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“Growing-up milk” marketing in Indonesia signals need for strengthened regulations

by Mary Champeny

in Blog

World Breastfeeding Week 2020 has sparked conversations about the broader environmental and social impacts of infant feeding decisions.

In our research, we have observed a trend of increased availability and promotion of breast-milk substitute products for young children. Beyond the carbon footprint generated in the production, packaging and distribution of a broader range of breast-milk substitutes, nutrition experts have raised health concerns about these so-called “growing-up milks.”

Helen Keller International’s ARCH Project recently assessed the sugar content listed on labels of growing-up milk (GUM)* products available for sale in Indonesia. Our team also evaluated the nutrient profiles of these products and compared the labels with local and international standards including the Codex Draft Revised Standard for Follow-up Formula (CXS 156-1987) and the International Code of Marketing of Breast-milk Substitutes. Our findings revealed almost three quarters (70%) of GUMs assessed have high sugar levels which classify them as unhealthy according to the UK Food Standards Agency Nutrient Profiling Method, leading to questions about whether these products are appropriate for feeding children between 12-36 months as indicated on the labels. Our recently published report also indicates that GUMs in Indonesia are nine times more expensive than cow’s milk, which is an appropriate nutrient-dense drink for non-breastfed children over 12 months of age.

Lack of regulation of GUM product claims and labeling practices are cause for concern and can lead to misinformation and the overall promotion of inappropriate child feeding. These findings from Indonesia provide insights into the marketing of GUMs in a specific context as well as reflect international trends of unethical marketing of breast-milk substitutes.

These findings from Indonesia, published here will provide insights into the marketing of growing-up milks in a specific context. However, the proliferation of these products reflects international trends and a long history of unethical marketing of breastmilk substitutes:

Timeline of key events in the history of breastmilk substitute production and marketing (from Changing Markets Foundation)

Marketing portrays GUMs as the next step for children using infant formula, leading to consumer confusion

GUMs are increasingly marketed as essential parts of entire child nutrition product lines. These products have been sold under a variety of names, including “follow-up formulas,” “toddler formulas”, and “growing-up milks.” Since the 1980s, these products have become a prominent and growing segment of the approximately $70 billion USD breastmilk substitute (BMS) industry.1  They are labelled similarly to infant formula products and positioned as sequential steps for child feeding from birth through the first few years of life.2

Similar color schemes, logos, and marketing copy appear on labels of brands’ breastmilk substitutes, with different product names or stages usually appearing in smaller lettering to indicate the appropriate age of introduction. This practice, along with cross-promotion of GUMs and infant formulas observed in retail sales promotions, has been criticized as an indirect means of promoting breastmilk substitutes for earlier age ranges without contravening national regulations.3–5 Also of concern is the potential misuse of GUMs due to ambiguity in labeling and branding, especially since GUMs are usually priced to be cheaper than infant formulas. GUMs are not nutritionally sufficient for infants in the first year of life, but evidence suggests that caregivers perceive them as interchangeable with infant formula.6–8 

Examples of cross-promotion of infant formula through similar branding elements on growing-up milk labels2

Companies market GUMs aggressively, claiming unfounded health benefits

In addition to traditional promotional channels (like print advertisements, point-of-sale displays, billboards, posters, etc.), GUMs are also marketed to consumers through in-person company representatives and promotional events in many parts of the world.9,10 They are also included in longstanding and controversial health facility-based breast-milk substitute marketing strategies such as distribution of branded discharge packs for new mothers11,12 and provision of financial incentives to health workers.13,14 Breast-milk substitute companies also engage in sponsorship of national and regional pediatric organizations, a practice which presents conflicts of interest and provides another avenue for indirect promotion by encouraging brand loyalty among care providers.15 Online breast-milk substitute brand and product promotion is also becoming common, through interactive web pages, social media presences, and sponsored posts on parenting sites in addition to e-commerce activities.16

Common claims of GUMs include improved cognitive development, greater intelligence, weight management, better immunity and improved digestion.17–19 These claims are inconsistently supported by scientific evidence, but a solid evidence base is not required by the Codex Alimentarius Standard for Follow-up Formula to back these claims.20–22 GUMs are also positioned as solutions for picky toddlers to get more nutrients into their diet,23 which is often achieved through added sweeteners and flavorings designed to appeal to young children.24

Nutrition experts uphold that for children over 12 months of age, whole cow’s milk is an appropriate substitute for breastmilk.25 Commercial GUMs do not provide necessary nutrients beyond what can be achieved through complementary diets in most settings. Use of GUMs may also displace continued breastfeeding in the diets of toddlers, who can still benefit from the reduced morbidity, mortality, and risk of childhood obesity associated with longer breastfeeding durations.26,27

Comparison of key nutrients between growing-up milk and cow’s milk24
Brand and product NPI score Calories (kcal) Sat fat (g) Total sugar (g) Sodium (mg) Fiber (g) Protein (g)
Happy Tot Grow & Shine 72 68.2 0.0 2.9 24.3 0.0 1.9
Milk, low-fat, fluid, 1% milkfat 72 42.0 0.6 5.2 44.0 0.0 3.4
Nido Fortificada (Fortified) 70 59.1 1.8 4.1 38.8 0.0 2.2
Gerber Good Start Grow 70 63.3 0.2 4.9 24.3 0.0 1.9
Milk, reduced-fat, fluid 2% milkfat 70 50.0 1.3 5.1 47.0 0.0 3.3
Nido Kinder 1+ 70 70.2 0.9 5.5 35.1 0.4 2.2
Milk, whole 68 61.0 1.9 5.1 43.0 0.0 3.2
Enfagrow Toddler Next Step 68 75.0 1.2 5.2 37.5 0.4 2.8
Go & Grow by Similac ** 68 55.2 0.0 5.5 16.6 0.3 1.5
Milk, chocolate, reduced-fat 66 78.0 1.2 9.6 66.0 0.7 3.0
Milk, chocolate, whole 62 83.0 2.1 9.5 66.0 0.8 3.2
Enfagrow Toddler Transitions Soy 60 58.7 6.9 1.1 21.1 0.0 1.9
Enfagrow Toddler Transitions 58 58.7 6.3 1.4 21.1 0.0 1.5
Enfagrow Toddler Transitions Gentlease 58 58.7 6.2 1.4 23.5 0.0 1.5

*Per 100 grams **All products have the same nutrient content. Source: 2016 Rudd Center product analysis

While breastfeeding is recognized by The World Health Organization (WHO), UNICEF, and countess other experts as the best way to feed an infant, there will continue to be cases where families need or want an alternative. The use of GUMs, which are both unnecessary and expensive, has the potential to displace healthy diets and put young children at risk for undernutrition and poor health later in life. As advertising efforts and consumption of GUMs continue to rise around the world, there is an increasing need to strengthen international and national regulations on the marketing and labeling of these products.

*The ARCH Project uses this term to refer to animal or alternative milk-based powdered, concentrated or ready to feed breast-milk substitutes for children from 12 to 36 months of age

References:

  1. Rollins NC, Bhandari N, Hajeebhoy N, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet [Internet] 2016 [cited 2016 Jan 30];387(10017):491–504. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26869576
  2. Pereira C, Ford R, Feeley AB, Sweet L, Badham J, Zehner E. Cross-sectional survey shows that follow-up formula and growing-up milks are labelled similarly to infant formula in four low and middle income countries. Matern Child Nutr [Internet] 2016 [cited 2017 Jan 12];12(S2):91–105. Available from: http://doi.wiley.com/10.1111/mcn.12269
  3. Helen Keller International. CCNFSDU 2019: Review of the Codex Standard for Follow-Up Formula [Internet]. 2019 [cited 2020 Apr 30];Available from: http://doi.org.10.1016/S0140-6736
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