No more infant formula advertising in The BMJ
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1279 (Published 21 March 2019) Cite this as: BMJ 2019;364:l1279All rapid responses
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The BMJ Advertisement Policy to stop ‘Advertisement’ of ‘Infant Formula’ (a ‘Breastmilk Substitute’) is courageous and salutary [1]. Among the varied reactions to the BMJ Policy is the demand for ‘Scientific Data’ confirming the superiority of ‘Breastmilk’ over ‘Infant Formula’/ ‘BMS’ which necessitated some recent ‘Contributions’ [2,3]. The ‘Microorganism Content’ of ‘Breastmilk Composition’ was not addressed in the previous Presentation [3] and is, therefore, the focus of this ‘Contribution’ which furnishes more ‘Scientific Facts’ for the unquestionable ‘Breastmilk Superiority’!
The ‘Microorganisms’ (including Bacteria) in ‘Human Breastmilk’ contribute significantly to the establishment of the ‘Infant Microbiome’ which represents the ‘Total Population of Microorganisms (‘Microbiota’) living within and on the body of an individual and their ‘Comprehensive Genetic Make-up’ existing in a synergistic equilibrium with the individual and resultant positive ‘Health Outcomes’ for the ‘Life Span’ and potentially ‘Across Generations’’ [4]. The ‘Infant Microbiome’ develops in ‘Stages’: ‘Prenatal’, ‘During Delivery’, ‘Immediate Postnatal’, ‘Birth to 6 months’ and ‘Beyond 6 months’. ‘Human Breastmilk’ through ‘Breastfeeding’ contributes, in a determinant manner, to the latter 2 ‘Stages’. The unique ‘Breastmilk Microorganism Composition, in a simplified manner, includes mostly the Bifidobacteria Species, Lactobacillus Species etc which are absent in BMS with no possibilities for ‘Fortification’. A stable equilibrium between the ‘Protective Organisms/ Commensals’ and the ‘Potential Pathogens’ is ‘Eubiosis’ with positive ‘Health Outcomes’ while a disequilibrium is ‘Dysbiosis’ with untoward sequelae.
Some reported factors (Maternal and Child) determine the ‘Infant Microbiome’: Maternal Oral Health, Antibiotics Exposure, Stress and Diet and for the Infant: Mode of Delivery, Antibiotics Exposure, Feeding Pattern/ Breastfeeding and Stress. The ‘Mechanisms’ by which these ‘Factors’ influence the ‘Infant Microbiome’ development will not be explored further in this ‘Contribution’ but are merely mentioned for their existence as verifiable ‘Scientific Facts’! A ‘Microbiome Diversity’, assured by ‘Breastmilk’, is beneficial for long-term ‘Health Outcomes’. ‘Stress’ reduces ‘Microbiome Diversity’ with its undesirable health consequences! The ‘Microbiome Taxonomy/ Phyla’ in ‘Breastfed Infants’ include: Actinobacteria (Bifidobacteria, Corynebacterium, Propionibacterium and Atopobium Species), Bacteroidetes (Bacteroides and Prevotella Species), Firmicutes (Lactobacillus, Enterococcus, Clostridium, Ruminococcus, Streptococcus and Staphylococcus Species) and Proteobacteria (Enterobacter Species). This ‘Microbiome Phyla and Diversity’ cannot be achieved through ‘Formula-feeding’ or ‘Fortification’! Therefore, BMS are lacking significant ‘Determinats’ of optimal ‘Holistic Health and Development’. The ‘Firmicutes/ Bacteroides (F/B) Ratio’, determined by ‘Breastmilk Microorganism Composition’, correlates with the ‘Fat/ Lean Mass Composition’ with the Obese having higher Firmicutes and reduced Bacteroides. Alteration of the ‘Breastfed Infant Microbiome F/B Ratio’ occurs deleteriously with ‘Formula-feeding’!
The ‘Infant Microbiome’ is critically important for future ‘Health Outcomes’:
1. Development and Activation of the ‘Immune System’
2. Digestion, Absorption and Metabolism of ‘Foods’
3. Trophic Effect with ‘Gut Epithelial Maturation’
4. Neurocognitive Development
5. Behavioural and Social-Affective Development
6. Prevention of ‘Adult Disease Induction’; the ‘FOAD Hypothesis’ and the ‘Pre-FOAD Hypothesis’ [5]
The critical and unique importance of the ‘Infant Microbiome’ is suggested to be mediated via the ‘Bidirectional’ ‘Microbiome-Gut-Brain Axis’ [6]. The ‘Microbiome’ integrates with the regulatory ‘Psychoneuroimmunological (PNI) Pathway’ to connect the Gut with the Brain! ‘Microbiome’ assures ‘Immune Status’ through ‘Local Process’ (Luminal Epithelial Integrity, Altered Acidic Milieu and Pathogen Nutrient Deprivation) and ‘Systemic Process’ (Cell Wall Lipopolysaccharide (LPS) and Small Bacteria Leakages into Peritoneal Cavity setting up ‘Pro-Inflammatory Responses’). The ‘Microbiome’ generates ‘Pro-Inflammatory Cytokines’ (Interleukin (IL)-6, Tumour Necrosis Factor (TNF)-α) to establish and activate the ‘Immune System’. The ‘Microbiome’ interacts, via ‘Cortisol Production, with the ‘Endocrine Pathway (Hypothalamus-Pituitary-Adrenal Axis (HPA))’ and the ‘Neural Pathway (Vagus Nerve)’ with the development and regulation of ‘Gut Health’. Also, the ‘Microorganisms’ interact with ‘Gut Wall Cells’ to release ‘Bioactive Substances’, including ‘Vasoactive Intestinal Peptides (VIPs), which stimulate the afferent fibers of the Vagus Nerve which regulate the Gut, assures Systemic Homeostasis, promotes ‘Anti-Inflammatory Response’ and influences Central Nervous System establishing the ‘Sickness Behavour’ (Depression, Insomnia, Anorexia and Fatigue) undergirding the ‘Individual Behaviour-Social Formation’ [7]. This also undergirds the ‘Microbiome-related Neurocognitive Development’ of the infant. The ‘Microbiome’ facilitates the digestion and absorption of aliments, Toxins Destruction, Iron Absorption and Synthesis of some Vitamins. The ‘F/B Ratio’, discussed earlier, correlates with ‘Body Composition’ which determines the predisposition to ‘Adult Disease Induction (ADI)’ including Obesity and other ‘Metabolic Syndrome Components’ as disposed by the ‘FOAD Hypothesis/ Barker Hypothesis/ Maternal Thrifty Phenotype Hypothesis’! Also, the ‘Pre-FOAD Hypothesis’, starting with ‘Exclusive and Optimal Breastfeeding’ coupled with the ‘Child Survival Interventions’ and optimizing the ‘Two Growth Spurts’ (First 6 months and Pre-Pubertal) assuring optimal ‘Pre-Pregnancy Maternal Phenotype’ and ‘Developmental Plasticity’ for ‘Trans-generational’ optimal ‘Birth Body Composition’5, also explains the protection of ‘Breastfed Infants’ against ADI unlike ‘Formula-fed Infants’! The predominance of Clostridium Species (especially C. difficile) in the ‘Formula-fed Microbiome’ predisposes to ‘Atopy’.
Recent Advances in ‘Culture-Independent Methods’ with Genetic Analyses have assured better study of the ‘Infant Microbiome’: Fluorescence In-Situ Hybridization (FISH), Real-Time Polymerase Chain Reaction and High Throughput Meta-genomic Analyses (‘OMICS Technology’) among others. These have consistently amplified the ‘Yawning Gulf’ between the ‘Infant Microbiome’ of ‘Breastfed’ and ‘Formula-fed’ infants [8]! Exclusive and Optimal Breastfeeding optimizes the beneficial utilization of the postnatal ‘Critical Window’ within the ‘First 1000 Days of Life’ for ‘Optimal Infant Microbiome’ Development! The ‘Prohibition’ of ‘BMS Advertisement’, most likely with misleading ‘Health and Nutritional Claims’ and no amplification of the ‘Scientific Facts’ of ‘Breastmilk Superiority’, is ‘Programmatically Appropriate’!! Bravo BMJ for this courageous bold ‘Organizational Advertisement Policy’, worthy of emulation by other ‘Biomedical Journals’ and, indeed, other ‘Media Outfits’, to stop ‘Advertisement’ of ‘Infant Formula’/ ‘BMS’ to Protect, Promote and Support Exclusive and Optimal Breastfeeding for ‘Optimal Holistic Child Survival, Health, Nutrition, Protection and Development’!! As previously indicated [3], ‘Scientific and Factual Information’ concerning ‘Foods for Special Medical Purposes (FSMP)’ should be submitted and subjected to the usual rigorous ‘Peer Review Mechanism’ for ‘Editorial Acceptance’ to be published as ‘Scientific Product Publications’ and not as ‘Promotional Commercial Product Advertisements’ which violate ‘The Code’9 (WHA 34.22/ 1981)!!!
REFERENCES
1. Godlee F. No more infant formula advertising in The BMJ. BMJ 2019; 364: l1279 of 21st March 2019
2. Eregie C.O. There is no Breastmilk Substitute (Including Infant Formula) and Prohibition of its Advertisement is Programmatically Appropriate for Optimal Child Health. https://www.bmj.com/content/364/bmj.l1279/rr-4 of 28th March 2019
3. Eregie C.O. Still on the Superiority of Breastmilk over Breastmilk Substitutes (Including Infant Formula): Further Justification for the Programmatic Appropriateness of the Prohibition of Advertisement of Breastmilk Substitutes. https://www.bmj.com/content/364/bmj.l1279/rr-5 of 2nd April 2019
4. Yang I, Corwin E.J, Dunlop A. The Infant Microbiome: Implications for Infant Health and Neurocognitive Development. Nurs Res 2016; 65:76-88
5. Eregie C.O. Programming the End from Before the Beginning: Juxtaposing Technology with the TEA Triad. 106th Inaugural Lecture, University of Benin, Benin City, Nigeria. University of Benin Press 2009; Benin City, Nigeria.
6. Cryan J.F, Dinan T.G. Mind-altering Microorganisms: The impact of Gut Microbiota on Brain and Behaviour. Nature Reviews Neuroscience 2012; 13. 701-712
7. Dantzer R., Kelley KW. Twenty years of research on Cytokine-induced Sickness Behaviour. Brain, Behaviour and Immunity 2007; 21:153-160
8. Bezirtzoglou E., Tsiotsias a, Welling GW. Microbiota Profile in Faeces of Breast- and Formula-fed Newborns by using Fluorescence in situ Hybridization (FISH). Anaerobe 2011; 17:478-482
9. Eregie C.O. Making the Code Work for Optimal Infant and Young Child Feeding: Rekindling ‘Health Professional Associations-Industry Funding Conversation’ and the ‘INAGOSICI Phenomenon’. https://www.bmj.com/content/364/bmj.1544/rr of 14th February 2019
Professor Charles Osayande Eregie
MBBS, FWACP, FMCPaed, FRCPCH (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 Code Implementation Project in Nigeria
*No Competing Interests.
Competing interests: No competing interests
The ‘BMJ Organizational Policy’ stopped ‘Advertisement’ of Infant Formula [1]. ‘Infant Formulas’ are ‘Breastmilk Substitutes (BMS)’ by ‘The Code’ [2] (WHA 34.22/ 1981). ‘The Code’ prohibits ‘Advertisement’ of ’BMS’. Diverse reactions re: ‘BMJ Advertisement Policy’ include the startling suggestion that no ‘Scientific Data’ confirm superiority of ‘Breastmilk’ over ‘Infant Formula’/ ‘BMS’ and hence my earlier ‘Contribution’ [3]. This further ‘Contribution’ addresses ‘Breastmilk Superiority’ over ‘BMS’!
My earlier ‘Contribution’ ventilated the tantalizing ‘8 Deficits’ in ‘BMS’ from my 2007 Presentation which make them not ‘Substitutes for Breastmilk’ and also a teaser from ‘Breastmilk is not Formula’ presented at the 2014 Academy of Breastfeeding Medicine Meeting [3]! More scientific facts are herein exposed to undergird the superiority of ‘Breastmilk’ over ‘BMS’.
‘Breastmilk’ is produced by ‘Mammals’ of different species to nurse their offspring and there are ‘Inter-Species Differences’ in the ‘Breastmilk Contents and Composition’. There are also ‘Intra-Species Differences’ in ‘Breastmilk Composition’ of different individuals. For a given individual, and in a very unique way, ‘Breastmilk Composition’ varies according to certain factors: Stage of Lactation, Phase of index Nursing, Maternal Ingestions/ Diet, Environmental Exposure, Maternal Health State, Infant Health State and Degree of Breast Fullness among several others.
‘Breastmilk Composition’ generically includes the following ‘Components’:
i. Macronutrients: Protein, Carbohydrates, Fats, Water and Energy. The ‘Whey-Casein Proportion’ is uniquely different between species and certainly between ‘Human Breastmilk’ and ‘Cow’s Milk’ and, indeed, synthetic ‘Formulas’! Taurine and Phosphoethanolamine are uniquely important for ‘Brain Development’ and are lacking in ‘Formulas’! The ‘Essential Fatty Acids’ (LCPUFAs etc) in ‘Human Breastmilk’ are uniquely important for ‘Brain Tissue Formation’ including myelination. The unique ‘Lactose Concentration’ is also important re: Renal ‘Solute Load’ and Gastro-intestinal ‘Acid-Base Status’ of the Breastfeeding Infant re: ‘Intestinal Flora’. These ‘Components’ are distinctly different in ‘Formulas’ with some resultant ‘Issues’: Bioavailability, Immunopathogenicity, etc!
ii. Micronutrients: Water-soluble and Fat-soluble Vitamins, Minerals particularly Calcium and Phosphorus with critical Hydroxyapatite for Bone/ Teeth Formation and Trace Elements especially Iron, Copper, Magnesium, Manganese, Molybdenum, etc; all these are uniquely and delicately maintained in ‘Human Breastmilk’ and clearly different from ‘Formulas’. Fortification with these ‘Micronutrients’ raises ‘Practicality-Utilization Issues’: Organoleptics, Bioavailability, Tolerability, Shelf-life, etc.
iii. Humoral and Bioactive Substances: Bombesin, Neurotensin, Immunoreactive Vasoactive Intestinal Peptides (VIPs), Insulin, Lactoferin, Bifidus Factor, Lysosomal Enzymes, Secretory IgA, IgM, IgG, etc. These cannot be synthesized for ‘Fortification’ of ‘BMS’ successfully.
iv. Living Cells: These include ‘Immune Cells’ and ‘Non-immune Cells’. The ‘Immune Cells’ include Leucocytes, Lymphocytes, Macrophages, etc. Among the ‘Non-immune Cells’ are: Luminal Cells, Myoepithelial Cells, Haematopoietic Cells among others. These are not in ‘Formulas’ and ‘Fortification’ is not possible!
Here are more facts on the ‘Breastmilk Living Cells (BLCs)’ [4]! ‘Human Breastmilk Cells (HBCs)’ were documented since the 17th Century [5]. ‘Human Breastmilk’ is populated with ‘Living Cells’ which ‘Composition’ changes dynamically. They are absent in ‘BMS’ with ‘Constant and Fixed Composition’! The ‘BLCs’ include:
1. ‘Immune Cells’: The Leucocytes account for < 2% of the ‘Living Milk Cells’ in a ‘Healthy Mother-Baby Dyad’ and this proportion changes with the ‘Health Status’ of the Dyad. Macrophages and Lymphocytes reflect the ‘Dyad Exposures’. Lysosomes (Organelles) are present.
2. ‘Non-immune Cells’: These include ‘Mammary Gland Milk Cells’ (Luminal Cells (Lactocytes), Myoepithelial Cells and Stem Cells) and ‘Extra-mammary Gland Milk Cells’ (Maternal Bone Marrow-derived Stem Cells and CD34+ Haematopoietic Cells)6. Luminal and Myoepithelial Cells account for about 98% of ‘Breastmilk Cells’ in the ‘Secretory Mammary Gland’.
Concerning the ‘Human Breastmilk Stem Cells (hBSCs)’, there is a mixed population of ‘Mature Uncommitted Cells’ and ‘Progenitor Cells’ depending on ‘Epigenetic Factors’ and are recognized with their ‘Pluripotency Genes’/ ‘Markers’ as ‘Cytokeratin (CK)18+ (Luminal Cell-destined)’, ‘CK14+ (Myoepithelial Cell-destined)’, ‘CK5+’, ‘Smooth Muscle Actin (SMA)+’ and ‘Nestin+’. Some hBSCs also have ‘Cluster Determinant (CD) Markers’: CD49f, CD24, CD29, CD34, CD73, CD90, CD105, etc. The hBSCs are ‘Pluripotent Multilineage Stem Cells’ and can be ‘Recruited and Committed’ to the ‘Tri-germinal Lineage’ in ‘Breastmilk’:
i. Ectoderm: Lactocytes, Myoepithelial Cells, Neuron- and Glial-like Cells
ii. Mesoderm: Osteoblasts, Chondroblasts, Adipocytes, Cardiomyocytes, etc
iii. Endoderm: Pancreatic β-Cells (Insulin), Hepatocyte-like Cells (Albumin), etc.
iv. Epithelial-to-Mesenchymal Transition (EMT): Some cells are in the ‘Transition Phase’ from one ‘Germinal Lineage’ to another.
The ‘Importance and Functions’ of the hBSCs is still being unearthed but some scientific facts are constantly emerging! The hBSCs have two broad functions: ‘Self-Renewal’ and ‘Differentiation through Progenitor Cells Stimulation’ into the ‘Multilineage Germinal Derivatives’ under Epigenetic ‘Pluripotency Genes’ influence. Here are ‘Tantalizers’ for ‘Starters’:
1. ‘Secretory Mammary Gland’: Under ‘Lactogenic Hormone Complex’ (Oestrogen, Progesterone, Prolactin, Human Placental Lactogen and Insulin), the Mammary Gland of the ‘Pregnant Woman’ is ‘Remodelled’ into the ‘Secretory Stage’ for ‘Breastmilk Production and Secretion’.
2. The Lactocytes and Myoepithelial Cells participate in the ‘Milk Ejection Reflex’
3. The predominant hBSCs are dictated by ‘Epigenetic Stimulation’ and produce the ‘Relevant Specific Substances’ to meet the ‘Dynamic and Changing Immunological, Nutritional and Developmental Needs’ of the ‘Growing Child’
4. ‘Mother-Child Transplant Acceptance’ through the ‘Micro-Chimerism Process’ as ‘Maternal Bone Marrow-derived Stem Cells’ are in ‘Breastmilk’, protected from Enzyme and Acid destruction in the gut and, through ‘Diapedesis’, integrate stably with the Nursling’s ‘Target Organs/ Tissues’ [7].
5. In the evolving ‘Revolutionary Therapy’ of ‘Regenerative Medicine’, hBSCs have been proposed as ‘Stable Non-Tumorigenic Teratoma-Negative’ and, therefore, superior to ‘Human Embryonic Stem Cells (hESCs)’ and ‘Induced Pluripotent Stem Cells (iPSCs)’ which are ‘Unstable Tumorigenic Teratoma-Positive’ [8,9]. ‘Teratoma-Positive Assays’ is the test for ‘Pluripotency’!
The hBSCs are currently being investigated for their importance in ‘Lactation Biology’, ‘Breastmilk Stem Cell Research’, ‘Regenerative Medicine’ and ‘Breastfeeding Medicine’. The ‘BLCs’ and other ‘Components’ in ‘Human Breastmilk’ exist/ are produced ‘Naturally’ and are absent in ‘BMS’ and largely cannot be synthesized for ‘Fortification Purposes’ and where attempted, Bioavailability, Immunopathogenicity and Organoleptic ‘Issues’ arise! Yet, there is a reason for everything in ‘Nature’!! The ‘Breastfed Child’ is the beneficiary of the illimitable benefits of these unique ‘Breastmilk Components’!!! What ‘Scientific Data’ are needed to confirm the distinct differences between ‘Human Breastmilk’ and ‘BMS’ and the unquestionable superiority of the former? ‘The Code’ prohibition of ‘BMS Advertisement’ is ‘Programmatically Apt’; Bravo BMJ on your new ‘Advertisement Policy’!
REFERENCES
1. Godlee F. No more infant formula advertising in The BMJ. BMJ 2019; 364: l1279 of 21st March 2019
2. Eregie C.O. A Major Programmatic Misstep in the 2018 Revised Ten Steps to Successful Breastfeeding. https://bmj.com/content/363/bmj.k5146/rr-7 of 16th January 2019BMJ Advert
3. Eregie C.O. There is no Breastmilk Substitute (Including Infant Formula) and Prohibition of its Advertisement is Programmatically Appropriate for Optimal Child Health. https://bmj.com/content/364/bmj.l1279/rr-4 of 28th March 2019
4. Hassiotou F and Hartmann P.E. At the Dawn of a New Discovery: The Potential of Breastmilk Stem Cells. Adv Nutr 2014; 5:770-778
5. Van Leeuwenhoek A. Epistola 106. Arcana naturae detecta delphis batavorum. Apud Henricum a Krooneveld 1695
6. Fan Y, Chong YS, Choolani MA, Cregan MD, Chan JK. Unravelling the Mystery of Stem / Progenitor Cells in Human Breastmilk. PLoS ONE 2010; 5:e14421
7. Zhou I, Yoshimura Y, Huang Y et al. Two Independent Pathways of Maternal Cell Transmission to Offspring through Placenta during Pregnancy and by Breastfeeding after Birth. Immunology 2000; 101:570-80
8. de Lazaro I, Yilmazer A, Kostarelos K. Induced Pluripotent Stem (IPS) Cells: A New Source for Cell-based Therapeutics? Journal of Controlled Release; Official Journal of the Controlled Release Society 2014; 185C:37-44
9. Lensch MW, Schlaeger TM, Zon LI, Daley GQ. Teratoma Formation Assays with Human Embryonic Stem Cells: A Rationale for One Type of Human-Animal Chimera. Cell Stem Cell 2007; 1:253-8
Professor Charles Osayande Eregie
MBBS, FWACP, FMCPaed, FRCPCH (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 Code Implementation Project in Nigeria
*No Competing Interests.
Competing interests: No competing interests
The BMJ is greatly appreciated for its ‘Organizational Policy’ to discontinue the ‘Advertisement’ of ‘Infant Formula’ in spite of the projected financial losses of £300, 000 by 2020 [1]! It will, however, honour its extant ‘Contractual Agreements’ for the next few months. This very bold decision is worthy of emulation by other reputable Biomedical Journals. Not surprisingly, reactions to this ‘BMJ Advertisement Policy’ have been protean. Some reactions are bothersome with very disturbing depositions and hence my ‘Contribution’. In particular, a deposition indicates that no scientific data exist confirming the superiority of ‘Breastmilk’ over ‘Infant Formula’. This is, indeed, very startling and revealing! This Presentation focuses on ‘Breastmilk Substitutes’ which includes ‘Infant Formula’.
The ‘1981 Code’ defined ‘Breastmilk Substitutes’ very clearly (WHA 34.22/ 1981). The adopted Code was the eventual ‘weakened’ outcome of the 1979 United Nations Meeting on Infant and Young Child Feeding convened to address the antecedent Triad (‘Milk-Malnutrition-Mortality’) and the resultant ‘Actions’ and ‘Counter-Actions’. ‘Milk’ referred to ‘Foods’ manufactured that were subsumed within the Code definition of ‘Breastmilk Substitutes’. For Code Implementation, the Provisions of the 1981 Code represent the MINIMUM to be implemented and complied with in their ENTIRETY. It is also instructive that ALL Subsequent Relevant World Health Assembly (WHA) Resolutions have, in one way or another, contributed to ‘strengthening’ the 1981 Code by addressing Uncertainties, Controversies, Clarifications, Ambiguities, Explanations and Expansions/ Inclusions/ Additions where appropriate. The 1981 Code definition of ‘Breastmilk Substitutes’ has not been vacated by any Subsequent Relevant WHA Resolution! A Technical Programmatic Term, ‘The Code’, refers to the ‘1981 Code’ and ‘ALL Subsequent Relevant WHA Resolutions’. ‘The Code’ ABSOLUTELY prohibits the ‘Advertisement’ of ALL Products covered by its Provisions. These Products include ‘Breastmilk Substitutes’ which subsume ‘Infant Formula’. It is instructive that even where and when these Products have been advertised, albeit inappropriately, the superiority of ‘Breastmilk’ is uniformly acknowledged, acclaimed and disposed by the Manufacturers! We are familiar with such statements in such ‘Advertisements’: ‘Only Breastmilk is better’, ‘Now closer to Breastmilk than ever’, ‘Breastmilk is best for your baby’, ‘Humanized’ etc. Some ‘Advertisements’ have pictorial depictions of the ‘Product Composition’ showing clearly the ‘Contents’ that are lacking/ deficient when compared with ‘Human Breastmilk’. The ‘Product Literature’ usually suggests that ‘Human Breastmilk’ is the ‘Reference Product/ Gold Standard’ in the formulation and production of the ‘Advertised Product’. It is, therefore, quite worrisome for presumed ‘Non-conflicted Scientists’ to suggest that scientific data do not confirm the superiority of ‘Breastmilk’ over ‘Breastmilk Substitutes’ (including ‘Infant Formula’)!
I made a Literature-backed Presentation in 2007 at a Symposium during the Annual Scientific Conference of the Paediatrics Association of Nigeria titled ‘Breastmilk Substitutes: Myth or Reality?’. Compared with ‘Breastmilk’, at least ‘8 Deficits’ were exposed in ‘Breastmilk Substitutes’ which made them ‘Not Substitutes for Breastmilk’! As a ‘Tantalizer’, the ‘8 Deficits’ included:
1. Constant and fixed Composition of Breastmilk Substitutes compared with the dynamic and changing Contents and Composition of Breastmilk,
2. Breastmilk Contents and Functions are known (Protein, Carbohydrates, Fats) but syntheses and inclusions in Breastmilk Substitutes have issues of Bioavailability, Immunopathogenicity, Renal Solute Load etc,
3. Breastmilk Contents and Functions are known (Micronutrients, Prebiotics etc) but syntheses and inclusions in Breastmilk Substitutes raise ‘Organoleptic Issues’ including Tolerability and Shelf-life,
4. Breastmilk Contents and Functions are known (Numerous Anti-infective Factors, Probiotics etc) but syntheses are not possible and, therefore, not included in Breastmilk Substitutes,
5. Breastmilk Contents are known but Functions are unknown (α-Fetoprotein etc), syntheses not undertaken and, therefore, not included in Breastmilk Substitutes,
6. Breastmilk Contents only recently discovered, Functions are known (Nerve Growth Factor, Epidermal Growth Factor, Anti-adherence Substance etc) but syntheses are not possible and, therefore, not included in Breastmilk Substitutes,
7. Breastmilk Contents only recently discovered (Relaxin, Neurotensin, Bombesin, Stem Cells etc), Functions unknown, syntheses not undertaken and, therefore, not included in Breastmilk Substitutes and
8. Breastmilk Contents possibly present but yet undiscovered, syntheses certainly not an issue and, therefore, clearly not included in Breastmilk Substitutes.
From the tantalizing plethora of ‘Deficits’, ‘Breastmilk Substitutes’ can never be a ‘Substitute for Breastmilk’. Concerning the ‘Dynamic and Changing Breastmilk Composition’, there is ‘Prepartal Milk’ which differs from the ‘Postpartal Milk’ in its different stages of production (Colostrum, Transitional Milk, Early Mature Milk, Late Mature Milk etc). Also, ‘Preterm Milk’ differs from ‘Term Milk’ and both also experience the postnatal changes in ‘Contents and Composition’. During an index ‘Nursing’, ‘Breastmilk’ also changes dynamically from ‘Fore-milk’, through ‘Mid-milk’ to ‘Hind-milk’ with varying ‘Composition’. The ‘Breastmilk’ from an infected mother also has different ‘Composition’ particularly concerning its ‘Anti-infective Factors’ for the protection of the ‘Nursling’. This Presentation was in 2007 and yet, in 2019, ‘Scientists’ are still searching for data re: superiority of ‘Breastmilk’ over ‘Breastmilk Substitutes’ just to oppose the new ‘BMJ Advertisement Policy’ now fully compliant with ‘The Code’ which prohibits ‘Advertisement’ of ‘Code Products’ which require ‘Special Treatment’ making the ‘Usual Marketing Practices’ very ‘Unsuitable’ (WHA 34.22/ 1981) [2]!
Incidentally, I attended the 2014 Annual Scientific Meeting of the Academy of Breastfeeding Medicine where there was also a great Presentation titled ‘Breastmilk is not Formula’. The thrust of the Presentation was that ‘Infant Formula’ had a ‘Constant and Fixed Composition’ while ‘Breastmilk’ had a ‘Dynamic and Changing Composition’. The Presentations in 2007 and 2014 clearly disposed ‘Breastmilk’ as a ‘Living Food’ responding to the ‘Changing Nutritional Demands’ of the ‘Growing Child’ which ‘Breastmilk Substitutes’ (including ‘Infant Formula’) cannot respond to! For those still in doubt in 2019 and still searching for scientific data re: superiority of ‘Breastmilk’ over ‘Breastmilk Substitutes’, the ‘Take-away’ is: ‘Breastmilk is not Formula and Formula cannot be Breastmilk’ and ‘Breastmilk Substitute is no Substitute for Breastmilk’!!
Concerning making information on ‘Foods for Special Medical Purposes (FSMP)’ available to ‘Health Professionals’, this should be presented in ‘Proper Scientific Product-Publications’ which go through the ‘Conventional Rigorous Peer-Review Process’ and will be devoid of tenuous and untenable ‘Health and Nutritional Claims’ as seen in promotional commercial ‘Product Advertisement’ in reputable Biomedical Journals! Bravo BMJ for this bold and courageous leap!!
REFERENCES
1. Godlee F. No more infant formula advertising in The BMJ. BMJ 2019; 364: l1279 of 21st March 2019
2. Eregie C.O. Making the Code Work for Optimal Infant and Young Child Feeding: Rekindling ‘Health Professional Associations-Industry Funding Conversation’ and the ‘INAGOSICI Phenomenon’. https://bmj.com/content/364/bmj.1544/rr of 14th February 2019
Professor Charles Osayande Eregie
MBBS, FWACP, FMCPaed, FRCPCH (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 Code Implementation Project in Nigeria
*No Competing Interests.
Competing interests: No competing interests
In response to this response.
If you are saying cow's because we are saying an allergy to the milk of the species the cow.... then why is soya milk not soya's milk, duck eggs should be duck's eggs (or I would argue ducks' eggs), we have allergies to sesame seeds not sesame's seeds and animal dander rather than animal's or animals' dander. I think you would be correct if you used either cow milk protein allergy or cows' milk protein allergy. I believe NICE have gone with cows' milk
Competing interests: No competing interests
We have used the singular here not because it's the milk of a particular cow but because it's the milk of the species "the cow," a single generic category, as opposed to the milk of the sheep or the goat (also singular), and is akin to phrases such as the "greengrocer's apostrophe," the product not of one single grammatically challenged greengrocer but by one mythical generic type.
Competing interests: No competing interests
In her editor’s choice Fiona Godlee talks of cow’s milk protein allergy, the placement of the apostrophe indicates that she is referring to an allergy to the milk protein of a single cow. Whilst it is not impossible to imagine a person who has only been exposed to the milk of one cow and had subsequently developed an allergy to that cow’s milk I’m sure this is not the concern of a journal such as the BMJ. I would imagine that this editorial is more concerned with the much more prevalent condition of being allergic to the milk of all cows i.e. cows’ milk protein allergy. Surely an esteemed journal that has been one of the world’s leading lights in publishing articles in the English language since 1840 should get the use of the humble apostrophe correct.
Competing interests: No competing interests
This comes across as an arbitrary, irrational and knee-jerk action.
Why exactly have these adverts been banned?
I agree that the use of formula milk should be based on unbiased sources of information, as the article explains is the WHO guidelines.
However, consider this: is there any substance - naturally occurring or man-made - that should be used on any other basis?
Which item or product would you say should be used following biased sources of information? None.
All things should consumed only after consulting unbiased sources of information. Formula milk is no different in this regard. Yet the article implies that it is a special case. This is not justified.
Show me the science or data that says that formula milk is bad or worse than breast milk, and then I’ll agree that such adverts should be banned. No such science or data exists.
This feels like a bandwagon move.
Competing interests: No competing interests
Bravo Fiona! This sort of response by editors of respectable journals is long overdue. I trust it will lead the way for others to follow suit on similar issues. Many pharmaceuticals continue to be advertised in leading journals. The BMJ has an excellent record of taking a stand on important social issues. I am certain most readers understand that journals (and their publishers of course) pay a price for these decisions and will reward Journals who do so in whatever way they can.
Competing interests: No competing interests
Re: refers to "From the Journals by Christopher Martyn, Education section, 23 March 2019 print BMJ, p493"
re prophylactic antbiotics after miscarriage
I note the use of the words "spontaneous abortion" in your article. Although technically correct many of us that work in the field try not to use the word "abortion" in all our work whilst using the word miscarriage whenever possible.
The word abortion is regarded by many as pejorative and many patients have in fact not had an "abortion" in the legal sense as in "I do not want this baby"
Imagine that you are a deeply religious person and have been trying to get pregnant for years then have the misfortune of losing your baby. Then someone tells you or writes in your notes that you have had a "spontaneous abortion" - would you not consider this as adding insult to injury? How would you feel?!
I appeal to all my colleagues and the Editor -in - chief to consider the sensitivities of our patients both at work and in all BMJ publications . I appeal to the good offices of the BMJ to help pass the message to all publications as well.
Here are more examples among others:
Threatened miscarriage - not abortion
Missed miscarriage - not abortion
Incomplete miscarriage - not abortion
Complete miscarriage - not abortion
Early fetal loss
Finally - "termination" - not abortion.
Competing interests: No competing interests