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RESEARCH: Hubert Barennes, Todisoa Andriatahina, Vattanaphone Latthaphasavang, Margot Anderson, and Leila M Srour Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and paediatricians in Laos BMJ 2008; 337: a1379 [Abstract] [Full text]

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Rapid Responses published:

Nestlé's works to ensure appropriate use of milk products

Roland Stieger   (19 September 2008)

Nestlé’s Violations of the International Code on the Marketing of Breast milk Substitutes

Hubert Barennes, Leila M Srour   (5 January 2009)

Misuse of coffee creamer as a breast milk substitute: a lethal case revealing high use in an ethnic minority village in Northern Laos

Gunther Slesak, Phouvieng Douangdala, Saythong Inthalad, Boualoy Onekeo, Somsouk Somsavad, Bounmi Sisouphanh, Leila M Srour, Hubert Barennes   (16 January 2009)

The latest step in a series of extraordinary labelling measures

Roland Stieger   (27 January 2009)

Will Nestlé’s Bears Continue to Mislead Parents and Threaten Infants Lives?

L M Srour, Barennes H   (3 March 2009)

Nestle's mommy bear does not breastfeed

Hubert Barennes, Leila M Srour   (26 May 2009)

Nestlé's works to ensure appropriate use of milk products 19 September 2008
Roland Stieger, Business Executive Manager Dairy, Nestlé (Thai) Ltd. Bangkok 10330 Send response to journal: Re: Nestlé's works to ensure appropriate use of milk products	Dear Sirs, Nestlé is very concerned that mothers in poor countries feed infants with inappropriate breast milk substitutes. These are frequently rice water, starch and water, whole cows’ milk, diluted family foods, or other foods, including milk-based products from various manufacturers, which are not designed as breast milk substitutes. The immediate issue raised in this article concerning BEAR BRAND Beverage Creamer in Laos has been resolved, as Nestlé stopped its distribution, and stopped an independent company which had licensed the brand, from producing it in February 2008. Nestlé recognizes that Barennes et al. raise legitimate questions, and is in the process of re-evaluating the BEAR BRAND brand for milk products and studying how to prevent any confusion with infant formula. This is a part of ongoing steps to stop the inappropriate use of non- infant formula products as breast milk substitutes. In the developing world, Nestlé puts on all coffee creamers and other milk products which are inappropriate for infant feeding a statement that “this product is not to be used as a breast milk substitute” or “not appropriate for infant feeding”. Additionally, in 2002 Nestlé introduced a pictogram on BEAR BRAND beverage creamer in Laos, - a bottle crossed out with large red ‘X’ to show that the product was not to be used as a breast milk substitute. This step, a result of discussions with and approval by the government, went beyond strict compliance with the local laws and regulations in order to further reduce the risk of confusion amongst both literate and illiterate mothers. We believe that successful long-term business is possible only if the interests of mothers and children are protected. Therefore, Nestlé will continue to explore ways to assure that products not intended for infant feeding are not confused with legitimate breast milk substitutes, working in collaboration with national and international health authorities. The author of this response is Roland Stieger, the Business Executive Manager for Dairy at Nestlé (Thai) Ltd. Competing interests: The author of this response is the Business Executive Manager for Dairy at Nestlé (Thai) Ltd.
Nestlé’s Violations of the International Code on the Marketing of Breast milk Substitutes 5 January 2009
Hubert Barennes, Training and Reasearch Coordinator Vientiane Laos, Leila M Srour Send response to journal: Re: Nestlé’s Violations of the International Code on the Marketing of Breast milk Substitutes	We are very concerned about the misunderstanding of the International Code on the Marketing of Breast milk Substitutes (ICMBMS) by Roland Stieger representing Nestle (Thai) Ltd. (1-2) The example of the coffee creamer is only the tip of the iceberg. The obvious and ongoing International Code Violations include: The marketing of formula and non-formula products with the logo of a baby bear held in the breast-feeding position (ICMBMS Article 5): Sweetened condensed milk (45% sugar, 20% skimmed milk powder & palm oil) with the Bear Brand logo was still on sale in Vientiane, September 2008. In neighboring Thailand, an aggressive advertising campaign began in 2007 with the Bear Brand logo on sweetened condensed milk, milk products and formula products. Advertising on the sky train in Bangkok of Bear Brand products is easily recognized, September 2008. (3) In 2004, large billboards marketing formula products and "follow-up formulas" (which fall within the scope of code, ICMBMS Article 2) with the Bear Brand logo appeared in Vientiane, the capital city, and in Pakse. (ICMBMS Article 5) (1,4). The Lao pediatricians appealed to the Ministry of Health to end this campaign (Figure 1). (5) Figure 1 Nestle representatives in Vientiane hospitals give gifts, trips and other incentives to Lao doctors and nurses (ICMBMS Article 7). This violation is particularly serious in a country where health care workers have very low salaries. A twisted violation of the code is the use of a baby bear, as pictures of infants are not allowed to appear on formula products (ICMBMS Article 9). Our research shows that the pictogram of the bottle with an X does not mitigate the appeal of the Bear Brand label.(6) Roland Stieger, Nestle representative, states that the pictogram was introduced in 2002.(2) However, in 2006, infants with severe malnutrition were being fed coffee creamer without the pictogram. This bottle with X did not appear in Vientiane markets until 2007. Our research was the first to explore the public’s (mis)understanding of the pictogram. Regarding Nestlé’s strict compliance with local laws, local laws and regulations in Lao are developing. Authorities were not aware of the seriousness of the problem. Why does Nestle prey on the poorest and least developed countries, where breast-feeding is the best intervention to save infants lives? (6) We are deeply concerned that nearly one half of Lao children in rural areas are stunted.(8) The lowest exclusive breast-feeding rates in the region occur in Thailand, Myanmar, Vietnam and Laos. How much of this results from the marketing of breast milk substitutes and unchecked violations of the International Code? Shantha Boleman, UNICEF’s East Asia and Pacific Regional office in a statement about malnourished Asian children states, “The advertising of formula is having a huge impact in South-east Asia, because it is a growing market for the companies”.(9) Nestle says they are very concerned that mothers in poor countries feed infants inappropriate breast milk substitutes and are taking “ongoing steps to stop the inappropriate use”. (2) Our question is how long and how many children will suffer and die before Nestle complies with the true purpose of the International Code, which is to promote breast feeding, the number one intervention to save infants lives.(7) Would it take so much time to change a similar logo that would strictly not be allowed in Switzerland or other informed countries? We thank the P8 Masters’ students of the Institut de la Francophonie pour la Médecine Tropicale (Agence Universitaire de la Francophonie), Drs P Chanthavilay, PN Newton, JP René, V Amstutz, G Slesak, J Krahn, K Surinder, M Anderson, C Chu. We thank M DeBlaise and Bryan Watt, P Lévy and D Benoit. We thank the Lao paediatricians and the staff of Health Frontier, Vientiane. 1 The International Code of Marketing of Breast Milk Substitutes, www.ibfan.org/english/resource/who/fullcode.html 2 Stiegler R. Nestlé’s works to ensure appropriate use of milk products. BMJ 2008 http://www.bmj.com/cgi/eletters/337/sep09_2/a1379 3 ThaiPR.net. Bear Brand protection joins hands. http://www.thaipr.net/nc/readnews.aspx?newsid=2CE2E9E0EF7CAC9C95942A0EE2FA2F3A 4 World Health Assembly. World Health Assembly resolution 39.2 http://www.ifanz-ibfan.org.nz/codes/whares3928.html 5 ABC Online. Lily Yan Laos parents mistakenly feeding infants coffee creamer. http://www.radioaustralia.net.au/programguide/stories/200809/s2361637.htm 6 Barennes H, Andriatahina T, Latthaphasavang V, Anderson M, Srour L. Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and paediatricians in Laos. BMJ 2008; 337; a1379. 7 Jones G, Steketee RW, Black RE, Bhutta Z A, Morris Saul S, Bellagio Child Survival Study Group; How many child deaths can we prevent this year? Child Survival II. Lancet 2003; 362. 8 WFP Laos. Comprehensive Food Security and Vulnerability Analysis for rural Lao PDR. 2006. http://documents.wfp.org/stellent/groups/public/documents/ena/WFP154796.pdf 9 Marwaan Macan-Marker. Children Under Five Straggling. Global Geopolitics Globalnewsblog.com; Inter Press Service, http://globalnewsblog.com/wp/2008/09/13/asia-pacific-mdgs-children-under- five-straggling/ Competing interests: None declared
Misuse of coffee creamer as a breast milk substitute: a lethal case revealing high use in an ethnic minority village in Northern Laos 16 January 2009
Gunther Slesak, SFE Medical Project Luang Namtha, Lao PDR, Phouvieng Douangdala, Saythong Inthalad, Boualoy Onekeo, Somsouk Somsavad, Bounmi Sisouphanh, Leila M Srour, Hubert Barennes Send response to journal: Re: Misuse of coffee creamer as a breast milk substitute: a lethal case revealing high use in an ethnic minority village in Northern Laos	The feeding of breast milk substitutes to infants is an important risk factor contributing to infant morbidity and mortality in developing countries, but published research is limited. Exclusive breast-feeding for the first six months of life is the number one intervention to save infants’ lives(1). When the mother dies, is unable to breast feed adequately or when a baby is adopted, breast milk substitutes or surrogates are necessary. In Laos poor parents use less expensive canned products, which they believe are appropriate for infants(2). Advertising encourages parents to view the products as good supplements, modern conveniences or status symbols (3;4). In January 2009 Barennes and Srour described the extent of this misleading advertising in Laos and recommended that such practices should be prohibited(3). Barennes et al. reported the overall misperceptions and misuse of coffee creamer as infant food in Laos(2). The focus was on a red label Bear Brand coffee creamer, a tinned non-dairy product whose first ingredient is sugar. The logo, a Nestle trademark, shows a mother bear holding her cub in the nursing position. The label on the coffee creamer contains a message in English and Lao, that the product is not a breast milk substitute. On the red label coffee creamer, a picture of a baby bottle with an X was added. Of 1098 adults surveyed, 96% believed that the can contains milk. 46% believed the Bear Brand logo indicates that the product is formulated for feeding to infants to replace breast milk. 80% had not read the written message on the can. Over 18% reported giving the product to their infant at a mean age of 4.7 months (2). Questions remain about the problems for infants fed inappropriate breast milk substitutes, the distribution of these products in remote areas and the effect of advertising on rural populations. In their paper, Barennes et al., documented two severe malnutrition cases, including one fatality, of infants fed the Red label Bear Brand coffee creamer. Our report is the second documented fatal case: a 6-month- old severely malnourished infant in Luang Namtha province (LNT), Laos, November 2008. The LNT province is located in northern Laos, bordering Myanmar and China. It is a multi-ethnic province with a low population density (16 people/km2) and a low literacy level. 69 % of the 148,797 inhabitants belong to one of 49 ethnic minorities, many living in remote mountain villages. Access to health care is limited by lack of infrastructure, culture and language differences and poverty. In November 2008, a 6-month-old female infant was admitted to the provincial hospital of LNT, with a 6-day history of watery diarrhoea, anorexia, fever, and underlying severe malnutrition. She was the second adopted child of a Hmong family. The parents are farmers living in a remote area. They bought 10 cans of the same Red label Bear Brand coffee creamer (0.80 $ per can in May 2008 in her first month of age. The infant was fed coffee creamer and boiled water for the first 3 months, 1 can every 3 days. Relatives had told the parents that this product would be good for children, which was reinforced by the logo of a baby bear drinking milk from the mother bear. In June 2008, the parents were unable to find cans of this type in the local district market and changed to a slightly cheaper brand (Palace, Daily Foods Co., Thailand, 0.69$) with a written message in Thai language: not to be fed to children under 1 year. They had not read the message, did not know Thai language, and the mother is illiterate. The seller told them that it could be given to children. The infant presented with diarrhoea and kwashiorkor and died with complications of severe malnutrition, diarrhoea and infection. We conducted a survey in December 2008 to investigate the extent of this nutritional practice in the infant’s village. The village, (416 inhabitants, 77 families, is located about 62 km from the provincial capital. It is an exclusively Hmong village with 1 primary school and 1 health centre. The Hmong are the 5th largest of the 17 ethnic groups in Luang Namtha with their own language and culture. We used a structured questionnaire and parents were shown coloured pictures of the Bear Brand products and the non-Bear Brand coffee creamer (Figure). Anthropometric measurements were performed for all children <5 years and analysed with WHO 2005 anthropometric software. Participants gave their informed consent to participate in the survey, which received the agreement of the local and regional health authorities. Figure: Picture chart used for the survey. And description of ingredients and warnings in English language Data were entered in EpiInfo (Version 3.4.3). Analysis was carried out with STATA, Versions 8 (Stata Corporation, College Station, TX, USA). Fisher’s exact tests, Students’ t-test and Wilcoxon test were used to compare categorical variables and continuous data, respectively. The survey was conducted in 49 families with children, anthropometric data were collected from all children below 5 years of age present in the village. The parents are farmers with a low literacy rate (45%). Mothers had breastfed their babies for an average duration of 14.6 months. Of 67 under 5 year old children, 54 (80.6%) were stunted (height/age<-2SD), and 28 (41.8%) were severely stunted (<-3SD). Red Bear Brand coffee creamer and non Bear Brand products were more popular than white Bear Brand coffee creamer and were well recognized by the parents (39/49 (79.6%), 34 (69.34%), and 24 (48.8%), p=0.005 respectively). Bear Brand product was more frequently recognized as a product for feeding children or infants than non Bear Brand products, (26 (53,1%)) versus 16 (32,7%), p=0.04) In total, 20 (40.8%) reported giving one or more of the coffee creamers to their infants: 15 (30.6%) the red Bear Brand coffee creamer, 6 (12.2%) the white Bear Brand can, 12 (24.5%) the other non Bear Brand coffee creamer. The sterilized milk can which is more expensive (1.25$) was only given by one parent, the non-fat sterilized milk never. The so called “advance formula” 1 was given by 2 parents (price: 6.7$). 10 parents (20%) started the coffee creamer within the first month. Parents started the Bear Brand coffee creamer earlier than the non Bear Brand coffee creamer (mean age of 3.6 months (95%CI : 1.8- 4.5), 7.0 months (05%CI: 2.6-11.3), respectively (p=0.03). 22 (44.9%) parents believed that the Bear Brand logo means that it is “a milk to feed infants and/or children”. Other parents believed that the coffee creamers would improve infant nutrition, supplement vitamins and make their child strong and fat. The uselessness of the pictogram with the crossed off baby bottle was similar to the report by Barennes et al: 31 (63.3%) did not know the meaning of the product’s pictogram of a crossed off baby bottle(2). Only 5 (10.2%) interpreted it correctly as not to be fed to children/babies. 39 (79.6%) had never read the red warning text. One had read it but understood the opposite: that the coffee creamer was intended for bottle- feeding of babies. Our study confirms the widespread misuse of coffee creamer as a breast milk substitute in the Hmong ethnic group. The cartoon logo of a baby bear held by its mother in the breastfeeding position contributes to the misperception and misuse of coffee creamer by parents. Despite the companies’ statement to have stopped its production and distribution for Laos in February 2008 (5), the product was available at the local district market in Muang Sing, Northern Laos until May 2008. The parents of the described patient were evidently misled by this logo and then continued feeding their child with a cheaper coffee creamer without the logo. Misuse of coffee creamer as a breast milk substitute in the patient’s village was 41%, much higher than the 18% found in a nationwide study in Lao PDR in 2007 (2). Reasons might be the lower educational level, the village location in a rural and remote area in Northern Laos, and the ethnic minority status. The misuse did not end after the coffee creamer with Bear Brand logo became unavailable locally in June 2008 but continued with other brands. The Bear Brand coffee creamer might have opened the door for other brands of coffee creamer, seen as cheaper alternatives. The fact that the Bear Brand coffee creamer is still widely sold in neighbouring Thailand is of continuing concern. Our findings show the imminent necessity for further measures to combat this health threat for infants in Laos. It is questionable if health education alone will be able to reach all the people in risk, especially the families in remote areas. One suggestion would be to replace such a misleading logo by the logo of a tea or coffee cup with no infants, children, bears or animals. Clear logo, warning pictograms and messages should support the the purpose of International Code on the Advertising of Breast milk Substitutes, the protection of breastfeeding(6). Warning labels should be tested for effective visual literacy with the different ethnic groups before their distribution in such areas. This is the second report of an infant’s death associated with the misuse of coffee creamer as a breast milk substitute, a common practice in this Hmong village. The Bear Brand logo is a twisted violation of the International Code on the Advertising of Breast milk Substitutes and threatens the health of infants in Laos and possibly other countries. Acknowledgements We thank the LNT province health authorities, LNT provincial hospital, Muang Sing district health department, and Service Fraternel d’Entraide staff, the village inhabitants, Health Frontier Vientiane, and Institut Francophone de Medicine Tropicale Vientiane. Contributors: GS was responsible for the overall coordination of the study. He will act as guarantor for the paper. GS, PD, SI and HB contributed to the study design and data analysis. PD, SI, BO collected the data. GS, LMS, H B, P D, B S, drafted the paper and revised it. LMS did the editing. All authors contributed to the writing of the paper. Funding: Service Fraternel d’Entraide All authors appraised and approved the final report. Competing interests: None declared 1. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year? Lancet 2003;362:65-71. 2. Barennes H, Andriatahina T, Latthaphasavang V, Anderson M, Srour L. Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and paediatricians in Laos. BMJ 2008. 3. Barennes H,.Srour LM. Nestlé's violations of the international code on the marketing of breast milk substitutes. BMJ 2009. 4. Marwaan Macan-Marker. Children Under Five Straggling. Global Geopolitics Globalnewsblog.com; Inter Press Service. http://globalnewsblog.com/wp/2008/09/13/asia-pacific-mdgs-children-under- five-straggling/ . 2008. 5. Stiegler R. Nestlé's works to ensure appropriate use of milk products http://www.bmj.com/cgi/eletters/337/sep09_2/a1379. BMJ 2008. 6. IBFAN. The International Code of Marketing of Breast Milk Substitutes. www.ibfan.org/english/resource/who/fullcode.html . 2009. Competing interests: None declared
The latest step in a series of extraordinary labelling measures 27 January 2009
Roland Stieger, Business Executive Manager Dairy, Nestlé (Thai) Ltd. Bangkok 10330 Send response to journal: Re: The latest step in a series of extraordinary labelling measures	We are concerned about inaccurate allegations that Nestlé is violating the WHO Code as contained in a letter by Barennes et. al. in the recent BMJ on-line Rapid Responses. In the past Nestlé has taken extraordinary labelling measures on products that are not intended for infants; especially on the sweetened condensed milk based "coffee creamers", but also on other products such as milk powders for children over the age of 1 year. Nestlé has gone even further than the requirements of the Code with printed statements in different languages to the effect that the product should not be used to feed infants, along with an additional warning pictogram which had been agreed with the Ministry of Health. We now have gone one step further in labelling changes and are removing the baby in the adult bear’s arms on all products not intended for use in feeding infants, and have replaced it with a glass. This new logo will be rolled out during the second quarter of 2009, although old products will still be on the shelves until retail outlets of older supplies are exhausted. Our communication with health professionals does not encourage the use of infant formula over breastfeeding, but rather educate about the use of legitimate breast milk substitutes instead of dangerous alternatives. We do not provide financial incentives to promote alternatives to breast milk. Small items of professional utility provided (with no infant formula brand) as well as institution-approved support of attendance at scientific and medical meetings are in no way in violation of the WHO Code. We reiterate our concern that infants are currently fed a wide variety of inappropriate and dangerous breast milk substitutes, particularly raw whole cow’s milk, sugar water, and rice water – or sweetened condensed milk based products. We will continue to do our part to reduce and eliminate the use of inappropriate substitutes. This also means that if babies are fed breast milk substitutes, it is vital that they are fed the only substitute approved by WHO/FAO Codex Alimentarius: infant formula. We are committed to babies having the best start in life, which means breast-feeding if at all possible, legitimate breast milk substitutes where they are needed, and nutritious complementary foods after 6 months of age. Competing interests: The author of this response is the Business Executive Manager for Dairy at Nestlé (Thai) Ltd.
Will Nestlé’s Bears Continue to Mislead Parents and Threaten Infants Lives? 3 March 2009
L M Srour, paediatric continuing medical education coordinator Vientiane Laos, Barennes H Send response to journal: Re: Will Nestlé’s Bears Continue to Mislead Parents and Threaten Infants Lives?	We are appalled by Nestlé’s allegations that our evidence-based statements are inaccurate (1; 2). We cannot forget the coffee-creamer fed infants who have died. (3;4) The only evidence of Nestlé’s “extraordinary” commitment to protecting infant health was the ineffective pictogram of an Xed bottle. Nestle claims the pictogram was introduced in 2002, but it was not seen in Lao markets until 2007.(5) Since 2004, we have informed Nestle about parents’ misunderstanding of the Bear Brand logo. We are appalled by the lack of awareness and reaction from Nestle. Instead of the ‘extraordinary’ measures Nestle describes we would prefer to see the following ordinary measures, which we believe, would have a positive impact on infant morbidity and mortality. Bears or other animals should be removed from the logos and labels of all milk and creamer products, whether or not they are intended for infants. Labels should illustrate their intended purpose, such as a coffee cup for coffee creamer. Follow-up and advance formulas, which could be misunderstood as breast milk substitutes, should not feature children, bears or other attractions. The written instructions on the label should be in the country language where the product is being used: Lao language in Laos, not just Thai or English. All warning pictograms should be tested for understanding by the different ethnic groups. Old products with the misleading labels should be recalled and removed from the shelves. Recipe books for mothers, advertising inappropriate breast milk substitutes, should not have pictures of infants (Figure 1) The lives of infants should not be threatened by these products. Figure 1: Nutrition Guide for mothers, 97 recipes (ISBN 976-7947-43-9) The recent death of a coffee creamer fed infant should result in urgent action to prevent further tragedies. (4) We are very concerned by Nestlé’s declaration of their next labeling change, which consists of" removing the baby in the mother bear's arms". Thirty years ago, the adult bear was feeding Sweetened Reconstituted Condensed Milk to a baby bear with a huge bottle (figure 2). This product was sold under license in the Philippines and Thailand in 1979. Is this an extraordinary measure? Dropping a bottle and then a baby within 30 years? Figure 2: Original Bear Brand 1979 Was the reassuring image of the mother bear which they plan to keep on the can tested for understanding by parents? Currently a condensed milk product with 44% sugar, 20% skimmed milk powder, and 8.5% palm oil is available with a young bear, a glass of milk and warning in English and Thai language. Is this the next step for Nestle? (Figure 3) Figure 3: Condensed milk can currently available (44% sugar, 20% skimmed milk powder, and 8.5% palm oil) We assume not only Lao infants are being fed inappropriate breast milk substitutes. Ethnic diversity, illiteracy and poor nutrition education are not limited to Laos but cross all borders. Would Nestle acknowledge the consequences of the advertising campaign with the Bear Brand logo? The trademark is their responsibility. Does Nestle really believe that they are not violating the code, Article 7.3, when they offer health professionals, with very low salaries, “small items” and financial support to attend medical meetings?1 What could be Nestlé’s motivation? We appreciate Nestlé’s concern that inappropriate and dangerous breast milk substitutes are fed to infants. Many thanks for their intention to reduce and eliminate the use of inappropriate substitutes. Our concern extends to all beverage companies in Asia, which might not be as responsible or communicative as Nestle. We hope that they will cooperate similarly. We sincerely appreciate Nestlé’s every effort to support the International Code, whose aim is:”the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.” (6) Nestle and others should be aware that infants fed sweetened condensed milk will tend to refuse breast milk, because it is not so sweet. This results in a lower daily breast milk intake and finally the use of excessive inappropriate sweetened condensed milk.(7) Lao mothers report that they believed their breast-milk was bad or insufficient if the infant cried after breast-feeding or refused the breast. (8) Then, they may decide to stop breast-feeding and use inappropriate breast milk substitutes. Perhaps the Bear Brand misleading logo will be a milestone towards the promotion of breast-feeding for all infants. Nestlé’s commitment should be demonstrated by a clear action plan regarding the promotion of exclusive breast-feeding for infants 0-6 months and continuing breast- feeding until 2 years of age. The protection of infant and child health will benefit all developing countries and Nestlé’s commercial interests. We feel that Nestle really should revise their latest step. We will appreciate the ordinary measures that will end the controversies. Most importantly, the promotion and protection of breast-feeding will protect the lives of infants. We do not have competing interest We would like to thank and acknowledge Elizabeth Sterken and Annelies Allain of IBFAN, Phanphraphone Tiaokhiao of Institut Francophone de Medicine Tropicale Vientiane. The doctors in charge of Nutrition Program from the Ministry of Health for their support. We thank Health Frontiers and Institut Francophone de Medicine Tropicale Vientiane. 1. Stiegler, R. The latest step in a series of extraordinary labelling measures. http://www.bmj.com/cgi/eletters/337/sep09_2/a1379 . 2009. 2. Barennes H,.Srour LM. Nestlé's violations of the international code on the marketing of breast milk substitutes. BMJ 2009. 3. Barennes H, Andriatahina T, Latthaphasavang V, Anderson M, Srour L. Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and paediatricians in Laos. BMJ 2008. 4. Slesak, G, Douangdala, P, Inthalad, S, Onekeo, B, Somsavad, S, Sisouphanh, B, Srour, L. M., and Barennes, H. Misuse of coffee creamer as a breast milk substitute: a lethal case revealing high use in an ethnic minority village in Northern Laos. BMJ. http://www.bmj.com/cgi/eletters/337/sep09_2/a1379#207174 . 16-1-2009. 5. Stiegler R. Nestlé's works to ensure appropriate use of milk products http://www.bmj.com/cgi/eletters/337/sep09_2/a1379. BMJ 2008. 6. IBFAN. The International Code of Marketing of Breast Milk Substitutes. www.ibfan.org/english/resource/who/fullcode.html . 2009. 7. Giugliani E,.Victora C. Complementary feeding. J Pediatr 2009;76:253-62. 8. Gillespie, A, Creed-Kanashiro, H, Sirivongsa, D, Sayakoummane, D, and Galloway, R. Consulting with Caregivers: Using Formative Research to Improve Maternal and Newborn Care and Infant and Young Child Feeding in the Lao People. World Bank. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/ EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/ 0,,contentMDK:20146328~menuPK:282594~pagePK: 210058~piPK:210062~theSitePK:282575,00.html . 2004. Competing interests: None declared
Nestle's mommy bear does not breastfeed 26 May 2009
Hubert Barennes, Research and training coordinator Institut francophone pour la médecine tropicale, Vientiane Laos, Leila M Srour Send response to journal: Re: Nestle's mommy bear does not breastfeed	Dear Editor, Breastfeeding is the best intervention to save infants’ lives especially in the developing world. Following our last response to Nestle that you kindly published (1), we posted the BMJ publications regarding the misuse of coffee creamer with the Bear Brand label in Laos to Mr Brabeck, President of Nestle S.A (2-6). We recently received the following response from Petraea Heynike, Executive Vice President of Nestle which means that Nestle will continue to use a teddy bear to promote milk products. This is, in our view, a persistent marketing trick to promote the use of breast milk substitutes. “In the new logo, we specifically selected a large glass which is not feasible for infants to hold, as a way of distinguishing the brand from infant products, and we have removed the baby bear.” Since other BMJ readers and the international scientific community are seriously concerned (7), you will find enclosed Nestle’s answer and our response sent to Nestle Vevey on 6 May 2009. We recommend NO BEARS on milk products, especially “Mommy Bears”, the current “Good Immune System for Unlimited Learning Opportunities” 40 millions Thai Bath (1162599 USD) marketing campaign of Nestle in Thailand. (8) From Petraea Heynike, Executive Vice President of Nestle Dear Drs Barennes and Srour, As Head of Marketing for Nestle, S.A., Mr. Brabeck has asked me to respond to your letter of March 22. I share your concerns about feeding inappropriate foods to infants, both professionally and personally as a mother. In order to avoid any potential confusion about Bear Brand milk products not marketed as breast milk substitutes being used as such, we have taken the precautionary measures described in Mr. Stieger's past correspondence. In the new logo, we specifically selected a large glass which is not feasible for infants to hold, as a way of distinguishing the brand from infant products, and we have removed the baby bear. (The American Academy of Pediatrics Developmental Milestones specify 18 months as the age when a child can hold a regular cup or glass without help). To test whether or not your assertion is correct that this logo with a bear holding a glass could be interpreted by mothers as indicating that the product is intended for infants (under 12 months of age), we will conduct a consumer test of this logo with a professional marketing research firm, and we will share the methodology and results with you when they are ready. Your letter of March 22 also raises other points that we believe are not based in fact, such as your assertion that the logo would not be permitted in Switzerland. These we would be happy to discuss. We also hope that your concerns go beyond commercial milks, and the Nestle Bear Brand. As you may know, many infants receive a range of inappropriate liquids, the most common ones being rice water, sugar water, and whole cow's milk. It is this wide-scale practice which must be stopped, principally by promoting exclusive breastfeeding for the first six months of life, by education on appropriate complementary foods, and by health professionals recommending infant formula over inappropriate liquids, when a mother doesn't breast feed. Nestle firmly believes in the importance and value of breastfeeding and appropriate complementary feeding. We are therefore open to work with any serious organization which wishes to promote exclusive breast feeding for the first six months, educate women on the proper complementary foods for infants and young children, and to educate doctors to recommend infant formula rather than cow's milk for infant feeding, when a substitute is needed. To this end, we would like to arrange a personal meeting with you to clarify the various issues you raise, and to discuss the broader issue of how to improve infant feeding practices in Laos. Our response sent to Nestle Vevey on 6 May 2009 Dear Ms. Petraea Heynike, Thank you for your letter. Thank you for your concerns about inadequate and inappropriate liquid feeding of infants in poor families. Thank you for your concerns about milk products marketed with the Bear Brand label. We are glad to know that the baby bear will be removed. Despite all your nice declarations and willingness, our concerns remain high regarding your proposition and the use of the Bear Brand in the Asian region. We fear a remake of the African scandals of the 70ties. We really encourage Nestle to adopt ethical behavior despite their huge commercial interest in the Bear Brand. The large glass held by the Mother Bear could be very confusing, as mothers are encouraged to introduce a cup to infants at six months of age. Any bears on milk products may be confused by parents, especially if they are unable to read the label. We recommend NO BEARS on milk products. Thank you for your plan for consumer testing of the logo. Will the test include illiterate ethnic minority parents? Will you be interested in an external evaluation that we or another independent team could do? What is your plan if the research reveals label confusion? The BEAR BRAND label continues to promote milk products in Lao. You should not believe that our concerns with the BEAR BRAND are restricted to Lao. It extends to nearby Thailand where very aggressive BEAR BRAND campaigns are ongoing : “Meanwhile, Nestle' (Thai) Ltd, the manufacturer and distributor of the Bear-branded powdered milk would also help its retailers cope with the current economic situation by strengthening their sales and merchandising capabilities through its Sales Blitz campaign….Roland Stieger, Nestle’s executive business manager for dairy and creamers, said that the current economic difficulties had negative impacts on all local industries as well as the decision-making of Thai consumers. To cope with the situation, the Bear brand has laid down plans to stimulate the local powdered milk market and assist its retail partners.” (8) Will this Sales Blitz campaign use the Bear Brand logo of the mother and baby bear? How long will the impact of this campaign last and how many infants will die? Due to huge commercial conflicts of interest, we do not believe that Nestle is appropriate to be in charge of educating women of the third world how to feed their infants. We strongly suggest another independent solution. Nestle’s willingness and expressed interest could be appreciated by their anonymous contribution to breastfeeding campaign promotions by well-known independent organizations. We welcome the opportunity to meet with Nestle representatives, together with the Lao Ministry of Health to discuss these issues. 1. Srour LM,.Barennes H. Will Nestle's Bears Continue to Mislead Parents and Threaten Infants Lives? BMJ 2009. http://www.bmj.com/cgi/eletters/337/sep09_2/a1379#208354 2. Barennes H, Andriatahina T, Latthaphasavang V, Anderson M, Srour L. Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and paediatricians in Laos. BMJ 2008. 3. Barennes H,.Srour LM. Nestle's violations of the international code on the marketing of breast milk substitutes. BMJ 2009. http://www.bmj.com/cgi/eletters/337/sep09_2/a1379#204311 4. Slesak, G, Douangdala, P, Inthalad, S, Onekeo, B, Somsavad, S, Sisouphanh, B, Srour, L. M., and Barennes, H. Misuse of coffee creamer as a breast milk substitute: a lethal case revealing high use in an ethnic minority village in Northern Laos. BMJ. http://www.bmj.com/cgi/eletters/337/sep09_2/a1379#207174. 5. Stiegler R. Nestle's works to ensure appropriate use of milk products http://www.bmj.com/cgi/eletters/337/sep09_2/a1379. BMJ 2008. 6. Stiegler R. The latest step in a series of extraordinary labeling measures. http://www.bmj.com/cgi/eletters/337/sep09_2/a1379. 7. IBFAN. The International Code of Marketing of Breast Milk Substitutes. www.ibfan.org/english/resource/who/fullcode.html. 8. K. Rungfapaisarn. Nestle introduces online Mommy Bear community. The Nation, May 14, 2009. http://www.nationmultimedia.com/2009/05/13/business/business_30102553.php Competing interests: None declared