How the Formula Industry Fooled the World
Its hard to imagine sales people donning the garments of nursing staff and patrolling hospital maternity wards to promote formula products to new mothers - but that’s one of the marketing tactics used to undermine women’s confidence in breastfeeding just a few decades ago.
"Milk nurses" in South Africa. "Some firms used "milk nurses" as part of their promotions. Dressed in nurse uniforms, "Milk nurses" were assigned to maternity wards by their companies and paid commissions to get new mothers to feed their babies formula. Mothers who did so soon discovered that lactation could not be achieved and the commitment to bottle-feeding was irreversible." -
Business: Its Legal, Ethical, and Global Environment, by Marianne M. Jennings
If you think that kind of thing can’t possibly happen any more, think again. Day care centres and kindergartens are given free samples of so-called “toddler” milk sachets to send home with children, taking brand awareness directly to expectant and new mothers through the hands of their own children. And you can bet formula brands were among the first to use online social media influencers to market their products through paid testimonials.
The Internet has allowed formula brands to reach right into the hands of breastfeeding women to kindly offer them support … and marketing!
Infant formula products are necessary when barriers to breastfeeding are insurmountable. As a final resort when all other possibilities have been exhausted. Breastmilk substitutes are not risk-free and parents should be making informed decisions based on medical advice before stopping breastfeeding or introducing formula supplementation. Yet in Australia and many other countries, you can pick it up in the supermarket next to the single-use nappies and baby wipes.
Formula use is seen as a lifestyle choice or an equal alternative to breastfeeding because of the way it is marketed: directly and subliminally. There is nothing accidental about the marketing tactics used by multi-national corporations to increase their market: every baby who isn't breastfed is a new customer. Many of the advertising and promotional techniques used would be familiar to the tobacco industry, who used similar to promote their products globally in the past. While tobacco and formula are not comparable products, they do both rely on brand awareness and perception that their product is superior to other brands, even though they are basically the same.
A brief history
In the 1860s, German chemist Justus von Liebig patented the first artificial milk, made of cow’s milk, baking soda, and a mix of wheat and malt flour. During the same period, a pharmacist named Henri Nestlé introduced his own formula. His formula consisted of crumbled wheat rusks that had been soaked in sweetened condensed milk and subsequently dried. Initially, these formulas were intended as a last resort for orphaned and malnourished infants. However, they were produced by commercial companies with a clear interest in generating profits. Before long, the promotion of infant formulas began stating the products would bestow babies with attributes such as "muscular strength, firmness of flesh, and a lively intelligent appearance," to borrow from Wagner's Infant Food's advertising language.
Around the same time period, the infamous Luther Emmett Holt - responsible for the “cry it out” terminology still referenced today -spoke of infant formula not as an alternative to breastfeeding, but a replacement altogether. It is worth noting that for several decades in the late 1800s and early 20th century, buying infant formula and patented baby foods required a visit to a paediatrician, a rapidly growing medical specialty. Holt was a founder member of the American Pediatric Society in 1888 and twice its President (1897 and 1923).
Many parents believe the word “formula” implies scientific assembly of key nutrients put together in a laboratory. However, it is really just a recipe which has cow milk as its base, which is dehydrated and made into powder form, with added vitamins, fats and sugars in the hope of making it more like human milk. The formula industry even fund research into breastmilk as it is in their interest to identify components and what they provide so they can be first on the market attempting to replicate that. It is all pretty experimental: in the 1990s, when researchers found the important fatty acid DHA was present in breastmilk, formula companies scrambled to try and recreate it in their products, using fish oils. Unsurprisingly, babies didn’t appreciate the fishy taste this gave their milk!
So effective is the marketing messaging that infant formula is almost the same as breastmilk, some people believe it is actually human milk, artificially created in a laboratory. This is why advocates demand protection for parents from advertising and urge they make informed decisions based on facts, not marketing spin. All infant formula in Australia needs to comply with Australian standards and vary little between brands. Similar requirements in the US to meet their own standards led to warnings against buying products from overseas markets such as Europe during the recent crisis after product recalls left families unable to feed their exclusively formula fed infants. The European Union has its own standards brands must comply with. There is no global infant formula standard. And sometimes, that leads to death and illness in our most vulnerable.
The China Infant Formula Catastrophe
In 2008, the China infant formula incident shook the nation. It was revealed that several Chinese companies had intentionally adulterated their infant formula products with melamine, a chemical compound used in the production of plastics. This unscrupulous act was employed to fool protein content tests, ultimately resulting in severe health consequences for thousands of infants across China. Melamine-contaminated formula led to urinary system problems such as kidney stones, with many infants suffering from acute kidney failure. It proved to be a devastating ordeal for affected families, and the incident exposed significant flaws in China's food safety regulations and oversight.
The incident had a profound impact on consumer confidence in domestically produced formula brands. Parents, understandably concerned about the safety and quality of these products, turned to alternative options to ensure the well-being of their infants. Alongside this incident, reports of other quality-related issues associated with Chinese brands further eroded trust.
Chinese parents began seeking safer alternatives for their infants, leading to a surge in the uptake of overseas formula brands. International brands, known for their stringent quality control measures and established reputations, gained prominence and became highly sought-after options.
Parents were attracted to the perceived safety and reliability of overseas brands, as they underwent rigorous testing procedures and adhered to tighter food safety regulations. Brands hailing from countries with robust food safety systems, such as Australia, Germany, and the Netherlands, quickly gained popularity among Chinese consumers.
The shift towards overseas formula brands had a significant impact on the Chinese market. Local manufacturers, grappling with the aftermath of the China infant formula incident, faced an uphill battle in restoring consumer trust. Realizing the need to regain confidence, these companies undertook extensive efforts to upgrade their manufacturing processes, improve quality control and try to convince parents to once again buy local products.
The Recent Shortages of Infant Formula in the US
The United States, like many countries, has been facing a shortage of infant formula in recent times. This scarcity has raised alarms among parents, caregivers, and health professionals nationwide. Understanding the causes and potential implications of these shortages is crucial in order to protect the well-being of our youngest and most vulnerable members of society.
The primary cause of the current shortages can be attributed to a combination of factors. One key factor is the disruption to global supply chains caused by the ongoing COVID-19 pandemic. These disruptions have affected various industries, including the production and distribution of infant formula. Manufacturers have encountered challenges in sourcing raw materials, such as dairy and soy products, as well as packaging materials, resulting in delays and reduced availability of formula products.
Compounding the issue, panic-buying and stockpiling by consumers have exacerbated the shortages. As news of the formula scarcity spread, concerned parents rushed to stores to secure supplies, leading to empty shelves and further exacerbating the problem for those in need.
The shortage of infant formula poses significant challenges for families across the country. Parents and caregivers are left grappling with limited options, potentially resorting to less desirable alternatives or struggling to find suitable alternatives altogether. This scarcity disproportionately affects low-income families who may struggle to access affordable formula or seek assistance through government support programs. A Special Supplemental Nutrition Program for Women, Infants, and Children--commonly known as WIC--is the largest purchaser of infant formula in the United States. Each State awards a sole-source contract to a formula manufacturer to provide its product to WIC participants. As a result, WIC participants can only redeem their WIC voucher for formula made by the manufacturer that holds the contract for that State. In 2008, three manufacturers accounted for almost 98 percent of all U.S. formula sales: Abbott, the manufacturer of Similac, had a 43-percent share of the market; Mead Johnson, maker of Enfamil, 40 percent; and Nestlé (now Gerber), maker of Good Start, 15 percent. Since the mid-1990s, these three firms have been the sole infant formula manufacturers awarded WIC contracts.
In early 2023, following the largest recall of infant formula for several decades, one of the largest formula production plants in the US was closed due to contamination. The US government has launched a criminal investigation against Abbott Laboratories. The FDA investigated reports that as many as nine children had died after consuming formula from the facility. Although unable to directly link the deaths to the plant, unsanitary conditions were found as well as bacteria that can potentially cause deadly infections in babies. Abbott has said its products and the bacteria have not been directly linked to the infections that killed the infants.
Why nobody talks about the risks of infant formula
You have probably been told about the benefits of breastfeeding. You can probably even list a few. There's that whole "breast is best" business.
Have you ever really considered what this means? If breastfeeding is natural, biologically designed and a natural progression after pregnancy and birth, why do we speak of it as beneficial? Shouldn't we just speak about breastfeeding as the normal way human babies are fed? How is it beneficial to just do what humans and other mammals are designed to do?
It all goes back to the adaptation of cow's milk to be more acceptable to the human digestive system. Cow's milk is perfect for baby cows but it needs modification to be tolerated by a baby's gut. And it needs additives to meet nutritional requirements. The same goes for goat's milk and milk alternatives made from soy beans. They can do an adequate job if modified.
However, last century formula manufacturers started to make all sorts of claims about formula in their marketing. So much so, people began to think of infant formula as superior to human milk and even safer! This marketing was done using some dubious tactics, like dressing sales people as nurses and sending them into hospitals and communities. They were even generous enough to give out free samples and merchandise to doctors and other health professionals.
Breastfeeding rates plummeted after World War Two. Pregnancy, birth and child care were medicalised and housewives were expected to keep homes germ-free. Chubby babies were seen to be healthy and formula plus solids as early as two weeks made sure those babies were Chubby!
By the 1970s, breastfeeding was almost extinct in the western world and severely under threat in developing countries. Formula brands had turned to populations in India, Africa, South America and Asia using the same advertising tactics. Only mothers in these countries lacked the money, water, fuel and facilities to safely formula feed. Their babies weren't chubby like those pictured on the billboards - their babies were sick and dying.
Globally, babies needed to be breastfed. More and more evidence showed that adults who were formula fed as babies were more likely to experience the chronic health conditions of middle age: diabetes, heart disease, obesity. Those Chubby babies had reached adulthood with more allergies, more asthma, more risks. But long before adulthood, not being breastfed meant higher risk of the conditions which put babies in hospital: respiratory and gastrointestinal infections.
Breastfeeding began to be promoted as a public health issue. Really, communities needed to be cautioned against using infant formula and protected from marketing tactics. The World Health Organization released a code of marketing for breastmilk substitutes, covering not only formula but infant foods like cereals and baby foods. In some parts of the world, this code became law. In others it was a voluntary agreement. In places like the USA, it was refused altogether.
The risks of not breastfeeding plus the risks of using formula in place of breastmilk are confronting. Telling people the risks associated with a product they feel they have no choice about using is very different to other health messages.
Skills in breastfeeding management declined alongside breastfeeding rates. Doctors and nurses were influenced by misinformation from the past and mothers were not given the right support. Without informed, skilled support women cannot always overcome breastfeeding challenges.
Recommendations aabout infant feeding are intentionally gentle. After every sentence stating "breastfeeding is the best start for your baby" comes the reassuring "but not all mothers can breastfeed". Rather than saying "formula fed babies have a higher risk of ..... "parents are told breastfed babies have a lower risk". Rarely does anyone ask "lower than who?"
This is in stark contrast to other areas of caring for babies: the blatant and sometimes terrifying cautions against co-sleeping would never be permitted to warn against introducing infant formula.
Each year, there are about 3,400 sudden unexpected infant deaths (SUID) in the United States. These deaths occur among infants less than 1 year old and have no immediately obvious cause.
The three commonly reported types of SUID include the following:
In 2020, there were about 1,389 deaths due to SIDS, about 1,062 deaths due to unknown causes, and about 905 deaths due to accidental suffocation and strangulation in bed.
Breastfeeding is one of the most effective ways to ensure child health and survival. If breastfeeding were scaled up to near universal levels, about 820 000 child lives would be saved every year (1). Globally, only 40% of infants under six months of age are exclusively breastfed.
Breast is best?
It's often quoted but exactly where does the Breast Is Best message come from? Is older than you might think!
If you have read A Time Line of Horrors: the History of Sleep Training then this might seem vaguely familiar. Frederick Truby King first stated that “Breast Is Best” but then went to great lengths to promote his techniques for “humanised” cows milk which he expected all babies to be weaned onto inevitably as mothers milk supply would fail. (Mothers following his rigidly strict schedules would certainly see their milk production plummet!)
In 1978, British authors Penny and Andrew Stanley wrote a book of this title, which went on to become a bestseller. At that time, breastfeeding rates in the UK - and most western countries - were so low that breastfed babies were the minority. Heavy marketing of formula had convinced people that bottle feeding was better and support to breastfeed was at an all-time low. In that context, the message Breast Is Best was necessary to increase awareness of why breastfeeding matters. Sadly, breastfeeding rates continue to be low in Britain.
“The UK and Ireland regularly battle it out for the dubious honour of having the lowest breastfeeding rates in the entire world. This isn’t to be mixed up with intention; we have plenty of women who really want to breastfeed. But their hopes and dreams for feeding and caring for their baby in a certain way seem to get rapidly dashed. During pregnancy women are urged to breastfeed and probably told ‘breast is best’ (I hate that phrase, more on that later) but after the birth they find that support, possibly from the health service, partners, family, workplaces and society in general just isn’t there or is even actively working against their intention. They end up with complications, confused about what to do, or simply finding it all too much, and end up stopping, often before they are ready. In fact, at least 80% of mothers who stop breastfeeding in the first six weeks are not ready to do so.”
Breast is no longer best: promoting normal infant feeding
Breastfeeding is not 'best', say Nina Berry and Dr Karleen Gribble, authors of the 2008 report of the same name - it is simply the normal way to feed human infants.
The report suggested that breastfeeding promotion and education programs should abandon the ‘breast is best’ message because it is misleading and fails to communicate the importance of breastfeeding. In fact, they may have done the opposite. By talking about the benefits of breastfeeding, we are presenting infant formula as the standard. Really, there are proven risks associated with using breastmilk substitutes, which parents have a right to know about as part of the decision making process.
Parents are encouraged to set the global recommendations as their own goals, yet are not given the resources need to reach them:
“It takes a great deal of support for mothers to reach these goals. However, mothers are not being provided with adequate support because the risks associated with early introduction of foods other than human milk are not well understood by health professionals. Furthermore, many health professionals are reluctant to talk to mothers about risks because they do not want to make mothers feel guilty. This is not about guilt. It is about a mother’s right to have all the information she needs to make an informed choice about how she should feed her baby – it is about ensuring that mothers have the support they need,” Ms Berry said.
By normalising breastmilk and increasing awareness of risks of premature weaning, we allow parents to truly make informed choices.
Breast is Best is now a marketing message
If breastfeeding advocates have moved away from the Breast Is Best slogan, why is it still out there?
Because it is part of the message used to promote infant formula! The one consistent place to see the variations on the message “Breastmilk Is Best” is in the fine print on formula packaging and marketing materials!
Nowhere is this more apparent than in the US, one only six countries worldwide who do not support the World Health Organization International Code of Marketing Breastmilk Substitutes, commonly referred to as the WHO Code. Without the Code to regulate them, formula companies use the full extent of media to sell their products, each with that little reminder about breastmilk being best.
“We learned from the best … so we could give you and your baby the best. Nothing else is breastmilk. Nothing else is (product name)”
“(Brand) recommends breastmilk as the best start for babies”
“Breastmilk is best. Ask your doctor”
The one consistent word in all is … BEST!
In response to criticism of their involvement in a Canadian panel about the child’s first 1,000 days, one formula brand was quick to respond:
“At (brand) we firmly believe breast milk is the best nutrition for infants….”
In the US, promotion of infant formula begins almost at conception – with targeted marketing strategies not only in the media, but sent directly to the family home. Once the baby arrives, hospitals hand out full-sized samples, with more likely to be on your doorstep when you take your baby home!
Jennie shares her experience:
“It was Spring in upstate New York in 2008 when I walked into the local Maternity Store. I was 8 weeks pregnant, and like most first time mums, I was excited to get my first maternity clothes. Checking out, the cashier asked me for my contact details – email, phone, mail – so they could send me coupons. Discount clothing? Score!
2 weeks later, I found a package at my front doorstep. Inside that box was the start of a flood, two full sized cans of formula and a packet of coupons for that same formula. I was 10 weeks pregnant. At 11 weeks I received another package, this time it was two full cans of the competitions formula, with coupons. I now had four full size cans. The deluge continued, with letters containing small sachets of formula, to small bottles of ready mix.
In hospital, the day of discharge with my daughter, we had breastfed fine. No problems – she was a natural. The nurse came in with my papers and said to me “If we write on your chart you are mix feeding you get a free bag.” In the bag? 2 bottles of ready mix, and a full can of formula. Not a jot about breastfeeding. When my daughter was 6 weeks old I got ill and had to bottle feed breast milk for 4 days due to medication. One night, after much screaming that she couldn’t get it from the source, I gave up and warmed a bottle of that ready mix.
I am thankful every single day that she refused to take it”.
When you know better, you do better
In parts of Europe, big changes are happening in hospitals around the care and support of babies and their families
Recently released on iTunes, the American documentary The Milky Way explores some of the barriers to breastfeeding in the US – and how these are being knocked out of the way in countries like Germany and Sweden.
The contrasts are stark:
· In Sweden, mothers get 18 months paid maternity leave – in the US: none
· European hospitals are moving away from the current model of care for premature babies, instead accommodating babies AND their parents together for the duration of the infants stay and using skin to skin contact to replace high-tech incubators.
· One German hospital sends new mothers home with ten weeks access to in-home midwife support to ensure they reach their breastfeeding goals.
· While in the US, breastfeeding mothers are bombarded with formula samples and advertising, in Sweden one company has its products removed from sale for six months as punishment for not abiding by the WHO Code.
When we truly support women to breastfeed, women will breastfeed.
Right now there is something we can do to protect parents from insidious marketing and that is to ban it. If infants have a genuine need to be partly or fully formula fed then their doctor should be able to diagnose why and prescribe the formula. This should be available at cost price from pharmacies only and in plain packaging. All products associated with infant feeding should be fully regulated, from the milk powder itself through to the bottles used to feed it (the discrepancy and inaccuracy in measurement markings particularly puts at risk babies who require formula to be mixed accurately).
A study by Western Sydney University has found more than half of infant feeding bottles have inaccurate or missing markings, sparking calls for Australia and other countries to introduce and enforce industry standards for bottles to prevent formula fed babies from becoming ill.
The study published in the journal of Maternal and Child Nutrition reported that Adjunct Associate-Professor Karleen Gribble from the School of Nursing and Midwifery and her colleagues purchased the entire range of infant feeding bottles available for sale in Australia.
Alarmingly, the testers discovered 20% of bottles had at least one marking that was deemed so inaccurate that it would fail to meet the requirements of the European standard: the only existing standard for bottles in the world. Markings underestimated and overestimated actual volumes by as much as 43%. A 100ml measurement was actually only 60ml, in one case.
Additionally, 2/5 of the bottles were missing at least one marking for a volume that instructions for reconstituting infant formula require parents to measure. In total, 57% had either inaccurate or missing markings.
The World Health Organization Code on the Marketing Of Breastmilk Substitutes needs to be enshrined in law around the globe. Formula advocates often claim it is only relevant in low-income countries however the health impacts of infant formula usage do not discriminate. All babies have a birthright to their mother’s breastmilk - directly from the breast or expressed. Where that is not possible, donor breastmilk should be freely available through milk banks - as it already is in countries like Norway and Brazil. Only where an infant has no access to human milk should infant formula be considered.
