Infant Feeding Policymaking – Need for Transformational Change

There are several fundamental issues that continue to fuel the infant feeding conflict. First, there are philosophical differences on the practice of infant feeding, ranging from idealism to realism and these conceptual differences are driving self-interest and division. Second. there are inherent methodological complexities and ethical considerations that impact on breastfeeding research, and consequently the evidence may not be sufficiently robust to prevent wide-ranging interpretation. Third, the issues of marketing of breastmilk substitutes have not been resolved and remain a major source of continuing conflict. Finally, with the conflict between stakeholders being allowed to endure for decades, acrimony and mistrust is now deeply embedded [1].

Developing public health policies with the aim of ensuring that infants and young children consume a healthy diet is complex as there are many nutritive and non-nutritive factors that can influence nutritional status. Although there is a general acceptance of the key principles that infants should be breastfed from birth, then be introduced to complementary foods and gradually progress to a nutritious young child diet this has been complicated by the World Health Organisation (WHO) recommending that each of these transitions takes place at a universal predetermined age that does not allow for individual biological variation in developmental milestones and this lacks scientific evidence [2,3]. It could be claimed that policymakers are attempting to programme infants who have already been programmed by the DNA they have received from their parents. It is the latter that underpins the thinking behind responsive feeding with the heterogeneity of nature contributing to the variation in infant feeding patterns [2]. It appears paradoxical that with breastmilk being promoted as a personalised nutritional product for the infant, biology then gives way to ideology and a depersonalized one-size-fits-all infant feeding regime is then imposed.

The world is rapidly changing and all policies, including those relating to infant feeding, need to respond to the socioeconomic, cultural, legislative, societal and geopolitical changes that impact on countries and their citizens. The WHO International Code of Marketing of Breastmilk Substitutes was introduced in 1981 [4] and the WHO Global Strategy for Infant and Young Child Feeding was published in 2003 [5] and neither have been subjected to a WHO initiated independent review during these lengthy time periods, despite their widespread non-compliance. By reflecting on contemporary and future needs, policies should be viewed as a mechanism for change. The reluctance of WHO to initiate an independent review of the International Code after four decades denies parents and health professionals the opportunity to express their views. In June 2023, WHO and UNICEF hosted a Global Congress on Implementation of the International Code of Marketing of Breast-milk Substitutes that excluded industry and individuals that they considered had “ties” with industry [6]. Consensus cannot be achieved through exclusion; this simply creates more conflict and division. For policies to be viewed as relevant there needs to be a continuing commitment and ownership from all stakeholders, and not just the stakeholder that wrote the original policy. Families who are not activists need to feel engaged and their views and wishes should be respected.

In relation to infant formulas, the view of most parents is that they will want infant formulas to be available and affordable if needed [7], and the products should reflect the best scientific and clinical evidence. In many countries, infants who are dependent upon infant formula may already be nutritionally and socially disadvantaged, and policies should therefore not create further disadvantage by not providing the best formulation. Governments need to ensure that availability is not limited by the cost to the family.

The global and national institutions are ultimately responsibility for ensuring there is a collective approach to feeding infants and they should not allow acrimony and division to obstruct the development of the best nutrition solutions. Transformational change should therefore clarify the roles and responsibilities of WHO, WHA and governments and ensure they are distinct and complementary, and that global and national recommendations are optimally balanced so parents receive recommendations that are sensitive to both the nutritional needs and living conditions of their children. Diversity of need requires diversity of action.

Clear lines of responsibility and action are required for regulating the marketing and promotion of breastmilk substitutes by industry. The role of WHO needs to be reviewed; is it appropriate that WHO has a lead role as both policymaker and regulator? Can it be assured that breastfeeding policy is independent from the issues relating to the marketing of infant formula or is there evidence of conflation? Policy and regulation should be independently delivered to avoid this potential conflict of interest. The breaches of the International Code are primarily trading standard issues and therefore the regulatory process should be led by trading standards authorities who have the knowledge, expertise and authority to regulate and impose sanctions and they can closely relate to Codex Alimentarius that has responsibilities for protecting consumers and ensuring that fair practices are adopted within the food trade [1,8].

Scientists and healthcare professionals are already under the jurisdiction of statutory regulatory systems, through which any concerns can be channelled. Breastfeeding advocacy and activist groups should also have to demonstrate that their organizations meet all relevant independent professional and financial governance standards. Most importantly, families need to be protected from dysfunctional behaviour between hostile stakeholders.

To formally address these policymaking concerns an independent review is urgently required and the remit may be to identify the priorities for change and provide a framework for action. Specific objectives could be to relate policy, practice, leadership and governance to global and national outcomes in infant and child health and to assess the individual performance of the key stakeholders who have been given responsibility to protect and support nutritional care. The likelihood is that no stakeholder will escape criticism and concerns will fall most heavily upon those whose behaviour and self-interest has dominated the policymaking process.

In relation to research interests SF has received grants from governments, national research funding organizations, charitable organizations and industry, and has received honoraria and expenses for presenting research findings at conferences in UK and abroad. He has undertaken consultancy work for United Kingdom and Scottish Governments, and for DSM an international company that manufactures nutrient ingredients, advising on fatty acids. DSM is not a breastmilk substitute manufacturer.

None.

The content of this article is based on a longstanding interest in infant feeding and the product of many discussions with key stakeholders. There is no financial conflict of interest.

1. Forsyth S (2023) The Wasted Years. A Critique of Infant and Child Nutrition. Policy, Practice and Politics. United Kingdom: Swan & Horn.
2. WHO Guideline for complementary feeding of infants and young children 6-23 months of age. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO.
3. Scientific Advisory Committee on Nutrition. Feeding young children aged 1-5 years. London. Gov.UK; 2023.
4. WHO International Code of Marketing of Breastmilk Substitutes. 1981.
5. WHO/UNICEF Global strategy for infant and young-child feeding. 2003.
6. WHO/UNICEF Global Congress on Implementation of the International Code of Marketing of Breast-milk Substitutes Summary Report June 20-22, 2023 World Health Organization Headquarters Geneva, Switzerland.
7. Jung J, Olynk Widmar N, Ellison B (2023) The Curious Case of Baby Formula in the United States in 2022: Cries for Urgent Action Months after Silence in the Midst of Alarm Bells. Food Ethics 8(1): 4.
8. Forsyth S (2022) Marketing of breast-milk substitutes revisited: new ideas for an old problem. World Review of Nutrition and Dietetics 124: 151-156.