Friday, 12 May 2017

Call to end formula milk firms' aggressive tactics: Competition Commission of Singapore; KKH rolls out Singapore's first breast milk bank

Competition watchdog flags tie-ups with private hospitals, as high prices cause concern
By Tiffany Fumiko Tay, The Straits Times, 11 May 2017

The authorities are calling for a halt to formula milk companies' aggressive marketing methods, including inducements to hospitals, in response to public concern about the steep rise in prices.

In particular, sponsorship and payment arrangements between manufacturers and private hospitals are "conflict of interest" deals that should be reviewed, they say.

This follows a new report by Singapore's competition watchdog which found that formula milk manufacturers are paying private hospitals to distribute their products to newborns.

Such practices have entrenched brand loyalty and helped propel formula milk prices in Singapore to among the highest in the world, said the Competition Commission of Singapore (CCS).

It released its 87-page report yesterday after a year-long inquiry into prices of infant formula.

The CCS said formula milk companies target hospitals to gain a "first-mover" advantage, given that most parents do not switch brands later.

It recommended that such tie-ups be reviewed.

Currently, only public hospitals are disallowed from entering into such arrangements . They have a rotation system to give different manufacturers equal opportunities.

The Ministry of Health told The Straits Times that it will "strongly encourage" all hospitals providing maternity services to achieve the Baby-friendly Hospital Initiative (BFHI) certification.

This prevents conflicts of interest by prohibiting sponsorship arrangements, and actively encourages breastfeeding.

No private hospital is currently BFHI-certified, although two - Thomson Medical Centre and Mount Alvernia - told ST that they were working towards it.

The aggressive tactics by manufacturers have seen the average price of a 900g tin of formula soar 120 per cent over the last decade.

Much of this, the CCS found, was due to manufacturers hiking their prices after convincing consumers that they were paying for "premium" and improved formulas.

They continually introduce new ingredients that purport to - among other things - boost mental development and vision. Experts have said there is weak scientific evidence to back such claims.

"What consumers face... are the aggressive marketing and 'premiumisation' messages driven by formula milk manufacturers, which perpetuate consumers' belief that the more expensive and the more ingredients there are in the formula milk, the higher quality it is," said the CCS report.

It outlined the strategies of the major manufacturers - Abbott, Mead Johnson Nutrition, FrieslandCampina, Nestle, Danone and Wyeth Nutrition - to persuade parents to shell out for milk powder.

Between 2010 and 2014, the amount they spent on marketing increased 42.4 per cent.

A significant share went to private hospitals, which receive sponsorships and "monetary contributions". In return, they lengthen the period during which certain brands are offered to new parents as the default formula.

The companies did not respond to queries by press time. Only one, FrieslandCampina, replied to say it is studying the report.

Lawyer M.Y. Yip, 39, who has two sons aged two and four, said of the manufacturers' marketing tactics: "I guess they are like any company that wants to win over customers. But it's worrying that the large marketing costs are passed to consumers, though I'm resigned to the high prices."

Spotlight on tie-ups between formula milk firms, private hospitals
Firms engage in sponsorships, payments to have brands as default formula for longer time: Competition watchdog
By Tiffany Fumiko Tay, The Straits Times, 11 May 2017

Whether it is by paying for hospitals' dinner-and-dance functions, or sponsoring the running of their shuttle buses, formula milk companies have waltzed their way into hospital maternity wards.

Some go further, giving hospitals outright monetary contributions in periodic lump sums.

In return, they get greater access to new parents and their babies, in the form of having their brands being offered as the default formula milk in maternity rooms for a longer period.

An inquiry report by the Competition Commission of Singapore (CCS) released yesterday said such deals have been on the rise, possibly reflecting hospitals' increasing needs and the importance of the hospital channel to the manufacturers as a form of marketing and brand outreach.

This first-mover advantage is key, given that many parents do not switch brands after their babies have got used to them.

To get that foot in the door, the manufacturers ensured their products stayed on the rotation schedules for longer periods, by providing sponsorship to the hospital or paying "rotation fees".

They also sponsor activities at public hospitals, but this does not influence their milk rotation schedule, said the CCS.

According to the hospitals it contacted, such payments and "in kind" monetary sponsorships by formula milk manufacturers help reduce the cost of running such activities, and defray the cost of nursing education and training.

Manufacturers sponsor a range of activities targeted at parents and parents-to-be, as well as hospital staff. They also underwrite hospital activities such as the printing of maternity brochures, as well as corporate dinner-and-dance events.

Some manufacturers also give sums of money, computed by how long they want their brands to be on rotation. If they give, for instance, twice as much as the standard fee, their brands can be on rotation for twice as long.

There are seven private hospitals in Singapore offering maternity services. Two responded to queries last night.

A Thomson Medical spokesman said brands are rotated on a monthly basis, and all suppliers contribute the same sum to be included in the rotation. He added: "We work with each milk company to a different extent, depending on how they can contribute towards our objectives of education and preparing parents for parenthood."

The companies do not sponsor the supply of baby milk formula to the hospital.

Thomson Medical is actively moving towards Baby-friendly Hospital Initiative certification, he said, with a 96 per cent breastfeeding rate at the time of discharge. For those who cannot breastfeed, they have access to all major brands of milk. Only when mothers do not have a preference are they given the default formula.

Mount Alvernia Hospital also said it does not accept milk powder sponsorship from manufacturers, and that it accepts sponsorship from formula milk manufacturers only if they are related to expanding patients' knowledge in baby care and nutrition. It did not say whether it receives rotation fees.

Parkway Pantai - which Gleneagles, Mount Elizabeth, Mount Elizabeth Novena and Parkway East hospitals are under - and Raffles Hospital did not respond to queries at press time.

Private hospitals reviewing formula-milk arrangements
By Tiffany Fumiko Tay, The Straits Times, 12 May 2017

Mount Alvernia Hospital yesterday said that it does not accept sponsorships or payments from infant formula milk makers to offer their brands to new mothers.

It does, however, allow these companies to sponsor activities which educate patients on baby care and nutrition.

The hospital's response came a day after a Competition Commission of Singapore (CCS) report on rising prices for infant milk powder found that manufacturers had been paying or sponsoring private hospitals to distribute their products.

While parents at most hospitals are free to choose a formula milk for their children if it is required, most do not have a preference and are provided with a brand.

Hospitals typically rotate brands throughout the year.

Formula milk companies invest significant marketing resources in hospitals to gain a "first-mover" advantage, the report said, noting that most parents do not switch formula brands later.

Meanwhile, Thomson Medical said suppliers pay the same amount each for their brands to be part of its monthly rotation, and most of the money is channelled to support activities that benefit patients.

Other private hospitals offering maternity services - Raffles and Parkway Pantai, which Mount Elizabeth, Mount Elizabeth Novena, Gleneagles and Parkway East hospitals are under - said that they will review their policies and practices, but did not say whether they accept sponsorships or fees for their milk rotation programmes.

Parkway Pantai said that milk companies sponsor and support nursing education, and it will review and align its practices, given the CCS recommendations.

Mount Alvernia also said it will study recommendations to review current sponsorship arrangements and make adjustments if necessary.

Raffles, Thomson and Mount Alvernia said that they are working towards Baby-friendly Hospital Initiative (BFHI) certification, which bars sponsorship arrangements with formula companies.

All three public hospitals offering maternity services - KK Women's and Children's Hospital, the National University Hospital and the Singapore General Hospital - are BFHI-certified.

Formula milk companies Danone Dumex, Abbott, Nestle and FrieslandCampina said they are studying the CCS report and are cooperating with the authorities. Mead Johnson Nutrition did not respond to queries on the report by press time.


Don't pass rising marketing costs to consumers, mums say
By Priscilla Goy, The Straits Times, 11 May 2017

Housewife Kay Park, 41, wanted to see a paediatrician, but on three occasions, she ended up being ambushed first by a formula milk company's marketer in the hospital clinic.

The representative from Dumex was "persistent", she said.

"I saw her inside the paediatric clinic, just outside the doctor's office, and each time, she asked what formula milk brand I used, and if I wanted to try her brand," said the mother of two sons, aged two and four.

"This happened in a clinic, not a supermarket. I think such an approach is overdoing it. I wouldn't be that concerned if it was just brochures or posters at the clinic."

While mothers interviewed by The Straits Times had mixed views on the companies' marketing strategies, most said such costs should not be passed on to consumers. Those interviewed were shocked to learn that marketing expenses were a key factor in the hike in formula milk's retail prices.

A report released by the Competition Commission of Singapore yesterday found that between 2010 and 2014, the amount that all major manufacturers spent on marketing increased 42.4 per cent.

The competition watchdog said that heavy spending in marketing and research likely led to the rise in the mark-up of wholesale prices.

This, in turn, was the main factor in hikes in retail prices - which have, on average, more than doubled over the past nine years.

Public servant Chiam Mei Si, 33, spends about $140 a month on formula milk for her 1½-year-old son.

She said: "It's shocking that their marketing costs have gone up by so much. The companies might be banking on the fact that mothers don't have much of a choice and want to buy the brand that works best for their children."

Pre-school educator Ng Mingzhu, 32, who has an 11-month-old daughter, added: "The companies usually say that the price increase is due to only higher R&D costs.

"That may play a part, but I think it's got more to do with aggressive marketing. It's disappointing, but I guess they are (profit-driven) private companies."

Most mothers said their doctors did not recommend specific milk brands, but cited instances of marketers from milk companies introducing their products at hospitals.

Lawyer M. Y. Yip, 39, who has two sons aged two and four, said: "They ask you to do a survey, get your e-mail address, put you on their mailing list and e-mail you their promotions.

"To thank you for doing the survey, they give you sachets of maternity milk and infant formula milk."

She added: "I didn't find the marketers particularly aggressive, and it doesn't bother me since I was waiting for my turn to see the doctor."

However, Ms Park has had worse experiences.

She said her older son was fed Nestle's Nan formula milk at the hospital the day he was born, and she was not asked about her preferred brand.

This may have led to him being unwilling to be breastfed and reluctant to switch to another brand that she preferred, she said.

Meanwhile, the Government plans to tighten regulations on labelling and advertising for formula milk for infants up to 12 months.

Most mothers said this is unlikely to affect how they buy formula milk, as they rely more on word of mouth and online reviews.

Still, housewife Melissa Lee, 22, welcomed the move. "Some companies claim that they added ingredients mentioned in the label, but it turned out to not be true.

"I hope the authorities would visit the factories and research the milk products."

But while Senior Minister of State for Trade and Industry Koh Poh Koon said on Monday that "cheaper (milk) options are no less nutritious", it may take some time before parents believe that.

Said Ms Lee, who spends about $190 a month on Dumex milk for her 16-month-old daughter: "I will not choose the cheaper brands... If they all meet the nutritional needs of infants, then why the price difference?"

Unfair to put blame on marketing tactics

As a marketer, I feel that the negative reports on the marketing efforts of formula milk manufacturers are unfair (Don't pass rising marketing costs to consumers, mums say; May 11).

Brands - from banks to condominium developers, hotels and airlines - use so-called premium images to sell an idealised vision of desirable outcomes derived from their products.

They wish to get consumers to form a specific perception about the brand, to buy the product or service, and hopefully entrench the consumer's loyalty to the brand.

This is the point of marketing.

Parents pay high prices for products that they perceive to have better quality and provide the best nutritional supplement for their children.

It is the same as drivers who pay more for a continental car than an Asian one - they feel that they are getting a better product.

Singling out marketing tactics for the rising prices of milk formula is unfair.

Will advertising for private kindergartens, tuition agencies and assessment books come under scrutiny next?

In its report, the Competition Commission of Singapore (CCS) did not give a conclusive breakdown of the cost components that make up a tin of formula milk's final recommended retail price.

Highlighting the 42.4 per cent increase in marketing costs as a standalone figure can mislead consumers into believing that marketing costs are to blame for the bulk of the price tag.

It should not be a surprise to anyone that marketing costs are factored into the retail price of a product, together with the cost of research and development, raw materials, manufacturing, packaging, transportation, testing, distribution, labour and rent.

The CCS report states also that parallel imports of milk formula could have helped mitigate price increases, but none of the supermarkets did so because it was too much work to go through the import process.

Perhaps retailers should also shoulder some responsibility in this matter.

It is important that all facts and figures are understood before measures are taken to intervene in open market economics.

Gurmit Singh Kullar
ST Forum, 17 May 2017

Nutrition claims, 'idealised' images on milk tins must go
By Tiffany Fumiko Tay, The Straits Times, 11 May 2017

Infant milk powder tins will soon have to change their labels to remove nutrition and health claims and "idealised" images, under stricter advertising and labelling restrictions by the Agri-Food and Veterinary Authority (AVA).

The stricter regulations, first announced by Senior Minister of State for Trade and Industry Koh Poh Koon in Parliament on Monday, are aimed at reining in the big spending on marketing activities and passing the cost savings on to consumers.

In response to queries, the AVA said that it aims to complete the review of the regulations by the end of this year. After a consultation period, the regulations will be gazetted, and, by law, industry members will be given one year's grace period to amend the labels.

Asked for examples of idealised images that AVA wants removed, the agency indicated that these could be pictures or text that idealise the use of infant formula over breast milk.

Parents and MPs said that some of the current labels may mislead parents into thinking that they can make children smarter, pointing to Abbott's Similac Gain IQ and Mead Johnson Nutrition's Enfamil A+ as labels that are misleading and should be changed.

Gain IQ, in which "IQ" stands for "intestinal quality", has previously come under scrutiny here by the Consumers Association of Singapore for its labelling.

The brand, whose formula is for children one year and above, will not, however, come under the tightened regulations, which apply only to formula milk for zero to 12 months, as after a year, formula milk is no longer required.

Pasir Ris-Punggol GRC MP Sun Xueling, referring to the prominent A+ on the labelling of the Enfamil formula, said: "Such images may create a sense of a premium brand, as parents may have the perception that their child can get A+ in their studies by consuming such products."

She added: "It is thus timely that the AVA will tighten its regulations... preventing a situation where customers are paying more so that manufacturers can then spend more on advertising and marketing, which is then charged back to consumers."

An estimated 95 per cent of formula milk sales in 2015 were for "premium" and speciality milk, with just 5 per cent for "standard" milk, which typically costs less than half the price, according to the Competition Commission of Singapore.

MacPherson MP Tin Pei Ling agreed: "Parents want the best for their children; they would rather sacrifice and go for premium brands."

Housewife and mother of two Rita Lee, 34, said: "I think the visual cues on some labels are misleading and can lead parents to subconsciously gravitate towards them."

To help parents make informed decisions, the Health Promotion Board will step up public education and embark on a multi-year campaign on the nutritional needs of children.

No point in buying expensive milk powder: Josephine Teo
All products sold here, regardless of price, provide enough nutrition
By Chew Hui Min, The Sunday Times, 14 May 2017

There is no reason to buy expensive premium milk powder, said Minister in the Prime Minister's Office Josephine Teo yesterday.

Her comments on Facebook came after the Competition Commission of Singapore (CCS) highlighted that the willingness of Singapore parents to pay for premium brands has led to a 120 per cent increase in formula milk prices in the last decade.

Only 5 per cent of Singaporeans who bought milk powder in 2015 opted for standard milk over premium or speciality ones, according to the commission's findings.

Parents also tend to stick with the brands their babies were exposed to in hospitals - some are sponsored by manufacturers.

Mrs Teo, who has three children, said that years ago, she too faced the dilemma of choosing formula milk.

"There were many brands and prices varied quite a bit. But were there significant differences in nutritional value? Did paying more mean helping baby develop better?" she wrote in a post at 11am.

The authorities have said breast milk is the best. The Health Promotion Board and World Health Organisation encourage mums to breastfeed for at least 12 months, Mrs Teo said. "However, for parents who need to supplement with formula, all brands sold in Singapore, regardless of price, provide enough nutrition for babies to grow healthily," she wrote. "After the child turns one, milk powder isn't even needed. Fresh cow's milk, as part of a balanced diet, works well enough."

It was earlier reported that all products sold here - even those that cost half the price of premium brands - must meet the safety and nutritional requirements set by the Agri-Food and Veterinary Authority. Claims by premium brands that formula milk can boost mental development and vision are also not backed up.

AVA has said it will tighten regulations on labelling and advertising, and prohibit health claims and idealised images. Expect more public education and a bigger push for breastfeeding, said Mrs Teo, who oversees population matters.

She said she bought whichever formula milk that was the cheapest.

"For my own journey, I concluded that milk is milk, however fancy the marketing. As long as AVA approves its import, the milk is good enough. I had no reason to pay more and would buy whatever was cheapest or on sale," she wrote.

"The kids didn't always like adjusting but did so anyway. That's what I found great about kids - they adjust given time and encouragement."

Parents should vote with their wallets to curb formula milk prices, say experts
By Tiffany Fumiko Tay, The Sunday Times, 14 May 2017

95% Percentage of formula milk sales in 2015 that comprised "premium" and speciality milk. Standard milk sales made up the other 5 per cent, and such formula typically costs less than half the price of "premium".

The best way to put the brakes on infant milk formula price hikes is for parents to vote with their wallets, economists and pricing experts say.

Its average price has more than doubled over the last decade, leading the Government to announce measures to address the issue last week amid public unhappiness. But a report by the Competition Commission of Singapore (CCS) found no evidence of anti-competitive practices by the six major manufacturers dominating the market here.

Instead, the companies had embarked on aggressive marketing efforts, competing with one another to build "premium" brand images and targeting hospitals to gain a "first-mover" advantage as parents tend not to switch brands, the year-long inquiry found.

It appears to be an effective strategy - an estimated 95 per cent of formula milk sales in 2015 comprised "premium" and speciality milk, with just 5 per cent for "standard" milk, which costs less than half the price of premium milk, according to the CCS.

High demand for products perceived to be of better quality is among the factors that have propelled formula milk prices here to one of the most expensive in the world, along with Hong Kong and China.

Managing partner at pricing consultancy Simon-Kucher and Partners Jochen Krauss said that while import and other costs account for part of the price differences across countries, firms ultimately fix prices based on the perceived value of its product and the spending power of consumers.

There are cheaper options available on shelves with little difference in nutritional properties, the authorities have said, as they plan to step up consumer education efforts.

Professor William Chen, director of Nanyang Technological University's food science and technology programme, examined the nutrition labels of three formula brands at different price points.

He found that while the more expensive ones had additional ingredients, all of them are found in human milk. There were varying amounts of some ingredients across formulas, though these "may not have any obvious correlation with positive effects in infants".

Marketing executive Hayley Pereira, 28, said stage one formula for newborns is the most costly. "The problem is that a lot of women need to supplement in the beginning. Stage one should be the cheapest because it is usually bought out of necessity," said the mother of one, with another child on the way.

"At baby fairs. there're always promotions for stage two onwards but nothing for stage one," she said.

A check by The Sunday Times at three supermarkets found that most stage one formulas range between $50 and nearly $70 for 800g to 900g tins. More price variety and discounts were found for higher stages.

Formula is not needed past the age of 12 months, but many of the products are for children aged above one, including those for children aged six years and above.

The authorities will be tightening advertising and labelling regulations for formula milk for infants up to 12 months, and prohibiting the use of nutrition or health claims and idealised images.

Many parents that The Sunday Times spoke to said some brands misleadingly imply on their labels that they can make children smarter. But Mr Abdul Rahman, 32, who has six-month-old twins, said: "Parents should take the responsibility of reading the labels carefully."

Additional reporting by Tang Fan Xi

Parliament: Govt to boost milk formula options
Govt will review import rules, so parents can have access to more affordable powder
By Tiffany Fumiko Tay, The Straits Times, 9 May 2017

Parents are hopeful that steps being taken by the Government to ensure access to affordable infant milk powder will put the brakes on rising prices.

The moves announced in Parliament yesterday include reviewing import requirements to facilitate more options on shelves here, and making more infant formula options available in hospitals.

The Agri-Food and Veterinary Authority will also strengthen restrictions on labelling and advertising of infant milk powder, said Senior Minister of State for Trade and Industry Koh Poh Koon.

While some infant formula companies give the impression that their particular brand of milk powder can do more for children, the scientific evidence for this is weak, he added.

He said all formula sold here, regardless of the price, meet food regulations and nutritional needs for infants to grow healthily.

"Parents should therefore be careful about relying on the claims made by infant formula companies, or be misled into using price as a proxy for quality of the product," he said. Cheaper options are no less nutritious, he stressed.

There is already a range of milk formula on the shelves, with prices for a 900g tin starting from about $20 to $30, up to about $60, he said, and consumer awareness efforts will be enhanced.

Dr Koh was responding to Ms Tin Pei Ling (MacPherson) and other MPs on concerns over the rising cost of infant milk powder.

Ms Tin said this has led parents who rely on formula to feel that they are being held "ransom".

The Straits Times reported in March that the average price of a 900g tin has increased 120 per cent over the last decade to $56.06, outstripping the increases for other dairy products and household staples.

Milk powder companies have told ST that the price hikes are due to research and development, and rising overhead costs.

Nestle said in response to queries that the price of the Nan formulation increased 7 per cent last month due to the significant rise in costs of raw materials.

While the Health Promotion Board encourages breastfeeding exclusively for at least six months owing to its health benefits, the Government recognises that, in some cases, infant formula is needed, said Dr Koh.

Children above 12 months old do not require formula, however, as cow's milk, together with a balanced diet, is adequate to meet their nutritional needs, he said.

Nestle, Abbott, Mead Johnson Nutrition, FrieslandCampina and Danone made up over 99 per cent of the fortified milk formula market share here last year, according to market research provider Euromonitor International.

Dr Koh said that to encourage more competition, the Government will simplify and streamline import requirements as well as remove unnecessary barriers to entry in order to bring in more options.

Supermarkets said they are supportive of the move and will work with suppliers and expand sourcing options to ensure greater variety of affordable options.

Parents said it is trial and error in finding a formula that babies will take to. Accountant Charlene Wong, 32, who spends over $200 a month on formula for her six-month-old, said: "It leaves you locked in at that price. Hopefully having more low-cost brands will push down prices."

But Mr Melvin Wu, 34, who runs a local parenting portal, said parents need to be educated on finding the most suitable formula.

New mum and marketing manager Stacy Lee, 29, said the cost of formula is just one of the expenses that come with a baby.

"I don't feel like there's a lack of choices though, so I'm not sure how much relying on supply and demand will affect prices."

* Health Promotion Board to launch campaign on kids' nutritional needs
It sets aside $1m a year for 5 years to ramp up education efforts amid formula milk debate
By Tiffany Fumiko Tay, The Straits Times, 19 May 2017

The Health Promotion Board (HPB) will be kicking off a multi-year campaign aimed at educating parents on the nutritional needs of children by the end of the month. The move comes amid a public debate over the high prices and the nutritional value of formula milk.

HPB chief executive Zee Yoong Kang told The Straits Times that $1 million has been set aside a year for the next five years. It will go towards advertising, brochures for hospitals and social media efforts, among others.

HPB will also be working with organisations such as the National Trades Union Congress and Singapore National Employers Federation to encourage more employers to create breastfeeding-friendly workplaces for mothers.

While the health authority has traditionally focused on encouraging breastfeeding, it will also ramp up education efforts on the nutritional composition of formula milk, to help parents who rely on it to make more informed decisions, said Mr Zee.

"While breast milk is best, we recognise that parents have good reasons to resort to formula milk. In that context, we have to reassure them that standard milk is sufficient, and provide more information on how to build a strong dietary foundation for kids, including weaning," he said.

An estimated 95 per cent of formula milk sales in 2015 comprised sales of "premium" and speciality milk, with just 5 per cent of sales for "standard" milk - which costs less than half the price, showed a report released by the Competition Commission of Singapore last week.

The average price of formula milk has more than doubled over the last decade to $56.06 for a 900g tin, leading the Government to announce measures to address the issue.

The authorities have said that all infant formula sold here meets safety standards and nutritional requirements, and urged against using price as a proxy for quality.

Dr Annie Ling, director of HPB's policy, research and surveillance division, analysed the nutritional labels of eight Stage 2 formula brands on shelves here. Stage 2 formula is for babies older than six months.

She concluded that there is little difference in the key nutrients between them, with differences found, for example, in levels of docosahexaenoic acid (DHA), an omega-3 fatty acid important for the development of the brain, nervous system and eyes.

It is present in varying amounts in breast milk and formula milk, but there is no recommended dietary intake level.

While some brands seek to differentiate themselves by adding supplemental nutrients such as higher levels of DHA, the evidence for its added benefit is inconclusive, said Mr Zee.

Further, not all of the more expensive brands have higher levels of DHA than the cheaper ones.

Dr Ling said there are lower-cost weaning foods that can be introduced at six months that contain more DHA than "premium" formula brands, along with protein and other nutrients needed by growing children.

"While milk is still important for key nutrients after six months, the focus should shift towards complementary food," she said.

Proper weaning is crucial, as delaying the introduction of food can lead to fussy eating and developmental issues.

"Rather than focusing on which (formula) brand is the best, parents should look towards building a balanced and nutritious diet for their children," she said.


Follow-on formula or growing-up milk is inadequate on its own to meet the nutritional needs of infants aged between six and 12 months, said Dr Chua Mei Chien, head of KK Women's and Children's Hospital's Neonatology Department.

It is important to start introducing weaning foods after six months to meet the changing nutritional needs of the growing infant, particularly of iron, she said.

Failure to introduce nutrient-rich weaning foods and an over-reliance on formula milk can lead to poor eating habits, she cautioned.

The World Health Organisation recommends exclusive breastfeeding for the first six months of a child's life, followed by the introduction of semi-solid foods.

The frequency of feeding with solids as well as the variety of weaning foods should increase as the infant develops from six to 12 months, with a corresponding decrease in milk intake, said Dr Chua.

Cup feeding can be introduced from six months, with an aim to stop feeding from the bottle by 12 months to 18 months, facilitating the transition to fresh milk.

The use of infant formula milk is only recommended to supplement breast milk, and babies have varying tolerance levels to different brands, she said.

Constipation is a common problem encountered in formula-fed infants as the casein in cow's milk- based formula is difficult to digest, she said. The iron and calcium in formula are also less well absorbed and can contribute to hard stools.

Conversely, some infants may have diarrhoea due to the fat blends in formula milk, which are mainly derived from a blend of vegetable oils with a simpler composition than that of lipids in breast milk.

While all infant formulas comply with international food standards and are nutritionally complete, none contains antibodies, growth factors, hormones, probiotics, live cells and other protective substances present in breast milk, said Dr Chua.

** KKH rolls out Singapore's first breast milk bank
It will help premature, sick babies of mums with insufficient supply
By Linette Lai, The Straits Times, 18 Aug 2017

Singapore's first breast milk donation bank has been set up by KK Women's and Children's Hospital (KKH) to help babies in need.

This includes premature or sick infants whose mothers cannot produce enough milk for them.

Up to 80 per cent of sick babies in the KKH Neonatal Intensive Care Unit and Special Care Nursery have to take formula either entirely or partially.

The milk bank, which was officially launched yesterday, is a $1.37 million pilot project funded by philanthropic organisation Temasek Foundation Cares.

The hospital hopes that around 375 mothers will step forward over the next three years to give their excess milk. This will help supply the needs of 900 babies.

Human milk is considered the best choice for babies, said Dr Chua Mei Chien, who heads KKH's neonatology department. It contains white blood cells and antibodies that protect babies against infections. Fat globules in breast milk also aid in brain development and the development of vision.

She added: "Premature babies have very immature immune and digestive systems.

"For these premature babies, exposure to cow's milk can predispose them to a lot of problems."

This includes increasing the risk of developing a serious bowel condition known as necrotising enterocolitis among premature babies, which can cause death.

To set up the milk bank, her team made a study trip to Australia to learn from experts in the field.

For the time being, milk donated under the project is free, as the costs of processing it are covered by the Temasek grant. Dr Chua said that KKH will look for new sponsors once the three years are up.

Mothers who wish to donate extra milk must undergo a stringent screening process to ensure they are healthy. Donated milk will also be pasteurised and tested for bacterial contamination before it is given to babies who need it. The hospital has at least 15 sign-ups from interested donor mothers so far.

Meanwhile, one of those who is eager for the programme to start officially is Madam Nor Adliyah Haryanie, 35. Her son was born on July 5 - two months before the due date - and weighed just 800g. The bank teller did not have enough milk to feed him. "I felt sad and angry with myself... especially when I saw other mothers with a lot of milk, but mine was getting less and less," she recalled.

When first told about the new scheme, she had her reservations, but warmed up to the idea after it was explained to her. "I thought: 'Why not give it a try? If you don't try, you never know'," she said.

Mothers who wish to donate their excess milk can e-mail KKH at They can also call 6394-1986, or visit

Checks to ensure milk is safe
By Linette Lai, The Straits Times, 18 Aug 2017

How does KK Women's and Children's Hospital ensure that donated milk is safe for babies?

First, it checks to make sure all potential donors are healthy. Mothers who wish to donate excess milk will be interviewed to make sure that they are not engaging in "high-risk" behaviour. This includes smoking, as well as consuming large amounts of caffeine or alcohol.

They will also have to undergo a blood test to check for infectious diseases such as the human immunodeficiency virus or HIV, hepatitis B and C, and syphilis.

Donors should have had babies within the last 12 months to ensure that the milk is suitable for newborns, as breast milk undergoes changes over time. Donors express milk at home, freeze it, and then take it to the milk bank. The milk is pasteurised for half an hour at 62.5 deg C, which kills bacteria while retaining its nutritional benefits. It is tested for bacteria before and after the process.

The Islamic Religious Council of Singapore has also issued a fatwa, or religious edict, saying that donated milk is permissible for premature Muslim babies to drink.

Some schools of thought believe that drinking such milk would establish ties of kinship that bar marriage.

However, Muis said that such ties are not established in a milk bank situation, as the milk is needed for the baby's well-being. In addition, babies will receive milk from different donors and are not breastfed.

It also said that it is permissible for Muslim babies to consume milk from non-Muslims as such milk serves a medicinal purpose by preventing illnesses and boosting babies' health.

*** Prices rise but parents still prefer familiar milk brands
Few picking cheaper brands introduced after last year's outcry over prices, CPI data shows
By Tiffany Fumiko Tay, The Straits Times, 3 Feb 2018

Parents remained loyal to their chosen brands of milk powder even as the average price of formula continued to tick upwards, nearly a year after concerns about affordability prompted the formation of a government task force and a flurry of new products to appear on shelves.

Despite the mitigating measures, the average price of a 900g tin of infant milk powder went up by 59 cents to $56.65 last year, according to the Consumer Price Index (CPI) released by the Department of Statistics (Singstat) last week.

Though one economist noted that the increase was much smaller than in previous years, analysts generally agreed that the index demonstrated the hold established brands have on consumer choice.

In response to queries, the Senior Minister of State for Trade and Industry and head of the task force, Dr Koh Poh Koon, said six new brands with 25 product lines have been introduced since May last year.

All are priced under $56.65 per 900g, while 16 cost no more than $35, said Dr Koh.

However, none of them made it into the weighted basket of goods used to measure CPI, which is made up of products commonly purchased by the majority of households. This, Dr Koh said, was because the new brands were "relatively new and do not yet account for significant market share".

The task force will provide a fuller update on formula milk measures in the coming weeks, he added.

Nonetheless, the numbers show that brand perception can be difficult to shake, said economist Jochen Krauss, a managing partner at international pricing consultancy Simon-Kucher & Partners.

"Consumers have been complaining but are still purchasing the expensive formula," he said. In fact, established brands had positioned their price valuations correctly, as there has been no pressure on them to lower prices despite new competition, said Dr Krauss.

CIMB Private Banking economist Song Seng Wun said: "It is hard to change that psychology, especially since parents want to give the best to their kids and milk powder is a short-term purchase."

But he noted that last year's average price increase was less than that of previous years, when there were jumps of as much as $6, so the public outcry and government scrutiny may have cautioned formula companies against further hikes.

"The days of the kind of big price increases we saw in the past are perhaps behind us, but (the firms) are still in a position to dictate prices because demand is still there," he said.

Some supermarkets said acceptance of new brands is growing, but Dairy Farm said that sales at Cold Storage and Giant for new brands such as Einmilk have been slow.

"As this category sees high brand loyalty among consumers, it may take some time for brands that are new to the market to establish trust and loyalty," said a spokesman.

Parents were by and large reluctant to try new brands that they did not know much about. But one was willing to switch to Einmilk to supplement her second baby's feeds.

Ms Juan Lim, 33, a marine and offshore engineer, spent about $240 a month on Similac for her first son, but her second is being breastfed, with the occasional supplement.

"This time I got a nanny and pushed myself to continue pumping more breast milk... Breastfeeding is cheaper and it is better for babies," she said.

**** Average prices of formula milk falling, survey between May and November 2017 shows
Govt task force's efforts to raise awareness and bring in more affordable options paying off
By Tiffany Fumiko Tay, The Straits Times, 9 Feb 2018

Efforts to address the rising prices of infant formula milk have yielded some early positive results, with surveys showing increased consumer awareness and an overall fall in average prices and demand for the breast milk substitute.

Senior Minister of State for Trade and Industry and National Development Koh Poh Koon shared this with the media in an update on the government task force's efforts yesterday.

Dr Koh heads the formula milk task force formed in May last year to tackle the issue of soaring prices here, which have more than doubled over the last decade to become among the highest in the world.

Between May and November last year, the average price of formula milk in Singapore fell 4.8 per cent according to retail data from Nielsen. Prices of formula milk for infants aged below six months fell by 13 per cent, while those for infants aged from six to 12 months fell by 9 per cent.

This stemmed from an increase in consumer awareness and the availability of more affordable formula options, Dr Koh said.

In the same period, total sales of formula milk fell by about 17 per cent. This indicates "hopefully that more mothers are breastfeeding", which is better for babies, he said.

The Straits Times reported last week that the average price of a 900g tin of infant milk powder ticked up 59 cents to $56.65 last year, according to figures released by the Department of Statistics.

Dr Koh told ST then that six new brands priced under $56.65 per 900g have been introduced since May, but none made it to the Consumer Price Index's weighted basket of goods as they were "relatively new and do not yet account for significant market share".

Nielsen's figures are drawn from sales at all major retailers in Singapore and reflect "what you see in terms of price difference", he explained yesterday.

It will take time for consumer behaviour to shift, and for the market to react accordingly, Dr Koh said. But "education efforts seem to be moving in the right direction, and people are now making more informed purchasing decisions".

Surveys conducted by the Health Promotion Board between July and September showed that more mothers are aware of infant nutrition, such as weaning, for example.

Moving forward, food-labelling regulations will be amended to prohibit health and certain nutrition claims by formula milk manufacturers as well as texts and images that idealise the use of infant formula.

The Agri-Food and Veterinary Authority had previously said it was gathering public feedback on this proposal, which is aimed at curbing excessive marketing and encouraging greater price competition.

Advertising that a product contains iron and calcium, or that calcium helps to build strong bones, for example, will be disallowed under the new rules.

"If it's not something that is unique to that particular formulation, we will forbid highlighting some of these upfront because it creates the impression that this particular tin of milk contains this and other products don't, when in actual fact many of these basic ingredients of formula milk are already (in the content list)," said Dr Koh.

The code of ethics is in the final stages of review and restrictions on the advertising, marketing and promotion of formula milk will be tightened, he said. While the task force has achieved its objectives, it will monitor the impact of measures introduced and take additional action if necessary, said Dr Koh.

How parents decide on baby milk purchases
By Hannah H. Chang, Published The Straits Times, 9 Feb 2018

Peruse the infant formula aisle in any supermarket.

One can easily spot an increasing number of infant formula brands, each offering a wide range of ingredients with claims of assorted health benefits.

DHA to increase the baby's cognitive development? Check.

Taurine to support the baby's mental and physical development? Prebiotics for a healthy digestive system? Iron and zinc to boost the baby's immune system? Check, check and check.

Of course, doing what we think is best for our babies is not without its price. Last year, Singapore parents reacted with concern following a report in The Straits Times in March that the average retail price of infant formula had gone up by about 120 per cent in the past decade from $25 per 900g (in 2007 dollars) to $56 per 900g (in 2017 dollars).

A fundamental question that has puzzled parents of newborns is: Why did the price go up so much in recent years?

Much has been written about the supply-side aspects of this price rise, including companies' marketing activities and hospital practices. A taskforce on formula milk was subsequently set up to look into the matter.

Less has been said from the perspective of consumer psychology, which examines consumption behaviour in the marketplace. This branch of psychology offers valuable insights into how consumers respond to and influence the market. It answers questions such as why we choose to buy the things we do, how we make decisions, how we perceive the marketplace and so on.

In the case of formula milk prices, consumer psychology offers at least five key insights, based on scientific findings and well-known tendencies in the way people make decisions.

First, consumers who are less familiar with a product category tend to rely on brand name and price information in making decisions. They tend to use price as a proxy for quality. This is known as the price-quality heuristic. It is well documented in numerous research studies in the past 30 years, and applies across many product categories beyond infant formula.

The price-quality judgment is, however, particularly relevant for infant formula.

Parents of a newborn, particularly if they are having their first child, tend to be less experienced and less familiar with this product category. They may thus rely on this heuristic in deciding which brand to buy, inferring that higher prices signal higher quality. If there is a positive relationship between price and quality, the parents would be correct in their decision-making. Yet it is also entirely possible that the price is determined by factors unrelated to quality.

Second, our decisions are more likely to be shaped by people we trust. This is particularly true when it comes to family members, close friends and experts. Parents tend to adopt the brands that hospitals use as healthcare professionals are perceived as highly knowledgeable domain experts.

Third, people tend to stick to the same brand. While it could be the result of brand loyalty, studies have found that people tend to stay with the same option even when they do not actually feel particularly loyal to the brand. Known as the status quo bias - a preference to stay with the default (status quo) option - this reflects our tendency to take our current situation as our reference point.

We resist change, seeing it as difficult and having a greater potential for regret. This pervasive human tendency suggests that if consumers start using certain brands of infant formula from the very beginning, they are more likely to stick to them.

The thinking of parents is why change brands if the young one does not react negatively to it? In other words, they would go for what they think is the "safer", more easily justifiable option.

Fourth, all else equal, consumers tend to be more price-sensitive with products they consume in larger quantities, and are less so for those they consume in smaller quantities. As most babies need formula milk for just a year or two, it means that parents are more willing to pay for expensive brands.

Finally, emotional factors can play a role too. There is strong scientific evidence that breastfeeding provides the best possible nutrition for a child, particularly in the first critical stages of their development. The World Health Organisation and United Nations Children's Fund recommend that mothers should breastfeed exclusively during a baby's first six months.

Based on the latest National Breastfeeding Survey in Singapore, parents of newborns seem to be increasingly aware of the health benefits of breastfeeding for their babies. This greater awareness for science-backed breastfeeding practice should be a good thing.

Yet, it might have inadvertently strengthened consumers' choice of formula milk with a premium price tag. Mothers may not be able to breastfeed their babies for the recommended period for many reasons, and may need to turn to infant formula as an alternative.

These parents may then overcompensate out of feelings of guilt, and hence go for what is perceived as the "best" (that is, the most expensive) infant milk formula on the shelf.

This is also consistent with my own research with Professor Michel Pham, a marketing professor at Columbia University. We found that people tend to be more price-insensitive in purchase decisions involving people to whom they are close.

Instead of making calculation-based decisions, they are more likely to rely on their feelings towards this person in deciding their willingness to pay. Hence, our research suggests that parents are more likely to be price-insensitive in buying infant formula for their child.

So what next, now that we have a better understanding of some of the factors that influence consumer decisions? In terms of improving the supply side of the market, the Agri-Food and Veterinary Authority's move to make it easier to import new brands of formula milk has widened the range available to parents.

Ongoing efforts by the Health Promotion Board to educate new parents on nutritional needs of children are also important. This encourages consumers to make more informed decisions, rather than relying solely on price or brand name.

The move by the public maternity hospitals to rotate affordable brands of formula milk from July is another helpful step that gives consumers the confidence that these brands are approved by healthcare professionals.

However, it is ultimately up to consumers what they choose to buy. Like parents everywhere, Singaporean parents want the best for their child. They are willing to go the extra mile to ensure their child has a good start in life.

Understanding the psychological underpinnings might help parents become more cognisant of their own decision-making processes, and realise that they have choices and can change their purchasing decisions without compromising the well-being of their child.

As Dr Dan Ariely - psychologist, professor and best-selling author of Predictably Irrational: The Hidden Forces That Shape Our Decisions - puts it: "If multiple perspectives are available and we are aware of the bias, then we know how to fix it."

The writer is associate professor of marketing at the Singapore Management University Lee Kong Chian School of Business, specialising in consumer behaviour research.

Competition Commission of Singapore's Findings From the Market Inquiry into the Supply of Formula Milk -10 May 2017
Ministry of Health (MOH) response to Competition Commission of Singapore's Recommendations on Formula Milk
MTI: Senior Minister of State Dr Koh Poh Koon's oral reply to PQ on prices of formula milk

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