Pharmacy Guide to Infant Feeding 2017-2018

2017-2018

IPnhafrmaancytGFuideeetoding

The complete guide to nutrition
from birth to 12 months+



2017-2018

IPnhafrmaancytGFuideeetoding

The complete guide to nutrition
from birth to 12 months+

Welcome to the 2017-18 edition of the Pharmacy Guide to Infant Feeding – the
comprehensive and essential training guide for the pharmacy team, brought to
you by Training Matters magazine.

Having a new baby in the home There is a great opportunity in the rules, advice and products in
is both a joy and a challenge. the pharmacy to answer these this category, this book is packed
Parents are given so much advice questions, allay concerns and deal with essential information to help
about caring for their newborn with uncertainties. But even for pharmacies make the most of this
that they can become confused pharmacy teams, the infant feeding category and provide trusted,
or overwhelmed and simply miss category can be confusing. With reliable advice.
things that are said. Infant feeding seperate guidelines for babies of
can be a particularly confusing different ages, plus regulations over This book can also be used for
area about which parents often who can and cannot recommend training by all members of the
have a multitude of questions. milks, it can sometimes be difficult pharmacy team. At the end of each
And sometimes they can feel to know how best to advise parents. chapter, you’ll find CPD notes,
uncomfortable asking what they And that’s why we’ve put together practice points and multiple
perceive to be a minor query this training and reference book. choice questions to help focus
to their GP or health visitor, or your learning outcomes. You can
don’t feel it’s worth making an Designed to help pharmacists, also visit: tmmagazine.co.uk to
appointment for. But this is where pharmacy technicians and answer the questions and receive
pharmacy can help. pharmacy support teams navigate a certificate of completion.

This guide would not have been possible without the generous support and sponsorship of the following brands:

We thank them for their support.

2017-2018

IPnhafrmaancytGFuideeetoding

The complete guide to nutrition
from birth to 12 months+

Editor Commercial Director Editorial Office
Gemma O’Sullivan Richard Roe Communications
International Group, Linen
Editorial Assistant Publishing Director Hall, 162-168 Regent
Helena Beer Tim Langford Street, London W1B 5TB

Designers Chief Executive Communications
Paulo Azevedo Felim O’Brien International
Peter Lawrence Group
Truprint Media Email: [email protected]

CHAPTER 1 BREASTFEEDING 50 Infant eczema
51 Faltering growth
10 Breast is best 52 Pre-term/low birthweight babies
11 The benefits of breastfeeding 54 Ask the experts
13 Why some mums don’t breastfeed 55 Training & CPD
14 Common breastfeeding problems 58 Specialist milks product information
15 Combination feeding
16 Ask the experts CHAPTER 5 6-12 MONTHS
17 Key ingredients of breast and infant
formula milk 68 Follow-on milks
70 Ask the experts
CHAPTER 2 EQUIPMENT 71 Training & CPD
74 6-12 months product information
19 Feeding equipment and sterilisation
21 How to prepare a bottle feed CHAPTER 6 12 MONTHS+
23 Storage of feeds
24 Ask the experts 77 Nutritional needs of toddlers aged
25 Training & CPD 12 months plus
78 Toddler/growing up milks
CHAPTER 3 0-6 MONTHS 79 Ask the experts
80 Training & CPD
27 Breast milk substitutes 82 12 months ­plus product
28 Tips for bottle feeding and bottle information
feeding guide 86 Infant formula milks compared
30 Feeding problems
31 Ask the experts CHAPTER 7 WEANING
33 Training & CPD
36 0-6 months product information 88 How to start weaning
90 Homemade versus ready-made
CHAPTER 4 SPECIALIST MILKS 92 Ask the experts
94 Training & CPD
41 Coping with colic 96 Manufacturers’ index
43 Reflux
45 Constipation and diarrhoea 2
48 Allergies and intolerances

The combination The role of the
of accessibility and pharmacy
trusted, reliable team
advice puts to advise customers and when to
pharmacy in a very refer them to the pharmacist or promoting and advertising infant
unique position another healthcare professional. formula milks. Put simply, they
to be able to help cannot be promoted in any way.
parents with infant If customers seek advice about That includes running special
feeding queries using infant formula milk for the promotions or displays and
and concerns first time or they want to change offering loyalty points for sales
from one milk to another, they of infant formula milks, as this
P harmacy is a fantastic should always speak to a can all be seen as inducing sales
source of information for healthcare professional, such to the public.
parents – truly offering as a pharmacist, pharmacy
healthcare on the high street. technician, midwife, health Follow on and toddler/growing
Its combination of accessibility, visitor or doctor, first. up milks are not breast milk
availability and advice puts it in substitutes and can be advertised
a unique position to help parents It is important to remember and promoted to customers.
of young children who will pop that there are restrictions on
in to their local pharmacy for
everything from nappies and
wipes to advice on vaccinations
and everything in between.

It is therefore important that the
whole pharmacy team is well
versed in the baby category, how

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THE PHARMACY GUIDE TO INFANT FEEDING

Pharmacy and TRAINING IS KEY
infant feeding
A pharmacy team that is
There are many reasons why pharmacies should engaged in the baby and infant
engage with the baby category, not least because if care category and confident in
pharmacy teams earn the trust of a parent early on in having customer conversations
their child’s life, they may just gain a customer for life relies on category and clinical
knowledge. Use this guide as
S ome pharmacies are have conversations with parents a basis for the whole team’s
reluctant to take on about common infant feeding learning needs, but check out
infant feeding as a major problems can have a huge impact these other resources too:
category and devote staff time on parents and the wellbeing of • Trade magazines and
and training as well as shelf their children. websites such as Training
space to an area that they feel is Matters (tmmagazine.co.uk)
dominated by the supermarkets. By offering good customer and Pharmacy Magazine
service to a parent, pharmacy (pharmacymagazine.co.uk)
But the baby milks sector is going teams can develop customer • The infant feeding category
from strength to strength. Total loyalty and the pharmacy hub at tmmagazine.co.uk for
sales of baby milks are currently may become the training, articles and sponsored
worth £319.8 million, up 7.6 parent’s­ destination SMA Nutrition content
per cent year on year, and this is for the whole • Aptamil’s CPD programme,
despite the growth of the total family’s healthcare. and website: eln.nutricia.co.uk
baby care category up only one So what have you • SMA’s Pharmacy Champion
per cent year on year to £1.47 got to lose? programme, and website:
billion (according to Kantar smahcp.co.uk.
Worldpanel data, 52 weeks
ending 9 October 2016).

Therefore, pharmacies can use
this category as an opportunity
to create and grow their business
as well as to support parents and
win customers for life.

Customers who come to
the pharmacy for advice and
support on infant feeding will
also purchase other baby care
accessories, says Mandeep
Mudhar, Numark’s director of
marketing. Adding: “Pharmacists
can provide that added element
of advice with a purchase that
the customer can’t get from
a supermarket.” What’s
more, training the whole
pharmacy team to

THE PHARMACY GUIDE TO INFANT FEEDING

3 What are the do’s and don’ts for improving the infant feeding category?
Do:

• Ensure the whole pharmacy team is well-trained and informed about infant feeding
• Advise breastfeeding as a first step
• Offer a friendly ear, advice and support at the point of purchase or when the customer

is browsing

• Link sales across the whole baby and infant care category
• Locate the baby and infant care category in an easily accessible area to allow

parents with pushchairs to access the shelves

• Ensure that merchandising makes it as simple as possible for time-pressed

parents and carers to select products.

✗ 5
Don’t:

• Offer any price promotions, including discounting short-dated products or use point

of sale material or special displays that could be seen to be promoting formula feeding

• Fall foul of the Infant Formula and Follow-on Milk Regulations, which specify

that only pharmacists, pharmacy technicians and other healthcare professionals
can give advice on baby milks.

Case in point

Weldricks, a pharmacy chain in South Yorkshire, What were the results?
conducted a 12-week pilot study with Nutricia
Early Life Nutrition, to improve the success of Compared to five control pharmacies which
baby category sales. did not make any changes to their baby care
marketing or service, the results of the pilot
What did Weldricks do? study showed:

• Pharmacists and pharmacy technicians • A 65 per cent sales uplift in the baby category,

completed an e-learning programme about compared with only seven per cent in the control
infant nutrition and infant feeding problems pharmacies

• Medicines counter assistants received face- • A 79 per cent sales uplift in baby milks,

to-face training to give them the confidence compared with only two per cent in the control
to engage with customers pharmacies

• Improved the display of the baby feeding • A 58 per cent sales uplift in baby accessories

range by separating core milks from specialist compared with 11 per cent in the control group.
milks and placing booklets and flip cards with
information about common feeding problems Commenting on the trial and its results,
on the shelves, signposting customers to ‘Ask the Weldricks superintendent pharmacist Richard
Pharmacist’ for advice Wells said: “Staff are now engaging with
customers and we are seeing some end results.
• Advertised the ‘baby advice service’ in the This is a customer base we might have lost in
the past.”
pharmacy window and in GP surgeries.

5

THE PHARMACY GUIDE TO INFANT FEEDING

Communication skills

It is essential for pharmacy teams to engage with each and every customer, listen
to their needs and recommend an appropriate product, advice or guidance. And
the key to each customer interaction is effective communication

B eing able to commuicate • Facing the customer without summarising what someone
effectively is an essential has said, and checking
skill for everyone in the any barriers such as a counter or both your own and their
pharmacy team. No matter how table in the way understanding during and after
in-depth your understanding of the conversation. Don’t be
medicines, nutrition and health • Smiling rather than frowning tempted to fill every pause in
conditions, the amount of • Maintaining eye contact a conversation, even if it feels
help you are able to provide a • Keeping your arms and legs a little uncomfortable, as these
customer is limited if you don’t gaps in exchanges provide
have good communication skills. relaxed instead of crossing them a good opportunity for the
customer to reflect on what
There is much more to this than • Nodding your head. they have said and heard so
knowing the right words to say; far, which often leads them to
it is about how you say them All of this demonstrates that you add further information or ask
and your body language. are being attentive. questions on anything they are
unsure about.
An open approach usually gets Similarly, adopting a friendly
the best outcome. In body tone of voice and asking open These skills are particularly key
language terms, this means: questions that prompt the when advising new parents who
customer to provide more details may require additional care.
instead of simply answering yes
or no. For example, asking “how
are you currently feeding your
baby?” rather than, “are you
breastfeeding?” is likely to be
more useful.

Active listening techniques
are also a must. These
include reflecting back and

6

THE PHARMACY GUIDE TO INFANT FEEDING

For instance, take the time to too, with some mums feeling the choice of breastfeeding,
consider what their individual pressure and even guilt about expressing breast milk or feeding
needs may be. They may be how they are feeding their baby. formula milk, will depend on
anxious and worried, especially the parent and baby’s individual
as a first-time parent, be Pharmacy teams have an circumstances and needs. The
receiving conflicting advice from important role in providing role of the pharmacy team is
family, friends or websites and reassurance and support to to support parents to make the
forums, and they will most likely parents. It is vital to be non- best choice for them and their
be sleep-deprived. Feeding is a judgemental: there are many baby, without their own beliefs
potentially emotional subject area ways to feed a baby and influencing the decision.

The WWHAM questioning protocol used when selling
medicines can also help you get to grips with an infant feeding
or nutrition problem that a parent or carer is seeking help with:

W ho is the person involved?
For queries of this nature, it will be an infant, but find out how old they are, including
if this is an “adjusted age” because they were born prematurely, as this potentially affects the situation.

W hat are the symptoms?
Sometimes the person talking to you will have identified what the issue is – constipation, for
example – but it doesn’t do any harm to run through any symptoms or signs that have led them to their
conclusion, as it gives you not only assurance that they have got it right, but also an opportunity to
identify any “red flags” that mean a referral to the pharmacist is required.

H ow long has the infant had the symptoms?
Some conditions that can go on for several days without having serious consequences in adults
and even older children can become dangerous very quickly for babies; diarrhoea is a prime example.
Pinpointing when an issue started is a good way of differentiating between situations that need urgent
attention and those that don’t, which in some cases will be because parents or carers are anxious about
something that is self-limiting, for example, colic. When in doubt, always check with the pharmacist.

A ny actions already taken?
Asking what the parent or carer has tried so far is a useful way of establishing other management
options, actions that may have exacerbated the problem as well as whether a referral is required.

M edicines being used or any other medical conditions?
Knowing what products are being used for the baby or what other conditions the baby may
suffer from helps avoid interactions and ingredient duplications, which can lead to an overdose, as
well as pick up on any problems that may have resulted from an adverse drug reaction. It is sensible to
ascertain how much of a medicine is being given and checking this with the pharmacist, as doses for
babies are very easy to get wrong because they are based on weight rather than age.

Support and reassurance

As well as offering advice on feeding issues, baby’s symptoms and making appropriate
recommendations, parents and carers will often be in need of some support and reassurance. Be sure
to listen carefully, empathise with the customer and provide support. This may be in the form of
support groups, signposting to baby and toddler groups, websites or help groups. Remember that
parents will often be sleep deprived, which hinders their ability to cope with new challenges. Simply
taking five minutes to ask how they are could make a difference to their wellbeing.

7

THE PHARMACY GUIDE TO INFANT FEEDING

Behind the
headlines

The health and wellbeing of pregnant women and
babies is never too far from the news and much has
happened in the last 12 months. Here are a few of
the stories that have hit the headlines, with an
explanation of the facts behind them

“Free vitamins for pregnant women in Scotland”

Scotland became the first UK It is hoped that the initiative, taking vitamins during pregnancy
nation to roll out the universal which has widespread support improves both the mother and
provision of free vitamins for among healthcare professionals, baby’s health. By offering them
all pregnant women on 1 April will improve the health of to all pregnant women we can
2017. both mothers and their babies. contribute towards giving every
Scottish public health minister baby a fair and equal chance – a
This means all pregnant women Aileen Campbell confirmed the move that is widely supported
living in Scotland, regardless of development at Edinburgh Royal by healthcare professionals.”
their income, will be entitled to Maternity Hospital and said:
supplements containing folic acid, “We are committed to giving Previously, only pregnant women
vitamin D and vitamin C. These every child in Scotland the very eligible for the Healthy Start
will be available from community best start in life and helping scheme and expectant mothers
pharmacies and dispensing women to enjoy a healthy under the age of 18 were eligible
practices, as well as from some pregnancy is a key part of this. for free vitamins, and this remains
midwives and health visitors. There is strong evidence that the case across the rest of the UK.

“Peanut-based foods in early life prevents allergies”

UK-led research that found regular consumption signs of allergies or eczema, peanuts can be
of peanut-containing foods in early life reduced introduced freely into the diet along with other
the risk of peanut allergy by 81 per cent, has solid foods, without seeking medical advice.
informed the basis of new US guidelines.
The evidence is currently being reviewed by the
These guidelines suggest that if an infant has Department of Health. At the time of printing,
severe eczema or an egg allergy, peanuts may UK guidelines say that if a child has eczema
be introduced at around four to six months, or a food allergy, or there’s a family history of
after seeking medical advice, while waiting allergy, parents should get medical advice before
longer may increase the risk of an allergy giving them peanuts for the first time. If there’s
developing. For infants with mild to moderate no family history of food or other allergies,
eczema, the guidelines recommend that peanuts can be crushed or ground into peanut
peanut-containing foods can be introduced butter and given from the age of six months.
around six months to reduce risk of developing Whole nuts should not be given to children
a peanut allergy, and that for babies with no under five years as they can choke on them.

8

THE PHARMACY GUIDE TO INFANT FEEDING

“Breastfeeding doesn’t boost intelligence”

While breastfeeding is known to protect babies Babies breastfed for up to six months showed
from infection in early life, its long-term impact no significant difference in cognitive abilities
on outcomes such as cognitive ability and or problem behaviours when compared to non-
intelligence is less clear. This was the focus of breastfed babies at ages three or five.
new research published in the March 2017 peer-
reviewed medical journal Pediatrics. Those babies who were exclusively or almost
exclusively breastfed for over six months had
The research concluded that when looking slightly lower hyperactivity levels at age three
at cognitive abilities and problem behaviours (as rated by parents) than those who were
at ages three and five years, breastfeeding never breastfed. This difference was not seen in
was only associated with a small benefit in those who were partially breastfed for this long,
hyperactivity at age three. There were no or by the time the children reached age five.
significant benefits seen in these outcomes at
age five, once the children were at school. An important point to note: the study should
not discourage women from breastfeeding, as
The study followed 8,000 babies in Ireland for the authors themselves note that it does not
five years to look at whether breastfeeding had bring into question the other known benefits
an impact on problem solving and vocabulary of breastfeeding, such as reduced infection
(cognitive abilities), and problem behaviours. rates in babies.

IMPORTANT

Pregnancy and infant feeding are popular
topics in the press and newspapers often use
scaremongering headlines and clickbait tactics,
which can make health stories overwhelming,
not to mention confusing, especially when they
concern babies and young children.

Remember to always check the sources of these
stories so you can separate fact from fiction and
best advise parents and carers.

9

CHAPTER 1 BREASTFEEDING

After reading this
chapter, you will have a
better understanding of:

• The benefits of

breastfeeding

• A mother’s nutritional

needs

• The stages of milk

production

• The typical problems that

mums can encounter while
breastfeeding.

The Department of Breast is best!
Health recommends
exclusive breastfeeding
until a baby is six
months old. Some
mums will need advice
and support when
trying to achieve this

B reast milk is a fantastic in November 2012, revealed were not breastfed beyond three
source of nutrition that while 81 per cent of months of age.
for babies. In fact, new mothers in the UK start
it is undoubtedly the best breastfeeding from the birth of From this data, it can be seen
source available, giving babies their baby (up from 76 per cent that the breastfeeding rates
everything they need for growth in 2005), only 23 per cent of UK could potentially be improved.
and development. Both the mothers are still breastfeeding Support and education for
Department of Health and the exclusively by the time their baby new mothers on the benefits
World Health Organization is six weeks old, and only one per of breastfeeding for both the
recommend exclusive cent manage the recommended child and the mother, and
breastfeeding for the first six six months. What’s more, the encouraging the use of support
months of a baby’s life, yet in the Department of Health’s Diet and networks may help.
UK this only happens in around Nutrition Survey of Infants and
one per cent of babies. Young Children 2011 found Pharmacy teams should be aware
that 22 per cent of children had of the benefits of breastfeeding
The latest Infant Feeding Survey never been breastfed. Of those to help support and encourage
2010, which was published who were breastfed, 57 per cent mums who wish to breastfeed
their babies. It is also important
Approximate % % exclusively to know where to refer
age of baby breastfeeding breastfeeding mums who may need further
support and to be aware of
Birth 81 69 the reasons why some mums
don’t breastfeed, as well as the
Six weeks 55 23 other options that are available,
including combination feeding
Six months 34 1 and bottle feeding.

10

CHAPTER 1 BREASTFEEDING

The benefits of • Contains substances such
breastfeeding
as long chain polyunsaturated
Breastfeeding has many benefits for both mum and fatty acids (LCPs), which have
baby, but what makes it so good? a key role to play in the normal
development of brain, vision and
O ver the years, research an infant’s immature digestive psychomotor functions
has investigated the system
composition of breast • Appears to protect infants
milk and confirmed that it • Changes its composition over
provides babies with perfectly from gastrointestinal infection
balanced nutrition, which is why time to provide the baby with the and reduces the risk of Crohn’s
both the Department of Health nutrients needed for growth disease
and the World Health
Organization (WHO) recommend • Contains antibodies and other • Appears to help prevent babies
exclusive breastfeeding for the
first six months of a baby’s life. immunological factors to protect from developing allergies such as
the infant from infection, which asthma and eczema, as well as
The main benefits of breast- cannot be replicated in infant diabetes in childhood, respiratory
feeding are that breast milk: formula milk tract infections and middle-ear
infections.
• Provides the correct balance • Contains enzymes to aid
In addition, breastfeeding:
of nutrients required for optimal digestion by the baby’s immature
growth and development in a digestive system • Provides close physical contact
form that is readily absorbed by
• Contains less protein and between mother and baby,
strengthening their bond, both
fewer electrolytes than cows’ physically and emotionally
milk, to ensure an excessive
burden is not placed on the • Is convenient – sterile breast
baby’s immature kidneys
milk is always available at the
right temperature with no need
for preparation or storage. It is
also free

• Can use up to 500 calories a

day, if exclusively breastfeeding

• Can reduce the risk of breast

and ovarian cancers.

CHAPTER 1 BREASTFEEDING

First milk and is rich in minerals and • Hind milk, which is produced
vitamins A, D and B12.
First milk (colostrum) is produced towards the end of a feed, is richer
in small volumes in the first few Mature milk in fat and calories to satisfy a baby’s
days after birth. It is yellow in hunger and support healthy
colour and thick and sticky in Colostrum gradually develops growth. It is impossible to tell when
consistency. Colostrum has a into mature milk over a period the composition of a mother’s milk
higher protein content than of about 10 days. Mature milk changes from fore to hind milk, so
mature breast milk, with the is thinner and whiter than first it is important that a baby empties
protein mostly composed of milk. Frequent breastfeeding one breast completely before
antibodies to protect infants from stimulates production of mature moving to the other to ensure the
infection until they can build up milk and helps to prevent breast benefits of both the fore and hind
their own immunity. This is why engorgement. The composition milk are received.
it is important for mothers to of mature milk also changes
start breastfeeding from birth, during a feed: It can take around six weeks
even if it is just for these early to fully establish breastfeeding.
days. Colostrum has a lower fat • Fore milk, which is thin and Frequent feeding is also important
content than mature breast milk to stimulate milk production.
high in volume to satisfy a baby’s
thirst, is produced first

Top tips for mum’s nutrition

A woman needs to look after herself while pregnant and breastfeeding to give her baby the best
possible start in life, and eating a healthy diet really makes a difference; helping her baby to grow
and develop and also keeping her fit and well. Advise women to take/eat:

Vitamin/Mineral Why? Potential sources
400mcg folic acid Supplement
daily when trying May prevent neural tube defects,
to conceive and for such as spina bifida
first 12 weeks of
pregnancy To help regulate calcium and Supplement
10mcg vitamin D phosphorus in the body and to help
provide the baby with vitamin D for Green, leafy vegetables
Iron the first few months of their life Lean red meat
May help prevent anaemia/ Dried fruit
Vitamin C tiredness Supplement if advised by GP/
midwife
Calcium Protect cells and aid absorption of Citrus fruits, broccoli, tomatoes
iron
For the development of baby’s bones Dairy products
and teeth Dried fruit
Green, leafy vegetables

• In addition, a woman’s diet should also provide omega-3 fatty acids (e.g. from oily fish), iodine

(e.g. from fish and grains), vitamin B6 (e.g. from poultry, eggs and vegetables), zinc (e.g. from
meat and dairy products) and riboflavin (e.g. from milk, eggs and rice).
N.B. Pregnant and breastfeeding women should speak to a healthcare professional before taking
any supplements.

12

CHAPTER 1 BREASTFEEDING

Top tips for breastfeeding

Breastfeeding is a skill that needs to be learned and it can take time and practice to get the hang
of it. Offer mums these tips to help:

• Feeds can vary in length, so ensure you are comfortable before starting to feed
• Wear a supportive, front-opening bra with breast pads in case of leakage
• Breast milk is around 87 per cent water, so ensure you drink at least six to eight glasses of fluid

every day

• Try to rest and take a nap when your baby does
• Talk to a healthcare professional if you have any concerns about your baby and feeding
• If you are experiencing problems, speak to a breastfeeding counsellor or join a breastfeeding

support group (see website details below).

Why some mums USEFUL WEBSITES
don’t breastfeed
• Breastfeeding network:
U nfortunately, some mums there will be some mums who will
cannot – or choose not just not want to breastfeed or breastfeedingnetwork.org.uk
to – breastfeed. who find it too difficult.
Circumstances when a mum may • NHS UK: nhs.uk/start4life/
not breastfeed include if she: Reasons for stopping
breastfeeding and nhs.uk/
• Is being treated with drugs Many mums start breastfeeding conditions/pregnancy-and-baby
after their baby’s birth and then
which are secreted in breast milk stop either days or weeks later. • Association of
(e.g. anticoagulants, narcotics, Some of the reasons for stopping
anticonvulsants, barbiturates or breastfeeding include: Breastfeeding Mothers:
steroids) abm.me.uk
• Not producing enough milk
• Has the human • National Childbirth Trust:
or the milk taking too long to
immunodeficiency virus (HIV) ‘come in’: babies may not be nct.org.uk
satisfied after breastfeeding,
• Is taking antiretroviral especially if the mature milk • La Leche League:
is delayed
medication laleche.org.uk
• Illness: if the mum has an
• Has untreated, active
underlying illness or had a
tuberculosis difficult birth, it can make
it hard to establish
• Is infected with human T-cell breastfeeding

lymphotropic virus type I or type II • Returning to work:

• Is using or is dependent upon this can prevent
breastfeeding
an illicit drug during the day
(unless mum
• Is taking prescribed cancer expresses
milk).
chemotherapy agents (e.g.
antimetabolites) that interfere with
DNA replication and cell division

• Is undergoing radiation therapy.

Some mothers cannot breastfeed
because of physiological problems
that cannot be overcome, while
others don’t wish to breastfeed for
religious or cultural reasons. Plus,

CHAPTER 1 BREASTFEEDING

Common breastfeeding problems

The success of breastfeeding Advise mum to feed her baby as speed up recovery. Mums
often lies in how the baby regularly as she can and suggest can also be advised to:
latches on to the mum’s breast. she expresses some milk before
If a mum is experiencing pain a feed. Mum should also check • Check the attachment of
or discomfort, there may be the fitting of her bra to ensure
latching issues. Health visitors, it is not too tight. baby at the breast
support groups and local
breastfeeding counsellors may Hard or lumpy breasts • Feed baby more often
be able to help. There is also • Let baby feed on the tender
a video on NHS Choices: nhs. Blocked milk ducts can cause
uk/conditions/pregnancy-and- a mother’s breasts to become breast first
baby/pages/breastfeeding- hard or lumpy, also known as
positioning-attachment.aspx. engorgement. • Hand express some milk to

Painful/cracked nipples This needs to be treated quickly relieve the fullness
by draining the breast (by
Some breastfeeding mums may feeding or expressing milk). • Place warm flannels on the
find that their nipples become A mum should feed her baby
sore and painful while they ‘on demand’ and try to massage breast or have a bath or shower
are feeding their baby. If this the lumps towards the nipple before a feed
happens, firstly advise mum to during feeds. She can also
take the baby off the breast massage the lumps while in • Gently stroke the lumpy or
and start again. Putting up the shower and should ensure
with the pain can make things underwear is not pressing into tender area towards the nipple
worse. Advise mum to check the breast. A warm flannel can when baby is feeding to help
that her baby is in the correct also be applied to the breasts the milk flow
position to latch on properly. to soften the lumps.
• Get as much rest as possible
Other tips include drying the Mums may also need to be • If possible, take a painkiller
nipples carefully after feeding shown feeding positions that
and keeping a dry breast pad empty different parts of the such as paracetamol or
in place until the next feed. breast – suggest they contact a ibuprofen.
Creams and ointments that are breastfeeding counsellor, who If there is no improvement
applied to the nipples between will be able to help with this. within 12-24 hours, or
feeds (e.g. chamomile ointment symptoms get worse, mums
or lanolin) and heated or Mastitis may need to see a GP for a
chilled gel pads can offer relief. course of antibiotics.
Nipple shields or protectors can If a mum has painful, red or
be used during feeds to prevent swollen breasts along with flu- Thrush infection
sore nipples becoming worse. like symptoms (e.g. fever or
aches), she may have mastitis Sometimes, if nipples are sore/
Sore breasts (inflammation of the breast). cracked, they may become
This condition can lead to an infected with the Candida
If a mum is producing more infection. Mastitis can occur fungus. Symptoms include
milk than her baby needs, her two to four weeks after giving severe pain in both breasts/
breasts can become tender and birth, and affects one in 10 nipples after feeding (when it
feel heavy. An over-supply of breastfeeding women. was previously pain free). This
milk can also occur if baby is not pain may last after feeding.
well attached (making it hard Mastitis can happen suddenly The baby may also become
to take the milk), if the breast is and get worse very quickly. It’s affected, with white patches in
not fully drained during a feed, important for mum to carry on the mouth or a nappy rash that
or if a feed is missed. breastfeeding, as this helps to won’t clear up. Treatment might
be with antifungal liquid/gel
for the baby, and an antifungal
cream for the mother.

Some of these difficulties can
be overcome with help and
support. Mums should be
encouraged to breastfeed for
as long as possible. Information,
advice and support are
available (see useful websites
on page 13).

14

CHAPTER 1 BREASTFEEDING

Combination feeding

S ome parents may wish method. It can also be used if milk at the right time. When
to feed their baby using a mother wishes to move away switching feeds, mums should
a combination of from exclusive breastfeeding and give their bodies time to adjust.
breastfeeding and bottle can be beneficial in providing a
feeding – using either expressed smooth transition from breast to The challenge for combination
breast milk or infant formula bottle feeding. feeding is to minimise any risk
milk. Also referred to as mixed to breastfeeding, as it will reduce
feeding, combination feeding How can it be introduced? the amount of breast milk that is
can be particularly useful if produced. This effect can be
mums are returning to work or Mothers can introduce their minimised if feeds are gradually
to enable someone other than babies to bottles via expressed changed.
mum (e.g. the father or a family breast milk before trying infant
member) to feed the baby. formula milk. If the baby is under The best chance of preserving
N.B. Mothers who are six months old then a first stage and increasing breast milk is
considering trying this should formula should be used. A bottle achieved by always offering the
discuss it with their health visitor feed should initially be given at breast first, when possible, and
or GP first. the same time each day. A not increasing the amount of
gradual transition to combination formula. Giving the baby infant
When can it be used? feeding will help reduce the risk formula milk alerts mum’s body
of the mother’s breasts becoming to produce less breast milk so
Combination feeding can be engorged and painful. mum must be sure to maintain
introduced when breastfeeding all other breastfeeds. It can be
is well established (usually around Mums should work out when a difficult and time-consuming
six weeks) to reduce the chance they’d like to breastfeed and process to reverse and to re-
of the baby preferring the when they’d like to use a bottle establish a milk supply adequate
sensation of bottle feeding, so that their bodies get used to enough to breastfeed exclusively.
which requires a different sucking producing the right amount of

Top tips for combination feeding

Some breastfed babies are reluctant to switch
to bottles at first. Parents can try:

• Different types of teats
• Holding the baby in a different position to that

used when breastfeeding

• Letting someone other than the mother give the

bottle to the baby.

CHAPTER 1 BREASTFEEDING

Ask the experts i

Breastfeeding is a complex and emotional subject. While mums will be able
to seek advice from their midwife, health visitor and GP, they will also often
turn to their local pharmacy. So what answers do the infant feeding experts
have for some of the common questions?

Q How does a mum know if her baby Q Does a woman need to eat
is getting enough milk? any special foods when she
is breastfeeding?
A Tanya Thomas BSc (Hons) RD, freelance
paediatric dietitian, says: “There are a A “Breastfeeding mothers do not need to
number of ways you can tell: eat any special foods but should aim to
eat a healthy, balanced diet including starchy
• The infant is thriving and gaining weight foods, protein rich foods, plenty of fruit and
vegetables and dairy products on a daily basis,”
(this may be a little slower than in bottle-fed explains Tanya. “The Government recommends
infants) that breastfeeding mums take a 10mcg
supplement of vitamin D per day and other
• The infant is having wet nappies (at least nutrients should be provided by a healthy diet.”

six per day) and passing stools regularly Dr Emma Derbyshire, independent nutrition
consultant and founder of Nutritional Insight
• The breasts feel softer after feeding Ltd, says: “It is important to be adequately
• Infant is happy and contented post feeds. hydrated. The European Food Standards Agency
advise women of childbearing age to aim for
“If the infant is not getting sufficient breast two litres of fluids per day (from foods and
milk then mum should be supported in her drinks) and that breastfeeding women drink an
decision to continue breastfeeding and not extra 700ml, or three to four glasses, on top of
be pushed to top up with bottle feeds, as this. This is due to women producing about 740-
this disrupts the supply and demand feeding 850ml breast milk per day, of which 88 per cent
cycle, diminishing breast milk production and is water.”
exacerbating the situation. Infants should be
put to the breast regularly to encourage milk
production.”

Q Can a woman breastfeed in
public?

A “Yes, the Equality Act 2010 has made it
illegal for anyone to ask a breastfeeding
woman to leave a public place such as a café,
shop or public transport,” says Tanya. “Some
women feel confident feeding in public but
others feel very self-conscious. It is possible
to breastfeed very discreetly in public. Some
women find it easier to use a breastfeeding top,
sling or scarf. Breastfeeding mothers need not
feel they need to feed in public toilets. Many
shops and venues now display the fact that they
are breastfeeding-friendly.”

16

CHAPTER 1 BREASTFEEDING

Key ingredients of breast
and infant formula milk

Fats

Due to their fast growth rate, babies require three to four times more energy per kilogramme of
body weight than adults. Fat contains a lot of calories and is a very concentrated source of energy,
accounting for half the energy content of breast milk. This high energy density is important because
babies have a limited stomach capacity. Fat also acts as the carrier for the fat-soluble vitamins A, D,
E and K. Breast milk and most infant formula milks also contain essential fatty acids and long chain
polyunsaturated fatty acids (LCPs), including arachidonic acid (AA) and docasahexaenoic acid (DHA).

Carbohydrates

The main carbohydrate is lactose, a natural milk sugar that provides 40 per cent of the energy content
of breast milk. Breast and infant formula milks also contain oligosaccharides, a type of carbohydrate
consisting of linked sugar units. Also included are fructo-oligosaccharides and galacto-oligosaccharides.

Proteins

Protein is required for growth as well as the maintenance of muscles and bones. There are two
main proteins: casein and whey, which occur in breast milk in a ratio of 40:60.

• Whey protein forms a soft curd which is easily digested. In breast milk, whey protein also

contains other important proteins: lactoferrin, lysozyme, alpha-lactalbumin, and immunoglobulins

• Casein protein has coagulating properties, so forms a firmer curd that may take longer to digest.

Vitamins

• Vitamin A: contributes to the normal function of the immune system, maintenance of normal
vision and skin, and helps the body metabolise iron

• Vitamin D: needed for calcium absorption, vitamin D contributes to the normal function of the
immune system and helps maintain normal teeth, muscle function and bones
••• VVViiitttaaammmiiinnn
E: helps to protect cells from oxidative stress and nervous systems. Increases
K: helps maintain normal bones and blood clotting
C: contributes to the normal function of the immune

iron absorption

• B vitamins: are important for energy metabolism.

Minerals

• Calcium: is needed for the maintenance of normal bones and teeth, and contributes to normal
blood clotting and muscle function
•• ZPhinocs:pchoonrturisb:uctoensttroibnuoterms taol
the maintenance of normal bones and teeth and vitamin A,
cognitive function, the metabolism of fatty acids

and the maintenance of normal bones, vision and immunity

••• SIIoreodlnein:neciuo: mnist:irmipbrpuootteretscattnsotcnefoollrrsmgfrraoolmwcotoghxnaidintaidvteinvfeourdnmacamtiloacngo.egnitive function
The iron content of breast milk is low as babies are generally able to rely on their own stores until

four to six months of age. At this age, babies need a dietary source of iron. Iron is more efficiently

absorbed from breast milk than infant formula milk, which is why infant formula milk contains

higher levels.

17

LOOK OUT FOR MORE
INFANT FEEDING
TRAINING MODULES
ONLINE

tmAvailable at
training matters

www.tmmagazine.co.uk

THE MAGAZINE FOR PROFESSIONAL ASSISTANTS

The modules will also be available within the following learning systems: NPA CPD Hub;
Numark Training; Avicenna Academy Plus; Sigma Advantage Academy; BPSA EduZone;
Celesio myLearn Plus; Boots Unscripted Learning Extra and the Day Lewis Academy Plus.

Communications THE PHARMACY
International NETWORK
Group
A COMMUNICATIONS INTERNATIONAL GROUP INITIATIVE

CHAPTER 2 EQUIPMENT

Feeding equipment
and sterilisation

The vast array of feeding equipment and guidelines for expressing breast milk
and preparing bottle feeds can make this category confusing for parents,
but getting it right can save them time and trouble in the long run

After reading this
chapter, you will have a
better understanding of:

• The equipment that

is required for bottle
feeding and expressing
breast milk

• The different methods

of sterilising feeding
equipment

• The importance of

storing formula and
expressed breast
milk correctly.

Avariety of equipment is colic bottles have air vents, tubes There is no evidence to suggest
needed to bottle feed or collapsible bags to prevent the that one is better than another –
a baby. Requirements build up of a vacuum inside the the choice is the baby’s. The flow
will vary depending on whether bottle during feeding. Disposable rate is determined by the hole(s)
the mother is feeding expressed bottles are sterile, but single-use. in the top of the teat:
breast milk, formula milk or if
she is combination feeding. Types of teat • Slow: suitable for newborns
• Medium: suitable for babies
Bottles are required for feeding Bottle teats can be wide, flat
a baby expressed breast milk or or shaped to mimic a mother’s from three to six months
formula milk. Most bottles hold nipple when in the baby’s mouth.
around 260ml (9oz), although In addition, there are specialist • Fast: suitable for babies from
smaller bottles are available (from teats, including:
60ml up to 125ml/4oz), which six months
are more suitable for pre-term • Anti-colic teats: these help
babies and newborns. Bottles are • Variable: the flow adjusts to
available in standard, wide and reduce the amount of air a baby
super-wide neck widths. Anti- swallows the baby’s sucking action and
is also suitable for thicker or
• Orthodontic teats: designed specialist feeds.

to minimise harm to developing Parents should check that the
teeth. milk comes out of the bottle at
the right speed for their baby.

19

CHAPTER 2 EQUIPMENT

Different types of breast pump

Mums may express breast milk for many reasons:
• To boost milk supply
• To enable them to go back to work
• If the baby isn’t feeding well
• To enable a partner or relative to give a feed.

There are three types of breast pump available:

• Manual – the suction cup is placed over the

nipple and the pump manually squeezed to extract
milk. These pumps are inexpensive to buy and cost
nothing to run. They are easy to use, quiet and put
the mum in complete control during use. However,
some mums find it hard to maintain suction while
holding and pumping, and find that their hand can
begin to ache

• Battery-operated – these are easy to use as

the machine does the hard work of extracting the
milk. However, they can be costly because mums
need to replace the batteries frequently and the
pump doesn’t work as well when batteries are
running low

• Electric – these are easy to use, quick and have

a constant power supply, which makes them good
for mums who are expressing frequently. However,
they can be quite noisy, depending on the model,
and are the most expensive to buy.

To help mums decide which type of pump is right
for them, ask them how often they are going to
be expressing milk and what their budget is. Breast
pumps can be hired so that mums can try them
out before buying their own. Suggest they contact
the National Childbirth Trust (nct.org.uk) or the
postnatal ward at their local hospital.

Too big? N.B. Some teats have multiple RESEARCH ACTIVITY
holes rather than just one large
If the hole in the teat is too or small hole. Take a look at the products in
big for the baby, the milk will your pharmacy and identify
come out too quickly, which may Wear and tear the different types of infant
cause the baby to ‘gulp’ the milk. feeding equipment. Here are a
Gulping milk can lead to choking Teats do wear out over time, few examples to start you off:
and difficulty feeding. so they should be checked
regularly for wear and tear • Bottles and teats
Too small? and replaced as necessary. • Storage bags for expressed

On the other hand, if the hole in Silicone or latex? breast milk
the teat is too small, the baby will
have to work very hard to get the Silicone teats are more durable, • Sterilising methods
milk and as such may become but latex teats are softer. • Machines to make up bottles
tired, irritable, full of wind and Obviously, they are not suitable • Bottle warmers.
still hungry. for babies with a latex allergy.

20

CHAPTER 2 EQUIPMENT

How to prepare
a bottle feed

To help protect babies from infection, knowing
how to make up feeds and sterilise equipment
correctly is essential

I t is important to remember poured into a bottle BOTTLE FEEDING
that powdered infant formula CHECKLIST
milk is not a sterile product. • The scoop provided with the
Correct preparation and handling Parents will need the
is therefore vital to reduce the infant formula milk should be following equipment,
risk of serious illness in babies. used to add the powder to the whether they are bottle
Each feed should be made up as water, levelling off each scoop feeding with infant formula
it is required. Storing pre-made with a leveller (provided in the or expressed breast milk:
infant formula milk may increase pack) or with the straight edge
the chance of a baby becoming of a clean, dry knife. The powder • At least three to four
ill and should be avoided. should not be ‘packed down’
into the scoop bottles with teats and caps
Clear instructions can be found
on infant formula milks, so take • The teat should be placed • A bottle and teat brush
time to familiarise yourself with • Sterilising equipment
the steps. Key points include: back onto the bottle, covered • Teat tongs.
and shaken gently to dissolve
• All equipment (e.g. bottles, the powder. The bottle can be Sterilising
held under cold water until it is
teats, caps, tongs) should be lukewarm before offering to the Babies are most vulnerable to
sterilised, surfaces cleaned and baby. Shaking a few drops onto infections during their first year
hands washed the inside of the wrist will test of life and as milk provides a
the temperature perfect medium for the growth
• Freshly run tap water should of bacteria, it is essential that
• Any remaining milk should be bottle feeding equipment is
be boiled in a kettle and allowed sterilised for the first year.
to cool to no less than 70ºC to thrown away when the baby has
kill any bacteria present in the finished feeding and within two Before sterilising, all equipment
powdered formula, which means hours of being made up. should be washed in a dishwasher
leaving the water for no more or in hot, soapy water, with
than 30 minutes, on average, N.B. Ordinary tap water is best. bottles scrubbed inside and out
after boiling. It is important that Artificially softened, filtered and with a bottle brush. Teats should
the water is still hot, otherwise repeatedly boiled water should be scrubbed and cleaned with
any bacteria present in the milk not be used to make feeds, as a teat brush and water squirted
powder may not be destroyed. mineral levels may be too high. through them to remove all
N.B. The required temperature When using still, bottled water, traces of milk. For mums who
for some specialist milks will vary the sodium level needs to be less are expressing breast milk, the
– always check the pack first than 200mg per litre and the parts of the breast pump that
fluoride level less than 1.5mg per come into contact with milk
• The instructions on the pack litre. Water or formula powder (e.g. suction cup) will also need
should not be added to make a to be sterilised before use. All
should be read by parents to find feed stronger or weaker unless equipment should then be rinsed
out the amount of water that advised to do so by a healthcare in water before sterilising.
is needed per feed; the correct professional. Food should never
amount of water should be be added to a baby’s bottle.

21

CHAPTER 2 EQUIPMENT

IMPORTANT it is totally submerged and there amount of water to the steriliser.
are no trapped air bubbles.
If sterilised bottles are not 2 Ensure that all of the bottle
being used immediately, they 3 Replace the lid and leave for and teat openings are facing
should be fully assembled at least 30 minutes (or as per downwards in the steriliser so
and used within 24 hours the manufacturer’s instructions). that they do not fill with water.
to prevent contamination.
4 Rinse items with cooled, 3 Replace the lid.
Sterilisation methods boiled water before use, 4 For electric steam sterilisers,
if necessary.
There are three main methods simply switch on. For
of sterilising: cold water, electric 5 Change the sterilising solution microwave sterilisers, place in
steam and microwave. every 24 hours. the microwave using the correct
power setting for the required
Cold water sterilising Electric steam/microwave amount of time.
sterilising
1 Following the manufacturer’s These are the fastest methods of 5 Allow the contents to cool
instructions, fill the steriliser sterilising and require no tablets, slightly before opening the
with water and add the sterilising liquid or rinsing of items. They lid. Refer to the manufacturer’s
liquid or tablets. are more expensive to buy and guidelines to see how long
may require regular de-scaling. equipment will be sterile for.
2 Completely immerse the Some microwave sterilisers don’t
equipment in the steriliser hold as many bottles as electric 6 Steam sterilisers need
using the float tray to ensure versions. de-scaling, on average, once a
month, depending on the hardness
1 Following the manufacturer’s of the water. Microwave sterilisers
instructions, add the required may require occasional de-scaling.

STEAM STERILISING: AN EXAMPLE OF ON-PACK INSTRUCTIONS

1 Wash hands thoroughly and wash the feeding equipment in hot,
soapy water. Scrub the insides and outsides of the bottles using
a bottle brush. Scrub the teats with a teat brush and squirt water
through them to help remove all traces of milk. Rinse all equipment
thoroughly under the tap.

2 Add the required amount of water to the steriliser (see
manufacturer’s instructions).

3 Load the steriliser with the equipment, including the teat tongs (making
sure that no items are facing upwards/able to fill with water). Put the lid
on the steriliser and either switch it on or put it in the microwave on the
required power and time setting (see manufacturer’s instructions).

4 When it has finished, the steriliser will usually turn itself off. Keep the
lid on the steriliser and allow the contents to cool slightly before
opening.

5 Always assemble the bottles using the sterilised teat tongs to avoid
contaminating the sterile equipment. If not being used immediately,
bottles should be fully assembled with teats and lids in place. Use bottles
within 24 hours (see manufacturer’s instructions, as this may vary).

22

CHAPTER 2 EQUIPMENT

Storage of feeds

Feeds should be made up as
required, but when travelling
or going out for the day,
this isn’t always possible

S toring prepared feeds for STORING PREPARED BOTTLE FEEDS
any length of time, even
in a refrigerator, increases
the risk of bacterial growth. This
is why it is now recommended
that feeds are made up as
required and not in batches.
So what should parents do
if this is not possible?

One option could be to use •• IIff stored at room temperature – use within two hours hours.
cartons or bottles of ready-to-use stored in a cool bag with an ice-pack – use within four
milk, as these are sterile and

convenient to use when out and

about. Parents may also need this will keep it above the for up to five days (at below 4°C),

sterilised bottles and clean required 70°C for several hours. in the freezer compartment of a

scissors to open the packs. It is not recommended to store fridge for up to two weeks, or in

prepared feeds in the fridge. a freezer for up to six months.

To prepare feeds when not at Prepared bottles should be used Breast milk should be refrigerated

home, parents should: as soon as possible. or frozen as soon as possible
after expressing. Frozen breast
• Place freshly boiled water into
a clean, sealed vacuum flask kept Any chilled feeds that are milk should be defrosted in the

solely for this purpose. This can transported in a cool bag with fridge or lukewarm water and

then be used to make up a fresh a frozen ice-pack should be used used straight away. Once it has

feed when needed within four hours. been defrosted and warmed, it
should be used immediately and
• Ensure that any bottles they
are taking with them are N.B. It is always safer to any leftovers thrown away, and

sterilised and will make up a fresh feed never re-frozen.

remain sterilised for “Breast milk whenever possible. Warming feeds
a suitable length should be
of time refrigerated or Storing When warming up feeds, parents
frozen as soon as expressed should be advised to use a bottle
• Measure the possible after breast milk warmer or container of warm
expressing” water – never a microwave. After
appropriate Breast milk should warming, the feed should be
number of scoops be expressed into a
of formula for each

feed into a sterile, sterilised bottle or shaken to remove any hot spots

air-tight container specially designed and the temperature of the milk
breast milk freezer bag or should be tested before giving to
• Prepare each feed
in a separate bottle. container that can be labelled, a baby. Warmed feeds should be

dated, sealed and stored. Breast used immediately and any

N.B. It is important to use a flask milk can be stored in the coolest unused milk should be discarded

to transport the boiled water, as part of a fridge (usually the back) within two hours.

23

CHAPTER 2 EQUIPMENT

Ask the experts i

Feeding equipment throws up a whole raft of queries and potential
problems. Here’s what the experts advise for some of the more
common questions

Q Why is it so important to follow good a hole that is too small, or the teat may collapse
hygiene practices when preparing if they seem impatient as they feed.
bottle feeds? “The teat sizes are:

A “Manufactured baby milks can sometimes • Slow – suitable for newborns
still contain bacteria that can multiply very • Medium – suitable for babies aged three
quickly in bottle feeds, particularly at room
temperature,” says Tanya Thomas, BSc (Hons) to six months
RD freelance paediatric dietitian. “An infant’s
immune system is not fully developed, so they • Fast – suitable for babies from six months
can pick up infections and get diarrhoea if • Variflow – the flow adjusts to the
feeding bottles and equipment are not sterilised
properly. Ideally feeds should be made up one baby’s sucking action and is suitable for
at a time as bacteria can still grow in bottles thickened feeds.”
kept in the fridge (although more slowly).
Water used to make up feeds should be Q What are the do’s and don’ts of
boiled tap water left to cool for no longer storing prepared bottle feeds?
than 30 minutes.”
A Tanya says: “Ideally, bottle feeds should be
Q There are several different types made up and used within two hours, but
of teats. How can I help a mother this is not always possible. If the feeds need to
decide which one is right for her baby? be stored they should be cooled quickly and
refrigerated at below 5˚C. Any feed not used
A “There is no evidence that one type of teat within 24 hours should be discarded. When
is preferable to another,” explains Tanya. reheating feeds, they should not be heated for
“Teats are made from either silicone or latex longer than 15 minutes, and never reheated
and babies tend to prefer one or the other. more than once.”
Latex teats tend to be softer and more flexible
while silicone teats may be more durable. The “Ready-made
flow rate of the feed depends on the number formula milk can be
of holes in the teat. The type of teat may need used if preferred,”
to be changed to suit individual infants. Infants Vicky adds.
may have to try more than one teat before “Cartons of opened
choosing the most appropriate.” but unused ready-
made formula
Boots UK nutritionist Vicky Pennington advises: milk can be stored
“Teat flow is very important when bottles are at the back of
first introduced. Parents should let babies guide the fridge (not in
them when it’s time to move to the next flow the door) for up
rate. For example, they may fall asleep with the to 24-48 hours at a
bottle if it’s too tiring to get their feed through temperature below
5˚C, depending on
the product.”

24

CHAPTER 2 EQUIPMENT

Training & CPD REFLECT

The following practice points and questions can be EVALUATE CCYPCDLE PLAN
used by individual members of the pharmacy team
and/or by the pharmacist for team training ACT

Practice points To help improve the advice that 2 Making up infant
you offer, take some time to formula milk correctly
1 A new mum asks for think about what is involved in is very important. But
your advice. She has either leaving a baby in someone exhaustion or a crying, fretful
been at home for the else’s care or taking a baby baby can make parents rush
first few days since giving outside of the home. and perhaps not take their
birth to her son, but wants time to follow the instructions
to take the baby out on a day Consider the following: as carefully as they should,
trip next week. What does which is important for the
she do about feeding him? • What concerns do you think wellbeing of both the baby
and the family.
You are likely to meet parents parents may have about feeding
who have such issues in the their baby themselves? If you have the opportunity, talk to
pharmacy. As well as days out a parent who is starting to bottle
and holidays, a significant • What concerns do you think feed their baby. Choose one infant
number of mums work outside formula, read the instructions and
of the home and need to entrust parents will have about feeding discuss in your team why these
the care, including the feeding, their baby when they are away must be followed. Think about:
of their baby to other people. from home?
• Why it is important not to add
• What advice would you Draw up a list of possible
concerns. This could include: more or less infant formula to
give to this customer if she a bottle than stated on the
is breastfeeding? • Making up feeds and how product’s instructions

• What advice would you give long to keep them for • Why it is important to boil the

to this customer if she is • How many bottles will be water used to make the feed
bottle feeding?
needed for a day-long outing? • Why it is important to use

• How can feeding equipment the feed at the appropriate
temperature.
be sterilised on a camping trip?
Parents may be encouraged
• How to express breast milk to follow instructions on infant
formula packs more accurately if
– what is the best breast pump they understand the reasons why.
and how should milk be stored? Do you feel confident in your
own understanding? Can you
• How to give sensible explain not only how to make up
an infant formula feed, but why
instructions to a carer without it is so important to follow the
appearing over-anxious pack instructions?

• How to avoid Look out for a parent who wants
to buy formula milk for the first
transmitting anxiety time. Take time to go through
to the baby when an the instructions with him or her.
unfamiliar routine is What may seem obvious to you
planned. may not be to a new parent.

Consider how you would
address these issues with
a customer in the pharmacy.
Consider developing a
checklist of feeding equipment
that parents would need to take
on holiday. Keep this in the
pharmacy for the whole team
to refer to.

25

CHAPTER 2 EQUIPMENT

YOUR CPD Multiple choice questions

Pharmacists and technicians 1. W hich of the following statements about the water used
– don’t forget to record your to make up formula feeds is TRUE?
CPD at: uptodate.org.uk
a. The water should be 100ºC when the powdered formula n
Reflection is added n
n
• What did you want b. Use freshly boiled water within two hours
to learn c. Bottled water is best for making up formula feeds n
• What other resources d. Freshly boiled water that has been kept in a clean
have you used?
vacuum flask can be used to prepare feeds when away
Planning from home

• Why is this learning 2. In relation to preparing and storing milk, which statement
important to you/your is FALSE?
team?
• When will the team a. Expressed breast milk can be stored for up to five days n
receive any further in a fridge, at a temperature of 4ºC
training? n
b. Cartons of ready-made milk must be heated to 70ºC, n
Action then cooled
n
• Take time to discuss the c. Feeds should not be warmed in a microwave
range of baby products d. Prepared feeds that are chilled can be transported in
with the team
• Complete the learning a cool bag, with ice packs, and used within four hours
• Set up signposting
information for
breastfeeding support 3. Electric breast pumps are: n
in your local area. n
a. Cheap to buy n
Evaluation b. Good for mums who are expressing frequently n
c. Quiet
• Make notes on when d. Powered by batteries
you have applied your
learning and the outcomes 4. W hich of the following is not a suitable way to sterilise
that occurred for your baby feeding equipment?
customers and the
pharmacy. a. Using cold water and sterilising tablets n
b. Using the hot cycle of the dishwasher n
c. Using a microwave steriliser n
d. Immersing items in cold water for at least 10 minutes n

Want to complete 5. W hich of the following n
this test online? should be considered when n
Visit: tmmagazine.co.uk choosing a bottle teat?
n
a. The baby’s age n
b. What the teat is made of
c. Whether the baby is

affected by colic
d. All of the above

26

CHAPTER 3 0-6 MONTHS

Babies aged After reading this chapter,
0-6 months you will have a better
understanding of:
When breast milk isn’t an option and cows’ milk isn’t
suitable, infant formula milk is the only accepted • Infant formula milks
substitute for babies aged 0-6 months
for babies aged 0-6 months

• Advice for parents on

feeding and winding

• When babies should begin

the weaning process.

B reast milk is the gold • Increasing the lactose content cows’ milk for an infant’s
standard for babies up immature kidney function
to six months of age, but by altering the carbohydrate
infant formula milk does have an concentration • Adding vitamins, minerals
important role to play when a
mother cannot or chooses not • Removing the fat from cows’ and other key ingredients (e.g.
to breastfeed or to rely on nucleotides, alpha-lactalbumin,
breastfeeding entirely. Cows’ milk and adding vegetable oils to long chain polyunsaturated fatty
milk (as a drink) is not increase the absorption of acids (LCPs) and oligosaccharides
recommended for babies under essential fatty acids such as FOS and GOS).
12 months, so infant formula
milk is the only accepted breast • Reducing the sodium (salt) Whole goat milk formula is also
milk substitute. Infant formula available as an alternative to
milk is based on cows’ milk, but content as this is too high in cows’ milk formula, following the
has been modified to make it European Food Standards Agency
nutritionally appropriate. (EFSA) scientific opinion. This
Modifications include: concluded that the growth and
nutritional outcomes provided by
• Altering the whey:casein whole goat milk formula did not
differ from those provided by a
ratio to be closer to mature
breast milk. Note: this will standard whey-based cows’
be different in milks for milk formula. This led to an
hungrier babies amendment of the infant
formula and follow on formula
regulations.

“Babies
undergo a rapid
growth phase during
the first six months
of life, with healthy
babies usually
doubling their

birthweight”

27

CHAPTER 3 0-6 MONTHS

Goat milk formula has a secretion Even today, we are still unable from day to day and week to
process and casein profile similar to replicate certain substances week. Advise parents to let their
to breast milk; is based on whole found in breast milk (e.g. babies be the guide as to how
milk so is less processed and is hormones, antibodies and hungry they are by looking out
easily digested, and there is no enzymes), but research continues for these signs:
need to add whey proteins. to try to identify their role in the
hope that they can be included in • When the baby has had
It may be used as an alternative all infant formula milks.
for babies with minor feeding enough, they will fall asleep
issues who are not settling on Appetite or let go of the teat
cows’ milk formula, but it is not
suitable for cows’ milk protein Babies are not all the same and • If a baby doesn’t want to finish
allergy, unless directed by a appetites will vary even among
healthcare professional. those of the same weight or age. a feed, don’t force them
A baby’s appetite will also vary
• If they are still awake and

interested in the bottle when the
feed is finished, they probably
need larger feeds.

Top tips for bottle feeding

• Feed the baby in a calm, relaxed atmosphere that is at a comfortable temperature
• Hold the baby fairly upright with his/her head supported so that he/she can breathe and swallow

easily and comfortably

• Make eye contact, chat and smile at the baby during a feed as this makes it more enjoyable for

the baby and encourages successful bonding

• Keep the teat full of milk at all times so that the baby is not taking in air
• As with breastfeeding, swap sides halfway through the feed. This helps the baby’s eyes and neck

to develop equally and also means that they won’t develop a ‘favourite’ side

• If the baby becomes unsettled during a feed then they may have wind – see page 29 for different

winding positions

• For mums who have had a caesarean, holding their babies under their arms or in a ‘rugby ball’ hold

can be more comfortable. A pillow across the lap can also help to support the baby

• Don’t lay the baby flat on his/her back as this can allow milk to flow into the nose or Eustachian

tube, leading to ear infections. Babies should also not be fed while propped up in a chair with
cushions or pillows.

Example on-pack feeding guide*

Each infant formula milk comes with guidelines on how much to give based on the age/weight of the baby.
The following table provides a general guide, but it should be noted that it does NOT apply to premature
babies or babies with a low birthweight.

Approximate weight Amount Feeds in 24
Approxi mate age of baby of milk hours
of baby
kg lb ml fl.oz 6
Birth-2 weeks 6
2-4 weeks 3.5 7.75 90 3 5
2 months 5
4 months 4.2 9.25 120 4 4
6 months
4.7 10.25 150 5

6.5 14.25 210 7

7.5 16.5 240 8

N.B. This table is only a guide – babies may need more or less than the amounts stated and should be fed
on demand. Newborn babies may only take small amounts of infant formula to start with.

*Powder weights vary by brand, so 28
always check the instructions on-pack.

CHAPTER 3 0-6 MONTHS

Winding after feeding THE HEALTHY START SCHEME

Some babies are not troubled Healthy Start is a Government scheme that provides weekly
by wind, while others suffer vouchers to eligible parents with children up to four years of
after every feed. The aim of age for infant formula milk suitable for babies from birth, cows’
winding babies is to remove air milk, or fresh or frozen fruit and vegetables. Follow-on milk, soya
from their stomachs because air formula and ready-made weaning foods are not included in the
can make them uncomfortable scheme. All pregnant women under 18 years of age qualify, along
and stop them settling. Babies with pregnant women or families with children under the age
can swallow air when they of four who are on certain benefits. Further information can be
drink, especially from a bottle, found at: healthystart.nhs.uk.
and when they cry. In general,
babies need to be winded The baby’s back should be rubbed Weaning
halfway through a feed and or patted until they bring up their
when they have finished. wind – often with a satisfying Weaning is the process of moving
burp! Some babies bring up a little babies on from only drinking milk
There are two main positions milk or ‘posset’ during winding, so to including solid foods in their
for winding: it can be useful to have a cloth or diet. The Department of Health
muslin square handy. recommends that babies should
• Lying the baby over be weaned at around six months
of age.
a shoulder

• Sitting the baby on a lap,

holding the back and chin.

IS BABY READY FOR WEANING? Advise parents that many babies
have a growth spurt at around
Signs to look out for that indicate a baby may be ready for four months, which can make
weaning include: them hungrier than usual.

• Staying in a sitting position, holding their head steady It’s important not to confuse this
• Co-ordinating their eyes, hands and mouth so that they can with the real signs of weaning
because an infant’s digestive
look at food, pick it up and put it in their mouth by themselves system needs time to develop
before solids are introduced.
• Swallowing food. Babies who are not ready will push their food In such cases, babies may benefit
from an infant formula milk for
back out. hungrier babies that contains
more casein protein. This may take
longer to digest, which can help
hungrier babies feel more satisfied.

Further details on weaning can
be found in Chapter 7.

N.B. If parents are thinking
about choosing a different
infant formula milk for their

baby, they should discuss
it with a healthcare
professional, such as

the pharmacist or
pharmacy technician,
first.

CHAPTER 3 0-6 MONTHS

Feeding problems

Colic The exact reason for colic Reflux and regurgitation
is not known, but the
Colic is one of the most symptoms and possibilities Reflux is when the contents
common feeding problems in are discussed in Chapter 4. of the stomach come back
babies, but normally resolves up into the oesophagus, and
by four months of age or six Frequently winding a baby mild cases are quite normal
months at the latest. There during feeding can sometimes in healthy babies. Winding
are several things to remember help. Special formula milks, the baby during a feed and
when considering colic – an anti-colic teats or over-the- holding them upright after
infant must display all of the counter medicines such as feeding can help to prevent
following symptoms from dimeticone (e.g. Dentinox reflux. Giving smaller feeds
birth to four months of age: Infant Colic Drops – GSL*), more often may also help.
• Bouts of irritability, fussing simeticone (e.g. Infacol – Thickened feeds may also be
or crying that starts and stops GSL*) or lactase drops (e.g. recommended. Regurgitation
without obvious cause Colief) may also be beneficial. (or posseting) is when the
• Episodes lasting three stomach contents come back
or more hours a day and Cows’ milk protein up to the baby’s mouth.
occurring at least three allergy
days per week for at least Constipation
one week Cows’ milk protein allergy
• No failure to thrive. is the most common allergy Babies, like everyone else,
in babies, often causing an differ when it comes to
immediate reaction and frequency of bowel motions,
symptoms such as irritation but when constipated they
and swelling of the eyes, skin, will pass infrequent, dry,
mouth and tongue, sneezing hard stools that may be
and blocked nose, abdominal accompanied by straining and
pain, diarrhoea and vomiting. pain. It is important to check
Delayed reactions can also that bottles are being made
occur, often with up correctly, as too much
gastrointestinal or skin- powder will make the feed
related symptoms (e.g. more concentrated, which
eczema). may lead to constipation.

Lactose intolerance IMPORTANT

Lactose intolerance can occur If parents mention any
in babies when there is a lack symptoms or behaviour in
of lactase, an enzyme needed a baby that seem unusual
for the digestion of lactose. or start alarm bells ringing,
A lactose-free infant formula refer them to the
pharmacist.
milk could be used, or
alternatively, lactase drops A healthcare professional,
(e.g. Colief) may such as the pharmacist, may
be used suggest a special infant
to break formula milk for babies
up some experiencing feeding
of the problems. See Chapter 4
lactose. for details.

*Prescribing information can be found at:
medicines.org.uk/emc

CHAPTER 3 0-6 MONTHS

Ask the experts i

Pharmacy teams are asked for advice on a wide
range of infant feeding topics. So how do the experts
suggest you respond to these common queries?

What are the signs that a bottle-fed A customer says her baby is unsettled

Q baby has had enough? Q after a feed. How can I help?
Vicky Pennington, nutritionist at Boots Freelance paediatric dietitian, Tanya

A UK, advises: A Thomas BSc (Hons) RD, says: “Has the

• The mother should be guided by her baby – infant taken enough feed? Do they have wind
or colic? Is it non-feed related: are they tired,
a baby will often let mum know by pushing the unstimulated, teething or unwell? In some
bottle away cases, the infant may be intolerant to the
feed, but check other possible reasons first
• A baby should not be forced to finish the before investigating this possibility further.”

bottle Q Is it acceptable for a hungry breastfed
baby to be topped up with formula
• The baby should appear content and
Amilk before the age of six months?
satisfied after their feeds. ”The Government advises mothers to
breastfeed exclusively for the first six
Dr Emma Derbyshire, independent nutrition months of life,” explains Tanya. “It is
consultant and founder of Nutritional Insight
Ltd, adds that if the baby has had enough, acceptable for hungrier babies to be topped
they’re likely to: up with formula if that is what the
mother wants. However, other avenues
• Be disinterested in their milk should be explored and exhausted
• Play with the bottle or flick the teat first. If the infant is coming up to six
• Not accept the feed and keep pushing months then consideration should be
given to weaning rather
it away. than topping up. The
Government
Q Why should cows’ milk not recommends weaning
be given to babies aged at six months, and
not before four
A0-6 months? months. All babies
Geraldine Goodman, community are different and
dietitian, Dietetic Department, some babies may be
Cumberland Infirmary, says: “Up ready for first
until six months [of age] a baby’s weaning solids
nutrients come from breast milk before six months.
or a suitable infant formula. Cows’ Topping up should
milk should not be given as it does not be considered
not contain the correct balance of the norm or
protein, vitamins and minerals that a the ideal.”
baby needs. At six months, cows’ milk
can be introduced as an ingredient in
foods such as custard or sauces but it
should not be given
as a main drink
until a baby is a
year old.”

INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY
BREASTFEEDING IS BEST FOR BABIES

Three good reasons
to choose
SMA® PRO First Infant Milk*

Clinically proven1

Made with SMA® Nutrition’s
exclusive protein process

Contains Omega 3 & 6 LCPs**
and GOS/FOS†

Learn more about SMA® PRO range at

www.smahcp.co.uk
www.smahcp.ie

SMA Careline UK: 0800 0 81 81 80 Supporting you
ROI: 1800 931 832 to support parents

IMPORTANT NOTICE: Breast milk is best for babies and breastfeeding should continue for as long
as possible. Infant milks should only be used on the advice of a doctor, midwife, health visitor, public
health nurse, dietitian or pharmacist, or other professionals responsible for maternal and child care.

*When bottle feeding is considered.
**LCPs = Long Chain Polyunsaturates
†In powder formulation only; GOS/FOS = Galacto-oligosaccharides/Fructo-oligosaccharides.
Reference: 1. Alexander et al. Am J Clin Nutr. 2016.

®Registered trademark SMA® Nutrition UK and Ireland NW079 ZTC1184a/05/2017

CHAPTER 3 0-6 MONTHS

Training & CPD REFLECT

The following practice points and questions can be EVALUATE CCYPCDLE PLAN
used by individual members of the pharmacy team
and/or by the pharmacist for team training ACT

Practice points • Do you understand the and discuss what they do? An
understanding of the health
1 Consider how you can anxieties that new parents face visitor’s role and making sure you
attract new parents to about ‘doing the right thing’? know when to refer will give you
your pharmacy. What is Ask a new parent about the confidence when talking to new
unique about your pharmacy? pressures they face from other parents and keep them coming
How can it be improved? parents, family and the media. back to your pharmacy
Discuss with your team, and How can you help a new parent
any parents that you know, to gain a balanced view on • What are the most common
what has made them develop feeding their baby and
loyalty to one particular place. confidence in putting this into feeding problems that new
practice? parents encounter? Again, you
Questions to think about include: could ask a health visitor to share
• Whose advice should a parent their experiences.
• Do you understand what it’s
listen to on infant feeding? Do 2 A mother of a three-
like to be a new parent? If you an internet search for useful month-old, who has
don’t have the experience information on infant feeding for been breastfeeding,
yourself, consider asking those new parents. Discuss this with wants to switch to formula
who have. Understanding and your team. Which is useful and milk. She has discussed this
showing empathy to customers appropriate and which is not? with her health visitor. What
is a great way to keep them advice would you give her?
coming back • Which members of the wider
Consider the following:
healthcare team give advice on
infant care and feeding during • What problems she might
the first six months of a baby’s
life? Do you know, for example, have when she stops feeding
your local health visitors? Do they
• How she can get the baby
come to the pharmacy?
to accept a bottle
• Could you ask a health
• The brand of formula she
visitor to come to a
team meeting at your might consider
pharmacy
• The differences between milks

for hungrier babies.

CHAPTER 3 0-6 MONTHS

YOUR CPD Multiple choice questions

Pharmacists and techniciiaannss 1. WAphpicrohxoimf tahtelfyohllowimnganisyN1O20Tmalwboayttlienswohf ifcehedcomwisg’hmt ilk
– don’t forget to record your
CPD at: uptodate.org.uk ias fmouord-iwfieedkt-olmd abkaebyfohramvuel?a milk?

Reflection a. Twheowhey:casein ratio is altered to be closer to mature n

s••ew•nclehDAiHhgweroeiomebnywmlyeeoog?uufcuioovmkrcinnnotsfho?gniewdfaiHedwdneevhantilotctahegriyseitvSoiytnaogrut b. bForeuars t milk nn
•caidri•InsnoediDfAfymgbvfaooiiruaccmneubueyltaooilrytettfnuoyotsiooe?uffuareaenmnmeeamsddd?wuue?iilnnmraasggrtmeawhpnheroidlorokfbtbsthhlaheaebmesys?
s••fpa•uorrADWcreomhorabehu?pylyoelroaoomudubmkoslaeinltwmykooosawsirurnteeowgry?oehuoffolauethttrrioeolonrinescff?aealrnt bc.. DSiexc reasing lactose content nn

H•PeWlaahlntohnyiisnSetgalirgtibSlcehefomret?he cd.. ERiegmhtov ing fat and adding vegetable oils nn

• Consider further resources d. Reducing sodium content n

yPoluacnonulidnugse to enhance 22.. WA thwichhaotfatgheesceantipcoswissr’emcoilmk mbeengdiveednwtohebnabbioetstlaes fteheediring?
a. Hmoalidn tdhreinbka?by fairly upright, supporting their head n
your knowledge of infant
•tc•omrroefaWRiqmltiekuhnhfspieirraneleentsgmtuhaeetwydr,nioidittlfuisliotrayoniknoofanynuilno?afwlanletdsge ab.. TFweeodmthoentbhasb y in a calm and relaxed atmosphere nn
aged up to six months. bc.. SMixakmeoenytehsco ntact and smile at the baby during feeding nn
cd.. AEilgl hotf mthoenatbhosve nn
AAccttiioonn
d. 12 months n
•• ACsokmyopulertsetatfhf etoleloaorkniantg
the infant formula milks you 3. Which of the following statements about winding is FALSE?
s•toFcakmainlidareinsesuyreouthreseylf with
uthnedeprrsotadnudctthreairnsgimesilainrities a. Winding removes air from the stomach, making the baby
aynodurdipffhearermncaecsy
• Ensure the pharmacy team a3bbc..... mITHImBaBBtthnaaaoiohdelbdbbwkraoiiieweeerseudsssscahbonoscwehbhe’amtyisiion,l:gnflcuifohgbatoolrsedefirtoestrmaewroitnbsnhunpoilneelrladbayadtirstutbemiaiinomdnemiglgiwbkescuytoivahpnnlaleydttpreiieeynrorndgebsftsrdaaetocthttmkoetdhmcubeoreoiwencvngsleod’rwsmoetihfrinlekttdho?isnehbgofreueealddset r n
c•aCnoannssiwdeerrqduiescsutiossnins ognthe cd.. nn
irneflaenvtafnotrmissuulaesmwilkitshanadlothcaatl n
ehveearlytohnveiskintoowr?s when to n
refer to the pharmacist nn

b•EeOvtwargleauennaisttehioaenmpheaertminagcy team d4.. WAnhtiicbhodoifetshaerefoalldodweidng statements about starting weaninng
is FALSE?
and the local health visitor.
• What have you learnt? 4a.. FFWHFSAmbTBbB orroheaaaeoeihgyrsecbbaswzmtiarkiilhcaeoDeetehumohknwssfealeuyroapwaintvunlthfrkaeSemihettrgtatdsohtahisrepmleraeekatuatitaaerrrfvedbsntaomioylrtglanelouonotofsoucuowfathtntrhrHerhidowneereusagfeab?ondalCatudynhbAriffynNormoegirNusocrwOwonremmTethahaeombdsnnneyeoitntnpffhhgodusaerswrgsycwhbehicloaelaaubapsnlienudecdissnnoh’wsg-thofiboortdehouidlndate n

Evaluation ab.. n
cbc... nn
• How have you applied dd.. n
•thAisr?e staff confident they nn
ctmy•oaoHonuinnoratfwnhacsosnw?etnfesffeureelqctdtuaiievtniregoienwfsroesrkemreliall0tse-?6d
• What have you learned their eyes, hands and mouth n
from this chapter? Will you
take any action to improve adc5ba5bc......... 1FFSFriWcMLEseaaoooic2xcauzhyTuruomekismRirrnhcemmiUnoghomwocgamEnwnoteoo?thctuneefnhahelpsnkotstntshsdhbinbp bsaegoeaebtxtfdytioacoloelldnsulseooysswmwwivtipnithenhteaogbtfmWrotseeotaooraslrftfitleetcdftemoeledHweeidfennso’iagtnrmlsmtgchaai?ulbknOlaoaprulpgrleteoavrwfngeeidynezetadrtriniemofgnlaupyxroblennnnmnnns
your service to new parents?
d. Colic usually resolves itself by four months of age n
tWtWhhiaiassnntttteetstsototococononmlmilninpepel?le?ettee
VViissiitt: :tmtmmmaaggaazzininee.c.coo.u.ukk



CHAPTER 3 0-6 MONTHS

Aptamil First Infant Milk 1 Nutricia Early Life Nutrition

Nutritionally complete Features Nutrition information:
breast milk substitute
for babies who are 3 C ontains a unique blend Per 100ml prepared feed:†
not breastfed or for of ingredients, including
combination feeding. Aptamil’s patented blend Energy 275kJ
of galacto- and fructo-
oligosaccharides (66kcal)

3 Contains omega-3 LCPs Fat 3.4g
3 Contains nucleotides
Saturates 1.5g
Suitable for:
Unsaturates 1.9g
3 Babies from birth
LCPs 0.024g
Available as:
Arachidonic acid (AA) 0.011g
3 9 00g powder (PIP code:
310-5889) Docosahexaenoic acid (DHA) 0.010g

3 2 00ml (PIP code: 269-9064) Carbohydrate 7.3g
and 1 litre ready-to-feed
Sugars 7.3g
3 S tarter pack (6x70ml bottles
and 6 teats) Lactose 7.0g

Fibre 0.6g

Protein 1.3g

Whey 0.8g (62%)

Casein 0.5g (38%)

Salt 0.04g

Aptamil Hungry Milk Nutricia Early Life Nutrition

Nutritionally complete Features Nutrition information:
breast milk substitute
for hungrier babies who 3 C ontains a unique blend Per 100ml prepared feed:†
are not breastfed or for of ingredients, including
combination feeding. Aptamil’s patented blend Energy 275kJ
of galacto- and fructo-
oligosaccharides (66kcal)

3 Contains omega-3 LCPs Fat 3.1g
3 Contains nucleotides
3 C asein dominant milk – forms Saturates 1.4g

a firmer curd in the stomach, Unsaturates 1.7g
which is digested more slowly
LCPs 0.023g
Suitable for:
Arachidonic acid (AA) 0.010g
3 Babies from birth
3 Hungrier bottle-fed babies Docosahexaenoic acid (DHA) 0.009g

Available as: Carbohydrate 7.7g

3 9 00g powder (PIP code: Sugars 7.6g
310-5913)
Lactose 7.4g
3 2 00ml (PIP code: 269-9056)
and 1 litre ready-to-feed Fibre 0.6g

Protein 1.6g

Whey 0.3g (19%)

Casein 1.3g (81%)

Salt 0.06g

Breastfeeding is best for babies.
Infant formula milk is suitable from birth when babies are not breastfed. It is recommended
that all infant formula milks be used on the advice of a doctor, midwife, health visitor, public
health nurse, dietitian, pharmacist, pharmacy technician or other professional responsible for
maternal and child care.

†All nutrition information is based on the powder format.

36There may be slight variations in the ready-to-feed formats.

CHAPTER 32 0-6 MONTHS

Aptamil Profutura First Infant Milk 1 Nutricia Early Life Nutrition

Nutritionally complete Features Nutrition information:
breast milk substitute
for babies who are 3 C ontains milk fat and Per 100ml prepared feed:†
not breastfed or for phospholipid-bound LCPs to
combination feeding. provide a better fat profile, Energy 275kJ
inspired by the structure of
fats within breast milk1,2,3 (66kcal)

Suitable for: Fat 3.4g

3 Babies from birth Saturates 1.6g

Available as: Unsaturates 1.8g

3 8 00g powder (PIP code: LCPs 0.026g
400-7704)
Arachidonic acid (AA) 0.012g
3 200ml ready-to-feed
(PIP code: 400-7696) Docosahexaenoic acid (DHA) 0.011g

3 S tarter pack (6x70ml bottles Carbohydrate 7.3g
and 6 teats)
Sugars 7.2g

Lactose 7.0g

Fibre 0.6g

Protein 1.3g

Whey 0.8g (62%)

Casein 0.5g (38%)

Salt 0.04g

Cow & Gate First Infant Milk 1 Nutricia Early Life Nutrition

Nutritionally complete Features Nutrition information:
breast milk substitute
for babies who are not 3 Contains oligosaccharides Per 100ml prepared feed:†
breastfed or for combination 3 Contains nucleotides
feeding. 3 Contains LCPs (AA and DHA) Energy 275kJ

Suitable for: (66kcal)

3 Babies from birth Fat 3.4g

Available as: Saturates 1.5g

3 9 00g powder (PIP code: Unsaturates 1.9g
310-5848)
LCPs 0.015g
3 2 00ml (PIP code: 251-1434)
and 1 litre ready-to-use Arachidonic acid (AA) 0.006g

3 S tarter pack (6x70ml bottles Docosahexaenoic acid (DHA) 0.006g
and 6 teats)
Carbohydrate 7.3g

Sugars 7.3g

Lactose 7.0g

Fibre 0.6g

Protein 1.3g

Whey 0.8g (62%)

Casein 0.5g (38%)

Salt 0.04g

Cow & Gate Infant Milk for Hungrier Babies Nutricia Early Life Nutrition

Nutritionally complete Features Nutrition information:
breast milk substitute for
hungrier babies who are 3 C ontains a different Per 100ml prepared feed:†
not breastfed or for balance of milk protein
combination feeding. for hungrier babies Energy 275kJ

3 Contains oligosaccharides (66kcal)
3 Contains nucleotides
3 C ontains LCPs (AA and DHA) Fat 3.1g

Suitable for: Saturates 1.4g

3 Babies from birth Unsaturates 1.7g

Available as: LCPs 0.014g

3 9 00g powder (PIP code: Arachidonic acid (AA) 0.006g
310-5855)
Docosahexaenoic acid (DHA) 0.006g
3 2 00ml (PIP code: 251-1426)
and 1 litre ready-to-use Carbohydrate 7.7g

Sugars 7.6g

Lactose 7.4g

Fibre 0.6g

Protein 1.6g

Whey 0.3g (19%)

Casein 1.3g (81%)

Salt 0.05g

†All nutrition information is based on the powder format.

37There may be slight variations in the ready-to-feed formats.

CHAPTER 32 0-6 MONTHS

HiPP Organic Combiotic First Infant Milk 1 HiPP UK

For babies who are not Features Nutrition information:
breastfed or for
combination feeding. 3 Low protein level of Per 100ml prepared feed:†
1.89g/100kcal
3 Includes high quality whey Energy 277kJ

protein alpha-lactalbumin (66kcal)
3 Contains a source of
prebiotic oligosaccharides Fat 3.5g
3 Certified organic
3 Contains omega-3 and 6 LCPs Saturates 1.2g

(AA and DHA) Unsaturates 2.3g

Suitable for: LCPs 20mg

3 Babies from birth Carbohydrate 7.3g

Available as: Sugars 7.2g

3 Starter pack 6 x 90ml ready Lactose 7.1g
to feed including teats
3 800g powder Protein 1.25g
3 200ml ready to feed
Whey 0.75g

(60%)

Casein 0.5g

(40%)

HiPP Organic Combiotic Hungry Infant Milk HiPP UK

For hungrier babies who Features Nutrition information:
are not breastfed or for
combination feeding. 3 Certified organic Per 100ml prepared feed:†
3 C ontains a source of prebiotic
Energy 281kJ
oligosaccharides
3 Contains omega-3 and 6 LCPs (67kcal)
(AA and DHA)
Fat 3.5g
Suitable for:
Saturates 1.1g
3 Babies from birth
Unsaturates 2.4g
Available as:
LCPs 14mg
3 800g powder
3 200ml ready to feed Carbohydrate 7.3g

Sugars 7.2g

Lactose 7.1g

Protein 1.6g

Whey 0.3g

(20%)

Casein 1.3g

(80%)

NANNYcare First Infant Milk NANNYcare

For babies who are Features Nutrition information:
not breastfed or for
combination feeding. 3 Nutritionally complete Per 100ml prepared feed:†
3 M ade with ‘whole’ goat milk
3 Minimal processing Energy 280kJ
3 N o unnecessary ingredients
(66kcal)
added
3 Mild taste Fat 3.4 g

Suitable for: Saturates 1.3g

3 Babies from birth to Unsaturates 2.14g
12 months
LCPs 448mg
Available as:
Carbohydrates 7.4g
3 4 00g powder (PIP code:
002-6542) Sugars 7.4g

3 9 00g powder (PIP code: of which lactose 7.4g
285- 8785)
Fibre Nil

Protein 1.3g

Whey 0.26g

(20%)

Casein 1.04g

(80%)

Salt 0.04g

†All nutrition information is based on the powder format.

38There may be slight variations in the ready-to-feed formats.

CHAPTER 32 0-6 MONTHS

SMA PRO First Infant Milk SMA Nutrition

Nutritionally complete Features 3 2 00ml (PIP code: 395-0169)
breast milk substitute and 1 litre ready-to-use liquid
for babies who are 3 T he only clinically proven milk (PIP code: 370-8450)
not breastfed or for first infant milk to achieve a
combination feeding. growth rate comparable with 3 S tarter pack (6x70ml bottles
a breastfed baby as defined with hygienic teats) (PIP code:
by WHO growth standards4 335-3208)

3 T he lowest protein formula Nutrition information:
available in the UK and
Ireland at 1.25g/100ml Per 100ml prepared feed:†
(1.87g/100kcal). Powder only
Energy 280kJ
3 H as a closer amino acid profile
(including insulinogenic amino (67kcal)
acids) to that of breast milk5
Fat 3.6g
3 GOS/FOS for softer stools
(powder only) Saturates 1.5g
3 Omega-3 and 6 LCPs
Unsaturates 2.1g
Suitable for:
LCPs 16.8mg
3 Babies from birth
3 Halal Arachidonic acid (AA) 8.4mg

Available as: Docosahexaenoic acid (DHA) 8.4mg

3 4 00g (PIP code: 347-3873) Carbohydrate 7.1g
and 800g powder (PIP code:
347-3865) Sugars 7.1g

Lactose 7.1g

Fibre (GOS/FOS) 0.4g

Protein 1.25g

Whey 0.88g

(70%)

Casein 0.37g

(30%)

SMA Extra Hungry Infant Milk SMA Nutrition

For hungrier babies who Features Nutrition information:
are not breastfed or for
combination feeding. 3 Specially tailored formula Per 100ml prepared feed:†
3 Nutritionally complete
3 C ontains omega-3 and 6 LCPs Energy 280kJ
3 Contains nucleotides (67kcal)
3 C asein dominant protein,
Fat 3.6g
which is digested more slowly6
Saturates 1.6g
Suitable for:
Unsaturates 2.0g
3 Babies from birth
3 Hungrier bottle-fed babies LCPs 19.4mg
3 Vegetarians (powder only)
3 Halal Arachidonic acid (AA) 12.3mg

Available as: Docosahexaenoic acid (DHA) 7.1mg

3 8 00g powder (PIP code: Carbohydrate 7.0g
347-3824)
Sugars 7.0g
3 2 00ml (PIP code: 395-0177)
and 1 litre (PIP code: 370- Lactose 7.0g
8591) ready-to-use liquid milk
Protein 1.6g

Whey 0.3g

(20%)

Casein 1.3g

(80%)

References:
1. Jensen RG et al. Am J Clin Nutr 1978;Jun:31(6)990-1016
2. Carnielli VP et al. J Pediatr Gastroenterol Nutr 1996;23(5):553-60
3. Kennedy K et al. Am J Clin Nutr 1999;70:920-7
4. Alexander, D., Yan, J., Bylsma, L. et al. (2016). Growth of infants consuming whey-predominant term
infant formulas with a protein content of 1.8g/100kcal: a multicentre pooled analysis of individual
participant data. The American Journal of Clinical Nutrition
5. Nestlé data on file, 2014
6. Billeaud, C. (1990). Gastric emptying in infants with or without gastro-oesophageal reflux according
to the type of milk. European Journal of Clinical Nutrition, 44(8), pp.577-583.

39 †All nutrition information is based on the powder format.
There may be slight variations in the ready-to-feed formats.

Aptamil Anti-Reflux Available in
most retail and
Specially formulated with pharmacy outlets
carob bean gum to reduce
regurgitation by up to 78%1

Provides greater viscosity on contact with stomach
enzymes compared to starch based thickened feeds2

Helps normalise oesophageal pH3

Shown to significantly reduce reflux episodes
and regurgitation severity scores1

Less irritability and discomfort for baby,
peace of mind for mum

Find out more at: www.eln.nutricia.co.uk
HCP helpline: 0800 996 1234

REFERENCES: 1. Wenzl TG et al. Pediatrics 2003;111:e355-9. 2. Danone Research (data on file). 3. Vandenplas Y et al. Eur J Pediatr 1994;153:419-23.
IMPORTANT NOTICE: Breastfeeding is best for babies. Aptamil Anti-Reflux is a food for special medical purposes. It should only be used under
medical supervision, after full consideration of the feeding options available including breastfeeding. Suitable for use as the sole source of nutrition
for infants from birth, and as part of a balanced diet from 6-12 months. This product is not for parenteral use.

CHAPTER 4 SPECIALIST MILKS

Specialist milks

Feeding problems such as colic, reflux
and allergies can be distressing for babies
and their parents. Clear advice from the
pharmacy team and the right nutritional
advice can make a big difference

After reading this
chapter, you will have a
better understanding of:

• The feeding problems

that babies can encounter,
including colic, reflux,
allergies and intolerances,
constipation and diarrhoea

• The nutritional needs of

babies who experience these
problems

• Why some babies fail

to thrive

• The needs of pre-term/

low birthweight babies

• The specialist formula

milks available to parents
with babies suffering from
these problems.

Coping with colic

C olic affects up to one in Symptoms Symptoms can also include a red,
five babies, making it one flushed face and babies may
of the most common To be classed as colic, an infant clench their fists, draw their
gastrointestinal (GI) complaints must display all of the following knees up towards their chest
in babies. symptoms from birth to four or arch their back.
months of age:
The first bout of colic usually Causes
occurs within a few weeks of • Bouts of irritability, fussing
birth and episodes can continue The exact cause is unknown, but
until around three to four or crying that starts and stops there are a number of theories:
months of age. It can be very without obvious cause
distressing and difficult for • An immature digestive system
parents to cope with. • Episodes lasting three or more
can lead to irregular gut motility,
hours a day and occurring at least excessive wind or an imbalance
three days per week for at least in gut flora
one week

• No failure to thrive.

41

CHAPTER 4 SPECIALIST MILKS

• Babies may be sensitive to • Are thicker in consistency to which cause the baby pain and
discomfort, and combine them
substances in breast or formula help babies take in milk more into bigger bubbles that are easier
milk, or they may have a reduced evenly with less air for the baby to bring up as wind
ability to digest lactose
• Have a reduced lactose • Lactase enzyme drops (e.g.
• Excess gas and taking in too
content to aid digestion Colief) help break down the
much air during feeds lactose in the milk.
• Are suitable from birth until
• Mothers who smoke during N.B. If a baby has severe colic
12 months of age. that has not responded to first
pregnancy may increase the risk line treatment, it may be due to
of their babies developing colic. Treatment a cows’ milk allergy and an
extensively hydrolysed formula,
Formula milks for colic Treatment is only necessary if (e.g. Aptamil Pepti 1), may be
parents are struggling to cope recommended by a healthcare
Parents need reassurance that and if the baby is not feeding or professional. Symptoms of
colic will resolve itself. If the not gaining weight. If parents are diarrhoea, vomiting and a fever
symptoms are not caused by an concerned, they should speak to of 38ºC or above (if under three
allergy, a healthcare professional a pharmacist for further advice. months of age) or 39ºC or above
may recommend a special infant (if aged three to six months) are
formula milk to manage colic Treatments that may help breast not associated with colic. In this
(such as Aptamil Comfort or Cow and bottle-fed babies include: case, refer to a pharmacist/GP.
& Gate Comfort). These products:
• Simeticone or dimeticone
• Contain partially hydrolysed
drops (e.g. Infacol – GSL,
(broken down) whey protein Dentinox – GSL). These drops act
to make them easier to digest on small, trapped bubbles of air

Top tips for easing colic

To help ease colic, parents can try the following:

• For breastfed babies, the mother could try removing caffeine

and spicy foods from her diet

• For bottle-fed babies, ensure the bottle is always tipped up

during feeding so that the teat is full of milk rather than air

• For bottle-fed babies, a vented bottle, fast-flowing or anti-

colic teat may help

• Check the size of the teat as holes that are too small can

increase the amount of air taken in during feeds

• Wind the baby during and after a feed (see page 29 for

winding tips)

• Try a warm bath or a cuddle with a blanket to comfort

the baby

• Provide the baby with a distraction (e.g. a dummy)
• Rock the baby, or take them for a walk

or a ride in a car

• Try having white noise in the

room (e.g. a vacuum cleaner
or washing machine) as this has
been shown to ease crying

• Enlist the help of family or

friends to allow for regular breaks

• Contact CRY-SIS, a national

support group for families with
excessively crying, sleepless and
demanding children:
cry-sis.org.uk.

42

CHAPTER 4 SPECIALIST MILKS

Clinical summary:

Colic should be suspected in any baby from care, there is little that can be done. The most
birth to around three to four months of age who useful intervention is support and reasurrance for
cries excessively and inconsolably in the late parents that colic will resolve. Soothing strategies
afternoon or evening. Symptoms typically include should be tried first, such as holding the baby
simultaneously clenching the fists, arching the during the episodes, bathing, rocking or pushing
back or drawing the knees up towards the in a pram, and using white noise as a distraction.
abdomen, and a red flushed face. Parents should be reassured that colic rarely
continues beyond three or four months of age,
Differential diagnoses include: and encouraged to look after their own wellbeing
by asking friends and family for support.
• Discomfort, for example due to hunger, thirst,
Nutritional solutions for formula-fed infants
the temperature of the environment, wind, the include partially hydrolysed formula with reduced
mother’s diet (too much caffeine, alcohol or spicy lactose content and a thicker consistency.
food) or another condition such as nappy rash
Treatments are only recommended if parents
• Constipation, though this is usually obvious are struggling to cope despite trying the above.
A one week trial of simeticone or lactase drops
when asking about symptoms can be tried, but only continued if the baby seems
to respond. If the treatment does seem effective,
• Gastro-oesophageal reflux, which can be it should be stopped by the age of six months at
the latest.
distinguished from normal infantile reflux by the
fact that there will usually be more than five Over-the-counter antimuscarinic dicycloverine
episodes of regurgitation a day, feeds are often should not be used in the treatment of colic
refused, and there is little or no weight gain because of side effects such as breathing
difficulties or coma.
• Cows’ milk protein allergy, though other

symptoms will often be present, i.e. skin reactions,
cough, wheezing, runny nose, nausea, vomiting

• Parental depression, anxiety or bonding issues.

According to the National Institute for Health and
Care Excellence (NICE) guidance on postnatal

Reflux

Reflux, or gastro-oesophageal reflux (GOR), affects
30 per cent of infants. Also called regurgitation, it
occurs when the stomach contents are brought back
up into the oesophagus or mouth

B abies often bring up milk • No retching, vomiting of oesophagus. As this muscle
during or shortly after matures, the frequency of reflux
feeding. However, babies blood, inhalation of food into the reduces and usually disappears
who repeatedly bring up their lungs, cessation of breathing for by 12-14 months of age.
food may have a more serious, 20 seconds or more, failure to
long-term form of reflux. thrive, feeding or swallowing Treatment
difficulties, or involuntary flexing
Symptoms or extension of the arms and legs. Guidance from NICE advises:

Infants will display the following Causes • If breastfeeding, a healthcare
symptoms between three weeks
and 12 months of age: The main cause is an immature professional should review mum’s
lower oesophageal sphincter technique
• Regurgitation twice or more muscle that allows stomach
contents to pass back into the • If formula feeding, a healthcare
a day for three or more weeks

43

CHAPTER 4 SPECIALIST MILKS

professional should review the carob bean gum) that thickens and during a feed. They can also
baby’s feeding history and reduce before feeding. The viscosity is be mixed with formula and fed
the volume of milk, if excessive for maintained and increases in the through a teat with a larger hole.
the infant’s weight. A trial of stomach, making it less likely that
smaller, frequent feeds can be the feed will be brought back up If a milk has been tried for a few
offered, if appropriate, followed weeks without success, referral
by a trial of thickened formula milk. • Can be used from birth until to a pharmacist or GP is necessary
because the infant may have an
Formula milks for reflux 12 months of age. allergy to cows’ milk, in which
N.B. Formula milks for reflux case an extensively hydrolysed
For formula-fed infants, a formula typically have different make up formula may be recommended.
milk, such as Aptamil Anti-Reflux, instructions to standard formulas. Alginate-containing sachets,
Cow & Gate Anti-Reflux or SMA which can help to prevent reflux,
Pro Anti-Reflux may be suitable. Feed thickeners, such as Cow & may also be prescribed as an
Formulated with cows’ milk, these: Gate Instant Carobel, increase alternative to thickened feeds.
the viscosity of a feed, which may N.B. If vomiting occurs with other
• Are casein-dominant, so they prevent it from coming back up. symptoms (e.g. diarrhoea and a
These can be added to expressed fever), refer to a pharmacist/GP.
take longer to digest breast milk or cooled, boiled
water and given as a paste before
• Contain a pre-cooked starch or

a gum-based thickener (e.g.

Clinical summary:

For infants experiencing symptoms of reflux and regurgitation, a feeding assessment is the first
line of approach for both breastfed and formula-fed babies. In formula-fed infants with frequent
regurgitation associated with marked distress, NICE recommends that after a review of the feeding
history, the following steps should be followed:

Reduce the feed
volumes, if excessive

1 2 3for the infant’s weight
Offer a trial of smaller, more frequent feeds, while Offer a trial
maintaining an appropriate total daily amount of of thickened
milk (unless feeds are already small and frequent) formula.

If this is unsuccessful, thickened feeds should symptoms (usually pain or discomfort) are either
be stopped and the infant should be offered severe enough to warrant medical treatment,
alginate therapy for a trial period of one to or are causing complications such as oesophagitis
two weeks. Breastfed babies whose symptoms or pulmonary aspiration. NICE clinical guidance
do not improve despite the mother following the states that premature infants and children with
recommendations of an expert should be given complex, severe neurodisabilities, both of whom
a trial of one to two weeks of alginate therapy. have a high incidence of GORD, should be under
Alginates should only be continued if they appear specialist care, which will include management of
effective, though they should be stopped at this condition.
intervals to see if the infant has recovered.
Red flag symptoms to be aware of include:
Acid-suppressing drugs (proton pump inhibitors
such as omeprazole or H2-receptor antagonists • Frequent projectile vomiting (which suggests
such as ranitidine) should only be prescribed for
infants with overt regurgitation and either hypertrophic pyloric stenosis)
unexplained feeding difficulties (such as refusing
feeds, gagging or choking), distressed behaviour • Bile-stained vomit (intestinal obstruction)
or faltering growth. Metoclopramide, • Haematemesis (upper GI blood)
domperidone or erythromycin should not be • Blood in stool or diarrhoea (bacterial
offered without specialist advice.
gastroenteritis or infant cows’ milk protein allergy)
Gastro-oesophageal reflux disease (GORD) differs
from the common and normal regurgitation of • Abdominal distension or tenderness (intestinal
feeds that affects many infants in that the
obstruction).

Symptoms that start after six months of age or
persist after the child’s first birthday also warrant
investigation, as do systemic symptoms such as
fever, altered responsiveness and dysuria.

44

CHAPTER 4 SPECIALIST MILKS

Top tips for easing reflux

To avoid reflux, advise parents to:

• Try to make each feed as calm and relaxing as possible
• Feed the baby little and often and as slowly as possible with regular pauses
• Use the correct sized teat for the baby
• Avoid letting the baby get too hungry so that air isn’t gulped down during a feed
• Wind the baby during as well as after a feed, ensuring there is at least one good burp!
• Keep the baby upright during and after feeding and avoid bouncing or active play after a feed.

Constipation
and
diarrhoea

It can be difficult to know
what’s ‘normal’ when it
comes to an infant’s bowel
movements. The frequency
and consistency of stools
can vary, but symptoms of
constipation and diarrhoea
are easy to spot

L ike adults, babies and • Two or fewer defaecations abdominal discomfort and pain.
infants are all different in These symptoms may disappear
terms of how often they per week after a bowel movement.
normally pass stools – for some,
it will be a few times a day, • History of exessive stool Causes
whereas others will only go a few
times a week. Parents may ask retention Constipation is common among
you for advice if their baby hasn’t babies and infants, although it
passed stools as often as normal. • History of painful or hard doesn’t usually occur in babies
who are exclusively breastfed.
Symptoms bowel movements The cause of the problem can
vary, and may include:
The criteria used to diagnose • Presence of large faecal mass
constipation in infants up to four • Diet and dehydration, if lacking
years of age is that two of the in the rectum
following symptoms must be in fluid, fruit or vegetables
present for one month: • History of large stools, which
• Toilet training
may obstruct the toilet. • Emotional causes (e.g. starting

Accompanying symptoms may nursery or a new sibling arriving)
include being irritable and
unhappy, loss of appetite,
tiredness, excessive flatulence,
foul smelling wind and stools, and

45

CHAPTER 4 SPECIALIST MILKS

• Medication side effects or move their legs in a clockwise, Toddlers who experience
• Not being very active. ‘cycling’ action to help stimulate constipation should be given
their bowels. regular, frequent meals and should
Treatment try to stay active. Parents should
For babies who have already been also encourage good toilet habits
If a baby has constipation and has weaned, recommend that parents to teach the child to go when
not yet been weaned onto solid give them plenty of water (a small they feel they need to.
foods, the first course of action is amount of diluted fruit juice can
to give them cooled, boiled water also be given to infants over 12 If the problem hasn’t improved
between their normal milk feeds. months) to drink and include after trying any of the above
Advise parents to continue more fruit and vegetables in their suggestions, you should refer
making up formula milk as usual diet. Fruits that are good for parents to a pharmacist or a
– it should never be diluted or constipation include apples, pears, GP, as the infant may need an
over-concentrated. You can also peaches, apricots, prunes, grapes, osmotic or stimulant laxative
suggest that parents gently raspberries and strawberries. (e.g. lactulose or senna).
massage their baby’s abdomen

Clinical summary:

Early diagnosis and management of medication is only recommended if oral
constipation is important in order to prevent treatments fail.
it causing complications, such as a painful anal
fissure or embarrassing continence issues such as If the infant doesn’t have faecal impaction, or
soiling, or becoming chronic. Additional obstacles once it has been relieved, maintenance therapy
exist in the form of a reluctance to seek advice in should be started (under the advice of a doctor).
the first place because of embarrassment, and the First-line treatment is with a macrogol, the dose
conflicting information that many people receive. adjusted according to symptoms and response.
Both can impact on the effectiveness of A stimulant agent may be added or substituted
treatments and lead to a great deal of frustration. if the macrogol does not work or is not tolerated.
The regimen should be followed for several weeks
In its clinical guidance on the topic, NICE states after regular bowel habits are restored, which
that a full assessment should be conducted may take several months. Frequent reassessments
before constipation is diagnosed. Underlying should be conducted, ideally by the same
causes and red flag symptoms, such as abdominal healthcare professional, in order to ensure that
distension with vomiting which could indicate re-impaction has not occurred and to provide
intestinal obstruction, should be excluded at advice on any other issues. Medication should
this time. not be stopped abruptly, but instead gradually
reduced over a period of months while keeping
First-line treatment for impaction is with an an eye on stool consistency and frequency.
oral macrogol (polyethylene glycol 3350 plus Therapy may be required for several years or
electrolytes). If this product isn’t tolerated, a on an ongoing basis.
stimulant laxative (sodium picosulfate, senna or
docusate sodium) may be given either on its own Information on diet and lifestyle interventions
or with the osmotic laxative lactulose. All infants should be provided, but are not considered first
should be reviewed within a week, and rectal line treatments on their own.

I t is quite normal to see some associated symptoms may include:  a baby passes six or more
variation in the consistency of diarrhoeal stools in 24 hours,
a baby’s stools, but if there is • Stomach cramps refer parents to a pharmacist/GP.
a sudden change in consistency • Nausea and vomiting
to loose or watery stools, it is • Headache Causes
classed as diarrhoea. • Loss of appetite
• Dehydration. A common cause of diarrhoea
Symptoms is a viral or bacterial infection.
If diarrhoea lasts longer than This is normally self-limiting and
As well as loose, watery stools, 48 hours in babies aged between will clear up on its own within a
three months and one year, or if

46

CHAPTER 4 SPECIALIST MILKS

couple of days. It may also be monitor them closely if they glazed eyes, and a dry mouth or
a sign that the baby is having have diarrhoea or sickness. tongue. If babies show any of
difficulty digesting lactose or Signs of dehydration include these signs, they should see a
has an allergy to cows’ milk drowsiness, passing little urine, doctor immediately.
protein.
Top tips for constipation & diarrhoea
Treatment
• The best way to avoid constipation is to make sure that an
Parents should continue to offer
the same feeds as usual. Older infant eats plenty of fibre. Fruit, which can be chopped or puréed
babies should be offered depending on the baby’s ability to chew, is a suitable option. The
frequent sips of water. If babies best fruits for managing constipation are apples, apricots, grapes,
don’t want to eat, drinks should peaches, pears, plums, prunes, raspberries and strawberries
still be offered regularly to
prevent dehydration. An over- • If a baby has diarrhoea, it is important that everyone in the
the-counter oral rehydration
solution may also be suitable. family washes their hands regularly with soap and warm water
to avoid spreading the infection.
Babies are at high risk of
dehydration, so parents should

Clinical summary:

The most common cause of diarrhoea in individuals who have had more than five
infants is gastroenteritis – mostly viral in origin, diarrhoeal stools or two bouts of vomiting in the
but sometimes caused by a bacterial or protozoal previous 24 hours or who cannot tolerate fluids
infection – and is usually self-limiting. (including breast milk).

According to NICE, red flag symptoms, i.e. In most cases, the main aim of treatment is to
those that indicate a diagnosis other than prevent dehydration by continuing breastfeeding
gastroenteritis, include: and other milk feeds, encouraging fluid intake
(though not fruit juice or carbonated drinks) and
• Fever (38ºC or higher in babies under three offering oral rehydration therapy (ORT). The latter
should be used in all individuals who show signs
months of age, or 39ºC in infants older than this) of dehydration, ideally frequently and in small
amounts.
• Shortness of breath
• Altered consciousness Intravenous fluids may be indicated if clinical
• Neck stiffness shock is suspected, and for children who cannot
• Bulging fontanelle tolerate ORT or who continue to deteriorate
• Non-blanching rash despite taking it. If the child is on solid foods,
• Blood or mucus in stools these should be stopped while ORT is being
• Bilious vomit given, but reintroduced immediately once the
• Severe or localised abdominal pain and child has become rehydrated. Antidarrhoeal
medicines, such as loperamide are not
abdominal distension or rebound tenderness. recommended, and antibiotics should not
be given routinely.
During assessment, healthcare professionals
should be alert to the signs of dehydration – Most children who have gastroenteritis can
altered responsiveness, decreased urine output, be safely managed at home, with advice and
sunken eyes, tachycardia, tachypnoea, reduced support from a healthcare professional on the
skin turgor and general malaise – and clinical need for scrupulous handwashing and other
shock, which may manifest as decreased level hygiene practices, awareness of the signs of
of consciousness, pale or mottled skin, cold dehydration and when to seek medical help.
extremities and weak peripheral pulses. These
are more common in infants aged under one year
(and particularly those younger than six months),
babies who were of low birthweight, and

47

CHAPTER 4 SPECIALIST MILKS

Allergies and
intolerances

Food allergies and food intolerances are not
the same and it is essential to understand how
to distinguish between the two conditions

A llergies and intolerances will most likely refer to a GP or Other symptoms can include
are not the same. A food health visitor for specialist advice. eczema, rashes and breathing
allergy is an adverse difficulties in severe cases (refer
reaction to the protein component Formula milks these cases to the pharmacist).
of a food, which evokes an Between 50 and 60 per cent of
immunological response. When Once lactose intolerance has been babies with atopic eczema will
this is severe, it may result in diagnosed, a lactose-free formula also have an allergy to cows’
anaphylaxis. An intolerance is an (e.g. Aptamil Lactose Free or SMA milk, causing their skin symptoms
adverse reaction to a ‘non-protein’ LF) may be recommended. These to worsen.
component in the food, which are nutritionally complete milks
does not involve the immune that can be used from birth for Causes
system and reactions may be infants who have a congenital or
delayed, the symptoms are often temporary lactase deficiency. The first time a baby has cows’
gastrointestinal or skin-related. These milks taste similar to routine milk (whether in an infant
infant formula milk, so babies formula milk or if it passes
LACTOSE INTOLERANCE should not notice a difference. through breast milk), their
immune system reacts to the
Lactose intolerance is caused by COWS’ MILK ALLERGY protein it contains as if it were a
a reduced level of the enzyme foreign substance. The next time
lactase, which breaks down the Cows’ milk allergy (CMA), also the baby has cows’ milk, the
lactose in milk so that it can be known as cows’ milk protein antibodies produced will trigger
absorbed into the blood. It is allergy (CMPA), is the most the various allergy symptoms.
often a temporary problem, common food allergy in infants
lasting between a few days and a and is more frequently seen in Treatment
few weeks. It can also occur after formula-fed than breastfed
gastroenteritis (an infection babies. It is thought to affect two If you think a baby may be
causing vomiting or diarrhoea). to 7.5 per cent of babies under allergic to cows’ milk, refer to the
It is also thought to be a possible one year of age, although the pharmacist as they may need to
cause of colic. majority will grow out of it by see a GP for a diagnosis. Total
the age of five.
Symptoms PROTEIN OR
Symptoms LACTOSE?
• Bloated stomach, possibly with
There are a number of different Babies can react to the cows’
abdominal pain symptoms, which generally milk protein that passes
involve the skin and one or more through breast milk or that is
• Wind other body system, including the used to make infant formula
• Loose stools or diarrhoea gastrointestinal and respiratory milk, or they may have difficulty
• Mild colic systems. Symptoms may include: digesting lactose (a natural
• Poor weight gain or even sugar found in milk). It is
• Swelling of the face, hives, important to ascertain whether
weight loss. it is the protein or the lactose
wheezing that is causing the problem.
Treatment
• Diarrhoea and vomiting
If a baby might be suffering from • Constipation, bloating and
lactose intolerance, refer the
customer to a pharmacist, who abdominal pain

• Colic.

48