Breast still best

Google “infant formula” and you’ll find two entries for Lazada, which now sells infant formulas online, and several articles with titles like “Trusted milk brands in the Philippines for babies” and “Best baby formulas of 2018,” all glowing endorsements of baby formulas.

So, what’s wrong with that, some of you might ask?

The problem is that for some 40 years now, the World Health Organization (WHO), using evidence from numerous scientific studies, has been unequivocal in declaring that breastmilk is still best for infants (children below the age of one).

You’ve heard that statement repeated over and over again, accompanying advertisements for infant formulas or, to use the more technical term, breastmilk substitutes (BMS). That advice on breastmilk being the best comes from the WHO, which in 1981 released an International Code on the Marketing of Breastmilk Substitutes, unequivocally recommending exclusive breastfeeding for the infant’s first six months, and calling on governments to impose strict restrictions on advertising of infant formulas, including prohibiting direct promotions of infant formulas to mothers and health professionals.

That Code did not come about without a long and difficult struggle. In the 1970s, consumer groups from around the world banded together realizing that breastfeeding was rapidly declining, even as the use of infant formulas was causing malnutrition and even, to be blunt, killing babies.

Cow’s milk for cows

One of the slogans from that period was, and I’m paraphrasing, “cow’s milk is best for cows and human milk is best for humans.” You just can’t duplicate mother’s milk when it comes to the nutritional content. Put another way, and I’m wearing my hat as a veterinarian, cow’s milk is higher in protein than human milk, because calves need to develop its muscle tissue much faster than human babies. Human milk is richer when it comes to the amino acid taurine, needed for brain development and infant formula manufacturers have capitalized on that.

But nutrition isn’t just a matter of ingredients, but of the correct mix of nutrients. In the 1970s, an American infant formula manufacturer, Syntex, reduced the sodium (salt) content of its infant formula as a health measure, but using that formula resulted in infants getting chlorine deficiency. The problem was serious enough to make the US government pass a law in 1980, specifying what nutrients should go into infant formula.

Going beyond nutrients and infant formula ingredients, the outrage over infant formulas was particularly strong because of the documentation of babies dying in developing countries from the use of the formula.

Some of the deaths came from, ironically, malnutrition. Because the formula was so costly in relation to poor families’ incomes, parents would not follow instructions on the proportion of milk powder and water, or, if they did follow the instructions, would restrict the babies’ consumption of the milk. The babies would end up severely malnourished, even dying from the deprivation.

Other deaths came from unsanitary conditions in preparing and storing the infant formula. Bacterial contamination, coming from dirty water, unwashed hands and exposure to the elements
between feedings, caused diarrheas that were often fatal.

Parents, and even health professionals, were not aware of all these deadly risks. Not only that, many were convinced of the superiority of infant formulas, thanks to aggressive promotional strategies of infant formula manufacturers. Physicians, midwives and even community health workers were given free trips to conferences abroad and “smaller” freebies from movie tickets to gambling chips.

Infant formula promoters had free run of hospitals, handing out free samples and materials like baby books extolling the superiority of formulas with particular brands.

The infant formula manufacturers were able to change infant nutrition practices very quickly, and sometimes through insidious ways. Hospitals, for example, would separate infants from mothers, citing infection control needs. The delay in mother-infant bonding meant a delay in breastfeeding and then, very conveniently, mothers would be told they could not breastfeed because their breasts were too small (a total myth—mothers are not gasoline pumps), or were too weak. Soon, grandmothers and fathers were joining the act, telling friends that breastfeeding was difficult so don’t bother.

And yes, there were bigger problems affecting the ability to breastfeed. The WHO’s recommendation for exclusive breastfeeding makes it almost impossible for working mothers because paid maternity leave is only for two months. (Yes, I know employers say six months would make them bankrupt but the International Labor Organization, which has gotten into breastfeeding promotion, says that paid maternity leave should come from social insurance, i.e., SSS or GSIS in our case.)

Philippines for model legislation

The Philippines was one of the countries with the most active campaigns to promote breastfeeding and restrict promotions of breastmilk substitutes but reforms at the government level were slow to come by. In 1986 though, after the Marcos dictatorship fell, legislative reforms came quickly, restricting promotions of the formulas. Since then, we have required rooming-in (keeping a newborn infant with the mother right after birth). The law also requires, for larger offices, “lactation stations” for mothers to breastfeed in private. (I know I said women are not gasoline pumps but lactation rooms are often called pumping stations.)

Despite those model laws, the struggle continues uphill and what had gotten me to google for infant formulas was an article in the British newspaper, The Guardian, investigating allegations of violations in the Philippines of the laws on promotions of infant formulas. The Guardian picked up on a recent report, “Superfood for Babies,” released by Save the Children.

What I described earlier, about the promotional gimmicks in the 1970s that had so alarmed the world’s experts on infant nutrition, continue to this day. Not only that, new venues for promotions have emerged, including the use of “mommy bloggers,” internet sites offering advice on parenting, to push infant formulas.

These are powerful channels for promoting infant formulas and as internet access spreads, we will find a powerful tool in aspirational advertising. One of the biggest handles used to promote breastmilk substitutes, from the 20th and into the 21st century, has been the line (the lie) that bottle-feeding is a mark of modernity, and of being “high class,” so for low-income women, bottle-feeding is an imitation of the upper class.

The Guardian exposé included interviews with urban poor mothers talking about how they scrimped on their family budgets to be able to bottle-feed. Look at the prices of infant formulas in supermarkets (or in the Lazada site) and you will find that a small 900-gram can of formula sells for the equivalent of two days’ minimum wage.

The poor complain about the high cost of living with “Mahal ang gatas” (Milk, meaning the breastmilk supplements, is expensive). Supermarkets catering to low-income households have a separate section to sell the infant formula, with its own checkout counters and guards. And among the blog discussions on infant formulas, I found one thread: recommended brands of cheap infant formulas.

Following The Guardian and Save the Children reports on the Philippines, the four implicated manufacturers have issued categorical denials of violations by their companies. The Department of Health, according to The Guardian, has started investigating the allegations.