by Dr Louise Santhanam, General Practitioner
The UK Department of Health and the World Health Organisation (WHO) recommend breastfeeding exclusively for six months, with continued breastfeeding thereafter alongside the introduction of complementary solid foods1, 2. If parents cannot, or choose not to breastfeed, infant formula based on modified cows’ milk or goats’ milk can be used as a breastmilk substitute for babies under 12 months old 3.
Some families feeding with formula milk will be doing so for medical reasons or will have made a personal decision to do so. Some families experience difficulties when breastfeeding, including inadequate support from healthcare professionals and relatives, or negative societal attitudes. It is important to be sensitive to the possible reasons as to why a mother may not be breastfeeding, and also to protect breastfeeding support services to enable those who wish to breastfeed to overcome any difficulties and continue to breastfeed for as long as desired.
Figures from the 2010 UK Infant Feeding Survey4 demonstrate that many infants in the UK are fed at some point with formula milk and it is therefore vital that GPs are familiar with the key points about these products, to be able to accurately advise on using them as safely as possible.
See the Glossary page for explanations of the terms used to describe infant milks in this website.
Medical Reasons for the use of Breastmilk Substitutes
For some rare infant medical conditions feeding exclusively with specialised infant milk is necessary (eg. classic galactosaemia, maple syrup urine disease). In some medical conditions carefully monitored breastfeeding may be possible alongside the use of specialised infant milk (phenylketonuria). Paediatric input is required in such cases. These milks are designated ‘Foods for Special Medical Purposes’ (FSMPs) and in the UK are governed by different regulations to standard infant formula. See the section on ‘Specialised Infant Milks’ below for more information.
Some maternal conditions may necessitate avoidance of breastfeeding either permanently, during periods of illness, for certain medical procedures, or in rare instances due to incompatibility with essential medication.
WHO and Unicef: Acceptable Medical Reasons for Use of Breast-Milk Substitutes Outlines infant and maternal medical conditions in which the use of breastmilk substitutes is medically necessary.
In some circumstances, despite optimal breastfeeding support, infants require supplemental feeding. The UK Department of Health states that:
‘All infants should be managed individually so that insufficient growth or other adverse outcomes are not ignored and appropriate interventions are provided’1.
Depending on the reason for supplementation, it may be possible to support a mother increase her breastmilk supply over time and reduce the volumes of supplemental feeds (see the GPIFN webpage on ‘Low Milk Supply‘).
Situations in which a baby may need supplemental feeding include:
- Unavoidable maternal separation due to illness
- Insufficient Glandular Tissue of the breast with low milk production
- Previous breast pathology/surgery resulting in low milk production
- Delayed Lactogenesis II (delay in the expected onset of copious milk secretion usually occurring between 32 and 96 hours postpartum)
- Poor milk intake/milk transfer despite good supply
- Infant unable to feed at the breast due to congenital malformation or illness
- Significant weight loss, dehydration or jaundice
The preference for choice of supplemental feed is suggested by the Academy of Breastfeeding Medicine as5:
- The mother’s own expressed breastmilk
- Human donor milk
- An appropriate choice of breastmilk substitute (formula)
and the choice will depend on individual circumstances6.
Supplemental feeds may be delivered via the following means, dependant on suitability to the individual case5:
- A supplemental nursing device at the breast
- Cup feeding
- Spoon or dropper feeding
- Syringe feeding
- Bottle feeding
Protecting the Health of Babies Fed with Infant Milks
The families of babies fed with infant milks can be supported with:
- Independent evidence-based information on the choices of infant milks
- Information on preparing and sterilising feeds
- Responsive/paced bottle feeding
- Promoting secure and loving relationships
- Care for the physical and mental wellbeing of mothers who for medical or personal reasons have been unable to breastfeed, or who stop breastfeeding before they are ready to do so7-9
NICE Guideline CG37 Postnatal Care up to 8 weeks after birth section 1.3.42 states ‘All parents and carers who are giving their babies formula feed should be offered appropriate and tailored advice on formula feeding to ensure this is undertaken as safely as possible, in order to enhance infant development and health, and fulfil nutritional needs’.
The Unicef UK Baby Friendly Initiative & First Steps Nutrition Trust: Infant Formula and Responsive Bottle Feeding This document is a simple summary which can assist parents with choosing infant milks.
Key Points on the use of Formula Milk Include:
- The composition of infant formula and ‘follow-on’ formula in the UK is controlled under The Infant Formula and Follow-on Formula (England) Regulations 2007. Ingredients deemed necessary must be included as standard in all formula.
- Powdered formula is not a sterile product and may be contaminated with pathogens. Correct preparation and handling reduces the risk of serious illness (see below). In contrast ‘ready to feed’ milks are sterile but more costly.
- If breastfed infants are given formula supplements, or if infants are are not breastfed, only ‘First Stage’ infant formula should be used up to six months of age. ‘First Stage’ infant formula is also appropriate for use throughout the rest of the first year of life, alongside the introduction of complementary solid foods.
- After 1 year of age full fat (whole) cows’ milk can become the main milk drink alongside a varied diet (unless cows’ milk allergy or lactose intolerance prevents this).
- Specialised Milks (FSMPs) are recommended to be used under medical supervision, whether obtained on prescription or over-the-counter.
- To protect dental health, bottle fed babies should be encouraged to use an open cup or a free-flow cup without a valve (to encourage learning to sip) from about six months. Bottles with teats should ideally not be used beyond one year of age.
- Infant formula is fortified with vitamin D but over 500ml per day is necessary to obtain the recommended daily amount. Babies who receive less than 500ml of infant formula will need vitamin D supplementation. Vitamin supplements containing vitamin A and C are also recommended once a child aged over six months is receiving less than 500ml of infant formula a day.
Independent Information on Infant Milks and Bottle Feeding
First Steps Nutrition Trust: Infant Milks Overview A range of guides including information aimed at health care professionals and parents on infant milks available in the UK, the costs and the scientific evidence.
First Steps Nutrition Trust: Infant Milks in the UK- A Practical Guide for Health Professionals Includes guidance on milk volumes according to age in Chapter 6. Scroll down for the first report (green).
NHS Website: Types of Formula Milk Clarifies issues around different types of formula and milks available and their suitability for babies and children. Soya-based formula should not be used unless recommended by a healthcare professional and is not recommended for use before 6 months of age.
NHS Website: How to Combine Breast and Bottle-feeding Information on ‘mixed feeding’.
Healthy Start UK-wide government scheme to improve the health of low-income pregnant women and families on benefits and tax credits. Provides vouchers which can be used to obtain fresh fruit and vegetables, cows’ milk, infant formula and Healthy Start Vitamins.
Preparing and Sterilising Bottle Feeds
NHS, Unicef UK Baby Friendly Initiative & Start4Life: Guide to Bottle Feeding Information on how to prepare infant formula and sterilise feeding equipment to minimise the risks to the baby in illustrated leaflet form.
NHS Website: How to Make up Baby Formula Includes a step-by-step guide.
NHS Website: Can I use bottled water to make up baby formula (infant formula)? It is not recommended to use bottled water to make up infant formula feeds in ordinary circumstances. If it has to be used it must be boiled as it is not sterile.
Department of Health: Preparation of Infant Formula (Letter to GPs January 2013) Stresses the importance of preparing standard infant formula and ‘follow-on’ formula with pre-boiled water at a temperature of 70°C or over. Specialist Formula (FSMPs) are not technically covered by this advice and should be used under medical supervision.
First Steps Nutrition Trust: Making up Infant Milks Safely Resources including the First Steps Nutrition statement about formula preparation machines. Outlines the reasons that First Steps Nutrition Trust currently believe that ‘there remains insufficient evidence that these machines are safe in the preparation of powdered infant formula’, and recommends that families follow guidance from the Food Standards Agency and the Department of Health (see above).
Responsive Bottle Feeding and Relationship Building
Care needs to be taken to avoid overfeeding a bottle fed baby. When a baby is healthy, offering a bottle in response to feeding cues (rather than on a fixed schedule), gently inviting the baby to take the teat, pacing the feeds and avoiding forcing the baby to finish the bottle reduce the risk of overfeeding. Encouraging parents to respond to their bottle fed baby’s feeding cues and to hold their baby close during feeds can also help to promote secure attachment.
Attachment Parenting UK: Responsive Bottle Feeding by Emma Pickett IBCLC Describes the technique and rationale behind responsive, paced bottle feeding.
Unicef UK Baby Friendly Initiative: How the Baby Friendly Initiative Supports Formula Feeding Parents Statement from the Baby Friendly Initiative detailing the important issues surrounding supporting formula feeding families.
Specialised Infant Milks
Specialised infant milks, designated Foods For Special Medical Purposes (FSMPs), are recommended to be used under medical supervision only. This includes milks for babies with metabolic problems (see above) as well as milks currently marketed for relief of colic, reflux, and cows’ milk allergy (CMA). In the UK some milks designated as FSMPs can be purchased without a prescription over the counter, but technically should still be used under medical supervision.
First Steps Nutrition Trust: Specialised Infant Milks in the UK September 2019- Report providing an overview of specialised infant milk products, their components, a critical review of the evidence for their efficacy, information on feeding guidelines and safe preparation. Scroll down to the bottom of the page for the purple report.
The Local Infant Feeding Information Board (LIFIB) Multidisciplinary group of healthcare professionals based in the northwest of England which critically appraises information and research on infant feeding issues (eg colic, reflux and CMPA), producing summaries for healthcare professionals.
- Department of Health Infant Feeding Recommendation 2003
- WHO: Infant and Young Child Feeding Factsheet Updated February 2018
- First Steps Nutrition Trust: Infant Milks in the UK- A Practical Guide for Health Professionals Updated June 2019 (green report)
- UK Infant Feeding Survey 2010
- ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate Revised 2017
- WHO & Unicef: Global Strategy for Infant and Young Child Feeding 2003
- Borra C, Iacovou M, Sevilla A. New Evidence on Breastfeeding and Postpartum Depression: The Importance of Understanding Women’s Intentions. Maternal and Child Health Journal. 2014;19(4):897-907.
- Brown A, Rance J, Bennett P. Understanding the relationship between breastfeeding and postnatal depression: the role of pain and physical difficulties. Journal of Advanced Nursing. 2015;72(2):273-282.
- La Leche League GB: When Breastfeeding Ends Suddenly