Promoting Breastfeeding and Interaction of Paediatric Associations with Commercial Providers of Nutritional Products: Are They Compatible?

Paediatric associations have been urged not to interact with and not to accept sponsorship from commercial manufacturers of breast-milk substitutes (BMSs), based on the assumption that such interaction would lead to diminished promotion of and support for breastfeeding [1, 2, 2]. Seven European Paediatric Associations previously shared their joint position on supporting fully transparent interaction with providers of nutritional products, based on current scientific, societal, and ethical standards [3], to facilitate providing paediatricians with the information needed to “fulfill their essential role in providing parents and other caregivers with information and support on optimal infant and young child feeding practices” [4].

In September 2022, Peter Liese, MD, MEP (European People’s Party), in collaboration with the European Academy of Paediatrics (EAP), invited stakeholders representing several paediatric national and European associations, the World Health Organisation (WHO) Regional Office for Europe, parent representatives, and the dietetic industry to a workshop held at the European Parliament Brussels to discuss these controversial issues. This initiative was also supported by Manuel Pizarro, MD, MEP (Socialists and Democrats), and Andreas Glück, MD, MEP (Renew Europe).

In his opening statement, Dr. Liese emphasized that a dialogue between commercial actors providing products used in health care and health care professionals (HCPs) was essential to enable HCPs to deliver the best services possible to their patients based on up-to-date information. He referred to the experience in the COVID-19 pandemic, where collaboration of industry, HCPs, and public bodies was essential in fighting the infection. He emphasized that public-private collaboration is also important to address and resolve problems such as inappropriate marketing activities. Dr. Liese said, “The question is not if, but how paediatricians and companies should interact.” Dr. Pizarro, who shortly after this workshop at the European Parliament was appointed as Minister of Health of Portugal, emphasized that breastfeeding rates in the European Union are not satisfactory and need to be improved. Paediatricians would have an important role and responsibility in supporting and improving breastfeeding practices and in helping to end inappropriate BMS marketing that can undermine breastfeeding, in particular rapidly expanding direct digital marketing to consumers.

The European Region of the WHO, comprising 53 countries, has the lowest rate of exclusive breastfeeding for 6 months among all the world’s WHO regions, said Dr. Martin W. Weber, WHO Europe. In his view, marketing of BMSs is an important contributing factor, but the implementation of the International Code of Marketing of Breast-Milk Substitutes adopted in 1981 [5] and subsequently updated, remains patchy, and enforcement is weak. Digital marketing through multiple online channels and social media platforms has become the dominant form of BMS promotion, responsible for >80% of exposure to BMS advertisements in some countries. Companies are able to access consumers by paying for social media and influencers, as well as using apps, online baby clubs, and other digital platforms. He concluded that digital marketing can evade scrutiny from enforcement agencies and requires tighter regulatory approaches.

Prof. Berthold Koletzko, representing the EAP, indicated the strong commitment of paediatricians and their associations to promote, support, and protect breastfeeding and their view that commonly applied, unacceptable consumer marketing activities for BMSs need to be ended. However, a unique focus on this issue alone would not suffice; other important factors with influence on breastfeeding success such as offering timely and sufficient breastfeeding counselling and support, adequate maternity leave conditions, socio-cultural aspects, and others also require attention. The paediatric associations stress the assumption of WHO that interaction of paediatricians and their organisations with companies providing BMSs would undermine support for breastfeeding and “compromise patient care” [2], which is not supported by accountable evidence. On the contrary, European paediatric organisations accepting support from commercial actors at the same time have taken strong positions against marketing activities that are considered inappropriate 6‒9. The great majority of paediatric national and subspeciality associations in Europe favour transparent interaction with commercial actors from a variety of sectors, including the dietetic industry [3]. Paediatricians need to use commercial products and services for patient care and require up-to-date information on available options and their properties. Professional conferences provide an appropriate platform for transparent and appropriate interaction of paediatricians and other HCPs with commercial providers of products and services for diagnostics, therapeutics, and prevention from all sectors, e.g., pharmaceutical, vaccine, medical device, and dietetic industries. Professional and ethical standards need to be strictly followed, and robust procedures must be established to mitigate risks of inappropriate behaviour, while establishing full transparency with regards to interactions with all industry sectors [10]. Setting different rules and standards for pharmaceutical, medical device or dietetic industries, or for different groups of HCPs, is not justified. In line with other biomedical associations [10], paediatric organisations demand that medical education should not be influenced by commercial interests in products and services but offered in an unbiased form by medical-scientific societies, professional organisations, governmental, or public bodies.

Silke Mader, parent organisation European Foundation for the Care of Newborn Infants, explained that more opportunities for breastfeeding must be given, while at the same time, active support for mothers who cannot or do not want to breastfeed is essential. She gave a very personal account of having been discriminated against for her inability to breastfeed her prematurely born baby after the other twin sibling died, even to the point where she was given the feeling that she was a bad mother. She emphasized that the need for knowledge exchange between different stakeholders is evident and that families must be given a voice in these discussions. Some babies require specialised nutrition, and their mothers need adequate information regarding substitutes, which well-trained medical professionals should provide. Parents expect their paediatricians to have up-to-date knowledge on available products and to be able to advise them, and they want their paediatricians to be well informed about the available offer of drugs, devices, and dietary products.

Prof. Udo Herz, representing the industry association Specialised Nutrition Europe, pointed out that when breastfeeding is not possible or chosen, infant formula provides the only safe alternative option. In this situation, healthcare professionals need unrestricted access to information about the latest innovations in BMSs. Prof. Herz defended the position that companies can support conferences and congresses under transparent and appropriate conditions, and there should be no limits on private providers’ support for sharing factual and scientific information on their products to HCPs. It was noted that the WHO staff does not necessarily consider the act of selling or hiring exhibition space at a conference to BMS providers as sponsorship [2], given that the International Code of Marketing of Breast-Milk Substitutes permits companies to provide health workers with scientific and factual information on their products [5].

A very lively discussion followed where country experiences and best practices were also shared. There was broad consensus among the attending representatives of national and European paediatric associations as well as parent representatives with respect to supporting public-private collaboration governed by detailed codes of conduct (e.g., 10‒12). At the end of the session, the panel members concluded that continued exchange and collaboration are needed to achieve progress and solutions that are impactful through the broad support of the relevant stakeholders.