Welcome to the July edition of our newsletter. Please see the contents below. But first, we wanted to explain what we’re doing with our resources, as you may have seen changes to our webpages.
Accessing First Steps resources
We are gradually changing the way users can access our resources, to gather info on how they are being used. When you download a PDF, you will be asked for some information about yourself, which will be anonymised and used solely to demonstrate our reach and relevance to our current and future donors. For our Eating Well resources, you will also be asked to consider contributing towards the costs of maintaining these resources, including keeping them up to date and in line with the latest UK public health recommendations*, and relevant to the changing context. Don’t panic - there is still the option to download for free!
Some resources are available for sale as hard copies. We don't make a profit from sales but we have had to slightly increase our prices to better account for the full costs of production, i.e. not just printing, postage, and packaging. These costs include technical staff time to update, designer costs to make amends, and administrator time to manage orders and mailouts. Current prices still don't fully cover these costs, so we will need to increase sales if we are to be able to continue offering hard copies.
If you have any suggestions or questions please don’t hesitate to get in touch with Vicky vicky@firststepsnutrition.org.
*We are in the process of updating our resources to take into account changes to NHS webpages made in April this year (see our May newsletter).
It’s election day! Sadly, we saw very little mention of babies or early years nutrition in any of the party manifestos. We’re poised for the election result and will be working hard thereafter to influence incoming politicians to take on board our policy asks as outlined in this position statement: Healthy Early Years Diets: Achieving the Best Start in Life, which we led on writing with the support of peers and the Obesity Health Alliance.
New survey: The Cost of Living and Maternity Leave
Maternity Action have published their third annual survey tracking the impact of the cost of living crisis on pregnant women and new mothers. The survey was promoted through social media outlets and includes information from 1,039 women.
Maternity leave has a significant financial impact on many women in the UK, who have some of the lowest rates of maternity pay among European countries. Most women are reliant on statutory maternity pay (£184.03 per week compared to £677 average weekly earnings), and others just Maternity Allowance. This is causing significant stress and worry not only during maternity leave, but throughout pregnancy and upon returning to work.
The survey also highlighted that women struggled to feed themselves and their children whilst pregnant or on maternity leave:
Half bought less healthy food and a quarter went without food themselves to prioritise feeding their children (38% of mothers were having smaller meals or skipping meals altogether).
13% struggled to afford to buy formula milk and 27% cut down on buying food for themselves or their family because of the high cost of formula.
Furthermore, 59% returned to work earlier than they wanted to because of money worries (this is the highest proportion since the survey began in 2022, at which point 42% returned to work earlier than they wanted to because of money worries). This has implications for women being able to achieve their breastfeeding goals.
Maternity Action outline a series of recommendations for Government to tackle ‘pregnancy poverty’ and ensure pregnant women and new mothers can access their rights and entitlements. We support these recommendations, whilst noting that new models of maternity, paternity and parental leave should protect the maternity leave necessary to support the breastfeeding rights of women and their infants, who have unique needs and vulnerabilities.
New paper: What factors drive parents’ choice of baby food products?
This paper by Hollinrake et al, provides important new insights into what motivates UK mothers to use commercial baby foods, and for those that avoid them, why. The study was undertaken in the summer of 2021 and used an online survey among self-selected parents of babies under 1, yielding a sample of 271 questionnaires from predominantly highly educated, White/White British mothers. 173 used commercial baby foods while 98 did not.
Building on previous limited research, they find that the top reason for choosing commercial baby foods is convenience (95% agreed/strongly agreed), followed by time saving (88%), baby liking them (77%), being safe (75%), then being perceived as a good way to introduce new tastes and textures (51%). Worryingly, 40% were motivated by a healthcare professional recommendation. Answers also indicated some influence of marketing, through money off coupons, promotion on social media and in baby magazines.
45% of mothers said they gave their baby commercial baby foods daily, and vegetable puffs/sticks were the top-ranking type offered (25% gave every single day).
Among the rich findings, the top motivations for using purées were versatility, enjoyment and convenience. Mothers liked the fact that their babies could suck straight from the pouch (against manufacturer and public health advice), and that they enjoyed them and didn’t refuse or waste them (not surprisingly – as pointed out by the authors - given their high levels of sugar). For baby snacks, convenience and no mess were motivations, as were their utility for distracting babies and keeping them happy, and self-feeding (the authors unpack the downsides of avoiding mess and using food for comfort). These products were considered safe (from choking) and healthy (because of low salt and sugar levels). Inquiry into brand perceptions revealed a high level of trust among mothers, who also buy in to marketing messages around ‘natural’ and nutritious ingredients, of high quality.
The 98 mothers who did not use commercial baby foods reported not needing them, not trusting them, finding them expensive, and preferring home-made foods which they perceived were healthier.
The authors recommend stronger legislation on commercial baby food composition and marketing to enable parents to make informed choices. They also highlight how those supporting parents with complementary feeding need to be aware of the study’s findings.
We agree with these recommendations and would like to highlight this statement in the Scientific Advisory Committee on Nutrition’s 2023 guideline on feeding young children aged 1-5 years: ‘Home-prepared foods are generally recommended to help introduce infants and young children to a range of appropriate flavours and textures’.
An additional observation we would like to make is that despite this view from SACN, the NHS guidance does not currently explicitly advise parents to choose home-prepared foods over commercial baby foods or advise caution in relation to baby food marketing. Until this guidance is clarified, and especially while marketing remains unchecked, our view is that misconceptions will persist among parents.
Updated: Recommendations on giving water in infancy
We’ve already had one heatwave warning this year, and there may be more, so we have updated our guidance on giving water in infancy available here and the accompanying infographic as shown. Please note that, as with all our resources, this advice is aligned with NHS guidance.
New report: Commercial determinants of non-communicable diseases in the WHO European Region
WHO Europe have published a report documenting the significant harm caused by the tobacco, ultra-processed food, fossil fuel and alcohol industries. The report outlines the tactics used by these commercial sectors, who have a disproportionate influence on health policy across the 53 member states of the European Region, driving inequalities, ill health and premature mortality. Globally, these industries contribute to 19 million deaths per year (34% of all deaths), of which 2.7 million deaths per year (7000 per day) occur in Europe.
The report documents the common goals of these commercial sectors, to generate profit, maximize product sales and drive consumption. This has enabled industries to consolidate into a small number of powerful transnational corporations with significant influence over the political and legal contexts in which they function. Case studies are presented which reveal common industry tactics, used to undermine public health and maximize profits. These include:
Obstructing public health regulations through political lobbying, harmful financial practices and shaping scientific evidence
Exploiting vulnerable groups (including children) through targeted marketing strategies, misleading consumers and making false claims about the health and nutritional benefits of their products
Shifting public discourse through spreading misinformation and disinformation in the media
These tactics are extensively documented in the Lancet Breastfeeding Series 2023, which gives an overview of the influence of the commercial milk formula industry on governments, science, and health-care systems. Further evidence of profiteering by formula brands, who protected or increased their substantial profit margins during the cost of living crisis, was provided by a report by the Competition and Markets Authority. Similar tactics are used by the commercial baby food industry to undermine public health recommendations on feeding young children from 6 months of age as outlined in our report on ultra-processed foods in the diets of infants and young children in the UK.
The report notes that, to date, efforts by Governments and intergovernmental organisations to prevent or limit commercial actions that are harmful to public health have been inadequate. They call on the 53 member states of the European Region to recognize the impact that the tobacco, ultra-processed food, fossil fuel and alcohol industries have on public health, and to take action to identify conflicts of interest to protect public policy and political economic systems from industry interference.
This echoes our call to UK Government that health policy must be protected from commercial influence through the development of fair and ethical principles for interacting with the food industry underpinned by the latest evidence on the commercial determinants of health; see more in our joint position statement with the Obesity Health Alliance: Healthy Early Years Diets: Achieving the Best Start in Life.
New: ESPGHAN position on anti-reflux and comfort milks
The ESPGHAN Nutrition Committee has published a new position statement on infant formulas for the treatment of functional gastrointestinal disorders (FGIDs) including regurgitation, colic and constipation. This is therefore relevant to infant milks marketed in the UK as ‘anti-reflux’ and ‘comfort’ milks. Their review, which included 72 papers, was conducted with the aim of providing evidence-based guidelines for clinical practice.
The committee identified 2 issues with current specialised infant milks formulated to address these common feeding issues:
the evidence supporting their effectiveness is limited
some have altered nutritional compositions when compared to standard formulas and so these products should only be used under medical supervision and upon medical advice - marketing and over‐the‐counter sales do not ensure proper medical guidance and supervision.
This corroborates some of the key points that we raised in our 2022 report ‘Infant milks marketed as foods for special medical purposes (FSMP): The case for regulatory reform to protect infant health’(summarised in our infographic, as shown)
In their review, the committee examined the safety and efficacy of different compositional modifications to infant formula marketed for the management of FGIDs. The key messages from their review included that in general, for breastfed babies with FGIDs, breastfeeding should not be stopped in favour of formula milk. Regardless of feeding method, non‐nutritional interventions should be used as the first line management of FGIDs, and parents should be reassured that FGIDs are normal, and most infants do not require treatment or a change of formula type. Where infants are experiencing one or a combination of mild FGIDs, breastfeeding should not be stopped - the use of specialised formula milks for combined FGIDs is generally not advised.
Review findings linked to functional constipation
The committee reported that formula milks with high β-palmitate and magnesium levels at the higher end of the regulatory threshold may be considered to soften stool, however there was insufficient evidence to support their routine use in the treatment of constipation. This recommendation is new as previous ESPGHAN and NASPGHAN evidence-based recommendations on infant constipation did not consider formulas with high β-palmitate and an elevated magnesium content in their evaluation. The EFSA review on infant formula composition (EFSA, 2014) included infant milks with increased levels of β-palmitate but reported no benefits for their use in infants. The NHS currently suggest that constipation in formula fed infants can be treated with additional drinks of water and there is no advice to change formula.
Review findings relating to colic
There is no evidence for the efficacy of specialised infant milks for colic. This supports NICE clinical guidance that does not include any recommendations related to formula milk but includes a range of strategies including soothing techniques babies and offering reassurance and information on sources of support for parents (NICE CKS, 2022). The NHS also suggest practical and soothing strategies for colic as well as signposting to sources of support for parents.
Review findings relating to simple regurgitation
The evidence review concluded that some ‘anti‐reflux’/ ‘anti-reflux’ thickened formulas reduce the number of visible regurgitations but there is no evidence that protein hydrolyzation or fermentation offers a further benefit to thickening. The subsequent recommendation is that in breastfed infants with regurgitation, breast milk can be expressed and supplemented with thickening agents and in formula fed infants, ‘anti-reflux’ formulas, or formulas with appropriately added thickeners can be considered in special cases under medical guidance. To avoid overfeeding it is generally preferred to use low‐energy thickeners such as locust bean or guar gum. This position differs from a previous 2002 ESPGHAN commentary on anti-regurgitation milk products for children in that it suggests that some thickened anti reflux milks may reduce visible regurgitation in some infants and may be considered in some cases for use under medical supervision. The 2002 commentary recognised that there is some evidence that anti-reflux milks can reduce regurgitation in some infants but their use in infants with simple reflux was not supported on the grounds that there is no conclusive information available on the potential effects of thickening agents on the bioavailability of nutrients and growth of children, or on mucosal, metabolic and endocrine responses.
This current ESPGHAN position supports NICE guidance and quality standards in the UK (NICE, 2015, NICE 2016), which states that regurgitation is a common and normal occurrence in infants and does not usually need any investigation or treatment, however a trial of thickener added to milk or a thickened infant milk is suggested only where (rarely) there are significant symptoms of frequent regurgitation with marked distress, and only after a review of feeding history, and a reduction in feed volumes where appropriate, or an increase in frequency of feeds, have been attempted.
Watch this space (and X/formerly Twitter) for a forthcoming editorial in which we share our latest thoughts on the marketing of infant FSMPs in the UK, building on our 2022 report.
During the 77th WHA discussion on Agenda item 15.2 on “maternal, infant and young child nutrition”, Brazil announcedthat 27 countries are advocating for a resolution on digital marketing of breastmilk substitutes to be tabled at the 78th World Health Assembly in 2025. This is an important commitment, and we look forward to seeing this progress.
Infant milk info webinar: online, Wednesday 17 July
Following our first webinar in June, we will be delivering our second webinar on Wednesday 17 July from 10:30am until 11:30am, to introduce healthcare professionals with an interest in infant milk feeding to our website dedicated to infant milk. The webinar will show users how to navigate the website and provide some insight on how it may be useful in their work. You can register here.
Breastfeeding Network conference: online, Saturday 5 October
Ticket sales are open for the BfN annual conference aimed their volunteers, parents, families and health professionals with an interest in breastfeeding and related topics. Speakers will be announced in due course. Find out more here.
Nourishing Futures Network conference: Newcastle, Tuesday 22 October
The Nourishing Futures Network is an international collaboration seeking to exchange and generate new knowledge to solve food insecurity during preconception, pregnancy, and early life. Their first international conference is taking place in Newcastle upon Tyne, UK on Tuesday 22nd October 2024. They want to bring together early-career, mid-career, and senior experts in food security during the first 2001 days, whose interests span mechanistic, social, policy, and practice dimensions. We will be exhibiting, so come and say hello. Early bird ticket sales end on Monday 22 July. More here.
Unicef Baby Friendly Initiative conference: online, 20 - 21 November
This year’s annual conference is online. They’ve opened applications for posters, with a deadline of Friday 9 August. We are among the speakers lined up and will be presenting our work on monitoring and advocating for regulation of infant formula prices, in the context of strengthening marketing restrictions. Early bird ticket sales end on Wednesday 31 July. Find our more here.
