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No more infant formula advertising in The BMJ

BMJ 2019; 364 doi: (Published 21 March 2019) Cite this as: BMJ 2019;364:l1279

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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!!

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’. 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

28 March 2019
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