General questions about infant feeding

Provision of breastfeeding support varies across the UK, so it is important to understand what is available for families in your local area. If you are unsure, check your local council or NHS Trust website or contact the community infant feeding lead.

Breastfeeding drop-in groups or cafes are a useful source of support for parents allowing them to get face to face assistance with breastfeeding issues in a supportive environment, alongside the opportunity to meet other parents and receive peer to peer support. Local groups may be run by either health professionals or volunteers and are usually drop in sessions. Check the provision in your local area. There are a number of services offered by peer supporters, breastfeeding counsellors and lactation consultants which can be face to face or through remote support.

National helplines and organisations that offer support with breastfeeding issues at any point during the breastfeeding journey.

  • National Breastfeeding Helpline – 0300 100 0212
    Lines are open from 9.30am to 9.30pm every day.
    The National Breastfeeding Helpline is staffed by trained volunteers from the Breastfeeding Network and the Association of Breastfeeding Mothers.
    The helpline can answer questions in English, Welsh and Polish.
  • La Leche League Helpline0345 120 2918
    Lines are open from 8am to 11pm every day.
    La Leche League is a charity who provide information and support for breastfeeding mothers. La Leche league volunteers staff the helpline, but parents can also visit https://www.laleche.org.uk/and find the contact number for their local LLL Leader.
  • NCT Infant Feeding Helpline  0300 330 0700
    Lines are open 8am to midnight every day.
    NCT is a charity who support new and expectant parents. The helpline is staffed by volunteers who are trained NCT Breastfeeding Counsellors.

Healthcare professionals in more than 91% of maternity settings, 89% of health visiting services, 74% of university midwifery courses and 20% of health visiting courses are working in their local area within, or towards, Unicef UK Baby Friendly Initiativeaccreditation (Dec 2019).  In addition, 21 Children’s Centres and 12 neonatal units have received full independent accreditation. The NHS Plan now requires maternity settings to take part in an accredited scheme like Baby Friendly and it is hoped that within 5 years all babies in the UK will be born in a Baby Friendly accredited setting.

Within the Baby Friendly accreditation scheme there is a clear pathway for offering support and advice to parents who formula feed their baby, and the key points are summarised here. For full details of the Unicef UK Baby Friendly Initiative and how health care professionals can support families with their infant feeding choices at all these stages, see www.unicef.org.uk

In pregnancy

  • Health care staff should have an open discussion about breast and bottle-feeding so that parents can make an informed decision about how they might want to feed their baby.
  • Parents-to-be should also have an opportunity to talk about things that can help them recognise their baby’s needs for food and comfort. Health professionals should discuss the importance of spending time in skin-to-skin contact after birth and keeping baby close, to enable parents to look out for cues that tell if baby may want to feed or be cuddled, regardless of how they choose to feed their baby.

After birth

  • The importance of skin-to-skin contact after birth is fully recognised in the Baby Friendly standards and is considered as a good way to calm a baby and let parents and baby get to know each other. It is likely that while baby is in skin contact he will start to show some signs of being ready to feed, such as rooting and moving his hand towards his mouth. Parents may wish to offer a breastfeed and some women do have a strong feeling to do this even if they had planned to bottle-feed.
  • However, health professionals will ensure there is no pressureon parents to do this and if they decide that they want to bottle-feed it can be lovely for parents to offer the first bottle whilst they are in skin-to-skin contact.

In the first two days

  • Parents should be given independent information about infant milks so they can choose the one most suited to all their needs. Parents should also be given all the information they need to make up bottles safely, and on how to sterilise feeding equipment.

At home

  • Parents should be supported so that they know their baby is feeding effectively, and growing well, regardless of how their baby is being fed. Healthcare professionals should support the maintenance of a close and responsive relationship with the baby when they are being fed.

How to bottle-feed

To encourage responsiveness and discourage overfeeding:

  • Hold the baby close and look into their eyes during feeds.
  • Respond to cues that baby is hungry.
  • Invite the baby to draw in the teat rather than forcing the teat into the mouth.
  • Pace the feed so that the baby is not forced to feed more than they want to.
  • Recognise the baby’s cues that they have had enough milk.

At about 6 months

Babies who are either breastfed, mixed fed or formula-fed should be introduced to complementary foods at about 6 months of age. Advice on this and on how to manage milk feeding alongside complementary feeding can be found at www.nhs.uk

The report Eating well: the first yearcan be accessed at www.firststepsnutrition.org

In children’s centres

  • Parents should be supported with appropriate infant feeding choices and in building a close and loving relationship with their baby.
  • Pregnant women should be supported to recognise the importance of early relationships to the health and well-being of their baby.

The Unicef UK Baby Friendly Initiative supports all families however they feed their babies, and a report explaining ‘How the Baby Friendly Initiative supports parents who formula feed’can be downloaded at www.unicef.org.uk

First Steps Nutrition Trust and Unicef UK Baby Friendly Initiative have also produced a one page leaflet on ‘What infant formula to choose’ www.unicef.org.uk

Unicef UK Baby Friendly Initiative and Start4life produce a booklet A guide to bottle feeding’ www.unicef.org.uk

Unicef UK Baby Friendly Initiativealso produce a report ‘Working within the International Code of Breastmilk Substitutes: A guide for health workers’ www.unicef.org.uk

First Steps Nutrition Trust have also produced a report ‘Working within the International Code of Breastmilk Substitutes: A guide for dietitians’, which is available at www.firststepsnutrition.org

Breastmilk is a unique living substance and it is impossible for any manufacturer to recreate it.
Breastmilk is a complex fluid that contains all the nutrients needed by an infant, in forms that are easily absorbed, and contains a range of protective substances tailored to each infant and the environment he or she lives in. Breastmilk contains: substances such as lactoferrin, a protein component that helps babies absorb nutrients and which binds iron in the gut so that pathogenic bacteria are inhibited; immunoglobulins and macrophages which protect the infant from infections; specific fatty acids which promote development; growth factors, anti-viral factors, anti-bacterial substances and living white blood cells. It is estimated that there are more than 100 substances present in breastmilk that are not present in artificial infant milks. In addition, the milk feed of each mother changes over time, both within the feed and between feeds, to provide the fluid and nutrients the baby needs. The protective effect of breastfeeding for infants and human populations is fully accepted by all scientific agencies and health departments worldwide.

Just because an ingredient can be isolated from breastmilk and recreated in a laboratory does not mean that that ingredient will have the same benefits, or properties, when put into infant formula. Manufacturers often make claims for ingredients that are similar to those isolated from breastmilk, but frequently these are found to have no benefit, and may potentially be a burden to a young infant’s metabolic system.

The European Food Safety Authority Scientific opinion on the essential composition of infant and follow-on formulae (EFSA, 2014) made the following important statement:

“Nutrients and other substances should be added to formulae for infants only in amounts that serve a nutritional or other benefit. The addition in amounts higher than those serving a benefit, or the inclusion of unnecessary substances in formulae puts a burden on the infant’s metabolism and/or physiological functions as substances which are not used or stored have to be excreted.”

 

 

The Royal College of Nursing (RCN) recommends that healthy infants are fed responsively and offered adequate food to satisfy their hunger (Royal College of Nursing, 2007). Healthy infants will naturally regulate their feeding and will take enough milk to meet their needs, and it is recommended that parents learn to recognise feeding cues given by their infants. An infant’s milk requirements may vary from day to day, but most full-term infants will need to be fed every 2-3 hours, day and night, in the early weeks of life. Parents should bottle-feed in the same way that they are encouraged to breastfeed, offering one-to-one contact and meeting each individual infant’s needs, being responsive to baby’s cues. Babies should be allowed to feed on demand and not be encouraged to ‘finish the bottle’. It is suggested that bottle-fed babies should be initially offered about 20ml infant formula/kg on the first day, divided into eight feeds, with the volume gradually increased over the following days to appetite, so that they are having about 150ml/kg by 7-14 days (Shaw, 2015).

Formula-fed infants have been shown to have higher milk intakes than breastfed infants, and this is particularly true in the first two weeks of life (Hester et al, 2012). Whilst there is variation in the amount of breastmilk consumed in the first few days of life, demand-fed babies in the Hester et al systematic review received about 20ml of milk on day 1, compared to 170ml in formula-fed babies. By day 14, breastfed babies received about 675ml a day compared to 760ml in formula-fed babies. The authors also noted that not only did formula-fed babies have a greater volume of milk in their early days, but infant formula is also higher in energy (65-67kca/100ml) than colostrum (54 kcal/100ml) and transitional milk (58kcal/100ml).

Most babies will need 150-180ml/kg/day of infant formula until they are 6 months old, although this will vary for the individual baby (Shaw, 2015). Using data from the Scientific Advisory Committee on Nutrition report on Dietary Reference Values for Energy(SACN, 2011), the volumes of milk required by infants by gender and age using average bodyweights have been calculated and are shown here.

Estimated amounts of infant formula required, using energy requirements from the SACN report Dietary Reference Values for Energy(2011)

This analysis suggests that the average infant formula requirements of infants are between about 130ml and 190ml/kg/day averaging at about 150ml/kg/day. The charts also highlight that at 4 months the energy requirement of infants drops slightly, reflecting changes in weight and growth patterns. This data suggests that infants in the first three months require about 170ml/kg/day, dropping to about 130ml/kg/day from 4-6 months. These are just guidelines as everyone is clear that feeding should be ‘baby-led’ but provide an evidence base for guidance.Manufacturers of infant milks provide guidelines on their packaging which show typical volumes of formula to use according to the age and weight of the infant. These can be confusing as they vary from brand to brand and do not always describe the same ages and stages. All feeding guidelines are, however, just guidance, and it is important that parents and carers do not become too concerned about their infant accepting the exact amounts of milk as stated on packaging, as long as the infant is growing and developing well. Appetites vary between individuals and over time. It is important never to force infants to finish the milk in their bottle.

References

Hester SN, Hustead DS, Mackey AD (2012). Is the macronutrient intake of formula-fed infants greater than breast-fed infants in early infancy? Journal of Nutrition and Metabolism: doi: 10.1155/2012/891201

Royal College of Nursing (2007). Formula Feeds: RCN Guidance for Nurses Caring for Infants and Mothers.London: Royal College of Nursing.

Scientific Advisory Committee on Nutrition (2011). Dietary Reference Values for Energy. Available at: https://www.gov.uk/government/publications/sacn-dietary-reference-values-for-energy

Shaw V (2015). Clinical Paediatric Dietetics.Fourth edition. Oxford: Wiley Blackwell Science.

By 7-9 months of age, infants should be getting significant amounts of nutrients from food, and the amount of infant formula consumed should be around 600ml a day. By 10-12 months of age, the amount of milk consumed should be around 400ml per day as food takes over as the main source of energy and nutrients. Breastfed babies will continue to take the amount of milk they need as they obtain increasing energy from food and it is not necessary to know the volume of this. For more information about milk and food in the first year of life, see www.firststepsnutrition.org

With the publication of its updated guideline on complementary feeding in 2023, the WHO has recently reiterated its pre-existing advice that for infants 6–11 months of age who are fed milks other than breast milk, either “milk formula” or animal milk can be fed. This recommendation is stated to be “conditional, low certainty evidence” which means that the Guideline Development Committee is less confident or certain about the balance between benefits and harms. Both its conditionality and the low certainty of the evidence mean the application of this recommendation should be approached with caution and the context should be considered. 

It is important to note that WHO’s advice is targeted at governments and health authorities rather than directly at parents and that it has  not changed UK public health guidance on milk feeding infants 6-11 months of age.

To avoid confusion and potential harm, we would encourage all health workers to promote current NHS advice to:

-Breastfeed or use infant formula (follow on formula is not necessary)

-Use cows’ milk in cooking but not as a drink until 12 months of age, because it does not provide enough iron

We have received many queries about this WHO recommendation. One question it raises is whether food insecure/low-income families struggling to formula feed their 6–11-month-old infants could simply switch to cows’ milk, which is far cheaper. Another is whether this recommendation might inadvertently undermine breastfeeding. We explain the basis of the WHO recommendation and outline our thoughts on the two questions arising from queries we have received below.

Basis of the WHO recommendation

The WHO recommendation was based on the results of a systematic review (of 9 studies, 8 in high income countries) which found that cows’ milk compared to “milk formula” may increase the risk of anaemia and iron deficiency anaemia, and result in lower serum ferritin concentrations. The results were mixed for haemoglobin concentrations. There were no differences between milks for the anthropometric or developmental outcomes assessed, gastrointestinal blood loss or diarrhoea. The certainty of the evidence for all outcomes was graded as very low or low certainty.

The report stated that “The Guideline Development Committee (GDC) was of the opinion that there was uncertainty in the balance of benefits and harms of animal milk compared to milk formula for infants 6–11 months of age… as it would vary widely by context. However, there was some agreement that there were probably some benefits for infants 6–11 months of age consuming milk formula rather than animal milk”, though this was judged as uncertain. These benefits relate to indicators of iron and vitamin D status, though the report notes that iron status can be improved through other means including consumption of animal source foods.

 

Questions on application of the WHO recommendation in the UK:

  1. Could food insecure/low-income families struggling to formula feed their 6-11 month old infants be advised to switch to cows’ milk, which is cheaper?

We advise not to do this while it contradicts current UK public health recommendations.

If UK public health guidance changed in line with WHO recommendations, then this could become a possibility. However, cows’ milk is a very poor source of iron and families struggling to afford infant formula may also not be able to afford the diverse diet needed to meet their baby’s iron needs. NHS recommendations are to give young children meat, fish, fortified breakfast cereals, green leafy vegetables, beans and lentils. Cows’ milk also contains a lot more protein, and average protein intakes for young children in the UK are far in excess of requirements, likely driving excess weight gain. This means that a switch from formula to cows’ milk may not be the simple solution it appears to meet the nutrient needs of a non-breastfed baby in a low-income household, especially where better interventions to address dietary inequalities are needed (e.g. improvements in Healthy Start). In addition, the values, preferences and acceptability of such a recommendation by these families would need to be considered. Lastly, given that we know some families give their babies follow-on formula before 6 months of age (which the NHS advise against), a change to recommend cows’ milk in infancy may risk some families giving cows’ milk before 6 months of age.

  1. Could recommending either formula or animal milk for 6–11-month-old infants receiving milks other than breastmilk undermine breastfeeding?

It has been suggested that this recommendation might inadvertently undermine continued breastfeeding IF reasons for continued breastfeeding are perceived inconvenience of formula feeding e.g. at night time or out of the home OR concern about formula safety (e.g. related to bacterial contamination, or the extent to which it is processed / contains additives). In short, mothers may choose to give their baby cows’ milk instead of continuing to breastfeed if they perceive it to be more convenient and/or safer than formula.

With this in mind it would seem important that any advice on giving formula or animal milk to babies is provided – where appropriate – in the context of messaging on the superiority of breastmilk and breastfeeding for infant/child and maternal health as per usual health promotion messaging on infant feeding.

There has been concern over a number of years that errors in the reconstitution of powdered milks might contribute to overfeeding of infants (Lucas, 1992). The potential for harm to infants from making up powdered infant milk feeds incorrectly is serious. Over-concentration of feeds may lead to hypernatraemic dehydration or obesity, while under-concentration may lead to growth faltering (Department of Health and Social Security, 1974; Chambers and Steel, 1975). A systematic review of formula feed preparation (Renfrew et al, 2003) reported that errors in reconstituting feeds were commonly reported and that there was considerable inconsistency in the size of scoops between milk brands. In addition there appears to be little information provided to parents antenatally on how to make up bottles appropriately. A study in which mothers at clinics were asked to measure powdered milk with the same scoop found wide variations in the amount of powder used, ranging from 2.75g to 5.2g per levelled scoop (Jeffs, 1989). Pre-weighed sachets of milk powder have been suggested as a way to reduce volume errors, although where part packets are required to make up smaller or larger feeds, it is likely that errors will still occur. Renfrew et al (2003) recommended that there should be a consistent approach in terms of uniform instructions in the making up of feeds and in scoop sizes to avoid confusion, led by the Food Standards Agency and the Department of Health, but these recommendations do not appear to have been taken forward. When preparing this report we made up powdered formula for the main first milk brands following the manufacturers’ instructions, and 900g of dried powder made between 6,625ml and 7,520ml of milk, suggesting some variation in the energy density of milks per scoop if the final products meet similar compositional standards.

References

Chambers TL, Steel AE (1975). Concentrated milk feeds and their relation to hypernatraemic dehydration in infants. Archives of Disease in Childhood, 50, 610-615.

Department of Health and Social Security (1974). Present Day Practice in Infant Feeding. Report on Health and Social Subjects 9. London: HMSO.

Jeffs SG (1989). Hazards of scoop measurements in infant feeding. Journal of the Royal College of General Practitioners, 39, 113.

Lucas A (1992). Randomised trial of RTF compared to powdered formula. Archives of Disease in Childhood, 67, 935-939.

Renfrew MJ, Ansell P, Macleod KL (2003). Formula feed preparation: helping reduce the risks; a systematic review. Archives of Disease in Childhood, 88, 855-858.

It is recommended that powdered infant milks are made up using fresh water from the cold tap. Bottled water should only be used if it specifically states that it is appropriate for making up infant formula as some bottled waters have a high level of some minerals. It is recommended that bottled waters used to make up formula should have less than 200mg sodium (Na) per litre and less than 250mg sulphate (SO4) per litre and that they are boiled before for use for infants under 6 months of age (NHS, 2020). However most bottled water has significantly less sodium than 200mg/litre and choosing a water with a level of 20mg Na/litre or less would ensure that a made-up infant formula was closer in sodium composition to breastmilk.

There has been some discussion of the risks of using bottled water if an emergency arises and mains water supplies are disrupted. When there has been flooding tap water may become contaminated. Often in these circumstances bottled water is made available to households and it is important that in emergency situations clear information is given to parents and carers on whether it is safe to use this for making up infant milks. A review of the safety of bottled water for making up infant formula concluded that this is likely to be a safe alternative to mains water in the event of an emergency and this should be made clear in appropriate guidance (Osborn and Lyons, 2010).

Bottled water should be boiled before use in the same way as tap water in the instructions for making up powdered infant milks safely. Instructions can be found here www.nhs.uk

References

NHS (2020). https://www.nhs.uk/common-health-questions/childrens-health/can-i-use-bottled-water-to-make-up-baby-formula-infant-formula/

Osborn K, Lyons M (2010). Is bottled water really unfit for making up formula? Community Practitioner, 83, 31-34.

Independent information about breastfeeding, infant formula and infant and child nutrition is available from the following organisations and websites: