Infant formula is a wonder product for some working mums and those who can’t or don’t want to breastfeed.
But it’s also a wonder product for big business, with an ever-renewing target market.
How to feed your baby can be a fraught decision at a time when emotions are running high and advice can be conflicting.
While the “breast is best” narrative is front and centre in Australia, the influence of infant formula companies on parents starts at local hospitals and supermarkets and travels to the corridors of the World Health Organisation and the White House.
Last week, the US government was accused of threatening Ecuador with sanctions unless it watered down a World Health Assembly resolution for all countries to “protect and promote” breastfeeding.
Closer to home, public health groups have sounded the alarm on formula marketing as the Australian Government revises its National Breastfeeding Strategy, at a time when only one in 10 babies is meeting national breastfeeding guidelines.
‘They should’ve given more information’
For many parents, hospitals are their first exposure to infant formula, which is a critical care option for babies who are losing weight or unable to feed.
But this can lock parents into its ongoing use, as babies can quickly develop a preference for bottle feeding, which can disrupt their mother’s milk supply.
Wendy Atkinson was recommended formula by a hospital in regional NSW when her daughter Chelsea was born five months ago.
“I wasn’t producing enough milk in the first few hours, which is pretty normal. The midwives said she’d need a full formula feed,” Ms Atkinson says.
“That started us on the path of mixed feeding and it took three months for me to wean her off formula. It completely disrupted my ability to produce milk — it took day after day of painstakingly retraining her to accept my breast.
“Everyone was doing what they thought was best for my baby, but I think they should’ve given me more information. It’s a dangerous thing to not make women aware, when they’re so desperately tired, that there’s a chance they won’t be able to breastfeed normally after that first bottle of formula.”
Canberra mother Julia O’Brien had a similar experience four months ago. She was encouraged to use formula when her baby lost more than 10 per cent of her birth weight in the first few days following breastfeeding difficulties.
“In principle, they seemed to be anti-formula, but then they pushed it on us quite swiftly and didn’t give us a plan for how to get off,” she says.
While many mothers report incomplete information around formula, others say they had trouble accessing formula at all.
“There was a lot of conflicting information from the hospital and I almost felt bullied into breastfeeding even when it became impossible,” says new mother Sonja Haben.
“For the first few nights, my son fed for six to nine hours consecutively,” says another, Amanda Lam. “It was draining mentally and physically. I’m disappointed that the midwives did not offer me formula until a paediatrician stepped in.
“Formula was definitely the right decision, however it baffles me that there isn’t more information on mixed feeding when it’s so common.”
A stopgap for problems
Misleading or incomplete medical advice around formula is described as a key theme in the stakeholder consultation for the National Breastfeeding Strategy.
“Health professionals lack expertise and in that void turn to artificial powder as a stopgap rather than address the cause and breastfeeding function for many problems faced,” Breastfeeding Advocacy Australia alleges in its submission.
NSW Health did not comment on how widespread this practice might be, but said it “educates and trains staff so they can support families to breastfeed their baby. Providing consistent advice and empathetic communication are essential aspects of this training.”
Better training of health workers is one of the initiatives in the draft National Breastfeeding Strategy.
While formula can sometimes be required to support a baby’s health, there is a risk that having free or low-cost formula on tap can demotivate hospitals from directing staff time to breastfeeding support, according to Dr Julie Smith, a public health expert from ANU.
Trump wades into the ‘formula wars’
Most infant formula sold in Australia is imported, as local producers can find higher prices in Asia. A decade on from the melamine scandal that killed six babies and made more than 300,000 sick, Chinese demand for Australian formula is still strong.
Four multinationals dominate the $70 billion industry globally: Nestle, Danone, Abbott and Mead Johnson, with Nestle and Danone having about 80 per cent of the Australian market.
Their pockets are deep and their relationships with governments can be cosy. Abbott Laboratories, for example, sponsored President Donald Trump’s 2017 inauguration.
The Trump administration has been widely accused of protecting formula giants’ interests with its intervention at the World Health Assembly in May.
After US delegates threatened Ecuador with trade sanctions and a withdrawal of military aid, a dozen other countries also dropped Ecuador’s motion supporting breastfeeding, according to the New York Times.
American delegates also allegedly threatened to cut the US contributions to the WHO that made up 15 per cent of its budget last year.
Ultimately, Russia reintroduced and passed the breastfeeding motion, but US negotiators watered down its calls to restrict marketing of infant formula.
Nestle told the Centre for Investigative Reporting that “we have not, nor would we ever, lobby any governments to oppose breastfeeding policies anywhere in the world”.
However its talking points at the WHO Assembly were clear: “Member states should consider measures other than simply recommending additional restrictions on the promotion of commercial baby food.”
During negotiations, Australia said it would only support a motion with “sufficient flexibility for countries to implement measures as appropriate in their national contexts” — in other words, a motion with some wiggle room.
‘Plain packaging’ in hospitals?
While lobbyists represent formula makers on the world stage, back at home, smaller but no less crucial deals are being made with local hospitals.
When it comes to infant formula, brand loyalty is fierce and hospital-stocked brands carry a tick of approval. Like many parents, the mothers interviewed by ABC continued using their hospital’s brand at home.
“Babies’ stomachs are really sensitive, so I didn’t want to risk changing it up,” says Ms Atkinson.
“You’re already having so many challenges so you’re just desperate to maintain the status quo.”
Some submissions to the government review suggested “plain packaging” infant formula in hospitals could help counter inadvertent marketing.
“Hospital contracts are immensely valuable, so I’ve heard of invoices [for formula] never paid by hospitals and never chased up by these companies,” says Dr Smith.
“They know if they get mothers started on free formula, they’ll ultimately make a fortune from them. It’s like getting a gambler hooked with some free spins on the pokies.”
NSW Health told the ABC that formula was procured at an individual level by hospitals.
“There is no statewide contract for the supply of infant formula to NSW public hospitals,” it said in a statement.
The industry sets its own rules
The WHO recommends that marketing guidelines for infant formula be legislated and enforceable. Instead, Australia has a voluntary agreement limiting advertising of formula for babies under 12 months.
It’s called the Marketing in Australia of Infant Formulas agreement and 97 per cent of brands have signed up. Complaints are determined by an industry tribunal with oversight from the Department of Health but there are no penalties besides reputational damage.
“But for these companies, that’s a huge penalty,” says Jan Carey, chief executive of the Infant Nutrition Council, a lobby group for formula manufacturers and distributors in Australia.
“They certainly are very careful about adhering to the agreement.”
Between 2008-2017, 10 complaints on formula marketing were upheld by the industry tribunal — which suggests that companies take their agreement seriously. But a further 169 were dismissed as “out of scope”, which breastfeeding advocates say demonstrates how “narrow” the agreement is.
Retailers aren’t covered by the industry agreement, so formula can be heavily promoted in-store, as well as on TV and online, despite the WHO recommending against point-of-sale advertising, discount coupons and giveaways.
Formula marketing is rife on social media, through explicit ads and more subtle “influencer marketing” and online “mothers’ clubs”.
Industry guidelines are only just being updated to include electronic marketing — though several big brands have already chosen not to advertise online.
Brands aren’t supposed to “promote” to health professionals under their agreement, but they can provide samples and “educational materials” about their products.
“Information for health professionals can’t be promotional,” says Ms Carey.
“It has to be scientific, factual information that has been substantiated. It’s a requirement so that parents can make informed choices about what they’re feeding their babies.”
Brands can likewise host training and education sessions on infant feeding for medical staff near hospitals that also showcase their products.
Toddler milk as a gateway
Critics call it a “gateway” to infant formula, allowing brands to advertise by proxy. Ads might show a happy toddler in place of a baby, but the message is similar: that this brand improves nutrition for very young children.
A 2010 study found expectant mothers perceived toddler milk ads to be marketing infant formula. They also believed the ads’ claims that formula had similar health benefits to breastfeeding.
The ACCC expressed concern that toddler milk advertising could be undermining the industry’s agreement when reauthorising it in 2016.
Toddler milk is often branded as part of a numbered sequence, with infant formula as the first step. This can result in cross-promotion between the two products.
“These milks were brought in to get around the rules on infant formula, but the industry discovered a new market,” says Dr Smith.
“Now they have ‘growing up milks’ and milks for pregnant women — their strategy is called ‘up-ageing’ and the mantra is basically ‘womb to tomb’.”
Australian government guidelines say “toddler milks are not required for healthy children” and preference should be given to regular foods. Yet toddler milk samples are distributed through childcare centres and some brands, like Aspen S-26, offer free samples through their website, with links circulated through parenting forums.
Like hospital staff, pharmacists’ endorsements carry weight, and many also hand out infant and toddler formula samples informally, according to Dr Smith.
“Some parents give toddler formula to their babies because it’s cheaper or because they think it’s the same as infant formula. That’s dangerous because it’s not designed for young babies’ nutritional needs,” she says.
Several countries have banned advertising of toddler milks, as recommended by the WHO. When Vietnam restricted advertising of toddler milk in 2012, the US embassy wrote in a letter to ministers:
“Several US companies have contacted the US Embassy regarding their serious concerns that [the ban] … could have a significant negative impact on their business. We share their concerns.”
The government responds
The evidence review for the National Breastfeeding Strategy found a combination of initiatives would be needed to lift breastfeeding rates, but expressed concern about formula marketing.
It noted that “self-regulation is ineffective and legislation is necessary,” but the draft National Breastfeeding Strategy says “mandatory regulations would be unlikely” as the government aims “to reduce regulatory burden on industry”.
Nestle Australia told ABC it would have “no concern with moving to a fully regulated environment” and that this would not “have any impact on our regulatory burden”.
Breastfeeding groups are disappointed by the strategy’s renewed support for self-regulation.
“Legislating the WHO Code is the only real way to increase breastfeeding rates in Australia,” a spokesperson for the Australian Breastfeeding Association said.
The system will still rely on people lodging complaints, but the Department of Health will now determine them after an independent review found “low awareness and visibility”, “poor timeliness” and “lack of transparency” in the industry tribunal’s process to date.
The review did note however that “self-regulation encourages high levels of consultation between government and industry and creates a sense of ownership by industry.”
With additional reporting by Freya Petersen