Why spill-over feeding of follow-on formulas is of even
greater risk to infants below six months of age than the
feeding of routine formulas
Spill-over feeding is defined as feeding infant formula products marketed for a specific age group to infants of a different age group. Although such products are nutritionally unsuitable for children so young, their low cost and similar appearance to routine formulas result in their being introduced too early, with potentially drastic consequences.
Code requirements
Over the past two decades, infant formula companies have sought ways to expand the duration of the use of their products by marketing baby milks as follow-on formula and more recently as toddler formulas, despite the fact that the World Health Organizations International Code of Marketing of Breast-milk Substitutes has declared these products unnecessary and gives notice that they should not be marketed1. The baby milk industries have deliberately ignored this provision of the International Code, and claim these products to be outside of its scope. But the WHO has recommended breastfeeding to two years and beyond,2 hence any commercial baby milks marketed for this duration must be seen as competing with breastfeeding and therefore do come under the scope of the Code.
Differences in ingredients between routine (top)
and follow-up (bottom) infant formulas highlight
nutritional dangers of artificial feeding.
Additionally, the cost (see Table I) of these so-called second stage formulas is lower than the cost of routine formulas.
The nutrient compositional differences do not justify the cost differentials;
Production and labeling costs are similar for both products;
The lower retail pricing of follow-up formulas must be seen as a marketing strategy to place the product in competition with much cheaper whole cows milk as a source of baby milk during the second half of the first year and beyond. The marketing is used to convince parents that follow-up formulas are nutritionally better than whole cows milk, and the pricing policy may act as an enticement for prolonged formula feeding well beyond the first six months of life.
Spill-over dangers
The lower cost of follow-up formulas can result in spill-over feeding of these products to infants between birth and six months of age. Mothers with lower economic capacity, who may decide not to breastfeed and to use alternative feeds, may be more at risk to select the cheaper alternatives instead of routine formulas. There are critical health implications associated with spill-over usage (see summary on page 9).
A recent UNICEF and National Child Trust survey, released September 2005 in the UK, found that nearly one in five mothers (17 per cent) who used follow-on milk said they started before their baby was three months old, even though its unsuitable for children of this age.3 In Canada as well,4 low-income mothers are more likely to use cheaper alternatives at inappropriate ages. The labeling of these formulas can also create much confusion for parents. Packaging of these products for various ages has indistinguishable colouring and near identical product names making it easy to purchase and use the wrong product, especially when pricing may determine the decision of which tin to take to the cash register.
References:
1. Resolution WHA39.28 (1986). [back]
2. Resolution WHA 54.15 (200) [back]
3. http://www.babyfriendly.org.uk/press.asp [back]
4. Dubois L, Girard M. Social inequalities in infant feeding during the first year of life. The longitudinal Study of Child development in Quebec LSCDQ 1998-2002 Public Health Nutrition
6: 773-783, 2003 [back]
Dangers to infant health: a very brief
summary of the risks of spill-over feeding
a) Higher solute load
The kidney capacity of newborn and young infants is uniquely designed for the low solute load of breastmilk. Routine cows milk based formula by virtue of its composition (see Table II) already puts an excessive burden on an infants developing kidneys, and the even higher chemical/solute load of follow-up formulas poses an even greater threat. Follow-up formulas contain levels of protein, calcium, phosphorus and sodium (see Table II) higher that those found in both breastmilk and routine formulas, and feeding infants these products for months on end overloads their capacity to process solute/chemical waste. The injury to an infants immature developing kidney, can, in the long term, lead to chronic kidney conditions, elevated blood pressure and cardiovascular disease; and in the short term to dehydration associated with excessive sodium intake.
b) Inappropriate carbohydrates; insufficient lactose
The composition requirements for follow-up formulas allow much cheaper forms of sugars to be used. These include glucose corn syrup and honey. The milk sugar of breastmilk is lactose, which performs functions such as nourishing the brains of infants. How are infants compromised when they receive insufficient lactose?
c) Inadequate fats and energy
The total fat content of follow-up milks and the amount of long chain fatty acids are lower than in routine formulas. Total fat and long chain fatty acids are important factors for brain and neurological development, which is most rapid during the first six months of life. Hence spill-over feeding of follow-on formulas, with lower levels of important fats, present an even greater risk for lower cognitive development than routine formulas as measured by IQ and neurological abnormalities. Breastmilk fat and energy content, on the other hand, increase over the duration of breastfeeding to meet the increasing nutritional and energy needs of growing infants.
d) Infection or death related to contaminated powdered formula
The risk of illness and death linked to Enterobacter sakazakii infections is a well-documented problem inherent in the use of powdered infant formulas and thus for powdered follow-up formulas as well. The powdered format is the cheaper and thus preferred choice for many parents. Contaminated powdered formulas have been associated with serious illness: sepsis, necrotizing enterocolitis, meningitis, and death. Premature, low-birth weight and newborn infants are particularly susceptible to the impact of contaminated formulas. Spill-over feeding into this vulnerable population will have even more serious health implications.
e) Prolonged use of plastic bottles and artificial nipples
Bisphenols, endocrine disrupting chemicals, are found in plastic baby feeding bottles, putting infants at increased risk for cancers and allergies. Children who suck artificial nipples for prolonged durations are more prone to dental caries, baby-bottle syndrome and oral malformation than breastfed infants.