High sugar intakes can contribute to childhood obesity and dental caries, which present major public health challenges around the world(1). In the UK, free sugars account for 10 % of calories consumed by children aged 1–3 years, which is double the national recommendation that free sugar intake should not exceed 5 % of total energy(2). Free sugars include all added sugars, all sugars naturally present in fruit juices, purees and similar products in which the structure has been broken down and all sugars in drinks (except dairy-based drinks)(2).
Many commercial infant foods and beverages (CIF) have a high sugar content but are marketed as healthy and appropriate for infants and young children up to the age of 36 months(Reference Hutchinson, Rippin and Threapleton3–5). A survey of 3427 CIF across twenty-seven European countries found that half included the message ‘no added sugar’, yet 35 % of these contained free sugars(Reference Grammatikaki, Wollgast and Caldeira6). Some parents report a general perception that CIF are healthy, which labelling such as this may contribute to(Reference Isaacs, Neve and Hawkes7). ‘Health halo’ statements such as ‘natural’ and ‘organic’ and images of fruit also add to the belief that products are healthier than their nutrient profile would indicate(Reference Brunacci, Salmon and McCann8,Reference Gallagher-Squires, Isaacs and Reynolds9) .
The WHO considers existing CIF composition and marketing regulations to be outdated and proposes new regulations, including clearer messaging relating to sugar content(1,10) . The UK Government has also made a commitment to support families to make healthier food choices. Leaving the European Union provides the UK greater flexibility for regulatory changes, such as making food labels clearer(11). A range of front-of-pack (FoP) label formats is in use around the world to communicate energy and nutrient information, including sugar content. Mandatory policies for displaying traffic lights, nutrition scores, nutrition warnings or health warnings have been shown to be effective in changing children’s and adults’ purchasing behaviour towards healthier products and away from less healthy products, according to a systematic review and meta-analysis of 156 studies(Reference Song, Brown and Tan12). In the UK, the government recommends including multiple traffic light labels on most packaged foods to provide information at a glance and support consumers in making healthier food choices(13). However, multiple traffic light labels are based on reference intakes for adults rather than infants or children, whose energy and nutrient requirements vary according to age(13). The WHO proposes the use of sugar warning labels (SWL) on CIF as, in addition to helping parents recognise high-sugar products, they may incentivise the CIF industry to reformulate products and/or change product ranges(1,10) . A scoping review of experimental studies of nutrient warning labels on sugar-sweetened beverages (SSB) and ultra-processed foods found that SWL helped adults and children to identify high-sugar products and discouraged them from purchasing these products(Reference Taillie, Hall and Popkin14). Both these reviews considered adults and children making food choices for themselves(Reference Song, Brown and Tan12,Reference Taillie, Hall and Popkin14) . No reviews could be found on the impact of FoP labelling policies for sugar on the choices made by parents and other primary caregivers (referred to as ‘parents’ throughout for brevity) on behalf of their infants and young children.
A particular issue with CIF is the perception that because products are strictly regulated, they must be low in sugar, which is not always the case(Reference Isaacs, Neve and Hawkes7). In addition, claims such as ‘no added sugar’ are common on CIF, as are claims about ‘natural sugar’, which is a term consumers may view more positively(1,Reference Garcia, Menon and Parrett4,15) . Also, fruit puree and concentrated fruit juice are commonly used to sweeten CIF, which are listed as such in the ingredients, although consumers are unaware that they contain high levels of free sugar(1,Reference Garcia, Menon and Parrett4,15) . It is important to bring together the available evidence to allow policymakers to better understand opportunities for policy levers to improve the labelling of CIF and identify any requirements for additional research.
The aim of this scoping review was to assess the published and unpublished evidence base to understand what is known about how the labelling of CIF impacts parents’ beliefs about sugar content and their related purchasing or feeding decisions. Specific review questions were: (i) what is known about how primary caregivers understand terms used on CIF to describe sugar? (ii) what is known about how primary caregivers might use SWL on CIF?
Methods
A preliminary search of MEDLINE, PROSPERO and the Cochrane Database of Systematic Reviews was conducted, and no current or underway systematic reviews or scoping reviews on the topic were identified. This scoping review was informed by the Johanna Briggs Institute methodology(Reference Peters, Godfrey and McInerney16) and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews (PRISMA-ScR, see online supplementary material, Supplemental File S1)(Reference Tricco, Lillie and Zarin17). The review protocol was preregistered with the Open Science Framework (doi: 10.17605/OSF.IO/S32CR).
Definitions and eligibility criteria
For the purposes of this review, CIF was defined as any commercially prepared food or drink labelled as suitable for children ≤ 36 months of age, excluding commercial milk formula. ‘Sugar’ included mono- and disaccharides, such as glucose, fructose and sucrose, including those found in fruit. ‘Food labelling’ referred to any information, symbols or statements on packaging, including nutrition panels, ingredient lists, traffic light labels and warning labels. ‘Understanding’ encompassed parents’ interpretation and use of labels and other packaging information, including images, nutrient or health-related statements, which may influence their perceptions of a product’s sugar content.
Eligibility of studies was determined using the population, concept and context framework(Reference Peters, Godfrey and McInerney18). Studies were eligible for inclusion if they included (i) parents of children aged ≤ 37 months choosing foods/drinks for their child and/or parents’ choosing CIF; (ii) sugar; (iii) food labelling; (iv) parents’ understanding; (v) participants living in Northern, Western or Southern Europe, North America, Australia or New Zealand (to increase the generalisability of findings to the UK population); (vi) were written in English; and (vii) were accessible in full text.
Studies were excluded if they (i) involved a broader age group without presenting subgroup analysis for the target age group of ≤ 37 months, unless specifically focused on CIF; (ii) focused exclusively on commercial milk formula, product sales or parents’ perceptions of baby food marketing beyond packaging; (iii) were conducted in larger geographical regions without relevant subgroup analysis; and (iv) were published in a language other than English.
Quantitative, qualitative and mixed-method studies were included, as well as meta-analyses, opinion papers and non-peer-reviewed reports from government departments and third-sector organisations.
To avoid omitting important insights, the original inclusion criteria were expanded. The protocol originally specified inclusion of studies with parents of children aged 4–36 months, but this was expanded to parents of children ≤ 37 months. It was also planned that only studies of CIF would be included, but this was expanded to other foods or drinks if the study focused on the provision of these products to children aged ≤ 37 months. Updated inclusion criteria allowed the inclusion of eleven additional studies, four meeting age but not CIF criteria, six about CIF where age was outside the 4–36 month range and one about drinks which included parents of children aged ≤ 37 months.
Information sources and search strategy
The search strategy was developed in consultation with a research librarian and designed to capture both published and unpublished studies. In May 2024, searches were conducted across six bibliographic databases: MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Web of Science (Core Collection) and Cochrane Library, with no date restrictions. A comprehensive search string incorporating keywords and indexed terms related to ‘parents’, ‘beliefs’, ‘sugar’ and ‘baby food labels’ was initially developed for MEDLINE and then tailored to each database and information source (see online supplementary material, Supplemental File S2). The reference lists of all included sources were also screened to identify additional studies.
To access unpublished or non-academic reports, a thorough grey literature search strategy was implemented. This strategy involved three key approaches: (i) Google searches, (ii) targeted website searches and (iii) consultations with experts in the field. These complementary approaches minimised the risk of omitting relevant sources. Data from grey literature were evaluated for inclusion and extracted using the same eligibility criteria as for peer-reviewed papers. The complete grey literature strategy, search terms and screening process are detailed in online supplementary material, Supplemental File S3.
Selection of sources of evidence
Identified citations were collated and uploaded into Covidence, where duplicates were removed. A rigorous two-step screening process was then undertaken. In the first stage, TD and CR independently reviewed titles and abstracts against the predefined inclusion and exclusion criteria, classifying each source as include, exclude or unclear. In the second stage, full texts of articles marked as include or unclear were retrieved and reassessed using the same criteria. Studies that met all the criteria were then included in the review.
To ensure unbiased selection, reviewers conducted their assessments independently and were blinded to each other. Consistency was maintained by TD and RC independently piloting the screening process with a random sample of twenty abstracts and ten full texts and discussing decision making before proceeding with the full literature review. Once both TD and RC had completed each stage of reviewing, disagreements were resolved through discussion. A summary of the selection process, including reasons for exclusion, is presented in Fig. 1.
Fig. 1 PRISMA flow diagram of search process.
Data charting process
A data extraction form was developed in Microsoft Excel, adapted from the Johanna Briggs Institute methodology for scoping review guidelines. The form was piloted by TD and RC on five studies and modified before being applied to the remaining studies. Data charting was performed by TD and validated by RC, with any disagreements resolved through discussion.
The extracted data included the source/year of publication, year of study, country, aims, population/sample size, study design, funding source, summary of findings and any additional relevant insights. In the original data extraction form described in the protocol, it was intended that findings related to parents’ beliefs about sugar content in baby foods would be recorded separately from those related to feeding and purchasing decisions. However, when piloting the form, it was not possible to separate results in this way, so findings were documented in a single column. Study findings were then summarised for presentation and organised according to primary themes to provide a narrative summary. As is typical for scoping reviews, the quality of the studies was not evaluated.
Results
Summary of research results
The academic literature search yielded 2071 records from six databases, with 1123 remaining after deduplication. After screening the titles and abstracts, eighty-eight records were retrieved for full-text review. Despite efforts to contact authors, one full-text article could not be retrieved and hence was excluded. Of the eighty-seven remaining records, nine studies (reported in eleven papers) met the inclusion criteria. Citation searching identified one additional article, bringing the total to ten studies (across twelve papers).
The grey literature search employed three strategies: (1) a customised Google search with predefined parameters (reviewing the first ten pages for three keyword searches and three site-specific search strings), (2) targeted searches on thirty-four websites and (3) consultation with forty-nine experts, yielding twenty-four responses. Together, the three grey literature search strategies identified twelve sources, with five being retained after screening, including two identified through targeted website searches, two through Google and Google Scholar searches and one from contacting experts. Three of the five sources were charity reports, one was a government report and one was a master’s thesis.
Figure 1 shows the selection process for both peer-reviewed and grey literature, with the most common reasons for exclusion being the lack of subgroup analyses for the target age range or insufficient focus on sugar.
Study characteristics
The source characteristics are summarised in Table 1. The review included fifteen studies published across seventeen papers published between 2015 and 2023. Geographically, five studies were conducted in the UK(5,Reference Isaacs, Neve and Hawkes7,Reference Gallagher-Squires, Isaacs and Reynolds9,19–Reference Lovelace and Rabiee-Khan22) , five in the USA(Reference Choi, Jensen and Fleming-Milici23–Reference Taillie, Higgins and Lazard27), four in Australia(Reference McCann, Woods and Mohebbi28–Reference Rowan, Mirosa and Heath31) and one in Portugal(Reference Sousa32). The research designs varied: seven studies employed quantitative methods(19,20,Reference Choi, Jensen and Fleming-Milici23,Reference Harris, Phaneuf and Fleming-Milici25,Reference Taillie, Higgins and Lazard27,Reference McCann, Woods and Mohebbi28,Reference Rhodes30) , seven utilised qualitative approaches(5,Reference Isaacs, Neve and Hawkes7,Reference Gallagher-Squires, Isaacs and Reynolds9,Reference Neve, Coleman and Hawkes21,Reference Lovelace and Rabiee-Khan22,Reference Fleming-Milici, Phaneuf and Harris24,Reference Morel, Nichols and Nong26,Reference Poirier, Hedges and Smithers29,Reference Rowan, Mirosa and Heath31) and one used mixed-methods(Reference Sousa32). All of the quantitative studies included cross-sectional surveys, and three also included a randomised controlled trial(Reference Harris, Phaneuf and Fleming-Milici25,Reference Taillie, Higgins and Lazard27,Reference McCann, Woods and Mohebbi28) . Qualitative data collection involved in-depth interviews (n 5), focus group discussions (n 2) and a netnographic analysis, which is a qualitative analysis of online communities. Two in-depth interview studies adopting a longitudinal approach. Sample sizes ranged from 83 to 1023 for quantitative studies and 11–227 for qualitative studies. Most studies were conducted online (n 10), with the remainder delivered in person (n 5).
Table 1. Characteristics of included studies (n 15)
CIF, commercial infant food; m, months; RCT, randomised controlled trial; SEP, socio-economic position; SSB, sugar-sweetened beverage; y, years.
Table 2. Summary of findings relating to parents’ beliefs about sugar content and choice of foods for their infants and young children (n 15)
CIF, commercial infant food; FoP, front of pack; m, months; NNS, non-nutritive sweeteners; RCT, randomised controlled trial; SWL, sugar warning label; T, timepoint.
* Natural feature includes ‘All natural’, ‘Organic’, ‘No HFCS’, ‘No artificial ingredients’ and ‘Non-GMO’.
One study exclusively recruited mothers, while others sought to recruit all parents or primary caregivers although their samples also primarily comprised mothers. Thirteen studies recruited parents of children ≤ 37 months, including three that included only parents with children < 24 months. The other two studies focused exclusively on CIF labelling but included parents with children ≤ 3 years and ≤ 4 years(Reference McCann, Woods and Mohebbi28,Reference Rhodes30) . Three studies included parents of older children too; therefore, only findings for younger children were extracted to ensure alignment with our target population(Reference Choi, Jensen and Fleming-Milici23,Reference Morel, Nichols and Nong26,Reference Taillie, Higgins and Lazard27) . Some studies specifically recruited participants from low-income neighbourhoods(Reference Fleming-Milici, Phaneuf and Harris24,Reference Morel, Nichols and Nong26) , non-homeowners receiving income support or healthy start vouchers(Reference Lovelace and Rabiee-Khan22) or those enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children(Reference Morel, Nichols and Nong26). One study required participants to have a child who had consumed at least one fruit drink in the past week for eligibility(Reference Taillie, Higgins and Lazard27). Four studies focused specifically on SSB(Reference Choi, Jensen and Fleming-Milici23–Reference Morel, Nichols and Nong26), which they defined as drinks with added sugar, with one study also including drinks with only non-nutritive sweeteners(Reference Harris, Phaneuf and Fleming-Milici25). Although definitions of SSB included products such as fizzy drinks and flavoured water, the focus was generally on fruit-flavoured drinks, excluding 100 % juice.
Results of individual sources of evidence and synthesis of results
Key findings from each study are summarised in Table 2.
Impact of labelling products as suitable for babies
Studies exploring general beliefs about CIF (n 8) found that most parents assumed products labelled as suitable for babies were inherently healthy and appropriate(5,Reference Isaacs, Neve and Hawkes7,Reference Gallagher-Squires, Isaacs and Reynolds9,19–Reference Lovelace and Rabiee-Khan22,Reference Poirier, Hedges and Smithers29–Reference Rowan, Mirosa and Heath31) . Even though parents avoided giving foods they regarded as high in sugar, their trust in CIF meant they didn’t perceive sugar to be something they needed to consider when choosing from the baby food aisle. Parents from low-income families in the UK described offering ‘baby biscuits’ and rusks in the belief that they weren’t high-sugar products(Reference Lovelace and Rabiee-Khan22). One participant noted, ‘I thought because they were baby foods, like baby stuff, they’d be careful about what sugar and stuff they put in them’ and another echoed this sentiment ‘With things like chocolate … we try to avoid that because obviously it’s gonna rot his teeth … we usually give him a couple of rusks or crisps … things like that’(Reference Lovelace and Rabiee-Khan22).
In an online survey of 1000 UK parents by Action on Sugar, brand trust was given as a key reason for choosing to buy CIF breakfast products(20). The impact of this trust was elucidated in a qualitative study, where parents described turning to brands for feeding guidance, one mother said ‘I quite like the Ella’s Kitchen … they do so many different flavours. I wasn’t put off by the ingredients as such. I find the organic pouches have got lovely ingredients in them. I don’t worry. I don’t think, oh, there’s too much sugar in this or there’s an E number or anything like that’(Reference Isaacs, Neve and Hawkes7). Netnographic analysis of online parenting forums in Australia also suggests parents generally have a positive view of CIF pouches and view them as healthy(Reference Rowan, Mirosa and Heath31). A poll of 1023 Australian parents specifically explored perceptions around regulation and found that 53 % falsely believed that CIF were regulated by the government to ensure they provided good nutrition for babies and toddlers and 41 % believed that CIF must be healthy or the government wouldn’t allow them to be sold(Reference Rhodes30).
Strategies to raise awareness of sugar content
Three studies conducted in the USA employed methods to increase awareness of the sugar content of products, including a randomised online experiment with SWL(Reference Taillie, Higgins and Lazard27), a randomised online experiment with counter-marketing videos(Reference Harris, Phaneuf and Fleming-Milici25) and a study where information sheets were discussed in focus groups(Reference Fleming-Milici, Phaneuf and Harris24). The first study involved a virtual shopping task, in which parents chose one of two snacks (with or without an ‘added label’). The ‘added labels’ were either a barcode control, text-only SWL or pictorial SWL. Among parents of 1-year-olds (n 83), 33 % chose a barcode control snack, while only 19 % selected the same item when an SWL was shown(Reference Taillie, Higgins and Lazard27). Statistical analysis was not performed for this subgroup of the larger sample of parents of 1 to 5-year-olds. In the second intervention study, parents viewed counter-marketing videos about SSB (described as sweetened fruit drinks) or videos about screen time (control group)(Reference Harris, Phaneuf and Fleming-Milici25). Videos about SSB highlighted that closer examination of labels showed high sugar content and the presence of ingredients that were forms of added sugar or non-nutritive sweeteners and recommended only giving water and plain milk to toddlers(Reference Harris, Phaneuf and Fleming-Milici25). After watching the videos, parents reported a reduced intention to serve SSB to their children, and they had less positive attitudes towards them, seeing them as less beneficial, convenient and good value. However, for parents who had recently served SSB, the videos did not significantly affect their intention to serve SSB. In the third intervention, parents in in-person focus groups reviewed ‘expert recommendation sheets’ and ‘concept sheets’ related to SSB (described as sugar-sweetened fruit-flavoured drinks)(Reference Fleming-Milici, Phaneuf and Harris24). The expert sheet used a traffic light system to guide parents’ choices (green for plain milk and water, orange for 100 % juice and red for SSB), while the concept sheets addressed how to identify sugars in ingredient lists, how to find the total sugar content of a product in the nutrition facts panel and the meaning of common marketing claims. Over the course of focus group discussions, parents’ attitudes towards fruit SSB became less positive, and they became less accepting of the way they are marketed(Reference Fleming-Milici, Phaneuf and Harris24).
In addition to the three intervention studies, a fourth study involved discussions with parents (n 9, USA) to explore the potential of using various strategies to promote avoidance of SSB(Reference Morel, Nichols and Nong26). Parents supported the use of illustrations of sugar content at the point of purchase and believed messages focusing on negative health consequences for children would be effective in changing parents’ feeding behaviour(Reference Morel, Nichols and Nong26).
Role of marketing claims
In eleven studies, parents reported being attracted to products labelled as having no added sugar, less sugar or only natural sugar(5,Reference Isaacs, Neve and Hawkes7,19,20,Reference Lovelace and Rabiee-Khan22–Reference Fleming-Milici, Phaneuf and Harris24,Reference McCann, Woods and Mohebbi28–Reference Rhodes30,Reference Sousa32) . Research from Public Health England described labels such as ‘no added sugar’, as well as more general claims such as ‘organic’ and ‘preservative free’ as reinforcing the parents’ trust in CIF brands to know what is best for babies and the perception that products were healthy(5). Evidence from Australia also points to the persuasive power of specific claims, with the majority of parents reporting that claims on packs were very or extremely likely to influence their choices, including ‘no added sugar’ (91 %) and ‘sweetened with fruit’ (87 %)(Reference Rhodes30). Similarly, an online survey of UK parents found that the belief that a product contained ‘naturally occurring sugars only’ was among the top five reasons given for choosing sugary toddler breakfast foods(20). An online survey in Australia also found parents relied on claims such as ‘pure fruit, no added sugar’, without realising the total sugar content of products, while the claim ‘no added sugar’ was interpreted as meaning a product was low in total sugar(Reference Poirier, Hedges and Smithers29). In longitudinal interviews too, parents in Australia, particularly those reporting not reading nutrition labels, described ranking the healthiness of baby foods on claims such as ‘no added sugar’(Reference Poirier, Hedges and Smithers29).
Misconceptions conferred by claims relating to added and natural sugar were further reinforced by the perception that ingredients were presented clearly, honestly and devoid of jargon, making parents feel confident in their choices(Reference Isaacs, Neve and Hawkes7). One parent, described as lower socio-economic position stated, ‘Basically they’re [Ella’s Kitchen are] easy to read ingredients wise. It is exactly what it says on the packet. There is no added salt, sugar, sweeteners. And obviously with me having to be careful with what I’m feeding [baby] they’re just very clear-cut and there’s no nonsense, and there are no scientific big words to try and decipher’(Reference Isaacs, Neve and Hawkes7).
Demand for clearer labelling
In all fifteen studies, there was an indication that parents were unaware of the high level of sugar in some CIF. In two quantitative studies and three qualitative studies, parents explicitly said that on-pack messaging was confusing or deceptive and/or that they wanted clearer sugar labelling. In a poll of parents of 6- to 36-month-olds (n 1000, UK), 87 % said they would find it useful if the amount of sugars added to baby and infant food and drinks were displayed clearly on the FoP(20). Similar views were expressed by parents in Australia (n 1023), with the vast majority supporting laws to regulate the content and marketing of CIF (90 %), the amount of harmful sugar in CIF (92 %) and words, images and claims on packs (90 %)(Reference Rhodes30).
In qualitative studies, after being alerted to back-of-pack information showing sugar content and sugar ingredients, parents in the USA described labels as highlighting fruit ingredients but hiding sugar, which they considered confusing, deceptive and misleading(Reference Fleming-Milici, Phaneuf and Harris24). Some parents went on to say that even if ingredient lists were more prominent, they might struggle to recognise which ingredients contain sugars(Reference Fleming-Milici, Phaneuf and Harris24). Some parents expressed anger over deceptive marketing, with one parent saying, ‘Marketing people know how to market – all natural, oh, 100 % of vitamin C, oh that’s cool. Yeah, but also 100 % of your sugar for the day. It didn’t mention that on the front’(Reference Fleming-Milici, Phaneuf and Harris24). In another study conducted in the USA, parents said they wanted clear information on sugar content, for example, expressed in terms of teaspoons, to empower them to compare products and make informed choices(Reference Morel, Nichols and Nong26).
In line with parents in the USA, those in Australia were annoyed to discover that products labelled ‘no added sugar’ sometimes had the highest sugar content(Reference Poirier, Hedges and Smithers29). One parent remarked, ‘[That]’s disgusting. They shouldn’t be able to make things like that, they should have a big sign on the front, [with] “high sugar content,” like they do with smoking’(Reference Poirier, Hedges and Smithers29). Parents also felt overwhelmed by the pervasive presence of sugar in foods and the difficulty in identifying truly healthy options. They emphasised the need for simple FoP labels to help balance health concerns with the demands of parenting, especially given time constraints. As one parent noted, ‘He’s very full-on, so [I] just feed him and then do my washing… It’s just too full-on to be able to [read nutrition labels]. If it had on the front of the packaging how many tablespoons of sugar, I’d probably think a second about getting him certain things, but it doesn’t. People don’t have time to read that. The mums that I know… they just go for what’s easy’(Reference Poirier, Hedges and Smithers29).
Discussion
This review presents a comprehensive synthesis of the available evidence regarding how the labelling of CIF impacts parents’ beliefs about sugar content and related purchasing and feeding decisions. Fifteen studies were identified, including eight that explored parents’ general beliefs about CIF, revealing an implicit trust that products labelled as baby foods were healthy. The impact of SWL was only assessed in one study, but this study, along with two other interventions that raised parental awareness of sugar content, resulted in less favourable opinions or reduced intentions to purchase. Claims such as ‘no added sugar’ distracted parents from recognising CIF containing high levels of sugar and parents reported finding such labels confusing or they explicitly expressed a desire for clearer labelling. None of the studies specifically explored understanding of terms such as added sugar, natural sugar or free sugar.
The widespread trust that products labelled as suitable for babies are nutritionally appropriate is incongruent with evidence showing high levels of sugar in many CIF. Analysis of 2632 CIF products from ten European countries found that on average, one-third of the calories in CIF came from total sugars, and for most product categories, sugar contributed more than 10 % of calories(Reference Hutchinson, Rippin and Threapleton3). As many CIF are pureed or sweetened with fruit juice, the sugars are largely free sugar, and therefore, the sugar content is inappropriately high given the recommendation that free sugar intake should not exceed 5 % of calories(2,5) . The perception that CIF are tightly regulated provided parents with confidence that products were low in sugar and meant they didn’t feel the need to scrutinise labels further. However, while legislation in place in the UK, as in many other countries, limits the amount of certain macro- and micro-nutrients in CIF, for most CIF, there is no limit on the total sugar content(33). The WHO’s Nutrient and Promotion Profile Model (NPPM) proposes setting a maximum limit of 15 % energy from total sugar in CIF meals and snacks(10). Parents appear to support such measures – a survey for Action on Sugar found 91 % of 1000 parents of children aged 6 to 36 months old in the UK wanted government action to ensure all food and drinks available in the baby food aisle are nutritionally appropriate according to National Health Service recommendations(20). This review didn’t expressly aim to assess support for sugar content regulation, but as parents perceived sugar limits were already in place or expressed a desire for such regulations, this supports WHO calls for action.
One of the specific questions this review aimed to address was to understand what is known about how parents might use SWL on CIF. Only one study tested this, finding that fewer parents chose a toddler snack with a SWL, although statistical analysis was not presented for the subgroup of participants meeting the review’s inclusion criteria(Reference Taillie, Higgins and Lazard27). Results from the full sample, which included parents of children aged 1–5 years (n 2219), found that participants exposed to a text or pictorial SWL were less likely to select the labelled snack than those in the barcode control group (21, 18 and 34 % respectively; P < 0·001 for both comparisons of SWL to control)(Reference Taillie, Higgins and Lazard27). The impact of text and pictorial SWL was similar despite the authors having anticipated that the pictorial SWL would elicit greater attention and have a larger effect(Reference Taillie, Higgins and Lazard27). Three-quarters of parents in the complete sample also reported learning something new from the SWL, compared with one-quarter of those viewing the barcode control, providing further evidence of current misperceptions surrounding sugar content(Reference Taillie, Higgins and Lazard27). The positive impact on children’s diets of raising parental awareness of sugar was also demonstrated by the studies using counter-marketing videos and information sheets; however, such strategies are unlikely to have as wide a reach as FoP labelling regulations(Reference Adams, Mytton and White34). Parents receiving information sheets felt that marketing and packaging of SSB misled them regarding fruit juice content, which was commonly regarded as a healthy, sugar-free option(Reference Fleming-Milici, Phaneuf and Harris24). This perception was due at least in part to interventions highlighting the sugar content of SSB without indicating that 100 % juice also contained sugar(Reference Fleming-Milici, Phaneuf and Harris24). Findings from these intervention studies, together with more robust evidence regarding adults and children choosing products for themselves, suggest that any form of intervention is likely to impact parents’ perceptions of sugar content and may positively alter feeding decisions. However, given the dearth of evidence specifically regarding SWL on CIF, particularly regarding what alternative foods parents might choose if SWL were added to CIF, further research is needed about the potential benefits and inadvertent harms to inform policy development.
The majority of studies (eleven of fifteen) found that parents were attracted to products labelled ‘no added sugar’ or similar. The misleading nature of such claims was highlighted in several of the studies reviewed; for example, Poirier et al. found parents in Australia (n 200) used such claims to rank CIF by sugar content, and they were shocked to discover products’ actual sugar content(Reference Poirier, Hedges and Smithers29). None of the studies expressly sought to explore parents’ understanding of the terms added sugar or natural sugar, which was a specific question for this scoping review. A rapid review of literature related to general consumer understanding of terms such as added sugar (seventeen studies) found that ‘natural sugars’ were perceived as healthier than ‘added sugar’, and only 22–65 % of consumers identified fruit juice on an ingredient list as being added sugar(15). As such claims are common, for example, ‘no added sugar’ or ‘less sugar’ was displayed on 58 % of 724 CIF examined in the UK, a clearer understanding of parents’ perceptions of sugar terminology is needed(Reference Garcia, Menon and Parrett4). This extends to ingredient lists as ‘no added sugar’ claims are common across Europe on CIF containing pureed fruit or concentrated fruit juice despite these ingredients being high in total and free sugar(Reference Hutchinson, Rippin and Threapleton3). As CIF display multiple claims (a median of 5 per product in the UK), parents’ perception of sugar terminology cannot be considered in isolation(Reference Garcia, Chee and Vargas-Garcia35). This review shows that claims such as ‘natural’, ‘organic’ or ‘no junk’ contribute to an overall assessment of products as ‘healthy’ and distract parents from scrutinising labels more closely(Reference Garcia, Menon and Parrett4,Reference Isaacs, Neve and Hawkes7) . Interestingly, parents’ increasing prioritisation of products perceived as ‘natural’, and their desire for ‘clean labels’ and limiting sugar is framed as an ‘opportunity’ in market research reports, rather than an area where clearer labels are needed to facilitate informed decision making(36,37) . The WHO argues that all marketing claims should be prohibited on CIF as they mislead parents and undermine public health messaging(10). When alerted to the high sugar content of some CIF, parents felt current labelling was misleading and deceptive, and they expressed a demand for clearer FoP sugar labelling.
Strengths of this review included using six electronic databases alongside a thorough grey literature search to identify both quantitative and qualitative evidence and allow for a comprehensive account of current evidence. Potential limitations of the review were the exclusion of articles not written in English and the reliance on behavioural measures, such as intentions to purchase or serve, which may not be representative of real-world behaviours.
In conclusion, most parents trusted that products labelled as suitable for babies were healthy and appropriately low in sugar. This perception was reinforced by health halo messaging, and when parents were alerted to the high sugar content of some products, they felt current labelling was deceptive and/or expressed a strong desire for clearer labels. Parents’ understanding of terms such as added sugar was unclear, as was the impact of introducing SWL. However, results show the current lack of regulation leaves parents vulnerable to making underinformed choices for their children. While results support calls for legislation to make CIF labelling clearer, to support parents to reduce the free sugar intake of infants and young children, they highlight the need for policy research to examine more carefully the relative benefits and harms of introducing SWL on CIF.
Supplementary material
For supplementary material accompanying this paper, visit https://doi.org/10.1017/S1368980025100827.
Acknowledgements
We would like to thank Debora Marletta at UCL for her assistance with developing the search strategy.
Authorship
C.L. and A.S. were involved in funding acquisition. R.C. and C.L. conceptualised the study. T.D. conducted searches. R.C. and T.D. conducted screening and analysis and wrote the results. All authors read and approved the final manuscript.
Financial support
This study was funded by the UK National Institute for Health and Care Research Policy Unit (PR-PRU-0916-21001; grant number 174868). The views expressed are those of the author(s) and not necessarily those of the National Institute for Health and Social Care Research or the Department of Health and Social Care.
Conflict of interest
There are no conflicts of interest.
Ethics of human subject participation
None required.
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