baby formula discharge packs

Early In the year 2000 the Task Force adopted an initiative to make an effort to eliminate formula discharge packs from nurseries throughout New Mexico. We consider these packs to be a serious obstacle to successful breastfeeding. After a hiatus of several years of published research, a new paper on this subject has been published in the American Journal of Public Health.(1) It concludes that women who received discharge packs were more likely to exclusively breastfeed for fewer than 10 weeks than were women who had not received the packs.   A number of papers in the literature have previously addressed the issue. Although some have concluded that there is no significant effect,(2-5) the consensus is that there is a definite adverse impact on breastfeeding from the distribution of discharge packs.(1,6-11) The overall effect is, as one would guess, inversely related to maternal age, education, parity, and socio-economic status.   Additionally, two meta-analyses of the problem have been published.(12,13) The first, written in 1994 includes six papers with a study population that includes data on 1212 women. The second is a Cochrane Review, revised in 2007, including 3730 women in nine studies. Both show a negative effect of discharge packs on breastfeeding. The Cochrane Review concludes that the effect is limited to exclusive breastfeeding. If one acknowledges, however, that the data suggest a controversy, it is perhaps because hospital discharge packs represent the last effort in a chain of advertising. A study in 2000 demonstrated the detrimental effect of           commercial educational packs given in obstetrical offices early on during prenatal care.(14)

Data from the PRAMS (Pregnancy Risk Assessment and Monitoring System) project indicates that New Mexico has exceeded Healthy People 2010 goals of a 75% rate of initiation of breast feeding (82.4%).(15) However, we are failing in the 6-month goal of 50% continuation of breastfeeding. Overall, here in New Mexico, at two months only 56.9% of women are continuing to breastfeed. When one considers working women or women in school, the figure drops to less than
50%.(16)

The Task Force concedes that young maternal age,
lack of education, workplace pressures, and other
issues are more important and need to be
addressed for a multitude of societal reasons
beyond breastfeeding. However, with such statistics,
it behooves us to create as favorable an environment
as possible.   We have no influence over a woman's
age, parity, education, income or need to return to
work. However, we can make a small, but real
difference if we eliminate commercial gift packs.
Certainly, there is no data to suggest that these gift
packs have a beneficial effect on breastfeeding.

The American Academy of Pediatrics is also on our side.
The latest AAP Policy Statement on Breast-feeding says that
pediatricians are encouraged to "work actively toward eliminating hospital practices that discourage breast-feeding (e.g., promotion of infant formula in hospitals including infant formula discharge packs and formula discount coupons...)(17)

Additionally, The International Code of Marketing of Breastmilk Substitutes adopted by the World Health Assembly in 1981 expressly forbids free formula samples to mothers.(18) In 1986 a WHO resolution was passed banning free and subsidized supplies of breastmilk substitutes to hospitals. As you may remember, the United States alone refused to sign the Code of Marketing. (The vote was 118 to 1). Since we are not signers, American companies are not subject to these provisions.
Their record is mixed in their third world marketing efforts, and   we could nudge them a little here at home. Consider that the practice is in some way illegal in the other 118 countries.

Finally, Lewis Margolis has published a very thoughtful commentary about the ethics of accepting gifts from pharmaceutical companies.(19) He found the practice problematic for a number of reasons, including the fact that promotional gifts ultimately increase the cost of the product to our patients. Discharge gift packs are not free! More recently this matter was brought to public attention in a New York Times editorial. The editorial ridicules the AMA for a campaign to remind the membership to avoid the "appearance" of a conflict of interest in accepting gifts from drug companies. The campaign's $750,000 budget came mostly from pharmaceutical companies!(20) Dr. Bob Goodman, an internist at Columbia Presbyterian in New York, explores this issue and presents the troubling data on "gifts" from pharmaceutical companies to physicians on his No Free Lunch website.

We hope you will give consideration to the above arguments. The Task Force would be pleased if health care providers and health care administrators in New Mexico will find enough validity in our point of view to adopt our initiative and begin to remove discharge packs from nurseries throughout the state. We recognize that there is considerable resistance to the idea. Formula companies have been able to adversely influence administrators, marketing departments, and even staff nurses.
We would be pleased to hear your comments about this issue. Please e-mail to jim_ml@swcp.com.

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1. Rosenberg K, Eastham, C, Kasehagen L, Sandoval, A. Infant Formula Marketing Through Hospitals: the Impact of Commercial Hospital Discharge Packs on Breastfeeding. Am J Public Health 2008 Feb;98(2):290-5
2.Neifert M, Gray J, Gary N, Camp B. Effect of two types of hospital feeding packs on duration of breast- feeding among adolescent mothers. J Adolesc Health Care 1988;9(5):411-3
3.Feinstein JM, Berkelheimer JE, Gruszka ME, Wong CA, Carey AE. Factors related to early termination of breast-feeding in an urban population. Pediatrics 1986;78(2):210-5
4.Bliss MC, Wilkie J, Acredolo C, Berman S, Tebb KP. The effect of discharge pack formula and breast pumps on breast-feeding duration and choice of infant feeding method Birth 1997;24(2):90-7
5.Dungy CI, Losch ME, Russell D, Romitti P, Dusdeiker LB. Hospital Formula Discharge Packages: Do they affect the duration of breast-feeding? Arch Pediatr Adolesc Med 1997;151:724-9
6.Bergevin Y, Dougherty C, Kramer MS. Do infant formula samples shorten the duration of breast-feeding? Lancet 1983; 21:1148-1151
7.Dungy CI, Christiansen-Szalanski J, Losch M, Russell D. Effect of discharge samples on duration of breast-feeding. Pediatrics 1992;90:233-237
8.Frank DA, Wirtz SJ, Sorenson JR, Heeren T. Commercial discharge packs and Breast-feeding counseling: Effects on infant feeding practices in a randomized trial. Pediatrics 1987;845-854
9.Snell BJ, Krantz, Keeton, R, Delgado K, Peckham C. The association of formula samples given at hospital discharge with the early duration of breast-feeding. Hum Lact 1992;8:67-72
10.Ryan AS, Wysong JL, Martinez GA, Simon SD. Duration of breast-feeding patterns in the hospital. Influencing factors. Results from a national survey. Clin Pediatrics 1990;29(2):99-107
11.Reiff MI, Essock-Vitale SM. Hospital influences on early infant-feeding practices. Pediatrics 1985;76(6)872-9
12..Perez-Escamilla R, Pollitt E, Lonnerdal B, Dewey KG. Infant feeding policies in maternity wards and their effect on breast-feeding success: An analytical overview. Am J Public Health 1994;84:89-97
13.Donnelly A, Snowden HM, Renfrew MJ, Woolridge MW. Commercial hospital discharge packs for breastfeeding women. Cochrane Database Syst Rev. 2007 Jul 18;(2):CD002075
14. Howard C, Howard F, Lawrence R, Andresen E DeBlieck E, Weitzman M. Office prenatal formula advertising and its effect on breast-feeding patterns. Obstet Gynecol 2000;95(2):296-303
15.New Mexico PRAMS: Multiyear Tables. http://www.health.state.nm.us/phd/prams/report_surveillance/multiyear9803.pdf
16. New Mexico PRAMS Surveillance Report http://www.health.state.nm.us/phd/prams/report_surveillance/14_breastfeed.pdf
17.American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2005; 115:496-506. http://www.pediatrics.org/cgi/content/full/115/2/496
18.World Health Assembly. International Code of Marketing of Breast-milk Substitutes. Resolution of the 34th World Health Assembly. No. 34.22 Geneva, Switzerland:WHO;1981
19.Margolis LH The ethics of accepting gifts from pharmaceutical companies. Pediatrics 1991;88(6):1233-1237
20.An unhealthy influence on doctors. New York Times, Opinion Page. September 10, 2001

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