Wednesday
Oct212009
Nestle Answers: Shifting Blame for Infant Deaths
Wednesday, October 21, 2009
This is one of a series of posts that features Nestle’s answers to my questions that came out of the Nestle Family event. To access the other questions and answers, go to follow-up questions for Nestle and click on the questions you are interested in. Answers will be posted as they are received and analyzed.
In discussions with the bloggers, your CEO mentioned that children died in the 1970s as a result of the misuse (wrong quantity, mixed with dirty water) of formula samples. Do you believe that deaths from the misuse of formula samples ended in the 1970s?
The WHO Code was adopted in 1981 to contribute to the provision of safe and adequate nutrition for infants, by protecting and promoting breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary.
Unfortunately, lack of clean water is still a reality in many developing countries. In these countries, mothers are advised not to use infant formula unless it is AFASS – acceptable, feasible, affordable, sustainable and safe.
However, if a baby is not breastfed for whatever reason, he or she needs a breast-milk substitute, whether or not clean water is available. Until all people have a safe water supply, the only solution is to teach mothers the importance of boiling water and how to prepare infant formula correctly.
All of Nestlé’s Infant Formula Labels contain the following text in the local language: “Warning: Unboiled water, unboiled bottles or incorrect dilution can make your baby ill. Only prepare one bottle at a time. Feed immediately. Do not keep unfinished bottle. Follow instructions exactly.”
In addition, the WHO Code states that it is the responsibility of health workers to advise mothers on infant feeding – first and foremost by encouraging and protecting breastfeeding, secondly to inform the mother about appropriate alternatives (advantages and disadvantages) which include instructions on how to prepare infant formula in a correct way.
It must also be underlined that the vast majority of women in developing countries breastfeed, and at the same time give their baby additional traditional foods, or just plain water. However, many poor mothers who need to use a breast-milk substitute cannot afford infant formula and therefore have to feed their babies with a potentially harmful substitute plain (including cornstarch water or other traditional food mixtures). The challenge is to educate mothers about appropriate breast-milk substitutes and complementary food that can be given to babies as well as to find a way to make appropriate substitutes available to those babies who really need it.
The reality, which Nestle did not mention in its answer, is that 1.5 million babies still die annually due to inadequate breastfeeding practices. The promotion and sale of infant formula products in developing countries continues to be a significant factor in those deaths.
From my perspective, there are a number of problems with Nestle's response to this question. I'll take a few quotes from Nestle's answer above and analyze them in more detail.
Who advises them of this?
Because from what I have seen, it certainly isn't Nestle.
In fact, Nestle packaging has big letters telling moms how the formula "PROTECTS" with only very small print about breastfeeding being best. Perhaps the product should have a plain label with no nutritional claims that very clearly warns women, in plain language, that breastfeeding is the correct way to feed their baby and that infant formula should only be used if it is acceptable, feasible, affordable, sustainable and safe. In plain language. Clearly.
This one sentence is problematic for a couple of reasons:
This above quote is exactly what Nestle and other infant formula companies would like health workers and parents in developing countries to believe.
Unfortunately, there are too many health workers around the world who do not have enough knowledge to be able to encourage and protect breastfeeding. We need to ensure more Certified Lactation Consultant training for health workers, rather than more visits from formula company representatives to their offices.
That may be true, but it doesn't negate the fact that infant formula still poses a significant risk to a baby's health (even if clean water is available).
In my post on the scientific benefits of breastfeeding, I outline where breastfeeding provides a statistically significant benefit over formula feeding in developed countries. All of the risks of formula in the developed world are even greater risks in developing countries because there is much greater potential for infants to be exposed to diseases and the lacking immunities from not being breastfed could put them at significant risk.
According to Dr. Linda Folden Palmer in the article Formula Feeding Doubles Infant Deaths in America [emphasis mine]:
The fact that women in developing countries use other breastmilk substitutes, does not make infant formula safe. True breastfeeding promotion, support, and knowledge is necessary because any artificial feeding method poses significant risks to infants.
No, the challenge is to ensure that there is true breastfeeding support for women and that women are educated about the dangers of breastmilk substitutes/infant formula. The challenge is to ensure that that appropriate breastmilk substitutes are made available through the health care system on a prescription-only basis to those babies who really need it.
Breastfeeding rates in most developing countries are dismal. Around 1.5 million infants die around the world each year because they were not breastfed. This is not a thing of the past. Infant formula continues to play a significant role in those deaths. More breastfeeding education is needed. Infant formula promotion needs to stop.
Image credit: babasteve on flickr
Question
In discussions with the bloggers, your CEO mentioned that children died in the 1970s as a result of the misuse (wrong quantity, mixed with dirty water) of formula samples. Do you believe that deaths from the misuse of formula samples ended in the 1970s?
Nestle's Answer
The WHO Code was adopted in 1981 to contribute to the provision of safe and adequate nutrition for infants, by protecting and promoting breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary.
Unfortunately, lack of clean water is still a reality in many developing countries. In these countries, mothers are advised not to use infant formula unless it is AFASS – acceptable, feasible, affordable, sustainable and safe.
However, if a baby is not breastfed for whatever reason, he or she needs a breast-milk substitute, whether or not clean water is available. Until all people have a safe water supply, the only solution is to teach mothers the importance of boiling water and how to prepare infant formula correctly.
All of Nestlé’s Infant Formula Labels contain the following text in the local language: “Warning: Unboiled water, unboiled bottles or incorrect dilution can make your baby ill. Only prepare one bottle at a time. Feed immediately. Do not keep unfinished bottle. Follow instructions exactly.”
In addition, the WHO Code states that it is the responsibility of health workers to advise mothers on infant feeding – first and foremost by encouraging and protecting breastfeeding, secondly to inform the mother about appropriate alternatives (advantages and disadvantages) which include instructions on how to prepare infant formula in a correct way.
It must also be underlined that the vast majority of women in developing countries breastfeed, and at the same time give their baby additional traditional foods, or just plain water. However, many poor mothers who need to use a breast-milk substitute cannot afford infant formula and therefore have to feed their babies with a potentially harmful substitute plain (including cornstarch water or other traditional food mixtures). The challenge is to educate mothers about appropriate breast-milk substitutes and complementary food that can be given to babies as well as to find a way to make appropriate substitutes available to those babies who really need it.
My Response
The reality, which Nestle did not mention in its answer, is that 1.5 million babies still die annually due to inadequate breastfeeding practices. The promotion and sale of infant formula products in developing countries continues to be a significant factor in those deaths.
From my perspective, there are a number of problems with Nestle's response to this question. I'll take a few quotes from Nestle's answer above and analyze them in more detail.
"Unfortunately, lack of clean water is still a reality in many developing countries. In these countries, mothers are advised not to use infant formula unless it is AFASS – acceptable, feasible, affordable, sustainable and safe."
Who advises them of this?
Because from what I have seen, it certainly isn't Nestle.
In fact, Nestle packaging has big letters telling moms how the formula "PROTECTS" with only very small print about breastfeeding being best. Perhaps the product should have a plain label with no nutritional claims that very clearly warns women, in plain language, that breastfeeding is the correct way to feed their baby and that infant formula should only be used if it is acceptable, feasible, affordable, sustainable and safe. In plain language. Clearly.
"However, if a baby is not breastfed for whatever reason, he or she needs a breast-milk substitute, whether or not clean water is available."
This one sentence is problematic for a couple of reasons:
- Nestle is creating a nice escape clause and excuse with the language "for whatever reason". This opens the door for women not breastfeeding because their doctor is being given gifts by Nestle, for women not breastfeeding because they were tricked by misleading labels, women not breastfeeding because the quality of breastfeeding advice and support was poor, and so on. The sentence should start with "For the very small percentage of babies that cannot be breastfed by their mothers for medical reasons...".
- Nestle is also being presumptuous by assuming that a baby needs a breastmilk substitute if it is not breastfed. If a baby cannot be breastfed directly, the next best options are pumping the mom's milk or another woman's pumped milk. Formula is only the fourth best option. Not the second. Instead of focusing on getting infant formula to developing countries, perhaps we should focus on getting human milk banks established and getting more breast pumps to those regions.
This above quote is exactly what Nestle and other infant formula companies would like health workers and parents in developing countries to believe.
"The WHO Code states that it is the responsibility of health workers to advise mothers on infant feeding – first and foremost by encouraging and protecting breastfeeding, secondly to inform the mother about appropriate alternatives (advantages and disadvantages) which include instructions on how to prepare infant formula in a correct way."
Unfortunately, there are too many health workers around the world who do not have enough knowledge to be able to encourage and protect breastfeeding. We need to ensure more Certified Lactation Consultant training for health workers, rather than more visits from formula company representatives to their offices.
"It must also be underlined that the vast majority of women in developing countries breastfeed, and at the same time give their baby additional traditional foods, or just plain water. However, many poor mothers who need to use a breast-milk substitute cannot afford infant formula and therefore have to feed their babies with a potentially harmful substitute plain (including cornstarch water or other traditional food mixtures)."
That may be true, but it doesn't negate the fact that infant formula still poses a significant risk to a baby's health (even if clean water is available).
In my post on the scientific benefits of breastfeeding, I outline where breastfeeding provides a statistically significant benefit over formula feeding in developed countries. All of the risks of formula in the developed world are even greater risks in developing countries because there is much greater potential for infants to be exposed to diseases and the lacking immunities from not being breastfed could put them at significant risk.
According to Dr. Linda Folden Palmer in the article Formula Feeding Doubles Infant Deaths in America [emphasis mine]:
Just like drugs or surgeries, when it's needed, infant formula is an extremely valuable substitute to have available. No breastmilk substitute meets the optimal nutritional needs for baby, and all artificial feeds fall quite short in providing the immunity needs of infants, leaving their tiny systems flailing. An infant's immune system has three aspects: her own immature, developing immune system; the small component of immunities that passes through the placenta during natural childbirth (and to a lesser degree with premature births and cesarean sections); and the most vast and valuable, living portion that is passed on through mother's milk on an ongoing basis. Remove any of these components and you take away a vital support structure.
The fact that women in developing countries use other breastmilk substitutes, does not make infant formula safe. True breastfeeding promotion, support, and knowledge is necessary because any artificial feeding method poses significant risks to infants."The challenge is to educate mothers about appropriate breast-milk substitutes and complementary food that can be given to babies as well as to find a way to make appropriate substitutes available to those babies who really need it."
No, the challenge is to ensure that there is true breastfeeding support for women and that women are educated about the dangers of breastmilk substitutes/infant formula. The challenge is to ensure that that appropriate breastmilk substitutes are made available through the health care system on a prescription-only basis to those babies who really need it.
Conclusion
Breastfeeding rates in most developing countries are dismal. Around 1.5 million infants die around the world each year because they were not breastfed. This is not a thing of the past. Infant formula continues to play a significant role in those deaths. More breastfeeding education is needed. Infant formula promotion needs to stop.
Image credit: babasteve on flickr
Reader Comments (14)
So, putting on my MPH hat, my first thought goes to the accessibility of their language.
First of all, how many women are literate? In the US, the *average* reading level is 6th grade, but some linguists have calculated it as low as 4th grade (which means many women read at a grade level below that). How can Nestle expect these women to understand the directions for using their formula if they aren't making their labels user-friendly?
In front of me I've got an Enfamil, so maybe it's very different than Nestle's brand, but I doubt it. Here is the first line of the directions: "Proper hygiene, preparation, dilution, use, and storage are important when preparing infant formula. Powdered infant formulas are not sterile..."
Sorry, but this is not in easy to read language. There are some pictures, but very general. The chart on how to prepare the formula is written and in small print, when graphics would make it easier. The company spends so much space promoting their brand with messages like "VISUAL AND MENTAL DEVELOPMENT" and a whole paragraph on how their brand is closest to breastmilk and what their website is and how to ask your doctor about their brand, that they have to squish the directions into small print in order for them to fit!
There is so much information crammed into one space that I completely missed that I was supposed to boil the water before giving my son the bottle. His pediatrician never mentioned it when I had to wean and asked for what to do, so I've just been using cold tap water. Maybe I'm the only one who has ever made this mistake, but I'm thinking not.
Sorry, Nestle, but I think this response is the most disgusting of all.
Great stuff Annie. An addition I'd like to make is that while most are focusing on the 'developing nations', I'd also like to make clear that the exclusive breastfeeding rate in the USA at up to 6 months is just 12%, when WHO recommends 100%. In fact, 25% of women in the USA never even try to breastfeed. In a country that is supposedly a world leader for the developed world, this is disgraceful. How lucky we are that Nestle provides alternatives to breastfeeding that are readily available in a country which does not legally support the WHO Marketing Code (/sarcasm).
My own question to Nestle (I only submitted one), was what they thought of this extremely low rate of breastfeeding in America, and why they think it exists.
I think it's a simple question, that Nestle should state an opinion on, given that it sells an alternative to breastmilk and is therefore interested in this market.
We're a few weeks into this dialogue now, and when I reminded them of my question, Nestle has said it is working on its answer to me. I'll let you know when they finish working on it.
What mothers need *especially* when clean water is not available is support for breastfeeding not a breastfeeding alternative to mix with dirty water.
@Mediamum: Yes - The situation in developed countries is an important one too. I will be touching on that when I write my reply to their answer to Question 4 from http://www.phdinparenting.com/2009/10/03/follow-up-questions-for-nestle/" rel="nofollow">my list of questions, as well as possibly questions 1, 2 and 3 (I don't have their answers to those yet). Please do let me know when you get your answer.
I lived in a town where the water was unsafe for babies when I was formula feeding my eldest. No one mentioned that though. I'm sure the formula.canister said to boil water etc, but alas, I must have missed the small print. We did, however distill the water because I thought of it on my own, but as an educated woman who does read directions, I question the accessibility of said wording on their packages, since we were using carnation good start (nestle) and enfamil.
Shame on them for suggesting that in countries with literacy rates comparable to the US's exclusive breastfeeding rates, that printing the words on the back of a canister are all they need to do to ensure infant safety.
@slee: Unfortunate but true... "in countries with literacy rates comparable to the US’s exclusive breastfeeding rates"
What about the safety of the formula cans themselves...? BPA and who knows what else. This seems to be completely unaddressed.
@Monica: Yes, it is. In my opinion BPA in cans is something we have the luxury of being concerned about in the developed world. I think we are right to be concerned, but I think there are bigger problems than the BPA in the developing world. But it should be eradicated from formula cans/tins completely.
BPA is in plastic and all our formula comes in tins, so it's not an issue for us (us being my family). However, BPA is leaked when the plastic is subjected to heat. So, if you buy the ready-made formula in the plastic containers BPA is not an issue unless you heat that container. It's a much big problem with bottles and the plastic containers we heat and store food in.
People in DEVELOPED countries are being forced to use formula not just developing and its a miracle that more children aren't sick or dead because of it. I was forced to stop breastfeeding when I sought help for PostPatrum Depression and denied use of a breastpump to even relieve my engorgement. I had voluntarily asked to have myself checked in to get treatment for my depression because I had attempted suicide. The doctors shoved pills at me and told me there was no medicines that were safe for breastfeeding even though that wasn't true (the medicines they proscribed happened to be safe for breastfeeding) and that if I tried to breastfeed/pump or refused to take the medicines they would have my son taken away from me. I was a 19 years old single mom and my son was 3 months old. It still upsets me that my son and I were manipulated to give formula and cease nursing something that really boosted my confidence as a young mother. Plus the sudden weaning was very hard on both of us and did temporarily make my depression worse but not as bad as the depression meds make me feel.
I read at a 10th grade level despite some college education and being an avid reader, I reluctantly admit. My mother has a BA in communications and minor in English and between the both of us we failed to see until my son was 10 months old that infant formula water should be boiled before being given. My son's father didn't know to boil the water either (and didn't believe me when I told him he needed to boil the water before giving formula) and as a result my son caught Rotavirus (the local drinking water was contaminated but didn't let us know until months later by mail) that nearly killed our son.
That was 7 years ago. The directions for mixing powdered formula has gotten smaller since. The newest formula from Nestle states on its label NOT to mix the formula with boiled water in larger print than it says to boil and cool the water before mixing it with the powder. Add to the fact that many parents when making formula have a crying hungry child that they are trying to get fed ASAP I doubt that many parents even have time to read the label or can given its small size.
BPA is also found in the lining of tins (almost all tin cans are lined with BPA). Sorry to be the bearer of bad news.
Even so, everything I have read (I did a big project on it for grad school) shows that BPA is only released when the container is heated. I hope the FDA bans it soon because it's dangerous stuff. But regardless, I'm off-topic :-)
I forgot to mention that formula companies do give formula away for free and then coupons that make it practically free and yes if you don't use their coupons they do send you larger coupons than if you do use their coupons. It is about the same marketing technique as in developing nations but because there is clean water here, and the government will help you out to buy formula so you don't have to dilute it to make it last if you don't have the money for it you don't have as many babies dying from it. Plus there is a way to get good support and information if it isn't provided by your doctor or family and let's face it that makes a huge difference for people who breastfeed in the developed world, because often there isn't support from family and doctors DON'T have any clue about breastfeeding.
[...] 12. In discussions with the bloggers, your CEO mentioned that children died in the 1970s as a result of the misuse (wrong quantity, mixed with dirty water) of formula samples. Do you believe that deaths from the misuse of formula samples ended in the 1970s? ANSWER HERE [...]