Which infant formula is the best?

UPDATE 3 February 2010: In response to some of the comments on this post, I have produced a short online film with information which I hope is useful for understanding the differences between brands and I will be maintaining a page on the formulas on the UK market. See:

Now back to the original post....

There has been a lot of discussion about the advertising of infant formula following the Wyeth/SMA promotion with an article on Katie Price (Jordan) and Peter Andre in OK! Magazine. See:

I've seen a couple of comments suggesting that the ban on formula advertising and other measures called for by the Baby Feeding Law Group and Breastfeeding Manifesto coalition in the UK is wrong. Similar bans on company promotion have been called for in recent days in China and Australia.

The comments suggest that advertising is necessary for mothers to gain information on infant formula so they understand which is the best for their baby. Campaigners argue that this information should not come from companies, which profit from a mother's decision, but through independent information from health workers.

Mothers who choose to use formula, for whatever reason, want to know which formula is best, which is closest to breastmilk. The government line is all formulas have to comply with composition standards and so any cow's-milk-based formula that is on the market is suitable for use as a breastmilk substitute (soy formulas and goat's milk formulas are another matter, but more on those another time).

This perhaps does not meet the demand of mothers for information. I read someone describing having to select a brand of formula from a cupboard in the hospital, with nothing to go on from the health workers as to which was the best.

So I am going to attempt to answer the question by looking at the information available from companies, information that would be advertised freely if the present weak marketing restrictions were not in place.

At first sight it seems easy to say which infant formula is the closest to breastmilk. Just read the labels.

Click on the image for a larger version.

Here is the red rectangle at the top right a little larger:

So if you can believe what is on the label, Milupa Aptamil claims it is 'The closest to breastmilk', presumably because 'prebiotics support natural defences'. As this has been sold in the UK for years with this claim, you could be forgiven for assuming that Milupa's claim to be the closest must be true. If it wasn't then surely the authorities would have done something about it.

Well, belatedly they have told Milupa to remove both these claims. Last year the Food Standards Agency wrote to the companies saying that claims such as this are 'non-compliant' with the UK law. See:

If you look around you will see this label is disappearing from the shelves. The new label says: "Inspired by breastmilk" - which again is non-compliant with the regulations. The law is clear. Guidance notes issued to Trading Standards officers set it out. There are only 6 claims which are permitted on labels. Don't take my word. You can download the guidance notes to read for yourself - click here.

Okay, you may say. That is the problem with regulations. If Milupa Aptamil really is the 'closest to breastmilk' then why can't the company say it?

UPDATE 22 July 2009: Since this post, the Aptamil brand has been relaunched with a new ingredient, branded as IMMUNOFORTIS. The Aptamil brand has also been taken over by Danone. An advertisement for Aptamil follow-on formula claimed: "This unique formulation helps to support your baby's natural immune system, making it the best follow on milk." I asked the UK Advertising Standards Authority to investigate whether these claims were true. Although the ASA refuses to even investigate most cases, this time it do and found the claims are not true. The ASA found the company had broken the advertising code clauses on substantiation, truthfulness and comparisons. See:
Even without this ruling there was an immediate problems about the claim that Aptamil is the best formula (as the original posting continues....)

This is a recent image from the Cow & Gate website:

It is also about prebiotics, like the Milupa Aptamil 'closest to breastmilk' claim and shows Cow & Gate is ahead of 'normal infant formula' in the race to be closest to breastmilk.

Again, you may say, well if it is not true that Cow & Gate is closest to breastmilk, they wouldn't be able to say it. Here there is a problem. Baby Milk Action has reported promotions on websites to the authorities many times without any action being taken. This is because the internet falls into a regulatory black hole. The Infant Formula and Follow-on Formula Regulations were introduced in 1995 and the internet wasn't a big route of information then, so doesn't figure. The advertising industry's self-regulatory body, the Advertising Standards Authority (ASA), refuses to examine content on websites. The ASA says it is not advertising. People choose to visit a website, they argue, so it is editorial content and there is no requirement for it to be "legal, decent, honest and truthful" as with other forms of advertising. Most print and television advertisements direct people to a website for information, but still you get nowhere with the ASA.

So there are no grounds for trusting what is on a company website. You might think you will believe the company is being honest.

Well, Cow & Gate has made its claim about prebiotics in a printed advertisement. It claimed: "Our range of follow-on milks all contain a bunch of goodies called prebiotics to help build natural defences."

This was for a follow-on milk, for the simple reason that it is illegal for companies to advertise infant formula. If some of the critics of our campaign have their way, companies would be free to advertise infant formula with claims such as this.

As I said above, there is a requirement that print advertisements must be "legal, decent, honest and truthful" so the Advertising Standards Authority (ASA) did investigate this claim about the formula that 'prebiotics help build natural defences' after a request from a mother. They asked Cow & Gate to provide the scientific proof and they found that the claim was not substantiated. The ASA upheld the complaint and told Cow & Gate it could not repeat this claim in an advertisement and stated: "Because they had not sent evidence to show a direct link between an infant taking their formula and it helping to build defences against a number of everyday illnesses or conditions to which they were susceptible, we considered that Cow & Gate had not substantiated the claim."

This ruling does not prevent Cow & Gate making exactly the same claim on its website or in other materials. Only a revised law would do that.

Okay, so the claims about prebiotics don't stand up. The most the ASA will let them say is prebiotics support 'some' natural defences, though this is not a permitted claim for infant formula.

Could it still be possible that Cow & Gate formula really is the closest to breastmilk?

There is another problem.

Heinz/Farley's have distributed a flier to clinics with this graph:

It says on the top: "No. of Nutrients Closest to Breast Milk". Breastmilk is in the red. Farley's is next to it in brown and is clearly better on this graph than the SMA, Milupa and Cow & Gate. So, on the basis of its graph, Farley's claims its formula is the 'Best Formula'.

This was on a flier for health workers, because companies can promote infant formula to health workers. Again you might think they wouldn't be able to say this if it was not true. Strictly speaking that is correct, because information for health workers has to be scientific and factual. However the basis of the claims in such materials does not stand up to much scrutiny and because of the weak state of the current law it is difficult to persuade the authorities to take any action.

If, as some suggest, companies are allowed to advertise infant formula, we would probably see graphs like this appearing in advertisements in parenting magazine and, who knows, OK! Magazine.

Would it mean mothers are better informed? On the basis of the information so far, we have learned that Milupa claims to be the closest to breastmilk, so does Cow & Gate and so does Farley's.

Wyeth/SMA claimed it was 'closer to breastmilk' until the crackdown on illegal claims. Its new slogan is 'love the milk you give' and it claims its formula has a 'new improved protein balance'. So perhaps SMA is the closest to breastmilk?

Looking at what companies say about themselves we are none the wiser.

What about some of the other claims they make? Can that help us decide?

I've already discussed the 'prebiotics help support your baby's natural defences' claim, which the ASA ruled against. Most companies make similar claims.

They are all promoting added LCPs in their formulas. These are Long Chain Polyunsaturated Fatty Acids. For example, Wyeth/SMA formula stated before the crackdown: "Helps brain & eye development." That was 'non-compliant', as the official guidance note to Trading Standards officers states.

You may say that taking this information from labels is denying mothers valuable information. But how reliable is the information Wyeth/SMA put on its labels in breach of the law?

An independent review of the science found: "At present there is little evidence from randomised trials of LCPUFA supplementation to support the hypothesis that LCPUFA supplementation confers a benefit for visual or general development of term infants".

This is from a review by a respected academic institute called The Cochrane Library. Don't take my word for it. You can read it yourself. Find the links here:

Companies love using these claims to promote their products. They know it makes them more attractive to consumers. Even if an ingredient has no proven benefit they will add it to use it in their marketing campaigns, exploiting whatever loopholes in the law they can to put across their message.

This is what market analysts Hambrecht & Quist said about the company Martek, which supplies the LCPs for most of the formula in the world, with its product launched as Formulaid:

"The history of infant formula has shown that virtually all similar examples have led to wide-scale introduction of such additives into infant formula, even if there was no evidence that the additives were important. Infant formula is currently a commodity market with all products being almost identical and marketers competing intensely to differentiate their product. Even if Formulaid had no benefit we think that it would be widely incorporated into most formulas as a marketing tool and to allow companies to promote their formula as 'closest to human milk.'"

So which is the best infant formula? If you try to decide on the basis of what companies tell you, then you get nowhere. They are commercial organisations and aim to convince that their formula is the best.

The official line that there is nothing to choose between the brands comes from the requirement that they comply with compositional standards. See article 8 of:

The logic is that infants should have the best formula possible. So the regulations require all formulas to contain the ingredients that are proven to be necessary and to have a beneficial effect.

A few points to close. I haven't mentioned Hipp formulas above. I am really concerned about their labels. As I wrote recently, powdered infant formula is not a sterile product and so may contain bacteria, which may lead to infection. The good news is there are simple steps to deal with this. The World Health Organisation states: "preparation of Powdered Infant Formula with water at a temperature of no less than 70 °C dramatically reduces the risk." The bad news is that Hipp says on its labels: "Boil water and leave to stand until temperature reaches 50 - 60 Deg. C".

Companies are lax in providing information on the importance of breastfeeding and the difficulty of reversing a decision not to breastfeed and the financial and other costs of using formula. But this is not just about protecting breastfeeding, it is about making formula feeding safer. Companies are required by law to include information on the health hazards of inappropriate foods or feeding methods, and, in particular, the health hazards of improper use of an infant formula.

Other companies do not give the important information on temperature of the water for mixing up powdered infant formula or warn parents that powdered infant formula is not sterile. See:

Another point is there is increasing medicalisation of infant feeding. Companies roll out specialised formulas. The claims for these need close scrutiny. I will go into these another time. It seems to me these confuse health workers as much as they confuse parents. The information companies distribute is not limited to scientific and factual information. Worse than that, companies offer gifts to health workers to try to get them to promote their particular brand.

It seems to me the present situation is highly unsatisfactory. But I don't see that scrapping regulations on formula companies, as some are suggesting, will make it better .

What do you think? Contact me or leave comments here. If you are a mother or carer using formula I particularly want to hear from you.

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