Intended for healthcare professionals

Editor's Choice

Disentangling ourselves from “Big Formula”

BMJ 2018; 363 doi: (Published 06 December 2018) Cite this as: BMJ 2018;363:k5146
  1. Fiona Godlee, editor in chief
  1. The BMJ
  1. fgodlee{at}
    Follow Fiona on Twitter @fgodlee

Despite decades of effort to curb the promotion of infant formula, sales are flourishing and breastfeeding is in decline, especially in the UK. Earlier this year we heard about the resurgent influence of “Big Formula,” with industry lobbying and funding for medical education harming babies and mothers around the world (doi:10.1136/bmj.k3577). This week we investigate one small but influential corner of the multibillion pound formula industry: the promotion of specialist formula for treating cow’s milk protein allergy (CMPA).

Chris van Tulleken finds a worrying range of deeply embedded relationships between formula manufacturers and doctors, dietitians, and professional bodies (doi:10.1136/bmj.k5056). The bones of the story are familiar. International guidelines are funded by the industry and written by experts who have their own industry ties. These guidelines, widely promoted to clinicians and the public through industry funded charities and educational meetings, promote the idea that non-IgE mediated CMPA causes a range of common non-specific symptoms, including colic, reflux, loose stool, and skin rash. Mothers are advised to exclude cow’s milk from their diet, which makes breastfeeding harder to maintain. Those who abandon exclusive breastfeeding are advised to use specialist formula. In contrast to IgE allergy, there is no diagnostic test for non-IgE CMPA, making it especially vulnerable to industry exploitation.

The tactics are clearly working. Between 2006 and 2016 in England numbers of prescriptions for specialist formula rose by nearly 500% to more than 600 000 a year, and the NHS now spends over £60m (€67m; $76m) a year, an increase of nearly 700% in the past decade. Some infants do have CMPA, but van Tulleken finds no evidence of such a huge hike in prevalence that would justify this surge in prescribing.

The story has all the hallmarks of overdiagnosis fuelled by commercial interests. To tackle this we will need experts who are free from financial conflicts to decide on tighter diagnostic criteria, draw up independent clinical practice guidelines, and deliver unbiased medical education. We also need clinicians and professional bodies to disentangle themselves from industry and to give their unconflicted support to breastfeeding.

The BMJ and its sister journals accept advertising for specialist breastmilk substitutes. The advertisements must be legal and honest and meet advertising standards, and we expect all claims of health benefit to be supported by published peer reviewed research. Last year the BMJ company received £200 000 for advertisements for breastmilk substitutes.

In light of van Tulleken’s investigation and our own growing concerns about the effect of aggressive promotion of breastmilk substitutes on rates of breastfeeding around the world, we are reviewing our policies on accepting advertising for these products. We welcome your thoughts on the issue and will report back in the new year.