Sir, I am writing to express my concerns about the following article recently published in the BDJ: A cross-country exploratory study to investigate the labelling, energy, carbohydrate and sugar content of formula milk products marketed for infants (BDJ 2020; 228: 198-212).

The title and abstract of this article refers to the sugar content of infant formula milk. The study looks at the sugar content of a wide range of products including fortified cows' milk and milk based nutritional supplements marketed at toddlers. These are not infant formulas or breastmilk substitutes as implied in the article.

Looking at the data, the sugar content of the infant formulas shows little variability and is comparable to that of breastmilk. As I understand it, this sugar content is necessary to meet the nutritional requirements of infants who rely on infant formula as a food source. The sugar content of the range of products targeting toddlers is more variable, as the authors note.

I am concerned that by referring to a wide range of milk products as 'infant formula', the article is misleading and may cause undue anxieties about the sugar content of infant formula.

I would be grateful if your journal could amend the original article to reflect the data it contains.

Authors Gemma Bridge, Marta Lomazzi and Raman Bedi respond: We thank the editor for the opportunity to reply to the letter from Dr Harpur. We are grateful to Dr Harpur for her letter. She raises concerns the article could be misleading and cause undue anxieties about the sugar content of formula milk amongst some parents.

We believe these anxieties are unfounded. The title of our published paper states that we investigated a range of formula milk 'products' marketed at infants, ie babies and very young children.

We found that many of the products were high in sugar and that the sugar content was not clearly stated on the products. We argue that those responsible for providing information to parents about infant feeding, including The Infant Feeding Alliance, an organisation that Dr Harpur is affiliated with, public health groups, industry and health professionals should be concerned about the sugar content of all products that are consumed by infants as there is a significant proportion of young children with early childhood caries. The risk of caries is increased by high sugar intake, especially in the first 1,000 days of life.

The purpose of our article was to describe the sugar content of a sample of infant formula products from across the world, and to assess what information is available to caregivers on the labelling of such products about the amount and type of sugar in the products. These aims were achieved. However, we recognise that this study is just the start and do strongly recommend and support the need for further research on the possible long-term health effects of a high sugar diet in infancy, and argue that sugar content and labelling regulations of formula milk products for infants under three are warranted.