Disentangling ourselves from “Big Formula”
BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5146 (Published 06 December 2018) Cite this as: BMJ 2018;363:k5146
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I just wanted to share my story with this CMPA research. I have been a UNICEF breastfeeding support worker for 3 years and work alongside the medical profession. I am aware of all the 'hype around CMPA, the increase in diagnosis over the past few years, the reality of the amount of CMP in breast milk and watched with interest Dr Van Tulakans program on the subject. However dispute all of this in July I had a premature baby. She had initial issues with weight and jaundice and was on lots of antibiotics but seemed to thrive after a month. Over night she became very upset after feeds, was repeatedly sick and passing mucus in her stools which were up to 16 times a day. She was readmitted to hospital with suspected rotavirus, supposedly caught whilst in hospital the previous week. She was discharged after 24 hours and told to come back in a week for a check up.
A week later with no improvement and signs of dry skin on her feet she was diagnosed with CMPA. Doing my job I know the common symptoms and that most babies will be sick and have colic at some point, but in my new mum sleep deprived state I wanted a fix and an answer. Being a breastfeeding support worker I was determined not to give up. I went strictly dairy free. Two weeks later no improvement, I cut out soya too. Four more weeks go by no improvement. I visit the infant feeding coordinator for the county. She suggests lactose intolerance and perhaps an inflamed and sensitive gut and suggests colief. Within 24 hours she is a different baby, Happy, smiling and not in so much pain. No improvement on the sickness and stools though, still full of mucus and 10 times a day, sickness between 70 and 80 times a day. Two weeks later see a paediatrician. He advises to remain dairy free but to try gaviscon and renitidine. The gaviscon she won't swallow but we keep going with colief and renitidine. Two weeks later the stools are one a day, occasionally mucus. The sickness is just posseting 10 times a day. Without medical say so I reintroduce dairy. She is absolutely Fine! It was never CMPA just a very sicky colicy baby. I'm so glad I didn't go with the suggestion to stop breastfeeding and persevered. Had I not been doing the job I am I reckon I would have given up. She is now 4 and a half months and just had a small amount of renitidine a day. She is a very well baby, the dry skin was sorted by some sensitive baby wash. I hope we are more careful about diagnosing CMPA and support and educate parents and the health profession not to mistake other things. Please contact me if you would like more to this story
Competing interests: No competing interests
“BIG FORMULA” IS STILL AT IT…..
It seems that cow’s milk protein allergy (CMPA) has added another element of complexity in the wars between breastfeeding and proprietary infant formula. (Tulleken, BMJ, 5 Dec 2018) Forty-one years ago I entered the trenches by publishing a study showing that breastfed babies were healthier than formula-fed babies, even among middle-class Americans. (Cunningham, J Pediatr 1977;90:726) The idea was revolutionary at the time, strange as that may seem today. Few American mothers breastfed, US pediatricians were generally unenthusiastic and, after the initial shock, manufacturers mounted a counterattack. Nevertheless, I fancy that my article helped stimulate a US renaissance in breastfeeding…..When the US was the only country among 118 member states to vote against WHO’s Code for Marketing Breastmilk Substitutes I became a minor celebrity. (De Witt. “Infant Formula Drive is Assailed”, NYTimes, 18 June 1981) Last May, the US once again was the only country to oppose a resolution supporting breastfeeding at the World Health Assembly. (Shenker, BMJ, 23 August 2018)
The diagnosis and management of CMPA is a tricky business; so is the support of nursing mothers with cranky babies. It is no surprise to learn that “Big Formula” is taking advantage of the situation to sell their very expensive products.
I know from long personal experience that the manufacturers are clever and persistent in marketing their products, often at the expense of breastfeeding.
ALLAN S. CUNNINGHAM
Competing interests: No competing interests
I imagine that Big Formula is thrilled by the resurgence, at least here in California, of “sleep training”, the rigid routine that overrides natural maternal and infant nursing signals and leads a mother, sooner or later, to abandon breastfeeding. Strict adherence to a crushingly precise schedule and scripted routine is ostensibly designed to help mothers get a good night’s sleep so they may function well when they return to work. Mothers are tethered to the home, controlling their infant's innate needs and functions. The baby must learn to sleep alone and may not fall asleep at the breast. While the baby is in its crib, the mother pumps. This is eventually unsustainable and, with sadness tinged with relief, she reaches for the formula.
Competing interests: No competing interests
'Big formula' companies violate 'The International Code of Marketing of Breast-milk Substitutes' (the WHO Code) widely around the globe on a daily basis. This leads to decreased breastfeeding rates and increased mortality and morbidity for infants and children in low, middle and high income countries. For this reason, WHO, UNICEF and various other UN agencies have specific policies on not engaging with the Code violators. At the very least, the BMJ should consider not engaging with companies who violate the WHO Code, in the form of advertisements and sponsorships.
Competing interests: No competing interests
Re: Disentangling ourselves from “Big Formula”
In relation to the article by van Tulleken1, and the editorial by Godlee2, it is important to point out that nutrition intervention studies in infants and young children cannot be undertaken without collaborating with nutrition companies as the intervention product needs to meet agreed nutrition and safety standards and this requires knowledge, expertise and technology that is not available in even the most prestigious academic research institutions. Moreover, it is important in these circumstances, that industry collaborates as a full member of the research team to ensure that compliance with the scientific, ethical, funding, and research monitoring standards are met. On completion of the project, it is then important that the manuscripts clearly define the roles of the collaborators, sources of funding, and any conflicts of interest. This will ensure that on submission to a journal, the information regarding all of the contributors is fully transparent. The external reviewers and the editorial team can then make an informed decision on whether to publish or not.
If this process has been followed, and the article is accepted for publication, subsequent undermining of the research on the grounds that it involved collaboration with industry, should be challenged as professional discrimination. Although many of us involved in infant nutrition research have tolerated this prejudice, young researchers, and clinicians today, are increasingly viewing this field of research as a “no-go” area. This is clearly not in the best interests of infants and their parents, who have largely remained the “forgotten people”, as global institutions continue their damaging war of attrition instead of collectively focusing on reducing the unacceptable levels of malnutrition and stunting across the world, and developing child feeding policies that reflect the diverse nutritional and socio-economic circumstances of infants and young children worldwide3.
The World Health Organisation is the body within the United Nations that has the responsibility for directing and coordinating health, and it needs to unify rather than divide by encouraging engagement and partnership with all key stakeholders (including industry), managing self-interest (including their own), balancing idealism with realism, ensuring there is multi-partnership governance (including industry), recognising the wisdom of compromise, and acknowledging the value of incremental change. Collective dialogue, conducted within an environment of trust and respect, is more likely to identify and deliver solutions that can resolve Code compliance, improve infant and young child nutrition globally, and ultimately save children’s lives4.
References
1. van Tulleken C. Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers. BMJ 2018;363:k5056
2. Godlee F. Disentangling ourselves from “Big Formula”. BMJ 2018;363:k5146
3. Forsyth JS. International code of marketing of breast-milk substitutes—three decades later time for hostilities to be replaced by effective national and international governance. Arch Dis Child 2010;95:769–70.
4. Forsyth S. Should the World Health Organization relax Its policy of non-cooperation with the infant food industry? Ann Nutr Metab. 2018;73:160-162.
Competing interests: I have received research grants from government, research charitable organisations and industry; and consultancy fees and honoraria from government and industry, including companies that produce infant formula. I currently receive consultancy fees from DSM Nutritional Products, an international ingredient supplier.