The Problem with Formula Milk

Breastfeeding and formula milk
Photo credit: c r z via Visual hunt / CC BY SA

Regarding breastfeeding and formula milk, a recent Mother and Child Foundation blog looked at the worrying problems that arise when good intentions are married to limited understanding.

Recent appeals in the media seemed to suggest that bottle-feeding was the answer for mothers caught in the tragedy of famine. While the wrong-headedness of this might not be immediately apparent to all, it highlights the popular public image of powdered milk substitutes as saviours, and takes the spotlight away from the fundamental issues of keeping mothers healthy enough to breastfeed properly.

Maternal health is the starting point of all the areas we cover, from mental health issues to the practicalities of sustainable marine agriculture. The reason, of course, is that the mother is the starting point of all new life. Breast milk contains the brain food which will dictate to a large extent how the growing child will fare as he or she travels through life.

The decline in breastfeeding

Poor breastfeeding rates are not a phenomenon of famine-stricken countries alone, by any means. The UK has the lowest breast-feeding rate in the EU, if not internationally.

During The Second World War (1939-45), all mothers breast-fed and were encouraged to do so. But what happened after the war? Looking back, my suspicions are that the companies marketing formula milk targeted the UK because of its strong influence in the many Commonwealth countries who, in those days, looked to Great Britain for guidance. “If the UK does it, it must be good” was the consensus.

Unfortunately, many babies died in Africa when mothers struggled to meet the high cost of the formula powder and started diluting it with unsafe water. Certain household name formula milk manufacturers gained the name of “the baby killer” as a result. In fairness, those companies had no intention of harming babies in any way, and were horrified when the stories came out.

Since then, the tainted water issue has been addressed. Progress has now been made in many developing countries, and organisations such as Baby Milk Action/IBFAN UK have done a great job in this area.

The science behind the issue

In 1976 my colleagues and I began publishing information on the essential fatty acid content of breast milk in several countries being much the same, with regard to arachidonic acid (ArA) and docosahexaenoic acid (DHA)[1]. We also underlined the absence of these in cow’s milk-based formula.

We suggested that the absence of – and the consistency of – ArA and DHA across several continents was fundamentally important, as these were required for brain growth. Moreover, the plasma levels of these fatty acids plummeted with infant formula compared to the status of breast-fed infants[2].

The fact that this was indeed meaningful was confirmed by an FAO-WHO joint international expert consultation on “The role of fats and oils inhuman nutrition”, held in 1976 and published in 1978. This said that substitutes for human milk should follow the composition of human milk with respect to these essential fatty acids. The companies responded by saying they had produced “humanised formula” by adding linoleic acid to protein-adjusted solids derived from cow’s milk. As far as they were concerned there was no need for any further action, and certainly no need to worry about omega-3!

Turning a deaf ear before turning the tide

We were dismissed in no uncertain terms by the policy makers of the time. Many derided the idea that fatty acids were in any way important. So, not surprisingly, no one wanted to fund further research. Those were very difficult times.

Then, in 1992, the German company Milupa broke ranks. This was following a consultation in Hamburg to hear the evidence first hand from several research groups demonstrating the importance of essential fatty acids. Milupa introduced ArA and DHA into their formula. Not long after this Milupa was bought by Nutricia, a Dutch firm which had previously (at a meeting I attended) bluntly denied the evidence and claimed there was no such need.

By then it was too late to act on what we already knew. The evidence accumulated between the 1960s and 1980s had to be repeated in preterm infants before the tide finally changed. There was a major battle in the USA, which only recently introduced the brain-specific essential fatty acids to formula milk. Cost and individual reputations were the real reasons behind this resistance, not science.

The argument continues

Even today the authorities are still sending out confused messages, with the European Food Safety Authority (EFSA) saying ArA is not required, although DHA is. Remarkably, EFSA employed someone person to review the research literature – but only that carried out after 2000. They therefore missed much of the ground-breaking, basic evidence, and indeed the 1982 Nobel Prize![3] It was particularly disappointing given a follow-up FAO-WHO report of 1994 (which put numbers on the ArA and DHA need for infants), and then again in 2008-2010. Each report involved pre-circulation of evidence, 30 or so experts in face-to-face discussion, and the same number of external peer reviewers.

Consequently, I am always suspicious when articles appear with slants pointing to problems of breastfeeding. One wonders if there is a conflict of interest lurking in the background.

In defence of the formula companies, there can be no doubt that their products are needed for preterm infants, and indeed there are genuine cases of need for term infant formula. At the same time, the composition of what is being given to very preterm infants is way off the mark, and its revision in line with placental nutrition (which is what is being missed) is urgently needed to prevent and treat some of the severe and lifelong morbidity to which these babies are at such high risk. There is nothing out there currently that is appropriate to meet this challenge.

[1] Crawford, M.A. and Hall, B. (1975) Breast feeding and maternal nutrition Br. Med. J. (3): 232‑233.

Crawford, M.A., Hall, B., Laurance, B.M. and Munhambo, A. (1976) Milk lipids and their variability. Curr. Med. Res. Opin. 4: (suppl. 1) 33‑43.

[2] Crawford, M.A., Hassam, A.G., Williams, G. and Whitehouse, W.L. (1976) Essential fatty acids and fetal brain growth. LANCET (i): 452‑453.

[3] Crawford MA, Wang Y, Forsyth S, Brenna JT. (2015) The European Food Safety Authority recommendation for polyunsaturated fatty acid composition of infant formula overrules breast milk, puts infants at risk, and should be revised. Prostaglandins Leukot Essent Fatty Acids. 2015 Dec;102-103:1-3. doi: 10.1016/j.plefa.2015.07.005. Epub 2015PMID:  26432509

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