Dr Chris van Tulleken investigates how baby milk formula producers may be influencing healthcare professionals and mothers through increases in the diagnosis of cows’ milk protein allergy (CMPA), a condition that is difficult to diagnose reliably.
In the first few weeks, breastfeeding is challenging. It’s a steep learning curve; very painful when it’s not working, and sleeplessness is largely inevitable. It can be a desperate time, when a baby is not gaining weight along the centile charts leading women to doubt the quality or the quantity of the breastmilk their babies are receiving. Common newborn problems include colic, irritability, excessive crying, variation in consistency of stools and rashes or eczema. These are precisely the symptoms of cow’s milk protein allergy, according to the array of information readily available to mothers, GPs and post-natal care-givers. Naturally, mothers questioning whether their baby has this condition will want to avoid the triggers and they are advised to exclude all cows’ milk products from their diets or switch to specialist baby formulas that are free of cows’ milk protein. The World Health Organisation promotes exclusive breastfeeding for the first six months of life. Introducing formula whilst breastfeeding reduces the supply and fuels the cessation of breastmilk production, this includes the use of “top up” formula feeds to supplement breast milk.
Women must be entitled to choose whether they breastfeed or not and to what extent and for how long, but if the information they use to make this decision is influenced by the 50 billion-dollar formula industry, then how independent is that decision? Chris van Tulleken’s BMJ investigation reveals that the formula industry provides financial support to the Royal Colleges of Paediatrics and Child Health and General Practitioners, it finances doctors’ and midwives’ educational events. Authors of the UK’s guidelines on management of cows’ milk protein allergy are funded by the industry. Advertising for formula products is prominent in the medical literature. Resources used by mothers are also influenced by the industry; it designs websites and online newborn nutrition advice platforms, including Mumsnet forums.
Van Tulleken reveals that prescriptions for specialist formula for infants with cows’ milk protein allergy increased by 500% between 2006 and 2016, to a total of over 600 000 per year. In the same period, the NHS increased its spending on specialist formulas by 700%, to totals over £60m annually. There is no reliable epidemiological data to indicate an increase in actual incidence of CMPA in this time span.
Chi Eziefula, Senior Lecturer in the Department of Global Health at BSMS, who was consulted in the investigation, worries that industry influence affects women most when they are working to establish breastfeeding. She said: “Current CMPA guidelines include formula recommendations for top-up feeds for exclusively breastfed infants, which is concerning.
“By definition, exclusive breastfeeding does not include the use of formula for top-up feeds. Such wording creates a guideline approved niche for the formula product that could interrupt breastfeeding. "In a culture where breastfeeding rates fall off sharply after birth, there must be no risk of industry influence on guidelines or education of postnatal and paediatric caregivers. Instead, we need more infrastructure to support continued breastfeeding.”
The last UK Infant feeding survey (in 2010) found that 81% of women initiate breastfeeding. But by six weeks, this figure has fallen to 24% in England, 17% in Wales and just 13% in Northern Ireland. Only 1% of mothers are exclusively breastfeeding at six months (as recommended by the World Health Organisation). The problem is that, whilst the notion that “breast is best” is clearly communicated during pregnancy and antenatal care, after birth, support for ongoing breastfeeding is woefully inadequate in the UK. Scotland has proven that improved support for breastfeeding increases the rates. 50% of women in Scotland are breastfeeding 6 weeks after giving birth. This is achieved largely by promoting high rates of skin-to-skin contact at birth (for babies born by caesarean section as well as vaginal delivery), making face-to-face breastfeeding support available throughout the breastfeeding journey, and supporting breastfeeding for premature and sick babies in neonatal units.
It is precisely when women are most susceptible to messages that their baby may be suffering from CMPA that the formula industry targets the sources of information they can access.
A personal journey - Dr Chi Eziefula
I was determined to breastfeed, because I’d studied the medical literature that suggests it could reduce the chance that my children would develop allergies and eczema, something that I suffer from. So I was confused when I came across advice on internet forums and through chats in local baby groups that my breastmilk could itself be a driver for cows’ milk protein allergy. I was lucky to have a strong role model for successful breastfeeding in my mother, so I understood that I could provide complete nutrition to my children through breastmilk, and I aimed to breastfeed exclusively for the first six months and then to continue breastfeeding them until they self-weaned. But it was not an easy ride. There were many desperate points when I thought the milk was inadequate and in my search for solutions I bought a packet of formula, believing it would fix my child’s sleeping habits or ease their irritability. The packet stayed on the shelf because such symptoms often come and go and, once I had got through the first three months, I was less susceptible to advertising and external messages and had more intuition. Many women have not known or seen enough women who are exclusively breastfeeding and can’t easily access the support and advice they need if they decide to go that way. The choice to breastfeed is a personal one. My concern is that, when women take the step to consult health professionals about breastfeeding, they may be receiving advice that is significantly influenced by the formula industry, rather than the impartial evidence-based information they should be entitled to.
Read the full investigation here >