated with the industry, including “greenhouse gas emissions, water use and pollution, and packaging waste”.

Not enough maternity leave

Co-author Professor Rafael Pérez-Escamilla from Yale University’s School of Public Health points out that “breastfeeding promotes brain development, protects infants against malnutrition, infectious diseases, and death, while also reducing risks of obesity and chronic diseases in later life”. 

“Yet, globally, many women who wish to breastfeed face multiple barriers, including insufficient parental leave and lack of support in healthcare systems and at the workplace, in the context of exploitative marketing tactics of the commercial milk formula industry,” adds  Pérez-Escamilla.

A systematic review of studies spanning the Americas, Asia, Africa, Europe, Oceania, and southeast Asia, found that women with three months’ maternity leave, paid or unpaid, were at least 50% more likely to continue breastfeeding compared with women returning to work before this time, and those with six months or more were 30% more likely to maintain 6 months of breastfeeding. 

The US is the only high-income country that does not have legislated maternity leave.

“There is a pressing need to reverse unfair work burdens placed on women, to make visible the economic value of breastfeeding and other unpaid work within mainstream economics, and to recognise breastfeeding as a globally distributed form of food production within food surveillance systems,” the series notes.

“Data collection on breastfeeding is particularly poor in high-income countries, allowing governments to avoid their responsibilities for progressing the rights of women and infants and young children everywhere.”

Ban marketing

Marketing of CMF products should not be permitted, argue the researchers.

“A framework convention, placing the rights of children and women at its heart, is needed to protect parents and communities from the commercial marketing of food products for and to children younger than three years old, including CMF marketing systems. The framework would restrict marketing but not the sale of these products.”

 Such a convention or treaty would obligate governments to fully legislate its provisions into national law. 

“The treaty must protect policymaking from industry influence, with obligations for senior public officials to divulge meetings with lobbyists and requirements for scientific organisations to disclose funding sources and members of expert advisory groups,” adds researcher Professor David McCoy from the United Nations University. 

“This would regulate the commercial milk formula industry while not restricting the sale of the products to those who need or want them. More generally, the global and public health community must also be much more critical about public-private partnerships that enable or tolerate conflicts of interest.”

The researchers also want requirements for research institutions, think tanks, professional organisations, and NGOs to disclose funding sources.

Image Credits: Ana Curcan/ Unsplash.