The Lancet 2023 series on breastfeeding: Unveiling the predatory tactics of the formula milk industry

Breastfeeding has proven health benefits for both mothers and babies in high-income and low-income settings alike, yet less than 50% of babies worldwide are breastfed according to WHO recommendations. For decades, the commercial milk formula industry has used underhand marketing strategies designed to prey on parents’ fears and concerns to turn the feeding of infants and young children into a multibillion-dollar business, generating huge benefits. The immense economic power accrued by commercial milk formula manufacturers is deployed politically to ensure the industry is under-regulated and that services supporting breastfeeding are under-resourced. These are the stark findings of this 2023 Lancet breastfeeding series.

The authors of this three-paper series outline the multifaceted and highly effective strategies used by commercial formula manufacturers to target parents, healthcare professionals and policy-makers. They describe how the industry’s dubious marketing practices - which are in breach of WHO’s International Code for the Marketing of Breastmilk Substitutes - are compounded by the lobbying of governments, often done covertly via trade associations and front groups, which act to erode breastfeeding protection laws and food standard regulations.

In the first paper of the series, Pérez-Escamilla et al (2013) describe how normal infant behaviours develop over the early months of their lives and how these influence feeding practices. They identify that common infant adaptations to the post-birth environment - including crying, unsettled behaviour and short night-time sleep durations - are often misconceived as signs of feeding problems, and that self-reported insufficient breastmilk continues to be one of the most common reasons for introducing commercial milk formula and stopping breastfeeding.

The second paper in this series (Rollins et al, 2023) addresses how the marketing of commercial milk formula operates. The authors document how the formula industry has reframed these normal behaviours to leverage parents’ anxieties and aspirations in promoting their products. The marketing of commercial milk formula is a multifaceted, sophisticated, well-resourced and powerful system of influence that generates demand for, and sales of, its products at the expense of the health and rights of families, women and children. Digital platforms and the use of individual data for personalised and targeted marketing have substantially enhanced the reach and influence of this system. Manufacturers claim their products can alleviate discomfort or improve night-time sleep, and also infer that formula can enhance brain development and improve intelligence - all of which are unsubstantiated. Infant feeding is further commodified by cross-promotion of infant, follow-on, toddler and growing-up milks using the same branding and numbered progression, all of which aims to build brand loyalty and is a blatant attempt to circumvent legislation prohibiting the advertising of infant formula.

The political and economic forces that enable this commercial influence and undermine breastfeeding in the context of major gender inequities are presented in the third paper of this series (Baker et al, 2023). The authors present several structural drivers that contribute to the widespread inadequacy of breastfeeding promotion, protection and support within healthcare systems, such as gendered and biomedical power systems that undermine culturally appropriate and women-centred maternity care; ideological factors that accept and encourage corporate influence within health systems; and economic policies that constrain public budgets. The inadequacy of governments and economic systems in recognising the value of breastfeeding and care work (which is predominantly done by women), as well as insufficient investments in maternity protection, are also factors underpinning the growth of commercial milk formula markets. Half a billion women worldwide, most of whom are in underpaid, precarious or informal work, are denied adequate maternity protection.

The authors therefore argue that the marketing of commercial milk formula products should not be permitted. A framework convention, placing the rights of children and women at its heart, is needed to protect parents and communities from the commercial marketing of food products for (and to) children younger than three years old, including commercial milk formula marketing systems. The framework would restrict the marketing, but not the sale, of these products.

Overcoming structural barriers to breastfeeding requires determined and wide-ranging reforms that extend beyond the health sector. These reforms include actions aimed at social and political mobilisation and at curtailing corporate and financial power. Governments have an obligation to ensure their citizens have access to impartial information about feeding infants and young children, as well as to enact policies that are free from commercial influence. The full and equitable support for women and children’s rights at home, at work, in public spaces and in healthcare is a societal responsibility.

Baker P, Smith JP, Garde A et al (Lancet Breastfeeding Series Group) (2023) The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress. The Lancet, 401, 10375, 503-524. https://doi.org/10.1016/S0140-6736(22)01933-X

The Lancet (2023) Unveiling the predatory tactics of the formula milk industry. The Lancet, 401, 10375, 409. https://doi.org/10.1016/S0140-6736(23)00118-6

Pérez-Escamilla R, Tomori C, Hernández-Cordero S et al (Lancet Breastfeeding Series Group) (2023) Breastfeeding: Crucially important, but increasingly challenged in a market-driven world. The Lancet, 401, 10375, 472-485. https://doi.org/10.1016/S0140-6736(22)01932-8

Rollins N, Piwoz E, Baker P et al (Lancet Breastfeeding Series Group) (2023) Marketing of commercial milk formula: A system to capture parents, communities, science, and policy. The Lancet, 401, 10375, 486-502. https://doi.org/10.1016/S0140-6736(22)01931-6