History of breastfeeding: the code on the marketing of breast-milk substitutes

Are you interested in how breastfeeding has evolved throughout history? In this blog, we are going to take a journey through the history of breastfeeding, from the earliest times to the present day. We will explore how mothers have faced different challenges over time, especially when they could not breastfeed their babies. We will discover the practices of wet nurses, women who breastfed other mothers' babies, as well as the use of animal milk as an option.

We will also look at the arrival of formula milks around 150 years ago, how they became commercial products and competed with breastfeeding. We will talk about the importance of the Code that regulates the marketing of these substitutes and how it has impacted the promotion of breastfeeding around the world.

History of breastfeeding

We are going to explore the evolution of breastfeeding and the options available from prehistoric times to the present day, based on some very exciting information from a 100% recommended course by EVES.

From the beginning of time

From ancient times until around 150 years ago, most human babies were usually fed with the milk of their mothers or of other women. Human beings belong to a group of animals called mammals, which produce milk in their mammary glands to feed their young.

We differ from other animals because we walk on two legs, which gave us advantages, such as seeing potential dangers from higher up and using our hands to make things. However, this also made our hips narrower, which caused problems during childbirth. As a result, our babies are born less developed and need more care and help.

Because of this, the milk produced by human mothers is different from that of other animals, with fewer concentrated substances and proteins. That is why human babies cannot drink the milk of other animals unless it has been modified.

If we look at how other species of mammals or less advanced societies did it, or read ancient texts such as the Ebers Papyrus in ancient Egypt, the Bible, Galen or the Koran, we would see that it was common for young children to be breastfed by their mothers until at least 2 or 3 years of age.

Wet nursing

Throughout history, we have seen that in many civilisations, women of different ages and social classes did not breastfeed their babies. Instead, other women looked after them, as mentioned in various historical texts, such as the Code of Hammurabi, the Bible, Soranus of Ephesus, the Koran and others.

From the Renaissance onwards in Europe, wealthy people began to let wet nurses look after their babies instead of breastfeeding them. This was partly because breastfeeding had a contraceptive effect, which meant that the working classes had fewer children, around one every two years. On the other hand, wealthy people had more children, but many of them died at an early age.

Several reasons influenced this tendency among the wealthier classes to use wet nurses instead of breastfeeding:

• The high infant mortality rate required wealthy families to have more children to ensure that some survived to inherit their property.
• Some people thought that milk was similar to menstrual blood, which was considered “impure” at the time.
• There were beliefs and taboos, such as thinking that breastfeeding weakened women or that having sex could affect the milk.
• Some people saw breasts as erotic objects that should not be shown in public.
• Breastfeeding was considered to be for the less privileged classes or for animals.

In the eighteenth and nineteenth centuries, in Spain, advertisements were published in newspapers offering work as wet nurses, which made up a large part of the job offers. Cantabrian wet nurses also became popular among the nobility, especially the Pasiegas, thanks to their good health and supposed “purity of blood”.

From the end of the nineteenth century onwards, improvements in the manufacture of artificial milk and the discoveries of Louis Pasteur began to replace the use of wet nurses.

Feeding infants with the milk of other animals

Artificial feeding of babies has been known for a very long time. In archaeological excavations dating back 2,000 years before Christ, many vessels with spouts have been found that were probably used as baby bottles.

Human babies, especially in the first months of life, cannot digest the milk of other animals well, because it contains more proteins and other substances than human milk. For example, cow's and goat's milk contain four times more protein than human milk, sheep's milk six times more, wolf's milk ten times more, and donkey's milk twice as much. Any attempt throughout history to feed babies with the milk of other animals has had very poor results, with a high death rate, especially in babies under 1 year old. A tragic example of this was in a place called the Rouen hospice in France, where between 1763 and 1765, of 132 children admitted, only five survived.

Even Titus Livy, who wrote about the history of Rome, thought that the story of Romulus and Remus being breastfed by a wolf was a legend, and that in reality, the woman who looked after them was a kind of sex worker, due to a misunderstanding of the Latin name for her profession (“lupa” in Latin translates both as “she-wolf” and as “prostitute”).

Donkey's milk, which is the most similar to human milk in terms of proteins, gave a slightly better chance of survival, but still did not prevent malnutrition.

History of feeding with breast-milk substitutes

At the end of the nineteenth century, with the arrival of the second industrial revolution, many women began working in factories in very difficult conditions. As a result, they had to leave their babies in the care of other people shortly after birth. Many of these women did not have the option of having other mothers breastfeed their babies or of hiring wet nurses. It was already known that giving babies the milk of other animals often caused their death. Sometimes, if the milk was diluted, some babies survived, but with malnutrition and deficiencies.

In response to this need, advances in chemistry and biology, including the work of Louis Pasteur, made it possible to modify cow's milk so that it was safer for babies. In 1867, a German industrialist named Henri Nestlé launched a product called “Nestlé Milk Food” that was very successful. It was made from boiled and diluted cow's milk, with sugar and wheat flour.

In the twentieth century, adapted formulas were created from cow's milk with added nutrients such as calcium, iron and vitamins. These formulas have been improved over time, including fatty acids, amino acids, oligosaccharides and more. Today, these formulas are considered fairly safe and acceptable food for babies who are not breastfed, at least in places where families can afford them and have access to drinking water.

However, ever since these products began to be sold, the baby food industry has grown enormously, with influential advertising campaigns. This has led to the mistaken belief that industrial products are better than natural ones, and this idea has been called “scientific motherhood”.

These campaigns were not limited to the developed world, but have also spread to developing countries and emerging economies such as China, Russia and India.

In the words of the paediatrician Bo Vahlquist, the change in infant feeding is “the world's largest uncontrolled experiment”, and it has had serious consequences, especially in impoverished areas with infections and malnutrition, and possibly in rich societies with more illnesses and medical consultations. In addition, there has been a loss of breastfeeding culture as mothers stopped breastfeeding their children, something they used to learn from their own mothers and grandmothers.

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Reactions to unfair trade

Many companies have been accused of carrying out misleading advertising, promoting products that replace breastfeeding. They have even been held responsible for a significant part of infant mortality in the twentieth century, since the use of their products often led to the abandonment of breastfeeding. These companies have been accused of running promotional campaigns, such as giving samples of their products to mothers in developing countries. These mothers often stopped producing breast milk through lack of stimulation, could not buy more formula products because of financial problems and had difficulties accessing clean water to prepare them.

As a result, many children died from infections due to the lack of the defences provided by breast milk, from drinking contaminated water, or from malnutrition caused by diluting the product too much, as it was expensive for their budgets. This situation has been called “commerciogenic malnutrition” (Dr. Derrick Jelliffe, 1968).

Some people began to speak out against these practices. In 1939, the paediatrician Cicely Williams gave a speech in which she harshly criticised the baby food industry, using strong words such as “massacre of the innocents” and “murder”.

In 1956, a group of women in Chicago founded La Leche League to support mothers who breastfeed. Today, it is a respected international breastfeeding support group.

In 1973, New Internationalist magazine published an article entitled “The baby food tragedy”, in which it accused the manufacturers of substitutes of being responsible for the deaths of thousands of children in developing countries due to the widespread use of their products and inappropriate marketing practices.

In 1974, the non-governmental organisation “War on Want” published a report called “The baby killer”, which denounced the aggressive advertising of companies such as Nestlé in many countries in Africa, Latin America and South-East Asia. This report led to a boycott of Nestlé, and the company sued the NGO for defamation.

In 1974, the 27th World Health Assembly warned of the decline in breastfeeding in many countries and linked it to the promotion of breast-milk substitutes. It recommended that member states take measures to correct this situation. The WHO and UNICEF kept insisting on this recommendation until the International Code of Marketing of Breast-milk Substitutes was approved in 1981. This code sets out rules to protect breastfeeding from unethical commercial practices.

The International Code of Marketing of Breast-milk Substitutes

The International Code of Marketing of Breast-milk Substitutes covers a series of rules relating to products such as infant formulas, complementary foods and baby utensils, such as teats and bottles. Here are some of the key points:

• Products must carry labels and information materials that clearly highlight the superiority of breastfeeding. They must also state that these products should only be recommended by qualified and independent professionals. A warning must be given about the risk of their use affecting breastfeeding and the difficulty of resuming it once it has been stopped.
• Images or illustrations of babies may not appear on packaging or labels, nor may any other elements be used that idealise the use of infant formulas. In addition, terms such as “humanised” or “maternised” or similar may not be used.
• In places of sale, such as pharmacies or supermarkets, advertising of these products is not permitted, nor is the giving of samples or utensils to pregnant women or mothers of babies and young children. Promotional methods may not be used to influence consumers to buy them.
• Healthcare centres must not promote these products, nor display them or propaganda materials for the products or their brand names. Manufacturers may not provide samples of breast-milk substitutes to health professionals or offer financial or material incentives to them or their families. Health professionals may not give free samples of substitutes to mothers either.
• Direct advertising of these products or any other form of promotion aimed at the general public, such as adverts on television, in the press or on social media, is not permitted.
• Sales incentive schemes for marketing staff must not include the sales volume of these products or set specific sales quotas for them.
• Monitoring of the application of the Code rests with governments, with the collaboration of professional groups.
• Today, 39 countries have fully or partially incorporated the Code into their legislation. In Spain, the Code is partially reflected in Royal Decree 867/2008, which establishes regulations on labelling, information materials and advertising for starter formulas (although not for products intended for babies over 6 months). Failure to comply with these regulations is considered a serious infringement.
  

After the International Code of Marketing of Breast-milk Substitutes

Despite the recommendations of the WHO, government regulation and the Code, breastfeeding rates in countries with a high GDP have been slow to improve and have still not reached the desired levels. This is largely due to two main problems: the loss of breastfeeding culture and the lack of knowledge among health professionals.

On the one hand, many people have stopped breastfeeding their children, and the passing on of knowledge about breastfeeding from generation to generation has weakened. In addition, some health professionals have, without meaning to, continued to apply incorrect practices in the care of mothers and babies in hospitals and paediatric clinics due to a lack of training and knowledge about breastfeeding.

In addition, companies that market infant feeding products often violate the regulations of the Code. They give away samples, run promotions and advertise in ways that in theory should not be allowed and that can be misleading.

The WHO and UNICEF have been working to promote and protect breastfeeding through initiatives such as the Innocenti Declaration, the Baby-friendly Hospital Initiative (iHAN) and the Global Strategy for Infant and Young Child Feeding, among others.

Recently, with the #EndExploitativeMarketing campaign (WHO-UNICEF 2022), they have warned that infant feeding companies are massively using social media to promote their products. This includes targeting pregnant women and mothers through groups on social networks, hiring “influencers” to promote their products and creating misleading advertising that undermines mothers' confidence in their ability to breastfeed exclusively. It is estimated that companies spend large sums of money on these campaigns and that they are widely violating the Code.

Conclusions: history of breastfeeding and the international code on substitutes

Throughout history, babies have been fed in various ways, but breastfeeding, which is the natural act of a baby feeding from its mother's breast, has been the most common way. However, in the nineteenth century, formulas made with modified cow's milk that babies could tolerate began to be produced. Throughout the twentieth century, the commercial strategies for promoting these artificial formulas led to a decline in breastfeeding, which had serious consequences, especially in less developed regions, where it caused high infant mortality rates.

In an effort to promote breastfeeding around the world and regulate the marketing of breast-milk substitutes, the World Health Organisation (WHO) and the United Nations Children's Fund (UNICEF) created in 1981 a set of rules called the “Code on the marketing of substitutes”. However, this code is still not widely respected in governmental, commercial and healthcare settings.

Knowing the history helps us not to fall into the same mistakes, although the current reality is that 75% of mothers will use a bottle during their motherhood, of which 50% will stop breastfeeding by using a generic bottle.

That is why our Happymami project was born, to offer a real solution to this situation. By creating a bottle custom-designed with the shape of each mother's breast, preventing the confusion factor, protecting breastfeeding.

Bibliography: history of breastfeeding and the international code on substitutes

1. Paricio Talayero JM, Jareño Roglán EJ, Segura Barrachina S. History of Breastfeeding. The Code on the marketing of substitutes. IHAN Initiative. Sources of information on breastfeeding. 6th and 7th Complete Training Courses on Breastfeeding for healthcare staff (blended). 32422716A and B. EVES (Valencia), 16 September – 22 November 2024.
2. Paricio Talayero JM. History of Breastfeeding. 3rd Complete Training Course on Breastfeeding for healthcare professionals. Hospital de Lliria, 20-22 February 2020.
3. Paricio Talayero JM. Historical aspects of breastfeeding; 2014. www.apilam.org.
4. Landa Rivera, L, Paricio Talayero, JM, Hernández Aguilar, MT. History of breastfeeding. In: Spanish Association of Paediatrics. Breastfeeding Handbook. Ed Médica Panamericana, Madrid 2009, pp 9-24.
5. WHO. Current patterns of natural breastfeeding. WHO, Geneva, 1981. http://apps.who.int/iris/bitstream/handle/10665/40109/9243560670. pdf;jsessionid= 6586CE781C69A78ECF3F59E1F3682F11?sequence=1
6. https://mammalia.info. The first complaints about aggressive commercial practices against breastfeeding, 19/11/2013.
7. Baby Milk Action. A long road. A history of the campaign to protect infant health. alongroad.pdf (babymilkaction.org)
8. War on want (Mike Muller). The baby killer. 1974. https://www.waronwant.org/sites/default/files/THE%20BABY%20KILLER%201974.pdf
9. Breastfeeding Committee of the Spanish Association of Paediatrics. What is the International Code of Marketing of Breast-milk Substitutes? 2016. https://www.aeped.es/sites/default/files/ documentos/201601-codigo-comercializacion-lm.pdf
10. WHO. Scope and impact of digital marketing strategies for promoting breastmilk substitutes. https://www.who.int/publications/i/ item/9789240046085

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