A shift toward breastfeeding may be coming with the cost of imported baby formula on the rise due to the economic crisis. (Credit: Ayman Lezzeik)
BEIRUT — Mazen Diab, a father of twin 8-month-olds in Beirut, is facing the same struggle feeding his infants as many parents across the country.
As Lebanon’s economic crisis worsens, parents of young children have found the search for formula milk increasingly challenging. Six months ago, Diab said, he used to search in three or four Beirut pharmacies before finding milk. About three months ago, Diab’s usual milk sources started drying up. The pharmacies that used to supply him were low on stocks and could not cater to as many people as before, if at all.
“I started going to areas in Mount Lebanon to secure milk for my kids,” he explained.
The challenge Diab and many parents like him now face points to a broader underlying issue that is deeply rooted in Lebanese society: the heavy reliance on formula milk.
Although health experts agree it’s better for infants to drink breast milk and that formula milk is not necessary for children aged 1 and older, marketing and social norms have pushed parents in Lebanon to rely on formula.
Amid the current currency crisis, which has led to shortages of imported goods while the prices of imports that can still be found skyrocket, that reliance has come back to bite the parents.
“The formula milk package for kids who are over 1 years old used to cost me LL34,000 before the economic crisis,” Omar Saab, a father to a 3-year-old from Khaldeh, said. “It is now priced at LL186,000.”
Formula milk for infants younger than 1 is sold only at pharmacies, as it is categorized as a pharmaceutical product, which means formula products for this age bracket are subsidized at the official, LL1,507.5 exchange rate to the US dollar, said Hani Bohsali, the head of the foodstuff importers’ syndicate. (The head of the pharmaceutical importers’ syndicate did not respond to requests for comment.)
Formula milk for children older than 1 is present in supermarkets and was previously subsidized, but now, as support is ended, these products are subject to the parallel market exchange rate.
Since October 2019, Banque du Liban has been subsidizing imported medicines, medical equipment and wheat at the LL1,507.5 rate, and basic foodstuffs at an exchange rate of LL3,900 to the dollar. Until recently, the central bank also covered 90 percent of fuel imports at the LL1,507.5 rate, but just last month, as BDL’s foreign currency reserves diminish toward their mandatory minimum threshold, it shifted to subsidizing 100 percent of fuel imports at the LL3,900 rate.
BDL’s subsidies program has hit another major snag in more recent months: prolonged payment delays. Outstanding invoices for formula milk, just as those for medicines, have allegedly been piling up at BDL. These invoices constitute a portion of the amount owed to medical supply importers.
Bohsali squarely blames BDL payment delays for the shortages, explaining that “importers refuse to distribute products if they don’t receive the subsidized payments.”
A central bank spokesperson told L’Orient Today on Wednesday that he was unable to provide information about BDL’s payments for formula milk products.
A week ago, caretaker Health Minister Hamad Hassan told the press that he has asked UNICEF, the UN agency responsible for children’s well-being, to support in feeding infant and young children amid the crisis.
In response, UNICEF officials said it was prepared to support initiatives to promote breastfeeding and carry out a survey to identify the nutritional status of young children.
Hassan, who appeared to be looking for donations of imports, responded that the campaign suggestion was “far from justice” and that the ideas of international organizations sometimes “do not fit the Lebanese reality.”
However, pediatric health experts have pointed out that the current Lebanese reality — apart from relying on expensive imported products — is not ideal for children’s health.
Although formula milk can be a suitable alternative for women unable to breastfeed or in other exceptional cases, breast milk meets infants’ protein needs and is rich in prebiotics and probiotics. It also contains vitamins and minerals needed by babies and is more easily digested than formula milk.
Yasmine Haddad, a licensed pediatric dietitian at My Pedia Clinic in Dubai, pointed out that the World Health Organization recommends that infants younger than 6 months old should be exclusively breastfed. After that, food should be introduced to infants’ diets as complementary to breastfeeding, which can go on until 24 months or more.
Bottle feeding after 12 months increases bacterial growth in the mouth and creates dental issues, she said. There are very few cases in which children should rely on formula milk rather than calcium-rich food, Haddad added, including in cases of metabolic disorders and failure to thrive.
Yasmina Dakik, a pediatric nutritionist and cooking expert based in Lebanon, agreed. After 12 months, she noted, parents can shift from breast and formula milk to cow’s milk. However, the child’s diet should not exceed two cups of any of these three types of milk per day, she noted. Instead, calcium-rich foods like walnuts, almonds, broccoli, strawberries, lentils and dates can be introduced to the diet.
Low rates of breastfeeding have health repercussions on society, said Lara Nasreddine, a researcher and an associate professor of human nutrition at the American University of Beirut, where she chairs the nutrition and food sciences department. Exclusive breastfeeding can shape the risk of diseases later on in the babies’ lives, she added.
“Breastfed infants are less likely to develop allergies, diabetes, obesity, heart diseases and other chronic diseases,” Nasreddine noted.
A culture of formula
Despite the evidence in favor of breastfeeding, the breastfeeding rate in Lebanon is very low.
“Routine infant and young child feeding practices in Lebanon fall short of international recommendations, with exclusive breastfeeding rates at 40 percent in 1-month-old infants and only 2 percent in 4–5-month-old infants,” Yukie Mokuo, UNICEF’s representative in Lebanon, told L’Orient Today in an email.
Based on research conducted by AUB’s nutrition and food science department in 2020 under the title “Exclusive Breastfeeding During the 40-Day Rest Period and at Six Months in Lebanon: A Cross-Sectional Study,” only 12 percent of infants are exclusively breastfed during their first six months of life.
The reasons reported include a lack of support at home, a lack of breastfeeding awareness and a lack of education at hospitals, along with misconceptions around breastmilk being insufficient or not good enough.
May Farhat, a mother of two girls, aged 3 months and 5 years, told L’Orient Today that her firstborn used to cry when she would try to breastfeed her. Farhat’s mother-in-law and husband pointed out that her breast milk “might not be edible or liquid enough for feeding,” which drove the new mother to switch to formula milk.
Farhat faced the same issue with her second child, but because of formula milk shortages in the country, Farhat decided it would be better to breastfeed her baby and so sought a lactation consultant to help her overcome the challenges she faced on her previous breastfeeding attempt.
“I came to learn that there is no such thing as inedible breast milk. I was just not holding my daughters in the correct breastfeeding position,” she said.
Joanne Makhoul, the president of Lactica, an NGO that aims to protect, promote and support breastfeeding by giving consultations and creating breastfeeding groups, explained that it is common for mothers to start out breastfeeding but quickly be discouraged from continuing.
“Most mothers start breastfeeding, but the continuation rate decreases one month after the other, due to the lack of support and education for mothers,” she said, adding that in many cases, incorrectly positioning the infant while breastfeeding leads mothers to think their milk supply is insufficient.
Mothers’ work schedules can also lead to difficulties in breastfeeding, Makhoul added.
In some cases, Makhoul said, hospitals actively push formula feeding. Makhoul noted that her group has been “shocked to find out that some hospitals refuse to give the [newborn] babies to their mothers for breastfeeding and choose to give them bottled milk assertively instead.”
Mothers should also know that some hospitals give babies bottles of milk immediately after they are born and that they have the right to refuse this and insist on breastfeeding their infant instead, she said.
Marketing has also played a role in convincing parents that formula is superior to breast milk.
Milk formula manufacturers have a history of marketing their products in the media and in hospitals and pediatricians’ clinics, Makhoul said. This phenomenon discourages breastfeeding among many mothers, particularly those residing in developing countries.
Dakik explained that formula milk companies introduced products aimed at children older than 1 in a way that made them seem indispensable to parents seeking to give their offspring the most nutritious start in life. The product aimed at 1–2-year-olds was sold as “formula +,” while that aimed at infants older than 24 months was “formula junior” and that for children older than 3 was “formula +++ calcium needed.”
“It is indeed a fallacy that without formula milk at the ages of 12-plus months, children will stop growing taller or that their body and brain development is halted,” she added.
According to Makhoul, there is also a lack of awareness on breastfeeding among pediatricians. Thus, when parents face difficulties with breastfeeding, doctors often advise them to convert to formula milk.
Haddad said, “Mothers who are having difficulties breastfeeding can resort to formula milk, although there is nothing more superior to breastmilk. These mothers are advised to seek lactation consultants before they call it quits.”
Promoting breastfeeding
Some see in the current crisis an opportunity for a societal shift.
“Although the formula milk shortages in Lebanon are challenging, it could be an opportunity to encourage new moms [toward] breastfeeding,” Nasreddine said.
According to her, with support from experienced women, new moms are more likely to breastfeed. This help is especially needed during the initiation phase, within 72 hours of giving birth, when mothers activate or turn on her breast milk production.
To encourage breastfeeding, the WHO initiated the Baby Friendly Hospital Initiative, which is applied in 22 public and private hospitals across Lebanon. The hospitals participating in the initiative, which encourages mothers to breastfeed,don’t offer formula, and they place the baby on the mother’s chest upon birth to achieve so-called kangaroo care to promote early initiation of breastfeeding.
Both Makhoul and Nasreddine believe it is essential that this initiative spread to all hospitals.
According to a study done by faculty from Johns Hopkins University and members of the Clemenceau Medical Center titled “Effects of a ‘Baby-Friendly Hospital Initiative’ on Exclusive Breastfeeding Rates at a Private Hospital in Lebanon: An Interrupted Time Series Analysis,” BFHI reforms succeeded in increasing the exclusive breastfeeding rate among CMC patients and sustaining it.
Nasreddine said the government should further develop policies that seek to make breastfeeding the norm rather than the exception, such as Law No. 47, issued in December 2008, which encourages breastfeeding by prohibiting formula milk companies from advertising their products. For example, Nasreddine recommended that the government could extend mandatory maternity leave policies and require that workspaces give mothers breaks to be able to pump or breastfeed their infants.
Meanwhile, Mokuo said UNICEF is set to launch an infant and young child feeding campaign in line with a Parliament initiative later this month, with the aim of promoting and protecting “optimal maternal nutrition, breastfeeding practices (0-6 months) and complementary feeding (6-23 months).” The initiative will encompass “counseling and support on lactation and complementary feeding through the IYCF Hotline” and help “identify, through robust assessment processes, infants requiring artificial feeding support and [support the provision of] referrals to appropriate service delivery points.”
Mokuo cautioned that simply bringing more formula to the market is not a sustainable solution.
“We are concerned about mass and untargeted distribution of infant formula because it may not easily reach to most in need in this difficult time and be provided for as long as it is needed, putting lives of infants and young children at risk,” Mokuo said.
