Infant Nutrition Q&A

Breastmilk gives babies the best start in life and provides many benefits. It contains all of the nutrients babies need for the first few months of life and also provides immunological advantages which may reduce the incidence of illness. Studies have shown that breastfeeding offers protection against gastrointestinal and respiratory infection and reduces the risk of allergy.[1]

These benefits may also extend into later childhood. In the longer-term, breastfeeding has been associated with lower incidence of obesity and therefore Type 2 diabetes, lower cholesterol and blood pressure and higher performance on intelligence tests but these benefits have not been consistently demonstrated in all studies.[2]

The maternal benefits of breastfeeding include a lower risk of breast and ovarian cancer and evidence suggests that breastfeeding has a protective role against type 2 diabetes and cardiovascular disease;[2], [3]

Breastmilk is hygienic, convenient, the correct temperature, readily available and free.

The breastfeeding prevalence for England at 6-8 weeks is[4]:

• 42.7% for 2017-2018
• 44.4% for 2016-2017
• 43.1% for 2015-2016
• 43.8% for 2014-2015

Women were given the legal right to breastfeed in public following the 2010 Equality Act coming into force. It is now an act of sexual discrimination to treat a woman unfavourably because she is breastfeeding in public.

The majority of women do not need to go on a special diet during pregnancy but should continue to eat a normal, healthy diet. The NHS Choices website provides information for pregnant women on healthy eating during pregnancy alongside information on the vitamins and minerals that are especially important during this time. This includes recommendations on vitamin D and folic acid supplementation.

For those mums who cannot, or choose not to, breastfeed, infant formula is recognised as the only safe alternative for babies. Infant formula has been specifically developed to contain all the necessary ingredients needed to meet an infant's nutritional requirements. The World Health Organisation (WHO) recognises that infant formula has a legitimate role to play in feeding infants up to six months of age.[5]

Babies may be fed a first infant formula (breastmilk substitute), exclusively until 6 months, and as part of a complementary diet from 6 months onwards.

Infant milk formula needs to be prepared fresh exactly according to the manufacturer's instructions and used within the time limit stated by the manufacturer on the packaging. Before making up infant formula, all bottles and teats must be cleaned and sterilised, and the preparer must wash their hands thoroughly with soap and water. Bottles should be prepared as the baby needs it and fed immediately.

1L of water should be boiled in order to ensure any bacteria present in the water is killed. Next, the water is cooled for no more than 30 minutes, this will ensure it remains above 70^oC. 70^oC is optimal mixing temperature for formula powder, but will still ensure potential bacteria in the formula powder are killed.

Ordinary tap water is best, taken fresh from the cold tap, but if this is not available, some types of still bottled water are suitable such as those with low mineral contents. If the label says the sodium content is less than 200mg per litre, and the fluoride content is less than 1.5mg per litre this water is safe for your baby. Most bottled waters are well below 200mg sodium per litre, but it is best to check the label. Most types of artificially softened water are not suitable for babies. If there are any doubts it is best to check with the manufacturer or a healthcare professional before using.

Ready-to-feed liquid formula, sold in bottles or cartons, doesn't need to be mixed and is sterile.

A booklet on preparing infant formula, written by the Department of Health's Start4Life initiative, is available at: Start4Life Guide to Bottlefeeding.

*Some formula milks, especially specialist formula milks for infants, may require alternative preparation. Please always follow the manufacturer’s instructions.

The manufacturers of infant milks and foods in Europe are amongst the most highly regulated in the word. This ensures the highest standards in quality – above those required for all other types of food.

The raw materials used in the manufacture of baby milks and the final product itself must meet very strict specifications and high standards.

The manufacturing process involves heat treatment which ensures the microbiological safety of the product. Quality control procedures are very strict and stringent standards of hygiene are in force throughout. Levels of contaminants are kept to an absolute minimum complying with national and/or international recommendations. By law, pesticide residues must be below 10 parts per billion (0.01mg/kg) and are usually either absent or at levels so low they cannot be detected. Rigorous tests for shelf-life, microbiological safety, nutrient levels and suspected contaminants are carried out.

There is no conclusive evidence to support a relationship between obesity and formula feeding. Obesity is a multi-dimensional disease that is affected by many factors. The findings of the many studies carried out over the last two decades are not consistent.

Some studies show a small protective effect of breastfeeding against childhood obesity, but the evidence is inconclusive.[6] Studies showing an effect of breastfeeding against overweight and/or obesity also show that the effect is reduced when other factors such as maternal obesity and socio-economic status are considered.[6] Many studies factored out some of the possible confounding factors, but none factored out all of them.

Infant formula manufacturers must comply with stringent national legislation when formulating and marketing their products. Manufacturers are always looking at how to optimise nutrient blends to improve products. Should scientific evidence become available to show a clear link between formula and obesity, manufacturers will modify their products in accordance with any recommendations made by scientific and government authorities.

The EFSA (2014) opinion on the essential composition of infant and follow-on formula recognised that cow’s milk, goat’s milk and soy protein were suitable protein sources for infant formula and follow-on formula.[7]

Soya infant formulae should only be used on the advice of a GP or other healthcare professional.

The Department of Health and Social Care (DHSC) advises that soya infant formulae should not be used as the first choice of formula before six months, but recognises that there may be circumstances where they may be needed, for example, in older infants who are refusing hypoallergenic formula. About 10-14% of children with cow’s milk allergy (CMA) are also allergic to soya; this may be higher in non-IgE mediated CMA.[8] [9] In addition, soya formulae may be used for infants of vegetarian parents who are not breastfeeding or infants who find the alternatives unacceptable.

To ensure infants receive adequate protein, it is acknowledged that there is a clinical need for soya formulas for infants under 6 months in the following:[10]

• - Infants with cow’s milk allergy or intolerance who refuse extensively hydrolysed or elemental formulas
• - Infants whose parents want to offer a vegan diet. Vegan parents/caregivers who are unable to breastfeed or choose not to do so
• - Infants with galactosaemia, galactokinase deficiency and lactose or sucrose intolerance

In rare incidences, cases of dental caries have arisen from prolonged ad lib breastfeeding and inappropriate bottle feeding. This is because both breastmilk and infant formulae contain sugars, either in the form of lactose, or in the case of soya infant formulae, glucose syrups.

Duration and frequency of feeding are important factors in reducing the risk of dental caries and current advice is that babies should never be left alone with a bottle and should be encouraged to drink from a beaker or cup as soon as they are ready to make the change. Bottles should never be used as comforters.

Companies include reminders on packs about safe bottle feeding but if concerned, parents should also seek advice from a healthcare professional.

There are a range of formulas available which are specifically formulated to meet the nutritional requirements of pre-term babies and those affected by allergies, metabolic and other conditions which impact on the decision a parent or carer makes about feeding their infant.

Parents or carers are advised to seek advice from their GP, midwife or health visitor before using these specialist products.

Follow-on formula has been developed to meet the nutritional needs of infants from six months old as part of a mixed weaning diet. The composition of follow-on milk is similar to that of infant formula except for two nutrients – iron and vitamin D, which are important nutrients that growing babies need when they move onto solid foods. Iron contributes to normal cognitive development of children whilst calcium and vitamin D are needed for normal growth and development of bones in children.

Unmodified cow’s milk is not recommended as a drink for babies under 12 months because of concerns over iron intake and status, associated in part with the low iron content and bioavailability in cow’s milk.[11]

Direct advertising to consumers of breastmilk substitutes (i.e. infant formula) for infants under 6 months of age is prohibited. This includes media such as TV, radio, newspapers, antenatal and baby magazines.

The advertisement of follow-on formula is permitted under strict conditions and must comply with labelling guidance including the font size of the term ‘follow-on’; provide clear age indications; and have a colour scheme clearly differentiated from infant formula. Follow-on formula is intended for infants over six months of age and should not be used as a breastmilk substitute.

The provision of information on infant formula to health professionals in scientific publications is permitted so long as it complies with the regulations. This is because it is important to keep healthcare professionals informed about new product developments in order for them to provide informed and balanced advice to parents. Trade advertising is also permitted to inform pharmacists and retailers of the latest product developments and prices.

Manufacturers of infant formula must follow strict regulations to ensure high standards are always maintained. They have a responsibility to operate in a responsible, professional and ethical manner. Industry has a legitimate right to communicate with healthcare professionals to ensure the availability of accurate, representative and up-to-date information to ensure formula foods are used appropriately. They require evidence based information and materials to enable them to provide objective and consistent advice to parents.

All member representatives acknowledge and support the superiority of breastmilk and breastfeeding and recognise it as the optimal food for healthy infants.

Industry members support the right of parents and caregivers to have all the information they need to enable them to make informed choices about their infant's nutrition. In doing so, they take great care in ensuring that all information and educational materials intended to reach the general public always refer to the superiority of breastfeeding.

Thousands of parents contact our member companies’ helplines and online forums every month. This shows the high demand for information and guidance from parents. Information provided to parents via e.g. carelines, websites, mother and baby clubs, or any advertisements for these, is factual information only.

Manufacturers take the trust that parents have in their brands and products very seriously and adhere to the strict regulations regarding advertising and the provision of educational material.

In line with the INI Code, samples of infant formula are never provided to the general public.

Provision of formula foods for professional evaluation (PPE) can be given to HCPs at their request. PPE are provided specifically for the purpose of professional evaluation or demonstration purposes, and only on the request of a HCP, which is recorded by the company.

No. The infant nutrition industry is a science based, responsible and highly regulated industry that only makes supported and authorised health claims on labelling and advertising. Only a limited number of nutrition claims and one health claim are permitted to be made on infant formulae.

Any nutrition and health claim is strictly controlled by EU legislation [Regulation (EC) No. 1924/2006; EC Directive 2006/141/EC] and must be approved by EFSA or its predecessors, the Scientific Committee for Food (SCF). Enforcement is carried out by Trading Standards. All claims made by formula milk companies are fully substantiated; nothing is published that is not fully supported by evidence.

Under the new Commission Delegated Regulation (EU) 2016/127 (applicable after 22 February 2020) nutrition and health claims on infant formula will no longer be allowed. (The DHA claim is allowed to me made for 5 years.)

It is important that industry collaborates with academics and conducts clinical research, measures outcomes and continually strives to improve products. Collaboration between industry and academic /external research institutes supports the generation of new research questions, sharing of research best practices and capabilities and peer review. Clinical studies are necessary to assess the safety, clinical outcomes and efficacy of formula foods. Industry members operate under strict guidelines to ensure there is no undue or improper influence on clinical study participants, results or outcomes.

The results of such research are used to further our knowledge of infant nutrition and breastmilk.

Not necessarily – the nutrient density of a meal depends on a number of factors including the type of food that is offered, the amount eaten and the way it is prepared.

As such whilst some home cooked meals have the potential to be highly nutritious, it will depend upon what is offered. A recent study which looked at the nutritional content and food variety of commercial meals for children available in the UK compared to home-cooked recipes found that the majority of commercial meals provided an appropriate energy density with greater vegetable variety.[12] In comparison, whilst home-cooked recipes were the cheaper option, the majority exceeded recommendations for energy and fats.

Consumer insights suggest that many parents do not choose to offer homemade meals but instead opt to provide commercially prepared adult food products, which have not been specifically designed with infants. For example, the standard children’s cereal has a total sugar content of 26.9g/100g vs the average infant plain cereal sugar content of 8g/100g.[13]

Manufactured weaning foods are specially developed to provide the nutrients a baby requires in appropriate amounts. Contrary to popular opinion, manufactured baby foods, when compared with general foods, contain very little sugar and salt. There are legal controls on the total amount of carbohydrate (including sugars) they may contain and the sugars present typically come from the sugars naturally present in fruit, vegetables and milk.

It is of note that many members have undertaken extensive proactive reformulation to improve the nutritional quality of products in the past few years.

Regardless of the type of meal offered babies should be introduced to eating with the family. Social interaction with the rest of the family at mealtimes is essential for development

Commercial baby foods are nutritionally balanced, comply with strict compositional criteria, including pesticide controls, meet high standards of quality and safety, contain no artificial additives, minimal added salt and provide appropriate textures to help the transition to family foods.

Baby foods have been found to offer greater variety than homemade options.11 They can provide a convenient way for parents to introduce new tastes and some recipes can be suitable for special diets (e.g. gluten-free, egg-free, milk-free, vegetarian, halal).

Complementary foods are designed to be specifically appropriate for infants and young children and are convenient for parents and carers; there is no need for any special kitchen equipment; a wide range of foods are quick and easy to prepare with no cooking required; and there is little or no wastage of dried baby foods. Finally, commercial baby foods may be especially convenient when away from home such as on day trips, holidays, and when a child is left with relatives or other carers.

Commercial baby foods are manufactured to very high standards and all ingredients must meet very strict food safety and quality specifications. The ingredients have to be produced at a chosen farm in suitable soil away from contaminants and under strict guidelines that ensure pesticides, pollution and nitrates are kept to a minimum.

Legislation bans the use of some pesticides and requires the level of most other pesticides to be below 10 parts per billion (0.01mg/kg). This is set on the basis of a precautionary principle. More severe limitations are set for a small number of pesticides or metabolites of pesticides.

Additionally, and by law, artificial additives including preservatives, colourings, antioxidants and intense sweeteners are not permitted in baby foods. There are strict limits on all other additives, restricting the range and levels of additives. Both safety and technological need are determining factors which govern the use of any additives. If an additive is not necessary for technological reasons, even if it is proven to be safe, then it is not used.

All manufacturing is carefully controlled with extensive quality control. Whatever the manufacturing process, heat treatment combined with strict hygiene standards ensures that all products are microbiologically safe. Production and packaging processes are carefully selected to ensure that the products are safe for infants and young children.

All stages of production are monitored from inspection of suppliers’ premises and testing of raw materials through to manufacturing and packaging of the product. The packaging of baby foods is very important to protect the product from contamination and to keep it in the best possible condition throughout its shelf-life.

Commercially available infant foods are specifically designed to meet the nutritional needs of infants and young children. This includes limiting the amount of added salt and sugar.

• Salt

The level of sodium in baby foods is carefully controlled and salt (in the form of sodium chloride), if present at all, is kept to a minimum. Sodium in foods either comes from ingredients which naturally contain sodium or from salt (sodium chloride).

The majority of commercially available infant foods are without added salt. If salt is present at all in baby foods, it is generally because some ingredients may contain salt for technological purposes, such as cheese, yeast extract and ham.

• Sugar

Contrary to popular opinion, very little added sugar is used in commercial baby foods. In fact, there are legal controls on the total amount of carbohydrate (including sugars) that baby foods may contain and manufacturers have already undertaken extensive reformulations to reduce the sugar content of commercially available infant foods.

The majority of products only contain sugars that are naturally occurring in the fruit, vegetable and milk ingredients. It is important to recognise that infants and young children do need moderate amounts of sugars and carbohydrates in their diet. Breastmilk itself contains sugars in the form of lactose. Sugars are a readily digestible energy source.

Starches are the main storage carbohydrates of seeds and roots and are naturally present in foods such as potatoes, cereals, rice and flour. They are used in commercial baby foods, just as flour or cornflour are used in the home, to achieve the right texture and consistency. This is very important for babies because food needs to be sucked from a spoon without being too runny or too solid. Starches also have the advantage of providing energy in the form of easily digestible carbohydrate without too much fibre.

Modified starches are food starches which have been modified to increase their tolerance to processing and stability in storage. (They have nothing to do with genetic modification.) They are safe, digestible food ingredients which may be used at low levels as a stabiliser in some baby foods in jars. Only modified starches that are permitted to be used in strict legislation for complementary foods would be added to baby foods, and only if technologically required.

Modified starches are used in some baby foods for technical reasons, for example, to ensure a uniform suspension during processing and to reduce the astringency of some fruit flavours in products. They are typically only used when other starches are not suitable.

Maltodextrins have a long and safe history of use in foods. They are usually made from corn starch and consist of a mixture of medium and long chain carbohydrates with a small proportion (typically less than 10%) of maltose and glucose.

Maltodextrins mix readily with water and help to ensure that baby foods mix easily, providing a smooth texture and consistency. They absorb very little water from the atmosphere so keeping baby foods which flow free from the packet dry.

Maltodextrins are mostly used, in conjunction with other cereal ingredients, in those dried baby foods that need only the addition of water for their preparation. These baby foods must provide all the appropriate nutrients as well as an appropriate energy density in the dried product. Maltodextrins are used in some recipes to help provide an appropriate energy density whilst maintaining a consistency and texture suitable for babies.

Organic foods are grown in accordance with European legislation for organic foods.

In the UK, the Soil Association is the main organisation responsible for certifying that foods are 'organic' and its symbol will appear on the label of the 'organic' food. More recently, an EU organic logo has been introduced. Other organisations, including some from other countries, can also legally certify products as organic. The EU also has an equivalence arrangement with the US. This means that as long as the terms of the arrangement are met, organic operations certified to the USDA organic or EU organic standards may be labelled and sold as organic in both countries.

For any food to be labelled ‘organic’ at least 95% of the agricultural ingredients must be certified organic. The remaining 5% has to be approved by the Organic Accreditation body

Complementary feeding (also called weaning) is the process of gradually transitioning from a solely milk-based diet to one made-up of a variety of foods and drinks. Complementary feeding is important to ensure that infants are able to meet their nutritional requirements and also begin to develop feeding skills and taste preferences that will allow the transition to a family diet.

The UK Department of Health recommends six months exclusive breastfeeding with the introduction of complementary foods at around 6 months. In Europe the recommendation, based on a review of scientific evidence by the European Food Safety Authority and paediatric nutrition expert groups, is that babies are ready for weaning between four and six months of age.

The Department of Health and Social Care and the NHS publish advice and guidance on when to wean and the foods that are appropriate at different stages of weaning.

Parents are encouraged to seek advice from a healthcare professional when they are thinking about weaning their child onto solid foods. It is important to remember that each baby will transition through weaning stages at different times and will have varying needs.

All foods have different nutrients so ensuring a baby eats a wide variety of food is important to give them a balanced diet for their healthy growth and development and to establish healthy eating practices from an early age.

Breast milk or infant formula will continue to be important and should be offered alongside foods whilst weaning.

Every baby is an individual and grows and develops at its own rate.

The World Health Organisation recommends exclusive breastfeeding until 6 months of age, and then the introduction of complementary foods. This recommendation has been supported by the UK Department of Health and Social Care (DHSC), who support exclusive breast feeding for the first 6 months of life with the introduction of complementary foods alongside continued breastfeeding at around 6 months of age.

However, reviews of the scientific evidence by the European Food Safety Authority (EFSA) and the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) suggest that it may be more appropriate that babies are weaned according to individual needs (but not before 17 weeks of age and weaning should have commenced by 6 months of age).

We recommend that any queries on weaning a baby should be directed to a healthcare professional.

Cow’s milk should not be used as a main drink for a baby under 12 months of age.[14]

However, cow’s milk can be used as a food ingredient from six months of age, for example when making up cereals, cheese sauces or in recipes.

Cow’s milk can be used as the main drink once an infant has reached 12 months old. It is recommended that young children 1-2 years old should be given whole (full fat) milk, not skimmed or semi-skimmed milk. Full-fat dairy products are advised for children under 2 as they need the extra energy and vitamins.[15]

As toddlers' diets become more varied, nutrients and energy are provided by lots of different foods, so they need less milk. However, milk continues to provide valuable protein, energy, vitamins and minerals, some of which are hard to get from other foods.

Milk-based drinks for young children, also called ‘toddler milk’ or ‘growing up milk’, which are suitable for young children over 12 months of age, can also be a useful addition to the diet of a young child. Milk-based drinks for young children are fortified milk products which provide key nutrients that may be limited in the diets of young children of this age, including iron and vitamin D. Milk-based drinks for young children provide these nutrients in smaller volumes of milk compared to other formulae, reflecting the fact that young children aged 1-3 years have a reduced reliance on milk drinks as the range of other foods they eat increases.

The Government provides a range of support programmes and advice for parents and healthcare professionals looking to provide the best nutritional start for babies and toddlers.

Healthcare professionals play a critical role in implementing infant feeding policy and providing hands-on support for parents and carers.

The infant nutrition industry uses scientific research to educate the general public and HCP’s. This information is always scientific and factual.

Government support programmes

There is a vast amount of knowledge and expertise in both the public and private sectors that helps to continually advance knowledge in infant nutrition. Research takes place independently in both sectors, as well as in collaboration.

Some of the sites which carry out infant nutrition research within the UK include:

• Imperial College - The Neonatal Data Analysis Unit (NDAU)
• King’s College - Department of Paediatric Allergy
• The University of Cambridge - MRC Epidemiology Unit
• The University of Nottingham - Maternal Health and Wellbeing Research Group and The Early Life Nutrition Group
• The University of Leeds - The Human Appetite Research Unit (HARU) infant laboratory
• University College London’s Childhood Nutrition Research Centre, which is part of the Institute of Child Health
• The University of Lancashire’s Maternal and Infant Nutrition and Nurture Unity (MAINN)
• The University of York’s Mother and Infant Research Unit
• Leeds Beckett University – Born in Bradford Cohort
• University of Southampton – Early Life Nutrition Group
• University of Oxford – The National Perinatal Epidemiology Unit (NPEU)

The infant nutrition industry plays a major role in advancing research and development into optimal nutrition for infants to: improve our understanding of their needs; improve product formulation; and provide parents with greater choice. This action continually improves standards across the infant feeding sector. Company-led research has also provided further evidence to support the importance of breastmilk and breastfeeding.

Globally, the infant nutrition industry invests an estimated 3-4% of its annual turnover into research and development.

All research complies with high standards of scientific integrity and is conducted in an open and transparent manner. Full clinical research papers are published in scientific peer reviewed journals.

Manufacturers of infant milks and foods are highly regulated, ensuring the highest standards in safety and quality – above those required for other types of food. The composition of, and process for producing infant milks and food are based on scientific research and strict regulation governed by the EU and UK authorities.

In the UK, manufacturers of infant formula and follow-on formula comply with all UK regulations and legislation, which incorporate principles of the World Health Organization (WHO) International Code of Marketing of Breast Milk Substitutes. For more information on regulation visit our infant nutrition regulation page here.

The UK Government and its regulating agencies are responsible for the implementation of the EU legislation into UK law. This is done by assessing whether domestic law is consistent with EU law, and legislating through Statutory Instruments in Parliament.

Relevant departments will also issue guidance on how regulations should be implemented. These include:

• The Department of Health and Social Care (DHSC). It is responsible for setting policy on infant nutrition and will implement all regulations, including those relating to infant formula, follow-on formula and other foods for infants and young children. The Scientific Advisory Committee on Nutrition (SACN) is an advisory committee of independent experts that provides advice to the Department of Health, as well as other government agencies and departments.
• The Food Standards Agency (FSA). Its role is to protect public health in relation to food throughout the UK with a focus on food safety. It also works closely with the European Food Safety Authority (EFSA), which provides scientific advice to the European Commission on all areas of food policy.
• The Department for Environment, Food and Rural Affairs (Defra). It is the primary authority for food policy in the UK. Defra works closely with the DHSC, FSA and others to deliver policy and legislation of food, and its enforcement.

As with all food, Trading Standards Officers enforce national regulation at a local level. The Advertising Standards Authority (ASA) regulates advertising across all media.