Most infant formulas in the United States contain a high percentage of added sugars instead of natural lactose, “jeopardizing” infant health and development, says researchers at the University of Kansas in a new analysis of commonly marketed formulas. 

“Infants may consume upwards of 60 grams of added sugars per day, or the equivalent of two soft drinks per day if they are entirely formula-fed,” researchers say in the study, published last week in the Journal of Food Composition and Analysis. 

The publication came as the Food and Drug Administration (FDA) delayed implementation of a rule that tightens what foods manufacturers are allowed to label as “healthy.”

The study, which analyzed 73 infant formulas available in 2022, found that “gentle” and lactose-free formulas contained the highest proportion of added sugar, with median levels reaching 85% and 90% of total sugars, respectively. On average, formula-fed infants consume 7-8 grams of added sugar per serving – a quick form of energy, but lacking in nutritional value. 

Health experts warn that high sugar consumption in infancy, in the form of sucrose, glucose, and high-corn fructose, may contribute to rapid weight gain and early obesity, increasing the risk of chronic conditions such as diabetes later in life. 20% of US children have obesity – a figure that is only expected to rise in the coming decades. 

Babies exposed to sugary foods also develop a strong preference for more sugar, says the authors.

But “lax” federal guidelines make it difficult for parents and caregivers to avoid added sugars in infant formula because of the “staggering extent” to which US formula contradicts federal healthy diet recommendations. The FDA does not require manufacturers to report sugars in US formulas, in “sharp contrast” to adult food regulations, which must display a breakdown of total carbohydrates and added sugars, despite federal dietary guidelines recommending zero added sugars for infants under two years old. 

“As a result, parents and guardians may unknowingly feed their infants formula that contains substantial quantities of added sugars… which likely present a substantial risk to their infant’s health and development.” 

A systemic issue

Even though the researchers build upon a body of evidence showing the risks to formula feeding – including an increased risk of gastroenteritis, diarrhea, ear infections, and chronic illnesses – they acknowledge that larger, systemic issues bar families from breastfeeding.

The World Health Organization (WHO) recommends that parents exclusively breastfeed for the first six months. But in the US, “extremely” limited social support, no paid maternity leave, and the lack of affordable early childcare means that reliance on formula is a “necessity” for most parents, the authors say. Those from low socioeconomic status backgrounds are the most disadvantaged.

“[T]he structure of the US system and environment often leaves parents and caregivers with little choice but to use formula in some capacity,” write study authors Audrey Rips-Goodwin, Daiil Jun, Adrianne Griebel-Thompson, Kai Ling Kong, and Tera Fazzino. 

“[W]e reason that the focus on an individual-level solution (breastfeeding promotion to women and caregivers) is not well matched to addressing the systemic nature of the problem and places an unfair burden on women and families who are expected to navigate this systemic issue. 

“Ideally, the US labor system should support breastfeeding, and healthcare professionals should be properly trained and incentivized to promote it.”

“At the federal level there is no requirement for paid maternity/paternity leave and very little structural support to promote breastfeeding. Given the vast limitations in systemic support of new mothers and parents, most turn to using formula out of necessity. US parents deserve an infant formula supply that does not jeopardize infant health due to the presence of added sugars,” said Dr Tera Fazzino, study author and associate professor of psychology and associate director of the Cofrin Logan Center for Addiction Research and Treatment at the University of Kansas.

Formulas with lactose could be safer, if made available

Lactose, which is naturally found in breast milk and cow and goat milk, is sometimes used as a base for formula. Infants digest the more complex form of sugar slower, boosting their nutrition and metabolism, and engaging in hunger satiation hormones. Unlike the added sugars in most formulas – high fructose corn syrup, glucose, sucrose – lactose does not cause the same blood sugar spike. 

“These non-lactose sugars also typically garner more pronounced neurochemical reward responses and glycemic responses relative to lactose. Therefore it is really important for infants to consume lactose and avoid consumption of other types of added sugars, which is in line with US Dietary Guidelines,” said Fazzino.

Only 8% of US formulas contained primarily naturally lactose, but the type is no longer available in the US. And it is unknown whether any other formulas use the safer sugar. 

“When people have free choice, the choices should include options that promote infants’ health and development. In the case of the US formula supply, our findings indicate that parents and caregivers in the US largely do not have a choice with the formula supply; most of the supply has substantial added sugars that may jeopardize healthy infant development,” said Fazzino.

The researchers argue that lactose-containing formulas are safer for infants, and that efforts should focus on “requiring formula companies to produce products that primarily contain naturally occurring lactose and are designed to minimize risks to healthy infant development.”

Unclear if FDA will improve labelling after delay 

Even with increased rhetoric around chronic diseases in the US, notably HHS Secretary Robert F Kennedy’s push to “Make America Healthy Again,” the role of infant formulas to early-life infant weight gain is largely overlooked. 

The FDA has delayed implementing a rule that would redefine which foods can be labeled as “healthy.”

The regulation, which aims to prevent manufacturers from marketing sugary juices, processed sweets, and certain meats as “healthy” options, was initially set to take effect on 25 February but has now been pushed back to 28 April, according to HHS.

The delay stems from a broader freeze on new rule proposals across the Trump administration, and an upheaval of firings in the past weeks. The department lost several thousand employees, including those working in food safety. 

Currently, infant formula labels do not disclose added sugar content, allowing products with high levels of sucrose, glucose, and corn syrup solids to be sold without clear warning. 

During the first Trump administration, US officials tried to derail a resolution at the 2018 World Health Assembly to promote breastfeeding, attempting to remove language urging governments to “protect, promote and support breast-feeding” and restrictions on the promotion of food unhealthy food products to children.

The original sponsor of the resolution, Ecuador, withdrew after US threatened it with trade sanctions.

“We need much clearer labeling requirements for formulas in the US, specifically regarding the reporting of added sugars,” Fazzino told Health Policy Watch. “Support from the federal government and associated entities is really needed to improve infant formula labeling requirements.” 

But Fazzino acknowledged that labelling reform is “not on their radar;” rather, the FDA is more concerned about shoring up the formula supply chain after shortages in 2022 rocked the US market.

The FDA declined to respond to Health Policy Watch’s request for comment.

Formula companies deploy “same tactics” as tobacco industry

Formula companies were among those identified in a 2023 Lancet series on the mechanisms and scope of commercial determinants of health, examining how the private sector influences health through activities like product design, packaging, supply chains, lobbying, research funding, and marketing. 

These companies “are escalating avoidable levels of ill health, planetary damage, and inequity.” These include formula milk companies’ extensive lobbying networks and “predatory” marketing tactics that derailed progress on breastfeeding education. 

In response, just last month the WHO at its Executive Board meeting proposed a resolution to regulate digital marketing of breastmilk substitutes, after the WHO’s findings that the formula industry uses “exploitative” marketing strategies. The resolution focuses on the fact that digitial marketing – through influencers and paid content – rely on personalized data to “innapropriately” promote infant formula, and undermine recommendations from healthcare providers and national authorities.

The threat of targeted misinformation led the WHO to issue guidance on “regulatory measures aimed at restricting digital marketing of breast-milk substitutes” in November 2022, following its report that “the global formula milk industry, valued at some $55 billion, is targeting new mothers with personalized social media content that is often not recognizable as advertising.”

The study also follows investigations into how formula companies promoted their product as “healthy” in lower-and middle-income countries, despite high levels of added sugar.

But as the authors note, hidden added sugars also plague US infant formulas. 

“Ultimately, caregivers and infants in the US deserve a formula market that promotes healthy infant development and does not promote early obesity risk.”

Image Credits: FDA, University of Minnesota , Enfamil.