Eating habits of children aged 16 to 18 months: report

Q: References

Griffiths LJ, Parsons TJ and Hill AJ. ‘Self-esteem and quality of life in obese children and adolescents: a systematic review.’ International Journal of Pediatric Obesity 2010: volume 5, issue 4, pages 282 to 304. Kininmonth A, Smith A, Carnell S, Steinsbekk S, Fildes A and Llewellyn C. ‘The association between childhood adiposity and appetite assessed using the Child Eating Behavior Questionnaire and Baby Eating Behavior Questionnaire: a systematic review and meta-analysis.’ Obesity Reviews 2021: volume 22, issue 5. Wardle J, Guthrie CA, Sanderson S and Rapoport L. ‘Development of the Children’s Eating Behaviour Questionnaire.’ Journal of Child Psychology and Psychiatry 2003: volume 42, pages 963 to 970. Wardle J, Sanderson S, Guthrie CA, Rapoport L and Plomin R. ‘Parental feeding style and the inter-generational transmission of obesity risk.’ Obesity Research 2012: volume 10, pages 453 to 462.

Q: Annex 3: acknowledgments

This report was prepared by: Ipsos OHID The authors want to thank all Children of the 2020s families who have generously given their time to take part in the eating habits survey. We would also like to thank everyone who has contributed to the development of the survey and the report, in particular: OHID DfE UCL Ipsos members of the SACN subgroup on maternal and child nutrition

Question 1

Summary

Accepted Answer

This summary outlines the main findings from a survey of primary caregivers of children aged 16 to 18 months in England in 2023. The survey was conducted by Ipsos on behalf of the Office for Health Improvement and Disparities (OHID) in the Department of Health and Social Care (DHSC).

Children of the 2020s study

Participants in the survey were members of the Children of the 2020s (COT20s) study. This is a large-scale nationally representative cohort study following the lives of around 8,500 children (and their families) born in England at the start of the 2020s (‘the cohort’).

The COT20s study has been commissioned by the Department for Education (DfE) and is being led by University College London (UCL), in partnership with Ipsos.

You can find full details of the COT20s study, including the survey methodology, in the DfE report Children of the 2020s: first survey of families at age 9 months.

While there are several studies in England that collect information on childhood diet and nutrition, there is no current nationally representative data collection on the diet and nutrition of children aged between 11 and 18 months and influencing factors. So, there is a gap in the evidence base and the eating habits survey within the COT20s longitudinal study was an opportunity to help fill this gap.

Eating habits survey design and completion

OHID and Ipsos designed a survey on the eating and drinking habits of children aged 16 to 18 months to collect information on:

current behaviours and practices of interest
factors that might influence these

The eating habits survey was completed online by 2,620 primary caregivers from the COT20s cohort in March and April 2023. The response rate was 34% of people who were invited to participate.

Ipsos weighted the final survey data to adjust the responding sample so that its profile more closely matches the population by region, household size and gender of the child. For more information about weighting, see the section ‘Survey weighting’ in annex 1.

Caring arrangements and meal provision

Caregivers reported that children in the survey were predominantly looked after by their primary carer, who also prepared most of their meals. However, children were also cared for on a regular basis by relatives who lived outside their home or a nursery school, day nursery, pre-school or play group who were most likely to provide children’s lunch and snacks when they were caring for them.

Food at 16 to 18 months

UK government guidance on infant and young child feeding is communicated to parents and carers in England through the NHS, with advice on:

feeding children over 12 months in the NHS Better Health Start for Life programme
what to feed young children
foods to avoid giving babies and young children
vitamins for children

You can find further details on the advice in place at the time of the survey in annex 2.

UK guidance states that, from 12 months, young children’s diets should include a variety of foods including:

vegetables
fruit
starchy foods (such as bread, potatoes, pasta and rice)
protein foods (such as meat, fish, eggs, beans and pulses)
dairy (such as cheese and yoghurt)

Foods high in saturated fat and salt, and sugary foods and drinks should be limited.

Caregivers reported that the majority of children in the COT20s survey ate vegetables (62%) and fruit (77%) at least once a day.

Children also consumed a variety of starchy foods. Almost all caregivers said their child ate different types of starchy foods once a week or more, including:

rice or pasta (97%)
potatoes or potato products (96%)
bread (96%)

Other foods children in the survey ate regularly included:

cheese, yoghurt and fromage frais - 95% ate these at least once a week and 55% ate them daily
biscuits, sweets, chocolates or cakes - 38% ate these between 2 and 4 times a week

UK guidance advises that salt should not be added to children’s food. However, 37% of COT20s families often or sometimes added salt to their child’s food.

Just over a third of children (36%) were given purchased ready meals for infants or young children (such as jars, pouches, tubs or trays) at least once a week, with 4% having them daily. Children were given purchased finger foods or snacks (such as bars, puffs, sticks, fruit shapes, biscuits or wafers) more often, with 21% of children consuming them daily, and 84% at least once a week.

UK guidance advises that, from 12 months, children may need 2 healthy snacks in between meals. Just over half of COT20s families (56%) reported that their child had 2 snacks a day, 22% had one snack and 14% had 3 snacks. Caregivers reported that nearly half of children (49%) had one ‘treat’ a day (such as chocolates, crisps, sweets or ice cream), 17% had 2 treats and a third (33%) did not have a daily treat.

UK guidance recommends that children aged 16 to 18 months should be given supplements containing vitamins A, C and D daily. Just over half of COT20s families (53%) gave their child vitamin drops. Of these families:

38% gave their child vitamin D as well as other vitamins
15% gave their child vitamin D only

Drinks at 16 to 18 months

UK government guidance on drinks for young children in England is communicated to parents and carers through NHS advice on:

drinks for children over 12 months in the NHS Better Health Start for Life programme
drinks and cups for babies and young children
water, drinks and hydration

You can find further details on this advice in annex 2.

The advice above recommends that, in addition to breast milk, the best drinks to give young children are water and milk.

Caregivers reported that the main drinks consumed by children in the COT20s survey were water and milk. Of the children in the survey, at least once a day:

94% drank water
63% drank plain cows’ milk
23% drank breast milk

When asked what children have as their main milk drink, caregivers reported that around half (55%) had whole milk (cows’ or goats’) and a sixth (16%) had breast milk. Eight per cent of children had plant-based alternatives to milk as their main milk drink (including 2% who drank plant-based alternatives to toddler or growing-up milks).

UK guidance advises that infant formula, follow-on formula or growing-up milks are not needed beyond the age of 12 months. However, 18% of children in the survey drank one or more of these at least once a day and 8% had one of these as their main milk drink.

UK guidance recommends that sugary fizzy drinks, squash and juice drinks should not be given to young children. Only a few children in the survey (5% or less) drank fizzy drinks, but 52% drank squash, with 21% drinking this at least once a day. Fruit juices and fruit smoothies were consumed less often, but at least once a week by 29% and 25% of children, respectively.

UK guidance recommends that young children use an open cup or free-flowing cup without a valve when drinking, to protect their teeth. Only around 3 in 10 (28%) children in the survey usually used an open cup or free-flowing cup. Similar proportions usually used a cup or beaker with a valve (27%), or a bottle (24%).

Eating and feeding behaviour at 16 to 18 months

The survey assessed 2 eating behaviour metrics, which were:

food responsiveness (eating in response to food cues such as the sight or smell of food)
satiety responsiveness (eating in response to internal feelings of fullness)

Individual children’s scores for both metrics ranged across the survey participants. The majority fell around the middle, with only a minority receiving a high score for food responsiveness or a low score for satiety responsiveness, both of which are associated with higher body mass index (BMI) (Kininmonth and others, 2021).

When asked about their child’s food likes and dislikes, over half of primary caregivers (57%) said their child was ‘choosy’ (with 8% saying ‘very choosy’) compared with 43% who said they were not.

The survey also looked at 2 parental feeding style metrics:

emotional feeding (offering food in response to children’s emotions)
caregivers’ control over children’s eating (whether parents decide when and how children should eat)

Most caregivers’ scores were low for emotional feeding, and high for control.

Sources of support

Primary caregivers most commonly used online sources and personal networks for information and support on feeding their children. The survey showed that of the primary caregivers in the survey:

42% used NHS websites
33% used social media, discussion forums or video-sharing platforms
36% used other websites
37% went to a partner, friend or relative
25% went to a health professional

Healthy Start scheme

The Healthy Start scheme provides help for families and pregnant women on low incomes in England to get healthy food, milk and vitamins.

A fifth (20%) of primary caregivers in the survey reported being currently eligible for the Healthy Start scheme, with 74% of those eligible saying they had registered for the scheme.

The people who had registered for the scheme had used their Healthy Start vouchers or pre-payment card to buy:

vegetables (86%)
fruit (88%)
cows’ milk (77%)
infant formula (44%)

Only 2% of those who had registered for the scheme had not used the vouchers or card yet.

Food security

While a majority of caregivers did not have concerns about, or issues relating to, affording food over the past year, a significant minority reported having experienced this, as:

33% reported they worried sometimes or often about whether their food would run out before they got money to buy more
30% reported they sometimes or often could not afford to eat balanced meals
25% reported that sometimes or often the food they bought did not last and they did not have money to get more

Nearly a fifth of caregivers (19%) said that they or another adult in their household had cut the size of their meals or skipped meals in the past 12 months because there was not enough money for food.

Feeding from birth

Caregivers were asked to recall their experiences of feeding their child in the first year after birth.

UK guidance, as communicated through NHS advice Your breastfeeding questions answered, recommends that babies are only fed breast milk for around the first 6 months of their life. And, alongside solid foods, they can continue to be breastfed into the second year of life or beyond.

Most children (78%) in the survey had been breastfed or been given expressed breast milk at some stage. Of those given breast milk, 30% continued to be breastfed or receive expressed breast milk at the age of 16 to 18 months (equating to 25% of all those surveyed).

Most children in the survey had been given formula milk at some stage (80%), and 58% of children had received breast milk and formula milk.

UK guidance states that first infant formula is the only suitable alternative to breast milk in the first 12 months of a baby’s life. Follow-on formula is not suitable for babies under 6 months and there is no need to introduce it after 6 months.

Among COT20s families, the most common type of formula milk used was infant formula, given by 72% of primary caregivers who had given formula milk to their child, and 57% of all those surveyed. Follow-on formula was the second most common formula milk used, given by 32% of primary caregivers who had used formula milk and 25% of all those surveyed. Of all primary caregivers surveyed, 10% had used growing-up milk and 9% had used prescribed specialist formula.

Over half (57%) of COT20s families said that their child had solid food for the first time aged around 6 months, in line with UK guidance. A third of children in the survey (33%) were given solid food before this.

Dental hygiene

UK guidance, communicated through NHS advice Looking after your baby’s teeth, recommends that caregivers should start brushing children’s teeth with a small smear of fluoride toothpaste as soon as they start to come through.

Nearly all primary caregivers reported that their child had their teeth brushed (98%). Half of COT20s families (50%) used toothpaste containing fluoride. Nearly two-thirds (65%) said they were yet to take their child to the dentist.

Sociodemographic differences

Across the topics covered by the survey, there were some differences between subgroups. Caregivers who were more affluent (as shown by having higher household incomes or living in less deprived areas) were more likely to align with UK guidance, compared with caregivers with lower household incomes or those living in more deprived areas. For example:

children living in higher-income households were more likely to eat vegetables and fruit at least once a day (71% and 83%, respectively), compared with children living in households with an income of less than £32,500 a year (55% and 71%, respectively)
caregivers in more affluent areas were more likely to have given their child breast milk (82% of those in the least deprived areas, compared with 70% in the most deprived areas)

Conclusion

The findings from this survey provide information on aspects of the diet and eating behaviours of children aged 16 to 18 months, and how these compare with UK guidance and dietary recommendations.

The COT20s study provided an opportunity to collect data from caregivers of children in this age group as part of an existing cohort, providing some new information on the eating habits of young children. Although the survey does not provide a detailed dietary assessment, it does provide information on the types and frequency of consumption of a variety of foods and drinks.

The survey has some limitations. Although the COT20s cohort is nationally representative, some of the survey results suggest that participants may differ from the general population. This may be due to the sample having been drawn from a cohort study where participants may be more engaged and interested in their child’s development.

The survey findings show some inconsistencies in caregivers’ responses to different questions - for example, on the consumption of foods such as biscuits, confectionery, cakes and snacks, and use of growing-up or toddler milks. These may be due to the way questions were asked in the survey, and differences in interpretation by caregivers.

The report highlights some areas of concern in the eating habits of children aged 16 to 18 months, including:

sugary foods as a regular part of children’s diets
salt added to food for young children
frequent use of purchased snacks and ‘treats’ (such as sweets, crisps, chocolates and ice cream)
use of drinks other than breast milk, water or milk
use of formula milks (including infant formula and follow-on formula) after 12 months of age, and growing-up or toddler milks

This report identifies opportunities for further support and guidance for families with young children, particularly about healthy snacks and drinks, and advice on feeding from birth including breastfeeding.

The government continues to monitor the eating habits and diets of infants and young children. A new infant feeding survey for England (including children from birth to 10 months of age) will report in 2025.

The National Diet and Nutrition Survey currently reports regularly on the diet and nutrition of UK children aged from 18 months and, from 2024, children aged between 12 to 18 months are also included.

Question 2

Background and methodology

Accepted Answer

Context

Childhood overweight and obesity are a significant health concern for children and their families. Children living with obesity are at higher risk of:

becoming adults living with obesity
morbidity, disability and premature mortality in adulthood

Children and adolescents living with obesity are at risk of poor mental health and low self-esteem (Griffiths and others, 2010).

Data from the National Child Measurement Programme annual report 2023 to 2024 indicates that, in England, a fifth (22.1%) of children are overweight or living with obesity by the time they start primary school. OHID’s report Changes in the weight status of children between the first and final years of primary school found that the majority of children (75.9%) who were overweight or living with obesity or severe obesity in reception remained in these weight categories in year 6. Preventing ill health, including obesity, is a main goal for the government.

For young children, the introduction of solid foods and the early development of eating behaviours can shape eating habits through childhood and beyond. Government guidance to support parents in feeding young children a healthy diet is communicated through the NHS website and the Better Health Start for Life website.

However, the Scientific Advisory Committee on Nutrition (SACN) report Feeding young children aged 1 to 5 years found that the diets of young children in the UK do not meet current dietary recommendations for several nutrients.

Gaps in the evidence base

There are several studies that collect information on childhood diet and nutrition. But there is no current nationally representative data collection on the diet and nutrition of children aged between 11 and 18 months and influencing factors. So, there is a gap in the evidence base.

A 2011 survey, the Diet and nutrition survey of infants and young children (DNSIYC) provided information on the diets of UK infants and children aged 4 to 18 months. However, changes in the commercial food environment in recent years mean that the data in DNSIYC may not reflect young children’s current diets.

Undertaking an eating habits survey with the Children of the 2020s study (COT20s) cohort presented an opportunity to help fill the gap in the evidence base. Ipsos and OHID designed a survey on the eating habits of children aged 16 to 18 months to collect information on:

current behaviours and practices of interest
factors that might influence these

The survey was conducted among COT20s families and asked questions on topics including:

children’s eating patterns and behaviours
parental feeding styles
foods and drinks consumed
how children were fed from birth
oral hygiene
use of the Healthy Start scheme
food security

This report summarises the findings of this eating habits survey.

About the Children of the 2020s study

The COT20s study is a large-scale nationally representative cohort study following the lives of around 8,500 children (and their families) born in England at the start of the 2020s. It is the first birth cohort study in England in 2 decades and is designed to generate contemporary evidence on the:

early developmental outcomes of children growing up in England
main predictors and moderators of inequalities in these outcomes

The study has been commissioned by DfE and is being led by UCL, in partnership with Ipsos.

The DfE report Children of the 2020s: first survey of families at age 9 months provides information on the cohort sampling methodology and the characteristics of the children and their families.

The eating habits survey

OHID commissioned the eating habits survey.

The survey took place between 8 March and 10 April 2023. This was between year 1 and year 2 of the COT20s study.

All eligible members of the COT20s study were invited to take part in the survey. Those invited to take part were the child’s primary caregiver, defined as the person who spends the most time caring for the child - for example, feeding them or changing their nappies (as recorded in the first survey in the longitudinal study). All children were aged between 16 and 18 months when the survey took place. Participants received a £5 voucher as thanks for their time.

Ipsos weighted the final survey data to adjust the responding sample so that its profile more closely matches the population by region, household size and gender of the child. They also applied additional weights to correct for the over-sampling of families in the most deprived areas in the COT20s study. For more information about weighting, see the section ‘Survey weighting’ in annex 1.

The report comments on differences in the data between different subgroups in the total sample surveyed, where sample size permits. For example, differences in practices between caregivers of different income levels. The size of the sample did not allow for analysis by region or ethnicity. Only differences that were statistically significant at the 95% confidence interval are commented on in this report.

When presenting information in a table, we show cells with values of less than (<) 1% but greater than 0% as ‘<1’. Where figures do not add up to 100%, this is the result of rounding or where participants are able to select more than one response option.

The report is structured to reflect how questions were asked in the survey. We outline each question followed by a table and chart of how people responded.

You can find further detail about the survey methodology in annex 1.

Participant profile

Of the 7,756 members of the COT20s study invited to take part in the eating habits survey, 2,620 responded (a response rate of 34%). Primary caregivers that responded were typically female (96%) and were aged between 30 and 34 years old (the median age was 32). Over 8 in 10 (87%) were from a White ethnic background and 13% were from an ethnic minority background.

Households in areas of higher deprivation were more likely to be invited to take part in the survey. This is because these households were over-sampled for the COT20s study due to a tendency among this group for lower response rates over time. For this reason, households that responded to the survey were more likely to be from deprived areas. The final survey data has been weighted to account for this.

The tables below show the profile of caregivers who responded to the eating habits survey.

Table 1: profile of achieved sample by gender of caregiver

Gender	Number of completed surveys	Proportion of final sample (%)
Female	2,515	96
Male	105	4

Table 2: profile of achieved sample by age of caregiver

Age	Number of completed surveys	Proportion of final sample (%)
Under 25	224	9
25 to 29	600	23
30 to 34	971	37
35 to 39	601	23
40 or over	209	8

Table 3: profile of achieved sample by ethnicity of caregiver

Ethnicity	Number of completed surveys	Proportion of final sample (%)
White ethnic background	2,272	87
Ethnic minority background	340	13

Table 4: profile of achieved sample by region

Region	Number of completed surveys	Proportion of final sample (%)
North East	140	5
North West	360	14
Yorkshire and Humber	311	12
East Midlands	251	10
West Midlands	318	12
East of England	315	12
London	244	9
South East	394	15
South West	287	11

Table 5: profile of achieved sample by Index of Multiple Deprivation (IMD)

IMD quintile	Number of completed surveys	Proportion of final sample (%)
1 (most deprived)	616	24
2	546	21
3	542	21
4	485	19
5 (least deprived)	431	16

Note: IMD ranks how disadvantaged a person’s neighbourhood is based on a range of factors including income, employment, education, health, crime and housing. To enable comparisons, areas are classified into quintiles (fifths).

The profile of caregivers is similar to the profile of the COT20s cohort study, except for ethnicity. In the first wave of the COT20s research (conducted between June and November 2022), 93% of caregivers who responded were female and 7% were male. Their average age was 32 years old and 79% were from a White ethnic background (compared with 87% of those who responded to the eating habits survey).

The ‘Children of the 2020s: first survey of families at age 9 months’ report found that, overall, the COT20s cohort appeared to represent a good cross-section of the population of babies and their families in England at this time. This was based on comparisons with available population statistics such as multiple births, gender ratio, ethnicity, primary caregiver age, employment status and family size.

The sample for the COT20s study was taken from the HM Revenue and Customs (HMRC) child benefit records for all registered births between September and November 2021. The database included information about the:

number of children registered (for example, whether caregivers were registering a single birth or multiple birth)
gender of the child
region where the registration took place

So, it is possible to compare the profile of the eating habits survey participants to the profile of HMRC child benefit records on these aspects to assess response bias.

The profile of caregivers who responded to the eating habits survey is similar to the profile of those who registered a birth with HMRC between September and November 2021, according to child gender. Over half (52%) of those that responded were the primary caregiver of a male child and 48% were the primary caregiver of a female child.

There are some differences by region, which are likely due to over-sampling of households in more deprived areas.

Question 3

Food and drinks at 16 to 18 months

Accepted Answer

This chapter examines the eating and drinking habits of children at 16 to 18 months, specifically:

the types of foods and drinks most often consumed
the frequency with which children eat purchased meals or snacks
how often COT20s families add salt to their child’s food
the types of cups used for drinking
whether children are provided with recommended vitamin supplements

Caring for children

When not being looked after by their primary caregiver, children in the survey were most often looked after by a:

relative that lives outside of their home (for example a parent or grandparent)
nursery school, day nursery, pre-school or playgroup

Half (50%) the children were looked after by a relative that lives outside their home on at least one day a week. And a third (34%) were looked after by a nursery school, day nursery, pre-school or play group on at least one day a week.

A minority of COT20s families reported ever using a:

childminder (10%)
friend or neighbour (4%)
professional nanny or au pair (2%)

Table 6: caring arrangements for children in the survey - ‘In a typical week, how many days is your child looked after by any of the following people or places?’

Frequency	A relative who does not live with you (for example another parent or grandparent) (%)	Nursery school, day nursery, pre-school or play group (%)	Childminder (%)	Friend or neighbour (%)	Professional nanny or au pair (%)
Never	50	66	90	96	98
Half a day a week	12	2	1	3	1
1 or 1.5 days a week	18	7	2	1	<1
2 or 2.5 days a week	11	10	3	<1	<1
3 or 3.5 days a week	5	9	3	<1	<1
4 or 4.5 days a week	2	3	1	No responses	<1
5 or 5.5 days a week	1	3	1	No responses	<1
6 or 6.5 days a week	<1	No responses	No responses	No responses	No responses
7 days a week	<1	<1	<1	<1	<1

Base (unweighted): all primary caregivers (2,620).

Meal provision

The provision of meals to children in the survey reflected the caring arrangements of COT20s families for their children.

Most often a child’s meals were provided by their primary caregiver. The frequency with which meals were provided to children by someone other than their primary caregiver reflected the frequency with which children were cared for by someone else. For example, relatives that live outside the home were most likely to care for and provide children with a meal or meals up to 3 days a week.

On the days that they look after the children, relatives that live outside the home, nursery schools, day nurseries, pre-schools and playgroups were most likely to provide the child with their morning snack, lunch or afternoon snack. Breakfast and tea or dinner were typically provided by the primary caregiver on these days.

Table 7: frequency with which different meals are provided by the primary caregiver - ‘On average, how many days a week are the following meals provided for your child by yourself or your partner?’

Frequency	Breakfast (%)	Morning snack (%)	Lunch (%)	Afternoon snack (%)	Tea or dinner (%)
Never	2	3	1	2	1
1 to 3 days a week	11	19	18	19	9
4 to 7 days a week	87	77	81	78	90

Base (unweighted): all primary caregivers (2,620).

Table 8: frequency with which different meals are provided by a relative that lives outside the home - ‘On average, how many days a week are the following meals provided for your child by a relative that lives outside the home (for example, another parent or grandparent)?’

Frequency	Breakfast (%)	Morning snack (%)	Lunch (%)	Afternoon snack (%)	Tea or dinner (%)
Never	59	37	33	32	55
1 to 3 days a week	39	60	62	64	44
4 to 7 days a week	2	4	5	5	2

Base (unweighted): among those where a relative that lives outside the home cares for the child at least half a day a week (1,409).

Table 9: frequency with which different meals are provided by a nursery school, day nursery, pre-school or playgroup - ‘On average, how many days a week are the following meals provided for your child by a nursery school, day nursery, pre-school, or playgroup?’

Frequency	Breakfast (%)	Morning snack (%)	Lunch (%)	Afternoon snack (%)	Tea or dinner (%)
Never	34	10	12	14	38
1 to 3 days a week	54	72	70	70	52
4 to 7 days a week	12	18	18	16	10

Base (unweighted): among those who use a nursery school, day nursery, pre-school or playgroup to care for their child at least half a day a week (1,028).

Eating habits

UK government guidance on infant and young child feeding is communicated to parents and carers in England through the NHS Better Health Start for Life programme, including advice on feeding children over 12 months. You can also find advice on the NHS website, which includes information on what to feed young children and foods to avoid giving babies and young children. You can find further details on this advice in annex 2.

Following the publication of the SACN report ‘Feeding young children aged 1 to 5 years’ in July 2023, the NHS has updated its advice based on updated government guidance. As the eating habits survey was conducted in March and April 2023, we refer to guidance available at the time.

UK advice states that, from 12 months, young children’s diets should include a wide variety of foods including:

vegetables
fruit
starchy foods (such as bread, potatoes, pasta and rice)
protein foods (such as meat, fish, eggs, beans and pulses)
dairy (such as cheese and yoghurt)

Foods high in saturated fat and salt, and sugary foods and drinks should be limited.

Vegetables and fruit

Caregivers’ responses to a question on how often different types of foods were eaten (see table 10) showed that 62% of children in the survey ate vegetables, and 77% ate fruit, at least once a day. Fewer than 1% of children never ate vegetables or fruit.

Caregivers were asked in a different question about how many times their child ate vegetables and fruit each day. Average frequency of consumption was 2.1 times a day for vegetables and 2.6 times a day for fruit. These findings suggest some inconsistency in caregivers’ responses on their child’s consumption of vegetables and fruit. This may be due to:

differences in the way these questions were asked in the survey
limited answer options, or differences in the interpretation of the ‘daily consumption’ question

Starchy foods

A variety of starchy foods were also consumed, with almost all caregivers reporting that at least once a week their child ate:

rice or pasta (97%)
potatoes or potato products (96%)
bread (96%)

Other foods

Other foods reported as eaten at least once a week by COT20s children included:

cheese, yoghurt and fromage frais (95%)
breakfast cereals (88%)
butter, margarine and other spreads (86%)
crisps or corn snacks (82%)

When asked about how often biscuits, sweets, chocolates or cakes were eaten, 38% of caregivers reported that they were eaten by children between 2 and 4 times a week. One in 10 (13%) children were reported to eat these foods every day, and a similar proportion (9%) never ate them.

Foods that can trigger allergic reactions

UK guidance, communicated through NHS advice Food allergies in babies and young children, recommends that foods that can trigger allergic reactions (including eggs and nuts) can be introduced from around 6 months as part of a baby’s diet just like any other foods. Once introduced and, if tolerated, these foods should become part of a baby’s usual diet to minimise the risk of allergy.

Caregivers reported that 72% of children in the survey consumed eggs and 35% consumed nuts at least once a week. Nearly 1 in 10 (9.7%) caregivers in the survey had previously reported that their child had allergies or intolerances - these caregivers were more likely to say they avoid foods like eggs and nuts.

A quarter (26%) of children with an allergy or intolerance had never eaten eggs compared with 7% of children without allergies. The difference was smaller for nuts, with 44% of children with an allergy or intolerance not eating nuts compared with 40% without allergies.

Table 10: frequency with which children in the survey eat different types of food (%) - ‘How often does your child eat the following foods?’

Food type	Every day (%)	5 to 6 days a week (%)	2 to 4 days a week (%)	Once a week (%)	Less than once a week (%)	Never (%)
Fruit	77	12	9	2	1	<1
Vegetables	62	19	16	2	1	<1
Cheese, yoghurt, fromage frais	55	19	18	3	1	4
Breakfast cereals	43	13	26	7	5	7
Bread	30	22	38	6	3	2
Butter, margarine and other spreads	25	17	36	9	7	7
Puddings and desserts	17	8	31	14	15	13
Crisps and corn snacks	14	14	41	14	10	8
Biscuits, sweets, chocolate or cakes	13	10	38	15	15	9
Potatoes, potato products (including chips, waffles, shapes)	11	18	57	10	3	1
Rice or pasta	7	15	64	11	2	1
Chicken or other poultry	4	10	58	17	5	5
Eggs	4	6	37	25	18	10
Beans, lentils, chickpeas	4	7	41	24	15	10
Nuts (including ground nuts)	2	2	13	17	26	39
Beef	1	1	25	31	26	16
Pork (including ham)	1	2	21	23	23	30
Fish (including tuna)	1	3	34	38	17	7
Tofu, Quorn, textured vegetable protein	1	1	9	8	13	67
Lamb	<1	<1	6	13	41	40

Base (unweighted): all primary caregivers (2,620).

When asked about specific dietary patterns, only 5% of COT20s families reported feeding their child a:

vegetarian diet (3%)
pescatarian diet (2%)
vegan diet (1%)

Purchased ready meals and snacks

Home-prepared foods can help introduce infants and young children to a range of appropriate flavours and textures. Commercially manufactured foods and drinks marketed specifically for infants and young children are not needed to meet nutritional requirements.

Just over half (55%) of COT20s families fed their child purchased ready meals for young children (such as jars, pouches, tubs or trays). Just 4% did so daily, but 36% did so at least once a week.

Figure 1: frequency with which children in the survey have purchased ready meals for infants or young children - ‘How often does your child have purchased ready meals for infants or young children (such as jars, pouches, tubs or trays)?’

Frequency	Proportion of participants
Everyday	4%
5 to 6 days a week	3%
2 to 4 days a week	17%
Once a week	13%
Less than once a week	19%
Never	45%

Base (unweighted): all primary caregivers (2,620).

Purchased finger foods or snacks (such as bars, puffs, sticks, fruit shapes, biscuits or wafers) were given more regularly. Just over 8 in 10 (84%) children in the survey were given one of these items at least once a week and a fifth (21%) were given them on a daily basis. Only 7% of children were never given them.

Figure 2: frequency with which children in the survey have purchased finger foods or snacks for infants or young children - ‘How often does your child have purchased finger foods or snack for infants or young children (such as bars, puffs, sticks, fruit shapes, biscuits or wafers)?’

Frequency	Proportion of participants
Everyday	21%
5 to 6 days a week	17%
2 to 4 days a week	36%
Once a week	10%
Less than once a week	8%
Never	7%

Base (unweighted): all primary caregivers (2,620).

Snacks and treats

UK guidance advises that, from 12 months, children may need 2 healthy snacks in between meals. COT20s families reported that:

56% of children had 2 snacks a day
22% of children had one snack a day
14% of children had 3 snacks a day
5% of children had 4 or more snacks a day

COT20s families were also asked how many ‘treats’ their child had each day. Treats were described as foods such as chocolates, crisps, sweets or ice cream. COT20s families reported that, on average:

49% of children had one treat a day
33% of children did not have a daily treat
17% of children had 2 or more treats a day

Figure 3: number of snacks and treats given to children in the survey daily - ‘On average, how many snacks does your child have per day (snacks do not include milk, or ‘treats’ such as sweets, crisps, chocolate or ice cream)?’

Snacks and treats	0	1	2	3	4 or more	Total
Average number of snacks per day	3%	22%	56%	14%	5%	100%
Average number of ‘treats’ per day	33%	49%	14%	3%	1%	100%

Base (unweighted): all primary caregivers (2,620).

Nearly half (49%) of caregivers said they gave their child a treat once a day. This appears to be inconsistent with responses to an earlier question where caregivers said 13% of children had ‘biscuits, sweets, chocolate or cakes’ every day, and 14% had ‘crisps and corn snacks’ every day. This may be due to:

differences in the way these questions were asked in the survey
limited answer options in the ‘treat’ question
differences in the interpretation of ‘treats’ by caregivers

Adding salt to food

UK guidance recommends that salt should not be added to food for babies and young children. Children aged 1 to 3 years should have no more than 2 grams (g) of salt a day (0.8g sodium). This is about a third of a teaspoon and a third of adults’ recommended maximum intake.

Just 8% of COT20s families reported often adding salt to their child’s food, although 3 in 10 (29%) said they sometimes did so.

Figure 4: frequency with which COT20s families add salt to their child’s food - ‘Do you, or other household members, ever add salt to your child or children’s food, including adding salt when the food is being cooked?’

Response	Proportion of participants
Yes, often	8%
Yes, sometimes	29%
Never	62%
Do not know or prefer not to say	1%

Base (unweighted): all primary caregivers (2,620).

Drinking habits

UK guidance on drinks for young children is communicated to parents and carers in England through NHS advice on:

You can find further details on this advice in annex 2.

UK guidance recommends that, in addition to breast milk, the best drinks to give young children are:

water
milk

Young children should not be given:

sugary fizzy drinks
squash
juice drinks

Responses to a question on how often children had different types of drinks (see table 11 below) indicated that 94% of children in the survey drank water, and 63% drank plain cows’ milk, at least once a day. Nearly all children drank water - only 2% never drank it. Reflecting patterns of breastfeeding (24% of all children in the survey were breastfed or given expressed breast milk), nearly a quarter (23%) of children in the survey drank breast milk daily.

After breast milk, milk and water, squash was the drink given most frequently, with 21% of children in the survey drinking squash at least once a day and 42% drinking it at least once a week. The question did not distinguish between squash containing sugar and ‘no added sugar’ squash.

Fruit juice and fruit smoothies were consumed less frequently. Of COT20s families, 54% never gave fruit juice and 61% never gave fruit smoothies to their child. However, 29% and 25% of children did consume fruit juice and fruit smoothies respectively at least once a week.

Almost all COT20s families said their child never drank fizzy drinks, including those that contain sugar (96%) and those that are sugar free (95%).

UK guidance advises that infant formula, follow-on formula or growing-up milks are not needed beyond the age of 12 months. However, 18% of children in the survey drank one or more of these at least once a day.

Table 11: frequency with which children in the survey drink different drinks - ‘How often does your child have the following drinks?’

Frequency	At least once a day (%)	5 to 6 days a week (%)	2 to 4 days a week (%)	Once a week (%)	Less than once a week (%)	Never (%)
Water	94	1	2	<1	1	2
Plain cows’ milk	63	2	7	3	4	21
Breast milk	23	<1	<1	No response	1	75
Squash	21	3	11	7	10	48
Growing-up or toddler milk	11	<1	1	1	2	85
Fruit juice	8	1	11	10	16	54
Plant-based milk substitute (for example soya, almond, oat drinks)	8	1	3	2	5	81
Infant formula	8	<1	<1	<1	1	90
Follow-on formula	7	<1	1	1	1	90
Fruit smoothie	5	1	8	10	14	61
Other fruit drink	4	1	4	6	8	77
Flavoured milk drinks (for example, chocolate, strawberry or banana)	3	1	3	5	10	78
Lactose-free milk alternative	2	<1	<1	1	2	95
Fizzy drinks (sugar free)	<1	<1	1	1	2	95
Fizzy drinks (containing sugar)	<1	No response	<1	1	3	96

Base (unweighted): all primary caregivers (2,620).

Main milk drink

UK guidance recommends that babies are fed breast milk only for around the first 6 months of their life. And, alongside solid foods, they can continue to be breastfed into the second year of life or beyond.

A sixth (16%) of children in the survey drank breast milk as their main milk drink.

Where children are not breastfed, UK guidance at the time the survey was conducted recommended giving pasteurised cows’ (or goats’ or sheep’s) milk as a main milk drink for children from 12 months old. Children aged 2 years and under should have whole milk.

Half (55%) of children in the survey drank whole cows’ (or goats’) milk as their main milk drink. Small proportions drank semi-skimmed and skimmed cows’ (or goats’) milk as their main milk drink (4% and 1%, respectively). Eight per cent of children drank plant-based alternatives to milk as their main milk drink (including 2% who drank plant-based alternatives to toddler or growing-up milks).

Table 12: main milk or milk substitute drink for children in the survey - ‘Which of the following does your child have as their main milk or milk substitute drink?’

Milk or milk substitute drink	Proportion of participants (%)
Whole cows’ or goats’ milk	55
Breast milk	16
Plant-based milk substitute	6
Semi-skimmed cows’ or goats’ milk	4
Growing-up or toddler milk (cows’ or goats’ milk)	4
Infant formula	3
Follow-on formula	3
Growing-up or toddler milk (plant-based milk substitute)	2
Skimmed cows’ or goats’ milk	1
1% cows’ or goats’ milk	1
Child does not have milk or milk substitutes	2
Other (unspecified)	1

Base (unweighted): all primary caregivers (2,620).

Using a cup for drinking

UK guidance recommends children use an open cup or free-flowing cup without a valve to consume their drinks to protect their teeth. Fewer than a third of children in the survey used one of these items to consume their drinks:

21% used a cup or beaker with a free-flowing spout
7% used an open cup

Children in the survey were most likely to use a cup or beaker with a valve (27%) or a bottle (24%).

Table 13: items used by children in the survey most often to consume drinks - ‘Which of the following does your child usually use for their drinks?’

Item used	Proportion of participants (%)
A cup or beaker with a valve	27
Bottle	24
A cup or beaker with a free-flowing spout	21
Cup with a straw	20
An open cup	7
Other	1
Net: uses recommended item	28

Base (unweighted): all primary caregivers (2,620).

‘Net’ shows all responses where children use either an open cup or a cup or beaker with a free-flowing spout.

Use of vitamin supplements

UK guidance, communicated through NHS advice on vitamins for children, recommends that all children aged between 6 months and 5 years old should be given supplements containing vitamins A, C and D daily. Just over half of COT20s families (53%) gave their child vitamin drops:

38% give their child vitamin D as well as other vitamins
15% give their child vitamin D only

Figure 5: proportion of primary caregivers giving their child vitamin drops - ‘Do you give your child or children any vitamin drops?’

Giving vitamin drops	Proportion of participants
Yes, vitamin D only	15%
Yes, vitamin D and other vitamins	38%
No	47%

Base (unweighted): all primary caregivers (2,620).

Just over two-thirds of caregivers giving their children vitamin drops bought them (69%). One in 5 (21%) bought Healthy Start vitamins, and around half (48%) bought vitamins other than Healthy Start. A minority got free Healthy Start vitamins (10%), but this rose to nearly 4 in 10 of those who were registered for Healthy Start (37%), who are eligible to receive the vitamins for free.

Figure 6: sources of vitamin drops - ‘How do you usually get the vitamin drops for your child or children?’

Getting vitamin drops	Proportion of participants
I buy vitamins other than Healthy Start	48%
I buy Healthy Start vitamins	21%
I get them in other ways	18%
I get free Healthy Start vitamins	10%
I get vitamins on prescription	2%

Base (unweighted): all those who give their child or children vitamin drops (1,395).

Sociodemographic differences

Across the topics covered by the survey, there were some differences between sociodemographic groups and primarily these relate to affluence.

Caregivers who were more affluent (as shown by having higher household incomes or living in less deprived areas) were more likely to align with UK guidance when feeding their children, compared with caregivers with lower household incomes or those living in more deprived areas. For example, compared with children living in households with an income of less than £32,500 a year, children living in higher-income households:

were more likely to eat vegetables at least once a day (71% compared with 55%)
were more likely to eat fruit at least once a day (83% compared with 71%)
were less likely to have salt added to their food (30% compared with 41%)
consumed fruit drinks less frequently (16% compared with 41% who consumed fruit juice at least once a week, and 15% compared with 30% who consumed smoothies at least once a week)
were more likely to be given vitamin drops (57% compared with 49%)

Question 4

Eating and feeding behaviours at 16 to 18 months

Accepted Answer

This chapter looks at eating behaviours among children aged 16 to 18 months, alongside the feeding behaviours of their primary caregiver. It also considers sources of information and support that caregivers have used to inform their feeding practices.

Child eating behaviours

The Children’s Eating Behaviour Questionnaire (CEBQ) is a validated question set used to assess 8 dimensions of eating style in children (Wardle and others, 2003). The question set has been shown to capture how differences in appetite contribute to the risk of children becoming over or underweight (Kininmonth and others, 2021).

The following 2 scales from this question set were included in the eating habits survey as they are measures of appetite that research has shown have an association with children’s BMI:

‘food responsiveness’, which is positively correlated with higher BMI among children (higher scores are associated with higher BMI)
‘satiety responsiveness’, which is negatively correlated with higher BMI among children (lower scores are associated with higher BMI)

Food responsiveness

Food responsiveness measures eating in response to food cues (such as the sight or smell of food). Of caregivers surveyed:

33% said their child was ‘always’ or ‘often’ asking for food
32% said their child would eat most of the time if given the choice
32% said their child finds room to eat their favourite food even if they are full

Smaller proportions said their child would ‘always’ or ‘often’ have food in their mouth if given the chance (19%) and would eat too much if allowed to (13%).

Figure 7: child eating behaviours (food responsiveness statements) - ‘For the next questions, please read the following statements and tick the boxes most appropriate to your child’s eating behaviour’

Statement	Always	Often	Sometimes	Rarely	Never	Total
My child is always asking for food	8%	25%	43%	20%	4%	100%
Given the choice, my child would eat most of the time	9%	24%	33%	25%	9%	100%
Even if my child is full up, they find room to eat their favourite food	9%	23%	32%	23%	13%	100%
If given the chance, my child would always have food in their mouth	6%	12%	26%	32%	24%	100%
If allowed to, my child would eat too much	5%	9%	20%	36%	31%	100%

Base (unweighted): all primary caregivers (2,620).

Note: totals may not add to 100% due to rounding.

This part of the CEBQ is scored as:

never = 1
rarely = 2
sometimes = 3
often = 4
always = 5

The chart below shows the distribution of individual children’s mean scores (across the 5 statements) for the food responsiveness metric. The largest proportion of children scored around the middle, with only a minority scoring highly (research has shown high scores to be associated with higher BMI). The average (of the mean scores) was 2.73 (standard deviation (SD) 0.809).

Here, standard deviation tells you how far the average deviates from the mean. A high standard deviation indicates that the average score is spread out over a wider range, while a low standard deviation suggests that the average score is closer to the mean.

Figure 8: child eating behaviours (food responsiveness) mean scores

Mean score	Frequency
1.00	15
1.20	44
1.40	67
1.60	103
1.80	154
2.00	208
2.20	249
2.40	264
2.60	269
2.80	245
3.00	231
3.20	189
3.40	135
3.60	117
3.80	89
4.00	70
4.20	59
4.40	38
4.60	31
4.80	21
5.00	22

Base (unweighted): all primary caregivers (2,620).

There were small differences in food responsiveness scores relating to affluence, as follows.

Children of caregivers who earned less than £15,000 were more likely to have a higher mean score. The average of the mean scores in this group was 2.9, compared with 2.7 for caregivers earning £23,000 or more.

Similarly, the average of the mean scores for children of caregivers who were receiving benefits was higher (2.8) compared with those who were not (2.7).

Satiety responsiveness

Satiety responsiveness measures the ability to recognise and adjust eating in response to internal feelings of satiety or fullness. It is negatively correlated with higher BMI among children, meaning that a lower score for this set of questions is associated with higher BMI in young children (Kininmonth and others, 2021).

Primary caregivers were most likely to say their child ‘always’ or ‘often’ leaves food on their plate at the end of a meal (36%) and that their child gets full before their meal is finished (29%). Smaller proportions of caregivers said their child always or often cannot eat a meal if they have had a snack just beforehand (18%), and their child gets full up easily (15%). This reflects the fact that a large proportion of caregivers (58%) felt their child ‘always’ or ‘often’ has a big appetite.

Figure 9: child eating behaviours (satiety responsiveness statements) - ‘For the next questions, please read the following statements and tick the boxes most appropriate to your child’s eating behaviour’

Statement	Always	Often	Sometimes	Rarely	Never	Total
My child has a big appetite (note 1)	20%	38%	33%	7%	2%	100%
My child leaves food on their plate at the end of a meal	9%	28%	45%	15%	3%	100%
My child gets full before their meal is finished	5%	24%	50%	19%	3%	100%
My child cannot eat a meal if they have had a snack just before the meal	3%	15%	32%	34%	16%	100%
My child gets full up easily	3%	12%	35%	41%	9%	100%

Base (unweighted): all primary caregivers (2,620).

Note: totals may not add to 100% due to rounding.

The same scoring system as above is applied. However, the scale is reversed for statements marked with ‘(note 1)’.

The chart below shows the distribution of individual children’s mean scores (across the 5 statements) for this metric. The largest proportion of children scored around the middle, with only a small minority scoring towards the lower end (which research has shown to be associated with higher BMI). The average (of the mean scores) was 2.76 (SD 0.666).

Figure 10: child eating behaviours (satiety responsiveness) mean scores

Mean score	Frequency
1.00	10
1.20	13
1.40	33
1.60	68
1.75	1
1.80	110
2.00	177
2.20	238
2.40	294
2.60	323
2.80	294
3.00	280
3.20	219
3.40	196
3.50	1
3.60	147
3.80	87
4.00	56
4.20	38
4.40	14
4.60	13
4.80	5
5.00	3

Base (unweighted): all primary caregivers (2,620).

There were small differences in satiety responsiveness mean scores relating to whether or not primary caregivers were receiving benefits, but not for income.

The average of the mean scores was higher for children of caregivers who were not receiving benefits (2.8) compared with those who were (2.7).

Food likes and dislikes

When it comes to food likes and dislikes, over half of primary caregivers (57%) said their child was ‘choosy’ (with 8% saying ‘very choosy’), compared with 43% who said they were not.

Figure 11: children’s likes and dislikes with respect to food - ‘Does your child have definite likes and dislikes as far as food is concerned?’

Response	Proportion of participants
Yes, very choosy	8%
Yes, quite choosy	49%
No	43%

Base (unweighted): all primary caregivers (2,620).

Primary caregiver feeding behaviour

The Parental Style Feeding Questionnaire (PFQ) has 4 scales looking to capture different aspects of caregivers’ feeding style (Wardle and others, 2012). The following 2 scales from this question set were included in the survey:

‘emotional feeding’ (feeding children in response to their emotions)
‘control over eating’ (whether caregivers decide when and how children should eat)

These were chosen as they are the issues most relevant to the age group of children in this survey.

Emotional feeding

For emotional feeding, most primary caregivers said they ‘rarely’ or ‘never’ gave their child something to eat if they were:

angry (89%)
worried (88%)
bored (86%)

However, 22% said they ‘always’, ‘often’ or ‘sometimes’ give their child something to eat to make them feel better when they are hurt.

The most common form of emotional feeding was caregivers giving their child something to eat when they are feeling upset (41% said they did this at least sometimes).

Figure 12: primary caregiver feeding behaviour (emotional feeding statements) - ‘Please read the following statements and tick the appropriate boxes to show how you deal with feeding your child or children’

Statement	Always	Often	Sometimes	Rarely	Never	Total
I give my child or children something to eat to make them feel better when they are feeling upset	1%	6%	35%	32%	26%	100%
I give my child or children something to eat to make them feel better when they are hurt	1%	3%	18%	31%	46%	100%
I give my child or children something to eat to make them feel better when they are feeling angry	1%	1%	8%	19%	70%	100%
I give my child or children something to eat if they are feeling bored	No response	2%	12%	26%	60%	100%
I give my child or children something to eat to make them feel better when they are worried	1%	1%	10%	20%	68%	100%

Base (unweighted): all primary caregivers (2,620).

Note: totals may not add to 100% due to rounding.

This scale of the PFQ is scored as:

never = 1
rarely = 2
sometimes = 3
often = 4
always = 5

The chart below shows the distribution of individual caregivers’ mean scores (across the 5 statements) for the ‘emotional feeding’ metric. Most primary caregivers had low scores, with only a small minority scoring highly. The average (of the mean scores) was 1.65 (SD 0.608).

Figure 13: primary caregiver feeding behaviour (emotional feeding) mean scores

Mean score	Frequency
1.00	564
1.20	364
1.40	379
1.60	288
1.80	258
2.00	223
2.20	171
2.40	114
2.60	84
2.80	58
3.00	58
3.20	25
3.40	11
3.60	7
3.80	6
4.00	2
4.20	3
4.40	1
4.60	1
4.80	2
5.00	1

Base (unweighted): all primary caregivers (2,620).

There were small differences in emotional feeding scores related to affluence. The average mean score among caregivers earning less than £15,000 was 1.8, compared with 1.6 among those earning £46,000 or more.

Control over eating

When looking at control in caregivers’ feeding behaviours, high proportions of primary caregivers said they ‘always’ or ‘often’ decide the times when their child eats their meals (84%) and what their child eats between meals (77%).

Fewer said they ‘always’ or ‘often’ decide how many snacks their child has (63%) and when it is time for their child to have a snack (61%).

Of all primary caregivers:

49% said they ‘never’ or ‘rarely’ allow their child to decide when they have had enough snacks
51% said they let their child eat between meals whenever they want
65% said they let their child decide when they would like to have their meal

Figure 14: primary caregiver feeding behaviour (control statements) - ‘Please read the following statements and tick the appropriate boxes to show how you deal with feeding your child or children’

Statement	Never	Rarely	Sometimes	Often	Always	Total
I decide the times when my child or children eat their meals	2%	2%	12%	42%	42%	100%
I decide what my child or children eat between meals	2%	3%	18%	37%	41%	100%
I decide how many snacks my child or children should have	5%	9%	23%	33%	30%	100%
I decide when it is time for my child or children to have a snack	3%	7%	29%	38%	22%	100%
I allow my child or children to decide when they have had enough snacks to eat (note 1)	29%	20%	23%	14%	14%	100%
I let my child or children eat between meals whenever they want (note 1)	21%	30%	34%	11%	4%	100%
I let my child or children decide when they would like to have their meal (note 1)	33%	32%	27%	6%	2%	100%

Base (unweighted): all primary caregivers (2,620).

Note: totals may not add to 100% due to rounding.

The same scoring system as above is applied. However, the scale is reversed for statements marked with ‘(note 1)’.

The chart below shows the distribution of individual caregivers’ mean scores (across the 5 statements) for the ‘control’ metric. The distribution skews towards the higher end of the scale, reflecting that caregivers in this survey had a relatively high level of control over when and how their children eat. The average (of the mean scores) was 3.82 (SD 0.631).

Figure 15: primary caregiver feeding behaviour (control) mean scores

Mean scores	Frequency
1.00	2
#1.14	1
#1.43	1
#1.57	3
#1.86	3
#2.00	6
#2.14	8
#2.29	16
#2.43	25
#2.57	26
#2.71	51
#2.86	60
#3.00	102
#3.14	111
#3.29	174
#3.43	192
#3.57	235
#3.71	224
#3.86	220
#4.00	223
#4.14	202
#4.29	180
#4.43	160
#4.57	123
#4.71	111
#4.86	80
5.00	81

Base (unweighted): all primary caregivers (2,620).

There were small differences in ‘control’ behaviour mean scores according to affluence, as follows.

Caregivers earning less than £15,000 had an average score of 3.7, compared with 3.9 among those who earned £46,000 or above.

Caregivers who did not receive benefits were more likely to have higher scores (an average of 3.8), compared with those who did (3.7).

Sources of information and support for feeding children

Primary caregivers most commonly used online sources and personal networks for information and support relating to feeding their children. Of the online sources used:

42% of caregivers used NHS websites
33% used social media, discussion forums or video-sharing platforms
36% used other websites

Caregivers tended to use personal networks for information and support, with more than a third going to a partner, friend or relative for help or information about feeding their child (37%). A quarter (25%) went to a health professional.

Nearly a fifth of caregivers (19%) said they had not needed help or information with feeding their child.

Figure 16: sources of help and information regarding feeding children - ‘Where do you go to get help or information with feeding your child or children if you need it?’

Place for help or information	Proportion of participants
From NHS websites such as Start for Life	42%
Partner, friend or relative	37%
Online - website	36%
Online - social media, discussion forum, or video-sharing platform	33%
Health professional (midwife, health visitor, GP)	25%
Books, leaflets, magazines or newspapers	18%
Sure Start Centre, children’s centre, children’s health clinic or Family Hub	11%
Infant feeding support group	4%
National Breastfeeding Helpline	3%
Food manufacturer - website or mailings	3%
Television (including streaming services)	2%
Voluntary or charitable organisation	2%
Radio (including podcasts or audio-streaming services)	1%
From elsewhere	2%
I have not received any help or information with feeding my child or children	7%
I have not needed help or information with feeding my child or children	19%

Base (unweighted): all primary caregivers (2,620).

Question 5

Healthy Start scheme

Accepted Answer

This chapter looks at eligibility and uptake of the Healthy Start scheme.

The Healthy Start scheme provides help for families and pregnant women on low incomes in England to get healthy food, milk and vitamins.

A fifth of primary caregivers in the survey (20%) reported being currently eligible for the Healthy Start scheme. Nearly three-quarters of those who were aware they were eligible said they had registered for the scheme (74%).

Note that a description of the Healthy Start scheme was given within the questionnaire.

Eligibility for the scheme includes pregnant women (at least 10 weeks into pregnancy) and families with a child under 4 years old claiming any of the following benefits:

Income Support
Income-based Job Seeker’s Allowance
Child Tax Credit (with an annual family income of £16,190 or less)
Universal Credit (with family take-home pay of £408 or less per month)
Pension Credit

Figure 17: self-reported eligibility for the Healthy Start scheme and registration status - ‘Based on the above description, are you currently eligible for the Healthy Start scheme?’

Self-reported eligibility	Proportion of participants
Yes	20%
No	70%
Do not know	9%

Base (unweighted): all primary caregivers (2,620).

Have you registered for the Healthy Start scheme?

Registration status	Percentage
Yes	74%
No	22%
Do not know	3%

Base (unweighted): all caregivers who are eligible for the Healthy Start scheme (375).

Caregivers who had registered for the scheme had most commonly used their vouchers or pre-payment card to buy:

fruit (88%)
vegetables (86%)
cows’ milk (77%)

Less than half had used it to buy infant formula based on cows’ milk (44%) and around a fifth had used it to buy pulses (19%).

A very small minority of caregivers who had registered for the scheme reported having not used the vouchers or card yet (2%). Of this 2% (7 participants), reasons selected for not having used the card or vouchers were mixed, including:

having applied for the Healthy Start scheme but waiting for the pre-payment card
being unsure of what to buy
having forgotten to use the card

Figure 18: products purchased with Healthy Start vouchers or pre-payment card - ‘Since you registered, if you have used your Healthy Start vouchers or pre-payment card, what have you spent them on?’

Product	Proportion of participants
Fruit (fresh, frozen or tinned)	88%
Vegetables (fresh, frozen or tinned)	86%
Cows’ milk	77%
Infant formula based on cows’ milk	44%
Pulses (fresh, dried or tinned)	19%
Other products	14%
I have not used my Healthy Start Vouchers or pre-payment card	2%

Base (unweighted): all caregivers who are eligible for the Healthy Start scheme and have registered for it (282).

Question 6

Food security

Accepted Answer

This chapter examines the extent to which participants in the survey had experienced some element of food insecurity over the previous year. The survey took place in March to April 2023, and so the ‘past year’ that participants were responding to was March 2022 to April 2023.

While a majority of caregivers did not have concerns about, or issues relating to, affording food over the past year, a significant minority reported having experienced this, as:

33% reported they worried sometimes or often about whether their food would run out before they got money to buy more
30% reported they sometimes or often could not afford to eat balanced meals
25% reported that sometimes or often the food they bought did not last and they did not have money to get more

Figure 19: experiences of food insecurity over the past 12 months - ‘Please say whether each statement below was often true, sometimes true or never true for you or people in your household in the last 12 months’

Statement	Often true	Sometimes true	Never true
I or we worried whether my or our food would run out before I or we got money to buy more	10%	24%	64%
The food that I or we bought just didn’t last, and I or we didn’t have money to get more	7%	18%	71%
I or we couldn’t afford to eat balanced meals	7%	23%	67%

Base (unweighted): all primary caregivers (2,620).

Of those who said that any of the 3 statements above were ‘often’ or ‘sometimes’ true in the last 12 months, around half (45%) said that they or another adult in their household had cut the size of their meals or skipped meals because there was not enough money for food. This was almost a fifth of all participants (19%). This figure broadly aligns with figures from the Food Foundation, a charity tracking food insecurity among households with children in the UK. In January 2023, round 12 of the Food Foundation’s Food Insecurity Tracker found that 22% of households with children said their children had directly experienced food insecurity in the past month.

Among caregivers in the survey who said they were cutting the size of meals or skipping meals:

39% reported that they did so almost every month
38% reported doing so some months but not every month
16% reported this only happened during 1 or 2 months in the year

Figure 20a: proportion skipping, or cutting the size of, meals due to not having enough money - ‘In the last 12 months, did you or any other adult in your household ever cut the size of your meals or skip meals because there wasn’t enough money for food?’

Response	Proportion of participants
Yes	45%
No	46%
Do not know	9%

Base (unweighted): all who said often or sometimes true to previous questions about food security (925).

Figure 20b: frequency of those skipping, or cutting the size of, meals due to not having enough money - ‘How often did this happen, almost every month, some months but not every month, or in only 1 or 2 months?’

Response	Proportion of participants
Almost every month	39%
Some months but not every month	38%
Only 1 or 2 months	16%
Do not know or prefer not to say	7%

Base (unweighted): all who said they or another adult in the household cut the size of their meals or skipped meals in the last 12 months because there was not enough money for food (406).

The proportion of families reporting that they or another adult in their household had cut the size of their meals, or skipped meals because there was not enough money for food, was higher in this survey (19%) than the proportion in the ‘Children of the 2020s: first survey of families at age 9 months’ report (9%). This may be due to the:

changing economy (summer and autumn 2022 to spring 2023)
differences in the way the questions were asked in each survey
differences between participants in the original COT20s cohort and those who took part in the eating habits survey

Question 7

Feeding from birth

Accepted Answer

This chapter examines feeding practices from birth, looking at the:

prevalence of breastfeeding
use of formula milk or milk substitutes
introduction of solid food

Caregivers were asked to recall their experiences of feeding their child in the first year after birth. This information is indicative, but detailed information on national infant feeding practices among caregivers of infants from birth to 10 months old will be available following publication of the new infant feeding survey in 2025.

Breastfeeding

UK guidance recommends that babies are fed breast milk only for around the first 6 months of their life. And, alongside solid foods, they can continue to be breastfed into the second year of life or beyond.

Being breastfed or given expressed breast milk

Caregivers reported that 78% of children in the survey had been breastfed or given expressed breast milk at some stage. This is broadly in line with data from NHS England’s Maternity Services Data Set (version 2.0), which is published as part of OHID’s Public Health Outcomes Framework data on baby’s first feed breastmilk. This showed that, in 2020 to 2021, 71.7% of babies had breast milk for their first feed. Data collected in NHS England’s Infant Feeding Survey - UK, 2010 showed that 83% of children in England were breastfed or given expressed breast milk at some point.

Of those ever given breast milk, 3 in 10 continued to be breastfed or given expressed breast milk at the age of 16 to 18 months (30%). This was a quarter of all children in the survey being breastfed or given expressed breast milk at this age (25%). The ‘Infant Feeding Survey - UK, 2010’ recorded levels of breastfeeding up until babies were 9 months of age, at which point 24% of mothers in England were breastfeeding.

Figure 21a: proportion of children ever breastfed - ‘Has your child ever been breastfed or given expressed breast milk?’

Response	Proportion of participants
Yes	78%
No	22%

Base (unweighted): all primary caregivers (2,620).

Figure 21b: proportion of children continuing to be breastfed - ‘Is your child still breastfeeding or being given expressed breast milk now?’

Response	Percentage
Yes	30%
No	70%

Base (unweighted): all children who have ever been breastfed or given expressed milk (2,066).

Age of child when last given breast milk

Of the children in the survey who had been breastfed or received breast milk at some point but were no longer being given breast milk, 42% last had breast milk aged 0 to 3 months. Smaller proportions had breast milk for the last time at a later timepoint:

18% at 4 to 6 months
12% at 7 to 9 months
28% at 10 to 18 months

Looking at the first 9 months of life, if children were no longer given breast milk, this was most likely to occur in the first month. Of caregivers whose child was no longer being given breast milk, 15% said their child last had breast milk aged under one month or 0 to 3 weeks.

Figure 22: age of child when last given breast milk - ‘How old was your child when they last had breast milk?’

Age	Proportion of participants
0 months or 0 to 3 weeks	15%
1 month or 4 to 7 weeks	10%
2 months or 8 to 11 weeks	8%
3 months or 12 to 15 weeks	9%
4 months or 16 to 19 weeks	6%
5 months or 20 to 23 weeks	4%
6 months or 24 to 27 weeks	8%
7 months or 28 to 31 weeks	5%
8 months or 32 to 35 weeks	3%
9 months or 36 to 39 weeks	3%
10 to 12 months or 40 to 51 weeks	12%
13 to 15 months or 52 to 63 weeks	11%
16 to 18 months or 64 to 75 weeks	5%

Base (unweighted): all who say their child was breastfed or given expressed milk at one point but is not now (1,457).

Using formula milk

Caregivers reported that 80% of children in the survey had been given formula milk at some stage. The ‘Infant Feeding Survey - UK, 2010’ (in stage 3 when the children were 8 to 10 months old) reported that 89% of mothers had given their baby formula milk in the last 7 days.

Figure 23: proportion of children ever given formula milk - ‘Has your child ever been given formula milk?’

Response	Proportion of participants
Yes	80%
No	20%

Base (unweighted): all primary caregivers (2,620).

Using breast milk and formula milk

Most commonly, primary caregivers had fed their child with both breast milk and formula milk. This was the case for 58% of children in the survey. Roughly similar proportions had only breastfed (20%) or only formula fed (22%).

Figure 24: proportion of children given breast and formula milk, only breast milk and only formula milk

Response	Proportion of participants
Only breastfed	20%
Only formula fed	22%
Breast and formula fed	58%

The variable at Figure 24 above is derived from answers to the following questions:

‘Has your child ever been breastfed or given expressed breast milk?’
‘Has your child ever been given formula milk?’

Base (unweighted): all primary caregivers (2,620).

Types of formula milk used

UK guidance recommends infant formula (based on either cows’ or goats’ milk) as the only suitable alternative to breast milk in the first 6 months of life. It is also the only formula milk needed alongside solid foods from 6 to 12 months of age. NHS advice on Types of formula states that, while follow-on formula can be given from 6 months of age, there is no need to introduce it (and that follow-on formula should never be fed to babies under 6 months old).

The most common type of formula milk used by COT20s families was infant formula (given by 72% of those primary caregivers who had ever given formula milk to their child, and 58% of all those in the survey). Follow-on formula was the second most common formula milk to have ever been given to children (given by 32% of primary caregivers who had ever used formula milk, and 26% of all those in the survey).

Other types of formula milk had been less commonly used, though, of all primary caregivers surveyed, 10% had used growing-up milk (toddler milk) and 9% had used prescribed specialist formula. This appears to be inconsistent with responses to an earlier question where caregivers said 15% of children drank growing-up or toddler milks. This may be due to differences in the:

way these questions were asked in the survey
categorisation of growing-up or toddler milks (as drinks or as formula) by caregivers

Figure 25: types of formula milk used - ‘Which of the following types of formula milk has your child ever been given (ready made or powdered)?’

Type of formula milk	Base: all	Base: caregivers who say their child has ever been given formula
Infant formula	58%	72%
Follow-on formula	26%	32%
Growing-up milk (toddler milk)	10%	13%
Prescribed specialist formula	9%	11%
Anti-reflux (stay down) formula	6%	7%
Hungrier baby formula (hungry milk)	6%	7%
Comfort formula	5%	6%
Lactose-free formula	3%	4%
Soya formula	1%	2%
Other	3%	4%

Base (unweighted): all primary caregivers (2,620); all who say their child has ever been given formula milk (2,100).

Compared with primary caregivers who had exclusively formula fed their children, caregivers who had breastfed and used formula milk were more likely to have given their child:

follow-on formula (34% compared with 25%)
growing-up milk (14% compared with 10%)

Reasons for using formula milk

Primary caregivers were asked the reasons they decided to use each specific type of formula milk, apart from infant formula. Common responses for why they used other types of formula were:

caregivers’ previous experience with another baby
advice provided by a health professional

For follow-on formula (the second most commonly used formula milk among COT20s families in the survey):

24% said previous experience was their reason for using it
15% said they were advised by a health professional
15% explained its use as an alternative to breast milk (or used in combination with breast milk)
12% named practical considerations such as it being convenient or other people being able to feed their child

Table 14: reasons for giving different types of formula milk to children - ‘What were the reasons you decided to give [type of formula milk] to your child?’

Reason	Follow-on formula (%)	Growing-up milk (toddler milk) (%)	Anti-reflux (stay down) formula (%)	Hungrier baby formula (hungry milk) (%)	Comfort formula (%)	Lactose-free formula (%)	Soya formula (%)
Previous experience with another baby	24	20	8	26	18	9	2
A health professional advised me to	15	12	69	22	50	77	46
My partner, friend or relative advised me to	9	10	6	20	15	4	No response
I read leaflets or other literature that advised me to	7	9	4	<1	2	No response	8
They were not gaining enough weight	4	2	6	8	2	3	3
I saw or heard an advert on the TV, radio, or online	3	3	1	No response	No response	No response	2
Not sure	9	9	1	3	2	No response	No response
Base (unweighted)	665	256	147	129	114	80	30

Note: you should take caution in the interpretation of findings where the base is low (less than 100) or very low (less than 50).

Table 15: reasons for giving different types of formula milk to children - ‘other’ responses

This table shows where responses to the ‘other, please specify’ answer options have been grouped together into themes.

Reason	Follow-on formula (%)	Growing-up milk (toddler milk) (%)	Anti-reflux (stay down) formula (%)	Hungrier baby formula (hungry milk) (%)	Comfort formula (%)	Lactose-free formula (%)	Soya formula (%)
Alternative to breast milk (or used in combination with)	15	5	No response	No response	4	2	7
Practical considerations (for example, convenient)	12	10	No response	3	2	No response	8
Weaning or next step	7	8	1	No response	No response	No response	2
Diet and nutrition (for example, vitamins)	3	6	No response	No response	No response	No response	No response
Child preference	2	11	No response	No response	No response	No response	5
Adverse reactions (for example, reflux or colic)	1	2	17	<1	18	14	25
Hunger	2	1	No response	27	1	No response	No response
To aid sleep	<1	1	No response	4	1	No response	No response
Other reasons (fewer than 5 mentions)	5	3	3	3	2	No response	4
Base (unweighted)	665	256	147	129	114	80	30

Note: you should take caution in the interpretation of findings where the base is low (less than 100) or very low (less than 50).

Specialist formula

Primary caregivers who had ever given their child specialist formula were asked who prescribed this for them. Two-thirds of caregivers (65%) reported that specialist formula was prescribed by a doctor or GP. Smaller proportions had specialist formula prescribed by a paediatrician (28%) or dietician (28%). Few were prescribed specialist formula by a doctor in a specialised care unit or neonatal ward (11%).

Figure 26: health professionals that prescribed specialist formula - ‘Who prescribed specialist formula milk (for example, hypoallergenic, preterm) for your child?’

Response	Proportion of participants
Your doctor or GP	65%
A paediatrician	28%
A dietician	28%
A doctor in a specialised care unit or neonatal ward	11%
Other health professional	6%

Base (unweighted): all who say their child has ever been given specialist formula milk (240).

Age of introduction of solid food

UK guidance recommends that babies are introduced to solid food when they are around 6 months old. Just over half of COT20s families (57%) said their child first had solid food at around 6 months (24 to 27 weeks) old.

A third of children in the survey were given solid food before this (33%). In the main, this was when they were 5 months old (21%), though some were given solid food when 4 months old (10%).

The mean number of weeks when children were first given solid food was 25.8 weeks.

Figure 27: age of child when first had solid food - ‘How old was your child when they first had any kind of solid food apart from milk?’

Age	Proportion of participants
0 to 3 months or 0 to 15 weeks	2%
4 months or 16 to 19 weeks	10%
5 months or 20 to 23 weeks	21%
6 months or 24 to 27 weeks	57%
7 months or 28 to 31 weeks	5%
8 months or 32 to 35 weeks	2%
9 months or 36 to 39 weeks	1%
10 to 18 months or 40 to 75 weeks	2%

Base (unweighted): all primary caregivers (2,620).

Sociodemographic differences

There were some differences between sociodemographic groups in relation to whether children had ever been breastfed or received any breast milk, mainly relating to deprivation. More affluent caregivers were more likely to have ever given their child breast milk.

Of caregivers with household incomes of £32,500 or above, 85% had given their child breast milk compared with 71% of those with an income below £32,500. Of caregivers in the least deprived IMD quintile, 82% had given their child breast milk compared with 70% in the most deprived quintile.

Similar differences were seen when looking at children who continued to be given breast milk when aged 16 to 18 months. Those living in the least deprived areas were more likely to be giving their child breast milk at this age (34% of caregivers in the least deprived IMD quintile, compared with 25% in the most deprived quintile).

Caregivers living in the most deprived areas were more likely to have given their child formula milk at some stage (84% of caregivers in the most deprived IMD quintile, compared with 76% in the least deprived quintile).

There were few differences evident in the type of formula milk provided to children according to deprivation, except for hungrier baby formula. Primary caregivers living in more deprived areas were more likely to give this type of formula milk to their child. For example, 9% of those in the most deprived IMD quintile who had given their child formula milk had used hungrier baby formula, which steadily declined to 2% in the least deprived quintile.

Differences by affluence were also apparent according to when caregivers first gave their child solid food. Those with lower household incomes were more likely to have given their child solid food before 6 months (36% of caregivers with household incomes of less than £32,500, compared with 31% of those with incomes of £32,500 or more).

Question 8

Dental hygiene

Accepted Answer

This chapter examines the dental hygiene habits of children aged 16 to 18 months, looking at:

the age at which children have their teeth brushed
the use of fluoride in toothpaste
visits to the dentist

Age at which toothbrushing started

Although nearly all primary caregivers said their child had their teeth brushed (98%), there was some variation in the age at which they began. Most children in the survey began having their teeth brushed before they reached the age of one (83%) and just under a fifth began before they were 6 months old (17%).

UK guidance recommends that children’s teeth should begin being brushed as soon as they start to come through, which is on average at around 5 to 7 months. In line with this guidance, the most common age to begin brushing children’s teeth was between the ages of 6 months and 1 year (66%). This is higher than the 50% reported by parents of children in England in NHS England’s Child Dental Health Survey 2013.

Figure 28: age at which toothbrushing started - ‘How old was your child when they started brushing their teeth or having their teeth brushed for them?’

Age	Proportion of participants
Under 6 months of age	17%
Between 6 months and 1 year of age	66%
Between 1 and 2 years of age	14%
They do not brush their teeth or have them brushed for them	2%

Base (unweighted): all primary caregivers (2,620).

Fluoride in toothpaste

UK guidance, communicated through NHS advice on Children’s teeth, recommends that babies’ teeth should be brushed with a tiny smear of fluoride toothpaste. Half of the COT20s families in the survey (50%) used a toothpaste containing fluoride.

Just under a fifth (17%) said they used toothpaste without fluoride, but nearly a third (30%) did not know if the toothpaste they used for their child contained fluoride or not. A very small percentage did not use toothpaste at all (3%).

Figure 29: use of toothpaste containing fluoride - ‘Does the toothpaste you use most often for your child contain fluoride?’

Response	Proportion of participants
Yes	50%
No	17%
Do not use toothpaste	3%
Do not know	30%

Base (unweighted): all who say their children brush their teeth or have their teeth brushed for them (2,572).

Age of first dentist visit

UK guidance advises that children should start going to the dentist when their first teeth appear - however, nearly two-thirds of caregivers surveyed reported that they were yet to take their child to the dentist (65%).

Of the children who had been to the dentist, the mean age for their first visit was 10.3 months old, with the most common answer being 10 to 12 months (10%).

Figure 30: age of first dentist visit - ‘How old was your child when they first went to the dentist (in months)?’

Product	Proportion of participants
Fruit (fresh, frozen or tinned)	88%
Vegetables (fresh, frozen or tinned)	86%
Cows’ milk	77%
Infant formula based on cows’ milk	44%
Pulses (fresh, dried or tinned)	19%
Other products	14%
I have not used my Healthy Start Vouchers or pre-payment card	2%

Base (unweighted): all primary caregivers (2,620).

Sociodemographic differences

Few clear patterns emerged among sociodemographic groups when considering dental hygiene. However, children living in households with lower incomes were more likely to have not yet visited the dentist (69% of children living in a household with an income of £32,500 or below, compared with 58% for those with a household income above £32,500).

Question 9

Conclusion

Accepted Answer

The findings from this survey provide information on aspects of the current diet and eating behaviours of children aged 16 to 18 months, and how these compare with UK guidance and dietary recommendations. Before this survey, the DNSIYC provided the most recent information on children in this age group.

The COT20s study provided an opportunity to collect data from caregivers of children in this age group as part of an existing cohort, providing some new information on the eating habits of young children. Although the survey does not provide a detailed dietary assessment, it does provide information on the types and frequency of consumption of a variety of foods and drinks.

Areas of concern

This report highlights some areas of concern in the eating habits of children aged 16 to 18 months, including:

sugary foods as a regular part of children’s diets
salt added to food for young children
the frequent use of purchased snacks and ‘treats’ (such as sweets, crisps, chocolates and ice cream)
the use of drinks other than breast milk, water or milk - specifically the use of formula milks (including infant and follow-on formula) after 12 months of age, and growing-up or toddler milks

Sugary foods

UK guidance states that sugary foods and drinks should be limited for young children. The results of this survey showed that foods such as biscuits, sweets, chocolate or cakes were consumed regularly (90% of children consumed these, 61% on at least 2 days a week).

Purchased snacks and treats

Caregivers reported often giving ‘treats’ (described as foods such as chocolates, crisps, sweets or ice cream) to children (67% had these foods daily).

The survey results also highlight the common use of purchased finger foods or snacks among children aged 16 to 18 months (93% of children have these at least once a week and 21% have them daily).

The Commercial infant and baby food and drink: evidence review identified that the nutrient composition of some purchased foods aimed at young children was inconsistent with UK dietary recommendations for this age group, particularly for sugar and salt. In its ‘Feeding young children aged 1 to 5 years’ report, SACN recommended that commercially manufactured foods and drinks marketed specifically for infants and young children are not needed to meet nutritional requirements.

The use of drinks other than breast milk, water or milk

Although nearly all children often drank water and milk, caregivers also reported that around half of children consumed squash and fruit juice.

Some children were also continuing to drink formula milks (infant or follow-on formula) after 12 months of age, as well as growing-up or toddler milks (18% of children in the survey drank one or more of these at least once a day), with some having these as their main milk drink.

This is despite UK guidance stating that these are unnecessary for children aged over one year. SACN’s report ‘Feeding young children aged 1 to 5 years’ raised concerns about the contribution that these drinks make to children’s free sugars intake.

Salt intake

Previous evidence from dietary surveys has shown that salt intake is higher than recommended. Despite the recommendation not to add salt to food for young children, nearly 1 in 3 caregivers reported that they sometimes or often added salt to their child’s food.

Survey limitations

Although the COT20s cohort is nationally representative, some of the survey results suggest that participants may differ from the general population. This is evident in the relatively high proportion of children continuing to be breastfed at 16 to 18 months. This may be due to the sample having been drawn from a cohort study where participants may be more engaged and interested in their child’s development.

The survey findings show some inconsistencies in caregivers’ responses to different questions - for example, on the consumption of foods such as biscuits, confectionery, cakes and snacks, and use of growing-up or toddler milks. These may be due to the way questions were asked in the survey, and differences in interpretation by caregivers.

Due to differences in the age range of children surveyed, survey design and types of data collected, it is not possible to directly compare findings from this survey with other surveys such as the National Diet and Nutrition Survey and infant feeding survey.

Opportunities for further support and guidance

This report identifies opportunities for further support and guidance for families with young children, particularly about providing:

healthy snacks and drinks
advice on feeding from birth, including breastfeeding, which is recommended up to the age of 2 years and beyond

The government continues to monitor the eating habits and diets of infants and young children. A new infant feeding survey for England (including children from birth to 10 months old) will report in 2025.

The National Diet and Nutrition Survey currently reports regularly on the diet and nutrition of UK children aged from 18 months onwards and, from 2024, the survey also includes children between 12 to 18 months old.

Question 10

References

Accepted Answer

Griffiths LJ, Parsons TJ and Hill AJ. ‘Self-esteem and quality of life in obese children and adolescents: a systematic review.’ International Journal of Pediatric Obesity 2010: volume 5, issue 4, pages 282 to 304.

Kininmonth A, Smith A, Carnell S, Steinsbekk S, Fildes A and Llewellyn C. ‘The association between childhood adiposity and appetite assessed using the Child Eating Behavior Questionnaire and Baby Eating Behavior Questionnaire: a systematic review and meta-analysis.’ Obesity Reviews 2021: volume 22, issue 5.

Wardle J, Guthrie CA, Sanderson S and Rapoport L. ‘Development of the Children’s Eating Behaviour Questionnaire.’ Journal of Child Psychology and Psychiatry 2003: volume 42, pages 963 to 970.

Wardle J, Sanderson S, Guthrie CA, Rapoport L and Plomin R. ‘Parental feeding style and the inter-generational transmission of obesity risk.’ Obesity Research 2012: volume 10, pages 453 to 462.

Question 11

Annex 1: technical details

Accepted Answer

Overview of methodology and approach

Ipsos conducted this survey on behalf of OHID using a ‘push-to-web’ survey approach. A push-to-web survey is a quantitative data collection method in which offline contact modes are used, such as letters, phone or face to face, to encourage sample members to go online and complete a web questionnaire. Ipsos selected the sample from a cohort of caregivers participating in the longitudinal COT20s study.

Ipsos invited the COT20s families to complete the eating habits survey between 8 March and 10 April 2023, which was between the first and second waves of the COT20s longitudinal study. Ipsos contacted them up to 3 times using various methods (including letter, email and text message) depending on the availability of contact information.

The aim of the survey was to better understand aspects of the diet and eating behaviours of children aged 16 to 18 months in England. The government can use the data from this research to inform policies aimed at improving diets and preventing childhood obesity to ensure that all children have the best start in life.

Survey development

To create this survey, we adapted questions from existing questionnaires, including the:

infant feeding survey 2024
Infant Feeding Survey - UK, 2010
Child Eating Behaviour Questionnaire (Wardle and others, 2003)
Parental Feeding Style Questionnaire (Wardle and others, 2012)
Scottish maternal and infant nutrition survey 2017
Child Dental Health Survey 2013, England, Wales and Northern Ireland
adult oral health survey 2021

Ipsos worked with OHID and UCL to refine and develop the existing questions to align them with the agreed areas of interest and ensure they were appropriate to the current context. Also, the questions were amended where needed to ensure consistency throughout the survey for participants.

Ipsos’ scripting team wrote the survey and the research team conducted rigorous quality checks before the survey was live. These consisted of:

checks for logical inconsistencies, such as ensuring that participants were not able to select more than one answer when only one was required
routing checks to ensure that participants were only asked questions of relevance to them
checks of question wording and text fills to ensure that the online questionnaire reflected the questionnaire that had been signed off by OHID

If the research team found errors with the script, they were corrected. Once signed off, the script was shared with the UCL team who also conducted their own internal checks.

To maximise responses, the questionnaire was device agnostic, meaning that it could be completed on a device of the respondent’s choosing (for example, a desktop or laptop computer, a tablet or a smartphone). The survey was also scripted using Ipsos’ accessibility template to make it as accessible as possible for all participants.

Sampling

Ipsos selected the sample for the original COT20s study from HMRC child benefit records for all registered births between September and November 2021. The sample was selected in 3 stages:

Ipsos selected a random sample of 746 primary sampling units (PSUs), defined by individual or merged postcode sectors.
Ipsos randomly selected the months of the births that were to be covered in the sample in each PSU.
Ipsos extracted all births in the sampled PSUs for the selected months from the child benefit records.

You can find full details of the COT20s sampling approach in the ‘COT20s wave 1 technical report’ in Children of the 2020s: first survey of families at age 9 months.

Ipsos invited a subset of the COT20s participants to participate in the eating habits survey. To identify the sample to invite, Ipsos applied inclusion and exclusion criteria, which were to:

only include primary caregivers
only include children who would be 16 to 18 months old at the time of fieldwork
exclude participants who have not given, or withdrawn, their consent to be contacted as part of the COT20s study
exclude participants selected for the COT20s re-contact survey (about 800) to avoid over-burden
exclude participants selected for the COT20s wave 2 pilot survey
exclude participants who requested their data was deleted following the COT20s wave 1 interview
exclude participants who had given a new address update for an address outside England

Once these criteria were applied, Ipsos invited all eligible respondents to participate. In total, 7,756 primary caregivers were invited to participate. Of these, 2,260 responded (a response rate of 34%). All children were aged between 16 and 18 months when this survey took place. See the ‘Participant profile’ section in ‘Background and methodology’ above for a full breakdown against the main characteristics.

Fieldwork administration and management

Fieldwork was carried out between 8 March and 10 April 2023, between the first and second waves of the COT20s study. All participants who completed the survey and supplied a valid email address received a £5 voucher by email as a thank you for their time.

Participants received up to 3 types of contact prompting them to participate in the survey, including:

an invitation letter: a paper letter introducing the survey and inviting respondents to take part online
an email or text message invitation: an email or text message introducing the survey and inviting respondents to take part online
a text message or email reminder: a text message or email reminding them to take part online

The contact approach differed depending on the availability of each participant’s contact details.

Participants who supplied an email address and a mobile number received:

an invitation letter
an email invitation
a text message reminder (only to those who had not responded by this stage)

Participants who supplied an email address but no mobile number received an:

invitation letter
email invitation
email reminder (only to those who had not responded by this stage)

Participants who supplied a mobile number but no email address received:

an invitation letter
a text message invitation
a text message reminder (only to those who had not responded by this stage)

Participants who had not supplied an email address or mobile number received an invitation letter only.

Mailings were sent on the following dates:

invite letter: 7 March 2023
email or text message invite: 10 March 2023
email or text message reminder: 24 March 2023

Thank you emails, containing the £5 e-voucher, were sent out periodically throughout the fieldwork period.

All of the mailings were approved by UCL’s ethics committee and signed off by OHID.

Data processing procedures

The Ipsos data processing team produced a spreadsheet containing the weighted data tables and an SPSS (data management and analysis software) file with weighted data.

The Ipsos research team reviewed the data from open-ended questions and coded them into themes. They also removed any information that may identify participants from the SPSS file before sharing it with UCL and OHID.

Survey weighting

Households in areas of higher deprivation were more likely to be invited to take part in the eating habits survey. This is because higher deprivation households were over-sampled for the COT20s cohort study due to a tendency among this group for lower response rates over time. For this reason, households that responded to the survey were more likely to be from areas of high deprivation. Final survey data has been weighted to account for this.

The data for this survey was weighted using the same approach taken for the COT20s study. This consisted of 3 stages:

‘selection weighting’ to correct for the over-sampling of families in the most deprived quintile of areas
‘non-response weighting’ to adjust the responding sample so that its profile more closely matched that of the issued sample and, by extension, the profile of the population
‘calibration weighting’ to ensure that the weighted profile of the responding sample perfectly matched the population estimates for the 3 birth months of the study

You can find the full details of the weighting approach in the ‘COT20s wave 1 technical report’ in ‘Children of the 2020s: first survey of families at age 9 months’.

Data limitations

The percentage figures presented in this report should be interpreted with care. All surveys are subject to a range of potential sources of error, including:

sample imbalances that are not easily identified and corrected through weighting
errors in participants’ interpretation of survey questions and response options

The data reported relies on participants’ self-reported behaviours. Errors could occur due to:

imperfect recollection
participants’ tendency to over-report behaviours that are perceived as desirable and under-report undesirable behaviours

For the most part, we only comment on subgroups with 100 or more participants in this report. However, it should be noted that, the smaller the size of the subgroup, the less we can rely on the survey estimates to be true representatives of the population as a whole. In some cases, we comment on subgroups comprising fewer than 100 participants, so these should be treated with particular caution and are flagged as such in the report.

The report comments on differences in the data between different subgroups within the caregivers surveyed. A difference has to be of a certain size to be considered statistically significant. Only differences that are statistically significant at the 95% confidence interval are commented on in this report. Significance testing should only be applied to random probability samples. In practice, good-quality quota sampling is almost as accurate.

Thirty-three caregivers answered the survey about twins, meaning they were asked some questions twice. To apply statistical significance testing, the answers for one of these twins were taken at random.

Where figures do not add up to 100%, this is the result of rounding or where participants are able to select more than one response option (multiple response questions). We have noted where scores of less than 0.5% but greater than 0% appear in this report.

Question 12

Annex 2: recommendations and advice for feeding infants and young children

Accepted Answer

Feeding infants

Breastfeeding and infant formula

SACN reviewed the scientific evidence underpinning recommendations on feeding infants in its report Feeding in the first year of life.

SACN’s recommendations on breastfeeding included that:

infants should be breastfed exclusively for around the first 6 months of their life and continue breastfeeding for at least the first year of life
infant formula (based on either cows’ or goats’ milk) is the only suitable alternative to breast milk for babies who are under 12 months old

SACN noted that soya-based formula should only be used on medical advice and that the government should keep the possible health effects of soya-based formula under review.

Solid foods

On introducing solid foods, also known as complementary feeding, SACN’s recommendations included that:

most infants should not start solid foods until around 6 months of age
breast milk, infant formula and water should be the only drinks offered to children between 6 and 12 months of age
a wide range of solid foods should be introduced in an age-appropriate form from around 6 months of age
dietary, flavour and texture diversification should proceed incrementally
in view of the high intakes of salt (sodium chloride) and free sugars in this age group, there is a need to re-emphasise the risks associated with added salt and free sugars in foods given to infants

Complementary feeding means introducing foods other than breast milk (and/or infant formula) to complement the nutrients provided by breast milk (and/or infant formula) when breast milk (and/or infant formula) alone is not sufficient to meet the nutritional requirements of the growing infant. Introducing solid foods diversifies the infant diet while breastfeeding (and/or infant formula feeding) continues during the early years of life.

You can read more detailed recommendations on complementary feeding in the report ‘Feeding in the first year of life’.

Feeding young children aged 1 to 2 years

Dietary recommendations

SACN reviewed the scientific evidence underpinning recommendations on feeding young children in its report Feeding young children aged 1 to 5 years.

SACN’s recommendations included:

between 1 to 2 years of age, children’s diets should continue to be gradually diversified in relation to foods, dietary flavours and textures
UK dietary recommendations on average intake of free sugars (that free sugars intake should not exceed 5% of total dietary energy intake) should apply from age 1 year
milk or water, in addition to breast milk, should constitute the majority of drinks given to children aged 1 to 5 years
pasteurised whole and semi-skimmed cows’ milk can be given as a main drink from age 1 year, as can goats’ and sheep’s milks, but pasteurised skimmed and 1% cows’ milk should not be given as a main drink until 5 years of age
children aged 1 to 5 years should not be given rice drinks
children aged 1 to 5 years should not be given sugar-sweetened beverages
dairy products (such as yoghurts and fromage frais) given to children aged 1 to 5 years should ideally be unsweetened
formula milks (including infant formula, follow-on formula, growing-up or other toddler milks) are not required by children aged 1 to 5 years
specialised formulas (including low-allergy formula) are usually not required after the first year of life
foods (including snacks) that are energy dense and high in saturated fat, salt or free sugars should be limited in children aged 1 to 5 years
commercially manufactured foods and drinks marketed specifically for infants and young children are not needed to meet nutritional requirements
salt should not be added to foods given to children aged 1 to 5 years
children aged 1 to 5 years should be presented with unfamiliar vegetables on multiple occasions (as many as 8 to 10 times or more for each vegetable)
deliberate exclusion of peanuts or hen’s eggs (and foods containing these) beyond 12 months of age may increase the risk of allergy to these foods
children aged 1 to 5 years should continue to be offered a wide range of foods that are good sources of iron
children aged 1 to 5 years should be given a daily supplement of 10 micrograms (400 International Units) vitamin D and 233 micrograms vitamin A unless, contrary to recommendations, they are consuming more than 500 millilitres of formula milk per day

Oral health

OHID and NHS England guidance Delivering better oral health: an evidence-based toolkit for prevention includes advice on diet and feeding practices to prevent caries in children aged up to 3 years.

Recommendations include that:

infants should be breastfed exclusively for around the first 6 months of life and continue breastfeeding while introducing solids from around the age of 6 months
only breast milk, infant formula or cooled boiled water should be given in a bottle (from 6 months of age, infants should be introduced to drinking from a free-flow cup and, from age 1 year, feeding from a bottle should be discouraged)
sugar should not be added to baby foods or drinks
the frequency and amount of sugary food and drinks should be reduced
sugar-free medicines should be recommended
only milk or water should be drunk between meals

National Institute for Health and Care Excellence public health guideline Maternal and child nutrition also includes recommendations on diet and feeding practices to improve oral health.

The guidelines recommend that parents and carers should:

use a bottle for expressed breast milk, infant formula or cooled boiled water only
offer drinks in a non-valved, free-flowing cup from age 6 months to 1 year
discourage feeding from a bottle from 1 year onwards
limit sugary foods to mealtimes only
avoid giving biscuits or sweets as treats
encourage snacks free of salt and added sugar (such as vegetables and fruit) between meals
provide milk and water to drink between meals (diluted fruit juice can be provided with meals at 1 part juice to 10 parts water)
not add sugar or any solid food to bottle feeds
not add sugar or honey to foods
not offer baby juices or sugary drinks at bedtime

Summary of government advice

The following summaries include relevant government advice for feeding young children aged 1 to 2 years communicated at the time the eating habits survey was conducted (March to April 2023). All advice was available on the NHS website.

We have summarised the advice into 5 main topics, which are:

food
breastfeeding and use of formula
drinks
vitamins
dental hygiene

Food

Advice about food at the time of the eating habits survey included that:

children should be having 3 meals a day
children may also need 2 healthy snacks in between meals (for example, fruit, vegetable sticks, toast, bread or plain yogurt)
children do not need salt or sugar added to their food or cooking water
children should now be able to manage mashed, lumpy, chopped and finger foods
children should eat a varied diet including starchy carbohydrates, full-fat dairy products, cheese, protein (beans, pulses, fish, eggs, meat and other sources) and iron-containing foods
parents and caregivers should introduce lots of different types of vegetables and fruit, and try to include them in every meal
parents and caregivers should limit the amount of foods that are high in saturated fat (such as crisps, biscuits and cakes)
parents and caregivers should limit the amount of sugary foods and drinks, and these should only be offered with meals rather than as a snack
parents and caregivers should avoid giving sugary foods to children before bedtime

Breastfeeding and formula use

Advice about breastfeeding and formula use at the time of the eating habits survey included that:

breastfeeding can continue, alongside solid foods, for as long as both the mother and child want
first infant formula is not needed and toddler milk, growing-up or goodnight milks are also unnecessary

Drinks

Advice about drinks at the time of the eating habits survey included that:

from 1 year, children can drink whole cows’ milk and have full-fat dairy products (full fat for children under 2 years, and semi-skimmed milk from 2 years onwards if they’re eating and growing well)
parents and caregivers should avoid giving sweet or sugary drinks, especially at bedtime
if giving fruit juice, parents and caregivers should only give it at mealtimes and diluted to 1 part juice to 10 parts water
parents and caregivers should offer drinks in a non-valved free-flowing cup
once a baby is 1 year old, parents and caregivers should avoid feeding them from a bottle

Following the publication of the SACN report ‘Feeding young children aged 1 to 5 years’, the NHS website updated its guidance to reflect updated UK government advice that pasteurised whole and semi-skimmed cows’ milk, or goat’s or sheep milk, can be given as a main drink from the age of 1 year.

Vitamins

Advice about vitamins at the time of the eating habits survey included that parents and caregivers should give all children aged 6 months to 5 years vitamin supplements containing vitamins A, C and D every day.

Dental hygiene

Advice about dental hygiene at the time of the eating habits survey included that parents and caregivers should:

brush children’s teeth at least twice a day: just before bed and at another time that fits in with your routine
use a tiny smear of toothpaste for babies and toddlers up to 3 years old

Question 13

Annex 3: acknowledgments

Accepted Answer

This report was prepared by:

Ipsos
OHID

The authors want to thank all Children of the 2020s families who have generously given their time to take part in the eating habits survey.

We would also like to thank everyone who has contributed to the development of the survey and the report, in particular:

OHID
DfE
UCL
Ipsos
members of the SACN subgroup on maternal and child nutrition

Age	Proportion of participants
1 to 3 months	1%
4 to 6 months	6%
7 to 9 months	6%
10 to 12 months	10%
13 to 15 months	6%
16 to 18 months	4%
Not yet been	65%

Cookies on GOV.UK

Applies to England

Summary

Children of the 2020s study

Eating habits survey design and completion

Caring arrangements and meal provision

Food at 16 to 18 months

Drinks at 16 to 18 months

Eating and feeding behaviour at 16 to 18 months

Sources of support

Healthy Start scheme

Food security

Feeding from birth

Dental hygiene

Sociodemographic differences

Conclusion

Background and methodology

Context

Gaps in the evidence base

About the Children of the 2020s study

The eating habits survey

Participant profile

Food and drinks at 16 to 18 months

Caring for children

Meal provision

Eating habits

Vegetables and fruit

Starchy foods

Other foods

Foods that can trigger allergic reactions

Purchased ready meals and snacks

Snacks and treats

Adding salt to food

Drinking habits

Main milk drink

Using a cup for drinking

Use of vitamin supplements

Sociodemographic differences

Eating and feeding behaviours at 16 to 18 months

Child eating behaviours

Food responsiveness

Satiety responsiveness

Food likes and dislikes

Primary caregiver feeding behaviour

Emotional feeding

Control over eating

Sources of information and support for feeding children

Healthy Start scheme

Food security

Feeding from birth

Breastfeeding

Being breastfed or given expressed breast milk

Age of child when last given breast milk

Using formula milk

Using breast milk and formula milk

Types of formula milk used

Reasons for using formula milk

Specialist formula

Age of introduction of solid food

Sociodemographic differences

Dental hygiene

Age at which toothbrushing started

Fluoride in toothpaste

Age of first dentist visit

Sociodemographic differences

Conclusion

Areas of concern

Sugary foods

Purchased snacks and treats

The use of drinks other than breast milk, water or milk

Salt intake

Survey limitations

Opportunities for further support and guidance

References

Annex 1: technical details

Overview of methodology and approach

Survey development

Sampling

Fieldwork administration and management

Data processing procedures