Relationships between paediatricians and infant 
formula milk companies 

Relationships between paediatricians and infant formula milk companies C M Wright, A J R Waterston 
Paediatricians should recognise the influence of infant formulamilk companies and avoid intentionally or inadvertently promoting them The promotion of breast feeding is a high priority for most paediatricians, 
yet many, inadvertently, assist infant formula milk companies (IFMCs) in their marketing, thereby undermining breast feeding. This article examines how infant formula manufacturers achieve this and how such promotion 
can be avoided. WHY THISISIMPORTANT It is now known that the use of infant formula instead of breast milk is one of the most important causes of preventable mortality in infancy world wide.1–3 However, there is growing evidence that this is not just an issue for poorer countries. Research in the United Kingdom has shown associations with increased morbidity,45 reduced later intelligence quotient (IQ),6 and increased risk of adult ill health,7 and a recent paper from the United States showed an association with excess infant mortality.8 This places the use of infant formula high among the avoidable risks to health to which children in 
the United Kingdom are exposed. Yet in the United Kingdom, breast feeding rates are stagnant, after encouraging rises in recent decades, and there is a clear social class disparity, which means that children in the poorest families, already facing multiple adversities, predominantly start life without the protective benefits of breast milk.9 Globally, breast feeding is also under threat, with signs of reverses in rates of exclusive breastfeeding in many countries.10 WHY INFANT FORMULA MANUFACTURERS SPONSOR PAEDIATRICIANS Infant formula manufacturers have a duty to their shareholders to maximise sales of their products, which by definition means minimising exposure of infants to breast milk. Hence while publicly stating their commitment to breast feeding, as required by law, IFMCs are, in fact profiting from the failure of breast feeding. With growing knowledge of the hazards of infant formula, manufacturers need to seek ever more sophisticated ways of promoting their products as scientific and safe. Any link with paediatricians or other health professional is thus likely to enhance their products’ credibility and sales. IFMCs are therefore happy to provide funds from their advertising budgets to achieve this. There are three main ways by which IFMCs forge these links with paediatricians: through educational activities, support of a department or organisation, and funding of research. Sponsorship of an educational event promotes a company and its products at a number of levels. The firm’s name is linked to that of the institution on widely distributed publicity, those 
attending the course receive material such as pens bearing the firm’s logo, and all involved will then tend to have subtly enhanced respect for that company and their products. When companies fund clinical activity or support health related organisations, this also conveys an impression of the company as being ‘‘health giving’’ even if their products may cause net harm to chil-dren’s health. Research into formula milks, although ostensibly necessary, in fact serves an important role in promoting the use of infant formula, as the results 
are then used to enhance the impression of their ‘‘equivalence’’ to breast feeding, once compounds present in breast milk, such as ‘‘pre-biotics’’, are added. Every supposed enhancement of an infant formula, which EU law only requires be tested in trials of equivalence to other formulas, can then be advertised as making the formula ‘‘even closer to breast milk’’ even though there is no evidence that any such enhancements have actually increased the safety of formula. Paediatricians also tend to attach great significance to the role of IFMCs in developing specialist formulas, which may be useful for a tiny number of infants, without necessarily recognising that far more infants suffer because they were deprived of the protective benefits of breast milk by 
the use of that company’s products. WHY PAEDIATRICIANS SHOULD AVOID IFMC SPONSORSHIP The relationship between doctors and both their patients and society as a whole is termed a ‘‘fiduciary’’ relationship; doctors have specialised knowledge and expertise and hold the trust of 
others, which implies a particular duty to avoid conflicts of interest. Sponsorship by its nature creates a 
conflict of interest. Whether it takes the form of gift items, meals, or help with conference expenses, it creates a sense of obligation and a need to reciprocate in some way. The ‘‘gift relationship’’ thus influences our attitude to the company and its products and leads to an unconscious unwillingness to think or speak ill of them. Even if individuals are uninfluenced by sponsorship and subsequently act wholly responsibly in relation to breast and formula feeding, by accepting sponsorship or speaking at an IFMC meeting they still lend credibility to the company by the visible association of their name and position with that company. This is why UNICEF and WHO have for many years advocated the complete separation of health professionals from IFMCs at an organisational level. This is a vital step in the promotion of breast feeding, as it is almost impossible for any individual health worker to avoid, or even be aware of, the influence of IFMC promotion. The WHO code remains a vital tool in this respect11 (box 1). The UNICEF 
Baby Friendly hospital award is potentially achievable by all maternity hospitals in the United Kingdom, and there is evidence12 that hospitals that are Baby Friendly show improved breast feeding rates compared with those who are not. It is also worth noting that only 9% of births in England currently occur in Baby Friendly accredited hospitals, although the figure is 54% in Scotland.13 Paediatricians who wish to take this up with their chief executive will find a model letter on the Baby Friendly website ( uk). 
ARE PAEDIATRICIANS INFLUENCED? The willingness of IFMCs to pour money into the support of paediatricians indicates that they believe the link will increase their companies’ success. There is an analogy with drug company sponsorship, which also attaches great importance to medical opinion formers relationship-building activities and then provide them with a programme of Box 1: The WHO code of marketing breast milk substitutesExists to protect and promote breast feeding and to ensure the safe use of breast milk substitutes by provision of adequate information and restricting promotional activities 
Article 5.1: There should be no advertising or other form of promotion to the general public of products within the scope of the code 
Article 6.2: No facility of the healthcare system should be used for the purpose of promoting infant formula or products within the scope of the code. This code does not, however, preclude the dissemination of information to health professionals as provided in article 7.2. 
Article 7.3: No financial or material inducements to promote products within the scope of the code should be offered by manufacturers or distributors to health workers or members of their families, nor should these be accepted by health workers or members of their families WHA 49.15 
Member states should ensure that the financial support for professionals working in infant and young child health does not create conflicts of interest, especially with regards to the WHO/UNICEF Baby Friendly Hospital Initiative Box 2: Pharmaceutical Marketing Journal (quoted in the Guardian 
Oct 2004) ‘‘Seek careful identification of the people you should be working with. The key is to evaluate their views and influence potential, to recruit them to specially designed appropriate communications platforms.’’ 
matters. Avoiding IFMC sponsorship can be a lonely and unrewarding business; we suggest that the time has come for UNICEF or the RCPCH to establish the concept of ‘‘Baby Friendly’’ practitioners who, like institutions, could be rewarded symbolically for consistently avoiding IFMC sponsorship. 
CONCLUSIONS If breast feeding, with all its benefits, is to be established as a majority activity, we paediatricians must learn to recognise the elaborate web woven around us by formula manufacturers, which currently ensures our goodwill and support for a product that we may acknowledge, but 
would mostly not wish to actively promote. Fifty years ago nearly everyone, including doctors, smoked and it was perceived to be a necessary and inescapable part of our culture. Now it is unimaginable that we would smoke in front of our patients or accept gifts from cigarette manufacturers. It is time for a similar shift to take place with respect to formula milk. Just because many mothers currently choose to bottle feed their infants and a tiny number of infants cannot be breast fed, it does not mean we should be seen to be endorsing 
a product that causes net damage to the health of children. The time has come for paediatricians to recognise the influence of IFMCs, shake off their silken chains, and become truly uncompromised advocates 
for breast feeding and against the hazards of formula milk. A review14 showed that meetings with pharmaceutical representatives were associated with increased requests by doctors for their drugs to be added to the hospital formulary and to changes in prescribing practice, while attending sponsored educational events and receiving funding were associated with increased prescription rates of the spon-sor’s medication. 
Since the Royal College of Paediatrics and Child Health (RCPCH) stopped accepting direct sponsorship from IFMCs, there have been no adverse financial effects, despite gloomy predictions. Where a certain amount of sponsorship is routinely available, conference budgets tend to reflect this, in terms of the level of accommodation and catering offered, travel expenses and honoraria paid, leading to the perception that 
sponsorship is essential. Yet many United Kingdom organisations run successful and affordable meetings using no sponsorship of any kind. The Pakistan Paediatric Association, in one of the poorest countries in the world, refuses all IFMC funding, yet regularly runs large meetings at profit. 
It can be difficult for individuals to navigate the complexities of what actually constitutes sponsorship and how exactly to define an IFMC. From our experience of this we have developed a draft code of practice (tables 1 and 2) that others might like to draw on in discussion with their colleagues on these Definitely Arguably 
lTable 2 What sort of sponsorship should be avoided Within a unit Reason to be avoided 
The use of leaflets or posters displaying IFMC company logos Promotes the company to public in trusted environment Support from IFMCs for teaching sessions or meetings Publicity will associate your unit with the company Support for staff salaries, equipment, or research Unit will be indebted to the company, tending to stifle expressions of doubt about their products or practices As an individual Reason to be avoided 
Accepting gifts of stationery, pens, clinical equipment You promote the company to your patients by using them Speaking at meetings visibly badged by IFMCs Publicity will be used to promote the company and link your name to it Support for attending a conference or course You will feel indebted to the company and inclined to expect such support in future Table 1 Which types of companies should be avoided Any company whose main product is breast milk substitutes, bottles or teats, e.g. SMA, Milupa, Cow&Gate, Farleys 
Any company who markets other clinical products using a name clearly identified with breast milk substitutes, e.g. Nestle, Nutricia Not usually Any company that, among other products, makes or sells infant formulas, e.g. a supermarket might generally be an acceptable sponsor, but not if this was inked to 
their promotion of formula milk
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7 Singhal A, Cole TJ, Lucas A. Early 
nutrition in preterm infants and later 
We are grateful to Nick Spencer, David Stone, 1 WHO. Effect of breastfeeding on infant and child blood pressure: two cohorts after 
and Andrew Radford for commenting on mortality due to infectious diseases in less randomised trials. Lancet 2001;357: