Why were follow-on and toddler formula invented?
For most of the 20th century, “formula” described a modified cows milk product used to feed babies in place of breastmilk. Initially this was simply a mix mothers would make up at home using a recipe given by their doctor or nurse. Proprietary brands then started marketing products for that purpose before the industry of an all-in-one powdered product was created. By the 1970s, promotion of these had become so out of control globally that breastfeeding rates plummeted to an all time low. Around the world, concerns were being raised about the ethics of marketing artificial feeding as being superior to human milk and unethical methods being used to discourage women from breastfeeding and putting their infants lives at risk.
The International Code of Marketing of Breastmilk Substitutes (the Code) is an international health policy framework to regulate the marketing of breastmilk substitutes in order to protect breastfeeding. It was published by the World Health Organization in 1981 and is an internationally agreed voluntary code of practice.
The Code was written in response to the marketing activities of the infant feeding industry which were promoting formula feeding over breastfeeding, in turn leading to dramatic increases in maternal and infant morbidity and mortality.
The underlying basis for the Code is the belief that the health of babies is so important that the usual rules governing market competition and advertising should not apply to products intended for feeding babies. Therefore, all Governments should legislate to prevent commercial interests from damaging breastfeeding rates and the health of their population.
THE INTERNATIONAL CODE OF MARKETING OF BREASTMILK SUBSTITUTES
Initially, The WHO Code focused on products marketed to replace breastmilk in the first six months. And this led to a multinational marketing strategy the tobacco industry would have been proud of:
The invention of products known by various names:
follow-on milk
stage two milk
growing up milk
step two
progress
Making claims that babies needed to progress from the formula products they were now prevented from promoting, the global formula industry scrambled to access the loophole which inadvertently allowed products to be advertised for babies older than six months.
Despite health authorities around the world refuting the need to change products, parents responded to the implied recommendation they saw in print and television advertising and sales saw an increase in formula profits.
The World Health Organization amended the Code to be inclusive of these products specifically in 1986:
When the Code was amended to protect parents of babies throughout the first year, businesses quickly reapplied their marketing strategy and created another new product they could market:
They invented toddler formula.
And advertising once again saturated the media.
Why does it matter.
Infant feeding is an emotive topic. There would be very little need for any formula products if all women had optimal support and resources to breastfeed. The World Health Organization wouldn’t need to spend time and money protecting and promoting breastfeeding if manufacturers didn’t pitch their marketing to undermine confidence in both health professionals and parents.
Globally, $US55 billion is spent every year marketing formula products.
Anyone who believes the formula industry is about infant health is a victim of successful advertising. And the opportunities have increased in the 21st Century.
What’s the difference?
Both breastmilk and formula contain Fat, Protein and Carbohydrates, necessary for the rapid development of human babies. So called “humanized” formula usually begins with cows’ milk (or goats’ milk).
To increase the fat content, vegetable oils are added - commonly palm oil, sunflower, safflower or canola oil, soy or coconut oil. Sometimes fish oil or fat derived from algae are used.
The protein content in milk comes from the liquid (whey) and solid (casein) components. This is the case in human milk and the milk of other mammals but the quantity and ratio vary significantly between species.
This is where it gets technical:
Human colostrum has a whey:casien ratio of 90:10
Mature Human breastmilk has a whey:casien ratio of 60:40 (later in lactation, this becomes a 50:50 ratio)
Cow milk has a whey:casien ratio of 20:80 -This is one reason why unmodified cows milk is not an appropriate breastmilk substitute in the first 12 months.
Infant formula has no standard whey:casien ratio - manufacturers around the world use different ratios
Casien is the “curd” of the milk, which takes longer to digest than the liquid whey. Some infant formula products have a mixture of whey and casien (described as being “whey -dominant” or “casien-dominant” while others are 100% whey-based. Whey is digested more quickly than casien.
The quantity of protein in milk also varies between species. It is measured as grams per 100 ml
Mature Human breastmilk is around 1-1.1grams per 100ml
Cow milk is around 3.3 grams per 100ml - 3 times that of human milk
Infant formula varies - there is no global standard. However:
The protein content in infant formulas available in Australia is in the range of 1.3–2.0 g protein per 100 ml
The United States Food and Drug Administration (FDA) recommends a protein content ranging between 1.8 and 4.5 g/100 kcal
The European Food Safety Authority has lowered the maximum protein content of infant formula to 1.8 g – <2.0 g/100 kcal
Formula products marketed for babies aged 6-12 months often have different protein compared to products marketed for 0-6 months, despite the lack of evidence supporting need. Parents believe higher protein levels will lead to increased sleep. They might also choose higher protein if they feel their baby is not gaining enough weight. However, there are concerns that high protein infant formula may be a factor in childhood obesity, which is 12 - 14% more common in formula fed children. Around one in four children in the UK and Australia are considered obese, while the rate in the US is one in three.
Carbohydrates
The natural carbohydrate in breastmilk is lactose - around 7%. Lactose is also present in cow’s milk, slightly less at 5%. Infant formula also includes the lactose present from the cow’s milk, however some products have other, added sugars.
Other types of sugars include fructose, sucrose and glucose. Sucrose is made up of the simple sugars glucose and fructose. Sucrose, glucose, and fructose are found naturally in many foods but are also added to processed products.
Glucose is not generally added to infant formula, however some lactose-free or soy-based products do include added glucose to achieve the desired energy intake with an acceptable level of sweetness. Infant milk with glucose as the main carbohydrate is likely to contribute to higher levels of dental decay in infants (Grenby and Mistry, 2000).
Fructose and sucrose are rarely used in infant formula. They are restricted as they could cause serious illness and death in young infants with hereditary fructose intolerance. Whilst hereditary fructose intolerance is rare, it could affect up to 1 in every 20,000 infants (Koletzko et al, 2005).
Maltodextrin is commonly added to formula products. Maltodextrin is a type of carbohydrate, but it undergoes intense processing. It comes in the form of a white powder from rice, corn, wheat, or potato starch. Its makers first cook it, then add acids or enzymes to break it down some more. In the US, nearly half of infant formula sales are now lactose-free products. These formulas replace some or all of the lactose with corn sugars; most often corn syrup solids, sometimes maltodextrin. The European Union limits the amount and types of sugars allowed in standard formulas, and bans corn syrup. A recent study in the US followed 15,000 infants and suggested a higher risk of obesity at age four for those who were fed corn-syrup-based formula compared to those who were fed lactose-based formula.
It is important that all infant formula products are strictly regulated and monitored to ensure they provide the recommended nutritional needs of babies. Without global standards, consumers are left with the variables we see between authorities.
Most health and nutrition claims on infant formula not supported by robust clinical trial evidence. Researchers reviewed health and nutrition claims for infant formula products in a group of high, middle, and low-income countries and evaluated the validity of the evidence used to support these claims. 88% of registered trials had authors who either received formula industry funding or were directly affiliated with industry.
"These findings support calls for a revised regulatory framework for breast milk substitutes to better protect consumers and avoid the harms associated with aggressive marketing of such products."
Cheung, K.Y., et al. (2023) Health and nutrition claims for infant formula: international cross sectional survey. BMJ. doi.org/10.1136/bmj-2022-071075.
You might wonder why the formula industry would be motivated to fund or facilitate research into the composition of human milk. The answer is nothing to do with health: it is to do with profit. When components of breastmilk are identified and associated with infant development, the market for formula products is weakened. When DocasaHexanenoic Acid (DHA) - an important omega 3 fatty acid needed by babies for brain development - was highlighted for its importance in the 1990s and its presence in human milk recognised, manufacturers scrambled to try and replicate it … by adding fish oil to their products. Advertising pivoted to assure parents that their products "helps/supports development of brain and/or eyes and/or nervous system". Breastfeeding women began to worry that they might not have sufficient sources of DHA in their own diet - and therefore their breastmilk.
Toddler Milks
The introduction of formula products aimed at parents of infants aged 12-36 months followed on from regulations around promotion and advertising expanding to cover follow-on formula aimed at the 6-12 month age group. Having introduced solid foods into their babies diet, parents of babies in the second year of life experience the age-typical picky eating and fussiness which is common. Marketing products to overcome perceived nutritional gaps in children’s diets, manufacturers targeted those concerns. Saturation advertising for toddler formula appeared everywhere in markets not exposed to promotions for infant or follow-on milks for a decade or more. Brand awareness - employing new key words like “gold” and “platinum” - grew for all products, as packaging was carefully duplicated across products, with only the discrete distinction of a stage or number to distinguish them. Parents, faced with walls of product on supermarket shelves (a far cry from the previous customer service at the local pharmacy) experienced mix-ups where young babies were inadvertently fed products intended for older babies or toddlers. Despite calls to separate toddler drinks away from infant products, merchandising experts knew too well that product placement within the store was crucial.
Toddler milks overpriced, high in sugar and potentially harmful to health Health groups call for crackdown on aggressive marketing to families
VicHealth recently called for an end to aggressive marketing of toddler milk formulas, as new research reveals some products are up to four times more expensive than regular milk, but with more sugar and fewer key nutrients. The Deakin University and VicHealth study of 50 milks targeted at children aged 12 months and over found some cost up to $1.02 per 200mL serve, while regular cow’s milk costs just 26 cents a serve – if drank daily, toddler milk would cost a family as much as $23.56 more per month than regular milk. VicHealth CEO Dr Sandro Demaio said toddler milks are incredibly expensive and completely unnecessary. “This research shows that toddler milk formulas are up to four times more expensive than their regular fresh milk counterparts. They’re also less nutritious, containing more sugar and less protein than regular milk, while many also offer less calcium,” Dr Demaio said. “Despite this, manufacturers are using Instagram influencers, targeted digital advertising and on-pack claims to try and lure Australian families into believing these ridiculously priced products are ‘essential’ for their child’s health. “At a time when many families are finding it hard to afford healthy food, the last thing they need is to be guilted into thinking they should fork out excessive amounts of money on these unnecessary products.”
Why do parents choose to replace infant formula and/or breastmilk with these products?
Before follow-on and toddler products were invented, babies were breastfed, formula fed or mixed fed before weaning onto cows milk as part of the transition to family foods. Babies as young as 6-9 months were given cow’s milk as a drink from a cup or to replace formula in a bottle. Infant formula is suited to babies from birth to 6 months and continues to meet their needs from six months and beyond when complemented with family foods. Beyond 12 months infant formula can still be offered however there is no nutritional need to do so.
Parents generally consider follow-on and toddler formula products as nutritional supplements, even when there is no medical evidence confirming deficiency. Marketing focusing on the nutritional make-up of these products feeds into these parental fears. Changes to infant eating, sleeping and other behaviour is interpreted as indicating infant formula is no longer meeting the baby’s needs. Common advertising claims make products appear superior:
“The formula milk industry uses poor science to suggest, with little supporting evidence, that their products are solutions to common infant health and developmental challenges,” said Linda Richter, a developmental psychologist at the University of the Witwatersrand in South Africa.
Baby Formula Industry Misleads People With Its Marketing, World Health Organization Says
Those transitioning to formula products from breastfeeding are particularly attracted to products which appear to be like breastmilk. Breastfeeding is recommended globally for two years and beyond. Parents whose personal goals were similar are more likely to choose follow-on or toddler products, assuming these are superior to infant formula.
Excessive milk intake is a common cause of nutrient deficiency in young children
While dairy products (e.g. cow’s milk, cheese, natural yogurt) are an important source of calcium for toddlers, they should be given in moderation as part of a balanced diet.
Toddlers who drink lots of cow’s milk (more than 500ml in 24 hours) can become low in iron and fibre, often because they don’t eat as much food as they should because they are full on milk. This means they miss out on key vitamins and minerals found in healthy foods. Having too much milk with meals may also prevent the body’s ability to absorb iron from food.
Limit your child’s cow’s milk intake to no more than 500ml in 24 hours, and to reduce tooth decay avoid putting children to bed with a bottle of milk.
Continue breastfeeding or formula feeding while foods are introduced through the first year of life. Keep breastfeeding for as long as mum and baby desire, but stop bottles and infant formula from around 12 months. Offer cow’s milk from a cup after 12 months.
Water from a cup can be offered from 6 months of age and should be the main drink from 12 months.
Nutrition – babies and toddlers Royal Children’s Hospital
The World Health Organization has called for an end to marketing of formula products with false or misleading claims such as:
Formula products with added ingredients improve brain development and immunity
Formula products are needed after 12 months of age;
That breast milk is inadequate for the nutrition of older infants and children;
That formula keeps babies fuller for longer and therefore helps them sleep,
That the quality of breast milk declines with time.
“These are all untrue. They hurt children, and they hurt mothers.”
Around the world, action to end “Exploitative” and “underhand” marketing of formula milk … preventing millions of women from breastfeeding” has followed a report published in The Lancet in February 2023.
In the UK, experts called for immediate action. “The UK government, despite being one of the strongest supporters of the code in 1981, still has a poor record on support for breastfeeding and a narrow law that bans promotion of formula (not bottles and teats) and then only to six months,” said Patti Rundall, policy director at Baby Milk Action and global council member at the International Baby Food Action Network. “So there is widespread advertising of a wide range of follow-up formulas and products that are cross promoted with infant formula and industry-linked groups who all conspire to mislead parents and undermine breastfeeding.”
In Australia, the ACCC has reauthorised their agreement with formula manufacturers regarding a ban on infant formula advertsing but have admitted concerns about the rising impact of toddler formula advertising.:
The MAIF (Marketing in Australia of Infant Formula) agreement has been in place since 1992, as a self-regulatory agreement code of conduct between manufacturers and importers of infant formula. Now, the ACCC has accepted the MAIF Agreement will continue to maintain restrictions on promoting breastmilk alternatives, and the Agreement has been authorised until 2024.
ACCC deputy chair, Delia Rickard, said: “without this agreement among infant formula manufacturers and importers there is a risk of an increase in the marketing of infant formula, both directly to consumers and indirectly through references to infants in the marketing of toddler milk.”
“A continued ban on infant formula advertising is likely to result in public benefits by protecting rates of breastfeeding, which has significant public health benefits.” However, the ACCC has new concerns about the promotion of toddler milk, which they say could be “significantly undermining” the affectiveness of the MAIF Agreement. At present, the Agreement doesn’t stop companies promoting toddler milk.
“The ACCC has noted the rise in advertising for toddler milk products, and is aware of concerns that this may be used as a proxy to market infant formula,” continued Rickard.
“Our decision on whether to authorise this agreement was finely balanced as a result.”
More than 40 years after the initiation of The International Code of Marketing of Breastmilk Substitutes, parents and health professionals are still under the influence of global businesses making unsubstantiated health claims about products targeting the most vulnerable members of society. Product ranges now include formulations for pregnant women - allowing for unregulated marketing to commence prior to conception. Brand awareness and loyalty as well as cross-promotion means breastfeeding confidence is undermined right from the start.
