Overview

The availability and marketing of breast milk substitutes or infant formula is a contentious issue for many public health organisations, health professionals and breastfeeding mothers. However, when breast milk in any form is not available the only suitable alternative nutrition for infants is infant formula.

What is infant Formula?

Infant formula is an industrially produced milk product designed for infant consumption; an infant is defined as being a person aged up to 12 months. Usually based on cow’s milk, formula has added vitamins and enzymes and different fats that infants need. Infant formula is not equivalent to breast milk. It lacks many of the factors present in breast milk, including numerous types of living cells, cholesterol, polyamines, free amino acids, glycosamine and enzymes and other bioactive substances.¹

The most recent data on rates of infant formula use is from the National Health Survey in 2001. This data showed that there was an increase in formula and solids use from 1995 to 2001 in infants three months or less in age (see Figure 8.1).

The Queensland Health Infant and Child Nutrition in Queensland report released in 2005 found that 12 per cent of children commenced regular formula use on the first day of life and 23 per cent had commenced regular consumption before four weeks of age.²

There is a wide range of infant formula available and most of them are of similar quality and nutritional value although there is some evidence that suggests formula with added long chain poly-unsaturated fatty acids (LCPUFAs), naturally found in breast milk, assists in brain development.³ It should be noted that any benefits that LCPUFAs in infant formula offer for cognitive development are smaller than the advantage of breast milk over formula for infants.⁴

Critical to the safe use of infant formula are the following requirements:

• a safe water supply;
• sufficient family income to meet the costs;
• effective refrigeration;
• clean surroundings; and
• satisfactory arrangements for sterilising and storing equipment.⁵

Standards for the quality, composition and labelling of infant formula sold in Australia are regulated through Standard 2.9.1 in the joint Australia and New Zealand Food Standards Code. Standard 2.9.1 provides for the compositional and labelling requirements for foods intended or represented for use as a substitute for breast milk. This Standard applies to all infant formula products whether in powder, liquid concentrate or ‘ready to drink’ forms. This standard also provides for infant formula products intended for infants with special nutritional requirements. Infant formula products are regarded as a special purpose food and as such have both specific and stringent standards that infant formula manufacturers need to follow regarding composition and labelling.

There is a second standard for foods for infants, Standard 2.9.2. This covers products that are not milk based; for example, canned infant foods, infant cereal products and products that may be sold in jars. This standard indicates that the label on a package of food for infants must not include a recommendation, whether express or implied that the food is suitable for infants less than four months old. Currently Food Standards Australia New Zealand (FSANZ) is reviewing the minimum age labelling requirements of foods for infants under standard 2.9.2. The purpose of this review is to align the labelling requirements for infant foods currently prescribed in the code with the NHMRC Dietary Guidelines, which recommend exclusive breastfeeding for six months. FSANZ noted that it hopes to have this completed by the end of 2007.⁶

The committee considers that the minimum labelling requirement of foods for infants should be changed to reflect the NHMRC infant feeding guidelines. The committee notes that several participants to the inquiry provided evidence of the labelling of infant foods as being suitable for four to six months of age;⁷ there was concern that this labelling clearly contradicted the NHMRC Dietary Guidelines that recommend a baby should be exclusively breastfed for the first six months.

Infant formula information

The Director General of the World Health Organisation reported to the World Health Assembly in 1992 on infant and young child nutrition.  In this report, it was pointed out that even from a viewpoint of fostering competition, direct advertising to mothers with infants in the first four to six months of life was singularly inappropriate because:

• advertising infant formula as a substitute for breast milk competes unfairly with normal, healthy breastfeeding, which is not subject to advertising, yet which is the safest and lowest cost method of nourishing an infant; and
• advertising infant formula as a substitute for breast milk favours uninformed decision making, bypassing the necessary advice and supervision of the mother’s physician or health worker.⁸

In this respect, the Director General’s report concluded, it can be considered that advertising of infant formula fails to achieve the objectives of ensuring best quality and the lowest cost and creating an informed public, which are among the benefits assumed to be a result of direct advertising.⁹

Infant formula manufacturers contend that they need to be able to provide information to mothers who have made the choice to use infant formula.¹⁰ Nestlé notes that:

• their website contains positive and supportive information and advice on breastfeeding;
• information on infant nutrition and products is shown on the website only after visitors read and accept a statement on the positive health benefits and superiority of breastfeeding; and
• the website does not promote, through pictures or words, formula over breastfeeding, but does provide factual information on the use of formula should individuals make the choice to do so.

Heinz Australia are concerned that the use of formula is being politicised and would like to see ‘…the use of formula milk be depoliticised and treated objectively as a routine aspect of baby care, rather than as a moral issue ...’ and that while breastfeeding is encouraged, mothers who do not breastfeed are not made to feel inferior.¹¹

Breastfeeding advocates and consumers have criticised the marketing of infant formula in Australia where it is marketed as a remedy for common infant behaviour, such as loose bowel motions, not sleeping and being hungry.¹² Professor Colin Binns notes that an authoritative guide, the Dietary Guidelines for Children and Adolescents in Australia, to the use of infant formula has been prepared and is readily available. He contends that infant formula companies could assist by publicising its existence and by distributing reprints.¹³

WHO Code

The WHO Code:

• bans all advertising and promotion of products to the general public;
• bans samples and gifts to mothers;
• requires information materials to advocate for breastfeeding, warning of the risks of artificial feeding and not containing pictures of babies or text that idealise the use of breast milk substitutes;
• bans the use of the health care system to promote breast milk substitutes;
• bans free or low-cost supplies of breast milk substitutes;
• allows health professionals to receive samples but only for research purposes and bans gifts;
• demands that product information be factual and scientific;
• bans sales incentives for breast milk substitutes and contact with mothers;
• requires that labels inform fully about the correct use of infant formula and the risks of misuse;
• requires labels to not discourage breastfeeding.¹⁶

Subsequent World Health Assembly resolutions have added clarification to aspects of the code including, for example, resolution 47.5 (1994) which addressed the provision of samples, to ensure that there are no donations of free or subsidised supplies of breast milk substitutes and other products covered by the International Code of Marketing of Breast-milk Substitutes in any part of the health care system.¹⁷

The Marketing in Australia of Infant Formulas: Manufacturers and Importers (MAIF) Agreement

Australia has not fully implemented the WHO code even though it was one of the early signatories. Instead, in 1992 the Commonwealth Government introduced the Marketing in Australia of Infant Formulas: Manufacturers and Importers (MAIF) Agreement, to set out the obligations of manufacturers and importers of infant formulas in Australia. The MAIF Agreement is a voluntary self-regulatory code of conduct between manufacturers and importers to Australia of infant formula. It was authorised in 1992 under the Trade Practices Act 1974¹⁸ but is not legally binding.¹⁹

The MAIF Agreement covers the marketing in Australia of infant formulas when such products are marketed or represented to be suitable for use as a partial or total replacement to breast milk. It also covers the quality and availability of such products and the provision of information concerning their use. It applies only to manufacturers and importers of infant formulas for use up to 12 months of age, not to retailers or distributors and does not include other milk products, foods, beverages or feeding teats.

The aim of the MAIF Agreement is to help ensure safe and adequate nutrition for infants:

• through the protection and promotion of breastfeeding;
• by ensuring the proper use of breast milk substitutes when they are necessary²⁰ on the basis of adequate information; and
• through appropriate marketing and distribution.²¹

The WHO Code and MAIF - differences

The major points of difference between the MAIF and the WHO Code were recently described by the International Baby Food Action Network (IBFAN) (See Figure 8.2).

Advisory Panel on the Marketing in Australia of Infant Formula (APMAIF)

A government advisory panel, the Advisory Panel on the Marketing in Australia of Infant Formula (APMAIF), has been established to monitor compliance with, and advise the Government on, the Marketing in Australia of Infant Formula: Manufacturers and Importers (MAIF) Agreement. The panel comprises an independent Chair, a community and consumer representative, a public health and infant nutrition expert, and an industry representative. The Commonwealth Minister for Health and Ageing has responsibility for the appointment of all members except the representative of the infant formula industry.²²

The APMAIF’s terms of reference are to:
receive and investigate complaints regarding the marketing in Australia of infant formulas;
act as a liaison point for issues relating to the marketing in Australia of infant formulas;
develop guidelines on the interpretation and application of the MAIF Agreement; and
provide advice to the Commonwealth Government Minister for Health and Ageing, on the operation of the Agreement.

Anyone can lodge a complaint about an alleged breach of the MAIF Agreement. Breaches of the MAIF are reported in the APMAIF annual reports which are tabled in Parliament. The latest Annual Report for the period 2003-04 was tabled in March 2005.

Between 1999 and 2005 the APMAIF recorded 13 breaches of the Agreement.²³ However, more than 180 complaints were received between 2002 and 2004. Of these complaints 138 concerned retail activity (which is beyond the scope of the MAIF). In addition, where a breach has been found to have been committed by a signatory to the agreement, the panel has no powers to impose a penalty as it can only recommend remedial steps.²⁴

Review of MAIF and APMAIF

The MAIF Agreement and the APMAIF were the subject of an independent review in 2000.²⁵ The subsequent report was known as the Knowles report and it made a number of recommendations.²⁶ The Knowles report indicated that if the recommendations in the report were implemented it would enable Australia’s commitment to the WHO Code to be honoured through a voluntary agreement. If the changes do not achieve such an outcome, then the Knowles report considered it necessary to consider a legislated statutory framework.²⁷

The Knowles report recommended among other things, that the Commonwealth with the states and territories establish a Public Health Partnership to develop strategies to promote breastfeeding but also provide support to mothers who decide not to breastfeed. A further recommendation was the establishment of an Infant Nutrition Coordinator at the national level, to be advised by an expanded APMAIF panel. The Knowles report also recommended that retailers, including supermarkets and pharmacies, develop a voluntary code of practice.²⁸

The Government implemented a number of recommendations in the Knowles Report, but did not accept the recommendation to establish a Public Health Partnership, or the development of a voluntary code of practice for retailers.²⁹ The Knowles report noted that there was ‘basic disagreement’ on the purpose of the MAIF Agreement with key stakeholders and that this was reflected in the differing views of the advocates of breastfeeding and the local infant formula industry.

The Australian Breastfeeding Association (ABA) has criticised the MAIF Agreement, arguing it is nowhere near as extensive or powerful as the WHO code because it applies only to manufacturers and importers of infant formulas but not to retailers. Furthermore, it only covers infant formulas and not other milk products such as follow-on milk for toddlers, or feeding bottles and teats. The ABA is also critical of the voluntary nature of the agreement.³⁰

Infant formula manufacturers view the agreement as providing a ‘framework’ for the provision of information to both mothers who breastfeed and those who use infant formula to feed their infants. A case in point raised in the Knowles report was the issue of samples. Industry was adamant that the provision of samples to health professionals for evaluation was consistent with the Agreement, whereas breastfeeding advocates argued the provision of such samples would result in women being given them free, which would lead to the undermining of breastfeeding.³¹

The Australian context

Significant evidence was provided to the committee that demonstrated infant formula manufacturers in Australia advertise their products in a manner which would clearly breach the WHO Code.³² Although the WHO Code is not currently implemented in Australia the committee considers the Commonwealth Government should be doing more to protect breastfeeding and the limited scope of the MAIF Agreement falls short of providing an appropriate level of protection.

As an example, the committee is quite concerned by the practice of manufacturers using health professionals as surrogate marketers of their products via distribution of free infant formula sample packs to new mothers. The committee considers that the implicit endorsement of a product given when a health professional provides a free sample to a person should not be underestimated. The committee received consistent evidence that samples of infant formula are being made available to mothers through health professionals such as early childhood nurses, doctors and hospitals.³³

The marketing practices of retailers such as pharmacies and supermarkets are also worrying.  As mentioned earlier, from the 180 complaints received by the APMAIF between 2002 and 2004, 138 concerned retail activity which is outside the scope of the MAIF Agreement.  These marketing practices are likely to be in breach of the WHO Code if it was implemented.  The marketing of bottles and teats is also of concern, with the Knowles report encouraging the Government to develop an appropriate agreement on marketing of bottles and teats to reflect the WHO Code as closely as possible.³⁴

The committee also received a wide range of evidence of the ineffectiveness of the MAIF Agreement, ³⁵ although it must be noted that many of the issues described in evidence are beyond the scope of the MAIF Agreement.  There were a total of 170 complaints about possible breaches of the MAIF Agreement made to the APMAIF in 2002, which resulted in only one breach. The following year 60 complaints were made, again resulting in one breach. The Justice and International Mission Unit of the Uniting Church in Australia was informed that both complaints were submitted by a competing company in the infant formula industry who is also a member of the APMAIF.³⁶

The committee was very unimpressed with the timeliness of APMAIF, including their investigating time and reporting to the Commonwealth Parliament. It is not satisfactory to the committee that the most recent report is the 2003-04 report which was tabled in 2005. Another concern is a perception that there is a potential lack of independence from the industry in the APMAIF. Currently, 70 per cent of the APMAIF is sponsored by the infant formula industry, and the industry has a representative on the panel of four people.³⁷

Additionally when the MAIF Agreement was developed, some aspects of the WHO Code were not feasible to implement because some of the pricing restrictions contained in the WHO Code could not be authorised under the Trade Practices Act 1974. In 1988 the Trade Practices Commission concluded that ‘the voluntary implementation of a self-regulatory scheme, based on the full WHO Code, was not feasible. The pricing restrictions contained in the WHO Code amounted to breaches per se of the Trade Practices Act and could not be authorised in any circumstances’.³⁹

In contrast, infant formula manufacturer Nestlé does not consider that there is any evidence to support the introduction of new measures with respect to marketing of infant formulas.⁴⁰

The Justice and International Mission Unit of the Uniting Church in Australia provided a recent legal opinion that challenges the ruling of the Trade Practices Commission. The opinion states that the Commonwealth Parliament would not be restricted from passing legislation which enacted the WHO code by virtue of the Trade Practices Act provided the instrument introducing the WHO Code complies with the National Competition Principles Agreement (CPA). The CPA is an intergovernmental agreement which was signed by the Commonwealth and all states and territories in 1995. The agreement provides that legislatures can pass legislation which restricts competition, as long as they have undertaken an analysis and formed the conclusion that the public benefits of the restriction outweigh any potential detriment that may flow.⁴¹ The committee considers that there is clear evidence of significant public benefit through the introduction of the WHO Code.

Implementation of the WHO Code

The World Health Organisation has consistently stated that the appropriate marketing and distribution of breast milk substitutes is only one of several important factors when considering the protection of healthy practices of infant feeding, such as breastfeeding.⁴² The committee agrees that any strategy to improve the rates of breastfeeding in Australia needs to consider the provision of support and advice to expectant and new mothers in addition to providing protection for breastfeeding. 

In light of the earlier recommendations, the committee considers it is time to make a decisive and clear statement of the importance of breastfeeding to the Australian community by implementing the full WHO Code and subsequent WHA resolutions.⁴³ The committee notes that there are two main forms in which the WHO Code and subsequent WHA Resolutions could be introduced into Australian law. These are:
Commonwealth legislation; or
a prescribed mandatory industry code of conduct under the Trade Practices Act.⁴⁴

The committee recognises that the implementation of the WHO Code is a significant action but believes that if the Commonwealth Government wants to achieve the goal of 80 per cent of mothers exclusively breastfeeding for the first six months of their baby’s life, the WHO Code needs to be implemented in Australia. The committee recommends accordingly.

Breastfeeding information – other sources

According to The Sydney Morning Herald newspaper, Australians spent over $38 million on books in the Family, Health and Relationships category. Of those, 25.4 per cent had titles about pregnancy and parenting.⁴⁵ The impact that information from books can have on prospective or new parents is significant. Some inquiry participants raised concerns about the accuracy of information about breastfeeding in pregnancy and parenting books and the effect these books might have.⁴⁶

I have felt it mostly in the plethora of sleep training books available, and the implicit holy grail of parenting, i.e. if your baby is not sleeping through the night by 3-4 months of age, you have failed as a parent. I have read several of the most popular ones, and the breastfeeding information in these is inaccurate, and in many cases would lead to a mother unable to breastfeed as it would interfere with her milk supply, or feeling that she has to stop breastfeeding as it interferes with the child sleeping for longer stretches.⁴⁷

Online parenting websites and forums have also become increasingly popular. There is an increasing range of these, both based in Australia and internationally. They can be linked to a commercial interest, such as the Mother and Baby magazine or run by organisations such as the ABA. Forums are a source of information and peer support for many mothers. However, they are often a place where myths about both breastfeeding and infant formula can be observed.⁴⁸

EMAP, a publisher of parenting magazines in Australia, noted that their news stand magazines and commercial discharge packs, as of April 2007, will not contain any sales promotion of infant formula or related products which encourage alternatives to breastfeeding.⁴⁹ They will continue to contain educational material which actively encourages breastfeeding. EMAP estimated that they have so far turned away advertising revenue of approximately $1 million.⁵⁰ There were some participants in the inquiry who were disappointed by this decision as they feel that it further marginalises women who, for whatever reason, use infant formula and removes a source of potential information and advice.⁵¹

EMAP is also responsible for the majority of distribution of Bounty bags in Australia. These commercial discharge packs are a means of providing mothers with samples of useful products. Bounty bags are provided to mothers at three stages during the pregnancy. There is a mother-to-be bag, a new mother bag and a new baby bag.

Although these bags are very popular with mothers, research has found that the distribution of written material has been ineffective in increasing breastfeeding rates. Additionally the distribution of commercial discharge packages that contain samples of infant formula or promotional material for infant formula given to mothers as they leave hospital increases the likelihood of infant formula being used over breast milk.⁵² Concern was expressed that new mothers in hospital should not be seen as a ‘captive’ market for advertisers, being bombarded with large quantities of information and advertising when they were extremely vulnerable.⁵³

The committee commends the action of companies such as EMAP in becoming WHO Code compliant across their portfolio and welcomes this proactive stance to protect and promote breastfeeding as the normal way to feed a baby.

Toddler milks

The recent advent of ‘toddler milks’ into the marketplace is of great concern to many inquiry participants.⁵⁴ Toddler milks are typically powdered cow’s milk that has been fortified with vitamins and minerals marketed at the 12 months plus age group. The Infant Formula Manufacturers Association notes that toddler milk products can play an important public health role in fulfilling the nutritional needs to young children when their diets are unsatisfactory, particularly in the instance of iron deficiency.⁵⁵

The Australian Lactation Consultants Association gave evidence to the committee that into the second year of life, milk is actually a subsidiary and solids start to take the primary role. They stated that if a child was given a large amount of milk with high protein and high fat content such as toddler milk, the child was not hungry for the rest of the feed. The result can be eating disorders, where parents force their children to eat, using sweets to reward and keep them eating because they think they are starving, or the child is missing a vital opportunity to learn a variety of diet.⁵⁶

The NSW Government considers that 12 months is not a recommended end point for breastfeeding and commercial formulas promoted for toddlers from 12 months may be regarded as breast milk substitutes. They consider that there is no nutritional requirement to provide toddlers with commercial artificial milk substitutes; however, these products are being strongly marketed due to limitations of the MAIF agreement. The NSW Government believes that measures are needed nationally to address this problem, particularly through strengthening the national codes and agreements.⁵⁷

Concern has been expressed about how toddler milks are advertised.⁵⁸ Toddler milks are not subject to the MAIF Agreement so they can be advertised. It has been comprehensively reported to the committee that toddler milks are in similar packaging and have similar names to infant formula, often with the toddler milk being branded as number 3 (where infant formula and follow-on formula are 1 and 2). Participants to the inquiry consider that this may create an incorrect perception about the necessity of toddler milk and are concerned that it could also lead to brand recognition.

Toddler milk is beyond the scope of the inquiry and so the committee will not be making a recommendation. However, during the course of the inquiry the committee observed the concern that many in the community have about the promotion and marketing of toddler milks. The committee concludes that it is vitally important that infants are exclusively breastfed for six months and then appropriate solids are introduced after this point following the information provided in the Dietary Guidelines chapter Enjoy a wide variety of nutritious foods.⁵⁹ Unless there is a medically indicated condition such as low-birthweight, toddlers should be obtaining the required nutrients from a balanced and appropriate diet, rather than a nutritional supplement such as toddler milk.

Hon Alex Somlyay MP

Chair

National Health & Medical Research Council, Dietary Guidelines for Children and Adolescents in Australia (2003), p 391; Rothenbury A, sub 15, p 3. Back

McVeagh P,‘The World Health Organization Code of Marketing of Breast milk substitutes and subsequent resolutions (The WHO Code),’ NSW Health Bulletin vol 16 (3-4), 2005, pp 67-68. Back