The Youngest Market: Baby Food Peddlers Undermine Breastfeeding

by Annelies Allain and Yeong Joo Kean.

Scientific evidence from hundreds of studies over the past 25 years confirms that breastfeeding — and especially exclusive breastfeeding during the first six months of a baby’s life — is the optimal way to nourish and nurture infants. Breastmilk contains all the essential nutrients babies need, as well as antibodies that counter infection. No infant formula made of cow’s milk, soy or other ingredients can ever equal this natural way of feeding.

Human milk decreases risks for a large number of acute and chronic diseases including respiratory infection and diarrhea — which kills 1.7 million babies and children under 5 each year, according to the India-based Rehydration Project. Breastfeeding supplies half the baby’s nutritional requirements between six and 12 months and up to one third between 12 and 24 months. Even in the most affluent conditions, where water is clean and mothers are highly educated, an artificially fed infant is more likely to suffer from respiratory illnesses, gastrointestinal infections and allergies.

Recognizing the severe health harms stemming from the use of breastmilk substitutes, public health campaigners starting in the 1970s began focusing on why mothers were giving substitutes instead of breastmilk to their babies. What stood out — and continues to stand out — is the role of baby food companies in convincing new mothers to use a nutritionally inferior product. A long, ongoing campaign to eliminate inappropriate marketing has ensued.

A watershed occurred in 1981, when the World Health Assembly (WHA) — the governing body of the World Health Organization (WHO) — adopted the International Code of Marketing of Breastmilk Substitutes as a “minimum” standard to help protect and promote breastfeeding in all countries. The Code’s preamble explains that “the marketing of breastmilk substitutes requires special treatment which makes usual marketing practices unsuitable for these products.” The Code provisions prohibit promotion of breastmilk substitutes, including: no promotion to the public, no gifts to mothers or healthcare workers, no promotion to healthcare workers or facilities, no free samples or supplies, adequate labels including clear information with no baby pictures, no promotion of complementary foods before they are needed, and food safety and quality.

Since its adoption, the Code has been reaffirmed by the WHA on at least 12 occasions and new resolutions with the same legal status as the Code have been adopted to clarify certain provisions and to attempt to keep up with changing products and practices.

Although companies are called upon to abide by these provisions independent of government action, they continue to bend and break the rules. The International Baby Food Action Network (IBFAN), based in Penang, Malaysia, monitors compliance with the Code. Based on information gathered in more than 65 countries, the latest IBFAN monitoring report shows that the world’s largest baby food companies are violating the Code, or stretching the restrictions of the Code, with abandon.

Gifts to Health Workers

The Code notwithstanding, perhaps the worst baby food marketing abuse — commercial promotion of breastmilk substitutes through the healthcare system — remains pervasive. This includes the distribution of so-called “information for health workers” — mostly blatant promotion for products, contrary to Code provisions which require such information to be factual and scientific. It also includes, in Azerbaijan, for example, direct payments to doctors for each baby formula product they prescribe. In many other countries, baby food companies distribute colorful prescription pads where doctors can recommend products by just checking a packshot — a photo of the baby formula package. There are also reports of direct payments to hospitals for distributing samples.

The baby food companies have become more sophisticated at targeting health professionals and their associations over the years. The companies are increasingly offering gifts, both small and large, to health professionals (pens, prescription pads, diaries, calendars, website design, measuring tapes, thermometers, watches and chances to win money) as well as to healthcare facilities (posters, clocks, sign boards, incubators, water coolers, baby scales and covers). Most if not all of such gifts carry the name of a manufacturer or a brand of infant foods on them; quite a few also carry advertising slogans.

Manufacturers of infant foods frequently sponsor conferences, seminars and training sessions for pediatricians, nurses, midwives and nutritionists. They often subsidize individual health workers to attend “educational” events at fancy hotels or holiday resorts. There is increasing recognition, however, that “manipulation by association” does occur, and in 2007 the International Pediatric Association publicly reaffirmed its own guidelines that specifically prohibit endorsement and sponsorship from companies covered by the Code.

Blédina, owned by the French company Danone, is one brand that distributes prescription pads showing packshots and promotional text. These appear to violate a basic tenet of the Code, which prohibits promotion in healthcare facilities. They undermine the obligation of health workers to encourage breastfeeding and confer valuable medical endorsement on products. In the Middle East, some of the prescription pads have English on one side, and Arabic on the reverse. Both show colorful packshots. Blédina could not be reached for comment.

Heinz distributes to Chinese hospitals a nutritional guide for children 0-2 years entitled “A Good Start.” The guide wrongly claims that breastmilk does not meet the nutritional requirements of babies from four months. One of Heinz’s baby formula brands, Farley, distributed to hospitals in the United Arab Emirates a different booklet — “Farley’s Guide to Weaning” — with the slogan, “From baby’s solid food to family meals.” The guide wrongly advises that “all babies can be offered cooled, boiled water from birth if they seem thirsty.” Health campaigners say both booklets not only violate the International Code, which only allows factual and scientific product information to be distributed to health professionals, but also violate Heinz’s own Global Code of Conduct, which requires that “all communications must be honest, truthful and not misleading.”

“The information provided in China is accurate and never states that breastmilk does not meet the nutritional requirements of babies,” says Michael Mullen, director of corporate affairs for Heinz. “Heinz places the health and well being of infants and young children first at all times. Heinz will always comply with local legislation, or the WHO Code if a country has no local legislation, in all the countries in which it sells directly or to which it exports infant formula. Heinz fully supports the WHO advice that breastfeeding is the best form of nutrition for babies.”

The German company Humana violates the Code section that prohibits financial or material inducement for healthcare providers to promote products. In Azerbaijan, Humana offers doctors a 5 percent commission for every Humana product — such as its early infant formula or “Baby-fit 1” formula — they prescribe on a preprinted form. Humana did not respond to requests for comment.

More than any other baby food company in the Middle East, Wyeth uses doctors to help them get through to mothers. A multitude of Wyeth prescription pads are in circulation in health facilities in the United Arab Emirates and Saudi Arabia. Promotional messages on writing pads include “Now closer than ever to breastmilk,” and “The first and only infant formula with a protein profile similar to breastmilk.” Tear-off prescription leaflets are provided, displaying Wyeth’s range of formulas, which include S-26, Promil and SMA, with check boxes next to product packshots. Wyeth did not respond to requests for comment.

Promoting to Parents   

The baby food companies frequently promote breastmilk substitutes directly to consumers, in violation of another key section of the Code. A growing trend in “mother care” booklets — available in pharmacies and at baby fairs and sometimes handed to mothers by staff before or after delivery — is the use of scare tactics under the guise of warnings about babies’ potential allergies, colic, reflux, constipation or vomiting. The promotional material, portrayed as educational, emphasizes such problems and almost always points to specific products as the solution. None of the materials stress the fact that most babies, if breastfed from birth, are much less prone to such “feeding problems.”

In supermarkets, companies employ special displays, brightly colored signs, offers of gifts and toys, discounts and coupons. Some shops, especially in Eastern Europe, even allow special sales staff to promote a particular formula or other breastmilk substitute.

Manufacturer websites commonly offer advice on infant feeding, child rearing and health issues. While some offer helpful tips, most of them use information about breastfeeding as an immediate jump to the second-best product. Openly or surreptitiously, most commercial websites promote products, often with inducements such as discounts, coupons and free gifts. While the Code prohibits companies from contacting mothers directly, hotlines and websites entice mothers to contact them instead, with the promise of attractive gifts and prizes.

In one opportunistic marketing campaign after the war in Lebanon in 2006, Danone’s Blédina assigned a pediatrician to check on sick babies at a health center while sales promoters offered mothers Blédina gift packages containing promotional leaflets. Mothers also received a card with the Blédina hotline from the attending pediatrician. In another post-war promotional activity, free Blédina gift packages were distributed at a health center with a high number of refugees.

In the Netherlands, where Friesland has its headquarters and where the European Union Directive on baby food marketing stops short of prohibiting the promotion of follow-on formula, the company aims to get mothers who are breastfeeding to start bottle feeding. After submitting a coupon, mothers receive a letter from Friesland, the maker of Friso formula, containing information on switching from breastfeeding to infant formula. The company poses the provocative question: “Is breastfeeding going well, or would you like to switch to infant formula?” In addition to the informational materials, mothers also receive a baby suit with the name of their child and the Friso 1 brand name printed on it.

In China, where millions of parents cannot afford premium-priced baby food products, Heinz has introduced a lower-cost version of cereal products. Promotional material by Heinz in China is imprinted with the logo of the Chinese Child Nutrition and Health Research Center, bearing the slogan “Brand of first choice.” Such product endorsement is incompatible with the Code, as health workers, and by extension the institutes they work for, are required to encourage breastfeeding.

Hipp has cannily tapped into the growing fad in Europe for organic products by marketing its products with the catch-phrase, “with bio organic ingredients,” and turning the phrase into a product logo synonymous with quality for Hipp products. The company motto is, “The best nature has to offer, the best for nature,” but it implicitly discredits natural breastfeeding by offering its products as “the best food for your baby right from the start.” The Food Commission in the UK found that Hipp biscuits have more sugar (21 percent) than a jam doughnut (19 percent), even though the biscuits are labeled “sugar reduced.”

Discouraging breastfeeding in Lebanon, the label of a Hipp infant formula states, “Hipp 1 probiotic starter infant formula is close to the composition of breastmilk and provides your baby from birth onwards with all important vitamins, minerals and nutritional substances.”

At a baby fair in the Netherlands, Mead Johnson, the maker of Enfalac, Enfamil and Enfapro formulas, promotes its products by offering parents Enfa gift bags filled with promotional materials on its products. Question-and-answer booklets provided to parents advise mothers with colicky babies to “stop breastfeeding for a few days” and give the baby Mead Johnson’s Pregestimil formula to find out if the child has any allergies.

In the UK, Wyeth sends an SMA-branded “Newborn Know How” video to mothers if they respond to a magazine advertisement or register via the company hotline. The video indicates that breast is best but emphasizes negative reactions from mothers like, “It seemed I was destined to feed her for the next two years,” “Actual feeding of her was pretty much a disaster” and “What you don’t expect is the crying in between.” The video asserts that if mothers want to bottle feed, their babies will thrive as well as a breastfed baby, but no information is given about the risks of formula feeding. There is even a suggestion that bottle feeding is better than breastfeeding, as it allows mothers to measure the amount of food given to their child.

Misleading Marketing

Baby food companies are making ever more strident functional claims in ads and on labels. The health and nutrition claims now made by manufacturers cleverly give the impression that their products are the same or even better than breastmilk, the traditional gold standard. Each new ad or claim tries to outdo “ordinary” formula and breastfeeding in some way. Some of the promotions give the deceptive impression that the new ingredients are necessary additions to the natural product — breastmilk.

Selling intelligence is also extremely effective. There is great stress on brain development of the baby, banking on the natural desire of parents to see their children grow up intelligent, and implying that without the company’s product the child will not succeed. Countless labels carry drawings of babies or toy animals with graduation mortarboards, promising success in school. There are beautiful ads with tiny tots hammering away at laptops, impressing parents with intelligence available from a tin.

Any mother who sees these labels, or reads the leaflets and advertisements for the new “gold” formulas would be forgiven for believing that they are the best she can give to her baby.

In Australia, an aggressive campaign for the Novalac range of formula products — sold by the German company Bayer AG — paints normal infant behavior as problematic. Novalac markets a product that it calls “unique in the infant formula market” — Novalac Sweet Dreams. This formula is supposedly designed to provide a feeling of fullness for infants who wake often due to hunger. Novalac ads describe the normal conditions of “hungry” and “growing” as “feeding problems that need to be put to bed.” Health workers and breastfeeding groups in Australia denounced the Novalac campaign in conjunction with a parliamentary inquiry on obstacles to breastfeeding. The “put feeding problems to bed” was a common theme in numerous pamphlets and flyers available in pharmacies in Australia and South Africa. Bayer did not respond to requests for comment.

Banking on parents’ desires for their children to do well academically, Mead Johnson’s Enfamil packaging and promotional materials are filled with “A+” symbols and drawings of baby owls wearing mortarboards. The U.S. Enfamil website claims that Enfamil LIPIL “has been shown to promote eye and brain development” and that “infants who were breastfed for six weeks or four to six months and then weaned to Enfamil LIPIL experienced improvements in visual acuity at 12 months of age.” Comparisons are drawn with breastmilk, suggesting that Enfamil LIPIL is equivalent.

In May 2006, the U.S. Food and Drug Administration (FDA) rejected an attempt by Nestlé USA to put a claim on Good Start Supreme infant formulas that would have implied that the product reduces the risk of some food allergy symptoms. Nestlé could not provide evidence for such a claim.

That ruling didn’t stop Nestlé from making those claims in other countries, however. A line of brochures distributed in the Middle East is cleverly designed to convince the medical profession that its formula is “the modern way of allergy prevention,” while charts and diagrams claim that active allergy prevention is justified “for all infants.”

In the Philippines, Nestlé’s Nestogen 1 infant formula with iron is marketed in 180 gram packs with the DHA logo (an omega-3 essential fatty acid). The marketing claims assert that the formula has DHA and more calcium, which function as “brain building blocks” and “bone builders.” 

However, when pressed, Pedro Dy-Liacco, the Nestlé Philippines communications and marketing services director, says, “There is certainly no scientific evidence that demonstrates IQ improvement with drinking a certain milk. What is known is that IQ is mainly influenced by genetics, the right stimulation of the child in his or her upbringing and proper nutrition.”

Making Progress

Spurred by the high profits from sales of infant formula, follow-on formula, complementary foods and feeding equipment, baby food companies continue to deliberately ignore World Health Organization standards so as to compete intensely with one another and with breastfeeding.

For all of the ongoing problems, however, some countries have shown the political will to end harmful marketing practices. Brazil and Bangladesh successfully outlawed the promotional Gerber baby face, and in Tanzania, law enforcement forced Nestlé to remove its new logo of a mother bird feeding its chicks. Advocates hope examples like these will prompt other governments to actively enforce their laws to crack down on labels that are promotional or give misleading information.

Annelies Allain is co-founder of the International Baby Food Action Network (IBFAN). Yeong Joo Kean is a legal advisor at IBFAN. This article is based their latest report “Breaking the Rules, Stretching the Rules 2007.”