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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

Rapid Response:

Re: Disentangling ourselves from “Big Formula”; 'A MAJOR PROGRAMMATIC MISSTEP IN THE 2018 REVISED TEN STEPS TO SUCCESSFUL BREASTFEEDING

The BFHI ‘Ten Steps to Successful Breastfeeding’, in the WHO/ UNICEF Joint Statement in 1989, was an array of Policies, Procedures and Practices to improve Breastfeeding Rates (BFR), particularly Exclusive Breastfeeding Rates (EBFR)1. Improved BFR evolve with sustained consistent implementation of the ‘Ten Steps’2,3. ‘Change’ is desirable but you do not change a ‘Winning Formula’! Hence the compelling critique of the ‘2018 Revised Ten Steps’ 3. I shall comment only on the ‘Revised Steps 1a and 9’!

It is salutary that Step 1a states ‘Comply fully with the International Code of Marketing of Breastmilk Substitutes and relevant World Health Assembly Resolutions’. The pervading systemic and systematic violations of ‘The Code’ (1981 Code and ALL Subsequent Relevant WHA Resolutions) by Manufacturers of Infant and Young Child Foods and related Products (Feeding bottles, Teats, Pacifiers etc) covered by ‘The Code’ confounded by the overt and covert collaboration by Health Professionals in the Infant and Young Child Feeding (IYCF) Enterprise have been deleterious in undermining Optimal IYCF globally. Health Professionals are enmeshed in ‘Conflict of Interest’ (COI) with continued receipt of ‘Industry Funding’. The COI, diagnosed by the ‘Potentiality’ of its existence, is a monstrosity that is better avoided as it is intractable. The 1981 Code and several Subsequent Relevant WHA Resolutions have, therefore, persistently and consistently addressed COI. The Royal College of Paediatrics and Child Health (RCPCH) voted to decline all forms of ‘Industry Funding’ following a robust ‘Motion Debate’ on the 27th April 2016 at its Annual General Meeting (AGM) in Liverpool. This antedated the WHA Resolution 69.9 in May 2016 which included the ‘WHO Guidance’ on ‘Ending Inappropriate Promotion of Foods for Infants and Young Children’4. The RCPCH Council, in spite of its AGM ‘Debate Decision’ and the complementary 2016 WHA Resolution, commissioned a ‘Post-AGM Membership Survey’ on ‘Industry Funding’ in September 2016 and published the ‘Survey Findings’ in October 2016 to continue accepting ‘Industry Funding’ with ‘Internal Due Diligence’ and the ‘Framework for Engagement of Non-State Actors (FENSA)’ and, therefore, upturned the AGM Decision5,6. As a Speaker in support of the Motion, and the only Speaker uniquely permitted by the RCPCH President to speak twice, I felt a compelling responsibility, as other Paediatricians and NGO7-9, to react to this unacceptable ‘Modus Operandi’ of the RCPCH Council which proposed the defeated ‘Counter-Motion’ and, therefore, wrote a treatise to the RCPCH President titled ‘Health Professional Associations and Industry Funding; Systemic and Systematic Examination of Well-formed Conscience: Is RCPCH Oiling The Wheel of Conflicts of Interest?’. The Science, Logic, Ethics and Morality of the ‘Post-AGM Survey’ were diligently analyzed and critically flawed in the Communication! This Communication was also attached to my Formal Presentation titled ‘FMOH-convoked Stakeholders’ Meeting on The Code and the Adopted Revised National Regulations; 13th February 2018’ to the Nigerian Minister of Health as a ‘Follow-up’ to the Ministerial Meeting convened to address issues canvassed by the Paediatrics Association of Nigerian against strict implementation of the ‘Provisions’ of the 2016 ‘WHO Guidance’ particularly its ‘Prohibition of Industry Funding for Health Professionals and their Scientific Meetings’ and also reflected in the ‘Revised Nigerian Regulations’ for Code Implementation. Similar uncomplimentary difficulties have been reported concerning ‘Industry Funding’ and the resurgent influence of ‘Big Formula’ with Industry and ‘Conflicted Health Professionals’10,11. Considering the 5 Stakeholder-Groups, based on ‘Code Commitment’, present at the 1979 UN Meeting on IYCF and at the 1981 Code adoption, I have since 2010 technicalized that ‘Health Professionals/ Experts’ are ‘Toti-Code’ (coined from Stem Cell ‘Totipotency’; The ‘Piper’s various Tunes dictated by the Payer’!), UN Systems and NGOs are ‘Pro-Code’ and Industries and Governments are ‘Anti-Code’! For improved BFR, we must be ‘Pro-Code’ and ‘Make The Code Work’. Programmatically, ‘Step 1a’ is a promising development! Industry and Health Professionals must comply with all ‘Provisions’ of ‘The Code’ as a ‘Minimum’ and in its ‘Entirety’!

The new ‘Step 9’: ‘Counsel Mothers on the use and risks of feeding bottles, teats and pacifiers’ is riddled with the ‘Potentiality’ of wreaking significant havoc on the gains of our ‘Breastfeeding Campaign’. For Optimal IYCF, Breastfeeding Physiology and Appropriate Lactation Management, what are the critical benefits of the ‘Use’ of these ‘Products’? Of course, there are illimitable ‘Risks’ concerning their use! Breastfeeding Infants’ suckling capabilities are compromised through ‘Nipple Confusion’ and this undermines effective suckling at the breasts: the most important stimulus for adequate ‘Milk Production’ and Infant Nutrition. The soothing of Breastfeeding Infants with ‘Soothers or Pacifiers’ compromises normal ‘Psychosocial and Personality Development’ with reduced opportunities for appropriate ‘Mother-Child Dyadic Bonding-Relationship’. Inadequate hygiene and uncertain cleanliness in their use are an invitation to avoidable childhood diarrhoeal disorders. There is also compromised anatomical development of the oro-facial structures using these ‘Products’. Pacifiers reduce Breastfeeding duration12. Industry compliance with ‘The Code’ is a huge challenge and the new ‘Step 9’ courts their further aggressive marketing of these ‘Related Products’ (Feeding bottles, Teats, Pacifiers etc). Juxtaposing critically this ‘Revised Step 9’ with the original ‘Step 9’ (‘Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants’) disposes a clear and remarkable difference which practically makes the ‘Revised Step 9’ a ‘Major Programmatic Misstep’; a ‘Wrong Step’ indeed! A ‘Change’ that is replete with a plethora of ‘Risks’ for Optimal Child Health, Nutrition, Growth, Development and Protection is obviously a ‘Misstep’ and it is fervently hoped that the 2019 WHA will revisit and reverse the ‘Misstep 9’ to optimize Breastfeeding; a low-cost high-impact Nutrition Intervention!

Advertisement of ‘Products’ covered by ‘The Code’ (‘Code Products’) (including ‘Foods for Special Medical Purposes (FSMP)’) is prohibited as ‘Normal Marketing Practices (including Advertisement) are ‘Not Suitable’ for these Products‘ (Last Preamble to 1981 Code Adoption) and this calls for strict compliance by all ‘Information Media’ including reputable widely-circulated Biomedical Journals; The BMJ advertising FSMP is a systemic and systematic Code Violation and victimizes voiceless, defenceless, unreached and unserved vulnerable children13! The Inappropriate Marketing of ‘Code Products’ undermines Breastfeeding and enlarges the ‘Market’ for Breastmilk Substitutes!! Let us ‘Make The Code Work’!!!

REFERENCES
1. WHO/ UNICEF. Protecting, Promoting and Supporting Breastfeeding: The Special Role of Maternity Srvices; A Joint WHO/ UNICEF Statement. Geneva, WHO 1989.
2. WHO. Evidence for the Ten Steps to Successful Breastfeeding. Division of Child Health and Development. Geneva. WHO 1998
3. WHO. Ten Steps to Successful Breastfeeding (Revised 2018). Geneva. WHO 2018
4. WHO Sixty-ninth WHA. Ending inappropriate promotion of foods for infants and young children. WHA 69.9. http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_R9-en.pdf; May 28th 2016. Accessed 24th February 2017.
5. Thornton J. Paediatricians vote for college to continue accepting funds from formula companies. BMJ 2016; 355: i5827
6. Modi N. The RCPCH and funding from infant formula companies. BMJ Blogs Oct 31, 2016; http://blogs.bmj.com/bmj/2016/10/31/neena-modi-the-rcpch-and-funding-from infant-formula-companies. Accessed 24th February 2017.
7. Waterston T and Mason E. Why the RCPCH should stop taking funds from the baby food industry.(Accessed 20th January 2018). BMJ Blogs 4 Nov 2016. http://blogs.bmj.com/bmj/2016/11/04/why-the-rcpch-should-stop-taking-fun...
8. Costello A, Branca F, Rollins N, Stahlhofer M, Grummer-Strawn L. Health Professional Associations and Industry Funding. Lancet 2017; 389 (10069): 597-598.
9. Baby Milk Action response to RCPCH relationship with formula milk companies. http://www.babymilkaction.org/archives/11135. Accessed 6th March 2017
10. Anand RK. Healthworkers and the Baby Food Industry. BMJ 1996; 312:1556
11. Shenker NS. The resurgent influence of big formula. BMJ 2018; 362:k3577
12. Howard CR, Howard FM, Lanphear B et al. The effect of early pacifier use on breastfeeding duration. Pediatrics 1999, 103:E33
13. Godlee F. Disentangling ourselves from ‘Big Formula’. BMJ 2018; 363:K5146

Professor Charles O. Eregie
MBBS, FWACP, FMCPaed, FRCPCK (UK), Cert. ORT (Oxford), MSc (Religious Education)
Professor of Child Health and Neonatology, University of Benin,
Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria
UNICEF-Trained BFHI Master Trainer
ICDC-Trained in Code Implementation
*Technical Expert/ Consultant on the FMOH-UNICEF-NAFDAC Project on Code Implementation in Nigeria
*No Competing Interest

Competing interests: No competing interests

16 January 2019
CHARLES OSAYANDE EREGIE
MEDICAL DOCTOR
Professor of Child Health and Neonatology, University of Benin and Consultant Paediatrician and Neonatologist, University of Benin Teaching Hospital, Benin City, Nigeria. Also, UNICEF-Trained BFHI Master Trainer and ICDC-Trained in Code Implementaion. Also a Technical Expert/ Consultant on FMOH-UNICEF-NAFDAC Project on Code Implementation in Nigeria
Institute of Child Health, University of Benin, PMB 1154, Benin City, Nigeria