A recent Twitter thread by the World Health Organization (WHO) has sparked quite a bit of discussion online. This series of postings is not the first time that the WHO has made statements promoting breastfeeding as the “best” (which if you’ve read my previous blog post, you know is not a statement I like or endorse). There is a story behind their plight however, and I’m here to shine a light on that (the Nestlé formula scandal) and discuss the issues within this thread.

What did the WHO say?

So in the Twitter thread I mentioned and have linked again here, the WHO is linking to their news statement on the marketing of formula during the COVID-19 pandemic. Under the International Code of Marketing of Breast-milk Substitutes (a code put forward by the WHO in the 1980s), promotion of breast-milk substitutes (i.e. formula) should be prohibited – whether this be public promotion, or promotion done by a healthcare professional. It also states that samples should not be given to mothers (current or to-be) and families. Per the WHO, currently 136 countries have in place some legal guideline related to the code – but they do not necessarily all prohibit its promotion in hospitals or other facilities, nor do they all discourage the use of samples or sponsorship of events or meetings for healthcare professionals.

The Twitter thread breaks down the news article they link to as well as related documents. As the message is related to COVID-19, the WHO states that formula feeding is not safer if mom is COVID positive – rather, mom should continue to breastfeed (if they were already, though this is NOT mentioned in detail in the thread) if physically possible, or turn to expression or donor milk until they are able to start breastfeeding again (I actually covered this recommendation in a previous blog post on COVID-19).

So before I get into the issues that exist within this thread, I want to discuss the Nestlé Baby Milk scandal.

What is the Nestlé baby milk scandal?

In the 1970s, Nestlé was involved in a scandal related to the marketing of their formula to less developed countries. Sales people dressed up as healthcare professionals and distributed samples in the hospitals; they used poor marketing and misled mothers so that they would essentially become reliant on formula (since they stopped breastfeeding, their supply would drop and then they’d have to continue using the formula provided to them by the company).

Infant deaths followed. One major reason for this would be the use of water that was contaminated to make the formula. Another is related to the fact that many were diluting the formula due to the cost of it, leading to cases of malnutrition.

A boycott started and the WHO was at the head of it, fighting for the rights of women and children. In 1981, the code was adopted by the WHO to fight against Nestlé (and other companies producing formula) and their frankly criminal actions against innocent mother-baby dyads in less developed countries.

So what’s wrong with the WHO thread?

I just want to start off by saying I am 100% against the aggressive (in my opinion, criminal) marketing of formula to mothers and families in less developed countries (or aggressive marketing tactics in ANY country to ANYONE). I acknowledge that I am in a position of privilege in that I had the option to feed my baby formula, if wanted or needed, in a safe way (meaning I have access to clean water); that I could afford to buy formula if I needed to use it. What Nestlé did was horrible. I am not in anyway saying that this is acceptable – we should be working as a society to prevent anything like this from ever happening again.

Even though the WHO’s fight against formula companies is primarily geared at protecting innocent women and children (which once again, I support wholeheartedly), their language and strong opposition against formula still matters in today’s day and age. Especially when you’re making these statements on a social media site for all to see.

I do agree with many key parts of the code – I don’t think that formula companies should be able to essentially buy healthcare professionals or people. I don’t think hospitals should be used as a functional advertisement for specific brands of formula. I do think that formula labels should be succinct and provide accurate nutritional and health information.

What I don’t like is the “breast is best” message. I’ve discussed this before – but breast isn’t always the best option for everyone. In the case of women who don’t have access to clean water or can’t afford formula – breast may (or is likely to) be the best option, in which case we should be supportive of that. But what if it isn’t the best option for the mom? WHO should be putting their time and efforts towards improving access to clean water, medical care with a focus in women’s health, and low-cost or free formula. This should be where effort/time/money are going, instead of fighting the formula vs breast fight, which is old and tired. It’s no easy task, but it’s something the WHO (and we, as a society) could work towards.

We know that there are many excellent benefits to breast feeding – if there wasn’t, we wouldn’t have been doing it as long as we have. There is lots of research supporting this. Often breastfeeding has a positive impact on both mother and baby – however, sometimes it has a negative impact on the mother and this is important to acknowledge. The expectation of breastfeeding can be mentally and emotionally destructive to women who either choose not to breastfeed, or can’t breastfeed for various reasons. Perinatal mood/anxiety disorders can be exacerbated by the stress of trying to meet this expectation which is not realistic nor desired by everyone. It is very well possible for ANY woman to experience breastfeeding struggles or to simply prefer not to breastfeed for various very personal reasons.

Although there are of course cultural differences, women in less developed countries can still struggle with PMADs, latch issues, or simply a lack of desire to breastfeed – what we (and the WHO) should be focusing our energy and time on is improving overall conditions for these families. Women/families could keep their children safe while also potentially being able to feed their babies the way that works for them.

I recognize my privilege in having access to both options – and I’d like to see nothing more than that privilege being extended to every woman. Every woman or family should be able to have options. As I said – this is not an easy dream. It’s not as easy as just telling everyone they should breastfeed – but it may be a more satisfying long-term goal for the health and well-being of women and children everywhere.

Some issues I have with the code:

The code states that breastfeeding and its benefits should be emphasized to mothers by healthcare professionals as well as in any educational materials provided by providers or facilities. That doesn’t make sense for a mother who has already made clear her intentions to use formula. It does make sense for a mother who wants to breastfeed, but I also think these mothers should be provided with information on both feeding options (if they want)- because sometimes life throws curveballs and things change. It would be very possible to provide general information on formula in a way that is not advertising a product, but answers common questions for moms who are planning to use it, end up having to use it and so on.

I also don’t like the prohibition of samples or low-cost options. If a mother has told you she has intentions to, or an interest in, formula feeding (or even if they are intending to breastfeed) then isn’t it helpful and supportive to provide them with samples? Some people may need to try various types to find what works for baby. Some people may need assistance in access – even for people living in the Americas or Europe, the cost of formula can be a lot. If we have the ability to provide low-cost options, shouldn’t we support that? I understand the poor history of this with what happened with the scandal – but we could work to find a way that is mutually beneficial for formula companies and those who need formula. It’s been done with other necessary items in the past, so there are lots of examples to work from.

I could argue several other points that are very similar to the above. In the end, my message is the same – we should support what is best for the mother and child, or the family. This could be dependent on income/social status, geographical location, preference, or medical need. It could be dependent on many factors. What is important is that we don’t use language or actions that shame anyone for how they feed their infant. The WHO is using outdated thinking and language – we know breastfeeding has benefits. I don’t think anyone wants to see a scandal similar to the Nestlé scandal happen again – we want aggressive marketing to stop. We want mothers to be informed about their health, and about any products they are using. We want every mother to have access to whatever is best for themselves and their infant.

So we should support breastfeeding, but we should also support formula feeding – the WHO is a health organization for the world, and many women/families in the world use formula. Formula feeding should not be seen as the “lesser” option (because we’re all already familiar with the benefits of breastfeeding) but rather, another way of feeding and providing nutrition to your baby. We should be open-minded and supportive, while also being cognizant of the history and the privilege many of us have to be able to use formula, if needed or desired.

Let us support women feeding their infants. Let us work to make both options accessible to all women.

N.B. I use the words woman and women here a lot – however I also mean families. Some families don’t involve a woman or have lost a mother, and although donor milk is an option to some, formula might also be.

*Disclaimer: This blog is intended for informational purposes only. The information on this blog should not be used as a substitute to medical advice or medical treatment. As always, your Primary Care Provider, a doctor, or another health professional is your best resource for specific questions and medical advice. If you believe you or a loved one are experiencing a medical emergency, please contact 911.*