Infant feeding needs the support of politics

Vicky Fallon is PhD student in the Institute of Psychology, Health and Society:

“Infant feeding has entered the world of politics this year. Alison Thewliss, SNP MP for Glasgow Central was recently given leave of the House of Commons to bring forward her Feeding Products for Babies and Children (Advertising and Promotion) Bill. The new law is being drafted in response to prolonged, excessive, and misleading marketing techniques employed by the formula industry.

This isn’t the first attempt to prevent aggressive marketing practices. A World Health Organisation (WHO) International Marketing Code was set up in 1981 to contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breast milk substitutes.  However, only 1 in 5 countries has fully implemented the code and the UK is not one of them.

The Feeding Products for Babies and Children Bill intends to change that with the following key aims:

1.       To establish a body, totally independent of industry, to test all products and verify the claims of manufacturers prior to them being licensed for sale

2.       Ban the use of misleading terms such as “follow-on” or “growing-up” formula milks

3.       Stop companies from circumventing existing laws by introducing a ban on identical packaging for stage two and subsequent products;

4.       Prohibit formula companies from advertising in health journals and magazines

5.       Bring forward tougher penalties for companies who flaunt the legislation, including greater financial fines and prison sentences for company CEOs

6.       Ban advertising of formula milks on TV, social media, the internet and through parenting clubs

7.       Introduce plain packaging for all formula milks

In a nutshell, Thewliss wants to provide mothers with scientifically accurate information, kerb promotional efforts targeted at both mothers and health professionals, and penalise companies that don’t conform. Given the suspect tactics employed by formula companies and the lack of current legislation in this area, this sounds like a huge step in the right direction.  However, the final component of an otherwise very promising piece of legislation has left me feeling a little conflicted.

Standardised or “plain” packaging is designed to remove all branded features of a product. The first three sub-clauses of this element of the bill call for a) plain packaging or packaging of a specified colour; b) use of a specified font, including its size and colour, for text on the packaging; and c) use of specified graphics and photographs.

The idea behind this is to eliminate the effects of formula packaging as a form of advertising and promotion, and to address package design techniques that may suggest that some products are more beneficial than others without valid evidence.  However, the effects of plain packaging have implications that extend beyond the prevention of misleading advertising alone, particularly when considered in relation to the infant feeding literature.

Plain packaging implies health risks

The only other industry with a plain packaging enforcement is tobacco, with legislation rolled out on all products in May last year. Tobacco use is the primary cause of preventable illness and death and kills nearly half of all long-term smokers. However, in higher-income countries like the UK, there is no evidence to suggest that formula is associated with severe illness or mortality risks if it is stored, prepared, and used according to guidelines.  Rather, the literature demonstrates that formula is an acceptable substitute source of nutrition if breastfeeding cannot be achieved in the first six months of life.

The fact that formula is the next product in line after tobacco for plain packaging is therefore a little strange given that there are many other products which pose more immediate public health risks to our population (alcohol, fizzy drinks, and high-fat, high-sugar foods for instance).  The message this conveys to mothers is really concerning – that in terms of health risks, formula is somehow on a par with tobacco or more risky per se than alcohol or other products known to negatively impact health. To enforce plain packaging on a product which is not inherently harmful is neither justifiable nor proportionate.

Plain packaging discourages product purchasing

Plain package enforcement with tobacco is designed to discourage the consumer from purchasing the product. Again, within the context of tobacco this deterrent approach seems justified. However, this could be dangerous within the context of formula purchasing. Once the decision to use formula has been made, it is not a choice that can be easily reversed and there are no alternative infant feeding options. The evidence base for donor breast milk is expanding but it is not widely available in all areas of the UK.

Given that formula milk is currently the only WHO approved breast milk substitute, these women are faced with buying a product that is perceived as “risky” for the remainder of their infant feeding journeys.  Practically, this could lead to mothers’ feeling unwilling to buy formula which in turn may increase the risk of infant dehydration; result in the uptake of milk products that have not been scientifically approved and tested, or encourage the early introduction of complementary foods.  All of these outcomes are detrimental to infant health.

Plain packaging elicits negative emotions for consumers

In tobacco studies, plain packaging has been associated with inducing a plethora of negative emotions in the consumer including guilt, embarrassment, disgust, shame, anger, and fear. For smokers, provoking these negative emotions again helps to deter the consumer from using the product (WHO, 2016). However, stimulating these emotions in new mothers could be counterproductive and in some cases damaging to maternal mental health.  There is a considerable body of evidence that mothers who supplement with or switch to formula already experience negative emotions as a result of their feeding decisions.

Consistent with this, our 2016 studies published in Maternal and Child Nutrition found that some of these emotions were more pronounced in those who expressed an intention to breastfeed but were unable to following the birth of their child, or those who initiated after birth but stopped prior to the six month recommendation. By provoking negative emotions in these groups, we may be unintentionally punishing the women who already feel emotionally vulnerable about not meeting breastfeeding recommendations. There is evidence to suggest that women who do not breastfeed are physiologically at a higher risk of postnatal mental illness.  Negative early breastfeeding experiences have also been linked to poor maternal mental health.  Intensifying negative emotions in those already at risk through the use of plain packaging may have adverse consequences for maternal mental health.

To conclude, I support MP Thewliss’s rationale and agree that it is high time efforts were made to uphold areas of the WHO marketing code that are relevant to the UK. However, it is essential this is achieved in a manner that is simultaneously mindful of the impact these efforts could have on maternal and infant wellbeing, particularly when it comes to plain packaging. We know that there is a population of women out there who are unable to breastfeed their babies and another cohort who simply don’t want to and we need to respect and support their individual decisions about feeding behaviour.  Infant feeding is a fundamental component of parenting and ensuring that the marketing of breast milk substitutes is conducted ethically and responsibly is essential, but this should not come at an expense to infant health or maternal mental health.  Optimal infant nutrition is crucial for child health and development.  However, when maternal mental health is compromised, the consequences for the mother-infant dyad are as far-reaching as those around nutrition.

One potential means of avoiding these pitfalls is to remove the focus on formula milk and extend the bill to address industry practices on marketing food products targeted to the first two years of life. Importantly, this holistic approach would help to remove the emphasis from the polarising breastfeeding vs formula feeding debate that MP Thewliss has clearly stated she does not wish to further exacerbate. Additionally, it offers multiple opportunities to improve infant nutrition and subsequent health outcomes.  Ultimately, breast milk substitutes should be appropriately marketed in ways that do not compromise recommended infant feeding practices, but they should also be marketed in ways that do not inadvertently jeopardise maternal and infant health.”

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