literature review about nestle

Mortality from Nestlé’s Marketing of Infant Formula in Low and Middle-Income Countries

Infant formula use has been implicated in tens of millions of infant deaths in low and middle-income countries over the past several decades, but causal evidence of its link with mortality remains elusive. We combine birth record data from over 2.6 million infants across 38 countries in the Demographic and Health Surveys (DHS) with reconstructed historical data from annual investor reports on the timing of Nestlé entrance into infant formula country markets. Consistent with the hypothesis that formula mixed with unclean water could act as a disease vector, we find that infant mortality increased in households with unclean water sources by 19.4 per thousand births following Nestlé market entrance, but had no effect among other households. This rate is equivalent to a 27% increase in mortality in the population using unclean water and amounts to about 212,000 excess deaths per year at the peak of the Nestlé controversy in 1981.

We thank Claire Boone, Ingvild Madsen-Lampe and Carol Spector for outstanding research assistance, and Jere Behrman, Melissa Binder, Kitt Carpenter, Janet Currie, Andrew Dustan, Gregory Heath, Russell Mask, Ted Miguel, Nigel Rollins, Kira Villa, and Tom Vogl as well as seminar participants at UC Berkeley, UC Davis, Princeton, Vanderbilt, Notre Dame, Covenant College, University of New Mexico, University of Minnesota, Montana State University, and the 2017 International Economic Association Meetings in Mexico City. The authors have no financial or material interests in the results in this paper. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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• March 30, 2018

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• Published: 08 April 2020

Corporate political activity of the baby food industry: the example of Nestlé in the United States of America

• Hacer Tanrikulu 1 ,
• Daniela Neri 1 ,
• Aileen Robertson 2 &
• Melissa Mialon 1  

International Breastfeeding Journal volume  15 , Article number:  22 ( 2020 ) Cite this article

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The marketing practices of the breastmilk substitutes industry have been known for decades, but little is known about the influence of the baby food industry, more generally, on public health policy, research and practice, also known as ‘corporate political activity’ (CPA). In this study, the baby food industry refers to for-profit companies that manufacture, market or distribute breastmilk substitutes and food products for infants and young children under two years. In addition, trade associations, public relations firms, marketing agencies and individuals or groups affiliated with the baby food industry are also considered to be part of the baby food industry. The aim of the current study was to systematically identify and monitor the CPA of the baby food industry in the USA, shown by the activities of Nestlé, the largest industry actor in this sector in the country.

The case study consisted of an analysis of publicly available information for data published between January and November 2018. We included documents from the industry, the government and other sources, including professional organisations, charities and consumer associations. We analysed data using an existing framework to classify the CPA of the food industry.

During the period of data collection, Nestlé employed a list of action-based ‘instrumental strategies’. The most prominent strategy was ‘information strategy’, used to fund, produce and disseminate industry-preferred information. Nestlé was further found to ‘establish relationships with key opinion leaders and health organisations, and the media’, ‘seek involvement in community’ and directly influence policies and programs through indirect access and the placement of actors in government policy settings. The company also used argument-based ‘discursive strategies’ to frame the debate on diet- and public health-related issues.

This study showed that Nestlé used various CPA strategies which may have influenced public health policy, research and practice in ways favourable to the baby food industry. These results could be used to further recognise and pre-empt the influence of corporations on health, in order to ensure that commercial interests do not prevail over public health goals.

In the USA, early nutrition is compromised in the first two years of life by low rates of exclusive breastfeeding [ 1 ], exposure to breastmilk substitutes, early introduction of complementary foods [ 2 ] and high consumption of ultra-processed foods [ 3 ], practices that go against the World Health Organization (WHO) recommendations [ 4 ].

Ultra-processed foods contribute to 58% of all calories consumed by the US pre-school population [ 3 ] and there is increasing recognition of the association between dietary patterns based on these products, as defined by the NOVA food classification system [ 5 ] and adverse health outcomes [ 5 ].

In the USA, among infants born in 2015, only 25% of infants were exclusively breastfed for 6 months, while 17% received breastmilk substitutes within the first 2 days of life, and 28 and 34% before the age of three and 6 months, respectively [ 1 ]. In addition to the use of breastmilk substitutes, inadequate and inappropriate complementary feeding practices such as the early introduction of complementary food (before 6 months of age) and frequent consumption of unhealthy foods, to which ultra-processed foods belong, put infants and young children at an increased risk of overweight, obesity and related non-communicable diseases later in life [ 3 ].

There is growing evidence that the ‘corporate political activity’ (CPA) of the food industry is a major barrier to the development and implementation of public health policies to promote healthy food environments [ 6 ]. The CPA refers to some of the strategies employed by businesses to protect or increase their market shares, by influencing public policy, research and practice [ 6 ]. The CPA strategies of the food industry are very similar to those described for the tobacco industry, often referred to as the ‘playbook’, for which we have access to millions of pages of internal documents, after litigation against that industry [ 6 , 7 , 8 , 9 ]. The CPA of the food industry consists of a list of so-called action-based ‘instrumental strategies’ and argument- based ‘discursive strategies’ [ 8 , 10 ] (Table  1 ).

‘Instrumental strategies’ aim to achieve industry-preferred policy outcomes and include: ‘coalition management’; ‘information management’; ‘direct involvement and influence in policy’; ‘legal action’ [ 8 , 10 ]. ‘Discursive strategies’ refer to industry arguments to create the impression that proposed policies may harm public health, the economy or the society [ 8 , 10 ].

There is growing evidence of the global food industry’s CPA strategies in: Asia [ 11 ]; the Western Pacific [ 12 , 13 ]; Europe [ 14 ]; Latin America and the Caribbean [ 15 ]. In Brazil, Chile, Ecuador and Fiji, for example, companies in the food industry developed nutrition and physical activity programmes in schools, giving the impression that they were credible experts in these fields, while exposing children to their brands [ 12 , 15 ]. These programmes also served to shift the blame away from the healthiness of the industry’s products and to the lack of physical activity in the non-communicable diseases epidemic [ 6 , 16 ]. Lobbying, political donations and other practices that have a direct influence on policy were also regularly used by food industry actors in Australia and Thailand, for example [ 11 , 17 ].

To date, however, there is limited published evidence of the CPA of the food industry in the infant and young child’s market. The CPA strategies of businesses producing breastmilk substitutes have been known to, and monitored for decades by WHO and UNICEF as well as advocacy groups, such as the International Baby Food Action Network [ 18 , 19 ]. A recent review by Granheim et al. provided additional supporting evidence on the potential interference of the baby food industry on public health policy through the use of CPA strategies common to the tobacco industry [ 20 ].

In 2018, the US delegation caused global outrage for its reported attempts to oppose resolutions promoting breastfeeding at the World Health Assembly and threatening other countries into backing off the resolution, although no clear link with the baby food industry was established [ 21 ].

Nestlé is among the leading companies in terms of sales of packaged foods in the USA [ 22 ]. In 2014, Nestlé led the US baby food industry by capturing 34% of the market [ 23 ]. Nestlé’s political influence such as lobbying the US government and agencies has been documented by civil society organisations [ 24 ], but there is currently little published evidence and research on this topic.

The aim of the current study was to systematically identify and monitor the CPA of the baby food industry in the USA for the period January to November 2018, shown by the activities of Nestlé, the largest industry actor in this sector in the country. Our intention was to emphasise the necessity to investigate and document the day-to-day CPA of that industry, rather that its influence on a specific policy or event.

This study employed a step-by-step systematic approach recommended by Mialon et al. [ 6 ].

Selection of food industry actors

In this study, the baby food industry refers to for-profit companies that manufacture, market or distribute breastmilk substitutes and food products for infants and young children under 2 years. In addition, trade associations, public relations firms, marketing agencies and individuals or groups affiliated with the baby food industry are also considered to be part of the baby food industry.

We conducted a pilot study with data from Nestlé as the most prominent actor in the baby food industry. We were able to locate a large amount of data for the company. This led our decision to only select this industry actor for our study.

For this study, we included the following actors from the company:

its subsidiary Gerber;

Gerber BabyNes;

the Nestlé Nutrition Institute;

the Nestlé-owned Wyeth Nutrition Science Center;

the global operator Nestlé SA activities that were US-based.

Identification of sources of information

We collected publicly available information on the internet. Sources included industry’s own materials (from its websites, Twitter accounts); government materials (registers for lobbyists or websites of agencies responsible for infants and young children nutrition and health-related issues); and websites of: universities; professional organisations; charities; civil society organisations; and consumer associations [ 6 ]. We also conducted searches on Google News. In total, we searched more than 60 websites, as described in Additional file  1 .

Data collection and analysis

HT led the data collection and analysis. We collected data that was published between January and November 2018. We included the most recent data from annual or occasional events and publications, including the latest annual reports from Nestlé [ 25 ].

We collected data over a 3-month period, between August–November 2018. We collected information from the BabyNes webpages after the completion of data collection as they had been missed during that period.

We undertook a thematic qualitative analysis in an iterative process. Data collection involved reading all sources of information followed by identifying and categorizing CPA practices according to the adapted Policy Dystopia Model [ 8 , 10 ]; data were collected in an Excel spreadsheet. All data are available as Additional file  2 . Each piece of data is allocated with a unique code starting with the letter A followed by a number (e.g. A1).

DN reviewed 100% of all codes, including their categorization in themes. MM and AR reviewed a random sample of 10% of all the codes. Mutual agreement was reached between the four researchers, through discussions, for the final categorization of CPA practices.

Adapted from the tobacco industry, the CPA practice ‘constituency recruitment- internal’, already identified in the literature for the tobacco industry [ 8 ], was added within the category ‘coalition management’. This practice enables the establishment of alliances among with organisations and associations whose founding members are representatives of corporations that recruit their employees to carry out action on their behalf [ 8 , 10 ].

Results are presented through a narrative synthesis with illustrative examples of the most prominent CPA strategies employed by Nestlé in the USA during the period of analysis. The use of direct quotations of collected data is employed to illustrate examples in the results section.

Table  2 gives an overview of the different CPA strategies and practices used by Nestlé for the period of analysis. We documented four hundred and thirty-eight examples of CPA practices. Nestlé, for the period of analysis, used all ‘instrumental strategies’ previously identified in the literature, with the exception of the ‘legal action’ strategy. We also found evidence that Nestlé employed argument-based discursive strategies (we collected sixty-three examples) which could influence public opinion. ‘Information management’ was documented as the most prominent CPA strategy, followed by: ‘coalition management’; ‘discursive strategies’; and ‘direct involvement and influence in policy’.

Information management

Two hundred eighty-one examples were categorized within the strategy ‘information management’.

The practice of ‘production’ refers to industry-funded research including through academics, ghost writers, own research institutions and front groups and is used to produce industry-favorable information [ 8 , 10 ]. In this study, we collected 48 examples under this CPA practice.

The Nestlé Research Center in Switzerland conducted the ‘Nestlé Feeding Infants and Toddlers Study (FITS)’ (A403), which is described as the largest dietary intake study in the USA to examine the eating habits of infants and children under the age of four (A404, A413, A420, A436–7). Advisers were a “team of pediatric experts and nutrition scientists from leading academic, medical, government and research institutions” (A404), and authors of the published data included employees at the Nestlé Research Center and Nestlé Nutrition/Gerber Products Company (A429, A421–435). Nearly 10,000 parents and caregivers were surveyed across three FITS surveys and the results of the project were published in more than 50 peer-reviewed scientific articles published over fifteen years (A395).

Amplification

The practice of ‘amplification’, with 231 documented examples, was applied through different mechanisms including: selecting industry-preferred evidence; disseminating industry-sponsored and preferred information and evidence; providing industry-sponsored education; and participating in and hosting scientific events.

As a self-described “leader in early childhood nutrition” (A219), Nestlé emphasized that “research informs everything (we) do” (A219) at Nestlé US subsidiary Gerber “from the products we make, the nutrition education we deliver and the services we offer” (A219). Nestlé repeatedly drew on data from the FITS study (A203, A251) to “provide resources (…) for health care professionals at Medical.Gerber.com and for parents at Gerber.com ” (A219).

Nestlé used key FITS findings to provide dietary recommendations and tips for parents (A163, A229, A231, A278). FITS findings were further used to disseminate information through education programs for parents (A203) and scientific events (A284, A350). Gerber developed new products in response to the results of the study. Then, key finding from FITS were in turn used to highlight nutritional shortcomings, such as lack of micronutrients and unhealthy eating behaviour, among infants and young children and promote these new products to parents (A243, A251, A271, A276, A278).

FITS findings were used for references in the handbook for Pediatric Nutrition published by the American Academy of Pediatrics (AAP) to highlight low rates of children consuming iron-fortified cereals (A387) and low fat intake among young children (A388). Nestlé referred to the AAP also as a source for the nutritional value of their products (A180) and to emphasise that Nestlé resources were consistent with AAP nutritional guidelines (A181). Nestlé regularly stated that the latest FITS research findings were “well-timed to inform food policy discussions, including the development of the Dietary Guidelines for Americans 2020-2025 and reconsideration of the benefits offered in the WIC food package which was last revised in 2009” (A349).

Nestlé’s website for healthcare professionals is apparently a platform where paediatric health care professionals can access information, resources and tools to support their daily practice and share with their patients (A181, A220). Such resources included: menu planners (A181, A221) and nutritional guidelines for infants and young children (A181).

Nutritional guidelines according to this system were given depending on infants and young children’s “oral motor development capability” (A227) where for example, infants older than 4 months of age, also referred to as the “supported sitter” stage (A230), were stated to be ready to be introduced to solid foods, such as infant cereals, vegetables and fruits (A223, A227, A230, A232, A306-A308).

Nestlé further provided WHO growth charts to medical professionals (A211, A385), as resources to support parents track the development of their infants (A211). On the chart, Nestlé placed their own Gerber logo next to the US’s Centers for Disease Control and Prevention logo (A385). This creates the impression of potential endorsement by health organisations.

The company also disseminated information through its online support center called “Gerber Start Healthy, Stay Healthy Resource Center” (A224), where a Nestlé-backed team of nutrition experts, including Registered Dietitians (A224, A235, A380), International Board Certified Lactation Consultants (A170, A224) and Breastfeeding Educators/Certified Lactation Educators (A235), provide information about infant and young child nutrition. Nestlé’s Registered Dietitians were “available for questions on prenatal nutrition and nutrition for infants and young children 0–48 months” (A224), while Lactation Educators were “available for live counselling on a one-to-one basis” (A224) to “(d)iscuss any breastfeeding concerns” that mothers may have (A170).

Credibility

Credibility is defined as a CPA practice that attempts to conceal the links or support that an industry has to the creation of information, such as enlisting scientists who are paid to be advisers or spokespersons on infant health and nutrition [ 10 ]. In a press release published on the company’s website, a researcher expressed her support for the “need for dietary guidance (that) starts very early at birth or even earlier” (A390) and welcomed the FITS findings to help create such guidance. However, this researcher’s responsibilities as a co-author and coordinator of the FITS supplement (A423) were not transparent. Similarly, researchers’ affiliation to FITS were not disclosed in the list of speakers for a Nestlé-sponsored event called “A Healthy Start: The Infant and Early Childhood Nutrition” (A389) where key health officials, including congressional members, lawmakers and experts came together to discuss policies on early childhood nutrition.

Coalition management

We classified sixty-nine examples of CPA as ‘coalition management’.

Establish relationships with key opinion leaders and health organisations

Nestlé established relationships with key opinion leaders, health organisations and universities by promoting public-private interactions. For example, as a member of the AAP’s “Corporate Friends of Children Fund” (A57), Nestlé provided over US$50,000 to enable the AAP to “continually generate new knowledge about the best way to care for children” (A57). In return, donors “receive significant acknowledgement in several AAP publications visible to (…) 60,000 members” (A57). This might explain why Nestlé was acknowledged in an online version of AAP’s handbook for Pediatric Nutrition (2013) where Nestlé provided a grant to render an online version of the handbook to be accessible for the general public free-of-charge (A40). Moreover, three members of the Gerber Advisory Council held important positions at the AAP including: being members of the AAP’s Committee on Nutrition (A33, A34); and being an associate editor of the AAP handbook (A35). A former chair of the AAP’s Committee on Nutrition (2012–2013) was further involved in the preparation of the AAP handbook (A33) [ 26 ], while also serving both on the Editorial Board of a paediatric journal, ‘Annales Nestlé’ and on the Executive Committee of the Nestlé Nutrition Institute (see the declarations in [ 27 ]). In addition, Nestlé appeared to be one of the founding sponsors of the AAP’s Institute for Healthy Childhood Weight (A28-A31, A38, A41), which focuses on paediatric obesity prevention by providing funds to successful applications submitted to the Institute (A29). One example of funded program is “Healthy Active Living for Families” which is designed to prevent early childhood obesity (A41-A44, A58). Table  3 lists examples of professional organisations, events and conferences that Nestlé supported.

Seek involvement in local communities

The CPA practice ‘seek involvement in local communities’ refers to activities such as undertaking corporate philanthropy or supporting events and community-level initiatives [ 8 , 10 ]. In this study, Nestlé supported local community initiatives: in the State of New Jersey, for example, Nestlé in partnership with Rutgers University-Newark and the New Jersey YMCA State Alliance, supported “Start Healthy, Stay Healthy”, an early nutrition education program implemented in five different locations across the country (A1, A3, A5, A7-A11, A13-A15, A19–20).

“Gerber continues the Early Childhood Nutrition Education program in an effort to tackle childhood obesity rates in local communities by teaching parents and caregivers of young children simple ways to improve the diets of infants, toddlers, and pre-schoolers. The program covers topics including the importance of breastfeeding, hunger and fullness cues, introduction to solids, transitioning to table foods, healthy snacking, and feeding the fussy toddler.” (A3).

Another initiative Nestlé supported was the 28th National Baby Food Festival in Fremont, Michigan, where the Nestlé Gerber headquarters is located (A2, A6). As part of the festival, adults enrolled in ‘baby food eating contest’, wearing Gerber T-shirts and tasting Gerber baby food products.

Establish relationship with media

Nestlé established relationships with the media by facilitating media advocacy: while one Nestlé representative discussed FITS findings on TV (A68), another presented in an interview, published in a newspaper, an initiative where parents were supported with an educational program including infants and young children feeding (A69).

Constituency recruitment - internal

Two examples have been documented in this research and show Nestlé’s use of ‘internal constituency recruitment’ from within the baby food industry. Nestlé was part of two industry-led umbrella organisations, namely the Infant Nutrition Council “an association of manufacturers of infant formulas, follow-up formulas or growing up milks” (A21) with members including Abbott Nutrition, Perrigo Nutritionals and Reckitt Benckiser (A21) and a new trade association called Sustainable Food Policy Alliance, which Nestlé launched along with the U.S. divisions of Danone, Mars and Unilever in 2018 (A22).

Direct involvement and influence in policy

We classified twenty-five examples of CPA as ‘direct involvement and influence in policy’. For example, it was noted that businesses tend to “work with the U.S. Department of Agriculture and Health and Human Services on helping to shape science-based recommendations for encouraging healthy diets at all life stages” (A93), especially when Dietary Guidelines for Americans are being developed. Also as a member of the “National Strategic Partners through the USDA (United States Department of Agriculture) Center for Nutrition Policy and Promotion’s Nutrition Communicators Network”, Gerber was involved with the development of “MyPlate”, the current food guide icon used to share information from the dietary guidelines, and “(t)hrough this partnership, Nestlé brands (including Gerber) share nutrition information to promote the Dietary Guidelines for Americans” (A89).

Discursive strategies

During data collection, we identified sixty-three examples of discursive strategies, where Nestlé used different arguments that would be beneficial to its company and activities. One example of CPA appeared to emphasize the company’s role in supporting the economy by creating new jobs (A87). We found sixty-two examples under ‘frame the debate on diet- and public health-related issues’. Nestlé showed its support for physical activity to prevent obesity during infancy (A95–6). The company also emphasised its support for breastfeeding practices (A150, A153,) and the WHO Code of Marketing of Breastmilk Substitutes (the WHO Code) (A116, A157), and said that it never lobbied governments, including the US government, to undermine breastfeeding policies (A144).

A case study of WIC and the CPA of Nestlé

In 2018, in almost all US states, Nestlé was the company contracted by government programs (A71) [ 28 , 29 ]. Nestlé’s products were used by Medicaid and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which provides, among others, infant formula (designated for infants 0–12 months) for low-income families at no cost. WIC can serve as an illustration of how the company combines different CPA strategies in the USA.

Infant formula, a breastmilk substitute designated for infants aged 0–12 months, is profitable in the USA, for two reasons: cow’s milk, the main ingredient,; is cheap due to federal subsidies [ 30 ]; and government purchases for the WIC program account for more than half of all infant formula sold in the country [ 29 ]. WIC procures the designated breastmilk substitutes through a bidding process, in which manufacturers like Nestlé offer discounts in the form of large rebates, so that WIC ends up paying only about 8% of the wholesale price [ 29 ]. Despite large discounts, it has been shown that winning a contract with WIC increased breastmilk substitutes manufacturers’ market share by 74%, mostly due to WIC recipients switching to the newly contracted brand and a spill-over effect, in which sales of breastmilk substitutes purchased outside WIC increased [ 29 ]. Considering the profitability of the WIC program, it comes with no surprise that Nestlé employed various CPA strategies, appearing to support and stress the importance of the continuation of this program (Fig.  1 ).

‘Policy Dystopia Model’ adapted to the baby food industry in the USA. Footnote: Adapted from Ulucanlar S, Fooks GJ & Gilmore AB. The Policy Dystopia Model: An Interpretive Analysis of Tobacco Industry Political Activity. PLoS Med. 2016; 13, 1–21

In the past, Nestlé’s interest in the WIC program was shown through its lobbying activities. The Center for Responsive Politics documented that the company spent US$160,000 lobbying the US government on issues related to the WIC program in 2014 [ 31 ]. Our study findings suggest that Nestlé’s participation and efforts to support the WIC programme create a conflict of interest, where commercial interests may undermine optimal breastfeeding practices.

We also noted that the company intended to employ its own WIC manager to carry out “(n)etworking and identifying WIC state key decision makers.” as well as attending “WIC contract meetings to provide WIC State Nutritionist staff with Gerber Good Start educational assets and support (materials, webinars, etc.)” (A82).

In addition, the latest Nestlé-led data showed that WIC is effective is enabling low-income parents to purchase specific foods such as breastmilk substitutes, including infant formula (A106).

“WIC works by providing mothers vouchers to purchase specific, nutrient-dense foods, such as iron-fortified formula and cereal, fruits, vegetables, milk and whole grain breads. The latest data shows the program is helping small children get the nutrients their growing bodies need during the most critical stages of development. (…) WIC vouchers make it possible, and easy, for parents to give their children these important nutrients. By supporting early childhood nutrition - whether through individual efforts, government programs like WIC or the work we do at Nestlé - we’re setting kids up for happy, healthy and successful lives.” (A106).

In this study, we documented a total of 438 examples of CPA practices used over a period of 10 months, during 2018. We found that ‘discursive strategies’ were mostly used to ‘frame the debate on diet- and public health-related issues’, and these were often used in combination with ‘instrumental strategies’, as illustrated in our case study of the WIC program.

‘Discursive strategies’ stressed the industry ́s good intentions (education programs); focused on the role of parents; and promoted industry preferred solutions (education, voluntary instead of mandatory regulatory measures). For example, public health efforts to prevent early childhood obesity were provided through offering parental education and recommending voluntary marketing regulations for food and beverages. Voluntarily offering assistance to be part of the solution and not part of the problem [ 6 ] appears to help the industry gain goodwill and so have more potential to shape public opinion and persuade policy makers to influence policies, programs or regulations towards industry interests [ 8 ].

The most frequent instrumental CPA documented in this study where those strategies classified under ‘information management’. Information on infant and young children nutrition and health, created by the industry, was targeted both at the general public, including mothers and caregivers, and health professionals. Indeed, Nestlé employed nutrition and health professionals whose role is to provide information to parents and health professionals free of charge. Concerns have frequently been raised about these kinds of activities and their potential conflict of interest [ 18 , 32 , 33 ]. Other examples exist where Nestlé attempted to frame the debate around the WHO Code. Nestlé’s industry-led breastmilk substitutes policy differed from the Code in several aspects, potentially creating opportunities for continued promotion of breastmilk substitutes [ 18 ]. Nestlé built coalitions with key opinion leaders such as: health professionals; researchers; civil society organisations; and local communities. Such alliances seem to help to create platforms that strengthen a company’s credibility and provide a forum to present arguments and take actions to influence public policies and programs. Some paediatricians who were members of AAP committees also had ties with the companies. This may have influenced the AAP’s dietary guidelines for infants and young children. At the very least an infant food company is likely to gain respect and credibility from the general public and goodwill from health professionals where collaboration is established. In addition, if these services are not available through the public health care system it allows opportunities for actors of the infant food industry to directly contact the public, which is a violation of the WHO Code [ 18 ]. This Code recognises that many “health workers, women, and families are susceptible to direct and indirect marketing strategies” [ 34 ]. Nestlé’s membership of the Sustainable Food Policy Alliance raises questions about the potential conflict of interest and ability to lobby the US government policy, including nutrition (A71). The use of legal action was not found in this study.

This study has a number of limitations. We only collected information from the public domain. This could have led to an incomplete analysis of the entire range of CPA strategies used within the infants and young children food sector. Moreover, our results are based on this information, and, perhaps, if more data were available, different conclusions might have been made. Practices such as lobbying directly towards policy makers through private interactions are not usually transparent and not readily available in the public domain [ 6 ]. Other similar studies carried out interviews with key informants to obtain additional information [ 12 , 17 ]. Another major limitation is that this study attempts to document the CPA strategies used by only one infant food industry. Limiting the study to only one actor may result in the findings not being generalizable and representative of all the CPA strategies being used within the infants and young children food sector. However, this allowed an in-depth investigation to be carried out. In addition, the data represents only a snapshot of CPA practices that were carried out during a 10-month period and does not illustrate whether or not there are different trends over time. Future investigations could include: a larger range of different industry actors; conducting interviews with key opinion leaders; and collect data looking at trends over time. Moreover, this research documents a range of CPA strategies and cannot provide direct evidence of intent to influence [ 6 ]. Yet the most likely incentive for the use of CPA strategies is similar to those of marketing which is to the increase market share and protect the interests of shareholders [ 35 ]. There is a risk that such practices may be translated into political power to protect companies’ profits at the potential expense of public health [ 6 , 22 ]. For example, Nestlé’s CPA may help: undermine optimum levels of breastfeeding; prevent the adoption and implementation of the WHO Code of Marketing of Breastmilk Substitutes; delay the cessation of the availability of free infant formula within the WIC program; and undermine the development of optimal US dietary guidelines for infants and young children.

The CPA strategies described here are similar to strategies previously documented as used by other industries [ 10 , 12 , 15 , 18 , 30 , 36 , 37 ] including the baby food industry [ 20 ], the alcohol and tobacco industries [ 6 , 8 , 22 ]. We have used an existing framework for classifying the CPA of the tobacco industry [ 8 ], adapted to the food industry [ 10 ] and an existing approach to data collection to identify and monitor the CPA of the food industry [ 10 ]. Given the similarity between the strategies used by different industries, the findings of the present study, lend strength and validity to the used methods. Therefore, this study can be expected to be replicated using the same systematic approach in order to study the CPA of the baby food industry in other countries.

While there is a large literature on violations of the WHO Code, there is limited research that documented the corporate influence of the baby food industry at the country level. Hence, more research and continued monitoring of the CPA of prominent actors of the baby food industry could help to persuade policy makers to develop regulatory and policy measures to challenge and bring an end to the interference of the baby food industry in public policies and programs. At a minimum, such measures should include efforts to improve transparency and accountability for any private-public interactions between governments, health professional associations, civil society organisations and the private sector such as the food industry.

This study showed that Nestlé used various CPA strategies which may have influenced public policy, research and practice in ways favourable to the industry. The findings of this study could be used by public health advocates, civil society originations, the media and the public to further recognise and pre-empt the influence of corporations on health, in order to ensure that commercial interests do not prevail over public health goals.

Availability of data and materials

All data generated or analysed during this study are included in this published article (and its additional files).

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Acknowledgements

MM and DN received Fellowships from the São Paulo Research Foundation (FAPESP), Brazil (grant number 2017/24744–0 and 2016/25853–4 respectively). The authors are solely responsible for the opinions, hypotheses and conclusions or recommendations expressed in this publication, and they do not necessarily reflect FAPESP’s vision.

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Sources of information for the study of the CPA of Nestlé in the USA. List of sources consulted for data collection.

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Tanrikulu, H., Neri, D., Robertson, A. et al. Corporate political activity of the baby food industry: the example of Nestlé in the United States of America. Int Breastfeed J 15 , 22 (2020). https://doi.org/10.1186/s13006-020-00268-x

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CADBURY VS NESTLE: A STUDY OF THE CHOCOLATE WAR

This research paper focuses on how the two firms in the same industry: The study is based in the city of Mumbai. Cadbury and Nestle sell similar products and yet manage to have huge product differentiations in their own way. It throws light on how the two confectionery firms chosen are in monopolistic competition and how the products are differentiated via branding, which include the 4Ps, attributes of the products, target markets and the segmentation.

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International Edition

• Systematic Review
• Open access
• Published: 30 May 2024

Patient experiences: a qualitative systematic review of chemotherapy adherence

• Amineh Rashidi 1 ,
• Susma Thapa 1 ,
• Wasana Sandamali Kahawaththa Palliya Guruge 1 &
• Shubhpreet Kaur 1  

BMC Cancer volume  24 , Article number:  658 ( 2024 ) Cite this article

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Metrics details

Adherence to chemotherapy treatment is recognized as a crucial health concern, especially in managing cancer patients. Chemotherapy presents challenges for patients, as it can lead to potential side effects that may adversely affect their mobility and overall function. Patients may sometimes neglect to communicate these side effects to health professionals, which can impact treatment management and leave their unresolved needs unaddressed. However, there is limited understanding of how patients’ experiences contribute to improving adherence to chemotherapy treatment and the provision of appropriate support. Therefore, gaining insights into patients’ experiences is crucial for enhancing the accompaniment and support provided during chemotherapy.

This review synthesizes qualitative literature on chemotherapy adherence within the context of patients’ experiences. Data were collected from Medline, Web of Science, CINAHL, PsychINFO, Embase, Scopus, and the Cochrane Library, systematically searched from 2006 to 2023. Keywords and MeSH terms were utilized to identify relevant research published in English. Thirteen articles were included in this review. Five key themes were synthesized from the findings, including positive outlook, receiving support, side effects, concerns about efficacy, and unmet information needs. The review underscores the importance for healthcare providers, particularly nurses, to focus on providing comprehensive information about chemotherapy treatment to patients. Adopting recommended strategies may assist patients in clinical practice settings in enhancing adherence to chemotherapy treatment and improving health outcomes for individuals living with cancer.

Peer Review reports

Introduction

Cancer can affect anyone and is recognized as a chronic disease characterized by abnormal cell multiplication in the body [ 1 ]. While cancer is prevalent worldwide, approximately 70% of cancer-related deaths occur in low- to middle-income nations [ 1 ]. Disparities in cancer outcomes are primarily attributed to variations in the accessibility of comprehensive diagnosis and treatment among countries [ 1 , 2 ]. Cancer treatment comes in various forms; however, chemotherapy is the most widely used approach [ 3 ]. Patients undergoing chemotherapy experience both disease-related and treatment-related adverse effects, significantly impacting their quality of life [ 4 ]. Despite these challenges, many cancer patients adhere to treatment in the hope of survival [ 5 ]. However, some studies have shown that concerns about treatment efficacy may hinder treatment adherence [ 6 ]. Adherence is defined as “the extent to which a person’s behaviour aligns with the recommendations of healthcare providers“ [ 7 ]. Additionally, treatment adherence is influenced by the information provided by healthcare professionals following a cancer diagnosis [ 8 ]. Patient experiences suggest that the decision to adhere to treatment is often influenced by personal factors, with family support playing a crucial role [ 8 ]. Furthermore, providing adequate information about chemotherapy, including its benefits and consequences, can help individuals living with cancer gain a better understanding of the advantages associated with adhering to chemotherapy treatment [ 9 ].

Recognizing the importance of adhering to chemotherapy treatment and understanding the impact of individual experiences of chemotherapy adherence would aid in identifying determinants of adherence and non-adherence that are modifiable through effective interventions [ 10 ]. Recently, systematic reviews have focused on experiences and adherence in breast cancer [ 11 ], self-management of chemotherapy in cancer patients [ 12 ], and the influence of medication side effects on adherence [ 13 ]. However, these reviews were narrow in scope, and to date, no review has integrated the findings of qualitative studies designed to explore both positive and negative experiences regarding chemotherapy treatment adherence. This review aims to synthesize the qualitative literature on chemotherapy adherence within the context of patients’ experiences.

This review was conducted in accordance with the Joanna Briggs Institute [ 14 ] guidelines for systemic review involving meta-aggregation. This review was registered in PROSPERO (CRD42021270459).

Search methods

The searches for peer reviewed publications in English from January 2006-September 2023 were conducted by using keywords, medical subject headings (MeSH) terms and Boolean operators ‘AND’ and ‘OR’, which are presented in the table in Appendix 1 . The searches were performed in a systematic manner in core databases such including Embase, Medline, PsycINFO, CINAHL, Web of Science, Cochrane Library, Scopus and the Joanna Briggs Institute (JBI). The search strategy was developed from keywords and medical subject headings (MeSH) terms. Librarian’s support and advice were sought in forming of the search strategies.

Study selection and inclusion criteria

The systematic search was conducted on each database and all articles were exported to Endnote and duplicates records were removed. Then, title and abstract of the full text was screened by two independent reviewers against the inclusion criteria. For this review, populations were patients aged 18 and over with cancer, the phenomenon of interest was experiences on chemotherapy adherence and context was considered as hospitals, communities, rehabilitation centres, outpatient clinics, and residential aged care. All peer-reviewed qualitative study design were also considered for inclusion. Studies included in this review were classified as primary research, published in English since 2006, some intervention implemented to improve adherence to treatment. This review excluded any studies that related to with cancer and mental health condition, animal studies and grey literature.

Quality appraisal and data extraction

The JBI Qualitative Assessment and Review Instrument for qualitative studies was used to assess the methodological quality of the included studies, which was conducted by the primary and second reviewers independently. There was no disagreement between the reviews. The qualitative data on objectives, study population, context, study methods, and the phenomena of interest and findings form the included studies were extracted.

Data synthesis

The meta-aggregation approach was used to combine the results with similar meaning. The primary and secondary reviewers created categories based on the meanings and concept. These categories were supported by direct quotations from participants. The findings were assess based on three levels of evidence, including unequivocal, credible, and unsupported [ 15 , 16 ]. Findings with no quotation were not considered for synthesis in this review. The categories and findings were also discussed by the third and fourth reviewers until a consensus was reached. The review was approved by the Edith Cowan University Human Research Ethics Committee (2021–02896).

Study inclusion

A total of 4145 records were identified through a systematic search. Duplicates ( n  = 647) were excluded. Two independent reviewers conducted screening process. The remaining articles ( n  = 3498) were examined for title and abstract screening. Then, the full text screening conducted, yielded 13 articles to be included in the final synthesis see Appendix 2 .

Methodological quality of included studies

All included qualitative studies scored between 7 and 9, which is displayed in Appendix 3 . The congruity between the research methodology and the research question or objectives, followed by applying appropriate data collection and data analysis were observed in all included studies. Only one study [ 17 ] indicated the researcher’s statement regarding cultural or theoretical perspectives. Three studies [ 18 , 19 , 20 ] identified the influence of the researcher on the research and vice-versa.

Characteristics of included studies

Most of studies conducted semi-structured and in-depth interviews, one study used narrative stories [ 19 ], one study used focus group discussion [ 21 ], and one study combined focus group and interview [ 22 ] to collect data. All studies conducted outpatient’s clinic, community, or hospital settings [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 ]. The study characteristics presented in Appendix 4 .

Review findings

Eighteen findings were extracted and synthesised into five categories: positive outlook, support, side effects, concern about efficacy and unmet information needs.

Positive outlook

Five studies discussed the link between positivity and hope and chemotherapy adherence [ 19 , 20 , 23 , 27 , 28 ]. Five studies commented that feeling positive and avoid the negativity and worry could encourage people to adhere in their mindset chemotherapy: “ I think the main thing for me was just keeping a positive attitude and not worrying, not letting myself worry about it ” [ 20 ]. Participants also considered the positive thoughts as a coping mechanism, that would help them to adhere and complete chemotherapy: “ I’m just real positive on how everything is going. I’m confident in the chemo, and I’m hoping to get out of her soon ” [ 23 ]. Viewing chemotherapy as part of their treatment regimen and having awareness of negative consequences of non-adherence to chemotherapy encouraged them to adhere chemotherapy: “ If I do not take medicine, I do not think I will be able to live ” [ 28 ]. Adhering chemotherapy was described as a survivor tool which helped people to control cancer-related symptoms: “ it is what is going to restore me. If it wasn’t this treatment, maybe I wasn’t here talking to you. So, I have to focus in what he is going to give me, life !” [ 27 ]. Similarly, people accepted the medical facts and prevent their life from worsening; “ without the treatment, it goes the wrong way. It is hard, but I have accepted it from the beginning, yes. This is how it is. I cannot do anything about it. Just have to accept it ” [ 19 ].

Finding from six studies contributed to this category [ 20 , 21 , 23 , 24 , 25 , 29 ]. Providing support from families and friends most important to the people. Receiving support from family members enhanced a sense responsibility towards their families, as they believed to survive for their family even if suffered: “ yes, I just thought that if something comes back again and I say no, then I have to look my family and friends in the eye and say I could have prevented it, perhaps. Now, if something comes back again, I can say I did everything I could. Cancer is bad enough without someone saying: It’s your own fault!!” [ 29 ]. Also, emotional support from family was described as important in helping and meeting their needs, and through facilitation helped people to adhere chemotherapy: “ people who genuinely mean the support that they’re giving […] just the pure joy on my daughter’s face for helping me. she was there day and night for me if I needed it, and that I think is the main thing not to have someone begrudgingly looking after you ” [ 20 ]. Another study discussed the role family, friends and social media as the best source of support during their treatment to adhere and continue “ I have tons of friends on Facebook, believe it or not, and it’s amazing how many people are supportive in that way, you know, just sending get-well wishes. I can’t imagine going through this like 10 years ago whenever stuff like that wasn’t around ” [ 23 ]. Receiving support from social workers was particularly helpful during chemotherapy in encouraging adherence to the chemotherapy: “ the social worker told me that love is courage. That was a huge encouragement, and I began to encourage myself ” [ 25 ].

Side effects

Findings from five studies informed this category [ 17 , 21 , 22 , 25 , 26 ]. Physical side effects were described by some as the most unpleasure experience: “ the side effects were very uncomfortable. I felt pain, fatigue, nausea, and dizziness that limited my daily activities. Sometimes, I was thinking about not keeping to my chemotherapy schedule due to those side effect ” [ 17 ]. The impact of side effects affected peoples’ ability to maintain their independence and self-care: “ I couldn’t walk because I didn’t have the energy, but I wouldn’t have dared to go out because the diarrhoea was so bad. Sometimes I couldn’t even get to the toilet; that’s very embarrassing because you feel like you’re a baby ” [ 26 ]. Some perceived that this resulted in being unable to perform independently: “ I was incredibly weak and then you still have to do things and you can’t manage it ” [ 22 ]. These side effect also decreased their quality of life “ I felt nauseated whenever I smelled food. I simply had no appetite when food was placed in front of me. I lost my sense of taste. Food had no taste anymore ” [ 25 ]. Although, the side effects impacted on patients´ leisure and free-time activities, they continued to undertake treatment: “ I had to give up doing the things I liked the most, such as going for walks or going to the beach. Routines, daily life in general were affected ” [ 21 ].

Concern about efficacy

Findings form four studies informed this category [ 17 , 18 , 24 , 28 ]. Although being concerned about the efficacy of the chemotherapy and whether or not chemotherapy treatment would be successful, one participant who undertook treatment described: “the efficacy is not so great. It is said to expect about 10% improvement, but I assume that it declines over time ” [ 28 ]. People were worried that such treatment could not cure their cancer and that their body suffered more due to the disease: “ I was really worried about my treatment effectiveness, and I will die shortly ” [ 17 ]. There were doubts expressed about remaining the cancer in the body after chemotherapy: “ there’s always sort of hidden worries in there that whilst they’re not actually taking the tumour away, then you’re wondering whether it’s getting bigger or what’s happening to it, whether it’s spreading or whatever, you know ” [ 24 ]. Uncertainty around the outcome of such treatment, or whether recovering from cancer or not was described as: “it makes you feel confused. You don’t know whether you are going to get better or else whether the illness is going to drag along further” [ 18 ].

Unmet information needs

Five studies contributed to this category [ 17 , 21 , 22 , 23 , 26 ]. The need for adequate information to assimilate information and provide more clarity when discussing complex information were described. Providing information from clinicians was described as minimal: “they explain everything to you and show you the statistics, then you’re supposed to take it all on-board. You could probably go a little bit slower with the different kinds of chemo and grappling with these statistics” [ 26 ]. People also used the internet search to gain information about their cancer or treatments, “I’ve done it (consult google), but I stopped right away because there’s so much information and you don’t know whether it’s true or not ” [ 21 ]. The need to receive from their clinicians to obtain clearer information was described as” I look a lot of stuff up online because it is not explained to me by the team here at the hospital ” [ 23 ]. Feeling overwhelmed with the volume of information could inhibit people to gain a better understanding of chemotherapy treatment and its relevant information: “ you don’t absorb everything that’s being said and an awful lot of information is given to you ” [ 22 ]. People stated that the need to know more information about their cancer, as they were never dared to ask from their clinicians: “ I am a low educated person and come from a rural area; I just follow the doctor’s advice for my health, and I do not dare to ask anything” [ 17 ].

The purpose of this review was to explore patient’s experiences about the chemotherapy adherence. After finalizing the searches, thirteen papers were included in this review that met the inclusion criteria.

The findings of the present review suggest that social support is a crucial element in people’s positive experiences of adhering to chemotherapy. Such support can lead to positive outcomes by providing consistent and timely assistance from family members or healthcare professionals, who play vital roles in maintaining chemotherapy adherence [ 30 ]. Consistent with our study, previous research has highlighted the significant role of family members in offering emotional and physical support, which helps individuals cope better with chemotherapy treatment [ 31 , 32 ]. However, while receiving support from family members reinforces individuals’ sense of responsibility in managing their treatment and their family, it also instils a desire to survive cancer and undergo chemotherapy. One study found that assuming self-responsibility empowers patients undergoing chemotherapy, as they feel a sense of control over their therapy and are less dependent on family members or healthcare professionals [ 33 ]. A qualitative systematic review reported that support from family members enables patients to become more proactive and effective in adhering to their treatment plan [ 34 ]. This review highlights the importance of maintaining a positive outlook and rational beliefs as essential components of chemotherapy adherence. Positive thinking helps individuals recognize their role in chemotherapy treatment and cope more effectively with their illness by accepting it as part of their treatment regimen and viewing it as a tool for survival. This finding is supported by previous studies indicating that positivity and positive affirmations play critical roles in helping individuals adapt to their reality and construct attitudes conducive to chemotherapy adherence [ 35 , 36 ]. Similarly, maintaining a positive mindset can foster more favourable thoughts regarding chemotherapy adherence, ultimately enhancing adherence and overall well-being [ 37 ].

This review identified side effects as a significant negative aspect of the chemotherapy experience, with individuals expressing concerns about how these side effects affected their ability to perform personal self-care tasks and maintain independent living in their daily lives. Previous studies have shown that participants with a history of chemotherapy drug side effects were less likely to adhere to their treatment regimen due to worsening symptoms, which increased the burden of medication side effects [ 38 , 39 ]. For instance, cancer patients who experienced minimal side effects from chemotherapy were at least 3.5 times more likely to adhere to their treatment plan compared to those who experienced side effects [ 40 ]. Despite experiencing side effects, patients were generally willing to accept and adhere to their treatment program, although one study in this review indicated that side effects made some patients unable to maintain treatment adherence. Side effects also decreased quality of life and imposed restrictions on lifestyle, as seen in another study where adverse effects limited individuals in fulfilling daily commitments and returning to normal levels of functioning [ 41 ]. Additionally, unmet needs regarding information on patients’ needs and expectations were common. Healthcare professionals were considered the most important source of information, followed by consultation with the internet. Providing information from healthcare professionals, particularly nurses, can support patients effectively and reinforce treatment adherence [ 42 , 43 ]. Chemotherapy patients often preferred to base their decisions on the recommendations of their care providers and required adequate information retention. Related studies have highlighted that unmet needs among cancer patients are known factors associated with chemotherapy adherence, emphasizing the importance of providing precise information and delivering it by healthcare professionals to improve adherence [ 44 , 45 ]. Doubts about the efficacy of chemotherapy treatment, as the disease may remain latent, were considered negative experiences. Despite these doubts, patients continued their treatment, echoing findings from a study where doubts regarding efficacy were identified as a main concern for chemotherapy adherence. Further research is needed to understand how doubts about treatment efficacy can still encourage patients to adhere to chemotherapy treatment.

Strengths and limitation

The strength of this review lies in its comprehensive search strategy across databases to select appropriate articles. Additionally, the use of JBI guidelines provided a comprehensive and rigorous methodological approach in conducting this review. However, the exclusion of non-English studies, quantitative studies, and studies involving adolescents and children may limit the generalizability of the findings. Furthermore, this review focuses solely on chemotherapy treatment and does not encompass other types of cancer treatment.

Conclusion and practical implications

Based on the discussion of the findings, it is evident that maintaining a positive mentality and receiving social support can enhance chemotherapy adherence. Conversely, experiencing treatment side effects, concerns about efficacy, and unmet information needs may lead to lower adherence. These findings present an opportunity for healthcare professionals, particularly nurses, to develop standardized approaches aimed at facilitating chemotherapy treatment adherence, with a focus on providing comprehensive information. By assessing patients’ needs, healthcare professionals can tailor approaches to promote chemotherapy adherence and improve the survival rates of people living with cancer. Raising awareness and providing education about cancer and chemotherapy treatment can enhance patients’ understanding of the disease and its treatment options. Utilizing videos and reading materials in outpatient clinics and pharmacy settings can broaden the reach of educational efforts. Policy makers and healthcare providers can collaborate to develop sustainable patient education models to optimize patient outcomes in the context of cancer care. A deeper understanding of individual processes related to chemotherapy adherence is necessary to plan the implementation of interventions effectively. Further research examining the experiences of both adherent and non-adherent patients is essential to gain a comprehensive understanding of this topic.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. on our submission system as well.

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Wandering spleen presenting in the form of right sided pelvic mass and pain in a patient with AD-PCKD: a case report and review of the literature

• Yitagesu aberra shibiru   ORCID: orcid.org/0000-0003-3645-9115 1 ,
• Sahlu wondimu 1 &
• Wassie almaw 1  

Journal of Medical Case Reports volume  18 , Article number:  259 ( 2024 ) Cite this article

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Wandering spleen is a rare clinical entity in which the spleen is hypermobile and migrate from its normal left hypochondriac position to any other abdominal or pelvic position as a result of absent or abnormal laxity of the suspensory ligaments (Puranik in Gastroenterol Rep 5:241, 2015, Evangelos in Am J Case Rep. 21, 2020) which in turn is due to either congenital laxity or precipitated by trauma, pregnancy, or connective tissue disorder (Puranik in Gastroenterol Rep 5:241, 2015, Jawad in Cureus 15, 2023). It may be asymptomatic and accidentally discovered for imaging done for other reasons or cause symptoms as a result of torsion of its pedicle and infarction or compression on adjacent viscera on its new position. It needs to be surgically treated upon discovery either by splenopexy or splectomy based on whether the spleen is mobile or not.

Case presentation

We present a case of 39 years old female Ethiopian patient who presented to us complaining constant lower abdominal pain especially on the right side associated with swelling of one year which got worse over the preceding few months of her presentation to our facility. She is primiparous with delivery by C/section and a known case of HIV infection on HAART. Physical examination revealed a right lower quadrant well defined, fairly mobile and slightly tender swelling. Hematologic investigations are unremarkable. Imaging with abdominopelvic U/S and CT-scan showed a predominantly cystic, hypo attenuating right sided pelvic mass with narrow elongated attachment to pancreatic tail and absent spleen in its normal position. CT also showed multiple different sized purely cystic lesions all over both kidneys and the pancreas compatible with AD polycystic kidney and pancreatic disease.

With a diagnosis of wandering possibly infarcted spleen, she underwent laparotomy, the finding being a fully infarcted spleen located on the right half of the upper pelvis with twisted pedicle and dense adhesions to the adjacent distal ileum and colon. Release of adhesions and splenectomy was done. Her post-operative course was uneventful.

Wandering spleen is a rare clinical condition that needs to be included in the list of differential diagnosis in patients presenting with lower abdominal and pelvic masses. As we have learnt from our case, a high index of suspicion is required to detect it early and intervene by doing splenopexy and thereby avoiding splenectomy and its related complications.

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Introduction

Wandering spleen is a rare clinical entity characterized by hypermobility of the spleen as a result of absence or abnormal laxity of its suspensory ligaments which in turn can be congenital or precipitated by a number of risk factors like repeated pregnancy, trauma, surgery or connective tissue disorder. The spleen therefore migrates from its normal left hypochondriac position, to other parts of the peritoneal cavity especially the pelvis [ 3 ]. Since the first case report in 1667, there have been less than 600 cases reported in the literature so far [ 1 , 3 ].

Wandering spleen can have different clinical presentations ranging from asymptomatic incidental finding on imaging to features of acute abdomen as a result of complete torsion of the pedicle and total infarction of the spleen or complete obstruction of adjacent hollow viscus due to pressure effect. Less dramatic presentation includes chronic lower abdominal pain, swelling and symptoms of partial obstruction of bowel especially of the colon [ 3 , 4 , 5 , 6 ].

Diagnosis is confirmed by imaging usually abdominal ultrasound or CT which reveals that the spleen is absent from its normal anatomical position but seen somewhere else in the new location within the peritoneal cavity [ 3 , 9 , 10 ]. Once diagnosed, surgical intervention is required either by splenopexy or splenectomy depending on the viability of the organ [ 3 , 5 ] and can be done laparoscopically or by laparotomy.

Owing to its rarity, a high index of suspicion is required and this condition should always be considered as a possible differential diagnosis in patients presenting with lower abdominal swelling and pain. We present this case to share our experience in diagnosing and managing such a rare pathology and once again bring it to the attention of fellow clinicians handling this sort of abdominal conditions.

Case summary

Our patient is a 39 years old female Primi-para Ethiopian, who presented with lower abdominal dull aching pain of one-year duration which got worse over the last few months associated with right lower abdominal swelling, easy fatigability, LGIF, loss of appetite and weight. She is a known case of RVI on HAART for the past 18yrs and hypertensive for the last 8 years for which she was taking enalapril and atenolol. Her only child was delivered by C/section 10 years ago.

On examination , she looked chronically sick with her vitals in the normal range. The abdomen was flat with a lower midline surgical scar and a visible round mass on the right paraumblical and lower quadrant areas. The mass was well defined, smooth surfaced, slightly tender and mobile (Fig.  1 —black arrow).

Black arrow shows the splenic mass, red arrow shows the stomach, cyan arrow shows previous CS scar

Her hematologic tests revealed WBC of 8.7 × 103, Hgb of 12.3 and PLT count of 544 × 10 3 . Serum electrolyte and liver function tests were all in the normal range. Creatinine was 1.4 mg/dl.

Abdominal ultrasound

Multiple bilateral renal, liver and pancreatic cysts. An ehcocomplex mainly hypoechoic, 13 cmx8cm well defined right sided abdomino-pelvic mass, with absent color Doppler flow. Spleen was not visualized in its normal anatomic site.

Contrast enhanced abdomino-pelvic CT

Described the mass as a hypoattenuating, well circumscribed lesion with no contrast enhancement located at right abdomino pelvic cavity (Fig.  2 ). Its long torsed pedicle could be traced to the region of the tail of the pancreas and the spleen was missing from its normal location. (Fig.  3 ) Majority of the renal parenchyma is almost replaced with different sized cystic lesions with imperceptible wall causing bilateral renal enlargement. (Fig.  3 ) The liver and the pancreas too is filled with similar cysts. The portal vein were not visualized and replaced by periportal enlarged collateral vessels. (Figs.  3 , 4 ).

Infarcted spleen

Absent spleen in the splenic fossa

Spleen seen in the abdomino-pelvic cavity

With a diagnosis of wandering spleen located in the right abdomino pelvic region with torsion of the pedicle and infarction, she was admitted and underwent laparotomy. Intraoperatively, dense adhesion encountered between the anterior abdominal wall, omentum, the wandering spleen and small bowel. The spleen was whitish, distended and grossly infarcted with its long stalk torsed > 360°. (Fig.  5 ) Adhesions were gently released and splenectomy done. The splenic mass was sent for biopsy.

The intra-op picture of our patient upon exploration

She was discharged on the 3rd postoperative day and her post-operative course was uneventful. She was seen after a month on follow up clinic with no report of complication. Her biopsy result showed splenic tissue. She got her pentavelant vaccine on the third week.

Wandering spleen is a rare clinical entity characterized by splenic hypermobility from its left hypochondriac position to any other abdominal or pelvic position caused by absent or abnormal laxity of the suspensory ligaments [ 1 , 2 ].

The first case of wandering spleen was reported by Von Horne in 1667. So far less than 600 cases are reported world wide [ 1 , 3 ].

Anatomically a normal spleen is found in the left hypochondriac region suspended by ligaments to the stomach, kidney, pancreas, colon and left hemi-diaphram by the gastrosplenic, splenorenal, pancreaticosplenic, splenocolic, splenophreni ligaments and presplenic folds [ 1 ]. Our patient presented with RLQ palpable abdominal mass which is against the commonest presentation being in the LLQ of the abdomen (Fig.  1 ).

It could result from either a developmental failure of the embryonic septum transversum to fuse properly with the posterior abdominal wall which results in absent/lax ligaments [ 4 ] or from acquired conditions that result in lax suspensory ligaments as in pregnancy or connective tissue disorders [ 3 ]. The spleen is found in any quadrant of the abdomen or the pelvis though mostly in the left quadrants attached only by a long and loose vascular pedicle. Our patient presented with RLQ mass.

It is mostly seen in multiparous women [ 4 ] though the incidence is found to be nearly equal in both sexes in the prepubertal age group [ 3 ]. Our patient was a Para 1 mother and presented with 01 year history of abdominal pain which got worse in the past 06 months. Otherwise she had no any other pressure symptoms. She had visible umbilical area mass which was mobile up on examination

Wandering spleen can have different presentation ranging from asymptomatic incidental finding on imaging or upon surgical exploration for other surgical conditions to a presentation that mimics acute abdomen [ 3 , 5 ]. Mostly it presents as an on and of type acute/ subacute non-specific abdominal pain due to torsion and spontaneous de-torsion of the loose splenic pedicle [ 3 , 4 ]. This chronic torsion results in congestion and splenomegaly [ 3 , 5 ]. Hence patients could have palpable mobile mass [ 6 ] which is the typical presentation of this patient. The other presentations are usually related to the mass effect of the enlarged spleen and patients could present with GOO, bowel obstruction, pancreatitis and urinary symptoms [ 3 , 6 ].

In some cases it is reported to be associated with some other disorders like gastric volvulus [ 7 ] and distal pancreatic volvulus [ 8 ].

Ultrasound is one of the imaging modalities to investigate patients whom we suspect had wandering spleen. It usually shows absent spleen in the splenic fossa and a comma shaped spleen in the abdomen or pelvis [ 9 ]. Doppler study might help us see the vascular condition and ads up to a better preoperative plan. CT scan shows absence of the spleen in the left upper quadrant, ovoid or comma-shaped abdominal mass, enlarged spleen, a whirled appearance of non-enhancing splenic vessels and signs of splenic hypo-perfusion: homogenous or heterogeneous decreased enhancement depending on the degree of infarction [ 3 , 9 , 10 ].

Our patient was scanned with US and showed 13*8 cm large midline abdomino-pelvic well defined oval mass which was predominantly solid with areas of cystic component with absent color Doppler flow. Otherwise the spleen was not visualized in the splenic fossa. Bilateral kidney and liver has multiple different sized cystic lesions. With this image Abdomino-pelvic CT was done and shows spleen is located in the lower abdomen and appears to have torsed vascular pedicle and the whole splenic parenchyma is hypodense and no enhancement seen. Majority of the renal parenchyma is almost replaced with different sized cystic lesions with imperceptible wall causing bilateral renal enlargement. The whole liver is filled with cystic lesions with imperceptible wall. The portal veins were not visualized and replaced by periportal enlarged collateral vessels (Figs.  6 , 7 ).

Usually surgical management is the rule once a patient is diagnosed with wandering spleen [ 3 , 5 ]. Most patients; 65% as reported in some studies will have torsion of the vascular pedicle at some point of their life [ 5 , 6 ]. Hence splenopexy or splenectomy shall be considered when a wandering spleen is found incidentally up on surgical exploration for some other purposes [ 6 ]. Complicated wandering spleen like infarcted, signs of hypersplenism, huge in size and splenic vein thrombosis needs splenectomy while others can be managed with splenopexy [ 3 , 5 , 6 ]. Nowadays though laparoscopic technique is the gold standard, open technique can be used for splenopexy and splenectomy [ 3 , 5 ].

Partial infraction of a wandering spleen might necessitate partial splenectomy and splenopexy or splenectomy and splenic implantation [ 6 , 11 ].

The spleen might get fixed by different methods [ 8 , 9 ].

Simple splenic fixation involves simple tacking the splenic capsule to the peritoneum

Retroperitoneal pouch splenopexy- Tissue [ 11 , 12 ]/Mesh splenopexy (sandwich technique) [ 13 ].

Omental and peritoneal pouch splenic fixation [ 14 ].

In our case, Spleen was absent from the normal anatomic splenic fossa and the spleen in the abdomino-pelvic area looks infarcted. Hence she was managed with splenectomy and the patient was extubated on table and having a stable postoperative course .

Wandering spleen is a rare form of splenic pathology. Such a rare pathology presents commonly as an acute torsion with infarction. Spleen in the RLQ with chronic torsion and infarction is a very rare presentation for wandering spleen. In addition there is no report of such a presentation in a patient with AD-PCKD.

Recommendation

We recommend Clinicians to consider wandering spleen in their differential diagnosis in a patient presenting with RLQ abdominal mass and chronic abdominal pain.

Availability of supporting data

Data related with this case report is available at Addis ababa university, Tikur Ambesa Tertiary Hospital.

Abbreviations

Autosomal dominant polycystic kidney disease

Blood pressure

Low grade intermittent fever

High active anti-retroviral therapy

Right lower quadrant

Retro viral infection

Hypertension

White blood cell count

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Acknowledgements

We would like to thank the managing team of this patient including all the ward staffs who played a great role in the peri-operative management of this patient. We also appreciate the support of our consultants, residents and member of the department of surgery and HPB unit. Our kind gratitude goes to the family of this patient for their unreserved support in post-operative period that helped for the fast recovery of this patient

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Dr. Yitagesu Aberra, Main author of this case report, is an HPB surgery fellow in the department of surgery, college of health science, Addis Ababa University who was the leading surgeon in the management of this patient. Dr. Sahlu Wendimu is an HPB surgery subspecialist and Assistant professor of General Surgery who was the consultant in duty during the management of this patient. Dr.Wassie Almaw is a 2nd year pediatric surgery resident attaching at HPB surgery unit who took part in the management of this patient.

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shibiru, Y.a., wondimu, S. & almaw, W. Wandering spleen presenting in the form of right sided pelvic mass and pain in a patient with AD-PCKD: a case report and review of the literature. J Med Case Reports 18 , 259 (2024). https://doi.org/10.1186/s13256-024-04580-6

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