COVER STORY
FOLLOW-ON FORMULA: FRIEND OR FOE? Judy Paterson Registered Dietitian, Hampshire Hospitals NHS Foundation Trust
Judy has worked as a Paediatric Dietitian for two years in general paediatrics and neonates, with a special interest in gastroenterology. She is passionate about evidencebased nutritional care and promoting the role of the dietitian.
Follow-on formula milk (FOFM) is targeted at infants starting to introduce complementary foods from six to 12 months of age. This article discusses the definition, purpose and suitability of FOFM for infants and the effects of the marketing of such on breastfeeding in the UK. The legal definition of FOFM from the Department of Health (DH) is: ‘foodstuffs intended for particular nutritional use by infants when appropriate complementary feeding is introduced and constituting the principal liquid element in a progressively diversified diet of such infants.’1 The main difference between first infant formula milk and FOFM is the iron content.2 The other subtle differences include vitamin D, protein and carbohydrate content (see Table 1). Prior to 2014, FOFM had higher protein levels which are associated with risks of obesity.2-4 As a result of guidance from the European Food Safety Authority (EFSA), protein content has been reduced in recent years,5,6 but is still higher than estimated in breastmilk, due to disparities in amino acid profile between breastmilk and bovine milk.2-5 Regulations require infant formula to contain an available quantity of each amino acid at least equal to that found in human breastmilk.3-6 FOFMs contain more carbohydrate and are sweeter than first infant milk. Two FOFMs (see Table 1) also contain maltodextrin which reduces their sugar content, although it is not clear whether this also reduces their sweetness. Finally, the cost of FOFM is marginally higher than first infant milk in the region of £0-2 per month.
Goats’ milk based FOFM, which was previously excluded from the European market due to safety concerns, became available in the UK market following a revision of guidance by EFSA in 2012.7 These have not been included in Table 1 overleaf. However, it is likely to present additional challenges for healthcare professionals with respect to claims of being ‘free from cows’ milk protein’, whilst also being more expensive than their cows’ milk based counterparts. MICRONUTRIENT COMPOSITION
A possible advantage to using FOFM over first infant formula is related to its fortification with iron. Iron-deficiency anaemia is one of the most common nutritional deficiencies in infants and toddlers.8 Babies’ iron stores are much reduced at around six months of age and require iron-containing solids to be introduced in complementary feeding to meet demands for growth.9 A recent study10 found FOFM to be positively associated with iron status in late infancy, whilst cows’ milk was www.NHDmag.com April 2017 - Issue 123
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PAEDIATRIC Table 1: A comparison of the most commonly used FOFM to the same brand’s first infant milk in the UK per 100ml of prepared feed (figures based on powder formula) Brand
Energy Protein GOS/ Omega-3 Total (kcal) (g) FOS LCPs CHO (g) (g)
Total sugar (g)
Iron (mg)
Vitamin pence pence D (μg) /100ml /500ml
Cost per mth (500ml/ day)#
8.6
8.5
1.0
1.5
13.5
73.5
£22.05
7.3
7.3
0.53
1.2
14.7
67.5
£20.25
7.8
7.6
1.0
1.2
13.7
74.9
£22.47
Cow & Gate FOFM
68
1.4
0.8
Cow & Gate First
66
1.3
0.8
HiPP FOFM
70
1.5
0.5
HiPP First
66
1.25
0.3
7.0mg DHA
7.3
7.2
0.5
1.2
15.0
68.5
£20.56
SMA Pro FOFM
67
1.3
0.4
8.8mg DHA
7.9
5.5*
1.0
1.2
17.2
86.2
£25.87
SMA Pro first
67
1.25
0.4
8.4mg DHA
7.1
7.1
0.7
0.9
16.5
82.5
£24.75
Aptamil FOFM
68
1.4
0.8
1.8mg EPA 8.6mg DHA
8.6
6.5*
1.0
1.4
18.0
89.8
£26.95
Aptamil first
66
1.3
10mg DHA
7.3
7.3
0.53
1.2
16.5
82.5
£24.75
6.0mg DHA
* Sugars mainly from lactose, but includes maltodextrin # Costing derived from Tesco supermarket online website, using powdered formula
negatively associated. Breastfeeding, however, did not impact negatively on iron status. FOFM was also found to be beneficial for improving iron stores of babies and toddlers, but not beneficial for their development or growth.11 Thus the evidence shows extra iron may help stores, but the context for this benefit in infants fed a usual weaning diet alongside formula milk is not clear.12 Equally, there have been concerns about infants having too much iron in their diet given the possible reduced absorption of other essential trace elements.9 EFSA published their scientific opinion on the essential composition of infant and followon formulae and made the following important statement: ‘Nutrients and other substances should be added to formulae for infants only in amounts that serve a nutritional or other benefit. The addition in amounts higher than those serving a benefit, or the inclusion of unnecessary substances in formulae puts a burden on the infant’s metabolism and/or physiological 12
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functions as substances which are not used or stored have to be excreted.’7 It is notable that both the World Health Organisation (WHO) and DH do not recommend FOFM and consider these products to be unnecessary.13 With these clear messages from scientific experts, why is it that large proportions of babies are given FOFM in the UK? BREASTFEEDING
Breastmilk is uniquely tailored to each individual human baby and contains both known and unknown properties which promote survival and development.14 There are more than 100 substances present in breastmilk which are not present in artificial infant milks.14 Despite WHO and DH advice that mothers should breastfeed exclusively to six months of age and continue breastfeeding as long as is desired, UK breastfeeding rates are amongst the lowest in the world, with only 1% of babies being breastfed exclusively to six months15 vs 36% globally.16
The majority of mothers in the UK say that they wanted to breastfeed for longer (90% who stopped by six weeks; 63% of mothers interviewed when their babies were six to eight months old15). So why do mothers stop? It is often reported that mothers “did not have enough milk” or did not receive support when needed.17 Could messages from the media (advertising/social media/ television) be affecting mothers’ choices?13,16-18 Does advertising legitimise the switch from breastfeeding to formula feeding? Also, does advertising to healthcare professionals affect our advice when asked whether to use FOFM? THE INFLUENCE OF MARKETING
Marketing claims for FOFM include the following: “Help support a weaning diet” “Targeted at the specific nutritional needs of babies” “Fortified with iron to help normal cognitive development” “Contains omega-3 and 6 essential fatty acids to support normal development and growth” Advertisements influence social norms - or the shared understanding about expectations of behaviour within a social group - by illustrating that the behaviour is common and accepted in the population.20 Try to remember the last formula advert you watched on television. Do you remember the warm feeling associated with it, the baby girl spinning around becoming a ballerina? These feelings help us to remember formula milk and link it to a baby’s development. The messages help to tell us not just that it’s OK to use formula but that it will improve a baby’s development. No improvements in infant development have been found in researching composition of formula milk in comparison to breastmilk.2,11 Did you recall that the advert was for FOFM and not first milk for infants? The International Code for marketing regulation of infant formula (put in place to promote breastfeeding) by the WHO in 1981,21 bans the advertisement of first infant milk; however, as FOFMs are not considered breastmilk substitutes within the EU, this enables FOFM to be freely advertised.
Research into the effects of advertising on first time mothers found that health claims made by the marketeers were accepted uncritically and understood to pertain not only to FOFM but to first infant formula alike.22 Advertising messages imply that choosing to formula feed is a lifestyle choice rather than a difficult decision with health consequences.19 The media also convey that breastfeeding is difficult and that breastmilk substitutes help to settle fussy babies.23 It has been argued that FOFM was created by formulae manufacturers in order to advertise their products,2 and if so, retail sales figures indicate that these marketing strategies are effective. The retail value of the baby milk industry is growing. Global sales of milk formula (including infant formula and FOFM) have increased 20-fold between 1987 to 2013, and account for two-thirds of all baby food sales internationally.24 Growth continues to be strong in the UK in particular, with figures of 4% equivalent to other middle income countries, and larger than the US and France.24 Regulation and monitoring of law in order to reduce unethical marketing with meaningful penalties to protect breastfeeding, is important. However, despite legislation existing, it is not comprehensive and is poorly enforced in the UK.25,26 UNICEF UK recommended following a report published in 2012 that the UK government fully implement the International Code of Marketing of Breastmilk Substitutes and subsequent resolutions. This would result in the banning of advertising of FOFM.27 NEW LEGISLATION
An Infant Feeding All Party Parliamentary Group has brought a bill which at time of writing of this article was due to go through its second reading in the House of Commons on 24th March 2017.28 The new legislation will: • introduce plain packaging for all formula milks; • establish a body, totally independent of industry, to test all products and verify the claims of manufacturers prior to them being licensed for sale; • ban the use of misleading terms such as ‘follow-on’ or ‘growing-up’ formula milks; www.NHDmag.com April 2017 - Issue 123
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From birth to discharge and beyond, the ESPGHAN-Compliant1 Nutriprem range has been designed to aid the development of preterm babies.
So, for a range of products that support feeding with breastmilk and contain ingredients that help preterm babies thrive, choose Nutriprem.
Important notice: Breastmilk is best for babies. Nutriprem Breastmilk Fortifier is a nutritional supplement designed to be added to expressed breastmilk for feeding preterm and low-birthweight infants. Nutriprem Protein Supplement, Hydrolysed Nutriprem, Nutriprem 1 and 2 are foods for special medical purposes. They should only be used under medical supervision, after full consideration of the feeding options available, including breastfeeding. Hydrolysed Nutriprem, Nutriprem 1 and 2 are suitable for use as the sole source of nutrition for preterm and low–birthweight infants. Reference: 1. Agostoni C et al. J Pediatr Gastroenterol Nutr 2010; 50:85–91.
PAEDIATRIC • stop companies from circumventing existing laws by introducing a ban on identical packaging for stage two and subsequent products; • prohibit formula companies from advertising in health journals and magazines; • bring forward tougher penalties for companies who flaunt the legislation, including greater financial fines and prison sentences for company CEOs; • ban advertising of formula milks on TV, social media, the internet and through parenting clubs. If this bill is passed in the future, it is clear that consumers will be better protected from unethical marketing. It is also hoped that it will work to increase future breastfeeding rates in the UK,29 although this is not certain.30
IN CONCLUSION
Follow-on formulae are not necessary nor recommended for use in infants. They are targeted at infants between six to 12 months of age and advertising is likely to continue to promote their use for the foreseeable future. As healthcare professionals, it is vital that dietitians understand the potential impacts of indirect advertising and interpret marketeers’ health claims correctly and, as such, do not endorse nor promote these products inadvertently. If parents choose to use these products, careful communication about their dispensability is worth considering. However, where this is not successful in changing parent’s choices, it is the professional’s duty to help to identify the best possible option considering their costs, product similarity and limit protein and sugar content where possible.
References 1 Department of Health (2013). Guidance Notes on the Infant Formula and Follow-on Formula Regulations 2007 (as amended). www.gov.uk/government/uploads/ system/uploads/attachment_data/file/204314/Infant_formula_guidance_2013_-_final_6_March.pdf. Accessed 03/03/17 2 Crawley H and Westland S (2017) for First Steps Nutrition Trust. Infant Milks in the UK: A Practical Guide for Health Professionals. http://firststepsnutrition.org/ newpages/Infants/infant_feeding_infant_milks_UK.html. Accessed 3/3/17 3 Crawley H and Westland S (2016). for First Steps Nutrition Trust. Infant Milk Composition. www.firststepsnutrition.org/pdfs/Infant_milk_composition_February2016.pdf Accessed 3/3/17 4 Koletzko B, Bhutta ZA, Cai W et al (2012). Compositional requirements of follow-up formula for use in infancy: recommendations of an International Expert Group coordinated by the Early Nutrition Academy. Annals of Nutrition and Metabolism, DOI: 10.1159/000345906 5 Koletzko B, Koletzko S, Ruemmele F (2009). Drivers of Innovation in Pediatric Nutrition. Nestlé Nutrition Institute 6 European Food Safety Authority (2014). Scientific opinion on the essential composition of infant and follow-on formulae. EFSA Journal, 12 (7), 3760. Available at www. efsa.europa.eu/en/efsajournal/doc/3760.pdf Accessed 03/03/17 7 European Food Safety Authority (2012). Scientific opinion on the suitability of goat milk protein as a source of protein in infant formulae and in follow-on formulae. Available at: www.efsa.europa.eu/en/efsajournal/pub/2603.htm Accessed 03/03/17 8 Stoltzfus RJ (2003). Iron deficiency: global prevalence and consequences. Food Nutr Bull. 24(4 Suppl):S99 9 SACN (2010). Iron and Health. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/339309/SACN_Iron_and_Health_Report.pdf Accessed 03/03/17 10 Thorisdottir AV, Ramel A, Palsson GI, Tomassson H and Thorsdottir I (2013). Iron status of one-year-olds and association with breast milk, cows’ milk or formula in late infancy. European Journal of Nutrition, 52(6 ) 1661-1668 11 Morley R, Abbott R, Fairweather-Tait S, MacFadyen U, Stephenson T and Lucas A (1999). Iron fortified follow-on formula from nine to 18 months improves iron status but not development or growth: a randomised trial. Archives of disease in childhood, 81(3), pp 247-252 12 Daly A, Macdonald A, Aukett A, Williams J, Wolf A, Davidson J, Booth IW (1996). Prevention on anaemia in inner city toddlers by an iron supplemented cows’ milk formula. Archives of Disease in Childhood 75(1): 9-16 13 World Health Organisation (WHO 2013). Information concerning the use and marketing of follow-up formula. www.who.int/nutrition/topics/WHO_brief_fufandcode_ post_17July.pdf Accessed 03/03/17 14 Ballard O, Morrow AL (2013). Human milk composition: nutrients and bioactive factors. Pediatric Clinics of North America, 60, 49-74 15 McAndrew F, Thompson J, Fellows L, Large A, Speed M and Renfrew MJ for Health and Social Care Information Centre (2012). Infant Feeding Survey 2010. http:// content.digital.nhs.uk/catalogue/PuB08694/Infant-Feeding-Survey-2010-Consolidated-Report.pdf Accessed 3/3/17 16 McFadden A, Mason F, Baker J, Begin F, Dykes F, Grummer-Strawn L, Kenney-Muir N, Whitford H, Zehner E, Renfrew MJ (2016). Spotlight on infant formula: coordinated global action needed. Lancet 387(10017): 413-5 17 Odom E, Li R, Scanlon K, Perrine C and Grummer-Strawn L (2013). Reasons for earlier than desired cessation of breastfeeding. Pediatrics, 18, 2012-1295. Available at: http://pediatrics.aappublications.org. Accessed 4/3/17 18 Stewart-Knox B, Gardiner K and Wright M (2003). What is the problem with breastfeeding? A qualitative analysis of infant feeding perceptions. Journal of Human Nutrition and Dietetics, 16: 265-273. doi:10.1046/j.1365-277X.2003.00446.x 19 Piwoz EG, Huffman SL (2015). The Impact of Marketing of Breast Milk Substitutes on WHO-Recommended Breastfeeding Practices. Food and Nutrition Bulletin 36 (4), pp 373-386 20 Schultz PW, Nolan JM, Cialdini RB, Goldstein NJ and Griskevicius V (2007). The constructive, destructive and reconstructive power of social norms. Psychological science, 18(5), pp 429-434 21 World Health Organisation (WHO 1981). International Code of Marketing of Breast Milk Substitutes. Geneva: Available from: www.who.int/nutrition/publications/ infantfeeding/9241541601/en/. Accessed 3/3/17 22 Berry NJ, Jones S, Iverson D (2010). It’s all formula to me: women’s understanding of toddler milk ads. Breastfeeding Review, 18, 1, 21-30 23 Parry K, Taylor E, Hall-Dardess P, Walker M, Labbok M (2013). Understanding women’s interpretations of infant formula advertising. Birth 2013; 40: 115-24 24 Rollins N, Bhandari N, Hajeebhoy N, Horton S, Lutter C, Martines J et al (2016). Why invest and what it will take to improve breastfeeding practices? Lancet 387: 491-504 25 Save the Children. Breastfeeding: policy matters. Identifying strategies to effectively influence political commitment to breastfeeding: a review of six country case studies. London: Save the Children, 2015 26 World Health Organisation (WHO 2013). Country implementation of the International Code of Marketing of Breast Milk Substitutes: status report 2011. Geneva 27 Renfrew MJ et al, for UNICEF UK (2012). Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK. http:// dspace.brunel.ac.uk/bitstream/2438/10266/1/Fulltext.pdf Accessed 3/3/17 28 http://services.parliament.uk/bills/2016-17/feedingproductsforbabiesandchildrenadvertisingandpromotion.html 29 Baby Milk Action Group. www.babymilkaction.org/archives/8042. Accessed 3/3/17 30 Balogun OO, O'Sullivan EJ, McFadden A, Ota E, Gavine A, Garner CD, Renfrew MJ, MacGillivray S. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews 2016, Issue 11. Art. No.: CD001688. DOI: 10.1002/14651858.CD001688.pub3, Issue 11. Art No: CD001688. DOI: 10.1002/14651858.CD001688.pub3
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