water and infant feeding
Milk Action briefing. Paper copies are available. Contact
us for further details.
is the best start in life for a child. The Word Health Organisation
(WHO) estimates that one and a half million infants die
each year because they are not breastfed. However, despite
the proven benefits of breastfeeding, women throughout the
world are under pressure to use artificial milks as a result
of the unethical marketing practices of the baby food industry.
In 1981 the World Health Assembly adopted the International
Code of Marketing of Breast-milk Substitutes, to ensure
that babies, carers and health workers were protected from
commercial pressure to favour artificial feeding. Subsequent
Resolutions have been adopted since to address new marketing
strategies and scientific knowledge and to resolve questions
Baby Milk Action and our partners in the International Baby
Food Action Network (IBFAN) shows that companies continue
to promote artificial infant feeding in violation of the
International Code and Resolutions. A further worrying
development has now come to our attention. Baby milk companies
are producing and marketing bottled water for the preparation
of infant formula. Bottled water is also promoted as a water
drink for infants.
In this paper
we look at the implications for health, existing controls
on bottled water and the marketing activities of the companies
involved. Finally, we examine the reality of infant feeding
in Pakistan, a country targeted as a test market for this
promotional strategy by one company.
for Valvert bottled water in a Russian parenting magazine
is used to promote artificial infant feeding. The
baby's bottle appears to contain infant formula and
the text says, "...be careful with the quality of
his feed... we recommend mineral water which is ecologically
pure. It is good for the baby's organs. It is natural..."
is owned by Nestlé, the company which controls
about 40% of the world baby milk market. When asked
to stop promoting artificial infant feeding in this
way Nestlé said in December 1997, "...in view
of our support for breastfeeding [sic], we have decided
that in future we will not make references to bottles
and formula in materials produced."
the same advertisement was still appearing in Russia
in April 1998.
need to protect breastfeeding
that breastfeeding be promoted as one of the most important
measures for preventing diarrhoea, which takes the lives
of 2.2 million children yearly and leaves millions more
underweight, mentally and physically stunted and immunosuppresse
(Ref. 1). There
is conclusive evidence that breastfeeding confers significant
protection against illness and death associated with diarrhoea.
This is not only because it removes the risk of unsafe water,
but because breastmilk is a living substance containing
the mother's antibodies and immuno-globulins. A study carried
out in Brazil (Ref.2)
found that infants who did not receive any breastmilk were
at 14.2 times the risk of death from diarrhoea compared
with infants who did not receive artificial milk. It was
also found that supplementation with tea, water or juice
increased the risk of death resulting from diarrhoea.
Code of Marketing of Breastmilk Substitutes regards
any product that is promoted to substitute that part of
the infant and young child's diet that would normally be
made up of breastmilk as a breastmilk substitute. The World
Health Assembly recommends that additional foods are not
introduced until about 6 months of age (Resolution WHA47.5).
Hence, any substance promoted for use before 6 months is
substituting for breastmilk. It is recommended by WHO and
UNICEF that breastfeeding continues into the second year
of life and beyond and so products promoted for use during
this period as replacements for breastmilk also come within
the scope of the International Code.
applies to ...beverages ...when marketed or otherwise represented
to be suitable , with or without modification, for use as
a partial or total replacement of breastmilk" Article 2,
International Code "
be no advertising or other form of promotion to the general
public of products within the scope of the code” Article
5.1, International Code
water - a suitable solution?
Is bottled water
a suitable way to tackle the problem of diarrhoea? There
are several reasons to doubt it:
* marketing of
bottled water for infants is being conducted in violation
of the International Code and Resolutions in ways
that undermine breastfeeding, suggesting that this is an
attempt to by-pass these restrictions.
* bottled water
is an added unnecessary expense for those mothers who struggle
to buy infant formula once pursuaded not to breastfeed.
breastfeeding and safe, local water supplies is better for
health and the environment.
feeding with bottled water may be detrimental to health.
risks to infants fed with commercial bottled drinking water
In 1993 two
infants were admitted to a hospital in Wisconsin and treated
for seizures associated with low sodium levels caused by
excessive water intoxication(Ref. 3).
In the first
case, a 55-day-old infant suffered epileptic fits as a result
of low sodium levels in her blood. Furthermore, the infant
also experienced respiratory depression. The infant had
been fed with infant formula supplemented with bottled water.
The mother reported using bottled water as a supplement
because the product was inexpensive and because she interpreted
the labelling to indicate that the product had been produced
specifically for infants and contained nutrients adequate
for use as a feeding supplement.
In the second
case, a 56-day-old infant was admitted to hospital following
an apparent brief seizure. Again, the seizure was diagnosed
as a result of low sodium levels. In this case, the mother
had used bottled water to supplement feedings of soy based
formula. Once again, the mother indicated that she believed
the bottle label depicted a product specifically made for
the greatest killer of infants worldwide(Ref.
4) and requires Oral Rehydration
Treatment to replace lost fluid and minerals. The promotion
of bottled water as suitable for infants may encourage parents
to use this product to rehydrate their children so increasing
the risk of low sodium related seizures.
Too high a concentration
of minerals may also put infants at risk. In a 1994 report,
Weaning and the Weaning Diet, the UK Department of Health
states that (Ref. 5):
intake is undesirable especially in infancy."
content of water is one of the causes of methaemoglobinaemia
in infants. Where the concentration exceeds 50 milligrams
per litre (as nitrate ion) water undertakers [providers]
are obliged to inform the health authorities and professions
in the affected area. Water with a concentration of nitrate
greater than 100 milligrams per litre is not suitable for
of nitrate and sulphur are present in some natural mineral
waters. High sulphate levels of 400 - 500 milligrams per
litre may be purgative [cause excessive bowel movements]
especially in children."
waters may contain varying amounts of fluoride and those
with high levels are unsuitable as part of an infant's diet
or for making up dried foods or drinks because of the risk
of fluorosis of the tooth enamel."
Legislation covering water
is no binding legislation relating to the composition and
use of bottled water, the Department of Health has indicated
other than those labelled 'natural mineral water', are expected
to conform to essentially the same standards as the public
water supply and they are therefore suitable for giving
to infants or for preparing feeds. As with tap water, bottled
waters should be boiled and cooled before using to make
up infant formula feeds."
mineral water' is covered by less comprehensive regulations
than tap water and may contain higher concentrations of
solutes such as nitrate, sodium, fluoride and sulphate which
might lead to solute overload if these waters are given
to young infants."
The tap water
that we drink every day contains only chloride and flouride
- all minerals are removed during the treatment process.
However, with mineral water the composition is unchanged
- extra minerals are neither added nor removed from it.
sent to health authorities (Ref.6),
the Department of Health recommends:
label and avoid using water in bottles labelled 'natural
mineral water' - they are not required to meet all the standards
for tapwater and other bottled waters."
greater than those given in the box should be avoided for
infant feeding according to the Department of Health guidelines
Maximum mineral concentrations for drinking water
(UK Department of Health)
Sodium 200 milligrams per litre (mg/l)
Nitrate 100 mg/l (best below 50 mg/l)
Nitrite 3 mg/l
Sulphate 500 mg/l
The Food and
Drug Administration (FDA) in the U.S.A. has published a
"final rule" governing regulations on bottled water, including
mineral water. The regulations require accurate labelling
of bottled waters marketed for infants. Any product labelled
"sterile" must be processed to meet the FDA's requirements
for commercial sterility. If the water is not sterile, the
labelling should indicate this. In this instance it should
only be used in the preparation of infant formula as directed
by a Doctor or according to infant formula preparation instructions.
In U.S.A. the
FDA has recommended to the International Water Association
that the labels of bottled water products should indicate
clearly their contents and appropriate uses and that they
should not be used in lieu of infant formula.
European Community, there are currently no standards governing
sterilization of bottled water.
promoting bottled water
As part of Gleneagles
Spring Waters Company, Saint Mungo's have recently introduced
onto the UK market a pure spring water for babies - "All's
Well". The drink is marketed for babies and infants from
4 months upwards and is packaged in a ready-to-feed bottle.
The label on the product asserts that it is "Ready to Serve
No Need To Boil". A spokesperson for Gleneagles stated that
they use a "purity protection process" to kill bacteria.
However, the labelling not only contravenes the UK Department
of Health recommendation that all bottled water should be
boiled, it also contravenes the recommendation of the World
Health Assembly that no additional foods should be introduced
until about 6 months of age.
infant formula in Germany and is now producing "baby water"
which they claim is suitable for preparing infant formula.
Currently their product is only being marketed in Germany,
but the company suggests that (Ref. 7),
"our water would be suitable for Third World Countries"
but "the transport is too expensive."
Milupa, a subsidiary
of Nutricia (which also owns Cow&Gate), markets a tablewater
for use in the preparation of infant formula, drinks and
teas for children. Currently this water is only distributed
in Germany, and Milupa say that they have no plans to distribute
the water in the Third World. Milupa also states its opinion
that water does not fall with the WHO Code as it is not
a breastmilk substitute (Ref.8)
- even when promoted for use in making up formula!
An article in
the London newspaper, the Evening Standard (Ref.
9), on 12 September 1997, suggested
that Nestlé plans to introduce a new brand of mineral
water with a "lower than average mineral content" designed
for babies. According to the report, another mineral water
is being developed as a "hush-hush" project for distribution
in the Third World. The report does not acknowledge the
risk of supplementary feeding with water, the added expense
for families persuaded to use bottled water for infant feeding
or the environmental impact of bottling and transporting
water instead of developing local supplies. On the contrary,
the paper presents the secret project as a way to counter
the international Nestlé boycott, "which" it reports,
"began in 1977 because poor families were putting babies
at risk by over-diluting the powder, using polluted water
or not sterilising equipment. Its new products could help
to solve this problem."
Nestle has been buying up bottled water companies, and now
controls over 10% of the world market. Perrier, the Nestle
bottled water subsidiary is present in more than 120 countries.
It owns over 50 brands, including:
Buxton, Perrier, Vittell, Ashbourne, Contrex and Valvert
A German magazine
article on 21 November 1997 suggests that Dr. Kalscheuer,
Chief Executive Officer of Perrier (Nestlé) is hoping
to develop the Asian market (Ref. 10).
It suggests that in 1998 Pakistan will be a test market
for Nestlé's mineral water. Nestlé has already
opened bottled water factories in China and the Philippines.
Valvert water has been used to promote artificial infant
feeding in a number of countries, including Côte d'Ivoire
and Russia (see page 4). Baby Milk Action featured Nestlé's
advertisement in Russia in the October
1997 Campaign for Ethical Marketing action sheet.
In December 1997 Nestlé promised to stop promoting
artificial infant feeding through its marketing of bottled
water, yet stated that, "Thanks to its low mineral content
Valvert is suitable for use with infants and this fact will
be mentioned where appropriate." As the discussion on
health explains, supplementary feeding with water may lead
to seizures due to low sodium levels.
in this way comes within the scope of the International
Code, but Nestlé claims that it does not.
was still using the advertisement shown on page 4 months
after it promised to end this promotional method.
sales of Nestle water (in millions of litres).
Rey, a member of the Nestlé Perrier Vittel Water
Institute, is an influential member of the Codex Alimentarius
Commission, which sets international food standards under
the UN system. Until recently he was also a member of the
European Commission's Scientific Committee for Food, which
advises on food standards. (He resigned from this position
after his links with Nestlé were exposed amidst the
controversy surrounding his public support for Nestlé
when it was claimed he spoke as an "independent expert.")
The latest monitoring
report of the International Baby Food Action Network (IBFAN),
called Breaking the Rules, Stretching the Rules 1998,
reports promotion of artificial infant feeding through the
marketing of water by other companies: Font Vella in Colombia
and Spain, National in Malaysia and Gulfa in Pakistan.
Case Study - Pakistan
to provide an ever-promising market for the promotional
and sales tactics of multinational corporations. It has
a population of 140.5 million with 5.5 million babies born
baby food industry is strongly represented. This can be
judged by the fact that Nestlé's infant formula Lactogen
1 appears at number 66 in the list of best-selling products
in Pakistan, with sales worth Rs 67 million in 1995 (Ref.11).
Now it is reported that Nestlé plans to use Pakistan
as a test market for its mineral water.
a poor country. In 1994 its GNP / Capita was only US$430,
as compared to US$18,340 in the United Kingdom
(Ref.12). Even more disturbing
is the fact that 60% of the population in Pakistan earns
less than the average per capita income. All the same, the
baby food industry is making headway as it attempts to expand
its market in Pakistan.
report, the Feeding Fiasco, was published by the Network
of Association for Rational use of Medication in Pakistan
in March 1998 and is available from Baby Milk Action (£5.00
plus 50 pence postage and packing in the UK). The report
"But the reality
is that in Pakistan today, the breastfeeding culture is
a dying one. Bottle-feeding is being accepted as the rule,
rather than the exception. Mothers unnecessarily 'supplement'
their own milk with other milks, water and foods before
it is nutritionally required by the baby."
in Pakistan (Ref.12)
of children exclusively breastfed to 3 months
56% of mothers still breastfeeding at 20-23 months
was one of the countries that recommended the adoption of
the World Health Assembly Code in 1981, it has not been
properly implemented as a result of political and economic
constraints on the government and powerful commercial interests.
by Nestlé resulted in breastmilk substitutes being
removed from a list of products which could only be sold
in pharmacies. Today these products are sold in groceries
and at street markets.
a report in the newsletter (Ref. 13)
of the Network of Association for Rational use of Medication
in Pakistan, the cost of Pakistan’s imports of milk powder
and baby food doubled during the first 10 months of the
1995-1996 financial year compared with the previous one.
9,500 tonnes of baby foods at a cost of US$ 43.5 million
between July 1995 and April 1996. According to the report,
this upsurge coincides with new aggressive marketing tactics
about the cost to the average household?
the report Feeding Fiasco the average cost of infant formula
for feeding a baby from birth to six months in Pakistan
is Rs 1,480 per month - this equals the average monthly
income in Pakistan and is for milk powder only. It did not
include bottles, teats, fuel, or labour time. The obsenity
of Nestlé's plan to launch mineral water in Pakistan
to reduce the risks associated with using unsafe water for
mixing formula can now be appreciated. It is not for the
health of infants - mothers are better advised to breastfeed
- it is to make additional profit and will increase the
financial burden on families.
A further problem
is the low status of women in general - the outcome is a
bias which heavily favours males, particularly in access
to education. Female literacy is only 24% as compared to
male literacy of 50%12 . Consequently, poverty and ignorance
result in poor women being particularly susceptible to the
marketing practices of baby milk companies which aim to
undermine breastfeeding, and susceptible to harmful information
which convinces them that that they are "unable" to breastfeed
for reasons like - not enough milk, poor quality milk etc.
is a growing culture amongst the middle classes which views
breastfeeding in public as "shameful". Although poor women
in rural areas continue to breastfeed in public, they are
also susceptible to this view. Marketing is one way of speeding
up this process.
is high at 95 per 1000 live births, compared with 6 per
1000 in the UK (Ref. 12). Hundreds
of thousands of children die each year in Pakistan as a
result of diarrhoeal dehydration. Many of these deaths could
be avoided through the promotion of breastfeeding.
of mineral water in Pakistan will not solve the problem
of diarrhoeal deaths and infant malnutrition. It will merely
be an inducement for many to climb further into the poverty
trap, whilst enriching multinational corporations.
* It fails to
solve the complicated and costly process of sterilizing
bottles and teats.
* It fails to
solve the time-consuming task of preparing formula in a
country where most women already face a heavy burden of
* It fails to
solve the problems of low female literacy which can result
in malnourishment of the infant if formula fed.
* It increases
the overall cost of artificial infant feeding.
* It encourages
supplementation with water, which may put infant at risk.
If supplementation becomes part of the infant feeding culture
those unable to afford bottled water may resort to using
other supplies of water which pose an even greater hazard
of bottled water for infant feeding may undermine breastfeeding,
poses risks to health and has an adverse impact on family
finances and the environment.
of bottled water is not an appropriate way to reduce the
risks to infant health posed by artificial infant feeding
- bottled water has to be boiled like any other supply of
water and its mineral content may not be appropriate. In
addition, encouraging supplementation with water may lead
to seiéures due to reduced sodium levels. It makes
far more sense to support schemes to provide safe water
and adequate sanitation while supporting, promoting and
protecting breastfeeding. The cost to consumers of a safe
community supply of water is usually significantly less
than bottled water.
There are worrying
indications that at least one baby food company is attempting
to develop the market for bottled water for infant feeding
in developing countries and elsewhere in the pursuit of
profit and to counter criticism of its marketing of infant
Organisations (NGO's), health professionals, UN bodies and
governments should be alert to the marketing of bottled
water. It should be made clear to companies that when bottled
water is promoted for use with infants it comes within the
scope of the International Code and the subsequent, relevant
Resolutions of the World Health Assembly.
Khan. AH. The sanitation gap: Development's deadly menace,
The Progress of Nations, 1997. UNICEF New York, pp 5-9.
Victora CG et al. Infant feeding and deaths due to diarrhoea,
American Journal of Epidemiology, 129(5): 1032-1039.back
Bruce RC, Kliegman RM. Hyponatraemic seizures among infants
fed with commercial bottled drinking water - Wisonsin 1993.
Morbidity and Mortality Weekly Report, 43(35), 9 Sept
1994, pp 641-643.back
United Nations Children's Fund (UNICEF). Re-slicing the
cause-of-death pie, The Progress of Nations, 1997.
UNICEF New York, pp 28, attributes 19% of under-5 deaths
Department of Health, Report on Health and Social Subjects
45, Weaning and the Weaning Diet, HMSO, London, 1994.back
Communication from Dr. Michael Waring, Senior Medical Officer,
Environmental Pollutants Unit, Department of Health.back
Communication from Humana Export Department, 29 October
Communication from Milupa Corporate Affairs Manager, 20
Evening Standard (London), page 40, 12 September 1997.back
Lebensmittelzeitung, 21 November 1997. back
The Network of Association for Rational Use of Medication
in Pakistan, The Baby and the Beast, Feeding Fiasco,
The Network, March 1998, page 16-21. back
UNICEF. Tables, State of the World's Children, 1997.
UNICEF New York, page 80-86.back
The Network of Association for Rational Use of Medication
in Pakistan, Baby Milk Boom, The Network's Newsletter,
March 1996, page 13. back