The debate around formula marketing

The debate around baby formula is polarised – but has it resulted in making some women avoiding formula when its benefits over breast feeding might be clear-cut?

Companies selling formula are engaging in “predatory” marketing, knowingly obfuscating information — and even deliberately spreading misinformation — about the benefits of formula in order to undermine breastfeeding.

But the science also says that there are situations where people have to – or ought to – use baby formula.

Baby formula is big bucks: globally, it’s an $80bn (US$55 billion) market every year, of which about $4.3 billion (US$3 billion) a year is spent on marketing. This hyper focus on marketing is why fewer than half of infants under six months are exclusively breastfed, according to the World Health Organization’s best practice guidelines.

The science also says that there are situations where people have to – or ought to – use baby formula.

An argument put forward by a group of researchers in a recent series in the respected British Medical Journal The Lancet, says that the global baby formula industry uses “exploitative” marketing, including claiming that their products can alleviate fussiness and colic, improve sleep and increase a child’s intelligence in order to dupe women into giving up breastfeeding.

Lead author Dr Phil Baker, from Deakin University’s Institute for Physical Activity and Nutrition,says The Lancet papers are not about “stigmatising mothers and blaming parents about the decisions they make”, but about the systemic “violations of basic rights … such as the right to accurate and fact-based information”.

“All women have a right to maternity protection which enables them to breastfeed,” he says. This includes access to adequate paid maternity leave, which signals that a society values a woman’s time and the effort to raise, nurture and nourish a child.

“Mums and babies are especially vulnerable at this time … and a lot of anxiety comes with not doing the right thing,” Baker tells Cosmos Weekly. “The industry knows this stigma and shame very well, and they prey on these anxieties to market their products.”

“The [formula] industry knows this stigma and shame very well, and they prey on these anxieties to market their products.”

Baker says typical infant behaviours such as crying, fussiness and poor night-time sleep are portrayed by the formula industry as pathological and framed as reasons to introduce formula, when in fact these behaviours are common and developmentally appropriate.

Many other studies support The Lancet’s views, such as a recent British Medical Journal study that evaluated 757 infant formula products and concluded: “referenced claims were not supported by robust clinical trial evidence”.

But because Australia is one of only a few countries in the world that has not implemented the WHO International Code of Marketing of Breastmilk Substitutes into national law (adopted in 1981) — choosing instead to have a voluntary code of conduct of self-regulation — the authors say it remains one of the most vulnerable countries to baby formula marketing manipulation.

Australia remains one of the most vulnerable countries to formula marketing manipulation.

While more than 95% of Australian children under three received breast milk in the last financial year, just one in three (35.4%) were exclusively breastfed to six months.

Baker says that social and economic factors such as inequitable maternity policies; an under-appreciation of the time and effort it takes to care for a child; and the anxiety that parents, especially mothers, feel at this time in their lives, are exploited by the formula industry.

“There are huge structural barriers to breastfeeding in Australia. Just compare that to our neighbour New Zealand, where you can take 26 weeks parental leave and really have the time to breastfeed for longer”.

“Consider what this says about what and who we value as a society. By not providing these resources for mothers we are saying what they do is not important or valuable, and that is deeply unfair.” 

Not all researchers agree that baby formula is bad

Dr Amy Tuteur, an obstetrician gynaecologist and former clinical instructor at Harvard Medical School, has dedicated much of her career discussing breastfeeding and formula claims on her website, The Skeptical OB.

“I went to medical school in the early 80s and had my first child in 1987, and back then breast milk was not liquid gold, it was just food,” she says.

Tuteur says the global push for breastfeeding began as a reaction against the multinational food and drink processing corporation Nestlé, which, in the early 1970s, was accused of causing illness and infant deaths in poor communities in developing countries by promoting their infant formula products at the expense of breastfeeding.

“Breast milk was not liquid gold, it was just food.”

Dr Amy Tuteur

“Everything goes back to the time when Nestle tried to get women in Africa to formula feed with dirty water,” Tuteur says. “They did a terrible thing, and in an effort to punish them, people began to make all sorts of claims about breastfeeding that, at first, they had no data for.”

While there is a lot of research which seems to show that breastfeeding reduces childhood infectious diseases, mortality, malnutrition and the risk of later obesity, and that mothers who breastfeed have decreased risk of breast and ovarian cancers, type 2 diabetes, and cardiovascular disease, Tuteur says most of those benefits disappear when maternal socio-economic status is taken into account.

Breastfeeding in industrialised countries is socially patterned; better educated, wealthier women are more likely to breastfeed. The purported benefits of breastfeeding are actually benefits of higher socio-economic status, she says.

“They did a terrible thing, and in an effort to punish them, people began to make all sorts of claims about breastfeeding that, at first, they had no data for.”

Dr Amy Tutuer

“I remember a paper about an African tribe that had a 100% breastfeeding rate, but because the women didn’t breastfeed immediately after birth they were deemed as doing it wrong,” she says. “Activists have fabricated requirements that are so rigid that even African women who breastfeed for years can’t meet them.”

She cites another example of the Himba, an ethnic group that lives in the desert of northern Namibia, which has also been revered for its breastfeeding practices, but “whose astronomical infant mortality rate, despite all the breastfeeding, has been ignored”.

Tuteur believes that many breastfeeding advocates obfuscate or ignore the benefits of baby formula, such as in the instances where breastmilk does not come in (about 18% of all women), or the normalising of infants losing 10% of their body weight after birth as a result of breast milk coming in late.

The Lancet articles touch on this: “Perceived pressure, or inability, to breastfeed – especially if it is at odds with a mother’s wishes – can have a detrimental effect on mental health, and systems should be in place to fully support all mothers in their choices.”

But Tuteur says despite the knowledge that there are benefits to using formula, there remains for many people a reluctance to use it when appropriate.

“In the US, the leading cause of newborn readmission is not enough breast milk. It is crazy to me that we prioritise the act of breastfeeding over actually feeding an infant.” 

“It is crazy to me that we prioritise the act of breastfeeding over actually feeding an infant.”

Dr Amy Tuteur

In Australia, one 2022 study that looked at four New South Wales hospitals found the majority of readmissions of infants to hospital are feeding‐related (72.9%), while another 2018 study found that babies who got a small amount of formula after each breastfeeding, until the mother’s milk was fully in, compared to those who didn’t, were less likely to be readmitted to hospital, and no less likely to be breastfeeding a month out.

Dr Sue Ieraci, an Australian doctor and emergency specialist with more than three decades’ experience in the public hospital system, says that while formula companies make “false claims about benefits of formula, so do breast milk proponents”.

“[While formula companies make] false claims about benefits of formula, so do breast milk proponents.”

Dr Sue Ieraci

“There are definitely dangers from use of formula in impoverished communities – where there are no guarantees of clean water and where poverty leads to dilution, which leads to malnutrition,” she tells Cosmos.  “Having said that, women who are malnourished also pass deficiencies in their breast milk – notably low iron – which undiluted formula does not cause.”

While the Lancet article does take socioeconomic status into account, Ieraci points out that many studies don’t control for this,  and she points to breastfeeding advocacy and support organisation La Leche League’s claims as an example.

“The references for their claims are old and weak, and none of them control for SES, which is a very strong determinant of health status, and also correlates with breastfeeding rates and duration (because more privileged women have more agency to start and continue breastfeeding),” Ieraci explains.

“There is also lots of propaganda about breastfeeding relating to ‘bonding’ and a range of purported outcome benefits that are not based on good evidence.”