Why shouldn't formula companies sponsor training events for health workers?

An event is taking place in Manchester tomorrow - billed as a Journal of Family Health Care 'free conference bringing together health and social care professionals - designed to improve outcomes for mothers, babies and children.' Among the exhibitors are Nestle, HiPP Organic, and Danone Nutricia Early Life Nutrition; Nestle Nutrition UKs Head of Medical and Scientific Affairs, Dr Liz Greenstreet, is giving a presentation about 'optimal growth and feeding issues in the first 1000 days'. Other similar events take place regularly in the UK and elsewhere.

As a volunteer for and member of several impoverished organisations, I can understand how tempting it is to snap up funding that is on offer to make it easier to arrange events and training. It can be hard to see where the harm is; a sponsor pays for an expert speaker, the topic is not related to infant feeding, the sponsor may not even directly promote their products at the event. The sponsor is not the 'brand' itself, but their 'Nutrition Foundation', or educational or charitable arm, which has been set up, apparently, with the aim of providing high-quality education for health professionals. We all know that our NHS is underfunded and under threat. Why not use some money from private companies to fill in some of the gaps? Health workers work hard - long hours, modest pay and benefits. Who doesn't love a free lunch and a day out at a study day or conference? It's a welcome break from the stresses of working in a creaking organisation. The trouble is that there really is no such thing as that free lunch.

To understand the problems, we need to start by understanding the market for formula and baby food (for the purposes of this post I'm talking about the UK, but similar situations exist in many countries).

- the market for infant formula depends for its existence on women who do not or cannot breastfeed. When breastfeeding rates increase due to effective initiatives and good support, the market for formula milk decreases. More breastfeeding means fewer profits for the formula companies; it's a direct relationship.

- the formula companies are no different from most other companies - they exist to make money for their shareholders. To fulfil their duties to their shareholders they must maximise profits. This means that they must design marketing and sales strategies that aim to increase the market, and their share of that market. Job advertisements for posts at formula companies show this explicitly. (More on this, from Baby Milk Action, here.) Much like the energy companies that fight to drill for oil - although we know that burning the oil they produce will contribute to catastrophic climate change - formula companies must aggressively promote a product that is known to carry health risks in order to satisfy the demands of investors.

- formula companies are regulated by laws in many countries. The International Code of Marketing of Breastmilk Substitutes (and subsequent Resolutions), drafted by the World Health Organisation and adopted at the World Health Assembly by nearly every country in the world, forms the basis for the law; in the UK our laws do not fully implement the Code but they do restrict the marketing and promotion of first infant formula. Because they are limited by the law, companies must continually try to find new ways to market their products that get around the restrictions. Since they cannot market directly to mothers, they must target those who have contact with them - health workers. (Follow-on milk - an unnecessary product - was invented to get around these restrictions too. In countries where all formula advertising is restricted, follow-on milk does not exist.)

- formula companies are regulated because breastfeeding is the normal way to feed babies, and formula feeding carries known health risks for mothers and babies. Formula milk may be an infant's sole source of nutrition and must be suitable and nutritionally adequate (though it is not, and can never be, close or similar to breastmilk) so there are strict regulations about its composition. This means that the differences between products are very small, and often claimed differences do not stand up to scientific scrutiny. What really matters to companies is 'brand awareness'. What can they do to ensure that the buyer of formula, whoever that is, chooses one brand and not another? One answer is to get that brand, or information about it, on to materials that will be seen by their target market (which is hard, because they are restricted from marketing directly to mothers), or those that advise them - midwives, doctors, health visitors, community nurses and so on.

You might think that health workers should be immune to the effects of marketing - surely they know all this, and can make their own informed decisions? In fact research shows that none of us are immune to marketing. The effects of even small, trivial gifts such as pens and notepads have been shown to cause the recipient to feel good about the giver. Larger gifts, such as free study days (which delegates might otherwise have to pay for themselves, or apply to their employers for the money) have a greater effect. The speaker paid by the sponsor feels good about the sponsor too. Might that influence the content of what they say? It certainly suits a formula company to have both health workers and experts feeling good about their name or brand. When a health worker who attends a study day goes back to the office and tells colleagues about the event, might they mention the sponsor by name? Or show others the programme for the day that carries the sponsor's logo? It's only a short step from here to saying to a new mother, 'Well we're not supposed to give advice, but xxx is meant to be good'. (Hands up if you work in breastfeeding and have heard that one before?)

To sum up, sponsoring an event may benefit the sponsor in many ways:

- goodwill from the participants/organisers
- promotion of the name/logo/brand - on advertising for the event and materials given out
- networking opportunities for staff from the sponsor organisation who may attend the event
- product promotion (some events allow product promotion/stands by sponsors)
- the chance to obtain personal/workplace contact details from participants

Given the above, I think it's clear that formula companies should not be sponsoring training - any training, not just in breastfeeding - for health workers, and that organisations should have policies in place to avoid conflicts of interest.

The Guardian and Danone infant feeding roundtable - and why the politics of breastfeeding matter

A couple of weeks ago I Tweeted my disappointment that the Guardian had decided to run a roundtable discussion in association with Danone Nutricia; yesterday an article reporting on the debate appeared in the paper's society section; a full page, with the Danone Nutricia Early Life Nutrition logo clearly displayed, and an explanation that the content is editorially independent (which presumably means that the journalist, Joanna Moorhead, wrote her piece reporting on the discussion without having the text approved by Danone). As Helen Crichton, head of public affairs for Danone Early Life Nutrition took part in the discussion itself, and Danone was able to suggest topics to be included in the discussion, the term 'editorially independent' is at best only partially accurate.

Mike Brady, Baby Milk Action's campaigns coordinator, has already published an excellent response to the Guardian article; you can read it here. What follows is my personal response to the article, which attempts to explain some of the reasons it made me so uncomfortable/furious.

Participants
Paul Lindley, founder of Ella's Kitchen
Helen Crichton from Danone itself;
Judy More, freelance dietician. Her website reveals that she is on the editorial board of the Journal of Family Health Care, which runs training events sponsored by formula companies including Nestle, Danone and Hipp Organic, and that she has worked for the Infant and Toddler Forum:

"The Infant & Toddler Forum is supported by an educational grant from Danone Nutricia Early Life Nutrition. The views and outputs of the group, however, remain independent of Danone Nutricia Early Life Nutrition and its commercial interests."

Professor Paul Gately from Leeds Metropolitan University. He has previously been a speaker at an event sponsored by the Infant and Toddler Forum.

Four of seven panel members have a clear conflict of interest in the discussion, because they are currently, or have been in the past, paid by companies that make profits marketing and selling products aimed at babies and young children. Judy More and Paul Gately's conflicts of interest were not made clear in the article; I found their earlier links to Danone with a simple search.

A major problem with this sort of 'invitation' roundtable discussion sponsored by a formula company is panel selection. Anyone who's had any sort of training on the International Code of Marketing of Breastmilk Substitutes, who works in breastfeeding, public health or in a Baby Friendly accredited NHS Trust should refuse to be involved. (For more about health worker conflicts of interest, see here).

Content/discussion
Reading the article I found myself occasionally incredulous. Paul Lindley (Ella's Kitchen) is quoted as saying, 'Food is what brings people together, but they're not eating together very often and very young children aren't learning the art of conversation or the joy of eating with others.' This from a man who founded a company that makes pouches of ready-made pureed baby food that babies can slurp alone in their pushchairs without making a mess! Is it just me?

Dr Lucy Cooke said 'There's a lot of confusion about breastfeeding. The Department of Health says breastfeed to six months, but baby foods say 4-6 months on the jar'. Both Lindley and More, who should both surely understand the Code, the Department of Health guidelines and how information is given to new mothers, given their work, instead perpetuated the confusion, with Lindley appearing to advocate early weaning by saying that the earlier you give children vegetables, the more likely they are to eat them later on. What he didn't say was that early feeding (before six months) with pureed foods like apples, carrots and parsnips, which his company supplies in pouches, displaces breastmilk in a baby's diet and may reduce their overall nutrition rather than improve it.

I was also deeply uneasy about the suggestion that 'one change that would make a huge difference was to encourage better collaboration between the government and the food industry'. The food industry already has extensive access to contacts in government, and will lobby hard for its own interests. There is plenty of evidence that if companies are not regulated, then they will not restrain their marketing practices voluntarily. If the industry is so keen to do good, surely it should first put its own house in order: in the case of Danone, with 39 pages of marketing Code violations worldwide in the IBFAN Breaking the Rules, Stretching the Rules 2014 report, it would seem that the company has plenty of work to do before embarking on seemingly generous public health campaigns. Ella's Kitchen too could look at its early weaning guidance and labelling so that it better reflects the information that mothers are actually given.

And mothers are often given good information; but we didn't hear anyone talking about it in this debate because of the inherent conflict of interest. Health visitors, midwives and breastfeeding supporters could have painted another picture; one where UNICEF Baby Friendly and the First Steps Nutrition Trust are sources of clear, independent information for parents. The LIFIB (Lancashire Infant Feeding Information Board) is a great example of how information from companies can be critically reviewed and challenged before being passed on to health professionals (see @The_LIFIB).

I could go on, and on. I won't, but I will leave you with this quote from my forthcoming book with Gabrielle Palmer for Pinter and Martin Why The Politics of Breastfeeding Matter, which sums up my thoughts.

"When ‘knowledge’ comes from company promotion [which is what Danone-sponsored activities are] and poorly trained or corrupt health workers, parents and children suffer. Knowledgeable and supported families, who are aware that breastfeeding is normal, that artificial feeding carries risks, and that cheaper, safer baby foods can be made from locally available ingredients, end up healthier and less poor. The Code states that governments are responsible for ensuring that objective and consistent information on infant and young child feeding is provided. But it is hopeless to invest public money in providing such information if it is eclipsed by promotional untruths."

Nutrimum: new product, same old formula company tactics

This morning the First Steps Nutrition Trust newsletter hit my inbox (if you don't get this already I highly recommend it). They've issued a statement on nutrimum, a new product on the market that I'd heard about thanks to a Facebook post from Michael Walne at Your Nutrition Matters (who is busy writing evidence-based nutrition books for the Pinter and Martin Why It Matters series at the moment).

Nutrimum is a range of cereal bars and granola aimed at pregnant and breastfeeding women, made by Nutricia, owned by Danone, which makes Cow & Gate and Aptamil infant formula. The new products are currently available through Boots stores and are heavily marketed on the Boots website, with advertorials accompanied by 'buy now' prompts. The advertorials stress the importance of maternal nutrition during pregnancy and breastfeeding; the clear implication is that the nutrimum bars and cereals can form part of the healthy diet that is being discussed. Associating general nutrition information with specific products is a deliberate strategy. Marketing products that combine food
and supplements through a store such as Boots, which although it has dropped 'the chemist' from its name still has a reputation for selling pharmacy products, also helps to support the idea that these products are somehow 'scientific' or 'beneficial' (they aren't). Using partner organisations for 'reputation transfer' is a tactic often used by formula manufacturers: for example in 2013 Danone sponsored a 'Big Toddle' in aid of Barnardos to promote its Cow & Gate brand.

The First Steps Nutrition Trust statement on nutrimum explains how the products undermine public health by stating that women should stop taking other supplements (which will have been recommended to them by midwives or health visitors in accordance with current guidelines) while consuming the products. Folic acid (which is recommended for those who are planning a pregnancy and pregnant women) and vitamin D (recommended for all pregnant and breastfeeding women) supplements are widely available in supermarkets and pharmacies at low cost, or may be free on the Healthy Start scheme. The nutrimum products are expensive: the cereal bars cost £4.99 for five bars, or £1 a day. A large part of the cost of the product will go on marketing. (As with infant formula, the marketing is paid for by those who buy the product.) Equivalent vitamin D and folic acid supplements cost just pennies per day. The cereal bars and granola are highly processed and high in sugar; the main ingredient (listed first in the ingredients list) in the bars is glucose syrup (sugar). A crucial difference between granola/cereal bars and vitamin supplements is that the granola/bars are food - they will fill you up, and increase your blood sugar levels, potentially displacing more nutritious foods (vegetables, fruit, nuts, eggs, meat) in your diet. Tablets and liquid supplements do not have this effect.

When formula companies stress the importance of nutrition while breastfeeding, they do so in order to make breastfeeding seem difficult, expensive and inconvenient - an unachievable ideal. Mothers who doubt the quality of their breastmilk may turn to formula for 'reassurance' that their babies are getting all that they need. In reality there is little difference in the nutritional profile of breastmilk worldwide: mothers everywhere, despite wide variations in diet, produce milk that will nourish their babies and keep them healthy. A mother needs good food for her own health, not to support breastfeeding. Mothers in the UK (where nutrimum is marketed) have access to better, cheaper food than these highly processed cereal products that are high in sugar and expensive. As First Steps Nutrition say:

'Good nutrition from food is perfectly possible for pregnant and breastfeeding mums and we show how nutrient requirements can be met through simple, cost effective menu choices in practical eating well resources. The money spent on these supplements could be more wisely used buying fresh and minimally processed foods for the household.'

Formula companies target medical and health workers to promote their products. Perhaps the most disturbing part of the First Steps Nutrition statement on nutrimum is the section about how company representatives have contacted infant feeding coordinators and NHS staff. An email to an infant feeding coordinator in February 2015 states that the product is:

‘designed to meet all the nutritional requirements for mum during pregnancy…and that neonatal nurses are particularly interested in Nutrimum for breastfeeding mums with babies in special care baby units’

It's this that makes me actually want to scream. For the last few months I've been working on a short book about the politics of breastfeeding, and this type of contact with health professionals, implying that the product is beneficial for mums breastfeeding special care babies (for which there is certainly no evidence), is reminiscent of all the marketing abuses I've been writing about. That this isn't infant formula doesn't matter. These products offer no benefits, play on fears mothers have about their own and their babies' nutrition, and the profits will line the pockets of the world's second biggest baby milk manufacturer. Thank goodness for the work of First Steps Nutrition and other organisations like Baby Milk Action that scrutinise and monitor the companies. Do visit their websites and join or donate to support their work if you can. And if you work with mothers, tell them that these products are unnecessary, expensive and heavily marketed (and that if they buy them, they are paying for the marketing).

Advertising infant formula - WHO cares?

Last month, online retailer Ocado distributed, in print and online, a magazine that carried a feature advertising first-stage infant formula. They've now (after an initial delay) amended the online version of the magazine, which you can see here. The article on p34 originally had an image of a box of six ready-to-feed SMA bottles in the 'S is for Sleep' section (see right) - in fact the whole section looked as though it spelt out S.M.A. The first problem? It's illegal in the UK to advertise first-stage infant formula: the relevant legislation is here.

So far, so simple. Ocado were pulled up on their mistake, and they responded with an apology:

The SMA First Infant Milk product was included in the feature by mistake. The mistake occurred purely through human error and we are satisfied this is an isolated incident. We are very sorry that this has happened and we have made some changes to the ocadolife production process to ensure this cannot happen again. We take compliance very seriously at Ocado and as a responsible retailer we have voluntarily approached the relevant authorities to discuss this matter with them. We can also confirm SMA did not provide any funding for the inclusion of their product in the feature and we also extend our apologies to them for our error.

An end to the matter? Not really. The whole incident brought some of the issues affecting infant feeding in the UK sharply into focus. So much is wrong with the picture. That this image of formula milk appeared in the 'sleep' section of the article reflects a common misconception that formula feeding aids infant sleep (when in fact it increases the risk of SIDS). That the image appeared at all demonstrates a worrying lack of awareness of the law among editors, copyeditors, proofreaders... And a storm of comments on Facebook (I saw them on the Association of Breastfeeding Mothers page, and on the Ocado page) demonstrated just how poorly the general public understand the law itself, and the reasons for it (which reminded me of the comments made about breastfeeding in swimming pools that I blogged about here.) A small selection:

I don't see what's wrong with this. Some people formula feed, so what!!!

In today's world of equality and freedom of choice its a disgrace that such a law even exists... it hits a bit of a raw nerve when I read so many people trying uphold a law that in my opinion should never have been passed.

...not allowing advertising of first milk is making some mothers' failure at breastfeeding even more apparent... don't we need to be looking at the nhs midwifery service and the support (or lack of) that new mothers receive rather than the advertising...?

If these infant formulas were actually bad for baby and caused harm... then they wouldn't be allowed to be produced never mind advertised.

Adverts are allowed for everything else under the sun claiming to be healthy such as high sugar cereals, breakfast bars and alcohol!!!... but adverts aren't allowed when it comes to offering choice or advice on formula milk!!!

So why is it illegal to advertise formula?

I just don't get why people are so up in arms about a very small picture in a publication.

The law exists because of pressure groups who don't feel that people should be allowed to make their own choices.

The problem with this law is that it prevents the balanced info that you claim you want parents to have. 

Let me make it clear. The law exists to protect mothers and young babies, whether breastfeeding or artificial feeding. We know (and by we, I mean that it is common knowledge) that breastfeeding is the normal way to feed human infants, and we know, thanks to an ever-expanding wealth of scientific research, that not doing so carries a host of increased health risks for both babies and their mothers. Yes, even in the UK. It seems logical then that the marketing of breastmilk substitutes for infants, which are artificially-fed babies' sole source of nutrition, should be subject to checks and controls.

It's also clear, from even the most cursory look at the advertising practices of the formula manufacturers, that they will go to great lengths to promote their products, often making pseudo-scientific claims that do not stand up to scrutiny (cases have been brought against them, and won), adding ingredients of unproven benefit and cynically targeting health care professionals when they are denied direct access to parents. Baby Milk Action, and the UK Baby Feeding Law Group, monitor the activities of the various formula companies: you can find a great deal of further reading on their websites (my most-read post ever is about this topic too, here.) It seems obvious that companies aiming to maximise their profits are not best placed to offer objective information about formula feeding.

The above has been known for some time, and is recognised worldwide. Hence WHO (the World Health Organisation) created the International Code of Marketing of Breast-milk Substitutes, adopted in 1981, the aim of which is to:

...contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, 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.

Can anyone find anything there to disagree with? It sounds perfectly sensible. In 2003, WHO and UNICEF, as part of a global strategy for infant and young child feeding, called for governments to 'review progress in national implementation of the Code, and consider new legislation or additional measures as needed to protect families from adverse commercial influences.' Unfortunately, in the UK we have still only partially implemented the WHO Code, which, as Emma Pickett IBCLC, co-chair of the ABM, explains:

...could be argued to have done more harm than good. It has led directly to the 'invention' of follow-on formula, which is not subject to the same advertising controls as first-stage formula. In countries that have fully implemented the Code, there is no follow-on formula at all - if it really were a distinct and medically necessary product, as the manufacturers would have UK parents believe, surely it would be available worldwide? Here in the UK we have evidence from the Diet and Nutrition Survey that 32% of parents have given follow-on formula before six months: proof, if any more were needed, that advertising really works.

She also describes a situation that breastfeeding supporters everywhere will recognise:

You meet mothers every day who use formula alongside breastfeeding and end exclusive breastfeeding because the messages they receive from advertising are far more powerful than the information they are drily given about the benefits of exclusive breastfeeding. The TV adverts stick in the mind long after someone mumbling something about gut flora and allergy prevention.

It's grimly ironic that those parents complaining about the law against advertising first-stage formula are the very same parents that are being ripped off, both financially and through misinformation, by the formula manufacturers. Rough calculations (companies won't reveal their figures) suggest that of an annual spend by parents of £436.54 on Aptamil powdered formula, for example, between £231 and £349 goes on marketing and profit. Still think the companies are acting in the best interests of consumers?

As for where parents should go for better information, UNICEF, First Steps Nutrition, Which? and others all have guides to artificial feeding for those who need them, freely available on the internet.

But there's even more to it than this. Want to see how deep the rabbit-hole goes? In this post on the Alpha Parent James Akre describes our culture of acceptance of formula feeding thus (my italics):

Given the mass of compelling scientific and epidemiological evidence about the harm caused by routine artificial feeding, it’s hardly farfetched to qualify as collective delusion the unquestioned faith that the general public and health professionals alike in many settings continue to place in infant formula...

...Infant formula will sustain life in a pinch, and thank goodness this is so. But as I describe elsewhere, from a nutritional and developmental standpoint, most people do not understand just how hugely inferior it is to breast milk...The idealized view of normalized infant formula feeding that manufacturers are so adept at portraying – and, regrettably, so many consumers, health professionals and politicians are inclined to accept – doesn’t allow for even a hint of this disenchanting reality.

Given all the evidence, why do you think we haven't fully implemented the Code in the UK? And why don't we make more use of the laws we have? Don't be fooled into thinking that the reasons have anything to do with any doubts about the benefits, in terms of public health, of doing so. It's an uncomfortable truth that we cannot rely on governments to act as they should, even in the face of overwhelming evidence and firm guidance from WHO (which has no power to compel countries to implement the Code). The pressure, on governments and other organisations, from vested interests within the baby food industry and elsewhere, is immense: the power of corporations, at the highest levels of politics and policy-making, cannot be dismissed as conspiracy theory. When so much profit is at stake, the interested parties will do all they can to exert an influence. This month a letter appeared in the Journal of the World Public Health Nutrition Association about conflicts of interest in the area of infant nutrition:

...concerned with the equally deep penetration of the transnationals and their associated or supportive organisations, into the scientific community, into nutrition policy-making at the highest level, and into public health programmes that affect the health and lives of hundreds of millions of people.
We see this largely as a consequence of the failure of elected governments to fulfil their first duty, which is to govern. We also feel that some policy-makers and many scientists, including those working at the highest level, underestimate or overlook the consequences of their own actions.
The influence of Big Food can be subtle, and may, in the opinion of reasonable people, be seen to affect the judgement of public policy agenda-setters who act in good faith and whose personal integrity is not at issue. We are not questioning the motives of any of the people mentioned in this letter. We are though, deeply concerned about the possible effects of their activities.

Our specific situation in the UK is part of a global issue that has far-reaching implications for mothers and babies. Just today Baby Milk Action posted this press release on their website about formula companies bribing hospitals in China - yes, those same formula companies that advertise and sell products in the UK.

I've covered a lot of ground: from a tiny image of first-stage formula in an Ocado magazine, to global politics, nutrition policy and economics, in one helter-skelter ride. And really, this is still only scratching the surface. I just hope I have gone some way towards showing how that one little article is part of a much bigger picture that should concern us all.

Baby milk shortages - formula manufacturers, the politics of infant feeding, breastfeeding

The news that Danone, which makes Aptamil and Cow & Gate formula milks, has imposed sales restrictions on parents in the UK has been all over the media this week. Shoppers are now limited to purchasing two packs of powdered infant formula per day. Supposedly this is to prevent bulk buying and informal export of formula to China - at least, that is the explanation that Danone have given on the brands' respective websites, in a letter from managing director John Sykes.

However, there can be no denying that the story has generated massive publicity for the brands involved. For example, in this segment on the BBC website the mother is filmed using Aptamil formula, and this article from the Daily Mail carries a prominent shot of both Danone brands on supermarket shelves, complete with shelf-edge explanation of the buying restrictions.

What better way to add cachet to the Danone brand than to let its UK market know how highly prized its products are in China? The fact that millions of Chinese consumers (in a country beset by formula milk scandals, where formula advertising is aggressive and unregulated, and breastfeeding rates are on the way down) trust the brand and will pay inflated sums for it is surely something worth (from Danone's perspective) instilling in the minds of UK consumers. In addition, products in short supply have 'rarity value' - it's like must-have toys at Christmas, or petrol, or limited-edition designer handbags - that 'value', in the minds of consumers, is great news for retailers and manufacturers. Crucially, 'news' stories are not seen as 'advertising', although in practice, as anyone involved in the media knows, they fulfil the same function - there is truth in the old maxim 'all publicity is good publicity'.

The knock-on effects of all this on our culture of infant feeding on the UK are more subtle. A slew of articles about formula feeding normalises it further - a shortage that affects millions of parents across the UK gives the message that 'everyone' is using formula as opposed to breastfeeding. Images of specific brands accompanying the articles make it more likely that parents, faced with a shelf full of products and with little access to accurate, unbiased information about infant formula, will reach for the product they recognise. As shown by the Daily Mail article mentioned above, a focus in the media on formula feeding can bring with it a wave of anti-breastfeeding feeling. The author of the article claims that "the breastapo are out in force, berating the formula feeding pariahs who feed our babies this manufactured 'poison'." I don't believe this or see any evidence of it; all this article shows is that, given a convenient peg to hang it on (news of a formula shortage), the same tired elements of a FF v BF argument that helps no one and only serves to divide women and line the pockets of the formula manufacturers, can be trotted out yet again.

(A separate, but I suspect related, article in the Mirror about vitamin D deficiency mentioned Cow & Gate Growing Up Milk by name, causing me to wonder whether the article had been 'inspired' by a Danone press release... the formula companies are very keen for parents to know that children consuming more than 450ml of first stage or follow-on formula per day do not need vitamin D supplements.)

Consider the context of all this. We already know from the Infant Feeding Survey 2010 that in the UK many parents are unaware of the differences between infant (first stage) formula and follow-on formula (suitable from six months) - the latter being an unnecessary product specifically designed to circumvent the restrictions on marketing infant formula imposed by the WHO code on the marketing of breastmilk substitutes, which is not even fully implemented in the UK. We also know that the formula companies will battle incessantly for market share with a huge array of marketing tactics (carelines, baby clubs, marketing to health professionals, roadshows... the list goes on). All this is funded by marketing budgets, paid for by formula consumers. Increased market share means increased profits. In this sort of climate a shortage of product makes perfect sense as an aggressive marketing ploy.

In case you think I'm overstating the case here, I'd like to highlight the work of Baby Milk Action, which has recently published a new report Look What They're Doing in the UK!. In the press release that accompanies the report Mike Brady, Campaigns and Networking Coordinator, says:

"Given the massive production capacity that Danone has in nearby Ireland there is something about this story that does not ring true: it is surely more likely Danone that is prioritising other markets than people exporting supermarket stocks. Danone is locked in fierce competition with Nestlé, particularly in Asia. Danone is gaining massive publicity for its products on the back of this shortage scare, but parents who use formula can heed Department of Health advice and switch to other brands. Claims made that one particular brand is better than another do not stand up to scrutiny. As our Look What They're Doing in the UK report demonstrates, companies are endlessly imaginative in how they push their products."

In the BBC report on the issue, Nestle, the second largest formula manufacturer in the UK market, said that it had not seen an increase in demand due to unofficial exports, and that there was no shortage of its products. (Nevertheless, some supermarkets are limiting sales of Nestle brands too.)

It seems to me that what's needed, as usual in reference to infant feeding, is wider access to clear, unbiased information that doesn't come from the formula manufacturers themselves, and this article in the Telegraph made the same point. UNICEFs Babyfriendly initiative publishes A guide to infant formula for parents who are bottle-feeding, which is a great place to start. Another good source (aimed at health professionals, but anyone can download the report) is Infant Milks in the UK.

It's also not unreasonable, as part of the ongoing discussion, to talk about breastfeeding. It's not shaming of those who use formula to point out that, on a population level, increased breastfeeding would mean both improved public health and less reliance on commercially-driven formula milk manufacturers. The 'shortage' story could be seen as demonstrating perfectly some of the most amazing qualities of breastfeeding: most mothers can produce hundreds of litres of breastmilk (incomparable to formula) for a zero carbon footprint - no food miles, no energy costs of manufacture or reconstitution, no supply-chain issues. 

I've been considering the implications of all this for breastfeeding support. I had a conversation with a formula-feeding mother while I was planning this article: she asked me what, as a breastfeeding peer supporter, I would do if someone asked me about formula feeding. I thought hard about what I could do in this situation, aside from talking to the mother about her reasons for switching to see if there was anything I could help her with before she stopped breastfeeding, and discussing the option of mixed feeding (on the grounds that any breastfeeding is better than none). I realised there's a lot of information I can give, although I would be upfront about my lack of personal experience of bottle or formula feeding. I do, however, know about the most recent guidelines for making up bottles and the reasons for them, and am happy to talk to mothers about them. I have also read the guides above and feel that I could tell a mother that since the composition of formula in the UK is regulated, and claims about differences between brands don't hold water, her decision can be based on price and what her child seems to prefer, and she needn't be restricted to one brand. I'd hope, in doing this, to leave the mother feeling better-informed about her options, and not let-down by a sudden lack of support when her circumstances change. I'd love to hear what other breastfeeding supporters think about this.