On July 19th 2017, Public Health England (PHE) published a draft of the Scientific Advisory Committee on Nutrition (SACN) 'Feeding in the First Year of Life' report. SACN comprises independent experts that advise the government on issues related to nutrition, diet and health.
The report is out for public consultation until 13th September 2017 and any changes to government advice on infant feeding will be provided once the consultation is complete.
Background to UK recommendations on infant feeding
This is the first comprehensive UK government scientific review on infant feeding since the Committee of Medical Aspects of Food Policy (COMA) published the ‘Weaning and the weaning diet’ report in 1994. The most significant change to UK infant feeding recommendations since the COMA report was in 2001 when SACN endorsed the World Health Organization’s (WHO) recommendation that infants should be exclusively breastfed for the first 6 months of life (the previous UK advice was for solid foods to be introduced between 4 and 6 months).
What changes might there be to infant feeding recommendations?
Existing advice to breastfeed exclusively for around the first 6 months, after which complementary foods should be introduced alongside continued breastfeeding, has been upheld by this report and it’s emphasised that offering complementary foods before 4 months is associated with increased risks of gastrointestinal, respiratory and ear infections in infants. The report highlights the continued need to increase breastfeeding rates and to support women in breastfeeding for as long as possible. Recommendations around avoiding adding sugars and salt to complementary foods, limiting infants’ intake of sugars-sweetened drinks, vitamin D supplementation, introducing non-valve free-flowing cups at 6 months, discouraging bottle feeding from 12 months, and not giving cows’ milk as a main drink to infants aged under 12 months have not changed.
SACN make the new recommendation that routine vitamin A supplementation in infants (see here) should be reviewed due to the low uptake of supplements and low prevalence of vitamin A deficiency in infants in the UK. Wording around existing advice that peanuts and hens’ eggs can be introduced from 6 months may be modified in light of SACN’s recommendation that deliberate exclusion of these foods during the 6-12 month complementary feeding period can increase risk of allergy to these foods. For the first time, behavioural aspects of complementary feeding were considered by SACN and familiarising infants with a wide range of flavours and textures from 6 months is highlighted as important, although no recommendations are made about appropriate parental/caregiver feeding styles (e.g. responsive feeding).
Recommendations from the draft report
SACN’s draft report covers the following topics: infant feeding, growth and heath; energy requirements; infant feeding, body composition and health; micronutrients; eating and feeding of solid foods; oral health; UK infant feeding practices; risks of chemical toxicity in relation to the infant diet; and risks arising from the infant diet and development of atopic and autoimmune disease.
The main recommendations are:
- The evidence reviewed for this report strengthens current guidance to breastfeed exclusively for around the first 6 months of the infant’s life and to continue breastfeeding throughout the first year. This makes an important contribution to infant and maternal health.
- Given the rapid decline in the proportion of women breastfeeding over the first few weeks of an infant's life, greater focus should be given to reducing the numbers of women who give up on breastfeeding and supporting women who make the informed choice to breastfeed for as long as possible. Increasing the proportion of women who continue to breastfeed or express breast milk beyond 6 months of age would yield additional health benefits.
- Current advice that most infants should not start complementary foods until around the age of 6 months, having achieved developmental readiness, should continue. No infant should commence complementary feeding prior to 4 months of age.
- First complementary foods should be encouraged from around 6 months of age and should include a wide range of foods and flavours, including iron- and calcium-containing foods.
- Dietary and texture diversification should proceed incrementally throughout the complementary feeding period, taking into account the variability between infants in developmental attainment and the need to satisfy nutritional requirements. When introducing new foods it should be recognised that they may need to be presented on many occasions before they are accepted, particularly as infants get older.
- In view of higher than recommended salt (sodium chloride) and sugars intakes in this age group, there is a need to re-emphasise the risks associated with adding salt and free sugars to infants’ food during the complementary feeding period.
- To optimise iron status throughout the first year of life, NICE and SACN recommendations on delayed cord clamping should be implemented and monitored. Healthy infants of appropriate birthweight do not require iron supplements. In keeping with current advice, cows’ milk should not be given as a main drink to infants under 12 months of age. Infants should be offered breastmilk, formula or water.
- The low prevalence of vitamin A deficiency in the healthy infant population, despite the current low uptake of supplements, suggests the need to review recommendations on routine vitamin A supplementation.
- The government should keep the risks to infants from vitamin A, lead, soya-based formulas, acrylamide and arsenic under review. Efforts to reduce the levels of inorganic arsenic in food and water, and levels of acrylamide in commercially produced and home-cooked foods should continue. In addition, government should consider opportunities to strengthen advice in relation to supplements and foods containing vitamin A. The use of soya-based formula should only be on medical advice.
- Existing guidance relating to dental caries prevention in under 3 year olds includes:
- from 6 months of age infants should be introduced to drinking from a nonvalve free-flowing cup to enable children to learn the skill of sipping, which is important in the development of the muscles used for talking. From age one year onwards, feeding from a bottle should be discouraged;
- sugar should not be added to complementary foods or drinks;
- the frequency and amount of sugary food and drinks should be reduced. Only plain milk or water should be provided between meals and offering baby juices or sugary drinks at bedtime should be discouraged.
- Advice on complementary feeding should state that foods containing peanut and hen’s egg need not be differentiated from other complementary foods. Complementary foods should be introduced in an age-appropriate form from around 6 months of age, alongside continued breastfeeding, at a time and in a manner to suit both the family and individual child.
- The deliberate exclusion of peanut or hen’s egg beyond 6 to 12 months of age may increase the risk of allergy to the same foods. Once introduced, and where tolerated, these foods should be part of the infant’s usual diet, to suit both the individual child and family. If initial exposure is not continued as part of the infant’s usual diet, then this may increase the risk of sensitisation and subsequent food allergy. Families of infants with a history of early-onset eczema or suspected food allergy may wish to seek medical advice before introducing these foods.
- There is a need to reinstate a form of national monitoring of the incidence and prevalence of breastfeeding, use of nutritional supplements, and use of foods other than breastmilk in infancy. The questions and definitions previously adopted in the 5-yearly Infant Feeding Survey should be used in order to allow tracking of secular trends and changes in practice consequent to new recommendations and guidance.
Comment from BNF
BNF welcomes the publication of SACN’s comprehensive 'Feeding in the First Year of Life' report. Following public consultation and publication of the final report, government advice for parents and health professionals on infant feeding (e.g. www.nhs.uk/Conditions/pregnancy-and-baby/Pages/solid-foods-weaning.aspx and www.nhs.uk/start4life) is likely to be modified. However, the report indicates that core messages related to breastfeeding, age of introduction to solid foods and diet during the complementary feeding period are unlikely to change.