Introducing cows’ milk to an infant’s diet - Is there a perfect time?

This raises the question why are recommendations not getting through to parents; some of the possible reasons include:

1. Confusing messages from Healthcare Professionals
As a Dietitian and a new parent, I understand it is easy to give parents the message that cows’ milk is acceptable in family cooking prior to 12 months of age, but does this then give some parents the message that cows’ milk is acceptable as a main drink? As Healthcare Professionals we need to know how the information we communicate will be interpreted by the recipient to ensure that the right message is received. In a recent survey it was found that 56% of Healthcare Professionals recommend introducing cows’ milk as the main drink in an infant’s diet at around 11-12 months³. Cows’ milk may be acceptable in the diet of those children receiving a nutritionally balanced weaning diet, but sadly this is often not the case and many infants and young children present with nutritional deficiencies.

2. Misconceptions of the nutritional value of cows’ milk
It is recommended that all children under five years of age take dietary supplements of vitamins A, D and C¹; however, the reality is quite different with only 21% of children aged 1.5 to 4.5 years taking dietary vitamin and mineral preparations². In a study of 100 infants (mean age 7.8 months) that had been given cows’ milk before 12 months, only 9% of mothers had used vitamin drops. Some mothers commented that they believed that cows’ milk contained all the vitamins necessary for growth and therefore, vitamin supplements were not needed⁴.

3. The Healthy Start Scheme
Healthy Start, which replaces the Welfare Food Scheme, was launched nationally in November 2006. The scheme provides vouchers which can be exchanged for cows’ milk, infant formula or fresh fruit and vegetables to those on income support. Whilst the scheme aims to better meet the nutritional needs of pregnant women and children, it cannot ensure that the items obtained via the scheme are given to those individuals in need and the possible food choices may promote the early introduction of cows’ milk.

For more information on Healthy Start visit www.healthystart.nhs.uk

Why is cows’ milk inappropriate as a main drink prior to 12 months of age?
The Department of Health recommends exclusive breastfeeding for the first six months of life. After six months and not before 17 weeks, solids should be introduced and given in conjunction with breastmilk and/or if used, infant formulae or follow-on formulae. Whole cows’ milk is not recommended prior to 12 months as it is not nutritionally adequate to meet the nutritional needs of the infant. Whole Cows’ milk, compared with human milk, contains more protein, less calcium, magnesium, copper and vitamin C⁵.

Iron
The 1995 National Diet and Nutrition Survey (NDNS)² indicated that 12% of children between 1.5-2.5 years had a haemoglobin level consistent with iron deficiency anaemia and 28% of the children had depleted iron stores¹. The prevalence of iron deficiency in Asian children appears to be greater with 29% of Pakistani, 25% of Bangladeshi, and 20% of Indian children having a haemoglobin level of less than 110g/l, the cut off point for iron deficiency anaemia⁶.

While breastmilk is undoubtedly the best form of nutrition, those infants that continue to receive breastmilk only after the first 6 months of life are at increased risk of some nutritional deficiencies. The small amount of iron present in breastmilk is well absorbed, but the level is insufficient to meet requirements after 4-6 months when their stores become rapidly depleted and their iron needs increase. Breastfeeding may continue after 6 months so long as other foods providing available iron are included in the diet.

Since humans have relatively low amounts of iron stores compared with total body iron, there is a relatively small buffer zone to protect developing tissues from iron deficiency. There is evidence that rapid growth in infancy leads to a depletion of iron stores and it has been shown that treatment with iron increased weight gain⁷. Therefore, relatively large infants that have undergone rapid growth in the first year of life are likely to have depleted iron stores and be more at risk of developing iron deficiency anaemia.

The small amount of iron in cows’ milk is largely present as insoluble phosphate or it is attached to casein in an unabsorbable complex; consequently cows’ milk is a significant factor in iron deficiency anaemia⁸. Asian children are particularly at risk of iron deficiency as they consume meat less frequently⁹. In addition, Asian mothers tend to introduce cows’ milk as a main drink earlier and they may encourage young children to drink large quantities, with up to 60% of the energy intake at 18 months derived from cows’ milk⁶.

Dietary factors can have a significant impact on iron absorption and this becomes important in the weaning diet when the intake of iron may be borderline and requirements are high¹⁰. Vitamin C promotes iron absorption; however, 40% of children aged 1.5-2.5 years are not achieving the Reference Nutrient Intake for vitamin C². This has implications for the nutritional adequacy of the diets of all toddlers and young children.

In some infants, small daily blood losses from the gastrointestinal tract may occur with cows’ milk¹¹. Wilson and associates found that 50% of infants with iron deficiency anaemia had occult gastrointestinal bleeding that was induced by the consumption of cows’ milk¹². Anyon and Clarkson reported that 44% of infants receiving a diet of cows’ milk¹³ had occult blood in the stools at 4 months of age. This loss is nutritionally important, particularly when the intake of iron is on or below requirements, then such blood losses may contribute to iron deficiency anaemia¹⁴

Vitamin D
Vitamin D deficiency is a long-standing risk in the UK. Infants and young children are particularly vulnerable to poor vitamin D status due to greater requirements generated by the high level of calcium incorporation into bone¹⁵. The problem of poor intake maybe compounded when weaning starts as it has been shown that the amount in the weaning diet is generally low¹⁶. This is another reason not to use cows’ milk as a main drink prior to 12 months of age, as it is a poor source of vitamin D.

Protein
Cows’ milk has a higher protein content which could place unnecessary pressure on the kidneys, especially as they are not fully developed until around 12 months of age.

What are the risks of introducing cows’ milk into the diet of older infants and young children?
Children should receive sufficient nutrients from their weaning diet; consequently providing cows’ milk as a main drink should be acceptable in older children. However, despite recommendations from Healthcare Professionals many families do not achieve a healthy weaning diet for their children for a variety of reasons. These include lack of understanding of a child’s requirements; poor knowledge of the weaning process; chaotic home situation where there are no facilities to eat at a table; no fixed mealtimes where grazing through the day is more likely to be the pattern of eating; and lack of cooking skills and equipment. Current practices are often handed down from family and friends and are intuitive rather than informed.

Food and nutrient intakes in young children have deteriorated since 1950¹⁷. The National Diet & Nutrition Survey (1995) found that the foods consumed in the largest proportion were biscuits, bread, savoury snacks, cows’ milk, potatoes, chocolate confectionery and soft drinks². Meat consumption was low, contributing 14% of the iron intake. Commercial infant foods and formulas were an important source of iron.

Optimal nutrition for infants and young children – is it possible?
Achieving the optimal nutrition for infants and young children can be a challenge as shown by the meal pattern below:

Typical Daily Meal Pattern for a Child aged 12 months

Breakfast: Baby cereal with cows’ milk
Mid-morning: Slice of bread with cheese spread
Lunch: Fish Fingers, Baked Beans, Banana
Mid Afternoon: Digestive biscuit
Evening Meal: Shepherds Pie, Peas, Fromage Frais

Children in the second year of life are particularly vulnerable to nutritional deficits. It is a time of growing individuality, they are beginning to feed themselves and many factors can impede good nutrition, such as faddiness, food refusal and ill health etc. Extended feeding with a follow-on formula (or growing up milk) can help to prevent iron deficiency anaemia¹⁸ and it may provide developmental benefits¹⁹.

Milk and milk products continue to play an important role in meeting the nutritional needs of children beyond the age of 12 months. There is a risk that if the child is not receiving a well balanced diet, for the reasons highlighted above, that cows’ milk may replace solid food intake. This may result in the child becoming nutritionally deficient; consequently a follow-on milk or growing up milk, provided as an alternative to cows’ milk, may play a valuable role in meeting the nutrient needs of the child during this important developmental period.

Conclusion
In light of all the research and the issues discussed what advice does the Healthcare Professional give to parents and carers regarding the introduction of cows’ milk?

• The role that Healthcare Professionals play in advising and supporting children and their families is vital. The Healthcare Professional needs to give appropriate information on health and lifestyle including infant feeding, weaning and the role of cows’ milk in the diet.
• The message that cows’ milk should not be offered as a main drink prior to 12 months of age, at the earliest , needs to be reinforced.
• Cows’ milk can safely form part of a well balanced diet that meets all the nutritional needs of the child beyond 12 months of age. However, where the diet is nutritionally inadequate or dietary intake is compromised, then there is no doubt that follow-on formulas/ growing up milks can provide a nutritional safety net.

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For more information visit (click each link to access)

Cow & Gate Weaning Foods
Cow & Gate Growing Up Milk
The Infant and Toddler Forum website

For parents - for practical advice and information and advice weaning and suitable products, visit the Cow & Gate website using this link:

Cow & Gate parents website – information and advice about weaning

References

1. Report of the Working Group on the Weaning Diet of the Committee on Medical Aspects of Food Policy. 1994. Weaning and the Weaning Diet. Report on Health and Social Subjects 45. London: HMSO
2. Social Survey Division of the Office of Population Censuses and Surveys and the Medical Research Council Dunn Nutrition Unit. Volume 1: Report of the diet and nutrition survey. 1995. National Diet & Nutrition Survey: children aged 1.5-4.5 years. London: HMSO
3. Toddler HCP U&A Study by TNS Healthcare. Jan-Mar 2005
4. Daly A, MacDonald A et al., 1998. Diet and disadvantage: observations on infant feeding from an inner city. J. Hum. Nutr. Diet. 11; 381-389.
5. Food Standards Agency. 2002. McCance and Widdowson’s The Coposition of Foods. RSC.
6. Lawson M.S. Thomas, M. et al., 1998. Iron status of Asian children aged 2 years living in England. Arch Dis Child. 78;420-426
7. Sherriff A, Emond A et al., 1999. Haemoglobin and ferritin concentrations in children aged 12 and 18 months. Arch. Dis. Child. 80;153-157.
8. Bramhagen A.C, Axelsson I, 1999. Iron status of children in southern Sweden: effects of cows’ milk and follow-on formmula. Acta Paediatr. 88;1333-7
9. Harris R.J, Armstrong D et al., 1983. Nutritional survey of Bangladeshi children aged under 5 years in the London borough of Tower Hamlets. Archs Dis Child; 58; 428-432
10. Kuhn I.N, Monsen E.R et al., 1968. Iron absorption in man. Journal Lab. Clin. Med. 71;715-721
11. Mills A, Tyler H. 1992. Food and nutrient intakes of British infants aged 6- 12months. HMSO. London.
12. Prynne C.J, Paul A.A et al., 1999. Food and nutrient intake of a national sample of 4 year old children in 1950: comparison with 1990s. Public Health Nutr 2(4);537-547.
13. Daly A, Macdonald A et al., 1996. Prevention of anaemia in inner city toddlers by an iron supplemented cows’ milk formula. Arch Dis of Child. 75; 9-16.
14. Williams J, Wolff A. et al., 1999. Iron supplemented formula milk related to reduction in psychomotor decline in infants from inner city areas: randomised study. BMJ 318; 693-697.