All parents want the best for their children, so they could be forgiven for thinking that infant nutrition brands prioritize the same. But then there’s toddler formula.
Toddler formulas, or toddler milks, are beverages often sold in the same product lines as infant formulas, framed as a sort of natural nutritional continuation for the 9-to-12-month-old being weaned off traditional infant formula or breast milk. Unlike infant formulas, however, toddler milk is unregulated in the U.S., and as a result is not required to meet the same nutritional standards. For years, it’s been an open secret among pediatric health experts that the toddler milk market has run wild with deceptive marketing and less-than-healthy formulations, but with sales growing, the American Academy of Pediatrics (AAP) has released a formal call for regulatory action. The physician’s organization is hoping that their report, published on Oct. 20, will at minimum provide more education for caregivers.
Understanding toddler milk’s role in the market today, says Jennifer Pomeranz, an associate professor of public health policy and management at New York University, means looking back at the policies that laid the groundwork for its popularity. Since its invention, infant formula has been a good alternative for mothers who can’t breastfeed, though “there’s zero question that breast milk is better for an infant,” says Pomeranz, especially in terms of nutrition and immune development. This deficiency has made formula a bit political, and never more so than in the run-up to the 1980s. For a few decades, it was a hot alternative to breastfeeding that mothers saw everywhere they looked; pitched in the pages of magazines and given out in sample packets by pediatricians. Between the late 1930s and late 1960s, the proportion of U.S. babies who were breastfed dropped from around 77% to 25%. But the formula boom came with dangers, since companies didn’t always provide guidance on how to use it correctly. Soon enough, “infants were dying,” says Pomeranz, due to malnutrition in lower-income countries and communities, where formula was being watered down or otherwise prepared improperly.
In 1981, the World Health Organization (WHO) stepped in, writing up a set of guidelines that asked countries to bar all direct-to-consumer and some industry marketing of infant formulas, and to clarify nutrition labels and hazards of use. In response, many countries passed laws reflecting the WHO’s recommendations. In the U.S., where the Food and Drug Administration (FDA) had already begun to regulate the products more heavily a year prior in 1980, additional marketing restrictions were never adopted.
Confronted with the potential revenue loss of restricted marketing worldwide, manufacturers began to push a product just different enough to avoid the now-established rules. So-called ”toddler milk” allowed brands to print ads with their logos and packaging, while simultaneously selling an additional product on the back of the public’s trust in infant formulas.
The strategy worked. When infant formula sales decreased by 7% from 2006 to 2015, the sales of toddler milks increased by 158%—and have continued growing, says George Fuchs, vice chair of clinical affairs for the pediatrics department at the University of Kentucky and an author of the AAP’s new report.
Fuchs and his colleagues agree that there’s no functional role for toddler milks in a young child’s diet. Toddler milks don’t just lack nutritional value, they eschew it— their primary ingredients are powdered milk, high-calorie sweeteners, and vegetable oil. One study from earlier this year found that 60% of toddler milks had excess sugar, while many were higher in sodium and lower in protein than cow’s milk, the pediatrician-recommended option for tots. And then there’s corn syrup, a common ingredient that definitely isn’t in cow’s milk. And because of poor regulation, these products can get away with false marketing: at least one product the study looked at had branding suggesting it was iron-fortified, but had less iron than the FDA requires in similarly-branded infant formula.
Toddler milk as a whole is “just junk,” says Pomeranz. “It’s unnecessary and not needed.” She previously found that 60% of caregivers believed that toddler milks contained essential nutrients that their kids couldn’t get elsewhere.
“So many of them have undesirable attributes that could have consequences for health,” Fuchs says of the products. In particular, he worries about toddler milks potentially hijacking the sensitive period in early childhood where taste preferences are programmed. There’s a lot of evidence that high sugar intake during infancy is a key contributor to childhood obesity; there’s also a well-documented link between early excess sodium intake and poor cardiovascular health later in life.
What concerns experts the most is that toddler milks are often found on store shelves right alongside, or even mixed in with, the infant formulas. They also often have packaging that makes them look like only slight variations of reliable products. This makes them incredibly easy to confuse, particularly if parents don’t know, for instance, that the FDA has a special format of nutrition label used exclusively for infant formulas. Sometimes the word “toddler” appears, but there are various other terms used interchangeably for these products, such as “follow-up,” “transition,” or “weaning” formulas, or “growing-up milk.” In her research, Pomeranz has learned that even physicians sometimes aren’t sure of the differences between these products and well-regulated infant formula.
There are many simple solutions that regulators could easily implement. The AAP’s suggestions include mandating more distinct branding on toddler milks, banning the use of the word “formula” on their labels, and requiring that they be stocked on shelves separately from infant formulas. Pomeranz would like to see a required warning label on all toddler milks explicitly stating that they’re not for infant use.
Fuchs, who has worked with the FDA before, is skeptical that any real regulatory change will come out of the AAP’s recommendations anytime soon, particularly because of what he describes as Congress’s “opposition to anything that places restrictions on business.” But with enough pressure from parents and physicians, he thinks manufacturers could be convinced to take some of these changes on themselves.