Helen Crawley and Victoria Sibson, First Steps Nutrition Trust – Written evidence (FPO044)
First Steps Nutrition Trust is a public health nutrition charity that supports good nutrition from pre-conception to five years, primarily through the provision of expert and independent information to health workers and policy makers. We will focus our evidence on issues relating to the early years of life. We are happy to discuss any of the following points further and to provide more information as required. Please contact firstname.lastname@example.org.
- Food insecurity and poor diets in pregnancy can have negative impacts on birth outcomes but there is currently no data available on food insecurity among pregnant women in the UK. Whilst young (under 18 years of age) and low-income pregnant women are eligible for the Healthy Start scheme, very few young women access the scheme and it is not known what proportion of eligible pregnant women do, or at what stage of their pregnancy. For more information on Healthy Start see the report ‘Healthy Start: What Happened? What next? available at www.firststepsnutrition.org/healthy-start.
- Women who are food insecure are more likely to be overweight or obese. Obesity also impacts on pregnancy outcome, with obese mothers more likely to have bigger babies (who are more likely to go on to be overweight and obese children), gestational diabetes, miscarriage, pre-eclampsia, thromboembolism and obesity increases the risk of maternal death.
- Food security for infants under 12 months old requires that they are breastfed (the optimal choice) and/or receive an appropriate first infant formula made up properly. For the first 6 months, babies only require breastmilk and/or infant formula. Infants may therefore experience food insecurity if carers who want to breastfeed cannot do so successfully, or if they cannot provide a safe and appropriate infant formula. From 6 months of age, infants and young children may also experience food insecurity if their carers cannot provide them with the balance of foods alongside milk, to meet their nutritional needs.
- The UK has persistently low breastfeeding rates. The most recent data indicates that only 58% of babies received breastmilk as their first feed (NHS Digital, 2019) and the drop off rate within the first weeks is extremely high (less than half of babies are still breastfed at 6-8 weeks of age (PHE, 2019)). Eight out of ten mothers who stop breastfeeding in the first weeks want to breastfeed for longer, but stop because they find it difficult, exhausting and painful and because they have not received skilled support (McAndrew et al, 2012). Negative social attitudes and a lack of familial support further undermine women’s efforts to breastfeed (Brown et al, 2011) as does the inappropriate marketing of breastmilk substitutes resulting from weak and poorly enforced legislation.
- Food insecurity in families who formula feed can be exacerbated by the high cost of infant formula, as outlined in the All Party Parliamentary Group on Infant Feeding and Inequalities report in 2018 (http://www.infantfeedingappg.uk/appg-inquiry-infant-formula-costs/). The costs of infant formula have risen substantially over the last decade and are highly variable despite regulations which ensure all are of a similar nutritional composition. Brands market ranges of infant milks with similar packaging to cross-promote their products, and to get around advertising restrictions on infant formula. Many families buy the more expensive products, believing they are the best for their baby. This can cause financial hardship and reduce the funds available for food for other family members. Some families even resort to overdiluting powdered infant formula to make it last longer, resulting in their baby not getting the nutrients he/she needs for healthy growth and development.
- The ‘Healthy Start’ welfare food scheme also provides food vouchers for low-income families with infants which allow them to purchase plain frozen fruits and vegetables, cows’ milk and first infant formula. However, the food voucher value has not been changed since 2009 and does not cover the current costs of infant formula. The scheme is also not designed to support breastfeeding. The eligibility and uptake of Healthy Start has also been in decline (particularly among young women) and numerous difficulties with the scheme mean it needs root and branch reform. This includes ensuring the system promotes and supports breastfeeding. For a full review of Healthy Start see the report: Healthy Start: what happened? What next? Available at https://www.firststepsnutrition.org/healthy-start.
- Breastfeeding is the normal way to feed an infant and provides many well documented health benefits for the mother and child (https://www.unicef.org.uk/babyfriendly/about/benefits-of-breastfeeding/):
- Breastfeeding protects children from a vast range of illnesses including infection, diabetes, asthma, heart disease and obesity, as well as cot death (Sudden Infant Death Syndrome).
- Breastfeeding also protects mothers from breast and ovarian cancers and heart disease.
- Breastfeeding supports the mother-baby relationship and the mental health of both baby and mother.
- The benefits of breastfeeding are seen in both high- and low-income countries: a study published in The Lancet in 2016 found that increasing breastfeeding rates around the world to near universal levels could prevent 823,000 annual deaths in children younger than five years and 20,000 annual maternal deaths from breast cancer.
- Very low rates of breastfeeding, consequent to lack of protection and support, remain a key barrier to lowering rates of childhood obesity. Childhood overweight and obesity tracks into adolescence and adulthood. Breastmilk is the optimal food for infants under 6 months of age and conveys nutritional and health benefits to babies for as long as breastfeeding continues. However, as outlined above, women can find breastfeeding difficult without support, and this is exacerbated in a context of inadequate legal protection. There is a lack of up to date data on breastfeeding beyond the first weeks, but the data that is available indicate important demographic and geographic differences. Younger white women in routine and manual occupations or those who had never worked have the lowest breastfeeding initiation rates (McAndrew et al, 2012). Overall, breastfeeding is less common in some of our poorest communities. James Grant who was Director of Unicef from 1980-1995 famously said:
‘Breastfeeding is a natural 'safety net' against the worst effects of poverty ... Exclusive breastfeeding goes a long way toward cancelling out the health difference between being born into poverty and being born into affluence ... It is almost as if breastfeeding takes the infant out of poverty for those first few months in order to give the child a fairer start in life and compensate for the injustice of the world into which it was born’.
- Geographically, initiation rates are highest in London and lowest in the North East of England. In certain localities (Brighton and Hove, and the London Boroughs of Kingston upon Thames, Lewisham and Tower Hamlets) over 50% of mothers are exclusively breastfeeding their 6-8 week old while between 71% and 86% are partially breastfeeding (PHE, 2019). Geographic differences suggest that improvements in breastfeeding practices are possible with greater practical and cultural support.
- The low breastfeeding rates seen in many of our poorer communities are the result of an entrenched bottle-feeding culture: to reverse this we need strategic action and leadership at a national level, as well as considering the role of local authorities. England needs to follow Scotland’s lead through the clarity of a national maternal and infant nutrition strategy, consistent and comprehensive investment in support services and full Unicef Baby Friendly accreditation for all of its maternity and health visiting services, all of which are contributing to higher breastfeeding rates and more appropriate infant feeding in the first year of life. Scotland has recently reviewed how it can better improve breastfeeding rates through participation in a global scheme called ‘Becoming Breastfeeding Friendly’ and has published its findings here https://www.gov.scot/publications/becoming-breastfeeding-friendly-scotland-report/. Wales recently produced its own breastfeeding strategy (https://gov.wales/sites/default/files/publications/2019-06/all-wales-breastfeeding-five-year-action-plan-july-2019_0.pdf ) using some of its learning from the Becoming Breastfeeding friendly project. England have not yet reported from the Becoming Breastfeeding Friendly Project and still have no strategy to improve breastfeeding rates or maternal and infant nutrition. It is therefore impossible to see how England will better support its poorest families to breastfeed successfully and reduce the inequalities that begin at birth. The Unicef Call to Action on breastfeeding highlights four key things that need to happen if we are to make change:
- Develop a National Infant Feeding Strategy Board including members from all relevant government departments and tasked with developing a comprehensive National Infant Feeding Strategy and implementation plan.
- Include actions to promote, protect and support breastfeeding in all policy areas where breastfeeding has an impact.
- Implement evidence-based initiatives that support breastfeeding, including the Unicef UK Baby Friendly Initiative, across all maternity, health visiting, neonatal and children’s centre services.
- Protect babies and their families from harmful commercial interests by adopting in full the International Code of Marketing of Breastmilk Substitutes.
- Local Authority-funded Children’s Centres, Health Visitors and other family services are essential to ensure lower income families can be supported to feed their infants and young children both well and cost-effectively. The decline in the number of Children’s Centres, the loss of Health Visitors and cuts to public health budgets across the country means that many families are now missing out on this support. Local authorities need to be assured of sufficient, ring-fenced funding to provide comprehensive services universally.
- Local authorities also have a role to play in improving the enforcement of existing legislation related to the marketing of infant formula and follow on formula via their Trading Standards officers.
- There are no mandatory standards for food in early years settings and many low-income children who benefit from the free 15 hours of childcare from 2 years of age and/or free 30 hours from 3 years of age do not qualify for free food in these settings. Early Years settings provide an ideal opportunity for children to learn about food, try new foods, eat well in a communal setting and for families to share some of that learning. Example menus and recipes are already available for early years settings as is practical advice on menu planning and food provision, but settings are currently not obliged to follow these recommendations.
- Food banks are a vital resource. However, supporting healthy eating for pregnant women and infants living in difficult circumstances requires more than ad hoc provision of free foods, infant formula and/or baby food. Food bank clients who are pregnant and/or care for infants and those requesting infant formula should be referred to health care professionals according to local referral pathways, so that the child can get the comprehensive and longer-term support that they require. See the BFLG-UK’s Food Bank Toolkit on supporting pregnant women and families with infants, available here: https://www.bflg-uk.org/news-and-events#publications
- There are UK regulations governing the marketing of infant formulas and follow on formulas. However, they are poorly enforced and inadequate in relation to the WHO International Code of Marketing of Breastmilk Substitutes (and subsequent World Health Assembly resolutions) and therefore do little to safeguard breastfeeding or to protect formula feeding families from exploitation. Cross-promotion of follow on formula and other branded milks and baby foods are intended to increase the sales of infant formula (https://www.who.int/nutrition/publications/infantfeeding/information-note-cross-promotion-infant-formula/en/). The Baby Feeding Law Group represents 26 health and family support organisations and their website contains information about the current laws, the WHO Code and why we need better legislation (www.bflg-uk.org).
- As per Code article 11.3, the breastmilk substitute industry and the retailers of their products need to held responsible for their marketing practices (“Independently of any other measures taken for implementation of this Code, manufacturers and distributors of products within the scope of this Code should regard themselves as responsible for monitoring their marketing practices according to the principles and aim of the Code, and for taking steps to ensure that their conduct at every level conforms to them”). They should also be properly held to account vis a vis current regulations, by their proper enforcement and the regulations need to be strengthened in line with the WHO Code.
- Infant feeding choices have an impact on the environment, and the global ‘Green Feeding’ project, coordinated by IBFAN (The International Baby Food Action Network), encourages countries to think about how infant feeding interacts with human and planetary health https://www.ibfan.org/infant-and-young-child-feeding-health-and-environmental-impacts/
- It is not just dairy based infant formula and other infant milks which are damaging for the environment but also commercially produced baby foods. All these industrial products are over-processed, over-packaged and over-promoted. They require energy and water to manufacture, materials for packaging, fuel for transport and water, fuel and cleaning agents for daily use. Commercial baby foods are also very expensive and families who see this as a healthy choice for their infants may find themselves spending a considerable proportion of the family food budget on unnecessary commercial foods. For more information on baby foods in the UK see https://www.firststepsnutrition.org/babyfood-composition
- Encouraging families to provide a sustainable and healthy diet for infants and young children has not received significant attention and yet establishing eating patterns among young children that they can carry with them into later childhood and adulthood would seem an essential and important part of ensuring both healthy, sustainable and cost-effective diets for the whole population. Clear information on how infants and young children can eat well sustainably and practically is needed, with early years settings and relevant health professionals able to provide consistent information.
- The current focus on promotion of breastfeeding, with limited support and inadequate legal protection is insufficient to improve breastfeeding practices. Breastfeeding support needs to
be made universally available, existing laws on marketing of infant milks need to be enforced and upgraded in line with the WHO Code, and statutory requirements are required to enable and support breastfeeding in the workplace.
- Many countries have food and nutrition policies and take a life course approach to ensure that the needs of all age groups are considered. Steps to tackle food security, poverty, health and the environment need to explicitly address the nutritional needs of pregnant women, infants and young children and their families.
Brown A, Raynor P and Lee M (2011). Healthcare professionals’ and mothers’ perceptions of factors that influence decisions to breastfeed or formula feed infants: A comparative study. J Adv Nurs 67, 1993-2003.
McAndrew F, Thompson J, Fellows L, et al (2012). Infant Feeding Survey 2010. https://digital.nhs.uk/data-and-information/publications/statistical/infant-feeding-survey/infant-feeding-survey-uk-2010
NHS Digital (2019). Maternity Services Monthly Statistics, England, May 2019. https://digital.nhs.uk/data-and-information/publications/statistical/maternity-services-monthly-statistics/may-2019/babies
PHE (2019). Breastfeeding at 6-8 weeks after birth: 2018 to 2019 quarterly data. https://www.gov.uk/government/statistics/breastfeeding-at-6-to-8-weeks-after-birth-2018-to-2019-quarterly-data
Helen Crawley and Victoria Sibson, First Steps Nutrition Trust
12 September 2019
Room 3.04, The Food Exchange, New Covent Garden Market, London SW8 5EL. E: Helen@firststepsnutrition.org T: 07590 289182
Trustees: Professor Amy Brown, Professor Barrie Margetts, Dr Vicky Thomas, Anna Rosier, Marjon Willers, Rob Percival
Director: Dr Helen Crawley