5

Messaging, Media, and Marketing

This chapter explores the messaging and media environment related to breastfeeding promotion. It also describes the current U.S. regulation of messaging and marketing of commercial milk formula, which can disrupt breastfeeding across a variety of settings.

BREASTFEEDING MESSAGING, MEDIA, AND CAMPAIGNS

This section offers a primer on public health communication and describes global evaluations of breastfeeding promotion campaigns. It then reviews U.S. national breastfeeding promotion campaigns, the available evidence on effects of these efforts, and the key actors who are delivering these messages. Chapter 4 explores other public health programs and initiatives.

The media environment (including entertainment, advertising, print, news, and digital and social media) plays an important role in shaping public understanding of health issues, establishing norms for social behavior, setting the agenda for what issues are deemed important, and framing those issues in ways that invite assigning blame for social problems and responsibility for addressing them (Shehata et al., 2021). Social actors compete for limited public attention through paid (marketing, advertising, promotion, and sponsorship across platforms) and unpaid efforts (advocating for favorable portrayals in entertainment, news, and social media) to shape the public communication environment about a particular health topic.

Public health agencies and advocates often develop media campaigns as part of a larger, multilevel strategy for health promotion (Niederdeppe et al., 2025). These efforts—sometimes conceptualized as social marketing

campaigns, other times as public health communication campaigns—have been implemented across the globe on a wide variety of health topics and concerns (Pérez-Escamilla et al., 2012). Public health communication campaigns use a variety of media channels and platforms (including broadcast, print, digital and social media) to reach targeted audiences with messages designed to promote public health and well-being (Niederdeppe et al., 2025). All told, there is an abundance of evidence that media campaigns can contribute to meaningful changes in health behavior at the population level (Wakefield et al., 2010). Successful campaigns operate in coordination with community-, systems-, and policy-level interventions that increase opportunities for repeated, multifaceted, and consistent messaging; a supportive social and normative environment; and the elimination of financial and structural barriers to engaging in the behavior. Public health scholars and practitioners generally agree that media campaigns are a key component of comprehensive population health promotion efforts (Community Preventive Services Task Force, 2014; U.S. Department of Health and Human Services, 2010; Wakefield et al., 2010), including promoting breastfeeding (Pérez-Escamilla et al., 2012; U.S. Department of Human Services, 2011).

Systematic reviews of the literature and social and behavioral change frameworks for public health communication campaigns identify components that enhance the likelihood of their success: (a) sufficient and sustained funding to ensure that the campaign can achieve frequent and widespread message exposure; (b) widespread access to relevant services and resources that support the behavior; (c) a public policy environment that reduces barriers to performing the behavior, creates financial or social incentives for engaging in it, and reduces exposure to competing marketing; (d) rigorous and ongoing formative research to inform the development of campaign messages; and (e) rigorous independent evaluation of the campaign to document its impact and inform its ongoing evolution (Wakefield et al., 2010; see Table 5-1).

One ongoing challenge to breastfeeding promotion campaigns across the globe is a lack of systematic evaluation and documentation of effects. The committee reviewed available evidence from peer-reviewed journals (e.g., previous National Academies of Sciences, Engineering, and Medicine [National Academies] consensus reports, U.S. federal government documents) to examine available evidence on mediated breastfeeding promotion campaigns and their effects. One common theme in the literature on breastfeeding promotion over the last 35 years is acknowledgement of the lack of systematic campaign evaluations. Green (1989) noted that the full potential of mass media campaigns to promote breastfeeding were not yet realized, as few systematic or large-scale media campaigns existed. Two decades later, Wakefield et al. (2010) lamented that “although mass

TABLE 5-1 Key Components of Public Health Communication Campaigns

NOTE: CDC = U.S. Centers for Disease Control and Prevention; HHS = U.S. Department of Health and Human Services; USDA = U.S. Department of Agriculture; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children.

SOURCE: Committee generated. Material from Wakefield et al., 2010.

media programmes to promote breastfeeding have been mounted, reviews from the 1990s onwards seem scarce or non-existent” (p. 9). More recently, Rollins et al. (2016) observed,

Evaluation of Breastfeeding Promotion Campaigns: Global Examples of Success

Despite these limitations to the broad body of evidence, several studies from countries across the globe suggest that media campaigns are an important component of comprehensive breastfeeding promotion efforts. See Box 5-1 for an extended example of successes from efforts in Brazil.

Additionally, a two-year breastfeeding promotion campaign (1988–1990) in Jordan that included placement of messages on radio and television was attributed in part to increases in initiation of breastfeeding within six hours of birth at public hospitals and among home births (McDivitt et al., 1993). The 10-year, USAID-funded LINKAGES¹ program to improve breastfeeding practices in Bolivia, Ghana, and Madagascar included behavior change communication messaging via interpersonal communication, community mobilization efforts, and mass media (Quinn et al., 2005). Repeated, cross-sectional population surveys revealed increases in each country in early initiation of breastfeeding (within 1 hour) and exclusive breastfeeding at six months. The six-year Alive & Thrive campaign (2009–2014) in Bangladesh and Vietnam included mass media alongside interpersonal counseling, community mobilization, and policy advocacy to promote exclusive breastfeeding; it used a cluster-randomized trial to demonstrate large increases in

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¹ LINKAGES = Linkages Across the Continuum of HIV Services for Key Populations Affected by HIV

exclusive breastfeeding in both countries and increases in early initiation of breastfeeding in Bangladesh (Menon et al., 2016; see Rollins et al., 2016, for additional detail on the campaign). While early initiation declined in both intensive and nonintensive intervention groups in Vietnam, declines were significantly slower in the intensive intervention group (Menon et al., 2016). Another evaluation of the Vietnam Alive & Thrive campaign associated exposure to breastfeeding television spots to higher rates of exclusive breastfeeding (Nguyen et al., 2017). Finally, a three-year intervention study (2017–2020) in Egypt employed social marketing approaches through print media as part of a community-based breastfeeding promotion intervention in two villages (Metwally et al., 2024). Post-test surveys found that rates of exclusive breastfeeding increased in the intervention village and were higher than in the control communities in the post-test assessment. The Alive & Thrive–supported breastfeeding programs strongly demonstrate the merits of including social and behavioral change communications approaches as part of national breastfeeding programs (Pereira-Kotze et al., 2025).

Previous National Breastfeeding Promotion Campaigns in the United States

The committee’s review of the available evidence revealed that breastfeeding promotion campaigns in the United States have not been subject to the same level of rigorous evaluation as these international case studies. The National Breastfeeding Ad Campaign, developed by HHS in partnership with the Ad Council from 2004 to 2006, was the first coordinated national effort to promote breastfeeding in the United States (Merewood & Heinig, 2004). The campaign was designed to increase breastfeeding rates to 75%, with a particular focus on increasing rates among African American women and first-time mothers, and to encourage exclusive breastfeeding for the first six months. Focus groups were conducted in several areas before ad development. According to Haynes (2011), while the campaign relied on donated airtime, it received the equivalent of $30 million in advertising in its two years, in contrast to the $80 million spent by the commercial milk formula industry on advertising over the same period. Billboards were the most popular vehicle and “Babies were born to be breastfed” the most popular message, though the broader campaign strategy emphasized the risks of not breastfeeding, as opposed to the benefits of doing so (Institute of Medicine, 2011). A third component of the campaign was a Breastfeeding Helpline, managed on weekdays from 9 am to 5 pm and a website for breastfeeding information.

The campaign reported that about 30% of U.S. women saw the campaign and that 38% of mothers with less than high school education were aware of the ads (Haynes, 2011). At the same time, they also reported that

women who were aware of the campaign had lower rates of breastfeeding for more than one month (66% for those aware vs. 71% for those who were not) and more than six months (35% for those aware vs. 41% for those not aware) and exclusive breastfeeding for more than three months (16% vs. 41%; Haynes, 2011). However, these data were never reported in a peer-reviewed journal and there are insufficient methodological details available to assess the rigor and validity of the analysis and whether alternative explanations (i.e., that the campaign’s strategy of targeting low-income women produced a spurious association between exposure and breastfeeding rates) may explain these patterns. The campaign did spark widespread controversy and backlash, however, over its decision to emphasize the risks of not breastfeeding and emphasize individual decisions of the mother over the broader social, structural, and policy environment that is not conducive to supporting women who breastfeed (e.g., Kukla, 2006; Wolf, 2007). As reported by Merewood and Heinig (2004), the decision to emphasize risks was based on an intuition that messaging about risks was more likely to produce behavioral changes than messages about benefits and was informed by an extensive set of focus groups among expectant mothers, formula-feeding mothers, breastfeeding mothers, expectant fathers, and expectant grandmothers. A wide body of research has since documented that there is no inherent advantage to risk-versus-benefits-based messaging. In fact, O’Keefe and Jensen (2007) suggested a slight persuasive advantage for framing messages in terms of benefits (see also O’Keefe & Jensen, 2006). Furthermore, many pitfalls are associated with formative research strategies that rely exclusively on focus group assessments of the perceived impact of campaign messages at scale (see O’Keefe, 2018). A broader set of formative research methods (including population-based surveys and small-scale, pilot-randomized messaging trials) is typically recommended before launching a large-scale, national media campaign (see Niederdeppe et al., 2025).

Current Breastfeeding Promotion Campaigns in the United States

While U.S. breastfeeding promotion campaigns have not been subject to systematic evaluation, the committee saw value in characterizing current campaigns by federal agencies designed to promote and support breastfeeding. These descriptions helped to inform recommendations about best practices for funding mechanisms and media campaign interventions for promoting and supporting breastfeeding.

Loving Support Makes Breastfeeding Work

Since 1997, the U.S. Department of Agriculture (USDA) has supported the longest-running breastfeeding promotion campaign in the United States.

From 1997 to 2018, the campaign ran under the slogan, “Loving support makes breastfeeding work.” The campaign incorporated social marketing principles to increase breastfeeding initiation rates and duration among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC; Pérez-Escamilla, 2012). Several studies have explored use and perceptions of Loving Support materials, toolkits, training activities, and outreach (Mitra et al., 2003a,b; Pellechia et al., 2017), and the campaign has periodically convened communication experts to advise the campaign’s development (Institute of Medicine, 2011); however, the campaign’s impact on breastfeeding rates has not been evaluated comprehensively.

The campaign followed best practices for using rigorous formative research to inform campaign design. For instance, in 2011, the USDA Food and Nutrition Service (FNS) commissioned the National Academies to convene experts to determine whether there was a need to redesign the campaign and, if so, how (Institute of Medicine, 2011). The committee recommended that FNS redesign the campaign to make it more relevant to women’s current breastfeeding support needs and to the WIC program itself. In response, in 2014, FNS hired a marketing firm to conduct a three-year formative research process, which led to the “WIC Breastfeeding Support: Learn Together, Grow Together” breastfeeding promotion and support campaign. This revised campaign replaced WIC’s Loving Support campaign in 2018 (USDA, n.d.a).

WIC Breastfeeding Support: Learn Together, Grow Together

WIC Breastfeeding Support is a social marketing campaign based on the 4 Ps approach (Pérez-Escamilla, 2012). Its tagline, “Learn together. Grow together,” acknowledges that breastfeeding is a journey that takes learning and support to succeed and that it gets easier along the way (USDA, n.d.a). The campaign’s primary target audiences are WIC-enrolled women in late pregnancy and moms in the first six weeks postpartum. The secondary audience is the mother’s support system, and the tertiary audience is the WIC state and local staff and community partners. The primary goal of the program is to provide support, encouragement, and resources to moms who choose to breastfeed. The key behavioral outcome is to increase the proportion of women who meet their breastfeeding goals (which can include any breastfeeding and exclusive breastfeeding). The program focuses on (a) improving participants’ awareness of WIC breastfeeding services; (b) increased knowledge about breastfeeding biology and physiology, with a strong emphasis on milk production; (c) increased breastfeeding skills, including reading babies’ feeding cues; (d) proper latching and positioning; (e) breastmilk expression; (f) increased breastfeeding self-efficacy; and (g) increased support from family, friends, and others (USDA, n.d.a).

WIC Breastfeeding Support integrated existing breastfeeding resources—such as breastfeeding and nutrition classes, trained peer counselors, and providers with the International Board Certified Lactation Consultant^® designation—with newly developed resources, including a comprehensive website (USDA, n.d.b), posters, educational materials, videos, digital and social media engagement activities, and a “buddy” program. There are also materials available for state and local WIC staff and partners on ways to implement and benefit from WIC Breastfeeding Support (USDA, n.d.c).

The campaign website is designed as an easy-to-follow four-stage process along the breastfeeding journey. (a) The Learn, stage (before baby is born) takes the user to a host of educational materials addressing key topics such as breastfeeding benefits, setting breastfeeding goals, breastfeeding basics (e.g., how breastmilk is produced), common breastfeeding problems that can be anticipated and how to prevent them, breastfeeding rights, and creating social support for breastfeeding. (b) The Start stage adds topics such as how to get breastfeeding support form WIC, maternal nutrition during lactation, baby’s latch and positioning, and managing common breastfeeding problems (e.g., engorgement, low milk supply, sore nipples, milk expression, expressed milk feeding and storage). (c) The Overcome stage acknowledges that breastfeeding is not easy and that it requires a lot of support to make it work. It covers in greater depth and adds to the topics covered in the previous two stages, including breastfeeding accommodations at work and child development topics, as well as a series of videos featuring a wide diversity of women explaining how they overcame breastfeeding challenges. (d) In the last stage, Thrive, women and their babies are congratulated for their success with their breastfeeding journeys and specifically asked to become a peer counselor. Additional information includes bottle use, traveling with baby, returning to work or school, and introduction of complementary foods.

Although the WIC Breastfeeding Support campaign is based on sound social marketing principles and formative research, the committee could not identify studies assessing the implementation process or impact of the campaign. As noted earlier, the lack of rigorous and independent evaluation of breastfeeding promotion campaigns in the United States (including the campaigns discussed in this section) is a major gap in knowledge that needs to be addressed.

It’s Only Natural

The most recent breastfeeding ad campaign through the HHS Office on Women’s Health (OWH) is titled “It’s Only Natural: Mother’s Love, Mother’s Milk.” This campaign includes web-based education on various topics, including “What is so great about breastfeeding?,” “What makes a

good latch?,” and “What do other moms say about breastfeeding?” (Office on Women’s Health, 2022). Other resources include sections on breastfeeding basics, secrets to success, addressing myths from the African American community, overcoming challenges, and fitting breastfeeding into your life, as well as videos with mothers telling their breastfeeding stories and down-loadable handouts (Office on Women’s Health, 2022). The OWH National Women’s Health and Breastfeeding Helpline is still available to families 9 am–6 pm (Eastern time) and answered by peer counselors, who can refer them for additional help if needed. Like the WIC campaign described above, the committee could not identify published studies assessing the implementation process or impact of this campaign.

Community-Led Campaigns

Communities have also developed their own ad campaigns to promote breastfeeding. For example, in Memphis, Tennessee, an ad campaign started with black-and-white billboards and bus stop signs that read “Babies were born to be breastfed” in an area of high infant mortality and low breastfeeding rates. With buy-in from community partners in the infant mortality reduction space, the next phase included a billboard with a local mother of color breastfeeding the newborn while the father and toddler looked on. This billboard was in a strategic location and maintained for two years, and many bus stop signs also displayed the image. The campaign distributed posters with this image to multiple health care facilities in the area and most birth hospitals. Finally, after community focus group work, a third campaign was launched, with images of multiple races, ethnicities, ages, religion, and abilities. The slogans were designed by focus group participants. As is the case for USDA and WIC campaigns, the committee could not identify studies assessing the implementation process or impact of this campaign.

DIGITAL AND SOCIAL MEDIA AND ONLINE SUPPORT

The committee also examined available evidence from studies about breastfeeding promotion and support messages in digital and social media. This provided the committee with additional information about the potential for media campaign interventions to support breastfeeding and address racial/ethnic and socioeconomic variances in the availability of information and sources of social support.

An emerging body of research has explored how breastfeeding mothers seek, share, and receive social support in online communities (Orchard & Nicholls, 2022; Reicher & Spatz, 2024). Breastfeeding mothers regularly seek informational, emotional, and instrumental support (e.g., to coordinate milk sharing; see Perrin et al., 2014) through a variety of online platforms. These platforms range from commercial sites designed to reach

parents (e.g., babycenter.com’s Breastfeeding Support and Help community forum; Lebron et al., 2020); organically emergent groups within social media platforms, such as Facebook, Twitter/X, and Instagram (Black et al., 2020; Bridges et al., 2018; Marcon et al., 2019; Morse & Brown, 2021; Moukarzel et al., 2020; Robinson et al., 2019); and smartphone apps designed to provide breastfeeding information and support (Dauphin et al., 2020; Galvão et al., 2021). Breastfeeding mothers from a wide variety of backgrounds and identities value social media and online support groups in their breastfeeding journey (Asiodu et al., 2015; Griauzde et al., 2020) and regularly seek these sources of support in response to urgent and unmet information needs; desire for culturally informed support, community, and empowerment; and/or lack of support or perceived social stigmatization from health care providers (Haley et al., 2023; Jackson & Hallam, 2021).

While many of the studies on social media and online support have been qualitative and/or observational, at least two randomized controlled trials conducted outside of the United States have shown that online social network interventions can increase self-efficacy for breastfeeding (Uzunçakmak et al., 2022) rates and duration of exclusive breastfeeding (Cavalcanti et al., 2019). Two other trials, however, did not find differences between intervention and control groups for a peer support (in Finland; Niela-Vilen et al., 2016) and a smartphone app-based intervention (in the United States; Lewkowitz et al., 2020). In a systematic review of the literature on social media and breastfeeding practices, Orchard and Nicholls (2022) concluded that the success of social media groups in promoting breastfeeding depends on a variety of factors, including the content of discussions (e.g., levels of judgment and polarization in the discussion; see Regan & Brown, 2019) and the composition and dynamics of the group (e.g., whether or not trained peer breastfeeding counselors are part of the group; see Bridges et al., 2018). Nevertheless, lactating parents and their partners regularly report that online and social media support groups are among the most important sources of emotional and informational support in their breastfeeding journey (Galvão et al., 2021; Morse & Brown, 2021; Reicher & Spatz, 2024; Robinson et al., 2019). Efforts to promote and support breastfeeding through digital and social media compete for attention on these platforms with commercial initiatives that promote infant formula, and levels of exposure to commercial milk formula marketing via social media platforms—including Facebook, Instagram, and YouTube—can be substantial (Duckett, 2022; Hernández-Cordero & Pérez-Escamilla, 2022; United Nations Children’s Fund, 2022). According to a marketing research survey of Facebook and Twitter, Abrahams (2012) found that infant formula companies had already established a strong presence in social media by the late 2000s and early 2010s; more recent reviews suggest that marketing of infant formula through digital media continues to be on the rise, making use of a variety of tactics that include incentives for “mom influencers” to create content about specific brands and products (Harris & Pomeranz, 2020). Tactics used to

market infant formula in social media mirror those used in other media, and are designed to “influence social norms by making formula use seem to be extensive, modern, and comparable to or better than breast milk” (Piwoz & Huffman, 2015, p. 373; see also Rollins et al., 2023).

Conclusion 5-1: Media campaigns, programs, and social support interventions to promote breastfeeding exist in a competitive digital media environment that includes widespread and well-funded efforts to market commercial milk formula to mothers, families, health care providers, and health systems. In addition, many women and parents experience guilt, shame, and a sense of failure for not meeting their goals even though the social, structural, and policy environment does not support their breastfeeding journey. While there is a large, robust evidence-base that shows that media campaigns can contribute to meaningful population-level changes in health behavior, the current environment makes it exceedingly difficult to communicate about the health, social, and emotional benefits of breastfeeding in a way that precludes judgment and competes with commercially funded promotion of commercial milk formula.

Recommendation 5-1: The U.S. Department of Health and Human Services, in collaboration with organizations engaged in breastfeeding support at the federal, state, tribal, and local levels, should invest in a multifaceted, coordinated national communication strategy on the importance of breastfeeding and the need for comprehensive support for breastfeeding families from all of society across the lactation journey.

1. The strategy should consider the full range of audiences: (a) women who may breastfeed; (b) their partners and family members; (c) community members and community organizations, including faith-based organizations; (d) health care providers, health systems, pharmacies, health professional societies, and insurers; (e) business leaders and a wide range of employers, including childcare centers, schools, transportation agencies, the military, and the criminal justice system; (f) public health systems and authorities; and (g) policymakers at the federal, state, tribal, and local levels.
2. The strategy should apply established social and behavior change communication frameworks and ensure that all stages of campaign development involve members of impacted communities, including historically underserved populations.
3. The strategy should also include information about what resources are available and where and how to access them (e.g., in the health care setting, in community and public health settings, payment requirements for services and supplies).

In almost all of the criteria that predict the likelihood of their success, breastfeeding promotion campaigns in the United States face challenges: (a) failure to employ robust social and behavioral change communication frameworks; (b) limited funding and thus limited message exposure; (c) insufficient access to breastfeeding support in health systems and communities; (d) a policy environment that does not provide adequate financial, material, or structural supports for breastfeeding (family leave protections, universal basic income); and (e) a powerful commercial milk formula industry that dramatically outspends breastfeeding promotion efforts (Wakefield et al., 2010).

The United States has a variety of opportunities to promote breastfeeding:

First, the success of tobacco control efforts in the United States offers a well-established example of the successful use of social and behavioral change communication campaigns to shift social norms and behavior even in the context of a powerful, competing industry (National Cancer Institute, 2008). There is also strong or moderate-strength evidence that social and behavior change communication campaigns have contributed to population-level shifts in other health domains, including road safety, prevention of cardiovascular disease, physical activity, nutrition, HIV prevention, and screening for some cancers (Wakefield et al., 2010). Several global examples—in Brazil, Bolivia, Ghana, Madagascar, Bangladesh, Vietnam, and Egypt—further emphasize the potential for media campaigns to contribute to meaningful gains made by national breastfeeding promotion efforts (Menon et al., 2016; Metwally et al., 2024; Nguyen et al., 2017; Quinn et al., 2005). Combined, these efforts offer a blueprint for a successful strategy in the United States.

Second, most mothers want to breastfeed and initiate the behavior at first (Hamner et al., 2021; Pérez-Escamilla et al., 2023). This provides a strong starting point for efforts to increase breastfeeding duration and exclusivity and underscores the strategic need to reduce the societal barriers that impede women from meeting their prenatal breastfeeding duration goals (Pérez-Escamilla et al., 2023). While culture, systems, and policy changes are not easy, social change communication can also support these efforts with evidence-based strategies for discussing and reframing health and social issues in a way that centers systems change, policy solutions, and collective action (National Academies, 2022; Niederdeppe et al., 2025; Tomori, 2023).

Third, the principles of social marketing can identify areas where breastfeeding has inherent advantages and opportunities for growth when appropriately protected, promoted, and supported. Social marketing can help counter commercial milk formula marketing efforts that violate the International Code of Marketing of Breast-Milk Substitutes (The Code; see discussion below) and undermine breastfeeding across a wide range of settings, including in health care. The combination of a national breastfeeding promotion social and behavioral change communications campaign and

regulation of the commercial milk formula industry can help promote and support breastfeeding.

THE MARKETING AND REGULATION OF COMMERCIAL MILK FORMULA

Breastfeeding promotion media campaigns, programs, and social support interventions occur in a competitive media environment that includes well-funded and highly coordinated marketing efforts by the commercial milk formula industry to engage caregivers, families, providers, scientists, and policymakers using sophisticated strategies that include multiple contacts with caregivers from gestation across different categorical entry points (Baker et al., 2023, Froley et al., 2025; Pérez-Escamilla et al., 2023; Rollins et al., 2023; Vilar-Compte et al., 2024). These studies show that caregivers are frequently exposed to messages claiming health benefits in these products that are not supported by evidence (Baker et al., 2023; Froley et al., 2025; Pérez-Escamilla et al., 2023; Rollins et al., 2023; Vilar-Compte et al., 2024). The claims, which are disseminated via multiple channels, including artificial intelligence-driven digital and social media, are designed to lead caregivers to believe that commercial milk formula is equivalent or superior to breastfeeding and that formula is needed because breastfeeding is very difficult. According to Rollins et al. (2023) and Vilar-Compte et al. (2022), the latter claims are often based on pathologizing baby behaviors that are typical of healthy babies, including frequent crying, short sleep/wake cycles, and milk regurgitation. Both small and large cross-national studies demonstrate that these marketing efforts are highly effective in shaping caregivers’ perceptions and decision-making, as well as health professional advice about infant feeding (Rollins et al., 2023). These marketing efforts also take advantage of insufficient structural support in other sectors, such as the health system and the workplace, further enhancing the efficacy of commercial milk formula marketing (Rollins et al., 2023). Marketers also exploit cultural tropes and the portrayal of breastfeeding as an individual responsibility that falls on women (Froley et al., 2025; Hastings et al., 2020), a theme that was critiqued in earlier breastfeeding campaigns.

As reported by Rollins et al. (2023), the global commercial milk formula industry spends about $3 billion per year marketing its products, which is larger than the investments that governments, including the U.S. government, can make in promoting breastfeeding (see also Baker et al., 2023). In contrast, the largest U.S. breastfeeding promotion campaign in history achieved the equivalent of $30 million in advertising over a two-year period from 2004 to 2006 (adjusting for inflation, this figure is $47.9 million 2024).

The committee examined previously published studies and reviews on the impact of commercial milk formula marketing on breastfeeding-related

attitudes, norms, and behaviors. Studies consistently show that exposure to commercial milk formula marketing through diverse media channels, including digital and social media spaces, influences infant feeding perceptions, attitudes, and practices (Aureoles-García et al., 2025; Döner & Kul Uçtu, 2024; Harris & Pomeranz, 2020; Howard et al., 2000; Huang et al., 2013; Piwoz & Huffman, 2015; Unar-Munguia et al., 2022; Zhang et al., 2013). A review of the global evidence on the impact of commercial milk formula marketing (Piwoz & Huffman, 2015) concluded that this marketing influences social norms by making formula use appear to be common, modern, and comparable to breastmilk. It also found that providing free samples in maternity facilities and promotion through health workers consistently had a negative impact on breastfeeding initiation and exclusive breastfeeding. Furthermore, the review also found a link between recall of direct-to-consumer marketing and feeding decisions (Piwoz & Huffman, 2015). In addition, Froley et al. (2025) conducted a qualitative thematic analysis of online infant formula messaging in the United States; they noted that common themes of marketing campaigns focus on “health benefits,” “nurture,” and “science” (p. 1). Similar findings have been made for toddler milk marketing that offers products for infants and toddlers that are packaged in a very similar way to commercial milk formulas of the same brands with; this marketing sometimes also targets feeding for infants under nine months old (i.e., cross-marketing; Richter et al., 2024).

A literature review by Harris and Pomeranz (2020) described the marketing tactics employed by the commercial milk formula industry in the United States. The authors argued that these marketing tactics disregard the principles of The International Code of Marketing of Breast-Milk Substitutes (the Code), which was established to prevent misleading or unethical marketing of commercial milk formula products. Similarly, in a recent study of top infant formula brands sold in the online shopping environment in the United States, no products were found to be compliant with the Code (Froley et al., 2025). Harris and Pomeranz (2020) also examined the relationship between commercial milk formula marketing and infant feeding choices in the United States, based on observational and experimental studies, including those that analyzed data from the longitudinal Infant Feeding Practices Study II, which measured exposure to infant commercial milk formula marketing and reasons for formula switching. Zhang et al. (2013) reported that mothers’ recall of infant formula print advertising was associated with shorter intention to breastfeed exclusively and that exposure to formula information on websites was associated with lower odds of intention to breastfeed and breastfeeding initiation. Self-reported exposure to TV/radio marketing was not related to breastfeeding intentions or outcomes (Zhang et al., 2013). Additionally, caregivers are also exposed to formula marketing in health care settings. In a study by Huang et al. (2013), over half (57%) of mothers chose a specific formula at one month postpartum

because it was used in their hospital or their doctor recommended it, 20% because they received a sample or coupon, and 13% through another form of direct-to-consumer marketing. Furthermore, 14% indicated that they were given the formula through WIC, while 19% reported using the formula they fed to a previous child (Huang et al., 2013). Harris and Pomeranz (2020) also found that provision of free infant formulas through the health sector—via “gift” bags or other means in the maternity facility—negatively influences breastfeeding outcomes. A randomized trial showed that “gift” packs containing commercial milk formula reduced any breastfeeding duration by 35 days and exclusive breastfeeding by 11 days among women who were uncertain or intended to breastfeed for less than 12 weeks, which were 44% of breastfeeding women (Howard et al., 2000). Harris and Pomeranz (2020) concluded further that the empirical evidence indicates extensive marketing of infant formula and toddler milks likely misinforms parents about potential benefits to children and contributes to suboptimal feeding practices. The authors considered this evidence to be sufficient to justify pushing for strong regulation of commercial milk formula marketing in the United States, following the principles outlined in The Code (Harris & Pomeranz, 2020). These findings are consistent with global evidence (e.g., Baker et al., 2023; Rollins et al., 2023).

The International Code of Marketing of Breast-Milk Substitutes

The Code, originally adopted by the World Health Organization (WHO) in 1981, addresses multiple aspects of commercial milk formula marketing and is embedded in a human rights framework. While the United States voted against its adoption, the Code’s principles are an important international standard for evaluating the regulation the marketing of commercial milk formula in the United States. The Code applies to infant and young children up to age three years and is complemented by additional resolutions that clarify and update its provisions. The World Health Assembly (WHA) reviews the Code every other year to address changes in the industry and update the Code as needed. These subsequent resolutions provide guidance on applying the Code to the proliferation of commercial milk formula products from ages 0–36 months, infant and young child feeding in emergencies, interaction of the commercial milk formula industry with health professionals, and increasing marketing efforts in the digital space.

Sasson (2016) and Anttila-Hughes et al. (2025) wrote that the Code was initially developed in response to growing concern by public health and health care workers and grassroot activists about aggressive marketing tactics by the commercial milk formula industry that undermined breastfeeding and caused substantial illness and death, particularly in low- and middle-income settings. Additional researchers have identified that these marketing efforts have continued and accelerated, especially in the digital

space, over the past 40 years and are pervasive across high-, middle-, and low-income settings, including in the United States (Baker et al., 2023; Han et al., 2022; Rollins et al., 2023). Across settings, inappropriate marketing practices contribute to health variances (Baker et al., 2023; Harris & Pomeranz, 2020; Tomori & Palmquist, 2022).

The Code has been adopted by most countries in the world but has been fully implemented and enforced in only a handful of them; as noted above, the United States voted against its adoption (World Health Organization, 2024). Key challenges for implementing and enforcing the Code worldwide include (a) its voluntary nature; (b) lack of formal legislation on it in most countries; and (c) successful lobbying by commercial milk formula companies of governments, international agencies (e.g., WHA member states meetings); and global infant and young child feeding regulatory initiatives (e.g., Codex Alimentarius, which sets the global standards for commercial milk formula products) against regulation of their products (Baker et al., 2023; Pérez-Escamilla et al., 2023; Rollins et al., 2023). Although the United States has made some headway with breastfeeding support investments and outcomes (Baker et al., 2023; Hernández-Cordero et al., 2022; Pérez-Escamilla et al., 2021), according to the authors, these impacts continue to be mitigated or diluted because of the lack of adoption, implementation, and enforcement of key provisions of the Code (Pérez-Escamilla et al., 2012; Tomori & Palquist, 2022).

Box 5-2 describes key principles of the Code, and the following sections describe how some provisions of the Code might be approached in the United States.

Potential Approaches to Adopting the Marketing Principles of the Code in the United States

The United States has many opportunities to adopt principles of the Code regarding the marketing of commercial milk formula. First, the Baby-Friendly Hospital Initiative’s (BFHI) Ten Steps to Successful Breastfeeding could be implemented across all birthing settings (see Chapter 6 for additional discussion about the BFHI). BFHI requires all maternity facilities designated as Baby-Friendly to “comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.” Currently, approximately 25% of births take place at Baby-Friendly hospitals (Baby-Friendly USA, 2024). A national study could document how Baby-Friendly hospitals are complying with this requirement in order to understand Code implementation barriers, facilitators, and impacts in maternity facilities and to achieve universal BFHI implementation. This could have significant health equity implications, since families from racialized minority and marginalized groups do not have equal access to birth facilities that support breastfeeding (Lind et al., 2014; Tucker et al., 2025).

Second, although WIC staff are strongly supportive of breastfeeding, the program is the largest distributor of free infant formula in the world (see Chapter 4). The commercial milk formula industry provides WIC with strongly discounted products (National Academies, 2024), which is not allowed by the Code. Furthermore, even though in the past WIC food benefits have been calibrated to nudge women towards selecting the breastfeeding package, the commercial value of the commercial milk formula package is still much higher (see Chapter 4).

Third, health professional associations and scientific societies related to nutrition could take immediate, impactful action to adopt principles of the Code (Harris & Pomeranz, 2020; Rollins et al., 2023). For example, these associations could cease to receive funding from the commercial milk formula industry for professional activities, including conferences, health professional education, and philanthropic endeavors. Additionally, all health professionals serving childbearing and infant populations could receive basic education on the importance of breastfeeding and the principles of the Code and agree to comply with those principles in their practice (see Chapter 6). This would have considerable health equity impacts as the most trusted sources of information on infant feeding are health professionals (Rollins et al., 2023).

These opportunities to adopt the principles of the Code cover a wide range of marketing venues (e.g., health care settings) and methods (e.g., free products). The next section directly addresses the regulation of the labeling and advertising of commercial milk formula in the United States. It focuses on current U.S. law, which covers a narrower set of requirements than those covered by the Code.

Regulation of the Labeling and Advertising of Commercial Milk Formula in the United States

The major federal agencies responsible for regulating the labeling and advertising of commercial milk formula are the Food and Drug Administration (FDA) and the Federal Trade Commission (FTC). Their regulation

influences how commercial milk formula products are presented as substitutes for or complements to breastfeeding. Recall that commercial milk formula includes infant formula, follow-up formula or milk, and toddler milk.

FDA regulates the marketing and labeling of commercial milk formula in the context of setting and enforcing food standards and good manufacturing practices (see Chapters 3 and 4 in National Academies, 2024). As listed by Pomeranz and Harris (2019), the FDA enforces regulations related to package food labels,² including specifications for package food labels (e.g., principal display panel, information panel, identity and name of the food, ingredients, name and place of business, declaration of net quantity of contents, nutrition labeling, nutrient content claims, health claims, reference amounts customarily consumed [i.e., serving size]), and misbranding of food. Importantly, regulations focus on nutritional composition and instructions for preparing, using, and storing formula.

FDA is also responsible for regulating commercial milk formula claims in labeling. These claims frame product use and benefits. FDA regulations cover allowed nutrient content claims, which characterize the level of a nutrient in a food or compare the level of a nutrient in a food to that of another food. While required to be truthful, claims about nutrition and health impacts do not necessarily require substantiation, unless they meet the narrow definition of a health claim. A health claim describes the relationship between a food and a particular disease. FDA reviews these claims, which must meet the requirements of significant scientific agreement standards (Munblit et al., 2020). However, the majority of claims on formula labels (and in marketing materials) are structure/function claims, which link a particular component or characteristic of the product to a broader health concept, such as “DHA supports your infant’s brain development” (Harris & Pomeranz, 2020; Munblit et al., 2020). FDA does not require substantiation of structure/function claims (Pomeranz et al., 2025). Additionally, qualified health claims may be allowed. Such claims “characterize the relationship between a substance and a disease or health-related condition but is a claim that has not been approved by FDA under the ‘Significant Scientific Agreement’ standard that characterizes health claims, and thus must be accompanied by a disclaimer or otherwise qualified in such a way as to not mislead consumers” (FDA, 2023, p. 8). Although this regulation has wording requirements, qualified health claims do not require the same level of scrutiny as health claims. All of these regulations fall far below the levels required for medications (Munblit et al., 2020).

Comments by FDA (2023) on the labeling of infant formula indicate that it views a variety of labels used by manufacturers as noncompliant with its labeling guidance. For example, FDA (2023) noted, “We are

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² Labels include the package itself and can be extended to marketing (e.g., web-based info).

concerned particularly about the number of infant formula products that bear the same or similar statements of identity but are different in composition or intended use” (p. 3). And it stated, “We have also noticed an increased use of nutrient content claims that render products misbranded under the Federal Food, Drug, and Cosmetic Act (FD&C Act)” (FDA, 2023, p. 3). FDA has the authority to issue warning letters to manufacturers to enforce against misbranding of food products but rarely uses this authority in the context of commercial milk formula labeling. Pomeranz et al. (2025) noted that this may be partly because of a lack of resources and limited authority.

The FTC (n.d.) is empowered “to investigate and prevent unfair methods of competition, and unfair or deceptive acts or practices affecting commerce” (para. 2). Its enforcement against deceptive marketing extends to all media, including the internet. Current law requires the FTC to enforce truth in advertising, under which advertisements “must be truthful, not misleading, and, when appropriate, backed by scientific evidence” (FTC, n.d., para. 1). The FTC takes enforcement action by bringing cases against companies that it believes engage in unfair or deceptive advertising. It also publishes Competition and Consumer Protection Guidance Documents; “these guidance documents are not substantive rules and do not have the force or effect of law. They are administrative interpretations of the statutes and rules administered by the Commission, and they are advisory in nature” (FTC, n.d., para. 1). None of these guidance documents address commercial milk formula directly.

An example of how FDA and the FTC can regulate the labeling and advertising of commercial milk formula relates to Nestlé Nutrition’s marketing of its Gerber Good Start Gentle Formula. FDA (2014) issued a warning letter in October 2014 stating that the product was misbranded because of unauthorized health claims used on its label and website. Pomeranz and Harris (2019) noted, “FDA issued a close-out letter for the case in July 2015, which means that FDA found Nestle took corrective action to address the violations contained in its Warning Letter” (p. 44). Also in 2014, the FTC (2014) charged Nestlé Nutrition with deceptively advertising the same product. That case was settled in 2019 between the FTC and Nestlé with Nestlé agreeing, among other things, not to make “any representation that the covered product a) prevents or reduces the risk of developing allergies or b) is effective in the cure, mitigation, or treatment of any disease; unless the representation is non-misleading and, at the time of making such representation, Defendant possesses and relies upon competent and reliable scientific evidence substantiating that the representation is true” (Federal Trade Commission v. Gerber Products Co, 2019, p. 4). These actions show that FDA and the FTC have the authority and ability to regulate the labeling and advertising of commercial milk formula.

Researchers have described examples where commercial milk formula products, marketing materials, and websites in the United States were alleged to make misleading claims about health and nutrition that lack scientific evidence (Cheung et al., 2023; Harris & Pomeranz, 2020; Munblit et al., 2020; Pomeranz et al., 2023). The researchers described instances where information about infant feeding presented by commercial milk formula manufacturers may have inaccurately elevated these health claims over documented health impacts of breastfeeding (Harris & Pomeranz, 2020; Hastings et al., 2020; Pomeranz et al., 2023). These approaches have been documented globally and have been shown to undermine breastfeeding (Rollins et al., 2023).

Researchers and health professionals have proposed a series of recommendations to address these regulatory gaps. For FDA, research suggests that a first step could include a requirement to substantiate any nutrition and health claims on product labels, including those in the digital marketing environment, with high-quality evidence. This could include the current definitions of structure and function claims, imagery that evokes similar claims, and qualified health claims. In 2016, FDA (2016) issued nonbinding guidance, Substantiation for Structure/Function Claims Made in Infant Formula Labels and Labeling, but this guidance was not finalized (FDA, 2016; Harris & Pomeranz, 2020; Hughes et al., 2017). FDA does not have authority to require submission of substantiation documents for claims by companies, which limits its ability to challenge claims (U.S. Government Accountability Office, 2011). Guidance and enforcement could also be enhanced to recognize principles of the Code (Harris & Pomeranz, 2020; Hughes et al., 2017). For example, the draft structure/function guidance explicitly excluded guidance on “labeling claims that suggest that the product contains constituents found in breast milk or that the product is ‘closer’ to breast milk than other formulas” because they are not structure/function claims (FDA, 2016, p. 5). In addition, the literature has called special attention to additional elements of claims that address specialty products such as those labeled “gentle” or “sensitive” (Rollins et al., 2023).

Further recommendations proposed in the literature include higher standards for formula preparation that correspond with international recommendations. This could include, for example, a warning that powdered commercial milk formula is not sterile and the provision of instructions for safe preparation. Another suggestion is to include a discussion of the risks of feeding preterm and sick infants commercial milk formula when mother’s own milk or donor human milk is available.

Finally, recent recommendations by the American Academy of Pediatrics (2023) highlight its view that toddler formulas are unnecessary and

potentially harmful. FDA could implement requirements for labeling that would ensure that these products are not labeled as “formula” to avoid misleading parents and to provide a warning that these products are not necessary and may be associated with health harms, such as obesity.

For FTC, recommendations from the literature relate to the enforcement of the truthfulness in advertising law. “When consumers see or hear an advertisement, whether it’s on the Internet, radio or television, or anywhere else, federal law says that ad must be truthful, not misleading, and, when appropriate, backed by scientific evidence. FTC enforces these truth-in-advertising laws, and it applies the same standards no matter where an ad appears—in newspapers and magazines, online, in the mail, or on billboards or buses” (FTC, n.d., para. 1). To date, FTC enforcement actions related to commercial milk formula have been limited. However, FTC has the authority, for example, to bring actions against structure/function claims for infant formula on the market that it believes to be unsubstantiated and to require that companies provide evidence to support their claims.

Pomeranz and Harris (2019) noted that, “U.S. regulation and enforcement actions have not kept pace with the introduction of new products and product categories and the profusion of labeling and marketing claims questionably implying nutritional and developmental benefits from these products” (p. 33). Overall, the committee for the present study observes that the current FDA and FTC regulation of the labeling and advertising of commercial milk formula is inadequate (see Conclusion 5-2).

Conclusion 5-2: Because the United States has not implemented the Code, the regulatory environment for commercial milk formula does not adhere to global recommendations or sufficiently address the harmful influence of commercial milk formula marketing on breastfeeding. Specifically, the current regulatory structure that includes regulation of labeling by U.S. Federal Drug Administration and advertising by U.S. Federal Trade Commission is inadequate to address allegations of wide-ranging, misleading claims in labeling and physical and digital marketing efforts targeting caregivers, health professionals, and the public. Substantial literature demonstrates that misleading marketing has adverse impacts on breastfeeding.

Recommendation 5-2: The U.S. Food and Drug Administration and U.S. Federal Trade Commission should coordinate to rigorously regulate the marketing, including labeling and advertising, of commercial milk formula for infant and young child feeding, informed by the principles outlined in The International Code of Marketing of Breast-Milk Substitutes, across media, retail, health care, and other settings.

REFERENCES

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