Is an unprecedented infant feeding transition underway?

To ensure children get the best start in life the World Health Organization recommends that infants are exclusively breastfed to six months of age with ongoing breastfeeding for up to two years of age and beyond. Yet worldwide the prevalence of infants exclusively breast fed to six months hovers at around 37% and has improved only marginally in recent decades.

In contrast, our research shows that global milk-based formula sales are booming. In just the five-years between 2008 and 2013 world total milk formula sales grew by 40.8% from 5.5 to 7.8kg per infant/child, a figure projected to increase to 10.8kg by 2018.

We have described this recent surge in formula sales as indicative of a global 'infant and young child feeding transition' i.e. a shift from lower to higher formula diets at the population level. Although the idea of such a transition is not new, the rate and scale of change we describe is potentially unprecedented.

Growth has been especially rapid in several industrialising countries in Asia: China, Indonesia, Malaysia, Vietnam and Thailand. As home to the world's second largest infant/child population (~41 million aged 0-36 months in 2013) the most significant absolute change has been in China. Other countries undergoing rapid change include South Africa, Iran, Turkey, Brazil and Peru.

This global sales boom applies not only to infant formula (for consumption by infants aged 0-6 months) but also to follow-up (7-12 months) and toddler (13-36 months) formulas, which can displace ongoing breastfeeding if marketed and consumed inappropriately.

These results are troubling because formula-fed children experience poorer health and developmental outcomes than breastfed children including an increased risk of death, pneumonia, diarrhoea, obesity and type-2 diabetes, ear infections and asthma. Formula feeding also harms mothers due to the forgone protective effects of breastfeeding against breast and ovarian cancer.

Global drivers and national-level modulators

This led us to speculate about what or who might be responsible for driving these trends, and why the Asian countries in particular?

Infant formula sales tend to increase as countries get richer, more urbanised, and as more women enter into the workforce (often called a 'nutrition transition'). In this view, the formula sales boom is at least partly explained by Asia's rapid economic development and the entry of millions of women into the formal workforce, especially in the regions vast manufacturing zones.

Market factors are also key. Free trade agreements have allowed transnational formula companies to more easily enter and establish operations in developing countries. In some countries this has spurned the growth of domestic formula companies, with competition in the world's largest markets, especially China, reaching fever-pitch. The largest companies wield considerable market power; Nestle, Danone, Mead Johnson and Abbot Laboratories together control about 55% of US$44.8 billion global market value.

Marketing by these companies powerfully shapes social norms about infant and young child feeding by portraying formula as a symbol of modernity, as comparable or superior to breast-milk and formula feeding as extensively practiced (i.e. normalised). Formula is marketed directly to consumers through online and print advertising, and indirectly through health systems, sponsorship of professional organizations, and lobbying of policy-makers. We estimate that the industry's global marketing expenditure exceeded $US4.48 billion in 2014, a figure comparable with WHO's annual budget.

The sales boom in the follow-up and toddler formula categories likely reflects a market segmentation strategy whereby the companies are exploiting the incorrect perception that breastfeeding applies to the first six months only, and not to continued breastfeeding. The branding, packaging and labelling of these product categories frequently resembles and is commonly mistaken for infant formula, allowing companies to circumvent regulations focused on the 0-6 month age bracket only.

However, there is wide variation between countries at similar levels of economic development, suggesting an important role for policies and regulations adopted in the various countries.

Among the most important is the World Health Organization's International Code of Marketing of Breast-Milk Substitutes (the Code). This outlines the actions governments should take to prevent unethical formula marketing. However, there is wide variation between countries in the scope and extent of Code adoption into national law. For example, while sales in China are booming they have flat lined at low levels in India, at least partly reflecting the effectiveness of regulations in the respective countries. In many countries companies are marketing directly to health professionals and even to mothers in maternity wards.

Ineffective maternity protection regulations also tell part of the story, because these determine the compatibility of infant and young child feeding choices with formal maternal employment. In the context of absent or ineffective regulation the choice of whether to formula-feed or breastfeed is not a true choice – for many, formula-feeding is the only choice if the alternative is the loss of employment and income. Indeed, it is more common for new mothers to stay employed and use formula rather than leave work or school in order to breastfeed.

Conclusions

Infant and young child feeding is typically portrayed as an individual behaviour, as a matter of free parental choice. Our research offers a counter-view – feeding choices are powerfully shaped by transformations to wider social, economic and political systems associated with commercial globalization and capitalism.

In this view, the global infant and young child feeding transition we describe is driven largely by the marketing of infant formulas, the shift of labour and production out of the home, and the failure of regulations and policies designed to promote, protect and support breastfeeding in these new contexts.

These findings are important for several reasons. The results raise serious concern that the rapid changes observed are not being captured in a timely manner by existing international nutrition monitoring systems.

Existing regulations intended to protect the health of children and mothers and to prevent unethical formula marketing are not working effectively – renewed efforts towards the implementation, monitoring and enforcement of the Code, including stronger accountability mechanisms for governments and industry are urgently needed.

This can only come about through greater political priority and strengthened governance mechanisms for infant and young child nutrition.

This story is republished courtesy of PLOS Blogs: blogs.plos.org.