The AAP and its relationship with an infant formula manufacturer

The American Academy of Pediatrics, a well-respected group of physicians, has allowed their logo to be placed on the tag of Mead Johnson's Enfamil-infant formula discharge bag. Because The AAP clearly promotes breastfeeding due to the undeniable health benefits; this collaboration sends an opposing message. The AAP, maternity hospitals, obstetricians, pediatricians, and all allied health services should avoid the practice of dispersing formula or discharge bags. These are not free samples meant to assist new mothers. Distributing formula companies' discharge bags or printed materials is only providing free advertisement for the formula companies. Unfortunately this practice undermines new mothers breastfeeding endeavors. www.BabyFirstLactation.com

IBLCE Calls Upon the American Academy of Pediatrics to Terminate Arrangement with Formula Manufacturer


As a certification body, the International Board of Lactation Consultant Examiners® (IBLCE®) typically only issues statements directly related to IBCLC® certification matters.

However, due to IBLCE’s strong support of the International Code of Marketing of Breast-milk Substitutes, IBLCE is compelled to take the somewhat unusual step of calling upon the American Academy of Pediatrics to terminate its recent arrangement with a formula manufacturer which included the printing of the AAP logo on the formula company discharge bags.

This arrangement does not accord with some of AAP’s own policy statements as well as the evidence base regarding the importance, and primacy of, breastfeeding.

Therefore, IBLCE calls upon the AAP to terminate this arrangement and to demonstrate its commitment to optimal health and nutrition by unequivocal support and promotion of breastfeeding.








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What is the WHO Code and why is it important?

Defeating The Formula Death Star: Using Social Media to Advocate for the WHO Code Posted April 1st, 2013 by Jeanette McCulloch and Amber McCann As presented at the 8th Breastfeeding and Feminism Symposium: March 21, 2013 “Oh no. It looks like the Death Star.” – WHO Code advocate Last year, the world’s largest infant formula company, Nestle, rolled out a new center for managing its social media, described by Reuters as Nestle’s site for reaching consumers and “engaging with the online enemy.” Nestle’s new “digital acceleration center,” designed to both reach consumers and manage conflict, “looks like mission control” with walls of screens where red lights flash when online dissent is detected. Advocates for the fair marketing of formula were disheartened but not surprised to see this well-funded effort to reach mothers and diffuse controversy. How infant feeding choices are marketed matters. It matters enough that formula companies are reported to spend more than $50 million annually in the US alone. It matters enough that the World Health Organization developed an entire set of rules (known as the WHO Code) around how formula should – and should not – be marketed worldwide. Now, the efforts to ensure accurate information about feeding choices have moved online to social media. Those that defend those rules – WHO Code advocates – are working to ensure that those rules are upheld online. But defenders of the WHO Code are up against formula companies that are better-funded and are using the most up-to-date tools and strategies for reaching mothers using the Internet. Sound like David and Goliath? Once you see the technological power of the digital acceleration team, you will see why the online efforts of the formula companies feels like the Death Star of the Star Wars franchise fame. This “formula Death Star” is not going unchallenged. Using the incredible capacity of social media for the advocacy, education, and the mobilization of grassroots efforts, a rag-tag group of rebel forces–online WHO Code activists–are working to protect the WHO Code and breastfeeding families everywhere. What is the WHO Code? The International Code of Marketing of Breastmilk Substitutes (commonly called the WHO Code) was written with the goal of reducing the impact of marketing practices that aim to mislead new and expectant mother into believing that infant formula is nutritionally, immunologically, and otherwise comparable to breastmilk. Despite common misconceptions, the code DOES NOT limit access to or use of formula or related products. The code addresses marketing–and for good reason. When marketing spending on formula goes up, breastfeeding rates go down. The WHO Code was written and adopted in 1981 by the World Health Organization by a vote of 118 to 1 (the United States cast the lone dissenting vote). Thirty-two countries have adopted the code as national law, with 76 others adopting portions of it as law. Ethically and morally, the code should be considered worldwide, even where it has not yet been adopted as law. As providers who work with women, we believe in their capacity to make the best choices for their families, when presented with evidence-based information. If that’s our goal, we have two options: • We can increase marketing budgets for breastfeeding to the levels of formula companies. In the past years, they have spent at least $50 million..OR • We can uphold the WHO Code. We want to make abundantly clear that our support of the WHO Code comes from a desire to ensure ALL families have good information, not from any motivation to instill guilt or shame in families who use formula. The WHO Code does not limit options for mothers. It takes away the barriers to informed choice. As Bettina Forbes of Best for Babes puts it: “The only people who should feel guilty are those who know about the negative impact of formula marketing and do it anyway.” Meeting Us Where We Are Means Using Social Media Social media represents a revolution in communication that rivals the introduction of the printing press. For those of us of childbearing age, the notion of checking into Facebook on our iPhones, tweeting a photo of our dessert or going to Pinterest for a classic recipe instead of our family cookbooks, is second nature. Ninety-three percent of the “Millennial Generation” (those born after 1982 and who “get” technology because they grew up with it being an integral part of their lives) are communicating online, and in the United States, nearly 3 of 4 of them are using a social networking Website, such as Facebook, Twitter, or Pinterest. While the stereotype of the white, suburban mom certainly exists, we access social media widely, regardless of race, ethnicity, or socioeconomic status. We as mothers are the “power users” of social media…and marketers know it! These changes are having a significant impact on how we talk about, learn about, and share information around birth and breastfeeding. More than half of all women responding to one survey expressed their intention to share their birth experience, as it happens, on social media. Moreover, time online increases after the birth—44% of US women spend more time online after a new baby is born, and the likelihood that a new mother will seek breastfeeding information and support online is high. We Are Seeking Information About Health Care — Including Breastfeeding — Online Research tells us that health care providers continue to be the “first choice for most people with health concerns, but online resources, including advice from peers, are a significant source of health information in the United States.” Eighty percent of U. S. Internet users have sought health care information online, and birth and related topics are an area of focus. We are using social media not only to seek information online, but we are also sharing our knowledge with others . . . and our iPhones make it as easy as sending a tweet or replying to a Facebook status update. The savvy marketers at corporations who produce infant formulas are fully aware of these changes. We argue that it is our responsibility, as advocates for breastfeeding families, to understand these changes. We know that there is POWER in using social media to reach and rise up and converse with mothers to affect change. Formula Companies Are Making Significant Investments In Social Media Savvy institutions understand what we’d teach in any “Social Media 101” presentation: social media is an unprecedented tool for listening to and engaging with an audience. Nestle has become a leading example of the use of social media both to reach consumers and to manage conflict and dissent. Nestle is the world’s largest food company and is also among the world’s most controversial corporations. Nestle was founded on the formulation of artificial infant milk. However, Nestle is not alone in its use of social media to reach parents. 10 out 11 infant formula brands commonly available in the United States, have a social media presence. Examples of their use included Facebook pages, Twitter accounts, YouTube channels, mobile apps, sponsored reviews on blogs, and interactive websites. How Do the TOP Breastfeeding Profiles Stack Up? Nestle and other formula companies have used large budgets to build their audiences. While overall marketing budgets are not generally available, at least $50 million was spent on formula advertising in 2004 and Nestle has been reported to have doubled their social media spending in recent years. Compare this to the resources of top breastfeeding organizations. La Leche League International, the breastfeeding advocacy organization with the most significant financial resources had total revenues of $1.5 million in 2011 and spent a little over $115,000 on “public relations, external relations, and advocacy.” Other organizations, like KellyMom, Best for Babes, and Breastfeeding USA have small budgets and rely largely on volunteer efforts. The result? Although all of these organizations make a significant impact on the women they reach, compare the total number of all of their followers on Facebook: about 145,000 as of this writing, to that of Gerber (the Nestle owned brand that manufactures Good Start formula) at more than five million followers. Nestle has used its significant financial resources to hire social media experts and develop tools that have made it a shining example of effective corporate social media strategy. Nestle’s “Digital Acceleration Team” has a trained staff that monitors every mention of Nestle’s brands across various social media platforms. Team members identify negative “emerging issues” by the volume of mentions and respond to those with a high level of engagement with a scripted playbook for team members. http://www.youtube.com/watch?v=ktsMa8hfgY0 The Formula Death Star, as it has become known to WHO Cde activists, can feel overwhelming, both because it limits our capacity to reach families and because it can feel impossible to influence change at the world’s largest food company. However, it is encouraging to remember that Nestle developed these tools in response to its inability to manage an onslaught of angry advocates and consumers. In 2010, Greenpeace activists were able to enact significant changes in how Nestle sources palm oil, thanks to a YouTube video spoof that garnered over 1.5 million views, along with a resulting social media campaign that netted more than 200,000 e-mail complaints. Policy change at Nestle, based on calls from all of us, is possible. Examples of Efforts to Support the WHO Code Online Although Nestle may have the Death Star, rebel forces are pulling together to provide much needed social media support for the WHO Code. A recent campaign demonstrates the power of social media to organize individuals, even without an official organizing body like Greenpeace. A blog post exposing that the Pan-American Health Organization — the regional representative in the Americas for the World Health Organization–accepted more than $150,000 in donations from Nestle sparked outrage among activists who were concerned that the fox was helping to buy the hen house. Within days, a private Facebook group was birthed and experienced rapid growth to 400 members, now at almost 1000 members as of this writing. Each day, members were given specific action steps, including suggested scripts for tweets directed at PAHO and WHO. Members shared impromptu trainings on Twitter use and etiquette, researched the money trail, and quickly developed strategy, including a decision to target WHO and call for a rejection of the Nestle funding. The result: A relatively small group of consumers and advocates, through the use of Facebook and Twitter alone, were able to force the World Health Organization to respond. More importantly, the group began to organize and mobilize motivated individuals (including breastfeeding professionals, volunteers, families, researchers, and advocates!) who will come to the next battle more organized and prepared to engage. How The Rebel Forces Can Defeat The Death Star As the Greenpeace example shows, social media provides all of us with a unique opportunities to influence how companies do business. With ongoing support to the rebel forces, much-needed pressure can be put on Nestle to change its policies; but this will not come without significant work. Some areas that need support: Ongoing consumer support and education around the WHO Code: In our experience, families generally are unaware of the WHO Code, or, if they have heard of it, they believe that it limits access to formula rather than limiting the marketing of breastmilk substitutes. The importance of the WHO Code needs to be distilled into social media-friendly images and infographics to build awareness and support for all future efforts. Ongoing education of maternal health advocates. The WHO Code is about more than just breastfeeding. Anyone concerned with infant and maternal health should be aware of and providing support for the adoptions and enforcement of the WHO Code worldwide. Bring even more social media savvy to the table. After Nestle’s run-in with Greenpeace, it brought in a top notch social media strategist to revamp its approach and provide training for its social media team. Nestle uses sophisticated tools to monitor and respond to issues. The Friends of the WHO Code–and any group hoping to use social media for impact–needs people on hand who are savvy in the use of social media and the funding for some basic tools to make the job collaborative. Keep doing what we know best. One the greatest results of the PAHO/WHO crisis was the assembly of a worldwide community with much work still to do. This and other groups need to use traditional community organizing strategies, incorporating social media to create a more level playing field. To learn more about what you can do to help promote the WHO Code through social media, join the group “Friends of the WHO Code” on Facebook. An earlier version of this post originally appeared in Science and Sensibility. You might also like: Read more: http://www.momsrising.org/blog/defeating-the-formula-death-star-using-social-media-to-advocate-for-the-who-code/#ixzz2PGC4jDLa

The AAP is making progress towards supporting breastfeeding efforts.

AAP passes resolution to limit formula marketing

July 26, 2012
Elk Grove Village, IL– The American Academy of Pediatrics has passed a resolution advising pediatricians “not to provide formula company gift bags, coupons, and industry-authored handouts to the parents of newborns and infants in office and clinic settings.” The resolution, passed last month, was unveiled on the AAP’s breastfeeding website today.
The AAP asserts the breastfeeding is the normal physiologic way to feed newborn infants. It draws on parallels with conflicts of interest with the pharmaceutical industry (which controls most of the infant formula market in the US, too). They note that the practice constitutes marketing, and that research shows that it adversely affects breastfeeding duration and exclusivity.

The AAP resolution joins the growing voices against marketing of infant formula in medical environments, citing support from the Government Accountability Office, American College of Obstetricians and Gynecologists, the Centers for Disease Control and Prevention, the American Public Health Association, and previous statements from AAP.

Recently, all 49 Massachusetts maternity facilities banned of formula marketing discharge bags. The AAP resolution gives strength to such practice as an important public health measure.

Breastmilk vs. Formula

Supporting Studies on Infant Formula Marketing

Reference these studies when you talk to the media, healthcare providers, or hospital administrators.

Studies on the prevalence of formula sample distribution in the U.S.

1. Sadacharan, R., Grossman, X., Sanchez, E., & Merewood, A. (2011). Trends in US Hospital Distribution of Industry-Sponsored Infant Formula Sample Packs. Pediatrics, 128(4), 702-705.

Study of 1239 hospitals in 20 states found that most US hospitals continue to distribute industry-sponsored formula sample packs, but trends indicate a significant change in practice; increasing proportions of hospitals eliminate these packs. Change was more significant in states where higher proportions of hospitals had already eliminated packs in 2007. Based on the CDC’s breastfeeding report care for 2010, average breastfeeding initiation rates were significantly higher in the states with the best-record of banning samples when compare to those with the worst records (81.5 percent vs. 67 percent). Similarly, the rate of breastfeeding at six months was higher in states with the best record of banning sample bags (52.7 percent to 37 percent).

2. Merewood, A., Grossman, X., Cook, J., Sadacharan, R., Singleton, M., Peters, K., et al. (2010). US hospitals violate WHO policy on the distribution of formula sample packs: results of a national survey. Journal of Human Lactation, 26(4), 363.

Cross-sectional telephone survey of 3209 US maternity sites, conducted from 2006 to 2007. Found that 91% of hospitals distributed formula sample packs, and a trend toward discontinuation of the practice was statistically significant. Most US hospitals distribute infant formula samples, in violation of the WHO Code and the recommendations of public health and healthcare provider organizations.

3. Merewood, A., Fonrose, R., Singleton, M., Grossman, X., Navidi, T., Cook, J. T., et al. (2008). From Maine to Mississippi: hospital distribution of formula sample packs along the Eastern Seaboard. Archives of Pediatrics and Adolescent Medicine, 162(9), 823.

Studied 21 eastern states and the District of Columbia. Rates varied by region. Found that 94 percent of hospitals distributed formula sample packs. Regional trends were evident. The proportion of distributing hospitals ranged from 70.4 percent (New Hampshire) to 100.0 percent (4 states-New Jersey, Maryland, Mississippi, and West Virginia-and Washington, DC). The proportion of hospitals that do not distribute sample packs has risen significantly between 1979 and 2006.

Studies on the effects of industry-sponsored formula samples on breastfeeding

1. Rosenberg, K. D., Eastham, C. A., Kasehagen, L. J., & Sandoval, A. P. (2008). Marketing Infant Formula Through Hospitals: the Impact of Commercial Hospital Discharge Packs on Breastfeeding. Am J Public Health, 98(2), 290-295.

Among women who had initiated breastfeeding, 66.8 percent reported having received commercial hospital discharge packs. Women who received these packs were more likely to exclusively breastfeed for fewer than 10 weeks than were women who had not received the packs

2. Donnelly A, Snowden HM, Renfrew MJ, Woolridge MW. Commercial hospital discharge packs for breastfeeding women. Cochrane Database Syst Rev. 2000

Nine randomized controlled trials involving a total of 3730 women from North America were analyzed. Commercial discharge packs reduced exclusive breastfeeding.

3. Wright, A., Rice, S., & Wells, S. (1996). Changing Hospital Practices to Increase the Duration of Breastfeeding. Pediatrics, 97(5), 669-675.

Duration of breastfeeding was longer in women who did not receive commercial discharge packs with formula samples or coupons for formula samples.

4. Perez-Escamilla, R., Pollitt, E., Lonnerdal, B., & Dewey, K. (1994). Infant feeding policies in maternity wards and their effect on breast-feeding success: an analytical overview. American journal of public health, 84(1), 89.

A meta-analysis of 18 studies showed that commercial discharge packs have a detrimental effect on exclusive breastfeeding at one month and any breastfeeding at four months.

5. Dungy, C. I., Christensen-Szalanski, J., Losch, M., & Russell, D. (1992). Effect of discharge samples on duration of breast-feeding. Pediatrics, 90(2), 233.

Women who received a manual breast pump in their discharge bags instead of formula samples were more likely to exclusively breastfeed their babies for a longer number of weeks (4.18 weeks compared to 2.78 weeks).

6. Snell, B., Krantz, M., Keeton, R., Delgado, K., & Peckham, C. (1992). The association of formula samples given at hospital discharge with the early duration of breastfeeding. Journal of Human Lactation, 8(2), 67.

At 21 days, there was a significant relationship between receipt of a gift pack and the decline of exclusive breastfeeding among a group of low-income Hispanic women. A larger proportion of breastfeeding women who received a gift pack either began by supplementing with formula or changed to bottle-feeding by three weeks.

7. Bergevin, C., Dougherty, Y., & Kramer, M. S. (1983). Do infant formula samples shorten the duration of breast-feeding? The Lancet, 321(8334), 1148-1151.

New mothers receiving formula giveaways were less likely to still be breastfeeding at one month and more likely to have introduced solid foods by 2 months These trends became more significant in three vulnerable subgroups: less educated mothers, primiparas, and mothers who had been ill post-partum. Results suggest that infant formula samples may shorten the duration of breast-feeding and hasten the age at which solids are introduced.

Selected studies on health benefits of breastfeeding

1. Ip, S., Chung, M., Raman, G., Chew, P., Magula, N., DeVine, D., et al. (2007). Breastfeeding and maternal and infant health outcomes in developed countries. Agency for Healthcare Research and Quality Publication, U.S. Department of Healthcare and Human Services. Retrieved 2 November, 2011, from http://www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf

Found that a history of breastfeeding was associated with a reduction in the risk of acute otitis media, non-specific gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma (young children), obesity, type 1 and 2 diabetes, childhood leukemia, sudden infant death syndrome (SIDS), and necrotizing enterocolitis. For maternal outcomes, a history of lactation was associated with a reduced risk of type 2 diabetes, breast, and ovarian cancer. Early cessation of breastfeeding or not breastfeeding was associated with an increased risk of maternal postpartum depression.

2. Harder, T., Bergmann, R., Kallischnigg, G., & Plagemann, A. (2005). Duration of Breastfeeding and Risk of Overweight: A Meta-Analysis. American Journal of Epidemiology, 162(5), 397-403.

Meta-analysis of 17 studies shows that a longer duration of breastfeeding is associated with a larger decrease in risk of overweight.

3. Arenz S., Ruckerl R., Koletzko B., Von Kries R.(2004).Breast-feeding and childhood obesity: a systematic review. International Journal of Obesity and Related Metabolic Disorders, 28, 1247-

Children who are breastfed are 22 percent less likely to be obese.

4. Labbok, M. H. (2001). Effects of Breastfeeding on the Mother. Pediatric Clinics of North America, 48(1), 143-158.

Breastfeeding reduces the risk for postpartum blood loss by increasing the rate of uterine contraction, premenopausal breast cancer, and ovarian cancer. In addition to reducing the severity of anemia, breastfeeding may cause changes that help to protect mothers against bladder and other infections. Epidemiologic studies seem to indicate that women who breastfeed may be at reduced risk for spinal and hip fracture after menopause. In addition to the direct health effects, breastfeeding seems to provide a sense of bonding, a sense of well-being, and an improved sense of self-esteem for many women.

Studies on the economic benefits of breastfeeding

1. Bartick, M., & Reinhold, A. (2010). The Burden of Suboptimal Breastfeeding in the United States: A Pediatric Cost Analysis. Pediatrics, 125(5), e1048-e1056.

Finding that if 90 percent of US families could comply with medical recommendations to breastfeed exclusively for 6 months, the United States would save $13 billion per year and prevent an excess 911 deaths, nearly all of which would be in infants ($10.5 billion and 741 deaths at 80 percent compliance).

2. Oliveira, V., Prell, M., Smallwood, D., & Frazao, E. (2001). Infant Formula Prices and Availability: Final Report to Congress. Retrieved 2 November, 2011, from http://www.ers.usda.gov/publications/efan02001/efan02001.pdf

Finds that the average price of brand name infant formula is close to two thirds more than store brand formula. Parents who use brand name formula may spend $700 per year more than those who use store brand formula.

3. Weimer, J. (2001). The Economic Benefits of Breastfeeding: A Review and Analysis. Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture. Food Assistance and Nutrition Research Report No. 13. Retrieved 2 November 2011, from http://www.ers.usda.gov/publications/fanrr13/fanrr13.pdf

A minimum of $3.6 billion would be saved if breastfeeding were increased from current levels (64 percent in-hospital, 29 percent at 6 months) to those recommended by the U.S. Surgeon General (75 and 50 percent). This figure is likely an underestimation of the total savings because it represents cost savings from the treatment of only three childhood illnesses: otitis media, gastroenteritis, and necrotizing enterocolitis.

4. Cohen, R., Mrtek, M. B., & Mrtek, R. G. (1995). Comparison of maternal absenteeism and infant illness rates among breast-feeding and formula-feeding women in two corporations. American Journal of Health Promotion, 10, 148-148.

Finds that one-day absences from work to care for sick infants occurred more than twice as often among formula-feeding mothers than breast-feeding mothers.

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