Improving nutritional outcomes in infants

Feeding babies exclusively on breast milk until at least six months of age, and then continuing breastfeeding as other foods are introduced, is known to be the best possible nutritional start to life. This pattern also reduces the chances of the child becoming obese, and lowers their risk of developing heart disease and diabetes later in life. Currently, however, formula milk is big business, and the product is aggressively marketed worldwide. This is in spite of efforts to restrict advertising under the World Health Organisation’s International Code of Marketing of Breast-milk Substitutes, adopted in 1981. The issue is particularly challenging in low- and middle-income countries, where paying for a product rather than using a free natural alternative may be perceived positively by an aspirational population.

This project aimed to ascertain the extent of existing literature in both countries; to examine a snapshot of current advertising for formula milk; and to explore the impact of formula advertising on parents’ and health professionals’ attitudes and practices around infant feeding.

Methods

The same study protocol was used in two sites (one urban and one rural) in Australia and four (two urban and two rural) in Indonesia. There were three phases to the study:

A literature review of Australian and Indonesian databases, looking for studies on the influence of formula advertising. This served as the literature review for the main study and was useful in identifying gaps in information available on, for example, exclusive breastfeeding rates in both countries.

A snapshot of formula advertising and availability in each study location. Surveillance in supermarkets and other locations recorded health and nutrition claims on packaging, price promotions and incentives for packaged infant foods, the display of infant foods and point-of-sale promotions, and co-located and co-branded formula milks for pregnant or nursing mothers or growing-up milks (those identified as for 12 months of age or more).

In-depth interviews with health professionals, mothers and community members in the chosen sites.

Findings

Literature on the impact of advertising and marketing on infant feeding is generally of low quality in both Indonesia and Australia. There is evidence that formula milk companies incentivise staff in Indonesia through providing free samples, training sessions and the like. Providing information for staff also occurs in Australia, where there is work showing that women perceive any formula advertising (e.g. for follow-on milks) as advertisements for baby formula. There is great need for more sophisticated and high-quality studies to assess the impact of formula advertising.

In both Australia and Indonesia, formula milk is very easy to find. There is a wide range of products other than newborn infant milk – e.g. follow-on milks for toddlers, formula for pregnant and lactating mothers, and formula for the elderly. This may serve to normalise the product in the minds of the public.

Co-branding is very common, with newborn formula often packaged in exactly the same way as formula for older children. Code-compliant advertising for toddler milks can easily be interpreted as promoting newborn formula.

In Australia, the snapshot identified point-of-sale promotion, cross promotion, health claims, a telephone advice service provided by a manufacturer, and relationship marketing. In Indonesia, the snapshot identified point-of-sale promotions, gifts with purchase, volume sales incentives, cross promotion, health and nutrition claims, and aspirational presentation.

The main findings from health professional interviews were similar in both countries. They include:

• That health workers have limited access to independent information and education about formula milk.
• That in the absence of information, many health workers turn to advertising.
• That in Indonesia, some health workers promote or supply formula milk products personally (in their private practice).
• That in Australia, some health workers abandon parents to advertising messages.
• That when health workers have limited capacity to assess and rectify breastfeeding problems, formula milk offers a ‘low cost’ solution.

Interviews with mothers showed that:

• They need more support in breastfeeding, especially at the start.
• A lack of independent information about formula is a challenge.
• An evangelistic approach to breastfeeding (especially in Australia) may compromise the relationship between mothers and their health care workers.
• Mothers tended to ‘medicalise’ normal newborn issues – e.g. regarding posseting as reflux – suggesting that they are vulnerable to formula milk advertising that offers solutions.