WHO code and marketing of breastmilk substitutes - with Vicky Sibson

This week, I’m delighted to be joined by Dr. Vicky Sibson, Director of the First Steps Nutrition Trust, to talk about the challenges and regulations surrounding infant formula marketing. Vicky explains the importance of the WHO Code, which aims to protect infant health by regulating the marketing of breast milk substitutes, and clarifies what infant formula companies should and shouldn’t be doing in the UK. We also talk about the impact of digital marketing, the high costs of formula, and the role of baby clubs in undermining breastfeeding, and Vicky gives her advice on how to approach buying formula in a supermarket.

My new book, ‘Supporting the Transition from Breastfeeding: a Guide to Weaning for Professionals, Supporters and Parents’, is out now.

You can get 10% off the book at the Jessica Kingsley press website, that's uk.jkp.com using the code MMPE10 at checkout.

Follow me on Twitter @MakesMilk and on Instagram  @emmapickettibclc or find out more on my website www.emmapickettbreastfeedingsupport.com

Find out more about formula on InfantMilkInformation.org

And find out more about infant nutrition and the work of First Steps Nutrition Trust on their website - https://www.firststepsnutrition.org/

This podcast is presented by Emma Pickett IBCLC, and produced by Emily Crosby Media.

Transcript

Emma Pickett  00:01

Hi. I'm Emma Pickett, and I'm a lactation consultant from London. When I first started calling myself Makes Milk, that was my superpower at the time, because I was breastfeeding my own two children. And now I'm helping families on their journey. I want your feeding journey to work for you from the very beginning to the very end. And I'm big on making sure parents get support at the end to join me for conversations on how breastfeeding is amazing. And also, sometimes really, really hard. We'll look honestly and openly about that process of making milk. And of course, breastfeeding and chest feeding are a lot more than just making milk. 

Emma Pickett  00:45

Today, I'm really honored to be joined by Dr Vicky Sibson, who is the director of the First Steps Nutrition Trust. I love this organization. I love this charity. We're going to be talking about this charity and their work, and we're also going to be talking about some important questions about how we can support parents and families to get access to unbiased information like commercial influence, free information about infant feeding, because we do need to protect families from that commercial influence. It does not always have their interests at heart, despite what the companies might say. You might have heard of things like the who code and not being quite sure what that means, or you might be a bit confused about why your local supermarket can't put formula on sale. Or you might be worried about what you're seeing happening on social media with influencers talking about certain products that undermine breastfeeding. Hopefully, if that's all true, this is the episode for you. We're going to try and unpick some of those issues and see what we can do without our brains exploding on a Monday morning. Thank you very much for joining me today. Vicky, can I just start by asking, How did you join First Steps Nutrition, Trust?

Dr Vicky Sibson  01:50

So I first heard about First Steps as a mum when I was invited to a session being run by a community dietician all about starting solids. This is in London. I used to live in London, and my son was five months old at the time, and I'm a public health nutritionist by background, by training. I've been working for over 10 years with a focus on infant and young child feeding. But funnily enough, I felt like I knew what I was meant to do, but I didn't quite know how. And she shared with us first steps eating well guide on eating well in the first year. And I found it great, really. Found it useful as I navigated complimentary feeding for the first time. And I looked into first steps and looked at what it did, scope of work, and what is trying to do in the UK. And I got really excited, really interested. I thought that if I could get a job with them, I could make use of my work. To date, I'd worked overseas, but like I said, always on Maternal, Infant and young child nutrition and feeding and yeah, To cut a long story short, I got in touch, and eventually I got a job. And here you find me today as the director, 

Emma Pickett  03:04

being the director, yeah, well, I'm glad that you had that session that all worked out. You mentioned the eating well guides, which I absolutely love. They are and I mean, you're two things that I love, particularly about first steps are your eating well guides and your information on infant milks. And you've got a separate website, which is infant milk info.org It must be a massive job to keep that updated and keep that going. What will people find on that website? 

Dr Vicky Sibson  03:30

Yeah. So a few years ago, we took all of our work on infant milks and decided to create this central repository. So it's meant to be a one stop shop for everything on infant milks first on sale in the UK. And to give you a summary of what's on there, we've got all different information on all the different types of formula milk. So for example, the infant formulas and then specialized milks follow on formulas, and we have them all organized with all the different product types, and for each product, we give nutritional information and then, for example, practical information like cost and whether they're halal or kosher. For people who want to know information like that, I should have said we've got an overview for each product type to try and say a little bit about what they're for, or whether they're suitable, or indeed not suitable. So that's sort of the that's, I guess, the main information you'll find there. But we also have a page which gives an overview on the regulations, which govern marketing and composition as well. And then we have a page which puts all the cost information in one place, and analysis we do on costs, because that's been quite important over the last increasingly important over the last years. And then lastly, and I think this is particularly useful for your listeners, we have an FAQ section, so we provide answers to the most commonly asked questions. We get a lot of emails, and this covers every. Thing from, for example, are rapid cooling devices safe to is organic formula better than standard formula? How does formula compare to breast milk? So we've got lots of information on that web page, and I guess the last thing to say is the purpose of having this website, like I said, it's meant to be a one stop shop for impartial, evidence based information, but it's also meant to be an alternative to having to go to companies. The issue being that companies don't simply provide information. They're they're trying to sell products. So they're also, you know, it's also, it's always going to be in the context of marketing, meaning it can be hard to get a simple answer to some question. So this is just there, freely accessible for people to look up. It's meant to be used by healthcare professionals working with parents, and that's what it's there for, 

Emma Pickett  05:51

yeah, and it is just the most amazing resource. And it feels to me is that no one else does quite what first steps nutrition does. I mean, you do this quite unique job. I mean, what would you say makes you different from other charities that work in this kind of early feeding space?

Dr Vicky Sibson  06:07

The main thing that sets us apart is that we're fiercely independent, and we have a very stringent conflict of interest policy, which means we're trying to keep ourselves at arm's length from the influence of the baby formula and baby food industry, so that we can offer truly independent advice and information. And unfortunately, that is not the case for a lot of other organizations working in this space. And What's difficult is you can't often see that. So just that's what makes us different, is we, we don't take funding from we don't work with companies. And then in terms of how we work, more specifically, there's two parts to what we do. The first is producing evidence based impartial, independent information about eating well from preconception to age five. Like you said, it covers infant milks specifically because we've perceived a gap there where parents and healthcare professionals need that information, and then also all the eating well guides, so sort of the complimentary feeding and feeding up to age four and eating well in pregnancy as well. So we've got all of that information side of things. And then on the other side, we seek to influence policy to enable all children to eat well from the start of life. So we do advocacy work to try and create, yeah, create this an environment which better enables parents to put into practice what healthcare professionals are telling them to do. So, for example, we do a huge amount of work on trying to call out marketing, and try strength and marketing of formula milk, but also baby foods. So all the all the massive array of products on the baby food aisle, that's just one example, 

Emma Pickett  07:59

yeah, yeah, your eating well guides are just gorgeous to look at. They've got these lovely photographs of serving sizes, and they're incredibly helpful. But if it's okay today, I'd just like to focus on on milk, because that's the main focus of my podcast. So I'm going to ask some really basic questions today. And there are some people listening to this who may already be super familiar with the rules around marketing, and this may all be really old news for them, but I'd like to sort of talk about some of the real simple concepts of that that's all right. So in the UK, we've got so many products available to families, and that's just the, you know, the first formulas, the early formulas, for the first six months. It's such an overwhelming choice, and lots of families, I think, assume that a more expensive product is going to be better for their babies. How do you kind of respond to that assumption?

Dr Vicky Sibson  08:45

Yeah, I mean, I do really feel sorry for parents. We just have this proliferation of products. It feels like there's there's more and more, and the baby food is getting bigger and bigger all the time. There is a common belief that the more expensive the formula, the better it's going to be, sort of, I mean, it's intuitive, it's sort of, we're all subject to marketing. This sort of makes sense, doesn't it? Do you feel like you're getting more for your money if you're spending more? And it's actually a pricing tactic that companies use called premiumization. So what they're doing is they're offering a selection of formula milks, with some more expensive than others. So and what happens is, understandably, parents want what's best for their babies. They are wanting to go for that higher priced option, assuming that it's better. And actually what's really sad is that we know that even when times get tough, that persists. So you know, families, mums might even skip meals because they still want to buy that formula. And it's really unfortunate because actually what's absolutely critical. To know is that infant formula is a really highly regulated product, and the reason is, is because it's the only if you've got a non breastfed baby up to six months of age, that's the only food that they are meant to have to support healthy growth and development. So it's really, really important that it's able to do that, which means that all these infant formulas on the supermarket shelves all must be nutritionally equivalent. There's a very set nutrition composition, by law that they must all meet so that they provide very, very similar levels of energy, fat, protein, and then this really long list of micronutrients. So basically, it's all a mirage that the companies are creating, and because they know that particularly well. We live in a formula feeding culture. A lot of women want to breastfeed. There's very, very complicated. Unfortunately, a lot of women don't meet their breastfeeding goals. Some women choose not to breastfeed. So you've got a lot of formula being used, and so the companies basically are having parents families over a barrel, putting forward these products and trying to basically take advantage of parents. But all first infant formula are nutritionally equivalent, so cheaper, more expensive. It doesn't matter. They're all going to they're all judged to be safe and suitable to support adequate growth and development. So that's sort of the key thing to know. 

Emma Pickett  11:30

Yeah, that that word premiumization, that's, that's a good word, isn't it? That really, kind of, it really taps into those deep emotional feelings about, you know, what good parents do and how, you know, good parents surely would want to spend more money and buying the cheap, supermarket owned brand isn't what good parents do. There's so much profound psychology stuff going on and lots of money being invested into that psychology stuff that we'll talk about in a bit more in a minute. I mean, it was decided quite a long time ago that the formula industry couldn't quite be trusted when it came to policing themselves, and some awful things came to light in the sort of 70s and 80s which led to the establishment of what's known as the the who code, or the World Health Organization code. You know, lots of us in breastfeeding support throw that term around the who code. I don't want to ask you to have to give us a in depth history lesson, because there's lots more to talk about. But, but what is the who code? If you had to kind of give a basic summary, 

Dr Vicky Sibson  12:22

yeah. So the code is an international health policy framework, and what it's meant to do is inform domestic laws. So in short, it's basically like a legal template, and it's a template that's covering the regulation of the marketing of breast milk substitutes. So that's formula milks, bottles and teats. And the idea is it's meant to stop aggressive and inappropriate marketing to protect infant health. And so as you say, it was first developed in 1981 it came out of Yeah, a difficult period in the 70s when nestle in particular, were accused of aggressive marketing of infant formula to women in poor countries where there wasn't clean water and conditions needed to make it up safely, and babies were getting sick and dying, and an investigative report was written about it, and somewhere along the way, this quite shocking headline was used Nestle's killing babies, and it led to a libel suit, and that is what led to the code being developed. So it was developed in 1981 what's quite important to know is that it is kept up to date with the change in context. I mean, it's over 40 years old, and over that time, we've seen a proliferation of products our whole, you know, marketing environment has changed with digital marketing. And, you know, the world changes. So we've got World Health Assembly resolutions, which are passed every two years, which basically create, new provisions to try and make sure that it's relevant to the changing context and can still do what it's meant to be doing. And just to clarify So, it's about protecting infant health. It's about protecting and promoting breastfeeding and ensuring the proper use of formula when necessary. And the words, I think the words I looked these up before talking to you, so I wanted to get it entirely right, the proper use of formula when necessary, on the basis of adequate information and through appropriate marketing and distribution. So it's about protecting breastfeeding, but it's about also enabling parents, for whatever reason, who are using formula to be able to do so safely. 

Emma Pickett  14:39

Yeah, yeah. So it's about all families. It's not just about breastfeeding promotion. I think that's really important. I think a lot of people misunderstand and think it's about undermining formula families, formula using families. And that is not the case at all. Lots of people sort of say, Oh, it's okay. So it was about developing countries. It was about these aggressive practices, you know, people pretending to be doctors and wearing white. Coats and and, you know, giving money to doctors to reduce the breastfeeding in their practices. And you know, these are countries that have not much access to clean water, and you know, maybe high levels of fraud or corruption. We don't need it in the UK. You know, we don't need the protection from Formula companies. We're all much more reasonable. We you know, formula is safer here. Why would you say to somebody it matters in the UK to to have these protections?

Dr Vicky Sibson  15:24

I think it's a really good question. It's important to understand, and it's sort of obvious that breastfeeding is a matter of life or death for many babies in less developed countries, because infectious diseases are more common and clean water and formula may not be available, but we do have evidence that tells us that no matter where a baby is born and raised, breastfeeding still makes a difference difference to their health at the at a population level, so including high income countries like the UK, so we know from research that breastfeeding protects Mothers Against breast and ovarian cancers, and then for babies, it protects them from infections like gastrointestinal infections, respiratory, ear infections. And we know that in the UK, breastfed babies are less likely to be hospitalized with infections than babies who are not breastfed. And we also know that breastfeeding protects against diet related ill health so that includes overweight and obesity, cardiovascular disease, type two diabetes and other things like SIDS, sudden infant death syndrome, leukemia, allergies. So there's a massive list of health benefits for mums, for babies, and that is why the UK public health recommendation is to breastfeed, and that we we have these laws which are meant to protect breastfeeding, including stopping formula companies marketing formula in a way which undermines breastfeeding but also ensures that parents can make informed decisions about how they feed their babies. So yeah, it's important everywhere in the world. That's just, that's what the evidence tells us, 

Emma Pickett  17:03

yeah, yeah. I think that's, that's super important, that message, and as you say, as we'll touch on a bit later on, you know, if a formula, if a family choose to use formula from birth, this is about protecting them too, because if formula companies run rampant, they are not going to get access to the right information. They'll be paying vast amounts of money for marketing. It just, you know, especially with the cost of living crisis still being an issue, it's about protecting every family. So you mentioned it as a kind of legal template. And the idea was, it was sort of like, you know, here's an example of what you might choose to bring into domestic law. And different countries around the world adopted it in different ways. So, so in America, none of it went into domestic law, but in the UK, we took a bit of it. Can you just say a bit more about what UK law says about Formula promotion? 

Dr Vicky Sibson  17:50

Yes, yeah, we do have some provisions of the code in our UK law. So there's actually an independent report that's done every year that outlines, it's called the status of the code, and it covers as many countries as it can in the world, and gives them a score. And the UK score is 40 out of 100 so that's sort of that's the, you know, quantifies and the extent to which the code is in law. And that's why we say some some of the provisions are in law. So some of the detail that's important to know, our law says that infant formula cannot be advertised to the public. Can be advertised to healthcare professionals, but it's meant to be scientific and factual. There's not allowed to be any point of sale advertising or samples or promotions to induce sales. There's not meant to be free or subsidized products as samples or gifts to the public. There's not meant to be health or nutrition claims on product labels. And the labels of different product types, infant formula follow on formula and specialized amounts. They're meant to look different from one another to avoid confusion, and what's called cross promotion. So there's quite strict laws that are governing infant formula marketing, but unfortunately, there are two big issues. The first is they're not enforced properly, so all companies are breaking them routinely. And the second thing is there are quite strict theoretical limits on marketing of infant formula, but not on other formulas. And this is creating a loophole that companies are taking advantage of.

Emma Pickett  19:28

So when you said earlier that we know you can't advertise formula, I bet 100 people just went, hang on. Those are TV adverts. I've seen TV adverts advertising formula with pretty small babies in the arms of somebody being, you know, being formula fed. So what's going on there? Why is that happening?

Dr Vicky Sibson  19:44

Yeah, it's because infant formula, I think you said at the very, very beginning, you've got formula milks marketed. You talked about formula for babies up to six months. Actually, infant formula can be used for the full first year. But to circumvent the laws in the UK, companies invented follow on formula. So follow on formula can be marketed from six to 12 months. There's no restrictions on that. So what companies are doing is taking full advantage of that and and as you were saying, they do things like have pictures of babies that look I mean, there might be six and a half months, there might be seven months, but they look, they look to, you know, the public, just like maybe a five month old. They so they're sort of very, very much stretching the rules, and in doing so, they are very effectively marketing infant formula. They're marketing their brand. And that's, that's sort of really powerful. So, yeah, we've got, we've got a we've got a problem, we've got some laws. The laws are not strict enough. They're not enforced, and that's why we see, yeah, pervasive marketing, which is really sort of messing with parents. It's really undermining self efficacy and breastfeeding, undermining confidence. And also for parents who have chosen to use formula, who are using formula, it's meaning that they're buying really expensive products or products that are not necessary. So it's basically a bit of a mess. 

Emma Pickett  21:21

I mean, I think a lot of people be surprised to hear you say that follow on formula was literally a product invented to get around these advertising restrictions. And genuinely, an 11 and a half month old can have first formula and there's they're not missing out on anything. Some people think, oh, but surely they need, you know, they need more iron. That's why you have to get follow on formula. No, not the case. It's absolutely fine to use that first formula the whole time and and it was invent. There are countries that don't have follow on formula as a product because it wouldn't be able to be advertised anyway. So there will be no point with having the extra cost of introducing a new product. So it really is to get around the advertising rules. What I mean, you've spent a lot of time looking at what formula companies do to kind of get round some of these rules and find loopholes. What are some of the sort of scariest or the most worrying practices you've seen that you know could be seen to undermine a family as a right to have accurate information?

Dr Vicky Sibson  22:10

I think the first thing that springs to mind is the baby clubs. I just think they are. It's just, it's just so aggressive all the formula companies have baby clubs which prospective parents can sign up to, but the way they work, you know they're getting in there at the earliest available opportunity, making use of the way the internet works. So you know what, as soon as I'm as a woman thinks she's pregnant, she'll be Googling her due date, and then she'll pop up. All these ads will pop up and get sucked in, signed into these baby clubs, which are they basically have their own professionals, like midwives and nutritionists who sort of front them and their pose as trusted professionals and friends who are there any time of the day and night. You can, you know, they've got these sort of you can ask a question right now, trying to, well, they acknowledge that it's a really sort of a time of life where you've got loads and loads of questions. It's very, very daunting. And they're there to ask anything you might want to know. You can sign up. They've got blogs, they send emails, and there'll be often about subjects that have nothing to do with feeding babies. Like, bear in mind, these are companies that are selling products to feed babies, but they'll be about diets in pregnancy and massage, you know, exercise in pregnancy. And and it's really, it's just really dodgy, because what they're doing is trying to get across that brand to that parent to get or that prospective parent to to, like I said, get in there and be seen as a friend. And they will advocate for breastfeeding. They'll also be specific content. 

Emma Pickett  24:00

That's a scary bit for me, isn't it, they actually have breastfeeding pages, and I've spent quite a lot of time looking at some of these pages, and one of the things that strikes me is that they present, if you want to breastfeed, you've got to eat super healthily. So they always have photographs of food pyramids and piles of vegetables and oily fish lined up neatly on a little wooden platter. There's just that really subtle, subtle message that, if you're going to breastfeed, Oh, absolutely, we support you, because, you know, as an accompany, we support breastfeeding, and it's even written on our tins. But are you going to be good enough to breastfeed? Are you going to be perfect enough? Are you going to nicely the perfect day?

Dr Vicky Sibson  24:35

They're trying to make out like, it's, it's so subtle, and it's and it's, yeah, it's so wrong, and they sort of instilling this doubt from the beginning. So you do have, you know, it's not surprising we have this pervasive misunderstanding that, you know, what women eat and directly affects the quality and the quantity of their breast milk, and a really low level of understanding that actually, our bodies work in an amazing way. And. Um, so that, yes, you should try and eat healthily, as we should all do, regardless of whether we're pregnant or not, but your body will still produce nearly all the time enough, um, breast milk for your baby. Yeah. I mean, that's, that's, that's one of one example I've got. I was thinking about other examples too, other than the baby clubs. And so a lot of people listening might have heard of Emma's diary. So it's a commercial scheme to support new mums. And certainly, when I had my babies, I was given the Emma's diary gift pack from my midwife, and it includes like, samples of things like pseudo cream and and washing fairy washing up liquid and lots. And, you know, washing powder for the for the washing machine. But this actually has formula sponsorship, and they're giving out information on formula which is not accurate at all. So that's that's really problematic is, you know, a way that they're sort of getting in, in there with new parents. And then we've also talked about, a little bit about marketing, a follow on formula. And there's also growing up milks, the formulas that are marketed from one year and up. And yeah, you were talking about how it says you added iron, and that's that's entirely true. On the labels. It says vitamins ACD, iron they're marketing. It is a good way to ensure baby gets all the nutrients they need. And for growing up, milks, the clues in the name growing up. These are used by over a third of families with 12 to 18 months old. And the marketing we've been looking into this recently, it really speaks to parents anxiety about fussy eating. So it's really common for fussy eating to start in the second year of life, and the marketing is all about you know, these products are really just as such a useful safety net. Don't worry if your child's PC and get all the nutrients they need from this really expensive, unnecessary, sugary formula milk. And of course, you know, breastfeeding is recommended that it continues into the second year and beyond. So it's, it's a problem. It's undermining. It's sort of change. It's changing social norms and undermining, undermining breastfeeding.

Emma Pickett  27:11

A little advert just to say that you can buy my four books online. You've Got It In You, a positive guide to breastfeeding is 99p as an e book, and that's aimed at expectant and new parents. The Breast Book published by Pinter Martin is a guide for nine to 14 year olds, and it's a puberty book that puts the emphasis on breasts, which I think is very much needed. And my last two books are about supporting breastfeeding beyond six months and supporting the transition from breastfeeding. For a 10% discount on the last two, go to Jessica Kingsley Press. That's uk.jkp.com and use the code MMPE10, Makes Milk Pickett Emma 10. Thanks. 

Emma Pickett  27:58

Would you support the UK adopting the whole of the who code. I'm not sure that's realistically going to be happening anytime soon, the way that the formula companies seem to have political sway, but, but I know some countries have adopted the whole of the who code. Do you think that's something that we should do in the UK? 

Dr Vicky Sibson  28:13

That is something that we have long advocated for, and we will, we'll continue to do that. So about loan lined, what the code is designed to do, and the problems that arise from the fact that we've only got some of the provisions of the code, it really creates a problem. So it really is quite important to see the code as a minimum package as a whole. So our view is, yes, our we our laws, should be upgraded to reflect the code and resolutions as a minimum they need to be enforced, and this, like we've been talking about, this would be beneficial for all babies that would protect breastfeeding and safe and appropriate formula feeding. And what's really important to know also is that research has shown that the stronger domestic policies are in line with the code, the higher the prevalence of exclusive breastfeeding in those countries. So it does seem like a very like a long shot, but we will, we will continue advocating for it, and it's also important in light of the fact that we know that most women in the UK want to breastfeed, and 80% say they stopped breastfeed before they wanted to. And this is at least in part because their efforts are being undermined by the formula industry's aggressive marketing. So there's lots of good reasons why the code being implemented would be important. And yeah, we'll keep advocating for that. 

Emma Pickett  29:39

Yeah, I think some people who are choosing to use formula from birth, or have, you know, moved on more happily, are sort of angry about some bits of the code. They sort of say that they're almost being demonized for formula feeding when they, you know, they go into supermarkets and they're not allowed to use, you know, Club points, or they're not allowed to use vouchers. Or, you know, formula. Milk can't be put in the sort of, you know, sales section. Why are some of those details part of the protections? Why do they matter? 

Dr Vicky Sibson  30:09

So this comes back to the fact that there's not meant to be inducements sales inducements for infant formula. So that's a provision of the code, and it's also in the UK law. So I mean a price promotion on infant formula is a really clear example. I mean, everyone gets that, like, buy one, get one. Half price would be a sales promotion or a reduction. And, you know, short term reduction, because whatever the commodity, we know that, though, that marketing works and it makes people buy these products or buy more of these products. So that's a really clear example. And then we know that if families are induced to buy formula or more formula, and when they wouldn't have done because of this on sale, that will undermine breastfeeding, because it's evidence that supplementation with formula in a breastfeed breastbed Baby reduces breast milk supply and hastens the cessation of breastfeeding. So that's, you know, that's how that works. But the whole, like loyalty scheme, points and vouchers issue is quite a lot more complicated. So if we break it down, getting points for buying infant formula is a clear inducement, you know, you know that, let's say they said, Oh, you're going to get a massive amount, like, 150 points. That translates into, you know, massive amount. It's clearly going to that would work to make people buy infant formula, but the redemption of points accrued from other shopping is not necessarily so you've got to sort of look into it. And the issue is that all the schemes work differently. And the bottom line is it's the retailer's legal obligation to ensure that, however their scheme works, it doesn't induce infant formula purchase. So there's different people involved here, like different actors, and yeah, there's a need to break it down and look at the these things in detail. The voucher side of things is also unclear, and the media doesn't help in this. The media has been reporting on this concept of Food Bank vouchers, but as far as we understand these don't exist as our understanding that food banks give store cards and then store cards allow these to be redeemed, some stores allow them to be redeemed on infant formula, and some don't. And as for the whole issue of the redemption of loyalty points. It's the retailer's legal obligation to ensure that, however their scheme works, it doesn't induce infant formula purchase. But I mean, with I think we do need to take a big step back, because what's really important to remember in all of this debate about marketing restrictions is they're not meant to hinder accessibility to formula for families that need it, they are about stopping inappropriate marketing, which undermines breastfeeding and safe and appropriate formula feeding. So that's what's really important to know. No one's trying to stop infant formula being accessible, and the laws are not the laws aren't written in that way, and the code isn't written in that way, and it's up to those. Is up to retailers selling these products to understand the law and implement it in a way which, yeah, doesn't makes formula, infant formula available, but doesn't induce sales.

Emma Pickett  33:15

Yeah, I think a lot of the focus on, you know, vouchers and loyalty points, etc, is a big smoke screen away from the fact that these products are so highly priced, you know, the bad the bad guys become the, you know, the pro breastfeeding fanatics. We're trying to stop people using their points rather than the company that charges an enormous amount of money for a product that's gone up, you know, 30, 40% in X number of years. And one of the things I know that the you know, first steps nutrition does is really talk a lot about cost and what's fair for families. And, you know, in your, you know, infant milk reports, you talk a lot about costing. And, you know, let's compare this to this and, and you're involved with the, the A PPGs work on, on costing. You know, why does it matter so much to talk about pricing with infant formula, and what's been going on there? 

Dr Vicky Sibson  33:59

Yeah, you're, you're precisely right. The the some of these issues are total red herrings. The if people are worried about how they access formula and wanting to, you know, looking for deals, and why should they be looking for deals on a product that they need to feed their baby? The formula should be cheaper, cheap enough, affordable enough, or at all times so that they can access it if they need it. And it is because of that that more than 10 years ago, we started looking at the price of infant formula, and well, a range of formula milks. And back then, even back then, we were worried about how high prices were and the extent to which for some infant formula might not be affordable. So in 2018 we led an inquiry for the all party parliamentary group on incompeting and inequalities into infant formula prices, and we at that time, highlighted how high the prices were and the risks this posed. And then fast forward and. And in 2021 2022 2023 our routine cost monitoring data has really come into its own, because this has been the, you know, the period of the cost of living crisis, and the high prices became even more of an issue, not only because they were high in the first place, but also what we found looking at the data was that companies were profiteering. They were taking advantage of this this period to push up their prices. Um, knowing that you can't stop buying it if you need it. You know, it's an essential product for families that are using formula. And this was confirmed by the government watchdog called the, it's called, The Competition and Markets Authority and an investigation last November, and that that investigation relied on our data, it got massive media coverage, and companies have started to react. So some companies have brought down some of their prices a little bit, which has been a step in the right direction, but not enough. But the good news is that that and that investigation last year was infant formula was just one commodity in 10 that the the competition and market authority were looking at. And having taken that initial look at infant formula, they realized how complicated this was and how serious it was, and so they've been spending this year doing a comprehensive, what they called a market survey looking at infant formula, but also in the context of other formulas for sale, because it's all interrelated. The marketing, as we were talking about, you need to understand how follow on formula and specialized milks are being marketed, and they're going to report on this in October, so we'll see what happens. It's only around the corner, and we've inputted into this extensively, and one of the things we've been pushing all along, and that we hope will be understood, is that we actually need our viewers. We need stronger regulations on the marketing formula in line with the code to try and address the high prices, amongst amongst other actions, but stronger regulations on marketing we think would make a difference. Another example of something that we would, we really think would make a difference would be plain labeling of infant formula within the NHS, because companies really take advantage of this is, you know, a captive audience and the maternity ward and the black the brand loyalty that parents show to to infant formula. 

Emma Pickett  37:27

This episode will be going out in October, so we'll, we'll see whether it coincides with the report, and I'll make sure I talk about that in social media when I, when I promote the episode. So in summary, some people will be saying, well, hang on, don't you want it to be more expensive? Don't you want to? You know, isn't that protecting breastfeeding to make it more expensive? But that's not what it's about. We actually, we just want to remove, you know, we want to remove the sexiness of the advertising around formula. We don't want someone to walk into a, you know, someone who's combination feeding, to walk into a supermarket say, oh, you know, buy one, get one free, because that's what's undermining breastfeeding. But if someone is using formula with the right support, with the right information, day in, day out. You know, they deserve to have a product that is priced fairly Absolutely. And nobody who's advocating for breastfeeding is going to say, oh, yeah, make it more expensive. If, actually, in fact, if you listen to us, we're talking about, you know, National Milk and the government creating their own formula milk and removing companies from it entirely, and making it as absolutely cheap as possible. Cheap as possible. It's about having a product available that isn't manipulating parents and isn't causing parents more harm by laying on emotions and and, you know, using all those tactics that they spend billions of pounds using. It's taken a bit of time for sort of the digital marketing bit to catch up. I think social media sort of took people by surprise. And you know, even this weekend, we've had people who claim to be breastfeeding supportive on Instagram, obviously taking money from companies they shouldn't be taking money from. I know there's been discussion around that in the World Health Assembly around tightening that up. What's where are we at the moment with that?

Dr Vicky Sibson  38:57

Yes. So it's my colleague Katie, who's been doing a lot of work on this. So, yeah, the situation is like for, you know, our life in general, and everything digital marketing has really been evolving massively over recent years, and that's affecting formula and formula marketing, and it's so fast that the regulations don't seem to be able to keep pace, because it takes a long time to to change regulations, and the whole process is inherently slow. But what happened was, in 2020 the World Health Assembly asked for a report on the scope and impact of digital marketing of breastmont substitutes, and then this was published by the WHO in 2022 and then, as a result, the World Health Assembly asked for recommendations on regulatory measures to address the problem, and they were published last year in November. And yeah, Katie, my colleague, contributed to that, and we also made a submission to the whole consultation process. And we had hoped for a new resolution to be passed in 2024 so, you know, talked about this, the WHA resolutions, which keep the code up to date. So we'd hoped that there'd be a new resolution, and this would make it into the code, and the code would encompass digital marketing. Unfortunately, that's been pushed back to 2025 but basically, it's all in progress. And you know, what's also worth noting? It would be great, and we will sure at some point in the future, we will have a World Health Assembly Resolution which covers digital marketing, but member states can take forward the recommendations without that happening. So you know, if the UK Government wanted to, we could have stronger laws that address digital marketing without that resolution. Resolution, it's just that if the resolution is passed, and it's sort of, you know, something we can advocate for. And so that's where we're at, and there's a way to go. But, you know, through this process of investigating and reporting and recommendation setting, we sort of know more that what needs to be done, and now it's trying to get those recommendations put into practice. 

Emma Pickett  41:03

Yeah, but if today, someone's looking on their Facebook group and they see someone talking about a particular product that's first formula for under six month old, and someone is promoting that, that would be breaking a UK law, and they could take action against that. What? What is that? Is that right? And what could someone do if they see something online or in the real world that they know is breaking UK law? What's the next step they could take? 

Dr Vicky Sibson  41:28

So the formal process is to report to trading standards, and typically you do that through going through your local Citizens Advice Bureau. So any member of the public can do that. And what is quite important, you've got to follow the formal process if you hope for there to be formal action. So I would recommend anyone to do that. It doesn't take very long. And actually, the more people that could do that, the more you basically sends this indication that there is a problem. So that's the that's what could be done. And, I mean, unfortunately, we know that that a lot of the time things, it doesn't change things, but that is the process that you're meant to follow. And the more that, more we could do that, the more we might see action. If the code is being broken, it's a bit different, because the code is not in UK law, so no action will be taken. 

Emma Pickett  42:17

Yeah, so someone's talking about bottles or teats on Instagram, that's, you know, and even if there's breast milk in it, technically, the code does cover promotion of bottles and teats as well.

Dr Vicky Sibson  42:27

You can report that to Baby Milk Action. So some people might be familiar with baby milk action, or you can Google it. And again, that's that would be useful to keeping abreast of the issue and having Yeah, information, having examples to put forward in our in our advocacy work,

Emma Pickett  42:47

yeah. I mean, the thing about bottles is, obviously, you know, as a lactation consultant, the vast majority of people I work with use use bottles. And it's a bit like the conversation around formula, the more expensive bottles are seen as the better ones, and they're the ones that can often pay influencers and get access to people's Instagram feeds, but actually often for breastfeeding babies, or even not breastfeeding babies, it's the bog standard bottle that is cheaper, easier to get hold of, easier to find replacement teats. You know, those are the ones that are going to work for families, not the crazily expensive one that's this, you know, fancy color that costs x amount of money and you can never get another tea unless you another T unless you get it shipped from or Oregon or whatever I mean. So that's also about protecting families, even though it might seem like we're restricting information about bottles, it's actually about not letting the more expensive products dominate that conversation and and mislead families.

Emma Pickett  43:36

Okay, let's take a pause in the conversation around promotion. I want to ask you a question about cow's milk, because there was a bit of a chat going on online about how, oh, there's this new thing. Have you seen that says, you know, you can give cow's milk as a main drink under 12 months, whereas we've always said in the UK, you know, it's not safe as a main drink under 12 months. You really have to wait till your baby's a year old before they have cow's milk as their main drink. Has there been a change around that? What's going on there with that conversation?

Dr Vicky Sibson  44:05

So that's a really interesting one. And what happened last year was that the who issued updated updated guidance on complementary feeding, and it restated their recommendation at a global level, that animal milk can be given to non breast fed babies from six to 11 months. You know, it's an either or animal milk or formula milk, particularly if there's no infant formula available or it's not safe to make up. So this is, it's not a new recommendation, it's a global recommendation. But it's sort of there was this flurry activity because the guidelines were updated and it was sort of restated. And like you said, there's been a fair amount of interest in this in the UK, largely because giving cows milk instead of infant formula would be a lot cheaper in our current context. And this is really. Quite complicated. I think the issue is that there are potential benefits and harms of infant formula versus cow's milk from six to 11 months, depending on the context. I mean, that's the that's the critical thing. And in this, in the process that the who went through to restate this recommendation, they looked at what they call domains in that need to be considered in context, values and preferences, resources, cost, effectiveness and acceptability and feasibility. So there's, there's a lot to unpack there, and we think it would be great if this could be explored for the UK. And we've actually asked the Scientific Advisory Committee on nutrition, who advises the government to look into it. But at the same time, we've also flagged the importance of considering any unintended effects on breastfeeding if they change the messages, and the messages get interpreted. So if there was a change in guidance, what you would you know, there's some sort of potential fear there that cow's milk gets used before six months, which would be really harmful, potentially harmful, or that some women switch to cow's milk from breastfeeding because they find it easier. But remember, this is not about cow's milk versus breastfeeding. This is about cow's milk as a potential alternative to infant formula. So the bottom line, what we've been saying as first steps is for now, we believe it's important to make clear that the current UK recommendations have not changed, that for non breastfed, partially breastfed babies from six to 12 months old, infant formula should be given as the main milk drink. But we are. We really do hope that this is looked into and we'll see, and maybe at some point this guidance will change. But it's quite important, because parents need to have consistent information. We don't want mixed messages that this is the current government guidance. 

Emma Pickett  46:50

Yeah, the current guidance was about, you know, the risk of anemia maybe for just drinking cow's milk. So when you just drink cow's milk, it does potentially increase anemia, and the protein levels might not be quite as appropriate for younger babies. Is that right? 

Dr Vicky Sibson  47:03

That's right. So that's when we talk about benefits and harms. The harms, the concern Yeah, is about iron. Yeah, they get weight. They need to get weighed up in in different contexts. And currently, the position still is that yeah, cow milk is inappropriate, largely because of the iron levels,

Emma Pickett  47:21

but as you said, more information needed on that. But I know the cost of living crisis, especially when families are quite angry about how formula companies are behaving, very tempting to just go and buy your friendly cow's milk and something that you already probably have in your house, but we need to hold off, I think, until we get more information and we understand you know what the issues are in the UK. Okay, so if I could wave my magic wand and I could put you in a room with sort of some important UK politicians, let you probably are in rooms with important UK politicians, but, but if you were able to sort of tap into somebody and give them a sort of little bit of a mini Matrix download, what would you want them to know about infant milks and infant feeding in the UK. 

Dr Vicky Sibson  48:04

So I think what I would want to get across, because I think it's you sort of see what politicians have quoted as saying in the press, and they really need to understand and think about infant formula as a very unique product. Infant formula is highly regulated. Is a highly regulated food. It's essential for some babies who, for whatever reason, cannot be breastfed, and it needs to be accessible, it needs to be affordable. But because it's a unique product, the way that it's marketed really needs to be very tightly controlled to protect babies. You know, there's a distinction. So the product, the user, the marketing, it can and should all be looked at separately, and the focus needs to be on clamping down on company profiteering and inappropriate marketing. So it's really important for politicians to take on board that criticisms of formula company marketing is not criticisms of formula. It's not critical, you know, it's not criticisms of formula, or families that use formula, but the marketing and the prices need to be, need to be, action needs to be taken on them, so that babies can be the babies that are being fed formula. Can, can, can receive the formula that they need and that their parents can, can access that in a reliable fashion and not be spending more than they should and having anxiety about, yeah, not being able to feed their baby properly in the current context.

Emma Pickett  49:37

Yeah, yeah. Three cheers for that. I think, I think your dog also supports that view. I can hear in the background as well. Yeah. I mean, I think one of the things that we, I would probably say, is, if you ever see a newspaper article that says, Oh, the these evil, you know, marketing restrictions and these, you know, the fact we can't use vouchers, and it's, I know, everyone's clamping down on formula, you know. And if anyone writes an article that gives you. The impression that formula users are being demonized. Don't be don't be sucked in by that someone is behind that message. Some very powerful companies making an enormous amount of money, are trying incredibly hard to twist this conversation to make it seem like an organization like first step nutrition is anti formula, when that is the last thing anyone could pin on your organization. You were working so hard to support formula feeding families. And someone who supports the Who Code, oh, the anti formula, absolutely not true. It's about protecting all families. And if someone is giving you the wrong impression, think about where that is coming from. And as you say, they may not be have they may not have the logo of a formula company on their website. There's three or four layers where it's being filtered through. So they're a foundation, or they're this particular, you know, think tank, or this particular organization formula companies are very clever at hiding, and they will hide behind different different organizations and different groups. You know, we shouldn't be sucked in by this. We need to make sure we do protect families. So let's imagine we're talking to someone listening to this, who's going to buy their first Potter formula, their first counter formula, at some point in the next few days, they're going into that supermarket. They're really overwhelmed by all the products on the shelves. What do you want them to think about when they're making that choice?

Dr Vicky Sibson  51:15

I've got a few key messages. Firstly, for a healthy baby, any first infant formula will be fine, and you can go for one that's based on cow's milk or goat's milk. Cheap is fine, as they're all safe and suitable. So you you know, don't even really need to look at the price tag if you know all the first infant formulas are a nutritionally equivalent. And then a few things to avoid, avoid hungry baby formula and avoid Sawyer formula. They're technically first infant formula, but hungry baby formula isn't proven to work, and Sawyer formula should only be used from six months of age and only under medical supervision. The other thing is, there'll be other formulas or other formula milks on the shelves, and on the label, it will say, use under medical supervision might be really, really small letters. The types of products that that that say that are comfort milks, lactose free, anti reflux. The really important thing about all of these if, even if it's on the supermarket shelf, you can, you can just buy it there without any advice. If it says, Use under medical supervision, it really is meant to be used under medical supervision. So it may be good for your baby, if your baby has a specific problem, but you need to take advice of a health professional, and they can support you to use that noting actually that comfort milks aren't evidence based. So it's, you know, it's a bit of a minefield. The main thing to know is that for healthy babies, any first infant formula will be fine, yeah.

Emma Pickett  52:45

And what you said about goat's milk and soy milk's really important. I think goat's milk, there's no evidence that goat's milk is gentler or better or different or less allergenic. I mean, we, you know, babies react to goat's milk too. And Sawyer, I think some people are surprised about that. I think some vegan families are surprised to hear that, and they think, you know, we want to reduce our child's access to cow's milk as much as we can. Why is there that recommendation around not you giving soy milk to young babies?

Dr Vicky Sibson  53:13

Soya milk contains phytoestrogens, and the phytoestrogens are there's a risk that they may affect reproductive development of the growing baby. It's a very small risk. But the the, you know, the public health advice that is not used, the view, is that it's, it's a risk that's worth avoiding. Okay, that's why they say don't use it, except maybe inserting conditions from six to 12 months, and then it can be discussed with the prescribing healthcare professional.

Emma Pickett  53:47

Yeah, and those formulas aren't vegan anyway, because they have vitamin D from sheep's wool and fish oils and things. So we don't actually have a vegan formula in the UK.

Dr Vicky Sibson  53:56

We don't have a vegan formula in the UK. So the important thing is, you know, encouraging women and supporting women to understand that breastfeeding is, you know, the best for their baby if they can, and if they want to use a formula, then, you know, at the moment, the only safe alternatives are not vegan. So I think it's about putting off, if you wanted to raise your child as a vegan, doing so until they don't, you know, after one when they don't need formula anymore. But you've got to be really, really careful what you're doing there to ensure that your baby gets all the nutrients that they need to grow and develop healthy. 

Emma Pickett  54:36

Yeah, one of your Eating Well Guides, which I like, is that is the one for vegan families. So people can go and find that on your on your website. Thank you very much, Vicky for letting me look into your brain for a little bit of time. I know there's a lot in there, and we could have talked about lots of different things, but I am really grateful for all your your help today and and people can find the first steps nutrition Trust website, I'll put that in the show notes. I'll put the infant milk info. Dot org website in the show notes as well. And you know, people know where to find you to get more accurate information. Thank you for all your work. I mention first steps every week, at least several times, and I'm just really, really grateful. Thank you very much for everything, Vicky. 

Dr Vicky Sibson  55:14

Thanks, Emma, great to talk to you.

Emma Pickett  55:20

Thank you for joining me today. You can find me on Instagram at Emma Pickett IBCLC and on Twitter @MakesMilk. It would be lovely if you subscribed because that helps other people to know I exist. And leaving a review would be great as well. Get in touch if you would like to join me to share your feeding or weaning journey, or if you have any ideas for topics to include in the podcast. This podcast is produced by the lovely Emily Crosby Media.