Breast, bottle, whatever: How You Feed is a shame-free series on how babies eat.
The recent national baby formula shortage — which continues to see retailers setting limits on how many cans shoppers can buy — has ignited a range of discussions and debates about racial disparities around baby feeding, the monopoly on formula production and pediatrician warnings not to DIY. It has also reignited age-old arguments about breastfeeding and a mom's right to choose breast or bottle, and it has served as a reminder of the many, many situations — adoption, surrogacy, fostering, preemies, low milk supply, a mother's death or illness — that nix nursing as an option from the get-go.
The crisis, triggered by the perfect storm of supply-chain issues plus a recall by Similac manufacturer Abbott Nutrition, prompted President Joe Biden to invoke the Defense Production Act to boost supply. Meanwhile, bipartisan lawmakers approved bills granting the federal government emergency authority to approve a wider array of formulas that can be purchased with WIC benefits, which represent about half the formula sold in the U.S.
But when, how and why did commercial infant formula come about to begin with? The history of baby formula is one filled with various mammal milks, trial and error, chemistry, marketing, racism, controversy and, ultimately, formulas governed by nutrition and safety requirements, making for well-fed babies and grateful parents everywhere.
"There have always been cases in which infants have not been able to be breastfed," Rima Apple, professor emerita of women's studies and nutrition at the University of Wisconsin-Madison School of Human Ecology and author of Mothers and Medicine: A Social History of Infant Feeding, 1890-1950, tells Yahoo Life. "Mothers die; mothers are ill; for some reason a baby can't latch on." Often, centuries ago, one solution was to hire a wet nurse, she explains, although that came with a vast range of problems, from fleeting availability to the fact that anyone employed as a wet nurse would likely need to neglect her own baby's needs in the process.
Also, "historically and archeologically, we know, going back to the Egyptians and even earlier, there were attempts to duplicate human milk in any way you could," with homemade riffs on formulas made from the milk of other mammals, such as donkey milk or goat milk, mixed with sugar and olive oil, says Apple.
But starting in the 19th century, she says, "we get more sophisticated chemistry that starts breaking down components of human milk and then trying to duplicate that recipe for infants. [Justus von] Liebig was the most famous to do this."
The first commercial formulas
In 1846, Liebig, an acclaimed German chemist, had described all living tissue, including food, as being composed of different proportions of fats, carbohydrates and proteins, Apple explains in her book. Using that knowledge, in the 1860s, he constructed what he believed to be the perfect infant food: wheat flour mixed with cow's milk and malt flour, with bicarbonate of potash to reduce the flours' acidity. "He determined this provided the infant with all the nutritive elements of human milk. He also claimed it was more digestible, as in the cooking process the malt converted the starch of the wheat flour into dextrin and glucose," Apple's book says. By 1869, baby formula from Liebig's Food was on sale in the U.S., first fresh and, soon, powdered.
There were others too — including Dr. A.V. Meigs of Philadelphia, who in 1884 published "the chemical analyses of human and cow's milk that have served as the basis for modern infant feeding," Apple writes. Using more refined, up-to-date laboratory techniques, Meigs determined that human milk contained approximately 87.1% water, 4.2% fat, 7.4% sugar, 0.1% inorganic matter (salts or ash) and only 1% casein (protein), while cow's milk contained approximately 88% water, 4% fat, 5% sugar, 0.4% ash and 3% casein — which coagulated more easily than that of human milk, making it harder to digest. As a solution, Apple writes, "He suggested diluting it with lime water to reduce the casein and make it alkaline; he also added cream to correct the fat proportion and augmented sugar with milk sugar."
Other doctors proposed similar recipes during the last third of the 19th century, with those of Meigs and Atlanta physician William H. Cumming being the most popular. Then came Swiss merchant Henri Nestlé, who entered the market with a passion for chemistry and ending infant mortality. He believed the solution was in "placing within the reach of all" the "good Swiss milk" of cows fed on nutritious Alpine grass, Apple writes, so he combined said milk with sugar and wheat flour, cooking the wheat with malt to convert the starch into more easily digested dextrin. By the 1870s, Nestle's Milk Food Company was selling its product throughout Europe, Australia and the Americas, while yet another version came from English chemist Gustav Mellin.
Still, there were issues with milk and its availability in some places, not to mention concerns about possible bacteria in raw milk versus the possibility of losing nutrition through sterilization. Responding to these worries was Gail Borden, who invented sweetened condensed milk in 1853. Its sales grew during the Civil War, as the government ordered it as a regular field ration, and by the end of the war, the Borden Company was advertising its Eagle Brand for feeding infants.
"By now, you have more sophisticated chemical analyses, and formulas get more and more complicated, and they have to be constructed in laboratories and changed every month, because infants' needs change," Apple says. "Meanwhile a lot of companies are saying, 'Oh, this is a good market to get into,' so by the end of the 19th century you have a large number of infant foods being sold, most in Western countries, especially the U.S. and U.K."
Early formulas, however, weren't always safe or nutritionally complete. "So before the advent of modern commercial formula (in the 1950s), a lot of babies died of illness or starvation because they couldn't breastfeed and the alternative foods were not safe or adequate,” infant-feeding historian Carla Cevasco pointed out in a viral Twitter thread recently, spurred on by those offering unhelpful and unsolicited advice to "just breastfeed" and seemingly criticizing proponents of commercial formula.
Speaking with Newsweek on the subject, Cevasco added, "Existence of a safe, nutritional alternative to breast milk is not something we should take for granted. In the past, parents knew they were taking a risk when they fed their children foods other than breast milk, and children died."
There will ALWAYS be people who need formula for a whole hosts of reasons.
— Carla Cevasco, PhD (@Cevasco_Carla) May 11, 2022
A recent New York Times opinion piece addresses this debate, stressing: "It’s also worth noting that formula, whatever you think of it, is better than the alternative, which in many cases is letting babies starve. Before the advent of modern formula, this is what often happened, especially if women did not have access to communities of other women who could feed their babies for them."
Doctors get on board, and controversies arise
A number of social and cultural factors continued to increase the popularity of formula, Apple explains, including the largely successful idea of manufacturers getting doctors to help push product by offering them free samples to share with patients. That's when many moms start to see it as a smart, scientific alternative, whether they were in a position to breastfeed or not.
"In the 19th and early 20th century, you have a lot of physicians saying, ‘Well, it has to be the right breast milk; if you're stressed out or tired, it's not going to be good,' so you have mothers worried and physicians saying, 'Oh, we have a good substitute,'" Apple explains. "So, the combination of three things — the growth of industry, worried physicians, worried mothers — make bottle-feeding increasingly popular through the 20th century. Physicians were, on the whole, very concerned with the health of the infants, and there was a new specialty — called pediatrics — and infant feeding was a perfect first step into a pediatric practice. If you were successful in getting that infant feeding and healthy, you'd have that mother for the rest of the child's life."
Apple continues, "There was a push, from the early 20th century on, [that] to be a good, modern, scientific mother included feeding babies by the clock, and a lot of babies don't [do that]. When you're in a hospital — and we're talking about the first half of the 20th century — it was typical to take a baby upon birth and put the baby in the nursery, then bring baby to mom on a four-hour schedule. They never got used to each other, because it was much easier to bottle-feed, so partly it was hospital routines that fed into the popularity of formula."
Add to that, she says, "as women increasingly enter the workforce and want to go back after their child is born, they can't breastfeed, which is particularly true of women who are working-class. So, the substitute is a bottle. Against that, you have La Leche League and other groups trying to help mothers breastfeed and go against hospital routines, but it takes a while for those counterbalances to really kick in."
Breastfeeding activists acknowledged the need for formula while also stressing consistent studies that cite breastfeeding as the healthiest option for babies (decreasing risks of ear infections, asthma, allergies, diarrhea and many other issues) and cause it to be recommended by the American Academy of Pediatrics and the World Health Organization. They also began to criticize hospitals for marketing formula to mothers and sending them home from the hospital with formula swag bags, thus influencing their decisions. (By 2011, due to pressure from organizations such as Ban the Bags, nearly half of about 2,600 hospitals in a survey by the Centers for Disease Control and Prevention said they had stopped giving formula samples to breastfeeding mothers, up from a quarter in 2007.)
Andrea Freeman, a University of Hawaii professor of law and food policy, health and critical race theory researcher and author of Skimmed: Breastfeeding, Race and Injustice, argues that today's formula shortage is a racial justice issue dating back to the mid-20th century, which she illustrates with her eye-opening history of how formula marketing has disproportionately targeted Black women. That started, she writes, with the birth of the Fultz quadruplets in North Carolina in 1946.
The first documented set of Black quadruplets born in the U.S., they became the celebrity faces of baby formula company Pet Milk after the doctor who delivered them sold rights to their story to the highest bidder. The girls lived in poverty while Pet Milk's profits from the previously untapped market of Black moms took off, inspiring other brands to try similar marketing. Over half a century later, baby formula is a nearly $60-billion-a-year industry and Black mothers have the lowest breastfeeding rates in the country.
"That aggressive marketing, combined with societal pressures and structures that made it impossible or really difficult for Black moms to breastfeed, create a perfect storm for formula use, creating this racial disparity," Freeman tells Yahoo Life. "So when formula just disappears, that's also disproportionately affecting Black moms. … There should be recognition of the racial disparity in formula use and acknowledgment of compensating and getting it to [Black moms]. Because if it's a racial justice issue, and I believe it is, then it should be approached that way."
Nestlé boycott and the continued dangers of aggressive marketing
That drive for profit became clear on a large-scale level in the 1970s, when a series of exposés, most notably "The Baby Killer," published by the U.K. anti-poverty charity War on Want in 1974, called out Nestlé for aggressive baby formula marketing practices to mothers living in poverty in Asia, Africa and Latin America. It allegedly persuaded new mothers that the Western formula was vital to the health of their babies, providing samples without the information needed to use the formula properly, and even hiring "sales girls in nurses' uniforms (sometimes qualified, sometimes not)" to stop by homes, unannounced, and sell the moms on baby formula. It prompted a 1977 boycott in the U.S. that extended into Europe in the 1980s (and though it was largely dropped in 1984, notes Nestlé, some activists continue to support the ban to this day).
Many mothers did not understand that overdiluting the formula, especially with contaminated water, could lead to malnutrition and sickness, as reported by the New York Times in 1981 and also by War on Want, which was sued by Nestlé for libel in 1976. Nestlé won, on one condition: that the company "modify its publicity methods fundamentally."
In 1981, the World Health Organization (WHO) released the International Code of Marketing and Breast-Milk Substitutes, a public health agreement whose goal was to "stop the aggressive and inappropriate marketing of breast milk substitutes."
However, a recently released series of reports from WHO and UNICEF claim that formula makers have not changed their ways — using marketing methods that include targeting women on social media with direct messages and paying influencers to target new moms, using false and incomplete scientific claims about the health of formula and providing incentives such as gifts and trips to health workers who promote formula. (Nestlé, for its part, told NPR that the company "has been leading the industry on responsible marketing of breast milk substitutes since publication of the WHO Code.")
Still, today's formula is desperately wanted back on shelves by parents who rely on formula. As Apple notes, accepting the good with the bad is simply part of the bargain.
"It's always a problem when we have something that has been commercialized. We have to figure out how much and how far we can take the commercialized product, and manufacturers will try to push it further than it should go," she says of the formula industry. "But that doesn't mean we don't need it. … We need these kinds of substitutes. And we also need to produce a society that enables women who want to breastfeed to have the advantages of breastfeeding — like not having to go back to work too quickly."
This story was originally published on May 20, 2022 and has been republished.
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