Infant food insecurity: summary report

In recent months the Scottish Government has progressed work with cross-sectoral partners in the context of heightened concerns over reports of some parents/carers unable to afford formula milk for their babies. The nutrition that babies under six months need is either breastmilk, formula milk or a combination of both, depending on parents’ choice of infant feeding method. The majority of babies who are fully formula fed are from the most deprived SIMD quintiles, and most babies receive some formula milk in the first 12 months of life. Formula milk is not required after 12 months (where babies can move to cow’s milk, or where they are breastfed, this can also continue) and from six months, complementary feeding, where solid foods are introduced, provides an additional route for to meet some of their nutritional needs.

The focus of this work, therefore, is on infants from birth to 12 months and their families, recognising that costs associated with formula feeding (noting that unit price of infant formula has risen significantly over past few years), equipment (bottles/teats, sterilisers, etc) and what is required to do this safely (fuel, hot water, etc), can put additional pressures on some families budgets and potentially lead to health harm in our youngest babies that is largely avoidable. It is also important to ensure that support for breastfeeding remains constant and can be provided where a family requires this.

These emergency pathways should be considered in the context of wider supports for maximising household incomes and meeting ongoing challenges some families may face around food insecurity, noting that the number of families likely to be in these specific emergency situations, at any one time, remains relatively small. However, recognising that all babies need to be fed responsively, alongside the need to reduce the reliance on foodbanks and move to a cash-first approach where possible, these discussions have been given a priority to ensure that there is local governance and accountability, and that learning can be shared across the country on how to do this well. 

An initial stakeholder roundtable discussion was held in March 2023 which aimed to continue to raise awareness of the unique needs for babies under one and the role of all sectors in developing multi-agency and multi-faceted approaches to protect and promote infant health through nutrition and diet, as advocated for by Unicef UK and the World Health Organisation (WHO), to better understand the scale and nature of infant food insecurity in Scotland, and to begin to build a picture of local responses and support currently in place. 

Following that initial scoping, a further session, held in June 2023, brought together a wider range of stakeholders including the NHS, local authorities and third sector organisations, and involved those most likely to be routinely supporting families with babies and young children. 

The objectives of the day were: 

• to place the work within context of relevant Scottish Government policy priorities and provide update on Scottish Government work in this area since the March roundtable 
• to share examples of good practice in emergency pathways for infant formula and cash-first solutions 
• to seek feedback and reach a consensus on a set of draft principles 
• to explore data requirements to support local monitoring and improvement
• to understand more about local actors, systems and decision makers

The day was also themed into four main sections to facilitate roundtable discussion:

• pathways – barriers and enablers
• tools – to aid local responsiveness
• draft principles – to be considered at all system levels
• governance and accountability – looking at data, key actors and local structures

Pathways to emergency support

Presentations were given by Denise Forsyth, Welfare Team Leader, Aberdeenshire Council, and Jodi Moodie, Senior Health Promotion Officer/Gillian McMillan, Infant Nutrition Coordinator, from NHS Tayside on the pathways they have developed or are developing in their areas. 

Attendees then discussed these, considering what they felt to be the strengths, challenges and opportunities for similar work in their local contexts. The following common themes emerged from the table discussions, based on notes collated: 

Good relationships and collaboration

It was recognised that effective pathways rely on good relationships between families and service providers as well as between organisations/across sectors involved in providing support. Collaboration between services was seen to be critical to establishing and delivering robust pathways. Involving the third sector in meaningful ways in all stages of the process was also considered important. 

Early intervention

Some participants suggested engaging with parents before the baby is even born, to raise awareness of support available and identify families who may be at risk, linking them into income maximisation, could help prevent crisis from occurring. 

Timeliness of support

Families in crisis need immediate help and the NHS Grampian pathway in particular noted that applying for other supports, such as the Scottish Welfare Fund (SWF) can take time for payments to be received. The use of PayPoint as highlighted in the Grampian pathway was considered effective because cash is made immediately available and doesn’t bring the same challenges as payments into bank accounts.

Stigma, shame, blame and judgement

The stigma associated with experiencing financial difficulties and some families being unable to afford buy the food their baby needs was widely discussed. Barriers to effective pathway delivery resulting from this issue of stigma include:

• perceived judgemental attitudes from service providers who might be reluctant to provide cash for formula milk, and also lack confidence in where to refer people to for appropriate help
• families feeling shame and not wanting to admit to the difficulties they may be facing. Need to consider impacts on parental mental health also mentioned. 

This issue highlights the need for:

• trusting relationships between families and those working with them
• training for health visitors and other health professionals who work with pregnant women and families with young children, in poverty awareness and to build confidence in having conversations about financial difficulties with families. Examples of good practice were shared including use of the Independent Food Aid Network (IFAN) ‘worrying about money leaflets’ as training tool with health visitors in Grampian, and Money Counts training to health visitors in Highland

Identifying families

There is a lot of ‘hidden need’ in this area. Not all families who are experiencing food insecurity are reaching out for help, due to fear of being judged on their ability to care for their baby/children. Identifying the scale of the issue remains a challenge. Again, this highlights the need for training and support for health visitors and those working most closely with pregnant women and new parents, in having conversations with families to identify issues and put appropriate support in place. 

Out of hours provision

Emergency support needs to be available when people need it and where people are. Particular challenges in rural areas were highlighted. Some examples were given of using community venues/services such as fire stations to hold crisis monies/vouchers. 

Making sure families know support is available

The need for improved communications so families know where to go if they need infant formula in an emergency. This could also help reduce stigma if people have better awareness that emergency help is available. 

Data sharing 

It can be complicated and time-consuming to get appropriate data sharing agreements in place. This is particularly true in data sharing across multi-agency partners, and the complexity increases if third sector partners are a key touchpoint in the local pathways. 

Connecting with existing pathways

There are already financial inclusion pathways and similar cross-sectoral collaborations in many areas. It was felt important for any new work on emergency pathways to build on and connect with these existing structures. There was recognition that it is important not to reinvent the wheel and create separate pathways which could add complexity and confusion, reporting and data collection should also utilise existing structures and mechanisms, where possible. 

Role of retailers

Suggestions were raised around their potential role in a pathway including supporting families in crisis. There was consideration of protocols that may increase stigma and judgement through things such as increased security measures on infant formula milk that may be applied because it is a high value product rather than recognising that it is one that some families rely on to feed their babies. 

Sharing good practice

Attendees welcomed this opportunity to hear about and discuss good practice and would like to be able to continue to engage in this way, particularly as new pathways are developed elsewhere. There were suggestions of face-to-face events, virtual events and a virtual online platform to share local practice – possibly as part of an existing networks. 

Tools to support responses 

The purpose of this part of the day was to consider examples of tools already in use that could be applied elsewhere to support healthcare providers in particular to better respond to infant food insecurity families may be facing. 

This included a presentation from Karin O’Hagan of Glasgow Health and Social Care Partnership on the use of Section 22 payments by health visitors, ordinarily only authorised by social work, to give families in extreme hardship ready access to a crisis payment to buy formula milk. 

Attendees were very interested in this approach and group discussions highlighted benefits of this model: 

• empowering heath visitors and family nurses and reducing need for social work involvement 
• getting help to families more quickly 
• could potentially be used as a blueprint for other areas – Glasgow example seen as helpful in sharing locally about what is possible. 
• positive that it is available for asylum seekers/people with No recourse to public funds (NRPF) status
• was suggested national partners e.g. Scottish Government, could co-ordinate the sharing and promotion of the Section 22 approach at national level

Potential challenges were also discussed, including:

• silo working and services being protective of their resources could make it difficult to replicate in other areas. The length of time it took for Glasgow’s model to be set up is reflective of this. 
• data sharing
• questions were raised as to low level of spend on this so far in Glasgow and whether this is true reflection of level of need

It was also highlighted that a crisis payment such as this needs to dove-tail with wider and on-going support, recognising that families’ difficulties can take a long time to resolve. 

The second tool presented was from Emma Österberg of the Independent Food Aid Network (IFAN) on the locally-tailored ‘cash-first’ leaflets which they have co-produced with local services across Scotland. The leaflets are intended to support staff and volunteers, as well as individuals experiencing food insecurity, to find advice and support to maximise income depending on a person’s circumstances. 

Attendees considered the leaflets to be a great resource, particularly as a ‘conversation opener’ on finances for health visitors and family nurses to use with families. It was highlighted that IFAN offers free training to accompany these resources and to see IFAN’s website or contact them for details.

Draft principles on infant food insecurity responses 

The Scottish Government presented a set of draft principles on infant food insecurity responses and invited attendees to discuss and offer views. The intention being for a final set of principles to be adopted by national partners and to form the basis for development of local pathways for support across Scotland. 

Groups provided a lot of helpful, thoughtful and detailed feedback on the wording and framing of the principles and these will be redrafted and shared separately. Common themes from discussion included:

• the need to clarify the purpose of the principles and who the intended audience is
• importance of engaging with people with lived experience to ensure principles are meaningful to them
• language should be easy to understand
• could be restructured as brief principles with greater detail below
• there should be a separate principle on leadership to ensure accountability for the pathway
• time-sensitivity (e.g. support being available quickly) seen as crucial and may need further defined
• more specificity is needed on what is meant by ‘local area’

Mapping of key actors and decision-makers

Families with young babies may come into contact with a wide range of services, groups, and community settings. In developing a pathway for emergency support to access infant formula there is a need to identify those actors that need to be involved. There is also a need for buy-in and oversight from key decision-makers to ensure effective delivery and accountability for local pathways. Attendees were asked to map and discuss those local and national actors. 

Discussions highlighted the wide range of services involved with families with babies, including:

• health: health visitors, family nurses, midwives, GPs, A and E, pharmacies
• education: early years and other childcare providers, schools
• community spaces: libraries; community centres
• faith groups
• local community/voluntary groups: playgroups, food banks/pantries/ babybanks
• national third sector with local presence: Home Start, One Parent Families Scotland, Aberlour, Barnados, Breastfeeding Network, NCT, NSPCC
• welfare advice services, Social Security Scotland
• police, social work 
• retailers, local shops

The challenge of mapping community groups, including very small local food groups and keeping that map up to date, was identified. It was also noted as important to find out what the very local community hubs are/where people go for help/info etc in their communities. 

On leadership/governance, it was noted that there are some existing cross-sector structures that might have a role, such as community planning partnerships. 

When asked what was needed from national partners, suggestions included: 

• a platform for sharing learning
• funding/human resource 
• a clear vision and communication strategy 
• more quality improvement work
• more consistent partnership working between Scottish Government, health boards, local authorities and the third sector

Reflections on data and monitoring

The Scottish Government and Public Health Scotland (PHS) provided a presentation considering the data needed to understand the extent of issues with infant food insecurity to help - plan responses; assess equity in responses and; monitor for improvements. Attendees were then asked to discuss in groups the current gaps in data and possible sources of data to help develop our understanding of the issue. 

Discussion considered:

• possible sources of data: third sector data on formula distribution; records on theft of formula; hospital admissions; data gathered by health visitors routinely (red book), routine or one-off survey data, e.g. Maternal and Infant Nutrition Survey
• the need for more qualitative data to better understand lived experiences of infant food insecurity and families’ journeys/outcomes from engagement with pathways
• it was suggested that recording the feedback/outcomes from health visitors’ routine enquiry on money worries would be another source of data

Participant feedback and actions

Attendees were asked to write down something they liked about the session; anything they felt had been missing; and one action they will do following the event. 

Participants reported valuing the opportunity to hear about good practice and to discuss and network with the range of services and organisations represented. 

Participants were clearly motivated to take action. Several indicated they intend to initiate discussions locally and with colleagues, senior managers and local forums on establishing or developing local pathways/mechanisms for supporting families experiencing infant food insecurity. There was also interest in developing capacity to initiate conversations about financial wellbeing with families. 

Next steps

Some participants expressed interest in further opportunities to network and learn from others, and there was a keenness among participants to continue to be involved and see this work progress at local and national levels. 

In the coming months the Scottish Government and partners will:

• establish as short life working group to develop the draft principles further and explore the benefits of a toolkit to support this work locally (by September 2023)
• identify an appropriate way to gather views from people with lived experience of poverty 
• work with others on developing the revised principles and other resources to support pathway development for publication and dissemination (by October 2023)
• raise awareness of this work with professional bodies, sectors and groups not already engaged (by November 2023)
• identify and plan further networking opportunities to support development of local emergency pathways for infant formula (by December 2023, possible event early 2024)

Overarching reflections

• culture – we need to find ways to identify and support families in immediate need in a supportive, inclusive way – being clear that they are entitled to and should be encouraged to ask for support where and when they need it
• communication – what is available to families, how they access it, and how those who support them, regardless of what sector or organisation they come from, should be clearly and consistently communicated across communities and local areas. Ensuring that information is shared, before babies are even born, and during the earliest weeks and months of a baby’s life should be the norm
• collaboration – only by all local partners and agencies working together with the needs of these families at the centre of decision making and processes, will we better understand who is in need (and how to move to a more pro-active, preventative approach), and whether they are getting the help they need in a timely, responsive way
• consistency – any family, regardless of how they enter local systems and pathways, should have a consistent response that is adapted to meet their individual circumstances and continued for as long as they need it

We expect the outcome for this work is to have clear emergency pathways for infant formula for those parents facing a crisis across all areas of Scotland, aligned to the (developing) draft principles.

Scottish Government
August 2023

Glossary

SIMD quintiles 

Scottish Index of Multiple Deprivation (SIMD) splits Scotland into data zones which are given ranking from most deprived to least deprived.

This data set contains population weighted quintiles and deciles for health board, council area, and health and social care partnership where appropriate. Also available is an indicator as to whether a data zone is in the 15% most deprived or 15% least deprived data zones in Scotland.

Scottish Welfare Fund

The Scottish Welfare Fund (SWF) is a national scheme, underpinned by law [1 , 2] and delivered on behalf of the Scottish Government by all 32 local authorities. It aims to provide a safety net to people on low incomes by the provision of Crisis Grants and Community Care Grants.

Independent Food Aid Network (IFAN)

IFAN is the UK's network of independent food aid providers

IFAN is working to promote a cash-first approach to food insecurity in a number of ways. These include:

• advocating for all local authorities to provide adequate, well-promoted and easy accessible cash payments to people in financial crisis
• advocating for systemic changes that would see social security payments and wages match the cost of living and the root causes of food insecurity and poverty addressed
• co-developing and circulating cash-first referral leaflets across multiple local authorities
• supporting their member organisations to use shopping cards or vouchers and/or cash grants instead of or alongside food parcels or other food support

Section 22

Section 22 of the Children (Scotland) Act 1995 sets out the local authority’s duty to safeguard and promote the welfare of children in its area who are ‘in need’. Help can be given under section 22 either in cash or in kind. Section 22 powers are often used to make occasional or short-term payments, but are also sometimes used to make regular payments. Section 22 payments can be made for a wide range of purposes and so it is important to know what the payment is for.

The information below has been extracted from recent information for your organisation to refer to if required and use to prioritise local action.

Unicef UK guide (October 2022)

As we adapt from the response to recovery phase of the pandemic and feel the impacts of the cost of living crisis, many local authorities and health boards are working to support families who are experiencing food insecurity to achieve food resilience.

To support these efforts, the UNICEF UK Baby Friendly Initiative, First Steps Nutrition Trust and the National Infant Feeding Network (NIFN) have updated this for local authorities and health boards to support relevant teams to work together to ensure that babies and families at risk of food insecurity are given the most appropriate support to meet their needs, with the aims of optimising short- and long-term health and wellbeing outcomes and minimising risk.

This guidance has been developed using the evidence to promote, protect and support the health and wellbeing outcomes of infants under 12 months based on three key principles:

• a duty of care for the safeguarding of all infants under 12 months of age affected by family hardship, however they are fed
• provision of infant feeding support during financial hardship or food crisis that conforms to the World Health Assembly International Code of Marketing of Breastmilk Substitutes and subsequent resolutions (the Code)
• the development of pathways of wraparound care which enable families to access additional services to meet ongoing needs

Food insecurity will be making it both harder for some women to breastfeed, and for some families to afford to formula feed. It may also be affecting the sufficiency of the diets of pregnant women and young children, especially as healthy foods are generally more expensive than unhealthy foods. Living in food insecure households will have negative effects on children’s diets, and therefore their short and long-term health and development.

First Steps Nutrition Trust Cost of Living report (updated May 2023)

Between March 2021 (before food prices started to rise) and April 2023 the seven standard powdered first infant formulas sold by the market leaders increased in cost by an average of 24% (range 17-31%), and the only ‘own-brand’ infant formula increased by 45% (ALDI’s Mamia brand).

• the Government and those working with young families should publicise messages about appropriate, healthy and economical food choices for babies and young children. Messages about formulas should include, that: All infant formulas are nutritionally adequate and there is no need for families to buy more expensive infant formulas 
• growing up milks and toddler milks are all unnecessary Infant formulas marketed as Foods for Special Medical Purposes may be more expensive than brand-equivalent standard infant formulas, may have no benefit, could cause harm, and should be used under medical supervision
• attempts by parents to cut costs, for example by reducing feeding frequency, ignoring best before dates, or over-diluting powdered infant formula, come with worrying health risks as babies and young children are more susceptible to food-borne illness than adults and have high energy needs for growth and development

Scottish Government – Cash-First – Towards Ending the Need for Foodbanks Plan (June 2023)

The Scottish Government published its Cash-First Plan towards ending the need for food banks in June 2023. The plan focuses on improving the response to crisis and using a cash-first approach so that fewer people need to turn to emergency food parcels. The plan sets out nine collaborative actions over the next three years. 

Action 1 of the plan focusing on supporting new local partnerships to deliver cash-first responses. Part B of the plan – Action Over the Next Three Years to Improve the Response to Crisis (page 12)

Linked to this, we will also work with partners, including Public Health Scotland, NHS Scotland and local authorities, to ensure robust pathways are in place locally to meet the particular needs of families with infants under one facing financial crisis. These pathways will build on existing good practice, maximising access to appropriate emergency help and wider advice and support, while reducing the need for food banks.

The Food Foundation Kids Guarantee Update: Infant Milk Formula (July 2023)

The Food Foundation data shows that 27% of UK households home to children under the age of four experienced food insecurity in January 2023, which is higher than for those households with only school-age children or no children at all.

Anna Taylor, Executive Director of The Food Foundation, said: "First infant milk formulas are becoming increasingly expensive for many low income families.

"This is a huge risk to children’s health given that where breastfeeding is not chosen or possible, infant formula before the age of six months is the only option parents have for feeding their infants, and is a key source of both calories and other essential micronutrients between six months and the age of one."