Q. (14 August 2007) What is the substantiation for the claims on your Give Nescafé the boot flier?

A. Our flier is based on research findings and monitoring evidence.

Our A6 flier showing a baby giving Nescafé the boot is one of our most popular items. Contact us if you would like to have some for a leafleting event or download here. They are colourful and so people gladly take them if you hand them out outside a supermarket or other outlet with Nestlé products, or just on the street. We ask that you don't cause an obstruction and don't force leaflets on people if they don't want them.

Each of the statements on the leaflet, as last printed, are given below with background information.

• Nestlé, the maker of Nescafé, promotes artificial infant feeding around the world, breaking a World Health Organisation (WHO) code of marketing.

Monitoring on the ground by members of the International Baby Food Action Network (IBFAN) finds Nestlé to be responsible for more violations than any other company. Monitoring evidence is provided in the codewatch section of the Baby Milk Action website.

In 1996 the Advertising Standards Authority (ASA) called on Baby Milk Action to justify statements made in the advertisement shown here, following a complaint. The claims were: "Every day, more than 4,000 babies die because they're not breastfed. That's not conjecture, it's UNICEF fact." and "They [Nestlé] aggressively promote their baby milk, breaking a World Health Organisation code of marketing." We justified our claims and the complaint was rejected. For full details see the ASA Monthly Report Number 62.

In 1999 the UK Advertising Standards Authority ruled against a Nestlé anti-boycott advertisement in which it claimed to market infant formula ‘ethically and responsibly’ and that ‘The Nestlé Charter concerns Nestlé's commitment to the WHO International Code in developing countries.’

Nestlé was warned not to repeat these claims. Nestlé also lost its appeal against the ruling. Click here for further information. While it does not make them in advertisements, it does make them in public relations materials and public statements, which are not subject to the same requirement that they be ‘legal, decent, honest and truthful.’

Nestlé has long disputed IBFAN's evidence of on-going malpractice. Over ten years ago this prompted the Church of England to join together with other faith, development and academic organisations to conduct independent research. The 27-member Interagency Group on Breastfeeding Monitoring (IGBM) published the report Cracking the Code in 1997, noting 'systematic' violations by Nestlé and other companies (click here). UNICEF commented that IBFAN's monitoring was 'vindicated'.

The British Medical Journal has published peer-reviewed studies based on this (click here) and other monitoring (click here).

• According to UNICEF: “Improved breastfeeding practices and reduction of artificial feeding could save an estimated 1.5 million children a year”.

This quote is from the State of the World’s Children 2001. Available at: http://www.unicef.org/sowc01/maps/maps/map1nf.htm

It has been given in various other forms by UNICEF and WHO. The UNICEF website states (on 14 August 2007):
http://www.unicef.org/programme/breastfeeding/challenge.htm

"It has been estimated that improved breastfeeding practices could save some 1.5 million children a year. Yet few of the 129 million babies born each year receive optimal breastfeeding and some are not breastfed at all. Early cessation of breastfeeding in favour of commercial breastmilk substitutes, needless supplementation, and poorly timed complementary practices are still too common. Professional and commercial influences combine to discourage breastfeeding, as do continued gaps in maternity legislation."

In a 1997 press release responding to the Cracking the Code report referred to above, UNICEF stated:

"Marketing practices that undermine breastfeeding are potentially hazardous wherever they are pursued: in the developing world, WHO estimates that some 1.5 million children die each year because they are not adequately breastfed. These facts are not in dispute."

However, the figures are disputed by Nestlé (see Your Questions Answered).

In 1995 Baby Milk Action was required to defend the statistic before the Advertising Standards Authority after stating in a Nestlé boycott advertisement shown above:

"Every day, more than 4,000 babies die because they're not breastfed. That's not conjecture, it's UNICEF fact."

We did so successfully and, as the ASA report notes, this was with the support of WHO.

A 2003 study in the Lancet examined the question “How many child deaths can we prevent this year?” and concluded that promotion, protection and support of breastfeeding is potentially a more effective health intervention than provision of save water, sanitation and vaccination. Improved breastfeeding rates could prevent 13% of under-5 deaths in the 42 countries where most occur, amounting to 1.3 million. Appropriate introduction of complementary foods could prevent 6% of deaths.
http://www.who.int/child-adolescent-
health/publications/CHILD_HEALTH/Lancet_CS.htm

• Where supplies of water are unsafe, a bottle-fed baby is up to 25 times more likely to die as a result of diarrhoea than a breastfed child.

The original reference for the '25 times' figure is the following paper. The words 'up to' are used because of risk factors and findings of other studies giving a lesser figure.

Why promote breastfeeding in diarrhoeal disease control programmes? Isabelle de Zoysa, Marina Rea and José Martines. Diarrhoeal Disease Control Programme, WHO, Switzerland. Health Policy and Planning; 6(4): 371-379. http://heapol.oxfordjournals.org/cgi/content/abstract/6/4/371

An extract:

Breastfeeding and the risk of diarrhoea

Impact on mortality

In their review, Feachem and Koblinsky (1984) found limited (mostly pre-1950) literature on the relative risks of mortality in infants on different feeding modes. Most of the studies showed that breastfeeding protected substantially against death from diarrhoea. When infants who were receiving no breast milk were contrasted with infants on exclusive breastfeeding, the median relative risk of death from diarrhoea during the first 6 months of life was 25.

When partially and exclusive breastfed infants were contrasted, the median relative risk of death from diarrhoea was 8.6. In a recent case-control study of infant mortality in southern Brazil (Victora et al. 1987), infants who received no breast milk were 14 times more likely to die of diarrhoea than infants who were fed breast milk without food supplements, after allowing for confounding variables, including age.

Also, infants who received cow’s milk or milk formula in addition to breast milk were three to four times more likely to die of diarrhoea than infants who were fed breast milk without food or milk supplements; even feeding with water, tea or juice, in addition to breast milk, was associated with an increased risk of diarrhoeal death (Victora et al. 1989).

A dose-response relationship was observed in which each additional daily breastfeed was associated with a substantial decrease in the risk of diarrhoeal death.

Findings from another peer-reviewed paper:

Effect of breastfeeding on infant and child mortality due to infectious diseases in less developed countries: a pooled analysis WHO Collaborative Study Team on the Role of Breastfeeding in the Prevention of Infant Mortality. The Lancet. Vol 355: 451-455.
http://www.thelancet.com/journals/lancet/article/
PIIS0140673600820115/abstract

Extract:

Findings: We identified eight studies, data from six of which were available (from Brazil, The Gambia, Ghana, Pakistan, the Philippines, and Senegal).

These studies provided information on 1223 deaths of children under two years of age. In the African studies, virtually all babies were breastfed well into the second year of life, making it impossible to include them in the analysis of infant mortality.

On the basis of the three studies, protection provided by breastmilk declined steadily with age during infancy (pooled odds rations: 5.8 [95% CI 3.4-9.8] for infants < 2 months of age, 4.1 [2.7 – 6.2] for 2-3 month-olds, 2.6 [1.6-3.9] for 4-5 month-olds, 1.8 [1.2 – 2.8] for 6-8-month-olds, and 1.4 [0.8 – 2.6] for 9-11 month-olds).

In the first 6 months of life, protection against diarrhoea was substantially greater (odds ratio 6.1 [4.1 – 9.0]) than against deaths due to acute respiratory infections (2.4 [1.6 – 3.5]). However, for infants aged 6-11 months, similar levels of protection were observed 91.9 [1.2 – 3.1] and 2.5 [1.4 – 4.6], respectively). For second-year deaths, the pooled odds ratios from five studies ranged between 1.6 and 2.1. Protection was highest when maternal education was low.

• Expensive baby foods can also increase family poverty. Poverty is a major cause of malnutrition.

The impact of the cost of baby foods has been documented since the Baby Killer report in the 1970s, which noted:

“In Nigeria, the cost of feeding a 3 month old infant is approximately 30% of the minimum urban wage. By the time that infant is 6 months, the cost will have risent to a crippling 47%. In Nigeria, as in most developing countries the minimum wage is what the majority earn.

“The situation is similar in most developing countries. The Protein Advisory Group of the United Nations (PAG) published a table giving the cost of artificially feeding a baby as a percentage of the minimum wage in some of these countries.” [See the report].

Bringing it bang up to date, in 2007 the financial impact of artificially feeding a child was reported in a film from UNICEF Philippines.

• Poor people often over-dilute the baby milk powder to make it last longer. The baby may then become malnourished.

Looking back to the early history, The Baby Killer booklet quotes the UN Protein Advisory Group:

“’In the less technically developed areas of the world… immediate and serious basic difficulties attend attempts to artificially feed young infants on a cows’ milk formula’ (milk powder) says the PAG Manual on Feeding Infants and Young Children. ‘These include lack of sufficient money to buy adequate quantities, poor home hygience (including water supply, fuel, feeding utensils, storage etc.) and inadequate nutritional knowledge of the mother. Under these conditions, usual for the majority in less developed countries, artificial feeds means the use of too diluted, highly contaminated solutions of cow’ milk.”

Studies on the appropriateness and safety of using infant formula in interventions to improve health outcomes for infants of HIV-infected mothers have provided more recent data. A study by Dr. Mickey Chopra et al of the University of the Western Cape Public Health Programme found:

All the HIV positive mothers were struggling financially and there were a number of examples of over-diluted formula milk or insufficient amounts being given to nonbreastfed babies to save expense.”

Summary of the Findings and Recommendations from a Formative Research study from the Khayelitsha MTCT Programme, South Africa. Chopra M, Shaay N, Sanders D, Sengwana J, Puoane T, Piwoz E, Dunnett L. University of the Western Cape Public Health Programme; USAID/SARA Project; DoH Provincial Authority of Western Cape. May 2000. See: http://www.linkagesproject.org/media/publications/Technical%20Reports/
InfantFormula_UNICEF_Art&Science.pdf

A WHO paper for South East Asia on action in an economic crisis, updated 4 September 2006 noted http://www.searo.who.int/EN/Section1243/Section1310/Section1343/
Section1344/Section1351/Section1683_7189.htm

“Rather than the protective effect of exclusive breast-feeding (and the fact that breast milk is free), infants will potentially be weaned to an infant formula that may be overly diluted (because of its expense, even if subsidized) and prepared with contaminated water (because of the difficulty and expense of boiling or using bottled water for proper formula preparation) in situations with unsafe water supplies.”

The 2007 film from UNICEF Philippines also refers to the risks from over-dilution of formula.

• Breastfeeding saves lives. Even undernourished mothers can breastfeed.

A report prepared for the 15th anniversary of the Innocenti Declaration on breastfeeding support in 2005, suggested breastfeeding saves 6 million lives every year. See our report in Update 37 which has links.

According to UNICEF: "If a mother is moderately malnourished, she will continue to make milk of good quality, better than infant formula. If she is severely malnourished, the quantity of breastmilk produced for each feeding may be diminished. In both cases, for the health of the mother and the child, it is safer and better to feed the mother adequately while helping her to continue breastfeeding."

See:
http://www.unicef.org/programme/breastfeeding/related.htm

IBFAN actively works with the Emergency Nutrition Network to ensure that field staff are trained to support breastfeeding mothers and to ensure that locally-sourced breastmilk substitutes are used safely should they be necessary.

• Nestlé marketing encourages mothers and health workers to favour artificial feeding.

The idealizing nature of Nestlé's marketing can be seen from the monitoring evidence cited above.

There have been many studies showing the impact of promotion on infant feeding advice and decisions.

Office prenatal formula advertising and its effect on breast-feeding patterns. Howard C et al. Obstetrics and Gynaecology Vol 5, No 2, Feb 2000 p296-303 This study of 547 pregnant women, compares the effect of formula company-produced materials about infant feeding to breast-feeding promotion materials without formula advertising on breast-feeding initiation and duration. Although breast-feeding initiation and long-term duration were not affected, exposure to formula promotion materials increased significantly breast-feeding cessation in the first 2 weeks. Additionally, among women with uncertain goals or breast-feeding goals of 12 weeks or less, exclusive, full, and overall breastfeeding duration were shortened. The study concludes that formula promotion products should be eliminated from prenatal settings.

Evidence for the 10 Steps to successful breastfeeding, Tables 1.1, and 6.4 and 6.5. WHO Geneva 1998 This (and many other useful documents) can be downloaded from WHO’s website:
http://www.who.int/child-adolescent-
health/publications/NUTRITION/WHO_CHD_98.9.htm

The influence of Infant Food Advertising on infant feeding practices in St Vincent, International Journal of Health Services Vol 12 No 1 1982 p 53 to 75.

A Social Science Perspective on Gifts to Physicians from industry, Dana J et al, JAMA, July 9, 2003 - Vol 290, no 2: 252-255. (published after the trial.)

Breastfeeding in Norway – where did they go right? A Gerrard, British Journal of Midwifery, 2001 May, vol. 9, no. 5, p: 294-5, 297-300, (21 ref), http://www.cinahl.com/cgi-bin/refsvc?jid=1450 ISSN: 0969-4900. This comparative paper between Scotland and Norway, analyses the historical, social and cultural factors that influence the prevalence of breast-feeding. It concludes that the strong cultural norm to breast-feed in Norway is partly because of a more relaxed attitude towards the naked human body, a healthier lifestyle in general but also because strategies to reverse the effects of commercial promotion of formula milk, and inconsistent advice by health professionals were implemented at an early stage of the declining trends.

Do consumer infant feeding publications and products available in physicians' offices protect, promote, and support breastfeeding? Valaitis RK, Sheeshka JD, O'Brien MF. School of Nursing, McMaster University, Hamilton, ON, Canada. J Hum Lact. 1997 Sep;13(3):203-8.

Commercial hospital discharge packs for breastfeeding women (Cochrane review). Donnelly A., Sonwden HM, Renfrew MJ, Woolridge MW. In: The Cochrane Library, Issue 2, 2002 Oxford: Update Software.

The U.S. infant formula industry: is direct-to-consumer advertising unethical or inevitable? Cutler BD, Wright RF. Health Mark Q. 2002;19(3):39-55. T, Until Nestle's entry into the U.S. infant formula market in 1988, there was little direct-to-consumer promotion of infant formula. This article provides a historial background of infant feeding in the United States and looks at how mothers' make their infant formula selection.

Violations of the international code of marketing of breastmilk substitutes: prevalence in four countries. Taylor, A BMJ 1998;316:1117-1122. This study by Anna Taylor of the Interagency Group on Breastfeeding Monitoring (IGBM) is based on interviews of 3050 women and 466 health professionals in 165 health facilities in Bangladesh, Poland, South Africa, and Thailand. See above.