Sugar Content in Infant Formula: Accuracy of Labeling and Conformity to Guidelines

Abstract

Background:
Infant formulae are a primary source of nutrition during the first years of life, to which sugars are frequently added. This may contribute to adverse dental health problems if consumed excessively when coupled with prolonged and nocturnal feeding habits.

Aim:
To assess the amount and type of dietary sugars in commercially available infant formulae in the UAE.

Design:
Sucrose, glucose, and fructose were measured in 71 different brands of commercially available infant formulae for retail sale in the UAE. Analysis was performed using high-performance liquid chromatography with refractive index detection. Sugar values were compared with nutritional labels. Comparison between findings, products' labels, and international standards for infant formulae was performed.

Results:
Of the 71 samples, 23 had detectable sugar levels, varying between sucrose, glucose, and fructose. Ten samples were found to have sugars contributing to more than 5% of total energy intake ranging between 5.68 - 27.06%. All infant formulae packages had carbohydrate levels mentioned on the labels, but very few mentioned the added sugar content.

Conclusions:
Many infant formulae products tested contained sugars that exceeded the standard recommended intake. Tighter regulations that monitor the amount of sugar in infant formulae and guidelines for comprehensive labelling systems are required.

Full text

Int J Paediatr Dent. 2022;00:1–11. wileyonlinelibrary.com/journal/ipd
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© 2022 BSPD, IAPD and John Wiley & Sons Ltd.
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INTRODUCTION
Tooth decay is a multifactorial disease that results from a
complex interaction between bacteria capable of produc-
ing acids and fermentable sugars in the biofilm in contact
with the tooth surface.1 Early childhood caries (ECC),
specifically, has been on the rise across the world and
has become a major health problem.2 In the United Arab
Emirates (UAE), the prevalence of caries in preschool
children was reported to be 74.1%3 and 80.95% in the Gulf
Cooperation Council (GCC) countries.4 Evidence examin-
ing possible various risk factors known to cause ECC is
scarce.5 According to the American Academy of Pediatric
Dentistry (AAPD), bottlefeeding with milk at night, espe-
cially if prolonged, and ad- libitum breastfeeding are asso-
ciated with ECC initiation in children.6 Although studies
Received: 25 October 2021
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Revised: 26 February 2022
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Accepted: 25 April 2022
DOI: 10.1111/ipd.13014
ORIGINAL ARTICLE
Sugar content in infant formula: Accuracy of labeling and
conformity to guidelines
RawanAwad1
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MawloodKowash2
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IyadHussein2
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AnasSalami2
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MohamedAbdo2
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ManalAl- Halabi2
1Department of Pediatric Dentistry,
Tufts University School of Dental
Medicine, Boston, USA
2Hamdan Bin Mohammed College
of Dental Medicine, Mohammed Bin
Rashid University of Medicine and
Health Sciences, Dubai, United Arab
Emirates
Correspondence
Manal Al- Halabi, Hamdan Bin
Mohammed College of Dental
Medicine, Mohammed Bin Rashid
University of Medicine and Health
Sciences, Dubai, United Arab Emirates.
Emails: manal.halabi@mbru.ac.ae;
manal.halabi@gmail.com
Abstract
Background: Infant formulae are a primary source of nutrition during the first
years of life, to which sugars are frequently added. This may contribute to adverse
dental health problems if consumed excessively when coupled with prolonged
and nocturnal feeding habits.
Aim: To assess the amount and type of dietary sugars in commercially available
infant formulae in the UAE.
Design: Sucrose, glucose, and fructose were measured in 71 different brands of
commercially available infant formulae for retail sale in the UAE. Analysis was
performed using high- performance liquid chromatography with refractive index
detection. Sugar values were compared with the reported levels on the nutritional
labels. A comparison between findings, product labels, and international stand-
ards for infant formulae was performed.
Results: Of the 71 samples, 23 had detectable sugar levels, varying between su-
crose, glucose, and fructose. Ten samples were found to have sugars contributing
to more than 5% of total energy intake ranging between 5.68% and 27.06%. All
infant formula packages had carbohydrate levels mentioned on the labels, but
very few mentioned the added sugar content.
Conclusions: Many infant formula products tested contained sugars that ex-
ceeded the standard recommended intake. Tighter regulations that monitor the
amount of sugar in infant formulae and guidelines for comprehensive labeling
systems are required.
KEYWORDS
early childhood caries, infant formula, liquid chromatography, sugar

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AWAD et al.
have shown that cow milk has low cariogenicity due to its
low lactose level,7 children sleeping with sweetened milk
bottles are at high risk of having ECC. The combined ef-
fect of prolonged exposure to cariogenic sugars with an
inadequate clearance of sugars as they are consumed at
night increases the likelihood of fermenting these sugars
by cariogenic bacteria into acid and therefore demineral-
izing enamel.8
Although human milk and breastfeeding are considered
the ideal form of infant feeding as it provides many benefits
for the child's well- being, including nutritional, develop-
mental, and psychological advantages,9 many infants can-
not be breastfed and therefore need infant formula milk.
The composition of these infant formulae is often altered to
either add or remove a few components such as corn syrup,
sucrose, and lactose. Due to their carbohydrate content,
infant formulae are anticipated to have a high- cariogenic
potential. The potential cariogenicity of milk and infant
formulae, which are the most common bottle contents, re-
mains uncertain and largely inconclusive.10
To ensure infants receive safe products that meet their
nutritional requirements, global standards by international
committees were developed. An example is the Codex
Alimentarius Commission, which was created by the Food
and Agriculture Organization (FAO) of the United Nations
and the World Health Organization (WHO) to develop
food standards and guidelines in food quality and safety,
which aim to protect public health. Codex Standard 72 on
Infant formula11 was adopted as a worldwide standard in
1981, which was then revised as ESPGHAN (European
Society for Pediatric Gastroenterology Hepatology and
Nutrition) Recommended Standards for the Composition
of Infant Formula.12 As stated in the standard, lactose and
glucose should be the preferred carbohydrate in infant for-
mulae. This preference is because lactose is predominant
in human milk and of newborns' ability to hydrolyze it.
Comparatively, glucose is present in low levels in human
breastmilk and therefore unsuitable for routine use in in-
fant formula.12 Small amounts of glucose, however, may
help mitigate the disagreeable taste of infant formulae.
Furthermore, fructose addition may lead to severe side ef-
fects, including death in young infants with hereditary fruc-
tose intolerance, a disease that can lead to severe symptoms,
including poor feeding, vomiting, and failure to thrive.13
Sucrose is a disaccharide containing glucose and fructose, so
it is considered to have similar side effects as fructose. Given
the possibility of life- threatening symptoms in infants with
hereditary fructose intolerance in early infancy,13 sucrose
and fructose should not be added to infant formulae. The
addition of fructose or sucrose does not have any advantage
over lactose, but, due to their greater sweetness, it may in-
crease the preference for sweet taste in infants.14
Although the cariogenicity of various bottle contents
is controversial, the cariogenic potential of sucrose-
containing solutions in the baby bottle has been well re-
ported.15 A high- cariogenic potential of infant formulae
can be expected, owing to their varied carbohydrate con-
tents.16 The available evidence on the cariogenicity of
different types of infant formulae in humans is scarce.
Infant formulae were reported to be as cariogenic as su-
crose.17Their cariogenic potential, however, varied across
other studies, and no definite conclusions could be
drawn.10,17
Several techniques have been developed to evaluate
the sugar content in food, such as gas chromatography
(GC).18Even though GC is a sensitive and reliable method
for sugar analysis, its process is strenuous and lengthy. GC
was the dominant technique for analyzing carbohydrates
until the mid- 1970s when the high- performance liquid
chromatography (HPLC) method became the leading
method. This technique is used for its accuracy and rapid-
ity compared with the GC method. Due to its reported sat-
isfactory precision and sensitivity, the HPLC method was
used in our study. To the best of our knowledge, the level
and type of dietary sugars in infant formulae available for
retail sale in the UAE have not been studied. This study
aimed to assess the amount and type of dietary sugars in
commercially available infant formulae in the UAE. The
levels of glucose, fructose, and sucrose in infant formulae
were measured and compared with the reported levels on
the nutritional labels. The amount of daily consumption
of sugar in infant formulae was calculated. Furthermore,
we calculated the contribution of carbohydrates in the
infant formulae to the total daily calorie intake and com-
pared that with that of the international recommended
standards.
Why this paper is important to paediatric
dentists
• Paediatric dentists must be aware of the guide-
lines for sugar content in infant formulae.
• It is essential to acknowledge that in many re-
gions of the world, the available formulae con-
tain cariogenic sugars. Paediatric dentists need
to provide advice to the parents of their patients
on this matter.
• Paediatric dentists should raise awareness and
advocate tighter regulations that monitor the
amount of sugar in infant formulae and pro-
vide a comprehensive labeling system that ac-
curately discloses the sugar levels.

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AWAD et al.
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MATERIALS AND METHODS
This study involved measuring sucrose, glucose, and
fructose in 71 different brands of commercially available
powdered infant formulae for retail sale in the baby food
sections in major supermarkets in the UAE. The inclusion
criteria were as follows: organic and non- organic milk-
based, goat milk, soy- based, hydrolyzed rice, and lactose-
free formulae, which were recommended for healthy
infants from birth until 3 years of age. Infant formulae for
special medical purposes were excluded.
2.1
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Experimental analysis
The experimental analysis was conducted in a food test-
ing laboratory in Dubai (Geoscience Testing Laboratory).
Samples were sent to the laboratory, each in a coded con-
tainer, to assure the laboratory technicians were blinded
to the brand and nutritional labels of the formulae tested.
Tests quantifying sucrose, glucose, and fructose were per-
formed using high- performance liquid chromatography
with refractive index detection (HPLC- RI). The machine,
Agilent HPLC 1260™ with RI Detector™, was calibrated
before being used to test the samples. Calibration was
performed by a trained laboratory technician. Study and
control cycles were run using the HPLC RID VWD soft-
ware™. Calibration was done using a stock standard con-
sisting of 1 g of glucose, 1 g of fructose, 1 g of sucrose, 1 g
of lactose, and 10.4 g of maltose monohydrate mixed with
HPLC- grade water up to 10ml marking in a volumetric
flask. From this stock standard, five calibration standards
were made and then placed in glass vials and put in a vor-
tex mixer for homogeneity. Samples were then prepared;
the infant formulae were reconstituted according to the
manufacturer's instructions using distilled water, as de-
tailed in the AppendixS1.
Each formula was measured and stirred manually in a
glass beaker, then transferred into a sonicator (Ultrasonic
bath XUBA3™) for 15 min to ensure homogeneity of the
prepared samples. Two milliliters of the homogenized
sample was taken and added to 1.5ml of distilled water
and incubated at 60°C for 10min. Samples were then al-
lowed to cool before adding 0.25 ml of Carrez solution I,
0.25 ml of Carrez solution II, and 1ml of acetonitrile. The
samples were then centrifuged again for 10min.
The resultant upper aqueous layer was removed by fil-
tration, using a 0.45- microliter nylon filter, injected into
a 2- ml HPLC vial (Figure1) and then into the HPLC. To
ensure the accuracy of the results, a duplicate sample was
taken from each sample at this point, with the resultant
two vials of the same sample injected into the HPLC, and
the average reading was recorded. Moreover, a quality
control sampling was performed simultaneously to en-
sure that laboratory analysis results were consistent, com-
parable, and accurate within specified limits of precision.
During every testing batch, verification standards were
run along with the sample, and the response was mea-
sured. If the response varied by more than 20% from the
initial calibration peak, the instrument was recalibrated.
A blank sample was injected between every two consecu-
tive samples to ensure stability and to allow the refractive
index to return to baseline between samples. The mea-
sured readings of sucrose, fructose, and glucose appeared
on the software at the end of the testing cycle. The HPLC
machine used for testing is run by the limit of quantitation
(LOQ) and the limit of detection (LOD) methods. LOD is
the smallest concentration of an analyte in a test sample
that can be distinguished from zero, whereas LOQ is the
smallest concentration of an analyte in a test sample that
can be determined with acceptable repeatability. LOD was
set at 0.1, which meant that the lowest concentration of
any of the three sugars tested that could be reliably de-
tected was 0.1 g/100 ml.
2.2
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Data analysis
Descriptive analysis was performed using tables. A
comparison between this study's findings, data on
the product labels, WHO standards, and ESPGHAN
Recommended Standards for the Composition of Infant
Formula was performed. The total grams of measured
sugar per day was calculated for each infant formula
according to the manufacturer's recommendations.
FIGURE  Aqueous layer (pointed with red arrow) injected
into high- performance liquid chromatography (HPLC) vial by
filtration

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AWAD et al.
The number of scoops, water volume per serving, and
the number of servings per day were obtained from the
product labeling as detailed in AppendixS1. Values were
obtained from the following equation: grams of sugar
per serving=[(water volume per serving (ml) × meas-
ured sugar (g))/100 ml]. This value was then multiplied
by the recommended number of servings per day to get
the total grams of measured sugar per day. Moreover,
the total calories in kcal per 100 ml were recorded from
the package labeling; then, the total calories per day
were calculated, based on the recommended number of
servings per day. The percentage of total calories from
sugar was derived from the following equation: % total
calories from sugar=[(total g of sugar per day × 4)/total
calories per day] × 100.
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Ethical considerations
Exemption from ethics approval for this in vitro
study was obtained from the Mohammed Bin Rashid
University of Medicine and Health Sciences Research
and Ethics Committee (MBRU- IRB- 2020- 008_27 Feb
2020).
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RESULTS
3.1
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Sugar content of the infant formula
samples
The total number of infant formulae tested was 71. These
were tested for sucrose, glucose, and fructose. All tested
samples were manufactured outside the UAE, except
one (Nestle Nido One Plus©). Of the 71 samples, 23
had detectable sugar levels. Twelve samples had glu-
cose and were recommended for children from birth
and 36 months. Only one sample had detectable fructose
(Similac Total Comfort 1©) with a value of 4.6 g/100 ml.
This sample belonged to the infant formula category, in-
tended for use between birth and 6 months. Sucrose was
detected in 10 samples, which belonged to the follow- on
formula category marketed for children between 6 and 12
and between 12 and 36 months. The infant formulae in
which the three sugars were detected are listed in Table1,
arranged according to total grams of sugar per day.
3.2
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Daily sugar consumption from the
tested samples
Following the daily recommended manufacturer's prepa-
ration guidelines, the daily sugar consumption from the
23 samples in which sugar (glucose, fructose, and sucrose)
was detected was calculated and compared with the rec-
ommended intake, as detailed in Table1.
The total grams of measured sugar per day was cal-
culated for each infant formula according to the manu-
facturer's recommendations. One sample (Similac Total
Comfort 1©) contained above 30g of sugar per day, and
this was the only sample with fructose detected.
To compare the labeled carbohydrate levels against the
standard, the labeled carbohydrate level per 100 kcal was
calculated for each sample. Only one sample (Nutrilac
3©) exceeded the recommendation with a value of 24.14g
of carbohydrate per 100 kcal.
The contribution of sugars to daily caloric intake was
calculated and is presented in Figure2. Of all the infant
formula products analyzed, eight were found to have sug-
ars contributing to more than 5% of total energy intake,
and two samples to more than 10% (Similac Total Comfort
1© and Nutrilac 3©).
3.3
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Comparison between labeled and
measured sugar contents
All tested samples had the total carbohydrate level
mentioned on the label. Of all 71 tested samples, only
nine had the fructose level labeled; none of these nine
samples, however, were found to have fructose when
tested. Fructose was reported on the labels as fructo-
oligosaccharides (FOS) or oligofructose. Glucose was
reported on the label of 11 samples. Sucrose, also la-
beled as saccharose, was found on the label of only one
sample, and the labeled level was higher than that found
when tested. Table2 compares the labeled and meas-
ured glucose, fructose, and sucrose levels in all tested
samples.
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DISCUSSION
This study examined an important element in infants'
nutrition, namely milk formula. Many mothers resort to
using infant formulae early in their babies' lives alone or
combined with breastfeeding.19 This practice may con-
tinue into the primary dentition phase and beyond, thus
negatively affecting teeth.20 The American Academy of
Pediatrics recommends exclusive breastfeeding for the
first 6 months of life, and the introduction of complemen-
tary foods along with breastfeeding during the first year
of life.21Many infants, however, cannot be breastfed and
therefore need infant formula milk partially or solely.
The present study investigated the levels of three
types of sugar in 71 different brands of commercially

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AWAD et al.
available infant formulae in the UAE. In descending
order of cariogenicity, sucrose, glucose, and fructose
have been well established as cariogenic sugars,22 and
therefore selected to be investigated in this study. All
samples were powdered infant formulae, as premixed
formulae are not commonly found in the UAE. Although
the list of products included might not be comprehen-
sive, it is likely to be representative of the products avail-
able in the market.
Of the 71 samples, 23 had detectable sugar levels, and
none of these samples had any combination of detected
sugars. These results differed from those of Walker and
Goran's study in 2015, where it was found that sugar con-
tent in infant formulae was distributed among lactose, su-
crose, maltose, or glucose.23 According to the ESPGHAN
Recommended Standards for the Composition of Infant
Formula,11,12 lactose and glucose should be the preferred
carbohydrate in a formula based on cow's milk protein and
hydrolyzed protein, and fructose should not be added to
infant formulae intended for use during the first 6 months
of life.12
The current study did not analyze the lactose content
because lactose has low cariogenicity.712 samples, how-
ever, had glucose and ranged for use between birth and
36 months, and tested glucose levels ranged from 0.17
to 0.28 g/100 ml. One sample had detectable fructose
(Similac Total Comfort 1©) with a value of 4.6 g/100 ml.
This is of primary concern as this sample belonged to
the infant formula category, which is intended for use
between birth and 6 months of age, and this contradicts
TABLE  Daily consumption of sugar as per the manufacturer's preparation instructions and label data, in samples in which sugar was
detected
Brand name
Measured sugar levels (g/100 ml) Daily sugar consumption
Glucose Fructose Sucrose
g of sugar
per day
g of (labeled)
carbohydrate/100 kcal
% of total
calories from
sugar
Aptamil 3 0.18 <0.10 <0.10 0.97 11.75 1.14
Bebelac 3 0.18 <0.10 <0.10 0.97 11.88 1.04
Humana 3 0.28 <0.10 <0.10 1.02 12.24 1.67
Aptamil 2 0.17 <0.10 <0.10 1.07 11.49 1.01
Primalac Lactose Free 0.23 <0.10 <0.10 1.24 11.06 1.39
NAN Lactose Free 0.20 <0.10 <0.10 1.26 11.64 1.19
Bebelac 2 0.22 <0.10 <0.10 1.39 11.64 1.31
Aptamil 1 0.18 <0.10 <0.10 1.51 11.23 1.11
Aptamil Lactose Free 0.18 <0.10 <0.10 1.51 11.06 1.09
Humana 1 0.17 <0.10 <0.10 1.53 10.44 1.00
Bebelac 1 0.20 <0.10 <0.10 2.10 11.23 1.23
Bebelac Lactose Free 0.21 <0.10 <0.10 2.21 11.36 1.27
Blemil Plus 3 <0.10 <0.10 0.80 3.84 11.59 4.64
Similac Gold 3 <0.10 <0.10 1.07 5.78 10.41 5.78
Similac Total Comfort 3 <0.10 <0.10 1.05 7.56 10.82 5.68
Biomil Plus 3 <0.10 <0.10 1.47 7.94 11.04 8.78
Illuma 2 <0.10 <0.10 1.01 9.09 12.09 6.03
Similac Gold 2 <0.10 <0.10 1.12 10.08 10.81 6.05
Nutrilac 2 <0.10 <0.10 1.42 10.22 7.12 5.84
Isomil 2 (Soy Follow- On
Formula)
<0.10 <0.10 1.16 11.14 12.17 6.72
Similac Total Comfort 2 <0.10 <0.10 1.47 13.23 10.82 7.95
Nutrilac 3 <0.10 <0.10 2.87 15.07 24.14 13.20
Similac Total Comfort 1 <0.10 4.60 <0.10 49.68 10.44 27.06
The Significance use of color shadings includes values which exceeded the recommended standards.(Nutrilac 3©) exceeded the recommendation with a value
of 24.14 g of carbohydrate per 100 kcal, Eight samples contribute to more than 5% of total energy intake, and two samples to more than 10% (Similac Total
Comfort 1© and Nutrilac 3©).
The Significance use of Bold values indicates two samples to more than 10% (Similac Total Comfort 1© and Nutrilac 3©).

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AWAD et al.
the above- mentioned recommendation.12 Not to mention
that although fructose is less cariogenic than sucrose, it
is still considered a cariogenic sugar.22 The ESPGHAN
Recommended Standards for the Composition of Infant
Formula also recommend that sucrose should not be
added to infant formula until 6 months of age.12 The cur-
rent study results demonstrated compliance with this
recommendation, as the 10 samples where sucrose was
detected belonged to the follow- on formula category,
marketed for ages 6– 12 and 12– 36 months. Nevertheless,
as sucrose has been identified as the most cariogenic
sugar,24 the detected sucrose in 10 samples ranging be-
tween 0.8 and 2.87g/100 ml is disconcerting given the
cariogenic potential of sucrose- containing solutions in
the baby bottle.15
An objective of this study was to calculate the contribu-
tion of sugars in the formulae to the total daily calorie in-
take and compare that with that of the recommendations.
The results of this study showed that eight of the infant
formulae tested were found to have sugars contributing to
more than 5% of total energy intake, and two samples to
more than 10%. The WHO has a strong recommendation
for both adults and children that added sugar should pro-
vide less than 10% of total energy intake, or less than 60
grams per person per day, whichever is lesser, and a con-
ditional recommendation for a further reduction in the
intake of free sugars to below 5% of total energy intake.24
There are no specific recommendations for infants; the
ESPGHAN Committee on Nutrition, however, states that
free sugar intake in infants and toddlers should be even
lower than 5% of the energy intake.25 The percentages of
the sugar contribution to total energy intake calculated
in the present study (eight samples >5% and two samples
>10%) were based on the values of detected sugars and fol-
lowing the manufacturer's recommendations for numbers
of servings per day. These findings may somewhat be lim-
ited by the possibility that not all infants are on a feeding
regimen that follows these recommendations; some in-
fants might be exclusively formula- fed, and others might
be formula- fed along with breastfeeding (mixed feeding).
Moreover, infants may have been introduced to comple-
mentary feeding from 6 months, so other food products
FIGURE  Percentage of total
calories from sugars available in the infant
formulae tested

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AWAD et al.
TABLE  Amount of sugar detected and labeled in tested samples
Brand name
Glucose Fructose Sucrose
Measured Labeled Measured Labeled Measured Labeled
Aptamil 1 0.18 0.20 <0.10 Not labeled <0.10 Not labeled
Aptamil 2 0.17 0.20
Aptamil 3 0.18 0.30 Sucrose free
Aptamil Lactose
Free
0.18 0.20 Not labeled
Baby & Me Organic
1
<0.10 Not labeled
Baby & Me Organic
2
Baby & Me Organic
3
Bebelac 1 0.20 0.20
Bebelac 2 0.22 0.20
Bebelac 3 0.18 0.20
Bebelac Lactose
Free
0.21 0.20
Biomil Plus 1 <0.10 Not labeled
Biomil Plus 2
Biomil Plus 3 1.47
Blemil Plus 1 <0.10 Not labeled <0.10 Not labeled <0.10 Not labeled
Blemil Plus 2
Blemil Plus 3 0.80 2.10
Blemil Plus HR 1
(hydrolyzed rice
protein)
<0.10 Not labeled
Blemil Plus HR 2
(hydrolyzed rice
protein)
HiPP Organic 1
HiPP Organic 2
HiPP Organic 3
Humana 1 0.17 0.20
Humana 2 <0.10 0.20
Humana 3 0.28 0.20
Illuma 1 <0.10 Not labeled 0.30
Illuma 2 0.30 1.01
Illuma 3 0.30 <0.10
(Continues)

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AWAD et al.
Brand name
Glucose Fructose Sucrose
Measured Labeled Measured Labeled Measured Labeled
Isomil 2 (Soy
Follow- On
Formula)
<0.10 Not labeled <0.10 Not labeled 1.16 Not labeled
Jovie Organic (Goat
Infant Milk) 1
<0.10
Jovie Organic (Goat
Infant Milk) 2
Jovie Organic (Goat
Infant Milk) 3
Kabrita 1 (Goat
Milk Based)
Kabrita 2 (Goat
Milk Based)
Kabrita 3 (Goat
Milk Based)
Lipto Growl Plus 3
Liptomil Plus 1
Liptomil Plus 2
Liptomil Plus
Lactose Free
NAN Lactose Free 0.20
NAN Optipro 1 <0.10
NAN Optipro 2
NAN Optipro 3 <0.10 Not labeled <0.10 Not labeled <0.10 Not labeled
NAN Supreme
HA 1
NAN Supreme
HA 2
NAN Supreme
HA 3
Nanny Care (Goat
Milk Based)
Nestle NIDO One
Plus
No sucrose added
Novalac 1 Not labeled
Novalac 2
Novalac Genio
Vanilla Flavor
Sucrose free
Nutrilac 1 Not labeled
Nutrilac 2 1.42
Nutrilac 3 2.87
Primalac Lactose
Free
0.23 <0.10
Primalac Premium
1
<0.10
TABLE  (Continued)

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AWAD et al.
contribute to the total energy intake. It is, however, safe
to assume that these findings are applicable to infants ex-
clusively formula- fed. It is also worth mentioning that in
this study, only three types of sugars were tested, namely
sucrose, glucose, and fructose. There are perhaps other
added sugars that will also increase the percentage of
added sugars' contribution to the total energy intake, such
as maltose, galactose, and lactose, which in turn can lead
to an increased caries risk.
The ESPGHAN Recommended Standards for the
Composition of Infant Formula12 recommended that the
total carbohydrate level should optimally be between 9
and 14g/100 kcal. There are no recommendations for each
sugar, and for that reason, it was not possible to correlate
this value with our tested sugar values. We, however, com-
pared the labeled carbohydrate levels mentioned on the
package against the standard. Only one sample (Nutrilac
3©) exceeded the recommendation with a value of 24.14g
of carbohydrate per 100 kcal. Almazrooy et al. compared a
smaller sample of five types of infant formula brands, and
they all were compliant with the standard, with a carbohy-
drate content of 9– 14g/100 kcal.
One of the objectives of the current study was to com-
pare the labeled and measured glucose, fructose, and su-
crose levels for the samples in which sugar was detected. It
should be assumed that manufacturers of infant formulae
comply with standards. Few studies have been conducted
to determine the possible discrepancy between the actual
and labeled nutritional contents.26 A Saudi study compared
the package labels of infant formulae with ESPGHAN
Recommended Standards for the Composition of Infant
Formula27 and reported that all formulae studied were
safe and nutritionally adequate. Unlike our study, their
comparison was made between the information provided
on the labels of the formulae's containers and ESPGHAN
Recommended Standards for the Composition of Infant
Formula, and no laboratory testing was involved. A sim-
ilar study investigated the labeling, energy, carbohydrate,
and sugar content of formula milk products.28 Their data
were collected from the information reported in the pack-
aging of products and concluded that most of the sampled
products were high in total carbohydrates. In 2015, Walker
and Goran conducted a similar study and reported that
the nutrient label data can underestimate or overestimate
actual sugar levels and that many products contain sugars
in amounts that exceeded the recommended daily levels
and differ from nutritional labels.29 The present study's re-
sults are consistent with those of the latter study, in which
a range of differences was noted. In infant formulae in
which glucose was detected, the difference between the
Brand name
Glucose Fructose Sucrose
Measured Labeled Measured Labeled Measured Labeled
Primalac Premium
2
<0.10 Not labeled <0.10 Not labeled <0.10 Not labeled
Primalac Premium
3
S- 26 Lactose Free
Gold
S- 26 Pro Gold 1 0.50 0.00
S- 26 Progress
Gold 3
0.50 0.00
S- 26 Promil Gold 2 0.50 0.00
Similac Gold 1 0.20 Not labeled
Similac Gold 2 0.20 1.12
Similac Gold 3 0.20 1.07
Similac Total
Comfort 1
4.60 Not labeled <0.10
Similac Total
Comfort 2
<0.10 1.47
Similac Total
Comfort 3
1.05
SMA Pro 1 <0.10
SMA Pro 2
SMA Pro 3
TABLE  (Continued)

10
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AWAD et al.
labeled and measured glucose levels was very minimal,
ranging between 0.03 and 0.12 g/100 ml, with some of
these samples having more detected glucose than labeled,
and others with less. Likewise, for the infant formula in
which fructose was detected, no fructose level was la-
beled on the package. In most infant formulae— all except
one— in which sucrose was detected, no sucrose level was
mentioned on the label. In the only product, which had
the sucrose level mentioned on the package, the labeled
sucrose was higher than that measured. These findings
are rather disappointing, because although total carbohy-
drate level was labeled, not mentioning sugars and their
values on labels can be misleading to parents. The Abu
Dhabi Agriculture Food and Safety Authority (ADFSA)
regulates the quality of infant formula products sold in
the UAE, and although it states that infant formula labels
should include carbohydrate value,30 manufacturers and
retailers are not mandated by law to disclose the specific
sugar content.
Another cause of concern is the usage of unclear terms
on the package labeling. Fructose, for example, was re-
ported on the labels as fructo- oligosaccharides in the
abbreviated form (FOS) or oligofructose, and this confus-
ing labeling may be challenging to interpret by parents.
In accordance with the present results, Bridge et al. also
reported that nutritional information on infant formula
products was unclear and inconsistent.28
To the best of our knowledge, this is the first comprehen-
sive study to use laboratory analysis to test the actual con-
tent and levels of sugars in infant formulae available in the
UAE. Our findings agree with other studies, which suggest
that children could be exposed to more added daily sugars
than recommended.24 A major area of concern was the lack
of sugar labeling on most of the products. To help prevent
future adverse health outcomes, including ECC, which are
secondary to the overconsumption of sugar, having inter-
national guidelines and standards for accurate labeling is
necessary. Additionally, it is also important to emphasize
that cariogenic feeding habits such as bottlefeeding at night
contribute to the development of ECC, and advice should
be given to parents on this matter. Interestingly, only one
infant formulae brand (Jovie Organic Goat Infant Milk 2
and 3©) noted friendly advice to parents: “make sure your
baby's teeth are cleaned after the last feeding.”
There may be some possible limitations in this study.
The first was a limitation related to the HPLC method
used in our study. The limit of detection (LOD) was set at
0.1, which meant that any sugar value below 0.1 g/100 ml
was just recorded as <0.1 and not precisely detected.
Additionally, although the calculated values of sugar
contribution to the total energy intake are applicable for
exclusively formula- fed infants, they must be interpreted
with caution for infants who are mix- fed or introduced to
complementary feeding.
Although the findings should be interpreted with cau-
tion, this study has several strengths. The market in the
UAE is an open market, and since most of the formulae
are manufactured outside of the UAE, they are more likely
to be consumed by children in many other countries, es-
pecially in the Gulf Cooperation Countries (GCC) and the
Middle East and North Africa (MENA) regions. Therefore,
it is possible that the findings may be generalizable to a
broader range of countries. In the sample of infant milk for-
mulae commercially available in the UAE, it was found that
many infant formula products labelled for consumption by
infants and toddlers contained sugars contributing to the
total dietary energy intake in amounts exceeding the recom-
mended intake. In addition, there were many discrepancies
between the labeled and measured sugar levels in the study
samples. Tighter regulations that monitor the amount of
sugar in infant formulae and guidelines for comprehensive
labelling systems are required and recommended.
AUTHOR CONTRIBUTIONS
R.A. and M.A.H conceived the ideas, collected the data,
analyzed the data, and led the writing. M.K., I.H., and
A.S. conceived the idea, analyzed the data, and edited the
manuscript. M.A. collected the data, analyzed the data,
and edited the manuscript.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
DATA AVAILABILITY STATEMENT
The data that supports the findings of this study are avail-
able in the supplementary material of this article.
ORCID
Mawlood Kowash https://orcid.
org/0000-0002-4721-3789
Iyad Hussein https://orcid.org/0000-0002-7682-5573
Manal Al- Halabi https://orcid.
org/0000-0001-9482-4614
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SUPPORTING INFORMATION
Additional supporting information can be found online
in the Supporting Information section at the end of this
article.
How to cite this article: Awad R, Kowash M,
Hussein I, Salami A, Abdo M, Al- Halabi M. Sugar
content in infant formula: Accuracy of labeling and
conformity to guidelines. Int J Paediatr Dent.
2022;00:1-11. doi: 10.1111/ipd.13014