Fighting Commercialisation for Child Health
Formula milk is one of the fastest growing food commodities nowadays. In Hong Kong, according to a local advertising database, the trade spent $2.8 billion on advertising formula milk for young children under 36 months of age in 2015. In spite of breastfeeding and nutritious foods being the gold standard of infant and young child feeding, these formula milk products compete with and undermine their status.
Combating the Aggressive Marketing of Breastmilk Substitutes
The Government launched the Hong Kong Code of Marketing of Formula Milk and Related Products, and Food Products for Infants and Young Children (HK Code)1 in June 2017 as part of a comprehensive strategy to protect, promote and support breastfeeding. The HK Code covers formula milk, bottles and teats, and prepackaged food products for infant and young children under 36 months of age. It aims to protect healthy infant feeding practices, irrespective of whether the baby is breastfed or formula fed, from commercial influences of breastmilk substitutes, on the basis of adequate and unbiased information and through appropriate marketing.
Other equally important elements of the comprehensive strategy include implementing the baby-friendly initiative in health care facilities, promulgating breastfeeding-friendly workplaces and public premises, strengthening public education on breastfeeding, enhancing breastfeeding surveillance, etc.
Evolving Marketing Strategies of the Industry since the Launch of the HK Code
Since the launch of the HK Code, formula milk companies have tactfully adjusted their marketing strategy by promoting formulae for older children (three years and above) and pregnant and lactating women, which all have a similar look and feel as their infant and young child (under 36 months) counterparts. Cross-promotion (brand extension) is a powerful marketing strategy in this instance. A survey conducted by the Department of Health in 2013 revealed that mothers could not easily distinguish what target age of children the formulae were for in advertisements or promotions.2
Are Follow-up and Young Child Formula necessary?
A Word Health Organisation (WHO) Statement (2013) maintained that “follow-up formula is unnecessary and unsuitable when used as a breastmilk replacement from six months of age onwards, due to its content. It is marketed in a way that may cause confusion and have a negative impact on breastfeeding.”3 In the Scientific Opinion on the Essential Composition of Infant and Follow-on Formulae (2014), the European Food Safety Authority Panel on Dietetic Products, Nutrition and Allergies (EFSA NDA Panel) concluded that young-child formula (for ages 1 to 3 years) was not a necessity to satisfy the nutritional requirements of young children. To increase intake of the critical nutrients such as iron, DHA, vitamin D and iodine in the normal diet of young children of 1 to 3 years old, there are more appropriate alternatives including introduction of meat and fish early from the stage of complementary feeding with regular consumption and intake of other foods e.g. fortified cow's milk and fortified cereals.
For parents who opt for formula milk, it is not necessary to switch to young-child formula and infant formula can be continued beyond the first year.4
The Myth of the Additive ‘Human Milk Oligosaccharides' (HMO) in Formula Milk
Formula milk with the additive ‘Human Milk Oligosaccharides' (HMO) has been made widely available after the EFSA NDA Panel5 and the US Food and Drug Administration (FDA)6concluded their use in food supplements was safe. Subsequently, HMO has been heavily marketed as “supporting infant immune systems” by formula milk companies.
Human breastmilk contains over 100 structurally different oligosaccharides (complex sugars). Breastfed infants are naturally exposed to high concentrations of complex and diverse combinations of oligosaccharides, the profiles of which are highly variable among mothers. Different oligosaccharide structures produce distinct functions which include promoting the growth of good gut bacteria (the “prebiotic effect”), preventing infections by binding to pathogens and blocking their adhesion to the gut lining, and antimicrobial effects.7
As additives to formula milk, the term “HMO” is extremely misleading as the substance does not come from human milk nor is it functionally comparable to the oligosaccharides in human milk. The artificial oligosaccharides can be made by various means, including fermentation of genetically engineered bacteria and yeasts; chemical or enzymatic synthesis, or extraction from cow milk. Currently, only a few types of simple HMOs have been produced at a large scale.8 The available limited research evidence does not suggest that infants consuming formula milk supplemented with HMO develop immune functions similar to that of breast-fed infants, as claimed commercially. 9
Protecting the Health of Young Children
Health professionals providing care for mothers, babies and young children are obliged to support families in making well-informed choices on infant feeding. They should provide correct and unbiased information from credible sources and assist families to achieve their goals with professional knowledge and skills.
The health and other child-related professionals are recommended to familiarise themselves with the aims and principles of the HK Code and ensure promotional messages, gifts and free samples of formula milk are NOT disseminated through their premises.
1 A Summary of Hong Kong Code of Marketing of Formula Milk and Related Products, and Food Products for Infants & Young Children. http://hkcode.gov.hk/en/the-hk-code-summary.html (Accessed on 6 August 2018)
2 Survey on Mothers' Views of Formula Milk Promotion and Information on Infant and Young Child Feeding. Family Health Service, Department of Health, HKSAR. 2013. http://www.fhs.gov.hk/english/archive/files/reports/Survey_on_Mothers_views_on_FM_promotion_full_2016_final.pdf (Accessed on 6 August 2018)
3 Information concerning the use and marketing of follow-up formula. World Health Organization. 2013. https://www.who.int/nutrition/topics/WHO_brief_fufandcode_post_17July.pdf
4 Scientific Opinion on the essential composition of infant and follow-on formulae. EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA), European Food Safety Authority (EFSA), Parma, Italy. EFSA Journal 2014;12(7):3760. https://www.efsa.europa.eu/en/efsajournal/pub/3760
5 Statement on the safety of lacto-N-neotetraose and 2'-O-fucosyllactose as novel food ingredients in food supplements for children. EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA), European Food Safety Authority (EFSA), Parma, Italy. EFSA Journal 2015;13(11):4299. https://www.efsa.europa.eu/en/efsajournal/pub/4299
6 GRAS Exemption Claim for 2'-O-Fucosyllactose (2'-FL). GRAS Notice (GRN) No. 650. US Food and Drug Administration. April 2016. https://www.fda.gov/Food/IngredientsPackagingLabeling/GRAS/NoticeInventory/ucm541223.htm
7 Bode L. The functional biology of human milk oligosaccharides. Early Hum Dev. 2015 Nov ;91(11):619-22. doi:10.1016/j.earlhumdev.2015.09.001. https://www.sciencedirect.com/science/article/abs/pii/S0378378215001784
8 Ravindran S. Producing Human Milk Sugars for Use in Formula. SPLASH! milk science update: October 2015. International Milk Genomics Consortium. http://milkgenomics.org/article/producing-human-milk-sugars-for-use-in-formula/
9 Bode L and Jantscher-Krenn E. Structure-Function Relationships of Human Milk Oligosaccharides. Adv Nutr.2012 May; 3(3): 383S–391S. https://academic.oup.com/advances/article/3/3/383S/4591535