Following the lead of World Health Organization, the U.S. Department of Health and Human Services now endorses exclusive breastfeeding for six months, a time period widely recognized as necessary for long-term disease resistance for both mothers and babies.
The U.S. Surgeon General launched a campaign in January 2011 to reduce the obstacles to breastfeeding.
First Lady Michelle Obama has added breastfeeding to her "Let's Move" project to fight childhood obesity.
The Internal Revenue Service is on board too, ruling in February that breast pumps and other nursing supplies could qualify for tax breaks.
And the health reform law required many employers to provide nursing women on their payrolls with lactation breaks starting in January 2011.
However, the federal program with arguably the greatest practical influence over the nation's infant-feeding practices--the Special Supplemental Nutrition Program for Women, Infants and Children, better known as WIC--continues to distribute more than half the infant formula sold in the U.S. each year. That formula, which is provided to WIC at a discount, cost taxpayers an estimated $627 million in 2008, the most recent figure available (equivalent to a $2 billion value on the retail market).
And the habits and brand loyalty formed by the WIC rebate system can hook women on paying retail prices for formula once their stipend runs out each month.
WIC, which provides extra nutrition to low-income pregnant women and infants who may not be able to afford the food they need, enrolls women and children who live at or below 185 percent of the federal poverty level, or below $27,214 per year for a single mother and her child.
WIC helps feed 2.14 million women and 2.17 million infants a year; roughly half of all U.S. infants.
On the one hand, WIC was the first U.S. agency to join the global consensus on breastfeeding in 1997--far ahead of the Health Department or any White House programs. That year, it joined the American Academy of Pediatrics in formally recommending six months' exclusive nursing. In 2004, WIC also began hiring breastfeeding peer counselors and in 2009, it began distributing more food to enrollees who breastfeed than those who do not.
On the other hand, WIC, which provides formula to low-income mothers who need it for health reasons or who choose not to breastfeed their babies, continues to funnel what critics say is too much money to infant-formula makers, propping up products its own counselors call second-best.
This contradiction is partly due to an extremely effective press blitz by formula companies, which have met official U.S. breastfeeding promotion with a barrage of ads and in-hospital promotions that health advocates have been unable, politically, to do much about.
Touting new chemical ingredients in their products, formula makers target many of the neighborhoods that WIC serves--low income communities of color--with ads claiming that their new, enhanced formulas offer the nutritional equivalent of mother's milk. Manufacturers also offer mothers free hospital discharge packs, free product shipments to their doorsteps, and discount shopping coupons.
"Formulas containing [common additives] DHA and ARA have been shown to provide visual and mental development similar to that of the breastfed infant," assert promotional materials from the International Formula Council, an industry trade group in Washington, D.C. The group describes these ingredients as backed by "years of research studying the clinical effects…in infants."
Most of that promising research, the council neglects to point out, was industry funded.
In the face of the formula industry's sophisticated PR campaign, WIC is facing an uphill battle to instill the practice of six months of breastfeeding among its own participants. Few mothers in WIC are currently achieving that goal.
The importance of that target was laid down decades ago, in 1990, by UNICEF, the world advocate for children, through an international proclamation that "all infants should be fed exclusively on breast milk from birth to 4-6 months of age."
That recommendation came in response to an accumulation of independent studies showing immense health benefits from breastfeeding.
For women, breastfeeding is considered statistically helpful for everything from weight loss after pregnancy to improved odds of avoiding diabetes, osteoporosis, and breast and ovarian cancers. For infants, breastfeeding is statistically linked to higher IQs and improved defenses against asthma, ear infections, diarrhea, diabetes, obesity and respiratory problems.
Exclusive use of formula, meanwhile, was associated in independent studies in the 1990s and 2000s with asthma, allergies, diabetes, obesity, skin rashes and ear and respiratory tract infections.
The United States has long balked at enforcing UNICEF's 1990 proclamation, even though it is among the 32 countries--including Indonesia, Italy, India and England--that have officially signed on. "For decades, the U.S. has failed to implement the breastfeeding guidelines outlined in this document," says Dr. Barbara Philipp, a breastfeeding advocate and professor of pediatrics at Boston University School of Medicine. "Few doctors or nurses know what the UNICEF code is, and practically no one follows it."
WIC Moved Ahead
But WIC moved ahead and in 1997 began recommending that mothers who could breastfeed--women with HIV, for example, should not--give their infants nothing but breast milk for the first six months of life.
One beneficiary of that advice is Brianna Arrieta, a college student in Coachella, Calif.
When Arrieta became pregnant she wasn't sure whether to bottle- or breastfeed.
Her boyfriend favored bottle feeding, saying it was the custom of his Mexican-immigrant family.
Arrieta and her boyfriend were also encouraged by TV ads that made strong claims about infant formula's new nutritional additives.
Arrieta was torn though, because her mother and some of her friends urged her to breastfeed. And then, once Arrieta learned from a neighbor that WIC could help her make ends meet and signed up for the program, there was her persistent WIC counselor.
"Other moms told me that mother's milk was best," says Arrieta, who has breastfed her daughter Evangeline since she was born in October 2010 and is beginning to wean her now. "But it was Lupe, my consultant from WIC, who really convinced me that this was healthiest for little Evangeline, speaking to me in Spanish and giving me concrete examples of how breastfeeding could help my daughter avoid respiratory infections and help me stay healthier, too."
Since WIC began actively promoting breastfeeding in 1997, the number of participants who breastfeed has spiked 42 percent.
But Arrieta's breastfeeding story is still an exception.
According to Elizabeth Frazao, an economist and WIC researcher for the U.S. Department of Agriculture, which oversees WIC, Arrieta is one of the less than 34 percent of WIC mothers who have breastfed for at least six months. And according to health advocates, that six-month mark is essential for infants to get the full protective benefits of nursing.
Most WIC mothers still bottle feed with formula, using WIC vouchers to consume the retail equivalent of $2 billion worth of the product each year. This makes the federal program the product's largest purchaser nationally, accounting for between 57 and 68 percent of its sales.
That $2 billion market value is more than 50 percent higher than the equivalent number in 1997, the year WIC began to promote breastfeeding, when total WIC distribution of formula had a market value of just $1.3 billion.
Deep discounts were brought about by WIC's 1989 shift to a state-by-state exclusive contract bidding process. Before that, WIC was paying the full retail price for formula. Now the program's discount is, as a national average, about 85 percent.
Dr. Ruth Lawrence is past chair of the breastfeeding committee for the American Academy of Pediatrics, based in Elk Grove Village, Ill. She says part of the reason WIC mothers buy so much formula is those TV ads Arrieta saw touting the new nutritional additives.
"Ads for ARA and DHA-laced formula, found on public billboards and even in the offices of some WIC state agencies, are very effective at doing their job," says Lawrence. "WIC mothers are rushing to buy formula because these ads have convinced them that the new formulas are just as good as, if not better than, the milk that their bodies produce."
Data from the Economic Research Service of the USDA indicate that inflation has contributed to WIC's higher spending on formula, as has a 16 percent increase in infants enrolled in WIC between 1997 and 2007.
But higher-priced formula additives are also in the mix.
According to the USDA, nearly 10 percent of WIC's spending on infant formula is attributable to higher-priced formulas that contain additives. The agency found that formula with costly new "nutritional" or "functional" ingredients is 6 to 31 percent more expensive than formula without them.
Two of the best known additives are ARA (promoted as enhancing "visual acuity") and DHA (touted for advancing "neurological development"), which are synthetic versions of fatty acid chains found in breast milk.
These ingredients are now in 99.5 percent of formula sold in the United States, according to their leading producer, Martek Biosciences of Columbia, Md.
Claiming they were improving their products, formula makers in 2002 started adding DHA and ARA to formulas sold both on the retail market and through WIC.
Enfamil, made by Mead Johnson in Glenview, Ill., which commands an estimated 50 percent of the WIC infant formula market, was among the first to sell formula with these additives. Other major brands quickly followed suit.
Laurie True is executive director of the California WIC Association, based in Davis, which has member agencies that counsel WIC recipients about the risks of using powdered or liquid-milk substitutes compared to breastfeeding. "Moms are coming in to WIC offices and saying, "'I don't want to breastfeed because I want these new formulas that are just as healthy for my baby as breastfeeding,'" she says.
Paying a Steep Price
But women can pay a steep price for that conviction, since their WIC vouchers are not sufficient to get them all the way through the month.
WIC has spending caps, explains Dr. Miriam Labbok, a health professor at the University of North Carolina at Chapel Hill. "So WIC recipients who use formula continuously instead of breastfeeding need to go out and buy formula on their own to supplement their monthly WIC subsidies," she says. "Vouchers for individual WIC formula supplies don't last a full month."
This means women who get formula from WIC can find themselves in a financial booby trap. It looks free at first, but each month they could be out of pocket around a hundred dollars once they hit their cap.
If a mother can't get on WIC's limited rolls--or if she leaves the program--she might end up spending $300 a month retail to feed her baby infant formula.
For a single mother at the poverty level, who scrapes by on just $14,700 per year, formula could suck up roughly a quarter of her monthly income.
Because many mothers mistakenly believe that new formulas are as healthy as breast milk, True says it's a David-versus-Goliath struggle against the claims of formula makers.
"We have an uphill battle trying to convince mothers that formula is not only expensive, but coming at the expense of their families' health," she says.
Additives such as ARA and DHA are not only showing up in formula. They are increasingly being included in baby food, juice, milk, eggs, bread and other WIC-allowable items. Indeed, nucleotides, probiotics, antioxidants and other "functional food additives" have become a booming, $60-billion-a-year business.
The nutritional claims made about these additives can seem boundless.
These additives help offer "complete nutrition," claims the website for Similac, the top-selling infant formula.
ARA and DHA are "important nutrients that support brain and eye development," say ads for Enfamil, another popular brand.
The industry doesn't disclose that formula makers funded most of the research that bolsters these claims. Nor does it acknowledge that health authorities say such claims are trumped up.
At least one company, Enfamil, has lost three federal lawsuits brought by a rival product maker over its advertised nutritional claims.
Over the past five years, the Food and Agriculture Organization of the United Nations, the World Health Organization and the Cochrane Collaboration (an independent research organization that receives funding from the government but none from the formula industry) have all published research concluding that ARA and DHA are not effective at improving infant's visual and neurological development.
"Independent studies on ARA and DHA often reach a very different conclusion than studies done by scientists whose work was funded by the formula industry," says Labbok.
Labbok says there is no nutritional substitute for breast feeding. "ARA and DHA may be present in both formula and human milk. But when they are delivered during breastfeeding, they have a very different effect, because breastfeeding is not only natural and of human origin, but the milk is ever-changing to meet the infant's changing needs, changing throughout the feedings, from day to night, and as the baby grows."
The U.S. Food and Drug Administration, based in Silver Spring, Md., places few restrictions on the claims that food manufacturers can make about how ingredients affect the body's function (e.g. "this product contains ARA for visual acuity"). "As long as functional ingredients aren't described as preventing or curing disease, no one in the federal government has to approve the claims that are made," says Zoë Neuberger, a senior policy analyst for the Washington-based Center on Budget and Policy Priorities.
Under U.S. law, WIC (like other infant formula purchasers) doesn't have any control over what ingredients formula manufacturers put in their products or how makers advertise these ingredients. Formula makers can add any ingredients they want--and charge whatever they want--as long as they can prove to the FDA that these ingredients don't cause any harm.
Explains Neuberger, "If the only formulas that are offered to a state WIC program are formulas with functional ingredients, then the WIC program has to provide formula with functional ingredients."
Now 99.5 percent of infant formula sold to WIC contains ARA and DHA, and formula makers have used these functional ingredients' added costs to bolster their own bottom lines.
"Introducing expensive 'new and improved' formulas with unsubstantiated claims is the best way for formula makers to increase their profits in the WIC program," says Meredith McGehee, a public policy strategist in Washington, D.C. who lobbies for the California WIC Association on Capitol Hill. "It may come at the financial expense of the WIC program. It may come at the expense of the health of WIC-fed infants. But it may be the best way to get this program--and the nation--hooked on expensive new food additives."
The political action committee for Abbott Laboratories, the maker of U.S. market leader Similac, spent more than $1.5 million in contributions to federal and congressional candidates during the last election cycle, according to the Center for Responsive Politics, a Washington-based watchdog of campaign contributions. "It's hard to track the exact amounts all these companies are donating," says Doug Weber, a political campaigns analyst for CRP. "In many cases, these corporations peddle influence by making donations in their employees' names and not in the names of their political-action committees."
When asked by Women's eNews about their lobbying on Capitol Hill, the three major suppliers of WIC infant formula--Abbott Labs, Mead Johnson and Nestle--all declined comment, but ARA and DHA additive maker Martek, whose sales in its infant formula division now total $300 million a year, said that it pays a staff of "government affairs experts" on Capitol Hill to help lawmakers "make fully informed decisions."
Health advocates pushing for a government study of formula additives recently suffered a defeat against formula makers' lobbyists on Capitol Hill.
The California WIC Association, the American Academy of Pediatrics, the National WIC Association and the United States Breastfeeding Committee joined forces in 2008 to educate the authors of the Healthy, Hunger-Free Kids Act of 2010.
This bill, which comes up every five years, reauthorizes the WIC program, so health advocates used it to press for study of the array of "functional" ingredients that have entered the market since ARA and DHA were introduced.
As recently as 2005, the Institute of Medicine examined every other food item offered through WIC, but left functional ingredients ARA and DHA out of this review because it was not yet clear how widespread these ingredients would become. These additives had only been on the market for three years at that time and were not yet standard. "We argued leading up to the 2010 bill that this common-sense provision would have marked an important step toward establishing a science-based, decision-making mechanism," says Neuberger of the Center on Budget and Policy Priorities.
As efforts were being made to include provisions on additives in the Healthy, Hunger-Free Kids Act, a group of WIC supporters, including the National WIC Association, the Center for Budget and Policy Priorities, the California WIC Association and the American Academy of Pediatrics, met twice with officials at the FDA. "At the second meeting, Margaret Hamburg, the new FDA commissioner, attended, and told the group that she was as frustrated as they were about this," says McGehee. "She said she couldn't change FDA regulations that allow these ingredients to be added with little scrutiny, but that she welcomed the idea of further government review." Hamburg's spokespeople confirmed this was so.
Lanny Davis, a prominent Washington lobbyist whose client list, as The New York Times has noted, "includes coup supporters in Honduras [and] the dictator of Equatorial Guinea," was then the lobbyist for Martek, the company that makes ARA and DHA. Davis sent a scorching e-mail around Capitol Hill, reported on by the Times in December 2010, claiming the study of the additives "was being pushed by 'lactivists' who wanted to force women to continue breastfeeding."
Congressional insiders say Davis lobbied members of the Black Congressional Caucus and argued that misguided breastfeeding zealotry could deprive WIC recipients, and specifically women of color, of premium-brand formula.
"Davis lobbied Sen. Blanche Lincoln, the author of the Senate bill, to drop the provision," says McGehee. "Barbara Mikulski [D-Md] sent letters to Lincoln from the president of Martek, which is based in her state, warning of the provision's 'grave consequences for infant nutrition as well as for our business.'"
In the wake of this lobbying, the provision calling for further study of functional ingredients was dropped from the Senate version of the bill. A House bill including a similar provision was approved by the relevant Committee, but the full House enacted the Senate bill instead.
Leading the charge to authorize the Healthy, Hunger-Free Kids Act in the Senate--without the ARA/DHA provision--was Sen. Richard Lugar, a Republican whose home state, Indiana, is the site of a 430,000-square-foot, $26 million Pediatric Nutrition Institute opened in Evansville in October 2010 by Mead Johnson, the second-leading infant formula maker in the United States.
When Women's eNews pressed Lugar for information about the ARA/DHA provision, he replied that he was not available for an interview. His press aide responded by cutting and pasting a December 2010 news release about the Healthy, Hunger-Free Kids Act into an e-mail. Focusing on the bill's support of school lunches and ignoring the issue of infant formula, the e-mail boasted that the bill would give millions of children "access to nutritious food" and that it passed "without a single dissenting vote in the United States Senate."
"Now that this provision has been defeated and the bill without it has been passed in both the Senate and House, our hands are essentially tied on this front," says True. "Formula with expensive additives can continue being sold to WIC for the next several years because the next child nutrition act won't be reauthorized until 2015."
WIC Budget Strained
The WIC program has battled for decades to afford the billions of dollars that it spends on infant formula and other nutrition initiatives for the poor.
In fiscal year 2010, when was it last up for approval, WIC's budget was slashed to $6.73 billion from $7.25 billion (a 7-percent cut). With the economy floundering, WIC is a ripe target for the next round of budget cuts, for fiscal year 2012. The GOP-led House has proposed cuts so severe, True says, that it would mean California WIC alone would have to trim 111,000 women from its rolls.
It is difficult to track how much of WIC's spending is funneled back to formula makers in the form of profits. "The actual cost of production to the manufacturers is quite small," notes George Kent, a professor of political science at the University of Hawaii in Honolulu and author of the forthcoming book "Regulating Infant Formula." "For name brand formulas, the cost of the ingredients purchased by the manufacturer may be less than 10 percent of the retail price."
WIC, which has separate offices in 50 states and dozens of Native American nations (and a total of 90 different contracts with formula makers) does not track formula profits, either.
"If we could save money by using less formula or spending less on it, we could provide nutrition to more low-income women and young children," says True. "We can only serve as many needy people as our limited budget allows."
Infant formula began as niche product.
An estimated 10 to 15 percent of mothers have trouble breastfeeding, and women with certain health concerns--such as HIV, tuberculosis, toxic exposure or dependence on medications that are excreted through breast milk--can compromise their infants' health if they nurse.
Such women cannot obtain breast milk from other women on the open market, because U.S. regulations treat breast milk as human tissue and prohibit its free sale.
Laws against buying and selling breast milk, established only in the last century, would have likely shocked women in the 1700s and 1800s, when it was common for wet nurses to nourish children whose mothers chose not to breastfeed or could not do so.
In 1867, Swiss pharmacist Henri Nestle came up with a synthetic substitute for wet nurses and introduced commercial infant formula, which derives its protein from soy or from purified cow's milk whey and casein.
Nestle's product took hold, and, with the creation of commercial formulas and mass advertising, the market for infant formula exploded in the 1950s and 1960s.
By 1971, the year before WIC was created, the product had grown so popular that 75 percent of American infants and 95 percent of American six-month-olds were consuming formula instead of breast milk--even though the vast majority of their mothers had no health reasons for doing so.
Soon, formula makers began to play a quasi-official role in the field of infant health.
For decades, Ross Laboratories, the precursor to Abbott Labs, collected the only comprehensive information on the prevalence of breastfeeding in the United States. The Atlanta-based Centers for Disease Control and Prevention, the federal agency that collects data on a range of other health markers, only started tracking breastfeeding statistics in 1994.
Ruth Lawrence, the American Academy of Pediatrics' breastfeeding committee's past chair, says formula companies' influence has shaped U.S. policy in a variety of ways, for example by inhibiting U.S. hospitals from joining UNICEF's Baby-Friendly Initiative, which requires hospitals to promote breastfeeding and refuse promotional handouts from formula makers.
In Sweden and Norway, notes Baby Friendly USA spokeswoman Pat Kelly, an estimated 90 to 100 percent of hospitals have signed on. In the United States it's less than 4 percent. "Even after we became Baby Friendly and stopped distributing formula discharge bags, formula companies still came knocking on the doors of other clinical sites offering free office supplies," says Ocean Berg, a perinatal clinical nurse specialist at San Francisco General Hospital.
Infant formula is now a product turning over billions in global sales each year for several American and European companies. In the United States, it is the exclusive form of nutrition for roughly a quarter of newborns.
This article was reported in partnership with The Investigative Fund at The Nation Institute.
See two related series focused on African American maternal and infant health, supported by generous grants from the W.K. Kellogg Foundation.
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