Infant Formula in the Digital Age: How US Online Formula Marketing Targets Parents

ABSTRACT

Despite recommendations by the International Code of Marketing of Breastmilk Substitutes (the Code), regulatory bodies in the United States continue to permit commercial milk formula (CMF) marketing that threatens public health. The increasing popularity of online shopping highlights the need for more research on virtual CMF product marketing. To assess marketing strategies from the e‐customer standpoint, we analyzed a sample of 26 bestselling virtual infant formula (IF) products from three US‐based e‐commerce giants. All product display content, including visual and audible components, was evaluated according to Code guidelines, analyzed thematically and assessed for theme co‐occurrence. No IF labels were compliant with the Code due to widespread health benefit claims and idealization of IF. Furthermore, no US‐based products were compliant with critical Code guidelines for powdered IF reconstitution instructions. Thematic analysis of virtual product web pages revealed 17 themes, of which four were novel to public health literature: purity, nature, innovation and eco‐friendly. These themes co‐occurred in patterned ways to capture consumers. The most popular online IF products in the United States combine Code violations with compelling online materials that idealize IF and shape cultural expectations about infant feeding and care. These practices reinforce the formula industry's well‐documented efforts to undermine breastfeeding. A review of US regulations and implementation of the Code is urgently needed to protect public health.

The online marketing materials used to display bestselling US infant formula products violate the International Code of Marketing of Breastmilk Substitutes with health claims, formula idealization, and unsafe preparation guidelines. Novel themes like ‘purity’ and ‘innovation’ highlight the need for stricter regulation of marketing practices to protect public health.

Summary

• Labels of bestselling online IF products violated the Code by incorporating health claims and idealizing formula feeding.

• Popular online US brands of IF consistently endangered infant health by not complying with the Code's recommendations for instructions on safe preparation.

• IF marketing materials deployed an array of themes, including four novel ones, that evoke cultural values and concerns to persuade consumers. Science, health benefits and nurture most commonly co‐occurred across products.

• The adoption and enforcement of the Code are urgently needed to protect the public from the sophisticated marketing strategies of IF products sold online.

1. Introduction

A large body of recent research has documented that commercial milk formula (CMF) marketing practices persistently violate regulations recommended by the International Code of Marketing of Breastmilk Substitutes (the Code) (Pérez‐Escamilla et al. 2023; Rollins et al. 2023; United Nations Children's Fund 2023). The industry's successful trajectory to a USD $55 billion enterprise has followed the same playbook championed by the tobacco, fossil fuel and opioid industries (Pomerantsev 2020; Kellie 2022; Lacy‐Nichols et al. 2022; Rollins et al. 2023; Tomori 2023; World Health Organization 2023a). CMF marketing targets parents, medical professionals and policymakers globally with sophisticated tactics to compete with breastfeeding for customers, or ‘share of stomach’ (Rollins et al. 2023, 489). These marketing strategies shape cultural narratives about infant nutritional standards, reproductive values and capacities, and ultimately generate profits at substantial costs to public health (Russ et al. 2021; Tomori and Palmquist 2022; Rollins et al. 2023; Tomori 2023; World Health Organization 2023a, 2023b).

The adoption of global recommendations for breastfeeding—early initiation, exclusive breastfeeding for infants of 0–6 months and continued breastfeeding with complementary foods for 2 years or beyond—could prevent 823,000 annual deaths globally in children younger than 5 years and 100,000 annual deaths related to ovarian and breast cancer in mothers (Victora et al. 2016; World Health Organization [WHO] & United Nations Children's Fund [UNICEF] 2022; Tomori 2023; World Health Organization 2023a). Breastfeeding is a universal mammalian adaptation that confers a wide range of beneficial impacts on infants, including optimal hydration and nutrition, protection from infectious and chronic diseases, and foundational support for cognitive and psychosocial development (WHO and UNICEF 2022; Pérez‐Escamilla et al. 2023). It also plays a critical role in ensuring food security during emergencies, such as when safe water or electricity is not available (Tomori 2022). However, globally, only 48% of infants are exclusively breastfed for their first 0–6 months, while the rate in the United States is closer to 25% (Centers for Disease Control and Prevention 2022a). Several structural determinants contribute to the high global consumption of CMF, including health system factors, workplace policies, and a loose regulatory environment for CMF marketing (Baker et al. 2023; Pérez‐Escamilla et al. 2023). Across low‐middle‐ and high‐income settings, CMF marketing holds demonstrable influence over purchasing decisions (Russ et al. 2021; Rollins et al. 2023). Moreover, CMF marketing often compounds inequities by encouraging formula feeding among parents who already face significant barriers to breastfeeding, including insufficient support in the healthcare system and in the workplace (Vilar‐Compte et al. 2022; Baker et al. 2023; Rollins et al. 2023; Tomori and Palmquist 2022; United Nations Children's Fund [UNICEF] 2023).

To protect the public from the harmful effects of CMF marketing, the Code explicitly discourages the use of idealizing imagery on product labels (Article 9.2), as well as the use of nutrition or health claims (World Health Assembly [WHA] Resolution 58.32) (World Health Organization 1981; WHA 2005). A recent study undertaken by the World Health Organization (WHO) and United Nations Children's Fund (UNICEF) (2022) demonstrated that marketing strategies, including health benefit claims, price manipulation, use of medical endorsement and scientific terminology, were highly effective in influencing perceptions about CMF and ultimately shaping infant feeding decisions (Rollins et al. 2023). Idealized product presentation, such as the use of shiny gold accents, hearts, and subtle references to science (i.e., images of white lab coats or acronyms like ‘DHA’), were shown to stand out to parents and evoke feelings of trust in CMF brands and products (Rollins et al. 2023, 492). Unar‐Munguía et al. (2022) found that parents who self‐reported high levels of CMF marketing exposure were more likely to feed their children formula and reference nutritional claims as their prime motivation for doing so.

To date, most nations and regulatory agencies around the world, including the US Food and Drug Administration (FDA), have not yet taken the critical step of implementing laws that substantially align with the Code to address CMF marketing (Pomeranz and Harris 2019; Russ et al. 2021; Lutter et al. 2022; Access to Nutrition Initiative 2024; Topothai et al. 2024). As a result, the misalignment between evidence‐based guidelines about infant and young child nutrition and CMF marketing practices has not only persisted, but escalated in the digital age. The internet has become a prominent source of CMF marketing in many countries, yet fewer than one in five have specific laws to restrict online CMF promotion in accordance with Code recommendations (Unar‐Munguía et al. 2022; World Health Organization 2022). Digital media, such as online search engines, social media platforms, company websites and e‐commerce sites, drive the widespread use of inexpensive and effective advertising fueled by consumer data and ever‐advancing targeted marketing algorithms (World Health Organization 2022). It remains exceedingly difficult to monitor the scope of digital CMF marketing and establish policies that can effectively protect parents and infants (Lara‐Mejía et al. 2022).

CMF marketing takes advantage of these regulatory gaps and exploits identified parental concerns, or ‘pain points,’ with corresponding claims of product use‐related intelligence, sophistication, superior health, nourishment, and reliability (Hastings et al. 2020; WHO and UNICEF 2022; Rollins et al. 2023). Previous literature has identified a wide range of marketing approaches that draw on cultural themes, which include common cultural concerns, values and beliefs, and can be deployed and tailored to make marketing more compelling. Some common cultural themes that have been explored both in public health and social scientific literature include CMF as a response to concerns about infant behaviour and health, CMF as part of nurturing practices, the value of the authority associated with medical endorsement and science supporting CMF, the association of CMF with a desirable lifestyle, the connection of CMF with progressive gender norms and feminist values, the notion that ‘premium’ products are superior (premiumization), and the importance of economic value or benefits (Tomori et al. 2018; Hastings et al. 2020; Han et al. 2022; Rollins et al. 2023). Additionally, anthropological and historical literature has explored a wide range of cultural constructs related to breastfeeding in relation to CMF marketing, some of which have not yet been fully connected to public health research on marketing themes (Tomori et al. 2018; Quinn et al. 2023).

Despite numerous studies on CMF marketing strategies and consequences, there is a scarcity of data that quantifies Code compliance in the United States online shopping environment, which plays an increasingly prominent role in parents' and caregivers' decisions about infant feeding. More parents are shopping online for CMF than ever before; as a whole, the US market size of online baby product sales grew 13.1% per year from 2018 to 2023 (IBIS World 2024). Additionally, only a few studies formally explore the cultural themes that are deployed in the virtual shopping environment to achieve marketing objectives (Hastings et al. 2020; Han et al. 2022; Rollins et al. 2023). This study evaluates Code compliance among bestselling online infant formula (IF) products, which is a subset of CMF marketing that targets the youngest and most vulnerable group of infants 6 months and younger (USDA n.d.). We complement this assessment with an analysis of commonly used cultural themes in online marketing materials (Hastings et al. 2020; Han et al. 2022; Rollins et al. 2023). Our goal is to illuminate online IF marketing and its implications for public health in a regulatory environment that has not enacted the Code (UNICEF 2023; Tomori and Palmquist 2022).

2. Methods

2.1. Data Collection

To estimate the most popular IF products sold online in the United States, we collected data on bestselling formulas from the three top online stores in the Toys & Baby segment in the United States across a span of 3 weeks: Amazon.com, Walmart.com and Target.com (Statista Research Department 2024). Each company's top 10 best‐selling IF products were tracked at regular intervals of 7 days for three repetitions (4, 11 and 18 September 2023) to increase the likelihood of capturing an accurate representation of the market. Only IF within the top 10 best‐selling lists were considered for inclusion. IF, a subcategory of CMF, was selected for this study to narrow the scope to marketing practices for the only appropriate substance outside of breastmilk for consumption by infants from birth to 6 months of age (USDA n.d.). IF products contain a regulated standard composition; therefore, focusing on this subcategory of CMF allowed product marketing and display to be isolated as the main variables of interest, with minimal variation in ingredients or purpose (U.S. Food & Drug Administration 2024). The data collection process resulted in the identification of 30 products per website. After the removal of duplicate listings, a final count of 26 unique IF products belonging to seven different brands was included in the study. Two brands originated from outside of the United States (four products from Australia and two products from the United Kingdom). The five US brands largely correspond with the top IF brands in the United States (Enfamil, Similac, Parent's Choice, Bobbie and Mama Bear), which constitutes a highly concentrated market and is dominated by Abbott (Enfamil), Mead Johnson (Similac) and Perrigo (which acquired Gerber and Nestlé's IF in 2022 and owns Bobbie and Parent's Choice) (Euromonitor International 2024), with the exception of Mama Bear, which is owned by Amazon and is a smaller label. The two foreign brands (Kendamil and Aussie Bubs) are popular, albeit much smaller, alternatives in niche markets (Szalinski 2024). The study received IRB approval from Johns Hopkins University (IRB# 00403148).

2.2. Label Compliance Assessment

To evaluate product label compliance with Code recommendations, each IF label was scored using a modified version of the periodic UNICEF NetCode Form 7: Desk Review of Product Labels (see Appendix SA), which provides a functional checklist of criteria for CMF product label recommendations (World Health Organization 1981; United Nations Children's Fund 2017). This tool was designed by the Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast‐milk Substitutes and Subsequent Relevant World Health Assembly Resolutions (NetCode) to identify gaps in Code compliance that national regulations have failed to address (United Nations Children's Fund 2017, 6). According to the NetCode document, Form 7 specifically operationalizes Article 9 of the Code, although other areas of related guidelines appear to overlap, such as with WHO Article 7.2 that recommends against implying CMF is equivalent or superior to breastfeeding, WHA Resolution 58.32, which discourages the use of health claims and urges labels to warn against the risk of pathogenic microbes, and WHO Addendum 69/7 on age‐appropriate labelling (World Health Organization 1981; WHA 2005, 2016). Seventeen criteria from the original 30‐item Form 7 checklist were selected for the assessment of IF labels (see Table 1). These criteria were chosen based on their relevance to the experience of an online customer in the United States browsing through best‐selling IF options on Amazon, Walmart or Target e‐commerce sites.

Table 1.

Criteria included from the periodic UNICEF NetCode Form 7.

Form 7 number	Criteria content
7.3	Contains any nutrition and/or health claims
7.4	Conveys an endorsement by a health worker or health professional body
7.5	Includes the recommended or appropriate age of introduction
7.7	Contains promotional devices to induce sales of the company's products under the scope
7.8	Includes a list of the ingredients
7.9	Displays nutritional composition of the product
7.10	Contains storage instructions
8.1	Includes the words ‘Important Notice’ or their equivalent
8.2	Includes a statement on the superiority of breastfeeding
8.3	Contains text or images that may idealize the use of breast milk substitutes
8.4	Contains text or images that may discourage or undermine breastfeeding
8.5	Contains text information that implies or crests a belief that breast milk substitute products are equivalent or superior to breast milk
8.6	Contains a statement that the product should be used only on the advice of a health worker
8.7	Contains a statement on the need for health worker advice on the proper method of use
8.8	Contains a warning against the health hazards of inappropriate preparation and usage
8.9	IF IN POWDERED FORM, contains a warning that powdered baby milk products may contain pathogenic microorganisms
8.10	IF IN POWDERED FORM, contains instructions for appropriate preparation: A. The label shows clear graphic instructions illustrating the method of preparation B. Instructions show the use of hygienic practices, e.g., clean hands, preparation surfaces C. Instructions show the need to boil water and sterilize utensils D. Instructions show necessity for powdered formula to be prepared one feed at a time E. Instructions show necessity for powdered formula to be prepared one feed at a time F. Instructions show the need to cool the formula before feeding if using hot water for reconstitution G. Instructions show that left overs of the product need to be discarded immediately

Note: For Criteria 8.10, subcriteria E is a repeat of D and was thus excluded from this point forward.

Criteria referring to the physical nature of product labels (i.e., how ‘well attached’ they were), language appropriateness and non‐IF products were excluded to instead focus on criteria that would most likely affect the virtual shopping experience of an e‐customer located in the United States (see Appendix SA). Using the modified Form 7 checklist as a rubric, we quantified each label's compliance as a quotient of compliant criteria divided by 17, the total number of relevant criteria. Product label materials that complied with NetCode criteria earned a ‘pass’, or 1 point, while criteria violations earned a ‘fail’, or 0 points. Products were scored according to their level of alignment with the list of modified NetCode criteria (i.e., a product meeting 17 out of 17 relevant criteria would earn 100%) and the mean, standard deviation and range of compliance were calculated for all 26 IF labels. To evaluate the compliance of formula preparation instructions with the Code, we referenced NetCode Form 7 criteria 8.10: ‘IF IN POWDERED FORM, contains instructions for appropriate preparation’, which includes six sub‐criteria (see Table 1). To determine patterns of compliance among criteria, similar calculations were performed by criterion (vs. product). The rate of label compliance per criterion was evaluated by dividing the number of labels that complied with each criterion by 26, the total count of labels. To display these patterns of compliance, the 17 criteria were arranged from least to most complied with in a table. All Form 7 criteria evaluation was repeated independently by two researchers (S.F. and C.W.). Any discrepancy was evaluated by the senior researcher (C.T.) and discussed with the entire research group until consensus was achieved.

2.3. Qualitative Analysis of Marketing Themes

To explore the marketing content an e‐customer would likely interact with when shopping for IF online, we examined the online presentation of 26 best‐selling IF products on their respective retail web pages. All textual, audible, and visual elements of each product label and retail web page were documented in a spreadsheet and then underwent thematic analysis. This analytical process entailed multiple rounds of reading and preliminary coding by one researcher (S.F.), followed by additional review and discussion of the online marketing materials for each product with the senior researcher until consensus was reached. These codes were triangulated with existing themes from relevant public health and anthropological literature. We examined the correspondence of our codes with those previously documented in public health CMF marketing research (Hastings et al. 2020; Han et al. 2022; Rollins et al. 2023). We then triangulated the remaining codes with anthropological work on breastfeeding primarily derived from ethnographic research (for an overview, see Quinn et al. (2023) and Tomori et al. (2018)). Final themes were organized, defined and exemplified with excerpts from virtual IF product display content.

2.4. Quantitative Analysis of Theme Occurrence and Co‐Occurrence

Once the process of theme development was complete, virtual product display materials, including their visual, textual and audible components, were assessed for the presence of established themes. Two researchers (S.F. and C.W.) independently tallied theme occurrences for each IF product, which were then reviewed by the senior researcher. This process involved a binary answer (YES/NO) to the question, ‘is X theme present anywhere in this product's virtual display materials?’ For example, if a product's online presentation included evidence of medical endorsement (i.e., an image of a person wearing a white coat and stethoscope on the retail webpage), that product would be marked as a ‘YES’ for the theme of medical endorsement.

Final theme occurrence tallies were then organized into a co‐occurrence matrix on Microsoft Excel that displayed how often themes occurred together for the same IF product (see Appendix SB). Co‐occurrence matrices highlight the relationships between entities (in this case, themes) to enable a clear presentation of their prevalence, patterns and associations. Data from the co‐occurrence matrix were visualized as a force‐directed graph using Python (a common programming language) and a code informed by multiple libraries (Pandas, NumPy, NetworkX, Matplotlib and openpyxl) on the open‐source code editor, Visual Studio Code (Python Software Foundation n.d.; Microsoft n.d.). Data analysis and visualization were performed using the following libraries: Pandas (McKinney 2010) for data manipulation, NumPy (Harris et al. 2020) for numerical operations, NetworkX (Hagberg et al. 2008) for network analysis, Matplotlib (Hunter 2007) for plotting and openpyxl (Gazoni and Clark n.d.) for reading Excel files. The theme co‐occurrence matrix was visualized as a force‐directed graph to illustrate the strength of relationships (with connecting lines or edges) between themes (nodes) (Kobourov 2013). In a force‐directed graph, attractive forces, such as high co‐occurrence rates, pull nodes closer together, while repelling forces, such as low co‐occurrence rates, push nodes farther apart. Thus, themes that frequently occurred together in virtual IF product display materials were visualized within close proximity to generate node ‘clusters’, while nodes representing themes that never or rarely appeared together were positioned farther apart. To highlight the relationships between strongly co‐occurring themes, the force‐directed graph only connected nodes representing themes with co‐occurrence rates of 80% or more.

2.5. Ethics Statement

The project received IRB approval from Johns Hopkins University (IRB# 00403148).

3. Results

3.1. Label Compliance

No IF product label complied fully with the modified NetCode Form 7 (M = 0.60, SD = 0.13). Labels earned 10.2 (60%) of the 17 total available compliance points on average, with a standard deviation of 0.13 points. Compliance scores ranged from 41% to 82%, with the lowest result adequately meeting less than 7 out of 17 criteria. IF owned by foreign companies (Australia and the United Kingdom) earned a compliance score of 76% on average (SD = 0.09), compared to the 50% average (SD = 0.05) for US brands. Patterns of noncompliance among criteria ranged from 0% (criteria 7.3 and 8.3) to 100% (criteria 7.8, 7.9, 7.10, 8.7 and 8.8; see Table 2).

Table 2.

Patterns of compliance with NetCode Form 7 criteria from low to high compliance.

NetCode form 7 criteria	No. of labels reviewed	No. of violations	Quotient of compliance per label
7.3 Contains any nutrition and/or health claims	26	26	0.0
8.3 Contains text or images that may idealize the use of breast‐milk substitutes	26	26	0.0
8.1 Includes the words ‘Important Notice’ or their equivalent	26	21	0.19
8.2 Includes a statement on the superiority of breastfeeding	26	21	0.19
8.10 IF IN POWDERED FORM, contains instructions for appropriate preparation	24	18	0.25
8.5 Contains information that implies or creates a belief that breast‐milk substitute products are equivalent or superior to breast milk	26	17	0.35
7.4 Conveys an endorsement by a health worker or health professional body	26	15	0.42
8.6 Contains a statement that the product should be used only on the advice of a health worker	26	10	0.62
7.7 Contains promotional devices to induce sales of the company's products under the scope	26	10	0.62
8.9 IF IN POWDERED FORM, contains a warning that powdered baby milk products may contain pathogenic microorganisms	24	5	0.79
7.5 Includes the recommended or appropriate age of introduction	26	3	0.88
8.4 Contains text or images that may discourage or undermine breastfeeding	26	1	0.96
7.8 Includes a list of the ingredients	26	0	1
7.9 Displays nutritional composition of the product	26	0	1
7.10 Contains storage instructions	26	0	1
8.7 Contains a statement on the need for health worker advice on the proper method of use	26	0	1
8.8 Contains a warning against the health hazards of inappropriate preparation and usage	26	0	1
M (SD)			0.60 (0.38)

Note: Two liquid ready‐to‐feed products were not applicable for evaluation by criteria 8.9 and 8.10. Only products meeting all six sub‐criteria of criterion 8.10 were marked as compliant.

All sampled labels were found to violate the Code by including components that idealized the use of IF and claims about their health and nutritional benefits. Idealizing text can include product names and descriptions that evoke an idealized or desirable state, such as ‘Advantage Premium’ (Parent's Choice), ‘Similac Pure Bliss’, ‘Goodness from the farm’, (Aussie Bubs), ‘An inspired way to nourish’, (Enfamil Enspire) or ‘Award‐winning formula made with love in Europe’ (Kendamil). Idealization can also occur through visual components such as blue ribbons that say ‘#1’ (Similac), shiny gold or silver packaging and idyllic farm scenes or visuals of smiling animals (Aussie Bubs, Mama Bear). More than four out of five labels failed to include a statement on the superiority of breastfeeding or the words ‘Important Notice’ or their equivalent to highlight this statement. Only a quarter of labels demonstrated adequate instructions for the appropriate preparation of powdered IF by meeting all six sub‐criteria of criterion 8.10. Nearly two‐thirds of the sample implied that IF products are equivalent or superior to breast milk with prominent phrases such as ‘Modelled After Breast Milk’, ‘Inspired By Breast Milk’, and claims about special ingredients that are also found in breast milk, such as ‘Enfamil Gentlease has DHA and Choline, brain‐nourishing nutrients that are also found in breast milk’.

Preparation instructions were extracted from the 24 powdered IF labels and scored according to the six sub‐criteria for Form 7 criterion 8.10. The six foreign IF products in our data set were 100% compliant with these sub‐criteria, while the 18 US‐based products only complied with 50% of them (A, B and G) (see Table 3).

Table 3.

Preparation instruction criteria result from low to high compliance.

Criteria 8.10	No. of labels reviewed	No. of violations	Per cent of compliance per label
c. Instructions show the need to boil water and sterilize utensils	24	18	25%
d. Instructions show necessity for powdered formula to be prepared one feed at a time	24	18	25%
f. Instructions show the need to cool the formula before feeding if using hot water for reconstitution	24	18	25%
g. Instructions show that leftovers of the product need to be discarded immediately	24	0	100%
a. The label shows clear graphic instructions illustrating the method of preparation	24	0	100%
b. Instructions show the use of hygienic practices, e.g., clean hands, preparation surfaces	24	0	100%
M (SD)			0.63 (0.41)

Note: Products were marked as compliant with Criteria A if they showed at least three instructive images. Only products meeting all six sub‐criteria were marked as being compliant with Criterion 8.10.

3.2. Marketing Themes

IF product packaging and retail page descriptions, images and videos were evaluated for marketing themes. Seventeen themes were identified. Thirteen of these corresponded with previously established cultural concepts sourced from a combination of studies (Hastings et al. 2020; Han et al. 2022; Rollins et al. 2023) (see Table 4).

Table 4.

List of themes and their previous discussion in the public health literature.

Themes	Hastings et al. (2020)	Han et al. (2022)	Rollins et al. (2023)	Novel
Health benefits	X	X	X
Nurture	X	X
Gentle			X
Happiness	X		X
Medical endorsement	X	X	X
Trustworthy	X
Science	X		X
Premium	X	X	X
Purity				X
Specialty	X		X
Nature				X
Closeness to breastmilk	X		X
Gender	X		X
Cost‐effective	X
Convenience			X
Innovation				X
Eco‐friendly				X

The most frequently used themes were health benefits, nurture and science, which appeared in the virtual display of every product in our sample. Health benefit claims were evident in online product titles like ‘Enfamil Gentlease Baby Formula, Reduces Fussiness, Gas, Crying and Spit‐up in 24 h, DHA and Choline to support Brain development’, product descriptions and visual cues such as cartoons of ‘immunity’ shields, beneficial microbes, stool, and eczema that were paired with health claims (e.g., on Nutramigen's IF product web page). The theme of nurture was communicated through photos and videos of smiling, close families in addition to overt claims like ‘At Mama Bear, nurturing is our nature. And an important part of nurturing your baby is feeding him or her a formula that you feel good about’, which was accompanied by feel‐good imagery of hearts, smiley faces and cute animals. On labels, nurture was evident through statements like ‘Let's fuel the wonder’ (Enfamil Enspire) and comforting imagery of smiling mama‐baby animal duos and heart shapes. Ideas of science were also conveyed multimodally, through abstract chemical structures resembling molecular models, scientific acronyms like ‘DHA’, ‘ARA’, ‘MFGM’ and ‘HMO’, claims that began with ‘clinically proven to…’ and videos of scientists in white coats and goggles measuring out what are presumably CMF ingredients with professional laboratory equipment (Similac).

Additionally, four novel themes were identified: purity, nature, innovation and eco‐friendly. The first three of these themes have been discussed in previous anthropological literature on the cultural themes associated with breastfeeding in relation to the development and growing marketing of commercial IF (see Tomori et al. (2018) and Quinn et al. (2023) for an overview) but have not been discussed in the public health literature we drew on for this study. The eco‐friendly theme had not been delineated in either the anthropological literature or the public health literature we employed. The notion of purity was evoked by references to products free of ingredients that may be perceived as unnecessary or harmful, as well as visual cues representing the association of infants with innocence and an angelic nature. For example, the title of Similac's ‘Pure Bliss’ product was written in puffy, white, cloudlike font with an angelic halo over the ‘P’. On the front of the container, the label stated that the product does not contain additives such as artificial growth hormones, GMOs and corn syrup solids. The theme of nature was evoked through the imagery of animals and idyllic, green fields, paired with descriptions like: ‘Imagine a place covered by lush green grass, where the majority of the water used to feed the grass comes from natural rainfall. Imagine grass‐fed cows having the freedom to graze outdoors’ (Similac Pure Bliss). These words and imagery present nature in an idealized form. The theme of innovation appeared through competitive language, such as ‘Only Enfamil NeuroPro has both expert‐recommended brain‐building DHA and an exclusive HuMO6 immune blend’, a claim sourced from an image of a smiling baby leaning on furniture to stand up (Enfamil NeuroPro). The same product claimed to have a new health benefit in its textual description: ‘5‐YEAR BENEFIT: MFGM components clinically shown to support cognitive, motor and communication development now through age 5’. This innovative messaging portrays the IF product as being on the cutting‐edge of nutritional research, distinguishing it from other brands and earlier formulations. The theme of eco‐friendly was identified in descriptions of sustainably sourced ingredients. Each theme was described and exemplified with excerpts from IF marketing materials in our sample (see Table 5).

Table 5.

Theme definitions and examples.

Theme	Description	Examples
1. Health benefits	Descriptions of how the product can support the health or development of infants through formula ingredients and additives. Emphasizes the product's role in ensuring nutrition, healthy development and culturally normative behaviour of infants.	‘NeuroPro Gentlease has an exclusive immune blend of ingredients to support your baby's immune health, including 2′‐FL HMO, Vitamin C & E, Selenium, partially hydrolyzed protein, reduced lactose’
2. Nurture	Evokes an emotional connection between parents and their infants, emphasizing the product as a source of nourishment and comfort that fosters the bonds within the family. Claims and images convey closeness, love and prioritization of the infant's needs.	‘At Mama Bear, nurturing is our nature. And an important part of nurturing your baby is feeding him or her a formula that you feel good about—formula that meets your baby's nutritional needs. Growing cubs are hungry cubs; feed them with love’.
3. Gentle	Product information that depicts a relationship between the ‘sensitive infant’ and the ‘gentle formula’ that is easy to digest. These claims and imagery evoke feelings of nurture and comfort. Linked to claims about infant behaviour, digestive ease, nurture, and speciality products (hypoallergenic).	‘Gentlease’ (Enfamil product name) ‘Gentleness of soy to soothe the tummy’ (Enfamil Gentlease)
4. Happiness	Depictions and descriptions of happiness position formulas as a key ‘ingredient’ (created by happy scientists and cows) to infant and family happiness. Happiness is evoked through playful designs, images of smiling infants, idealized images of family members, and directly communicated through claims.	‘All‐in‐one comfort for happiness’. (NeuroPro Gentlease) ‘Happy tummy, happy baby, happy you!’ (NeuroPro Gentlease)
5. Medical endorsement	Prominent or subtle displays of endorsement by a health worker or health professional body. Messaging aims to build trust and credibility.	‘#1 recommended by paediatricians’. (Enfamil) ‘The #1 brand fed in hospitals’ (Similac) Prominent display of medical caduceus (Similac, Enfamil)
6. Trustworthy	Conveys a sense of reliability and integrity, emphasizing the product's commitment to quality, safety, and transparency. Messaging is designed to assure parents that the product's reliability has been tested by time, regulations and health professionals. Linked to the ideas of science, purity, medical endorsement, and nature.	‘TRUSTED FOR OVER 17 YEARS: Founder Kristy Carr, a mom of three, has a mission to inspire the next generation of happy babies, with Clean Label nutritional products that provide the foundation for setting up a lifetime of good eating habits’. (Aussie Bubs)
7. Science	Scientific claims highlight the research, development, and innovation that goes into formulating the product. Includes references to specific ingredients, nutritional breakthroughs, or scientific studies that support the formula's benefits. Imagery depicts the idea of science through molecular designs and scientists in lab coats.	‘Enriched by research’. (Kendamil) ‘Based on a clinical study with Alimentum Ready to Feed without DHA, ARA, 2′‐FL HMO, lutein, and beta‐carotene. A crossover clinical study of infants experiencing colic symptoms due to cow's milk protein sensitivity showed 5 of 6 infants initiated on Alimentum during the first week achieved a reduction in excessive crying’.
8. Premium	Claims and imagery convey a sense of exclusivity and high quality, suggesting products are sophisticated and top tier. Packaging may feature elegant design elements, distinctive branding, and language that highlights the product's unique qualities. Premium themes often draw on the reputation of European superior quality.	‘Award‐winning formulas meet the highest standards for infant formula set forth by Europe and the United States guaranteeing exceptional quality for your family’. (Kendamil) Packages feature shiny gold/silver accents.
9. Purity	Messaging that conveys the idea of clean ingredients that are free from contaminants or anything artificial. Imagery depicts pristine environments, official certification labels of purity or the idea that infants themselves are pure/uncorrupted. Purity crosscuts the themes of premiumization, nature/natural and trustworthiness.	‘No artificial colours, flavours, or preservatives, and selected for Clean Label Purity Award’. (Bobbie) The product title ‘Pure Bliss by Similac’, is in soft, white, playful font, and features image of an angel halo over the ‘P’
10. Specialty	Speciality products are conveyed as being (a) distinctive and unique or (b) designed for a specific infant population/health issue. Messaging emphasizes how these products (a) stand apart from the mainstream or (b) are tailored solutions designed to support/cure specific infant conditions.	‘#1 Added Rice Starch Formula’ (Enfamil A.R.) ‘Similac NeoSure supports better rates of growth during a premature baby's first year compared to term infant formula. It has increased protein, vitamins, and minerals compared to term infant formula, and nucleotides for the developing immune system’.
11. Nature	Messaging that invokes a connection to the natural world, emphasizing the natural origin and wholesome quality of formula and its ingredients. Features images of natural landscapes, plants and animals.	Imagery of green pastures and free‐range goats eating grass. On the front of the container is an image of a smiling stuffed animal baby goat. (Aussie Bubs) ‘Kendamil Organic infant formula combines only the finest quality and sustainably sourced organic ingredients, starting with natural whole milk fats (present with MFGM identified in breast milk and shown to support cognitive development) and lactose from grass‐fed cows ‐ replacing palm oil, soy, and corn syrups while creating a naturally creamy formula closer to breast milk and wholesome by nature’.
12. Closeness to breastmilk	This theme is designed to appeal to parents seeking the closest alternative to breastmilk. Products claim that special ingredients closely mimic the unique components of breastmilk.	‘Enspire has MFGM and Lactoferrin, two key components found in breast milk, making it our closest formula ever to breast milk’. ‘Gentle nutrition modelled after breastmilk. When you are ready to turn to infant formula but you don't want to compromise, look to Pure Bliss by Similac’. ‘HMOS are immune‐nourishing prebiotics structurally identical to those in breast milk’. (Similac)
13. Gender	Gender‐related messaging that reassures and empowers mothers. Claims and imagery highlight women's independence, empowerment and modernity. Seeks to provide emotional support for mothers while addressing the complex feelings and expectations surrounding infant feeding, including alleviating potential feelings of guilt in those who cannot/do not breastfeed.	‘As the only mom‐founded women‐led infant formula company, we get it because we built Bobbie not only for our babies but for yours’. Product video of the founder of Bobbie speaking to the camera, imagery of mothers working, being CEOs, and staying at home with the kids, visuals of moms working from home.
14. Cost‐effective	Messages that highlight the cost‐effectiveness of products, product eligibility for payment assistance programmes, or promotional devices to induce sales.	‘MySimilac rewards for a strong start: get nutrition guidance for you and baby, exclusive benefits, coupons, and much more’. ‘Enfamil family beginnings. exclusive savings and rewards’. (with QR code)
15. Convenience	Often found on ready‐to‐feed products, messaging conveys the ease of use of formula and their packaging.	‘Fuss‐free guarantee’. (Parent's Choice) ‘The perfect bottle anywhere, anytime’. (Similac 360 Total Care Ready to Feed)
16. Innovation	Messaging that idealizes the product as being the ‘first’ to attain a certain forward‐thinking feature that other products do not have.	‘The first leading infant formula brand with no artificial growth hormones’. (Similac Advance) ‘Our biggest formula breakthrough, with 5 of the most abundant HMOs found in breast milk’. (Similac 360 Total Care)
17. Eco‐friendly	Language that emphasizes the sustainability of ingredients or labels them as being ‘plant‐based’ versus dependent on livestock.	‘Sustainably sourced ingredients’ (Kendamil) ‘Vegetarian: using plant‐based DHA with no animal‐rennet, learn about our happy cows and our eco‐friendly mission’ (Kendamil)

3.3. Theme Co‐Occurrence

Theme co‐occurrences across labels demonstrated theme relationships that were quantified with a co‐occurrence matrix (see Appendix SB) and illustrated with a force‐directed graph (see Figure 1). Themes with stronger relationships were positioned as connected and clustered nodes, while weaker connections were depicted farther apart and without connecting lines.

Figure 1.

Force‐directed graph of theme co‐occurrences (top 20% of connections). Node colours are arbitrary and randomly assigned.

Themes of health benefits, nurture and science consistently appeared across all online products in our sample. The force‐directed graph algorithm placed these three popular themes central to the figure, illustrating their high rates of co‐occurrence with other themes. In this graph, shorter edges demonstrate stronger co‐occurrence (closer to 100%), while longer edges show weaker co‐occurrence (closer to 80%). Several visual clusters are evident, including the health benefits, nurture and science clusters, as well as the nature, premium and gender clusters.

Some themes were found to cluster in particular products or product families. For example, the three brands with certified organic products in our data set simultaneously conveyed the natural origins of ingredients, communicated their premium status through references to Europe, high quality and images of families in luxurious settings and attire and emphasized their nurturing qualities. The theme of gendered messaging, evoking feminism (i.e., ‘As the only mom‐founded women‐led IF company, we get it because we built Bobbie not only for our babies but for yours’, Bobbie) was also common to the organic products, and frequently co‐occurred with happiness (i.e., ‘thoughtfully created to support new generations of happy and healthy bubs’, Aussie Bubs), nurture, health benefits and trustworthiness (i.e., ‘We trust it because it has organic ingredients and clean label certification’, Bobbie).

Labels on speciality formulas included themes of helping reduce behaviours like crying, which are normal infant behaviours. For example, a video for Enfamil NeuroPro Gentlease claimed the product would ‘Help calm their tummy in just 24 h’ over the sounds of a thunderstorm and a sad‐faced stormy cloud animation positioned over a crying infant's abdomen. Infant sleep behaviour was referenced in a Similac Alimentum webpage photo of a sleeping infant that was described with the text ‘…after initiation of Alimentum, 62% of parents reported good to excellent quality of infant sleep vs. 10% after initiation’. Another normal infant behaviour, spit‐up, was referred to frequently with claims such as ‘REDUCES SPIT‐UPs: Enfamil A.R. spit‐up baby formula with iron is a gentle milk powder formula made with rice starch clinically proven to reduce frequent spit‐up by over 50% in 1 week’. Such health claims frequently co‐occurred with the theme of gentle, a key word that describes the purported soothing effect of certain formulas for gastrointestinal upset.

4. Discussion

This study used a unique combination of established public health and social scientific approaches to document how, and to what extent, the labels of popular online IF products in the United States violate the Code as well as how surrounding online promotional materials contribute to problematic marketing practices. Quantitative analysis revealed that all IF product labels in our sample violated the Code, and that US‐based brands were especially non‐compliant with recommendations about the proper reconstitution of powdered IF. In addition to Code violations on the labels themselves, qualitative analysis results revealed 17 distinct marketing themes, including four novel ones to public health literature, that were used in various combinations to capture consumers. Collectively, these labels and themes work together to promote and idealize IF use and maintain its normalized status in the cultural environment in the United States. Our findings provide unique insight into the combined power of marketing messages that simultaneously omit or circumvent necessary labelling information and draw on a large array of cultural themes that create multiple lines of positive emotional associations with IF that ultimately lead to more sales.

Our findings on the prevalence of label violations align with literature from organizations such as the Access to Nutrition Initiative (2024), which assessed CMF's labeling adherence to Code recommendations in five countries. Their results similarly revealed that no CMF product labels marketed in the US fully complied with the Code, with common violations for health claims and not explicitly communicating the importance of breastfeeding. Our study also identified several key mechanisms for undermining breastfeeding and reinforcing CMF as the cultural norm for infant feeding.

First, our study highlights the importance of the association of IF with health benefits and medical authority. All labels in our sample featured idealizing components and claims endorsing CMF health benefits, while few included a statement on the superiority of breastfeeding as recommended by the Code. Additionally, more than half (58%) of CMF product labels commonly evoked medical authority via health professional endorsement to bolster their claims. The use of medical endorsements is particularly notable because health professionals are considered the primary authorities on infant care and feeding in the United States. Therefore, these endorsements capitalize on the cultural importance and social power of medicine (Quinn et al. 2023). This contributes to undermining public health messaging about the importance of breastfeeding for health and contributes to misleading caregivers about infant feeding decisions.

Second, our study highlights the use of a wide array of marketing themes that were deployed in a relatively small number of best‐selling products. The 17 themes documented in this study highlight how IF companies draw on and respond to cultural values and concerns that caregivers and families may have about infant care and feeding. In accordance with previous research, these marketing themes constitute a core part of industry efforts to establish IF as an ideal form and a culturally normative standard of infant feeding (Hastings et al. 2020; Rollins et al. 2023). The deployment of these themes relies less on delivering information than on creating emotional connection between the consumer and the product, establishing it as beneficial, trustworthy and reliable, and assuaging any anxiety and concerns (Hastings et al. 2020). Our study broadens the description of documented themes in the literature about CMF marketing by identifying four novel themes. Of these, three have been previously discussed in the anthropological and the historical literatures describing the rise of IF marketing in the 20th century, but have not been formally characterized or integrated with the public health literature. For instance, references linking IF to ‘nature’ have been a long‐running theme in IF marketing (Apple 1987), and questions about what is a ‘natural’ way of feeding infants have been a sustained source of cultural controversy (Tomori et al. 2018). Eco‐friendly appears to be a more recent marketing theme to help appeal to environmental concerns, which is notable in light of recent work on the harmful environmental impacts of CMF production (cf Smith et al. 2024).

Third, our study revealed a core triad of themes that repeatedly co‐occur across these products: science, health benefits and nurture. To our knowledge, this pattern has not been examined in previous literature. These findings underscore the importance of not merely examining marketing themes on their own, but to explore how they are deployed in combination. The portrayals of IF being simultaneously scientific, and replete with health benefits, exploits social trust in science to validate health claims on labels and further these associations. The use of nurturing messages in combination with ideas of health and science creates another line of positive associations by aligning IF with an idealized notion of infant care. Together, these marketing practices idealize IF and reinforce the narrative that formula feeding is at least as good as (if not better than) breastfeeding. It is for this reason that Article 9 of the Code and WHA Resolution 58.32 discourage the use of idealizing imagery, nutrition claims, and health claims in CMF marketing materials (World Health Organization 1981; WHA 2005). Previous work demonstrates that the scientific foundation for most health claims is often poor or lacking altogether, and persistent conflicts of interest in the research cited for the authentication of marketing claims threaten the integrity of both the scientific and medical fields (Rollins et al. 2023). Misleading claims supporting the idea that IF is scientifically interchangeable with breastmilk (down to a molecular level) lie at the foundation of the CMF industry's success. The promotion of these claims also misleads healthcare professionals, who in turn recommend IF as a solution for typical infant behaviours (Rollins et al. 2023). The central themes of science, health benefits, and nurture portray IF as a sophisticated, scientifically tested product, with optimal and tailored components that simultaneously fulfill the human infant need for comfort, care, and love. Our findings suggest that the consistent clustered deployment of these three themes is not coincidental but strategic. Together, they compete with the public's growing awareness of the far‐reaching impacts of breastfeeding on maternal and infant health, well‐being and social development.

Fourth, our study highlights that the co‐occurrence of certain themes may be a part of market segmentation strategies that target specific concepts that have been demonstrated by market research to be effective for particular consumer groups. Hastings et al. (2020) demonstrated that market segmentation is a key strategy for reaching the broadest possible groups of people and to address their specific concerns and desires. Some of these messages appear to be in alignment with one another, while others that may seem at odds are working to create an impression of alignment. For instance, themes of nature and science, while appearing to belong on different ends of a spectrum, co‐occurred closely across products to idealize IF for both the customer who may be concerned about IF containing ‘artificial’ ingredients they may view as harmful, and technical‐leaning customer who may be swayed by associations of IF with the concept of ‘science’.

Fifth, our study reinforces previous work (WHO and UNICEF 2022) that marketing messages on best‐selling CMF labels and retail web pages frequently portray normal infant behaviours as problematic, such as crying, fragmented sleep or spit‐up as described above. Previous research has documented that IF marketing messages reference normal infant behaviours to ‘…create and nurture pain points’, among customers (WHO and UNICEF 2022, 10). Exaggerating customer ‘pain points’ clears the way for marketing narratives to frame CMF as the perfect solution. This effective strategy has spurred a rise in available ‘specialty’ CMF products that normalize and idealize the use of CMF as the solution to typical infant behaviours (Rollins et al. 2023).

Finally, our findings have growing importance in a time when multiple emergencies have threatened food security (Pérez‐Escamilla 2017; Tomori 2023). To protect infants from the risk of infection, WHA Resolution 58.32 recommends that labels contain an explicit warning that powdered baby milk products may contain pathogenic microorganisms (137). Yet over 20% of the products examined lacked a warning that product contents ‘may not be sterile’, an indirect phrasing of the recommendation. Only one‐quarter of labels for powdered IF contained instructions for appropriate preparation. Label preparation instructions for US‐based IF products lacked several important phrases that the Code recommends implementing to keep infants safe, such as the need to boil water and sterilize bottle‐feeding equipment that can become reservoirs for pathogens. However, the FDA only mandates IF label instructions for ‘…sterilizing water, bottles, and nipples when necessary before preparing infant formula’, (US FDA 2023, 9). US‐based brands circumvented Code recommendations while complying with FDA requirements using phrases like, ‘Ask your baby's doctor about the need to use cooled, boiled water for mixing and the need to boil (sterilize) bottles, nipples and rings before use’ (Similac). Without clear instructions to boil water before preparing formula, parents may unwittingly expose their infants to pathogenic microorganisms (Centers for Disease Control and Prevention 2022b, 2023). Young infants are particularly vulnerable to drinking water contaminants, including E. coli, norovirus, and Giardia (America's Children and the Environment 2023) The United States has recently faced several instances of contaminated formula that led to cases of infant sickness and deaths, and to a major plant's shutdown, causing a formula crisis (Hobbs 2023; Tomori and Palmquist 2022). Additionally, the United States has a high prevalence of water insecurity (DigDeep and US Water Alliance 2019), which is further threatened by a growing number of climate‐driven emergencies (Tomori 2022; IPCC 2023). Combined, low access to water or unsafe drinking water and contaminated IF put infants at increased risk for negative health outcomes.

Collectively, our findings underscore the lack of action by the US government to legally adopt and enforce the Code as part of larger efforts to create structural support and enabling environments for breastfeeding (Pérez‐Escamilla et al. 2023; Rollins et al. 2023). As a commercial determinant of health, the marketing of IF has been linked to dramatic shifts in the way that we feed and care for our infants, with devastating consequences for maternal and infant health (Unar‐Munguía et al. 2022; Pérez‐Escamilla et al. 2023; Rollins et al. 2023; World Health Organization 2023b). Due to their dependence on adults, infants are especially vulnerable to the negative effects of commercial determinants, and the health and human rights costs of these violations have a disproportionate impact. The Code's recommendations for CMF marketing regulations were passed in 1981 to protect breastfeeding and the health of the public, and their implementation is considered important to ensuring adherence to human rights law under the right to health and the United Nations Convention on the Rights of the Child (CRC) (World Health Organization 2017; Russ et al. 2021; Rollins et al. 2023). Over 40 years later, we know that undermining breastfeeding has far‐reaching and life‐long impacts on maternal, infant and young child health, yet IF (and all categories of CMF) marketing has only grown (Pérez‐Escamilla et al. 2023). With virtually unrestricted ability to generate a wide and flexible variety of claims and imagery that accompany CMF products online at the point of sale, the CMF industry is likely to continue to scale its influence to undermine breastfeeding while negatively impacting maternal and infant health and health equity worldwide (World Health Organization 2022; Mota‐Castillo et al. 2023; Rodríguez et al. 2023). To date, the primary agency responsible for regulating IF safety and nutrition standards in the US, the Food and Drug Administration (FDA), has not taken action to regulate marketing claims on formula labels in compliance with Code recommendations (FDA 2016; Hughes et al. 2017). Additionally, the Federal Trade Commission (FTC) has the unique authority to protect consumers from ‘…unfair and deceptive acts and practices, including marketing’ (Pomeranz and Harris 2019, 38) but ironically has a strong record of allying with CMF companies to weaken marketing regulations (Waldron and Vogell 2024). The FTC and FDA should take all evidence linking CMF marketing exposure to reduced breastfeeding rates into account, along with the extensive costs of undermining breastfeeding, without the influence of industry. The use of generic labelling requirements for these products would be a great first step in providing consumers with necessary information on ingredients and safe preparation without misleading marketing messages. The collective cost of inaction is great and will only grow with the impacts of the climate crisis. The Code should be universally adopted, implemented and legally enforced to protect consumers from the manipulative influence of CMF marketing on labels, retail websites and beyond.

4.1. Limitations

Our small sample size limits the scope of analysis. Investigating the above‐identified themes and their co‐occurrence in a larger data set would improve the generalizability of findings and capture a more complete scope of the marketing themes that are deployed to sell CMF. Future research should focus on longitudinally tracking how families interact with these marketing materials, including the co‐occurring themes we have documented and instances of targeted CMF marketing, as well as examining how these materials influence their decisions about infant feeding and care. This study could provide a foundation for how to develop public health interventions to counter these marketing strategies.

5. Conclusion

This study highlights the sophistication of multifaceted IF marketing strategies that consist of a combination of labelling violations and the deployment of a wide array of powerful cultural themes that undermine breastfeeding and idealize as well as normalize the use of IF. At the same time, our study highlights the inadequacy of current United States CMF marketing regulations and the extent to which they permit the industry to violate global recommendations to promote breastfeeding and protect public health. These marketing practices play a harmful role in undermining breastfeeding, contributing to health inequities and high healthcare costs, and making communities less resilient to food and water insecurity and the impacts of the climate crisis(Tomori 2022). Our findings provide further evidence to support global calls to strengthen CMF marketing regulations and to end the unethical marketing of CMF (Pérez‐Escamilla et al. 2023).

Author Contributions

S.F., C.T. and C.W. performed the research and wrote the paper. S.F. and C.T. designed the research study. S.F. and C.W. analyzed the data, with final review and approval by C.T.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendices_‐_Edited.

Data Availability Statement

The data that support the findings of this study are available in the Supporting Information of this article.