The International Code of Marketing Breast-Milk Substitutes and subsequent, relevant World Health Assembly resolutions are a starting point for the consideration of ethics in the world of infant feeding. There is a surfeit of misleading marketing of breast-milk substitutes to parents who are often information hungry, unclear about the differences between breastfeeding and infant formula feeding, hoping to find the ‘best’ product for their babies, or thinking that they need to purchase the most expensive products. At the same time we read simplistic under-researched media stories that perpetuate the fantasy that breast-milk can be replicated and breastfeeding replaced. This dominant milieu influences the general public who may have limited awareness of marketing tricks. Because prime marketing strategy involves forming health alliances it is essential that health workers have a clear understanding of the issues of conflict of interest, endorsement by association and the importance of breastfeeding. It is also essential that they become sources of unbiased commercial-free information for parents on all aspects of infant feeding.
Key words: International Code, Breastfeeding, Breast-Milk Substitutes, Infant feeding, Infant formula, Marketing, Conflict of interest, Health workers, Price placebo, Puffery
We regularly see media releases heralding the scientific discovery of yet more amazing components in breast milk but most of the scientists quoted, if media reports are to be believed, appear to see their latest discoveries as a way to develop ingredients to add to cow’s milk formulas to make them closer to breast milk (Medical Xpress 2013). Regardless of this science fiction fantasy, because it is indeed a fairy story, the media perpetuate the news stories, usually without a balanced perspective, and industry continue to make misleading claims about their products already on the market. As all infant formula products are required to meet legislated criteria regarding ingredients, the nutritional composition of the majority of products is exactly the same. Kevin Frick notes that companies use substantial resources to differentiate themselves from each other for the purpose of competition. This monopolistic competitive quest for parental attention, which is inappropriate due to the vulnerability of infants and the critical importance of what they are fed, results in a market not operating efficiently to provide goods at minimum cost, with the benefits to infants of this broad range of products being unclear (Frick 2009). The International Code of Marketing Breast-Milk Substitutes (World Health Organisation 1981), and subsequent, relevant World Health Assembly resolutions provide the framework necessary to control misleading health and nutrition claims but the majority of countries do not have regulations or legislation in place to enforce the Code. Instead many allow industry to write, monitor and enforce their own voluntary codes of practice.
The International Code of Marketing Breast-Milk Substitutes is a set of recommendations from the collective membership of an international body in the field of health, the World Health Assembly. It does not ban the sale or use of breast-milk substitutes, or any particular company’s products, but instead it is directed at unethical marketing practices, and false and misleading advertising. The Code is also clear that there are legitimate reasons for using breast-milk substitutes, and it is concerned that parents who use breast-milk substitutes have access to accurate, safe and unbiased information. The International Code always needs to be considered alongside the subsequent, relevant World Health Assembly (WHA) Resolutions as they keep the Code, which was written in 1981, up to date. In 2010 a WHA resolution item,11.6, called for an end to the inappropriate promotion of food for infants and young children and highlighted the need to ensure that nutrition and health claims shall not be permitted for foods for infants and young children (Baby Milk Action 2010; World Health Assembly 2010).
The vulnerability of infants in the early months of life and the risks involved in inappropriate feeding practices underpins the International Code and this is described in the preamble to the Code. It is this infant vulnerability which makes the usual marketing practices we are exposed to relentlessly in our everyday 21st century lives, unsuitable for breast-milk substitutes.
There are a range of marketing messages tailored to appeal to parents with claims about immune system development support, beneficial gut flora support, brain development and abilities to solve infant feeding problems. However, robust independent scientific evidence for the efficacy of added novel functional ingredients is limited and unclear (Ackerberg 2012; Schulzke et al 2011; Simmer et al 2011; Starling 2010; Vy 2002; Yau 2003). A parent, Roberta, who is a Momsrising member, posted about what she termed “New Parent Infant Formula Selection Paralysis” (Farber 2010).
“The few times I had to buy formula for my son, I was paralyzed by the wall of options in the grocery store. Each brand made a different claim about what their formula would do for my son’s health, and the more claims there were, the more expensive the can. Even my son’s paediatrician couldn’t recommend a choice”.
In marketing there is a phenomenon called price placebo which is based on consumers believing that if they pay more for a product then it means it must be a better product. So at the same time parents using breast-milk substitutes are trying to decide which product to buy for their babies they are not only influenced by health and nutrition claims but by price, and they are likely to buy the high-price-high-claim products. Some parents who find it hard to afford the breast-milk substitutes for their infants, have been found to practice what is referred to as ‘formula-stretching’ which involves reducing feed amounts/times and/or watering down feeds. Formula stretching practices are associated with serious short and long-term consequences such as failure to thrive and developmental deficits (Burkhardt et al 2012). Burkhardt et al also found that 58% of the urban parents in their study would not use the cheaper generic formulas, and 50% believed that generic formulas and brand name formulas were not equivalent. The reason for this is simple – marketing.
The aim of commercial marketing is to eliminate choice or to establish a strong bias towards only one choice, rather than to increase the choices for consumers (Heinig 2006). The ultimate aim being to increase profits for your shareholders by giving consumers the impression that they need your product, and in the case of breast-milk substitutes, that parent consumers need to continue to use product for longer than recommended by global infant feeding guidelines.
Berry et al in Australia, found that toddler milks function as indirect advertising for other breast-milk substitute products such as those marketed for infants below six months –stage one – and those marketed for above six months to one year – follow-on products (Berry et al 2010). Neither the follow-on, nor the toddler products are necessary, as infants can continue up to one year on the ‘from birth’ products and after one year infant formulas are not needed as cow’s milk is considered appropriate for the majority of toddlers.
The reach of marketing has expanded significantly with the explosion of social media and sites such as Facebook and YouTube. Abrahams found that out of the eleven brands she examined, eight had Facebook pages and five a YouTube presence (Abrahams 2012). This is significant because of the reach of social media but also because of the difficulties in both monitoring and regulating this relentless marketing.
Parents buying breast-milk substitute products making health and nutrition claims are being exposed to what could be termed a form of puffery. Puffery on consumer products is recognized and accepted by industry, regulators and consumers and is described as being about the legitimate and harmless exaggeration of advertising claims to overcome natural consumer scepticism and to make a product look better than those of the competing brands. Because the claims in ‘puffery’ are described as being vague and subjective, they are not believed to be misleading to most consumers. The assumption is that consumers expect advertisers to claim that their products are the best but that they will not believe this to be true (Adams & Maine 1998).
Winstanley & Cressey reported that parents taking part in a survey about the preparation of powdered infant formula in New Zealand were ‘information hungry’ and that the information on the infant formula tin seen was seen as ‘available, authoritative and trusted’. Although the report was primarily concerned with how parents were interpreting instructions and preparing feeds it did find that some parents avidly read about ingredients and the differences between brands. One parent considered the information on the tin as a ‘legal document written by experts’ and another stated that the ‘tins did not lie’ (Winstanley & Cressy 2008). As previously described, the Code preamble clearly states that the marketing of breast-milk substitutes requires special treatment, which makes the usual marketing practices unsuitable for these products, and the assumed ‘harmless exaggeration’ is unlikely to be harmless and is therefore totally inappropriate.
Health professionals need to know about the International Code and resolutions, but they also need to consider issues such as sponsorship, conflict of interest and endorsement by association. Conflict of interest is defined as a situation in which financial or other personal, employment or professional considerations have the potential to compromise or bias professional judgment and objectivity. The International Baby Food Action Network, in their position statement concerning sponsorship and conflict of interest, ‘call upon all health care workers, including health professionals and their associations, to avoid accepting any donations or funds, offers of assistance in cash or kind from companies with a commercial interest in infant and young child health and development, particularly in the feeding of babies’ (IBFAN).
Health professionals who work with parents, infants and young children need to know about all aspects of infant and young child feeding, understand the responsibility to protect breastfeeding, and also provide non-judgmental information about the use of breast-milk substitutes to parents who require this information. There is no dispute about the value of research which could lead to an improved breast-milk substitute. However, perpetuating mythology and making claims suggesting that breast milk, containing around 150 long chain polyunsaturated fatty acids, 130 oligosaccharides, lymphocytes, secretory IgA, lactoferrin, lysozyme, nucleotides, hormones, growth factors and the recently reported over 700 beneficial bacteria, just to name a few of the components of human, living, synergistic breast milk, can ever be replicated is pure science fiction. Unfortunately as explained by Lewandowsky et al, repeated exposure to a story or statement is known to increase its acceptance as ‘true’ (Lewandowsky et al 2012), so continued work is necessary to counter misleading media reports. Davies also highlights another ever increasing concern, ‘churnalism’. This is when journalists no longer gather news but instead passively process whatever material comes their way (Davies 2009). Hence we see inaccurate, unbalanced, under-researched stories echoed all around social media sites and the internet.
Learning more about the International Code and resolutions helps to keep the policy issues on infant and young child feeding alive internationally, and at national and local levels, and provides the understanding needed for health workers to become advocates and watchdogs in regards to breastfeeding protection, safe infant feeding and formula usage and appropriate marketing. It would be valuable for health workers involved with infant feeding to support breastfeeding protection and safe infant feeding advocacy work by reporting Code violations to the appropriate monitoring bodies, keeping up to date with what is happening in the world of breast-milk substitutes and countering inaccurate stories doing the rounds in the media. Each contribution is important for infant and young child health. As Martin Luther King Jr said, “You don’t have to see the whole staircase. Just take the first step”.
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