The scientific evidence that exclusive breastfeeding is best for infants is very strong. Yet, some baby milk formula companies continue to use questionable methods to create demand for their products, thereby undermining breastfeeding.
The issue was highlighted in a recent series of articles published in the peer-reviewed journal The Lancet that set out the economic and political power of the dominant formula companies and the alleged public policy failures that result in millions of women not breastfeeding as recommended.
This, the authors say, has a negative impact on infants and their development.
Exclusive breastfeeding for six months is recommended by the World Health Organization (WHO) for optimal health and growth of infants, but it is not a common practice in South Africa.
'Poor science'
One common reason women introduce baby formula is that they misinterpret unsettled baby behaviour, especially disrupted sleep and persistent crying in the first few months of life as signs that their breastmilk is insufficient.
"Commercial milk formula marketing portrays breastfeeding, and thereby women's bodies, as inherently difficult, unreliable, and inconvenient," according to the series. "CMF (Commercial breastfeeding) marketing reframes and bends public health messaging to further promote its products, for example, capitalising on the WHO recommendation to exclusively breastfeed for six months to suggest that CMF is necessary after this age because breastmilk alone is purportedly insufficient. This false message undermines women's confidence in their own bodies and their ability to make informed decisions about continued breastfeeding, according to the Lancet Series.
Exploitative marketing and political lobbying have turned the sale of commercial milk formula into a multi-billion-dollar industry.
In The Lancet this week, a new Series calls for #breastfeeding to be better supported, promoted, and protected: https://t.co/EUQvfOXLDY pic.twitter.com/IwzZFarnSH
-- The Lancet (@TheLancet) February 10, 2023
Professor Linda Richer from the Centre of Excellence for Human Development at Wits University and one of the co-authors of the Lancet papers says, "The formula milk industry uses poor science to suggest, with little supporting evidence, that their products are solutions to common infant health and developmental challenges.
"Adverts claim specialised formulas alleviate fussiness, help with colic, prolong night-time sleep, and even encourage superior intelligence. Labels use words like 'brain', 'neuro', and 'IQ' with images highlighting early development, but studies show no benefit of these product ingredients on academic performance or long-term cognition.
The formula milk industry uses poor science to suggest, with little supporting evidence, that their products are solutions to common infant health and developmental challenges. - Prof Linda Richter
"These marketing techniques," Richter says, "violate the 1981 World Health Organization International Code of Marketing of Breastmilk Substitutes, to which countries agree that labels should not idealise the use of formula, nor exploit poor science to create an untrue story to sell more product."
The new review of 153 studies, conducted for The Lancet Series, details how marketing practices in violation of the Code have continued in nearly 100 countries - including South Africa - and in every region of the world since its (voluntary) adoption more than forty years ago.
In 2012, South Africa published regulations relating to foodstuffs for infants and young children to implement the Code into law.
According to Mota Mota, Head of External Communications at Nestlé East and Southern Africa, Nestle "supports the World Health Organization's recommendation of exclusive breastfeeding for the first six months of a baby's life, followed by the introduction of adequate nutritious complementary foods along with sustained breastfeeding up to two years of age and beyond". "We do not promote formula for infants 0-6 months across the world," he says. "In 163 countries, most of which have high rates of malnutrition, we apply a stricter policy and do not promote formula for infants 0-12 months."
The most effective way to secure World Health Organization (WHO) Code compliance, he says, is through well-drafted and well-implemented legislation. Nestlé is willing to actively engage with stakeholders to encourage implementation of the Code and subsequent relevant resolutions into national laws.
In the series, the authors state that industry lobby groups resisted some of the legal and regulatory changes that took almost nine years to implement.
According to Naazneen Khan, dietician and chairperson of the lobby group, the Infant Feeding Association, however, they are not aware of a nine-year delay. "It is unclear which part or parts of the regulations the authors deem IFA to have unduly influenced. Legislation in South Africa now prohibits marketing, advertisements, sponsorships, donations, and a variety of activities relating to the designated products - all of which IFA and its members adhere to."
Khan calls The Lancet series "general in nature and not specific to South Africa" so not all statements are applicable to South Africa. "We, therefore, urge a careful reading of the text of the three articles and an assessment of the supporting footnotes, as not all statements are universally applicable or applicable to South Africa and/or members of the IFA. The IFA always and will continue to support the establishment of exclusive breastfeeding for the first six months of life," she says.
'Confidence undermined'
According to the Lancet series and based on follow-up interviews, experts say that often expectant mothers are targeted with information such as if they don't eat well, it may affect the baby. The mother's confidence in her own body to produce breastmilk is undermined. Normal infant behaviour is "problematised" and the solution offered is formula.
According to the series, of the most pervasive suggestions is that milk formula will encourage superior intelligence.
One real-life label (figure 3 and 4) indicates that relief from these infant behaviours can be accomplished within 24 hours and brain development will be enhanced at the same time. The words gentle, sensitive, soothe, and comfort appear frequently to reassure parents, and terms such as premium appeal to emotional values, strengthening these associations.
According to the series, of the most pervasive suggestions is that milk formula will encourage superior intelligence. Yet intervention studies and systematic reviews show no benefit of the ingredients added to these products on academic performance or long-term cognition.
The science of breastmilk
Dr Helen Mulol from the University of Pretoria's Research Centre for Maternal, Foetal, Newborn, and Child Health Care Strategies, undertook a study some years ago to determine the breastmilk output volumes and maternal body composition objectively at five different time points in the first year of the infant's life.
She explains to Spotlight how this was done. The mother is given a 30mL dose of deuterium oxide, also known as heavy water, which is a stable isotope of water. It is safe for mother and baby in the low levels given and is not radioactive.
It acts almost identically to water in the body and mixes with the water in the mother's body. A saliva sample is taken from mother and baby before the dose is given to the mother and then on days 1,2,3,4,13, and 14 after the dose was given.
If the baby is breastfeeding, the breastmilk will contain some deuterium, which can then be measured in the baby's saliva. These saliva samples are measured for deuterium content by an analytical chemistry method and the deuterium levels are entered into a spreadsheet, which compares the results to model curves.
The main output of the method is the breastmilk intake, but the method also tells you whether the infant is receiving something else in addition to breastmilk (such as water, tea, juice, or formula) or whether the infant is exclusively breastfed.
The results were clear. The infants who were breastfed exclusively were leaner. "So, the results showed that early infant feeding practices affected the body composition of the infant. Given the worldwide trends towards obesity even in child populations, it shows the importance of early infant feeding on later outcomes," says Mulol.
The Lancet 2023 Breastfeeding Series, launching online from UWC on the 10 Feb 2023 - register at https://t.co/3OZyZJJyJm. pic.twitter.com/Wy0vn2jF3L
-- Linda Richter (@LindaRichterECD) February 3, 2023
At birth, breastmilk is also known as colostrum. It is produced in very small quantities, but the baby's stomach is also small, Mulol explains. It has a different colour to the later breastmilk and is a yellow/orange colour packed with nutrients, vitamins, and minerals as well as antibodies to protect the newborn baby from any diseases or infections from the birthing process.
Colostrum is also thought to line the baby's gut, which prevents the passage of pathogens. Without this, the gut can be inflamed and can give rise to infections. This article shows that the higher the percentage breastfeeding of the babies, the lower was the gut inflammation measured by mRNA markers. It explains in part why infants who are exclusively breastfed have fewer infections.
After the first few days, the composition of the breastmilk changes to a more "milky" colour. The volume that the baby can ingest also increases at this time.
Breastmilk is the ideal nutrition and protection for the growing baby. It contains proteins, sugars, vitamins, and minerals, as well as antibodies to protect the baby against infections. It changes from day to day according to what food the mother consumes and the composition changes according to the age of an infant so the composition of the milk given to the baby at one month will be different from that given at six months, says Mulol.
Research has shown that even in hot climates, it is not necessary to give the baby extra water as breastmilk is sufficient. Breastmilk contains maternal antibodies, which protect the baby against illnesses, and many other components which act like probiotics, encouraging the growth of healthy gut bacteria. For example, exclusively breastfed infants have a predominance of the beneficial Bifidobacteria, and the establishment of healthy gut microbiota has been shown to affect not just the early infant feeding period but also into childhood and adulthood.
"Breastmilk is the ideal nutrition for infants so a mother should consider breastfeeding or as second-best using donor breastmilk from a breastmilk bank if she is, in very rare cases, unable to breastfeed herself before starting a baby on formula. Numerous studies have shown that breastfed infants are less likely to get sick and perform better on intelligence tests later in life.
"Although the manufacturers would like us to believe that infant formula is almost the same as breastmilk, it is not. Breastmilk is a dynamic substance which, as previously mentioned, changes in composition from day to day and month to month," says Mulol. This is in stark contrast to the tinned formula, which is the same every day and does not contain the active ingredients naturally present in breastmilk, she says.
It is difficult to overfeed a breastfed baby as there is a lot of "work" involved in breastfeeding, whereas with formula feeding from a bottle, the flow is not controlled and it is easier to overfeed the baby.
Although breastfeeding is a common practise for most women in South Africa, exclusive breastfeeding is not. The latest South African Demographic and Health Survey from 2016, which collected data on infant feeding practices, reported that breastfeeding rates decreased from about 80% at 0-1 months to about 73% at 4-5 months and about 59% at 6-8 months. Exclusive breastfeeding rates were 44% at 0-1 months, which decreased to 24% at 4-5 months. Any exclusive breastfeeding under the age of six months was 32% in South Africa.
Many mothers reported giving water and complementary foods in addition to breastmilk. Often this is due to perceptions of the baby being thirsty or that there is insufficient breastmilk.
What about HIV?
About 24% of all women of reproductive age, 15-49 years, were living with HIV in 2021).
A previous policy advised that mothers should not breastfeed at all, but this changed because when mothers were not breastfeeding their infants, more infants died from causes such as diarrhoea than previously died from HIV infection. This could be because mothers were not sterilising the bottles or were using unsafe water or were diluting the formula too much, says Mulol.
With the advances in antiretroviral treatment (ART) for mothers living with HIV, it is considered safe for mothers to breastfeed their babies, but some mothers and healthcare workers may still be uncertain about the changing messages.
Such an important launch... the Lancet breastfeeding series focuses on understanding what is normal infant behaviour. #Whobreastfeeding pic.twitter.com/JwAbQBklWU
-- Martina Donaghy (@DonaghyMartina) February 8, 2023
"If one looks at the 'monetary value' of breastmilk in terms of replacement costs, consequences for hospital admissions as well as loss of productivity for parents when the infant is sick, it is costly not to breastfeed. In some developed countries, breastmilk is sold. They call it 'liquid gold' because of its value.
Sign up for free AllAfrica Newsletters
Get the latest in African news delivered straight to your inbox
In 2010, donor mothers in Denmark were paid US$24 per litre of breastmilk or US$90 per litre when banked. Also, in areas or countries with unsafe drinking water, breastfeeding is the best and safest feeding method," according to Mulol.
Professor Linda-Gail Bekker, Desmond Tutu Health Foundation CEO and Director of the Desmond Tutu HIV Centre at the University of Cape Town says vertical HIV transmission is possible.
"This is currently one of our most common times of transmission. Either from a mother who is known to be HIV positive but not diagnosed during pregnancy, not on ART or not yet virally suppressed, or a mom who becomes infected during the lactation period.
"Mothers should be tested and retested during pregnancy and lactation to pick up undiagnosed or new infections," she says. "They can be offered pre-exposure prophylaxis if not positive, but they perceive themselves to be at risk of HIV acquisition.
"If they are living with HIV, it is critical they receive ART and adhere well to ensure viral suppression. Babies can also be offered prophylactic ART," says Bekker.
It is known that when viral load is undetectable as it is when consistently on sensitive therapy, then the likelihood of transmission during pregnancy or peri-partum is much reduced, she says. It is also significantly reduced in lactation, but there is still a very small and rare risk of transmission even when the viral load appears to be fully suppressed in the blood of women who are breastfeeding.
If a woman becomes HIV positive during pregnancy or lactation, Bekker says their infection may go undetected and viral load can shoot up, which increases the risk of transmission.
Real-world barriers
Dr Chantell Witten, of the Centre of Excellence in Food Security at the University of the Western Cape who wrote an editorial for The Lancet series, tells Spotlight there are still many social structural barriers preventing women from exclusively breastfeeding, such as working in the informal sector where women do not receive paid maternity leave.
The slow violence - malnutrition - does not happen at age five. It starts at birth. - Dr Chantell Witten
Creating an enabling environment for mothers to optimally breastfeed their babies needs a whole-of-society approach, with stronger monitoring and enforcement of our regulations to control the marketing of formula milk for children, she adds.
One solution is to "normalise" seeing a mother breastfeeding in public and the less stigmatised it will become. "If you are uncomfortable, don't look," she says.
"The slow violence - malnutrition - does not happen at age five. It starts at birth... Formula is expensive and that is why many women buy a tin for a month when they need a tin a week. Women aspire to use formula because of the messaging.
"We have taken the emotion of breastfeeding away from the mother and baby interaction where it should be and placed it on her emotion to do the best for her child. And that aspiration is in a tin," says Witten.
