Professional and non‐professional sources of formula feeding advice for parents in the first six months

Abstract

1. INTRODUCTION

Breastfeeding provides many health benefits to both the mother, such as reduced risk of diabetes, breast and ovarian cancer, and infant, such as reduced risk of ear and respiratory tract infections, dermatitis, asthma and diabetes (Ip, Chung, Raman, Trikalinos, & Lau, 2009). Breastfeeding exclusively for the first six months of life and continuing breastfeeding alongside solid foods up to two years of life is the current recommendation from the World Health Organization (World Health Organization, 2018). Yet, many infants are fed with infant formula, alongside or in place of breast milk. In the most recent national infant feeding survey in Australia it is reported that at age one month 40.3%, and at six months 55.1%, of infants had consumed non‐human milk or infant formula (Australian Institute of Health and Welfare, 2011), but the report did not specify a difference between formula and any other non‐human milk (Amezdroz, Carpenter, O'Callaghan, Johnson, & Waters, 2015). More recent Australian studies based in two different states provide more specific data of the frequency of formula. In one study from the state of Victoria (n=466), 60% of infants aged between one and three months and 75% of infants aged between six and eight months were consuming formula (Amezdroz et al., 2015). In another study from the state of Queensland (n=202), at six months of age, 46.3% of infants were consuming formula (Newby & Davies, 2015).

Considering this high prevalence of formula feeding it is important that parents who are formula feeding their infants are provided with advice on both correct preparation and best practice formula feeding. This is important as formula feeding is related to adverse health outcomes such as rapid weight gain (RWG; Appleton, Russell, et al., 2018; Mihrshahi, Battistutta, Magarey, & Daniels, 2011) and overweight or obesity (Wen, Baur, Rissel, Xu, & Simpson, 2014). It is not clear what proportion of parents formula feeding follow preparation guidelines correctly. Research from the United States (n=1533) found that up to 55% of parents reported incorrect practices (Labiner‐Wolfe, Fein, & Shealy, 2008), and research from the United Kingdom (n=15 724) found that up to 51% of parents reported incorrect practices (McAndrew et al., 2012). There is no recent research from Australia. Regarding the relationship between formula feeding and RWG, a recent systematic review found that formula with higher protein content, adding cereals into the formula or providing more frequent or larger feeds than an infant requires, could contribute to an infant experiencing RWG (Appleton, Russell, et al., 2018). The review also found that unresponsive feeding practices such as putting an infant to bed with a bottle and feeding to a schedule rather than infant demand may also contribute to an infant experiencing RWG (Appleton, Russell, et al., 2018). Providing information to parents on correct preparation and best practices to implement when feeding with formula may reduce the risk of these negative health outcomes.

Parents rely on a number of sources for advice on infant feeding, including their own experience, non‐professional sources (such as family, friends and online) and professional sources (such as doctors, nurses, midwives and pharmacists; Chouraqui et al., 2018; Eisenberg et al., 2015; Gildea, Sloan, & Stewart, 2009). Evidence suggests that first time, younger mothers and those with infants less than 12 months old were most likely to seek health professional advice (Chouraqui et al., 2018). Generally, in Australia, breastfeeding information is readily available and accessed (Newby, Brodribb, Ware, & Davies, 2015) and increasing breastfeeding rates is a public health priority (Council of Australian Governments Health Council, 2019). However, some have argued that this important focus on breastfeeding has contributed to a lack of information about formula (Hvatum & Glavin, 2017; Lagan, Symon, Dalzell, & Whitford, 2014; Lakshman et al., 2012). Many of those parents who are formula feeding do not get information from health professionals (Lagan et al., 2014; Lee, 2007a) and may instead rely on other information sources such as family, friends (Berry, Jones, & Iverson, 2011) or the tin (Smith et al., 2016). In a study in Australia, mothers of six‐month‐old infants were asked about a range of professional and non‐professional sources of information for their infant feeding. Although 51% were formula feeding or mixed feeding (with breast and formula milk), only 38% had ever obtained information about formula feeding from health professionals (Newby et al., 2015). In an Irish study, parents who were formula feeding indicated that they relied upon more non‐professional sources as their main sources of infant feeding information compared with those who were mixed feeding; 72.3% of mothers formula feeding used non‐professional sources compared with 58.6% of mothers mixed feeding (Tarrant, Sheridan‐Pereira, McCarthy, Younger, & Kearney, 2012). Similarly, other studies in the United Kingdom have found that those mothers currently breastfeeding feel more supported by health professionals compared with those mothers mixed feeding (Komninou, Fallon, Halford, & Harrold, 2017) and those mothers formula feeding from birth were more likely to name family as a source of information (Fallon, Komninou, Bennett, Halford, & Harrold, 2016). A lack of information contributed to mothers feeling uncertain and unsafe in their practice when they first started using formula (Ellison et al., 2017; Hvatum & Glavin, 2017) and contributed to a feeling of guilt for not breastfeeding (Hvatum & Glavin, 2017; Lagan et al., 2014; Lee, 2007a).

Other studies suggest that there is a gap in the provision of infant formula feeding advice and support within some health services (Berry et al., 2011; Dykes, Richardson‐Foster, Crossland, & Thomson, 2012; Hegedus & Mullan, 2015). A qualitative study with health professionals in two maternity or primary health care sites in North‐west England found a focus on breastfeeding promotion and a lack of resources, such as time and access to information, impeded their ability to provide support to those mothers who were formula feeding (Dykes et al., 2012). A qualitative discourse analysis of group antenatal education classes run by midwives in Australia found that formula feeding was only portrayed negatively and specific formula feeding information was not discussed (Fenwick, Burns, Sheehan, & Schmied, 2013). In another study of maternal and child health nurses (MCHNs) from two local health districts in the Australian state of Victoria, all were “very confident” in providing both breastfeeding and formula feeding advice, but although 59.3% routinely provided advice and support on breastfeeding, only 37% routinely provided advice on correct formula preparation (Laws et al., 2015).

Non‐professional sources of formula feeding advice include the family, friends (Berry et al., 2011; Cairney & Barbour, 2007; Nevo, Rubin, Tamir, Levine, & Shaoul, 2007), advertising (Berry et al., 2011) and the tin/packet (Labiner‐Wolfe et al., 2008; Lakshman et al., 2012; Smith et al., 2016). Importantly, these sources may not provide evidence‐based information and could be inaccurate. A recent review of infant care and feeding found around 20% of infant care and feeding advice given by family was not in line with current health care recommendations (Eisenberg et al., 2015). Furthermore, advertising and the information on the tin/pack are formula marketing, which aims to influence attitudes and social norms in communities to promote the use of their products (Piwoz & Huffman, 2015) and is therefore lest trustworthy than health professional advice. Although some of the information on the tin is regulated, such as the ingredients and nutrients lists, preparation table and warning statement (about correct preparation and that breastfeeding is the optimal infant nutrition), other information found on the tin, in stores or on the formula manufacturers' website are not (Food Standards Australia New Zealand, 2017). This marketing will be biased in favour of their particular brand of formula. This marketing may also influence the advice provided to parents. Indeed, research about perception of formula advertising indicates that mothers, grandmothers and health professionals alike trust advertised health messages (Berry et al., 2011).

Parents expect that health professional will be a source of support for infant feeding (Sheehan, Schmied, & Barclay, 2009). In Australia, health professionals such as MCHN and midwives provide information, advice and resources to parents as a core part of their role in caring for infants and their parents during the infant's first year. Midwives primarily work within the hospital setting and so they see women and infants in the early postnatal period, although some work in primary health care community settings. MCHN primarily work in primary health care community settings; they can provide routine vaccination, infant health checks (which include discussing infant feeding) and support to new parents; this may include home visiting, but this varies within the different states and territories. Similarly, practice nurses (PNs), who work alongside General Practitioners, may also see infants during their routine vaccinations and infant health checks as parents can choose to do these with the MCHN service or at their general practice. Pharmacists may also come in contact with parents during their infant's first year, particularly with those using formula, as this is one of the places formula can be purchased as well as in the grocery store or online.

There are potential negative health outcomes for infants fed with formula (Appleton, Russell, et al., 2018; Mihrshahi et al., 2011) and negative emotional experiences for mothers (Hvatum & Glavin, 2017; Lagan et al., 2014; Lee, 2007a) that could possibly be avoided or diminished if these mothers are provided formula feeding advice and support. Health professionals such as MCHN or midwives are well placed to give this advice and support (Eronen, Pincombe, & Calabretto, 2010; Redsell et al., 2013; Redshaw & Henderson, 2012). However, some parents feel unsupported by these professional sources (Komninou et al., 2017; Thomson, Ebisch‐Burton, & Flacking, 2015) and may rely on non‐professional sources (Tarrant et al., 2012). One recent Australian study found that only 38% of mothers had ever obtained information about formula feeding from health professionals, and overall the mothers sought less formula feeding advice than breastfeeding advice (Newby et al., 2015). But this study did not investigate any difference between professional and non‐professional advice or difference in advice seeking between those breastfeeding and those formula feeding. The aim of this paper is to explore the sources of advice (professional and non‐professional) used by parents using formula to feed their infants, to explore factors associated with receiving formula feeding advice from professional or non‐professional sources and to compare the sources of advice used by those formula feeding and those breastfeeding their infants. To meet these aims, a secondary data analysis of an Australian cohort study was conducted.

2. METHODS

3. RESULTS

4. DISCUSSION

Four fifths of mothers who were formula feeding their infant at six months of age received advice from both professional and non‐professional sources. However, a fifth of mothers formula feeding reported receiving no advice from any professional sources, and almost all reported that the tin/packet of formula was the predominant source of advice. For a minority the tin/packet was the only source of helpful advice. This supports other studies showing that parents feeding with formula depend on marketing and commercially provided information (Berry et al., 2011; Tarrant et al., 2012; Trickey & Newburn, 2014). It is unclear which aspects of the information on the tin parents use, but it may be both the regulated information and advertising. Previous research has identified that neither mothers nor health professionals regard the information on the tin as advertising, but rather as a source from which you can check the advertised claims by reading the information provided on the tin (Berry et al., 2011). This information on the tin as well as other marketing does influence formula feeding practices: information from the feeding tables, which provide estimates of the amount and number of feeds an infant needs, influence how much formula parents offer (Appleton, Laws, et al., 2018; Lakshman et al., 2012; Russell et al., 2016) and marketing via health professionals and direct to consumer influences the choice of formula (Appleton, Laws, et al., 2018; Huang, Labiner‐Wolfe, Huang, Choiniere, & Fein, 2013).

Although it is unsurprising that the information on the tin is used, because it is readily accessible, it is an important finding to highlight. The Marketing in Australia of Infant Formulas (MAIF) agreement, which is the enactment of many of the principles of the WHOs' International Code of Marketing of Breast Milk Substitutes (World Health Organization, 1981), regulates advertising of formula, including what is on the tin (Australian Government Department of Health and Ageing, 2003). Under the MAIF agreement, which is voluntary, infant formula (for infants up to age 12 months) advertising is regulated and advertising to the general public is banned, but toddler formula is not included. Toddler formula advertising is often interpreted as advertising for all types of formula (Berry et al., 2011; Cattaneo et al., 2015). Further research is need to understand how all the information on the tin is interpreted by parents and how it influences their formula feeding practices, with policy implications about how successfully the MAIF attains its aim of the “… protection and promotion of breastfeeding.. by ensuring the proper use of breast milk substitutes, when they are necessary, on the basis of adequate information and through appropriate marketing and distribution” (Australian Government Department of Health and Ageing, 2003, p. 1).

Other non‐professional sources identified in this research were family, friends and online. Reports of how helpful or unhelpful these sources of advice were were mixed: advice from friends was found to be helpful for just over half the participants, but family was reported as the most unhelpful source. This may reflect the mothers' trust or distrust in the quality of the advice given by these sources. Other research about general infant feeding information sources found that parents trusted other parents (Bramhagen, Axelsson, & Hallström, 2006) and family often gave out‐dated advice that was not in line with current recommendations (Redsell et al., 2013). Regarding advice from online sources, the current study found that around 80% of mothers breastfeeding used advice from online sources but only around 50% of mothers formula feeding used advice from online sources. These are higher proportions compared with other recent studies (Eisenberg et al., 2015; Newby et al., 2015). This is likely due to the nature of our sample strategy, which was based on online advertising. Given this, it was interesting that there were still significantly fewer reports of using online sources for formula feeding advice than breastfeeding advice. This is similar to a recent Australian study where 59% of mothers used general internet searches for breastfeeding information, but only 30% used this for formula feeding information (Newby et al., 2015). This study also showed that overall the mothers sought less formula feeding advice than breastfeeding advice (Newby et al., 2015), which was also found in the current study. That formula feeding advice is less sought after may be related to the confidence some parents feel in their formula feeding practice. If parents do not have any problems, they may not seek further information, advice and support (Bramhagen et al., 2006; Russell et al., 2016).

Although many of the participating mothers received advice from professional sources, a fifth did not. It is important to understand the enablers and barriers to using professional sources of advice so these professionals can be best enabled to meet the needs of all parents. In a French national survey, mothers were more likely to use professional sources (i.e., medical advice) to inform their infant feeding practice if they were younger (less than 30) and first time mothers (Chouraqui et al., 2018). The current study did not find these associations with age and parity for formula advice, which indicates that these differences do not impact whether mothers used professional sources for formula feeding advice. Although, being secondary analysis, the study may have been underpowered to find these differences. When considering the source of formula feeding advice (professional or non‐professional), only one of the included variables was significant in the model; those who were fully formula feeding when infants were aged less than three months were more likely to access professional advice than those who were breastfeeding at baseline. This might reflect that those mothers who had been formula feeding longer had more time to access advice from professional sources or that accessing these professional sources occurred when infants were younger. There is often greater contact with health professionals in the early months, particularly MCHN, and these health professionals may be more attentive in giving advice to those using formula with younger, rather than older, infants. On the other hand, it may reflect perceived barriers to accessing formula feeding advice from health professionals. Qualitative interviews with a subsample of the BFF cohort, reported elsewhere, found that two perceived barriers to getting formula advice from health professionals were (a) that health professionals did not talk about formula (Appleton, Laws, et al., 2018), which is in line with previous research (Lagan et al., 2014; Lee, 2007b), and (b) that health professionals only focus on breastfeeding (Appleton, Laws, et al., 2018), which is also in line with other research (Russell et al., 2016; Sheehan et al., 2009). Similar to previous findings on general infant feeding advice (Gildea et al., 2009), formula advice from the pharmacy was uncommon. That this is the case of formula advice is surprising considering that this might be a place formula was purchased (Berry et al., 2011).

Differences in the professional support or advice given to, or accessed by, those who are breastfeeding and formula feeding have been described in many recent studies (Laws et al., 2015; Newby et al., 2015; Tarrant et al., 2012). In the current study we found that although both breastfeeding and formula feeding groups reported comparable support with advice from MCHNs, this was not the case for the other professional groups examined, midwives and PNs. In the case of midwives this may reflect that mothers do not feel comfortable discussing formula with midwives because of the barriers discussed above. Or it may be that midwives do not have the resources or knowledge (Battersby, 2010; Dykes et al., 2012) or do not believe it their role to discuss formula with mothers (Battersby, 2010). Alternatively, it may simply reflect the time period in which parents interact with midwives, which is generally in the perinatal period the participants may have been still exclusively breastfeeding when they had an interaction with midwives. Considering Australia's high breastfeeding initiation rate of 96% (AIHW, 2011) this is likely, indeed, in the BFF cohort only, eight (2.4%) infants were fully formula fed from birth.

It is interesting that for PNs, it was in fact formula advice that was more frequent than breastfeeding advice. It is likely that this reflects the timing of mother interaction with PNs, which is around infant immunisation visits (around six week, four months and six months of age). These visits may coincide with parents considering moving to mixed or formula feeding. Perhaps it is also that PNs are considered a more neutral or general source of advice on infant feeding compared with midwives or MCHN that may be seen as more supportive of breastfeeding and unsupportive of formula feeding (Lagan et al., 2014; Lee, 2007b). It may also reflect the scope of practice for PNs. In a survey in the United Kingdom, general practitioners (GPs) and PNs provided infant feeding advice less often and were less confident than health visitors (similar to MCHN in Australia; Redsell et al., 2011). Some also described infant feeding advice as the health visitor's role, not the GP or PN (Redsell et al., 2011). PNs do not necessarily have professional education in infant feeding or breastfeeding (Redsell et al., 2011), and it is possible that PNs may perceive providing advice about formula feeding as less complex and within their scope than advice for breastfeeding. Further research exploring and observing midwives', MCHN's and PN's knowledge and practice of providing infant feeding advice is needed to understand this.

5. CONCLUSION

The findings of this study suggest that some parents who are feeding their infants formula are underserviced by health professionals and rely on non‐professional sources of advice to inform their infant feeding. There is opportunity for health professionals to improve the provision of up to date evidence based infant formula feeding information and advice to parents feeding with formula. This may in turn have positive impacts on infant's current and future health.

CONFLICTS OF INTEREST

The authors declare that they have no conflicts of interest.

CONTRIBUTIONS

JA, RL, CGR, KJC and EDW were part of the Growing healthy; the Growing healthy team designed the survey and collected the data. The analysis was conducted by JA with input from CGR, RL and EDW. JA led the drafting of the manuscript with input from RL, CGR, CF, KJC and EDW. All authors have read and approved the final version of this manuscript.

ETHICAL STATEMENT

The Baby's First Foods study was granted approval through the Deakin University low risk Human Ethics Advisory Group (HEAG‐H 162_2014) and ratified by the University of Technology Sydney Human Research Ethics Committee (UTS HREC 2015000668).

ACKNOWLEDGMENTS

Notes

Appleton J, Fowler C, Laws R, Russell CG, Campbell KJ, Denney‐Wilson E. Professional and non‐professional sources of formula feeding advice for parents in the first six months. Matern Child Nutr. 2020;16:e12942 10.1111/mcn.12942 [PMC free article] [PubMed] [CrossRef] [Google Scholar]

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