Infant Milks in the UK: A Practical Guide for Health Professionals (February2017)

1. Why a guide is needed

The infant formula market in the United Kingdom is diverse and rapidly evolving. While breastfeeding remains the optimal source of nutrition, many families rely on commercially prepared infant milks for medical, social or personal reasons. Health professionals must therefore be able to:

• Identify the appropriate product for a given clinical situation.
• Explain the regulatory framework that assures quality and safety.
• Offer evidencebased advice on feeding practices and the management of common problems.

This guide summarises the key points from the February2017 evidence review, aligning them with current UK legislation and clinical best practice.

2. Regulatory environment

2.1 The EU FoodforSpecialMedicalPurposes (FSMP) and Infant Formula Regulations

In 2017, infant formula (IF) and followon formula (FOF) were governed by EU Regulation 609/2013 (as amended by Commission Delegated Regulation 2020/65). Key requirements include:

• Mandatory nutrient composition (e.g., protein, fat, carbohydrate, vitamins, minerals).
• Limits on contaminants such as heavy metals, dioxins and pesticide residues.
• Labelling that must contain a growing up statement, preparation instructions, and a clear declaration that breastfeeding is best.

2.2 UK-specific considerations postBrexit

Following the transition period, the UK retained the EU standards under the Food Safety Act 1990 and the Food (Composition and Labelling) Regulations 2019. Products already on the market continued to be sold, and any new formulations must meet these retained standards.

3. Classification of infant milks

Infant milks are grouped according to the age range they are intended for and their intended purpose.

3.1 Standard infant formula (IF)

For infants from birth up to6months. Must contain:

• At least 1.8g protein per 100kcal.
• Essential fatty acids (LA and ALA) and longchain polyunsaturated fatty acids (DHA, ARA) optional but recommended.
• Minimum levels of iron (0.8mg/100kcal) and vitamin D (10g/100kcal).

3.2 Followon formula (FOF)

For infants 6months and older, complementing solid foods. Composition is slightly lower in protein and higher in iron and vitamin D compared with IF.

3.3 Growingup milks (GUM)

Targeted at children aged 12months to 3years. They are **not** a replacement for a balanced diet and are only recommended when there is a specific nutritional need.

3.4 Therapeutic milks (FSMP)

Designed for infants with diagnosed medical conditions (e.g., cowmilk protein allergy, metabolic disorders). These products are prescribed and must be used under specialist supervision.

4. Choosing the right product a decisionmaking framework

Use the following algorithm when advising a family:

1. Assess the infants age and health status. If the infant is <6months and healthy, standard IF is the first choice.
2. Identify any clinical contraindications. Look for signs of allergy, lactose intolerance, or metabolic disease.
3. Consider special formulation needs. For cowmilk protein allergy, use a hypoallergenic extensively hydrolysed formula or an aminoacidbased formula if severe.
4. Check for feeding difficulties. Thickened formulas may aid infants with reflux; lowenergy dense formulas help premature infants.
5. Review parental preferences and cultural factors. Some families request organic, soybased or goatmilk derived formulas; ensure they meet legal nutrient standards.

Document the decision and provide written information that includes preparation instructions, storage guidance, and when to seek further medical review.

5. Common clinical scenarios

5.1 Cowmilk protein allergy (CMPA)

Approximately 23% of infants develop CMPA. Recommended approach:

• First line: Extensively hydrolysed formula (eHF) proven to support growth and reduce allergic symptoms.
• If eHF fails or the infant has severe anaphylaxis: Aminoacidbased formula (AAF).
• Breastmilk feeding with maternal allergen avoidance is an alternative when possible.

5.2 Preterm or lowbirthweight infants

These infants have higher nutrient needs. Use a preterm formula that provides:

• Higher protein (2.53.0g/100kcal) and energy (8090kcal/100ml).
• Increased calcium, phosphorus and vitamin D to support bone mineralisation.
• Close monitoring of weight gain (aim 15g/kg/day).

5.3 Infant with gastrointestinal malabsorption

For conditions such as cholestasis or shortbowel syndrome, consider:

• Mediumchain triglyceride (MCT) enriched formulas.
• Elemental (AAF) formulas when fat malabsorption is severe.

5.4 Iron deficiency anaemia

After six months, ironfortified IF or FOF should be continued. If anaemia persists, evaluate for additional supplementation (e.g., ferrous sulphate drops) and review dietary intake.

6. Practical advice on preparation and storage

• Always wash hands and sterilise feeding equipment.
• Use water that is at least 70C for the first preparation; allow to cool to 37C before feeding.
• Follow the manufacturers powdertowater ratio precisely; avoid overconcentration.
• Prepared formula can be stored at 4C for a maximum of 24hours. Discard any leftovers after a feed.
• Never reuse a bottle that has been partially consumed.

7. Monitoring growth and development

Growth monitoring remains the cornerstone of infant nutrition assessment.

Deviations from expected growth trajectories should trigger a review of feeding practices, formula type, and potential underlying pathology.

8. Communication with families

Effective counselling includes:

• Using nonjudgmental language and respecting parental choices.
• Providing clear written instructions and visual aids.
• Explaining the bestpractice hierarchy breastmilk first, then appropriately prescribed formula.
• Highlighting that growingup milks are not necessary for most children and may displace nutrientdense foods.

9. Key resources for professionals

• British Dietetic Association Infant Feeding Guidelines (updated 2022).
• National Institute for Health and Care Excellence (NICE) NG30: Infant feeding.
• European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Position papers on formula composition.
• UK Food Standards Agency Food Labelling Regulations.

10. Summary

The February2017 practical guide provides a concise framework for selecting, prescribing and supporting the use of infant milks in the UK. By understanding the regulatory backdrop, product classifications, and evidencebased clinical pathways, health professionals can ensure safe, nutritionally adequate feeding for all infants, regardless of their feeding method.