Wednesday, March 10, 2010

What's your milk worth?

This is the text of a talk I gave to the La Leche League Ireland Conference on 7 March 2010. The accompanying PowerPoint presentation is attached to the posting of this blog on our website. See:

Many thanks for the invitation to speak at the Conference. I bring greetings from everyone at Baby Milk Action. No doubt many of you are in contact with Patti Rundall, our Policy Director, and Sarah Hansen, our Office Manager.

I've been asked to speak on the topic: "What is your milk worth?"

And I've been thinking about the different ways to answer this. My immediate thought was there's a short answer and a long answer.

Here's the short answer. [SLIDE: Baby Quinn poster]

If a picture is worth a thousand words, then a smile is worth a thousand more.

But I guess you do want some words from me too, so here's the long answer.

What's your milk worth?

Well, a La Leche League Conference doesn't need me to explain how babies without breastmilk suffer greater short and long-term illness. Your milk is worth better health for your babies, which is priceless.

But I'm going to try to be a bit more precise than priceless.

So how does Euros 130/litre sound for the value of breastmilk? [SLIDE: € 130/l]

That's how much neonatal units in hospitals in the UK pay to milk banks - but that's not for the milk, that for the processing costs of the milk bank that collects and pasturises it. Premature babies fed on it have better chances of surviving.

That's one figure. We can also consider the number of lives lost through babies not being breastfed and the cost to our health services. Breastmilk is the most locally produced natural food there is - replacement feeds require processing and transport which has an environmental impact. Mothers aren't paid to breastfeed their babies, but if they don't breastfeed, they have to pay for breastmilk substitutes, so we can think about the cost of that and the multi-billion Euro industry that has arisen and the harm that it does.

I imagine as you've asked me here from Baby Milk Action you'd like to know something about company marketing and what can be done to stop it. We can also turn this question around and ask, "What is breastmilk worth to us?" What will we do to defend breastfeeding.

These are the issues I'm going to explore in a bit more depth, starting with breastmilk being worth Euros 130/litre for neonatology units.

A litre will provide nourishment and protection to many babies, of course, as a few millitres is enough to fill the stomach of a premature baby. [SLIDE: Stomach sizes]

This image shows the stomach size of a normal new-born baby to get an idea. This comes from a reliable source - the LLL International website.

The reduction in Necrotising Enterocolitis is one of the main reasons for having donor milk for babies if they cannot receive their mother's milk while in intensive care or undergoing Kangeroo care. NEC is where the tissue of the bowel dies and it is a big killer of premature babies. I visited the donor milk bank in Chester this week and they rarely have cases of NEC. Breastfeeding has sometimes been described as the continuation of the placenta and it finishes the job of the development of the digestive system.

Other hospitals where babies are dying from NEC are starting to source donor breastmilk from Chester. And just last month the National Institute for Clinical Excellence published its guidelines. I know there is a milk bank across the border in Irvinestown Health Centre in County Fermanagh and I understand it operates across Ireland and is providing donor milk to 700 babies per year. Like many milk banks, I also understand it relies to some extent on fundraising.

The figure I gave for the cost of processing human milk comes from Chester which is a charity and has to raise all its operating costs itself, about € 130,000 per year, and it processes 1000 litres. Someone once said, wouldn't it be strange if health had all the money it needed and the army had to hold jumble sales for weapons. But in the world we live in, it is breastfeeding supporters who hold the jumble sales.

But that does not mean the work is not professional. [SLIDE: Chester conference] Chester is holding a milk bank conference in May - you can find out more information on their website. You'll be able to find the notes for my talk on the Baby Milk Action website next week, but here is the address of the Chester site if you want to note it. This is particularly relevant to Neonatologists, so you might like to suggest your contacts attend.

The mothers who donate the milk are volunteers, of course. They do it, because they know the value of breastmilk.

I started out with Baby Quinn. A picture of contentment. But not just contentment. It is a picture of nurture and protection coming from the living substance that is breastmilk and the warm and love with which it is delivered.

You know better than me that breastfed babies are optimally fed. Denied breastmilk and fed with cow's milk or soya milk, however much it is processed and adapted, they will have greater risk of short and long-term illness. Breastfeeding is worth life and health.

And illness costs not only the individual, but society as a whole. In 2006 we made a submission to the UK government as it was revising our Infant Formula and Follow-on Formula Regulations to implement a revised EU Directive. We made a submission calling for the government to implement the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant Resolutions of the World Health Assembly in legislation. [SLIDE: The Code]

The Code and Resolutions, for short, set out how companies can and cannot market their products and came about as a direct result of the Nestlé boycott and wider campaign. The Code itself was adopted in 1981 and aims to protect breastfeeding and babies fed on formula.

BFLG submissionGovernments are called on to implement it and we asked our government to do so. We had built a coalition called the Baby Feeding Law Group [SLIDE: BFLG], consisting of the major health worker organisations and mother support groups and the submission (shown left) had the backing of all these organisations. If you don't have such a coalition in Ireland, then it might be something to think about.

One of the questions in the UK Government consultation was about costs and we pulled together the figures available to us to make an economic case for protecting breastfeeding. [SLIDE: NICE report]

In the UK, a NICE costing report evaluated possible savings from Baby Friendly Initiative accreditation. They said.

“The evaluation assumes that a 10% improvement in initiation rates is a realistic target.

“On the basis of medical literature we assume that an increase in the number of babies that breastfeed will lead to a reduction in healthcare expenditure because of avoided cases of otitis media, gastroenteritis and asthma. On the basis of an annual birth rate of 605,634 a 10% improvement in breastfeeding would mean that 60,563 additional babies would be breastfed.”

[SLIDE: Cost savings]

• about 17,000 cases of otitis media avoided at a saving of £509,000.

• almost 3900 cases of gastroenteritis being avoided, at a saving of £2.6 million

• over 1500 cases of asthma being avoided, at a saving of £2.6 million.

• a reduction in the cost of teats and formula of £102,000

NICE. Postnatal care: routine postnatal care of women and their babies. Costing report: Implementing NICE guidance in England. London: National Institute for Health and Clinical Excellence; 2006. pp 36.

A US Study looked at savings to their welfare scheme from breastfeeding. [SLIDE: WIC]

Compared with formula-feeding, breastfeeding each infant enrolled in WIC saved US$478 (€350) in WIC costs and Medicaid expenditures (the US welfare schemes) during the first 6 months of the infant’s life.

Montgomery DL, Splett PL. Economic benefit of breast-feeding infants enrolled in WIC. J Am Diet Assoc 1997 Apr;97(4):379-85

They also looked at broader savings to the economy [SLIDE: 3.6 billion]

The US study found a minimum of $3.6 billion would be saved if breastfeeding was increased from current levels (64 percent in-hospital, 29 percent at 6 months) to those recommended by the U.S. Surgeon General (75 and 50 percent), for each year at the higher rate. Pro rata to the population of Ireland, this equates to € 40 million per year of improved breastfeeding.

Figure based on treatment of only three childhood illnesses: otitis media, gastroenteritis, and necrotizing enterocolitis.

This does not count the savings of the cost of formula.

It does include the loss of earnings of the 720 babies who were estimated to die each year in the US from Necrotizing Enterocolitis who would not have died if breastfed.

Weimer. The economic benefits of breastfeeding: A review and analysis, Food Assistance & Nutrition Research Report No. 13. Wash.D.C., USDA, 2001.

In our submission in the UK, we recommended the government commission research on environmental impacts of babies not being breastfed – our figures are out of date. There is no food more locally produced and unprocessed than breastmilk. For formula we need to consider: [SLIDE: Environmental impact]

• Methane from cows is a greenhouse gas. Transport and processing impact.

• Resources used for packaging: 86,000 tons of tin plate would be used each year if every US baby was formula fed, with 550 million discarded tins (1991 figures).

• In 1987, 4.5 million feeding bottles were sold in Pakistan alone.

• A formula-fed 3-month old baby requires a litre of water a day for preparing formula and the equivalent of 73 kg of firewood per year, contributing to deforestation in poor countries.

Radford, A. Breastmilk: A world resource, Baby Milk Action, Cambridge, UK, 1991.

Sore boobsThe UK Government, like the Irish Government, did not listen to the calls for implementing the Code and Resolutions and has done the bare minimum to implement the EU Directive. [SLIDE: Montoring report]. We produce monitoring reports on behalf of the Baby Feeding Law Group, which show the strategies companies are using. You see advertising for follow-on formula on television and idealising claims on formula labels, as well as promotion to health workers, sponsored events, misleading information and so on. The same as you have in Ireland. This is a Cow & Gate mailout after the company signed up a mother. [SLIDE: Sore boobs]

I bought some formula yesterday from the supermarket and I want to demonstrate what the companies are doing. [Formula Race - you had to be there to appreciate this!].

But these claims are misleading. Let's look at the claims made about LCPs - Long Chain Polyunsaturated Fatty Acids. [SLIDE: LCPs]

Longchain polyunsaturated fatty acid supplementation in infants born at term

It has been suggested that low levels of long chain polyunsaturated fatty acids (LCPUFA) found in formula milk may contribute to lower IQ levels and vision skills in term infants. Some milk formulas with added LCPUFA are commercially available. This review found that feeding term infants with milk formula enriched with LCPUFA had no proven benefit regarding vision, cognition or physical growth.

Simmer K, Patole S, Rao SC. Longchain polyunsaturated fatty acid supplementation in infants born at term. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD000376. DOI: 10.1002/14651858.CD000376.pub2.

[SLIDE: DH study]

Mothers are misled. ‘Myths stop women giving babies the best start in life’ Department of Health survey, May 2004:

“Myth: Over a third (34%) of women believe that modern infant formula milks are very similar or the same as breast milk

“Fact: Infant formula milk does not contain the antibodies, living cells, enzymes or hormones present in breastmilk. Breastmilk is designed for each individual baby and changes over time whereas infant formula milk is designed for every baby.”

So these and other claims are untrue, but companies base their marketing strategies upon them. This can have a devastating impact in developing countries where access to health care to treat sick infants is often lacking.

According to the Lancet series on child survival, improved breastfeeding could save 1.3 million under-5 babies every year.

[SLIDE: Lancet]

By improved breastfeeding, they mean 90% exclusive breastfeeding to 6 months, with continued breastfeeding for 99% of babies during the first year. We are a long way from that at present. But if it were not for breastfeeding, many more millions of babies would die each year.

Improving breastfeeding rates in the 42 countries where most under-5 deaths occur, could prevent 13% of those under-5 deaths. [SLIDE: Lancet comparison] That’s more than would be saved by:

• universal provision of safe water and sanitation (3%)

• universal provision of HIB, Tetanus and Measles vaccines (4%, 2%, 1%).

(Combined total 10%)

Appropriate introduction of complementary foods could save a further 6%.

[SLIDE: World Bank estimate] The World Bank has estimated that meeting the health Millenium Development Goals of providing universal access to safe water and sanitation by 2015 at US$ 30 billion (€22 billion) per year. Of course, there needs to be the improvements to water, sanitation and vaccination, but this give an indication of the value of increasing breastfeeding, which could save more lives. Indeed, many of the children who survive unhealthy conditions would have died if they had not been breastfed.

The Costs of Attaining the Millennium Development Goals, World Bank, accessed March 2010,

Where is the money and support for breastfeeding? Putting money into breastfeeding support and taking action over marketing are political decisions. And the baby food industry is big money. [SLIDE: Baby food industry]

The retail value of the global baby food market in 2008 according to analysts Euromonitor was € 23 billion. Two-thirds of this is formula. So there's about a € 15.3 billion industry because of babies not receiving breastmilk. Let's consider that some babies cannot be breastfed because they are abandoned or orphaned without access to alternative supplies of breastmilk or because the mother cannot breastfeed for medical reasons. Formula is essential for some babies, so let's knock off the formula required as a nutritional medicine and reduce the sum to € 15 billion to reflect the value of the breastmilk that is being substituted.

To defend this market, companies battle against regulation. According to Euromonitor: [SLIDE: Industry action].

“The industry is fighting a rearguard action against regulation on a country-by-country basis,”

“Government Regulation a Growing Constraint”.

“There are significant international variations in the regulations governing the marketing of milk formula, which are reflected in sales differences across countries.”

To finish, I want to turn this question around and ask you: "What is your milk worth?" By which I mean, what are you doing to defend breastfeeding?

In the discussion about the Politics of Breastfeeding yesterday, people were wanting to know what they could do. We'll be able to explore this more in the discussion, but I want to see if I can inspire you with a story from the Philippines. This is a country where, according to WHO, 16,000 babies die every year because they are not breastfed.

Nestle NestogenIn 2006 the Department of Health introduced regulations to stop companies marketing formula as if it would turn babies into geniuses. [SLIDES: Abbott, Nestlé].

Abbott's formula had an IQ logo, with the word 'eye' in the letter 'I', suggesting it benefits visual and mental development. Nestlé undermined the legally required 'breastmilk is best for babies' message with a colourful logo claiming its formula contains, "Brain Building Blocks". These are referring the the LCPs I mentioned before - where the Cochrane Library review found such claims are not proven.

The pharmaceutical companies that make formula took the government to the Supreme Court and the US Chamber of Commerce wrote to the President demanding the law be struck down or American companies would pull out of the country.

Here's what happened next [SLIDES: Philippine campaign - showing demonstrations, media work, letter-writing campaigns, petitions, UNICEF DVD, culminating in the 'brave breasts' protest outside the Supreme Court. Also see Update 40].

Now, topless protests might not be the thing to do in Ireland. But next time you see an advertisement you might like to remember this story and think, "What is breastmilk worth?" [SLIDE: Action ideas]

Is it worth a letter to the Advertising Standards Authority? Sending violations to La Leche Leage? Starting a campaign in Ireland?

[SLIDE: International ideas - boycott] Supporting the boycott of Nestlé, worst of the companies? Writing to all companies about practices that harm health. Our current priority is Nestlé's new strategy of claiming its formula 'protects' babies. This is about the LCPs we hear about earlier. This label shows that campaigning works. It is from Malawi, one of the world's poorest countries and Nestlé refused to translate it into the national language until we campaigned and shamed it on UK television.

Here's the challenge facing you in Ireland. [SLIDE: Breastfeeding rates]

"Ireland is in the unenviable position of having the lowest breastfeeding rates in Europe and this has been the situation for at least two generations.

"Currently only about 40% of new mothers in Ireland initiate breastfeeding and many of these cease doing do so before their infants are four months old."

Fallon M, Breastfeeding in Ireland, Department of Health and Children, Accessed March 2010,

I understand the situation has improved slightly from this figure, but rates are still low.

Here's the hope. [SLIDE: The hope]

La Leche League Ireland exists.

You have come to the Conference.

You know what your milk is worth!!

[SLIDE: Contact us]

Baby Milk Action can help. So do please visit our website and stay in touch. Also look out for an online training course on monitoring which is being added to our website.


Filippo il mulo said...

Hi Mike,
my name is Filippo and I'm a student of science communication in Italy. I'm doing some researches about Sven Carlsen and his claim about "Breast is NOT best".
May I have a contact (e.g. an e-mail address) in order to ask you some question about this issue? If you prefer, you can also wirte to me:

Mike Brady said...

Please see this blog for analysis of what Professor Carlsen actually said:

Anonymous said...

Hi Mike,
Someone needs to say the "F-word" ie "Formula" in relation to health care costs and stop focusing on breastfeeding. I note that Baby Friendly UK has a tender out for a research team to look at the "Cost analysis of breastfeeding in the UK." I found the title somewhat intriguing and wondered if they were going to attempt to look at the cost of mother's work in breastfeeding their babies (ie putting an economic measure on the value of breastfeeding- as you discuss in your talk). However, I discovered on reading the tender summary that they are in fact wanting to know what early cessation of exclusive and any breastfeeding is costing the UK. How absurd to describe it as looking at the costs of breastfeeding. Why are they not looking for a "Cost analysis of formula feeding in the UK?"

By the way Filippo Prof Carlsen spoke beyond his expertise but as someone interested in communication about infant feeding you might want to consider that "Breast is NOT best" is in fact correct. See Berry, Gribble (2008) Breast is no longer best. Maternal and Child Nutrition 4:74-79.
Karleen Gribble

Dr Karleen D Gribble PhD
Adjunct Fellow
School of Nursing and Midwifery
University of Western Sydney
+61 (0) 43 1118485

Mike Brady said...

Dear Karleen,

Thanks for the heads up on the Baby Friendly tender.

I've written on the 'breast no longer best' argument in the past (including a link to your talk) at:

Muddling Along said...

Given that mothers who donate their breastmilk are all volunteers I think they are hugely under appreciated. I pump to provide milk for my daughter whilst at work and express more than she needs to be able to donate to the milk bank but it does take time and is a fairly horrid process and yet I do it because I want other children to have the benefits of breastmilk. But a bit of appreciation and normalization of this would be nice