Formula Companies and their "Free" Gifts

A Second Opinion

This article originally appeared in the MCN AM JNL MAT/CHLD NSG 1999:24 (3) : 119
Internet permission to display this article granted by LLW

Should Nurses Offer Discharge Formula Samples to 
Women Who Plan to Breastfeed?

PRO              CON

Writing for the Con Position


The Impact of Formula Discharge Packs on Breastfeeding

Many health professionals today would say they support breastfeeding yet our actions speak louder than words. What message do we send to consumers of health care when we, the health care professional, distribute free formula to patients during their prenatal course, hospitalization and upon discharge? The US health care system is fraught with promotion of infant formula, a practice that needs to be discontinued.

Some believe that it is a wonderful idea to be able to give free samples of formula, literature and gifts to consumers of obstetrical health care, including literature produced by formula companies on breastfeeding. One might be tempted to look at the quality of the brochure or pamphlet only. However, there is a larger principle present that "free" materials aren't really free at all. Who pays the author, artist, printer etc to develop these materials? Certainly not breastfeeding women. The answer is the people who buy the products from the formula company. Mothers who don't breastfeed, either because they don't want to, can't, won't or shouldn't. American taxpayers, people like us, pay for the $600 million of "free" infant formula for WIC annually. People who run homeless shelters, food banks and other hunger programs also pay the price of "free" samples. According to the Attorney General of Florida, for each dollar charged for infant formula, the manufacturer spends only sixteen cents on production and delivery. With this astounding profit margin, is it no wonder that formula companies can afford to provide "free" literature, samples and gifts to consumers and health care professionals?

Distributing or accepting these and the myriad other free gifts that formula companies distribute to consumers and health care professionals means increasing a financial burden on bottle feeding mothers, taxpayers, and those who financially support hunger agencies. The fact of the matter is that formula companies produce breastfeeding literature and breastfeeding discharge kits for one purpose only-to increase the sales of their products. Is this in the best interest of our patients? Is this a conflict of interest for us as professionals?

There is a substantial body of scientific evidence to support our opinion that formula discharge packs do affect breastfeeding in a negative manner. A recent article in the journal "Birth" countered this evidence by concluding that the practice of distributing formula discharge packs did not affect breastfeeding. However, the women involved in this study were provided with appropriate follow-up, which doesn't happen everywhere in the US. Additionally, Ross Labs funded the study, a major manufacturer of infant formula. Who does one believe? The fact remains that exclusive breastfeeding, even in the early months of infancy, is not commonplace. Early supplementation reduces the mother's milk supply and increases her dependence on formula. How many "breastfeeding" brochures promote early supplementation with formula? This early supplementation is encouraged by formula manufacturers so that mothers buy their product for a longer period of time, wean from the breast earlier and continue using formula through the first year of life. What a brilliant marketing tool!

Some health care professionals may discard the formula, literature and coupons from the diaper bags and give mothers the diaper bag manufactured by the formula company. The problem with this practice is that the mother who receives the diaper bag only is still exposed to a marketing practice known as brand sampling or recognition. She'll recognize the name or logo on her bag with the formula company. If we discontinue this practice, some believe that mothers will feel cheated or left out because they didn't receive a free diaper bag at their hospital upon discharge. Is there data to support continuation of this practice? Of even greater concern is the mother who encounters a breastfeeding problem. In some situations, she may use the formula she received upon discharge from the hospital instead of seeking assistance from a knowledgeable health care provider or La Leche League Leader. The practice of formula discharge pack distribution impresses upon the mother that the hospital endorses that particular brand when in fact it is usually the lowest bidder who obtains the privilege to supply the hospital with that brand. Do health care professionals wish to continue being unpaid sales representatives for the formula companies? Some may argue that they aren't unpaid when they accept free food, training and gifts from a formula company, a practice that the authors, along with many other lactation professionals, discourage. These practices that occur in clinics and hospitals across the US are in direct violation of the WHO/UNICEF International Code of Marketing Breastmilk Substitutes. According to WHO/UNICEF, between one and two million infants worldwide die each year due to artificial feeding. It was also WHO that first recommended that infants be breastfed for at least two years.

While most of the United Nations countries signed onto the Code in the early 1980s, the US withheld it's support of the Code until the Clinton administration voiced it's approval in 1994. The Code bans all promotion of bottle-feeding and sets out requirements for labeling and information on infant feeding products. Any activity which undermines breastfeeding also violates the Code. The Code's main points are for no promotional efforts to consumers, health care professionals or hospitals yet these violations continue in hospitals and clinics across the country.

We have serious concerns about the ethics of this practice and the relationships many health care professionals, hospitals and clinics have with formula companies. For example, do other hospital units distribute free gifts or food from commercial companies to their patients? All other hospital units charge for patient food-why not the nursery? Perhaps the question we should be asking ourselves is not how do formula discharge packs affect breastfeeding and instead ask what would happen to formula sales if this practice were discontinued?


Bliss, M. C., Wilkie, J., Adrcolo, C., Berman, S., 6z Tebb, K. R (1997). The effect of discharge pack formula and breast pumps on breastfeeding duration and choice of infant feeding method. Birth: Issues in Perinatal Care and Education, 24, 90-97.

Dungy, C. h, Christensen-Szalanski, J. R., Losch, M., & Russell, D. (1992). Effect of discharge samples on duration of breast feeding. Pediatrics 90(2), 233-237

Frank, D.A., Wirtz, SJ., Sorenson, J.R., &: Heeren, T. (1997). Commercial discharge packs and breastfeeding counseling: effects on infant feeding practices in a randomized trial. Pediatrics, 80(6): 845-854.

CINDY CURTIS is Director; Lactation Center and Staff Nurse LDRP Unit, Culpeper Memorial Hospital, Culpeper, Virginia.

MAURENNE GRIESE is Director, Educational Services, Mercy Health Center of Manhattan, Manhattan, Kansas.

Writing for the Pro Position


In our opinion, it is a disservice to women to assume that the presence of formula samples will discourage breastfeeding in new mothers. Perinatal nurses know that breastfeeding is the best method for feeding infants during the first year of life. The United States has identified a national health goal of 75% of women choosing to breastfeed, and 50% continuing to breastfeed at 6 months postpartum. Few professionals would argue against the belief that breastfeeding is best for infants. However, nurses must also respect women's right to choose the feeding method they feel is best. Although the discharge diaper bags designed for breastfeeding mothers usually contain formula samples and coupons, most also have handy reusable ice packs and sterile bottles for storing frozen breast milk during an outing with the baby or for use to store milk after pumping while at work.

Much research has been done about this topic. As early as 1986 research showed that discharge packs containing formula samples did not sabotage breast-feeding (Feinstein, Berkelhamer, Grusz-ka, Wong, & Carey, 1986). This was a double-blind controlled study of 166 mothers that followed women for 4 months and found the variables with the greatest impact on the duration of breastfeeding were: initiation of nursing after 16-hours-of-age, partial breastfeed-ing (planned supplementation with formula), and formula supplementation in the hospital. Other research has yielded similar findings (Bliss. Wilkie, Acredolo. Berman, &z Tebb, 1997; Dungy, Losch. Russell, Romitti, & Dusdieker. 1997: Evans, Lyons, &T Killten, 1986). Bliss and colleagues (1997) studied more than 1,600 mothers who were given one of four discharge packs that contained either: powdered formula; breast pump; formula and breast pump; or neither. After a 6-month follow up that included three phone contacts, there was no over-all effect on the duration of breastfeeding and only a modest effect on the incidence of supplementation with the group that was given formula samples.

Some nurses feel that giving the gift packs constitutes an endorsement of the use of formula. If so, are the coupons and samples of disposable diapers we routinely give out an endorsement of disposables over cloth diapers? We don't think so. These are merely opportunities for mothers to examine a product and make an intelligent decision on their own.

In our opinion. to suggest that a discharge gift pack influences feeding options presumes that women do not make thoughtful choices about feeding their babies. Nursing support is a key element in successful breastfeeding. How many nurses have become frustrated with a sleepy newborn or a nervous mother? How many have suggested a "little formula" to get over the rough spots ,or to let the mother sleep in? If new mothers receive appropriate education and support during their hospitalizations, perhaps they will leave the hospital armed with the techniques and confidence to continue breastfeeding at home. Part of this education must include community resources such as professionally staffed hotlines, La Leche League, and new mothers' support groups. New breast-feeding mothers must feel that they are not alone, but rather part of a network of mothers providing the optimal source of nutrition for their newborns. Let's not give a diaper bag and formula powder more power than it deserves. It is easier to blame discharge packs than to focus on the more difficult areas of nursing practice and attitude. Let each of us do what we can to positively influence new mothers and provide the support and education that make it possible for all women who choose this method to successfully breastfed.

If perinatal nurses are committed to increasing the rate of breastfeeding among new mothers, we will modify our practice and make it a reality.


Bliss, M. C., Wilkie, J., Adrcolo, C., Berman, S., 6z Tebb, K. R (1997). The effect of discharge pack formula and breast pumps on breastfeeding duration and choice of infant feeding method. Birth: Issues in Perinatal Care and Education, 24, 90-97.

Dungy, C. h, Christensen-Szalanski, J. R., Losch, M., & Russell, D. (1992). Effect of discharge samples on duration of breast feeding. Pediatrics 90(2), 233-237

Evans. C.J., Lyons. N. B.. & Killion. M G (1986). The effect of infant formula samples on breast-feeding practce Journal or Obstetric Gyn,and Neonatal Nursing, 15, 401-405

Feinstein J. M.. Berkelhamer I. E.. Gruszka, M. E.. Wong, C A.. & Carey A E (1986). Factors related to early termination of breastfeeding in an urban
population. Pediatrics 78 210-215

DOTTIE C. JAMES is Assistant Professor, Saint Louis University School of Nursing, St. Louis, Missouri. MAUREEN PIMLEY was formerly a staff nurse in the nursery at United Regional Health Care Systems in Wichita Falls, Texas and has recently relocated to New Orleans, Louisiana.

Second Opinion columns are coordinated by Kathleen Rice Simpson. Dr. Simpson is a Perinatal Clinical Nurse Specialist at St. John's Mercy Medical Center; St. Louis, Missouri. She can be reached via e-mail at:

Articles About How Free Formula Impacts New Parents

Maternity Marketers by Ralph Nader 

Consumer Born Every Minute by Ralph Nader

Formula for Disaster by Katie Allison Granju

Message in a Bottle

Breastfeedingonline adheres to the
WHO International Code of Marketing of Breast Milk Substitutes
& the WHO/UNICEF Baby Friendly Hospital Initiative