The debate about the value of the BMJ comment piece rages on, with misleading stories and headlines falsely implying that breastfeeding is a risk to health and that the UK guidance is a rigid dictate to mothers forbidding any food other than breastmilk until the clock strikes midnight at the end of the 6th month. Since some of the media are also questioning whether the links between the authors and the baby food industry are relevant, I thought it might be helpful to explain our concerns about the paper, its timing and the authors' knowledge of the risks of media reporting.
First can I say that I acknowledge that the authors of the comment have published many good studies on infant feeding - indeed we quote from one recent one in our briefing on DHA fortified formulas (http://info.babymilkaction.org/node/265). We also accept that they may have genuine concerns about the duration of breastfeeding and agree with them that genuine scientific debate should never be stifled. However, as WHO and many other experts have commented, this is not a systematic review but the authors' personal interpretation of selected data, so it is of limited value. If the authors genuinely care about child health I hope they will be proactive in correcting the many misrepresentations about breastfeeding and the nature of the review that are circulating the world's media, and doing so much harm.
In relation to the conflicts of interest it is important to remember that the full Declaration of Interest made by the authors is only available on request, so the published declaration is not really informative. But I know that one of the authors, Prof Lucas, has a long history of extensive ‘involvement’ with the baby food industry and, for example, chaired the Advisory Group of INFORM, the industry's lobbying body. In 2003 I questioned Prof Lucas directly about his funding because he had decided to defend SMA Wyeth's illegal advertising in Court. To me he confirmed that although his research was now predominently publicly funded, until recently the majority of his funds came from baby food manufacturers. Interestingly he did not mention funding in Court until questioned by the prosecution, answering that 70% came from sources other than the Medical Research Council with more than half of the 70% coming from industry. In court he denied that he was funded by SMA and described his research relationship with the company as “symbiotic.”
Secondly, infant feeding is on the agenda of three important meetings this week: The World Health Assembly's Executive Board meeting in Geneva (which am am attending); the UK Scientific Committee on Nutrition (SACN) in London and the launch of the US Surgeon General's Call to Action to Support Breastfeeding in Washington DC.
This reminded me of how, in 2001, media coverage of another paper - again authored by Prof Lucas and others - could have derailed an important global health policy. At that time Brazil was proposing a new World Health Assembly Resolution to reinforce the 1994 Resolution which had recommended the introduction of complementary feeding at around 6 months. The draft Resolution recommended exclusive breastfeeding for 6 months, a position supported by the report of a systematic review of over 3000 studies by a WHO Expert Committee, published in March 2001. (1) The industry was trying to undermine the Resolution because labelling foods as suitable from 4 months (or even younger) is important from a marketing point of view: the introduction of solid foods before 6 months generally requires feeding purees and paps. If parents get the message that exclusive breastfeeding is all the baby needs and that ideally they should wait until the baby is developmentally ready to join in eating healthy family foods, they will be far less likely to rush out and buy processed foods. So - less profits for industry.
Two weeks before the Systematic Review was published, the Lucas study - which aimed to test a hypothesis that "duration of breast feeding is related to changes in vascular function relevant to the development of cardiovascular disease" - was published in the BMJ alongside 2 press releases and a leader article. It received worldwide media coverage including at least 5 reports in India the following day - with many headlines suggesting that breastfeeding after 4 months actually causes heart disease. From comments posted to UK discussion groups, we know that many women stopped breastfeeding immediately. (2, 3)
Certain salient points failed to appear in either the summary or the press releases and few read the actual text which stated: "We emphasise that our observational data do not establish a causal relation between length of breastfeeding and cardiovascular disease." Also, because the study relied on mothers' recall from 20-30 years earlier, there was no direct record of feeding method or duration. Despite this, the text specifically referred to participants as being 'exclusively breast fed.' A strange finding for the early 1970s and 80s when hardly anyone was talking about exclusive breastfeeding.
Thankfully, common sense prevailed and a strong Resolution was eventually passed in May 2001 (WHA 54.2) after over 15 hours of debate, with a recommendation for policy makers (not a dictat to mothers) about the importance of exclusive breastfeeding for six months and continued breastfeeding alongside appropriate complementary feeding for two years and beyond. Since then over 70 countries have adopted the six month recommendation as policy.
Specifically the Resolution urged Member States to: "strengthen activities and develop new approaches to protect, promote and support exclusive breastfeeding for six months as a global public health recommendation, taking into account the findings of the WHO expert consultation on optimal duration of exclusive breastfeeding,1 and to provide safe and appropriate complementary foods, with continued breastfeeding for up to two years of age or beyond, emphasizing channels of social dissemination of these concepts in order to lead communities to adhere to these practices..... to improve complementary foods and feeding practices by ensuring sound and culture- specific nutrition counselling to mothers of young children, recommending the widest possible use of indigenous nutrient-rich foodstuffs; and to give priority to the development and dissemination of guidelines on nutrition of children under two years of age, to the training of health workers and community leaders on this subject, and to the integration of these messages into strategies for health and nutrition information, education and communication." 1 As formulated in the conclusions and recommendations of the expert consultation (Geneva, 28 to 30 March 2001) that completed the systematic review of the optimal duration of exclusive breastfeeding (see document A54/INF.DOC./4).
So I ask readers - are the links between the authors of the new BMJ study and the baby food industry relevant or not?
1 The optimal duration of exclusive breastfeeding - Report of an expert consultation
2 Duration of breastfeeding and arterial distensibility in early adult life: population based study, BMJ, Vol. 322, (643- 647) Leeson et al, (2001) www.bmj.com/content/322/7287/643.full
3 BBC report on the Heart disease study: http://news.bbc.co.uk/2/hi/health/1222311.stm
4 2001 WHA Resolution on Infant and young child nutrition (WHA 54.2 )
5 Rapid responses posted on the BMJ website can be found here:
6 WHO's statement,Exclusive breastfeeding for six months best for babies everywhere, 15 January 2011 is available in several languages on the WHO website: www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/index.html
Other links to Baby Milk Action reports about Prof Lucas are here;