Issue 147 Follow on formula

PAEDIATRIC

FOLLOW-ON FORMULA Follow-on formula milk (FOFM) is marketed to infants aged 6-12 months who are receiving complementary foods. Although there are some subtle nutritional differences between first infant and FOFM, there is no real benefit for the majority of infants in switching from a first infant formula to a FOFM once complementary feeding has begun.

The legal definition of FOFM from the Department of Health is: ‘Foodstuffs intended for particular nutritional use by inference 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: FOFM has more iron than first infant formula.2 There are also other subtle differences in vitamin D, calcium and carbohydrate content (see Table 1). These additions are intended to address the fact that UK infants aged over six months are often lacking in iron and vitamin D.3 Prior to 2014, FOFM had a higher protein content, but this has since been decreased due to concerns about the association of high protein intakes in infancy with increasing risk of obesity.4 This was as a result of guidance from the European Food Safety Authority (EFSA), recommending that the protein content of FOFM should be lower than it was previously.5 BREASTFEEDING

The World Health Organisation (WHO) recommends breastfeeding for the first six months of life in order to achieve optimal growth, development and health.6 The WHO also states that even though FOFM is not necessary and is unsuitable when used as a breast milk replacement, it is marketed in a way that may cause confusion and have a negative impact on breastfeeding.6

A number of studies strongly suggest a direct correlation between marketing strategies for FOFM and perception and subsequent use of these products as breast-milk substitutes. In many instances, the packaging, branding and labelling of FOFM closely resemble that of infant formula. This leads to confusion as to the purpose of the product, ie, a perception that FOFM is a breast-milk substitute. This may result in its early introduction, thereby undermining exclusive breastfeeding up to six months of age and sustained breastfeeding for up to two years or beyond.8,9,10,11

This is very concerning because, in the UK, we have one of the lowest breastfeeding rates in the world, with only 1% of babies being exclusively breastfed to six months of age, compared with 36% globally.7 In the 2010 UK infant feeding survey, 81% of mothers initiated breastfeeding soon after birth, 17% were still exclusively breastfeeding at three months and 12% at four months of age.6 The majority of mothers in the UK who discontinue breastfeeding report that they would have liked to breastfeed for longer: 90% of mothers interviewed who stopped by six weeks and 63% who stopped when their babies were six to eight months of age.12 A recent study13 in Italy about FOFM advertisements and their perception by pregnant women, found that participants were unable to define what the advertised products were, due to the ambiguity of the age of the infants pictured in the advertisements and not knowing that the number ‘2’ represented FOFM, as well as the prominence of the brand name. The

Paula Hallam RD, PG Cert (Paed Diet) Specialist Paediatric Dietitian Paula is a Specialist Paediatric Dietitian and owner of Tiny Tots Nutrition Ltd. She helps families of babies and children with many nutritional concerns, such as fussy eating, iron deficiency anaemia, constipation, growth faltering and food allergies.

She also facilitates weaning workshops for new mums. www.tinytots nutrition.co.uk

REFERENCES Please visit the Subscriber zone at NHDmag.com

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PAEDIATRIC Table 1: FOFMs available in the UK, compared with human breast milk and first infant formula Brand per 100ml

Energy (kcal)

Protein (g)

CHO (g)

Fat (g)

Iron (mg)

Vitamin D (ug)

Calcium (mg)

Cost (£/kg)

Human mature breast milk

69

1.3

7.2

4.1

0.07

Tr

34

_

66-67

1.2-1.5

7.3-7.5

3.2-3.6

0.30.70

0.9-1.7

39-55

£9.38£20

Cow & Gate 2

68

1.4

8.6

3.0

1.0

1.5

68

£10

Aptamil 2

68

1.4

8.5

3.1

1.1

1.5

63

£13.57

SMA Pro 2

67

1.3

7.9

3.2

1.0

1.2

75

£12.50

HiPP organic 2

70

1.5

7.8

3.5

1.0

1.2

75

£11.88

SMA little steps 2

67

1.5

8.0

3.2

0.81

1.7

75

£9.38

Aptamil Profutura 2

68

1.4

8.8

2.9

1.0

1.3

64

£16.90

SMA Advanced 2

68

1.3

7.8

3.5

0.7

0.9

46

£20

SMA organic 2

67

1.35

8.1

3.2

0.87

1.7

58

£15

First infant formula

Table 2: Iron requirements in the first year of life* Age (months)

Iron (mg/day)

0-3

1.7

4-6

4.3

7-9

7.8

10-12

7.8

* Great Ormond Street Hospital nutritional requirements for children in health and disease, 2014

study concluded that advertisements for FOFM are perceived by pregnant women as promoting infant formula.13 The marketing of FOFM makes it confusing for parents, as adverts can make vulnerable new parents feel pressurised into switching from a first infant formula to a FOFM, or from breast milk to a FOFM. Many believe that FOFMs were created to circumvent infant formula regulations related to advertising,2 as the advertising of FOFM is permitted in the UK. REGULATIONS AND RECOMMENDATIONS

In the UK The UK Law prohibits the advertising and promotion of infant formula only (marketed for use from birth). FOFM (marketed for use from six months of age) and milks for older babies can be advertised and promoted; BUT this must not cross-promote infant formula through similar branding, or by it not being obvious that the product is for older babies.

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International Code and Resolutions The International Code is a unique and indispensable tool to protect and promote breastfeeding and to ensure that marketing of breastmilk substitutes, feeding bottles and teats is appropriate. The International Code was prepared by the WHO and UNICEF after a process of widespread consultation with governments, the infant feeding industry, professional associations and NGOs. It was adopted by the World Health Assembly in 1981.

The Code and Resolutions prohibit all advertising and other forms of promotion of breast milk substitutes, feeding bottles and teats.

The ban on promotion covers infant formula, FOFM and milks for older babies (up to 36 months). There is no restriction on products being sold, as long as they comply with labelling and composition requirements. Companies may provide scientific and factual information to health workers. Health workers are responsible for supporting parents.

PAEDIATRIC

As healthcare professionals, it is our role to support mums to breastfeed for as long as they would like to and where formulas are used, provide the advice and information as appropriate.

More information can be found via the International Baby Food Action Network (IBFAN) website: www.ibfan.org/what-is-theinternational-code/.

Is FOFM recommended?

No. The WHO, the UK Department of Health and NHS all state that the use of FOFM is unnecessary and unsuitable as a breast milk substitute and that infants six months and older, who are not being breastfed, are advised to continue on a first infant formula milk until 12 months of age. FOFM should not be given to babies under six months of age and care should be taken to avoid making a mistake, as the labels on FOFM can look very similar to those on first infant formula milk.6 NUTRITIONAL COMPOSITION

The main difference between first infant formula milk and FOFM, as already stated, is the increased iron content. There are also other subtle nutritional differences (see Table 1).

Iron The iron content of FOFM is higher than that of first infant formula, although there is considerable variation and, in some cases, the iron content in first infant formula and in FOFM is the same (in different brands). This higher iron content is marketed as a possible advantage to switching to FOFM from a first

infant formula. Iron deficiency anaemia is one of the most common nutrient deficiencies in the world in infants and young children.3 One in eight children in the UK between the ages of 1828 months are reported as having iron deficiency anaemia (low haemoglobin), whilst many more could be iron deficient (low serum ferritin – the iron storage marker).3,14 Babies born full term and of normal birth weight, are born with sufficient iron stores to last for around six months of age. Maternal iron status during pregnancy and delayed cord clamping have both been shown to have an influence on the iron status of the infant throughout the first year of life. It is for this reason that both ESPGHAN and NICE recommend that delayed cord clamping should be considered for all newborns.15 Formula companies have utilised the fact that iron requirements of infants increase from six to seven months of age due to decreased endogenous iron stores, and so market FOFM as being beneficial for infants from six months of age. A study from 201315 showed that FOFM was positively associated with iron status in late infancy, whilst cow’s milk was negatively associated. However, breastfeeding was not shown to impact negatively on iron status.

In another study17 it was found that FOFM improved iron stores of infants and toddlers, but it was not shown to be beneficial for development or growth. The evidence shows www.NHDmag.com August/September 2019 - Issue 147

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PAEDIATRIC that FOFM may be beneficial in improving iron stores of infants and toddlers, but it is not clear what benefit this will serve alongside an ironrich weaning diet. Globally, it is agreed that FOFM serves no nutritional purpose and WHO clearly states that FOFM is unnecessary.6 First Steps Nutrition Trust2 explain in their Infant milks in the UK report that there is also some evidence that excessive iron intakes may result in a reduced uptake of other trace metals, including copper,17 and that high iron intakes in iron-replete infants and toddlers may actually have an adverse effect on growth and development. A recent large study from Chile looking at the impact of ironfortified formula in infants aged 6-12 months on a range of cognitive and learning outcomes at 10 years of age, showed that iron-replete infants given iron-fortified formula did significantly less well in terms of long-term development than similar infants given low-iron formula, or irondeficient infants given high-iron formula.19 Calcium The calcium content of FOFM is higher than that of first infant formula milks and breast milk (see Table 1). In the UK, infants are recommended to have 525mg calcium per day until 12 months of age, after which calcium requirements drop to 350mg calcium per day for one to three-year olds. Calcium requirements can easily be met by a combination of breast milk/first infant formula and a small amount of yoghurt, cheese, or cow’s milk used within foods (see example below).

Additional calcium from FOFM is unnecessary.

Cow’s milk should not be given as a main drink until at least 12 months of age.

Example: • 600ml breast milk (estimate of intake) = approx 200mg calcium OR 600ml first infant formula = 234-330mg calcium (depending on brand of formula) • 15g cheese = 120mg calcium • 50g yoghurt (small pot) = 100mg calcium • 100ml cow’s milk (within foods or over cereal) = 120mg calcium Vitamin D Another nutritional feature of FOFM is a slightly higher vitamin D content compared to (most) 24

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first infant formulas. This fact is often used in the marketing campaigns of the FOFM companies to promote their formula. However, in the UK, vitamin D supplements of 8.5-10 micrograms are recommended for all breastfed infants and for formula-fed infants when formula intake is less than 500ml per day. First infant formula milks contain sufficient amounts of vitamin D when an infant is drinking more than 500ml per 24 hours.

THE COST OF FOFM

There are wide variations in the cost of FOFM, ranging from £9.38 to £20 per kg of powder, depending on the brand of formula. As an example, if a seven-month-old baby drinks 600ml of FOFM per day, this would cost a family £24.50 to £52.50 per month, depending on which brand of FOFM was used.

The All-Party Parliamentary Group on Infant Feeding and Inequalities and First Steps Nutrition Trust recently published a report20 on an inquiry into the financial impact of infant formula on family budgets in the UK. The inquiry found that the high cost of infant formula is reported to be having a seriously negative impact on a number of families in the UK, and that this may lead to unsafe feeding practices, as well as the possibility of parents limiting their own food intake, or that of other children, in order to make ends meet.20 CONCLUSION

FOFM contains more iron than first infant formula, as well as having other subtle nutritional differences. However, there is no clear evidence for its use in infants from six months of age, as long as iron-rich complementary foods are introduced from this age.

There are few advertising restrictions on FOFM in the UK and this increases the risk that infants may be inappropriately switched to a FOFM. As healthcare professionals, it is our role to support mums to breastfeed for as long as they would like to and where formulas are used, provide the advice and information as appropriate.

I personally would like to see the UK adopt the ‘International code and resolutions’ from IBFAN, so that the advertising of FOFM in the UK is prohibited by law.