Articles published on this blog are my opinion only, and may not necessarily reflect the views of any organisations with which I am associated. Please be aware that articles posted on this blog are not intended as a substitute for professional medical advice. If you have a medical problem relating to breastfeeding, please seek further advice from a Lactation Consultant (IBCLC) or trained Breastfeeding Counsellor.

Sunday, 23 January 2011

If you leave the back door open...

When the media erupted into a frenzy of "Breastfeeding may harm babies" headlines in the immediate wake of the release of an article entitled "Six months of exclusive breastfeeding: how good is the evidence?" published by the British Medical Journal (BMJ), everyone seemed surprised at the BMJ's apparent slip-up in the quality of its content.


Everyone, it seemed, except me. Call me cynical if you like, but I can't say I was too surprised.


A mother embarking upon a breastfeeding journey with her newborn baby (myself included) is usually blissfully unaware that breastfeeding is political. Nutrition in infancy has a lifelong effect upon that individual. It also means big money. To those passionate about infant health, minimisation of risk to both breast and formula fed babies is crucial. So it is incredibly frustrating when those of us who feel strongly about infant health issues are misinterpreted as "pushing breastfeeding" or "forcing women to breastfeed". Few people, it seems, give much thought to just how much pressure mothers are under to formula feed and introduce solid foods prematurely. Yet, despite all the associated risks, mothers are under immense pressure to formula feed and wean early - after all, infant formula and baby food manufacturers represent a multi-billion pound industry with an enormous advertising budget. And money is power.


The UK government does, to some extent at least, recognise that this pressure from advertisement by the baby feeding industry exists and is a problem.  New mothers and babies are particularly vulnerable groups of people, so some laws are in place in the UK which protect mothers and babies from the aggressive promotion of infant formula and baby foods.


Or do they?


30 years ago saw the birth of the World Health Organisation (WHO) International Code of Marketing of Breast-milk Substitutes, which aimed
"to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution"(1).


However, not only has the UK repeatedly failed to implement the WHO Code in its entirety, but the UK laws intended to offer mothers and babies protection from the promotion of breastmillk substitutes are weak and riddled with loopholes, and the baby feeding industry is only too happy to take advantage of them.


One such area where mothers and babies remain unprotected from the promotion of breastmilk substitutes is in scientific publications. For example, at the end of 2010, the BMJ ran this full-page advertisement for infant formula on the back cover of one of its issues:


"close to [...] breastmilk":
"information of a scientific and factual nature" (2)
...or creating "a belief that bottle-feeding is equivalent [...] to breast feeding" (2)?
Aha! There it is, in the small print - the obligatory "breastmilk is best" line. Thank goodness I brought my magnifying glass... But would a busy healthcare professional really read the small print?


OK, so it's not illegal in the UK to advertise infant formula in a scientific publication (see 2)... So what's my problem?


The first issue here is that such advertising neatly undermines the UK's ban on direct advertising of breastmilk substitutes to mothers (of babies under 6 months) by advertising them to health professionals instead: the very people a mother will turn to for advice and support if she encounters breastfeeding problems. Although such adverts are required by law to contain "information of a scientific and factual nature"(2), it is still advertising. Advertising is NOT information-giving. Advertising is selling. Advertising is the art of persuading people to buy or choose things that might not even be necessary. As the National Childbirth Trust put it, "Parents have a right to make decisions on how they feed their baby based on impartial and accurate information from health professionals, not based on advertising and promotional messages from commercial interests."(3) Yet can mothers really trust that the breastfeeding - or indeed formula feeding - information they receive from health professionals is truly 'impartial' or 'accurate' if the health profession remains unprotected from advertising and promotional messages from the infant feeding industry? If advertising of one brand makes no difference to BMJ subscribers' practices, why does SMA pay to advertise in the BMJ? (paraphrased from 4)


The second issue is that journals aimed at medical professionals, such as the BMJ and the British Journal of Midwifery (BJM) (5), are clearly accepting financial support (in exchange for advertising space) from the infant formula industry. They also publish research and other articles on human lactation. The problem with this is that, in pharmaceutical research for example, industry sponsorship has been associated with increased odds of a pro-industry conclusion (see 6, 7). In light of this, if journals are in receipt of sponsorship from the infant formula industry, how confident can we be that the articles they select for inclusion will be free of any kind of bias towards the infant formula industry? At the same time, such publications expect to be taken seriously as leading authorities in the field of human lactation. This of course begs the question: which do they support - the infant feeding industry or infant health? Can a respectable medical publication realistically expect to support both?


Here the BMJ apparently distance themselves from the journal article they published via a tweet to The Leaky Boob...
but are medical journals really powerless against how their articles are interpreted by the press?
Read the BMJ's press release and decide for yourself!


The concerns I raise over infant formula advertising in scientific/medical journals are not new: "The [WHO] Code and subsequent relevant WHA resolutions call for a total prohibition of any type of promotion of products that fall within their scope in the health services" (8). The WHO's International Code "makes no exception for any type of advertisement" (9). Furthermore, an EU directive issued in 2006 stated that Member States "may [...] prohibit" the advertising of infant formulae in scientific publications (10). And, shortly after that, the Baby Feeding Law Group, Baby Milk Action and the NCT issued a response to the Food Standard Agency's proposals for regulations on infant formula and follow-on formula, in which it recommended a change in the law to prohibit all advertising of infant formulae, restricting the infant formula industry to the provision of information of a scientific and factual nature to health professionals (9). This could have been a significant step forward in both safeguarding breastfeeding and ensuring the health of babies fed on formula too - at last mothers could have had access to impartial formula feeding information: all too often, mothers who find themselves formula feeding are abandoned in a sea of competing brands and distorted 'facts' designed to fit an advertising agenda.  However, the Advertising Association, together with industry, fought against this, and lists "revers[ing] a policy by the Food Standards Agency to ban infant formula advertising in professional/scientific publications" amongst its achievements of 2008 (11). Who benefits from such an 'achievement'? Breastfed babies? Formula fed babies? Healthcare professionals? Or the infant feeding industry? If advertising in scientific publications wasn't effective, would they seriously have bothered to fight this?


The simple fact that it is not illegal to advertise infant formula in scientific journals does NOT make it OK. Infant feeding should NOT be about how much we can get away with. It should be about protecting both breastfed babies and babies fed on formula. This isn't an issue of moral guardianship - this is about commercial morals. It is unethical to place profit above infant health.


Rather than promoting and sustaining a formula feeding culture through advertising breastmilk substitutes, medical journals like the BMJ and the BJM have a responsibility to provide professionals with accurate, impartial information about infant feeding. It is time for journals to comply with the WHO Code and subsequent WHA resolutions. The fact that it is not illegal to advertise infant formula in scientific journals does not mean journals cannot choose to refuse to do so. High profile journals such as the BMJ and BJM are in a wonderful position to lead the way in creating and implementing voluntary policies to ban all infant formula adverts in their publications. A voluntary ban on infant feeding industry adverts in scientific journals would be instrumental in:


  • preventing the infant feeding industry from using medical/scientific journals to undermine breastfeeding and breast milk donation through normalising bottle feeding and influencing health professionals' decision-making via advertising, and so potentially exposing fewer babies to infant formula feeding and its associated risks
  • giving scientific journals greater freedom to impart truly factual, impartial information about breastfeeding and infant formula (remember: advertising is NOT information-giving; advertising is selling)
  • making scientific journals less beholden to the infant feeding industry, decreasing the likelihood of selection of articles for publication which have an obvious bias towards the infant feeding industry
As recommended by the WHO Code and subsequent WHA resolutions, scientific journals should also ensure that the "information provided by manufacturers and distributors to health professionals regarding products should be restricted to scientific and factual matters" (8).

No, the media might not pounce on this story with quite as much glee as the infamous BMJ article, but if scientific journals voluntarily complied with the WHO code and subsequent WHA resolutions, it might just prevent the publication of dodgy, damaging research papers with obvious bias towards the infant feeding industry... and the public embarrassment and deterioration of reputation which inevitably follows.



But if you leave the back door open, what can you expect?


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Undoing the damage done to 6 months of exclusive breastfeeding...


Read the infamous BMJ article:
Click here to read the BMJ opinion piece.
Click here to read the BMJ's press release.


Now read the responses:


An excellent analysis from Analytical Armadillo
Responses from official organisations:
World Health Organisation
Unicef Baby Friendly Initiative
Baby Milk Action
Royal College of Midwives
La Leche League GB
Also worth reading are the rapid responses on the BMJ website


Information on Baby-Led Weaning can be found here:
Baby Essentials that Aren't, Part 7: Baby Food by Eco Child's Play
Guidelines for implementing a baby-led approach to the introduction of solid food by Gill Rapley on Kenniscentrum Borstvoeding
Rapley Weaning .com
Baby Led Weaning


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Bibliography & References


(1) Baby Feeding Law Group Why the UK Law must change if it is to protect infant health
(2) The Infant Formula and Follow-on Formula (England) Regulations (2007), Regulation 21
(3) NCT Campaign to protect mothers and babies from the effects of formula advertising
(4) Palmer G (2009) The Politics of Breastfeeding. London: Pinter & Martin, p317
(5) Royal College of Midwives Infant Formula Advertising Statement
(6) Beasley A & Amir L (2007) Policy on infant formula industry funding, support or sponsorship of articles submitted for publication International Breastfeeding Journal 2007, 2:5
(7) Bekelman J et al (2003) Scope and impact of financial conflicts of interest in biomedical research: A systematic review JAMA 2003 , 289:454-465.
(8) World Health Organisation (2008) The International Code of Marketing of Breast-Milk Substitutes Frequently Asked Questions, p5
(9) Baby Milk Action Line by Line response to Food Standards Agency proposals for Regulations on
(10)COMMISSION DIRECTIVE 2006/141/EC of 22 December 2006 on infant formulae and follow-on formulae and amending Directive 1999/21/EC Official Journal of the European Union, Article 14
(11) Advertising Association Advertising Association Acievements in 2008

1 comment:

  1. clever lady. You speak the truth and you speak it well!

    ReplyDelete

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