Working with companies that manufacture breastmilk substitutes: An EAACI position paper.

Breastmilk is the optimal source of nutrition for infants and should ideally be provided exclusively for the first 6 months of life, and alongside complementary food until 2 years of life. However, there are circumstances where a breastmilk substitute (BMS) may be required. This includes maternal and/or child conditions or personal preference. Whilst these circumstances should never be used as an opportunity to promote BMS, healthcare professionals (HCPs) need to have the knowledge of suitable alternatives and should always be guided by scientific and health motives when recommending a BMS. The Task Force 'Milk Formula Industry Sponsorship' from the European Academy of Allergy and Clinical Immunology (EAACI), provides with this publication recommendations for EAACI interactions with the BMS manufacturers and how this will be supervised.

Cross-sectional examination of commercial milk formula industry funding of international, regional and national healthcare professional associations: protocol.

INTRODUCTION: Commercial milk formula manufacturers often emphasise their role in supporting infant and young child nutrition and breastfeeding, but their commercial goals to increase volume and profit margin of formula sales conflict with these declarations. Healthcare professional associations have an important role in healthcare worker education, shaping clinical practice. When healthcare professional associations enter into financial relationships with formula manufacturers, conflicts of interest arise, which may undermine education and practice that promotes optimal infant and young child feeding. The World Health Assembly calls on all parties to avoid such conflicts of interest, but it is uncertain how often this recommendation is followed. This protocol documents a systematic method to identify funding from the commercial milk formula industry among international, regional and national associations of healthcare professionals. METHODS AND ANALYSIS: Using systematic search strategies in the Gale Directory Library and Google, we will identify international healthcare professional associations relevant to maternal and child health. Data regarding funding relationships with the commercial milk formula industry over the past 24 months will be extracted from the official websites or, in their absence, social media accounts by two independent analysts. The analysis will focus on the presence of conflict of interest or sponsorship policies and type of funding, such as sponsorship or payment for services. ETHICS AND DISSEMINATION: This study does not require ethical approval and will use data available in the public domain. The results will be disseminated through peer-reviewed journal articles, at conferences and among the healthcare professional associations.

Levelling up health in the early years: A cost-analysis of infant feeding and healthcare.

BACKGROUND: Although breastfeeding is recommended as the optimal form of nutrition in the first six months, it is not sustained as the predominant mode of feeding infants in Scotland. This study estimated the impact of infant feeding choices on primary and secondary healthcare service costs in a 13-year birth cohort. METHOD: Using linked administrative datasets, in a retrospective cohort design of 502,948 singletons born in Scotland between 1997 and 2009, we estimated the cost of GP consultations and hospital admissions by area deprivation and mode of infant feeding up to 6-8 weeks for ten common childhood conditions from birth to 27 months. Additionally, we calculated the potential healthcare savings if all infants in the cohort had been exclusively breastfed at 6-8 weeks. Discounting of 1.5% was applied following current health economic conventions and 2009/10 used as the base year. RESULTS: Over the study period, the estimated cost of hospital admissions in the cohort was £111 million and £2 million for the 2% subset of the cohort with primary care records. Within each quintile of deprivation, exclusively breastfed infants used fewer healthcare services and incurred lower costs compared to infants fed (any) formula milk. At least £10 million of healthcare costs may have been avoided if formula-fed infants had been exclusively breastfed within the first 6-8 weeks of birth. CONCLUSIONS: This study using a representative birth cohort demonstrates how breastmilk can promote equitable child health by reducing childhood illness and healthcare utilisation in the early years.

Powdered Baby Formula Sold in North America: Assessing the Environmental Impact.

Background: According to the Intergovernmental Panel on Climate Change, Greenhouse Gas emissions must decline by around 45% by 2030 and reach net zero in 2050. Biofuels, solar, and wind energy are obvious choices for reduction of the 75% of emissions from the energy sector (including transportation), but making reductions in the remaining 25%, the food sector, is more of a challenge. One way is to change our diets to increase low-carbon food alternatives. Objective: We chose to examine the impact of powdered baby formula products. The aim of this study is to compute a minimal estimate of green house gas (GHG) emissions for powdered baby formula products sold in North America comprising Canada, Mexico, and the United States. Results: We found that in 2016, the North America Greenhouse Gas emissions (in tons of CO2 eq.) attributable to sales of powdered formula for Canada was 70,256, for Mexico, 435,820, and for the United States, 655,956. The North American per capita emissions based on infants and toddlers from birth to 36 months of age in 2016 was, at a minimum, 59.06 kg of CO2 eq. Conclusion: The environmental and Greenhouse Gas impact of powdered baby formula, and related hazards arising from climate change, can be a relevant factor for health care providers in their advice to families on infant feeding. This study makes an innovative and potentially useful addition to the emerging evidence on this issue and should be considered when developing and funding infant and young child feeding policies and supportive programs.

The Economic Impact of Donor Milk in the Neonatal Intensive Care Unit.

OBJECTIVE: To assess the cost-effectiveness of mother's own milk supplemented with donor milk vs mother's own milk supplemented with formula for infants of very low birth weight in the neonatal intensive care unit (NICU). STUDY DESIGN: A retrospective analysis of 319 infants with very low birth weight born before (January 2011-December 2012, mother's own milk + formula, n = 150) and after (April 2013-March 2015, mother's own milk + donor milk, n = 169) a donor milk program was implemented in the NICU. Data were retrieved from a prospectively collected research database, the hospital's electronic medical record, and the hospital's cost accounting system. Costs included feedings and other NICU costs incurred by the hospital. A generalized linear regression model was constructed to evaluate the impact of feeding era on NICU total costs, controlling for neonatal and sociodemographic risk factors and morbidities. An incremental cost-effectiveness ratio was calculated for each morbidity that differed significantly between feeding eras. RESULTS: Infants receiving mother's own milk + donor milk had a lower incidence of necrotizing enterocolitis (NEC) than infants receiving mother's own milk + formula (1.8% vs 6.0%, P = .048). Total (hospital + feeding) median costs (2016 USD) were $169 555 for mother's own milk + donor milk and $185 740 for mother's own milk + formula (P = .331), with median feeding costs of $1317 and $936, respectively (P < .001). Mother's own milk + donor milk was associated with $15 555 lower costs per infant (P = .045) and saved $1812 per percentage point decrease in NEC incidence. CONCLUSIONS: The additional cost of a donor milk program was small compared with the cost of a NICU hospitalization. After its introduction, the NEC incidence was significantly lower with small cost savings per case. We speculate that NICUs with greater NEC rates may have greater cost savings.

Effects of United States WIC infant formula contracts on brand sales of infant formula and toddler milks.

The United States (US) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides free infant formula to low-income families with infants. State WIC agencies periodically solicit bids from manufacturers for the exclusive contract to provide infant formula in exchange for considerable rebates. Using Nielsen 2006-2015 retail scanner data, we estimated a difference-in-difference model to examine how winning a WIC infant formula contract affects sales of the new (winning) and former brands, including effects on sales of products not eligible for WIC (spillover). One year following a contract change, volume sales of WIC infant formula increased 322% (p < 0.01) for the new brand and decreased 77% (p < 0.01) for the former brand. Spillover effects included a 43% increase in sales of toddler milks for the new brand 2 years after the contract change. State WIC contracts allow manufacturers to market formula directly to consumers and may reduce breastfeeding policy effectiveness.

US toddler milk sales and associations with marketing practices.

OBJECTIVE: Extensive marketing of 'toddler milks' (sugar-sweetened milk-based drinks for toddlers) promotes unsubstantiated product benefits and raises concerns about consumption by young children. The present study documents trends in US toddler milk sales and assesses relationships with brand and category marketing. DESIGN: We report annual US toddler milk and infant formula sales and marketing from 2006 to 2015. Sales response models estimate associations between marketing (television advertising spending, product price, number of retail displays) and volume sales of toddler milks by brand and category. SETTING: US Nielsen retail scanner sales and advertising spending data from 2006 to 2015. PARTICIPANTS: Researchers analysed all Universal Product Codes (n 117·4 million) sold by seven infant formula and eight toddler milk brands from 2006 to 2015. RESULTS: Advertising spending on toddler milks increased fourfold during this 10-year period and volume sales increased 2·6 times. In contrast, advertising spending and volume sales of infant formulas declined. Toddler milk volume sales were positively associated with television advertising and retail displays, and negatively associated with price, at both the brand and category levels. CONCLUSIONS: Aggressive marketing of toddler milks has likely contributed to rapid sales increases in the USA. However, these sugar-sweetened drinks are not recommended for toddler consumption. Health-care providers, professional organizations and public health campaigns should provide clear guidance and educate parents to reduce toddler milk consumption and address misperceptions about their benefits. These findings also support the need to regulate marketing of toddler milks in countries that prohibit infant formula marketing to consumers.

Standard and Specialized Infant Formulas in Europe: Making, Marketing, and Health Outcomes.

Infant formulas are the only suitable substitute for human milk. The most common infant formulas are standard formulas based on cow's milk. In addition, there are formulas for infants showing signs and symptoms of intolerance and for clinical conditions such as allergy, prematurity, and gastrointestinal diseases. A comprehensive review of the literature was made to review the composition of standard and specialized infant formulas and analyze indications for use, real or presumed nutrition differences and properties, and impact on infant growth. A brief consideration on costs is outlined for each formula. Over the past few years, industrial production and advertising of infant formulas have increased. Human milk still remains the most complete source of nutrition for infants and should be continued according to the current recommendations. Few differences exist between infant formulas, both for the nutrition action and the macronutrient/micronutrient composition. Specialized infant formulas have limited indications for use and high costs. The role of the pediatrician is crucial in the management of infant nutrition, promotion of breastfeeding, and prescribing of specialized formulas only in specific clinical conditions.

A commentary on the carbon footprint of milk formula: harms to planetary health and policy implications.

Background: Infant formula requires mass production by the dairy industry, with plastic and other waste and degradation of land and waterways. Millions of babies, two thirds globally, now have milk formula, with breastfeeding in dramatic decline in Asia. Economic cost externalities and commercial incentives: Economic thinking clarifies that markets are not perfect - price incentives can lead to excessive and inefficient environmental damage. Market prices paid to produce or use a commodity may not reflect its true resource costs. The ongoing global transition in infant and young child feeding (IYCF) toward milk formula use makes urgent the investigation of its environmental costs, including greenhouse gas (GHG) implications. Socially vulnerable populations are also particularly exposed to climate change risks, but have the least voice and agency. The important role of public health advocacy: Few question the scale of the baby food industry, especially in major food exporting countries. Breastfeeding advocacy non-government organisations have led the investigations, and exposed the inequitable vulnerabilities. A ground-breaking study in 2016 showed emissions from just six Asia Pacific countries were equivalent to 6 billion miles of car travel. Each kilogram (kg) of milk formula generated 4 kg of (carbon dioxide (CO2) equivalent) greenhouse gas during production. Much of this was from unnecessary toddler formula. Recent research reveals that if looking at the full product lifecycle, including consumer use, GHG emissions per kg are actually three times higher than these pioneering estimates. Environment and health harms combined with economic evidence highlight the place for a strong public health response on this issue. Conclusion: Formula feeding is a maladaptive practice in the face of contemporary global environmental and population health challenges. Breastfeeding protection, support and promotion helps to safeguard planetary and human health by minimising environmental harm. It is a beneficial response to concerns about disease burdens and climate change. Breastfeeding populations are more resilient in emergencies. Effective and cost-effective policies and interventions exist for increasing breastfeeding and reducing unnecessary use of formula. Implementing such measures presents a rare opportunity to both reduce the greenhouse gas problem and improve human nutrition, health, and health equity.

Child health, infant formula funding and South African health professionals: Eliminating conflict of interest.

Despite clear evidence of the benefits of exclusive and continued breastfeeding for children, women and society, far too few children in South Africa (SA) are breastfed. One of the major impediments to improving this situation is the continued and aggressive marketing of breastmilk substitutes (BMSs) and infiltration of the BMS industry into contexts with exposure to health professionals. In this article we, as academics, practitioners and child health advocates, describe contraventions of the regulations that protect breastfeeding in SA and argue that bold, proactive leadership to eliminate conflict of interest in respect of the BMS industry is urgently required, together with far greater investments in proven interventions to promote and support breastfeeding.

An economic analysis of human milk supplementation for very low birth weight babies in the USA.

BACKGROUND: An exclusive human milk diet (EHMD) using human milk based products (pre-term formula and fortifiers) has been shown to lead to significant clinical benefits for very low birth weight (VLBW) babies (below 1250 g). This is expensive relative to diets that include cow's milk based products, but preliminary economic analyses have shown that the costs are more than offset by a reduction in the cost of neonatal care. However, these economic analyses have not completely assessed the economic implications of EHMD feeding, as they have not considered the range of outcomes affected by it. METHODS: We conducted an economic analysis of EHMD compared to usual practice of care amongst VLBW babies in the US, which is to include cow's milk based products when required. Costs were evaluated from the perspective of the health care payer, with societal costs considered in sensitivity analyses. RESULTS: An EHMD substantially reduces mortality and improves other health outcomes, as well as generating substantial cost savings of $16,309 per infant by reducing adverse clinical events. Cost savings increase to $117,239 per infant when wider societal costs are included. CONCLUSIONS: An EHMD is dominant in cost-effectiveness terms, that is it is both cost-saving and clinically beneficial, for VLBW babies in a US-based setting.

Assessing the Lifetime Cost-Effectiveness of Low-Protein Infant Formula as Early Obesity Prevention Strategy: The CHOP Randomized Trial.

BACKGROUND: Although there is a growing number of early childhood obesity prevention programs, only a few of them are effective in the long run. Even fewer reports exist on lifetime cost-effectiveness of early prevention strategies. This paper aimed to assess the lifetime cost-effectiveness of infant feeding modification aiming at reducing risk of later obesity. METHODS: The simulation model consists of two parts: (a) Model I used data from the European Childhood Obesity Project (CHOP) trial (up to 6 years) and the German Interview and Examination Survey for Children (KiGGS) (6-17 years) to evaluate BMI trajectories of infants receiving either lower protein (LP) or higher protein (HP) content formula; and (b) Model II estimated lifetime cost-effectiveness based on Model I BMI trajectories. Compared to HP formula, LP formula feeding would incur lower costs that are attributable to childhood obesity across all decades of life. RESULTS: Our analysis showed that LP formula would be cost-effective in terms of a positive net monetary benefit (discounted 3%) as an obesity prevention strategy. For the 19% of infants fed with formula in Germany, the LP strategy would result in cost savings of € 2.5 billion. CONCLUSIONS: Our study is one of the first efforts to provide much-needed cost-effectiveness evidence of infant feeding modification, thereby potentially motivating interventionists to reassess their resource allocation.

Cost-effectiveness analysis of infant feeding modalities for virally suppressed mothers in Canada living with HIV.

OBJECTIVE: The aim of the study was to determine whether exclusive breastfeeding or exclusive formula feeding is more cost-effective when a Canadian mother with HIV is adherent to antiretroviral therapy and has full virologic suppression. DESIGN: Current Canadian guidelines recommend that mothers with HIV practice exclusive formula feeding. This contradicts the updated World Health Organization (WHO) guidelines which recommend that mothers with HIV should breastfeed for ≥12 months while receiving support for antiretroviral therapy adherence. Due to the economic and health risks and benefits associated with each modality, there remains expert disagreement on whether the WHO recommendations should be adopted in high-income countries. METHODS: A microsimulation model was developed to estimate lifetime costs and effectiveness (i.e., infant's quality-adjusted life years) of a hypothetical group of 1,000,000 initially healthy, HIV-negative infants, if the mother with HIV was on antiretroviral therapy with full virologic suppression and either exclusive breastfeeding or exclusive formula feeding. The model was developed from the economic perspective of the Ontario Ministry of Health, taking into account direct costs associated with infant feeding modality as well as related indirect costs born out of the child's lifetime health outcomes. Uncertainties related to model parameters were evaluated using one-way and probabilistic sensitivity analyses. RESULTS: In comparison to exclusive formula feeding, exclusive breastfeeding was the dominant feeding modality (i.e., less costly and more effective) yielding cost-savings of $13,812 per additional quality-adjusted life year gained. Neither one-way nor probabilistic sensitivity analyses altered the conclusions. CONCLUSIONS: Despite the risk of HIV transmission, exclusive breastfeeding was more cost-effective than exclusive formula feeding. These findings merit review of current infant feeding guidelines for mothers with HIV living in high-income countries.

The World Health Organization Code and exclusive breastfeeding in China, India, and Vietnam.

Promoting exclusive breastfeeding (EBF) is a highly feasible and cost-effective means of improving child health. Regulating the marketing of breastmilk substitutes is critical to protecting EBF. In 1981, the World Health Assembly adopted the World Health Organization International Code of Marketing of Breastmilk Substitutes (the Code), prohibiting the unethical advertising and promotion of breastmilk substitutes. This comparative study aimed to (a) explore the relationships among Code enforcement and legislation, infant formula sales, and EBF in India, Vietnam, and China; (b) identify best practices for Code operationalization; and (c) identify pathways by which Code implementation may influence EBF. We conducted secondary descriptive analysis of available national-level data and seven high level key informant interviews. Findings indicate that the implementation of the Code is a necessary but insufficient step alone to improve breastfeeding outcomes. Other enabling factors, such as adequate maternity leave, training on breastfeeding for health professionals, health systems strengthening through the Baby Friendly Hospital Initiative, and breastfeeding counselling for mothers, are needed. Several infant formula industry strategies with strong conflict of interest were identified as harmful to EBF. Transitioning breastfeeding programmes from donor-led to government-owned is essential for long-term sustainability of Code implementation and enforcement. We conclude that the relationships among the Code, infant formula sales, and EBF in India, Vietnam, and China are dependent on countries' engagement with implementation strategies and the presence of other enabling factors.

The Economic Influence of Breastfeeding on the Health Cost of Newborns.

BACKGROUND: Breastfeeding provides health benefits for women and newborns. However, few studies have explored how these health benefits translate into economic savings. RESEARCH AIM: This study aimed to estimate the healthcare costs savings generated by exclusive breastfeeding for healthy newborns. METHODS: We designed a longitudinal two-group observational study that included healthy women and newborns ( N = 236) in Toledo, Spain. Over the first 6-months of the infants' lives, we reviewed their clinical histories to determine their consumption of healthcare resources and the type of nutrition provided. The sample was categorized into two groups: exclusive breastfeeding ( n = 46) and non-exclusive breastfeeding for 6 months ( n = 190). Two-part regression models were applied to determine whether there were differences in healthcare costs between the groups. RESULTS: The average age of the women was 32 ( SD: 5.3). The average birth weight of the newborns was 3.3 kg. ( SD: 0.38). At 6 months, 19.5% ( n = 46) of the women breastfed exclusively, 28.4% ( n = 67) combined breastfeeding with formula, and 45.8% ( n = 108) used formula only. Healthcare costs during follow-up reached €785.58 (44% for specialized care, 42% for primary care, 9.8% for medical emergencies, 3% for medications and approximately 1% for medical tests). The statistical analysis estimated a lower healthcare cost of between €454.40 and €503.50 for exclusively breastfed newborns. CONCLUSION: Breastfeeding generated savings in healthcare costs; therefore, it could be a cost-efficient option compared with alternatives. Researchers who evaluate the efficiency of strategies that promote breastfeeding can contribute to the sustainability of health services.

Co-occurrence of mycotoxins in commercial formula milk and cereal-based baby food on the Qatar market.

The present study was conducted to explore the occurrence of mycotoxins in commercial baby foods in Doha-Qatar. LCMS/MS- and HPLC-based analysis of baby food (n = 67) for 12 mycotoxins confirmed the presence of aflatoxin M1 (AFM1, 33%), ochratoxin A (OTA, 31%), deoxynivalenol (DON, 27%), aflatoxin B1 (AFB1, 22%), fumonisin B2 (FB2, 10%), zearalenone (ZEN, 4%) and T-2 toxin (2%). Noodles exhibited the maximum contamination percentage, with 33% of the samples being contaminated above the EU maximum limits, for at least one mycotoxin. Among the multi-grain flake samples, up to 28% and for the milk and milk-based-cereal samples, 14% contained at least one mycotoxin above the EU maximum limits. From all cereal-based food samples, 22%, 5%, 2% and 2% were concurrently contaminated with 2, 3, 4 and 5 mycotoxins, respectively. The occurrence of toxicological important mycotoxins in Qatari market warrants the implementation of strict regulatory limits to protect human health.