Breast
vs.
Bottle

Part I

Confidence in science and aggressive marketing by manufacturers were not the only reasons for the success of infant formula. Beginning in the 1920s, the breast was sexualized in a way that made public feeding potentially more sensitive than it had formerly been. Bottle-feeding was associated with scientific motherhood and at the same time with freedom from domesticity.

Some bourgeois European circles also welcomed bottle-feeding as a step against prolonged oral gratification and for the development of good habits. The result was a steady increase, though with many national and regional variations, in the proportion of bottle-fed infants between World War I and the 1960s.

In one American study of 1958, 63 percent of infants returning home from the hospital were already consuming only formula, and 21 percent were fed only breast milk. Few employers accommodated working mothers who had nursing infants, but even in the Sweden of the 1960s, where new mothers remaining at home with their infants received 90 percent of their professional salaries, bottle-feeding prevailed.

A revival of breast-feeding among middle- and upper-class women in North America and Europe began in the 1970s and remains a strong force, but it has delayed bottle-feeding rather than replaced it as a routine of upbringing.

In Europe and North America, the health effects of infant formula are still debated. In the great age of expansion of bottle-feeding from 1890 to 1950, infant mortality also dropped markedly --- from 140 to fewer than 40 deaths per 1,000 live births in New York City, for example. Reduction of digestive and respiratory ailments, notably diarrhea and pneumonia, was especially pronounced.

In Sweden, an even more pronounced decline in mortality had begun in the late eighteenth century and continued through the nineteenth and early twentieth. In neither the United States nor Sweden did the trend appear to be affected by the spread of bottle-feeding or by the Depression of the 1930s. All this suggests that in affluent countries, formula-feeding was indeed a good alternative to the wet nursing that had been practiced so widely in early modern Europe.

The great unintended consequence of artificial feeding has arisen not in the industrial countries but in the developing world. Especially since the late nineteenth century, North American and European farmers have produced abundant milk. Breeding and animal nutrition alone have raised the annual yield of a dairy cow from about 1,500 liters in the early nineteenth century to 6,500 liters --- and for some breeds as much as 10,000 liters --- today. Pasteurization has been commercialized since the 1890s, refrigerated trains have drastically reduced spoilage on the way to market or processing, and global beef imports have allowed more European farmers to specialize in dairying.

Meanwhile, the growth of cities and market economies in Asia and Africa made processed infant formula a valuable export. In these markets, infant formula remains costly for all but a small segment of families. The formula producers applied with great success the scientific appeals that had been effective in the West. Infant formula was also promoted as a sign of modernity and education; elites adopted it as a mark of their political and economic authority. In the rest of the population it was most influential in cities, where rapid migration and women's industrial labor helped disrupt the transmission of breast-feeding techniques. Urban slum life and disease can also interfere with lactation.

And even low-income women came to share the privileged classes' view of infant formula as a progressive and scientific alternative to breast-feeding, and the Westernized taboo on the public display of breasts. Advertising linked formula with infant health as well as with prosperity and modernity.

Intentionally or not, it persuaded many mothers who could have established lactation successfully that they suffered from "insufficient milk" syndrome. In some countries, "milk nurses" receiving sales commissions, some of them with real nursing credentials and all easily confused with hospital staff, promoted manufacturers' products to new mothers in hospitals. Inadvertently, distribution of millions of pounds of powdered milk for starving babies by the United Nations Children's Fund (UNICEF) and other agencies in the 1960s helped legitimize substitute food in new markets. What helped the sick would surely benefit the well.

The result instead was malnutrition and death. The first prominent crusader against formula-feeding in the Third World, the pediatrician Dr. Cicely Williams, had promoted condensed milk in combating kwashiorkor, a severe protein-calorie deficiency disease, in Africa. But in 1939, Dr. Williams, then working in Singapore, was disturbed by the consequences of feeding infants sweetened condensed milk.

In those days the product was not supplemented with vitamins D and A, so it had contributed to many cases of rickets and blindness. Speaking on "Milk and Murder" to the Singapore Rotary Club, Williams accused the producers of callous neglect of infant life in the interest of profit.

Well-meaning agencies as well as commercial interests could work against breast-feeding. Two leading pediatric public health specialists, Derrick and Patrice Jelliffe, call the distribution of powdered milk by feeding programs in the 1940s and 1950s a "nutritional tragedy." In the absence of health education programs, the product encouraged a shift to bottlefeeding. The commercial distribution of formula, far from reducing the rate of nutritional deficiencies, increased them seriously. Bottle-fed babies gain weight more slowly than breast-fed ones, and are more likely to suffer from bacterial and viral infections and parasites in their second year.

Marasmus --- a form of severe growth failure closely connected with the lack of high-calorie foods --- is linked with bottle-feeding. Dilution of cow's milk formulas to reduce costs is a special risk factor for marasmus in many poorer countries. Since mother's milk may be the only safe liquid in many regions and feeding bottles may be impossible to keep clean without refrigeration or sanitary storage areas, formula-feeding also promotes infections, especially diarrheal diseases that inhibit appetite and lead to malnutrition and more illness.

Meanwhile, the bottle-fed infant receives none of the protective substances in mother's milk. In seven villages in the Punjab studied in the 1950s, mortality among infants bottle-fed from birth was fully 95 percent during the first eleven months, compared with 12 percent among infants breast-fed from birth.

United Nations-sponsored efforts to encourage industry regulation faltered. In the 1970s, social activists armed with the damaging statistics and with Derrick Jelliffe's identification of "commerciogenic malnutrition" in Jamaica began to urge restrictions on the marketing of infant formula in the developing world. A boycott of Nestlé, begun by religious groups and others, was resolved with a vote of the World Health Organization's (WHO's) World Health Assembly in 1981 establishing a UNICEF code restricting advertising and the distribution of samples and intended to put proprietary formulas under strict medical supervision. Manufacturers' literature now extolled the virtues of mother's milk while encouraging an early transition to bottle-feeding. But activists, believing formula manufacturers were trying to circumvent the UNICEF code despite several amendments designed to close loopholes, renewed the boycott in 1988.