Report to Congressional Addressees

United States Government Accountability Office

GAO 

February 2006 BREASTFEEDING

Some Strategies Used 

to Market Infant 

Formula May 

Discourage 

Breastfeeding; State 

Contracts Should 

Better Protect against 

Misuse of WIC Name 

GAO-06-282 
Page i GAO-06-282 Breastfeeding 

Letter 1

Appendix I Briefing Slides 6 

Appendix II Advertising Data 36 

Appendix III Literature Review 37 

Appendix IV Studies in Literature Review 39 

Abbreviations 

CDC Centers for Disease Control and Prevention 

FNS Food and Nutrition Service 

NIS National Immunization Survey 

USDA United States Department of Agriculture 

WIC Special Supplemental Nutrition Program for Women, 

 Infants, and Children 

Contents 

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page 1 GAO-06-282 Breastfeeding 

February 8, 2006 

The Honorable Robert Bennett 

Chairman 

The Honorable Herb Kohl 

Ranking Minority Member 

Subcommittee on Agriculture, Rural Development, 

 and Related Agencies 

Committee on Appropriations 

United States Senate 

The Honorable Henry Bonilla 

Chairman 

The Honorable Rosa L. DeLauro 

Ranking Minority Member 

Subcommittee on Agriculture, Rural Development, 

 Food and Drug Administration, and Related Agencies 

Committee on Appropriations 

United States House of Representatives 

The Honorable Tom Harkin 

Ranking Minority Member 

Committee on Agriculture, Nutrition, and Forestry 

United States Senate 

Millions of U.S. mothers and infants each year forgo the health benefits of 

breastfeeding and rely on infant formula. Infants who are breastfed are 

less likely to develop infectious diseases and chronic health problems, 

such as diabetes and asthma, while breastfeeding mothers are less likely to 

develop certain types of cancer. Recognizing the health benefits of 

breastfeeding for infants and mothers, the U.S. Department of Health and 

Human Services’ Healthy People 2010 campaign has recommended that 

more U.S. infants be breastfed and that babies be breastfed for longer 

periods of time. According to the U.S. Department of Agriculture (USDA), 

the U.S. would save a minimum of $3.6 billion in health care costs and 

indirect costs, such as parents’ lost wages, if breastfeeding increased to 

meet these Healthy People goals. 

Breastfeeding rates are particularly low among infants who participate in 

the Special Supplemental Nutrition Program for Women, Infants and 

Children (WIC). WIC is administered by the USDA’s Food and Nutrition 

United States Government Accountability Office

Washington, DC 20548 
Page 2 GAO-06-282 Breastfeeding 

Service (FNS) in cooperation with state and local agencies. The program 

provides free food and infant formula to improve the health and nutritional 

well-being of low-income women, infants, and young children. Nearly half 

of infants born in the U.S. receive benefits through WIC. 

Although formula manufacturers agree that breastfeeding is best, they 

market infant formula as an alternative for mothers who do not 

exclusively breastfeed. A congressional committee asked us to review the 

potential impact of infant formula marketing on breastfeeding rates, 

especially for infants in the WIC program.1

 We answered the following 

questions: 1) What are the estimated breastfeeding rates for infants in the 

general population and for infants on WIC, and how do these rates 

compare to recommended breastfeeding rates? 2) How is infant formula 

marketed to women in general and to women on WIC in particular? 3) 

What is known about the impact of infant formula marketing on the 

breastfeeding rates of women in the general population and women on 

WIC? 

On December 14, 2005, we briefed interested congressional staff on the 

results of our analysis. This report formally conveys information provided 

during that briefing. In summary, we reported the following findings: 

• WIC and non-WIC breastfeeding rates fell short of most national goals, 

but rates were substantially lower for WIC infants. 

• Infant formula marketing targets non-WIC mothers and also reaches 

WIC mothers. Some of these marketing efforts use the trademarked 

WIC acronym in promotional materials. Although FNS requires states 

to restrict this practice in their WIC contracts, most states do not. 

• A majority of studies we reviewed that examine giving free formula 

samples to mothers at hospital discharge found lower breastfeeding 

rates among both WIC and non-WIC mothers. However, little is known 

about the impact of most types of marketing. 

In order to better protect the WIC acronym and logo from being 

inappropriately used in infant formula advertisements, we are 

recommending that the Secretary of Agriculture educate all states about 

 1

 The Senate Committee on Appropriations asked in the 2005 Agriculture, Rural 

Development, Food and Drug Administration, and Related Agencies appropriations report 

(Senate Report 108-340) that we conduct this study. 
Page 3 GAO-06-282 Breastfeeding 

FNS’ policy restricting the use of the WIC acronym and logo and ensure 

that all state formula contracts include provisions restricting the use of 

these trademarks in infant formula advertisements. 

We used the following methodologies to develop our findings. To identify 

breastfeeding rates, we analyzed 2004 data from the Centers for Disease 

Control and Prevention’s (CDC) National Immunization Survey (NIS) and 

compared the breastfeeding rates of WIC and non-WIC infants to the 

Healthy People 2010 breastfeeding goals. We also interviewed officials 

regarding survey methodology, and we determined that the survey and 

analysis were sufficiently reliable for the purposes of this briefing. To 

examine how infant formula is marketed to women in general and women 

on WIC, we analyzed data from market research company TNS Media 

Intelligence on television, radio, print, and outdoor infant formula 

advertisements between 1999 and 2004. To assess the reliability of the 

data, we talked with company representatives about data quality control 

procedures and reviewed relevant documentation. We determined the data 

were sufficiently reliable for the purposes of this briefing. To supplement 

the data, we surveyed state WIC directors and conducted interviews with 

women on WIC and with officials from infant formula companies and the 

National WIC Association. We also corresponded with FNS and reviewed 

state infant formula contracts, FNS policies, and infant formula 

advertisements. To assess the impact of infant formula marketing on 

breastfeeding rates of non-WIC and WIC participants, we reviewed U.S. 

studies published between January 1980 and July 2005 on the impact of 

infant formula marketing on breastfeeding rates. We examined each 

study’s research methodology, including its sampling frame and analytic 

techniques, to determine whether the results should be included in our 

findings. Only two of the studies we reviewed included mostly WIC 

participants, and these studies had small samples. For additional 

information on our study review, please see appendixes III and IV. We 

conducted our work from June 2005 to November 2005 in accordance with 

generally accepted government auditing standards. 

This study focused on the marketing of infant formula and its impact on 

breastfeeding rates. We did not assess the impact of other factors that may 

affect breastfeeding rates, such as cultural factors and whether women 

work outside of the home, because this was beyond the scope of our work. 

In addition, available data did not allow us to assess whether there is a 

causal relationship between trends in infant formula marketing and 

historical breastfeeding rates in the U.S. 
Page 4 GAO-06-282 Breastfeeding 

We provided a draft of this report to officials of the U.S. Department of 

Agriculture for review and comment and incorporated their comments 

where appropriate. On January 6, 2006, the officials provided us with oral 

comments. They stated they agreed with our recommendation that the 

Secretary of Agriculture educate all states about FNS’ policy restricting the 

use of the WIC acronym and logo and ensure that all state formula 

contracts include provisions restricting the use of these trademarks in 

infant formula advertisements. 

The officials noted that it may be necessary to include language in the 

state contracts allowing for fair use of the WIC name and acronym, as 

allowed by federal trademark law. They also explained that such use may 

serve a helpful purpose by informing health care providers and WIC 

participants of the infant formulas and medical foods that are available 

through WIC. We noted that our recommendation language was 

sufficiently broad to allow USDA to include language it considers 

appropriate in protecting the WIC trademark, including allowances for fair 

use. 

Officials also noted that the report did not consider the impact of 

employment factors on breastfeeding rates and that such factors may be 

particularly important for WIC participants, many of whom are employed 

outside the home. We agreed and explained that assessing the importance 

of such factors was beyond the scope of this report. 

We are sending copies of this report to relevant congressional committees 

and other interested parties and will make copies available to others upon 

request. In addition, this report will be available at no charge on GAO’s 

Web site at www.gao.gov. If you or your staff have any questions about 

this report, please contact me at (415) 904-2272 or bellisd@gao.gov. 

Contact points for our Offices of Congressional Relations and Public 
Page 5 GAO-06-282 Breastfeeding 

Affairs may be found on the last page of this report. Patrick di Battista 

(Assistant Director), Melissa Emrey-Arras (Co-Analyst-in-Charge), Marissa 

Jones (Co-Analyst-in-Charge), Rachael Chamberlin, Vivian Horn, Jim 

Lager, Jean McSween, Karen O’Conor, Dan Schwimer, and Jay Smale also 

made significant contributions to this report. 

David D. Bellis 

Director, Education, Workforce, 

 and Income Security Issues 
Appendix I: Briefing Slides 

Page 6 GAO-06-282 Breastfeeding 

Appendix I: Briefing Slides 

Breastfeeding: Some Strategies Used to Market Infant Formula 

May Discourage Breastfeeding; State Contracts Should Better 

Protect against Misuse of WIC Name

Congressional Addressees:

The Honorable Robert Bennett, Chairman

The Honorable Herb Kohl, Ranking Minority Member Subcommittee on Agriculture, Rural Development, and Related Agencies Committee on Appropriations United States Senate

The Honorable Henry Bonilla, Chairman The Honorable Rosa L. DeLauro, Ranking Minority Member Subcommittee on Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Committee on Appropriations United States House of Representatives

The Honorable Tom Harkin, Ranking Minority Member Committee on Agriculture, Nutrition, and Forestry United States Senate

December 14, 2005
Appendix I: Briefing Slides 

Page 7 GAO-06-282 Breastfeeding 

Objectives

A Congressional committee asked that we conduct this study. We answered 

the following questions:

• What are the estimated breastfeeding rates for infants in the general 

population and for infants on WIC, and how do these rates compare to 

recommended breastfeeding rates?

• How is infant formula marketed to women in general and to women on WIC 

in particular?

• What is known about the impact of infant formula marketing on the 

breastfeeding rates of women in the general population and women on WIC?
Appendix I: Briefing Slides 

Page 8 GAO-06-282 Breastfeeding 

Scope and Methodology

Breastfeeding rates: We analyzed data from the Centers for Disease Control

and Prevention’s National Immunization Survey (NIS) for WIC and nonWIC infants, 2004.

Infant formula marketing:

• We analyzed market data from TNS Media Intelligence on television, radio, 

print, and outdoor advertisements, 1999-2004; 

• Interviewed women on WIC and officials from the National WIC Association 

and the three major formula companies;

• Surveyed state WIC directors and corresponded with FNS; and

• Reviewed state infant formula contracts, FNS policies, and infant formula 

advertisements.

Impact of marketing: We reviewed U.S. studies examining the impact of 

infant formula marketing on breastfeeding rates, published between 

January 1980 and July 2005.

Our review was conducted in accordance with generally accepted government

auditing standards.
Appendix I: Briefing Slides 

Page 9 GAO-06-282 Breastfeeding 

Key Findings

• WIC and non-WIC breastfeeding rates fell short of most national goals, but 

rates were significantly lower for WIC infants. 

• Infant formula marketing targets non-WIC mothers and also reaches WIC 

mothers. Some of these marketing efforts use the trademarked WIC

acronym in promotional materials. Although FNS requires states to restrict 

this practice in their WIC contracts, most states do not.

• A majority of studies we reviewed that examine giving free formula samples 

to mothers at hospital discharge found lower breastfeeding rates among 

both WIC and non-WIC mothers. However, little is known about the impact 

of most types of marketing.
Appendix I: Briefing Slides 

Page 10 GAO-06-282 Breastfeeding 

Background: Benefits of Breastfeeding

Health benefits of breastfeeding include:

• Infants: Less likely to get childhood 

diabetes or asthma and have fewer ear 

infections.

• Mothers: Less likely to get certain types 

of cancer.

Breastfeeding preferred form of infant

feeding:

• The U.S. Department of Health and 

Human Services has established 

breastfeeding goals through the Healthy 

People 2010 initiative.

• The U.S. would save at least $3.6 billion 

in direct and indirect health care costs if 

breastfeeding rates met federal Healthy 

People goals (USDA).1

• FNS/USDA has identified increasing 

WIC breastfeeding rates as a priority.

At birth: 75% of infants

6 months: 50% of infants

12 months: 25% of 

infants

Any breastfeeding

Healthy People 2010 Breastfeeding Goals

3 months: 60% of infants 

6 months: 25% of infants

Exclusive 

breastfeeding

1 Jon Weimer, The Economic Benefits of Breastfeeding: A Review and Analysis, Food Assistance and Nutrition Research Report No. 13 (Washington, 

D.C.: Food and Rural Economics Division, Economic Research Service, U.S. Department of Agriculture, March 2001).

Note: Healthy People 2010 proposed the exclusive 

breastfeeding goals for public comment in August 2005.
Appendix I: Briefing Slides 

Page 11 GAO-06-282 Breastfeeding 

Background: WIC and Infant Formula

WIC: Started in 1972, WIC provides free food to improve the health and

nutritional wellbeing of low-income women, infants, and young children.2 

• Nearly half of infants born in the U.S. receive WIC benefits.

• WIC promotes breastfeeding by:

• Educating mothers about how to breastfeed and providing 

breastfeeding aids

• Giving women who breastfeed benefits for a longer period of time

• Providing women who exclusively breastfeed enhanced food 

packages

• WIC provides free formula, usually through vouchers, to low-income 

women who choose not to exclusively breastfeed.

Formula companies: Mead Johnson, Ross Laboratories, and Nestle produce

most of the infant formula in the U.S. All three:

• Bid to be the primary WIC formula provider in states across the country. 

• Agree breastfeeding is best, but promote formula for mothers who choose not to breastfeed or who supplement breast milk with formula.

2 The WIC program serves women who are pregnant, postpartum, or breastfeeding, infants under the age of one, and children under the age of five. 

Eligible applicants must be low-income and nutritionally at risk (e.g. having a poor diet, low weight, or anemia) and must apply in the states in which they 

reside. WIC improves the health outcomes of low-income children, who often have less access to health care and poorer health.
Appendix I: Briefing Slides 

Page 12 GAO-06-282 Breastfeeding 

Background: Efforts to Limit Formula Advertising

WIC acronym and logo in ads:

• USDA registered the acronym WIC and the WIC logo with the U.S. Patent and 

Trademark Office in 1991. 

• FNS issued guidance to states in 1992 prohibiting the use of these trademarks in 

promotional materials by for-profit food manufacturers—this guidance applies to infant 

formula advertisements.

• FNS has since allowed for some exceptions to this guidance; however, the use of the 

WIC acronym and logo in formula advertisements remains restricted. 

Formula advertising in WIC clinics:

• FNS/National WIC Association have issued guidance discouraging WIC programs 

from displaying materials produced by infant formula companies (including pictures or 

actual formula cans) in WIC clinics.

State restrictions:

• Massachusetts and New York have regulations limiting the distribution of free formula 

samples to all mothers when they are discharged from the hospital (called hospital 

discharge packs).

World Health Organization:

• Restricts the marketing of infant formula. However, these restrictions are not legally 

binding in the U.S.
Appendix I: Briefing Slides 

Page 13 GAO-06-282 Breastfeeding 

Background: Breastfeeding Trends 

3 The Ross Mothers Survey has low response rates and other limitations but provides information on breastfeeding trends. From 1997 to 2001, the mail 

survey averaged a 28 percent response rate, and Ross officials we interviewed reported the rate had been about 20 percent in recent years. Because 

officials do not know the WIC status of nonrespondents, they are unable to measure nonresponse rates among WIC participants or to weight the data 

accordingly. Due to limitations in survey methodology and analysis, we determined that the data is sufficiently reliable for background purposes only.

Historical data collected by Ross Laboratories suggest:3

More infants fed at least some breast milk over last 25 years:

• Both in-hospital and 6-month rates have increased.

• Fewer WIC than non-WIC infants were breastfed.
Appendix I: Briefing Slides 

Page 14 GAO-06-282 Breastfeeding 

Background: Breastfeeding Trends

Ross data suggest:

Exclusive breastfeeding less common:

4 The Ross Mothers Survey defines exclusive breastfeeding as the provision of no infant formula and no milk except for human breast milk. 

However, solid foods may be provided.

Gap between WIC and non-WIC infants:

At 6 months of age, the rate of infants exclusively breastfed has remained fairly 

constant between 1999 and 2002 at an average of: 

• WIC: 10 percent

• Non-WIC: 22 percent

While more women have breastfed their 

infants, exclusive breastfeeding rates 

have remained lower, and the gap 

appears to have widened.4
Appendix I: Briefing Slides 

Page 15 GAO-06-282 Breastfeeding 

Background: Breastfeeding Trends

Why WIC rates may be lower: 

• Some observers – including formula company officials, researchers, and 

breastfeeding advocates – have expressed concerns that the WIC program 

itself may discourage breastfeeding by giving free formula to mothers. 

• However, USDA has noted that women on WIC may have lower 

breastfeeding rates because breastfeeding is less common among women 

with lower incomes and less education, and WIC serves this population. 
Appendix I: Briefing Slides 

Page 16 GAO-06-282 Breastfeeding 

Overview of Finding 1:

• Breastfeeding rates did not meet most Healthy People goals and were 

lower for WIC infants.

• WIC and non-WIC infants also failed to meet goals for exclusive 

breastfeeding.

• WIC and non-WIC breastfeeding rates were lower among infants of 

mothers who were young, not college-educated, and unmarried.

Breastfeeding Rates: Fell Short of Most 

Recommendations but Were Lower for WIC 

Infants
Appendix I: Briefing Slides 

Page 17 GAO-06-282 Breastfeeding 

Breastfeeding Rates: Did Not Meet Most Healthy 

People Goals and Were Lower for WIC Infants

NIS data show:5

Breastfeeding rates did not meet

most Healthy People goals in 2004:

• Non-WIC: Percentage of infants 

who had ever been breastfed 

exceeded goal, but rates at 6 and 

12 months did not.

• WIC: Rates failed to meet any 

Healthy People breastfeeding goal.

Rates were significantly lower for

WIC infants:

• 64 percent of WIC infants had ever 

been breastfed, compared to 78 

percent of non-WIC infants.

5 Because the NIS asks households with children 19 to 35 months to recall infant feeding practices, NIS data collected in 2004 reflect feeding practices 

for the previous several years. NIS data is collected through telephone interviews, and while NIS adjusts the data to account for households without 

telephones, FNS officials expressed concerns that the data may overstate WIC breastfeeding rates by omitting participants without telephones. FNS 

has found lower WIC breastfeeding rates than those identified by NIS. Rates from other sources also may vary due to methodological differences.

Source: National Immunization Survey

Note: “Any breastfeeding” includes infants who were breastfed 

but may also have received infant formula or other foods. In 

addition, the Healthy People 2010 goal associated with “ever 

breastfed” is for the early post-partum period. The Healthy 

People 2000 breastfeeding goals were 75 percent for the early 

post-partum period and 50 percent for infants at 6 months, but 

they did not include a goal for infants at 12 months.
Appendix I: Briefing Slides 

Page 18 GAO-06-282 Breastfeeding 

6 In 2004, NIS defined exclusive breastfeeding as feeding that included only breast milk and excluded water and other liquids and solids. 

While the NIS data do not allow us to examine WIC breastfeeding rates by state, FNS officials told us that WIC rates in some regions of the 

country met Healthy People 2010 breastfeeding goals.

Note: Healthy People 2010 proposed the exclusive 

breastfeeding goals for public comment in August 2005.

Breastfeeding Rates: Did Not Meet Goals for 

Exclusive Breastfeeding 

• Both WIC and non-WIC rates also 

fell short of Healthy People 2010 

proposed goals for exclusive 

breastfeeding.6

• 6-month rates were less than half 

of 3-month rates.
Appendix I: Briefing Slides 

Page 19 GAO-06-282 Breastfeeding 

Breastfeeding Rates: Associated with Age, 

Education, Marital Status, and Race

WIC and non-WIC infants were most likely to be breastfed if:

Their mothers were:

• Over 20 years old

• College graduates

• Married

Or the infants were:

• Hispanic, compared to non-Hispanic (WIC only)7

Infants were least likely to be breastfed if:

Their mothers were:

• Under 20 years old

• Not college-educated

• Unmarried

Or the infants were:

• African American, compared to other race groups (WIC only)8

7 For non-WIC infants, the rate of Hispanics were not significantly different from those of non-Hispanics.

8 For non-WIC infants, the rates of African Americans were lower than those of Asians and Whites but not significantly different from those of Native 

Americans, due in part to the small number of Native Americans in the study. 
Appendix I: Briefing Slides 

Page 20 GAO-06-282 Breastfeeding 

Breastfeeding Rates: Associated with Age, 

Education, Marital Status, and Race
Appendix I: Briefing Slides 

Page 21 GAO-06-282 Breastfeeding 

Overview of Finding 2:

• Formula companies target non-WIC mothers and reach WIC mothers 

through marketing to the medical community and consumers.

• Extent of marketing is difficult to quantify, but data show mass media 

advertising has increased.

• Companies have used WIC trademark to market infant formula.

• Most state WIC contracts do not comply with FNS restrictions on the use 

of the WIC acronym and logo in formula advertisements.

Formula Marketing: Targets Non-WIC Mothers, 

Reaches WIC Mothers, and Sometimes Uses 

WIC Trademark
Appendix I: Briefing Slides 

Page 22 GAO-06-282 Breastfeeding 

Companies report that they do not target WIC mothers:

• WIC participants generally cannot choose the formula brand they receive.

• Formula companies would prefer to target marketing resources, such as 

free samples, to non-WIC mothers who have greater choice over brands.

Nevertheless, formula marketing reaches women on WIC:

• Formula companies market formula as WIC-approved or WIC-eligible to 

health care providers, including promoting special formulas for infants who 

have medical or dietary problems.9

• Women on WIC are exposed to advertising directed at the general 

population (about half of all infants are on WIC).

Formula Marketing: Companies Target Non-WIC 

Mothers and Reach WIC Mothers

9 Doctors can prescribe these formulas for WIC infants with particular health problems. In states in which more than one special formula brand is 

approved for WIC clients, formula companies can compete to persuade doctors to prescribe their formula brand for WIC clients or to persuade 

mothers to request certain brands.
Appendix I: Briefing Slides 

Page 23 GAO-06-282 Breastfeeding 

Formula companies primarily market to the general population in two ways:

Through the medical community (examples):

• Formula ads and free samples given to pregnant women in doctors’ offices

• Free or reduced-price formula given to hospitals for use in the hospital

• Free formula samples in hospital discharge packs

• “Dear Health Care Provider” letters explaining the benefits of particular 

formulas

• Training for health care professionals about various infant formula products

• Promotional items (e.g., pens, baby name cards, calendars)

Directly to the consumer (examples):

• Mass media advertising: television, radio, and print ads

• Coupons and free formula sent to the homes of pregnant women and new 

mothers

• Web sites promoting infant formula products

• Prominent displays of infant formula products on grocery store shelves to 

directly appeal to shoppers10

Formula Marketing: Companies Target Non-WIC 

Mothers and Reach WIC Mothers

10 Formula companies reported that by contracting with state WIC programs, they are able to acquire greater shelf space in grocery stores 

and better market their products to non-WIC consumers.
Appendix I: Briefing Slides 

Page 24 GAO-06-282 Breastfeeding 

11 Hospitals that are certified as "baby friendly" do not distribute free formula samples to new mothers. The American Academy of Pediatrics 

discourages the distribution of formula discharge packs. 

12 Nazli Baydar, Margaret McCann, Rick Williams, Eric Vesper, Final Report: WIC Infant Feeding Practices Study (Alexandria, VA: U.S. Department 

of Agriculture, Office of Analysis and Evaluation, Food and Consumer Service, November 1997). Study covered the 48 contiguous states.

Measuring extent of infant formula marketing is difficult:

• Marketing data is generally proprietary and not regularly collected by 

government agencies.

However, GAO found that some forms of marketing are widespread and

increasing: 

• Officials from two major formula companies noted that most U.S. hospitals 

provide formula discharge packs to new mothers.11

• An estimated 86 percent of WIC mothers received these discharge packs, 

according to a 1997 national USDA study.12

• Additionally, GAO purchased market research data and identified an 

increase in mass media advertising between 1999-2004.

Formula Marketing: Extent of Marketing Difficult 

to Quantify; Data Show Mass Media Advertising 

Has Increased 
Appendix I: Briefing Slides 

Page 25 GAO-06-282 Breastfeeding 

Formula Marketing: Extent of Marketing Difficult 

to Quantify; Data Show Mass Media Advertising 

Has Increased 

• Annual number of TV and print ads 

in the US increased from about 

7,000 in 1999 to over 10,000 in 

2004, totaling over 40,000 during 

this period. 

Note: Each time an ad is shown, it is counted. However, it is possible that 

this is an underestimate of the number of ads shown across the country, 

because the data only tracks ads shown in major media markets in the 

U.S. Data are not available for the number of radio advertisements shown. 

For additional information on the advertising data, see appendix II.
Appendix I: Briefing Slides 

Page 26 GAO-06-282 Breastfeeding 

• Annual formula company 

expenditures for TV, print, and radio 

ads grew from an estimated $29M in 

1999 to over $46M in 2004, for a 

total of almost $223M during this 

period.

• More ads were placed through 

television than through any other 

type of mass media, 1999-2004:

Note: These estimates are based on official advertising costs in major U.S. 

media markets and do not include discounts negotiated by advertisers or the 

costs of creating the advertisements. We determined that the data were 

sufficiently reliable for the purposes of estimating trends in annual formula 

company expenditures. Data include expenditures for TV, print, and radio 

advertisements.

Formula Marketing: Extent of Marketing Difficult 

to Quantify; Data Show Mass Media Advertising 

Has Increased 

•Print advertising, including 

newspapers and magazines, 

was less common.

•Infant formula was rarely 

advertised on the radio, and we 

found no ads on outdoor 

billboards.
Appendix I: Briefing Slides 

Page 27 GAO-06-282 Breastfeeding 

Formula Marketing: Companies Have Used WIC 

Trademark to Market Infant Formula

Examples of formula marketing materials using WIC acronym:

• Prescription pad for doctors entitled “WIC Program Prescription for Special 

Formula.”

• Glossy posters for health care providers promoting a formula as “WIC 

Eligible” in big letters and depicting a flag with the WIC acronym.

• “Dear Health Care Provider” letter noting that a particular formula for 

babies with special medical needs is “approved for use by WIC patients in 

all 50 states” and that recommending this formula to patients “may save 

your state money.”

• A consumer advertisement and coupon indicating a formula for babies with 

colic is “WIC approved in all 50 states.”
Appendix I: Briefing Slides 

Page 28 GAO-06-282 Breastfeeding 

Formula Marketing: Companies Have Used WIC 

Trademarks to Market Infant Formula

Concerned that use of the WIC acronym and logo may imply a WIC 

endorsement of commercial products, FNS issued written guidance to 

states in 1992:

• Food manufacturers are forbidden from using the trademarked WIC 

acronym and logo in all advertisements.13

• While no exceptions for food manufacturers are noted in the written 

guidance, FNS has recognized some exceptions that allow formula 

companies to use the WIC acronym.14

• All state WIC contracts with food manufacturers are required to include this 

restriction; the guidance also instructs states to amend existing contracts 

accordingly.

• Having this restriction in state contracts provides greater legal 

protection for WIC’s trademarks.

13 FNS Instruction 800-2. FNS considers formula companies to be food manufacturers. 14 For example, FNS has permitted some uses of the WIC acronym in ads that are unlikely to mislead consumers into thinking that USDA prefers the formulas 

being advertised, sometimes referred to as “fair use”. In these cases, the WIC acronym is used to describe how consumers can obtain the formulas.
Appendix I: Briefing Slides 

Page 29 GAO-06-282 Breastfeeding 

Formula Marketing: Most State WIC Contracts 

Do Not Comply with FNS Restrictions

As of 2005, the majority of state WIC contracts with infant formula companies 

(at least 32) do not limit the use of the WIC acronym or logo in advertisements.

Note: Kentucky and New Hampshire reported having language in their state policies restricting the use of the WIC trademark, but they 

do not have such language in their infant formula contracts.
Appendix I: Briefing Slides 

Page 30 GAO-06-282 Breastfeeding 

Overview of Finding 3:

• A majority of the studies we reviewed found lower breastfeeding rates 

among women receiving formula samples in discharge packs. 

• WIC mothers who received formula discharge packs also had lower 

breastfeeding rates.

• Little is known about the impact of other types of formula marketing.

Impact of Marketing: Formula Samples in 

Discharge Packs May Discourage Breastfeeding
Appendix I: Briefing Slides 

Page 31 GAO-06-282 Breastfeeding 

Impact of Marketing: Majority of Studies Found 

Lower Breastfeeding Rates Among Women 

Receiving Formula Samples in Discharge Packs

15 See appendix III for information on our study identification and review, and see appendix IV for the list of studies. Two of these studies were 

supported by infant formula companies. 

16 B.J. Snell, Marie Krantz, Rebecca Keeton, Karen Delgado, and Carol Peckham, “The Association of Formula Samples Given at Hospital 

Discharge with the Early Duration of Breastfeeding,” Journal of Human Lactation 8:2 (1992).

In 7 of 11 sound studies we reviewed, breastfeeding rates were lower for

women receiving discharge packs:15

• These studies varied in the points in time rates were measured, and each 

found effects for at least one, but not necessarily all points in time. 

- For example, one study found lower rates at 3 weeks but did not find a 

difference at 1 week,16 while some other studies did not measure 

breastfeeding at these times. - More studies examined and found decreases in breastfeeding at 2 

weeks or later than examined and found decreases in the percentage 

of women who had ever breastfed. 

• The remaining 4 studies found no effects of infant formula discharge packs 

on breastfeeding rates. 

Findings may not apply to all U.S. mothers but are informative

Although the results we reviewed apply only to study participants, the studies

as a group help us examine the effects of infant formula marketing on

breastfeeding.
Appendix I: Briefing Slides 

Page 32 GAO-06-282 Breastfeeding 

Impact of Marketing: WIC Mothers Receiving 

Formula Discharge Packs Also Had Lower 

Breastfeeding Rates

17 See appendix IV for information on these studies. The Baltimore study focused exclusively on WIC participants, while the California study 

included mostly WIC mothers. Given study limitations such as small size, lack of random assignment, and not being racially representative of the 

entire WIC population, the results of these two studies are limited to study participants, and associations should not be considered causal.

Two of the 11 studies we reviewed included mostly WIC participants, and both

found lower breastfeeding rates.17 Mothers receiving discharge packs: 

• Were less likely to begin breastfeeding and less likely to still be 

breastfeeding at 7-10 days in a study of over 200 African-American WIC 

participants in Baltimore.

• Were less likely to breastfeed and more likely to use formula in a study of 

over 100 Indochinese refugee mothers in northern California.
Appendix I: Briefing Slides 

Page 33 GAO-06-282 Breastfeeding 

Impact of Marketing: Little Is Known about the 

Effects of Other Types of Formula Marketing

• Apart from discharge packs given to women after birth, one study found 

that giving formula samples and materials to pregnant women before birth 

decreased breastfeeding rates before leaving the hospital and shortened 

breastfeeding for women with uncertain or limited breastfeeding goals.18

• We cannot assess the impact of other types of formula marketing on 

breastfeeding rates because we found no rigorous studies of mass media 

advertisements, direct mail coupons, marketing through health care 

providers, or other advertising activities.

18 Cynthia Howard, Fred Howard, Ruth Lawrence, Elena Andresen, Elisabeth DeBlieck, and Michael Weitzman, “Office Prenatal Formula 

Advertising and Its Effect on Breast-Feeding Patterns,” Obstetrics & Gynecology 95: 2 (February 2000). The results of this study are limited to the 

study participants, and the study did not find that discharge packs affected overall breastfeeding initiation or long-term duration.
Appendix I: Briefing Slides 

Page 34 GAO-06-282 Breastfeeding 

Conclusions

• Too few U.S. infants breastfeed, according to national recommendations, and breastfeeding rates are even lower for infants on WIC. If rates do not increase, many 

mothers and infants will continue to miss out on the health benefits of breastfeeding. This is particularly important for low-income children, who often have less access to health care and poorer health. The U.S. will also spend billions of dollars more in avoidable health care costs.

• While the health community and formula companies agree that breastfeeding is best, advertising of formula is widespread and increasing. Studies have shown that 

some infant formula marketing, particularly hospital discharge packs, may 

discourage breastfeeding. WIC participants may not understand that the WIC program strongly recommends breastfeeding.

• To promote their products, some companies have used the WIC acronym in their marketing efforts. To avoid the perception that FNS is promoting formula feeding 

over breastfeeding, it is important that FNS protect its trademarks from potentially 

inappropriate use in infant formula advertisements. 

• States may be unaware of FNS’ policy restricting the use of the WIC trademark and may not fully understand what uses of the trademark are not allowed in 

advertisements. 

• FNS would be better able to guard against the misuse of the WIC acronym and logo if all state WIC contracts restrict the use of these trademarks in formula 

advertisements.
Appendix I: Briefing Slides 

Page 35 GAO-06-282 Breastfeeding 

Agency Recommendation

We recommend that the Secretary of Agriculture educate all states about its 

policy restricting the use of the WIC acronym and logo and ensure that all 

state formula contracts include provisions restricting the use of these 

trademarks in infant formula advertisements.
Appendix II: Advertising Data 

Page 36 GAO-06-282 Breastfeeding 

To understand how infant formula is advertised through the mass media in 

the U.S., GAO purchased and analyzed data from TNS Media Intelligence 

on infant formula advertising between 1999 and 2004 in major U.S. 

markets. These data identified infant formula advertisements in the 

following media outlets: 

Television 

• network TV, 

• spot TV, 

• cable TV, and 

• syndicated TV 

Print 

• magazines, 

• Hispanic magazines, 

• business to business publications, 

• national newspapers, 

• Hispanic newspapers, and 

• other newspapers 

Radio 

• national spot radio 

(Data was only available on radio advertising expenditures, not the 

number of ads aired.) 

TNS Media Intelligence also searched for infant formula advertisements on 

outdoor signs but did not find any during this time period. 

To assess the reliability of the data, we talked with company 

representatives about data quality control procedures and reviewed 

relevant documentation. We determined the data were sufficiently reliable 

for the purposes of estimating trends in marketing by formula companies. 

Appendix II: Advertising Data 
Appendix III: Literature Review 

Page 37 GAO-06-282 Breastfeeding 

To identify research that evaluates the impact of infant formula marketing 

on breastfeeding rates among the general population and WIC participants 

in particular, we searched relevant databases from January 1980 through 

July 2005 using Dialog, including Agricola, Biosis, and CAB. We also 

consulted with USDA, the Centers for Disease Control and Prevention, the 

National WIC Association, infant formula companies, and other experts in 

the field. In addition, we identified studies through citations in previously 

identified studies, as well as through online journals and search engines. 

In order to focus on evaluation of the impact of infant formula marketing, 

we identified studies that met the following criteria: 

• The document is an original research study or an analysis of research 

data evaluating the impact of infant formula marketing on 

breastfeeding rates among U.S. women in general or WIC participants 

specifically. 

• The document has been published in a refereed medium (for example, 

a journal article, book or book chapter, or USDA-issued report). 

• The document’s publication date is 1980 or later. 

• All of the research described in the document was conducted in the 

United States. 

• The document is in English. 

Some studies were excluded because the research was not conducted in 

the United States or because they did not otherwise meet our criteria. For 

example, we excluded one study of the impact of hospital discharge packs 

on breastfeeding rates because the study had been conducted in Canada. 

We identified 17 studies meeting our review criteria, and we conducted 

detailed reviews of each study’s research methodology, including its 

research design, sampling frame, selection of measures, data quality, 

limitations, and analytic techniques.1

 We excluded 5 studies due to 

methodological limitations and retained 12 for analysis (listed in 

appendix IV). 

 1

 The studies used different measures of breastfeeding, such as one week or one month, 

and defined exclusive breastfeeding in different ways, ranging from consumption of 

nothing but breast milk to consumption of no other milk or formula. 

Appendix III: Literature Review 
Appendix III: Literature Review 

Page 38 GAO-06-282 Breastfeeding 

Eleven of the remaining 12 studies examined the impact on breastfeeding 

of giving new mothers free infant formula samples in hospital discharge 

packages.2

 Only 2 of these studies included mostly WIC participants. One 

study examined the impact on breastfeeding of formula samples 

distributed to pregnant women in doctors’ offices. 

 2

 Some studies compared receipt of formula discharge packs to receipt of no packs, while 

others compared them to receipt of breastfeeding promotion packs or other infant supply 

packs. Two of the studies were supported by infant formula companies. 
Appendix IV: Studies in Literature Review 

Page 39 GAO-06-282 Breastfeeding 

Bliss, Mary Campbell, Joy Wilkie, Curt Acredolo, Susan Berman, and 

Kathleen Phillips Tebb. “The Effect of Discharge Pack Formula and Breast 

Pumps on Breastfeeding Duration and Choice of Infant Feeding Method.” 

Birth 24:2 (June 1997): 90-97. (This study was supported by infant formula 

manufacturer Mead Johnson.) 

Caulfield, Laura E., Susan M. Gross, Margaret E. Bentley, Yvonne Bronner, 

Lisa Kessler, Joan Jensen, Benita Weathers and David M. Paige. “WICBased Interventions to Promote Breastfeeding Among African-American 

Women in Baltimore: Effects on Breastfeeding Initiation and 

Continuation.” Journal of Human Lactation 14:1 (1998): 15-22. (Study 

focused exclusively on WIC participants.) 

Dungy, Claibourne I., Mary E. Losch, Daniel Russell, Paul Romitti, and Lois 

B. Dusdieker. “Hospital Infant Formula Discharge Packages: Do They 

Affect the Duration of Breast-feeding?” Archives of Pediatrics & 

Adolescent Medicine 151 (July 1997): 724-729. 

Evans, Cynthia J., Nancy B. Lyons, and Marcia G. Killien. “The Effect of 

Infant Formula Samples on Breastfeeding Practice.” Journal of Obstetric, 

Gynecologic, and Neonatal Nursing (September/October 1986): 401-405. 

Feinstein, Joel M., Jay E. Berkelhamer, Mary Ellen Gruszka, Cynthia A. 

Wong, and Ann E. Carey. “Factors Related to Early Termination of Breastfeeding in an Urban Population.” Pediatrics 78:2 (August 1986): 210-215. 

Frank, Deborah A., Stephen J. Wirtz, James R. Sorenson, and Timothy 

Heeren. “Commercial Discharge Packs and Breast-Feeding Counseling: 

Effects on Infant-Feeding Practices in a Randomized Trial.” Pediatrics

80:6 (December 1987): 845-854. 

Neifert, Marianne, Jane Gray, Nancy Gary, and Bonnie Camp. “Effect of 

Two Types of Hospital Feeding Gift Packs on Duration of Breast-feeding 

Among Adolescent Mothers.” Journal of Adolescent Health Care 9:5 

(1988): 411-413. 

Ryan, Alan S., Jeffrey L. Wysong, Gilbert A. Martinez, and Stephen D. 

Simon. “Duration of Breast-feeding Patterns Established in the Hospital.” 

Clinical Pediatrics 29:2 (February 1990): 99-107. (This study was 

conducted by infant formula manufacturer Ross Laboratories.) 

Romero-Gwynn, Eunice. “Breast-feeding Pattern Among Indochinese 

Immigrants in Northern California.” American Journal of Diseases of 

Appendix IV: Studies in Literature Review 

Studies of Infant 

Formula Discharge 

Packs Included in Our 

Review 
Appendix IV: Studies in Literature Review 

Page 40 GAO-06-282 Breastfeeding 

Children 143 (July 1989): 804-808. (Study included mostly WIC 

participants.) 

Snell, B.J., Marie Krantz, Rebecca Keeton, Karen Delgado, and Carol 

Peckham. “The Association of Formula Samples Given at Hospital 

Discharge with the Early Duration of Breastfeeding.” Journal of Human 

Lactation 8:2 (1992): 67-72. 

Wright, Anne, Sydney Rice, and Susan Wells. “Changing Hospital Practices 

to Increase the Duration of Breastfeeding.” Pediatrics 97:5 (May 1996): 

669-675. 

Howard, Cynthia, Fred Howard, Ruth Lawrence, Elena Andresen, 

Elisabeth DeBlieck, and Michael Weitzman. “Office Prenatal Formula 

Advertising and Its Effect on Breast-Feeding Patterns.” Obstetrics & 

Gynecology 95:2 (February 2000). 

Study of Prenatal 

Infant Formula 

Advertising Included 

in Our Review 

(130489) 
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