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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

Will Nestlé’s Bears Continue to Mislead Parents and Threaten Infants Lives?

We are appalled by Nestlé’s allegations that our evidence-based
statements are inaccurate (1; 2). We cannot forget the coffee-creamer fed infants who have died.
(3;4)

The only evidence of Nestlé’s “extraordinary” commitment to
protecting infant health was the ineffective pictogram of an Xed bottle.
Nestle claims the pictogram was introduced in 2002, but it was not seen in
Lao markets until 2007.(5)

Since 2004, we have informed Nestle about parents’ misunderstanding
of the Bear Brand logo.

We are appalled by the lack of awareness and reaction from Nestle.
Instead of the ‘extraordinary’ measures Nestle describes we would prefer
to see the following ordinary measures, which we believe, would have a
positive impact on infant morbidity and mortality. Bears or other animals
should be removed from the logos and labels of all milk and creamer
products, whether or not they are intended for infants. Labels should
illustrate their intended purpose, such as a coffee cup for coffee
creamer. Follow-up and advance formulas, which could be misunderstood as
breast milk substitutes, should not feature children, bears or other
attractions. The written instructions on the label should be in the
country language where the product is being used: Lao language in Laos,
not just Thai or English. All warning pictograms should be tested for
understanding by the different ethnic groups. Old products with the
misleading labels should be recalled and removed from the shelves. Recipe
books for mothers, advertising inappropriate breast milk substitutes,
should not have pictures of infants (Figure 1) The lives of infants should
not be threatened by these products.

Figure 1: Nutrition Guide for mothers, 97 recipes (ISBN 976-7947-43-9)

The recent death of a coffee creamer fed infant should result in
urgent action to prevent further tragedies. (4)

We are very concerned by Nestlé’s declaration of their next labeling
change, which consists of" removing the baby in the mother bear's arms".
Thirty years ago, the adult bear was feeding Sweetened Reconstituted
Condensed Milk to a baby bear with a huge bottle (figure 2). This product
was sold under license in the Philippines and Thailand in 1979. Is this an
extraordinary measure? Dropping a bottle and then a baby within 30 years?

Figure 2: Original Bear Brand 1979

Was the reassuring image of the mother bear which they plan to keep
on the can tested for understanding by parents? Currently a condensed milk
product with 44% sugar, 20% skimmed milk powder, and 8.5% palm oil is
available with a young bear, a glass of milk and warning in English and
Thai language. Is this the next step for Nestle? (Figure 3)

Figure 3: Condensed milk can currently available (44% sugar, 20% skimmed milk powder, and 8.5% palm oil)

We assume not only Lao infants are being fed inappropriate breast
milk substitutes. Ethnic diversity, illiteracy and poor nutrition
education are not limited to Laos but cross all borders. Would Nestle
acknowledge the consequences of the advertising campaign with the Bear
Brand logo? The trademark is their responsibility.

Does Nestle really believe that they are not violating the code,
Article 7.3, when they offer health professionals, with very low salaries,
“small items” and financial support to attend medical meetings?1 What
could be Nestlé’s motivation?

We appreciate Nestlé’s concern that inappropriate and dangerous
breast milk substitutes are fed to infants. Many thanks for their
intention to reduce and eliminate the use of inappropriate substitutes.
Our concern extends to all beverage companies in Asia, which might not be
as responsible or communicative as Nestle. We hope that they will
cooperate similarly.

We sincerely appreciate Nestlé’s every effort to support the
International Code, whose aim is:”the provision of safe and adequate
nutrition for infants, by the protection and promotion of breast-feeding,
and by ensuring the proper use of breast-milk substitutes, when these are
necessary, on the basis of adequate information and through appropriate
marketing and distribution.” (6)

Nestle and others should be aware that infants fed sweetened
condensed milk will tend to refuse breast milk, because it is not so
sweet. This results in a lower daily breast milk intake and finally the
use of excessive inappropriate sweetened condensed milk.(7) Lao mothers
report that they believed their breast-milk was bad or insufficient if the
infant cried after breast-feeding or refused the breast. (8) Then, they
may decide to stop breast-feeding and use inappropriate breast milk
substitutes.

Perhaps the Bear Brand misleading logo will be a milestone towards
the promotion of breast-feeding for all infants. Nestlé’s commitment
should be demonstrated by a clear action plan regarding the promotion of
exclusive breast-feeding for infants 0-6 months and continuing breast-
feeding until 2 years of age. The protection of infant and child health
will benefit all developing countries and Nestlé’s commercial interests.

We feel that Nestle really should revise their latest step. We will
appreciate the ordinary measures that will end the controversies. Most
importantly, the promotion and protection of breast-feeding will protect
the lives of infants.

We do not have competing interest

We would like to thank and acknowledge Elizabeth Sterken and Annelies
Allain of IBFAN, Phanphraphone Tiaokhiao of Institut Francophone de
Medicine Tropicale Vientiane. The doctors in charge of Nutrition Program
from the Ministry of Health for their support. We thank Health Frontiers
and Institut Francophone de Medicine Tropicale Vientiane.

1. Stiegler, R. The latest step in a series of extraordinary
labelling measures. http://www.bmj.com/cgi/eletters/337/sep09_2/a1379 .
2009.

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

3. 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.

4. Slesak, G, Douangdala, P, Inthalad, S, Onekeo, B, Somsavad, S,
Sisouphanh, B, Srour, L. M., and Barennes, H. Misuse of coffee creamer as
a breast milk substitute: a lethal case revealing high use in an ethnic
minority village in Northern Laos. BMJ.
http://www.bmj.com/cgi/eletters/337/sep09_2/a1379#207174 . 16-1-2009.

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.

7. Giugliani E,.Victora C. Complementary feeding. J Pediatr
2009;76:253-62.

8. Gillespie, A, Creed-Kanashiro, H, Sirivongsa, D, Sayakoummane, D,
and Galloway, R. Consulting with Caregivers: Using Formative Research to
Improve Maternal and Newborn Care and Infant and Young Child Feeding in
the Lao People. World Bank.
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/
EXTHEALTHNUTRITIONANDPOPULATION/EXTNUTRITION/
0,,contentMDK:20146328~menuPK:282594~pagePK:
210058~piPK:210062~theSitePK:282575,00.html
. 2004.

Competing interests:
None declared

Competing interests: No competing interests

03 March 2009
L M Srour
paediatric continuing medical education coordinator
Barennes H
Vientiane Laos