As just about every expert agrees, breast milk beats formula on every score, from the health of the baby to out-of-pocket costs. But that hasn’t stopped formula makers from pushing their products, cutting deeply into breastfeeding rates around the world.

Their current practices include using Covid-19 as a scare tactic: “Hey Mama, Now’s the Right Time to Start Giving Them Immunity Boosting Nutrition,” one of the best-known formula makers, Swiss-based Nestlé, told potentially fearful mothers in Pakistan on Facebook last year.

Pediatricians, nutritionists and others have been battling the industry for decades, leading the World Health Organization (WHO) to adopt the International Code of Marketing of Breast-Milk Substitutes, in 1981. But if 136 of the 194 WHO member countries have signed on, and most of those have given it teeth by also enacting legislation reflecting at least some of the code, violations are common — never mind that the United States, Australia, Canada, Japan and New Zealand are not signatories.

Consider the provision prohibiting companies from giving free formula samples and coupons to new mothers, just when a decision to not breastfeed is almost irreversible.

Unscrupulous marketing practices were common 40 years ago and still are today, said Grainne Moloney, a senior adviser on early childhood nutrition at Unicef. “They’re preying on the vulnerabilities of mothers, especially in the early days,” she said, “when you’re really struggling with breastfeeding at this kind of level.” She also noted, “They’re talking about products in a scientific way that [has] absolutely no evidence behind this.”

Small wonder that an industry that was valued at $60 billion in 2018 could see its worth jump to $119 billion in 2025, according to Alive and Thrive, a nonprofit global nutrition initiative.

Formula makers can thank Covid-19 for some of that momentum. Despite WHO/Unicef guidelines aimed at protecting babies from exposure — by keeping hands and surfaces clean and masking, for example — formula makers are suggesting that breastfeeding is simply not safe. Some are even making claims of unproven health benefits — claims that are barred by both the World Health Assembly and the Codex Alimentarius standards body for food products, Dr. Laurence Grummer-Strawn, head of WHO’s Department of Nutrition and Food Safety, told PassBlue.

They are saying here’s “this magic bullet that can protect your kid from Covid,” said Lesley Oot, associate director of programs at Alive and Thrive.

In fact, the health benefits of breastfeeding vastly outweigh babies’ potential exposure to Covid, whose “chances of transmission seemed to be pretty low,” Dr. Grummer-Strawn said.

Peddling Formula Where It Makes the Least Sense 

The impact of industry inroads is hard-felt in poorer parts of the world. “In many countries, the pandemic has caused significant disruptions in breastfeeding support services, while increasing the risk of food insecurity and malnutrition,” Unicef’s executive director, Henrietta Fore, and WHO’s director-general, Dr. Tedros Adhanom Ghebreyesus, said in an Aug. 2 statement marking World Breastfeeding Week. “Several countries have reported that producers of baby foods have compounded these risks by invoking unfounded fears that breastfeeding can transmit COVID-19 and marketing their products as a safer alternative to breastfeeding.”

While unethical formula-marketing practices are nothing new, they are now targeting “vulnerable populations and kind of prey upon a lot of the fears and concerns that Covid brought about,” said Karin Lapping, technical director at FHI Solutions, an affiliate of FHI 360, an international nonprofit group that promotes health and human development. The companies are also capitalizing on stressed health systems, “which Covid obviously has impacted tremendously,” Lapping said, reducing their ability to promote breastfeeding. “When you have those fractured services, it just creates another opportunity. . . . And they’re extremely sophisticated, certainly much better funded than we are.”

The WHO international code states flatly that there should be no advertising or other form of promotion to the general public; manufacturers, distributors and health workers should not provide product samples to pregnant women, mothers or family members; there should be no “point-of-sale advertising, giving of samples, or any other promotion device to induce sales directly to the consumer at the retail level”; and packaging should not include pictures of infants or other images or text “that may idealize the use of infant formula.”

Tightening the Code, if Not Enforcement

More recent resolutions by the World Health Assembly (WHA, the WHO’s governing body) call for member states to bar the marketing of infant food products, including foods and beverages marketed for babies under six months — when exclusive breastfeeding is recommended by the WHO — such as juices, baby teas and feeding bottles and nipples. Nutrition and health claims should not be permitted for breast-milk substitutes, including “follow-up formula” and “growing-up milks” (GUMS) for older infants and toddlers, which fall under the scope of the code. Finally, a 2016 WHA resolution says countries should not allow companies selling foods for infants and young children to donate funds to national health care systems or to sponsor professional and scientific health care meetings.

A 2017 update explicitly laid out the dangers of bottle feeding in developing nations, saying: “Artificial feeding is expensive, requires clean water, the ability of the mother or caregiver to read and comply with mixing instructions and a minimum standard of overall household hygiene — factors not readily met in many households in the world.”

According to research by Alive and Thrive, an initiative managed by FH Solutions, and the British-based Baby Milk Action, last year the Paris-based Danone company donated nutritional products for pregnant and lactating women as well as GUMS to Indonesia’s Central Java government, and in April 2020 it also gave masks and hand sanitizers to nurses at 50 government health clinics in Malaysia. Early in the pandemic, in India, Danone ran a video on YouTube showing a doctor advising mothers suspected of having Covid to stay six feet away from their babies and express breast milk rather than feed from the breast. While the video was later removed, Danone continues to run a “Voices of Experts” YouTube channel with videos from health care professionals on such topics as how to improve a baby’s immunity.

A February 2020 Facebook ad for ColosBaby, produced by the VitaDairy company in Vietnam, featured an unauthorized headshot of the WHO’s Dr. Ghebreyesus with the caption: “WHO raises COVID-19 threat warning to its highest level.” The ad’s use of the term “Colos” echoes the word “colostrum,” a key antibody found in a mother’s breast milk immediately after giving birth, and claims it can “boost the immune system” and “prevent respiratory and digestive infections caused by viruses and bacteria.”

It was last year when Nestlé, the world’s largest food and beverage company, donated NanGrow, a toddler formula, to families in Pakistan affected by the Covid lockdown, and had as its tagline on its Facebook page, read: “Hey Mama, Now’s the Right Time to Start Giving Them Immunity Boosting Nutrition.”

In Burkina Faso, in May 2020, Nestlé donated food and beverages to the Ministry of Women, National Solidarity and Family and the Ministry of Humanitarian Action for distribution to internally displaced people, breastfeeding women and children.

Nestlé’s Illuma, a product line of GUMS, ran a two-page ad last year in Singapore’s Mummys Market Pregnancy and Baby Guide touting the benefits of breastfeeding and its properties of immunity while also advertising its Illuma 3 formula containing the fatty acid “sn-2” and milk protein “A2 beta-casein,” properties normally found in breast milk.

Responding to questions from PassBlue, a Nestlé spokesperson, who requested anonymity, said: “We believe that breast milk is the ideal nutrition for infants. This is why we promote the World Health Organization (WHO) recommendation to exclusively breastfeed infants for the first six months of life, followed by the introduction of adequate nutritious complementary foods along with sustained breastfeeding up to 2 years of age and beyond.”

The spokesperson added: “For any donation, we strictly follow our Standard for Donations or Low-Cost Supplies for use in Emergencies and for Social Purposes. We do not donate products which are regulated under the local breast milk substitute (BMS) codes. In the specific cases of Pakistan and Burkina Faso, we donated a wide range of foods and beverages which are for older children and adults and therefore are not covered by the local BMS code, and in some markets, we donated much-needed supplies including hygiene supplies and respirators. The advertisement in Singapore is for a product that is not within the scope of the local code.”

A Danone spokesperson, Louise Belton, said: “At Danone we know breast milk is the best source of nutrition for babies and we believe breastfeeding should be protected and promoted. Danone is the first company to prohibit the promotion of baby formula for children aged 0-six months anywhere in the world, even where it is still permitted by local law. Recently Danone ranked no. 1 in the Access to Nutrition Initiative’s Index for the Marketing of Breast Milk Substitutes, reflecting our approach to ethical marketing of baby formula.”

Noting that “healthcare professionals are best placed to help parents with questions about feeding their little one,” Belton added, “When we talk with healthcare professionals, it’s on scientific and factual grounds.”

The WHO’s own fundraising arm, the WHO Foundation, which was launched in May 2020, in Geneva, created its own controversy when it accepted a $2.1 million gift from Nestlé in April for its Covid-19 Solidarity Response Fund, even thanking the company publicly on the foundation’s Twitter page.

According to a WHO Foundation spokesperson, who requested anonymity, Nestlé was one of 130 organizations that donated to WHO’s Covid-19 health response “to support the provision of vaccines, critical care, oxygen and other emergency support to save lives.”

In addition, “all donations the WHO Foundation accepted are based on the organization’s current Gift Acceptance guideline, which enables the Foundation to receive funds for urgent health responses to the COVID-19 pandemic. WHO Foundation can refuse contributions if a potential donor is acting in a manner that is not compliant with policies approved by the World Health Assembly.”

The spokesperson added, “Nestlé’s work on compliance with World Health Organization-related policies has been raised with the company, and these discussions are ongoing.”

A Nestlé spokesperson told PassBlue that the company’s contribution helped “scale up delivery of more than two billion doses of vaccines to the most high-risk and highly exposed populations globally.” The spokesperson added, “There were no conditions from our side.”

Assurances like this grate on critics like Moloney of Unicef. “The industry in the last 40 years has done nothing to align themselves with the code compliance, and they’re constantly looking for loopholes, they’re constantly looking for opportunities to exploit,” she said, adding that this means ongoing efforts to get mandatory regulations on the books is “really the only way to go.”

Patti Rundall, who works with a British affiliate of the International Baby Food Action Network (Ibfan), a coalition of citizens groups fighting false marketing, noted that suggestions of immune protection belie the known and extensive benefits of exclusive breastfeeding under six months. She drew comparisons with the HIV-AIDS epidemic, when HIV-positive moms were told not to breastfeed for fear of transmitting the virus, and in one country, Botswana, “loads of babies” died as a result.

The Empty Promise of Toddler Formula 

GUMS, made for both infants older than six months and older than a year, are “a completely unnecessary created product that does not need to exist, that children do not need, that is usually full of sugars,” Lapping said. “The way in which they’re marketing it is really problematic,” with packaging that often resembles formula products. “It’s like the Wild West beyond six months of age with these growing-up milks.”

Despite these challenges, Katherine Shats, a Unicef legal specialist who guides efforts to implement the code, thinks much progress has been made, at least in countries with strong legislation. “And you see that playing out in terms . . . of breastfeeding rates; I mean, there’s a direct correlation.”

A 2020 report issued by the WHO, Unicef and Ibfan states that as of April 2020, 70 percent of the 194 WHO member states had enacted legal measures with code implementation provisions. Of these, 25 countries had measures substantially aligned with the code; 42 had measures that were moderately aligned; 69 had included only some provisions; and 58 had no legal measures.

But the pandemic has jeopardized many of these gains. If “you’re trying to get any government to either prioritize passing a law during Covid or enforcing an existing law and there’s just so much else happening in the health care system,” Shats said, things fall through the cracks.

Emergency situations create an opening for violations, said Dr. Arun Gupta, a pediatrician and central coordinator of BPNI, the Breastfeeding Promotion Network of India. For example, once Covid struck, the Ladli Foundation Trust, a grass-roots nonprofit organization in India, teamed up with police there to distribute free Nestlé samples in at least four places in the country before Gupta said his network “started making the noise that this is wrong.” (A Nestlé India spokesperson told the BMJ health care publication a year ago that it had not donated any products to this initiative.)

Everything comes “back to the bottom line that we are asking companies to just market ethically and they seem incapable of doing so,” Lapping said. The one thing, she said, that can “really make a difference is the reputational risk. So we really do need consumers . . . to kind of keep chipping away at the issue.”

As Moloney put it, breastfeeding is “a human right.”

“And that’s,” she said, “what’s core to this.”