Are Hospitals’ Free Formula Samples a Help or a Hindrance to Breastfeeding?
A Parent Asks
When I had my first baby, I received a care package with infant formula samples in it, but I didn’t receive one after this birth. Why are hospitals no longer giving the free formula to new parents?
The Parent Coach Advises
Newborn feeding is one of the major topics about which new parents seek advice and guidance from medical professionals. The answer to this parent’s question becomes evident when the benefits of breastfeeding and the historical use of infant formula are reviewed.
Breastfeeding has been demonstrated to improve numerous infant health outcomes, including decreasing the risks of respiratory tract infections, otitis media, gastrointestinal tract infections, necrotizing enterocolitis, obesity, sudden infant death syndrome, and infant mortality.1
Major health organizations agree that breastfeeding is the optimal nutrition for infants. The American Academy of Pediatrics in 2012 reaffirmed its policy statement recommending breastfeeding for a baby’s first year of life, with breast milk as the sole source of nutrition for the first 6 months.1 Similarly, the World Health Organization (WHO) advocates that women breastfeed until their child is 2 years of age.2 In the United States, breastfeeding rates continue to rise.3 Still, only 14.1% of U.S. infants are breastfed exclusively for the first 6 months, well below the target goal of 25.5% proposed by the Healthy People 2020 objectives.4
A Historical Look at Formula
When infant formula was introduced in the United States in the 1860s, its success relied on the manufacturers’ premise that newborns require more than just breast milk to obtain adequate nourishment for growth.5 Today’s marketing strategies emphasize the similar chemical compositions of formula and breast milk.
Distributing free samples and coupons to new mothers has influenced many women to choose readily available formula over breast milk, thereby perpetuating the postpartum use of formula.5 In 2010, 72% of U.S. hospitals distributed industry-sponsored formula sample packs to new mothers upon hospital discharge, violating the WHO’s International Code of Marketing of Breast-milk Substitutes, which recommends against the provision of free formula samples to new mothers.6,7 Even though many U.S. hospitals continue to distribute industry-sponsored formula discharge packs to new mothers despite the potentially negative impact on breastfeeding, the number of hospitals distributing these packs has declined significantly in recent years.8
Providing formula samples to women who initiate breastfeeding while in the hospital presents conflicting messages, since health care providers may verbally oppose formula feeding and support initial breastfeeding attempts.9 Eliminating the provision of formula samples to mothers upon hospital discharge has been shown to increase new mothers’ duration of breastfeeding over the first 10 weeks postpartum.6 Similarly, women who are not given formula samples have been found to be significantly more likely to breastfeed exclusively for 6 months.10
Several evidence-based hospital practices, including providing no food to infants other than breast milk unless medically indicated, have been shown to increase breastfeeding exclusivity and duration and support maternal intention to breastfeed.11,12 Other such hospital practices include maintaining written breastfeeding policies, having trained staff to support the establishment of breastfeeding, and educating all pregnant mothers about the benefits of breastfeeding.11
The 4-D Pathway to Baby-Friendly (discovery, development, dissemination, and designation) has been designed to help hospitals create and maintain a supportive breastfeeding environment.13 Hospitals that complete all phases of the 4-D Pathway, including a verification process and the passage of an on-site assessment, may be granted a license to use the Baby-Friendly certification mark.11
Increasing a hospital’s Baby-Friendly practices improves a woman’s likelihood of breastfeeding for more than 6 weeks; a third of mothers who had experienced none of the Baby-Friendly practices during their hospital stay stopped breastfeeding before 6 weeks, despite their original intention to breastfeed for at least 2 months.14 The Baby-Friendly hospital program has increased breastfeeding rates even among low-income and Hispanic women, who traditionally have had lower breastfeeding rates.15
Hospitals and Formula Use
While breast milk is considered the optimal nutrition for infants, protocols from the Academy of Breastfeeding Medicine (ABM) provide guidance for the use of formula supplementation in full-term healthy infants.
According to the ABM, indications for formula include situations in which breastfeeding is not possible, such as the separation of mother and infant, an infant with an inborn error of metabolism, an infant who is unable to feed at the breast, and maternal use of medications that are contraindicated in breastfeeding.16 The ABM protocol also includes possible infant indications for formula supplementation, such as hypoglycemia that is unresponsive to frequent breastfeeding and evidence of dehydration, as well as possible maternal indications, such as primary glandular insufficiency.16
Supplemental formula in infants without a necessitating indication can have adverse effects on breastfeeding, including the establishment of maternal milk supply, which ultimately may affect breastfeeding duration.17 First-time mothers who note difficulty with breastfeeding, including the perception of inadequate milk supply, the perception of insufficient intake, and indications of poor latch-on, may benefit from lactation assistance, breastfeeding education, and reassurance; however, provision of in-hospital formula supplementation is not indicated in these cases.16,18 Offering in-hospital supplemental formula as a means of protecting these women from the anxiety and stress associated with breastfeeding doubled their risk of not fully breastfeeding between days 30 and 60 and tripled their risk of ceasing breastfeeding by day 60.18
The Take-Home Message
Strong evidence supports breast milk as the optimal nutrition for infants due to its numerous health benefits, and hospitals’ provision of industry-sponsored formula may negatively impact new mothers’ intention to breastfeed.6,10 Initiatives such as Baby-Friendly hospital practices are shifting the paradigm from the marketing of formula as a close approximation to breast milk to removing it from the standard maternal discharge package.13 Reducing in-hospital formula supplementation may increase the exclusivity and duration of breastfeeding among new mothers and ultimately allow expert recommendations and Healthy People 2020 objectives to be met.1,4,18
Nicole D. Garcia is a medical student at the West Virginia University School of Medicine in Morgantown, West Virginia.
Emily K. Nease, MD, is an assistant professor of pediatrics at the West Virginia University School of Medicine.
Linda S. Nield, MD—Series Editor, is a professor of pediatrics at the West Virginia University School of Medicine.
1. American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.
2. World Health Organization. Infant and young child feeding. Fact sheet 342. http://www.who.int/mediacentre/factsheets/fs342/en/. Updated February 2014. Accessed November 10, 2014.
3. Centers for Disease Control and Prevention. Breastfeeding Report Card United States/2014. http://www.cdc.gov/breastfeeding/data/reportcard.htm. Updated July 31, 2014. Accessed November 10, 2014.
4. US Department of Health and Human Services. Healthy People 2020: maternal, infant, and child health objectives. http://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health/objectives. Accessed November 10, 2014.
5. Kaplan DL, Graff KM. Marketing breastfeeding—reversing corporate influence on infant feeding practices. J Urban Health. 2008;85(4):486-504.
7. World Health Organization. International Code of Marketing of Breast-milk Substitutes. Geneva, Switzerland: World Health Organization; 1981. http://www.who.int/nutrition/publications/code_english.pdf. Accessed November 10, 2014.
6. Feldman-Winter L, Grossman X, Palaniappan A, et al. Removal of industry-sponsored formula packs from the hospital: does it make a difference? J Hum Lact. 2012;28(3):380-388.
8. Sadacharan R, Grossman X, Sanchez E, Merewood A. Trends in US hospital distribution of industry-sponsored infant formula sample packs. Pediatrics. 2011;128(4):702-705.
9. Rosenberg KD, Eastham CA, Kasehagen LJ, Sandoval AP. Marketing infant formula through hospitals: the impact of commercial hospital discharge packs on breastfeeding. Am J Public Health. 2008;198(2):290-295.
10. Sadacharan R, Grossman X, Matlak S, Merewood A. Hospital discharge bags and breastfeeding at 6 months: data from the Infant Feeding Practices Study II. J Hum Lact. 2014;30(1):73-79.
11. World Health Organization. Ten steps to successful breastfeeding. In: Protecting, Promoting and supporting Breast-Feeding and the Special Role of Maternity Services: a Joint WHO/UNICEF Statement. Geneva, Switzerland: World Health Organization; 1989. http://whqlibdoc.who.int/publications/
9241561300.pdf. Accessed November 10, 2014.
12. Perrine CG, Scanlon KS, Li R, Odom E, Grummer-Strawn LM. Baby-Friendly hospital practices and meeting exclusive breastfeeding intention. Pediatrics. 2012;130(1):54-60.
13. 4-D pathway resources. Baby-Friendly USA. http://www.babyfriendlyusa.org/get-started/4d-pathway-resources. Accessed November 10, 2014.
14. DiGirolamo AM, Grummer-Strawn LM, Fein SB. Effect of maternity-care practices on breastfeeding. Pediatrics. 2008;122(suppl 2):S43-S49.
15. Merewood A, Mehta SD, Chamberlain LB, Philipp BL, Bauchner H. Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics. 2005;116(3):628-634.
16. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeed Med. 2009;4(3):175-182.
17. Holmes AV, McLeod AY, Bunik M. ABM clinical protocol #5: peripartum breastfeeding management for the healthy mother and infant at term, revision 2013. Breastfeed Med. 2013;8(6):469-473.
18. Chantry CJ, Dewey KG, Peerson JM, Wagner EA, Nommsen-Rivers LA. In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. J Pediatr. 2014;164(6):1339.e5-1345.e5.