South Africa has celebrated World Breastfeeding Week since 1987, yet it continues to be challenged by low rates of breastfeeding and high levels of child malnutrition. The theme of this year’s global commemoration, observed from 1 to 7 August, is Step up for Breastfeeding – Educate and Support. 

Following the release of the 2022 World Health Organization report on the inappropriate and insidious marketing strategies of the infant formula industry, the food and nutrition fraternity is stepping up to the infant formula industry and its manipulative marketing strategies which undermine women’s infant feeding decisions. 

Generally, mothers hold the infant formula industry in high regard, but it repays them by cleverly exploiting their insecurities, leaving them with negative feelings of failure, discontent, and guilt when they are not able to successfully breastfeed. It has successfully masqueraded as a mother’s rescuer, while milking her insecurities and desires to do the best for her infant.

Infant formula displacing mothers’ milk

A hundred or more years ago, breastfeeding, or surrogate feeding known as “wet nursing”, was the only form of infant nutrition. The introduction of commercial infant formula, primarily promoted and distributed by medical doctors, positioned formula milk as superior to breastfeeding. Today, the false notion that formula is superior or the same as breast milk persists – essentially, it is the best perpetuated fake news to date. 

Every mother’s breast milk is unique to her, like her fingerprint. Her breast milk is tailored for her infant, personalised and customised for her infant’s unique microbiome, health exposures and biophysical condition. Breast milk is a living ecosystem with unique immunoglobulins and anti-infective properties. Breast milk is also continuously adapted to meet the infant’s feeding needs and to provide antibodies against pathogens that seasonally sweep through a given community, providing immune protection the infant cannot launch itself due to its immature immune system. 

Human breast milk helps lay the foundation for the new baby’s immune system. The first breast milk, colostrum, is rich in antibodies and molecules that slow the growth of harmful bacteria and coordinate white blood cell activity in the newborn. Colostrum is the baby’s first immune boosting injection, optimal nutrition, and optimal preventative medicine. 

Breast milk contains more than 200 different sugar molecules, compared with 30-50 molecules in cow’s milk. This rich composition of breast milk favours the colonisation of the infant’s gut with specific healthy bacterial groups that can in turn digest these sugar molecules. 

Breastfed babies have very different gut microflora than formula fed babies, which explains why formula fed babies have high rates of diarrhoea and respiratory tract infections. Formula does not afford babies the unique anti-infective properties that breast milk does – it never will, given that formula is a processed food. Furthermore, formula changes the gut microflora of infants, making them more susceptible to infections. This is especially problematic where there are water quality issues, poor hygiene and sanitation, and inappropriate mixing of the formula. 

Myth 1 busted! Formula is inferior and second best to breast milk.

Falsehood of perceived insufficient breast milk production

Sleek looking formula adverts with large bottles full of milk and plump smiling babies have led mothers, and society in general, to believe that babies drink bottles full of milk and need this to grow optimally. This is another misleading, long-held falsehood. 

Newborns, on average, consume about a teaspoon of colostrum per feed in the first 24 hours of life. Tiny babies have tiny stomachs that have not been fed for nine months. It should come as no surprise they cannot consume full bottles of milk. 

On day one, a baby’s stomach is about the size of a cherry. It holds about 5-7ml, or 1-1½ teaspoons of breast milk for each feeding. The overexaggeration about how much babies feed has fuelled a detrimental perception of what is enough breast milk production, resulting in an obsession with measuring and counting feeds, and counting nappies. It has led to mothers doubting and undermining their ability to produce enough breast milk for their infants. 

Perceived insufficient breast milk is the most common reason mothers introduce top-up feeds of formula.  Overfeeding and overconsumption are subtly sown through clever and misleading marketing ploys. Such manipulative marketing puts undue pressure on mothers to produce breast milk – “like cows”.  Often, mothers are left with feelings of failure, discontent, anxiety, and guilt. 

To counteract the fake news routinely fed to mothers through multiple platforms, it is imperative to educate and support them during the early phase of infant feeding. Interestingly, breastfeeding has been linked to lower stress and improved maternal mood in some studies. Mothers’ negative experiences due to perceived “low milk supply” need to be addressed immediately at delivery and during the first 24 hours.

Understanding that colostrum is produced in small amounts and dispelling unrealistic expectations of gushing volumes of milk will allay mothers’ fears of not producing enough breast milk. 

By day three, newborns’ stomachs have only grown to about the size of a walnut. Their stomachs are now able to hold between 22-27 ml per feeding. Mothers often misinterpret that frequent feeding equates to a hungry baby. Healthy newborns normally feed at least eight-10 times per day in the first week, which helps mothers produce an ample milk supply going forward. 

Myth 2 busted! Babies don’t feed by the litre, but in small frequent feeds which help mothers increase their milk production.

A feeding choice – at what cost?

While infant formula has made infant feeding more flexible and convenient for modern lifestyles, it has come with a plethora of health and development issues. 

There is a place for formula: when moms are separated from their infants by travel, return to work or school, in the case of adoption or critically ill mothers and babies. Yet for the vast majority of women in South Africa on Child Support Grants, infant formula is not an economically affordable decision. Mothers from low-income households are often forced to dilute formula or feed infants watered-down foods like cereal in a bottle. 

This inappropriate and inadequate feeding of infants is fueling South Africa’s high rates of childhood malnutrition, causing  stunting (poor or compromised length and growth), obesity, and unhealthy weight gain. Global evidence shows that infant formula feeding is associated with this double burden of malnutrition. Just as disturbing, poor infant feeding in the first two years of life is associated with poor health outcomes in adulthood such as obesity, diabetes, hypertension and cardiovascular disease. 

Globally, child malnutrition has several intersecting drivers – poverty, disempowerment, lack of agency and lack of protection from a profiteering food industry. Food and nutrition for child health starts with breastfeeding. 

Sadly, South Africa has not invested in a comprehensive maternity protection package. South Africa has one of the lowest breastfeeding rates on the African continent, not because women do not understand the importance of breastfeeding, but because they face a hostile environment to successfully breastfeed their children. 

Formula feeding costs money and resources like fuel for boiling water to reconstitute formula and sterilise feeding utensils. Poor formula feeding practices cost children’s lives in infancy and negatively impact their health in adulthood. 

Myth 3 busted! Formula feeding is not the healthiest choice. 

Building the enabling environment to protect, promote and support breastfeeding

Due to current global crises, with the impact of the Covid-19 pandemic and subsequent economic downturn, women are bearing the brunt of job losses. Female-headed households especially are experiencing a financial shock, with the Ukraine war and ever-increasing food prices compounding the burden of finding food for their families and caring for their children. 

In addition to the multitude of health benefits, breastfeeding means that the money used for formula can instead be directed to purchasing food to meet the needs of the family.  Another strong message from infant feeding manufacturers is that children continue to need these expensive follow-on milks after the age of one – this is not true.  Children can still be breastfed after one, and not be given full cream cow’s milk which is much more affordable. 

Myth 4 busted! 

Unfortunately, marketing exploits mothers’ concerns about children not growing well and positions these expensive products as the solution to meet nutrient needs. In South Africa, nearly one in two households is headed by females, placing the need to provide for their families unfairly on the already burdened shoulders of mothers. Known as “the fatherless nation”, South Africa has one of the highest rates of absentee fathers in the world. It is estimated that nine million children in South Africa grow up without fathers. 

Fathers should not only be seen as food providers. Fathering is also about stepping up to support mothers to breastfeed. Breastfeeding is excellent for infants and young children as a food source, for immune protection, for neurocognitive development, and for emotional self-regulation. 

The first step to creating a supportive, safe breastfeeding environment is to prevent the separation of mothers and babies at birth, especially in private hospitals. This leaves babies vulnerable to the inappropriate practice of top-up formula feeds by health service providers and the disruption of breast milk from the mother. 

The direct and indirect engagement of the infant formula industry with health service providers is regulated by law through the Regulations Relating to Foodstuff for Infants and Young Children, Regulations R991. Strict monitoring and control of the infant formula industry’s relentless engagement with health service providers through sponsorship of all kinds, professional development activities, conferences and learning events are necessary to counteract this insidious extension of the industry’s marketing strategies. 

The formula industry strategically builds relationships with health service providers to buy loyalty and build indebtedness. These wolf-in-sheep’s-clothing tactics have been exposed by the latest Word Health Organization report. In the words of Maya Angelou, “Do the best you can until you know better. Then when you know better, do better.” 

Myth 5 busted – the formula industry is not adhering to Regulation R991 by putting  undue pressure on mothers’ feeding choices. 

Given the body of evidence, promoting and supporting formula is not in the interest of child health and development. In fact, the World Health Organization has set a nutrition target of 50% exclusive breastfeeding for infants under six months by 2025. 

Global breastfeeding rates remain at 43% while South Africa trails behind at 32%. Breastfeeding rates cannot improve while formula companies strongly curtail women’s and families’ choices – often with manipulations so subtle that they go unnoticed and unchallenged.  

Step up for breastfeeding. 

Educate yourself and others and support breastfeeding mothers by calling out the aggressive and insidious marketing strategies of the formula industry. DM/MC

Dr Chantell Witten and Dr Nazeeia Sayed are from the University of the Western Cape, DST/NRF Centre of Excellence for Food Security, Contact: [email protected]