• Ethics
• Neonatology

The threat to breast feeding from the marketing practices of the commercial milk formula (CMF) industry has been widely recognised and condemned since the launch of the WHO International Code, over 40 years ago.1 While formula feeding is needed by some infants for medical and social reasons, it is widely agreed that CMF should not be directly marketed to consumers and this is already partially or totally forbidden in most countries. Despite this, the annual marketing expenditure of the CMF industry has increased and is now US$2.7–US$3.5 billion per annum,2 with a significant proportion of this used to sponsor healthcare professional associations (HCPAs) through education, research and individual support of practitioners as a form of marketing.

While relationships between the pharmaceutical industry and HCPAs are increasingly regulated, regulation of relationships with the CMF industry has lagged behind. Yet there is ample evidence that the CMF industry distorts science, alters public opinion and influences healthcare professionals and policy-makers.2 While some prominent organisations now take a firm stance on this matter,3 the majority of paediatric associations,4 as well as many other HCPAs, still argue in favour of sponsorship.5–7 Seven European paediatric societies recently considered this issue, via consensus discussion and a narrative review of the literature, but without a formal systematic review.6 They argue that interacting with industry is still necessary and that any conflict of interest (COI) can be avoided. The objective of this viewpoint is to consider and test those arguments.

It is argued that there is a lack of evidence that sponsorship harms breastfeeding or affects breastfeeding rates. Sponsorship of HCPAs is part of the marketing system of the CMF industry: ‘marketing targets health professionals and scientific establishments through financial support, corporate backed science and medicalisation of feeding practices for infants and young children’.2 The CMF industry invests in healthcare professionals, in order to increase the number of parents who use CMF.8 Recent evidence shows that as sales of CMF increased, countries experienced a decrease in breastfeeding rates.2 While this association may not be causal, sponsorship does affect professional attitudes.9 According to a private sector report,10 ‘The major global multinationals put a large part of their selling effort into health practitioners, rather than retailers as it works to sell product’.

It is argued that there are wide variations in breastfeeding rates between countries and that this is not related to marketing. Changes in breastfeeding rates are associated with multiple determinants, such as maternity and paternity protection policies, family and community attitudes, and quality of support by health professionals and/or peer counsellors. Yet the intensity of CMF marketing plays an important role. Analysis demonstrates how much the CMF industry has increased its marketing in recent years, as well as the effectiveness of this marketing.2 The process of sustaining and supporting breast feeding requires a multipronged approach and each intervention contributes to the overall gain. While CMF marketing may not be the only cause of low breastfeeding rates, it is an area where HCPAs can make a difference immediately. Multisectoral initiatives will be required for the other determinants and these inevitably take longer to show benefits.

It is argued that breastmilk substitutes (BMS) are not necessarily damaging to child health. This flies in the face of the wide evidence base leading the WHO to conclude that the use of BMS ‘is not in the best interest of child health’.1 The use of BMS has been shown to be associated with a wide range of immediate adverse health outcomes even in affluent settings, including gastroenteritis, respiratory infections and sudden infant death,11 as well as a wide range of other possible risks to child and mother.12 13

It is argued that children deserve access to safe products that the industry can provide. This is not a controversial statement, but ensuring the safety of CMF is no longer the task of professional associations, as CMF companies are subject to regulations to ensure that their products are safe and have no adverse side effects. Where expert advice is required, this should be provided by individual scientists and clinicians free from commercial interests.

It is argued, and this seems to be the central argument, that HCPAs need access to evidence based information and that learned societies rely on CMF funding for education and conferences to continue to function in their current manner. However, the education provided by CMF is highly selective and unbalanced and is usually linked to substantial hospitality, or other benefits that tend to create a sense of indebtedness and gratitude2 14: ‘Pitches to health professionals are presented as the sharing of scientific information or professional training, creating an image of the CMF company as an objective and respectable adviser’. Other professional societies already manage without such sponsorship.

Finally, it is argued that COIs can be managed to prevent harmful effects. There is now robust evidence that financial COI distort healthcare research, policies, guidelines and practice across public health, medicine and other sectors.9 BMS industries have a primary responsibility to their shareholders, not to child health, and they could not fund sponsorship of this kind if it did not result in increased sales and profits.15 In contrast, the primary interest of health professionals is to increase breastfeeding rates and to improve health and nutrition. ‘Managing’ COI is thus unlikely to be effective and the best option is to avoid and eliminate COI, sponsorship in this case.16

To conclude, we urge all HCPAs, including those representing paediatricians, nurses, midwives, obstetricians and nutritionists to understand that sponsorship by the CMF companies is part of a highly successful marketing strategy.2 Leaders of these associations should review their position with board members and initiate steps to end such sponsorship using internationally recognised guidelines, including transparency around existing relationships with the CMF industry.