Advertisements of follow-on formula and their perception by pregnant women and mothers in Italy

Toddler milk: a scoping review of research on consumption, perceptions, and marketing practices

Toddler milk is an ultra-processed beverage consisting primarily of powdered milk, caloric sweeteners, and vegetable oil. Pediatric health authorities do not support the use of toddler milk, and emerging evidence suggests that toddler-milk marketing practices may mislead consumers. However, studies have not synthesized the extent of toddler-milk marketing practices or how these practices affect parents' decisions about whether to serve toddler milk. We aimed to summarize the literature about toddler milk to identify what is known about: (1) parents' toddler-milk purchasing and feeding behaviors, (2) toddler-milk marketing, and (3) how marketing practices influence parents' beliefs and perceptions about toddler milk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we systematically searched 8 databases (PubMed, APA PsycINFO, Scopus, Cochrane Central, Embase, CINAHL, Communication & Mass Media Complete, and Business Source Premier). We identified 45 articles about toddler milk. Studies were conducted in 25 countries across 6 continents. Five types of findings emerged: (1) consumption and feeding behaviors, (2) demographic correlates of toddler-milk purchasing and consumption, (3) misperceptions and beliefs, (4) increased sales, and (5) increased marketing and responses to marketing. The included articles suggested that toddler-milk sales are growing rapidly worldwide. Findings also revealed that toddler-milk packages (eg, labels, branding) resemble infant formula packages and that toddler-milk marketing practices may indirectly advertise infant formula. Purchasing, serving, and consumption of toddler milk were higher in Black and Hispanic populations than in non-Hispanic White populations, and parents with higher educational attainment and income were more likely to offer toddler milk to their children. Findings suggest a need for policies to prevent cross-marketing of toddler milk and infant formula, reduce provision of toddler milk to infants and toddlers, and prevent caregivers from being misled about toddler-milk healthfulness.

Commercial milk formula marketing following increased restrictions in Singapore: A qualitative study

The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0-12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross-promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest.

Perceived influence of commercial milk formula labelling on mothers' feeding choices in Great Britain: a qualitative study

OBJECTIVE

To understand how mothers use commercial milk formula (CMF) labels to inform their feeding choices and explore mothers' understanding of differences between CMF products.

DESIGN

Qualitative study with recruitment via social media. Online semistructured interviews, including a product mapping exercise and thematic analysis.

PARTICIPANTS

Mothers (n=25) using CMF for children <3 years living in Great Britain (GB).

RESULTS

Mothers were drawn to brands they recognised from years of exposure to CMF advertising. CMF products were assumed to vary according to brand and stage, but participants found on-pack information did not explain how. This added to anxiety about choosing 'the best one' and mothers would have liked guidance from healthcare professionals (HCPs). Wide availability of CMF for older infants and children, and on-pack messaging suggesting progression from one product to the next, led many to believe these products were necessary. There was confusion over the appropriate use of specialist products. While mothers rarely mentioned on-pack health and nutrition claims, they were attracted to the overall appearance of packs and messaging relating to science, research and nature. References to breast milk and a logo perceived to represent a breastfeeding mother were taken as indicators of closer similarity to breast milk.

CONCLUSIONS

CMF legislation in GB should be updated to restrict brand advertising and the use of on-pack text and images that mothers perceive as indicating products have a closer similarity to breast milk. Greater input from HCPs was desired by new mothers and would support them to make more informed choices about CMF.

How the marketing practices of commercial milk formula companies impact infant breastfeeding practices in China

BACKGROUND

The marketing practices used by commercial milk formula (CMF) companies undermine breast feeding. However, it remains unclear how specific types of marketing practices result in suboptimal breast feeding.

OBJECTIVES

We aimed to examine the associations of CMF marketing practices with breastfeeding outcomes, determine the influencing pathways, how it changes the perceptions and attitudes of mothers towards CMF, and how it impacts breastfeeding outcomes.

METHODS

A cross-sectional survey was conducted in Beijing and Jinan, China that mapped the CMF marketing practices in 2020. Mothers were interviewed about the feeding practices for the youngest child under the age of 18 months. Maternal attitude towards CMF was assessed using a set of five questions. Six common CMF marketing practices were reviewed. A logistic regression was performed to examine the associations between the CMF marketing practices and predominant breast feeding, with adjustments for maternal age, education, occupation, socioeconomic class and caesarean section. Furthermore, a path analysis was conducted to explore the pathways between the CMF marketing practices, maternal attitude towards CMF and predominant breast feeding.

RESULTS

A total of 750 mothers were interviewed, with 20.0% of mothers predominantly breast feeding their young children. Two marketing practices, online engagement with CMF companies and promotions and discounts, were statistically associated with a lower likelihood of predominant breast feeding, with an adjusted ORs of 0.53 (95% CI 0.35 to 0.82) and 0.45 (95% CI 0.22 to 0.92). Furthermore, per CMF marketing practice increase mothers concurrently exposed to was associated with a 0.79 (95% CI 0.68 to 0.92) times lower likelihood of predominant breast feeding. In addition, online engagement and free formula samples distributed in hospitals had indirect effects on suboptimal breastfeeding outcomes, which was partly mediated by positive maternal attitude towards CMF.

CONCLUSIONS

CMF marketing practices were associated with a lower likelihood of optimal breastfeeding through influencing the maternal attitude towards CMF.

Content analysis of on-package formula labelling in Great Britain: use of marketing messages on infant, follow-on, growing-up and specialist formula

OBJECTIVE

To explore on-package formula messaging with reference to legislation and government-issued guidance in Great Britain (GB).

DESIGN

Formula products were identified, pictures of all sides of packs collated and on-package text and images were coded. Compliance with both GB legislation and guidance issued by the Department of Health and Social Care (DHSC) was assessed.

SETTING

All formula packs that were available for sale over the counter in GB between April and October 2020.

PARTICIPANTS

Formula packs (n 71) including infant formula, follow-on formula, growing-up formula and specialist formula were identified, coded and analysed.

RESULTS

In total, 41 % of formula packs included nutrition claims, and 18 % included health claims that may be considered non-permitted, according to DHSC guidance. Additionally, 72 % of products showed images considered 'non-permitted'. Breast Milk Substitute (BMS) legislation states infant and follow-on formula packs should be clearly distinguishable but does not provide criteria to assess similarity. Based on DHSC guidance, 72 % of infant and follow-on formula packs were categorised as showing a high degree of similarity. Marketing practices not covered by current legislation were widespread, such as 94 % of infant formula packs including advertisements for follow-on or growing-up formula.

CONCLUSIONS

Text and images considered non-permitted according to DHSC guidance for implementing BMS legislation were widespread on formula products available in GB. As terms such as 'similarity' are not defined in BMS legislation, it was unclear if breaches had occurred. Findings support the WHO call for loopholes in domestic legislation to be closed as a matter of urgency.

Marketing of commercial milk formula during COVID-19 in Indonesia

Baby food marketing poses a substantial barrier to breastfeeding, which adversely affects mothers' and children's health. Over the last decade, the baby food industry has utilised various marketing tactics in Indonesia, including direct marketing to mothers and promoting products in public spaces and within the healthcare system. This study examined the marketing of commercial milk formula (CMF) and other breast-milk substitute products during the COVID-19 pandemic in Indonesia. Using a local, community-based reporting platform, information on publicly reported violations of the International Code of Marketing of Breast-milk Substitutes and subsequent World Health Assembly resolutions (the Code) was collected. It was found that a total of 889 reported cases of unethical marketing of such products were recorded primarily through social media from May 20 through December 31, 2021. Our results suggest that the COVID-19 pandemic has provided more opportunities for the baby food industry in Indonesia to attempt to circumvent the Code aggressively through online marketing strategies. These aggressive marketing activities include online advertisements, maternal child health and nutrition webinars, Instagram sessions with experts, and heavy engagement of health professionals and social media influencers. Moreover, product donations and assistance with COVID-19 vaccination services were commonly used to create a positive image of the baby food industry in violation of the Code. Therefore, there is an urgent need to regulate the online marketing of milk formula and all food and beverage products for children under the age of 3.

Formula milk brands marketing on Chinese social media Weibo - a content analysis

Background

Parents' feeding practices in the first 2 years of life have profound effects on children's survival, health and development throughout their lives. Decisions on how to feed infants and young children should be based on the best information and evidence, not influenced by commercial interests. China is the largest and fastest-growing market for formula milk products. Social media has emerged as a distinctive marketing avenue that can reach consumers directly. Weibo is one of the most popular Chinese social media platforms. This study examined four of the most popular milk formula brands' official Weibo accounts: Biotime, Mead Johnson, YiLi-Prokido, and Friso.

Question

What messages posted and what marketing practices and tactics are used by formula milk brands on Weibo.

Methods

We manually downloaded all posts in the four accounts between 1 January and 31 December 2018. Based on previous studies, we developed a marketing practices coding framework and selected ten mutually exclusive categories for coding and analysing the posts.

Findings

Among 2667 original posts analysed, 65% were from three dominant categories: user engagement (939/2667, 35.2%), parenting advice (516/2667, 19.3%), and celebrity endorsement (327/2667, 12.3%). Other categories included making pseudo-health or nutrition claims and portraying breastfeeding as a painful or problematic experience.

Conclusion

Widespread marketing practices and tactics were found in the four examined Weibo accounts of formula milk brands. Monitoring and regulation of formula milk marketing on social media are urgently needed. Social media platforms should also be held accountable for protecting a supportive breastfeeding environment.

Marketing of commercial milk formula: a system to capture parents, communities, science, and policy

Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.

Some Japanese mothers do not follow package instructions of infant formula: a web-based analytical cross-sectional study

Background:

Not following the infant formula package instruction endangers infant health. Although infant formula misuse has been reported abroad, its incidence in Japan remains unknown. Furthermore, it is reasonable to assume that experience in childcare reduces the likelihood of making mistakes in using infant formula. This study aimed to examine the association between compliance with infant formula package instruction and childcare experience in Tokyo and surrounding prefectures in Japan.

Methods:

Using a web-based questionnaire, mothers with infants were analyzed cross-sectionally and surveyed regarding their infants’ nutrition and formula preparation methods in August 2021. Compliance with the infant formula package was determined according to (a) using unlabeled infant formula, (b) preparing infant formula without reading package instructions, (c) giving formula to children ≥ 2 h after preparing, and (d) adding other ingredients to the formula bottle. The association between the misuse of infant formula and childcare experience was examined by grouping the participants by infant age (< 6 months and ≥ 6 months), and by comparing first-born child status with later-born. Of the 333 mothers with infants, 3 were excluded due to out-of-scope responses, and 330 were included in the analysis.

Results:

The major sources of information on infant feeding methods among the participants were obstetric facilities (92.1%), internet (36.1%), and family (20.9%). The proportions of participants using infant formulas not labeled as “infant formula,” such as follow-up milk, not preparing at prescribed concentrations, feeding infant formulas > 2 h after preparation, and adding additional ingredients to the bottle were 7.9%, 4.1%, 23.1%, and 15.9%, respectively, which suggest the misuse of infant formula. These four answers did not differ significantly between mothers of children aged < 6 months and ≥ 6 months or between those with first-born and later-born children.

Conclusion:

This study suggested that some Japanese mothers do not follow package instructions of infant formula in Japan. The misuse of infant formula may not be related to the length of time spent in childcare or the presence or absence of childcare experience. Providing appropriate information on the correct use of infant formula to all caregivers, regardless of their parenting experience, is required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00615-7.

Informing Infant Nutrition: Timing of Infant Formula Advice, Infant Formula Choice and Preparation in the First 6 Months of Life

OBJECTIVE

To examine the sources and timing of advice formula feeding parents receive and how this and other factors influence the choice of formula product and formula preparation.

DESIGN

Components of a cross-sectional survey.

SETTING

A child and family health service in New South Wales, Australia.

PARTICIPANTS

Parents (n = 153) who were fully or partially formula feeding infants aged 0-6 months and who visited the service's facilities or its social media site.

VARIABLES MEASURED

Type of formula, preparation of formula, and use and sources of formula feeding advice.

ANALYSIS

Descriptive statistics, Mann-Whitney U or Pearson's chi-square tests, and inductive content analysis.

RESULTS

The most common source of formula feeding advice was the formula tin/packet (96.6%). Although 79.2% received advice from a health professional, only 18.9% reported receiving this advice before using formula. Approximately half (48.0%) of the parents chose a standard cow's milk-based formula. The most common reason for their choice of formula type/brand was a personal recommendation (53.0%). Parents' responses indicated that nearly half (46.3%) incorrectly prepared the formula.

CONCLUSION AND IMPLICATIONS

Although health professional advice was widely received, this was rarely before starting formula. Despite the current national infant feeding regulations, parents who were not exclusively breastfeeding their infants did not always receive timely, health professional advice about formula feeding.

Breastfeeding and humanitarian emergencies: the experiences of pregnant and lactating women during the earthquake in Abruzzo, Italy

Background

Emergencies have a great impact on infant and young child feeding. Despite the evidence, the recommended feeding practices are often not implemented in the emergency response, undermining infant and maternal health. The aim of this study was to explore the experiences of pregnant and lactating women during the earthquake emergency that occurred in L’Aquila on 6 April 2009.

Methods

The study design was qualitative descriptive. Data were collected by individual semi-structured interviews, investigating the mother’s experiences of pregnancy, childbirth, breastfeeding, infant formula or complementary feeding during the emergency and the post emergency phase. Data analysis was categorical and was performed by using N-Vivo software.

Results

Six women who were pregnant at the time of the earthquake were interviewed in January 2010. In addition to the essential needs of pregnant and lactating women, such as those related to the emergency shelters conditions, the main findings emerged from this study were: the reconfiguration of relationships and the central role of partners and family support; the need of spaces for sharing experiences and practices with other mothers; the lack of breastfeeding support after the hospital discharge; the inappropriate donations and distribution of Breast Milk Substitutes.

Conclusions

During and after L’Aquila earthquake, several aspects of infant and young child feeding did not comply with standard practices and recommendations. The response system appeared not always able to address the specific needs of pregnant and lactating women. It is urgent to develop management plans, policies and procedures and provide communication, sensitization, and training on infant and young child feeding at all levels and sectors of the emergency response.

Global evidence of persistent violations of the International Code of Marketing of Breast-milk Substitutes: A systematic scoping review

The influence of marketing on infant and young child feeding and health is well recognized, and an International Code was adopted by the World Health Assembly (WHA) in 1981 to reduce inappropriate marketing and protect breastfeeding. Yet the marketing and influencing continue. This scoping review systematically examined the published research evidence on the nature and extent of exposure to International Code violations from 1981 to August 2021. We used several search strategies involving multi‐language databases, organization websites, citation tracking, and expert consultation, to find research items meeting our inclusion criteria. We evaluated 657 items and retained 153 studies from at least 95 countries in the review. The majority of the studies (n = 113) documenting exposure to inappropriate marketing were published since 2010. Studies reported a broad range of marketing violations targeting mothers and families, health workers, and the general public. Marketing via digital platforms and brand extension has become more frequent. The evidence shows the use of misleading and inaccurate labeling and health and nutrition claims in breach of the Code. Our review confirms that violations of the Code have not ceased and calls for renewed attention from the WHA and national governments to protect the health of children and their mothers.

Exposure to inappropriate marketing continues across the world in health systems, public spaces, points of sale, media, emergency programs, and direct to mothers.

Studies have documented the emergence of products and marketing practices designed to circumvent the Code.

Labeling and health and nutrition claims were found that were misleading, inaccurate, and in breach of the Code.

Evidence of marketing through social media and other digital platforms has increased over time.

Future research, guidance, and policies would benefit from an accessible central repository of comprehensive and comparable measurement tools and evidence.

Marketing of sugar-sweetened children's drinks and parents' misperceptions about benefits for young children

Despite expert recommendations, US parents often serve sugar‐sweetened children's drinks, including sweetened fruit‐flavoured drinks and toddler milks, to young children. This qualitative research explored parents' understanding of common marketing tactics used to promote these drinks and whether they mislead parents to believe the drinks are healthy and/or necessary for children. We conducted nine focus groups in Washington, DC and Hartford, CT with parents of children (9–36 months) of diverse race/ethnicity and socioeconomic status (N = 50). Semistructured discussions elicited parents' responses to four concepts designed to correct common misperceptions about toddler milks and sweetened fruit‐flavoured drinks (fruit drinks and flavoured waters) by providing information about drink ingredients and potentially misleading marketing tactics. Participants expressed widespread misperceptions about sweetened fruit‐flavoured drinks and toddler milks, including perceived healthfulness and benefits for children and confusion between sweetened and unsweetened drink categories (sweetened fruit‐flavoured drinks vs. juice, toddler milk vs. infant formula). They confirmed that common marketing strategies contributed to misperceptions, including front‐of‐package claims and marketing messages that imply benefits for children and/or hide problematic ingredients; cross‐branding and product extensions from trusted brands; side‐by‐side shelf placement at retailers; lower price than healthier products; and targeted marketing to children and parents. Some parents expressed anger about deceptive marketing and supported increased regulation and consumer education campaigns. Findings support the need for policies to address potentially misleading marketing of sweetened fruit‐flavoured drinks and toddler milks and revealed opportunities to reduce parents' provision of these drinks through countermarketing campaigns communicated via trusted sources.

Marketing messages for sweetened fruit‐flavoured drinks and toddler milks can mislead parents to believe these sugar‐sweetened products are healthful options for young children.

Parents described front‐of‐package label claims, images, and other marketing messages on sugar‐sweetened children's drinks as confusing, deceptive, and misleading. They also raised issues about targeted marketing to children and parents and lower prices for less‐healthy products.

Findings support opportunities for countermarketing campaigns to correct misleading marketing messages and the need for government policies, such as restricting front‐of‐package claims and requiring consistent ingredient reporting, to assist parents in making healthier drink selections for their children.

Beliefs and Norms Associated with the Use of Ultra-Processed Commercial Milk Formulas for Pregnant Women in Vietnam

Commercial milk formula for pregnant women (CMF-PW) is an expensive, ultra-processed food with a high concentration of sugar, the consumption of which may be linked to negative health outcomes. However, CMF-PWs are promoted as beneficial for pregnant women and lactating mothers as well as their children. To date, little is known about the factors associated with the use of CMF-PW among pregnant women. We performed this analysis to examine the association between the use of CMF-PW and related beliefs and norms among pregnant women in Vietnam. We interviewed 268 pregnant women in their second and third trimesters from two provinces and one municipality representing diverse communities in Vietnam. Multinomial (polytomous) logistic regression, structural equation modeling (SEM), and propensity score matching (PSM) analysis were used to examine associations between beliefs and social norms related to CMF-PW and reported consumption, characterized as occasional, recent, and never during the current pregnancy. Overall, 64.6% of pregnant women reported using CMF-PW during the current pregnancy and 34.7% consumed CMF-PW on the day prior to the interview. Strong beliefs that CMF-PW will make a child smart and healthy (53.7%) and the perception that use of CMF-PW is common (70.9%) were associated with increased use on the previous day (beliefs: aOR: 3.56; 95% Confidence Interval (95% CI): 1.65, 7.71; p < 0.01 and social norms aOR: 2.29; 95% CI: 1.13, 4.66; p < 0.05). SEM and PSM analyses confirmed these findings for both occasional and regular CMF-PW use. Results are consistent with observations of CMF-PW product labels and marketing tactics in Vietnam. The prevalent use of CMF-PW in Vietnam is associated with the belief that these products make children smart and healthy and the perceived social norm that most mothers use these products, which mirrors marketing messages and approaches employed by the CMF industry.

The Impact of Formula Industry Marketing on Breastfeeding Rates in Native and Migrant Mothers

Introduction: Lifelong benefits of breastfeeding are far-reaching. However, optimal breastfeeding practices may be negatively affected by the marketing of different forms of breast milk substitutes. In addition, whether market factors have a different impact on migrants' breastfeeding practices when compared to natives has been poorly investigated. Objectives: Our study's aims are (1) to assess the effect of market factors on breastfeeding discontinuation (any and exclusive), (2) comparing migrant and native women. Methods: A longitudinal study was conducted within baMBINO, a nationwide project on perinatal health among migrant women in Portugal. Our final sample included 1,251 migrants and 1,150 natives recruited between April 2017 and March 2019 in 32 public maternities. Cox regression analysis was performed, adjusting for important confounders, and interactions were tested. Results: Market factors were associated with any and exclusive breastfeeding discontinuation. Participants receiving free formula samples from a health professional were more likely to stop exclusive breastfeeding (adjusted hazard ratios [aHR] = 1.37, 95% confidence intervals [95% CI] = 1.13-1.66, p = 0.002). Reporting exposure to formula discounts was associated with discontinuation of exclusive (aHR = 1.22, 95% CI = 1.09-1.38, p = 0.001) and any breastfeeding (aHR = 1.21, 95% CI = 1.00-1.46, p = 0.046). No interactions were found between being migrant and exposure to market factors. Conclusions: Market factors influence discontinuation of any and exclusive breastfeeding. The impact of marketing does not differ between native and migrant women.

Caregiver's Provision of Non-Recommended Commercially Prepared Milk-Based Drinks to Infants and Toddlers

OBJECTIVE

Assess milk type provision (commercially prepared infant and toddler formula, cow's milk, and plant milk) to infants and toddlers, accounting for sociodemographic characteristics and marketing claims.

PARTICIPANTS

Caregivers (N = 1,645) of children (aged 6-36 months) recruited through online panels in 2017.

METHODS

Cross-sectional survey analysis (system of probit equations) estimated associations between sociodemographics and agreement with marketing claims (independent variables) with milk type provision in the past month (binary dependent variable).

RESULTS

Most caregivers (63%) of infants (aged 6-11 months) provided only breastmilk and/or commercially prepared infant formula. Sixty-five percent of caregivers of 12-month-old infants provided commercially prepared infant formula, and 47% provided cow's milk. Most caregivers (64%) of toddlers (aged 13-36 months) provided cow's milk; some also provided other non-recommended milk types (51%).Associations between milk types suggested milk-based drink provision should be evaluated as a pattern and not as independent behaviors (all Ps < 0.048). Milk type provision was significantly associated with a child's age (months), household income, and race (all Ps < 0.049). Including agreement with marketing claims reduced the significance of associations between milk type provision and some sociodemographic characteristics.

CONCLUSIONS AND IMPLICATIONS

These findings suggest the need for additional expert guidance to discourage inappropriate and unnecessary milk for young children, provide strategies to transition from breastmilk (or commercially prepared infant formula) to cow's milk, and conduct outreach to communities at risk for health disparities about the dangers of serving milk that is not recommended for their child's age. Research is needed to understand how diverse populations interpret product claims and how marketing may perpetuate health disparities.

Digital Marketing of Commercial Complementary Foods in Australia: An Analysis of Brand Messaging

The digital marketing of commercial complementary foods (CCF) is an emerging area of concern in Australia. Although research into traditional methods has identified a range of problems, the marketing and messaging strategies employed within digital spaces have gone largely unscrutinized. This study sought to examine the methods used by CCF manufacturers to promote Australian baby foods and brands in a digital space. A multiple step approach was used to assess the CCF brands available in major Australian retailers, the social media platforms they used, and to thematically analyze the text and visual messages contained in posts published over a three-month period. Of the 15 brands identified, 12 had a digital presence, and all of these used Facebook. Four themes emerged from an analysis of 216 Facebook posts; (1) general product attributes, (2) socially desirable attributes (which included messaging related to taste (41%), self-feeding (29%) and fun (19%)), (3) concern-based attributes (including organic status (40%), age targets (39%) and additive-/allergen-free status (18%)) and (4) health-focused attributes (which included messaging related to healthy/nutritious ingredients (45%), and child development/growth (15%). Messages contained in Facebook posts were mostly positive brand/product aspects (Themes 1 and 2) or parental concern-based aspects (Theme 3 and 4). These themes match previous analyses of marketing content in traditional media and should be closely monitored due to the personalized nature of consumer social media interactions.

Toddler milk perceptions and purchases: the role of Latino ethnicity

OBJECTIVES

Toddler milk (i.e. a nutrient-fortified milk-based drink marketed for children 12-36 months old) is increasingly being marketed in the USA despite not being recommended for young children. There is evidence of targeted toddler milk marketing to Latinos in the USA. This study aimed to explore toddler milk perceptions and behaviours among Latino and non-Latino parents.

DESIGN

An online survey assessed toddler milk perceptions, behaviours and interpretations of nutrition-related claims. Multivariable logistic and linear regression explored socio-demographic correlates of parent reported past purchases and perceived healthfulness.

SETTING

Online.

PARTICIPANTS

National convenience sample of 1078 US parents of children aged 2-12 years (48 % Latino).

RESULTS

About half of parents (51 %) had previously purchased toddler milk and few (11 %) perceived toddler milk as unhealthy. Latino parents were more likely to have purchased toddler milk than non-Latino parents (P < 0·001), but there were no differences in perceived product healthfulness (P = 0·47). Compared to parents born in the USA, parents living in the USA 10 years or less were more likely to have purchased toddler milk (P < 0·001) and perceive toddler milk as healthier (P = 0·002). Open-ended interpretations of claims were primarily positive, suggesting 'health halo' effects.

CONCLUSIONS

Common misperceptions about toddler milk healthfulness suggest stronger labelling regulations are needed. Greater reported purchases by Latino parents and recent immigrants warrant further investigation.

First-food systems transformations and the ultra-processing of infant and young child diets: The determinants, dynamics and consequences of the global rise in commercial milk formula consumption

The inappropriate marketing and aggressive promotion of breastmilk substitutes (BMS) undermines breastfeeding and harms child and maternal health in all country contexts. Although a global milk formula ‘sales boom’ is reportedly underway, few studies have investigated its dynamics and determinants. This study takes two steps. First, it describes trends and patterns in global formula sales volumes (apparent consumption), by country income and region. Data are reported for 77 countries, for the years 2005–19, and for the standard (0–6 months), follow‐up (7‐12 m), toddler (13‐36 m), and special (0‐6 m) categories. Second, it draws from the literature to understand how transformations underway in first‐food systems – those that provision foods for children aged 0–36 months – explain the global transition to higher formula diets. Total world formula sales grew by 115% between 2005 and 2019, from 3.5 to 7.4 kg/child, led by highly‐populated middle‐income countries. Growth was rapid in South East and East Asia, especially in China, which now accounts for one third of world sales. This transition is linked with factors that generate demand for BMS, including rising incomes, urbanisation, the changing nature of woman's work, social norms, media influences and medicalisation. It also reflects the globalization of the baby food industry and its supply chains, including the increasing intensity and sophistication of its marketing practices. Policy and regulatory frameworks designed to protect, promote and support breastfeeding are partially or completely inadequate in the majority of countries, hence supporting industry expansion over child nutrition. The results raise serious concern for global child and maternal health.

Is the legal framework by itself enough for successful WHO code implementation? A case study from Ethiopia

Since 2016, Ethiopia has passed several proclamations and directives to regulate the promotion of commercial breastmilk substitute (BMS). Ethiopia's market potential will undoubtedly be the gravitating point for international infant formula companies due to growing urbanization, purchasing power, population, and the relatively low use of BMS to-date. The aim of this review is to assess the strengths and weaknesses of the existing laws, standards, and monitoring documents used to regulate the marketing of BMSs in Ethiopia and make future recommendations. The study findings highlighted that the regulation on marketing are comprehensive and strong to limit the promotion of infant formula. On the other hand, the regulation on marketing of follow-up formulas, complementary foods, and growing-up milk by manufacturers and distributors, media houses, and communication and advertisement agencies are underregulated, especially with regards to the international 69.9 regulation. The monitoring and enforcement of the existing marketing regulations remain limited in the absence of a formal coordination mechanism. Several violations of the national BMS regulations were observed. Forty-one percent of mothers reported observing the BMS advertising and logos were detected in 36% of health facilities assessed. In 100% of cases, the infant formula labels contained violations. As the lead national authority mandated to regulate food safety, the Ethiopian Food and Drug Authority needs to update its regulations related to the marketing of BMS to fill the loopholes and revise the national law in line with the international code of marketing of BMSs to protect breastfeeding.

Are our babies off to a healthy start? The state of implementation of the Global strategy for infant and young child feeding in Europe

Background

To protect children’s right to optimal nutrition, WHO/UNICEF developed a Global Strategy for Infant and Young Child Feeding, endorsed by all 53 WHO/EURO Member States. The World Breastfeeding Trends Initiative (WBTi) is a tool for monitoring implementation of the Global Strategy. It comprises 15 indicators, ten referring to policies and programmes, and five to feeding practices. Each is scored on a scale of 10, giving a total score of 150 for Global Strategy implementation. To date, 18 WHO/EURO Member States – Armenia, Austria, Belgium, Bosnia and Herzegovina, Croatia, France, Georgia, Germany, Italy, Lithuania, North Macedonia, Malta, Moldova, Portugal, Spain, Turkey, Ukraine and United Kingdom – have conducted a WBTi assessment and produced a report.

Methods

Between June 2018 and May 2019, all 18 WBTi European reports were carefully read and analysed by a group of national WBTi coordinators. Descriptive data analysis, including inter-country comparisons, was conducted using frequencies and percentages. This paper summarises the findings. The full 88-page report will be published on the WBTi website.

Results

Three-quarters of 18 European countries have adequate maternity protection, and two-thirds have breastfeeding initiation rates of 50% or higher. However, ‘Preparedness and planning for appropriate and safe Infant and Young Child Feeding (IYCF) in emergencies’ is seriously neglected. Breastfeeding duration is far below WHO recommendations, with an average of 8.7 months. Only three European countries have a budget allocated for implementing IYCF policies and plans, and a third currently have no Baby-friendly designated maternity facilities. Bottle feeding is prevalent, despite its inherent risks, monitoring of IYCF practices is inadequate, with most countries not routinely collecting data, and violations of the International Code of Marketing of Breast-milk Substitutes are commonplace.

Conclusions

European governments are not doing enough to protect, promote and support sound infant and young child feeding practices. Political commitment at the highest level and adequate funding are required to ensure optimal IYCF for Europe’s babies. This report highlights worrying gaps, thereby providing governments, international organisations and other concerned parties with an opportunity to invest in priority areas and, by doing so, hopefully create a better future for our babies.

Infant formula and toddler milk marketing and caregiver's provision to young children

The World Health Organization International Code of Marketing of Breast‐milk Substitutes prohibits claims and other marketing that may confuse caregivers about benefits of formula and other milk‐based drinks for infants and toddlers, but such marketing is common in the United States. This study assessed caregivers' provision of milk‐based products to their infants and toddlers and potential confusion about product benefits and appropriate use. Online survey of 1,645 U.S. caregivers of infants (6–11 months) and toddlers (12–36 months). Respondents identified infant formula and toddler milk products they served their child (ren) and provided relative agreement with common marketing claims. Logistic regression assessed relationships between agreement and serving these products, controlling for individual characteristics. Over one‐half of caregivers of infants (52%) agreed that infant formula can be better for babies' digestion and brain development than breastmilk, and 62% agreed it can provide nutrition not present in breastmilk. Most caregivers of toddlers (60%) agreed that toddler milks provide nutrition toddlers do not get from other foods. Some caregivers of infants (11%) reported serving toddler milk to their child most often. Agreement with marketing claims increased the odds of serving infant formula and/or toddler milks. For caregivers of toddlers, odds were higher for college‐educated and lower for non‐Hispanic White caregivers. Common marketing messages promoting infant formula and toddler milks may mislead caregivers about benefits and appropriateness of serving to young children. These findings support calls for public health policies and increased regulation of infant formula and toddler milks.

Promotions of breastmilk substitutes, commercial complementary foods and commercial snack products commonly fed to young children are frequently found in points-of-sale in Bandung City, Indonesia

Few studies have documented the marketing of commercial foods and beverages for infants and young children in West Java, Indonesia. To assess the prevalence of promotions at points-of-sale for commercially produced products commonly fed to young children in Bandung City, 43 small and large stores were visited in 2017. Promotions for breastmilk substitutes (BMS), commercially produced complementary foods (CPCF), and select types of commercial snack products were photographed and information recorded on promotion characteristics. There were 402 and 206 promotions observed with BMS and CPCF products, respectively. Sixteen promotions with BMS products for infants under 12 months were found in 42.9% of stores selling BMS, violating national regulations. Almost all BMS promotions (98.3%) included BMS products for ages 1 year and above ("growing-up milks"). Of all BMS products available for sale, half of all infant/follow-up formula and 77.2% of growing-up milks were promoted. CPCF were found in 97.7% of stores, and 81.0% of these stores had promotions; 70.5% of all available CPCF products were promoted. Of the 2,451 promotions observed for commercial snack products, 17.3% used promotional techniques targeting young children or caregivers. Joint-promotions were common, with BMS and CPCF marketed in combination with commercial snack products; 49.0% of BMS promotions were joint BMS-snack promotions, and 80.0% or more of infant/follow-up formula promotions included a commercial snack. Revising and enforcing infant food and beverage marketing regulations to ensure consistency with global standards are necessary to protect and promote optimal infant and young child feeding in Indonesia.

Professional and non-professional sources of formula feeding advice for parents in the first six months

Breastfeeding is beneficial to both the mother and infant, yet many infants are either partially or fully fed with formula milk. Those parents feeding with formula receive less support from professional sources than those breastfeeding and may rely on more non‐professional sources for advice, and this contributes to negative emotional experiences such as guilt. This paper explores the sources of advice for formula feeding, factors associated with using professional or non‐professional sources and compares these sources with those used for breastfeeding advice. A secondary analysis of Australian survey data from 270 mothers was performed. Mothers of six‐month‐old infants participated in an online survey, providing information on advice they received or read about formula feeding and/or breastfeeding from professional and non‐professional sources. A fifth of mothers who were formula feeding did not receive any formula feeding advice from professional sources, and only a small fraction (4.5%) of mothers breastfeeding did not received any breastfeeding advice from professional sources. Compared with those mothers breastfeeding receiving breastfeeding advice, fewer mothers formula feeding receive formula feeding advice from both professional and non‐professional sources. The tin of formula was the most used source of formula advice. Mothers feeding with formula at six months were more likely to have received formula feeding advice from professional sources if they had been fully formula feeding before their infant was under the age of three months. Further research is needed to understand the specific barriers to accessing formula feeding advice and what other factors influence access to formula feeding advice.

A Baby Formula Designed for Chinese Babies: Content Analysis of Milk Formula Advertisements on Chinese Parenting Apps

Background

China is the largest market for infant formula. With the increasing use of smartphones, apps have become the latest tool used to promote milk formula. Formula manufacturers and distributors both have seized the popularity of apps as an avenue for marketing.

Objective

This study aimed to identify and analyze milk formula ads featured on Chinese pregnancy and parenting apps, to build the first complete picture of app-based milk formula marketing techniques being used by milk formula brand variants on these apps, and to more fully understand the ad content that potentially undermines public health messaging about infant and young child feeding.

Methods

We searched for free-to-download Chinese parenting apps in the 360 App Store, the biggest Android app store in China. The final sample consisted of 353 unique formula ads from the 79 apps that met the inclusion criteria. We developed a content analysis coding tool for categorizing the marketing techniques used in ads, which included a total of 22 coding options developed across 4 categories: emotional imagery, marketing elements, claims, and advertising disclosure.

Results

The 353 milk formula ads were distributed across 31 companies, 44 brands, and 79 brand variants. Overall, 15 of 31 corporations were international with the remaining 16 being Chinese owned. An image of a natural pasture was the most commonly used emotional image among the brand variants (16/79). All variants included branding elements, and 75 variants linked directly to e-shops. Special price promotions were promoted by nearly half (n=39) of all variants. A total of 5 variants included a celebrity endorsement in their advertising. A total of 25 of the 79 variants made a product quality claim. Only 14 variants made a direct advertisement disclosure.

Conclusions

The purpose of marketing messages is to widen the use of formula and normalize formula as an appropriate food for all infants and young children, rather than as a specialized food for those unable to breastfeed. Policy makers should take steps to establish an appropriate regulatory framework and provide detailed monitoring and enforcement to ensure that milk formula marketing practices do not undermine breastfeeding norms and behaviors.

Prevalence, duration, and content of television advertisements for breast milk substitutes and commercially produced complementary foods in Phnom Penh, Cambodia and Dakar, Senegal

Promotion of breast milk substitutes (BMS) and inappropriate marketing of commercially produced complementary foods (CPCF), including through television, can negatively influence infant and young child feeding. The World Health Organization International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions prohibit such advertising and require manufacturers and distributors to comply with its provisions; however, such regulations at national level may vary. Advertisements require Ministry of Health approval in Cambodia but are not regulated in Senegal. Television stations were monitored for 13 months in Phnom Penh and for 3 months in Dakar to assess advertisements for BMS and CPCF. Ten television channels (out of 16) in Phnom Penh and four (out of 20) in Dakar aired advertisements for BMS. Three and five channels, respectively, aired advertisements for CPCF. All BMS advertised in Phnom Penh were for children over 1 year of age. BMS products for children 6+ months of age and 1+ years of age were advertised in Dakar. Average air time for BMS advertisements was 189.5 min per month in Phnom Penh and 29.7 min in Dakar. Air time for CPCF advertisements averaged 3.2 min per month and 13.6 min, respectively. Fewer than half of BMS advertisements and three quarters of CPCF advertisements explicitly stated an age of use for products. Nutrition and health claims were common across BMS advertisements. This study illustrates the need to adopt, regulate, monitor, and enforce legislation prohibiting BMS promotion, as well as to implement regulations to prevent inappropriate promotion of CPCF.

Infant formula feeding practices and the role of advice and support: an exploratory qualitative study

Background

Infant formula feeding practices are an important consideration for obesity prevention. An infant’s diet is influential on their later risk of developing overweight or obesity, yet very little is known about infant formula feeding practices. It is plausible that certain modifiable practices may put children at higher risk of developing overweight or obesity, for example how much and how often a baby is fed. Understanding how parents use infant formula and what factors may influence this practice is therefore important. Moreover, parents who feed their infants formula have identified a lack of support and access to resources to guide them. Therefore this study aimed to explore parents’ infant formula feeding practices to understand how parents use infant formula and what factors may influence this practice.

Methods

Using an explorative qualitative design, data were collected using semi-structured telephone interviews and analysed using a pragmatic inductive approach to thematic analysis.

Results

A total of 24 mothers from across Australia were interviewed. Mothers are influenced by a number of factors in relation to their infant formula feeding practice. These factors include information on the formula tin and marketing from formula manufacturers, particularly in relation to choosing the type of formula. Their formula feeding practices are also influenced by their interpretation of infant cues, and the amount of formula in the bottle. Many mothers would like more information to aid their practices but barriers exist to accessing health professional advice and support, so mothers may rely on informal sources. Some women reported that the social environment surrounding infant feeding wherein breastfeeding is promoted as the best option leads a feeling of stigma when formula feeding.

Conclusions

Additional support for parents’ feeding their infants with formula is necessary. Health professionals and policy around infant formula use should include how formula information may be provided to parents who use formula in ways that do not undermine breastfeeding promotion. Further observational research should seek to understand the interaction between advice, interpretation of cues and the amount formula fed to infants.

Electronic supplementary material

The online version of this article (10.1186/s12887-017-0977-7) contains supplementary material, which is available to authorized users.

Ethical Challenges in Infant Feeding Research

Infants have a complex set of nutrient requirements to meet the demands of their high metabolic rate, growth, and immunological and cognitive development. Infant nutrition lays the foundation for health throughout life. While infant feeding research is essential, it must be conducted to the highest ethical standards. The objective of this paper is to discuss the implications of developments in infant nutrition for the ethics of infant feeding research and the implications for obtaining informed consent. A search was undertaken of the papers in the medical literature using the PubMed, Science Direct, Web of Knowledge, Proquest, and CINAHL databases. From a total of 9303 papers identified, the full text of 87 articles that contained discussion of issues in consent in infant feeding trials were obtained and read and after further screening 42 papers were included in the results and discussion. Recent developments in infant nutrition of significance to ethics assessment include the improved survival of low birth weight infants, increasing evidence of the value of breastfeeding and evidence of the lifelong importance of infant feeding and development in the first 1000 days of life in chronic disease epidemiology. Informed consent is a difficult issue, but should always include information on the value of preserving breastfeeding options. Project monitoring should be cognisant of the long term implications of growth rates and early life nutrition.

Cross-sectional survey shows that follow-up formula and growing-up milks are labelled similarly to infant formula in four low and middle income countries

This cross-sectional survey assessed the characteristics of labels of follow-up formula (FUF) and growing-up milk (GUM) compared with infant formula (IF), including cross-promotion practices between FUF/GUM and IF manufactured by the same company, sold in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania. All products were imported. A wide recommended age/age range for introduction was provided by manufacturers across all sites, with products with an age recommendation of 0-6 months being most prevalent in three sites, representing over a third of all products. Various age categories (e.g. 1, 1+ and Stage 1) commonly appeared on labels. A number of descriptive names (e.g. infant formula and milk formula) per category of age of introduction were used with some appearing across more than one category. Images of feeding bottles were found on most labels across all age categories, but prevalence decreased with older age categories. The majority of FUF/GUM manufactured by IF companies across all sites displayed at least one example of cross-promotion with one or more of the company's IF: two-thirds or more contained similar colour schemes/designs and similar brand names; 20-85% had similar slogans/mascots/symbols. A wide and potentially confusing range of ages/categories of introduction and descriptive names were found, and cross-promotion with IF was common on FUF/GUM labels. Global guidance from normative bodies forms the basis of most low and middle income countries policies and should provide specific guidance to prohibit cross-promotion between FUF/GUM and IF, and all three categories should be classified as breastmilk substitutes.

Point-of-sale promotion of breastmilk substitutes and commercially produced complementary foods in Cambodia, Nepal, Senegal and Tanzania

In order to assess the prevalence of point‐of‐sale promotions of infant and young child feeding products in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania, approximately 30 retail stores per site, 121 in total, were visited. Promotional activity for breastmilk substitutes (BMS) and commercially produced complementary foods in each site were recorded. Point‐of‐sale promotion of BMS occurred in approximately one‐third of sampled stores in Phnom Penh and Dakar Department but in 3.2% and 6.7% of stores in Kathmandu Valley and Dar es Salaam, respectively. Promotion of commercially produced complementary foods was highly prevalent in Dakar Department with half of stores having at least one promotion, while promotions for these products occurred in 10% or less of stores in the other three sites. While promotion of BMS in stores is legal in Senegal, it is prohibited in Cambodia without prior permission of the Ministry of Health/Ministry of Information and prohibited in both Nepal and Tanzania. Strengthening legislation in Senegal and enforcing regulations in Cambodia could help to prevent such promotion that can negatively affect breastfeeding practices.

A Comparison by Milk Feeding Method of the Nutrient Intake of a Cohort of Australian Toddlers

Breastfeeding is recommended beyond 12 months of age, but little is known about the contribution of breastmilk and infant formula to the nutritional intake of toddlers as they transition to a family diet in the second year of life. This study is a cross-sectional analysis of data collected from a birth cohort study in Adelaide, Australia. Dietary intake data were collected when children were approximately 1 year of age by an interviewer-administered multi-pass 24 h recall and a mother-completed 2 days food diary. Children were categorized according to their milk feeding method, i.e., breastmilk, infant formula, combination or other, and their nutrient intakes compared with recommended nutrient reference values. Complete data were available for 832 children, of which 714 had plausible energy intakes. Breastmilk and formula made a substantial contribution to the nutrient intake of those toddlers, contributing 28% and 34% of total energy, and 16% and 26% of protein intake, respectively when not drunk in combination. In general, Australian toddlers transitioning to the family diet consumed nutritionally adequate diets, although almost one quarter of all children and half of breastfed children with plausible intakes had iron intakes below the estimated average requirement, placing them at risk of iron deficiency.

Global trends and patterns of commercial milk-based formula sales: is an unprecedented infant and young child feeding transition underway?

Objective

The marketing of infant/child milk-based formulas (MF) contributes to suboptimal breast-feeding and adversely affects child and maternal health outcomes globally. However, little is known about recent changes in MF markets. The present study describes contemporary trends and patterns of MF sales at the global, regional and country levels.

Design

Descriptive statistics of trends and patterns in MF sales volume per infant/child for the years 2008–2013 and projections to 2018, using industry-sourced data.

Setting

Eighty countries categorized by country income bracket, for developing countries by region, and in countries with the largest infant/child populations.

Subjects

MF categories included total (for ages 0–36 months), infant (0–6 months), follow-up (7–12 months), toddler (13–36 months) and special (0–6 months).

Results

In 2008–2013 world total MF sales grew by 40·8 % from 5·5 to 7·8 kg per infant/child/year, a figure predicted to increase to 10·8 kg by 2018. Growth was most rapid in East Asia particularly in China, Indonesia, Thailand and Vietnam and was led by the infant and follow-up formula categories. Sales volume per infant/child was positively associated with country income level although with wide variability between countries.

Conclusions

A global infant and young child feeding (IYCF) transition towards diets higher in MF is underway and is expected to continue apace. The observed increase in MF sales raises serious concern for global child and maternal health, particularly in East Asia, and calls into question the efficacy of current regulatory regimes designed to protect and promote optimal IYCF. The observed changes have not been captured by existing IYCF monitoring systems.

The Impact of Marketing of Breast-Milk Substitutes on WHO-Recommended Breastfeeding Practices

Background:

Suboptimal breastfeeding results in 800 000 child deaths annually. There are multiple causes of suboptimal breastfeeding, including marketing of breast-milk substitutes.

Objectives:

To describe sales and marketing of breast-milk substitutes and their influence on World Health Organization-recommended breastfeeding behaviors, focusing on low- and middle-income countries.

Methods:

Literature review.

Results:

Global sales of breast-milk substitutes reached US$40 billion in 2013. Growth in sales exceeds 10% annually in many low- and middle-income countries, while it is close to stagnant in high-income countries. Breast-milk substitutes are marketed directly to consumers via mass media and print advertisements and indirectly via incentives, free supplies, and promotions to and through health workers and facilities, retailers, and policy makers. Internet marketing via company web sites and social media is on the rise. Marketing influences social norms by making formula use seem to be extensive, modern, and comparable to or better than breast milk. Clear evidence of a negative impact is found when breast-milk substitutes are provided for free in maternity facilities and when they are promoted by health workers and in the media. Influences through other channels are plausible, but rigorous studies are lacking. It was not possible with the data available to quantify the impact of marketing relative to other factors on suboptimal breastfeeding behaviors. Marketing remains widespread even in countries that have adopted the International Code of Marketing of Breast-milk Substitutes to restrict such activities.

Conclusion:

Adoption of stricter regulatory frameworks coupled with independent, quantitative monitoring and compliance enforcement are needed to counter the impacts of formula marketing globally.