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Editor's Choice

No more infant formula advertising in The BMJ

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

Rapid Response:

Breastmilk, breastmilk substitutes (including infant formula) and infant microbiome: still more justification for the prohibition of the advertisement of breastmilk substitutes (BMS)

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)!!!

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. 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. 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’. 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

04 April 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