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Infant feeding culture: advice for mothers

Alison Wall
Health Visitor
Child Protection Professional Lead

Infant nutrition is a major public health issue, with ongoing research evidence strengthening the position of breastfeeding as the optimal diet for infants.
The Department of Health feeding guidelines state that exclusive breastfeeding is recommended for the first six months (26 weeks) of an infant's life.(1) However, the debate is fraught with political issues and a broad range of views.
Despite the evidence, the majority of parents are choosing to feed their infants with artificial formulas. Thirty per cent of infants are never breastfed, and only 25% of babies are fed beyond four months. Research shows that 85% of infants are formula-fed by the end of their first year.
Health professionals therefore need to continually update their knowledge and skills in this area in order to offer appropriate support. This is becoming increasingly difficult in the current climate.

What are the alternatives to breastfeeding?
Mothers can combine formula and breastfeeding, particularly when trying to establish the baby on the breast for the first 6-7 weeks. It is quite possible to breastfeed during the day and then offer one supplement in the evening. However, the advice should always be to try the baby on the breast first in order to empty whatever milk is supplied, then if the baby will not settle to offer the supplement at the end of the feed. If the infant takes 30ml or less then the extra formula was not required. Parents should be reassured that this will not compromise their success with breastfeeding but will help them to rest at the end of the day. Sometimes the mother quickly increases the number of formula feeds and then switches completely; this probably occurs because that was her intention anyway. I believe many mothers have been more successful at establishing breastfeeding where the health practitioner has adopted a flexible but informative role.
For some mothers, formula feeding may be the advisable option (see Table 1).(2,3)


Approximately 3-5% of women will experience one of these difficulties and should not be overlooked in our fervour to extol the virtues of breast over bottle.
There are basically four groups of formula:

  • Whey-dominant.
  • Casein-dominant.
  • Follow-on (six months plus in the UK/four months plus in Europe).
  • Special formulas, such as protein hydrolysate for cows' milk allergy, soya preparations.

Whey-dominant brands are the closest in protein mix ratio to breast milk.
Casein-dominant milk has the same calorific density but 60%:40% casein-to-whey mix, which seems to take longer to be absorbed through the gut, therefore giving a feeling of fullness for longer. Unfortunately these milks can cause constipation in some infants.
Follow-on formulas are enriched with iron and can play an important role when the infant may be reluctant to drink other milk preparations after six months or has a very limited weaning diet.
New evidence suggests that soya may have side-effects because of the presence of phytoestrogens; therefore it is recommended that it should not be the first choice for those with cows' milk protein allergy.(4)
Practitioners are often unsure of the differences between these milks, but there are key differences both between these and the different brands on the market.Four market leaders - Milupa, Cow & Gate, SMA and Farley's - all manufacture these groups of milk, but all have differing constituents.
Nucleotides, LCPs (long-chain polyunsaturates) beta-carotene and selenium have all been added following research demonstrating their efficacy, and two of the formulas also have prebiotics. This has resulted in formulas being closer in composition to breast milk.
Vitamins and trace minerals such as beta-carotene and selenium play a key role in the immune response. Nucleotides are vital for growth and may also play a part in the immune response. Prebiotics help to maintain the optimal balance of microorganisms in the gut. LCPs are present in breast milk, and it is believed that they aid cognitive and retinal development, but more research is needed.
The various formulas contain these additives in different proportions, which may have different health outcomes for infants.

Obesity and other issues
There is much debate and concern about the growing epidemic of obesity. Researchers are studying the influence of early nutrition and have stated that early nutrition is critical in influencing long-term health outcomes.(5)
The rate of growth in the first few weeks is important, particularly because a small or premature infant grows rapidly at this stage. The influence of formula versus breastfeeding is not conclusive, but the majority of studies are pointing to a protective effect from breastfeeding. More work needs to be done before we can make generalisations about the benefits of breastfeeding and claim that it prevents obesity, as some breastfed infants grow excessively and this may not result in optimal health outcomes.
We also do not have the evidence to state for how long breastfeeding is beneficial.(6) Evidence shows that vascular health deteriorates with prolonged breastfeeding. Bone health, cardiovascular risk and brain development have not been studied in relation to infant nutrition. Key nutrients may be deficient if infant-feeding policies are not backed up with sound scientific knowledge. Observational studies conducted in developing countries such as Belarus have formed the basis for the current government recommendations in the UK, despite the huge differences in practices and priorities between our cultures.
Gillian Harris, a clinical psychologist at Birmingham University, has completed some fascinating work looking at key stages for the infant to accept or reject certain tastes.(7) She describes a neophobic phase, when an infant will reject foods that are not recognisable. This phase generally is seen at the end of the first year. It is therefore important to quickly introduce a variety of foods once the weaning process begins.
In practice there is evidence that with the new recommendations to exclusively breastfeed until six months the infant is not experiencing these tastes at the critical times. If a range of tastes and textures is not sampled and accepted then there is concern that the child will develop into a faddy toddler and adult, and thereby suffer poor health outcomes as a result.
Another public health issue in the infant feeding culture is infection control.
The Food Standards Agency with the European Food Safety Authority has published a report highlighting the concern of contamination of formulas with salmonella and Enterobacter sakazakii.(8)
The panel advises that powdered formula should be prepared freshly for each feed, and any remaining formula should be discarded after the feed. They also advocate good hygienic measures, as would all health practitioners.
Healthcare managers are now suggesting that we should be advising parents to make up one feed at a time in order to minimise the risk of infection, in line with the panel's recommendations.
I would argue that this is unrealistic; feeds for the day will continue to be made and stored in advance.
It is now common to see parents using a microwave to warm a feed as they are likely to be unaware of the risks of uneven heat distribution.
Antenatal education needs to be reviewed, and practical advice about formula feeding needs to be high on the agenda.
The government is pushing its target of increasing the initiation rate of breastfeeding and encouraging the establishment of the Baby Friendly Initiative in both the hospital and the community. Mothers are no longer shown how to make up feeds until they expressly ask for support. In fact, in many units formula feeds are not even mentioned because of political pressures and the current cultural climate.
In response to this perceived imbalance in information and dearth of evidence on health outcomes, a group of clinicians in collaboration with industry have produced a broad-based overview of the role of infant formulas as a basis for policy and practical healthcare development.(9)
In conclusion, healthcare practitioners and policymakers need to look to the future. The evidence is clear that breastfeeding rates have not significantly increased despite the policy drivers set in place with that intent.In the future the NHS will be patient-led with a local commissioning focus. Health practitioners therefore need to be aware of all the options available in the area of infant feeding. We need to listen to parents and be aware of their agenda rather than our own. Public health is relevant in all areas of practice, not least in the field of infant nutrition.


  1. Department of Health. Infant feeding recommendation. May 2003. Available from
  2. Lucas A. Collaborative research with infant formula companies should not always be censored. BMJ 1998;317:337-8.
  3. Aggarwal R, Aggarwal A. Professional advice on common breastfeeding problems: a primary care study. Br J Gen Pract 1997;47:173-4.
  4. Donaldson L. Advice issued on soya-based infant formula. CMO Update 2004;37:2.
  5. Owen CG, Martin RM, Whincup PH, Smith GD, Cook DG. Effect of infant feeding on the risk of obesity across the life course. Pediatrics 2005;5(115):1367-77.
  6. Kramer MS, Kakuma R. The optimal duration of exclusive breastfeeding -a systematic review. Adv Exp Med Biol 2004;554:63-77.
  7. Blissett J, Harris G. A behavioural intervention in a child with feeding problems. J Hum Nutr Diet 2002;15:1-7.
  8. European Food Safety Authority (EFSA). Opinion adopted by the BIOHAZ panel related to the microbiological risks in infant formulae and follow-on formulae. EFSA J 2004;113:1-34.
  9. INFORM. Infant feeding in the UK. Available from

Infant feeding
in the UK