Submission to the APPGIFI inquiry on infant formula costs

The following response was submitted to the All Party Parliamentary Group on Infant Feeding & Inequalities (APPGIFI) inquiry on the costs of infant formula by Infant Feeding Support UK, who are now part of Feed. The report has since been published but there was a few key things they forgot to mention, in our opinion!

A heartfelt thanks once again to all of the families who contributed. Thank you to all of the parents who contacted us with comments and statements to forward to the inquiry. We were so grateful to receive your responses highlighting some common themes and we hope we have suitably conveyed your concerns to APPGIFI.

Question 1 a): How is the cost of infant formula affecting family food budgets in the UK?

Families report to us that the cost of formula is something they factor into their budget and they have to adjust accordingly. They feel that the restriction on special offers, vouchers or the ability to earn points on first infant formula is financially punitive and unfair.  One Mum said “you can earn points on breast pumps, nipple cream and nipple pads in Boots but if I buy formula I can’t. How is that fair?”

Question 1 b): Does the cost of infant formula impact on food purchasing for other family members?

In some cases, yes. Again, lack of ability to earn loyalty points on formula purchases was felt to be an issue as this makes up a substantial proportion of family food spending and could earn families points to spend on food for other family members.

Question 1 c): Does the cost of infant formula affect spending on other essential items?

In some cases, yes. Again, lack of ability to earn loyalty points on formula purchases was felt to be an issue as this makes up a substantial proportion of family food spending and could earn families points to spend on other essential items.

Question 1 d): Have you or other family members had to borrow money to provide infant formula?

Families who require specialist formulas, that cost substantially more than standard formula have had to borrow money to pay for formula. One mother wrote “I moved to the UK and the hydrolysed formula was way more expensive here. It cost me £22 for a 400g tub (compared to €16 for 800g where we had been living previously, which is still very expensive). I had to borrow money from my parents to help with formula costs until an NHS Paediatrician had confirmed the diagnosis & written us a prescription. Had the hydrolysed formula not been free on prescription there’s no way I could’ve afforded it and I have no idea what I would’ve done”. Infant Feeding Support UK strongly supports the free provision of infant formulas required for medical reasons on prescription.

Question 2 a): What factors affect choice of infant formula by families?

It seems that convenience is the key factor in choice. Most families told us they chose their infant formula brand based on the convenience of having a scoop leveller and a scoop clip in the lid! The ability to buy the same formula as ready to feed was also a deciding factor. Other reasons given for choice of brand included recommendation by a friend or family member, used that brand with a previous child, available as a follow on milk and cost.

Question 2 b): Was choice of infant formula affected by use of formula in hospital settings

Some parents reported being scared to change infant formula brands as they had not received adequate information on infant formula and had found information online that changing brands would cause distress to their infant. In those cases they chose to use the formula that the hospital had provided. Provision of information on infant formula to parents during the prenatal period would have given them the confidence to switch to a different brand.

Question 2 c): What recommendations have you received from health workers regarding choice of infant formula brand?

Parents have reported to us that following the focus on breastfeeding during infant feeding education, they are hesitant to ask HCP’s about infant formula. They turn to online groups and peers and can find conflicting advice. Parents also tell us that HCP’s appear reticent to discuss infant formula. One NHS midwife told us she is prevented by hospital policy from discussing the use of formula with parents until they bring the subject up “even when I can see supplementation would be beneficial”.

Question 3 a): What alternatives to infant formula are used to feed babies less than one year of age?

Most parents we have spoken to use first infant milk until a baby is a year old, with a smaller proportion choosing follow-on milks after 6 months of age for a variety of reasons, including the ability to earn loyalty points and thus relieve a tiny portion of the financial burden associated with the continuation of first infant milk. Parents expressed that they like having choice and they strongly reject the idea of plain packaging for infant formula or the notion that follow-on and toddler milks are unnecessary as had recently been suggested by the proposal of the Feeding Products for Babies and Children (Advertising and Promotion) Bill (HC Bill 95). These ideas were seen as punitive and removing parental choice.

Question 3 b): Where a family cannot afford infant formula, what other options do they use to feed their babies?

Parents and carers we consulted for this review adapted their budget to include formula and when money was tight cut other items from their food budgets, mostly for themselves. However, previously we have fielded many questions on dilution of infant formula or use of cows milk in children under a year old so this is clearly a concern for some families.

Question 3 c): In your opinion, do families get the support they need to make appropriate choices about infant formula use?

Not at all. Almost every formula feeding family of the thousands we have spoken to [over the past few years in our role as infant feeding advocates] state that they have received inadequate, misleading, judgemental or no information on infant formula from HCP’s. Infant feeding classes are labelled ‘breastfeeding classes’ and parents have been discouraged from talking about formula. One mum told us that in the class she attended at an NHS hospital in January 2018 she was told “don’t worry about formula” as “it is very rare that a Mum won’t produce breastmilk”. Another Mum told us that at the breast-feeding class she attended she was advised not to have formula in the house “or you’re setting yourself up to fail”. Unsurprisingly these Mums felt unable to ask for further information. These are by no means isolated incidents and this is a common theme we see across the board.

Question 4 a): What additional support should be provided to families who choose to use infant formula?

1. Equipment needed, cleaning, sterilising and storage. Bottle and teat types including that babies may prefer different types.

2. Types of formula (e.g. partially hydrolysed, hydrolysed, amino acid, soy etc.) and brand differences.

3. Safe formula preparation and storage.

4. Help in identifying feeding cues and normal vs abnormal infant feeding behaviours.

5. Help in identifying and resolving common formula feeding issues such as latch issues, identification of problems such as CMPA and other allergies, resolution of constipation etc.

6. Advice on combi-feeding.

7. Advice on changing formula brands.

8. Science based information on the efficacy (or not) of common feeding additives such as gripe water, infacol, probiotics, thickeners etc.

9. Inclusive infant feeding groups in which it is clear that all parents are welcome no matter whether they use infant formula, breastfeed or do both and in which negative language (e.g. ‘artificial milk’, ‘risks of formula feeding’) are avoided.

10. Inclusive, safe and science based infant feeding information provided throughout pre- and postnatal period. This would include absolute values for incidences of health issues associated with breast or formula feeding.

Question 4 b): How important is the Healthy Start scheme in supporting lower income families to buy appropriate formula?

Very, very important. We strongly support the continuation and expansion of Healthy Start.

Question 4 c): How could the Healthy Start scheme be expanded to offer better support to new mothers?

Vouchers specifically for the required amount of formula could be provided so that parents don’t have to make up the costs. Formula vouchers provided in addition to food vouchers so that other family members don’t have to go without in order to provide formula.

Question 4 d): What support should be provided to mothers who medically advised to formula feed, but do not have the financial resources to do so?

In addition to the points outlined in question 4a, parents who need to use formula for medical reasons should be provided formula free on prescription.

Question 5: Any further comments on the factors affecting infant formula choice, purchase and impact on family incomes?

Cost of infant formula is something that parents factor in when they are having a baby and some parents we talked to described it as irrelevant. They have expressed concern that the focus on cost is a distraction from the main issues facing them i.e. lack of inclusive infant feeding information and support for formula feeding in the pre and postnatal periods. One Mum expressed concern that the focus on cost of formula was “a false concern that will be used in the end to persuade mums to breastfeed because ‘it is cheaper’”. Many parents asked us why the costs they would experience by continuing to breastfeed aren’t considered in this review. These included lost earnings, cost of lactation consultants and breastfeeding aids including bras, creams, books, shields, shells, clothing and support group memberships. The cost of their baby’s readmission to hospital, their own treatment and occasionally readmission to hospital for breastfeeding complications (e.g. thrush, mastitis, breast abscesses and cellulitis) and the emotional costs that are more difficult to quantify exactly.

Parents expressed concern that while purchasing infant formula milks took a visible amount of money from their household budgets, this pales in comparison to the costs they would have incurred had they continued to breastfeed. We note that cost projections of money saved by breastfeeding don’t include the costs of readmission for infants affected by common infant feeding related conditions such as jaundice, hypoglycaemia and hyperbilirubinemia. Recent work published in the Journal of Paediatrics by Flaherman et al (2018) has shown that exclusively breastfed babies are more likely to be readmitted to hospital than their combination or exclusively formula fed peers. We are inclined to feel that any inquiry into the cost of infant formula milks should also account for these costs.

I confirm that I have read the Terms of Reference and Guidance on Written Submissions for the Inquiry – Yes

Would you be willing to be contacted to discuss your written submission? – Yes

Are you happy to have your consultation response published? – Yes

Would you be happy to give oral evidence at a future inquiry hearing? – Yes