Issue 125 infant and young child formula milks with ads

PAEDIATRIC

INFANT AND YOUNG CHILD FORMULA MILKS: THE CURRENT UK MARKET Jacqui Lowdon Paediatric Dietitian, Team Leader Critical Care, Therapy & Dietetics, RMCH

The infant and young child formula milk market in the UK is dominated by four major brands. However, there is an increasing range of formulae becoming available even though infant and young child formula milks* are amongst the most strictly regulated foodstuffs. Here, Jacqui Lowdon takes a look at the products on the market and the related legislation and regulations.

Presently team leader for Critical Care and Burns, Jacqui previously specialised in gastroenterology and cystic fibrosis.

Although her career to date has focused on the acute sector, Jacqui has a great interest in paediatric public health.

There are currently four major brands in the UK offering infant and young child formula milks: Aptamil (Nutricia, owned

by Danone), Cow & Gate (Nutricia, owned

by Danone), SMA Nutrition (owned

by Nestlé) and HiPP Organic (owned

by HiPP). This can make it difficult for parents to choose an appropriate formula for their infant, but also can make it difficult for health professionals to keep up to date (see Table 1, p21, 22).

There are three types of standard formula: • Infant formula (IF) is designed to fully satisfy the nutritional needs of babies from birth to six months old, where a mother cannot or chooses not to breastfeed.

• Follow-on formula (FOF) is designed to satisfy the nutritional requirements of infants from six months to 12 months in conjunction with complementary foods.

• Young child formula (YCF) is suitable for young children from 12 to 36 months.

• They can then be further divided into cows’ milk-based, goat milkbased and soya-based. There are then the formulae for lactose intolerance, reflux and partially hydrolysed formulae.

For full article references please email info@ networkhealth group.co.uk

LEGISLATION

Regulation EU No 2016/127;3 EU Directive 2006/141/EC41 Legislation is strictly enforced, incorporating the principles and aims of the World Health Organisation’s (WHO)

Code on Breastmilk Substitutes.2 In 2016, there was an increasing focus on the regulatory arena. In May, a call for banning of advertising of all formulae for the first three years of life was proposed by the World Health Assembly (WHA).3 At the same time, the Royal College of Paediatrics and Child Health (RCPCH) consulted its members on whether the RCPCH should receive any funding from formula milk companies. Later in 2016, a Bill was introduced to the House of Commons, Feeding Products for Babies and Children (Advertising and Promotion).4 Although “welcomed with appreciation” by its member states, the recent WHA Resolution was not ‘endorsed’, being concluded that its following proposals were too extreme: • to prohibit contact between healthcare professionals and industry; • to further restrict funding; and • to consider foods given to a child up to 36 months as breastmilk substitutes.

The membership agreed that the RCPCH should continue to accept funding from formula milk companies, obviously within strict, specified conditions.5 They felt that, although any promotion of IF milk over breastfeeding is unacceptable, an open dialogue between manufacturers, researchers and healthcare professionals relating to clinical research and product development, is essential, so long as it is transparent and accountable. www.NHDmag.com June 2017 - Issue 125

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Why we’re simply made from whole goat milk.

MILD TASTE

In the management of healthy babies who are not being breast-fed, Nannycare First Infant Milk provides an effective alternative to standard cow’s milk formula.

Made from fresh whole goat milk, it has a mild taste, requires minimal processing and has no unnecessary added ingredients.

Nannycare formulations, from the originator and innovator of goat milk formula worldwide for over 20 years, are fully regulated and approved for infant feeding.

Readily available in leading supermarkets:

For Healthcare Professional Use Only Helpline UK 0800 328 5826, ROI 1800 937 375 enquiry@nannycare.co.uk www.nannycare.co.uk IMPORTANT NOTICE: Breastfeeding is best for babies. Infant formula should only be used on the advice of a healthcare professional.

Good maternal nutrition is important for breastfeeding. Reversing a decision not to breastfeed is difficult and combined breast and bottle feeding in the first weeks of life may reduce the supply of your own breastmilk. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. Please note that Goat Milk formula is not suitable for confirmed cases of cow’s milk protein allergy (CMPA), unless directed by a suitably qualified healthcare professional.

The Bill that was put forward aimed to establish an agency (the ‘Infant and Young Child Nutrition Agency’) to set, monitor and evaluate compositional, safety and quality standards, labelling and nutritional claims for formula milks for babies and young children. However, this would merely duplicate the work already undertaken by existing law.

CURRENT REGULATION IN THE UK

In February 2016, the European Commission Delegated Regulation (EU) 2016/17,6 which updates the specific compositional and information requirements for IF and FOF, became a legal requirement, being fully applicable

by February 2020 (February 2021 for protein

hydrolysate-based formulae). The previous regulations under Directive 2006/141/EC remain in force until repealed at this date. This regulation specifies the nutritional composition of IF and FOF, including labelling and claims specific to this group.

It remains unclear how the UK may determine and enforce regulations as it negotiates an exit from the EU. REGULATIONS AND INNOVATION

In order to reflect the ever-increasing knowledge of infant nutrition, regulations are not fixed, but are subject to change. As would be expected, there is often a time lapse between our scientific knowledge and development.

Table 1: The standard infant and young child milk formulas presently available in the UK (reproduced from First Steps Nutrition, Infant milks in the UK 2017) IF suitable from birth (cows’ milk-based)

Aptamil 1 First Milk Aptamil Profutura 1 First Infant Milk Bebivita 1 First Infant Milk Cow & Gate 1 First Infant Milk HiPP Organic Combiotic First Infant Milk Holle Organic Infant Formula 1 Kendamil First Infant Milk Kendamil Mehadrin First Infant Milk Mamia First Infant Milk Similac First Infant Milk SMA Pro First Infant Milk

IF suitable from birth (goat milk-based)

Goat Milk Formula 1 Holle Organic Infant Goat Milk Formula 1 Kabrita Gold 1 Infant milk NANNYcare First Infant Milk

IF marketed for hungrier babies, suitable from birth (cows’ milk-based)

Aptamil Hungry Milk Cow & Gate Infant Milk for Hungrier Babies HiPP Organic Combiotic Hungry Infant Milk SMA Extra Hungry

Thickened (anti-reflux) IF suitable from birth

Aptamil Anti-reflux Cow & Gate Anti-reflux HiPP Organic Combiotic Anti-reflux SMA Staydown

Soya protein-based IF suitable from birth

SMA Wysoy

Lactose-free IF suitable from birth

Aptamil Lactose Free SMA LF

Partially hydrolysed IF suitable from birth

Aptamil Comfort Cow & Gate Comfort HiPP Combiotic Comfort SMA Comfort SMA HA

Table 1 continued overleaf www.NHDmag.com June 2017 - Issue 125

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PAEDIATRIC FOF suitable from 6 months of age

Aptamil 2 Follow-on Milk Aptamil Profutura 2 Follow-on Milk Bebivita 2 Follow-on Milk Cow & Gate 2 Follow-on Milk HiPP Organic Combiotic Follow-on Milk 2 Holle Organic Infant Follow-on Formula 2 Kendamil Follow-on Milk Mamia Follow-on Milk Similac Follow-on Milk SMA Pro Follow-on Milk

FOF suitable from 6 months of age (goat milk-based)

Holle Organic Infant Goat Milk Follow-on Formula 2 Kabrita Gold 2 Follow-on Milk NANNYcare Follow-on Milk

Good night milks

HiPP Organic Good Night Milk

Growing-up milks and toddler milks suitable from around 1 year of age (cows’ milk-based)

Aptamil 3 Growing Up Milk 1-2 Years Aptamil Profutura 3 Growing Up Milk Bebivita 3 Growing Up Milk Cow & Gate 3 Growing Up Milk 1-2 Years HiPP Organic Combiotic Growing Up Milk 3 Holle Organic Growing Up Milk 3 Kendamil Toddler Milk Kendamil Mehadrin Toddler Milk PaediaSure Shake Similac Growing Up Milk SMA Pro Toddler Milk

Growing-up milks suitable from around 1 year of age (goat milk-based)

Holle Organic Infant Goat Milk Follow-on Formula 3 Kabrita Gold 3 Toddler Milk NANNYcare Growing Up Milk

Soya protein-based growing-up milks and toddler milks suitable from 1 year of age

Alpro Soya +1 Complete Care

Growing-up milks and toddler milks suitable from around 2 years

Aptamil 4 Growing Up Milk 2-3 Years Cow & Gate 4 Growing Up Milk 2-3 Years HiPP Combiotic Growing Up Milk 4

For example, the decision to include DHA (omega-3) in the list of mandatory ingredients from February 2020.7 Clinical research has been ongoing in this area for the last 20 years and has clearly demonstrated the benefits of DHA for non-breastfed infants. This is also an example of where industry collaborating with healthcare professionals has produced an advancement for the benefit of babies who are not fed with breast milk.

UPDATE ON FOLLOW-ON FORMULAE

In January this year, the EFSA Panel on Dietetic Products, Nutrition and Allergies produced a draft scientific opinion on ‘The safety and suitability for use by infants of 22

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follow-on formulae with a protein content of at least 1.6g/100kcal’. The level of protein discussed represents a minimum protein content of around 1.1g/100ml. This is lower than the average for follow-on milk products currently available in the UK. It was concluded that the use of FOF with a protein content of at least 1.6g/100kcal from either cows’ milk protein or goat milk protein and complying with EU legislation is safe and suitable for infants living in Europe with access to complementary foods of a sufficient quality. The safety and suitability of FOF made from either protein hydrolysates or soya protein isolates could not be established with the available data.8

It is essential that health professionals keep themselves updated on the various formulae now available, in order to best advise parents.

WHAT IS THE FUTURE OF PRESCRIBABLE INFANT FORMULAE?

Within certain Clinical Commissioning Groups (CCGs), prescriptions of IF are at risk of being restricted. Proposals have included restrictions to soya-based IF, thickened IF, formulae for lactose intolerance and for cows’ milk protein allergy (CMPA). It is imperative that children with CMPA are diagnosed and managed with the most appropriate formula, be that an aminoacid based formula (AAF,) or extensively hydrolysed formula (eHF), as stated by NICE and the MAP Guideline.9,10 Already in some areas, CCGs are removing certain formulae from being prescribed. The risk is that shortterm financial savings may negatively impact on patient outcomes and effectively cost the NHS more money in the long term.

UPDATE ON PARTIALLY HYDROLYSED FORMULA

A recent systematic review by The Food Standards Agency11 concluded that there was no consistent evidence that partially hydrolysed formula reduces the risk of allergic disease. Furthermore, ESPGHAN working group consensus12 also concluded that evidence on efficacy of partially hydrolysed formula on prevention of atopic

disease is limited and highlighted the lack of any evidence on long-term metabolic consequences and outcomes of using these products.

UPDATE ON THICKENED FORMULA

The NICE Quality Standard (QS112, NICE 2016) outlines how gastro-oesophageal reflux should be diagnosed and managed in infants.

Regurgitation is a common and normal occurrence in infants, not normally requiring any investigation or treatment. Where there may be significant symptoms of frequent regurgitation with distress, a thickener added to milk or a prethickened formula can be recommended.

SUMMARY

It is essential that health professionals keep themselves updated on the various formulae now available, in order to best advise parents.

It is also essential that we understand and are knowledgeable on the legislation and regulation of these formulae to reassure parents on their suitability. * In this article, the term ‘infant formula milks’ is used generically to include infant formula, followon formula, young child formula and infant foods for special medical purposes (iFSMPs). www.NHDmag.com June 2017 - Issue 125

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