Day of Action: get out from under the influence of a lifetime of formula marketing

May 21, 2014 marks the 33rd anniversary of the World Health Organization’s adoption of the International Code of Marketing of Breast-Milk Substitutes (or “the Code”) in an effort to promote breastfeeding and limit formula companies’ influence over women’s infant feeding decisions.

Today more than 20 organizations and thousands of moms and citizens are participating in a day of action led by Public Citizen, directed at the largest formula makers in the U.S. and Canada – Mead Johnson (manufacturer of Enfamil), Abbott (Similac) and Nestle (Gerber Good Start — and aiming to end the unethical practice of promoting formula in health care facilities, particularly through the distribution of commercial discharge bags with formula samples – a longstanding violation of the code.  Efforts include the delivery of a petition with more than 17,000 signatures to Mead Johnson at its headquarters outside of Chicago as well as to Abbott and Nestle;  sending photos and messages to companies on Facebook, Twitter and other online platforms; and blogs such as this one.  The day of action is not meant to advocate against formula use in cases where it is necessary, but to focus on the need to give mothers unbiased information about infant feeding, information that hasn’t been influenced by formula companies.

In reflecting on the influence of formula companies, I realized that the history of my life  parallels the history of the Code:

 The 27th World Health Assembly in 1974 noted the general decline in breastfeeding related to different factors including the production of manufactured breast-milk substitutes and urged Member countries to review sales promotion activities on baby foods and to introduce appropriate remedial measures, including advertisement codes and legislation where necessary.

I was born a bit before this.   My mom says that she wanted to breastfeed me but that nobody, including hospital personnel, could tell her how.  My baby book contains the crib card with the formula company logo.

The 33rd World Health Assembly, in May 1980, endorsed in their entirety the statement and recommendations agreed by consensus at this joint WHO/UNICEF meeting and made particular mention of the recommendation that “There should be an international code of marketing of infant formula and other products used as breast-milk substitutes”.  To develop the code numerous and lengthy consultations were held with all interested parties. In May 1981 the Health Assembly debated and adopted the Code.

I entered medical school a bit after this.  My pediatrics rotation included a lecture on infant nutrition covering the varieties of formula and their composition.  There was no mention of breastfeeding.

Then I went on to pediatric residency.  The formula companies gave us textbooks, food and other gifts.  During my last year of residency one of our chief residents had her first baby and gave the rest of us a lecture about breastfeeding.  We didn’t get much out of it.

Then I went on to neonatology fellowship.  We mostly fed babies preterm formula, but if a baby’s mom brought in expressed milk there was human milk fortifier to add to it.  And I spent a year in public health school during fellowship and realized that breastfeeding is a “no-brainer” — even though it seemed that the majority of health professionals were skeptical, without “evidence”, that breastfeeding could have any effect on health.

Since fellowship  I have seen that evidence accumulate and breastfeeding become acceptable  if not “normal”.

Most of us who are health care providers are well aware that a large body of research shows that antibodies passed from a nursing mother to her baby helps reduce the risk or severity of many conditions among breastfeeding infants– from  ear and respiratory infections, diarrhea, and meningitis to allergies and SIDS (sudden infant death syndrome). Many of us are also aware that women who breastfeed also gain health benefits —  with a reduced risk of type 2 diabetes, breast cancer, obesity, ovarian cancer and other conditions.

In fact, due to this increasing awareness of the evidence, advocacy efforts have already led many hospitals to begin to limit formula promotion over the past decade. According to the Centers for Disease Control and Prevention (CDC) Maternity Practices in Infant Nutrition and Care (mPINC) surveys, 27.4 percent of hospitals had discontinued the formula discharge bags for breastfeeding mothers in 2007, and by 2011, 45.5 percent had ended the practice. All hospitals in Massachusetts and Rhode Island have voluntarily banned discharge bags, and a recent Public Citizen and Ban the Bags report found that 82 percent of the U.S. News and World Report’s top-ranked hospitals, and more than two-thirds of the highest ranked hospitals in gynecology, no longer hand out commercial formula discharge bags with samples.

Many of us — health care providers and parents — believe that because we are smart, we aren’t susceptible to marketing.  A lot of us aren’t giving out discharge bags any more.  And the formula companies now acknowledge the “superiority” of human milk to their product, so we can relax.  But they make use of the power of suggestion that breastfeeding is difficult  (when it is parenting that is difficult!) or that their product will reduce “gassiness” (because of course that must be what is making the baby cry).

And there is still plenty of unethical marketing going on in health facilities.  For example, formula companies distribute samples through doctors’ offices and clinics, often without the knowledge of health care providers within those offices.  Another commonly used advertising venue is those free parenting magazines in hospitals and doctors’ offices.  (I once discovered such an publication, full of formula promotion in its “educational” content as well as its ads, in my own hospital with “compliments of (MY OWN NAME)” printed on it.)

Yet another area of commercial influence is in “education” of health care providers.  Even in a hospital that doesn’t distribute commercial discharge bags to families,  it is not difficult for industry salespeople to gain access to the nursery and regularly bring in food, treats, advertising (eg badge holders) and coupons for their products.  Formula company sponsorship of lectures by guest speakers at upscale restaurants are welcomed by hungry, overworked health care providers; “in-service”  updates on nutrition for nursing staff are equally welcomed by cost-conscious administrators.

We need to realize that all this comes at a cost to women and their babies.  The company representative who brings doughnuts for Nurses’ Week isn’t doing it to be nice; she is doing it because she is paid to establish her brand in the minds of the staff.  The “free education” is not free of bias — it is marketing: spinning the data to make the product look useful or even necessary.  To me, the most egregious example of biased information is that of the review article in a peer-reviewed journal’s “supplement” (underwritten by the formula industry), containing false generalizations and even blatant misrepresentation of the research literature in hopes of convincing health care providers of the need to give patients (late preterm infants, in this case) a commercial product.

As health care providers, we are responsible for providing unbiased information to our patients.  The truth about “infant nutrition” is that human milk is NOT just nutrition — it is an amazingly complex fluid containing living cells, antibodies, growth factors and other substances that allow babies to thrive as well as to grow.   Why would we want to even suggest that families should spend their money on a substitute  if they don’t have to?  And yet, when we are handing out free samples or parenting magazines — or accepting “evidence” without questioning it — we are doing just that: helping to market formula.
Kimberly Lee is a neonatologist and member of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.