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Welcome to the February edition of our newsletter. This month we have lots of varied news items to share with you. But in case you missed it in our last newsletter, we have one important question as follows:
Can you help support FSNT?
First Steps Nutrition Trust is a registered charity and has been fortunate to be funded by a small number of generous individuals and grants over the past 13 years. As we are all aware, the world around us is changing rapidly, and to continue our work beyond next year, we need to urgently seek new sources of funding. Our principles of only accepting funding from conflict-of-interest free sources won’t be changing, but can you introduce us to any organisations, trusts and foundations, grant-makers or individuals that may be able to support our work? Please contact our Director, Vicky Sibson ( vicky@firststepsnutrition.org), if you are able to make any suggestions or introductions, or if you are interested and willing to support First Steps yourself. Thank you.
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News
Infant milk news
BFLG-UK news
Forthcoming
Happy reading!
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New report: “Breaking down the barriers to breastfeeding to support healthy weight in childhood”
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The Food Foundation published this report and launched it in parliament on Tuesday. Our Director, Vicky, was one of the expert advisers to the report authors. The report builds on our 2021 report “Enabling children to be a healthy weight: what we need to do better in the first 1000 days”, reiterating how enabling breastfeeding is critical to tackling persistently high rates of overweight and obesity. This new report repeats our report’s recommendations to:
- Increase the number of Baby Friendly Initiative accredited settings and services;
- Invest in universal breastfeeding support;
- Strengthen legislation to support breastfeeding mothers returning to work/study and to breastfeed in public;
- Invest in health visiting;
- Improve the Healthy Start scheme, so it better supports breastfeeding mothers
The Food Foundation make two additional recommendations: increasing statutory maternity pay and extending the Sure Start Maternity Grant, and a dedicated government team for breastfeeding.
It’s GREAT to see breastfeeding being put in the spotlight by the Food Foundation, whose vision is: “a sustainable food system which delivers health and wellbeing for all”. We’d like to say well done to all involved and fingers crossed for a positive policy response.
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Updated: Simple guide to breastmilk and breastfeeding
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We have updated our resource ‘Breastmilk and breastfeeding: A simple guide’. Although the guidance around breastfeeding has not changed, we have updated the language we use to better reflect the role of wider society in influencing how babies are fed and to acknowledge the costs associated with breastfeeding. We have also updated links and the list of sources of information and support. We hope you find it a useful resource in your practice.
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WHO recommendation on milk feeds for 6-11 month old infants who are fed milk other than breastmilk
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With the publication of its updated guideline on complementary feeding in 2023, the WHO has recently reiterated its pre-existing advice that for infants 6–11 months of age who are fed milks other than breast milk, either “milk formula” or animal milk can be fed. This recommendation is stated to be “conditional, low certainty evidence”. Recommendations are classified as conditional when the Guideline Development Committee is less confident or certain about the balance between benefits and harms. Both its conditionality and the low certainty of the evidence mean the application of this recommendation should be approached with caution, as well as considering the context.
We have received many queries about this recommendation. One question it raises is whether food insecure/low-income families struggling to formula feed their 6-11 month old infants could simply switch to cows’ milk, which is far cheaper. Another is whether this recommendation might inadvertently undermine breastfeeding.
Below we extract the key points from the WHO report to explain the basis of their recommendation, we provide our thoughts on the two questions arising from queries coming our way, and outline suggested next steps.
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UK public health guidance on milk feeding 6-11 months of age
The first key point is that UK public health guidance for milk feeding in the second half of infancy has not changed. To avoid confusion and potential harm, we would encourage all health workers to promote current NHS advice to:
-Breastfeed or use infant formula (follow on formula is not necessary)
-Use cows’ milk in cooking but not as a drink until 12 months of age, because it does not provide enough iron
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Basis of the WHO recommendation
The WHO recommendation was based on the results of a systematic review (of 9 studies, 8 in high income countries) which found that cows’ milk compared to “milk formula” may increase the risk of anaemia and iron deficiency anaemia, and result in lower serum ferritin concentrations. The results were mixed for haemoglobin concentrations. There were no differences between milks for the anthropometric or developmental outcomes assessed, gastrointestinal blood loss or diarrhoea. The certainty of the evidence for all outcomes was graded as very low or low certainty.
The report stated that “The Guideline Development Committee (GDC) was of the opinion that there was uncertainty in the balance of benefits and harms of animal milk compared to milk formula for infants 6–11 months of age… as it would vary widely by context. However, there was some agreement that there were probably some benefits for infants 6–11 months of age consuming milk formula rather than animal milk”, though this was judged as uncertain. These benefits relate to indicators of iron and vitamin D status, though the report notes that iron status can be improved through other means including consumption of animal source foods.
The summary judgement below shows the GDC opinions on benefits, harms and balance, alongside opinions on the other ‘domains’ informing the recommendation: values and preferences, resources, cost-effectiveness, acceptability and feasibility. Values and preferences and acceptability were all judged to vary by context and the latter by household resources. Although there was uncertainty, the GDG was of the opinion that consideration of resource implications would favour consumption of animal milks.
Milks for children fed milks other than breastmilk, summary judgement
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Questions on application of the WHO recommendation in the UK:
1. Could food insecure/low-income families struggling to formula feed their 6-11 month old infants be advised to switch to cows’ milk, which is cheaper?
We advise not to do this while it contradicts current UK public health recommendations.
If UK public health guidance changed in line with WHO recommendations, then this could become a possibility. However, cows’ milk is a very poor source of iron and families struggling to afford infant formula may also not be able to afford the diverse diet needed to meet their baby’s iron needs. NHS recommendations are to give young children meat, fish, fortified breakfast cereals, green leafy vegetables, beans and lentils. Cows’ milk also contains a lot more protein, and average protein intakes for young children in the UK are far in excess of requirements, likely driving excess weight gain. This means that a switch from formula to cows’ milk may not be the simple solution it appears to meet the nutrient needs of a non-breastfed baby in a low-income household, especially where better interventions to address dietary inequalities are needed (e.g. improvements in Healthy Start). In addition, the values, preferences and acceptability of such a recommendation by these families would need to be considered. Lastly, given that we know some families give their babies follow-on formula before 6 months of age (which the NHS advise against), a change to recommend cows’ milk in infancy may risk some families giving cows’ milk before 6 months of age.
While UK public health guidance stands, our view is that it remains important to take actions which increase accessibility to infant formula while protecting and supporting breastfeeding (relevant resources include: UNICEF UK Baby Friendly Guide for Local Authorities and Health Boards; FSNT policy recommendations; FSNT infant milks cost report).
2. Could recommending either formula or animal milk for 6–11-month-old infants receiving milks other than breastmilk undermine breastfeeding?
It has been suggested that this recommendation might inadvertently undermine continued breastfeeding IF reasons for continued breastfeeding are perceived inconvenience of formula feeding e.g. at night time or out of the home OR concern about formula safety (e.g. related to bacterial contamination, or the extent to which it is processed / contains additives). In short, mothers may choose to give their baby cows’ milk instead of continuing to breastfeed if they perceive it to be more convenient and/or safer than formula.
With this in mind it would seem important that any advice on giving formula or animal milk to babies is provided – where appropriate - in the context of messaging on the superiority of breastmilk and breastfeeding for infant/child and maternal health as per usual health promotion messaging on infant feeding.
Next steps:
We have shared with the Scientific Advisory Committee on Nutrition that many practitioners have raised questions with us about the WHO recommendation, as well as concerns that it may lead to changes in infant feeding practices which may or may not be in the best interest of the baby. We understand that they will be considering if and how to explore its appropriateness in the UK context. In the meantime, we recommend reiterating and supporting application of the current UK public health guidance on milk feeding from 6-11 months of age, as outlined above, including sharing the health benefits of breastfeeding.
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Dietary Intake in Scotland’s Children (DISH) survey
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This survey is live and if you work in Scotland, you are kindly asked to encourage questionnaire recipients to participate. Please see more information here and in the infographic below.
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New Report: The Grocer Baby and infant product report 2023
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In December 2023, the Grocer Baby and infant report was published, providing valuable insights into the performance of the UK's commercial milk formula and baby food market. While there was a small increase in the value of both sectors there were notable declines in volume sales. The report also highlighted considerable differences in performance among brands within these categories.
During 2023, the leading commercial milk formula brands – Aptamil, Cow & Gate, and SMA – experienced declines in both volume sales and brand value. This trend may be attributed to falling birth rates and some increase in breastfeeding. However, the category as a whole showed a 2% increase in value, with Kendamil alone increasing by £19.2m in 2023 (a 118.2% increase). Research findings indicate that branding plays a pivotal role in influencing the selection of commercial milk formula. In the context of an ongoing cost of living crisis and with a very large range in the prices of different infant formulas (which remain on the whole too expensive), it’s important for parents and carers to be aware that for healthy, non-breastfed/partially breastfed babies between birth and 12 months of age, any infant formula is suitable because the law requires that they all comply with the same nutrition composition standards (see our latest infographic below which is relevant to this point).
The report also showed that leading commercial baby food brands, including Ella’s Kitchen, Organix, Kiddylicious, Heinz, and Hipp Organic, all experienced declines in volume sales. However, Organix and Heinz still saw some growth in brand value. Our reports on children's food explain why many commercial baby foods do not support public health recommendations. Practical information on how to eat well in the early years, including how to prepare and feed children diets based on unprocessed and minimally processed foods, can be found in our Eating Well resources.
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All of our resources are free to download and some are available to purchase as hard copies via this link.
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New guidance: Making up powdered formula
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In light of the findings from the ‘Finding the Formula’ study in to home-based powdered infant formula preparation practices which was published in November (see our November newsletter), the NHS have updated their guidance on making up powdered infant formula as shown below (found here and also here). It is important that parents/carers using powdered formula are aware that it is not sterile, and to kill any bacteria that may be present in the powder, the (fresh tap) water used for reconstitution should be boiled and cooled to no less than 70 degrees C. Please see the full instructions on the NHS webpage for the other steps that are required to ensure that formula is made up as safely as possible, to minimise any risks to babies’ health.
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For more information on making up milks safely see our main website here as well as FAQs which are on our infant milk website here.
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New statement: Nutramigen recall
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At the end of 2023, Rickett Benckiser (owner of the Mead Johnson brand) took the precautionary step of recalling specific batches of the commercial milk formula powders Nutramigen LGG1 and Nutramigen LGG2 due to the possible presence of the bacteria Cronobacter sakazakii. Both products are foods for special medical purposes used for the dietary management of infants with diagnosed cows’ milk allergy who do not receive breastmilk or who are fed breastmilk and formula milk.
In response to the recall, on the 3rd of January this year, the FSA issued a food alert detailing which batches were affected and what parents who have bought these products should do. The symptoms caused by Cronobacter sakazakii usually include fever and diarrhoea, and in severe cases may lead to sepsis or meningitis which include symptoms in infants including poor feeding, irritability, temperature changes, jaundice (yellow skin and whites of the eyes) and abnormal breaths and movements (FSA, 2023).
We have issued a statement with more details about the recall and what parents using these products should do. It is intended to help health care professionals supporting affected parents/carers, and you can find it here.
This recall is a good reminder of why it is important to ensure parents/carers know, understand, and follow NHS advice on safer preparation of powdered infant formulas, which are not, and cannot be made to be, sterile.
You can find the NHS guidance on making up formula milk safely here. If you want to know more about making up powdered infant formula safely or the bacterial contamination of powdered infant formula you can find this here on our website. We also have a set of FAQs that address preparing infant formula safely on our infantmilkinfo.org website.
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News on infant formula prices
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In case you missed it, the Competition and Markets Authority published a report in November which used First Steps data and analysis on formula prices to confirm company profiteering (see more in our December newsletter). We were disappointed not to see any recommendations from this report, and coordinated on writing this letter to Andrea Leadsom, MP to call for urgent action. This got picked up by the press (see here) and our Director Vicky will be meeting Minister Leadsom in March to discuss. We are also feeding in to a follow up investigation by the CMA which will be reported on in the summer. In the meantime we’re pleased to see that companies are starting to react, with Danone bringing down the wholesale price of its premium product Aptamil by 7% (see this news report). Several retailers are passing on this saving, and also starting to bring down the cost of other brands too. This includes Aldi bringing their Mamia down by 40p to £8.99 a tin (see the Food Foundation's latest report on infant formula prices here). We’ll keep you updated with future changes.
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New infographic: How can families safely save on formula milk?
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Following on from our updated report ‘‘Costs of infant formula, follow-on formula and milks marketed as foods for special medical purposes available over the counter in the UK” which we signposted in our December newsletter - we have created an infographic to support health workers in their conversations with families struggling to afford formula. It summarises the key points from the updated cost report and suggests how families using formula can safely reduce their formula milk costs. You can access it here or click on the image below.
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For infant milk information please visit our website www.infantmilkinfo.org. If you can’t find what you’re looking for, please email Susan@firststepsnutrition.org
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Baby Feeding Law Group UK News
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New briefing: Clarifying misconceptions about the UK law on the marketing of infant formula
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On behalf of the BFLG UK we have produced this new briefing to clarify the intention of the current UK law on the marketing of infant formula, highlight and summarise relevant provisions, and to dispel recent misinterpretations of the law observed in the media. We hope it will be of use to journalists, policy makers, politicians and health care professionals.
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For more information about the Baby Feeding Law Group UK please visit our website Baby Feeding Law Group UK (bflg-uk.org) and sign up to our X (formerly Twitter) account @BflgUk. You can also email katie@firststepsnutrition.org
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All-Party Parliamentary Group on Infant Feeding and Inequalities (APPG IFI) meeting
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The next APPG IFI meeting is scheduled to take place towards the end of February 2023, with the date TBC. You can sign up for APPG IFI updates here.
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