What are Breast-milk Substitutes (BMS)?
In the context of infant and young child nutrition, the acronym BMS is most widely recognized by health and humanitarian organizations as referring to Breast-milk Substitutes. This category of products is defined by the World Health Organization (WHO) and UNICEF as any food marketed as a partial or total replacement for breast milk, regardless of whether it is suitable for that purpose. The list of products classified under this definition is extensive and includes much more than just standard infant formula. It also covers follow-up formulas, weaning formulas, and certain types of complementary foods marketed for infants. Even some cow's milk products, depending on their marketing and intended use for infants, can fall under the BMS designation.
Historically, the rise of modern industrial food production in the 20th century led to the aggressive marketing of these products, which resulted in a decline in breastfeeding rates, especially in low-income countries. This was often linked to significant increases in infant morbidity and mortality, as formula was sometimes prepared with unsafe water or diluted to stretch supplies, leading to both disease and malnutrition. The recognition of these severe public health consequences led to the development of global policy and regulation.
Products included under the BMS umbrella
- Infant Formula: Formulated for feeding infants from birth up to six months of age.
- Follow-on Formula: Designed for infants six months and older, intended to be used with complementary foods.
- Other Milk Products: Including certain milks and fortified soya products marketed for young children up to three years.
- Bottles and Teats: The marketing of these items is also covered by regulations, as they are part of the process of artificial feeding.
The International Code of Marketing of Breast-milk Substitutes
In response to the public health crisis caused by inappropriate BMS marketing, the World Health Assembly (WHA) adopted the International Code of Marketing of Breast-milk Substitutes in 1981. The Code provides a framework of recommendations to regulate the marketing of BMS products, ensuring their safe and appropriate use when necessary, while protecting and promoting breastfeeding. The Code is not legally binding on its own but is implemented through national legislation in many countries.
Key provisions of the Code include:
- No advertising of BMS products to the public.
- No free samples or supplies to mothers or health workers.
- No promotions in healthcare facilities or retail environments.
- No gifts or personal samples to health workers.
- Labels must include a statement on the superiority of breastfeeding and a warning about the health hazards of formula feeding.
- Labels must not feature images of infants or idealize artificial feeding.
When is BMS Used in Nutrition?
While public health guidelines prioritize and recommend exclusive breastfeeding for the first six months of life, and continued breastfeeding up to two years or beyond, there are specific circumstances where BMS is the appropriate choice. These decisions should always be made in consultation with a qualified healthcare professional.
Appropriate uses of BMS include:
- When a mother cannot breastfeed for medical reasons.
- For infants who cannot be breastfed, such as orphans in emergencies.
- When an infant has a medical condition, such as an inborn error of metabolism, requiring a specialized formula.
- As a last resort in emergencies, when other infant feeding options like relactation or donor milk are not feasible, and only under strict protocols to ensure safe and hygienic preparation.
BMS vs. Natural Breast Milk: A Comparison
| Feature | Natural Breast Milk | Breast-milk Substitutes (BMS) |
|---|---|---|
| Composition | Dynamic; changes with infant's age, time of day, and maternal diet. Contains living cells, enzymes, and hormones. | Static; standardized formula with fixed composition, but cannot replicate the biological complexity of breast milk. |
| Immunity | Provides crucial antibodies, immunoglobulins, and white blood cells that protect infants from infections and diseases. | Offers no natural immune protection. |
| Digestion | Optimized for easy digestion and absorption by the infant's immature digestive system. | Formulated to be digestible, but often contains proteins that are harder for infants to break down. |
| Availability | Available on demand, at the right temperature, and sterile. | Requires careful and hygienic preparation with safe water; storage and temperature must be managed. |
| Bonding | Associated with skin-to-skin contact and maternal-infant bonding. | Can support bonding through close physical contact during bottle-feeding. |
| Cost | Free and does not require purchasing or special equipment. | Can be expensive and requires additional costs for bottles, teats, and sterilization equipment. |
Health Risks Associated with Inappropriate BMS Use
When not used properly, particularly in unsanitary conditions, BMS can pose significant health risks to infants. The World Health Organization and UNICEF have extensively documented the dangers, especially in humanitarian emergencies, where conditions for safe formula preparation may not be met.
- Contamination Risk: Using contaminated water or unsterilized equipment to prepare formula can lead to diarrheal diseases and other life-threatening infections. This risk is especially high in crisis situations.
- Malnutrition: Over-diluting formula to make it last longer can deprive the infant of essential nutrients, leading to malnutrition. Conversely, over-concentrating it can put a strain on the infant's kidneys.
- Interference with Breastfeeding: Unnecessary introduction of BMS, especially through donations in emergency settings, can disrupt and ultimately end breastfeeding, removing the many benefits it provides.
The Broader Context of BMS: Addressing Other Meanings
While Breast-milk Substitutes is the dominant meaning of BMS in a public health context, it is important to acknowledge that the acronym can have other meanings in more technical fields, though they are less commonly discussed in general human nutrition. In the agricultural sciences, particularly animal and plant nutrition, BMS can sometimes refer to a Bio-Mechanistic System. This involves using advanced computer models to simulate and predict the biological processes and physiological responses of organisms to optimize nutrient use. For example, in animal production, it helps in formulating efficient diets that improve animal health and reduce environmental impact. It is crucial to distinguish these separate meanings to avoid confusion.
Conclusion: Promoting Healthier Infant Feeding
In nutrition, BMS is a term with a very specific and critical meaning, primarily related to breast-milk substitutes in the context of infant feeding. International guidelines, most notably the WHO's International Code, exist to regulate the marketing and use of these products to protect and promote breastfeeding. While BMS products, such as infant formula, serve a vital role when breastfeeding is not possible or insufficient, their use must be informed by qualified health workers to minimize risks. A clear understanding of what BMS represents, the associated risks, and the appropriate contexts for its use is essential for all parents, caregivers, and healthcare professionals. The ultimate goal is to support the healthiest outcomes for all infants and young children, prioritizing breastfeeding where possible, and ensuring the safe use of substitutes when needed.
For more information on the International Code and its principles, you can visit the WHO's documentation.(https://www.who.int/docs/librariesprovider2/default-document-library/bms-factsheet-2025.pdf?sfvrsn=271bf8b1_2&download=true)
Additional Considerations
Understanding BMS is not just about infant formula. It is a key public health issue, impacting infant feeding practices globally and involving significant ethical considerations regarding marketing and distribution. Continuous efforts by organizations like WHO and UNICEF are needed to monitor and enforce the Code, particularly in the digital age where marketing tactics are evolving.
Future of BMS and Nutrition
As nutritional science and technology advance, personalized nutritional approaches are emerging. While these may offer new ways to optimize nutrition, they do not diminish the importance of the guidelines surrounding BMS. The fundamental principles of protecting breastfeeding and ensuring safe alternatives will remain paramount, regardless of technological developments.
Why This Information Matters
For new parents, caregivers, and health workers, understanding BMS ensures that informed, safe, and ethical decisions are made about infant feeding. It empowers individuals to navigate complex choices, resist aggressive marketing, and prioritize the best nutritional start for infants and young children, in line with established global health recommendations.
