Breastfeeding is on the rise in Hong Kong - so why do so many mothers still believe formula milk is more nutritious?
Compared to health initiatives, milk powder scandals are a drop in the ocean when it comes to turning the tide in favour of breastfeeding
In the same week that another milk formula scandal hit the headlines, an annual survey showed the breastfeeding rate among Hong Kong mothers was at an all-time high.
But experts say the two have little to do with each other. Rather, the rise in breastfeeding rates in the territory during the past 20 years (85.8 per cent in 2012) is due to better public education, support, awareness and peer influence.
"The recent scandals play only a very small part, if any, in the increasing trend," says Dr Leung Wing-cheong, executive committee member of Unicef's Baby Friendly Hospital Initiative Hong Kong Association and chief of service at Kwong Wah Hospital's obstetrics and gynaecology department.
The impact of such negative press is "likely small and short-lasting", says Dr Agnes Marie Tarrant, an associate professor with University of Hong Kong's School of Nursing. "Once the scandals fade from the headlines, the effect does as well."
On August 3, the world's biggest dairy exporter, Fonterra of New Zealand, made headlines when it revealed that a dirty pipe at a processing plant might have tainted whey protein, used in dairy formula, with botulism-causing bacteria.
In serious cases, botulism can paralyse the muscles, leading to respiratory failure. Products from various manufacturers have been recalled in countries from China to Saudi Arabia.
The week the news broke also happened to be World Breastfeeding Week (marked each year from August 1 to 7), when the Unicef-linked Hong Kong association announced the results of its annual survey on breastfeeding (in which all eight public hospitals and 10 private ones in the city participated).
The breastfeeding rate has increased by 2.5 percentage points from 2011. It has been consistently rising from about 20 per cent in 1992.
Additionally, 89 per cent of hospitals refrained from promoting infant foods or drinks other than breast milk in 2011, while last year all of the hospitals refrained from doing so.
The World Health Organisation and Unicef launched the Baby Friendly Hospital Initiative in 1991 to improve hospital maternity care practices that support breastfeeding. Hospitals that implement the initiative's "10 Steps to Successful Breastfeeding" can achieve "Baby-Friendly" status.
In Hong Kong, although no hospitals have that status yet, efforts have been made to improve breastfeeding support.
Tarrant says the current breastfeeding rate - which is measured after the mothers are discharged from hospital - is "very good" and similar to many other developed countries. But it is still lower than the rates in Scandinavian countries (98-99 per cent), Australia (96 per cent) and Canada (87-88 per cent).
Of greater concern, says Tarrant, is the low continuation rate: only about half of all breastfeeding mothers do so for at least three months and about one-third for at least six months.
The lack of exclusive breastfeeding is another concern. The survey found that rates differed greatly among hospitals, from 14 to 56 per cent in public ones to zero to 95 per cent in private ones. "The ability to exclusively breastfeed before discharge could reduce the chance of early cessation of breastfeeding on going home," researchers say in the report.
The WHO recommends mothers breastfeed their babies exclusively up to six months, with continued breastfeeding up to two years of age or beyond.
Research shows that most Hong Kong mothers want to breastfeed, says Caroline Carson, a leader of the Hong Kong arm of La Leche League, a global charity run by volunteer breastfeeding mothers.
But many mothers often don't breastfeed or don't continue because they think they don't produce enough milk. Carson says few mothers lack milk; it is usually due more to a lack of knowledge of how breastfeeding works.
Other reasons for not breastfeeding include the lack of knowledgeable support - from family, friends and sometimes medical professionals - and the free availability and strong promotion of formula.
"Many people believe that formula is really nutritious and better for the baby. This scandal is spread by the formula manufacturing companies," says Liz Purnell-Webb, director of A Mother's Touch, a local maternity support company. Meanwhile, Tarrant says: "Infant formula should be avoided unless medically necessary. Research shows that even a small amount of infant formula in the early hours and days after birth is very detrimental to breastfeeding."
Studies have proven that breastfed babies have lower levels of infections and allergies and are less likely to be overweight, while mothers who breastfeed are less likely to develop certain cancers.
New studies suggest other benefits. A study last month by researchers from the Boston Children's Hospital found that infants who were breastfed for longer had better receptive language at three years of age, and verbal and non-verbal intelligence at age seven.
Another study, by US Ivy League Brown University, found that by age two, children who had been exclusively breastfed for at least three months had enhanced development in key parts of the brain compared to children who were fed formula or a combination of formula and breast milk.
The extra growth was most pronounced in parts of the brain linked with language, emotions and cognition.
Last month, Tel Aviv University reported that bottle-fed babies at three months of age were three times more likely to have attention deficit hyperactivity disorder than those who were breastfed. Breastfeeding also boosts a child's ability to climb the social ladder in adulthood and lessen chances of downward social mobility, according to a study published in the journal BMJ.
Going forward, the Hong Kong arm of the Unicef Baby Friendly initiative aims to further promote exclusive breastfeeding and provide additional support to mothers.
More training on the implementation of baby-friendly hospital policies will also be provided to obstetricians and paediatricians, as the survey found this to be a weak point.
The Hospital Authority will be recruiting more full-time designated nurses to support and teach mothers about breastfeeding, says Dr Alexander Chiu, chairman of the authority's steering committee on breastfeeding.
In addition, there are 27 "Baby-Friendly Angels" who provide peer support and counselling for breastfeeding in the authority's Maternal and Child Health Centres in Chai Wan, Sha Tin and Tsuen Wan.
As for the scandals, further legislation on formula milk could help curb inappropriate marketing for breast milk substitutes and prevent the discouragement of breastfeeding.
According to the survey, more hospitals observed text or pictures in marketing material that idealise artificial feeding, and more staff from milk formula companies approaching mothers and offering discounts.
The "Hong Kong Code of Marketing and Quality of Formula Milk and Related Products, and Food Products for Infants & Young Children" has been drafted and the public consultation was completed in February this year.
"We strongly hope that the code can be implemented very soon," Leung, the Unicef committee member, says. "This would be a crucial step to further protect and promote breastfeeding in Hong Kong from inappropriate marketing of breast milk substitutes."
There has been a series of milk-related scandals in the mainland. In 2008, six babies died of severe kidney damage and about 300,000 suffered from kidney stones after drinking formula tainted with melamine.
In December 2011 and July 2012, two Chinese companies recalled infant formula containing high amounts of aflatoxin, a carcinogen produced by fungus in cows' feed.
In a separate incident last year, another company issued a recall after unusually high levels of mercury were found in its main line of infant formula.
Purnell-Webb believes breastfeeding is a "no-brainer".
"The wonder of breast milk still amazes me, that nature has provided a complete package. No sterilising required, always available, changes to suit the climate and supplies all the nutrition and nurturing that baby needs," she says.
"The challenge is really letting mothers know the truth, so they can make an informed decision."