Breast Milk Substitutes

Luiz Eduardo Carvalho
Prof. Faculdade de Farmácia

1. History & Symbols

Romulo, Remo and the wolf are symbols of Roman Empire genesis. But that is just one example. The breast milk substitution - or even the mother substitution, as in Rome - is a representation which lives fixed in our minds. The market invisible hand, at the industrial societies, increases and makes such public perception stronger. How could we work for the health information about mother’s milk as a indispensable and no imitatable substance?

2. Nestlé, a letter

A letter was sent by a hypothetical mother, for the Nestle Consumer Relations Dept, asking about differences between theirs products Nan and Nestogen, both of them offered for infant feeding. That mother said she couldn’t breastfeeding her three months old child anymore. She informed she was reading the labels, at the supermarket, but all those dense and available information seemed impossible for understanding. Or not enough.

So, the mother asked if she should substitute the breast milk by Nan or by Nestogeno. And which the differences are between both of those products. 

3. Milk and Images

The public perception, about new processed foods, is being conventionally constructed, using available information offered for adds at TV and magazines, as well as in labels. Or by observations about other consumers behaviour.

For breastmilk substitutes, the national legislation, respecting UNICEF and WHO recommendations, have prohibited all kind of add. Any violations, anyway, here and there, when noted, are denounced and confronted, using the law power, using state’s bureaucratic instruments.

At that way, for conventional violations, conventional repression. But the problem, day by day, is changing, and now we have no-conventional violations, and against these one, conventional repression is definitively not effective.

4. Perception, media times.

Nowadays, in the society of consumption, food is not seen anymore as just a provider of energy and nutrients. The food you take, expresses and represents a behaviour, a personality, a social attitude. A Diet Coke won’t help a corpulent person to become slimmer but is taken by people who are not fat, to show that they are sportive and modern. Foods are like cars, cloth, hairstyles and sunglasses…

In this new context of consumption, the perception is also formed by new mechanisms. Labels are not sufficient anymore, or publicity on the radio, in journals and on TV. Racing cars, caps of sportsmen, shirts from celebrities, marketing in films and shows are new means of (in)formation.

The public perception of BMS seems formed by mechanisms which are even more indirect and complex. If before it was difficult to control the labels and the advertising, nowadays it is impossible to control the new mechanisms. At least not through the old instruments of health monitoring.

In the supermarkets you find on the shelves infant formula and BMS next to the weaning foods (like canned fruits, porridge and even milk powder). To make it worse, these last products are packed in similar tins and with similar labels and using the same brand name; they come from the same manufacturer. And if that is not enough, you also find on those same shelves, all kinds of other products which are not adapted and are completely inadequate as weaning food, like different types of starch. This leads to serious errors by consumers, with all the risks for the health of the baby. This practice also contributes in making the idea more common that it is possible to substitute mothers’ milk by manufactured formula.

Therefore we are not just dealing with the existing risk of substituting mothers’ milk by a manufactured product, by an infant formula like Nan, Nestogeno or Similac. Together with the image becoming more common, the practice becomes more common and the risk grows that a substitute will be used for a substitute. The growing risk that people will use cows milk in powder form or mere use starch or another milk flour, to substitute mothers’ milk.

Not even the most serious monitoring on labelling and advertising could prevent this from happening. The problem is, while commercial practice can look for informal ways, improvise in a rapid and mutant way, the health legislation remains static and formal. To resume: can legislation, as well as the organisms of the controlling body, not deal anymore with all those "creative" and non-conventional violations?

Or, in other words, for indirect violations, we need indirect coercions.

5. Perception, the traditional focus

What do we know and what do we want about breastfeeding and weaning? We want breastfeeding to continue for at least 4 months. We want that, if it is impossible to breastfeed, scientists will give us technically the best infant formula to feed our babies. And finally we want this formula to be used only in exceptional cases, always keeping in mind that it can never compete with breast milk.

How can we guarantee that these 3 rules are being followed? Information is important. Cultural values are fundamental and monitoring the market, to prevent a too early introduction of weaning foods, is indispensable.

We should not loose time trying to prove that infant formulas are inferior to breast milk, nor loose time trying to establish our own version of standards for identity and quality of these formulas. We simply are convinced that breast milk is unique. Those who pretend to process substitutes are the ones who need to prove, with scientific facts, and with proposals of standards, its potentialities, its intentions and a feasibility of control.

If manufacturers, lately, have used contaminated ingredients, or have forgotten to include certain nutrients which are indispensable, such as essential oil acids (?), this means a criminal act. Our role is to make that known; to point out mistakes and tendentiousnesses here and there in the standards they propose.

We can, eventually, comply with certain standards in which, in principal, and taken into account the available information, we do not encounter any serious incorrectness. But we are not here to agree with these standards. And least of all to elaborate a version of the standards. By doing that we would legitimate a product of which we are convinced that it can never compete with breast milk. Our efforts should be pointed towards affirming breast milk world-wide. The rest is detail, and can be dealt with by national delegations at the Codex Alimentarius.

We just have one wish and a proposal: that the industry and the scientists will succeed in producing a formula which is biologically identical to breast milk. But even then, we will be against your work, since breast feeding is not only nutrition and immunisation, but also love and ecology.

6. Standardisation and control

For conventional violations, like advertisements which contain lies and, in the case of infant feeding, any advertisement, by any means (which is prohibited), we always used conventional instruments of coercion: monitoring and fines etc.

But for the new violations, which can not be seen as direct and institutional violations, but are made by indirect means and are sublime, we need non-conventional instruments. Governments only work with legal and conventional instruments and, in view of this scenario, NGOs are rising with their typical manifestations, for example in the case of Green Peace.

Also referring to BMS, non-conventional actions, promoted by NGOs, are part of history. The Nestle boycott, as an instrument of pressure, against the commercial practices of this company, which provoked early weaning in, so called, risk groups, form an outstanding example of a very successful non-conventional action.

7. Nestle, the answer

Months after the letter was sent by the mother, Nestle responded, also by writing. They hesitated between recommending Nan or Nestogeno for her baby of 3 months old. They also informed her that, unfortunately, they were not able to give her an answer since the case was very complex. They recommended the mother to consult a paediatrician, ensuring her that Nestle keeps paediatricians regularly informed about how and when to use the products, which should guarantee her of a good advice.

Products like Nan and Nestogeno have labels with an extended volume of nutritional (pseudo)information. What’s the use of all that information, if it is not sufficient for a mother to decide between Nan and Nestogeno?

This is again an example of non-conventional advertising. In fact, the nutritional information on the labels do not give any information nor do they explain anything. They contain an extensive list of nutrients, quantifying the composition of the product. Only nutritionists will be able to understand the information without the help of technical literature. The information does not inform but establishes an image: that the product contains so many nutrients which makes it so nutritious that it is very good, even for babies.

Therefore, there is only one answer possible: before using a doctor needs to be consulted. If the label is altogether incomprehensible, the information can as well be left out. Just keep one advice on the label, as a warning: Consult a doctor before use!

8. No ads, no supermarket, no claims…

The International Standards, recommended by the WHO/UNICEF, represent a part of the Ethical Code. It is not a commercial contract between companies, where each can look for ways to cheat the spirit of the agreement, using the creativeness of their lawyers and trying to maximise their profits.

This Code prohibits any kind of advertising for BMS. But companies are looking for non-conventional ways, like exposing the products in supermarkets, or by marketing in the cinema and on TV. The labels are used to build misleading images.

In this context it is necessary to proceed with the control. It is not sufficient anymore to prohibit advertising. It is necessary to prohibit the presence in supermarkets etc. It is necessary to completely clear the label, leaving just the warning, written in colour: consult a doctor before use.

This looks radical but, as we see it, it was Nestle itself who indirectly proposed this in its response to the mother. In the letter, Nestle admitted that, although so much information is presented on the label, it is impossible to get sufficient and correct information on which to base the decision to use Nan or Nestogeno.