ABSTRACT

OBJECTIVE

To analyze the receipt of sponsorships from breast-milk substitute companies by health professionals in scientific events.

METHODS

Multicenter study (Multi-NBCAL) performed from November 2018 to November 2019 in six cities in different Brazilian regions. In 26 public and private hospitals, pediatricians, nutritionists, speech therapists, and a hospital manager were interviewed using a structured questionnaire. Descriptive analyses were carried out regarding the health professionals’ knowledge about the Norma Brasileira de Comercialização de Alimentos para Lactentes e Crianças de Primeira Infância, Bicos, Chupetas e Mamadeiras (NBCAL – Brazilian Code of Marketing of Infant and Toddlers Food and Childcare-related Products), companies sponsoring scientific events, and material or financial sponsorships received, according to profession.

RESULTS

We interviewed 217 health professionals, mainly pediatricians (48.8%). Slightly more than half of the professionals (54.4%) knew NBCAL, most from Baby-friendly Hospitals. Most health professionals (85.7%) attended scientific events in the last two years, more than half of them (54.3%) sponsored by breast-milk substitute companies, especially Nestlé (85.1%) and Danone (65.3%). These professionals received sponsorships in the events, such as office supplies (49.5%), meals or invitations to parties (29.9%), promotional gifts (21.6%), payment of the conference registration fee (6.2%) or ticket to the conference (2.1%).

CONCLUSION

The infant food industries violate NBCAL by harassing health professionals in scientific conferences, offering diverse material and financial sponsorships.

Breast-Milk Substitutes; Legislation, Food; Food Publicity; Scientific and Educational Events; Health Personnel

INTRODUCTION

The first years of a child’s life are characterized by the speed of growth and development, and breast milk is recognized as the gold standard for infant nutrition, as it presents modulatory function ¹1. Garwolińska D, Namieśnik J, Kot-Wasik A, Hewelt-Belka W. Chemistry of human breast milk: a comprehensive review of the composition and role of milk metabolites in child development. J Agric Food Chem. 2018;66(45):11881-96. https://doi.org/10.1021/acs.jafc.8b04031
https://doi.org/10.1021/acs.jafc.8b04031... , reduces infant morbidity and mortality, and provides immune protection to the child ²2. Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90. https://doi.org/10.1016/S0140-6736 (15)01024-7
https://doi.org/10.1016/S0140-6736 (15)0... . The World Health Organization (WHO) recommends exclusive breastfeeding during the first six months of life and breastfeeding complemented by healthy foods up to two years of age or more ³3. World Health Organization. Indicators for assessing infant and young child feeding practices: Part 1, Definitions. Geneva (CH): WHO; 2008. .

Aiming to protect breastfeeding, the WHO and the United Nations Children’s Fund (UNICEF), in the Joint Meeting on Infant and Young Child Feeding in 1979, proposed the creation of a set of regulatory standards that originated, in 1981, the International Code of Marketing of Breast-milk Substitutes ⁴4. World Health Organization. Marketing of breast milk substitutes: national implementation of the international code status report 2016. Geneva (CH): WHO; 2016. .

Inspired by the Code, the first Brazilian legislation to regulate the advertising and marketing of breast-milk substitutes was created in 1988. It underwent several updates over the years and is currently called Norma Brasileira de Comercialização de Alimentos para Lactentes e Crianças de Primeira Infância, Bicos, Chupetas e Mamadeiras (NBCAL – Brazilian Code of Marketing of Infant and Toddlers Food and Childcare-related Products), acquiring force of law in 2006 ⁵5. Prado ISCF, Rinaldi AEM. Compliance of infant formula promotion on websites of Brazilian manufacturers and drugstores. Rev Saude Publica. 2020;54:12. https://doi.org/10.11606/s1518-8787.2020054001327
https://doi.org/10.11606/s1518-8787.2020... . Law No. 11.265/2006 establishes that manufacturers of infant formulas, toddlers formulas, milks, commercial complementary foods, and related childcare products, as well as distributors of these products, can not offer material or financial sponsorship to individuals. Such sponsorship is only allowed to scientific education and research institutions, or to nationally recognized associations of pediatricians and nutritionists ⁶6. Brasil. Lei Nº 11.265, de 3 de janeiro de 2006. Regulamenta a comercialização de alimentos para lactentes e crianças de primeira infância e também a de produtos de puericultura correlatos. Diário Oficial da União. 4 jan 2006; Seção 1:1-3. . Decree No. 9.579/2018, which regulates this Law, defines sponsorship as the funding of materials, research, events, or of the participation of health professionals in activities, or any kind of incentive. Companies are allowed to provide one sample of infant formula or baby food to pediatricians or nutritionists at the time of the product launch ⁷7. Brasil. Decreto N º 9.579, de 22 de novembro de 2018. Consolida atos normativos editados pelo Poder Executivo federal que dispõem sobre a temática do lactente, da criança e do adolescente e do aprendiz, e sobre o Conselho Nacional dos Direitos da Criança e do Adolescente, o Fundo Nacional para a Criança e o Adolescente e os programas federais da criança e do adolescente, e dá outras providências. Diário Oficial da União. 23 nov 2018; Seção 1:49. . The Agência Nacional de Vigilância Sanitária (ANVISA – Brazilian Health Regulatory Agency) is responsible for monitoring and punishing companies that violate NBCAL ⁸8. Bartolini FLS, Amaral MPH, Vilela MAP, Mendonça AE, Vilela FMP, Amaral LH, et al. Official monitoring of the Brazilian Norm for Commercialization of food for nursling and children of first infancy, rubber nipples, pacifiers, and nursing bottles - NBCAL. Braz J Pharm Sci. 2009;45(3):475-82. .

Although the government and civil society organizations invest in protecting breastfeeding, marketing strategies of multinational corporations that produce breast-milk substitutes are constantly renewed and proved to be effective in increasing sales, which shows the importance of comprehensive national laws and proper monitoring of their practices ⁹9. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491-504. https://doi.org/10.1016/S0140-6736 (15)01044-2
https://doi.org/10.1016/S0140-6736 (15)0... . As marketing strategies, companies that produce infant formulas, teats, pacifiers, and baby bottles have been presenting their products as equally good or superior to breastfeeding ⁹9. Rollins NC, Bhandari N, Hajeebhoy N, Horton S, Lutter CK, Martines JC, et al. Why invest, and what it will take to improve breastfeeding practices? Lancet. 2016;387(10017):491-504. https://doi.org/10.1016/S0140-6736 (15)01044-2
https://doi.org/10.1016/S0140-6736 (15)0... and using the influence of health professionals on mothers and families to increase their market ¹⁰10. Lake L, Kroon M, Sanders D, Goga A, Witten C, Swart R, et al. Child health, infant formula funding and South African health professionals: eliminating conflict of interest. S Afr Med J. 2019;109(12):902-6. https://doi.org/10.7196/SAMJ.2019.v109i12.14336
https://doi.org/10.7196/SAMJ.2019.v109i1... .

The infant food industry attends scientific events to present its products and influence health professionals. The purpose of this industry’s harassment is to create links with health professionals, teachers, and students ¹¹11. Pereira TN, Nascimento FA, Bandoni DH. Conflito de interesses na formação e prática do nutricionista: regulamentar é preciso. Cien Saude Colet. 2016;21(12):3833-44. https://doi.org/10.1590/1413-812320152112.13012015
https://doi.org/10.1590/1413-81232015211... . This study aimed to analyze the receipt of sponsorships from breast-milk substitute companies by health professionals in scientific events.

METHODS

This is a cross-sectional study, part of the Estudo Multicêntrico de Avaliação do Cumprimento da NBCAL (Multi-NBCAL – Multicenter Study for NBCAL Compliance Assessment). The project was approved by the Fiocruz research ethics committee under protocol no. 2.912.729/2018.

The survey team consisted of a coordinator and vice coordinator specialist in surveys and NBCAL, as well as a field supervisor and from one to four interviewers per city. All supervisors and interviewers participated in 20-hour theoretical and practical courses on NBCAL—with practical sessions to assess its compliance in hospitals, drugstores, and supermarkets—and were instrumentalized in online data collection.

This study was carried out in hospitals with obstetric beds, according to a protocol adapted from the NetCode (NetCode periodic assessment) ¹²12. World Health Organization. Netcode toolkit: monitoring the marketing of breast-milk substitutes: protocol for ongoing monitoring systems. Geneva (CH): WHO; 2017. , which recommends the random selection of 10 maternity hospitals in the capital or the largest city of the assessed country, as well as the selection of more maternity hospitals in other settings, if financially possible.

The survey coordination chose to compare different types of hospitals, located in capitals with different Municipal Human Development Indexes and in a city in the interior of Brazil, in order to decentralize the study from the capital or the biggest city due to the great diversity and large extension of the country. The cities were chosen intentionally, according to the availability of institutions and researchers focused on the subject ¹³13. Boccolini CS, Oliveira MIC, Toma TS, Peres PLP, Santos EKA, Passos MC, et al. Metodologia e indicadores para monitoramento da NBCAL em estabelecimentos comerciais e serviços de saúde: estudo multicêntrico (Multi-NBCAL). Cad Saude Publica. 2021; 37 Sup 1:e00272920. https://doi.org/10.1590/0102-311X00272920
https://doi.org/10.1590/0102-311X0027292... . The survey was performed from November 2018 to November 2019 in six cities in different Brazilian regions: Rio de Janeiro, RJ (six hospitals), São Paulo, SP (five hospitals), Ouro Preto, MG (one hospital), Florianópolis, SC (four hospitals), João Pessoa, PB (six hospitals), and Brasília, DF (four hospitals).

In each city, all hospitals with obstetric beds with more than 500 births per year were listed via consultation in the Cadastro Nacional de Estabelecimentos de Saúde (CNES – National Registry of Health Establishments) ^aaMinistério da Saúde (BR), DATASUS. Cadastro Nacional de Estabelecimentos de Saúde – CNES. Brasília, DF; s.d. [cited 2022 May 22]. Available from: https://cnes.datasus.gov.br/ . They were categorized as public hospitals accredited by the Baby-friendly Hospital Initiative (BFHI), public hospitals non-accredited by the BFHI, and private hospitals. This study did not include private Baby-friendly Hospitals because, at the time, Brazil only had nine hospitals of this type, all located in interior cities ^bbMinistério da Saúde. Portal Saúde da Criança NET. IHAC - Iniciativa Hospital Amigo da Criança [cited 2022 May 22]. Available from: http://sisac.datasus.gov.br/saudedacrianca/ihacSobre.html# . The sample would come from two hospitals per stratum in each city and, if the number were higher than this amount in the municipality, they would be randomly selected. However, only four hospitals had obstetric beds in Florianópolis, SC, and all of the public ones were Baby-friendly Hospitals. In Ouro Preto, MG, only one hospital had obstetric beds and it was also a Baby-friendly Hospital. In João Pessoa, PB, all public hospitals were accredited by this initiative. In two cities, three maternity hospitals refused to participate in the study. Difficulties in obtaining the Termos de Autorização Institucional (TAI – Institutional Authorization Agreement) prevent this study from reaching the previously established sample ¹³13. Boccolini CS, Oliveira MIC, Toma TS, Peres PLP, Santos EKA, Passos MC, et al. Metodologia e indicadores para monitoramento da NBCAL em estabelecimentos comerciais e serviços de saúde: estudo multicêntrico (Multi-NBCAL). Cad Saude Publica. 2021; 37 Sup 1:e00272920. https://doi.org/10.1590/0102-311X00272920
https://doi.org/10.1590/0102-311X0027292... . Finally, this study assessed 11 Baby-friendly Hospitals, six non-accredited public hospitals, and nine private hospitals.

The interviewers carried out the survey in a single day, personally interviewing in each maternity a hospital manager, five pediatricians, and five nutritionists and/or speech therapists—a fixed number of professionals per maternity, according to the NetCode monitoring protocol ¹²12. World Health Organization. Netcode toolkit: monitoring the marketing of breast-milk substitutes: protocol for ongoing monitoring systems. Geneva (CH): WHO; 2017. . If less than 10 professionals of these categories were working in the maternity hospital on the day of the survey, all of them were interviewed. If more than 10 professionals were working, a hospital manager listed the pediatricians, nutritionists, and speech therapists present on the day of the survey and up to five pediatricians, five nutritionists and/or speech therapists, and one hospital manager were randomly selected. All interviewees signed an informed consent form ¹³13. Boccolini CS, Oliveira MIC, Toma TS, Peres PLP, Santos EKA, Passos MC, et al. Metodologia e indicadores para monitoramento da NBCAL em estabelecimentos comerciais e serviços de saúde: estudo multicêntrico (Multi-NBCAL). Cad Saude Publica. 2021; 37 Sup 1:e00272920. https://doi.org/10.1590/0102-311X00272920
https://doi.org/10.1590/0102-311X0027292... .

For the interviews, an online electronic questionnaire was applied using the MAGPI application, installed on mobile phones with Android operating system, with intuitive interface for data entry, electronic hosting on Fiocruz servers, data collection online monitoring, and possibility of exporting data to the most common statistical packages ¹⁴14. Abbot A. Paper, paper, everywhere. Nature. 2005;437(7057):310. .

The questionnaire used was adapted from the International Baby Food Action Network (IBFAN) ^ccRede Internacional em Defesa do Direito de Alimentar. Belo Horizonte, MG: IBFAN Brasil; 2022 [cited 2022 May 22]. Available from: http://www.ibfan.org.br and NetCode ¹²12. World Health Organization. Netcode toolkit: monitoring the marketing of breast-milk substitutes: protocol for ongoing monitoring systems. Geneva (CH): WHO; 2017. monitoring questionnaire, with content validation by expert panel ¹³13. Boccolini CS, Oliveira MIC, Toma TS, Peres PLP, Santos EKA, Passos MC, et al. Metodologia e indicadores para monitoramento da NBCAL em estabelecimentos comerciais e serviços de saúde: estudo multicêntrico (Multi-NBCAL). Cad Saude Publica. 2021; 37 Sup 1:e00272920. https://doi.org/10.1590/0102-311X00272920
https://doi.org/10.1590/0102-311X0027292... . The interviewees were asked about: (1) health professional profile: sex, age, skin color, profession, time since graduation, and sectors of activity (more than one sector could be mentioned: rooming-in, neonatal ICU, human milk bank); (2) knowledge about NBCAL: yes, regular (corresponding to the answers “I have an idea” and “I have heard about it”), or no; mentioned at least one product covered by NBCAL: yes (infant formula, teat, baby bottle, pacifier, toddlers formula, milk, or commercial complementary food) or no; participation in training in NBCAL by a course or class: yes or no; agency responsible for training: government agency, professional association, industry, private (corresponding to private university, private hospital, paid course, or other company, as distributors); participation in training in infant feeding: yes or no; (3) participation in a conference or symposium on infant feeding in the last two years: yes or no; event sponsorship by infant food or related products companies: yes or no; sponsor company (more than one company could be mentioned: Nestlé, Danone, Abbott, Mead Johnson, other); sponsorship received by the health professional (more than one could be mentioned: payment of the conference registration fee, ticket to the conference, meal or invitations to parties, office supplies, promotional gift; receipt of free samples of breast-milk substitutes): yes or no.

Descriptive analyses were performed according to the type of hospital, regarding the distribution of health professionals interviewed by city, their profile, their knowledge about NBCAL, their training in NBCAL, and the agency responsible for their course and training in infant feeding. The proportion of each agency responsible for training in NBCAL was estimated only among professionals who were trained.

To verify the homogeneity of the health professionals’ characteristics, as well as their knowledge and training in NBCAL and infant feeding, according to the type of hospital, a Pearson’s chi-squared test was applied, considering a 5% level of statistical significance.

The proportion of health professionals who attended scientific events in the last two years, according to profession, was analyzed. The proportion of those who reported that the event was sponsored by breast-milk substitute companies was estimated and each professional presented the companies that sponsored the events, being able to mention more than one company.

Finally, among the health professionals who attended scientific events sponsored by this industry, the frequency of those who received material or financial sponsorships in these events, as well as the frequency of those who received free samples of breast-milk substitutes, according to profession, was analyzed.

RESULTS

We interviewed 217 health professionals who worked in 26 hospitals in six Brazilian cities. Of these professionals, 44.2% worked in public hospitals accredited by the BFHI, 26.3% in public hospitals non-accredited by the BFHI, and 29.5% in private hospitals. Most health professionals interviewed were from Rio de Janeiro, São Paulo, and João Pessoa ( Table 1 ). Four health professionals refused to participate in the study (1.8%).

Most professionals interviewed were women, especially in private hospitals. Most health professionals were white, except in private hospitals, and 12.4% of the professionals did not declare their skin color. Among the interviewees, 48.8% were pediatricians, 29% were nutritionists, 18% were speech therapists, and 4.1% were hospital managers, and this distribution was relatively homogeneous among the different types of hospitals. Most professionals were 35 to 59 years old and had graduated from 11 to 24 years ago. The most frequent sectors of activity were neonatal ICU and rooming-in ( Table 2 ).

A total of 54.4% of health professionals knew NBCAL and 59.9% were able to mention at least one product covered by this legislation. This knowledge was higher among professionals who worked in Baby-friendly Hospitals and lower among those who worked in non-accredited public hospitals. A total of 30% of the interviewees participated in courses or classes on NBCAL, and this number was higher among professionals who worked in Baby-friendly Hospitals (40.6%). Among those trained in NBCAL, 93.8% reported that it was performed by a government agency. The participation in courses or classes on infant feeding was high (93.5%) in all types of hospitals ( Table 3 ).

Most health professionals attended scientific events in the last two years (85.7%) and 54.3% of them reported that breast-milk substitute companies sponsored these events, mainly pediatricians (71.1%). Nestlé (85.1%) and Danone (65.3%) were the most mentioned sponsor companies of scientific events ( Table 4 ).

Most health professionals who attended scientific events sponsored by breast-milk substitute companies received material or financial sponsorship from the sponsor company, such as office supplies (49.5%), meals or invitations to parties (29.9%), promotional gifts (21.6%), payment of the conference registration fee (6.2%), or ticket to the conference (2.1%). About one third of the interviewees did not receive sponsorship. A total of 22.7% of health professionals received free samples of breast-milk substitutes: 25% of pediatricians, 18.8% of nutritionists, a speech therapist, and another health professional ( Table 5 ).

DISCUSSION

Although prohibited by Law No. 11.265/2006, almost two thirds of the professionals who attended scientific events sponsored by breast-milk substitute companies received material or financial sponsorship in these events. Breast-milk substitute companies harass pediatricians, nutritionists, and speech therapists by paying registration fees and tickets to conferences—both high-cost items—as well as by inviting to parties and meals and offering bags, pens, notebooks, notepads, calendars, and promotional gifts—all low-cost items. Besides harassing health professionals by financial sponsorship and gifts, in scientific events, breast-milk substitute companies disseminate information favorable to the use of their products ¹⁵15. Tanrikulu H, Neri D, Robertson A, Mialon M. Corporate political activity of the baby food industry: the example of Nestlé in the United States of America. Int Breastfeed J. 2020;15(1):22. https://doi.org/10.1186/s13006-020-00268-x
https://doi.org/10.1186/s13006-020-00268... , aiming to influence pediatricians, whose relationship with patients is considered “fiduciary” in the prescription of these products, as they have specialized knowledge, experience, and the confidence of all ¹⁶16. Wright CM, Waterston AJR. Relationships between paediatricians and infant formula milk companies. Arch Dis Child. 2006;91(5):383-5. https://doi.org/10.1136/adc.2005.072892
https://doi.org/10.1136/adc.2005.072892... . Companies also establish relationships with opinion leaders and health organizations in order to influence health programs by accessing and placing actors in government policy contexts ¹⁵15. Tanrikulu H, Neri D, Robertson A, Mialon M. Corporate political activity of the baby food industry: the example of Nestlé in the United States of America. Int Breastfeed J. 2020;15(1):22. https://doi.org/10.1186/s13006-020-00268-x
https://doi.org/10.1186/s13006-020-00268... . They also aim to impair regulatory measures, prevent the approval of legislation, delay their implementation, or reverse measures already implemented ¹⁷17. Burlandy L, Alexandre VP, Gomes FS, Castro IRR, Dias PC, Henriques P, et al. Políticas de promoção da saúde e potenciais conflitos de interesses que envolvem o setor privado comercial. Cien Saude Colet. 2016;21(6):1809-18. https://doi.org/10.1590/1413-81232015216.06772016
https://doi.org/10.1590/1413-81232015216... .

The promotion of breast-milk substitutes by its manufacturers and distributors is a barrier to increase breastfeeding worldwide ¹⁸18. Sharfstein JM, Silver DL. Relationship between the American Academy of Pediatrics and infant formula companies. JAMA Pediatrics. 2017;171(7):613-4. https://doi.org/10.1001/jamapediatrics.2017.1257
https://doi.org/10.1001/jamapediatrics.2... , ¹⁹19. McFadden A, Mason F, Baker J, Begin F, Dykes F, Grummer-Strawn L, et al. Spotlight on infant formula: coordinated global action needed. Lancet. 2016;387(10017):413-5. https://doi.org/10.1016/S0140-6736 (16)00103-3
https://doi.org/10.1016/S0140-6736 (16)0... , especially in low- and middle-income countries, where sales of breast-milk substitutes grow 10% per year ²⁰20. Piwoz EG, Huffman SL. The impact of marketing of breast-milk substitutes on WHO- recommended breastfeeding practices. Food Nutr Bull. 2015;36(4):373-86. https://doi.org/10.1177/0379572115602174
https://doi.org/10.1177/0379572115602174... . In these countries, only 37% of children under six months of age are exclusively breastfed, and breastfeeding could save up to 823,000 children every year ²2. Victora CG, Bahl R, Barros AJD, França GVA, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475-90. https://doi.org/10.1016/S0140-6736 (15)01024-7
https://doi.org/10.1016/S0140-6736 (15)0... .

NBCAL prohibits breast-milk substitute companies to sponsor individuals, in order to protect mothers from inadequate commercial pressures, since the infant food industry uses various strategies to gain mothers’ loyalty in the consumption of their products ²¹21. Hastings G; Angus K; Eadie D; Hunt K. Selling second best: how infant formula marketing works. Global Health. 2020;16:77. https://doi.org/10.1186/s12992-020-00597-w
https://doi.org/10.1186/s12992-020-00597... .

However, in our study, about 60% of pediatricians who attended scientific events sponsored by these companies received material or financial sponsorships in these events. More than 40% received office supplies and almost a third were invited to parties or meals. Nutritionists and speech therapists were also heavily harassed by the infant food industry. A study carried out in Indonesia showed that multinational infant food companies also offers health professionals magnets, posters, thermometers, calendars, growth charts, and frequent visits to them ²²22. Hidayana I, Februhartanty J, Parady VA. Violations of the International Code of Marketing of Breast-milk Substitutes: Indonesia context. Public Health Nutr. 2017;20(1):165-73. https://doi.org/10.1017/S1368980016001567
https://doi.org/10.1017/S136898001600156... . When health professionals accept those gifts, they are indirectly promoting breast-milk substitute companies instead of supporting breastfeeding. Moreover, when health professionals have promotional gifts with the logo of infant food companies, their patients can understand it as an incentive to the use of these products ²³23. Pries AM, Huffman SL, Adhikary I, Upreti SR, Dhungel S, Champeny M, et al. Promotion and prelacteal feeding of breastmilk substitutes among mothers in Kathmandu Valley, Nepal. Matern Child Nutr. 2016;12 Suppl 2:8-21. https://doi.org/10.1111/mcn.12205
https://doi.org/10.1111/mcn.12205... .

Grummer-Strawn et al. ²⁴24. Grummer-Strawn LM, Holliday F, Jungo KT, Rollins N. Sponsorship of national and regional professional paediatrics associations by companies that make breast-milk substitutes: evidence from a review of official websites. BMJ Open. 2019;9(8):e029035. https://doi.org/10.1136/bmjopen-2019-029035
https://doi.org/10.1136/bmjopen-2019-029... , using data collected on the Internet, observed a strong presence of the infant food industry among pediatricians, as 60% of pediatric associations worldwide received some kind of financial sponsorship from breast-milk substitute companies, especially in the Americas (82%), Europe (66%), and Asia (50%). This reality is similar in Brazil, where a partnership between the Sociedade Brasileira de Pediatria (SBP – Brazilian Pediatric Association) and a breast-milk substitute company resulted in the Programa Jovens Pediatras: Nestlé Nutrition (Young Pediatricians Program: Nestlé Nutrition), a program to influence the professional training of residents in pediatrics ^ddAliança pela Alimentação Adequada e Saudável. Porto Alegre, RS; c2020 [cited 2020 Jul 10]. Available from: https://alimentacaosaudavel.org.br/blog/organizacoes-denunciam-conflito-de-interesse-em-curso-da-nestle-para-medicos-residentes-de-pediatria/8180/ .

When a health or nutrition conference in sponsored by an infant food company, it works as an endorsement to that brand. When an event is sponsored by breast-milk substitute companies, the event promoter must then support the use of the industry’s products or practices ¹⁰10. Lake L, Kroon M, Sanders D, Goga A, Witten C, Swart R, et al. Child health, infant formula funding and South African health professionals: eliminating conflict of interest. S Afr Med J. 2019;109(12):902-6. https://doi.org/10.7196/SAMJ.2019.v109i12.14336
https://doi.org/10.7196/SAMJ.2019.v109i1... . Financial support or any kind of sponsorship by manufacturers of breast-milk substitutes can build the loyalty of health professionals and professional associations to infant food companies ²²22. Hidayana I, Februhartanty J, Parady VA. Violations of the International Code of Marketing of Breast-milk Substitutes: Indonesia context. Public Health Nutr. 2017;20(1):165-73. https://doi.org/10.1017/S1368980016001567
https://doi.org/10.1017/S136898001600156... . Rea and Toma ²⁵25. Rea MF, Toma TS. Proteção do leite materno e ética. Rev Saude Publica. 2000; 34(4):388-95. https://doi.org/10.1590/S0034-89102000000400012
https://doi.org/10.1590/S0034-8910200000... , in one of the first national studies on the subject, highlight the conflicts of interest involved in the health professional–industry relationship, presenting results from a NBCAL monitoring carried out in more than 30 Brazilian cities, which observed ways breast-milk substitute companies use to attract health professionals, such as granting plane tickets, airport pickup, and conference registration.

Among multinational breast-milk substitute companies, Nestlé was the most mentioned by health professionals as sponsor of scientific events. Brazil is the second largest market and the fifth largest country in revenue of Nestlé. This company is the food industry leader, with 15 branches throughout Brazil, besides five distribution centers, four warehouses, and 26 factories ²⁶26. Zilber SN, Silva FL. Investigação sobre a existência de inovações disruptivas das grandes empresas multinacionais para o mercado brasileiro de baixa renda. Produção. 2013;23(2):283-96. https://doi.org/10.1590/S0103-65132012005000049
https://doi.org/10.1590/S0103-6513201200... . Similarly, in Mexico, managers of public and private hospitals pointed Nestlé as the manufacturer of infant food that most contacts them ²⁷27. Hernández-Cordero S, Lozada-Tequeanes AL, Shamah-Levy T, Lutter C, González de Cosío T, Saturno-Hernandez P, et al. Violations of the International Code of Marketing of Breast-milk Substitutes in Mexico. Matern Child Nutr. 2019;15:e12682. https://doi.org/10.1111/mcn.12682
https://doi.org/10.1111/mcn.12682... .

Although more than half of health professionals knew NBCAL and almost 60% were able to mention at least one product covered by it, less than one third participated in some course or class on the subject. Most courses or classes on NBCAL were performed by government agencies. Professional associations must present a greater commitment in training professionals to comply with NBCAL and the International Code of Marketing of Breast-milk Substitutes, as the lack of training promoted by them is impressive. Understanding this important legislation to protect breastfeeding would not prevent health professionals from promoting breast-milk substitute companies, but it could increase their perception on the conflicts of interest involved and reduce violations of this Law, contributing to the promotion of community health ²⁸28. Liu A, Dai Y, Xie X, Chen L. Implementation of International Code of Marketing Breast- Milk Substitutes in China. Breastfeed Med. 2014;9(9):467-72. https://doi.org/10.1089/bfm.2014.0053
https://doi.org/10.1089/bfm.2014.0053... .

Current medical school curricula are more focused on teaching their students how to feed babies with infant formula than on supporting mothers to breastfeed with counseling skills ²⁹29. Pérez-Escamilla R. Breastfeeding in the 21st century: how we can make it work. Soc Sci Med. 2020;244:112331. https://doi.org/10.1016/j.socscimed.2019.05.036
https://doi.org/10.1016/j.socscimed.2019... . A study performed with students from the Faculdade de Medicina da Universidade Federal de Alagoas observed that students in the last period know little about the International Code and NBCAL, showing that much must be done to promote teaching about breastfeeding in the medical school ³⁰30. Frazão SM, Vasconcelos MVL, Pedrosa CM. Conhecimento dos discentes sobre aleitamento materno em um curso médico. Rev Bras Educ Med. 2019;43(2):58-66. https://doi.org/10.1590/1981-52712015v43n2rb20180175
https://doi.org/10.1590/1981-52712015v43... .

In our study, professionals who worked in Baby-friendly Hospitals presented more knowledge and training in NBCAL, however, the expected was that all professionals knew this legislation, a mandatory content in their education. Continuing education is necessary for professionals with long time since training to improve their knowledge and for systematical training of professionals hired after the hospital being accredited by the BFHI ³¹31. Lamounier JA, Chaves RG, Rego MAS, Bouzada MCF. Iniciativa Hospital Amigo da Criança: 25 anos de experiência no Brasil. Rev Paul Pediatr. 2019;37(4):486-93. http://doi.org/10.1590/1984-0462/;2019;37;4;00004
http://doi.org/10.1590/1984-0462/;2019;3... . The BFHI was created to provide greater support to the practice of breastfeeding in hospitals with obstetric beds by training health professionals and adjusting hospital routines. A criterion to meet the first of the Ten Steps to Successful Breastfeeding ²⁴24. Grummer-Strawn LM, Holliday F, Jungo KT, Rollins N. Sponsorship of national and regional professional paediatrics associations by companies that make breast-milk substitutes: evidence from a review of official websites. BMJ Open. 2019;9(8):e029035. https://doi.org/10.1136/bmjopen-2019-029035
https://doi.org/10.1136/bmjopen-2019-029... , an initiative considered an important strategy, is the compliance with the International Code of Marketing of Breast-milk Substitutes. This strategy affects positively breastfeeding rates and is included in the Sustainable Development Agenda of the United Nations ³¹31. Lamounier JA, Chaves RG, Rego MAS, Bouzada MCF. Iniciativa Hospital Amigo da Criança: 25 anos de experiência no Brasil. Rev Paul Pediatr. 2019;37(4):486-93. http://doi.org/10.1590/1984-0462/;2019;37;4;00004
http://doi.org/10.1590/1984-0462/;2019;3... , ³²32. Pérez-Escamilla R, Martinez JL, Segura-Pérez S. Impact of the Baby-friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr. 2016;12(3):402-17. https://doi.org/10.1111/mcn.12294
https://doi.org/10.1111/mcn.12294... . The sustainability of its actions is a target of continuous monitoring in Brazil ³³33. Araújo RG, Fonseca VM, Oliveira MIC, Ramos EG. External evaluation and self- monitoring of the Baby-friendly Hospital Initiative’s maternity hospitals in Brazil. Int Breastfeed J. 2019;14:1-9. https://doi.org/10.1186/s13006-018-0195-4
https://doi.org/10.1186/s13006-018-0195-... .

Our study presented limitations: we do not know if the samples received by the pediatricians and nutritionists interviewed corresponded to products being launched, therefore, we could not evaluate to what extent the industry was violating Law No. 11.265/2006. However, in this study, other health professionals also received samples of breast-milk substitutes, violating NBCAL ⁷7. Brasil. Decreto N º 9.579, de 22 de novembro de 2018. Consolida atos normativos editados pelo Poder Executivo federal que dispõem sobre a temática do lactente, da criança e do adolescente e do aprendiz, e sobre o Conselho Nacional dos Direitos da Criança e do Adolescente, o Fundo Nacional para a Criança e o Adolescente e os programas federais da criança e do adolescente, e dá outras providências. Diário Oficial da União. 23 nov 2018; Seção 1:49. . Moreover, we asked health professionals information related to the receipt of sponsorships in conferences in the last two years, subject to memory bias, since forgetting the receipt of sponsorships may be more frequent than reporting non-existent receipt of sponsorships. This bias may underestimate sponsorships received, especially lower-cost gifts.

The NetCode ¹²12. World Health Organization. Netcode toolkit: monitoring the marketing of breast-milk substitutes: protocol for ongoing monitoring systems. Geneva (CH): WHO; 2017. methodology proposes to identify the most frequent violations of the International Code ⁴4. World Health Organization. Marketing of breast milk substitutes: national implementation of the international code status report 2016. Geneva (CH): WHO; 2016. (and NBCAL ⁶6. Brasil. Lei Nº 11.265, de 3 de janeiro de 2006. Regulamenta a comercialização de alimentos para lactentes e crianças de primeira infância e também a de produtos de puericultura correlatos. Diário Oficial da União. 4 jan 2006; Seção 1:1-3. ) by its method of random selection of maternity hospitals, and interviews. Multi-NBCAL adapted this protocol, assessing 26 maternity hospitals from different cities, including the capital and the largest city of the country. Our limitation was its non-probabilistic sample, which reduces the possibility of generalization of the results. Thus, the findings of this study present the reality of the professionals interviewed in the included maternity hospitals and may not be considered as the reality of the cities assessed. However, the results of this multicenter study are sufficient to discuss potential conflicts of interest in professional practices facing harassment of breast-milk substitutes companies.

A reliability study of the questionnaire is necessary to assess its psychometric properties, however, the constant monitoring of application of most questionnaires by experienced researchers, associated with the rigorous training of interviewers, may have reduced a potential interobserver variability. A reliability analysis of the questionnaire found a Cronbach’s alpha of 0.794 for the questions evaluated in this study (non-tabulated data), a pattern considered high.

Infant food industry marketing strategies focused on health professionals are frequent in education spaces, such as conferences and scientific symposia, showing that the existence of a regulation, even as a law, is not enough to prevent illegal practices to promote breast-milk substitutes, although the effect on child health is widely known ³⁴34. Robinson H, Buccini G, Curry L, Escamilla RP. The World Health Organization Code and exclusive breastfeeding in China, India, and Vietnam. Matern Child Nutr. 2019;15:e12685. https://doi.org/10.1111/mcn.12685
https://doi.org/10.1111/mcn.12685... . Inadequate monitoring of scientific events allows multinational breast-milk substitute companies to improperly involve health professionals in the promotion of their products without any punishment ¹⁹19. McFadden A, Mason F, Baker J, Begin F, Dykes F, Grummer-Strawn L, et al. Spotlight on infant formula: coordinated global action needed. Lancet. 2016;387(10017):413-5. https://doi.org/10.1016/S0140-6736 (16)00103-3
https://doi.org/10.1016/S0140-6736 (16)0... .

We recommend the development of government actions to increase knowledge and commitment to current legislation both by companies and health professionals. Moreover, the theme of conflicts of interest must be addressed since undergraduate health courses. As pediatricians are the health professionals with more influence on mothers—as they not only recommend, but also prescribe infant formulas—pediatric associations must collaborate with the continuing education of their professionals with an ethical commitment to breastfeeding and child health. Health surveillance also must have an effective performance in the NBCAL monitoring for a better compliance with current legislation. Conflict of interest cases between the infant food industry and health professionals must be urgently prevented for the protection of breastfeeding and child health.

REFERENCES

Publication Dates

History