The carbon footprint of breastmilk substitutes in comparison with breastfeeding

Allomilk: An Anthropogeny-Based Framework for Human Milk as a Climate Solution

Climate change is an urgent threat to perinatal and infant health, with the greatest effects of climate change exposures being felt disproportionately by global majority communities who have been most harmed by systems of oppression. Human milk feeding is one recognized solution to bolster climate resilience. Yet, policies and practices to support human milk as a climate solution are inconsistent and under-prioritized, which is unsurprising given the lack of alignment between human history and current cultural context with regard to lactation and human milk access. This paper presents a new framework on lactation as a climate solution, which is unique in its incorporation of the critical history of cooperative breastfeeding in our species. Rooted in anthropogeny, or the study of human origins, and antiracist principles of lactation, the Allomilk Framework highlights five concepts of the ideal application of human milk as a climate solution, bridging ancient allonursing with present-day lactation and human milk access. These ideal applications-and the proposed development of measures to operationalize them-will advance the field through a shared understanding of the qualities that should be prioritized in the assessment of policies and practices at the intersection of climate resilience and human milk access. Application of the Allomilk Framework to assess and design future policies and practices will advance the field by increasing the potential for climate resilience and climate mitigation while working with-rather than against-the importance of cooperative breastfeeding in human history.

Environmental impact of infant feeding type, accessories used and maternal dietary habits: The GREEN MOTHER-I project, a cross-sectional study protocol

INTRODUCTION

Breastfeeding (BF) is the healthiest form of nutrition for babies and is recommended exclusively (EBF) for at least the first six months of life. The carbon footprint of formula feeding (FF) has been studied, but that of BF is unknown.

AIM

To identify the environmental impact of three types of infant feeding taking into account the accessories needed and the diet of postpartum women in the baby's first month of life.

METHODS

This is a multicentre, cross-sectional study conducted in the Barcelona North Metropolitan Area (Catalonia, Spain). The participating sites are primary care settings that will recruit 408 postpartum women (4-6 weeks) as per inclusion/exclusion criteria. The data will be collected through a GREEN MOTHER Survey that includes 4 dimensions: 1) socio-demographic and clinical data; 2) data on the newborn and accessories used in infant feeding; 3) general data on the mother's diet (food consumption habits), and 4) recording of 24 h of the mother's diet. The data analysis will be performed to check the prevalence of infant feeding types at birth and month 1, as well as a comparative analysis of three types of infant feeding on environmental impact (climate change; water consumption, and scarcity).

ETHICS

This project was approved by the Research Ethics Committee of the Jordi Gol i Gurina University Institute Foundation for Primary Health Care Research (IDIAP) under code 22/101-P dated 22/02/2023.

DISCUSSION

A second phase of the GREEN MOTHER study is planned, which will consist of an educational intervention to promote breastfeeding, nutrition and sustainability. This intervention will be based on the results obtained in Phase I. We expect that the project results - through the publication and dissemination of scientific papers and reports among relevant stakeholders (association of community midwives, healthcare and primary care attention professionals and the public) - will increase public awareness of breastfeeding and its impact on sustainability.

TRIAL REGISTRATION

Both phases of the GREEN MOTHER study protocol were registered in ClinicalTrials.gov, NCT05729581.

Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background

Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives

To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design

Evidence syntheses with stakeholder engagement.

Review methods

Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops.

Results

We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence.

Limitations

There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics.

Conclusions

'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work

Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

Study registration

This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.

Estimating carbon and water footprints associated with commercial milk formula production and use: development and implications of the Green Feeding Climate Action Tool

Carbon offset frameworks like the UN Clean Development Mechanism (CDM) have largely overlooked interventions involving food, health, and care systems, including breastfeeding. The innovative Green Feeding Climate Action Tool (GFT) assesses the environmental impact of commercial milk formula (CMF) use, and advocates for breastfeeding support interventions as legitimate carbon offsets. This paper provides an overview of the GFT's development, key features, and potential uses. The offline and online GFT were developed using the DMADV methodology (Define, Measure, Analyze, Design, Verify). The GFT reveals that the production and use of CMF by infants under 6 months results in annual global greenhouse gas (GHG) emissions of between 5.9 and 7.5 billion kg CO2 eq. and consumes 2,562.5 billion liters of water. As a national example, in India, one of the world's most populous countries, CMF consumption requires 250.6 billion liters of water and results in GHG emissions ranging from 579 to 737 million kg CO2 eq. annually, despite the country's high breastfeeding prevalence among infants under 6 months. The GFT mainly draws on data for low- and middle-income countries (LMICs), as many high-income countries (HICs) do not collect suitable data for such calculations. Despite poor official data on breastfeeding practices in HICs, GFT users can input their own data from smaller-scale surveys or their best estimates. The GFT also offers the capability to estimate and compare baseline with counterfactual scenarios, such as for interventions or policy changes that improve breastfeeding practices. In conclusion, the GFT is an important innovation to quantify CMF's environmental impact and highlight the significance of breastfeeding for planetary as well as human health. Women's contributions to environmental preservation through breastfeeding should be recognized, and breastfeeding interventions and policies should be funded as legitimate carbon offsets. The GFT quantifies CMF's carbon and water footprints and facilitates financing breastfeeding support as a carbon offset initiative under CDM funding facilities.

Alimentation infantile et changements climatiques : une opportunité prometteuse

The method of infant feeding has consequences for the production of greenhouse gases (GHG) as well as for the risks to infants posed by climate change. Breastfeeding can reduce the carbon footprint associated with the use of commercial infant formula by nearly 50% while reducing its water footprint and waste. It is also an excellent way of coping with emergencies associated with climate change, such as water shortages, since breastfed children are better protected than those fed with formula. To ensure that the protection offered by breastfeeding can be realized, we present elements that can help decision-makers seize a promising opportunity: improve infant feeding support for women and families.

A proposal to recognize investment in breastfeeding as a carbon offset

Policy-makers need to rethink the connections between the economy and health. The World Health Organization Council on the Economics of Health for All has called for human and planetary health and well-being to be moved to the core of decision-making to build economies for health. Doing so involves valuing and measuring what matters, more and better health financing, innovation for the common good and rebuilding public sector capacity. We build on this thinking to argue that breastfeeding should be recognized in food and well-being statistics, while investments in breastfeeding should be considered a carbon offset in global financing arrangements for sustainable food, health and economic systems. Breastfeeding women nourish half the world's infants and young children with immense quantities of a highly valuable milk. This care work is not counted in gross domestic product or national food balance sheets, and yet ever-increasing commercial milk formula sales are counted. Achieving global nutrition targets for breastfeeding would realize far greater reductions in greenhouse gas emissions than decarbonizing commercial milk formula manufacturing. New metrics and financing mechanisms are needed to achieve the health, sustainability and equity gains from more optimal infant and young child feeding. Properly valuing crucial care and environmental resources in global and national measurement systems would redirect international financial resources away from expanding carbon-emitting activities, and towards what really matters, that is, health for all. Doing so should start with considering breastfeeding as the highest quality, local, sustainable first-food system for generations to come.

Secular trends in infant feeding practices during the first year of life in Norway: findings from 1998 to 2019 - the Spedkost surveys

The aims of the present study were to assess secular trends in breast-feeding and to explore associations between age at introduction of solid foods and breast-feeding duration. Data from three national dietary surveys in Norway were used, including infants born in 1998 (Spedkost 1, n 1537), 2006 (Spedkost 2, n 1490) and 2018 (Spedkost 3, n 1831). In all surveys, around 80 % of the infants were breastfed at 6 months of age. At 12 months of age, breast-feeding rate was 41 % in Spedkost 1, increasing to 48 % in Spedkost 2 and 51 % in Spedkost 3. Compared with earlier introduction, introduction of solid foods at ≥ 5 months of age was associated with a lower risk of breast-feeding cessation during the first year of life in the two most recent Spedkost surveys. In Spedkost 2, the adjusted hazard ratio for breast-feeding cessation during the first year of life for those introduced to solid foods at ≥ 5 months of age was 0·43 (95 % CI (0·31, 0·60)), P < 0·001, while the corresponding number in Spedkost 3 was 0·44 (95 % CI (0·29, 0·67)), P < 0·001. In conclusion, breast-feeding at infant age 12 months increased over time. Introduction of solid foods at ≥ 5 months of age was positively associated with breast-feeding duration in the two most recent Spedkost surveys. As breast-feeding contributes to numerous health benefits for infant and mother, and possibly improved dietary sustainability in infancy, findings point to the importance of continued protection, support and promotion of breast-feeding.

Sustainable Breastfeeding: A State-of-the Art Review

BACKGROUND

Disparities in breastfeeding rates and exclusivity exist across regions and countries despite multifaceted breastfeeding promotion efforts in recent decades. Markets for artificial milk formula continue to grow as its substitution for breastfeeding is common. A new approach is needed for breastfeeding promotion strategies.

RESEARCH AIM

This state-of-the-art review aimed to describe the implications of not-breastfeeding on the environment within the context of food system sustainability.

METHOD

A total of 19 peer-reviewed articles within a 20-year timeframe were included in this review. Authors searched five databases for articles including Science Direct, GreenFILE, Springer Link, ProQuest, and PubMed.

RESULTS

The demand for artificial milk formula production as a replacement for breastfeeding results in increased greenhouse gas emissions, water pollution, and waste, thereby aggravating problems with freshwater scarcity. A short duration of breastfeeding and limited exclusivity have been associated with close birth spacing and contributing to global population growth. Breastfeeding is a healthy, sustainable diet, and a culturally acceptable first food. It advances health equity and food security. Exclusive breastfeeding for the first 6 months of life can be promoted with emphasis on total carbon footprint reduction, prevention of waterway degradation, and natural birth spacing, thereby sustaining food systems at large.

CONCLUSION

It is important to reform food, nutrition, and environmental policies to protect exclusive breastfeeding while decarbonizing artificial milk formula production. More research is needed to provide directions for new breastfeeding promotion strategies connecting breastfeeding with environmental stewardship.

Barriers to promoting breastfeeding in primary health care in Mexico: a qualitative perspective

Objective

This article aimed to identify the main barriers related to promoting and counseling breastfeeding (BF) at the Primary Health Care (PHC) in Mexico.

Methodology

A qualitative study with a phenomenological approach was carried out in 88 health centers of the Ministry of Health in the states of Chihuahua, Oaxaca, Chiapas, Veracruz, Mexico, and Yucatan. From September to November 2021, we interviewed 88 key health professionals (HPs) (physicians, nurses, nutritionists, and others) from the PHC of the Ministry of Health in Mexico and 80 parents of children under 5 years old. In addition, nine focus groups were conducted with parents and caregivers. The data obtained were triangulated with information from focus groups and semi-structured interviews.

Results

Of the total interviews, 43.2% (n = 38) were nurses, 29.5% (n = 26) were physicians, 19.3% (n = 17) were nutritionists, and the rest were other health professionals. In the group of users, 97.6% (n = 121) were women. We identified contextual barriers, such as the lack of well-trained health professionals and the scarcest nutrition professionals, as material resources in the health units, without mentioning the low user attendance at their control consultations. Furthermore, we identified barriers related to the orientation and promotion of breastfeeding in health units, including a lack of specific strategies, ineffective communication, and the recommendations of commercial milk formulas.

Conclusion

The results presented reflect the reality of Mexico in relation to BF, making it urgent to take immediate action to improve the quality of nutritional care related to the promotion and orientation of BF at the PHC.

Breastfeeding and Environmental Consciousness: A Narrative Review of Environmental Implications and Potential Contributions to Reduce Waste and Energy Consumption

Breastfeeding is a natural and essential process that not only confers numerous health benefits to infants and mothers but also plays an important role in environmental sustainability. This narrative review explores the environmental implications of breastfeeding in comparison to formula feeding and examines the potential contributions of breastfeeding to reduce waste, energy consumption, and carbon footprint. By exploring the existing literature and research findings, this review sheds light on how breastfeeding aligns with environmental conservation efforts and reinforces the importance of promoting breastfeeding practices for a more sustainable and environment-friendly future.

Is proactive telephone-based breastfeeding peer support a cost-effective intervention? A within-trial cost-effectiveness analysis of the 'Ringing Up about Breastfeeding earlY' (RUBY) randomised controlled trial

OBJECTIVE

The 'Ringing Up about Breastfeeding earlY' (RUBY) randomised controlled trial showed increased breastfeeding at 6 months in participants who received the proactive telephone-based peer support breastfeeding intervention compared with participants allocated to receive standard care and supports. The present study aimed to evaluate if the intervention was cost-effective.

DESIGN

A within-trial cost-effectiveness analysis.

SETTING

Three metropolitan maternity services in Melbourne, Victoria, Australia.

PARTICIPANTS

First time mothers intending to breastfeed their infant (1152) and peer volunteers (246).

INTERVENTION

The intervention comprised proactive telephone-based support from a peer volunteer from early postpartum up to 6 months. Participants were allocated to usual care (n=578) or the intervention (n=574).

MAIN OUTCOME MEASURES

Costs during a 6-month follow-up period including individual healthcare, breastfeeding support and intervention costs in all participants, and an incremental cost-effectiveness ratio.

RESULTS

Costs per mother supported were valued at $263.75 (or $90.33 excluding costs of donated volunteer time). There was no difference between the two arms in costs for infant and mothers in healthcare and breastfeeding support costs. These figures result in an incremental cost-effectiveness ratio of $4146 ($1393 if volunteer time excluded) per additional mother breast feeding at 6 months.

CONCLUSION

Considering the significant improvement in breastfeeding outcomes, this intervention is potentially cost-effective. These findings, along with the high value placed on the intervention by women and peer volunteers provides robust evidence to upscale the implementation of this intervention.

TRIAL REGISTRATION NUMBER

ACTRN12612001024831.

Perinatal support for breastfeeding using mHealth: A mixed methods feasibility study of the My Baby Now app

Despite the well-known benefits of breastfeeding, breastfeeding rates remain suboptimal, particularly for women with lower socioeconomic position. Although popular, breastfeeding apps are often poor quality; their impact on breastfeeding knowledge, attitudes, confidence and intentions is unknown. A mixed method pre-post feasibility study was conducted to: 1) explore the feasibility of the My Baby Now app in providing perinatal breastfeeding support; 2) examine the impact on breastfeeding knowledge, attitudes, confidence and intentions; 3) to examine any differences in acceptability and impact of the app according to maternal education. The My Baby Now app was offered to pregnant women 20-30 weeks gestation. Breastfeeding knowledge and intentions were collected at baseline (T1) and 36-38 weeks gestation (T2); attitudes and confidence were collected at baseline, T2 and T3 (8-12 weeks post-partum). App engagement was measured via app analytics. Qualitative interviews were conducted with a purposeful sample following T3. Of 266 participants recruited, 169 (64%) completed T2 and 157 (59%) completed T3. Mothers without university education rated the app to be higher quality, more useful and impactful than mothers with university education. From T1-T2, breastfeeding knowledge (59.6% vs. 66.5%, p < 0.001) and exclusive breastfeeding intentions (76.6% vs. 80.9%, p < 0.001) increased. Breastfeeding attitudes and confidence scores also increased significantly across T1-T2 and T1-T3. App engagement during pregnancy predicted changes in breastfeeding attitudes from T1-T2 among participants without university education. App engagement did not predict changes in breastfeeding knowledge, confidence or intentions. Future randomised controlled studies should examine the effectiveness of mHealth interventions on breastfeeding outcomes.

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.

The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress

Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0-36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.

World Trends in Infant Formulas Composition Enhancement

This article provides the overview of the major strategies for infant formulas composition enhancement via modern technologies and trends in minimizing technology-related loads on the environment. Potential modifications of quantitative and qualitative characteristics of milk formulas nutrients have been determined. We also covered product contents changing over age, as well as the perspectives of using animal milk in formulas. The relevance of adding biologically active substances and living microorganisms (probiotics), their safety, and efficacy are discussed.

Low-Protein Infant Formula and Obesity Risk

Infant formulas have been designed to mimic human milk for infants who cannot be breastfed. The overall goal is to establish similar functional outcomes to assure optimal growth, development, maturation of the immune system, and programming of the metabolic system. However, after decades of improving infant formula, growth patterns and body composition development are still different in formula-fed infants compared to breastfed infants, which could contribute to an increased risk of obesity among formula-fed infants. It has been hypothesized that the lower protein concentration of breast milk compared to infant formula influences infants’ growth and body composition. Thus, several trials in formula-fed infants with different protein intake levels have been performed to test this hypothesis. In this review, we discuss the current evidence on low-protein infant formula and obesity risk, including future perspectives and implications.

Environmental Impact of Feeding with Infant Formula in Comparison with Breastfeeding

Young children have unique nutritional requirements, and breastfeeding is the best option to support healthy growth and development. Concerns have been raised around the increasing use of milk-based infant formulas in replacement of breastfeeding, in regards to health, social, economic and environmental factors. However, literature on the environmental impact of infant formula feeding and breastfeeding is scarce. In this study we estimated the environmental impact of four months exclusive feeding with infant formula compared to four months exclusive breastfeeding in a Norwegian setting. We used life-cycle assessment (LCA) methodology, including the impact categories global warming potential, terrestrial acidification, marine and freshwater eutrophication, and land use. We found that the environmental impact of four months exclusive feeding with infant formula was 35–72% higher than that of four months exclusive breastfeeding, depending on the impact category. For infant formula, cow milk was the main contributor to total score for all impact categories. The environmental impact of breastfeeding was dependant on the composition of the lactating mother’s diet. In conclusion, we found that breastfeeding has a lower environmental impact than feeding with infant formula. A limitation of the study is the use of secondary LCA data for raw ingredients and processes.

Examining the Environmental Impacts of the Dairy and Baby Food Industries: Are First-Food Systems a Crucial Missing Part of the Healthy and Sustainable Food Systems Agenda Now Underway?

Food systems are increasingly being understood as driving various health and ecological crises and their transformation is recognised as a key opportunity for planetary health. First-food systems represent an underexplored aspect of this transformation. Despite breastfeeding representing the optimal source of infant nutrition, use of commercial milk formula (CMF) is high and growing rapidly. In this review, we examine the impact of CMF use on planetary health, considering in particular its effects on climate change, water use and pollution and the consequences of these effects for human health. Milk is the main ingredient in the production of CMF, making the role of the dairy sector a key area of attention. We find that CMF use has twice the carbon footprint of breastfeeding, while 1 kg of CMF has a blue water footprint of 699 L; CMF has a significant and harmful environmental impact. Facilitation and protection of breastfeeding represents a key part of developing sustainable first-food systems and has huge potential benefits for maternal and child health.

Evidence of Violations of the International Code of Marketing of Breast-Milk Substitutes since the Adoption by the World Health Assembly in 1981: A Systematic Scoping Review Protocol

This is the protocol for a scoping review that aims to systematically explore and summarise the published evidence of violations of the International Code of Marketing of Breast-milk Substitutes (the Code) and subsequent World Health Assembly Resolutions globally. The planned scoping review will seek to identify what research has been conducted on the topic, examine the geographic spread and nature of violations, and summarise knowledge gaps. The Code was adopted in 1981 by the World Health Assembly to protect infant health, in particular from aggressive and inappropriate marketing of breastmilk substitutes including formula and related products. Non-compliance with the Code or violations are described in reports, however, no existing systematic review of the global research appears to have been conducted that encompasses the varied disciplines including health, economics, and gender. The review will inform international and national decision-makers on the nature of violations and potentially highlight the need for new modalities to regulate this marketing. The proposed scoping review will use the six-step process of Arksey and O’Malley which includes defining the research question; identifying the relevant literature; selecting studies; charting the data; collating, summarising and reporting the findings; and will include a consultative group.

Factors Associated with the Maintenance of Breastfeeding at One Year among Women in Chiang Mai, Thailand

This study aimed to investigate factors associated with breastfeeding for at least one year among women in Chiang Mai, Thailand. We conducted a cross-sectional study of 451 mothers with children aged between 12 and 24 months who visited the well-baby clinic among women who visited the well-baby clinic in secondary and tertiary hospitals. The data collected included maternal sociodemographic information, employment status, reasons contributing to continued breastfeeding, primary sources of information, and influential people affecting continued breastfeeding. Multivariable logistic regression analysis was used to investigate the relationship between explanatory variables and continued breastfeeding at one year. Reporting "easier to bond with baby" as a reason to continue breastfeeding (AOR 3.118, 95% CI: 2.022, 4.809) and multiparous status (AOR 1.588, 95% CI: 1.042, 2.420) were positive predictors of mothers who had breastfeeding at least one year postpartum while mothers with undergraduate education level (AOR 0.635, 95% CI: 0.404, 0.997) were more likely to discontinue breastfeeding. Our study highlighted that working mothers have lower odds of continued breastfeeding than stay-at-home mothers (SAHMs), which was found for work with day shifts (AOR 0.437, 95% CI: 0.261, 0.731), work with rotational shifts (AOR 0.481, 95% CI: 0.247, 0.934), and work from home jobs with a flexible schedule (AOR 0.439, 95% CI: 0.229, 0.838). These findings showed that both employment outside home and work from home were strong risk factors for discontinuing breastfeeding before 12 months. We suggest that a breastfeeding-friendly workplace policy is essential to enhance the continuance of breastfeeding. Additionally, working at home requires more research to explore breastfeeding barriers and establish more support strategies.

A pediatrician's guide to climate change-informed primary care

Despite the urgency of the climate crisis and mounting evidence linking climate change to child health harms, pediatricians do not routinely engage with climate change in the office. Each primary care visit offers opportunities to screen for and support children burdened with risks to health that are increasingly intense due to climate change. Routine promotion of healthy behaviors also aligns with some needed-and powerful-solutions to the climate crisis. For some patients, including those engaged in athletics, those with asthma and allergies, or those with complex healthcare needs, preparedness for environmental risks and disasters worsened by climate change is a critical component of disease prevention and management. For all patients, anticipatory guidance topics that are already mainstays of pediatric best practices are related closely to needed guidance to keep children safe and promote health in the setting of compounding risks due to climate change. By considering climate change in routine care, pediatricians will be updating practice to align with evidence-based literature and better serving patients. This article provides a framework for pediatricians to provide climate-informed primary care during the structure of pediatric well child and other visits.

Globalization, first-foods systems transformations and corporate power: a synthesis of literature and data on the market and political practices of the transnational baby food industry

BACKGROUND

The global milk formula market has 'boomed' in recent decades, raising serious concerns for breastfeeding, and child and maternal health. Despite these developments, few studies have investigated the global expansion of the baby food industry, nor the market and political practices corporations have used to grow and sustain their markets. In this paper, our aim is to understand the strategies used by the baby food industry to shape 'first-foods systems' across its diverse markets, and in doing so, drive milk formula consumption on a global scale. We used a theoretically guided synthesis review method, which integrated diverse qualitative and quantitative data sources.

RESULTS

Global milk formula sales grew from ~US$1.5 billion in 1978 to US$55.6 billion in 2019. This remarkable expansion has occurred along two main historical axes. First, the widening geographical reach of the baby food industry and its marketing practices, both globally and within countries, as corporations have pursued new growth opportunities, especially in the Global South. Second, the broadening of product ranges beyond infant formula, to include an array of follow-up, toddler and specialized formulas for a wider range of age groups and conditions, thereby widening the scope of mother-child populations subject to commodification. Sophisticated marketing techniques have been used to grow and sustain milk formula consumption, including marketing through health systems, mass-media and digital advertising, and novel product innovations backed by corporate science. To enable and sustain this marketing, the industry has engaged in diverse political practices to foster favourable policy, regulatory and knowledge environments. This has included lobbying international and national policy-makers, generating and deploying favourable science, leveraging global trade rules and adopting corporate policies to counter regulatory action by governments.

CONCLUSION

The baby food industry uses integrated market and political strategies to shape first-foods systems in ways that drive and sustain milk formula market expansion, on a global scale. Such practices are a major impediment to global implementation of the International Code of Marketing of Breastmilk Substitutes, and other policy actions to protect, promote and support breastfeeding. New modalities of public health action are needed to negate the political practices of the industry in particular, and ultimately to constrain corporate power over the mother-child breastfeeding dyad.

Achieving global targets on breastfeeding in Thailand: gap analysis and solutions

Background

Global advocates for breastfeeding were evident since the International Code of Marketing of Breast-Milk Substitutes (BMS Code) was adopted in 1981 and fostered by subsequent relevant World Health Assembly resolutions, using a framework that promotes, supports and protects breastfeeding. Global partners provided comprehensive support for countries to achieve breastfeeding targets while progress was closely monitored. This review identifies breastfeeding policy and implementation gaps in Thailand.

Main findings

Although Thailand implemented three Thai voluntary BMS Codes, ineffective enforcement results in constant violations by BMS industries. In light of strong resistance by the BMS industries and their proxies, it was not until 2017 that the Code was legislated into national law; however regulatory enforcement is a protracted challenge. A Baby-Friendly Hospital Initiative (BFHI), mostly in public hospitals, was successfully applied and scaled up nationwide in 1992, but it later became inactive due to lack of continued support. Several community-based and workplace programmes, which supported breastfeeding, also faced challenges from competing agendas. Although the Labor Protection Law offers 98 days maternity leave with full pay, the conducive environment for successful six- month exclusive breastfeeding (EBF) needs a significant boost. These gaps in policy were exacerbated by a lack of multi-sectoral collaboration, ineffective implementation of existing interventions, inadequate investment, and lack of political will to legislate six-month maternity leave.

As a result, the progress of EBF rate during the first 6 months as measured by previous 24 h was erratic; it increased from 12.3% in 2012 to 23.1% in 2015 and decreased to 14% in 2019. There was a deterioration of early initiation from 49.6% in 2006 to 34% in 2019. These low performances hamper the achievement of global targets by 2030.

Conclusions

We recommend the following. First, increase financial and human resource investment, and support successful exclusive breastfeeding in BHFI, communities and workplaces through multi-sectoral actions for health. Second, implement the active surveillance of violations and strengthen law enforcement for timely legal sanctions of violators. Third, revitalize the BFHI implementation in public hospitals and extend to private hospitals.

Climate Change and Infant Nutrition: Estimates of Greenhouse Gas Emissions From Milk Formula Sold in Selected Asia Pacific Countries

BACKGROUND

There is growing recognition that current food systems and policies are environmentally unsustainable. There is an identified need to integrate sustainability objectives into national food policy and dietary recommendations.

RESEARCH AIMS

To (1) describe exploratory estimates of greenhouse gas emission factors for all infant and young child milk formula products and (2) estimate national greenhouse gas emission association with commercial milk formulas sold in selected countries in the Asia Pacific region.

METHOD

We used a secondary data analysis descriptive design incorporating a Life Cycle Assessment (LCA) concepts and methodology to estimate kg CO₂ eq. emissions per kg of milk formula, using greenhouse gas emission factors for milk powder, vegetable oils, and sugars identified from a literature review. Proportions of ingredients were calculated using FAO Codex Alimentarius guidance on milk formula products. Estimates were calculated for production and processing of individual ingredients from cradle to factory gate. Annual retail sales data for 2012-2017 was sourced from Euromonitor International for six purposively selected countries; Australia, South Korea, China, Malaysia, India, Philippines.

RESULTS

Annual emissions for milk formula products ranged from 3.95-4.04 kg CO₂ eq. Milk formula sold in the six countries in 2012 contributed 2,893,030 tons CO₂ eq. to global greenhouse gas emissions. Aggregate emissions were highest for products (e.g., toddler formula), which dominated sales growth. Projected 2017 emissions for milk formula retailed in China alone were 4,219,052 tons CO₂ eq.

CONCLUSIONS

Policies, programs and investments to shift infant and young child diets towards less manufactured milk formula and more breastfeeding are "Triple Duty Actions" that help improve dietary quality and population health and improve the sustainability of the global food system.

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.

Breast-feeding promotion in hospitals and prospective breast-feeding rates during the first year of life in two national surveys 1997-1998 and 2017-2019 in Germany

OBJECTIVES

The present study aimed to assess the current state of breast-feeding promotion in hospitals and the prevalence of breast-feeding during the first year of life in Germany and to compare the results with a study 20 years earlier.

DESIGN

In the studies on 'breast-feeding and infant nutrition in Germany' named 'SuSe', a cross-sectional survey in hospitals was combined with a subsequent prospective survey of breast-feeding and infant nutrition during the first year of life (0·5, 2, 4, 6 and 12 months after birth) in mother-infant pairs who were recruited in the hospitals. Written questionnaires and phone calls were used in SuSe I and web-based questionnaires in SuSe II. Breast-feeding promotion and prevalence were evaluated using recommendations from the WHO and the UNICEF.

SETTING

Two nationwide surveys SuSe I (1997-1998) and SuSe II (2017-2019).

PARTICIPANTS

In SuSe I, 177 hospitals and 1717 mother-infant pairs and in SuSe II 109 hospitals and 962 mother-infant pairs were included.

RESULTS

In SuSe II, hospitals implemented seven of the WHO 'Ten Steps to Successful Breastfeeding' to a greater extent than the hospitals in SuSe I. More mothers exclusively breastfed for 4 months (57 % v. 33 %) and continued breast-feeding until 6 (78 % v. 48 %) and 12 months (41 % v. 13 %). In both studies, exclusive breast-feeding decreased between 4 and 6 months of age due to the introduction of complementary feeding.

CONCLUSIONS

In Germany, breast-feeding habits have come closer to the recommendations over the last 20 years.

Breastfeeding practices in Mexico: Results from the National Demographic Dynamic Survey 2006-2018

Although actions have been taken to improve breastfeeding in Mexico, trends over the last decade and their associated factors have not been analysed. We estimated trends in breastfeeding practices at the national, rural/urban, and regional level indigenous ethnicity and socio-economic level, and their associated factors using the National Demographic Dynamics Survey (2006, 2009, 2014 and 2018). We assessed breastfeeding indicators of women with children <24 months according to The World Health Organization recommendations. Logistic regressions models of pooled data were used to estimate trends and associations with biological and sociodemographic characteristics. Between 2006 and 2018, the prevalence of ever breastfed increased from 91.8% to 94.2% (p < 0.001), whereas early initiation of breastfeeding increased from 40.8% to 59.7% (p < 0.001), with similar increments by urban/rural level. Between 2009 and 2018, the prevalence of exclusive breastfeeding in children <6 months increased from 13.0% to 20.7% (p < 0.001). The largest increase was seen in Mexico City, in nonindigenous women and those with a high socio-economic status, whereas indigenous women and those from the South had the lowest or no improvements. Breastfeeding education during pregnancy [odds ratio (OR) 1.3; 95% confidence interval (CI) 1.1-1.5] was positively associated with exclusive breastfeeding, whereas being employed (OR 0.8; 95% CI 0.6-0.9) was negatively associated. Breastfeeding practices improved but are still far from recommendations. Implementing strategies like breastfeeding counselling and programmes and policies that promote and support breastfeeding for poor, indigenous, single and working mothers should be a priority for the government to ensure that all children have the best start in life.

Powdered Baby Formula Sold in North America: Assessing the Environmental Impact

Background: According to the Intergovernmental Panel on Climate Change, Greenhouse Gas emissions must decline by around 45% by 2030 and reach net zero in 2050. Biofuels, solar, and wind energy are obvious choices for reduction of the 75% of emissions from the energy sector (including transportation), but making reductions in the remaining 25%, the food sector, is more of a challenge. One way is to change our diets to increase low-carbon food alternatives. Objective: We chose to examine the impact of powdered baby formula products. The aim of this study is to compute a minimal estimate of green house gas (GHG) emissions for powdered baby formula products sold in North America comprising Canada, Mexico, and the United States. Results: We found that in 2016, the North America Greenhouse Gas emissions (in tons of CO₂ eq.) attributable to sales of powdered formula for Canada was 70,256, for Mexico, 435,820, and for the United States, 655,956. The North American per capita emissions based on infants and toddlers from birth to 36 months of age in 2016 was, at a minimum, 59.06 kg of CO₂ eq. Conclusion: The environmental and Greenhouse Gas impact of powdered baby formula, and related hazards arising from climate change, can be a relevant factor for health care providers in their advice to families on infant feeding. This study makes an innovative and potentially useful addition to the emerging evidence on this issue and should be considered when developing and funding infant and young child feeding policies and supportive programs.

Selling second best: how infant formula marketing works

Background

Despite the clear policy intent to contain it, the marketing of formula milk remains widespread, powerful and successful. This paper examines how it works.

Methods

The study comprised a mix of secondary analysis of business databases and qualitative interviews with marketing practitioners, some of whom had previously worked in formula marketing.

Results

The World Health Assembly Code aims to shield parents from unfair commercial pressures by stopping the inappropriate promotion of infant formula. In reality marketing remains widespread because some countries (e.g. the USA) have not adopted the Code, and elsewhere industry has developed follow-on and specialist milks with which they promote formula by proxy. The World Health Assembly has tried to close these loopholes by extending its Code to these products; but the marketing continues. The campaigns use emotional appeals to reach out to and build relationships with parents and especially mothers. Evocative brands give these approaches a human face. The advent of social media has made it easier to pose as the friend and supporter of parents; it is also providing companies with a rich stream of personal data with which they hone and target their campaigns.

The formula industry is dominated by a small number of extremely powerful multinational corporations with the resources to buy the best global marketing expertise. Like all corporations they are governed by the fiduciary imperative which puts the pursuit of profits ahead of all other concerns. This mix of fiscal power, sophisticated marketing, and single-mindedness is causing great harm to public health.

Conclusions

Formula marketing is widespread and using powerful emotional techniques to sell parents a product that is vastly inferior to breast milk. There is an urgent need to update and strengthen regulation.

Improving Breastfeeding by Empowering Mothers in Vietnam: A Randomised Controlled Trial of a Mobile App

Breastfeeding provides benefits to the infant and mother; however, the rates of breastfeeding, particularly exclusive breastfeeding, remain below optimal levels in many Asian countries. The aim of this study is to review the benefits of breastfeeding to mothers and infants and current rates of breastfeeding in Vietnam, and to evaluate the effectiveness of a mobile application on exclusive breastfeeding among mothers in Vietnam. A two-arm, parallel triple-blinded randomised controlled trial will be conducted among 1000 mothers in Hanoi City, Vietnam, during 2020-2021. Eligible participants are pregnant women who will seek antenatal care from health facilities at 24-36 weeks of gestation and plan to deliver at two participating hospitals, own a smartphone, and carry a singleton foetus. Permuted-block randomisation method stratified by maternal age, education and parity will be used to ensure an equal number of participants in each group. A smartphone app will be developed to deliver breastfeeding and non-breastfeeding information to the intervention and control group, respectively. Data will be collected at baseline, before hospital discharge, and at 1, 4, and 6 months postpartum. This study envisages demonstrating whether a smartphone-based intervention can be effective at improving breastfeeding in Vietnam. Trials registration: ACTRN12619000531112.

Enabling Breastfeeding to Support Lifelong Health for Mother and Child

The health benefits of breastfeeding are well documented, and more than 80% of US women initiate breastfeeding; however, mothers in the United States face substantial challenges in meeting their personal breastfeeding goals, with approximately 60% weaning earlier than they had intended. In addition, there are significant racial/ethnic inequities in infant-feeding behaviors, and these inequities are a major public health concern. Enabling women to meet their breastfeeding goals is a public health priority. Infant feeding should be addressed as a modifiable health behavior, rather than a lifestyle choice.

A commentary on the carbon footprint of milk formula: harms to planetary health and policy implications

Background

Infant formula requires mass production by the dairy industry, with plastic and other waste and degradation of land and waterways. Millions of babies, two thirds globally, now have milk formula, with breastfeeding in dramatic decline in Asia.

Economic cost externalities and commercial incentives

Economic thinking clarifies that markets are not perfect - price incentives can lead to excessive and inefficient environmental damage. Market prices paid to produce or use a commodity may not reflect its true resource costs. The ongoing global transition in infant and young child feeding (IYCF) toward milk formula use makes urgent the investigation of its environmental costs, including greenhouse gas (GHG) implications. Socially vulnerable populations are also particularly exposed to climate change risks, but have the least voice and agency.

The important role of public health advocacy

Few question the scale of the baby food industry, especially in major food exporting countries. Breastfeeding advocacy non-government organisations have led the investigations, and exposed the inequitable vulnerabilities. A ground-breaking study in 2016 showed emissions from just six Asia Pacific countries were equivalent to 6 billion miles of car travel. Each kilogram (kg) of milk formula generated 4 kg of (carbon dioxide (CO₂) equivalent) greenhouse gas during production. Much of this was from unnecessary toddler formula. Recent research reveals that if looking at the full product lifecycle, including consumer use, GHG emissions per kg are actually three times higher than these pioneering estimates. Environment and health harms combined with economic evidence highlight the place for a strong public health response on this issue.

Conclusion

Formula feeding is a maladaptive practice in the face of contemporary global environmental and population health challenges. Breastfeeding protection, support and promotion helps to safeguard planetary and human health by minimising environmental harm. It is a beneficial response to concerns about disease burdens and climate change. Breastfeeding populations are more resilient in emergencies. Effective and cost-effective policies and interventions exist for increasing breastfeeding and reducing unnecessary use of formula. Implementing such measures presents a rare opportunity to both reduce the greenhouse gas problem and improve human nutrition, health, and health equity.