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Formula Companies and Free Gifts
SECOND OPINION
COORDINATED BY
KATHLEEN RICE SIMPSON, PHD,RNC, FAAN
This article originally
appeared in the MCN AM JNL MAT/CHLD NSG 1999:24 (3) : 119
Internet permission to
display this article granted by LLW
Should Nurses Offer Discharge Formula
Samples to
Women Who Plan to Breastfeed?
PRO
CON
Many health professionals today would say
they support breastfeeding yet our actions speak louder than words. What
message do we send to consumers of health care when we, the health care
professional, distribute free formula to patients during their prenatal
course, hospitalization and upon discharge? The US health care system is
fraught with promotion of infant formula, a practice that needs to be
discontinued.
Some believe that it is a wonderful idea to be able to give free samples of
formula, literature and gifts to consumers of obstetrical health care,
including literature produced by formula companies on breastfeeding. One
might be tempted to look at the quality of the brochure or pamphlet only.
However, there is a larger principle present that "free" materials
aren't really free at all. Who pays the author, artist, printer etc to
develop these materials? Certainly not breastfeeding women. The answer is
the people who buy the products from the formula company. Mothers who don't
breastfeed, either because they don't want to, can't, won't or shouldn't.
American taxpayers, people like us, pay for the $600 million of
"free" infant formula for WIC annually. People who run homeless
shelters, food banks and other hunger programs also pay the price of
"free" samples. According to the Attorney General of Florida, for
each dollar charged for infant formula, the manufacturer spends only sixteen
cents on production and delivery. With this astounding profit margin, is it
no wonder that formula companies can afford to provide "free"
literature, samples and gifts to consumers and health care professionals?
Distributing or accepting these and the myriad other free gifts that formula
companies distribute to consumers and health care professionals means
increasing a financial burden on bottle feeding mothers, taxpayers, and
those who financially support hunger agencies. The fact of the matter is
that formula companies produce breastfeeding literature and breastfeeding
discharge kits for one purpose only-to increase the sales of their products.
Is this in the best interest of our patients? Is this a conflict of interest
for us as professionals?
There is a substantial body of scientific evidence to support our opinion
that formula discharge packs do affect breastfeeding in a negative manner. A
recent article in the journal "Birth" countered this evidence by
concluding that the practice of distributing formula discharge packs did not
affect breastfeeding. However, the women involved in this study were
provided with appropriate follow-up, which doesn't happen everywhere in the
US. Additionally, Ross Labs funded the study, a major manufacturer of infant
formula. Who does one believe? The fact remains that exclusive
breastfeeding, even in the early months of infancy, is not commonplace.
Early supplementation reduces the mother's milk supply and increases her
dependence on formula. How many "breastfeeding" brochures promote
early supplementation with formula? This early supplementation is encouraged
by formula manufacturers so that mothers buy their product for a longer
period of time, wean from the breast earlier and continue using formula
through the first year of life. What a brilliant marketing tool!
Some health care professionals may discard the formula, literature and
coupons from the diaper bags and give mothers the diaper bag manufactured by
the formula company. The problem with this practice is that the mother who
receives the diaper bag only is still exposed to a marketing practice known
as brand sampling or recognition. She'll recognize the name or logo on her
bag with the formula company. If we discontinue this practice, some believe
that mothers will feel cheated or left out because they didn't receive a
free diaper bag at their hospital upon discharge. Is there data to support
continuation of this practice? Of even greater concern is the mother who
encounters a breastfeeding problem. In some situations, she may use the
formula she received upon discharge from the hospital instead of seeking
assistance from a knowledgeable health care provider or La Leche League
Leader. The practice of formula discharge pack distribution impresses upon
the mother that the hospital endorses that particular brand when in fact it
is usually the lowest bidder who obtains the privilege to supply the
hospital with that brand. Do health care professionals wish to continue
being unpaid sales representatives for the formula companies? Some may argue
that they aren't unpaid when they accept free food, training and gifts from
a formula company, a practice that the authors, along with many other
lactation professionals, discourage. These practices that occur in clinics
and hospitals across the US are in direct violation of the WHO/UNICEF
International Code of Marketing Breastmilk Substitutes. According to
WHO/UNICEF, between one and two million infants worldwide die each year due
to artificial feeding. It was also WHO that first recommended that infants
be breastfed for at least two years.
While most of the United Nations countries signed onto the Code in the early
1980s, the US withheld it's support of the Code until the Clinton
administration voiced it's approval in 1994. The Code bans all promotion of
bottle-feeding and sets out requirements for labeling and information on
infant feeding products. Any activity which undermines breastfeeding also
violates the Code. The Code's main points are for no promotional efforts to
consumers, health care professionals or hospitals yet these violations
continue in hospitals and clinics across the country.
We have serious concerns about the ethics of this practice and the
relationships many health care professionals, hospitals and clinics have
with formula companies. For example, do other hospital units distribute free
gifts or food from commercial companies to their patients? All other
hospital units charge for patient food-why not the nursery? Perhaps the
question we should be asking ourselves is not how do formula discharge packs
affect breastfeeding and instead ask what would happen to formula sales if
this practice were discontinued?
REFERENCES
Bliss, M. C., Wilkie, J., Adrcolo, C.,
Berman, S., 6z Tebb, K. R (1997). The effect of discharge pack formula and
breast pumps on breastfeeding duration and choice of infant feeding method.
Birth: Issues in Perinatal Care and Education, 24, 90-97.
Dungy, C. h, Christensen-Szalanski, J. R.,
Losch, M., & Russell, D. (1992). Effect of discharge samples on duration
of breast feeding. Pediatrics 90(2), 233-237
Frank, D.A., Wirtz, SJ., Sorenson, J.R.,
&: Heeren, T. (1997). Commercial discharge packs and breastfeeding
counseling: effects on infant feeding practices in a randomized trial.
Pediatrics, 80(6): 845-854.
CINDY CURTIS is Director; Lactation Center and Staff Nurse LDRP Unit,
Culpeper Memorial Hospital, Culpeper, Virginia.
MAURENNE GRIESE is Director, Educational Services, Mercy Health Center of
Manhattan, Manhattan, Kansas.
Writing for the Pro
Position
DOTTIE C. JAMES, PhD, RN, and MAUREEN PIMLEY, RNC
In our opinion, it is a disservice to women to
assume that the presence of formula samples will discourage breastfeeding in
new mothers. Perinatal nurses know that breastfeeding is the best method for
feeding infants during the first year of life. The United States has
identified a national health goal of 75% of women choosing to breastfeed,
and 50% continuing to breastfeed at 6 months postpartum. Few professionals
would argue against the belief that breastfeeding is best for infants.
However, nurses must also respect women's right to choose the feeding method
they feel is best. Although the discharge diaper bags designed for
breastfeeding mothers usually contain formula samples and coupons, most also
have handy reusable ice packs and sterile bottles for storing frozen breast
milk during an outing with the baby or for use to store milk after pumping
while at work.
Much research has been done about this topic. As early as 1986 research
showed that discharge packs containing formula samples did not sabotage
breast-feeding (Feinstein, Berkelhamer, Grusz-ka, Wong, & Carey, 1986).
This was a double-blind controlled study of 166 mothers that followed women
for 4 months and found the variables with the greatest impact on the
duration of breastfeeding were: initiation of nursing after 16-hours-of-age,
partial breastfeed-ing (planned supplementation with formula), and formula
supplementation in the hospital. Other research has yielded similar findings
(Bliss. Wilkie, Acredolo. Berman, &z Tebb, 1997; Dungy, Losch. Russell,
Romitti, & Dusdieker. 1997: Evans, Lyons, &T Killten, 1986). Bliss
and colleagues (1997) studied more than 1,600 mothers who were given one of
four discharge packs that contained either: powdered formula; breast pump;
formula and breast pump; or neither. After a 6-month follow up that included
three phone contacts, there was no over-all effect on the duration of
breastfeeding and only a modest effect on the incidence of supplementation
with the group that was given formula samples.
Some nurses feel that giving the gift packs constitutes an endorsement of
the use of formula. If so, are the coupons and samples of disposable diapers
we routinely give out an endorsement of disposables over cloth diapers? We
don't think so. These are merely opportunities for mothers to examine a
product and make an intelligent decision on their own.
In our opinion. to suggest that a discharge gift pack influences feeding
options presumes that women do not make thoughtful choices about feeding
their babies. Nursing support is a key element in successful breastfeeding.
How many nurses have become frustrated with a sleepy newborn or a nervous
mother? How many have suggested a "little formula" to get over the
rough spots ,or to let the mother sleep in? If new mothers receive
appropriate education and support during their hospitalizations, perhaps
they will leave the hospital armed with the techniques and confidence to
continue breastfeeding at home. Part of this education must include
community resources such as professionally staffed hotlines, La Leche
League, and new mothers' support groups. New breast-feeding mothers must
feel that they are not alone, but rather part of a network of mothers
providing the optimal source of nutrition for their newborns. Let's not give
a diaper bag and formula powder more power than it deserves. It is easier to
blame discharge packs than to focus on the more difficult areas of nursing
practice and attitude. Let each of us do what we can to positively influence
new mothers and provide the support and education that make it possible for
all women who choose this method to successfully breastfed.
If perinatal nurses are committed to increasing the rate of breastfeeding
among new mothers, we will modify our practice and make it a reality.
REFERENCES
Bliss, M. C., Wilkie, J., Adrcolo, C.,
Berman, S., 6z Tebb, K. R (1997). The effect of discharge pack formula and
breast pumps on breastfeeding duration and choice of infant feeding method.
Birth: Issues in Perinatal Care and Education, 24, 90-97.
Dungy, C. h, Christensen-Szalanski, J. R.,
Losch, M., & Russell, D. (1992). Effect of discharge samples on duration
of breast feeding. Pediatrics 90(2), 233-237
Evans. C.J., Lyons. N. B.. & Killion. M G
(1986). The effect of infant formula samples on breast-feeding practce
Journal or Obstetric Gyn,and Neonatal Nursing, 15, 401-405
Feinstein J. M.. Berkelhamer I. E.. Gruszka,
M. E.. Wong, C A.. & Carey A E (1986). Factors related to early
termination of breastfeeding in an urban
population. Pediatrics 78 210-215
DOTTIE C. JAMES is Assistant Professor, Saint Louis University School of
Nursing, St. Louis, Missouri. MAUREEN PIMLEY was formerly a staff nurse in
the nursery at United Regional Health Care Systems in Wichita Falls, Texas
and has recently relocated to New Orleans, Louisiana.
Second Opinion columns are coordinated by Kathleen Rice Simpson. Dr.
Simpson is a Perinatal Clinical Nurse Specialist at St. John's Mercy Medical
Center; St. Louis, Missouri. She can be reached via e-mail at: GBJV77A@prodigy.com.
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