“Too many children are dying in the first month of life,” said Richard Horton, Editor-in-Chief of The Lancet at a recent launch event for the 2023 Lancet Series on Breastfeeding, hosted by The Royal Society of Medicine, London. Indeed, the global numbers are staggering. Horton observed that 2.3 million children died in the first month of life in 2021—that’s more than 6,000 newborns dying every single day.

Early and exclusive breastfeeding for the first six months of life has a very important role to reduce newborn and infant deaths by limiting a child’s exposure to untreated water and contaminated foods, said Horton. Yet, less than 50 percent of babies are breastfed according to the World Health Organization (WHO) recommendations to initiate breastfeeding within an hour of birth, exclusively breastfeed for the first 6 months of life, and introduce complementary foods in combination with breastfeeding until a child is 2 years old.

Why is this urgent advice so broadly unheeded by parents? In part, it is due to the strategic, effective, and manipulative marketing of commercial milk formula (CMF). The new Lancet Series examines key elements that aid that commercial enterprise, including a misinterpretation of ordinary infant behavior, the pervasive effects of marketing on parental beliefs, values and practices, and a failure to see breastfeeding as a collective responsibility.  

This three-paper Series isn’t about infant formula as a product. Nor does it seek to shame families who use formula, or advocate limited access to formula. “The Lancet Series is about unraveling reasons the greater majority of women choose to breastfeed, but are being prevented from doing so,” said Kathriona Deveraux, a documentary maker and science communicator. She believes a person’s ability to breastfeed is connected to factors including politics, economics, gender inequalities, and power dynamics.

At the center of the Lancet papers is the predatory CMF marketing practices that have displaced healthier feeding practices. “What this Series shows, in essence, is the present and future health of our children is manifestly harmed by an exploitative industry that really represents the unacceptable face of capitalism today,” said Horton.

Infant Behaviors, CMF Marketing, and Power

Nigel Rollins, a contributor to the Lancet Series and a scientist in the Department of Maternal, Newborn, Child and Adolescent Health at WHO noted that breastfeeding is crucially important to human biology, lifelong health and development, maternal health, and child survival. “800,000 child deaths are prevented each year due to breastfeeding,” he said. Yet research shows that the primary reasons to not exclusively breastfeed include perceived low milk supply, work constraints, poor support, and preference.

A number of these factors are used by formula manufacturers, whose sophisticated and multifaceted commercial formula marketing zeroes in on the insecurities of new parents. “It takes time and support for young babies to learn how to eat, settle, and sleep,” said Rollins.  Yet the marketing for CMF often labels typical behaviors like crying, fussiness, and not sleeping through the night as reasons to introduce formula, when, in reality, these are normal and developmentally appropriate behaviors. Low milk supply is another anxiety exploited by manufacturers. It is a potent selling point, especially when 45 percent of mothers globally cited perceived low milk supply as their reason for introducing CMFs before six months.

So when the CEO of the formula manufacturer Vitafoods stated, “We are selling sleep” and “We are selling peace of mind,” this message cannot help but influence the parent afraid of low milk supply or concerned their newborn isn’t sleeping through the night. Rollins pointed to effective counseling and support for parents to understand infant cues and improve breastfeeding and breastmilk production as necessary measures to counter these marketing messages and improve parents’ self-efficacy.

CMF is big business. The global formula industry is valued at $55 billion. Breastfeeding is not counted in GDP, but CMF sales are. Yet, if breastfeeding were included in measures of global GDP, the monetary value of the milk produced would contribute approximately $3.6 trillion.

Recognizing the collective benefits of breastfeeding is key. Gender inequality, caregiving, and women’s paid and unpaid work are interconnected domains that influence a person’s ability to breastfeed, even if it is their preference, said Professor David McCoy, a contributor to the Series and a Professor at United Nations University’s International Institute for Global Health. Inadequate maternity rights protection and poor working conditions make it difficult for women to continue breastfeeding once they return to work, he added. Breastfeeding must be a collective priority.

McCoy observed that governments and society must recognize and value care work and properly invest in maternity protections. They must also improve education on breastfeeding and infant behaviors for parents, healthcare providers, and communities. “Unless the imbalance in power between private commercial interests and those with a duty and mandate to protect the rights and needs of children and mothers is corrected, then nothing will change,” said McCoy.

The Lancet Series lays out an agenda to make progress on its conclusions. Its authors demand increased investment in programs and policies that support and protect breastfeeding, stricter regulations and enforcement of the International Code of Marketing of Breast-Milk Substitutes, and the need for policymakers to prioritize and recognize women’s paid and unpaid work and enact paid family leave and workplace policies to support breastfeeding.

“One additional purpose of this series has a larger goal of drawing neglected attention to women’s and children’s health,” said Horton.