Infant formula and toddler milk marketing: opportunities to address harmful practices and improve young children's diets

Maternal Recognition of Formula Food Brand Logos and Its Association with Breastfeeding

Background: Despite many well-documented benefits of breastfeeding, only 44% of babies worldwide are exclusively breastfed for the first 6 months. The aggressive marketing of formula food companies may be contributing to why mothers are choosing artificial feeding over breastfeeding. Objective: To identify when and how mothers become aware of infant formula food and the impact it has on breastfeeding. Methods: Four commonly used formula food logos were modified to unbranded versions using photoshop and shown to 444 participants at a tertiary level hospital. The participants included first-time pregnant women and mothers of infants aged 0-6 months. They were asked if they recognized the logos and how they knew them. Breastfeeding practices and media usage were also examined with a questionnaire. Results: The overall rate of logo recognition was 60.8%, increasing with the baby's age. Of the mothers who had never used formula, 51.6% still recognized them. Of the participants, 70.5% admitted to getting baby care ideas from the media, with the logo recognition rate being higher among them. Exclusive breastfeeding was lower among the mothers who were aware of the logos. Conclusion: The awareness of formula food was quite high among the group that needed to breastfeed exclusively. More than half of those who recognized the logos stated that they saw them through the media, highlighting its role in formula awareness.

"Figure it out or starve": The Impact of an Infant-Formula Shortage on Prenatal Infant Feeding Intentions

OBJECTIVES

Beginning in February 2022, the United States faced an infant formula shortage that severely impacted access and affordability. Little is known about how this shortage impacted infant feeding intentions among expectant mothers. Our study sought to determine the impact of the formula shortage on prenatal feeding intentions and to understand expectant mothers' feelings and perceived stress related to the shortage.

METHODS

This cross-sectional, exploratory, observational study of pregnant women (n = 57) residing in New York City utilized a self-administered online survey in May-July 2022.

RESULTS

The results indicate that ten (17.5%) respondents changed their feeding intentions during the infant formula shortage for months 0-3 or 3-6 of infancy to include more breastfeeding than originally intended. These mothers also reported significantly higher stress levels related to the shortage than their non-changing peers.

CONCLUSIONS FOR PRACTICE

Our results suggest that the formula shortage influenced feeding intentions among a subset of surveyed expectant mothers. The stress associated with the shortage influenced prenatal feeding intentions to include more breastfeeding than intended prior to the shortage. Prenatal healthcare providers should consider the availability of infant formula as one of myriad factors that influence infant feeding intentions, and that the stress associated with whether infant formula is readily available may influence these intentions as well.

Research on commercial milk formulas for young children: A scoping review

A scoping review of publications about commercial milk formulas intended for or consumed by children 12-36 months (CMF 12-36) was conducted. This review aimed to comprehensively map the existing literature, identify key concepts in the field and understand its evolution through time. A total of 3329 articles were screened and 220 were included, published between 1986 and 2024. Most works were published after 2016 (70.0%) and in high-income countries (71.8%). Original studies were the vast majority (81.8%) of publications. Most publications dealt with feeding practices or analysed the composition and/or contamination of specific products (44.1% and 35.9%), but since the late 2000s, publications about marketing, policy, legislation, and consumer perception started to appear. Most published works (65.5%) did not focus exclusively on CMF 12-36 and included formulas for other demographics or other foods. About half of the works (55.5%) did not consider CMF 12-36 to be a breast milk substitute. We found 81 distinct product denominations used to refer to CMF 12-36, Growing Up Milk was the most common (25.9%). CMF industry was involved in 41.8% of all analysed works, and industry participation and funding were not always clearly informed (22.5% lacked a conflict of interest statement, and 25.5% did not present any information about funding). In the last decade, publications about CMF 12-36 have increased in volume and diversified in scope and subject matter. CMF-industry participation has always been and still is present in the field, so possible vested interests should be taken into account when appreciating the literature.

A report card assessment of the prevalence of healthy eating among preschool-aged children: a cross-cultural study across Australia, Hong Kong, Singapore, and the US

Objective

This study aimed to initially adopt an International Healthy Eating Report Card for Preschool-Aged Children to assess the prevalence of healthy eating behaviours and favourable family home food environments (FHFEs) among preschool-aged children in Australia, Hong Kong, Singapore, and the US. We also examined which cultural contexts would exhibit significant differences in the report card scores among the four cultural contexts.

Methods

In this cross-cultural study, 2059 parent-child dyads, with approximately 500 dyads in each cultural context, were recruited. The parents were asked to complete the validated International Healthy Eating Report Card Scale to assess the dimensions of the Report Card [i.e., Indicator of Children's Eating Behaviours: (1) Children's Dietary Patterns and (2) Children's Mealtime Behaviours, and Indicator of FHFEs: (3) Parental Food Choices and Preparation, (4) Home Healthier Food Availability and Accessibility and (5) Family Mealtime Environments]. Each indicator received a letter grade [i.e., A (≥80%) = excellent, B (60-79%) = good, C (40-59%) = fair, D (20-39%) = poor, F (<20%) = very poor and including the plus (+) and minus (-) signs] to represent the proportion of participants who could meet the predefined benchmarks. We also employed ANCOVA and Bonferroni's post-hoc test to examine the differences in the report card scores between the four cultural contexts. A significance level was set at p < 0.05.

Results

The average overall report card grade across the four cultural contexts was "B-" (Good), ranging from "C+" (Singapore and the US) to "B-" (Australia and Hong Kong). The average grade for Children's Eating Behaviours was classified as Fair ("C-"), while the average grade for FHFEs was classified as Good ("B+") for all cultural contexts. A comparison of the overall report card scores revealed that Australia exhibited a significantly higher report card score than Singapore and the US, while Hong Kong achieved a significantly higher score than Singapore.

Conclusion

The International Healthy Eating Report Card provided an overview of the prevalence of healthy eating in different cultural contexts. We believe that the International Healthy Eating Report Card may offer new perspectives on interventions for fostering healthy eating in young children.

Reported Adherence to the 10 Steps to Successful Breastfeeding Is Higher Among Baby-Friendly Hospitals

OBJECTIVE

Quantify and compare reported breastfeeding support practices in the Baby-Friendly Hospital Initiative (BFHI) and non-BFHI facilities.

DESIGN

Cross-sectional survey.

SETTING

Regions across the US.

PARTICIPANTS

Two hundred and eighty-six facilities (110 BFHI and 176 non-BFHI) selected by a stratified (by hospital size) random sample of 50% BFHI and 50% non-BFHI facilities.

INTERVENTION

Emailed survey Fall 2019 through Spring 2020.

MAIN OUTCOME MEASURE

Reported adherence to the 10 Steps to Successful Breastfeeding.

ANALYSIS

Wilcoxon rank sum test with continuity correction, Pearson chi-square test of independence, and Fisher's exact test.

RESULTS

Baby-Friendly Hospital Initiative facilities were more likely to report adherence to the 10 Steps to Successful Breastfeeding. Only 2 of the reported steps were not significantly different: immediate postnatal care and responsive feeding.

CONCLUSIONS AND IMPLICATIONS

This research supports breastfeeding support interventions within hospitals as both BFHI and non-BFHI facilities have room for improvement. Interventions targeting non-BFHI facilities are an opportunity to close the disparity in breastfeeding care.

[Digital marketing of commercial infant formula in Argentina: a digital ethnographic study]

Although evidence of the benefits of breastfeeding is widespread, there are several challenges to initiate and sustain it. Infant formula companies use marketing strategies that violate existing regulations, contributing to its early abandonment. We explore the digital marketing exposure of infant formulas in Argentina by analyzing people's interactions with brands and the traces of these interactions in conversations engaged in Facebook groups during 2022, from a qualitative approach based on digital ethnography. Results show that companies deploy regulatory avoidance tactics and seek contact with mothers. Users do not interact with the accounts but are exposed to their strategies given the correlation between product attributes present in advertising with their motivations and aspirations. The mediators between marketing and mothers are medical professionals, used as marketing resources. We conclude that authorities should promote new agreements on the practices of medical professionals and develop regulations taking into account digital environments.

Toddler milk: a scoping review of research on consumption, perceptions, and marketing practices

Toddler milk is an ultra-processed beverage consisting primarily of powdered milk, caloric sweeteners, and vegetable oil. Pediatric health authorities do not support the use of toddler milk, and emerging evidence suggests that toddler-milk marketing practices may mislead consumers. However, studies have not synthesized the extent of toddler-milk marketing practices or how these practices affect parents' decisions about whether to serve toddler milk. We aimed to summarize the literature about toddler milk to identify what is known about: (1) parents' toddler-milk purchasing and feeding behaviors, (2) toddler-milk marketing, and (3) how marketing practices influence parents' beliefs and perceptions about toddler milk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we systematically searched 8 databases (PubMed, APA PsycINFO, Scopus, Cochrane Central, Embase, CINAHL, Communication & Mass Media Complete, and Business Source Premier). We identified 45 articles about toddler milk. Studies were conducted in 25 countries across 6 continents. Five types of findings emerged: (1) consumption and feeding behaviors, (2) demographic correlates of toddler-milk purchasing and consumption, (3) misperceptions and beliefs, (4) increased sales, and (5) increased marketing and responses to marketing. The included articles suggested that toddler-milk sales are growing rapidly worldwide. Findings also revealed that toddler-milk packages (eg, labels, branding) resemble infant formula packages and that toddler-milk marketing practices may indirectly advertise infant formula. Purchasing, serving, and consumption of toddler milk were higher in Black and Hispanic populations than in non-Hispanic White populations, and parents with higher educational attainment and income were more likely to offer toddler milk to their children. Findings suggest a need for policies to prevent cross-marketing of toddler milk and infant formula, reduce provision of toddler milk to infants and toddlers, and prevent caregivers from being misled about toddler-milk healthfulness.

A repeated cross-sectional analysis of the Icelandic baby food market surveyed in 2016, 2019 and 2021

World Health Organisation (WHO) has stated that countries need to know their local commercial baby food (CBF) market. Data from other countries suggest rapid changes in CBF options, highlighting the need for repeated analysis. In that context, this repeated cross-sectional study analysed the options and nutrient quality of different CBF types available in Iceland in years 2016, 2019 and 2021. Data was gathered on formulas, porridge flours, foods in jars and pouches, finger-foods, other CBF. They were classified into 26 subgroups based on ingredients and taste (sweet/savoury). Minimum consumer age as suggested by the manufacturers and nutritional content were registered. In each data-collection, 250-275 products were available. Over a third of products (37%-44%) were in pouches. Availability of products intended for 4-11-month-old infants decreased, driven largely by a 65% decrease in availability of food in jars (sweet/savoury) between 2016 and 2021. Availability of products intended from 12+ months or without age-labels increased, driven largely by quadrupling of finger-foods (predominantly sweet) between 2016 and 2021. The overall percentage of products classified as sweet increased from 65% (2016) to 73% (2019) and 77% (2021). Some finger-foods had high sugar content (up to 72 g/100 g), partly from fruit concentrate or sugar/syrup. Like other countries, the Icelandic CBF market has moved towards less availability of food intended in the first year and more availability of sweet finger-foods for an expanded consumer age. As sugar is added to some CBF, stronger regulations on promotion of foods for young consumers and updated recommendations for parents/caregivers may be needed.

Perceived influence of commercial milk formula labelling on mothers' feeding choices in Great Britain: a qualitative study

OBJECTIVE

To understand how mothers use commercial milk formula (CMF) labels to inform their feeding choices and explore mothers' understanding of differences between CMF products.

DESIGN

Qualitative study with recruitment via social media. Online semistructured interviews, including a product mapping exercise and thematic analysis.

PARTICIPANTS

Mothers (n=25) using CMF for children <3 years living in Great Britain (GB).

RESULTS

Mothers were drawn to brands they recognised from years of exposure to CMF advertising. CMF products were assumed to vary according to brand and stage, but participants found on-pack information did not explain how. This added to anxiety about choosing 'the best one' and mothers would have liked guidance from healthcare professionals (HCPs). Wide availability of CMF for older infants and children, and on-pack messaging suggesting progression from one product to the next, led many to believe these products were necessary. There was confusion over the appropriate use of specialist products. While mothers rarely mentioned on-pack health and nutrition claims, they were attracted to the overall appearance of packs and messaging relating to science, research and nature. References to breast milk and a logo perceived to represent a breastfeeding mother were taken as indicators of closer similarity to breast milk.

CONCLUSIONS

CMF legislation in GB should be updated to restrict brand advertising and the use of on-pack text and images that mothers perceive as indicating products have a closer similarity to breast milk. Greater input from HCPs was desired by new mothers and would support them to make more informed choices about CMF.

Oxidative Status of Ultra-Processed Foods in the Western Diet

Ultra-processed foods (UPFs) have gained substantial attention in the scientific community due to their surging consumption and potential health repercussions. In addition to their well-established poor nutritional profile, UPFs have been implicated in containing various dietary oxidized sterols (DOxSs). These DOxSs are associated with a spectrum of chronic diseases, including cardiometabolic conditions, cancer, diabetes, Parkinson's, and Alzheimer's disease. In this study, we present a comprehensive database documenting the presence of DOxSs and other dietary metabolites in >60 UPFs commonly consumed as part of the Western diet. Significant differences were found in DOxS and phytosterol content between ready-to-eat (RTE) and fast foods (FFs). Biomarker analysis revealed that DOxS accumulation, particularly 25-OH and triol, can potentially discriminate between RTEs and FFs. This work underscores the potential utility of dietary biomarkers in early disease detection and prevention. However, an essential next step is conducting exposure assessments to better comprehend the levels of DOxS exposure and their association with chronic diseases.

Healthcare professionals and commercial milk formula recommendations in the urban Mexican context

Introduction

Breastfeeding (BF) is considered an essential component of optimal care for child health and development. In the past two decades, global data have shown improvements in some, but not all, BF indicators. Despite these positive changes sales and per capita intake of commercial milk formula (CMF) have increased globally. The CMF industry invests millions of dollars in marketing, which targets families and healthcare professionals (HCP). In Mexico, more than half of the mothers (53%) who feed their infants with CMF chose their Brand on the recommendation of HCP. Understanding the reasons behind the current recommendations for the use of CMF by HCP is important for the design of BF interventions. The primary objective of this study was to explore Mexican HCP' beliefs, attitudes, perceptions, and practices about early infant feeding practices, and reasons for recommending CMF. The secondary objective was to explore pregnant women and mother's perceptions of the infant feeding recommendations they received from HCP, and of the factors that influenced their infant feeding decisions.

Methods

The study was based on a secondary qualitative data analysis of a WHO/UNICEF multi-country study. We analyzed focus group discussions (FGDs) and in-depth interviews (IDIs) from Mexico. Data were collected through convenience sampling in Mexico City and Guadalajara. HCP (n = 34) analysis was based on IDIs, and pregnant women or mothers of children 0-18 months (n = 74) on FGDs and IDIs.

Results

Through a thematic analysis, we identified the socioecology of BF and triangulated HCP and women's accounts. HCP, pregnant women, and mothers recognized that several factors might have influenced their infant feeding decisions including healthcare facilities' policies and maternal work conditions. Although HCP believed that BF is the best way to feed newborns and young children, they routinely recommended CMF. On the other hand, pregnant women and mothers had a strong belief that BF is the best way to feed their babies. However, when women sought support from HCP, the latter often recommended switching to CMF.

Discussion

This study highlights the discordance between HCP perceptions and mothers' experiences of HCP recommendations about infant feeding. Our findings support a national call for policy actions.

Toddler Milk Perceptions and Responses to Front-of-Package Claims and Product Warnings: A Qualitative Study of Caregivers of Toddlers

BACKGROUND

Toddler milk products are ultraprocessed milk-based beverages promoted for children aged 9 through 36 months. They often contain added sugars, which may contribute to unhealthy dietary habits. Aggressive promotion of toddler milk, particularly to the Latinx population, has likely led to rapid rises in sales.

OBJECTIVE

The study aims were to qualitatively explore caregivers' experiences with, beliefs about, and attitudes toward toddler milk; to explore caregivers' reactions to health claims and product warnings on toddler milk packaging; and explore whether perceptions of toddler milk differ by Latinx ethnicity.

DESIGN

Focus group discussions and in-depth interviews were conducted.

PARTICIPANTS

Fifteen online in-depth interviews and 4 online focus groups with US caregivers of children aged 9 through 36 months who reported serving toddler milk to their children were conducted in 2021.

STATISTICAL ANALYSES PERFORMED

Audio files were transcribed, coded, and analyzed in NVivo. A thematic analysis with a hybrid analytical approach of deductive and inductive coding was conducted.

RESULTS

Caregivers struggled to discern toddler milk from infant formula and perceived formula as a larger term that included toddler milk. Participants described offering toddler milk to their children for its convenience, nutritional profile, and perceived benefits tied to health claims present on the labels. Participants reported that health claims on toddler milk packaging attracted their attention; most participants did not express skepticism about the veracity of the claims. An "added sugar" warning increased understanding of the presence of added sugar in a toddler milk product. Latinx and non-Latinx participants largely reported similar perceptions, beliefs, and patterns of provision of toddler milk.

CONCLUSIONS

Health claims may lead caregivers to perceive toddler milk as a nutritionally adequate product. Research is needed to investigate caregiver-directed interventions for informing caregivers about the distinction between infant formula and toddler milk.

Human Milk, Infant Formula, and Other Milks Fed to Infants and Toddlers in the United States, NHANES 2007-2018

BACKGROUND

For the first time, the 2020-2025 Dietary Guidelines for Americans provide specific guidance regarding the types of foods and beverages that should be offered in the first 2 years of life. Milk, in various forms (eg, human milk, infant formula, and cow's milk) contributes a large proportion of key nutrients to the diets of infants and toddlers in the United States.

OBJECTIVE

The aim of this study was to determine the types of milk (human milk, infant formula, and other milk) fed to US infants and toddlers in the past 12 years and to describe trends over time.

DESIGN

This was a cross-sectional analysis of 2-day, 24-hour dietary recalls.

PARTICIPANTS/SETTING

Data from the 2007-2018 National Health and Nutrition Examination Survey were used for these analyses. Infants and toddlers aged 0 through 23.9 months with 2 days of dietary recall data (n = 3,079) were included.

MAIN OUTCOME MEASURES

The main outcome was proportion of infants and toddlers fed different milk types.

STATISTICAL ANALYSES PERFORMED

Survey-adjusted weighted percentages were used to report sociodemographic characteristics and the proportion of subjects fed each milk type category by age group and survey cycles. Binary and multinomial logistic regressions were used to assess differences in subject characteristics by age groups.

RESULTS

Sociodemographic characteristics did not differ by age group. The proportion of infants aged 0 to <6 months fed infant formula only was 60.2% in 2007-2012 and 44.8% in 2013-2018. The proportion of infants aged 6 to <12 months fed partially hydrolyzed infant formula only was 7.3% in 2007-2012 and 13.1% in 2013-2018. In toddlers (>12 months old), cow's milk was the predominant milk type in both 2007-2012 and 2013-2018.

CONCLUSIONS

The percentage of infants fed any human milk increased over the past decade. Unsweetened cow's milk was the most predominate milk type consumed among toddlers.

Content analysis of on-package formula labelling in Great Britain: use of marketing messages on infant, follow-on, growing-up and specialist formula

OBJECTIVE

To explore on-package formula messaging with reference to legislation and government-issued guidance in Great Britain (GB).

DESIGN

Formula products were identified, pictures of all sides of packs collated and on-package text and images were coded. Compliance with both GB legislation and guidance issued by the Department of Health and Social Care (DHSC) was assessed.

SETTING

All formula packs that were available for sale over the counter in GB between April and October 2020.

PARTICIPANTS

Formula packs (n 71) including infant formula, follow-on formula, growing-up formula and specialist formula were identified, coded and analysed.

RESULTS

In total, 41 % of formula packs included nutrition claims, and 18 % included health claims that may be considered non-permitted, according to DHSC guidance. Additionally, 72 % of products showed images considered 'non-permitted'. Breast Milk Substitute (BMS) legislation states infant and follow-on formula packs should be clearly distinguishable but does not provide criteria to assess similarity. Based on DHSC guidance, 72 % of infant and follow-on formula packs were categorised as showing a high degree of similarity. Marketing practices not covered by current legislation were widespread, such as 94 % of infant formula packs including advertisements for follow-on or growing-up formula.

CONCLUSIONS

Text and images considered non-permitted according to DHSC guidance for implementing BMS legislation were widespread on formula products available in GB. As terms such as 'similarity' are not defined in BMS legislation, it was unclear if breaches had occurred. Findings support the WHO call for loopholes in domestic legislation to be closed as a matter of urgency.

Infant feeding practices and parental perceptions during the 2022 United States infant formula shortage crisis

BACKGROUND

In May of 2022, parents living in the United States experienced a dramatic infant formula shortage caused by supply chain issues and the recall of several infant formula products over contamination concerns.

METHODS

An anonymous, electronic, cross-sectional survey was designed to understand infant feeding practices, parental experience and perceived support during the crisis.

RESULTS

Ninety-nine parents that lived in the U.S. and fulfilled study criteria completed the survey. 66% of respondents were female, and 75% of respondents were recipients of the Special Supplemental Nutrition Program for Women Infant Children (WIC). Parental mean age was 30.0 years, and the mean infant age was 26.8 weeks. The number of individuals that used at least one unsafe infant feeding practice increased from 8% before the infant formula shortage to 48.5% during the shortage (p < 0.001). 79% of parents fed their infants U.S. infant formula brands and 39% of parents fed their infants imported infant formula brands before the shortage which were significantly reduced during the shortage to 27% (p < 0.005) and 11% (p < 0.005), respectively. The percentage of parents that reported infant feeding practices before and during the infant formula shortage significantly increased from 2 to 28% for banked donor milk use (p < 0.005); 5-26% for use of human milk from informal sharing (p < 0.005); and 2-29% for use of watered-down infant formula (p < 0.005). The resources that parents reported as most helpful in navigating the crisis differed by parental sex and WIC recipient status and included other parents, friends, and family; lactation consultants; healthcare providers; and WIC.

CONCLUSIONS

Our study found that feeding practices in response to the infant formula shortage may pose health risks to infants including nutrition and food insecurity. These data suggest the need for policy changes within regulatory and the healthcare system to provide families with clinical prenatal and postnatal lactation support, access to pasteurized banked donor milk, and access to more commercially available products.

Nutrition Content of Young Child Formulas

OBJECTIVE

European Society for Pediatric Gastroenterology, Hepatology and Nutrition and the American Academy of Pediatrics state that young child formula (YCF) is not considered necessary for healthy children. Despite these recommendations, YCF accounts for approximately 13% of overall formula sales. Five percent of infants less than 1 year of age in the United States are being fed YCF. The purpose of this study is to identify the most Internet recommended and encountered YCF in the United States and determine if they meet nutritional recommendations for use in children 0-3 years.

STUDY DESIGN

We used the search terms "toddler formula," "toddler milk," "follow-up formula," or "young child formula" in Google and DuckDuckGo to identify the most like encountered or recommended YCF on the Internet. We compared their labeled nutrients to Food and Drug Administration (FDA) Infant Formula Act (IFA) and international nutrient recommendations, given the absence of US nutrient requirements for YCF recommendations, for children 12-36 months.

RESULTS

Twenty-nine YCF were reviewed. On average, YCF did not meet nutrient recommendations for infants and toddlers with 2.17 and 4.6 ingredients not meeting formula recommendations for younger and older infants, respectively, and between 3 and 4 ingredients for 12-36 months.

CONCLUSIONS

Nutrition content of YCF are variable and do not meet FDA IFA requirements or YCF international recommendations. Increased US regulation is needed for YCF. It is important for health care providers to ask patients what they are feeding their infants and toddlers so they can educate parents on potential nutritional safety concerns.

Dietary exposure assessment of infant formula and baby foods' oxidized lipids in the US population

Baby Foods (BFs) and Infant formulas (IFs) are the main sources of nutrition for an infant throughout the 1st year of life. Various enriched products are commercially available for parents seeking to fulfill their baby's nutritional needs. Consequently, different bioactive lipids are present in BFs and IFs, including dietary oxysterols (DOxS), whose known toxicity has been associated with mutagenicity, cancer, and other chronic diseases. In this work, we performed an exposure assessment of 25 bioactive lipids on IFs (n = 30) and BFs (n = 13) commercially available in the US. To determine dietary exposure, we used EPA's SHEDS-HT probabilistic model. Even though β-Sitosterol was the most exposed bioactive lipid with 75,410 μg/day, cholesterol was the most absorbed compound during the entire first year (19.3 mg/day). Additionally, we found 7α-hydroxycholesterol (7α-OH) as a potential DOxS biomarker of the BFs manufacturing process. This is the first time an infant's exposure assessment (including DOxS) after BFs and IFs consumption is performed, enabling much-needed information regarding these hazardous compounds and their potential effects on infants' health.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs for Population-Level Diabetes Prevention and Control: Recommendations From the National Clinical Care Commission

The etiology of type 2 diabetes is rooted in a myriad of factors and exposures at individual, community, and societal levels, many of which also affect the control of type 1 and type 2 diabetes. Not only do such factors impact risk and treatment at the time of diagnosis but they also can accumulate biologically from preconception, in utero, and across the life course. These factors include inadequate nutritional quality, poor access to physical activity resources, chronic stress (e.g., adverse childhood experiences, racism, and poverty), and exposures to environmental toxins. The National Clinical Care Commission (NCCC) concluded that the diabetes epidemic cannot be treated solely as a biomedical problem but must also be treated as a societal problem that requires an all-of-government approach. The NCCC determined that it is critical to design, leverage, and coordinate federal policies and programs to foster social and environmental conditions that facilitate the prevention and treatment of diabetes. This article reviews the rationale, scientific evidence base, and content of the NCCC's population-wide recommendations that address food systems; consumption of water over sugar-sweetened beverages; food and beverage labeling; marketing and advertising; workplace, ambient, and built environments; and research. Recommendations relate to specific federal policies, programs, agencies, and departments, including the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, the Department of Housing and Urban Development, the Environmental Protection Agency, and others. These population-level recommendations are transformative. By recommending health-in-all-policies and an equity-based approach to governance, the NCCC Report to Congress has the potential to contribute to meaningful change across the diabetes continuum and beyond. Adopting these recommendations could significantly reduce diabetes incidence, complications, costs, and inequities. Substantial political resolve will be needed to translate recommendations into policy. Engagement by diverse members of the diabetes stakeholder community will be critical to such efforts.

Perinatal Hospital Practices Are Associated with Breastfeeding through 5 Months Postpartum among Women and Infants from Low-Income Households

BACKGROUND

Breastfeeding (BF) provides optimal nutrition during the first 6 mo of life and is associated with reduced infant mortality and several health benefits for children and mothers. However, not all infants in the United States are breastfed, and sociodemographic disparities exist in BF rates. Experiencing more BF-friendly maternity care practices at the hospital is associated with better BF outcomes, but limited research has examined this association among mothers enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a population at risk of low BF rates.

OBJECTIVES

We assessed the association between BF-related hospital practices (rooming-in, support from hospital staff, and provision of a pro-formula gift pack) and the odds of any or exclusive BF through 5 mo among infants and mothers enrolled in WIC.

METHODS

We analyzed data from the WIC Infant and Toddler Feeding Practices Study II, a nationally representative cohort of children and caregivers enrolled in WIC. Exposures included maternal experience of hospital practices reported at 1 mo postpartum, and BF outcomes were surveyed at 1, 3, and 5 mo. ORs and 95% CIs were obtained using survey-weighted logistic regression, adjusting for covariates.

RESULTS

Rooming-in and strong hospital staff support were associated with higher odds of any BF at 1, 3, and 5 mo postpartum. Provision of a pro-formula gift pack was negatively associated with any BF at all time points and with exclusive BF at 1 mo. Each additional BF-friendly hospital practice experienced was associated with 47% to 85% higher odds of any BF over the first 5 mo and 31% to 36% higher odds of exclusive BF over the first 3 mo.

CONCLUSIONS

Exposure to BF-friendly hospital practices was associated with BF beyond the hospital stay. Expanding BF-friendly policies at the hospital could increase BF rates in the United States WIC-served population.

How midwives and nurses experience implementing ten steps to successful breastfeeding: a qualitative case study in an Indonesian maternity care facility

BACKGROUND

The in-hospital stay following childbirth is a critical time for education and support of new mothers to establish breastfeeding. The WHO/UNICEF 'Ten Steps to Successful Breastfeeding (Ten Steps)' was launched globally in 1989 to encourage maternity services to educate and support mothers to breastfeed. The strategy is effective, however its uptake within health systems and facilities has been disappointing. We aimed to understand midwives' and nurses' experiences of implementing the Ten Steps in an Indonesian hospital.

METHODS

This qualitative study was conducted in an Indonesian hospital which has been implementing the Ten Steps since the hospital's establishment in 2012. Fourteen midwives and nurses participated in a focus group in January 2020. Data were analyzed using thematic analysis.

RESULTS

We identified five themes that represented midwives' and nurses' experiences of implementing the Ten Steps in this Indonesian maternity unit: 1) Human rights of child and mother, 2) Dependency on precarious leadership, 3) Lack of budget prioritization, 4) Fragmented and inconsistent implementation of the Ten Steps across the health system, and 5) Negotiating with family, community and culture. The results highlighted a dependency on local hospital champions and a lack of budget prioritization as barriers to implementation, as well as health system gaps which prevented the enablement of mothers and families to establish and maintain breastfeeding successfully in Indonesian maternity services.

CONCLUSIONS

As Indonesia has one of the largest populations in South East Asia, it is an important market for infant milk formula, and health services are commonly targeted for marketing these products. This makes it especially important that the government invest strongly in Ten Steps implementation. Continuity of care within and across the health system and leadership continuity are key factors in reinforcing its implementation. The study findings from this Indonesian maternity care facility re-emphasize WHO recommendations to integrate the Ten Steps into national health systems and increase pre-service education on breastfeeding for health care professionals.

The Influence of Human-Milk Substitutes Marketing on Breastfeeding Intention and Practice among Native and Immigrant Brazilians

BACKGROUND

The International Code of Marketing of Breast-Milk Substitutes is a global public health policy aiming to protect breastfeeding from the influence of human-milk substitutes marketing. Brazil is one of the few countries substantially implementing it. Most countries adopted selected provisions, including Portugal.

RESEARCH AIM

To explore whether Brazilians' perspectives about breastfeeding intention and practice are influenced by human-milk substitutes marketing upon migration to Portugal.

METHODS

A qualitative, prospective, cross-sectional survey design was conducted in Brazil and Portugal (2018-2019). Qualitative semi-structured interviews were performed with native (n = 16) and immigrant (n = 15) Brazilians. Women aged 18 or above, mothers of 0-12 month infants, and without contraindications to breastfeed, were eligible for the study. Heterogeneity sampling was employed based on socioeconomic status and infants' age. Content analysis was conducted using NVivo.

RESULTS

Brazilian immigrants were more aware of the potential negative influence of human-milk substitutes marketing than natives. Sociocultural factors contributed to Brazilian immigrants being less permeable to the influence of human-milk substitutes marketing in the host country, where a less protective breastfeeding environment was perceived.

CONCLUSIONS

Sociocultural factors including breastfeeding promotion strategies and a strong breastfeeding culture in the home country appear to play a protective role on breastfeeding intention and practice among Brazilians migrating to Portugal.

Racial capitalism and the US formula shortage: A policy analysis of the formula industry as a neocolonial system

The U.S. is currently experiencing a formula shortage and an infant feeding crisis that began with a formula recall and the hospitalization of 4 infants, 2 of whom died. Since 1981, governments around the world have been calling for an end to blatant human rights violations made by the commercial milk formula (CMF) industry. These practices not only involve targeting nutritionally vulnerable populations of mothers and newborns to turn a profit, but also actively undermining the implementation of policies, legislation, and regulatory oversight that might compromise their accumulation of wealth. In this paper we analyze the 2022 formula-shortage-as-infant-feeding-crisis through the lens of the history of colonialism and critical theory in the anthropology of reproduction. First, we provide an overview of the colonial roots of the formula industry from a global perspective. We then focus on how the mechanisms of racial exploitation remain entrenched in the U.S. approach to infant feeding policies, regulation and investment, setting the stage for the current infant feeding crisis. Through our analysis of the 2022 infant feeding crisis we demonstrate how the multinational CMF industry perpetuates racial capitalism and racialized health inequities and disparities through its operations as a neocolonial enterprise. Finally, we offer policy interventions and potential solutions that are grounded in structural interventions for more equitable, anticolonial, antiracist infant feeding systems.

Effects of Sugary Drink Countermarketing Videos on Caregivers' Attitudes and Intentions to Serve Fruit Drinks and Toddler Milks to Young Children

Objectives. To test the effects of countermarketing videos addressing common misperceptions about ingredients and claims on children's sugary drinks. Methods. We conducted an online randomized controlled experiment in January 2021 with US caregivers (n = 600) of young children (aged 8‒37 months) to assess the effects of watching countermarketing versus control videos on intentions to serve sugary and healthy drinks (6-point scales) and attitudes (10-point scales) about fruit drinks and toddler milks. Results. The countermarketing videos significantly reduced positive attitudes about fruit drinks (mean difference = 0.92) and toddler milks (mean difference = 2.10), reduced intentions to serve both (mean difference = 0.50 and 0.92, respectively), and increased intentions to serve plain milk (mean difference = 0.52) versus control videos (all Ps < .001). Intentions differed by individual characteristics, but the videos remained effective after we controlled for these characteristics. Moreover, the videos were more effective for toddler milks versus fruit drinks, and effects on fruit drink intentions were greater for Black versus White caregivers and caregivers of children aged 24 months or younger. Conclusions. A countermarketing campaign aimed at diverse caregivers of young children designed to correct misleading children's drink marketing presents a promising public health approach for reducing sugary drink consumption in the first 1000 days. (Am J Public Health. 2022;112(S8):S807-S816. https://doi.org/10.2105/AJPH.2022.307024).

Extensive use of on-pack promotional claims on commercial baby foods in the UK

OBJECTIVE

To explore and categorise the nature of promotional claims on packaging of commercial baby foods (CBFs).

SETTING

UK METHODOLOGY: An online survey of CBFs (for infants up to 12+ months) in 7 UK supermarkets and Amazon in 2020. On-pack promotions were classified as marketing, composition, health, and nutrient claims using the WHO Nutrient Profile Model draft for infants and young children, and European Union regulation on health and nutrition claims.

MAIN OUTCOME MEASURE

Distribution and proportion of claim types, and association between product characteristics and claim types.

RESULTS

A total of 6265 promotional claims were identified on 724 products. Marketing (99%, n=720), composition (97%, n=705) and nutrient claims (85%, n=616) were found on the majority of CBFs, compared with health claims (6%, n=41). The median (Q1, Q3) number of total claims per product was 9 (7, 10), marketing 5 (3, 6), composition 2 (1, 2), nutrient 2 (1, 2), and 0 (0, 0) health. Marketing claims were mainly texture (84%, n=609, eg, super smooth) and taste related (70%, n=511, eg, first tastes). The main composition claim was organic (63%, n=457) while nutrient claims were mainly around 'no added' or 'less' sugar (58%, n=422) and salt (57%, n=417). Baby led weaning claims (BLW) (eg, encourages self-feeding) were found on 72% of snacks, with a significantly higher (p<0.01) number of BLW claims on snacks (99%, n=209) compared with other product types.

CONCLUSION

Promotional claims on CBF packaging are extensively used and, for the most part, unregulated. CBFs are promoted using 'healthy halo' connotations that might confuse parents. Regulations on their use should be implemented to avoid inappropriate marketing.

Exploring Infant Caregivers' Provision of Modified Formulas: Potential Demographic Differences and Reasons for Provisions

Background

Formula brands have modified the ingredients in standard infant formulas and extensively market modified formulas, claiming benefits for infants that are not supported by scientific evidence. This exploratory study examined the proportion of infant caregivers who reported serving modified formula, demographic differences, and reasons for providing them.

Methods

This is a cross-sectional online survey of US caregivers of infants (6–11 months) who provided formula in the past month (N = 436). Participants reported the type of formula served most often and agreement with potential reasons for provision. Logistic regression assessed the odds of serving modified formula by demographic characteristics. MANOVA examined differences in agreement with purchase reasons between caregivers by the type of formula provided.

Results

Approximately one-half (47%) of participants reported serving modified formula most often; sensitive and organic/non-GMO were the most common types provided. Caregivers in the middle-income group were most likely to serve modified formulas, but the provision did not differ by other demographic characteristics. Agreement with reasons for providing was highest for “pediatricians recommend” and “benefits my child” (M = 4.2 out of 5). Agreement with “my pediatrician prescribed” and “natural ingredients” was significantly higher for modified vs. standard formula providers.

Conclusion

Widespread provision of modified formula by infant caregivers raises concerns due to its higher cost and the lack of scientific evidence supporting benefits for babies. These findings suggest that regulations limiting unsubstantiated formula claims and restrictions on misleading marketing to consumers are necessary. Additional research is needed to understand pediatricians' perceptions of modified formulas and reasons for recommending them to patients.

Consumption of breast milk, formula and other non-human milk by children aged under 2 years: analysis of eighty-six low- and middle-income countries

OBJECTIVE

To investigate the prevalence and socio-economic inequalities in breast milk, breast milk substitutes (BMS) and other non-human milk consumption, by children under 2 years in low- and middle-income countries (LMIC).

DESIGN

We analysed the prevalence of continued breast-feeding at 1 and 2 years and frequency of formula and other non-human milk consumption by age in months. Indicators were estimated through 24-h dietary recall. Absolute and relative wealth indicators were used to describe within- and between-country socio-economic inequalities.

SETTING

Nationally representative surveys from 2010 onwards from eighty-six LMIC.

PARTICIPANTS

394 977 children aged under 2 years.

RESULTS

Breast-feeding declined sharply as children became older in all LMIC, especially in upper-middle-income countries. BMS consumption peaked at 6 months of age in low/lower-middle-income countries and at around 12 months in upper-middle-income countries. Irrespective of country, BMS consumption was higher in children from wealthier families, and breast-feeding in children from poorer families. Multilevel linear regression analysis showed that BMS consumption was positively associated with absolute income, and breast-feeding negatively associated. Findings for other non-human milk consumption were less straightforward. Unmeasured factors at country level explained a substantial proportion of overall variability in BMS consumption and breast-feeding.

CONCLUSIONS

Breast-feeding falls sharply as children become older, especially in wealthier families in upper-middle-income countries; this same group also consumes more BMS at any age. Country-level factors play an important role in explaining BMS consumption by all family wealth groups, suggesting that BMS marketing at national level might be partly responsible for the observed differences.

The Impact of Toddler Milk Claims on Beliefs and Misperceptions: A Randomized Experiment with Parents of Young Children

BACKGROUND

Toddler milk (ie, a nutrient-fortified milk-based drink marketed for children aged 12 to 36 months) has been marketed increasingly in the United States with structure/function claims on product packaging that are potentially misleading.

OBJECTIVE

This study examined how structure/function claims impact parents' beliefs and perceptions about a toddler milk product.

DESIGN

This was a 3-arm between-subjects randomized experiment.

PARTICIPANTS

A diverse sample of 2,190 US parents of children aged 1 to 5 years were chosen to take an online survey.

INTERVENTION

Participants were randomly assigned to view a toddler milk package with either an unrelated claim ("new and improved," ie, control condition), a "brain development" claim (ie, "brain" claim), or an "immunity-related" claim (ie, "immunity" claim).

MAIN OUTCOME MEASURES

Outcomes included perceptions, intentions, and beliefs about the toddler milk product.

STATISTICAL ANALYSES PERFORMED

Linear regression for continuous outcomes and logistic regression for dichotomous outcomes.

RESULTS

Parents who were exposed to the "brain" claim or the "immunity" claim were more likely to incorrectly believe that the toddler milk was as healthy or healthier than cow's milk compared with those who saw the control claim (89% for brain claim, 87% for immunity claim, and 79% for control; P < .001 for both comparisons). Parents exposed to either the brain or immunity claim had higher intentions to give the toddler milk to their child, higher perceived product healthfulness, and stronger beliefs that pediatricians would recommend the product compared with parents exposed to the control (all, P < .001).

CONCLUSIONS

These findings suggest that structure/function claims on toddler milk packaging may mislead parents and increase the appeal of toddler milk. Our findings support calls for public health policies to regulate marketing on toddler milk packaging.

U.S. Households' Children's Drink Purchases: 2006-2017 Trends and Associations With Marketing

INTRODUCTION

Sugar-sweetened beverages contribute a large proportion of added sugar in young children's diets; yet, companies market sugar-sweetened children's drinks extensively to children and parents. This study examines the changes in children's drink purchases by U.S. households with young children and the associations with marketing practices.

METHODS

Longitudinal Nielsen U.S. household panel data provided monthly volume purchases by children's drink category (sugar-sweetened fruit drinks and flavored water and unsweetened juices) among households with young children (aged 1-5 years) from 2006 to 2017. Differences by household race/ethnicity and income were assessed. The 2-part models examined the associations between household purchases and marketing (including price and brand TV advertising) for each category, controlling for sociodemographics. Data were collected and analyzed in 2019-2020.

RESULTS

Households' volume purchases of children's fruit drinks and unsweetened juices declined from 2006 to 2017, whereas flavored water purchases increased. Non-Hispanic Black households purchased significantly more fruit drinks (351.23 fluid ounces/month, 95% CI=342.63, 359.82) than non-Hispanic White (204.43 fluid ounces/month, 95% CI=201.81, 207.05) and Hispanic (222.63 fluid ounces/month, 95% CI=217.11, 228.15) households. Low-income households purchased more fruit drinks and fewer unsweetened juices than higher-income households (p<0.001). TV brand advertising was positively associated with purchases across all categories, and this relationship was stronger for low-income households (p<0.05).

CONCLUSIONS

Despite expert recommendations that young children do not consume Sugar-sweetened beverages, households with young children purchase more sweetened fruit drinks than unsweetened juices. Extensive TV advertising for children's drink brands may exacerbate the racial and income disparities in sugar-sweetened beverage purchases. Public health initiatives to address sugar-sweetened beverage consumption by young children and restrictions on marketing sugar-sweetened beverages to children are necessary.

The Nutritional Profile and On-Pack Marketing of Toddler-Specific Food Products Launched in Australia between 1996 and 2020

With the food system evolving, it is not clear how the nutrition and on-pack claims of toddler foods have been impacted. Data on the trends in Australia are lacking, so we sought to determine the changes in the nutrition and on-pack claims of toddler-specific packaged foods over time. A retrospective cross-sectional analysis was conducted using the Mintel Global New Products Database. The number of toddler-specific foods increased from 1996 to 2020. Over time, a lower proportion of meals and snacks were classified as “ultra-processed”, but a higher proportion of snacks were classified as “discretionary”. Meals launched after 2014 had higher median values for energy, saturated fat, and sugar than those in earlier years. Toddler snacks launched after 2014 had lower median values for sodium, and higher median values for fat, saturated fat, and sugar than those in earlier years. The mean number of total claims per package increased over time for snacks, with an increase in unregulated claims for both meals and snacks. Public health action is needed to ensure that the retail food environment for young children is health-promoting, including stringent and clear regulations for on-pack claims, and compositional guidelines and guidance on how to reduce the number of ultra-processed foods for toddlers.

Maternal guilt and shame in the postpartum infant feeding context: A concept analysis

Background After birth, guilt and shame are differentially experienced by breastfeeding and formula feeding mothers. Despite this, currently utilized guilt and shame definitions lack context specificity, leaving concepts open to misinterpretation. Objective The current study aimed to develop infant feeding-specific definitions of postpartum guilt and shame. Methods Study selection involved a three-stage systematic screening process, outlined in Jackson et al. (2021). Walker and Avant's (2005, 2019) concept analysis framework was then applied to included articles to identify guilt-specific, shame-specific, and overlapping attributes, antecedents, and consequences. Results A guilt-specific, shame-specific, and overlapping definition were generated based on exclusive and overlapping antecedents, attributes, and consequences. Guilt and shame belonged to the empirical referent Moral Emotions, which may explain some of the overlapping antecedents, attributes, and consequences identified during analysis. Conclusions The overlapping definition provides a broad scope for shared characteristics, while specific definitions allow for more in-depth and focused investigations of guilt and shame experiences within an infant feeding context. Utilising context-specific definitions may serve to improve research homogeneity. Shame was found to be uniquely associated with postnatal depression. As such, suggestions are made for future research to further investigate the relationship between shame, infant feeding, and maternal wellbeing outcomes. Implications Identified antecedents may be used by healthcare professionals to provide additional support to mothers at risk of experiencing guilt and shame, to prevent the occurrence and consequences of these emotions.

Which Milk during the Second Year of Life: A Personalized Choice for a Healthy Future?

Nutrition in early life is a crucial element to provide all essential substrates for growth. Although this statement may appear obvious, several studies have shown how the intake of micro and macronutrients in toddlers differs a lot from the recommendations of scientific societies. Protein intake often exceeds the recommended amount, while the intake of iron and zinc is frequently insufficient, as well as Vitamin D. Nutritional errors in the first years of life can negatively impact the health of the child in the long term. To date, no clear evidence on which milk is suggested during the second year of life is yet to be established. In this study, we compare the nutrient profiles of cow’s milk and specific formulas as well as nutritional risks in toddlers linked to growth and childhood obesity development. The purpose of this review is to resume the latest clinical studies on toddlers fed with cow’s milk or young children formula (YCF), and the potential risks or benefits in the short and long term.

The Impact of Formula Industry Marketing on Breastfeeding Rates in Native and Migrant Mothers

Introduction: Lifelong benefits of breastfeeding are far-reaching. However, optimal breastfeeding practices may be negatively affected by the marketing of different forms of breast milk substitutes. In addition, whether market factors have a different impact on migrants' breastfeeding practices when compared to natives has been poorly investigated. Objectives: Our study's aims are (1) to assess the effect of market factors on breastfeeding discontinuation (any and exclusive), (2) comparing migrant and native women. Methods: A longitudinal study was conducted within baMBINO, a nationwide project on perinatal health among migrant women in Portugal. Our final sample included 1,251 migrants and 1,150 natives recruited between April 2017 and March 2019 in 32 public maternities. Cox regression analysis was performed, adjusting for important confounders, and interactions were tested. Results: Market factors were associated with any and exclusive breastfeeding discontinuation. Participants receiving free formula samples from a health professional were more likely to stop exclusive breastfeeding (adjusted hazard ratios [aHR] = 1.37, 95% confidence intervals [95% CI] = 1.13-1.66, p = 0.002). Reporting exposure to formula discounts was associated with discontinuation of exclusive (aHR = 1.22, 95% CI = 1.09-1.38, p = 0.001) and any breastfeeding (aHR = 1.21, 95% CI = 1.00-1.46, p = 0.046). No interactions were found between being migrant and exposure to market factors. Conclusions: Market factors influence discontinuation of any and exclusive breastfeeding. The impact of marketing does not differ between native and migrant women.

Digital Marketing of Commercial Complementary Foods in Australia: An Analysis of Brand Messaging

The digital marketing of commercial complementary foods (CCF) is an emerging area of concern in Australia. Although research into traditional methods has identified a range of problems, the marketing and messaging strategies employed within digital spaces have gone largely unscrutinized. This study sought to examine the methods used by CCF manufacturers to promote Australian baby foods and brands in a digital space. A multiple step approach was used to assess the CCF brands available in major Australian retailers, the social media platforms they used, and to thematically analyze the text and visual messages contained in posts published over a three-month period. Of the 15 brands identified, 12 had a digital presence, and all of these used Facebook. Four themes emerged from an analysis of 216 Facebook posts; (1) general product attributes, (2) socially desirable attributes (which included messaging related to taste (41%), self-feeding (29%) and fun (19%)), (3) concern-based attributes (including organic status (40%), age targets (39%) and additive-/allergen-free status (18%)) and (4) health-focused attributes (which included messaging related to healthy/nutritious ingredients (45%), and child development/growth (15%). Messages contained in Facebook posts were mostly positive brand/product aspects (Themes 1 and 2) or parental concern-based aspects (Theme 3 and 4). These themes match previous analyses of marketing content in traditional media and should be closely monitored due to the personalized nature of consumer social media interactions.

Breastfeeding and breastmilk substitute use and feeding motivations among mothers in Bandung City, Indonesia

Suboptimal breastfeeding is common in Indonesia, with only half of infants 0-5 months of age exclusively breastfed and feeding of breastmilk substitutes (BMS) highly prevalent among infants and toddlers. Various factors influence these feeding practices, including social norms, limited health system support and BMS manufacturer marketing practices. This cross-sectional survey aimed to identify the prevalence of breastfeeding and BMS feeding among children aged 0-35 months, explore socio-demographic characteristics and motivating factors associated with these feeding behaviours and identify the prevalence of mothers' exposure to BMS promotions. Indonesian mothers of children <3 years of age (n = 595) were interviewed in Bandung City health facilities using structured questionnaires. Although all children were ever breastfed, half of children across all age groups received BMS in the previous day. Maternal employment outside the home and insufficient breastmilk production were associated with BMS use. The most important motivational factors for feeding BMS were perceived benefits for growth, intelligence and immunity. Despite Indonesian legislation restricting some BMS marketing, 93% of mothers reported observing a BMS promotion outside the health system, with television, social media and newspapers as the most common sources. Half of mothers (43%) reported observing a BMS promotion within the health system, and half (46%) reported receiving recommendations from health workers to use BMS. Such high prevalence of BMS marketing may be influencing caregivers' feeding choices; stronger national legislation and implementation of laws are needed to ensure mothers' ability to make feeding choices free from manufacturer influence.

Toddler milk perceptions and purchases: the role of Latino ethnicity

OBJECTIVES

Toddler milk (i.e. a nutrient-fortified milk-based drink marketed for children 12-36 months old) is increasingly being marketed in the USA despite not being recommended for young children. There is evidence of targeted toddler milk marketing to Latinos in the USA. This study aimed to explore toddler milk perceptions and behaviours among Latino and non-Latino parents.

DESIGN

An online survey assessed toddler milk perceptions, behaviours and interpretations of nutrition-related claims. Multivariable logistic and linear regression explored socio-demographic correlates of parent reported past purchases and perceived healthfulness.

SETTING

Online.

PARTICIPANTS

National convenience sample of 1078 US parents of children aged 2-12 years (48 % Latino).

RESULTS

About half of parents (51 %) had previously purchased toddler milk and few (11 %) perceived toddler milk as unhealthy. Latino parents were more likely to have purchased toddler milk than non-Latino parents (P < 0·001), but there were no differences in perceived product healthfulness (P = 0·47). Compared to parents born in the USA, parents living in the USA 10 years or less were more likely to have purchased toddler milk (P < 0·001) and perceive toddler milk as healthier (P = 0·002). Open-ended interpretations of claims were primarily positive, suggesting 'health halo' effects.

CONCLUSIONS

Common misperceptions about toddler milk healthfulness suggest stronger labelling regulations are needed. Greater reported purchases by Latino parents and recent immigrants warrant further investigation.

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.

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.

Lipid profiling and dietary assessment of infant formulas reveal high intakes of major cholesterol oxidative product (7-ketocholesterol)

Approximately two-thirds of US infants receive infant formula (IF) as a primary or sole nutritional source during the first six months of life. IF is available in a variety of commercial presentations; from a manufacturing standpoint, they can be categorized as powder- (PIF) or liquid- (LIF) based formulations. Thirty commercial IFs were analyzed in their oxidative and non-oxidative lipid profiles. We identified 7-ketocholesterol - a major end-product of cholesterol oxidation - as a potential biomarker of IF manufacturing. The statistical analysis allowed a re-classification of IF based on their metabolomic fingerprint, resulting in three groups assigned with low-to-high oxidative status. Finally, we modeled the dietary intake of cholesterol, sterols, and 7-ketocholesterol in the first year of life. The database provided in this study will be instrumental for scientists interested in infant nutrition, to establish bases for epidemiological studies aimed to find connections between nutrition and diet-associated diseases, such as sitosterolemia.

The "weanling's dilemma" revisited: Evolving bodies of evidence and the problem of infant paleodietary interpretation

Breastfeeding is known to be a powerful mediator of maternal and childhood health, with impacts throughout the life course. Paleodietary studies of the past 30 years have accordingly taken an enduring interest in the health and diet of young children as a potential indicator of population fertility, subsistence, and mortality patterns. While progress has been made in recent decades toward acknowledging the agency of children, many paleodietary reconstructions have failed to incorporate developments in cognate disciplines revealing synergistic dynamics between maternal and offspring biology. Paleodietary interpretation has relied heavily on the "weanling's dilemma," in which infants are thought to face a bleak choice between loss of immunity or malnutrition. Using a review of immunological and epidemiological evidence for the dynamic and supportive role that breastfeeding plays throughout the complementary feeding period, this article offers context and nuance for understanding past feeding transitions. We suggest that future interpretative frameworks for infant paleodietary and bioarchaeological research should include a broad knowledge base that keeps pace with relevant developments outside of those disciplines.

Parental Perceptions and Exposure to Advertising of Toddler Milk: A Pilot Study with Latino Parents

Marketing of toddler milk (i.e., typically sugar-sweetened nutrient-fortified milk-based drinks marketed for children 12-36 months) is an emerging public health problem in the US. The American Academy of Pediatrics recommends against the consumption of toddler milk because it often contains added sugar and can displace nutrient-dense foods. Studies have not examined toddler milk perceptions among Latinos, an important gap given Latino children in the US are at high risk of having poor diet quality, and toddler milk is extensively advertised on Spanish-language TV. This study used an online survey of a convenience sample of 58 Latino parents to examine parents' experiences with toddler milk, understand their perceptions of the healthfulness and the nutrition-related claims on toddler milk, and describe their exposure to toddler milk advertising. Nearly half (44%) of parents in the sample reported purchasing toddler milk. When asked to provide open-ended interpretations of claims on toddler milk, almost all parents gave positive answers, suggesting potential "health halo" effects of the claims. More than half (56%) of parents reported seeing toddler milk advertisements, most commonly on Spanish-language TV. The misperceptions about toddler milk identified should be explored in further research using larger, more representative samples.

Nutrition and packaging characteristics of toddler foods and milks in Australia

OBJECTIVE

To analyse nutritional and packaging characteristics of toddler-specific foods and milks in the Australian retail food environment to identify how such products fit within the Australian Dietary Guidelines (ADG) and the NOVA classification.

DESIGN

Cross-sectional retail audit of toddler foods and milks. On-pack product attributes were recorded. Products were categorised as (1) food or milk; (2) snack food or meal and (3) snacks sub-categorised depending on main ingredients. Products were classified as a discretionary or core food as per the ADG and level of processing according to NOVA classification.

SETTING

Supermarkets and pharmacies in Australia.

RESULTS

A total of 154 foods and thirty-two milks were identified. Eighty percentage of foods were snacks, and 60 % of foods were classified as core foods, while 85 % were ultraprocessed (UP). Per 100 g, discretionary foods provided significantly more energy, protein, total and saturated fat, carbohydrate, total sugar and Na (P < 0·001) than core foods. Total sugars were significantly higher (P < 0·001) and Na significantly lower (P < 0·001) in minimally processed foods than in UP foods. All toddler milks (n 32) were found to have higher energy, carbohydrate and total sugar levels than full-fat cow's milk per 100 ml. Claims and messages were present on 99 % of foods and all milks.

CONCLUSIONS

The majority of toddler foods available in Australia are UP snack foods and do not align with the ADG. Toddler milks, despite being UP, do align with the ADG. A strengthened regulatory approach may address this issue.