tag:theconversation.com,2011:/nz/topics/infant-formula-56573/articlesInfant formula – The Conversation2023-08-14T19:37:44Ztag:theconversation.com,2011:article/2047162023-08-14T19:37:44Z2023-08-14T19:37:44ZCanada’s welfare system is failing mothers with infants<figure><img src="https://images.theconversation.com/files/541320/original/file-20230805-15-xi8j4t.jpg?ixlib=rb-1.1.0&rect=0%2C82%2C3670%2C2351&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Food insecurity can impact both a mother’s ability or decision to breastfeed, and also the ability to purchase baby formula.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/canadas-welfare-system-is-failing-mothers-with-infants" width="100%" height="400"></iframe>
<p>The Canadian government issued a <a href="https://theconversation.com/federal-budget-2023-grocery-rebate-is-the-right-direction-on-food-insecurity-but-theres-a-long-road-ahead-201926">one-time grocery rebate</a> in July, targeted at low-income Canadians. While the rebate provided some relief to people struggling with soaring inflation, <a href="https://theconversation.com/federal-budget-2023-grocery-rebate-is-the-right-direction-on-food-insecurity-but-theres-a-long-road-ahead-201926">it is far from enough</a> to address the depth of poverty and intensity of food insecurity faced by the lowest income Canadians. </p>
<p>During the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4981537/">most vulnerable time of life</a>, mothers and infants living on welfare are experiencing food insecurity, which can have <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.0645">lifelong impacts</a>. Governments need to make policy changes to better serve mothers and their children. </p>
<h2>Infant food insecurity</h2>
<p>Food insecurity is defined as having “<a href="https://proof.utoronto.ca/food-insecurity/">inadequate or insecure access to food due to financial constraints</a>.” Maternal food insecurity can result in many health-damaging effects, ranging from <a href="https://bmjopen.bmj.com/content/10/1/e033296">adverse birth outcomes</a> to <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2015.0645">mental health issues</a>. Infant food insecurity can result in long-term developmental impacts, including effects on <a href="https://doi.org/10.1016/j.pcl.2019.12.004">cognition and brain development</a>. </p>
<p>Experts have outlined how <a href="https://theconversation.com/why-are-babies-going-hungry-in-a-food-rich-nation-like-canada-165789">food insecurity can impact a mother’s ability or decision to breastfeed</a>. Food-insecure mothers might cease breastfeeding much sooner because they feel they have inadequate breastmilk supply. In addition, they might struggle to afford infant formula.</p>
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<a href="https://images.theconversation.com/files/524793/original/file-20230508-29-dhs4uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman feeding a baby from a bottle." src="https://images.theconversation.com/files/524793/original/file-20230508-29-dhs4uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/524793/original/file-20230508-29-dhs4uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/524793/original/file-20230508-29-dhs4uw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/524793/original/file-20230508-29-dhs4uw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/524793/original/file-20230508-29-dhs4uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/524793/original/file-20230508-29-dhs4uw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/524793/original/file-20230508-29-dhs4uw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Mothers and infants living on welfare are experiencing food insecurity, which can have lifelong impacts.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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<p>While food-insecure mothers initiate breastfeeding at the same rate as food-secure mothers, <a href="https://www.ctvnews.ca/health/study-finds-moms-living-in-poverty-struggle-to-breastfeed-their-babies-longer-1.3853616?cache=yes">rates drop steeply within the first two months</a>. Mothers who are undernourished themselves might perceive they have less than adequate milk supply and often stop breastfeeding for this reason, <a href="https://www.ubcpress.ca/out-of-milk">believing the baby will suffer because they have an inadequate diet</a>. </p>
<p>For low-income mothers, breastfeeding might seem to be the most cost-effective way of feeding their infants. However, other research shows that <a href="https://pubmed.ncbi.nlm.nih.gov/32162282/">both formula and breastfeeding are unaffordable to mothers who receive welfare</a>. </p>
<h2>Problems with the welfare system</h2>
<p>Approximately <a href="https://maytree.com/wp-content/uploads/Social_Assistance_Summaries_All_Canada.pdf">four to six per cent of people</a> in most provinces and territories receive welfare benefits. The number is slightly lower in the Yukon and Alberta and significantly higher in Nunavut where it is just under 28 per cent. </p>
<p>While some provinces and territories provide more financial resources to pregnant women and mothers than others, incomes remain low and inadequate to achieve food security. </p>
<p>For example, Nova Scotia welfare recipients receive a total of <a href="https://novascotia.ca/coms/employment/documents/ESIA_Program_Policy_Manual.pdf">$51 per month in maternal nutrition allowance</a> during pregnancy and up to 12 months after birth. However, this is often not enough support for low-income mothers to adequately feed their infants.</p>
<p><a href="https://proof.utoronto.ca/2023/new-data-on-household-food-insecurity-in-2022/">COVID-19 increased household food insecurity rates for households with children in both Canada</a> and the <a href="https://www.ers.usda.gov/amber-waves/2022/february/food-insecurity-for-households-with-children-rose-in-2020-disrupting-decade-long-decline/">United States</a></p>
<p>Allowances for pregnant women and mothers of infants receiving welfare are similarly low across Canada. These low rates create food insecurity for these vulnerable families and must be rectified via provincial, territorial and federal government policies. </p>
<h2>Charity alone is not enough</h2>
<p>Some might assume that charities and food banks will provide vital support for low-income families. A recent study found that during the peak of the COVID-19 pandemic, many community organizations <a href="https://doi.org/10.1080/14927713.2022.2054460">answered the increased call for food</a>. </p>
<p>While community organizations were critical in filling pandemic gaps, they alone cannot address the root cause of food insecurity: inadequate incomes. That problem continues, and the number of people relying on food banks has <a href="https://www.cbc.ca/news/canada/toronto/60-rise-use-of-food-banks-programs-canada-2023-1.6711094">increased exponentially in the past couple of years</a>.</p>
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<p>Additionally, many food banks are <a href="https://ca.style.yahoo.com/at-breaking-point-canadian-food-banks-struggling-insecurity-inflation-214221464.html">struggling to provide enough food</a>. The demand for food now far outstrips the donations most food banks receive. A sustainable solution to food insecurity is needed, particularly for pregnant women and mothers of infants. </p>
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<a href="https://images.theconversation.com/files/541322/original/file-20230805-21-3ju57z.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A person in a grey t-shirt placing food items on a shelf" src="https://images.theconversation.com/files/541322/original/file-20230805-21-3ju57z.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/541322/original/file-20230805-21-3ju57z.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/541322/original/file-20230805-21-3ju57z.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/541322/original/file-20230805-21-3ju57z.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/541322/original/file-20230805-21-3ju57z.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/541322/original/file-20230805-21-3ju57z.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/541322/original/file-20230805-21-3ju57z.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">A volunteer places products on shelves at a food bank in Ottawa. Food banks alone cannot address the root cause of food insecurity: inadequate incomes.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Adrian Wyld</span></span>
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<h2>Child welfare laws</h2>
<p>In addition, child welfare laws need to be changed to stop them from unfairly penalizing poorer parents. In Nova Scotia, the <a href="https://policyalternatives.ca/sites/default/files/uploads/publications/Nova%20Scotia%20Office/2023/03/CCPAChildPovertyReportCardFINAL.pdf"><em>Children and Family Services Act</em> stipulates</a> that parents’ failure to provide adequate nutrition is grounds for child apprehension.</p>
<p><a href="https://policyalternatives.ca/sites/default/files/uploads/publications/Nova%20Scotia%20Office/2023/03/CCPAChildPovertyReportCardFINAL.pdf">The 2022 Report Card on Child and Family Poverty in Nova Scotia</a> recommended removing this stipulation. <a href="https://fernwoodpublishing.ca/book/ineligible">Experts have highlighted</a> the punitive nature of such requirements. These kinds of regulations punish mothers for their poverty and food insecurity, rather than increasing the financial support they receive.</p>
<h2>Impact of inflation</h2>
<p>There are also reforms that need to take place around welfare rates that would create a more liveable income source for mothers and infants in particular. </p>
<p>As the 2022 report card on poverty in Nova Scotia shows, welfare rates are not indexed to inflation in the province. This has resulted in <a href="https://www.cbc.ca/news/canada/nova-scotia/ns-income-assistance-rates-unchanged-1.6788662">benefits stagnating</a> despite a few modest increases in the past several years. Only three provinces and territories <a href="https://maytree.com/wp-content/uploads/Welfare_in_Canada_2021.pdf">index welfare rates to inflation:</a> New Brunswick, Québec and the Yukon. In Québec, <a href="https://inroadsjournal.ca/quebecs-distinct-welfare-state-on-poverty-among-families-with-children-quebec-%E2%80%A8and-the-rest-of-canada-have-taken-different-paths/">this has resulted in lower income inequality</a>. </p>
<p>The province has also recently launched a <a href="https://www.cbc.ca/news/canada/montreal/quebec-basic-income-program-begins-advocates-say-many-low-income-people-excluded-1.6730003">basic income program</a> and although the eligibility requirements exclude many, it does increase income recipients would otherwise receive from welfare benefits.</p>
<p>With inflation affecting the price of food, the depth of food insecurity for mothers receiving welfare payments will only grow. Welfare rates must reflect the income necessary to feed pregnant and new mothers and provide them the support they need to care for their children.</p><img src="https://counter.theconversation.com/content/204716/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Laura Fisher receives funding from the Social Sciences and Humanities Research Council of Canada.</span></em></p>Low-income mothers with infants are struggling with food insecurity, which can lead to long-term health impacts for both mothers and children.Laura Fisher, PhD student, Sociology, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2010852023-03-23T12:42:19Z2023-03-23T12:42:19ZInfant formula shortages forced some parents to feed their babies in less healthy ways<figure><img src="https://images.theconversation.com/files/515955/original/file-20230316-2480-ieroj6.jpg?ixlib=rb-1.1.0&rect=16%2C0%2C5267%2C3500&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Babies still need to eat even when formula is hard to come by.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/shelves-are-empty-as-natalia-restrepo-a-member-of-la-news-photo/1240791802">Joseph Prezioso/AFP via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em> </p>
<h2>The big idea</h2>
<p>One third of families who relied on formula to feed their babies during the COVID-19 pandemic were forced by severe infant formula shortages to <a href="https://doi.org/10.1111/mcn.13498">resort to suboptimal feeding practices</a> that can harm infant health, according to our research published in the journal Maternal and Child Nutrition.</p>
<p>Infant formula shortages left <a href="https://www.kff.org/medicaid/issue-brief/key-characteristics-of-infants-and-implications-of-the-recent-formula-shortage/">70% of U.S. store shelves bare</a> in May 2022, with 10 states reporting out-of-stock rates of <a href="https://news.bloomberglaw.com/health-law-and-business/us-baby-formula-shortages-hit-74-despite-biden-action">90% or greater</a>.</p>
<p><a href="https://scholar.google.com/citations?user=hI28SJIAAAAJ&hl=en&oi=ao">As psychology</a> <a href="https://jessicamarinocom.wordpress.com">researchers</a> who study breastfeeding, this situation left us concerned for the safety of infant nutrition. With two <a href="https://scholar.google.com/citations?user=mrwyVwIAAAAJ&hl=en&oi=ao">colleagues who focus</a> <a href="https://scholar.google.com/citations?user=NChgQR4AAAAJ&hl=en">on public health</a>, we conducted an online survey of over 300 infant caregivers in the U.S. to understand how many families had trouble obtaining infant formula and what they fed their babies when they did.</p>
<p><iframe id="dxSI9" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/dxSI9/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Considering the scope of the formula shortages, we were not surprised that 31% of the formula-feeding families we surveyed reported challenges obtaining infant formula, the most common being that it was sold out and they had to travel to more than one store.</p>
<p>But their babies still needed to eat. Being unable to get their hands on infant formula pushed caregivers to potentially unhealthy or even dangerous stopgaps. For example, 11% of the formula-feeding families surveyed said they practiced “formula-stretching” – diluting infant formula with extra water to make formula supplies last longer, which provides a baby with less nutrition in each bottle.</p>
<p>Furthermore, 10% of formula-feeding families reported substituting cereal for infant formula in bottles, 8% prepared smaller bottles and 6% skipped formula feedings for their infants, which all provide infants with less nutritious meals.</p>
<p>Exclusively breastfeeding families were insulated against these supply disruptions. Almost half of breastfeeding families surveyed reported that COVID-19 lockdowns actually allowed them time to increase their milk supply. </p>
<h2>Why it matters</h2>
<p>Our study suggests that the waves of formula shortages from 2020 to 2022 in the U.S. were more than just an inconvenience for parents. Instead, this study is the first to document that formula shortages likely had real and widespread adverse impacts on infant nutrition, given that a large proportion of parents surveyed resorted to feeding their baby in ways that can harm infant health.</p>
<p>For instance, studies have shown that adding extra water to “stretch” formula can result in infant <a href="https://wicworks.fns.usda.gov/sites/default/files/media/document/infant-feeding-guide.pdf">malnutrition, growth and cognitive delays</a> and even <a href="https://doi.org/10.1542/peds.100.6.e4">seizures and death</a> in extreme cases. Adding cereal to bottles increases the risk of <a href="https://wicworks.fns.usda.gov/sites/default/files/media/document/infant-feeding-guide.pdf">choking-related deaths</a> and <a href="https://wicworks.fns.usda.gov/sites/default/files/media/document/infant-feeding-guide.pdf">severe constipation</a>. Moreover, feeding infants age-inappropriate foods can have lifelong consequences for <a href="https://doi.org/10.1111/nure.12102">cognitive development</a> and <a href="https://doi.org/10.1093/ajcn/87.6.1852">growth</a>, leading to a higher <a href="https://doi.org/10.1159/000351486">risk for chronic illnesses</a> like obesity and cardiovascular disease.</p>
<p>Given that <a href="https://www.cdc.gov/breastfeeding/data/reportcard.htm">approximately 75% of infants</a> in the U.S. are fed with infant formula in the first six months of life, formula shortages could put roughly 2.7 million babies each year at risk for suboptimal feeding practices.</p>
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<span class="caption">President Biden met with baby formula manufacturers in June 2022 to discuss shortages.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-joe-biden-meets-virtually-with-baby-formula-news-photo/1400488773">Kevin Dietsch/Getty Images</a></span>
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<h2>What’s next</h2>
<p>A perfect storm of formula recalls, ingredient shortages and shipping delays <a href="https://theconversation.com/whats-causing-the-us-baby-formula-shortage-and-how-to-make-sure-it-doesnt-happen-again-182929">contributed to COVID-19-related formula shortages</a> in the U.S. Although President Joe Biden’s administration has taken some steps to <a href="https://highways.dot.gov/newsroom/biden-administration-announces-new-protect-formula-program-73-billion-bipartisan">improve distribution infrastructure</a>, the U.S. does not currently have infant nutrition disaster plans in place beyond <a href="https://www.hhs.gov/formula/index.html">common-sense recommendations for individuals</a>.</p>
<p>Unfortunately, <a href="https://theconversation.com/breastfeeding-can-help-tackle-climate-crisis-but-its-on-governments-not-mums-to-save-the-world-124676">climate change will likely increase the risk</a> of formula-supply disruptions over the next century because of the <a href="https://e360.yale.edu/features/how-climate-change-is-disrupting-the-global-supply-chain">increased frequency of natural disasters</a>.</p>
<p>The best way to protect infant nutrition from supply chain issues is to promote and support breastfeeding, which provides optimal infant nutrition and insulates infants from those disruptions. Since <a href="https://www.healthgrades.com/right-care/pregnancy/9-reasons-you-may-not-be-able-to-breastfeed">not all babies can be breastfed</a>, though, governmental policies could help prevent and address acute formula shortages and ensure equitable formula access for all.</p><img src="https://counter.theconversation.com/content/201085/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Many families in the US encountered empty shelves when they went in search of infant formula during COVID-19.Jessica A. Marino, Doctoral Student in Health Psychology, University of California, MercedJennifer Hahn-Holbrook, Assistant Professor of Psychology, University of California, MercedLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1830852022-05-19T17:36:02Z2022-05-19T17:36:02ZWhat you need to know about the Defense Production Act – the 1950s law Biden invoked to try to end the baby formula shortage<figure><img src="https://images.theconversation.com/files/464308/original/file-20220519-15-2p9dzb.jpg?ixlib=rb-1.1.0&rect=96%2C66%2C4836%2C3216&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Biden invoked the Defense Production Act to help end the shortage of baby formula. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/BabyFormulaShortage/cbffe3810313405ca11283cdc7531bf3/photo?Query=baby%20formula&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=265&currentItemNo=0">AP Photo/David J. Phillip</a></span></figcaption></figure><p>U.S. President Joe Biden on May 18, 2022, <a href="https://www.whitehouse.gov/briefing-room/presidential-actions/2022/05/18/memorandum-on-the-delegation-of-authority-under-the-defense-production-act-to-ensure-an-adequate-supply-of-infant-formula/">announced he is invoking</a> the Defense Production Act to help end the <a href="https://theconversation.com/baby-formula-industry-was-primed-for-disaster-long-before-key-factory-closed-down-183016">shortage of baby formula</a> stressing out parents nationwide.</p>
<p>He said he will direct suppliers of baby formula ingredients to prioritize delivery to formula manufacturers and control their distribution as necessary.</p>
<p>You might well wonder what babies going without formula has to do with defense production, which calls to mind big warships and weapons systems. While using the <a href="https://www.fema.gov/disaster/defense-production-act">Defense Production Act</a> to force companies to make baby formula would certainly be a novel use of the act, it would hardly be the first time the postwar law has been used beyond its originally intended purpose to support national defense.</p>
<p>And in fact, the law is used a lot more frequently than you might think. But as a <a href="https://michiganross.umich.edu/faculty-research/faculty/erik-gordon">business professor</a> who studies strategies to maximize efficient allocation of resources, I believe when presidents invoke the act it’s often more about political theater – showing the public you’re doing something – than addressing the problem in the most effective way.</p>
<h2>Sweeping authority</h2>
<p>The Defense Production Act was passed in 1950 and modeled on the War Powers acts of <a href="https://www.visitthecapitol.gov/exhibitions/artifact/hr-6233-bill-expedite-prosecution-war-effort-first-war-powers-act-december-15">1941</a> and <a href="https://www.govinfo.gov/app/details/USCODE-2009-title50/USCODE-2009-title50-app-secondwar">1942</a>. </p>
<p>The War Powers acts <a href="https://www.cfr.org/in-brief/what-defense-production-act">gave the president sweeping authority</a> to control domestic manufacturing. For example, it helped the U.S. <a href="https://www.si.edu/spotlight/wwii-aircraft">increase production of warplanes</a> from 2,500 a year to over 300,000 by the end of the war.</p>
<p>In 1950, America faced war in Korea, and Congress feared that growing postwar demand for consumer goods would crowd out defense production needed to face China and the Soviet Union, which both backed North Korea in the conflict. There were also concerns <a href="https://www.minneapolisfed.org/about-us/monetary-policy/inflation-calculator/consumer-price-index-1913-">about inflation</a> during that postwar period.</p>
<p>The <a href="https://sgp.fas.org/crs/natsec/R43767.pdf">Defense Production Act gave the president</a> – who later delegated this authority to Cabinet officials like the secretary of defense – broad powers to force manufacturers to make goods and supply services to support the national defense, as well as to set wages and prices and even ration consumer goods. </p>
<p>“We cannot get all the military supplies we need now from expanded production alone,” President Harry Truman <a href="https://www.presidency.ucsb.edu/documents/radio-and-television-address-the-american-people-following-the-signing-the-defense">told Americans in a radio address after signing the act</a> into law. “This expansion cannot take place fast enough. Therefore, to the extent necessary, workers and plants will have to stop making some civilian goods and begin turning out military equipment.” </p>
<p>The <a href="https://sgp.fas.org/crs/natsec/R43767.pdf">original law focused on</a> “shaping U.S. military preparedness and capabilities,” which limited the scope of the president’s authority. </p>
<h2>Routinely invoked</h2>
<p>Although the Defense Production Act makes news only when the president dramatically invokes it, the government uses the law – or just the threat of using it – routinely to force private companies to prioritize government orders. The Department of Defense, for example, <a href="https://www.fema.gov/sites/default/files/documents/fema-dpac-report-to-congress_2019.pdf">uses it to make</a> an estimated 300,000 contracts with private companies a year.</p>
<p>Congress <a href="https://www.investopedia.com/defense-production-act-dpa-5187806">has to reauthorize</a> the act every several years and has amended it frequently to expand or limit its scope. Over time, <a href="https://sgp.fas.org/crs/natsec/R43767.pdf">this has significantly broadened</a> the definition of national defense to include supporting “domestic preparedness, response, and recovery from hazards, terrorist attacks, and other national emergencies.” </p>
<p>The Department of Homeland Security invoked it about 400 times in 2019, mostly to help prepare for and respond to hurricanes and other natural disasters, such as by providing resources to house and feed survivors. And Presidents Bill Clinton and George W. Bush, for example, <a href="https://journals.library.columbia.edu/index.php/bioethics/article/view/8678">both used it to divert electricity</a> and natural gas to California during the 2000-2001 energy crisis. </p>
<p>The act has also been used extensively during the COVID-19 pandemic. President Donald Trump used it to <a href="https://trumpwhitehouse.archives.gov/presidential-actions/executive-order-prioritizing-allocating-health-medical-resources-respond-spread-covid-19/">prioritize the allocation of medical resources</a>, prevent hoarding of personal protective equipment and <a href="https://www.cbsnews.com/news/trump-defense-production-act-wartime-general-motors/">require General Motors</a> to build ventilators. He also <a href="https://www.cnn.com/2020/04/28/politics/defense-production-act-executive-order-food-supply/index.html">ordered beef, pork and poultry processing facilities</a> to stay open during the lockdowns to ensure a supply of protein for the American population. </p>
<p>Biden, for his part, has also already used the act a number of times, mainly to fight the pandemic. For example, in March 2021, <a href="https://www.npr.org/sections/health-shots/2021/03/13/976531488/defense-production-act-speeds-up-vaccine-production">he invoked it</a> to speed up vaccine production by ensuring extra facilities were up to snuff, as well as to expedite the production of critical materials, equipment, machinery and supplies. In March 2022, <a href="https://electrek.co/2022/03/31/biden-invokes-defense-production-act-to-boost-ev-storage-battery-minerals/">he issued</a> a directive to increase the supply of materials for large-capacity batteries that are used mainly in civilian electric vehicles.</p>
<p>Biden’s use of the Defense Production Act to address the baby formula problem illustrates a limitation of it. It can be used to set priorities for ingredients and manufacturing capacity, but it’s not a magic wand. A president can’t by decree make capacity that doesn’t exist instantly appear. And it isn’t clear how much it will do to quickly end the formula shortage – given the <a href="https://abbott.mediaroom.com/2022-05-16-Abbott-Enters-into-Consent-Decree-with-U-S-Food-and-Drug-Administration-for-its-Sturgis,-Mich-,-Plant-Agreement-Creates-Pathway-to-Reopen-Facility">main problem is manufacturing issues</a> that closed production at a key plant, not just a shortage of ingredients. </p>
<p>The act is widely used and has been widely useful, but it is no substitute for advance planning and preparedness.</p><img src="https://counter.theconversation.com/content/183085/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erik Gordon does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Biden said the Defense Production Act would help end the shortage by directing suppliers of baby formula to prioritize delivery to formula manufacturers.Erik Gordon, Professor of Business, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1830162022-05-19T12:23:54Z2022-05-19T12:23:54ZBaby formula industry was primed for disaster long before key factory closed down<figure><img src="https://images.theconversation.com/files/464068/original/file-20220518-15-f6cjil.jpg?ixlib=rb-1.1.0&rect=211%2C125%2C4204%2C2814&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cities are trying to address the baby formula shortage with community drives.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/BabyFormulaShortage/978d1f02dc1043938f71dadae095fe96/photo?Query=baby%20formula&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=263&currentItemNo=34">AP Photo/David J. Phillip</a></span></figcaption></figure><p>The conditions that led to a <a href="https://theconversation.com/whats-behind-the-us-baby-formula-shortage-and-how-to-make-sure-it-doesnt-happen-again-182929">shortage of baby formula</a> were set in motion long before the February 2022 closure of the Similac factory <a href="https://www.washingtonpost.com/business/2022/05/14/baby-formula-shortage-sturgis/">tipped the U.S. into a crisis</a>.</p>
<p>Retailers nationwide <a href="https://datasembly.com/news/out-of-stock-rate-in-april-2022-copy/">reported supplies of baby formula were out of stock</a> at a rate of 43% during the week ended May 8, 2022, compared with less than 5% in the first half of 2021. In some states, such as <a href="https://www.cbsnews.com/news/baby-formula-shortage-rationing-national-crisis/">Texas and Tennessee</a>, shortages were over 50%, which has prompted parents to <a href="https://www.wsj.com/articles/baby-formula-shortage-leaves-parents-scouring-country-for-supplies-11652466530">travel long distances</a> and <a href="https://www.eatthis.com/news-baby-formula-shortage-price-gouging/">pay exorbitant sums of money</a> to grab dwindling supplies of formula for their babies.</p>
<p>News that the Food and Drug Administration and Similac-maker Abbott <a href="https://www.nytimes.com/2022/05/16/health/baby-formula-shortage-fda.html">have reached a deal</a> to reopen the formula factory in Sturgis, Michigan, is welcome news for desperate parents, but it will do little to alleviate the shortage anytime soon. This is in no small part because of the very nature of America’s baby formula industry.</p>
<p>I <a href="https://ilitchbusiness.wayne.edu/profile/dx7877">research and teach supply chain management</a>, with a special focus on the health care industry. The closure of the Similac factory may have lit the fuse for the nationwide shortage, but a combination of government policy, industry market concentration and supply chain issues supplied the powder. </p>
<h2>What prompted the baby formula shortage</h2>
<p>On Feb. 17, Abbott <a href="https://www.similacrecall.com/us/en/home.html">initiated a voluntary recall</a> after <a href="https://www.miamiherald.com/news/recalls/article258913143.html">four infants</a> were hospitalized with infections from the bacteria <em>Cronobacter sakazakii</em> – two of them died – after consuming baby formula manufactured in their Sturgis facility. The factory was also shut down.</p>
<p>The FDA has identified no new cases but has <a href="https://www.washingtonpost.com/business/2022/05/14/baby-formula-shortage-sturgis/">not yet approved reopening</a> the Sturgis facility, which is responsible for about half of Abbott’s U.S. supply. Abbott said it <a href="https://abbott.mediaroom.com/2022-05-16-Abbott-Enters-into-Consent-Decree-with-U-S-Food-and-Drug-Administration-for-its-Sturgis,-Mich-,-Plant-Agreement-Creates-Pathway-to-Reopen-Facility">entered into a consent decree</a> with the FDA that paves the way to reopening the facility once certain conditions are met. </p>
<p>Shortages of baby formula have led major U.S. retailers including Target, CVS, Walgreens and Kroger to <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/baby-formula-shortage-forces-cvs-health-limit-purchases-2022-05-10/">restrict the amount of formula</a> a consumer may purchase. These shortages <a href="https://www.washingtonpost.com/health/2022/05/18/baby-formula-shortage-impact/">are disproportionately hurting low-income families</a> and those who do not have the resources to travel long distances to find alternative sources of baby formula. </p>
<figure class="align-center ">
<img alt="Shelves at a a grocery store are mostly bare with a small number of baby formula packages here and there" src="https://images.theconversation.com/files/464118/original/file-20220518-19-fb0u1m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/464118/original/file-20220518-19-fb0u1m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/464118/original/file-20220518-19-fb0u1m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/464118/original/file-20220518-19-fb0u1m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/464118/original/file-20220518-19-fb0u1m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/464118/original/file-20220518-19-fb0u1m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/464118/original/file-20220518-19-fb0u1m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Baby formula is in short supply across the U.S.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/BabyFormulaShortage/c7645da15acb467ba6b2bf3c6a588f82/photo?Query=baby%20formula&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=265&currentItemNo=105">AP Photo/Michael Conroy</a></span>
</figcaption>
</figure>
<h2>Government-created monopolies</h2>
<p>The root of the problem begins with a concentration of production. </p>
<p>Two companies – Abbott and Reckitt Benckiser, which makes Enfamil – <a href="https://www.wsj.com/articles/baby-formula-shortage-could-last-months-11652371827?mod=hp_lead_pos3/">dominate the industry with about 80% of the U.S. market</a>. Nestlé, which sells baby formula in the U.S. under its Gerber brand, controls another 10%. </p>
<p>Part of the reason these companies are so entrenched in their position is that Abbott, Reckitt and Nestlé <a href="https://www.ers.usda.gov/amber-waves/2011/september/infant-formula-market/">are the only makers approved</a> by the U.S. government to provide baby formula through the Special Supplemental Nutrition Program for Women, Infants and Children, <a href="https://www.fns.usda.gov/wic">known as WIC</a>, which provides supplemental food to low-income families. </p>
<p>WIC, which <a href="https://www.ers.usda.gov/amber-waves/2004/september/sharing-the-economic-burden-who-pays-for-wic-s-infant-formula/#:%7E:text=Taxpayers%20alone%2C%20however%2C%20do%20not,formula%20purchased%20by%20WIC%20participants.">reimburses companies at 15%</a> of the wholesale cost, <a href="https://www.ers.usda.gov/amber-waves/2011/september/infant-formula-market/">is responsible for 92%</a> of supermarket sales of milk-based powder formula in 12-to 16-ounce containers and 51% of all sales in other sizes. </p>
<p>The federal government provides WIC grants to each state, which then contracts with one of the three companies. While WIC is a critical program to feed the most vulnerable, government support of this program has the unintended consequence of creating a de facto monopoly in each state.</p>
<p>The amount of WIC funding to these three established companies makes it difficult for any startup to make significant inroads in the baby formula industry. There is little chance they can capture the market share necessary to justify a significant investment. Since only a handful of manufacturing facilities are approved for production of baby formula in the U.S., <a href="https://www.cnbc.com/2019/08/02/silicon-valley-is-eyeing-the-giant-market-for-infant-formula.html">startups don’t have the volume</a> required to produce in these facilities. </p>
<h2>Import restrictions</h2>
<p>Another reason for the intense concentration is import controls.</p>
<p><a href="https://www.whitehouse.gov/briefing-room/statements-releases/2022/05/12/fact-sheet-president-biden-announces-additional-steps-to-address-infant-formula-shortage/">About 98% of the formula consumed</a> in the U.S. is produced domestically, whether by a U.S. or international company. While facilities abroad such as those in Mexico, Chile, Ireland and the Netherlands meet the FDA’s nutrition standards, a <a href="http://www.doi.org/10.1097/MPG.0000000000002395">failure to meet its labeling guidelines</a> prevents them from exporting to the U.S. As a result, <a href="https://www.nytimes.com/2020/04/18/parenting/baby/european-formula.html">some consumers order unapproved formula</a> over the internet from Europe and elsewhere, which may then be confiscated at the border. </p>
<p>International manufactures also face high tariffs, which <a href="https://www.freightwaves.com/news/protectionism-red-tape-hinder-baby-formula-resupply-analysts-say">can be as high as 17.5%</a> depending on volume. That’s one reason Canadian producers, which are subsidized by their government, <a href="https://www.freightwaves.com/news/protectionism-red-tape-hinder-baby-formula-resupply-analysts-say">have mostly steered clear</a> of the U.S. market. And the United States Mexico Canada Agreement, which came into force in 2020, included a provision that made it even harder for Canada to ship baby formula south in an effort to protect domestic producers. </p>
<h2>‘Lean’ supply chains</h2>
<p>The pandemic-related problems that have beleaguered global supply chains have also played a role. </p>
<p>Like in other industries, baby formula makers have long tried to make their supply chains as “lean” and efficient as possible. That means they aimed to minimize the amount of time baby formula spent sitting – unprofitably – on warehouse shelves and send the goods from factory to retailer as quickly as possible. The problem is that when there’s a surge in demand or a drop in supply, shortages can result. The leaner the supply chain, the larger the potential disruption. </p>
<p>The WIC program also encourages a lean supply chain because <a href="https://www.ers.usda.gov/amber-waves/2004/september/sharing-the-economic-burden-who-pays-for-wic-s-infant-formula/#:%7E:text=Taxpayers%20alone%2C%20however%2C%20do%20not,formula%20purchased%20by%20WIC%20participants.">it reimburses just 15%</a> of the wholesale price. The huge volume means the companies can still be profitable, but the lower margins per sale encourage them to keep a very efficient supply chain.</p>
<p>In March 2020, <a href="https://www.theatlantic.com/ideas/archive/2022/05/baby-formula-shortage-abbott-recall/629828/">formula sales surged</a> as people stockpiled pretty much everything. But that led sales to drop as parents worked through all that extra formula. That prompted makers to reduce production. And now in 2022, demand jumped again, <a href="https://www.fda.gov/news-events/press-announcements/fda-takes-important-steps-improve-supply-infant-and-specialty-formula-products">especially after reports spread</a> of the Similac recall. And with demand soaring and supply down significantly because of the Sturgis plant’s closure, shortages were inevitable.</p>
<figure class="align-center ">
<img alt="A woman in a white lab coat and wearing a black mask holds a bottle of frozen breast milk in a big clear bottle" src="https://images.theconversation.com/files/464115/original/file-20220518-25-knccop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/464115/original/file-20220518-25-knccop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/464115/original/file-20220518-25-knccop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/464115/original/file-20220518-25-knccop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/464115/original/file-20220518-25-knccop.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/464115/original/file-20220518-25-knccop.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/464115/original/file-20220518-25-knccop.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Milk banks are trying to ease the formula shortage by distributing frozen milk donated by lactating mothers.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/BabyFormulaShortage/a37d842efd3c4a399e7604b62971dbee/photo?Query=baby%20formula&mediaType=photo&sortBy=arrivaldatetime:desc&dateRange=Anytime&totalCount=265&currentItemNo=42">AP Photo/David Zalubowski</a></span>
</figcaption>
</figure>
<h2>Shortage is far from over</h2>
<p>Both the Biden administration and companies have announced a variety of measures to end the shortage. </p>
<p>Some companies, such as Reckitt, say they <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/baby-formula-shortage-forces-cvs-health-limit-purchases-2022-05-10/">have stepped up production</a> and are running factories <a href="https://www.wsj.com/articles/why-baby-formula-shortage-11652188230?mod=article_inline">seven days a week</a> to get more formula to stores. </p>
<p>The FDA is expected to soon announce the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2022/05/12/fact-sheet-president-biden-announces-additional-steps-to-address-infant-formula-shortage/">loosening of import rules</a> for baby formula, and some states are allowing WIC recipients to use their rebates to buy formula from companies other than the one on the contract. Abbott has already agreed to <a href="https://www.washingtonpost.com/business/2022/05/14/baby-formula-shortage-sturgis/">honor rebates</a> for competitor products in states where they have WIC contracts. </p>
<p><a href="https://www.reuters.com/business/healthcare-pharmaceuticals/baby-formula-shortage-forces-cvs-health-limit-purchases-2022-05-10/">Abbott</a> and <a href="https://www.bloomberg.com/news/articles/2022-05-17/nestle-ships-baby-formula-to-us-from-europe-to-help-shortage">Nestlé</a> are also speeding up shipments from their FDA-approved facilities overseas. </p>
<p>The best way to end the shortage – getting the Sturgis plant online and its formula on retail shelves – <a href="https://www.fastcompany.com/90751300/baby-formula-shortage-panic-buying">will take two months</a>.</p>
<p>Ultimately, preventing this kind of situation from happening again will require changes to government policy and business practices. I believe the government’s de facto monopolies should be opened up to more competition. And formula makers may just have to accept a little less profit from supply chain efficiencies as a cost of doing business – and as a way to ensure families won’t again be faced with the loss of a product so vital to their babies’ survival.</p><img src="https://counter.theconversation.com/content/183016/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kevin Ketels does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The closure of a factory in Michigan is the incident that put new parents across the US on edge, but the real causes for the shortage of baby formula are many years in the making.Kevin Ketels, Assistant Professor, Teaching, Global Supply Chain Management, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1829292022-05-12T13:09:02Z2022-05-12T13:09:02ZWhat’s causing the US baby formula shortage – and how to make sure it doesn’t happen again<figure><img src="https://images.theconversation.com/files/462578/original/file-20220511-18-x6ls08.jpg?ixlib=rb-1.1.0&rect=53%2C341%2C6000%2C3646&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">No easy formula.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/grocery-store-shelves-where-baby-formula-is-typically-news-photo/1240603860?adppopup=true">Stefani Reynolds/AFP via Getty Images</a></span></figcaption></figure><p><em>A <a href="https://www.nytimes.com/2022/05/10/us/baby-formula-shortage.html">baby formula shortage</a> has added to the woes of American parents already confronted with the pressures of <a href="https://www.theatlantic.com/culture/archive/2021/03/isolation-becoming-new-parent-during-pandemic/618244/">raising an infant during a pandemic</a> in a country <a href="https://www.forbes.com/sites/marybethferrante/2019/06/21/unicef-study-confirms-the-u-s-ranks-last-for-family-friendly-policies/?sh=176ff24133ba">ranked low for family-friendly policies</a>.</em></p>
<p><em>Media reports have highlighted the plight of mothers, fathers and caregivers across the U.S. who have <a href="https://www.seattletimes.com/seattle-news/baby-formula-shortage-in-washington-has-caregivers-parents/">scrambled to find scarce supplies</a>, or <a href="https://www.wfaa.com/article/news/local/texas/lake-jackson-texas-mom-drives-hour-baby-formula-amid-shortage/287-d1638ecb-4153-415d-ab63-58e342ec764f">driven long distances</a> to buy formula.</em></p>
<p><em>But what is behind the shortage? And how can it be prevented from happening again? The Conversation asked Dr. Steven Abrams, a leading <a href="https://dellmed.utexas.edu/directory/steven-a-abrams">expert on pediatric health</a> at the University of Texas who has advised both the formula industry and government on infant nutrition, these questions along with what advice he could give parents facing problems getting adequate supplies of infant formula.</em> </p>
<h2>1. Why there is a shortage of formula now?</h2>
<p>There are really two factors that have driven the current shortage. First, we have the <a href="https://theconversation.com/4-reasons-americans-are-still-seeing-empty-shelves-and-long-waits-with-christmas-just-around-the-corner-168635">supply chain problem</a>, which has affected all manner of goods since the onset of the pandemic. It eased off a little, but then at the beginning of 2022 it <a href="https://www.wired.com/story/supply-chain-crisis-data/">became worse</a>.</p>
<p>Then in February a <a href="https://wwmt.com/news/local/baby-formula-shortage-crisis-intensifies-as-sturgis-plant-remains-shut-down">major baby formula manufacturing plant in U.S. went down</a>. The FDA <a href="https://www.nbcboston.com/news/national-international/fda-to-allow-closed-abbott-plant-to-release-baby-formula-supply-amid-shortage/2717440/">shut down Abbott Nutrition’s factory</a> in Michigan. The closure came after Abbott’s nationwide <a href="https://www.similacrecall.com/us/en/home.html">recall of multiple brands of formula</a>, including routine Similac cow milk-based formulas such as Similac Advance and several specialty formulas for allergic babies, including Similac Alimentum and and Similac EleCare.</p>
<p>Closing the factory had to be done amid an <a href="https://www.fda.gov/food/outbreaks-foodborne-illness/fda-investigation-cronobacter-infections-powdered-infant-formula-february-2022">investigation into bacterial infections</a> in connection to powdered formula produced at the plant, and the deaths of at least two babies. The problem is there just isn’t much redundancy in U.S. infant formula production. In other words, there aren’t enough other factories to pick up the slack when one goes down. The Michigan plant is the largest producer in the country, so when it goes down, it put added strain on the entire U.S. formula distribution system, especially for certain formulas for babies with high-risk allergic diseases and metabolic disorders.</p>
<p>Over the last couple of weeks the shortage has gotten worse. I can’t say for sure why this has happened. But I suspect there has been some hoarding going on as parents get anxious. Stores can limit the amount of formula that people can buy, but that doesn’t stop people going online to buy more.</p>
<p>On top of that, the shortage has gained wide publicity in newspapers, on TV and in political speeches. All that publicity feeds into public sense that the system is failing, prompting more panic buying and hoarding.</p>
<h2>2. Who is the shortage affecting?</h2>
<p>A majority of parents will feed babies with formula at some point to meet their nutritional needs, especially older infants. At birth and in days immediately after, around 80% of babies receive <a href="https://www.cdc.gov/breastfeeding/data/reportcard.htm">all their nutrition through breast milk</a>. But by the age of 6 months, the <a href="https://www.cdc.gov/breastfeeding/data/reportcard.htm">majority of babies get at least some formula</a>. The proportion of year-old babies receiving formula is even higher. This is largely the result of social dynamics and pressures - mothers going back to work after giving birth, but not receiving sufficient support to produce and store sufficient amounts of breast milk.</p>
<p>But the shortage will affect some parents more than others. Not surprisingly, the most affected parents are those on the lowest income. The federal food program for poorer women, infants and children, <a href="https://www.fns.usda.gov/wic">called WIC</a>, provides formula for a majority of babies in low-income families. But costs have gone up and formula has become scarcer.</p>
<p>I’m hearing of some families driving two hours to find stores selling formula. Obviously that will be harder to do for poorer families as there are costs involved. Likewise, more affluent parents may be able to buy more expensive, so-called elite brand formulas.</p>
<p>The other thing to note is that the shortage is affecting both regular infant formula, and <a href="https://www.fda.gov/news-events/press-announcements/fda-takes-important-steps-improve-supply-infant-and-specialty-formula-products">specialized versions</a>. Regular or standard formula is the type most families are familiar with, and around 95% of formula-fed babies get the standard type. Specialized formula is for babies with unusual requirements, due to allergies, damaged intestines or special nutritional needs. Before the Michigan factory closed, it made most of the specialized infant formula used in the U.S. So it is an absolute crisis for families needing that type of formula.</p>
<h2>3. What are the potential consequences of the shortage?</h2>
<p>In the first six months, babies should <a href="https://www.cdc.gov/breastfeeding/faq/index.htm">only have breast milk or formula</a> – anything else fed to them will be nutritionally incomplete. So there is a risk that a shortage will mean that babies will not be getting the nutrition they need to develop. That could lead to a range of health problems affecting their physical growth and brain development.</p>
<p>Then there are concerns that parents may be using unsafe alternatives, like watering down their baby’s formula. People have been known to try and make their own by mixing powdered milk or vegan milk with vitamins. Not only are these alternatives <a href="https://www.cdc.gov/mmwr/volumes/70/wr/mm7033a4.htm">not nutritionally complete</a>, they may not be entirely sterile.</p>
<p>After the age of six months, things get a little better once the infant is able to start eating solid food. But even then, formula or breast milk remains the primary source of nutrition. So there may still be a risk of nutritional deficiencies, such as iron deficiencies.</p>
<h2>4. Are there any viable alternatives?</h2>
<p>Over the age of six months of age, for only reasonably short periods of time, <a href="https://healthychildren.org/English/tips-tools/ask-the-pediatrician/Pages/Are-there-shortages-of-infant-formula-due-to-COVID-19.aspx#.Ynr6sYw9zEQ.twitter">parents can feed infants whole cow milk</a> and look into iron supplements.</p>
<p>It isn’t ideal, and only applies for older babies. For those under six months old, cow milk is a real problem. It doesn’t have the right protein blend for babies and has next to no iron – risking anemia in very young babies. Cow milk also has a misbalance of minerals, especially for younger babies.</p>
<h2>5. So what guidance is there for low-income parents?</h2>
<p>It is challenging and I can’t provide a magic answer. But food banks and the WIC program have been a crucial lifeline. The WIC program in particular has proved itself to be very flexible during this shortage. When Abbott had to recall products and then couldn’t provide enough non-recalled formulas in states in which they were the WIC provider, WIC was able to change providers and reprogram EBT cards to allow low-income parents to buy different brands.</p>
<h2>6. What can be done to prevent this situation happening again in the U.S.?</h2>
<p>First we need to help families regain confidence in the formula production and supply system. This will prevent problems such as hoarding or making home brew formulas.</p>
<p>Then we need to look at how to make sure one plant going down doesn’t affect the whole system. The federal government can’t stockpile formula in the same way it might stockpile oil, as formula has a shelf life. But diversifying infant formula production is a possibility. This would involve making sure multiple factories and companies are making the formulas that this country needs. This doesn’t necessarily mean increased costs – competition could potentially drive down prices.</p>
<p>I believe America also needs to look at the country’s breast feeding support system. Don’t get me wrong, some parents will always need formula. But those who want to breast feed need everything possible done to support them. That includes better family leave policies, and help for low-income mothers who want to pump and store milk while they work.</p><img src="https://counter.theconversation.com/content/182929/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steven A. Abrams received funding from Perrigo Nutrition for research related to food insecurity in Austin during the COVID-19 pandemic and has given paid presentations on nutritional physiology to Abbott Nutrition's educational unit, ANHI.</span></em></p>An infant nutrition expert explains what is behind the current formula shortage and what can be done to support hard-pressed parents.Steven A. Abrams, Professor of Pediatrics, The University of Texas at AustinLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1713012021-11-18T23:50:32Z2021-11-18T23:50:32ZCell-cultured breastmilk: scientists want to give formula-fed babies another option<figure><img src="https://images.theconversation.com/files/432331/original/file-20211117-17-d5l8dv.jpg?ixlib=rb-1.1.0&rect=26%2C0%2C1970%2C1328&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Science has made impressive gains in the art of producing animal products minus the animal. Now this emerging field of cellular agriculture is taking on its biggest challenge yet: breastmilk.</p>
<p>Breastmilk is a complex substance, and breastfeeding is even more complicated. We are a long way from recreating it in its entirety. </p>
<p>It’s one thing to produce a <a href="https://www.nature.com/articles/s41587-021-00855-1">chicken nugget</a> or even a <a href="https://www.nature.com/articles/s41467-021-25236-9">whole-cut steak</a> via cellular agriculture, but providing a developing child with every nutrient they need for the first year of life is another.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/432558/original/file-20211118-19-kpbx5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/432558/original/file-20211118-19-kpbx5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/432558/original/file-20211118-19-kpbx5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/432558/original/file-20211118-19-kpbx5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/432558/original/file-20211118-19-kpbx5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/432558/original/file-20211118-19-kpbx5g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/432558/original/file-20211118-19-kpbx5g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cultured ‘chicken bites’ are already on the market in Singapore. Breastmilk may be coming soon.</span>
<span class="attribution"><span class="source">Eat Just</span></span>
</figcaption>
</figure>
<p>But cell-cultured breastmilk could soon help non-breastfeeding parents who want a better option than existing formulas based on cows’ milk.</p>
<h2>How to make breastmilk</h2>
<p>Breastmilk cultivation has many similarities with the production of cultured meat. The basic steps are as follows.</p>
<p>First you need some of the milk-producing cells that line the breast ducts. These “mammary epithelial cells” can be cultured from donated milk.</p>
<p>Then you grow the cells in flasks with nutrients, allowing them to multiply.</p>
<p>Once you have enough cells to behave like healthy breast tissue, you transfer them to a bioreactor (a larger vessel of nutrients) with a similar structure to the mammary duct.</p>
<p><iframe id="tc-infographic-618" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/618/edbb34f20c14675aca798e28fdf45214d0744cac/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>Next, you add a hormone called prolactin to the bioreactor. This gives the cells the green light for milk secretion on one side while absorbing nutrients on the other. </p>
<p>Finally, you perform quality control and safety screening. </p>
<p>Eventually, further supplements naturally found in breastmilk could be added, such as beneficial antibodies and bacteria or even immune cells and stem cells.</p>
<h2>‘Let food be thy medicine, and medicine be thy food’</h2>
<p>Breastmilk sets the brain, immune system and metabolism on a <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889854520300280?via=ihub">lifelong course</a> of improved cognitive function, and reduced infection and chronic disease. For babies who are premature or sick, the value of breastmilk is particularly pronounced.</p>
<p>Breastmilk comprises an optimal balance of water, carbohydrates, fats, proteins, and micronutrients, along with a mix of maternal immune cells, stem cells, antibodies, and healthy bacteria that seed the child’s gut microbiome.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/breastfeeding-is-tough-new-research-shows-how-to-make-it-more-manageable-168432">Breastfeeding is tough: new research shows how to make it more manageable</a>
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<p>Breastmilk also changes over time to meet the changing needs of the developing child. It may even <a href="https://www.sciencedirect.com/science/article/pii/S1471490620300053?casa_token=_kHDnFgXSZQAAAAA:97Qy8VVhJdRRxknuPpFbkKnqdVzA3xsoux8ZNwNM_nsI7k3eBSVP6Oxhq2PjbX--to-S5dcUp5O3">directly help</a> with infections. When pathogens from the baby’s upper respiratory tract enter the mammary duct, the mother can mount an immune response and feed targeted immune cells and antibodies back to the child.</p>
<h2>The many downsides of current breastmilk alternatives</h2>
<p>For a wide variety of reasons, breastfeeding is not an option for many new parents. According to the <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/breastfeeding/latest-release">latest available report</a> from the Australian Bureau of Statistics (covering the 2017-18 financial year), only 29% of 6-month-olds were exclusively breastfed but more than half (53%) had not been introduced to solids.</p>
<p>This suggests around a quarter of babies are being fed formula. Infant formula is perfectly acceptable from a nutritional standpoint, but it can’t replicate the intricacies of the real thing.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/if-youre-feeding-with-formula-heres-what-you-can-do-to-promote-your-babys-healthy-growth-106165">If you're feeding with formula, here's what you can do to promote your baby's healthy growth</a>
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<p>Most infant formula is made from cows’ milk, which is optimal for a calf rather than a human baby, and lacks the more nuanced health-promoting factors such as the mother’s antibodies and beneficial bacteria.</p>
<p>Additionally, <a href="https://www.sciencedirect.com/science/article/pii/S0959652619307322?via=ihub">recent calculations</a> show that feeding babies formula generates more carbon emissions than breastfeeding. This accounts for the 500 additional calories a breastfeeding mother should eat, even when the mother was eating animal-based foods.</p>
<p>Donated milk is another alternative to breastfeeding, but it is hard to come by and milk banks prioritise preterm and sick babies. During the 2020-21 financial year, Australian Red Cross Lifeblood <a href="https://www.lifeblood.com.au/about/our-strategy/annual-reports">recorded</a> 2,320 litres of breastmilk donated to more than 1,000 vulnerable babies.</p>
<p>There are also online breastmilk markets on the likes of <a href="https://www.facebook.com/hm4hbvictoria/">Facebook</a> and Craigslist. These are unregulated, are potential sources of infectious diseases, and leave desperate parents vulnerable to exploitation.</p>
<h2>Startups galore</h2>
<p>While no cell-cultured breastmilk is yet commercially available, several companies are working on it. Some of those closest to releasing a product include US-based <a href="https://www.businessinsider.com/biomilq-lab-grown-breast-milk-startup-raised-a-21-million-2021-10">BIOMILQ</a>, Israeli <a href="https://www.haaretz.com/israel-news/business/.premium-israeli-synthetic-milk-company-intends-to-disrupt-dairy-industry-1.9285492">BioMilk</a>, and US-Singaporean <a href="https://www.wired.co.uk/article/lab-grown-breast-milk-turtletree-labs">TurtleTree Labs</a>. </p>
<p>In Australia, stem cell scientist and entrepreneur Luis Malaver-Ortega has founded a company called Me& Food Tech to produce breastmilk using novel cell-based technologies.</p>
<p>When will these products be available? It’s hard to say exactly.</p>
<p>There are appreciable hurdles in both fundamental research and regulation to overcome before cell-cultured breastmilk companies can manufacture at scale. But private investment in the industry is growing rapidly, as is interest among university-based researchers.</p>
<hr>
<p><em>The authors would like to thank Luis Malaver-Ortega for his assistance with this article.</em></p><img src="https://counter.theconversation.com/content/171301/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ruth Purcell is a consultant for Nourish Ingredients, a company producing animal-free lipids for alternative proteins, and Cellular Agriculture Australia, a nonprofit working to advance agricultural products such as meat, eggs, milk, and leather without using livestock.</span></em></p><p class="fine-print"><em><span>Bianca Le is the founder and executive director of Cellular Agriculture Australia, a nonprofit working to advance agricultural products such as meat, eggs, milk, and leather without using livestock.</span></em></p>Using ‘cellular agriculture’, scientists want to produce genuine human breastmilk as an alternative to infant formula.Ruth Purcell, PhD Graduate Researcher, The University of MelbourneBianca Le, Honorary Fellow, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1657892021-11-10T15:16:33Z2021-11-10T15:16:33ZWhy are babies going hungry in a food-rich nation like Canada?<figure><img src="https://images.theconversation.com/files/431095/original/file-20211109-17-1nj4al0.jpg?ixlib=rb-1.1.0&rect=22%2C8%2C1894%2C1218&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Whether they breastfeed or use formula, food insecure mothers are struggling to feed their babies. </span> <span class="attribution"><span class="source">(Hessam Nabavi/Unsplash)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/why-are-babies-going-hungry-in-a-food-rich-nation-like-canada" width="100%" height="400"></iframe>
<p>Jean, a 24-year-old mother of two, said: “People don’t think there’s hungry kids out there [in Canada].” She would like us to know “there definitely is.” </p>
<p>More than <a href="https://proof.utoronto.ca/food-insecurity/">1.2 million children in Canada live in food-insecure households</a>, including babies of the families as well. In Nunavut, that number is higher than any other part of Canada. Many of the children in food insecure families go hungry: parents often need to cut the size of meals, or skips meals altogether. </p>
<p>The first 1,000 days of a baby’s life is the <a href="https://doi.org/10.1002/ajhb.22952">most important time for growth and development</a>. There are special and <a href="https://www.canada.ca/en/health-canada/services/publications/food-nutrition/prenatal-nutrition-guidelines-health-professionals-iron-contributes-healthy-pregnancy-2009.html">costly nutritional needs for both mother and baby such as increased iron and folic acid for mothers</a>, <a href="https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/infant-feeding/nutrition-healthy-term-infants-recommendations-birth-six-months.html">vitamin D for breastfed babies, and commercial formula for those not breastfed</a>. But for many, this is also a time of diminished incomes. </p>
<p>People have often said to me that even the most undernourished women can successfully breastfeed and that the real cause of infant food insecurity too much access to infant formula. This misses the point I’m making.</p>
<p>At the heart of infant <a href="https://doi.org/10.2752/175174415X14101814953927">food insecurity in Canada is poverty and food access, which disrupts maternal eating and infant feeding habits</a> regardless of how and what babies are fed. </p>
<p>To really understand infant food insecurity, one needs to listen to mothers. While researching my book, <a href="https://www.ubcpress.ca/out-of-milk"><em>Out of Milk: Infant Food Insecurity in a Rich Nation</em></a>, I spoke to many mothers, those who were breastfeeding and those who had opted to use formula. Their stories reveal how poverty and food insecurity are disrupting their eating and infant feeding habits. I recount some of their stories here; all of the following names are pseudonyms.</p>
<h2>The breastfeeding paradox</h2>
<p>When breastfeeding works, it is praised by the mothers we spoke with as the ideal healthy and secure food system. Some mothers said they were drawn to breastfeeding because of health benefits and the high cost of food. Lorraine explained: “There is no risk of cross-contamination, it’s there, it’s ready, it’s the right amount, it’s the perfect food.” </p>
<p>Erica said: “You know your baby is never going to go hungry. You don’t have to worry about where you’re going to get food and where the money is going to come from.” </p>
<p>Yet the most food-insecure mothers stop breastfeeding after one or two months. Some never start. For them, breastfeeding is a non-sustainable food system. This is referred to as the “<a href="https://doi.org/10.2752/175174415X14101814953927">breastfeeding paradox</a>.” It means that those that can least afford to stop breastfeeding <a href="https://doi.org/10.1503/cmaj.170880">are actually more likely to do so</a>. </p>
<p>The reasons include the struggles of daily living: lack of practical support, insufficient public services and poverty brought on by inadequate income supports. A mother’s own lack of food is at the root — and like any food system, the system breaks down when producers are not supported.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&rect=75%2C117%2C5543%2C3622&q=45&auto=format&w=1000&fit=clip"><img alt="A woman browses infant formula at a grocery store." src="https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&rect=75%2C117%2C5543%2C3622&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417866/original/file-20210825-13-1r24eqa.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Mothers least able to afford infant formula are more likely to rely on it to feed their babies.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Mary said: “I don’t know if what I was producing was really enough, nutrient-wise, if it was … healthy enough for him, giving him what he needed. Plus, in order to be able to produce milk, the mother needs to be food secure, and you don’t have that all the time. You still have to buy food for yourself to keep yourself healthy and the price of fruits and vegetables and proper meat is really high.”</p>
<p>Another mother, Sally, challenged the idea that breastfeeding is free, saying: “It might be cheaper than formula feeding but it still costs.” </p>
<h2>Inadequate access to formula</h2>
<p>When breastfeeding fails and infant formula is not affordable, the outcomes are tragic. </p>
<p>Unlike <a href="https://www.fns.usda.gov/wic/about-wic">other developed countries</a>, Canada has no government-provided infant formula for low-income mothers. The reasons are, at a minimum, twofold: One, there are concerns that <a href="https://www.phac-aspc.gc.ca/hp-ps/dca-dea/publications/pdf/ppsb-ppsam-eng.pdf">supplying free formula will affect infant feeding choices</a>; and two, Canada doesn’t use food as a form of welfare benefits for anyone.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman feeds a baby with a milk bottle." src="https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417684/original/file-20210824-16536-1v68mcf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Without income supports, struggling mothers resort to using watered-down formula and buying it second-hand online.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>This, on top of a failed social safety net, leaves families struggling to feed their babies with limited options. Parents can look to food banks, <a href="https://doi.org/10.15353/cfs-rcea.v5i1.230">but infant formula may not be consistently available, if at all</a>. Reasons for its scarcity are embedded in the nature of food charity, which is marked by inconsistent donations, and more specifically, beliefs in Canada and elsewhere that <a href="https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2019/05/Provision-of-formula-milk-at-food-banks-Unicef-UK-Baby-Friendly-Initiative.pdf">formula provision in food banks may put breastfeeding and babies at risk</a>. </p>
<p>When we allow food insecurity to disrupt breastfeeding, or make formula inaccessible with the intent to protect breastfeeding, it punishes already struggling mothers.</p>
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<img alt="" src="https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/381818/original/file-20210201-13-1g0n3ld.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><a class="source" href="https://theconversation.com/ca/podcasts">Click here to listen to Don’t Call Me Resilient</a></span>
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<p>Unsurprisingly, <a href="https://globalnews.ca/news/4864964/baby-formula-under-lock-and-key-as-thefts-rise-say-winnipeg-retailers/">infant formula is now one of the most shoplifted items</a>, leading some retailers to keep it locked-up. </p>
<p>Desperate mothers are <a href="https://www.ubcpress.ca/out-of-milk">turning to online platforms</a> like Facebook Marketplace and Kijiji to get second-hand formula, which is sometimes already opened.</p>
<p>Heather said: “You take what you can get. It is a matter of being able to feed the baby at all.… We sold stuff. Stole stuff. Stole it to sell it and stole formula from the store. Whatever we had to do to feed them we did it — I am not proud of it but my kids are still alive.” </p>
<p>Mothers sometimes resort to watering-down formula to make it last longer and introduce solids and other liquids early when there is no formula to be found. These survival tactics show the lengths families must go to find food.</p>
<h2>A nutritious diet is expensive</h2>
<p>Most low-income families with babies who receive federal maternity benefits or income assistance cannot afford a basic nutritious diet. If they tried, according to <a href="https://doi.org/10.17269/s41997-020-00306-5">our research</a>, they would likely be short hundreds of dollars each month, whether they breastfeed or use formula. </p>
<p>According to many mothers, no matter where you live in the world, poverty and food insecurity is a threat to maternal and infant health. The consensus among mothers we spoke with say the solutions lie in their economic security. </p>
<p>Yes, breastfeeding is a robust physiological system and malnourished mothers can breastfeed. But we need real upstream policy solutions that ensure mothers and their babies don’t go hungry in the first place. Canada needs adequate social welfare that protects sustainable breastfeeding and ensures that non-breastfed babies have access to food. </p>
<iframe height="200px" width="100%" frameborder="no" scrolling="no" seamless="" src="https://player.simplecast.com/98b5cd5f-0305-4650-9bdf-731605667fb7?dark=true"></iframe>
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<p class="fine-print"><em><span>Lesley Frank receives funding from the Social Science and Humanities Research Council, Research Nova Scotia, and Acadia University. She is affiliated with the Canadian Centre for Policy Alternatives - Nova Scotia as a Research Associate and Steering Committee member of Campaign 2000. </span></em></p>With the high cost of infant formula, food-insecure mothers who cannot breastfeed are struggling to feed their babies.Lesley Frank, Tier II Canada Research Chair in Food, Health, and Social Justice, Acadia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1597712021-06-14T12:24:51Z2021-06-14T12:24:51ZNew technologies claiming to copy human milk reuse old marketing tactics to sell baby formula and undermine breastfeeding<figure><img src="https://images.theconversation.com/files/401396/original/file-20210518-23-ss0njf.jpg?ixlib=rb-1.1.0&rect=15%2C15%2C5099%2C3397&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Despite claims to the contrary, the real thing cannot be replicated.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mixed-race-mother-nursing-newborn-baby-royalty-free-image/601801509">Jose Luis Pelaez Inc/DigitalVision via Getty Images</a></span></figcaption></figure><p>New products that <a href="https://www.foodnavigator-usa.com/Article/2020/12/17/TurtleTree-Labs-raises-6.2m-to-support-cell-cultured-milk-platform">claim to replicate mother’s milk</a> have entered the lucrative market for infant formula. </p>
<p>To an <a href="https://scholar.google.com/citations?user=0VycH7AAAAAJ&hl=en">anthropologist and public health scholar</a> who studies breastfeeding, these claims appear to be built on old patterns of misleading scientific statements – and reveal the power of marketing to exploit gaps created by inadequate societal support for breastfeeding. </p>
<p>The costs of undermining breastfeeding are enormous. <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">Globally, over 823,000 child deaths</a> could be prevented annually with appropriate breastfeeding. Additionally, <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">20,000 maternal deaths</a> could be averted each year worldwide from breast cancer. Poor communities of color around the world disproportionately shoulder this harm.</p>
<h2>The rise of commercial formula</h2>
<p><a href="https://www.routledge.com/Breastfeeding-New-Anthropological-Approaches/Tomori-Palmquist-Quinn/p/book/9781138502871">Throughout most of history and across cultures</a>, communities understood that breastfeeding ensured the best chance for infants to survive and thrive. Breastfeeding continued, on average, <a href="https://www.doi.org/10.4324/9781315145129-10">from two to four years</a>, with caregivers introducing new foods while continuing to breastfeed.</p>
<p>Attempts to fully replace human milk, <a href="https://www.springer.com/gp/book/9783030273927">usually with animal milk and gruels</a>, were relatively rare. Such attempts were most common when mothers were ill or dead, and caregivers couldn’t locate a lactating woman. <a href="https://www.springer.com/gp/book/9783030273927">Compared with breastfeeding, replacement feeding reduced babies’ chances of survival</a>.</p>
<p>Efforts to mimic breast milk <a href="https://uwpress.wisc.edu/books/0655.htm">escalated with the rise of scientific thinking and industrial capitalism</a> in Europe and the U.S. in the late 18th and early 19th centuries. Mass migration to urban centers eroded community support – and poor labor conditions made breastfeeding challenging. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Old advertisement for Nestlé formula with lead text that reads 'Don't Wait Too Long Before You Wean the Baby.'" src="https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=875&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=875&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=875&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1100&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1100&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405394/original/file-20210609-14833-1th1a61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1100&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nestlé advertisement, 1911.</span>
<span class="attribution"><a class="source" href="https://www.aims.org.uk/journal/item/nestle">Nestlé</a></span>
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<p>From the first commercial milk formula <a href="https://yalebooks.yale.edu/book/9780300188127/milk">patented in 1865 by Justus von Liebig</a>, formula-makers drew on science to gain the trust of medical providers and <a href="https://uwpress.wisc.edu/books/0655.htm">argue their products were as good as</a> – or even superior to – human milk. A study prepared for and published by Nestlé in 1878 <a href="https://yalebooks.yale.edu/book/9780300188127/milk">asserted that mother’s milk was deficient in key nutrients</a> and infants aged 6 to 8 weeks already required supplementation – with Nestlé’s food.</p>
<p>Physicians often claimed to support breastfeeding while undermining it in practice with poor advice and an increasing focus on formula feeding. Pioneering American pediatrician Emmett Holt advocated <a href="https://uwpress.wisc.edu/books/0655.htm">his own method of making formula</a>. <a href="https://archive.org/details/carefeedingof00holt/page/20/mode/2up">In his bestselling book, first published in 1894</a>, Holt claimed infants could be harmed by mother’s milk that was corrupted by emotion. Holt also advised mothers to schedule brief breastfeeding sessions and limit physical contact. Such advice <a href="https://dro.dur.ac.uk/26620/1/26620.pdf">impeded the physiology of breastfeeding</a>, which relies on frequent, responsive feedings and close contact – and contributed to growing reliance on supplementation with formula. </p>
<p>Physicians ultimately <a href="https://uwpress.wisc.edu/books/0655.htm">incorporated formula into their routine medical practices</a> and institutionalized them in <a href="https://history.wisc.edu/publications/brought-to-bed-childbearing-in-america-1750-1950/">hospital childbirth protocols</a>. </p>
<h2>Global spread</h2>
<p>In the first half of the 20th century, colonial administrations spread these new “scientific” infant care norms and products around the globe. They saw bottle-feeding as a <a href="https://doi.org/10.1093/ahr/121.4.1196">solution to infant mortality, disease and malnutrition</a> – and ultimately as an answer to labor shortages in the colonies. </p>
<p>In the 1950s, Nestlé used marketing techniques perfected in Europe to <a href="https://doi.org/10.1080/03086534.2020.1816624">dramatically expand its market in Africa</a>, <a href="https://doi.org/10.1093/ahr/121.4.1196">Asia and other parts of the world</a>. The growing number of infant deaths associated with the use of these products drew international attention and ultimately led to the <a href="https://doi.org/10.1093/ahr/121.4.1196">Nestlé boycott in 1977</a>. </p>
<p>Nestlé’s practices were not unique among formula-makers. Growing concerns about the <a href="https://doi.org/10.1111/j.1753-4887.1972.tb04042.x">role of inappropriate marketing practices</a> in declining breastfeeding rates and infant illness and death led to the development of the <a href="https://www.who.int/nutrition/publications/code_english.pdf">International Code of Marketing of Breast-milk Substitutes</a>, which was adopted by the World Health Assembly 40 years ago, in 1981. The U.S. was the <a href="https://doi.org/10.1136/archdischild-2011-301299">only nation that voted against it</a>, driven by formula lobbying efforts.</p>
<h2>Milking profits</h2>
<p>In the 1950s through the 1970s, multiple social movements fueled <a href="https://doi.org/10.2307/2080604">increased interest in breastfeeding in the U.S.</a>. Medical experts supported these movements with a growing body of <a href="https://doi.org/10.1093/ahr/121.4.1196">scientific research demonstrating the importance of breastfeeding for infant, child and maternal health</a>. But despite <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">significant gains in breastfeeding</a> in some settings, like the U.S., the formula industry <a href="https://doi.org/10.1016/S0140-6736(15)01044-2">continues to expand</a>. </p>
<p>Between 2005 and 2019, global <a href="https://doi.org/10.1111/mcn.13097">formula sales increased 121%</a>, led by middle-income countries. The global industry is <a href="https://doi.org/10.1111/mcn.13097">currently valued at US$50.6 billion</a> and <a href="https://www.globenewswire.com/news-release/2021/01/29/2166545/0/en/Global-Infant-Formula-Market-Size-Will-Reach-USD-110-26-Billion-by-2026-Facts-Factors.html">projected to double by 2026</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman stands in front of a massive grocery store display of infant formula." src="https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401411/original/file-20210518-15-emjp6x.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Infant formula is big business.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/rear-view-of-young-asian-mother-groceries-shopping-royalty-free-image/1255253039">d3sign/Moment via Getty Images</a></span>
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<p>Formula-makers devote <a href="https://doi.org/10.1111/mcn.13097">billions of dollars each year to marketing</a> that co-opts scientific and medical authority and <a href="https://www.who.int/publications/i/item/9789240006010">undermines breastfeeding globally</a>. These marketing practices have <a href="https://www.who.int/publications/i/item/9789240006010">continued to defy the International Code of Marketing of Breast-milk Substitutes</a>. </p>
<p>As in the 19th century, <a href="https://www.savethechildren.org.uk/what-we-do/policy-and-practice/our-featured-reports/dont-push-it">formula marketing</a> still <a href="https://doi.org/10.1186/s12992-020-00597-w">presents breastfeeding as an inherently problematic</a>, unreliable process to which formula provides the solution. </p>
<p>Yet most breastfeeding challenges, like the perception of insufficient milk and the difficulties faced by lactating workers, are the product of <a href="https://doi.org/10.1016/S0140-6736(15)01044-2">structural and social conditions</a> that can be addressed by <a href="https://doi.org/10.1016/S0140-6736(15)01044-2">investing in policies</a> that provide quality perinatal care, skilled breastfeeding support, parental leave and workplace accommodations for lactating parents. </p>
<h2>More than a food</h2>
<p>Formula companies focus on human milk as the only important element of breastfeeding – and claim near equivalence between their product and human milk. Yet human milk is a living, life-sustaining substance with a <a href="https://www.routledge.com/Breastfeeding-New-Anthropological-Approaches/Tomori-Palmquist-Quinn/p/book/9781138502871">long evolutionary history and cultural meaning</a>. </p>
<p>Human milk is <a href="https://jhupbooks.press.jhu.edu/title/milk">specific to our species</a>. It is <a href="https://doi.org/10.1002/ajhb.23564">dynamic and adaptive</a> – ever-changing in response to local environments. Human milk contains <a href="https://doi.org/10.1002/ajhb.23564">bioactive compounds</a> and has <a href="https://doi.org/10.1002/ajp.22994">a unique microbiome that varies by setting and over time</a>. New technology, including <a href="https://www.foodnavigator-usa.com/Article/2020/12/17/TurtleTree-Labs-raises-6.2m-to-support-cell-cultured-milk-platform">the culturing of human cells</a>, cannot replicate any of this. </p>
<p>Through complex interactions among mothers, infants and their communities, breastfeeding provides infants with <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">optimal nutrition and protection from infectious disease</a>. Across cultures, lactation and human milk create <a href="https://www.routledge.com/Breastfeeding-New-Anthropological-Approaches/Tomori-Palmquist-Quinn/p/book/9781138502871">relationships that bind families</a> and communities together. </p>
<p>Families need accurate information free of commercial influence to make informed decisions about breastfeeding. I believe when lactation is not possible or desired, <a href="https://doi.org/10.1016/S2214-109X(19)30402-4">families could benefit</a> from <a href="https://doi.org/10.1177/0890334419850820">donor human milk</a>. <a href="https://doi.org/10.1016/S0140-6736(15)01044-2">Government investment in policies</a> that protect, promote and support breastfeeding remains key to creating an environment in which breastfeeding can thrive.</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p><img src="https://counter.theconversation.com/content/159771/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cecília Tomori has received funding from the National Institutes of Health, US Health Resources & Services Administration, Johns Hopkins University, and the University of Michigan.</span></em></p>Around the globe, 823,000 child deaths could be prevented annually with appropriate breastfeeding. Formula makers continue to defy a 40-year-old international code on marketing their product.Cecília Tomori, Associate Professor and Director of Global Public Health and Community Health, Johns Hopkins University School of NursingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1560082021-03-01T14:16:35Z2021-03-01T14:16:35ZWhy breastfed babies have improved immune development – new findings<figure><img src="https://images.theconversation.com/files/386995/original/file-20210301-17-65q5na.jpg?ixlib=rb-1.1.0&rect=40%2C0%2C6669%2C4476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Our study revealed breastfed babies had twice the number of regulatory T cells.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/serious-calm-careful-young-black-mom-1426845311">SeventyFour/ Shutterstock</a></span></figcaption></figure><p>Life outside the womb is tough – not least because of the many bacteria, viruses, and other pathogens that can harm a baby. Not only does a baby’s immune system need to be able to recognise and eliminate pathogens, it also needs to be able to distinguish harmless substances and helpful bacteria important for health – such as those in our gut microbiome, which help break down foods and protect us from pathogens. </p>
<p><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext">Breastfeeding</a> is known to be important for a baby’s immune development, and is also linked to numerous long-term health benefits, such as lower rates of obesity, asthma and autoimmune disorders compared to those who were formula fed. But until recently, researchers haven’t quite known why the immune systems of breastfed babies are better equipped compared to formula-fed infants.</p>
<p>Our <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/all.14736">latest study</a> may have the answer. We found that breastfeeding is important for helping babies to develop important immune cells in their first weeks of life. These immune cells, known as regulatory T cells, provide balance in the immune system by controlling its response to pathogens, and preventing autoimmune responses (where the immune system mistakenly attacks your body).</p>
<p>We studied blood and stool samples from a cohort of 38 healthy mother and baby pairs. All babies in the study were born by elective Caesarean section and samples were taken at birth and at three weeks of life.</p>
<p>We found that the population of regulatory T cells was nearly twice as abundant in breastfed babies at three weeks of age compared to babies who were formula-fed. This shows that these babies’ immune systems are better equipped to know which pathogens they should attack and which pathogens are harmless to the body. We demonstrated that this change is likely to be driven by interaction with the mother’s cells during breastfeeding.</p>
<figure class="align-center ">
<img alt="An image of regulatory T cells." src="https://images.theconversation.com/files/386996/original/file-20210301-19-bpwqbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386996/original/file-20210301-19-bpwqbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386996/original/file-20210301-19-bpwqbi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386996/original/file-20210301-19-bpwqbi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386996/original/file-20210301-19-bpwqbi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386996/original/file-20210301-19-bpwqbi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386996/original/file-20210301-19-bpwqbi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Regulatory T cells balance the immune system.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/tregt-lymphocytest-cells-3d-render-1233772858">ratlos/ Shutterstock</a></span>
</figcaption>
</figure>
<p>During pregnancy, the immune systems of the mother and baby are known to interact via cells moving through the placenta. Our results show that their immune systems continue interacting after birth via breastfeeding. We uncovered this by isolating immune cells from both the mother and baby, and growing them together in the lab. </p>
<p>The baby’s cells were less likely to see the mother’s cells as foreign if the baby was breastfed compared to formula-fed – an effect mediated by regulatory T cells. This means that the baby’s immune system “tolerates” these maternal cells from breastmilk and does not launch an immunological reaction, like it would do with any other foreign cell.</p>
<p>The early development of regulatory T cells is likely to be a key element in effective immune function in later life. This response is essential in <a href="https://www.jacionline.org/article/S0091-6749(16)30499-7/abstract">preventing allergies</a>, where the immune system mounts an undesirable response against harmless substances, and decreasing the risk of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0896841120300779">autoimmune disorders</a>, where the immune system reacts against the body’s own cells. </p>
<p>Regulatory T cells are also of great importance in <a href="https://www.sciencedirect.com/science/article/abs/pii/S1044532311001540?via%3Dihub">building an effective gut microbiome</a>, which evolves gradually after birth. If the immune system eliminated, rather than tolerated, these gut microbes in early life, several of their beneficial health effects would be hindered. For example, this could lead to digestive problems, or could increase the risk of intestinal infections.</p>
<p>We also examined the composition of the gut microbiome in stool samples collected from babies at three weeks of age to understand how it is linked with immune development. We found subtle but important differences between breastfed and formula-fed babies. Two distinct bacterial strains, <em>Veillonella</em> and <em>Gemella</em>, were more abundant in samples of breastfed babies. These strains are known to produce short-chain fatty acids which are essential for the <a href="https://www.nature.com/articles/nature12726">development and normal function</a> of regulatory T cells. Greater presence of these strains in the gut may contribute to regulatory T cells being more abundant in blood samples of breastfed babies. </p>
<p>Although the number of participants in our study may appear small, we worked with a unique cohort of babies, creating the largest study of its kind to date. But our study also had some other shortcomings. For instance, we only followed up participants up to three weeks of life. It will be interesting to see in future studies how long the observed changes are present for in the immune system, and whether the number of regulatory T cells equalises in later life between breastfed and formula-fed babies. </p>
<p>And while we intentionally studied babies born by Caesarean section to observe a group exposed to as similar birthing conditions as possible, it will also be interesting for future studies to see whether our observations are also true for babies born by normal delivery.</p>
<p>While breastfeeding is recommended for infant nutrition by the <a href="https://www.who.int/health-topics/breastfeeding#tab=tab_1">World Health Organization</a>, there are of course many reasons why a mother may need to formula-feed her baby. And in most developed countries, this alternative is safe for babies, and the composition of many infant formulas is frequently changed to be as close to breastmilk as possible. Although it’s unlikely that breastmilk can ever be fully mimicked, research like ours may help to guide the tailoring of formula milk to offer better health advantages to all babies.</p><img src="https://counter.theconversation.com/content/156008/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gergely Toldi does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Until now, researchers haven’t quite known why the immune systems of breastfed babies are better equipped.Gergely Toldi, Consultant Neonatologist, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1518202021-02-08T20:51:20Z2021-02-08T20:51:20ZBreastfeeding research improves lives and advances health, but faces conflicts<figure><img src="https://images.theconversation.com/files/380821/original/file-20210127-19-1a4si88.jpg?ixlib=rb-1.1.0&rect=207%2C0%2C5591%2C4012&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Research shows the breast milk of women who have recovered from COVID-19 offers a source of COVID-19 antibodies.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Breastfeeding and breast milk provide <a href="https://doi.org/10.1016/S0140-6736(16)00012-X">big opportunities to support maternal, infant and population health</a>. This is especially true during the current pandemic because breastfeeding can help alleviate food insecurity, and research shows the breast milk of women who have recovered from COVID-19 offers a source of <a href="https://doi.org/10.1016/j.isci.2020.101735">COVID-19 antibodies</a>. </p>
<p>Breastfeeding <a href="https://doi.org/10.1016/S0140-6736(15)01024-7">saves lives</a> and prevents illness. It is <a href="https://doi.org/10.1136/bmj.l5646">environmentally friendly</a> and profoundly important to children’s long-term development. After all, breast milk is the <em>only</em> food that has evolved specifically to feed humans. </p>
<h2>Breastfeeding matters</h2>
<p>Beyond supplying nutrition, breast milk provides personalized <a href="https://doi.org/10.1093/nutrit/nuz019">immune protection and shapes the developing microbiome</a>. Scientists have discovered enzymes, hormones, antibodies and live cells in <a href="https://doi.org/10.3345/cep.2020.00059">breast milk</a>, and these bioactive components could hold the key to <a href="https://doi.org/10.1007/s13577-019-00251-7">developing new therapies</a> — not only for COVID-19, but also autoimmune diseases, diabetes and cancer.</p>
<p>Yet, remarkably, we still don’t fully understand the composition of breast milk, or the biological basis for its many health effects. In fact, more scientific papers have been published on <a href="https://pubmed.ncbi.nlm.nih.gov/?term=headache&sort=pubdate">headaches</a> than <a href="https://pubmed.ncbi.nlm.nih.gov/?term=breastfeeding&sort=pubdate">breastfeeding</a>, and more federal research dollars from <a href="https://cihr-irsc.gc.ca/e/37788.html">Canadian Institutes of Health Research</a> and the <a href="https://www.nserc-crsng.gc.ca/db-tb/index-eng.asp">Natural Sciences and Engineering Research Council of Canada</a> have been invested to <a href="https://webapps.cihr-irsc.gc.ca/funding/Search?p_language=E&p_version=CIHR">study corn</a> than <a href="https://www.nserc-crsng.gc.ca/ase-oro/index_eng.asp">breast milk</a>. </p>
<p>The act of breastfeeding also <a href="https://doi.org/10.1089/bfm.2019.0106">supports mother-infant bonding</a> and helps to prevent <a href="https://doi.org/10.1111/apa.13102">breast and ovarian cancer in mothers</a>. Unfortunately, most mothers <a href="https://doi.org/10.1542/peds.2012-1295">do not even meet their own breastfeeding goals</a>, let alone <a href="https://www.who.int/nutrition/publications/infantfeeding/global-bf-scorecard-2017.pdf">achieve recommendations</a> of exclusive breastfeeding for six months, followed by 18 months of breastfeeding along with other foods.</p>
<p>This is particularly concerning during this pandemic, when mothers infected with COVID-19 may be <a href="https://theconversation.com/separating-mothers-with-covid-19-from-their-newborns-does-more-harm-than-good-141291">separated from their newborns</a> (despite <a href="https://www.who.int/news-room/commentaries/detail/breastfeeding-and-covid-19">World Health Organization guidance</a> to the contrary) and <a href="https://doi.org/10.1111/mcn.13088">breastfeeding support is often unavailable</a> because public health visits are being cancelled and lactation services have been suspended in many places.</p>
<h2>Tensions abound</h2>
<p>Every parent knows that infant feeding is a complex issue, often evoking strong emotions based on personal experience. Difficult or negative breastfeeding experiences can fuel a defensive “<a href="https://raisingwonder.wordpress.com/2019/08/08/its-time-to-talk-about-the-breastfeeding-science-backlash-movement/">breastfeeding denialism</a>” attitude.</p>
<figure class="align-right ">
<img alt="A woman with tattoos breastfeeding her infant" src="https://images.theconversation.com/files/380822/original/file-20210127-19-1345mev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/380822/original/file-20210127-19-1345mev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380822/original/file-20210127-19-1345mev.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380822/original/file-20210127-19-1345mev.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380822/original/file-20210127-19-1345mev.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380822/original/file-20210127-19-1345mev.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380822/original/file-20210127-19-1345mev.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Breastfeeding support such as public health visits may not be available during the pandemic.</span>
<span class="attribution"><span class="source">(Pexels/Anna Shvets)</span></span>
</figcaption>
</figure>
<p>Conversely, some breastfeeding advocates refuse to acknowledge that for some families, formula is necessary for medical, personal, societal or socioeconomic reasons. These extreme attitudes cause a tense and unproductive environment for researchers working to generate inclusive evidence-based guidance for infant feeding.</p>
<p>Industry partnerships also cause tension in this field because the infant feeding industry frequently violates the <a href="https://www.unicef.org/nutrition/index_24805.html">World Health Organization code for marketing of breastmilk substitutes</a>, and transgressions have <a href="https://doi.org/10.1016/S0140-6736(20)32119-X">worsened during the pandemic</a>. However, due to lack of funding for breastfeeding research, scientists are often faced with choosing between industry funding or no funding at all.</p>
<p>Unfortunately, these tensions often detract from the energy and resources that breastfeeding advocates, researchers, health professionals and policy-makers could be using to advance their shared goal of supporting maternal and child health.</p>
<h2>What can be done</h2>
<p>Of course, members of the diverse breastfeeding advocacy and research communities will not always agree — but we should aim to find common ground and work together. There are many stakeholders involved, each with a role to play:</p>
<p><strong>Governments and non-profit funding organizations</strong> should acknowledge the importance of breastfeeding and breast milk and invest more resources into this field.</p>
<p><strong>Researchers</strong> should build interdisciplinary teams to study breast milk as a biological system and think broadly about “breastfeeding challenges” in the context of complex social systems - including social inequities, parental leave policies, lactation difficulties and donor breast milk.</p>
<p><strong>Companies, researchers and advocacy groups</strong> should co-develop a conflict of interest framework for research on breastfeeding and breast milk and reporting of results.</p>
<p>Messaging is key to achieving these goals. All groups need to communicate effectively with each other, and with the health-care, research and public sectors. This means <a href="http://www.azadlab.ca/resources">providing or sharing clear resources</a> to convey scientific evidence free of conflict of interest, targeted to each audience, such as fact sheets for policy-makers, engaging videos for the public and infographics for health-care providers. </p>
<p>Stakeholders also need to actively discredit unfounded claims and misinformation, such as <a href="https://doi.org/10.1136/bmj.m875">unsubstantiated health claims made by infant nutrition companies</a>, or rumours about the transmission of COVID-19 via breastfeeding, when <a href="https://doi.org/10.1111/nyas.14477">there is no evidence of this occurring</a>.</p>
<h2>Looking forward</h2>
<figure class="align-center ">
<img alt="A woman breastfeeding a baby" src="https://images.theconversation.com/files/380826/original/file-20210127-17-54o1ip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380826/original/file-20210127-17-54o1ip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380826/original/file-20210127-17-54o1ip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380826/original/file-20210127-17-54o1ip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380826/original/file-20210127-17-54o1ip.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380826/original/file-20210127-17-54o1ip.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380826/original/file-20210127-17-54o1ip.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">COVID-19 has highlighted both the importance and fragility of breastfeeding support systems.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Progress in breastfeeding, breast milk and lactation research is being hampered by tensions among researchers, advocates and industry.</p>
<p>As breast milk scientists, breastfeeding researchers and lactation specialists, we are concerned about these tensions and their potential to impede or delay discoveries in our field. Last year, we <a href="https://www.chrim.ca/2020/breastfeeding-and-the-origins-of-health-interdisciplinary-perspectives-and-priorities/">held a workshop</a> to discuss these concerns and develop solutions.</p>
<p>Our <a href="https://doi.org/10.1111/mcn.13109">workshop paper</a> was written before the pandemic, but its recent publication is timely. The pandemic has brought researchers together in ways that seemed impossible before.</p>
<p><a href="http://doi.org/10.1001/jama.2020.15580">Breast milk research</a> that would normally take years has been completed in months with unprecedented efficiency. A <a href="https://doi.org/10.1016/S2352-4642(20)30134-6">global network of human milk banks</a> was established in a matter of days to share information about safe operations during the pandemic. Milk scientists and breastfeeding researchers are <a href="https://www.who.int/docs/default-source/mca-documents/research/working-group-document-22june2020.pdf?sfvrsn=fbb43e6c_2">meeting monthly with the WHO</a> to speed up the transition from discovery to policy. </p>
<p>We hope these trends will continue beyond the pandemic and become the new standard for doing and sharing research.</p>
<p>COVID-19 has also emphasized both the importance and fragility of breastfeeding support systems, which <a href="https://doi.org/10.1111/mcn.13088">have suffered considerably due to current restrictions</a>. The pandemic has also highlighted the potential of breast milk to inform new avenues of biomedical research, such as <a href="https://doi.org/10.1016/j.isci.2020.101735">milk antibodies</a> as potential therapeutics. </p>
<p>We hope this added urgency will encourage researchers, advocates, funders and policy-makers to work together to accelerate progress in supporting breastfeeding and breast milk research.</p><img src="https://counter.theconversation.com/content/151820/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Meghan Azad co-Directs the Manitoba Interdisciplinary Lactation Centre. She holds a Tier 2 Canada Research Chair in the Developmental Origins of Chronic Disease at the University of Manitoba and is a Fellow in the Canadian Institutes for Advanced Research (CIFAR) Humans and the Microbiome Program. She receives research funding from the Canadian Institutes of Health Research, Research Manitoba, the Canada Foundation for Innovation, the Bill and Melinda Gates Foundation, the Manitoba Children’s Hospital Foundation, Prolacta Biosciences, Mitacs, CIFAR, and the Garfield G. Weston Foundation. She regularly speaks at conferences and workshops on infant nutrition, some sponsored by Medela, the Institute for the Advancement of Breastfeeding & Lactation Education, and Prolacta Biosciences. She has contributed to online courses on breast milk and the infant microbiome produced by Microbiome Courses. She serves in a volunteer capacity as Secretary to the International Society for Research on Human Milk and Lactation and as a member of the National Academy of Sciences, Engineering and Medicine Committee on Scanning New Evidence on the Nutrient Content of Human Milk. </span></em></p><p class="fine-print"><em><span>Katie Hinde's research has been supported by grant funding from the National Science Foundation and the National Institutes of Health. </span></em></p><p class="fine-print"><em><span><a href="mailto:lbode@health.ucsd.edu">lbode@health.ucsd.edu</a> works for University of California San Diego. He receives funding from the National Institutes of Health and the Family Larsson-Rosenquist Foundation. </span></em></p><p class="fine-print"><em><span>Luisa Zuccolo receives funding from the UK Medical Research Council and the Jean Golding Institute at the University of Bristol. She consults for the Human Milk Foundation and sits on the Advisory Board of the UK National Institute of Health Research's Cochrane review on breastfeeding support strategies. She is a trained volunteer in breastfeeding peer support and co-chairs a breastfeeding peer supporter group, which is audited by the UK Baby Friendly Initiative. </span></em></p><p class="fine-print"><em><span>Merilee Brockway receives funding from The Molly Towell Perinatal Research Foundation and the Garfield Weston Foundation.</span></em></p><p class="fine-print"><em><span>Nathan Nickel, PhD is an Associate Professor of Community Health Sciences, Associate Director at the Manitoba Centre for Health Policy, and Co-Director of the Manitoba Interdisciplinary Lactation Centre. Dr. Nickel is the Scientific Chair for Breastfeeding at the American Public Health Association and he works with the Breastfeeding Committee of Canada and the Centre for Health Equity Education and Research. He receives funding for breastfeeding and population health research from the Public Health Agency of Canada, Health Canada, the Canadian Institutes for Health Research, Research Manitoba, and the Canadian Foundation for Innovation. </span></em></p><p class="fine-print"><em><span>Rafael Pérez-Escamilla, PhD is professor of public health and director of the Office of Public Health Practice, the Global, the Global Health Concentration, the Yale-Griffin CDC Prevention Research Center, and the Maternal Child Health Promotion Program at the Yale School of Public Health. He receives funding from The National Institutes of Health (NIH), the US Centers for Disease Control and Prevention (CDC), The World Health Organization, The Bill and Melinda Gates Foundation, The Robert Wood Johnson Foundation, The Kellogg Foundation, and The Family Larsson-Rosenquist Foundation </span></em></p>Researchers don’t fully understand the composition of breast milk and its benefits. Beyond nutrition, it contains enzymes, hormones and the mother’s antibodies — including antibodies for COVID-19.Meghan Azad, Associate Professor of Pediatrics and Child Health; Canada Research Chair in the Developmental Origins of Chronic Disease, University of ManitobaKatie Hinde, Associate Professor, School of Human Evolution and Social Change, Arizona State UniversityLars Bode, Professor of Pediatrics and Director of Mother-Milk-Infant Center of Research Excellence, University of California, San DiegoLuisa Zuccolo, Senior Research Fellow, Health Sciences, University of BristolMerilee Brockway, Post-doctoral Fellow, Department of Pediatrics and Child Health, University of ManitobaNathan C. Nickel, Associate Professor of Community Health Sciences; Co-Director MILC; Associate Director, Manitoba Centre for Health Policy, University of ManitobaRafael Perez-Escamilla, Professor of Public Health, Yale UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1496812020-12-07T15:27:45Z2020-12-07T15:27:45ZThe rise of commercial milk formulas matters for women and children<figure><img src="https://images.theconversation.com/files/369277/original/file-20201113-21-4pdes4.jpg?ixlib=rb-1.1.0&rect=46%2C0%2C5184%2C3453&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infant formula sales have doubled between 2005 and 2019.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/preparation-mixture-baby-feeding-on-wooden-554077681">279photo Studio/ Shutterstock</a></span></figcaption></figure><p><a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00210-5/fulltext">Breastfeeding</a> can play an especially important role in early-life nutrition. It can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6486667/">benefit</a> children’s future school performance and economic prospects in later life, as well as the mother’s health. </p>
<p>Health authorities across the world endorse the World Health Organization’s (WHO) <a href="https://www.who.int/health-topics/breastfeeding#tab=tab_2">recommendation</a> that newborns should where possible exclusively breastfeed from the first hour of life until six months of age, and thereafter receive safe and nutritious foods with continued breastfeeding up to two years of age or beyond.</p>
<p>Despite this, our <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.13097">recent study</a> shows that global commercial milk formula sales are booming. Between 2005 and 2019, world milk formula sales more than doubled from 3.5kg to 7.4kg per child. Total sales grew from 1 million tonnes to 2.1 million tonnes.</p>
<p>This growth in sales was seen in all types of formula, including “standard” formula for infants (0-6 months), “follow-up” formula (7-12 months), toddler milks (13-36 months), and so-called “specialised” formulas. So more children from a wider range of age groups are consuming formula. </p>
<p>Rapid growth <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.13097">has occurred</a> in many highly-populated countries, including the Middle East, north Africa, eastern Europe, central Asia, and parts of Latin America. The most remarkable growth has been in east and south-east Asia. China, in particular, accounted for only 14% of global formula sales in 2005 – but now accounts for 33% of all sales. </p>
<p>In south Asia and west and central Africa, the amount sold to each customer remains low and show no signs of growth. In Europe and North America, although per customer sales volumes remain high, they plateaued or slightly decreased between 2005-2019. </p>
<h2>Behind the sales ‘boom’</h2>
<p>There are <a href="https://www.who.int/nutrition/publications/infantfeeding/WHO_NMH_NHD_09.01/en/">medical reasons</a> for using safe and adequate breastmilk substitutes. And some women find continuing breastfeeding difficult depending on their circumstances, and may use formula as an alternative or complement to breastfeeding. <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.13097">Our study</a> also shows decisions and practices around formula use can be strongly shaped by wider societal forces, such as commercial marketing, rather than individual choice.</p>
<p>It’s known that milk formula sales increase as countries become richer and more urbanised, and as more mothers enter into formal employment. Asia’s formula sales boom may be partly explained by millions of women entering the paid workforce, especially in the region’s vast manufacturing zones.</p>
<p>Millions of women worldwide also lack adequate <a href="https://www.who.int/bulletin/volumes/98/6/19-229898/en/">paid maternity leave and social protection</a>. This means the decision to formula feed may only be done out of necessity, to avoid losing employment and income. We also know that many hospitals and healthcare settings aren’t equipped to help women establish breastfeeding, with few maternal and newborn care facilities worldwide meeting <a href="https://www.who.int/nutrition/publications/infantfeeding/bfhi-implementation/en/">standards</a> of care for breastfeeding mothers and newborns.</p>
<p>Commercial factors are also important. Just five companies control 57% of the global formula milk industry, worth US$56.6 billion (£42.5 billion) The industry spends <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.13097">an estimated US$5 billion on marketing every year</a>, which <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.12962">powerfully shapes social norms</a> about <a href="https://pubmed.ncbi.nlm.nih.gov/26314734/">feeding babies and children</a>. </p>
<p>Marketing messages can portray formula as modern, scientific and comparable or superior to breastmilk. The growth of social media enables companies to <a href="https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-020-00597-w#:%7E:text=Formula%20marketing%2C%20as%20for%20other,a%20brand%20and%20generic%20level.">target mothers</a> with personalised product offerings and ads.</p>
<p>Hospitals are a key marketing channel, too. Companies often engage health professionals to promote formula feeding. In many countries, health professionals are directly compensated to promote formula. But more commonly, companies influence health professionals indirectly by <a href="https://pubmed.ncbi.nlm.nih.gov/31401600/">sponsoring</a> their associations, conferences and education.</p>
<figure class="align-center ">
<img alt="A grocery store aisle full of baby and toddler formula products." src="https://images.theconversation.com/files/369278/original/file-20201113-23-cn8j5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/369278/original/file-20201113-23-cn8j5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=382&fit=crop&dpr=1 600w, https://images.theconversation.com/files/369278/original/file-20201113-23-cn8j5l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=382&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/369278/original/file-20201113-23-cn8j5l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=382&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/369278/original/file-20201113-23-cn8j5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=481&fit=crop&dpr=1 754w, https://images.theconversation.com/files/369278/original/file-20201113-23-cn8j5l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=481&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/369278/original/file-20201113-23-cn8j5l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=481&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Companies cross-promote products by using the same packaging.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/toronto-canada-november-22-2014-baby-233666974">ValeStock/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Companies also <a href="https://www.who.int/nutrition/publications/infantfeeding/information-note-cross-promotion-infant-formula/en/#:%7E:text=In%20summary%2C%20the%20now%20common,to%20breastfeeding%20and%20infant%20health.&text=As%20a%20result%2C%20young%20infants,cannot%20meet%20their%20nutritional%20needs.">cross-promote</a> their entire product range of follow-up and toddler milks by using packing and labelling that resembles standard infant formula. This allows companies to get around the stricter prohibitions on infant formula marketing.</p>
<p>Marketing regulations are also important. The fact that formula sales are booming in China but have flat-lined at low levels in India partly reflects contrasting regulatory environments – with regulations on marketing being stricter and more comprehensive in India. </p>
<p>Despite <a href="https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/international-code-marketing-breastmilk-substitutes-resources/the-code/">an international code</a> to stop <a href="https://www.who.int/nutrition/publications/infantfeeding/breastmilk-substitutes-FAQ2017/en/">aggressive and inappropriate marketing</a> of breast-milk substitutes, most governments haven’t fully incorporated it <a href="https://www.who.int/publications/i/item/9789240006010">into law</a>. And even when laws exist, marketing violations by formula companies often go unpunished. The formula industry has also been able to lobby against any strengthening of regulation, partly by promoting their own – much weaker – corporate policies on marketing.</p>
<h2>Health concerns</h2>
<p>Breastmilk and breastfeeding where it is possible has numerous advantages over formula and bottle feeding – which is why the growth of formula sales is concerning.</p>
<p>Breastfeeding has been shown to reduce the likelihood of children developing infections, and reduces a child’s risk of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6735804/#:%7E:text=Globally%2C%20595%20379%20childhood%20deaths,type%20II%20diabetes%20each%20year">developing chronic disease like obesity and diabetes</a> later in life. Breastfeeding is also associated with lower risk of developing <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext">breast and cervical cancer, or diabetes</a> among mothers.</p>
<p>Rising consumption of formula milk by toddlers and young children is also a worry, as these products are often <a href="https://theconversation.com/the-rise-of-ultra-processed-foods-and-why-theyre-really-bad-for-our-health-140537#:%7E:text=We%20found%20that%20more%20ultra,%2C%20salt%20and%20trans%2Dfats.">ultra-processed</a>, expensive, loaded with sugar and can introduce <a href="https://www.vichealth.vic.gov.au/media-and-resources/media-releases/high-sugar-toddler-milks-overpriced-harmful">poor dietary habits</a>. Their increased use could further contribute to increases of overweight and obese children globally.</p>
<p>Formula isn’t a sterile product and can be dangerous when prepared in unhygienic conditions, or when over-diluted or over-concentrated. It lacks the immune-boosting and other important elements of breastmilk, further increasing the risk of malnutrition and infectious illness. As a result, universal breastfeeding in place of formula use could prevent an estimated <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext">823,000 child deaths every year</a> (mainly in low- and middle-income countries), including 595,000 deaths from diarrhoea and pneumonia, and an estimated 20,000 maternal deaths from breast cancer (mainly in high income countries).</p>
<p>The global surge in formula sales is clearly a problem for global health. Given the power of the corporate milk formula industry to influence behaviour and understanding, more needs to be done to ensure that all mothers and children are protected from inappropriate promotion, and that they are enabled to breastfeed as long as they want to. This means <a href="https://www.who.int/nutrition/netcode/en/">strengthening laws</a> that ban harmful marketing practices, expanding access to paid maternity leave, and ensuring that all <a href="https://www.who.int/nutrition/publications/guidelines/breastfeeding-facilities-maternity-newborn/en/">healthcare facilities</a> meet global standards.</p><img src="https://counter.theconversation.com/content/149681/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David McCoy has recently received funding from the World Health Organization to conduct research on infant and young child feeding. He is also involved in a WHO-sponsored study on the marketing of breastmilk substitutes in the UK. He is a member of Medact, a UK-based charity that works on the upstream determinants of global health; and a Fellow of the UK Faculty of Public Health, the professional association for public health specialists, which supports implementation of the International Code of Marketing of Breastmilk Substitutes. </span></em></p><p class="fine-print"><em><span>Julie P. Smith receives funding from the Australian Research Council and the Australian National University Gender Institute. She has led consultancies on breastfeeding for the World Health Organization and the Australian Department of Health. She is a member of the Australian Breastfeeding Association and the Animal Justice Party. </span></em></p><p class="fine-print"><em><span>Phillip Baker currently receives funding from the World Health Organization to conduct research on infant and young child feeding. He has received funding from the Food and Agricultural Organization, World Bank, UNICEF, Department of Foreign Affairs and Trade, and the Australian Research Council. He is a member of the Independent Expert Group of the Global Nutrition Report. The findings of the research reported in this article, and the views expressed, are his alone and not necessarily those of the above organisations.</span></em></p>Industry marketing can shape beliefs about formula feeding.David McCoy, Professor of Global Public Health, Queen Mary University of LondonJulie P. Smith, Honorary Associate Professor, Australian National UniversityPhillip Baker, Research Fellow, Institute for Physical Activity and Nutrition, Deakin University, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1082552018-12-06T09:55:20Z2018-12-06T09:55:20ZInfant formula companies are behind the guidelines on milk allergy, and their sales are soaring<figure><img src="https://images.theconversation.com/files/249170/original/file-20181206-186052-1inle1h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infant formula manufacturers have been funding the development of guidelines for the diagnosis and treatment of cows' milk allergy in infants.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>There has been a six-fold increase in sales of infant formula prescribed for babies with cows’ milk protein allergy in the United Kingdom from 2006 to 2016. This is despite no evidence of a concurrent increase in the prevalence of infants with the allergy. </p>
<p>An investigation published today in the <a href="https://www.bmj.com/content/363/bmj.k5056">BMJ</a> found infant formula manufacturers have been funding the development of guidelines for the diagnosis and treatment of cows’ milk allergy as well as providing research and consultancy funds to those who wrote them.</p>
<p>Rates of cow’s milk allergy appear to have been <a href="https://www.ncbi.nlm.nih.gov/pubmed/25864712">relatively stable</a> – estimated at between 1-2% over the last decade. </p>
<p>Research has found the perception of an allergic response to cow’s milk protein in children is <a href="https://www-ncbi-nlm-nih-gov.ezproxy.uws.edu.au/pmc/articles/PMC3716921/">ten times greater</a> than what actual diagnosis would indicate. This means guidelines on allergy for doctors are really important.</p>
<p>In some cases, doctors who spoke to the BMJ said the guidelines were so vague that</p>
<blockquote>
<p>virtually every single infant could potentially be diagnosed using these symptoms. </p>
</blockquote>
<p>A diagnosis can only be made only by excluding cow’s milk protein from the maternal diet, observing symptoms, and then reintroducing it. But the BMJ paper notes that <a href="https://www.ncbi.nlm.nih.gov/pubmed/30306546?dopt=Abstract">evidence for advising</a> such exclusions to treat non-specific symptoms in breastfed infants is weak.</p>
<p>The paper also found much of the education for health professionals and parents about cows’ milk allergy was provided by organisations also funded by the infant formula industry.</p>
<p>Previous <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001500">research has found</a> that changes in diagnostic and treatment guidelines can have enormous effects on the revenue of pharmaceutical and nutritional products. Conflicts of interest due to industry funding have been <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1000352">found to affect</a> doctors’ prescribing behaviour, research results and the quality of patient care.</p>
<p>Parents are also vulnerable to marketing. They crave a happy, quiet, calm baby who sleeps, eats and poos in a predictable pattern. </p>
<p>But babies wake often. They can have difficulty adjusting to life outside the womb and their stomachs are getting used to digesting food. They vomit. They cry for reasons that are hard to understand. </p>
<p>Marketing takes this normal infant behaviour and turns it into a problem that can be solved by buying a product.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-advertisers-use-pictures-to-sell-pharmaceuticals-and-shouldnt-53968">Why advertisers use pictures to sell pharmaceuticals – and shouldn't</a>
</strong>
</em>
</p>
<hr>
<p>When businesses are allowed to shape the guidelines health professionals use to diagnose and treat, this can lead to guidelines that find normal infant behaviour is treatable – with a product. </p>
<p>Unfortunately there may similar pressures on doctors in Australia.</p>
<p>A variety of infant formula products available in Australia claim to be antidotes to normal challenges new parents face such as crying, vomiting and constipation. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/249161/original/file-20181206-186070-10nz4x9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An advertisement in Australian Doctor.</span>
<span class="attribution"><span class="source">.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The above advertisement is from the publication <a href="https://www.australiandoctor.com.au/">Australian Doctor</a> (which is available through subscription to medical professionals and includes drug advertising). It is a powerful piece of persuasion. It invokes every parent’s desire for a good night’s sleep and a contented, healthy baby to drive purchasing behaviour. Notice the presence of the mother in this picture. Although we can’t see her, we presume she is also sleeping somewhere. </p>
<p>When parents are desperate for help, doctors want to provide it. Colic is a variation of normal infant behaviour. It has no known medical cause or cure and this can make doctors feel powerless. However, this advertisement offers them a way to help. It gives doctors a solution – they just need to suggest the infant formula. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/my-baby-is-crying-is-it-colic-how-can-i-help-62952">My baby is crying. Is it colic? How can I help?</a>
</strong>
</em>
</p>
<hr>
<p>Parents are told to seek assistance from health professionals when they are concerned about their baby. However, if health professional guidelines and education is contaminated with marketing and influenced in other ways by infant formula manufacturers, the support they provide will be of poor quality. </p>
<p>Health professionals need independent, non-commercial information on infant feeding and parents should be protected from predatory marketing through effective enforcement of regulations.</p><img src="https://counter.theconversation.com/content/108255/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karleen Gribble is affiliated with the Infant and Young Child Feeding in Emergencies Core Group, the World Breastfeeding Trends Initiative, and the Australian Breastfeeding Association. </span></em></p><p class="fine-print"><em><span>Nina J Berry's research is supported by funding from Australian Government Department of Health; the Australia Indonesia Centre and the University of Sydney. Dr Berry is a member of the International Union for Health Promotion and Education; the Public Health Association of Australia; the Asian Studies Association of Australia; the World Public Health Nutrition Association; Collaboration on Social Science in Immunisation; the Sydney Global Child Health Research Network; the Sydney South East Asia Centre; the Sydney Lifespan Research Network; and volunteers as a trainer, assessor, and counsellor for the National Breastfeeding Helpline.</span></em></p>New research shows a six-fold increase in sales of infant formula prescribed for babies with cows’ milk protein allergy in the UK, despite no evidence of an increase in the incidence of the allergy.Karleen Gribble, Adjunct Associate Professor, School of Nursing and Midwifery, Western Sydney UniversityNina Jane Chad, Post-doctoral Research Associate, Sydney School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/999872018-07-23T23:00:32Z2018-07-23T23:00:32ZU.S. support of formula over breastfeeding is a race issue<figure><img src="https://images.theconversation.com/files/228905/original/file-20180723-189332-k5ycpp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The formula industry has responded to the decline in sales to white women at home by ramping up its marketing to Black and brown women overseas. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>When the United States <a href="https://www.nytimes.com/2018/07/08/health/world-health-breastfeeding-ecuador-trump.html">threatened Ecuador with trade and aid restrictions</a> if it did not withdraw a World Health Assembly breastfeeding promotion resolution that most people considered benign, if not banal, reactions ranged from shocked to amused.</p>
<p>Experts explained that the U.S. resistance, although extreme, was nothing new. The United States previously demonstrated its <a href="https://www.theatlantic.com/health/archive/2018/07/the-epic-battle-between-breast-milk-and-infant-formula-companies/564782/?utm_source=feed">allegiance to the formula industry</a> by refusing to sign on to the World Health Organization’s Ban on the Marketing of Breast Milk Alternatives. </p>
<p>This U.S. stance, like its intimidation of Ecuador, flew in the face of near universally accepted medical and scientific research proving that breastfeeding saves lives. Perhaps even more surprisingly, both acts perpetuate <a href="https://www.cdc.gov/mmwr/volumes/66/wr/mm6627a3.htm">an alarming racial divide in breastfeeding rates</a> that leads to significant racial health disparities. American support of the formula industry comes at the cost of the health and lives of Black and brown babies, at home and abroad.</p>
<p>Both the resolution and the U.S. opposition to it stemmed from a decline in formula sales in the United States. The industry has sought to make up for its considerable domestic losses on the global market. The racial aspects of this local-global dynamic are hidden in plain sight.</p>
<h2>The local-global connection</h2>
<p>Black women in the United States use formula at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410446/">consistently and disproportionately higher rates</a>. A complex combination of legal, policy and structural factors <a href="https://ir.lawnet.fordham.edu/cgi/viewcontent.cgi?article=5112&context=flr">severely constrict their infant feeding choices</a>. </p>
<p>White women, on the other hand, use formula less and less. Laws and regulations facilitate their breastfeeding and popular culture glorifies it. The formula industry has responded to the corresponding decline in sales to white women at home by ramping up its marketing to Black and brown women overseas. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/228899/original/file-20180723-189308-1arkm37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228899/original/file-20180723-189308-1arkm37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228899/original/file-20180723-189308-1arkm37.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228899/original/file-20180723-189308-1arkm37.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228899/original/file-20180723-189308-1arkm37.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228899/original/file-20180723-189308-1arkm37.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228899/original/file-20180723-189308-1arkm37.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">This Gap breastfeeding ad featuring model Adaora Akubilo and her son Arinze went viral, demonstrating a desire for positive images of Black women breastfeeding.</span>
<span class="attribution"><span class="source">Gap</span></span>
</figcaption>
</figure>
<p>This strategy opens the door to misleading and dangerous advertising that Ecuador’s resolution sought to curtail.</p>
<p>Racially targeted marketing of formula has dire consequences, at home and abroad. In the United States, Black mothers and children suffer disproportionately from a host of illnesses and conditions linked to formula use, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/">from ear infections to infant mortality</a>. </p>
<p>Overseas, families sold on the superiority of formula that lack the means to purchase sufficient quantities often dilute it, with sometimes deadly consequences. Inadequate nutrition and contaminated water lead to an estimated 800,000 infant deaths a year.</p>
<p>Racism — be it explicit, structural, or unconscious — accounts for the widespread indifference to the racially disproportionate effects of U.S. breastfeeding policies. At home, the <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3218514">stereotype of the “bad Black mother”</a> pervades popular culture, from Tyler Perry comedies to the Best Picture Oscar-winning film <em>Moonlight</em>. </p>
<p>Black women are the face of the Welfare Queen, a <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3218514">myth</a> manipulated by politicians and the media to raise support for cuts to welfare benefits based on the false perception that they go largely to the undeserving, Black poor. During slavery, whites prevented Black mothers from nursing their children, justifying this harm by dehumanizing Black women and devaluing Black motherhood. Mammy loved the white children in her care but neglected her own.</p>
<p>Similarly, today’s Welfare Mother has children solely to collect a fat government cheque. She has no business breastfeeding. She is fair game for the formula industry.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/BYbucnpFa8i/?utm_source=ig_web_copy_link","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<h2>Profits over people</h2>
<p>Similar disregard for the fates and well-being of migrant, non-white mothers and children is now infamous, as the world has watched the troubling and inhumane separation of families who arrive at U.S. borders seeking refuge. These separations disrupt the mother-child bond, causing health and emotional consequences yet to be measured. </p>
<p>This xenophobic world view leads Americans to discount the grave health risks that formula promotion poses globally. Protecting the interests of the pharmaceutical industry is paramount to a profit-driven administration. The consequent sacrifice of Black and brown infants abroad represents the inevitable casualties of trade wars, where all is fair.</p>
<p>Even the justifications for the opposition to the resolution echo in race and paternalism. Health and Human Services spokesperson <a href="https://www.politico.com/story/2018/07/09/trump-new-york-times-breastfeeding-703503">Caitlin Oakley asserted</a> the U.S. position stemmed from a desire not to stigmatize mothers who are not able to breastfeed. This claim evokes images of chivalry directed at frail white women. Whether or not these women exist, it is far more important to protect mothers and children from potentially life-threatening harms caused by formula feeding in sub-par conditions than to shelter some women from feelings of guilt.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/BlWbwWYlbw2/?utm_source=ig_web_copy_link","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<p>U.S. President Donald Trump also confused the issue <a href="https://www.nytimes.com/aponline/2018/07/09/us/politics/ap-us-trump-breastfeeding.html">by tweeting</a> that “the U.S. strongly supports breastfeeding but we don’t believe women should be denied access to formula. Many women need this option because of malnutrition and poverty.” </p>
<p>No part of the resolution proposed to deny women access to formula. Also, poverty makes breastfeeding, which is free, the more obvious choice. It is true that malnutrition poses a real problem for nursing mothers whose infants can drain them of much-needed nutrients. At the same time, breast milk fortifies infants with life-saving antibodies impossible to duplicate in formula in places where medicine and healthy food may be scarce.</p>
<p>Despite the U.S.’s eventual acquiescence to the resolution once Russia stepped in to propose it, formula sales are likely to continue to flourish in countries where breast really is best, for economic and health reasons. Let’s recognize this corporate victory for what it is: The triumph of business over individual interests and the exchange of Black and brown lives for the health and prosperity of white ones.</p><img src="https://counter.theconversation.com/content/99987/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrea Freeman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>American support of the formula industry comes at the cost of the health and lives of Black and brown babies, at home and abroad.Andrea Freeman, Associate Professor of Law, University of Hawaii William S. Richardson School of Law, University of HawaiiLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/996632018-07-11T11:15:35Z2018-07-11T11:15:35ZBreastfeeding has been the best public health policy throughout history<figure><img src="https://images.theconversation.com/files/227002/original/file-20180710-70051-vodnnl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A mother breastfeeding her infant. Breast milk is considered the best source of nutrition for babies. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mother-breastfeeding-her-little-baby-boy-522182809?src=lV62dE5td6aIeByOiqqHhA-1-0">Lopolo/Shutterstock.com</a></span></figcaption></figure><p>Breastfeeding has long been the gold standard for infant nutrition. The <a href="http://pediatrics.aappublications.org/content/129/3/e827">American Academy of Pediatrics</a>, <a href="https://www.aafp.org/about/policies/all/breastfeeding-support.html">American Academy of Family Physicians</a>, <a href="https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-Support-for-Breastfeeding-as-Part-of-Obstetric-Practice">American College of Obstetricians and Gynecologists</a>, and <a href="http://www.who.int/topics/breastfeeding/en/">World Health Organization</a> all recommend it. </p>
<p>Thus, the recent <a href="https://www.nytimes.com/2018/07/08/health/world-health-breastfeeding-ecuador-trump.html">New York Times</a> report of U.S. interference in the <a href="http://www.who.int/mediacentre/events/governance/wha/en/">World Health Assembly</a>’s attempt to adopt the resolution that “mother’s milk is healthiest for children and countries should strive to limit the inaccurate or misleading marketing of breast milk substitutes” alarmed many concerned about public health. </p>
<p>As a pediatrician and a nutritionist, I have provided direct patient care to breastfeeding mothers and children and also advocated for breastfeeding policies and practices. The scientific research in support of breastfeeding is overwhelmingly clear, and most mothers in the U.S. have heard that message and learned from it. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684040/">Marketing and sales of infant formula have surged</a> in developing countries, however. That’s created a dilemma for the U.S., which has not wanted to restrict the <a href="https://www.nytimes.com/2018/07/08/health/world-health-breastfeeding-ecuador-trump.html">US$70 billion infant formula business</a>.</p>
<p>This comes at another price. Lack of breastfeeding worldwide is blamed for <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext">800,000 childhood deaths</a> a year.</p>
<h2>Mother’s milk, for thousands of years</h2>
<p>Direct breastfeeding and exclusive human milk feeding were the only sustainable infant feeding for thousands of years. Initial efforts prior to the 1800s to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684040/">provide alternative animal milk sources</a> for infant feeding resulted in greater risk of disease, often from infection, dehydration and malnutrition, as well as death. </p>
<p>The ability to sterilize and evaporate cow’s milk in the early 1800s allowed for preparation of alternative infant feedings, however. Throughout the rest of that century, different brands of alternate feedings, almost all based upon cow’s milk, proliferated. </p>
<p>The American Medical Association first called for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684040/">standards for safety and quality</a> in 1929. With more women working outside of the home during and after World War II, the use of infant formula become more common. Formula makers began to market formula as a convenience item to allow for a freer lifestyle and to replace breastfeeding. U.S. breastfeeding rates began to drop, hitting an all-time low of <a href="http://web.archive.org/web/20070101052201/http:/www.ross.com:80/aboutRoss/Survey.pdf">24.7 percent initiation</a> in 1971. </p>
<p>Medical professionals were not trained to support breastfeeding at this time, but mothers demanded to reclaim breastfeeding through a grass-roots movement. The resurgence of breastfeeding in the U.S. has been attributed in particular to efforts of founders of <a href="https://www.llli.org/">La Leche League International</a>. </p>
<p>In 1981, the World Health Organization adopted the <a href="http://www.who.int/nutrition/publications/infantfeeding/9241541601/en/">International Code of Marketing of Breast-milk Substitutes</a>. All participants of the United Nations-affiliated World Health Assembly support breastfeeding and limit the marketing of alternative feedings, or infant formula, except the U.S.</p>
<p>The code restricts inappropriate marketing of infant formula to families and prevents formula companies from providing free formula to consumers or health care facilities. The code also calls upon all countries to enact legislation to enforce it. The code specifically does not restrict access to formula to those families who need or request to use it. </p>
<p>Also, the <a href="http://www.who.int/nutrition/publications/infantfeeding/9241541601/en/">International Baby Food Action Network</a> was formed to protect a mother’s right to breastfeed and an infant’s right to be breastfed, as well as to monitor compliance with the code. The WHO and UNICEF subsequently developed <a href="https://www.unicef.org/programme/breastfeeding/innocenti.htm">“The Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding”</a> in support of maternal and child health in 1990.</p>
<p>Among infants born in the U.S. in 2014, the most recent national data available, <a href="https://www.cdc.gov/breastfeeding/data/nis_data/results.html">82.5 percent were breastfed initially</a>, but disparities existed based upon socioeconomic and demographic status. </p>
<p>A <a href="https://www.thelancet.com/series/breastfeeding">Lancet series on breastfeeding</a> indicated that six- and 12-month continuation rates for breastfeeding remain low in most countries. The <a href="http://www.who.int/nutrition/publications/infantfeeding/global-bf-scorecard-2017.pdf?ua=1">WHO Global Breastfeeding Scorecard</a> also shows that no country is highly compliant on all indicators that monitor support and protection of breastfeeding. </p>
<h2>Why breastfeeding matters</h2>
<p>The <a href="http://pediatrics.aappublications.org/content/129/3/e827">benefits of breastfeeding</a> for children and mothers are irrefutable. Initiation of skin-to-skin contact immediately after delivery, with early onset of breastfeeding within the first hour of life, supports newborn stability and provides protective <a href="https://www.medicinenet.com/script/main/art.asp?articlekey=12077">immunoglobulins</a>, especially secretory IgA, and other immune protective factors. Human milk provides <a href="https://www.ncbi.nlm.nih.gov/pubmed/22350049">human milk oligosaccharides</a>, facilitating the colonization of the intestinal tract with <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4288270/">probiotics</a> and establishing a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5491547/">microbiome</a> that protects against <a href="https://www.merriam-webster.com/dictionary/pathogenic">pathogenic</a> bacteria.</p>
<p>In contrast, formula-fed infants face higher rates of gastrointestinal diseases, respiratory infections and a higher likelihood of sudden infant death syndrome. Longer term, they have a higher risk of obesity, type 2 diabetes, asthma and certain childhood cancers when compared to breastfed cohorts. </p>
<p>Also, mothers who fail to breastfeed according to current recommendations face higher <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/">risks</a> of postpartum hemorrhage, breast cancer, ovarian cancer, obesity, type 2 diabetes and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812877/">heart disease</a>, including hypertension and myocardial infarction, or heart attack. About 20,000 cases of preventable death from maternal cases of breast cancer are attributed to lack of breastfeeding, according to the <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01024-7/fulltext">Lancet series</a>. </p>
<p>Some of the poorest countries have the lowest breastfeeding initiation and duration and could gain the most in terms of health impact and <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01044-2/fulltext">economic benefit</a> from improving breastfeeding rates.</p>
<h2>What has the US done to support breastfeeding?</h2>
<p>Partnership between governmental and nongovernmental agencies resulted in the formal designation of the <a href="http://www.usbreastfeeding.org/">United States Breastfeeding Committee</a> in response to “The Innocenti Declaration.” The Department of Health and Human Services developed a <a href="https://webarchive.library.unt.edu/eot2008/20081104210737/http:/www.womenshealth.gov/breastfeeding/index.cfm?page=Campaign">mass media campaign</a> in 2008 to support and promote breastfeeding. </p>
<p>In 2011, the <a href="https://www.surgeongeneral.gov/library/calls/breastfeeding/index.html">U.S. Surgeon General’s Call to Action to Support Breastfeeding</a> recognized key elements required to support breastfeeding, including health care, families, communities and employment. The Centers for Disease Control and Prevention has supported quality improvement initiatives aimed at changing <a href="https://www.cdc.gov/breastfeeding/data/mpinc/index.htm">maternity care practices</a> to better support and promote breastfeeding. Breastfeeding efforts at the community level have involved obesity prevention efforts. </p>
<h2>Influence of infant formula makers</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/227003/original/file-20180710-70039-1jiaejf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/227003/original/file-20180710-70039-1jiaejf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/227003/original/file-20180710-70039-1jiaejf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/227003/original/file-20180710-70039-1jiaejf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/227003/original/file-20180710-70039-1jiaejf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/227003/original/file-20180710-70039-1jiaejf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/227003/original/file-20180710-70039-1jiaejf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Powdered infant formula must be mixed with clean water, which is often unavailable in many poor countries.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-infant-formula-on-background-171669089?src=tQJYzNCtTmLOv723KKfHYQ-1-3">Dima Sobko/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>As more infants were breastfed in the U.S., formula makers turned their sights to developing countries. This contributed to a <a href="http://www.who.int/nutrition/publications/infantfeeding/global-bf-scorecard-2017.pdf">global decline</a> in breastfeeding rates, similar to that seen in the U.S.</p>
<p><a href="http://www.who.int/nutrition/publications/infantfeeding/global-bf-scorecard-2017.pdf">Infants in developing countries</a> face the greatest risk from malnutrition, diarrhea, dehydration and death when fed formula that is contaminated by bacteria or parasites from unclean sources of water, or when bottles or nipples are not cleaned regularly in hot, soapy water. Diarrheal diseases and resultant dehydration are a leading cause of death in infants in poor countries, where breastfeeding may be lifesaving.</p>
<p>Good quality infant formula can be necessary and lifesaving when mother’s milk is not an option and pasteurized donor human milk is not available. However, the formula industry stands to gain the most financially when breastfeeding fails. The formula industry should not be influencing public health policy. The U.S. delegates to the World Health Assembly must lead the way in support of health policies based upon science. </p>
<p>As a member of the global community advocating for optimal public health and improving maternal child health outcomes, the U.S., I believe, bears responsibility to support evidence-based practices. In the area of breastfeeding support, the U.S. lags behind other resource-rich nations with a lack of universal health care, lack of paid maternity leave, and employment policies that do not provide universal support for employed mothers to continue breastfeeding.</p><img src="https://counter.theconversation.com/content/99663/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joan Y. Meek is affiliated with the American Academy of Pediatrics as a member and chairs the Section on Breastfeeding, in an elected, non-paid position. This article represents her opinion and not those of the American Academy of Pediatrics.</span></em></p>As US mothers returned to breastfeeding, the market for infant formula dried up, leading formula makers to seek new markets in developing nations. Here’s how that led to a recent outcry.Joan Y. Meek, Associate Dean of Graduate Medical Education; Professor, Clinical Sciences, Florida State UniversityLicensed as Creative Commons – attribution, no derivatives.