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Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and paediatricians in Laos

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1379 (Published 09 September 2008) Cite this as: BMJ 2008;337:a1379

Misuse of coffee creamer as a breast milk substitute: a lethal case revealing high use in an ethnic minority village in Northern Laos

The feeding of breast milk substitutes to infants is an important
risk factor contributing to infant morbidity and mortality in developing
countries, but published research is limited. Exclusive breast-feeding for
the first six months of life is the number one intervention to save
infants’ lives(1). When the mother dies, is unable to breast feed
adequately or when a baby is adopted, breast milk substitutes or
surrogates are necessary. In Laos poor parents use less expensive canned
products, which they believe are appropriate for infants(2). Advertising
encourages parents to view the products as good supplements, modern
conveniences or status symbols (3;4). In January 2009 Barennes and Srour
described the extent of this misleading advertising in Laos and
recommended that such practices should be prohibited(3).

Barennes et al. reported the overall misperceptions and misuse of
coffee creamer as infant food in Laos(2). The focus was on a red label
Bear Brand coffee creamer, a tinned non-dairy product whose first
ingredient is sugar. The logo, a Nestle trademark, shows a mother bear
holding her cub in the nursing position. The label on the coffee creamer
contains a message in English and Lao, that the product is not a breast
milk substitute. On the red label coffee creamer, a picture of a baby
bottle with an X was added. Of 1098 adults surveyed, 96% believed that the
can contains milk. 46% believed the Bear Brand logo indicates that the
product is formulated for feeding to infants to replace breast milk. 80%
had not read the written message on the can. Over 18% reported giving the
product to their infant at a mean age of 4.7 months (2).

Questions remain about the problems for infants fed inappropriate
breast milk substitutes, the distribution of these products in remote
areas and the effect of advertising on rural populations.

In their paper, Barennes et al., documented two severe malnutrition
cases, including one fatality, of infants fed the Red label Bear Brand
coffee creamer. Our report is the second documented fatal case: a 6-month-
old severely malnourished infant in Luang Namtha province (LNT), Laos,
November 2008.

The LNT province is located in northern Laos, bordering Myanmar and
China. It is a multi-ethnic province with a low population density (16
people/km2) and a low literacy level. 69 % of the 148,797 inhabitants
belong to one of 49 ethnic minorities, many living in remote mountain
villages. Access to health care is limited by lack of infrastructure,
culture and language differences and poverty.

In November 2008, a 6-month-old female infant was admitted to the
provincial hospital of LNT, with a 6-day history of watery diarrhoea,
anorexia, fever, and underlying severe malnutrition.
She was the second adopted child of a Hmong family. The parents are
farmers living in a remote area. They bought 10 cans of the same Red label
Bear Brand coffee creamer (0.80 $ per can in May 2008 in her first month
of age. The infant was fed coffee creamer and boiled water for the first 3
months, 1 can every 3 days. Relatives had told the parents that this
product would be good for children, which was reinforced by the logo of a
baby bear drinking milk from the mother bear. In June 2008, the parents
were unable to find cans of this type in the local district market and
changed to a slightly cheaper brand (Palace, Daily Foods Co., Thailand,
0.69$) with a written message in Thai language: not to be fed to children
under 1 year. They had not read the message, did not know Thai language,
and the mother is illiterate. The seller told them that it could be given
to children.

The infant presented with diarrhoea and kwashiorkor and died with
complications of severe malnutrition, diarrhoea and infection.

We conducted a survey in December 2008 to investigate the extent of
this nutritional practice in the infant’s village. The village, (416
inhabitants, 77 families, is located about 62 km from the provincial
capital. It is an exclusively Hmong village with 1 primary school and 1
health centre. The Hmong are the 5th largest of the 17 ethnic groups in
Luang Namtha with their own language and culture. We used a structured
questionnaire and parents were shown coloured pictures of the Bear Brand
products and the non-Bear Brand coffee creamer (Figure). Anthropometric
measurements were performed for all children <_5 years="years" and="and" analysed="analysed" with="with" who="who" _2005="_2005" anthropometric="anthropometric" software.="software." participants="participants" gave="gave" their="their" informed="informed" consent="consent" to="to" participate="participate" in="in" the="the" survey="survey" which="which" received="received" agreement="agreement" of="of" local="local" regional="regional" health="health" authorities.="authorities." p="p"/> Figure: Picture chart used for the survey. And description of ingredients and warnings in English language

Data were entered in EpiInfo (Version 3.4.3). Analysis was carried
out with STATA, Versions 8 (Stata Corporation, College Station, TX, USA).
Fisher’s exact tests, Students’ t-test and Wilcoxon test were used to
compare categorical variables and continuous data, respectively.

The survey was conducted in 49 families with children, anthropometric
data were collected from all children below 5 years of age present in the
village. The parents are farmers with a low literacy rate (45%). Mothers
had breastfed their babies for an average duration of 14.6 months. Of 67
under 5 year old children, 54 (80.6%) were stunted (height/age<_-2sd and="and" _28="_28" _41.8="_41.8" were="were" severely="severely" stunted="stunted" _-3sd.="_-3sd." p="p"/> Red Bear Brand coffee creamer and non Bear Brand products were more
popular than white Bear Brand coffee creamer and were well recognized by
the parents (39/49 (79.6%), 34 (69.34%), and 24 (48.8%), p=0.005
respectively).
Bear Brand product was more frequently recognized as a product for feeding
children or infants than non Bear Brand products, (26 (53,1%)) versus 16
(32,7%), p=0.04)

In total, 20 (40.8%) reported giving one or more of the coffee
creamers to their infants: 15 (30.6%) the red Bear Brand coffee creamer, 6
(12.2%) the white Bear Brand can, 12 (24.5%) the other non Bear Brand
coffee creamer. The sterilized milk can which is more expensive (1.25$)
was only given by one parent, the non-fat sterilized milk never. The so
called “advance formula” 1 was given by 2 parents (price: 6.7$). 10
parents (20%) started the coffee creamer within the first month.
Parents started the Bear Brand coffee creamer earlier than the non Bear
Brand coffee creamer (mean age of 3.6 months (95%CI : 1.8- 4.5), 7.0
months (05%CI: 2.6-11.3), respectively (p=0.03).

22 (44.9%) parents believed that the Bear Brand logo means that it is
“a milk to feed infants and/or children”. Other parents believed that the
coffee creamers would improve infant nutrition, supplement vitamins and
make their child strong and fat.
The uselessness of the pictogram with the crossed off baby bottle was
similar to the report by Barennes et al: 31 (63.3%) did not know the
meaning of the product’s pictogram of a crossed off baby bottle(2). Only 5
(10.2%) interpreted it correctly as not to be fed to children/babies. 39
(79.6%) had never read the red warning text. One had read it but
understood the opposite: that the coffee creamer was intended for bottle-
feeding of babies.
Our study confirms the widespread misuse of coffee creamer as a breast
milk substitute in the Hmong ethnic group. The cartoon logo of a baby bear
held by its mother in the breastfeeding position contributes to the
misperception and misuse of coffee creamer by parents. Despite the
companies’ statement to have stopped its production and distribution for
Laos in February 2008 (5), the product was available at the local district
market in Muang Sing, Northern Laos until May 2008. The parents of the
described patient were evidently misled by this logo and then continued
feeding their child with a cheaper coffee creamer without the logo.
Misuse of coffee creamer as a breast milk substitute in the patient’s
village was 41%, much higher than the 18% found in a nationwide study in
Lao PDR in 2007 (2). Reasons might be the lower educational level, the
village location in a rural and remote area in Northern Laos, and the
ethnic minority status. The misuse did not end after the coffee creamer
with Bear Brand logo became unavailable locally in June 2008 but continued
with other brands. The Bear Brand coffee creamer might have opened the
door for other brands of coffee creamer, seen as cheaper alternatives. The
fact that the Bear Brand coffee creamer is still widely sold in
neighbouring Thailand is of continuing concern.

Our findings show the imminent necessity for further measures to
combat this health threat for infants in Laos. It is questionable if
health education alone will be able to reach all the people in risk,
especially the families in remote areas.
One suggestion would be to replace such a misleading logo by the logo of
a tea or coffee cup with no infants, children, bears or animals. Clear
logo, warning pictograms and messages should support the the purpose of
International Code on the Advertising of Breast milk Substitutes, the
protection of breastfeeding(6).
Warning labels should be tested for effective visual literacy with the
different ethnic groups before their distribution in such areas.

This is the second report of an infant’s death associated with the
misuse of coffee creamer as a breast milk substitute, a common practice in
this Hmong village. The Bear Brand logo is a twisted violation of the
International Code on the Advertising of Breast milk Substitutes and
threatens the health of infants in Laos and possibly other countries.

Acknowledgements
We thank the LNT province health authorities, LNT provincial hospital,
Muang Sing district health department, and Service Fraternel d’Entraide
staff, the village inhabitants, Health Frontier Vientiane, and Institut
Francophone de Medicine Tropicale Vientiane.

Contributors: GS was responsible for the overall coordination of the
study. He will act as guarantor for the paper. GS, PD, SI and HB
contributed to the study design and data analysis. PD, SI, BO collected
the data. GS, LMS, H B, P D, B S, drafted the paper and revised it. LMS
did the editing. All authors contributed to the writing of the paper.
Funding: Service Fraternel d’Entraide

All authors appraised and approved the final report.

Competing interests: None declared

1. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many
child deaths can we prevent this year? Lancet 2003;362:65-71.

2. Barennes H, Andriatahina T, Latthaphasavang V, Anderson M, Srour
L. Misperceptions and misuse of Bear Brand coffee creamer as infant food:
national cross sectional survey of consumers and paediatricians in Laos.
BMJ 2008.

3. Barennes H,.Srour LM. Nestlé's violations of the international
code on the marketing of breast milk substitutes. BMJ 2009.

4. Marwaan Macan-Marker. Children Under Five Straggling. Global
Geopolitics Globalnewsblog.com; Inter Press Service.
http://globalnewsblog.com/wp/2008/09/13/asia-pacific-mdgs-children-under-
five-straggling/ . 2008.

5. Stiegler R. Nestlé's works to ensure appropriate use of milk
products http://www.bmj.com/cgi/eletters/337/sep09_2/a1379. BMJ 2008.

6. IBFAN. The International Code of Marketing of Breast Milk
Substitutes. www.ibfan.org/english/resource/who/fullcode.html . 2009.

Competing interests:
None declared

Competing interests: No competing interests

16 January 2009
Gunther Slesak
SFE Medical Project
Phouvieng Douangdala, Saythong Inthalad, Boualoy Onekeo, Somsouk Somsavad, Bounmi Sisouphanh, Leila M Srour, Hubert Barennes
Luang Namtha, Lao PDR