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I. Background
Young children rely on a balanced diet to meet their nutritional needs for optimal growth and
development as well as physical activities. While milk is rich in protein, calcium and other nutrients,
it constitutes only part of a balanced diet. In 2010, a Dietary Survey of Hong Kong Infants & Young
Children was conducted by the Department of Health (DH) and the Department of Medicine and
Therapeutics and the Centre for Nutritional Studies of the Chinese University of Hong Kong.
Preliminary findings revealed a prevalence of unbalanced dietary patterns with excessive milk
consumption among a significant proportion of young children. The majority of the surveyed
children relied on formula milk (FM) to obtain the major nutrients to meet their daily requirement.
Besides, most of the two-year-olds and half of the four-year-olds surveyed still used the bottle to drink
milk.
In view of the above, the DH has compiled a fact sheet for parents, putting forth recommendations on
milk intake for young children. This document sets out all the considerations for making these
recommendations, for the reference of health professionals.
Considerations:
a. Meeting the calcium requirement of young children
Hong Kong does not have its own population-specific Dietary Reference Values (DRV) to inform
the nutrient requirements of local children.
Milk is often regarded as a convenient and good source of calcium. Health Authorities of various
countries recommending milk intake for young children mainly consider milk as the major source
of calcium in meeting the recommended calcium requirements. The recommended milk intakes
range from 300 to 750 ml per day. (Table 1)
In UK, the Department of Health recommends that children above 1 year old consume
up to 360 ml of milk per day2, which largely fulfill the calcium requirement of UK
children (e.g. 350 mg / day for 1 to 3-year-old children3).
In countries such as USA and Canada with higher recommended calcium intake (e.g.
700 mg / day for 1 to 3-year-olds, 1000 mg/day for 4 to 8-year-olds4), about 2 cups of
milk a day (up to 480 ml) are recommended5.
i
Calcium salts are used as the coagulants in making tofu in the traditional methods. However, some prepackaged tofu
are prepared by other coagulants, thus the calcium content is low.
ii
WHO/FAO RNI of Calcium: 1 -3 years old children is 500mg /day, 4-6 years old children is 600mg /day.
Considerations
Cow milk generally provides about 110mg calcium/100 ml. An intake of 360 – 480 ml of cow milk
per day provides a significant amount of calcium to meet the requirement of children 1-5 years.
The calcium concentration of formula milk marketed locally for children above 1 year varies
between 64 and 115 mg/100ml (Table 4). Taking the example of a FM with the lowest calcium
content, 480 ml alone provides more than 60% of the calcium required per day. The rest can be
met by eating other foods in the diet (e.g. vegetables and other staple foods; the sample menus
in Table 6 provides around 190 mg Calcium)
During the transition from milk feeding to eating family meals, iron deficiency is a common
problem. Iron deficiency with or without anaemia during infancy and childhood may have long
term adverse effects on neurodevelopment19. From 6 months onwards, infants should consume
a variety of iron-rich foods, such as iron fortified cereals, meat and liver, fish, eggs, legumes, and
green leafy vegetables. Cow milk is low in iron. Iron-fortified formula milk provides an
additional source of iron for children not taking adequate iron-rich foods.
One should also take the caloric content into consideration when choosing between cow milk and
formula milk. Formula milk is more energy & nutrient-dense than cow milk, with a higher sugar
level (Table 3 & 4). Thus, when compared to cow milk, formula milk may not only displace more
of children’s appetite for other foods with the same quantity consumed, but also increase their
risk of becoming overweight or obese and developing dental caries. Moreover, children may get
accustomed to the sweet taste of formula milk and refuse to drink water and eat foods with
bland taste.
Considerations
Children using bottles are likely to consume more milk than those not using bottles, resulting in
overfeeding21. Besides, children will have a higher chance of developing dental caries especially
if they use to fall asleep with a bottle.
1 Feb 2012
Family Health Service, Department of Health
Table 4: Comparison between Whole Cow Milk and Some Formulae Targeted for children > 1 year.
Protein (g) 3.15 2.58 2.7 2.5 2.01 2.6 3.0 3.0 3.3 3.5
Total fat (g)) 3.72 3.62 2.5 1.82 2.99 3.0 3.0 3.9 3.1 3.2
Carbohydrate (g) 4.78 7.59 9.9 9.9 7.99 10 11.7 13.2 14.5 12.7
Iron (mg) 0.03 1.19 1.2 1.03 0.98 1.2 1.7 1.4 1.6 1.7
Zn (mg) 0.37 0.56 0.5 0.68 0.58 0.5 1.0 0.7 0.65 0.83
#
Nutrient Information Enquiry. Centre for Food Safety. The Nutrient Data Laboratory, United States Department of
Agriculture (SR22) (Milk, whole, 3.25% milk fat, without added vitamin A and vitamin D)
Link: http://www.cfs.gov.hk/english/nutrient/fc-introduction.shtml
Composition of the formulae was accessed from www.mims.com/Hongkong/drug/info on 4 November 2011
Choline Important in the formation of Many types of foods are rich in choline, among
cells and brain function. them, animal liver, milk, egg, beef broccoli and
brussel sprouts are good sources32.
Beta-carotene Converts into Vitamin A in the Yellow and orange fruits and dark green leafy
body, a potent antioxidant. vegetables
Prebiotics / FOS Can improve bowel health and Rich in fruits, soy and soy products, and whole
(Fructooligosaccharides) immune function 33 . However, grains.
there is no evidence to suggest
its function in preventing
allergy.34
Iron Involves in various body Meat, especially red meat, is a good source of
functions, including the delivery haem iron with high bioavailability.
of oxygen throughout the body. Non-heme iron in soy, green leafy vegetable,
nuts and iron fortified grain cereals are better
absorbed by the body when consumed with
vitamin C rich fruits.
Calcium An essential mineral in building Milk and dairy products (e.g. cheese, yoghurt).
strong bones and teeth. Some green leafy vegetables.
Calcium added Tofu prepared by calcium salt.
Vitamin D in the body can aid absorption of
calcium. Moderate exposure to sunlight, and
consumption of vitamin D rich foods like egg and
fish will improve vitamin D status in the body.
Zinc A mineral that helps the child’s Rich in most protein sources, such as milk,
development of immune system meats, egg and soy products.
and help prevent illnesses.
Remarks:
Probiotics Probiotic bacteria have been added to milk formulae to manipulate the intestinal
flora of formula-fed babies to mimic that of breastfed babies, with the anticipated
benefits of enhancing the immature immune system and protecting against
infections and allergies. The long term clinical benefits have not been demonstrated
based on current evidence.35
Snack Bread (1/2 pc) 24g 55.9 2.1 21.2 0.5 0.3
RNI (WHO)
1
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2
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on Medical Aspects of Food Policy. Department of Health, UK. The 5th Impression 2003.
3
Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report of the Panel
on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. Department of
Health, UK. The 18th Impression 2008.
4
Dietary Reference Intakes for Calcium and Vitamin D. Report Brief Nov 2010. Institute of Medicine
2010. Available at
http://www.iom.edu/Reports/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D.aspx.
Accessed on 8 November 2011.
5
U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary
Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office,
December 2010. Available at www.dietaryguidelines.gov. Accessed on 8 November 2011.
6
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ISBN978-7-5019-2895-8.
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8
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(2009-12-25). Available at http://www.fda.gov.tw/content.aspx?site_content_sn=285. Accessed on 30
October 2011.
9
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http://plan-consumer.fda.gov.tw/Children/Children/infant/infant.htm. Accessed on 30 October 2011.
10
Weaver CM. Calcium requirements: the need to understand racial differences. Am J Clin.Nutr
1998;68(6):1153-4.
11
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12
The Report of the Dietary Guidelines Advisory Committee on Dietary Guidelines for Americans,
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18
Fox MK, Reidy K, Novak T, Ziegler P. Sources of Energy and Nutrients in the Diets of
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2011.
23
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years. Available at http://www.health.gov.au/internet/healthyactive/publishing.nsf/Content/boy-1-3.
Accessed on 25 October 2011.
24
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years. Available at
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