Infant formula or cow’s milk? Perspective on the World Health Organization recommendations for Australian parents

The latest recommendations from the World Health Organization (WHO) that non breastfed infants aged 6–11 months can be fed either formula or animal milk has created a stir. The apparent contradiction between the recommendations and the current Australian Infant Feeding Guidelines is sparking confusion among parents and health professionals.

The National Health and Medical Research Council (NHMRC) have now released a statement reiterating current Australian Infant Feeding Guidelines that animal milks are not recommended for infants less than 12 months as the main drink.

The INFANT team, alongside other esteemed infant feeding experts from the Institute for Physical Activity and Nutrition and NHMRC Centre for Research Excellence in the Early Prevention of Obesity in Childhood, have reviewed the evidence underpinning the WHO recommendation and support the NHMRC’s view that in a high-income country like Australia, the current guidance to not consume cows milk as the main drink for infants less than 12 months of age remains appropriate.  Here are several key reasons why:

It is uncertain if the benefits of switching from infant formula to cow’s milk outweigh the harms, and this was recognised by the WHO guideline development group (GDG). In fact they state that ‘The GDG was of the opinion that there was uncertainty in the balance of benefits and harms of animal milk compared to milk formula for infants 6–11 months of age….there was some agreement that there were probably some benefits for infants 6–11 months of age consuming milk formula rather than animal milk P19.’ The benefits may outweigh the harms in countries where non breastfed infants don’t have access to animal source foods (such as meat) or where there is unsafe water, sanitation and/or access to infant formula. This is not the case in Australia.

Increased risk of iron deficiency anaemia– Despite the low certainty of evidence, there was consistency across the WHO-reviewed studies showing that cow’s milk consumed at 6-12 months led to reduced iron stores and increases the risk of iron deficiency anaemia in infancy at 12-18 months. This is a concern given Australian data suggest that one third of infants in some population groups in Australia don’t consume the recommended amounts of iron. Even more worrying is the number of parents relying on commercial pouch foods for infants which are a poor source of iron. One of few studies examining iron intakes in Australian infants reported that the main source of iron for infants was infant formula (43.5% of iron intake). While there is strong evidence that consuming  iron rich foods can help maintain adequate iron status amongst infants with insufficient iron stores, much work would need to be done to improve the quality of infants’ diets in Australia to avoid the increased risk of iron deficiency anaemia associated with switching from infant formula to cow’s milk.

Cow’s milk in infancy may increase obesity risk- While the WHO review reported no impact of cow’s milk on infant growth, this was only assessed to 12-18 months of age in 3 of the 9 studies reviewed (all low quality and 2 published more than 30 years ago). Cow’s milk has double the protein content of formula and breastmilk. There is convincing recent systematic review evidence based on high quality studies that higher protein intakes in infancy are associated with increased obesity risk in childhood. This is a concern in the Australian context.

Undermining breastfeeding- Media misinterpretations of the WHO guidelines as endorsing cow’s milk as a supplement or replacement for breastfeeding could undermine Australian Infant Feeding Guidelines to continue breastfeeding for 12 months or beyond (or 2 years and beyond for the WHO guidelines). This misinterpretation may encourage earlier cessation of breastfeeding hindering optimal infant nutrition. It is critical that any advice given on milks is done so in the context of  breastfeeding being the preferred option for both mother and child.

Equity considerations- Given formula milk can cost 5 times as much as cow’s milk, it is little wonder this recommendation grabbed the attention of parents struggling with the cost of living crisis. Families struggling to put food on the table who would benefit financially from switching to cow’s milk may also not be able to afford the diverse diet needed to meet their baby’s iron needs. While you could argue that if parents didn’t have to pay for formula, they would have more money to spend on nutritious food, the reality is more complex, as cost is only one factor influencing diet quality. A wide range of approaches are needed to support low-income families to eat a nutritious diet.

The Bottom Line:

Until the Australian Infant Feeding Guidelines undergo review, it is premature to recommend Australian infants aged 6–11 months switch from infant formula to cow’s milk. Potential harms, including increased risk of iron deficiency anaemia and obesity, may outweigh perceived benefits. In the meantime, it is prudent that health professionals provide advice consistent with the NHMRC Australian Infant Feeding guidelines and we don’t confuse parents and carers with conflicting information.

Want reliable and trustworthy information on infant feeding and active play?

Our team at the Institute for Physical Activity and Nutrition, Deakin University have developed an evidence-based program called INFANT. We have a training course for health and early years professionals as well as an app and group sessions for Mums, Dads and Carers