Parents may reasonably ask why, with research demonstrating the many and serious potential health hazards of routine bottle-feeding, do so many otherwise competent doctors continue to take a neutral or even pro-formula stance with their patients? As pediatrician and author Dr. Jay Gordon noted in the book "So That's What They're For: Breastfeeding Basics," by Janet Tamaro-Natt: "This [infant feeding] seems to be the one area where you can practice medicine in the 1990s -- with 1960s know-how -- and not get sued."
The failure of many medical professionals to fully inform their patients of the impact of infant feeding choices is due in large part to their own ignorance of the facts. Most obstetricians, pediatricians and nurses graduate from their professional training having had little or no exposure to the most up-to-date literature or clinical practice in this area. In fact, a recent AAP survey revealed that 45 percent of pediatrician respondents stated that they see formula-feeding and breast-feeding as equally acceptable methods for feeding an infant. The survey further noted that "nearly equal proportions of pediatricians agree and disagree as to whether formula-fed babies are just as healthy in the long run as breast-fed babies (34 percent vs. 38 percent); 27 percent are undecided." These statistics reveal a shocking unfamiliarity with the large and growing body of current research on this topic.
In many cases, health care providers' views on infant feeding are based on their own, highly personal experiences. A nurse who chose to formula-feed her own children or a doctor whose wife weaned her baby at three weeks is unlikely to be an effective advocate for breast-feeding. A large-scale study of physicians' knowledge of human lactation in a 1995 issue of the Journal of the American Medical Association reported that the most important factor influencing the effectiveness and accuracy of a doctor's breast-feeding advice to patients was whether the doctor herself, or the doctor's wife, had breast-fed her children. In a March 1999 report on breast-feeding promotion efforts by American doctors, Pediatrics magazine concluded, "A majority of pediatricians believe that breast-feeding and formula-feeding are equally acceptable methods for feeding infants. Furthermore, reasons given for not recommending breast-feeding include medical conditions such as mastitis, nipple problems, low milk supply, jaundice, and low weight gain, which have recognized therapeutic approaches that generally do not preclude breast-feeding."
"Doctors need to do better in giving their patients good information and support regarding infant feeding," says Dr. Gartner, who has traveled the country offering lactation training to physicians and hospitals. "But it takes a great deal more education to do this. It's easy to explain to parents why they should put their baby in a car seat, but human lactation is much more complex. Many, if not most doctors are carrying around a lot of wrong information about breast-feeding versus bottle-feeding. In order to be effective, they have to unlearn those misconceptions."
Infant formula companies have traditionally targeted health-care professionals as the quickest route to convincing mothers that formula-feeding represents a safe, nourishing option for their babies. Physicians and nurses in the U.S. routinely receive gifts, office supplies, meals, a year's supply of free infant formula for themselves or a relative and even pricey vacations from the infant-formula marketing representatives who haunt their offices. According to Dr. Dettwyler, some pediatric residency programs are largely underwritten by infant-formula manufacturers, an allegation verified by the National Association of Breastfeeding Advocacy and the International Lactation Consultants Association. Not surprisingly, more than 70 percent of surveyed pediatricians recently reported to the AAP that they recommend a particular brand of infant formula to their patients. (In contrast, Pediatrics reported that only 65 percent of pediatricians surveyed recommend exclusive breastfeeding for the first month after birth; only 37 percent recommend breastfeeding for the first year, as recommended last year by the AAP.)
The 1996 annual report from Abbott Laboratories, makers of Similac infant formula, took note of this cozy tie between the medical community and infant-formula manufacturers, stating that, "Abbott's close relationship with pediatricians and other health-care providers serves as the foundation for the company's solid market position in the United States. Pediatricians are also key to the success of the consumer education programs, such as the Welcome Addition Club ... a program that provides new and expectant parents with a broad range of information, from nutrition and breast-feeding tips to basic parenting skills."
In 1994, after years of stalling by Republican administrations that opposed it, the United States joined every other developed nation in the world as a signatory to the "WHO Code," an international agreement that, among other things, calls for an end to formula promotion and giveaways through the health-care system and includes a clause stating that "no financial or material inducements should be offered by [infant formula] manufacturers or distributors to health workers, or members of their families, nor should these be accepted." Despite the WHO Code, virtually all hospitals in the United States offering maternity services -- as well as the majority of individual obstetricians and pediatricians -- continue to provide massive free advertising from the huge pharmaceutical companies that produce and market formula in the United States. Such promotional material comes in the form of formula giveaways, patient "educational literature" produced by the formula companies and even free baby equipment such as diaper bags.
Obviously, marketing and product giveaways on this scale cost infant-formula companies millions and millions of dollars each year. But it pays off. Their own market research, as well as medical literature and anecdotal observations by lactation professionals, have demonstrated that these tactics make it statistically less likely that a women will breast-feed without supplementation or breast-feed at all. And once a woman stops nursing and begins feeding infant formula, these companies know that they likely have her "hooked" on their product, since even a brief interruption in the nursing relationship can cause a woman's own milk supply to dwindle or the baby to begin refusing breast in favor of bottle.
American hospitals have largely shrugged off the idea that accepting free formula and large cash "donations" in return for a particular formula company's right to market directly to its patients represents an ethical problem. Around the world, thousands of hospitals have become certified by the World Health Organization as "Baby-Friendly" by agreeing to aggressively and accurately promote breast-feeding and to end the practice of allowing infant-formula companies to offer freebies to personnel or patients. In the United States, however, fewer than 20 hospitals and birthing centers have received the Baby-Friendly designation.
"Hospitals should not be accepting free infant formula from these companies. They know that if they didn't accept it, they would have a reduced sense of obligation to promote formula. Their continued acceptance of this practice says something important," notes Dr. Cunningham.
Because the WHO Code hasn't been incorporated into federal law in the United States as it has in some other countries, it is impossible to enforce. And although American infant formula companies claim to voluntarily adhere to the code's provisions, including no direct marketing of infant formula to consumers, they openly flout the code and their own assurances of compliance. This can be made clear by flipping through any popular parenting magazine or watching any television program geared toward women in which appealing ads for infant formula are abundant. Nestli, the notorious maker of Carnation brand formulas, is perhaps most disingenuous when it comes to adherence to the WHO Code. On its Carnation Baby Web site, parents who live in other countries are asked to read a statement in which Nestli makes a feeble attempt to comply with the code by warning against bottle-feeding. American parents entering the site receive no such statement from Nestli.
Many breast-feeding advocates believe that infant-formula manufacturers are now attempting to influence parents through product placement in the entertainment industry. During the 1998-1999 television season, particular brands of infant formula were displayed on episodes of the television programs "Mad About You" and "Chicago Hope." In one notable episode of "Chicago Hope" from last season entitled "The Breast and the Brightest," the plot revolved around the death of a breast-fed infant due to malnutrition. Woven throughout the episode were inaccurate statements regarding the Baby-Friendly Hospital Initiative (BFHI) and breast-feeding in general. BFHI and La Leche League International, as well as Medela, a leading manufacturer of breast pumps, felt compelled to issue formal responses to the content of the program, characterizing it as a "gross misrepresentation."
Interestingly, the entire last season of "Chicago Hope" was sponsored by the Pharmaceutical Research and Manufacturers of America (PhRMA), whose membership is made up of pharmaceutical companies, including those that manufacture and market infant formula. According to a PhRMA press release, sponsorship of "Chicago Hope" was part of a collaborative effort between Johns Hopkins Medicine, PhRMA, CBS Television stations and 20th Century Fox, "to relate to viewers on medical concerns at a time when their awareness is heightened on such issues." PR Newswire reported in September 1998 that the PhRMA-sponsored episodes would "educate viewers" on "issues such as ... the risks associated with breast-feeding."
The reasons behind these marketing efforts are crystal-clear: The manufacture and sale of commercial infant formula is an unbelievably profitable enterprise. U.S. infant-formula sales reached approximately $2.59 billion in 1993, representing a 6-percent increase over 1992. Today that figure is estimated to be at $3 billion and climbing. Since 1989, when formula companies lifted their previous voluntary ban on marketing directly to consumers, the market has grown by 54 percent. The average bottle-feeding family in the United States spends between $800 and $2000 per year on infant formula. With such a lucrative product to promote, corporations have wisely enlisted the assistance of new parents' most trusted advisors -- health-care providers -- in order to retain and increase their markets.
Infant-formula manufacturers attempt to hide behind the empty-sounding "breast is best, but ..." disclaimer that most of them include with their advertising (although even this statement appears to be slowly disappearing from infant-formula advertising). However, the simple fact is that breast-feeding itself is the most dangerous and formidable competitor formula companies have. Every time a woman chooses to breast-feed instead of bottle-feed her baby, the pharmaceutical companies lose approximately $1,000 in sales. Because the companies that produce formula also develop and market medications and medical supplies, they must be acutely aware that the higher rates of illness suffered by formula-fed children as a group also affects their bottom line, possibly even more than the sale of the formula itself. For example, Abbott Laboratories, aside from making Similac and Isomil, also produces Pediasure, an oral rehydrating solution for infants and young children with diarrheal disease. The company also produces antibiotics widely used to treat infant infections, as well as products for diabetics.
Experts agree that there is a role for the appropriate use of commercial infant formula. It should always be used for infants under 12 months in lieu of any type of homemade formula or whole cow, goat, or soy milk. The problem, they say, is with the way it is marketed and represented to parents.
"Infant formula should be seen for what it is: a pharmaceutical product, not for routine use," says Dr. Dettwyler. "The way these companies market it as equivalent to breast milk and just one equal choice among several is wrong."
While commercial infant formulas are commonly perceived to be the medically recommended second-choice infant food after breast-feeding, the World Health Organization (WHO) actually states: "The second choice is the mother's own milk expressed and given to the infant in some way. The third choice is the milk of another human mother. The fourth and last choice is artificial baby milk." For mothers who are unable to breast-feed their own babies, a small network of human milk banks exists in the United States. The informal sharing of breast milk and wet nursing has been common throughout human history; the first U.S. milk bank opened in Boston in 1911. Today, the seven regional milk banks belonging to the Human Milk Banking Association of North America (HMBANA) follow strict health and safety guidelines -- similar to that of a blood bank -- for the collection, processing and distribution of milk donated by breast-feeding mothers. According to Andrea Morgan, Executive Director of the Mothers' Milk Bank at Austin, Texas, and HMBANA vice president, banked human milk is currently available by prescription only, and as more people seek an option other than infant formula for their infants, the demand continues to be greater than the supply.
"The limiting factor really is the amount of milk on hand," explains Morgan. "Healthy newborns have lowest priority, regardless of the status of the mother. There is simply too much demand from sick and premature babies and other gravely ill children, where mothers' milk represents survival and a decent shot at good health, with no real good alternative. More publicity helps to generate more donors. People call me all the time and say they've been dumping breast-milk because they didn't have room in the freezer and didn't realize there was an alternative. It also helps to spread the word to more physicians, who become interested in having this milk available to their sick patients."
Currently, the small scale on which human milk is processed and distributed makes it prohibitively expensive for most families compared to infant formula. It costs about $2.50 to purchase one ounce of processed, banked human milk. Infant formula, while still expensive -- costing between $75 and $175 per month for an exclusively formula-fed infant -- is based on abundantly available and cheap agricultural products such as cow's milk or soybeans.
"Some insurers pay [for banked human milk] if they realize that these patients will have lower overall health-care costs. Medicaid also pays in some states," says Morgan. "The processing fee that we charge covers only about half the cost to process the milk. And all milk banks exist because of some other type of support: Either they are located in a hospital that provides a substantial operating subsidy or, as in our case, a community-based, not hospital-based bank. We must constantly work to raise funds. But no medically needy recipient is denied milk for inability to pay."
With the current high cost and limited availability of banked human milk, commercially produced infant formula generally remains the only available alternative for those mothers who are truly unable to breast-feed their babies due to adoption, maternal HIV infection or other factors. And unfortunately, in the United States, because of inflexible work schedules, a lack of societal support and an epidemic of medical mismanagement, nursing is often made extraordinarily difficult for even the vast majority of women who are physically capable of breast-feeding their children. But Dr. Gartner believes that if more parents understood the stark realities of the risks inherent in artificial feeding, they would no longer stand for a situation in which they are literally forced by external circumstances to feed their babies an expensive, potentially hazardous product in lieu of a safe, available one -- their own breast milk.
"Women are simply not getting informed on this issue," says Gartner. "In many cases, advertising and promotion have led parents to believe that there is no substantive difference between breast-feeding and formula-feeding in the United States and of course, this is far from being the case. I urge parents to read and learn as much as they can about relative health outcomes in children before they decide how they will feed their baby. Studies have shown that when women are educated on this issue -- even when they then decide not to breast-feed -- they don't feel guilty. But most women, when they find out all the facts, do feel cheated and very, very angry."