Breastfeeding Medicine

Physicians blogging about breastfeeding

It’s time to disarm the formula industry

with 43 comments

The WHO Code is turning 35, and this vital public health policy is more critical than ever. The World Health Organization Code of Marketing of Breast Milk Substitutes was passed in 1981 to regulate predatory marketing tactics by infant formula companies. After World War II, formula sales boomed in the US, reaching their apex in the 1970s – the year I was born, just 22 percent of babies were ever breastfed. As they saturated the US market, formula companies looked overseas to expand markets for their products. They promoted formula as a modern, advanced approach to infant feeding, and dressed up sales representatives as nurses in clinics, pushing their product in communities where breastfeeding had been the norm for generations, and where clean water was in short supply.

Companies raked in profits, and babies died in droves. International outrage led the World Health Organization to adapt the Code, which banned marketing of artificial breast milk substitutes to consumers.

The US has never adapted the code, but formula companies did not market directly to consumers until the late 1980s  – when, coincidentally, breastfeeding rates were rising in the US, cutting into formula profits. Today, families are inundated with formula marketing and free samples, and the formula market is big business in the US. Formula sales totaled US$4.8 billion in 2013 – that’s  $1220.69 in sales for each of the 3,932,181 babies born in the United States in 2013.

Formula manufacturers secure this lucrative market with pervasive marketing campaigns. In the 2005-2006 Infant Feeding Practices Survey II, 57.4% of participants reported having received a free formula sample in the mail. Formula companies spend 10-15% of their net sales on advertising and promotion. Conservatively, therefore, formula manufacturers spend $480 million (10% of net sales) each year marketing infant formula in the US. That’s more than six times the $68 million in total US federal government expenditures for breastfeeding support through the WIC Peer Counselor program ($60 million) and CDC initiatives ($8 million).2

Both in the US and globally, the hottest growing market is for toddler “follow-on” formulas, dubbed “The Hello Kitty of Packaged Food” for its runaway success in Asian markets. According to the European Food Safety Authority, these products offer no additional value to a balanced diet, and many are sweetened with sugar or corn syrup, potentially contributing to the global obesity epidemic.

Aggressive formula marketing reaps profits for manufacturers at the expense of families. For example, corporations have long co-opted the credibility of hospitals and health professionals by distributing discharge packs stocked with samples of their most expensive formulas. A 1996 court case, Abbott Laboratories, Inc. v. Segura, provided a rare insight into detailing of health professionals: here’s what Abbott Labs told their sales representatives about nurses:

Ross Hospital Feeding System is designed to provide an early and convenient means of getting infants started on Similac … and ultimately sent home with instructions that they continue to use Similac.

Never underestimate the importance of nurses. If they are sold and serviced properly, they can be strong allies. A nurse who supports Ross is like an extra salesperson

In many US hospitals, postpartum nurses hand families a “gift bag” stocked with premium formula, implicitly suggesting that the top-shelf, newest formula was “recommended” by the maternity center.  I recently compared the cost of one of these premium formulas with a store-brand generic – the premium brand sold for $37.99, compared with $14.29 for the store-brand. Over a year of exclusive formula feeding, families that stuck with the fancy “hospital-recommended” brand would spend $2587.31, compared with $952.14 for store brand. Formula marketing in health facilities hurts formula-feeding families.

Hospital-based formula marketing pitches high-price, brand-name formula to families.

Hospital-based formula marketing pitches high-price, brand-name formula to families.

Companies also distribute “breastfeeding success” kits, which are meticulously engineered to undermine breastfeeding. A recent study by my colleagues at the Carolina Global Breastfeeding Institute found that pregnant women who reviewed formula company materials worried that their milk might not be as nutrient-rich as a commercial product:

But it still makes me wonder, then, is my breastmilk doing all those things too? Like I’m starting to feel a little bit of doubt because this is just…this covers everything. You know? I’m like “Well, actually I don’t know if my breastmilk will provide strong bones and brain and eye.” I don’t know. I’m feeling a little bit of doubt when I look at this.

And in Brazil earlier this year, Nestle funded an insidious campaign suggesting that mothers who did not eat a perfect diet were putting their babies at risk by breastfeeding, implicitly suggesting that formula feeding mothers have fewer constraints.

Companies use these tactics because rising breastfeeding rates are a well-recognized threat to formula manufacturers’ financial bottom line. Every time a baby goes to breast, a formula company loses a sale. In his Q1 2016 earnings call with shareholders, Mead Johnson CEO Peter Kasper Jakobsen stated:

The start to the year in our U.S. business was affected by market share losses from the highs we saw in the middle of 2015. On a positive note, we believe the strengthening labor market and workforce participation rates have caused a rise in breastfeeding rates to level off over the last four months or so. [italics added]

When CEOs celebrate “leveling off” of a health behavior, they profit at the expense of public health. It’s time for corporations to acknowledge that formula marketing, like promotion of sugar-sweetened beverages and high-fructose-corn syrup to children, is unacceptable. Families deserve non-commercial, unbiased information to enable each mother to make an informed decision regarding how to feed her infant.

Breastfeeding is under attack, in the US and around the world, by a burgeoning formula industry that is fighting a multi-million dollar battle for every infant’s first meal. This is a global battle, led by an industry with a retail value expected to exceed US$70.6 billion by 2019. As Alison McFadden and colleagues wrote in The Lancet earlier this year, “Promotion and marketing have turned infant formula, which should be seen as a specialised food that is vitally important for those babies who cannot be breastfed, into a normal food for any infant.”

To divert attention from this global offensive, the industry has deliberately conflated regulation of formula promotion with attacks on families who decide to formula feed. One is an issue of corporate governance and ethics; the other is a smokescreen, fueling the “mommy wars” to conceal predatory marketing tactics.

As an obstetrician-gynecologist, I passionately support each woman’s right to make her own informed reproductive decisions, including decisions to formula feed. For these decisions to be truly autonomous, women deserve accurate information about the risks and benefits of various feeding strategies. As the American College of Obstetricians and Gynecologists affirmed in their recent Committee Opinion:

Families should receive noncommercial, accurate, and unbiased information so that they can make informed decisions about their health care. Obstetric care providers should be aware that personal experiences with infant feeding may affect their counseling. In addition, pervasive direct-to-consumer marketing of infant formula adversely affects patient and health care provider perception of the risks and benefits of breastfeeding…

Obstetrician–gynecologists and other obstetric care providers should support each woman’s informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breast­feeding, mixed feeding, or formula feeding is optimal for her and her infant. (italics added)

Aggressive marketing of infant formula misleads families and derails informed decisions.

Indeed, much of the bile and vitriol around infant feeding is a direct consequence of pervasive formula marketing. We waste precious time and energy flinging pebbles at a $480 million marketing Goliath, rather than providing material support to help women make informed decisions and achieve their feeding goals. Against elegantly engineered narratives about “the sisterhood of motherhood,” our painstakingly crafted PSAs appear amateur, and our voices become so hoarse that we sound strident.

We can’t compete in a $480 million marketing arms race; instead, we need to disarm the formula industry.   Thirty-five years later, we need to #ProtectParentsAndBabies and enforce the WHO Code.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician and breastfeeding researcher. She is an associate professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the Gillings School of Global Public Health. You can follow her on Twitter at @astuebe.

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

Written by astuebe

May 20, 2016 at 4:01 pm

43 Responses

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  1. Reblogged this on Workstationny's Blog.


    May 20, 2016 at 6:49 pm

    • Dr Steube,

      You write, “Women deserve accurate (and non-commercial and unbiased) information about the risks and benefits of various feeding strategies”.

      Again, I ask, what exactly are the risks of formula and/or benefits of breastfeeding that you feel are supported by the science?

      Do you agree with the Lancet paper cited below that there is no effect of breastfeeding on atopic conditions, hypertension, cholesterol, and may increase tooth decay?
      Do you agree that the science on diabetes and obesity is only ‘probable’?

      I look forward to reading your response.
      Thank you

      Anne Risch

      May 22, 2016 at 7:24 pm

  2. Dr. Stuebe, could you provide any evidence that formula is harming any babies in the US? During the years when formula feeding rates were highest in the US, infant mortality dropped precipitously. As breastfeeding rates rebounded to their current levels, infant mortality continued to drop, albeit more slowly.

    Can you provide ANY population based data from the US that shows that breastfeeding has ANY impact on infant health? The US population is large enough and the changes in breastfeeding rates are large enough that if breastfeeding truly has health benefits, we should have been able to see them in population data.

    We can see such population based benefits for anti-smoking campaigns and for pro-vaccination campaigns. Why should we be spending any effort to increase breastfeeding rates further if we can’t find any benefits in the US population?

    Amy Tuteur, MD

    May 20, 2016 at 6:53 pm

    • It really baffles me when I see our physicians question the benefits of breastfeeding. I am not a doctor but I DO know that human milk saves lives in preterm infants who have developed NEC or sepsis. I also know that these infants have a higher mortality rate when the receive formula vs receiving human milk. This may not be the information you are looking for but it is enough. I am sure Dr. Stuebe will have a more relevant response to your inquiries but if you are so inclined to do a little research on your own before that reply is given, do a little more research on NEC (Necrotising Enterocolitis).


      May 20, 2016 at 8:37 pm

    • There are over 3000 human milk component patents owned by the infant formula, vaccine and drug industries as well as by various medical schools and hospitals, even the US Government has declared interests in human milk components, Most of those patents are on genetically engineering those human milk components to treat and prevent a large range of diseases but some are on the real component. Nestle, Mead Johnson and Abbott along with other infant formula companies believe that human milk components decrease morbidity and mortality in infants. John Hopkins and various medical hospitals as well as the US government also make similar claims on their patents. So these companies are willing to put their money on it through patenting and actual products on the marketplace.

      Valerie W. McClain

      May 21, 2016 at 7:43 am

    • Dr. Tuteur we know your opinion on this. However, I would hope that you can at least agree that advertising campaigns designed to undermine a woman’s confidence in her own body are sadly off-target and should not be tolerated. After all, aren’t we all on the side of our patients, not industry?

      • Dr. Rosen-Carole, I find posts like these to be thinly disguised efforts to change the subject from the dangers of aggressive breastfeeding promotion (dehydration, seizures, jaundice, skull fractures sustained falling from mother’s beds, and deaths from smothering while bed sharing) to demonizing the formula industry.

        If every US mother switched to formula feeding tomorrow, there would be no discernible impact on infant health, whereas if formula disappeared tomorrow, somewhere from 5-15% of babies would starve to death.

        Moreover, if the breastfeeding industry cared about women’s confidence, they would immediately change the shaming name of the BFHI from the “baby friendly” (a deliberate slap in the face to women who can’t or don’t breastfeed) to breastfeeding friendly, which is more accurate and less humiliating.

        Amy Tuteur, MD

        May 22, 2016 at 11:03 am

    • I’m a public health practitioner and researcher and I’m a bit baffled by this demand for population based data. For one thing, changes in infant wellbeing reflect many different trends — unlike vaccines or anti-smoking outcomes where there’s one clearly identifiable risk and one clearly identifiable endpoint. Secondly, you would need some kind of registry that accurately reflected infant feeding preferences, and as anyone with any familiarity with nutritional diaries know, that data is pretty unreliable. Lastly, there -is- a meta-analysis of a whole bunch of studies, published in the Lancet, cited below in this thread by Kathy Leeper, and dismissed by Tuteur as ‘extrapolation from small states’. A meta-analysis finds the average of multiple studies, weighted according to their size and quality, it isn’t ‘extrapolation’. It’s also considered the top of the hierarchy of quality of evidence sources — well above population data.


      May 22, 2016 at 5:01 am

      • It’s a direct challenge to the population claims of the lactivism industry that hundreds of lives and billions of dollars will be saved if more women breastfeed. Those claims are flat out false and demonstrated by the inability of anyone to provide data to support them.

        Amy Tuteur, MD

        May 22, 2016 at 11:05 am

      • So if you think that’s a mistake, why are you replicating that mistake in reply?


        May 22, 2016 at 11:49 pm

      • I find the public health approach to breastfeeding be extremely demeaning of women. The fact is, even if breastfeeding benefits exist, they are very small and marginal. On the other hand, breastfeeding is incredibly, incredibly demanding of women – of their time, energy, and bodies. And yes, money too if you’re going to delay going back to work or invest in pumping. And many times, the baby suffers too if the mother’s supply is insufficient. The fact is, women are NOT obligated to take on every single burden to themselves in order to increase their infants wellbeing by a small (if any) increment. For an American baby with access to good prenatal care and a healthy water supply and money for formula, the fact is that breastfeeding is an entirely optional parenting choice. Nothing more.

        Samantha Smith

        May 26, 2016 at 1:56 pm

  3. Dr Tuteur-

    From the recent Lancet Series ( Vol 387 January 30, 2016:

    Breastfeeding in the 21st century: epidemiology, mechanisms,
    and lifelong eff ect
    Cesar G Victora, Rajiv Bahl, Aluísio J D Barros, Giovanny V A França, Susan Horton, Julia Krasevec, Simon Murch, Mari Jeeva Sankar, Neff Walker,
    Nigel C Rollins, for The Lancet Breastfeeding Series Group*
    The importance of breastfeeding in low-income and middle-income countries is well recognised, but less consensus
    exists about its importance in high-income countries. In low-income and middle-income countries, only 37% of
    children younger than 6 months of age are exclusively breastfed. With few exceptions, breastfeeding duration is
    shorter in high-income countries than in those that are resource-poor. Our meta-analyses indicate protection against
    child infections and malocclusion, increases in intelligence, and probable reductions in overweight and diabetes. We
    did not fi nd associations with allergic disorders such as asthma or with blood pressure or cholesterol, and we noted
    an increase in tooth decay with longer periods of breastfeeding. For nursing women, breastfeeding gave protection
    against breast cancer and it improved birth spacing, and it might also protect against ovarian cancer and type 2
    diabetes. The scaling up of breastfeeding to a near universal level could prevent 823 000 annual deaths in children
    younger than 5 years and 20 000 annual deaths from breast cancer. Recent epidemiological and biological fi ndings
    from during the past decade expand on the known benefi ts of breastfeeding for women and children, whether they
    are rich or poor.

    Kathy Leeper

    May 20, 2016 at 8:33 pm

    • That study extrapolates from small studies. It’s not population data.

      The ironic thing about the Lancet study is that the supplementary data shows that countries with the highest breastfeeding rates have the HIGHEST infant mortality rates. That suggests that breastfeeding doesn’t have any impact on major causes of infant death.

      Amy Tuteur, MD

      May 20, 2016 at 8:48 pm

      • Can you provide the links to the studies you mentioned Dr. Tuteur?

        Alicia Corey

        May 22, 2016 at 8:17 am

      • Dr. Tuteur,
        Let me first say that formula was introduced in the early 20th century as a nutritional supplement for babies who did not have sufficient access to mothers own milk. Show me the studies with evidence that expanding the indication for formula, ie taking the place of breastmilk even when breastmilk is available, is safe, beneficial, and advantageous over breastfeeding. Swapping out breastfeeding for formula is probably the largest intervention in the health of children in the world, without any evidence that this was a safe and appropriate food for growth and development. And now we have to prove that it is bad? How about proving that it was safe and appropriate to begin with? At this point we have many studies that show poorer health outcomes for formula fed infants, and we have biologic studies to explain these findings. But we still have to prove that breastfeeding is better than something that has been shown to cause poorer outcomes?

        The reason for higher infant mortality rates has nothing to do with higher breastfeeding rates. The higher infant mortality rates have most to do with premature births as a result of health disparities, lack of breastfeeding in at-risk populations, and access to infertility treatments for women who are older and have chronic disease that render them infertile.
        African Americans in the USA have the lowest breastfeeding rates, and highest infant mortality rates- In the USA the white infant mortality rate is 5.1/1000, and 11.3 among nonHispanic blacks.
        As a member of a legislative committee for the state of Wisconsin studying the high infant mortality rate among African Americans in our state, we found that the main causes of infant mortality had to do with premature births among poor African American women who didn’t have equal access to appropriate prenatal care, either from the medical profession or from society. These mothers also have much lower breastfeeding rates, and it is clear that lack of access to mothers own milk increases the risk of necrotizing enterocoliitis, late onset sepsis, and pulmonary disease in these premature babies. These are illnesses that lead to morbidity and mortality. In addition, this population has been found to have a higher rate of SIDS in our state, with lack of breastfeeding as an underlying risk factor for SIDs.
        Please remember that as you throw knives and swords at breastfeeding, you are increasing health risks for vulnerable populations who don’t have voices.
        Relative to the grave health disparities between blacks and whites, it may seem like fluff to argue the risks of formula feeding for super healthy term, Caucasian babies born to professional middle and upper class women. However, as a family physician for nearly 30 years, I have had the honor of following 2500-3000 people over the course of time in my town where I practice. I have admitted scores of babies for diarrhea and dehydration over the decades BUT ONLY 2 were breastfed. I see more ear infections, chronic sinusitis, and more severe autoimmune illness among the formula feeders as they age. In addition, the difference in childhood obesity between the formula feeders and breastfeeders is remarkable in my population, as they age. All of these observations are supported in metanalyses by AHRQ, other than the difference in severity of autoimmune illness and sinusitis. And now there are several large population studying demonstrating the lower rates of leukemia and lymphomas in breastfed children. These findings are not without biologic plausibility.
        Have you ever thought about what your diet will look like when/if you are 90 years old? How would you feel if the doctor of your nursing home/assisted living (or maybe you will be lucky enough to stay at home with in home care) puts you on a formula diet of 6 servings of Ensure or Glycerna per day, as opposed to 5 servings of fruits and veggies, lean proteins, whole grains, and healthy fats each day? If you believe that Ensure or Boost is a good substitute for a healthy balanced diet, that would explain why you believe that a diet of infant formula can lead to equal health outcomes as breastfeeding.

        Anne Eglash MD

        May 22, 2016 at 10:10 am

      • Dr. Eglash, I find your arguments to be deeply disingenuous.

        Formula was NOT introduced as a supplement for babies who didn’t have access to their mothers’ breastmilk. It was introduced to save the lives of babies whose mothers CHOSE not to breastfeed them because of the difficulties and inconvenience of breastfeeding. They were using unsafe substitutes and formula is a safe substitute.

        Breastfeeding is one of TWO excellent methods of feeding infants. In countries with clean water there’s NO evidence that breastfeeding has any impact beyond a few less colds and episodes of diarrheal illness across the entire population of infants in the first year. You know that; I know that. Those trivial benefits do not justify the hysteria and moralization of breastfeeding promoted by the lactivism industry.

        I find the efforts to browbeat African-American mothers into breastfeeding to be particularly egregious. The problem of infant mortality among African-American babies is complex involving poverty, structural racism, limited access to healthcare, biological propensity to prematurity and other factors. There’s absolutely no evidence that it has anything to do with breastfeeding rates, which, of course are reflections of privilege.

        Blaming the behavior of black women (their “failure to breastfeed”) for the deaths of their babies is both unscientific and unspeakably cruel. Privileged Western, white women make their own choices normative because they have the power to do so, not because the choices of privileged Western, white women are actually superior.

        Lactivism is anti-feminist and deeply retrograde. La Leche League was started with the deliberate intention of forcing the mothers of young children to stay out of the workforce and wider world.

        Lactivism promotes the idea that women should be judged by the function of their reproductive organs, instead of their intellect, talents or character.

        Lactivism is profoundly ableist, insisting that all mothers produce enough breastmilk and shaming and blaming them when they don’t even though you and I both know that a large proportion of women are biologically incapable of producing enough breastmilk.

        Lactivism deprives women of bodily autonomy. They are her breasts, her baby and her body; it ought to be HER choice whether a woman breastfeeds, not anyone else’s!

        Amy Tuteur, MD

        May 22, 2016 at 11:25 am

      • Dr. Eglash,

        I think that you are associations with causal relationships. You cite the 2007 AHRQ report (in which in researchers found less of many conditions in breastfed babies)—but they cautioned that the relationship was not necessarily causal.

        Yes, breastfed babies have less health problems and do better on tests than babies who are fed formula, but when income, education, parental characteristics and lifestyle are factored in the differences are lessened by quite a bit, sometimes to nothing.

        Since higher income, better educated women, healthier, women with better health habits breastfeed at higher rates, just about anything exacerbated by poverty poor health, or health habits can be associated with not breastfeeding . Spend some time looking at individual studies, or fact-check some publications on breast feeding’s benefits and you might be suprized at what you see.

        Anne Risch

        May 22, 2016 at 7:57 pm

      • No, it would suggest that only if all other circumstances were the same. Increased mortality in certain countries is a result of poverty, unclean water, lack of medical care, etc. We don’t have the same degree of danger in the U.S. For an explanation, consult Mill’s methods (John Stuart Mill, A System of Logic, 1848).


        February 5, 2017 at 6:04 am

      • Dr. Tuteur, please also see your own words above that directly contradict the reasoning behind your assertion that breastfeeding has no impact on major causes of infant death: “The problem of infant mortality among African-American babies is complex involving poverty, structural racism, limited access to healthcare, biological propensity to prematurity and other factors. There’s absolutely no evidence that it has anything to do with breastfeeding rates…”


        February 5, 2017 at 6:16 am

      • I find this comment interesting: “Lactivism deprives women of bodily autonomy. They are her breasts, her baby and her body; it ought to be HER choice whether a woman breastfeeds, not anyone else’s!” Would you say the same for anti-smoking, healthy diet, exercise, safer sex, and vaccination encouragement campaigns? A public health message in no way deprives anyone of bodily autonomy. Most breastfeeding proponents I know acknowledge that in the presence of accurate information untainted by commercial interests, women absolutely have the freedom to choose how to feed their babies. Without truly informed choice, any freedom is merely illusory.


        February 5, 2017 at 6:23 am

      • this MD is so obnoxious, the kind of person it is so sad got their MD at all. have you ever even studied the benefits of breastmilk, or are you just parroting back the nonsense you learned ages ago in med school before we had all the current science on the many benefits of breastfeeding? remember the days before Harlow, when people like you wouldn’t even acknowledge the benefit of snuggling a baby, even going so far as to claim it was bad for babies? you’re doing the same thing except, foolishly, embarrassingly, after the science is clear. babies fed the breast alone have proper orofacial development and usually no need for braces (if they’re not badly K2-deficient); there are probiotics and antibodies the breast produces to protect the baby; the bonding that happens during breastfeeding facilitates better early attachment; the baby is less likely to die of SIDS; the baby is less likely to grow up to have food intake regulation disorders; the baby’s microbiome is more likely to have the proper components to reduce likelihood of allergies, ear infections, autoimmune disease, and obesity; breastfeeding is enjoyable and reduces breast cancer risk; breast milk is free, always warm, always available, without the hassle of bringing supplies in a bag; breastmilk can be applied to wounds & rashes to heal faster (baby or anyone in the family). the benefits really cannot be overstated. anyone who has an MD who doesn’t know this stuff should be ASHAMED of themselves. Tuteur, just retire, you’re not doing babies any good with this attitude. you are one of the reasons i feel so angry at our failing medical system. there are many reasons we lag behind other developed countries in infant mortality rates, but people like you—horribly uninformed people masquerading as experts—are no doubt one big part of the problem. truly! SHAME ON YOU.

        jamie ramirez

        July 10, 2018 at 4:45 pm

    • Ms. Leeper,

      Did you notice that this study concluded that breastfeeding had no effect on atopic conditions such as asthma (and I am assuming food allergies and eczema) as well has high cholesterol and high blood pressure. It also said that it only had probable effect on diabetes and obesity.

      It also stated that there was an increase in tooth decay with longer breastfeeding.

      How do you feel about promotion of breastfeeding using reduction in those conditions as a benefit

      Do you feel that this is ethical?


      Anne Risch

      May 22, 2016 at 7:14 pm

  4. When I was in a refugee camp in northern Greece a couple of months ago, I had a conversation with a lovely young mum. She was exclusively breastfeeding her bonny baby but told me that in Syria she had mixed fed. She also told me that she wasn’t formula feeding in the camp because it was clearly dangerous, nothing was clean. However, she was worried. Would her baby’s immune system be disadvantaged by not being fed some formula? THIS is what unethical marketing does! It makes parents believe things that are not true about infant formula, about bottle feeding, about breastmilk and breastfeeding. It prevents them from being able to make informed decisions.

    Karleen Gribble

    May 21, 2016 at 8:52 am

  5. It is very baffling that a physician making a statement that countries with higher breastfeeding rates have higher infant mortality. My own experience, practicing general pediatrics and breastfeeding medicine is exactly the opposite . Breastfeeding and back to sleep has reduced the number of infants dying from SIDS. Infants who are breastfed for 9 to12 months have very low rates of common infections. We have not had any infant mortality at all in our practice for many years, caring for about 8000 patients. We also witness that infants who are breastfed for one year or longer reach their developmental milestones. Additionally we see many children with autism spectrum disorder who were formula fed. These studies have been published in our Journal 2014 and in the J of Southern California Clinicians 2013.

    • How do you know those formula-fed autistic kids aren’t autistic and disabled because they starved while exclusively breastfeeding and now have to be formula fed because their mothers never produced milk? How do you know they didn’t develop hypoglycemia, jaundice and dehydration because the ABM protocol made them starve at the breast? Why does EVERYONE at the ABM talk about breastfeeding as if is a matter of choice to make breasts produce milk that can sustain a baby’s life? Have not learned from Alison Stuebe’s articles? You think those formula-fed kids are formula fed because their mothers just chose it? How do you know those babies are formula fed because their mothers witnessed them fail to thrive and get hospitalized from exclusive breastfeeding. I am sick of the ABM’s ignorance.

  6. Great post Dr. Stuebe, thank you for packing it with all those interesting links too. In the interest of full disclosure, I am a nurse and an ILCA board member. I would like to add some context to the comments about nurses, lest it be misleading. Specifically, you write “In many US hospitals, postpartum nurses hand families a “gift bag” stocked with premium formula, implicitly suggesting that the top-shelf, newest formula was “recommended” by the maternity center.” First, it is important to recognize that nurses don’t direct this piece of the “care” package. This is an institutional problem. This problem gets addressed from the top with the implementation of BFHI practices so the counter to this move, is to continue to call for hospitals to implement BFHI practices. In my 20 years experience in BFHI, it is my observation that once nurses and administrators understand the harmful effects of these “free gifts” they get on board with corrections. As an aside, nurses are often the ones skirting the system by removing the products and giving out the empty bags because it is expectation of their discharge plan and parents are asking for their free gift. Parents are asking because they are also targeted with coupons that say “don’t forget to ask.” I don’t suggest that removing the product is any less harmful to breastfeeding, only that nurses are trying to do the right thing in a flawed system.

    Next, industry’s use of health care professionals to do their bidding is not limited to nurses. With regard to the Ross quote: “Never underestimate the importance of nurses. If they are sold and serviced properly, they can be strong allies. A nurse who supports Ross is like an extra salesperson.” These companies know well that nurses in the U.S. are consistently ranked first in consumer trust among all health professionals which makes this practice even more unsavory but formula companies cover their bases by targeting other health professionals too. Mothers also receive shipments of “free” formula directly to their homes as a result of mailing lists that are generated by their prenatal provider’s offices, this is also where they get their coupons. Professional organizations of nurses and physicians also accept funding from these entities so that they can continue to provide their members with premium conferences. I think we need to collectively address professional organizations in our advocacy efforts similarly to what has been done in the UK with pediatric providers.

    Finally, as you highlight so well, the formula industry is a behemoth. As such, it’s my belief that we, as health care professionals will be stronger, working together in our opposition of the issue. In the U.S., we might find a way to collectively push policy makers to adopt the Code or at least implement provisions similar to what you mention above with regard to consumer safety. Our collective organizations can also continue to work together in our advocacy efforts as ABM and ILCA have done on the ground at the UN. At this time, ILCA is finalizing statements for the 69th World Health Assembly that call for stronger commitments to Code adherence among the world’s most vulnerable women and children. We will need lots more support from all types of partners including consumers to counter this behemoth.

    Michele Griswold

    May 22, 2016 at 7:26 am

  7. Dr Tuteur, your comments about the dangers of lactivism and the practice of breastfeeding medicine reveal your extreme lack of understanding of what lactation consultants and physician breastfeeding medicine specialists do to support all women. This is probably because you are not a clinician.
    Breastfeeding medicine specialists are likely the greatest advocates of formula use. We are extremely cautious and observant regarding infant growth and development. We do find that physicians who are not knowledgeable about infant feeding will allow faltering growth in order to support breastfeeding in cases where babies are not transferring milk well, or when mothers have low supply. The lack of physician and nurse education in infant nutrition in the USA leading to unsafe breastfeeding practices should not be a reason to halt all breastfeeding. That would be throwing the baby out with the bath water. It should be a call for more professional breastfeeding education.
    I think it is bizarre and laughable that the AAP, AAFP, ACOG, USPSTF, CDC, WHO all call for increased breastfeeding education for medical professionals, as well as increased breastfeeding support for communities based on science, while you proclaim that breastfeeding advocacy amounts to hog wash & browbeating women, and essentially stating that breastfeeding is unsafe. You know as well as those of us reading this blog that your rants are analogous to those of anti-climate change individuals, choosing to ignore carefully evaluated science, for your own personal gains.
    Breastfeeding specialists don’t become wealthy from their research and support of breastfeeding. Much of our time spent advocating to improve infant and maternal health is done thru volunteerism. You, on the other hand, can easily rake in money by promoting large multinational corporations.

    Anne Eglash MD

    May 22, 2016 at 12:14 pm

    • How many logical fallacies can one pack into a single post?

      1. Ad hominem: ” you are not a clinician.”

      2. Appeal to authority: AAP etc … Call for increased breastfeeding education …”

      3. Ad hominem: “anti-climate change individuals.”

      4. Red herring: “breastfeeding specialists don’t become wealthy.”

      5. Libel: “you can easily rake in money by promoting large multinational corporations.”

      I don’t get any money from industry and until you can prove that I do, I suggest you avoid lying about me in an attempt to deflect attention from the fact that you can’t respond to my claims.

      How about addressing my ACTUAL claims?

      1. In the US, the benefits of breastfeeding are trivial.

      2. The breastfeeding industry grossly exaggerates the benefits of breastfeeding.

      3. Lactivism HURTS babies by leading to an increased in hypernatremic dehydration, failure to thrive, skull fractures from infants falling from hospital beds, and infants smothering in their mothers’ hospital beds;
      And it HURTS mothers by deliberately shaming and humiliating them.

      4. Lactivism is anti-feminist, mandating that women use their reproductive organs in “approved” ways.

      5. Lactivism is ableist.

      6. Lactivism does not respect women’s right to bodily autonomy.

      The breastfeeding industry has gotten a pass for decades but those days are over. Women can and should push back against an industry that promotes the process of breastfeeding over the outcome of healthy mothers and healthy babies.

      Unless and until you can provide SCIENTIFIC EVIDENCE that increasing the breastfeeding rate ACTUALLY (not theoretically) saves lives and ACTUALLY (not theoretically) saves billions of healthcare dollars there’s no reason to believe the breastfeeding hype.

      Amy Tuteur, MD

      May 22, 2016 at 12:38 pm

      • how come in Scandinavia and, for that matter, developing countries, we see EVERY baby being breastfed? because it is a fallacy that a body can successfully do all the parts of making and birthing a baby and then somehow, inexplicably, be unable to do this one part of it (breastfeeding). it is beyond rare for a breast not to be able feed a baby after birth. they don’t perpetuate such harmful myths in other countries, which is why everyone successfully breastfeeds except for those in the US, who experience a disservice when they’re told their breasts can’t do it, that’s okay, that’s normal, instead of accepting that some people really just need extra support, some need a little extra time, and this is what hospitals SHOULD be doing, if we want to respect families the way they do in places like Scandinavia & Germany & other countries with a greater abundance of baby-friendly hospitals. they’re getting results we should definitely aspire to, and they’re spending less. the medical system here just has all its priorities scrambled.

        jamie ramirez

        July 10, 2018 at 5:00 pm

  8. we believe the strengthening labor market and workforce participation rates have caused a rise in breastfeeding rates to level off over the last four months or so.

    This quote from the Mead CEO doesn’t support the point you’re making. It suggests that the reason women are using formula isn’t marketing, it’s because it’s too difficult to work and nurse at the same time. Even if all formula marketing and advertising ended tomorrow, it wouldn’t do a thing to increase breastfeeding rates among women who simply can’t balance earning an income and nursing their babies.

    Alisa Rivera

    May 22, 2016 at 4:02 pm

    • Co-signed.

      Women don’t abandon breastfeeding because they’re handed a packet of sample formula. If you want to support women who choose to breastfeed you should focus on establishing a US paid maternity leave policy that is on par with the rest of the industrialized world.


      May 23, 2016 at 8:19 am

      • Paid leave is absolutely essential to improving breastfeeding rates. But Canada and the UK, countries with generous maternity leave benefits, have breastfeeding rates on par with or worse than the U.S. So there is merit to the argument that the pervasive and aggressive marketing of formula is undermining breastfeeding.


        May 24, 2016 at 8:54 am

  9. Well done piece, Dr. Stuebe! I would like to point out to other commentators that Dr. Stuebe is one of the most rigorous scientist/investigators that I have ever had the pleasure to work with. Her scientific articles, of which she has published a great many (unlike some of the commentators here), are extremely well thought out and she is very careful not to draw conclusions that cannot be made from the data collected. I would like to see Amy Tuteur obtain grant funding and conduct actual scientific research and publish it in a peer review journal so she would understand how it is actually done and what goes into this process. She has repeatedly demonstrated that she has no such understanding of science. Dr. Stuebe is one of the breastfeeding great investigators of our time. Thank you, Alison, for all you do.

    • For better or for worse, Dr. Bartick, all that the ABM members have been able to demonstrate is that they can’t support their claims with scientific evidence and therefore they resort to ad hominems.

      Surely, if there is so much evidence that breastfeeding saves lives and prevents serious illnesses you should be able to produce at least SOME EVIDENCE that breastfeeding saves lives and prevents serious illnesses.

      The other thing that ABM members have demonstrated is that they are far concerned with promoting breastfeeding than with protecting women’s mental health or bodily autonomy. I’m telling you that you are shaming and humiliating women, and many other women are telling you the same, yet the ABM appears not to care.

      Amy Tuteur, MD

      May 22, 2016 at 9:19 pm

      • I find you highly offensive, you talk about making unsubstantiated claims but continually make them yourself. You try to put blame on people who are there to help mothers who have chosen to breastfeed on their own after being given information. I worked for WIC as a peer counselor and CLC for 5 years. My job was to give women information on how to safely feed their infants whether that be by breast or by bottle, breast milk or formula. We encouraged women to choose for themselves and helped them through many issues and obstacles. I have seen many mothers who chose to breastfeed “brow-beaten” by family members friends and worst of all healthcare professionals with lack of understanding or any empathy to go against their decision to breastfeed without any provocation for it. They simply didn’t think the women should breastfeed any longer. Why don’t you take all the energy that you have or seething hatred as it seems toward “lactivism” and use it for something more worthy i.e. Safe sleep since you believe breastfeeding leads to unsafe sleep habits, or educating women how to know their child is getting enough milk(formula or breastmilk), teaching women not to water down formula and the deadly implications of doing so since you care so much about the under-privileged women and infants being pressured and advocate for choice. Breastmilk is free and when it’s done with help and proper following from educated professionals breastfed babies thrive for the sake of argument(or avoiding one) just as well as formula fed infants! If a woman is poor how is she to afford formula, even store brand, without help? Then she’s told she’s scum for needing assistance, she loses self esteem either way! Her medical insurance will however in most instances provide her a breast pump which with proper guidance she can use to avoid purchasing or reduce the need for purchasing infant formula. Please stop grouping all of the people who support breastfeeding into a category of fanatics which may exist in small number. Use all that energy for something positive I beg of you!


        May 26, 2016 at 4:25 pm

  10. Very interesting, thank you. SO glad that Alison and other similar people are standing up for mothers and all babies.

    Katsuyama Sarah

    May 24, 2016 at 4:38 am

    • Great post Alison! Yes we need to keep chipping away at the deceptive marketing practices of the infant formula industry. We are making a little progress, but only a drop in the bucket. We have 349 Baby Friendly hospitals in the US and 990 hospitals that have eliminated the distribution of commercial formula discharge bags. I found it interesting that Amy Tuteur suggested eliminating the term Baby Friendly Hospital Initiative and suggested the use of the term “breastfeeding friendly.” If I remember correctly, when the BFHI came to the US in 1991, there was resistance on the part of the government to adopt this initiative and a task force was formed to study it which was heavily influenced by the formula industry. In fact, the formula companies suggested the very term “breastfeeding friendly” be substituted for the international term “Baby Friendly.” Hmmm… While we take pot shots at the formula industry, they fire back with nuclear tipped guided missiles in the form of money, lobbying, and deception. Who is brave enough to get the Code legislated in this country, create a national maternity leave policy, and assure that ALL mothers have access to the services of a lactation consultant with the IBCLC credential through insurance coverage?

      Marsha Walker

      May 25, 2016 at 9:59 am

  11. Thank you Alison for such a wonderful post. It is certainly a struggle to promote and support breastfeeding when faced with the armaments of the behemoth infant formula industry. While we are throwing pebbles, some of them have resulted in a bit of chipping away at the deceptive marketing tactics used to peddle infant formula. We now have 349 Baby Friendly hospitals and 992 hospitals that have eliminated the distribution of commercial formula discharge bags.

    I also find the following quote from Amy Tuteur to be of interest, “Moreover, if the breastfeeding industry cared about women’s confidence, they would immediately change the shaming name of the BFHI from the “baby friendly” (a deliberate slap in the face to women who can’t or don’t breastfeed) to breastfeeding friendly, which is more accurate and less humiliating.” If I remember correctly in 1991 when the BFHI was first introduced into the United States, a task force was formed to study how it could be integrated into US hospitals. Abbot, the formula manufacturer, was sufficiently concerned that it wrote a letter to the task force saying that if the BFHI was adopted, Abbott would be forced to market formula directly to consumers! It suggested the term “breastfeeding friendly” be used instead. What an interesting coincidence that this same term surfaces in a reply to this blog post. Hmmm…

    Marsha Walker

    May 26, 2016 at 10:38 am

  12. Let’s simplify this a bit. First, Mark Twain is often quoted as saying “There are lies, damn lies . . and then there are statistics.” All studies have flaws, not the least of these is any bias of the researcher and/or sponsor. So, lets just use some common sense. First, ask any mother who has exclusively breast fed a child, and also exclusively formula fed a child. By far, most will say “the breastfed baby was not as sick”. Some even say that the breast fed baby did better in school (depending on how long breastfeeding occurred). Finally, if we look at photos of human milk and non-human milk, both taken the same day, at the same magnification (10x) by the same physician-researcher (Dr. Stephen Buescher), the difference of very clear to see. Human milk has a huge number of components, and especially living cells, which help protect the human baby and provide for optimal brain growth and development. Non-human milk has no living cells and offers very little, if any thing, in the way of active protection of the baby. Newer, more “gentle” formulas have decreased the amount of lactose, a milk sugar important for brain nourishment, up to 80% or more. It doesn’t take a rocket scientist, or a physician, and especially an informed woman to be able to figure out that there IS a difference, and that the difference translates into optimal vs. sub-optimal health, growth, and development for babies . . . and we won’t even mention the health advantages of the act of breastfeeding over the remaining life span for women.


    June 20, 2016 at 1:13 pm

  13. […] Stuebe AM. It’s time to disarm the formula industry. Breastfeeding Medicine Blog. May 20, 2016. Accessed online: […]

  14. First of all, Dr Steube- Wonderful article. I honestly DO NOT GET all of the anti-breastfeeding comments on here from actual medical professionals who took an oath to always give the patient the best care possible. How does supporting breastfeeding negate from that oath?? Ridiculous. This exactly is why I don’t trust most doctors… Any physician, clinician or what have you that doesn’t have my child’s best interest at heart, and by that I mean encouraging me to breastfeed, then I want no part of their practice. If there never were a Mead Johnson or Abbott Lab, then women would have no choice but to feed the way nature intended (since we are mammals after all).

    “BF is too demanding and hard on a woman’s body…” Pisshhh… What a laughable statement. You say this in the day and age of convenience that we currently live in. NOTHING is hard these days, for anyone, let’s be clear on that. There is ample help whether you wanna formula feed or breastfeed, be it from a government assistance program or your local lactation professional.
    To be bring up infant mortality and praise how ABM has somehow been the savior for these dying babies, that in itself sounds like your pockets are being lined from the coffers of the formula industry. Yes, babies have failed to thrive while breastfeeding AND while formula feeding, but unfortunately that is nature working as it should.

    For example: Say there are pups born to a female wolf or cubs born to a lioness in the wild. If their mothers’ are killed or unable to sustain them due to an injury, unfortunately, those litters would perish. Is it sad? Yes. Is it part of the cycle of life that has existed for mammals (such as ourselves) for millennia? Also yes. When babies die, it is a terrible, terrible thing for everyone, but to say that our biologically inclined way to feed our children is the worst way possible to prevent infant mortality is a bunch of insane nonsense. Especially coming from such an “educated” group of persons such as those on this thread.

    How exactly do you all think that we all made it to the 20th Century, before the “glorious” artificial breast milk substitutes were invented? By physically feeding our babies! No wonder other countries laugh at our so-called medical experts opinions and shake their heads at increasingly obese youth. Sad…


    June 27, 2016 at 11:20 am

  15. Could not just common sense prevail please. Cows feed calves cows milk, pig feed piglet pigs milk, cat feed kittens cat milk, humans feed babies human milk. Have you ever looked at a cow milk protein molecule and human milk protein under a microscope? The cow’s milk protein is huge compared to the human milk protein molecule, while this does not prove anything in terms of health adverse affect, it does tell the viewer straight away there is a huge difference already. If aliens would come and visit us and see that we do not feed our babies species specific milk they would be puzzled by that and to top it up we have to make laws that human species are ‘allowed’ to feed the human milk to their babies in pubic places e.g. restaurant but it is OK to feed non-species milk in public places? That would puzzle them even more.

    Ruth Martis

    June 29, 2016 at 2:42 am

  16. […] studies have shown that formula sales campaigns undermine mothers who choose to breastfeed, and co-opt medical professionals to promote expensive brand-name […]

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