May 2024

Blossoms
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Welcome to the May edition of our newsletter, featuring:
News Infant milk news BFLG-UK news Forthcoming Happy reading!

News

Updated: UK public health recommendations on infant and young child feeding
In July 2023 the Scientific Advisory Committee on Nutrition (SACN) published new guidelines on feeding young children aged 1-5 years. These guidelines made a series of recommendations and two weeks ago we were informed that the UK Government has accepted these recommendations and made changes to certain NHS webpages accordingly.

SACN reiterate that “current UK dietary recommendations as depicted in the Eatwell Guide should apply from around age 2 years with…exceptions” which are explicit in the web pages which have been updated, along with additional recommendations relevant to 1-5s.

The NHS web pages that have changed are:
The SACN 2023 recommendations that we can see made explicit in these webpages are:

Drinks:
  • Milk or water, in addition to breast milk, should constitute the majority of drinks given to children aged 1 to 5 years.
nb The NHS now states:
  • The World Health Organization recommends that all babies are breastfed for up to 2 years or longer.
  • Breastfeeding up to 12 months is associated with a lower risk of tooth decay.
  • Children aged 1 to 5 years should not be given sugar-sweetened beverages.
  • Formula milks (including infant formula, follow-on formula, ‘growing-up’ or other ‘toddler’ milks) are not required by children aged 1 to 5 years. 
nb The following additional details on the NHS webpages are important to inform advice/practice:
  • Squashes, flavoured milk, "fruit" or "juice" drinks and fizzy drinks are not suitable for young babies. They contain sugar and can cause tooth decay, even when diluted.
  • Fizzy drinks are acidic and can damage tooth enamel so they should not be given to babies and young children.
  • Diet or reduced-sugar drinks are not recommended for babies and young children. Even low-calorie drinks and no-added-sugar drinks can encourage children to develop a sweet tooth.
  • Pasteurised whole and semi-skimmed cows’ milk can be given as a main drink from age 1 year as can goats’ and sheep’s milks.
  • Pasteurised skimmed and 1% cows’ milk should not be given as a main drink until 5 years of age. These lower fat milks can be used in cooking.
  • Children aged 1 to 5 years should not be given rice drinks as they may contain too much arsenic.
Foods:
  • Children aged 1 to 5 years should be presented with unfamiliar foods/vegetables on multiple occasions (as many as 8 to 10 times or more for each food/vegetable) to help develop and support their regular consumption (nb SACN focus their recommendation on vegetables, whereas the NHS webpages talk about foods more generally).
  • Dairy products (such as yoghurts and fromage frais) given to children aged 1 to 5 years should ideally be unsweetened.
  • Deliberate exclusion of peanut or hen’s egg (and foods containing these) beyond 12 months of age may increase the risk of allergy to the same foods. Importantly, once introduced, these foods should continue to be consumed as part of the child’s usual diet in order to minimise the risk of allergy to peanut or hen’s egg developing after initial exposure.
  • Children aged 1 to 5 years should continue to be offered a wide range of foods that are good sources of iron.
  • Salt should not be added to foods given to children aged 1 to 5 years.
Vitamin supplements:
  • Children aged 1 to 5 years should be given a daily supplement of 10μg (400 IU) vitamin D and 233μg vitamin A unless, contrary to recommendations, they are consuming more than 500ml of formula milk per day. (nb. SACN go on to state: “Vitamin C supplements are not necessary for the general population. However, there is no evidence that taking vitamin C supplements at the current recommended level of supplementation has any adverse effects”. This in part explains why NHS recommendations to give vitamins D, A and C are unchanged). 
This recommendation of SACN is addressed implicitly:
  • Between 1 to 2 years of age, children’s diets should continue to be gradually diversified in relation to foods, dietary flavours and textures. A flexible approach is recommended to the timing and extent of dietary diversification, taking into account the variability between young children in developmental attainment and the need to satisfy their individual nutritional requirements.
These recommendations of SACN have not been addressed explicitly, but it is important that they inform health worker advice/practice:
  • Specialised formula, including low-allergy formula, are also usually not required after the first year of life.
  • Foods (including snacks) that are energy dense and high in saturated fat, salt or free sugars should be limited in children aged 1 to 5 years in line with current UK dietary recommendations.
  • Commercially manufactured foods and drinks marketed specifically for infants and young children are not needed to meet nutritional requirements.
On the latter, it is worth noting this statement by SACN (2023) (page 37): “Home-prepared foods are generally recommended to help introduce infants and young children to a range of appropriate flavours and textures”. And also this recommendation by NICE in the Maternal and Child Nutrition Guidelines (2014): “Encourage and support parents and carers to make home prepared foods for infants and young children, without adding salt, sugar or honey”.

Our opinion at First Steps Nutrition Trust is that more explicit messaging both encouraging the use of home-prepared foods and discouraging the routine use of commercial baby and toddler foods would be helpful to parents/carers. This is because research tell us parents/carers implicitly trust the widespread misleading marketing messages on such products, which do generally do not align with public health recommendations for feeding these age groups (as outlined by PHE in their 2019 evidence review).

Lastly, SACN also make these recommendations which are important health workers know, but not relevant for the NHS webpages:
  • UK dietary recommendations on average intake of free sugars (that free sugars intake should not exceed 5% of total dietary energy intake) should apply from age 1 year.
  • Children aged 1 to 3 years should, on average, aim to have no more than 2g of salt per day; the figure for children aged 4 to 6 years is 3g per day.
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Updated: First Steps’ Eating Well Packed Lunches for 1-under 5 year olds

We have updated our packed lunches Eating well guide to reflect the updated guidance on Feeding young children aged 1-5, published by the Scientific Advisory Committee (SACN) on Nutrition last July. The guide provides practical guidance for anyone who is preparing packed lunches for children aged 1-4 years and may be particularly useful to early years settings who want to provide guidance to families and child carers about how to provide a nutritious, cost-effective and practical packed lunch for children of this age. Packed lunches that cater for vegan, vegetarian, gluten-free, egg-free and dairy-free diets are included.
All recipes also meet the energy and nutrient requirements for a main meal for children aged 1 to 4 years and the guide includes photos of portion sizes appropriate for different age groups. Evidence linking greater portion sizes of meals and snacks offered in preschool settings to higher short-term food and energy intakes (SACN, 2023) highlights the importance of preparing appropriate
portion sizes for children.

All of our resources are free to download from here and some are available to purchase as hard copies via this link.
 
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New paper: “Either something is wrong or I am a terrible parent”
This qualitative systematic review by Amy Dobson et al, aimed to explore parents' experiences of unsettled babies (defined as perception of excessive crying with additional feature such as vomiting, skin or stool problems) and medical labels.
 
Background: Normal unsettled baby behaviours are increasingly attributed to medical causes such as cows' milk allergy and gastrointestinal disorders such as reflux. The formula industry contributes to this issue, through funding and influencing healthcare professional training and clinical guidelines, as well as marketing to parents in ways which heighten health concerns around common baby behaviours such as crying and vomiting. This undermines breastfeeding and leads to unnecessary or ineffective medication use, with associated risk of side effects.
  • NHS spending for specialist milk formula increased by 700% from £8.1 million to £60 million between 2006 and 2016, without evidence of any increase in allergy prevalence.
  • Prescribing rates of medications for reflux increased between 2010 and 2016, introducing risks of side effects and a range of potential negative impacts on dietary and nutritional outcomes for the parent and baby in the short and long term.
 
Results: The review included 10 studies globally (2 of which were conducted in the UK), and found that parents expressed fearing judgement, feeling guilty and out of control as a result of babies' unsettled symptoms, and sought strategies to construct an ‘Identity as a “Good Parent”’. The ensuing cycle of ‘searching for an explanation’ (including external, medical causes) leads to considerable distress which is exacerbated by feelings of guilt and failure.
 
Parents' accounts almost universally linked unsettled baby behaviours to feeding and parents often were quick to blame breastmilk. Negative emotions emerged around infant feeding and repeated changes were made to parent/baby diet.
 
Parent quote: ‘We started our cycle of chiropractors, reflexologists, homeopaths, medication for reflux; we changed his formula a hundred times; we have a hundred bottles, a hundred teats; it was this desperate clinging to something’ (Cox & Roos, 2008)
 
Implications for practice: The authors suggest that the insight gained from this review could inform interventions to support parents, reducing inaccurate medicalisation. It is recommended that health visitors, nurses and midwives should be aware that parents seeking help for unsettled baby behaviours frequently feel dismissed or ignored. Care should therefore be taken to validate the parent's experience and listen to their concerns, maintaining an awareness of key medical red flags. Health visiting teams supporting parents with unsettled baby behaviour could focus on supporting a positive parenting identity by managing expectations, normalising the continuum of infant behaviours, reducing feelings of guilt or uncertainty, and helping parents regain a feeling of control.
 
Read the full paper here.
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New manifesto: Our Children, Our Future parents’ manifesto
The Children’s Food Campaign, hosted by Sustain, commissioned a national polling of parents with children under 18 to find out their opinions on the biggest challenges faced by parents in the current food system and their top priorities for change. Over 2,000 parents were surveyed in January of this year. Their views and perspectives were used to develop a parent’s manifesto, which also incorporates the opinions of 13 children’s food parent ambassadors.
 
National polling revealed that parents are concerned about the cost of food, their children’s dietary habits (7 out of 10 expressed worry about what their children are eating) and promoting healthy eating habits among their children (8 out of 10 parents perceive that it is getting harder to promote healthy eating). Parents are also becoming increasingly concerned about the quantity of ultra-processed foods available to children.
 
Parents were asked to indicate their support for possible future government policies that could help to improve children’s food. Of note for infants and young children was parental support for policies including state-funded nurseries to provide food that is nutritious and healthy (supported by 86% of parents surveyed), the expansion of funding for voucher schemes for low-income families (supported by 80% of parents) and standards to ensure that ingredients and marketing of baby foods support good nutrition (supported by 78% of parents). These results provide valuable evidence for ongoing advocacy for government action to improve the Healthy Start scheme (as outlined in the Healthy Start Working Group policy position) and to improve the commercial baby food offer (see our recent written response to the latter here).
 
The Future parents’ manifesto outlines five key pillars for government action, including;
  • to make free, healthy and sustainable school food a priority for all children, including those in nursery
  • to ensure honest and trustworthy information on food and drink packaging, including removing misleading health claims on children’s food
  • to make nutritious food affordable and accessible for all families, including reforming the existing Healthy Start scheme
First Steps Nutrition Trust support this call to action, and we will continue working alongside peer organisations to advocate with Government to take actions to support safe and appropriate infant and young children feeding to ensure that all children can achieve optimal growth, development and health.
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Updated training modules: NHS Health Education England’s e-learning for healthcare: Healthy Child Programme. Growth and Nutrition modules
Did you know that elearning for healthcare (elfh) is an online platform that offers more than 400 e-learning programmes for healthcare professionals? These programmes are developed in collaboration with organisations like the Royal Colleges, Department of Health and Social Care and others. One collection of 13 modules available is the Healthy Child Programme (HCP). These modules focus on the health and well-being of children in the early stages of life from pregnancy through to the first five years of life. Module 8 of the HCP is all about Growth and Nutrition.
 
We at First Steps Nutrition Trust have been updating some sessions in this module. The updated sessions are:
   
The HCP resource is designed to support the range of healthcare professionals involved in caring for pregnant women, infants and young children, including health visitors, nurses, midwives, general practitioners, paediatricians and obstetricians, dietitians, and speech and language therapists. Health and care professionals need to register to access the e-learning portal and access is free.
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New: Access to Nutrition Initiative reports on the global commercial baby food and breastmilk substitute industries
 
On 26 March 2024, the Access to Nutrition Initiative (ATNI) launched their most recent global Breast-milk Substitutes (BMS) and Complementary Foods (CF) Marketing Indexes 2024. A recording of the 2-hour launch event is available here. Companies are assessed on two main components which evaluate the extent to which company policies and practices align with the various provisions of the Code and subsequent World Health Assembly (WHA) resolutions:
 
  • The Country Studies measure companies’ marketing practices in selected countries and for this Index, five countries were selected representing companies’ primary baby food markets (China, Germany, Indonesia, Vietnam and the USA).
  • While the UK was not included as one of the countries for this index, the Corporate Profile assessment examines global corporate policies and procedures and level of disclosure and Nestle, Danone, and HiPP which market their products in the UK, are all included in this assessment.
 
The BMS Marketing Index assessed company policies and practices on the marketing of breast-milk substitutes, for use from 0 months up to the age of three years. The 18 companies assessed on ATNI’s BMS Marketing Index 2024 represent approximately 76% of the global BMS market. There is a 63-page full report and 5-page executive summary. No companies achieved full compliance with the Code. Like findings observed in the UK, nearly all product labels assessed (98%) were found to contain one or more incidences of non-compliance with the Code, (e.g. including claims and the absence of a statement on the importance of exclusive breastfeeding in the first six months of life and continued breastfeeding for up to two years or beyond).
 
The CF Marketing Index assessed the marketing of commercial complementary foods (including baby porridge and cereals, snack foods, baby teas and juices for infants and young children aged 6-36 months). The 10 companies (including Danone, Hipp and Nestle) assessed represent approximately 49% of the global CF market. There is a 53-page full report and 5-page executive summary. None of the 10 companies assessed fully align with the Code and guidance on appropriate promotion of foods for infants and young children in policies and practice. A concerning finding was that not one company committed to stop selling complementary foods marketed under 6 months of age
 
While the results produced by ATNI are useful and highlight low compliance by companies, there have been some criticisms (including in peer-reviewed literature and by civil society organisations such as IBFAN) of the assessment methodology used. ATNI tends to rely on information that is provided by companies themselves and not always available in the public domain. ATNI also evaluates corporate efforts to influence public policy in a limited way, through self-disclosure by companies. Companies have also used the ATNI results for their own marketing purposes despite continued non-compliance with global guidance and national legislation. We would therefore advise caution when using this data.
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Infant milk news

Updated: infant milk costs report and trends analysis

Costs of infant formula, follow-on formula and milks marketed as foods for special medical purposes available over the counter in the UK
Our latest review of the cost of infant milks reveals the following:

Within brand, big packs (2 x 600g) remain one of the least expensive options for buying infant formula. Cow & Gate and Aptamil are both available as big packs and Nestlé have recently introduced a big pack format to their SMA Pro infant formula brand. The 1200g packs (2 x 600g) of SMA Pro offer better value for money (18p/100ml) than the equivalent 800g packs (21p/100ml).

For parents who are willing to switch brands, there are greater potential savings available. The least expensive standard sized pack of powdered infant formula (PIF) is Aldi Mamia (900g) at £8.49 a can (12p/100ml). The next least expensive PIF is Cow & Gate in a big pack format which costs £12 for 2 x 600g packs (13p/100ml), however buying big pack formats requires families to pay a greater up-front cost, and these packs are not available in all retail contexts.
For parents who are willing to shop around, there are some significant differences in cost between the same brand of infant formula or follow-on formula when bought from different high street retailers. Table 7 in our cost report shows that across the retailers we have looked at:
  • Cow & Gate infant milk powder in a big pack format (2 x 600g) which is one of the least expensive ways to buy infant formula varies in price between £12.00 (13p/100ml) at Asda, Boots, Tesco and Sainsbury’s and £12.50 (14p/100ml) at Morrisons.
The price of SMA Little Steps varies between retailers and if bought at Morrisons costs £7.90 per 800g can (13p/100ml) or £7.95 (13p/100ml) at Asda, Tesco Sainsburys or online at Iceland which makes it comparable to Cow & Gate big packs. Buying SMA Little Steps at Boots where it costs £9.75 (16p/100ml) is more expensive.

Cost of powdered infant formulas in the UK: How have they changed since January 2021?
Our latest infant formula cost trend analysis reveals that since November 2023 (when the CMA published its first report including analysis of infant formula using First Steps data):
  • The majority of infant formula prices have remained static.
  • Small reductions in the unit prices of Aptamil, Aptamil Advanced and Aldi Mamia have resulted in a decrease of 1.8% in the average price of powdered infant formula (compared to an average price rise of 22% over the period March 2021 to April 2023, from an already high base).
  • With the recent fall in price, Aldi Mamia has become again affordable with the Healthy Start allowance of £8.50/week (and based on the cost per 100ml of made-up formula, it costs £33.00/month to feed a 10 week old baby Mamia infant formula compared to the monthly value of the Healthy Start allowance of £34.00/month). No other branded products cost <£8.50/unit.
  • Price differentials between different brand’s ‘standard’ and ‘premium’ products are decreasing; there is now no difference in price between Aptamil (800g) and SMA Pro (800g) and a difference of 2.8% between Aptamil Advanced (800g) SMA Advanced (800g).
Graph 1. Unit cost of all brands cows’ milk based powdered infant formula.
As brand loyalty is a common factor influencing choice of infant formula, the latest price reductions on Aptamil are good news for brand loyal Aptamil customers, although it is important to note that Aptamil remains one of the more expensive infant formula brands and despite the recent very small price reductions, parents willing to swap brands could make further savings.

The DHSC has recently updated its wording on its NHS Better Health Start for Life website to state:

“All infant formulas will meet your baby's nutritional needs, regardless of brand or price.”

and 

“By law, all infant formula sold in the UK must meet the same standards, which means they are all suitable for your baby's growth and development.”

To summarise, some infant formula prices are coming down a little, but overall it remains an expensive and yet essential food item for many. Government action is needed to bring prices down more meaningfully across the board and in the long term, and to ensure accessibility for those families on low incomes that need it, while protecting and supporting breastfeeding. As reported in the First Steps April newsletter, we submitted this evidence and recommendations  into the Competition and Market Authorities latest investigation, which will report in September.

For those of you advising parents/carers on economical formula and food choices for their babies and young children, our infographics may be of use:
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New formula preparation product which claims to reduce colic
Tommee Tippee have introduced a new formula preparation device to their infant feeding range which claims to reduce colic in babies fed formula milk. The claims made for the Colicsoothe include:
  • This vacuum technology removes air from baby’s milk. For even less gas, even less stress and even more sleep.
  • Parents saw a 40% reduction in average crying time after 2 days of use*.
  • After using Colicsoothe, parents notice that their baby cries less, is more comfortable and less gassy*.
  • And 9/10 parents said it helped their baby feel better*.
  • Proven relief for reassurance when feeding, and a calm, comfortable baby.
Claims marked with an asterisk are based on a small in-home consumer test including 26 UK and 24 US parents who had self-identified their baby as having colic. Parents were asked to confirm the average time that their baby cried prior to using the product, and every day for 6 days whilst using the product. Parents reported that the average time that baby cried reduced from 91 minutes to 55 minutes over two days from using Colicsoothe. The degree of manufacturer involvement with the study is not clear from the information provided.

Using the device appears to be quite awkward as the feeding bottle containing the made-up formula must be placed without a lid and teat into a column shaped flask. The rechargeable lid of the flask creates the vacuum that removes air from the formula milk. The user must then manoeuvre the open bottle out of the flask before screwing the lid and teat back on.
Image credit: newbornbaby.com.au
Aside from the lack of scientific evidence to support the claims made, the Colicsoothe introduces a further handling stage and another container to the preparation process which increases the risk of bacterial contamination. This could be mitigated by ensuring that the flask and its lid are clean and dry before use, however, the flask cannot be cleaned in a dishwasher or sterilised and the lid of the flask is wipe clean only.

Swallowing air is only one of a few factors thought to contribute to colic and so the Colicsoothe only has the potential to be effective for babies who are unsettled due to swallowing air with feeds, and comments from parents on the manufacturer’s website seem to reflect this. Shaking formula powder to mix or using a prep machine are obvious ways for air to get into a feed, however leaving bottles to cool from reconstitution temperature to feeding temperature should allow much of the air to be released. The extent to which the Colicsoothe can increase air removal is not clear and excess air is not always the cause of colic. The NHS recommend positioning your baby in an upright position during feeding and winding after feeds as methods of soothing a baby who has colic which may be related to swallowing air with feeds.

The impact that an unsettled, frequently crying baby can have on parents is well understood (see above our reporting on Dobson et al’s paper “Either something is wrong or I am a terrible parent”) and so this product is likely to have broad appeal, however, it is important that any parents considering buying this relatively expensive (£39.99) and, in our opinion, unproven product are aware of its limitations and the increased risk of contamination.
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 

WHA 77 Side event on Maternal, infant, and young child nutrition: Digital marketing of breastmilk substitutes
The 77th World Health Assembly (WHA) will be  held in Geneva, Switzerland, from 27 May – 1 June 2024 with the theme All for Health, Health for All. 2024 is a reporting year for Maternal, infant, and young child nutrition (MIYCN) and so this is on the Agenda, item 15.2. A Side Event taking place on Tuesday 28 May 2024, on MIYCN with a special focus on the digital marketing, is being co-organised by the International Baby Food Action Network (IBFAN), the International Lactation Consultants Association (ILCA), Save the Children and UNICEF. This event aims to share experiences and discuss solutions for Member States to meet the challenge of digital marketing of BMS. The event will also contribute to the increasing momentum for stronger regulation both at the international and at the national level to the benefit of public health interests.
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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Forthcoming 

Consultation on updated NICE Maternal and Child Nutrition Guideline, Friday 7 June 2024
NICE will be sharing its draft, updated Maternal and Child Nutrition guideline and supporting evidence for consultation on 07/06/24. It will run for 6 weeks, closing on 19/07/24. You have to be a registered stakeholder to take part, and you can register here. To enable stakeholders to prepare for consultation you can access the economic plan and review questions for this NICE guideline on the project documents web page.
 
Our Director Vicky is on the committee for this guideline, and we’re excited that it will finally be published in November after more than two years of intense work. The guideline was last updated in 2014 (see the current PH11 guidelines here), so this update is significant. We encourage you to engage with the consultation to ensure that the guideline is a strong and informed as possible.
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iHV annual Evidence-based Practice Conference - in person in Manchester or virtual, Wednesday 3 July 2024
This year’s Evidence-based Practice Conference will focus on addressing health inequalities, addressing the questions: How can we ensure a healthier future, where all babies and children can thrive? How can we use the best available evidence and research to reduce health inequalities and strengthen health visiting practice?

Our Director, Vicky, will be presenting and attending in person, so please do come and say hello. Read more and make bookings here.
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Unicef UK annual Baby Friendly Initiative Conference – virtual, Wednesday 20 - Thursday 21 November 2024
Unicef UK have announced that the annual Baby Friendly Initiative (BFI) Conference will take place on 20-21 November 2024 and that the conference will be virtual this year. The discounted price of £65 per person is available for individual places booked before 5pm on 31 July 2024 or groups of 10 or more. The standard price is £75 per person. Booking and registration can take place here. We will share further details on the programme when this becomes available.