Tricks of the Infant Food Industry
By Naomi Baumslag, MD, MPH

If your lives were embittered as mine is, by seeing day after day this massacre of the innocents by unsuitable feeding, then I believe you would feel as I do that misguided propaganda on infant feeding should be regarded as murder. . . Anyone who, ignorantly or lightly, causes a baby to be fed on unsuitable milk, may be guilty of that child's death. —Dr. Cicely Williams, Milk and Murder, 1939

Cover image of The Baby Killer. Source: Andy Chetley, War on Want Report, United Kingdom, 1974. Photo courtesy: War on Want

The billion-dollar formula industry—two million dollars a day—is about money, not public health. Exclusive breastfeeding has been eroded and undermined despite its exceptional benefits for infants and mothers. Although scientific studies continue to attest to the superiority of breastmilk, bottle-feeding formula is becoming the norm. Aggressive formula marketing has deceived mothers into believing that formula is equivalent to breastmilk. Good lactating breasts have been removed from the mouths of infants and promoted only as sexual organs. The positive effect of breastfeeding on mothers' health has also been ignored. Throughout the world, scarce resources are used to buy formula when the money could be put to better uses.

Infant food companies influence government health policies and have made the medical profession their handmaiden. They use "science" to scare mothers, exploit women's working rights and men's desires to adapt to family realities. While they have stopped some promotion to mothers in the mass media, they have bought time and programs to undermine breastfeeding. They have taken baby faces off their formula tins only to put them on "follow up milks." They have grudgingly endorsed the WHO/UNICEF International Code of Marketing of Breastmilk Substitutes, but whittled it down, and still complain it's too restrictive. Through the World Trade Organization, they are amassing even more power. In spite of the Code, and in spite of the efforts of thousands of breastfeeding advocates, the infant formula market is thriving, formula companies are growing, and profits are mounting.

IT'S ALL ABOUT PROFITS

The chief aim of corporations is to maximize profits by expanding markets, increasing the use of products, inventing new products and extending the length of their use. Their greed appears insatiable as more and more babies suck rubber in vain search for the juice of life. Their main concern is profit, not public health. It's clear that breastfeeding is not good for the baby food industry. The baby food industry (which includes the production of bottles and nipples) is an eight-billion-dollar a year industry with an enormous profit margin and vicious intercompany competition. For every dollar wholesale received, only 16 cents go to research and development.

Corporations invest only to maximize their returns. Formula companies give money to doctors, nurses, medical students and departments of pediatrics for research, equipment, gifts, payments, conferences, travel and publications, with the goal of enlisting their endorsement and promotion of the products.

Money spent on promotion and lobbying means less for quality control, research and basic ingredients. WHO has recommended that docosahexaenoic acid (DHA), essential to infant brain development, be added to infant formula. Europe and Asia have done this but formula makers in the US have resisted. The FDA and Ross Pharmaceuticals (maker of Similac) say there is not enough scientific evidence to do so, but Ross also admits that it's too expensive. Ross's earnings from the WIC program (Women, Infants and Children Supplementation program) has decreased because of rebates and so profit loss may be a factor. Babies' health doesn't seem to have a high priority. Damage to the company's name is to be avoided at all costs so they do not lose the market, especially now as there is an increasing number of competitors selling baby foods, formula for pregnant women (at least ten such products are now available), bottles and nipples.

Most of the ingredients in infant formula are incredibly cheap. Powdered milk contributes to only one-sixth of the total cost. Soy protein isolate used in soy-based formula is even cheaper.

BEHIND THE SCENES

With restrictions to formula distribution, the corporations become more devious, lobbying governments, challenging the law and establishing clinics and hospitals as marketing agents and centers. When other promotion avenues fail, companies go directly to governments to meet their needs.

Breast milk substitutes are based on doctored cow's milk or highly processed soy protein. Nevertheless, the formula industry was able to persuade the FDA to classify formula as a food, not a drug, so that they would be subject to less stringent review. The FDA allows the use of soy protein isolate in soy formula even though it does not have Generally Recognized as Safe (GRAS) status.

Corporations influence the selection of delegates to international infant-feeding meetings, including those sponsored by WHO. They offer special deals for the purchase of breast milk substitutes for nutrition programs, famine relief and even for orphans, but require their logo to be used. Every opportunity to advertise their products is maximized.

There are financial incentives for governments to import infant foods. Governments get extra income through sales taxes and import duties. In Zimbabwe, income is generated for governments through the 17.5 percent sales tax on imported formula and a 10 percent import duty. Thus, the government shares in the profits when mothers abandon breastfeeding.

The infant food companies have special contacts in nutrition and child health divisions of various governments who are their advocates and look after their name and interests. They pay for delegates to attend international nutrition conferences to vote their line.

Formula companies and their agents even interfere with the production of breastfeeding educational materials. On one known occasion Nestlé wrote to the US Secretary of Health urging him to withdraw an innocuous HEW publication "Perspectives on Maternal-Infant-Feeding," which was in strong demand, as they feared its influence. The report was "unscientific," they claimed. However, as it had been reviewed by leading authorities in the field, their efforts came to nil. In Zimbabwe, a pro-breastfeeding publication "Baby Feeding," funded by UNICEF, was held up because of Nestlé's lobbying efforts. The Attorney General finally ordered that it be released for publication. We have no idea how many such publications have been successfully blocked.

When a breastfeeding group in Guatemala protested the use of baby pictures on Gerber baby foods, Gerber reacted with attempts to bribe the national breastfeeding committee. When that did not work, they threatened the government. If Guatemala did not allow Gerber to exercise their free trade rights, they said, they would take their business out of the country. Unfortunately, Gerber got its way.

National breastfeeding groups are continually thwarted by the formula makers which insist that their representatives be included in their workshops and conferences. These representatives then work to water down any recommendations that interfere with the sale of their products. The Australian Federal Bureau of Consumer Affairs and several formula companies have a marketing agreement that ostensibly includes the Code provisions, but the panel set up to receive and investigate complaints regarding the marketing of infant formula in Australia includes representatives of the companies being policed! The Philippines has a strong national Code that restricts formula marketing yet the government does nothing about the baby food companies' flagrant violations.

AIDS AND BREASTFEEDING

One of the most egregious examples of formula-promotion through spurious science is the current dogma that HIV-positive mothers should not breastfeed. Despite the incomplete and conflicting scientific evidence on the transmission of HIV through breastfeeding, the corporations have seized on the HIV-epidemic as an opportunity to push formula feeding to the third world. For the formula companies, AIDS is a window of opportunity that is exploited to the nth degree. In South Africa, the head of the health department in the Ministry of Health stated at La Leche League's 1998 national meeting that "we're in bed with the enemy" to solve the AIDS breastfeeding crisis.

Formula makers have used AIDS research presented at the AIDS International Meeting in Vancouver 1996, and cited on the front page of the New York Times, to pressure UNICEF to endorse formula for babies born to HIV-positive mothers. The industry endorsed this research even though it had not been published in a peer-reviewed journal. The author of the New York Times article interviewed six "breastfeeding experts" but never reported any of their views. He did, however, report the views of non-breastfeeding advocates such as Thad Jackson, an immunologist who formerly was a full-time employee of Nestlé and now works for them as a consultant. The report was very biased and accused WHO and UNICEF of dragging their feet and not looking out for third world infants. According to the Wall Street Journal, "UNICEF remains captive to a clutch of activists who have been leading boycotts and protests against the baby formula makers since the 1970s on the highly spurious grounds that the companies trying to supply better nutrition ‘exploit' the poor. . . If the toll of African AIDS babies continues to rise, the credibility of one of the most beloved UN agencies may sink." This statement was on the front page, not in the editorial section!

A recent study in Durban shows that there is no difference between the incidence of HIV in exclusively breastfed and exclusively formula-fed infants of HIV-positive mothers from birth till six months, but there are no lobbyists to herald this positive news. Furthermore, is clear that mixed feeding of infants of HIV-positive mothers has the worst possible outcome.

INTERFERENCE AND INFLUENCE

There are an untold number of examples of the infant food industry's interference and influence. When the International Nutrition Conference met in Geneva, the formula industry systematically infiltrated the meeting. The INC recommendations had to be formulated in secret and were delivered to the plenary session to the surprise of the baby food industry.

The Maternity Protection Convention, adopted by the International Labor Organization in 1952, calls for 12 weeks' maternity leave, cash benefits equal to two-thirds of previous earnings and breastfeeding breaks totalling at least one hour per day. At a 1999 International Labor Organization meeting in Geneva, the powerful transnational corporations lobbied for removal of the nursing clause. New Zealand, Australia, UK, USA, Canada, and other some European countries sided with the formula companies but Italy, Greece, Austria, Croatia, the Netherlands, Philippines, United Arab Emirates and all of Latin America and Africa, as well as non-governmental organizations including the International Confederation of Nurses opposed the recommended change. Although the vote was close, breastfeeding breaks remained. However the struggle is not yet over. As most of the world's women still breastfeed, weakening the Maternity Protection Convention (MPC) would make it harder for governments to promote breastfeeding in the work place, depriving women who want to breastfeed of their rights.

The latest gimmick by Nestlé is to seek endorsements from governments stating they are in compliance with the Code. Nestlé supplies "Certificates of Code Compliance" for government representatives to sign. This has already happened in Panama City and Nestlé is pressing other Latin American governments to sign.

The Western Cape Provincial government in South Africa is also under pressure but according to the International Baby Food Action Network (IBFAN), this strategy is backfiring as an increasing number of governments are using the opportunity to spell out Nestlé's shortcomings. The South African Department of Health asked Nestlé to change labels on some products because they suggest introducing complementary foods at 4-6 months rather than at 6 months as required by the WHO resolutions. The Ministry of Health also complained that Nestlé posters were in clinics and their brochures were freely available, resulting in the promotion of the company's image as well as its products.

"Formula Fix," an Australian IBFAN video, was banned for use in a training program in South Africa. The request came from a long time employee of the Ministry of Health nutrition section. Staff were instructed not to show the video at a breastfeeding workshop as Nestlé did not want their image affected while they were in negotiations with the Ministry of Health. It's now being used again.

Formula companies continue to violate the Code and are engaged in relentless efforts to water it down. Meanwhile, they produce publications for government and health professionals to refute allegations of code violations.

RETAIL SHOPS

Formula makers buy shelf space and flood stores with baby food products, posters and promotional materials. In the Philippines, for example, the supermarkets have been flooded with infant foods and materials to make them seem attractive and make mothers aware of brand names. Next to them on the shelf is Pedialyte for the diarrhea caused by formula when made up with unsanitary water. Now they are selling bottled water for making up the formula but still they don't have the immunological effect of breastmilk. Soy formula is also for sale for infants who developed allergies to the milk-based formula. As always, the hazards associated with use of these products are denied or minimized. In some US supermarkets, the infant formula shelf has a label saying "recommended by WIC," the US government Women, Infants and Children program. The formula industry has used government programs to promote their goods.

In Australia, the retail sector has not been a signatory of the Australian Agreement on the Code and it is being used as a loophole for exploitation. The baby bottle companies never signed, either. Previously, promotion materials were only in some pharmacies but now companies like Mead Johnson have orchestrated many pharmacies to have the same Baby Club inducements. Recently, supermarkets have become baby food centers carrying anti-breastfeeding messages with massive display advertisements in prime store locations. Pharmacies are now in competition with supermarkets to retain their old market share.

AT THE DOCTOR'S

Hospitals, clinics, maternities and doctors' offices have become distribution centers. The sales reps actually come into the wards and clinics with their products, promoting them with misleading information. In a hospital serving mainly south Africans in East London, nurses were told by the Abbott rep that Similac was not formula but a supplement for premature infants. Mothers seeing premature infants fed formula then think it's better than breastmilk. At Tygerberg Hospital in South Africa, Nestlé paid for nurses to teach infant care. They also funded a nutrition department at the University of Capetown. Doctors' offices dispense formula samples and educational materials. They even give out videos on breastfeeding that are produced by the baby food industry!

It has been shown that 93 percent of mothers who receive gift packs use the brand issued. The US government-sponsored WIC program and similar nutrition programs serve as distribution centers for formula. This hooks mothers on a particular brand. (Participants in the WIC program receive only enough formula to feed a nine-pound baby. When the baby needs more, the mothers must buy it themselves. Had they not been persuaded to formula-feed, they could have nursed their babies for free.) Hospitals are paid enormous sums for using and distributing only one company's product. Despite distributors not being allowed on the wards, they do come to nurseries and maternity wards. In South Africa, Abbott uses the forumla product Formance for pregnamt women falsely advertised to produce bigger babies and more milk, to gain access to prenatal and postnatal patients, a practice that is not banned by the Code. Once there, they promote other products.

HEALTH WORKERS

Health workers have a special responsibility for the success or failure of the Code. They are frequently the target for promotional practices and health care facilities are used by companies as the frequent channel for encouraging the use of their products. Health professionals are very naive and often don't realize that they are being used. The baby food industry has used and needs health professionals to endorse, distribute and sell its products. According to an Abbott Labs publication, "As the voice of Abbott, Abbott Topics can be a positive force molding the physicians' opinion of Abbott. In effect we are striving to make the physician a low-pressure salesman of Abbott."

In Pakistan, the reps have cards on doctors that include information on their birthdays, families and practices and this information is passed from rep to rep. The doctors with large pediatric practices and who teach are classified as type A and receive special attention.

Industry representatives attend medical, nutrition, breastfeeding conferences and meetings and also sponsor many of these. It should be noted that the infant food industry meetings never include doctors not in their employ unless the purpose of the meeting is to gain health profession support of their point of view. At a recent Code meeting of health workers in Capetown, ten official company representatives attended in order to undermine what was said about the Code and cause confusion. Additional Nestlé advocates who received funding and gifts from the company were at the meeting.

The formula companies even have the audacity to teach about breastfeeding when promoting formula and in so doing subtly undermine the process and make women and babies dependent on the products.

The Infant Formula Council produces publications to educate health professionals. One of these, a review on infant feeding methods, contains a step-by-step discussion arguing that formula is as good as breastmilk. When the International Group on Breastfeeding Monitoring published their expose "Cracking the Code," Nestlé produced a denial document called "A Missed Opportunity" and distributed it to physicians and health workers everywhere. Scientific studies showing deficiencies in human breast milk are also widely distributed but no one talks about improving the maternal diet. The object is to create fear and sell formula.

The companies do not give money for nothing. The American Association of Pediatrics (AAP) receives $1 million a year from formula companies and they got $8 million for their building fund. (It was after the $8 million grant that the AAP dropped its objection to soy formula.) Companies pay for conferences, special guests, functions, display products in exhibits, sponsor research, journals, publications, institutional premises, scholarships and yearly stipends. Some groups have resisted. The Indian Pediatric Association takes no "milk money" from the formula companies.

IN THE MEDIA

The media portrays women as sexual objects. Nursing women are shown in dressing gowns with fat bosoms like domestic cows. Men are shown bottle feeding and often men portray breasts as their goods. Women need to reclaim their rights and their breasts.

There is no question that the corporations have access to the media and make good use of it to push their case. Nestlé bought the time before and after a television segment on a breastfed baby who died because of stated insufficient milk and not getting formula. Abbott did the same for a report on an infant death due to medical neglect blamed on breastfeeding. The companies effectively use publications like the Wall Street Journal, Time and the New York Times to undermine breastfeeding but recalls of thousands of harmful cans of formula do not get attention.

The internet has become a very important marketing tool and formula makers are very smart in how they use it. Sometimes it's difficult to recognize how it's used to promote bottle feeding. Examples include "Women's Link" by Bristol Meyers and Mead Johnson; Robin Adler's campaign "Bottle Feeding Without Feeling Guilty" "Parents' Choice" by Wyeth (marketed by Walmart); "Bottle Buddy" and "Carnation Baby." Baby food companies are now organizing nutrition education for parent and baby groups with a focus on correct infant feeding. Is there conflict of interest?

CONSUMERS' ACTION

As powerful as these corporations seem to be, they can be compelled by market forces to behave in ways consistent with global and local progress, meeting human needs, doing no harm and building a better future for our children.

We have to take action to protect public health and end inferior feeding practices that interfere with breastfeeding and only benefit corporate profit. We need a system that will make regulations binding on corporations to protect the health of mothers and babies. Evidence-based studies are essential to ensure that all the baby foods are not harmful and that the claims made for them are substantiated. We must value mothers and ensure maternity entitlements. Society has to recognize the value of mothers and support them. But most of all, women need to recognize the unique importance of their ability to breastfeed and stand up for their rights.

Sidebar Articles

The WHO/UNICEF International Code of Marketing Breastmilk Substitutes

The aim of the Code is: . . .
to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding and by the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

The code includes ten main provisions:

• No advertising of breastmilk substitutes.
• No free samples of breastmilk substitutes to mothers.
• No promotion of products through health care facilities.
• No company mothercraft nurses to advise mothers.
• No gifts or personal samples to health workers.
• No words or pictures idealizing artificial feeding, including pictures of infants, on the labels of the products.
• Information to health workers should be scientific and factual.
• All information on artificial feeding, including the labels, should explain the benefits of breastfeeding and the costs and hazards associated with artificial feeding.
• Unsuitable products, such as sweetened condensed milk, should not be promoted for babies.
• All products should be of a high quality and take into account the climatic and storage conditions of the country where they are used.

WHAT'S IN INFANT FORMULA?

WATER: May contain high levels of fluoride.

CORN SYRUP: Contains glucose. Mother's milk contains lactose as the main carbohydrate. Not all brands of formula contain lactose.

SUCROSE: Contains no lactose. The wrong sugar for babies.

SOY OIL: Processed using high temperatures and chemicals, bleached and deodorized. Likely to be rancid.

WHEY PROTEIN: High temperature processing likely to destroy fragile whey proteins.

SOY PROTEIN ISOLATE: Highly processed, contains phytoestrogens that can adversely affect baby's hormonal development and depress thyroid function. Does not have GRAS status.

CARRAGEENAN: Extremely hard to digest. In most ready-mixed formulas, carrageenan is one of the main causes of digestive disorders in formula-fed infants, not lactose-intolerance. Caused liver problems and retarded growth in rats.

SOY LECITHIN: Extracted from the soy oil sludge. Likely to be high in pesticides.

SYNTHETIC VITAMINS: Often have the opposite effect of vitamins naturally occurring in food.

FREE GLUTAMIC ACID (MSG) and ASPARTIC ACID: Neurotoxins formed during processing of milk and soy protein powders. Levels are especially high in hypoallergenic formulas.

US INFANT FORMULA RECALLS 1982-1994

Class I: May cause serious health consequences.
Class II: May cause medically reversible health conditions.
Class III: Not likely to cause medically adverse health effects.

Adopted from Milk, Money and Madness 1995

THE IRON "PROBLEM"

One trick of the formula makers is to exaggerate the problem of iron deficiency. Mother's milk is very low in iron and the formula makers have seized on this fact to promote iron-fortified formula as an improvement on Mother Nature. Of the studies examining the evidence for iron supplementation of infants, 77% were industry-funded. Infants on this formula get 22 times as much iron as breastfed infants and risk contracting iron storage disease, but this appears irrelevant to researchers. Iron-fortified formula is more expensive than no-iron formula and presumably more profitable.

Actually, mother's milk is low in iron for at least two reasons. Low iron levels in human milk contribute to its antiviral effects. Iron also competes with zinc for absorption and the human infant needs a plentiful supply of zinc for the development of his brain and nervous system. In traditional societies, parents compensated for this in two ways. First, they allowed the umbilical cord blood to flow into the infant before cutting or tying the cord. This gave the infant an infusion of iron-rich blood without going through the digestive process. Then, at the age of about 4-6 months, baby was given his first food, usually iron-rich liver, which the mother had thoughtfully prechewed.

Iron-fortified formula can cause constipation and zinc blockage and should never be used. Modern parents should insist that their baby gets his cord blood, and then should supplement his diet with a little grated liver along with egg-yolk feeding at the age of four months. Of course, mothers should get plenty of iron-rich foods while nursing, to replenish iron stores lost during childbirth and to prevent anemia. In some cultures, the placenta was cooked in a stew and served to the mother for this very purpose.

WORLD HEALTH RESOLUTION

47.5 At the World Health Assembly meeting in Geneva in May 1994, the United States reversed its lone opposition to the WHO/UNICEF International Code of Marketing of Breastmilk substitutes. The Code was adopted by international consensus. Here is a summary of what was gained:

1. In theory, the United States is now in support of the Code. The door is open at last for the United States to do what the Code calls for: "To take action appropriate to the social and legislative framework and overall development objectives to give effect to the principles and aim of this Code, including the enactment of legislation, regulations or other suitable measures."
2. WHA Resolution 47.5 clarifies Resolution 39.28 (passed in 1986) and affirms that all products under the scope of the Code, not just infant formula, are not to be provided for free or at subsidized cost. It states that this is intended for the whole health care system, not just maternity wards and maternity hospitals. This language closes significant loopholes claimed by the industry.
3. WHA 47.5 also corroborated the position of the health care community that most babies need no other food than breastmilk until the age of about six months and also emphasizes the need for local foods—not expensive, imported, processed foods or follow-up milks—and continued breastfeeding.

About the Author
Naomi Baumslag, MD, MPH is Clinical Professor of Pediatrics at Georgetown University Medical School, and President, Women's International Public Health Network, Bethesda, MD.