CHAPTER 4 SPECIALIST MILKS
avoidance of cows’ milk protein up of individual amino acids so for lifestyle reasons, such as
is usually required, which may that it does not trigger allergic vegetarians and vegans.
involve mothers of breastfed reactions. AAFs are considerably
infants avoiding cows’ milk and more expensive, so are usually N.B. Vegan diets are not
dairy products, alongside taking reserved for those with severe recommended for babies.
appropriate supplements (e.g. cows’ milk or multiple food
calcium and vitamin D). The allergies who cannot tolerate Help for parents
situation should be monitored EHFs.
using a food and symptom diary, Parents may require additional
with cows’ milk being periodically The Department of Health support and information, ideally
reintroduced at intervals under recommends that soya-based from a dietitian, especially as
medical supervision. For formula- formula milks (e.g. SMA Wysoy) their baby gets older and starts
fed infants, a suitable formula are not used before six months of weaning onto solid foods.
will need to be found that is age. This is because infants may Knowing plenty of milk-free
tolerated as a drink, and for use also be allergic to soya protein recipes will be helpful. There
in cereals and cooking. and these formulas increase are also a number of dairy-free
exposure to plant phytoestrogens products available to buy now.
Formula milks while babies’ organ systems are The labels of all foods should
immature and vulnerable. be checked for their contents
The latest guidance advises using However, some milks are as milk can be present where
an extensively hydrolysed formula marketed from birth, as for some it is not expected.
(EHF) such as Aptamil Pepti 1 or babies this may be all that they
2, which is still based on cows’ can tolerate. They can be used USEFUL WEBSITES
milk, although the proteins have for babies who cannot tolerate
been broken down to make them the EHFs as they are more •• nmhilsk.u.cko.uk
less allergenic. There are also palatable, or for those who
amino acid-based formulas choose soya-based formula
(AAFs) where the protein is made
Clinical summary:
Food allergy is an adverse immune response Management of the suspected food allergy
and may be immunoglobulin-E (IgE; an antibody)- depends on whether or not IgE is thought to be
mediated or non-IgE-mediated (in which case T-cells responsible. If an IgE-mediated reaction is believed
are thought to be responsible), or both. IgE- to be causing the infant’s symptoms, a skin prick
mediated reactions are acute and often have a test or blood test for specific IgE antibodies to the
rapid onset, e.g. skin reactions, angioedema of the suspected food and co-allergens should be
lips, tongue and palate, nausea and vomiting, conducted. For non-IgE-mediated allergies, the
respiratory symptoms (sneezing, rhinorrhoea, suspected allergen should be eliminated from the
cough, wheezing or shortness of breath). Non-IgE- diet for between two and six weeks and then
mediated reactions tend to be delayed, e.g. itching, reintroduced (under medical supervision).
atopic eczema, gastro-oesophageal reflux disease
(GORD), changes in stools, tiredness and faltering If cows’ milk protein allergy is suspected, the mother
growth. should be provided with advice on food avoidance
if she is breastfeeding, or information on the most
According to NICE, diagnosis should be considered appropriate formula or milk-substitute if formula-
in a child whose symptoms do not adequately feeding. A referral to a dietitian may be required,
respond to treatment for atopic eczema, GORD or as may signposting to support groups. Specialist
chronic GI problems including constipation, aided care is recommended for individuals who experience
by taking an allergy-focused clinical history (e.g. faltering growth accompanied by GI symptoms that
personal and family history of atopy, symptom type, are thought to indicate a food allergy, have had
severity, duration and reproducibility, and dietary one or more acute systemic or severe delayed
details). The child should also be assessed for reactions or have not responded to a single-allergen
physical signs of malnutrition or faltering growth, elimination diet, or if there is suspicion of multiple
and signs of any allergy-related comorbidities. food allergies (even if test results are negative).
49
CHAPTER 4 SPECIALIST MILKS
Infant eczema
When discussing infant formula milks, you may not
automatically think of atopic eczema. Yet intact
cows’ milk protein can increase the risk of eczema
in babies with a family history of allergy
A topic eczema causes skin Environmental factors, irritants Formula milks
to become itchy, red, dry such as scratchy woollen clothes,
and cracked. It often stress, heat and sweat can also Research has shown that infants
starts between the ages of two worsen symptoms. with a family history of allergy
and four months and affects who are fed infant formula milk
around one in five children. A GP will often be able to based on intact cows’ milk
diagnose atopic eczema by protein have double the risk
Symptoms assessing the child’s skin. of developing atopic eczema
compared to those who are
Common symptoms include Treatment breastfed.
patches of red, dry, itchy skin
on the cheeks, forehead and There is no cure for atopic Breastfeeding provides the best
scalp, behind the ears and in the eczema, but the condition often protection against allergy
creases of the neck, knees and improves as children get older. It development, but if exclusive
elbows. The condition can also is, however, important to manage breastfeeding is not possible, an
‘flare up’. When this happens, symptoms. An effective skincare infant formula milk (such as SMA
symptoms will worsen and the routine is a key part of controlling H.A. Infant Milk) that can help
skin can become infected. symptoms. Parents are advised to: reduce the risk of an infant
developing atopic eczema could
Causes • Bathe their infant using an be suitable. It should be used
from the first formula feed
The cause of eczema is unknown, emollient wash onwards, either in combination
but it tends to be common in with breast milk or on its own.
families that have a history of • Apply an emollient cream
eczema, hayfever, and asthma. An independent clinical study,
‘Atopic’ means sensitive to generously and frequently, the German Infant Nutritional
allergens. It may also be including after bathing, to relieve Intervention (GINI) study,
triggered by food allergies, dry skin. demonstrated that SMA H.A.
including an allergy to cows’ This is known as complete Infant Milk reduces the risk of
milk. Flare-ups may be triggered emollient therapy. developing atopic eczema by
by exposure to allergens such as over 50 per cent in the first year
house dust mites. A topical corticosteroid may be of life and has a sustained,
prescribed for use during flare- 10-year long-term effect.
ups, alongside emollients. This
will reduce redness and swelling
and is safe as long as it is used
as directed by a GP.
IMPORTANT
SMA H.A. Infant Milk should
not be used if a baby has
already been diagnosed
with, or is suspected of
having, an allergy to cows’
milk protein.
CHAPTER 4 SPECIALIST MILKS
Clinical summary:
According to NICE clinical guidelines, an steroids regularly for two consecutive days per
assessment of atopic eczema should consider the week rather than when needed
impact of the condition on quality of life and
wellbeing as well as the state of the skin, bearing • Localised bandaging – using either medicated
in mind that the two may not be directly related.
or dry dressings – over emollients can help treat
Management is stepped: flares or localised skin thickening. Whole body
wrapping, whether wet or dry, requires specialist
• Avoidance of trigger factors, which may include supervision
irritants, skin infections and contact, food and • Non-sedating antihistamines may be offered as
inhalant allergens. Inhalant allergy should be
considered in eczema associated with asthma a trial, where there is severe itching/uticaria. This
or allergic rhinitis and in children who experience should be reviewed regularly
seasonal exacerbations or have facial symptoms,
particularly around the eyes. Food allergy should • Sedating oral antihistamines are occasionally
be suspected in cases where other management
strategies have not worked and GI symptoms prescribed for seven to 14 days for children aged
(colic, vomiting, diarrhoea) or failure to thrive are six months or over if an acute flare is disturbing
present. A six- to eight-week trial of extensively sleep to the extent that it is having a significant
hydrolysed protein or amino acid formula in place impact on the child or parents.
of cow’s milk products may be appropriate
Potent topical corticosteroids are not usually
• Emollients used continuously, even when the prescribed for infants under one year of age,
and topical calcineurin inhibitors (tacrolimus,
skin is clear, for washing as well as moisturising pimecrolimus) are not recommended in children
the skin under two years of age.
• Topical corticosteroids, at the lowest effective Education is a core element of eczema
management. Important aspects to cover include
potency, applied only to areas of active atopic how much of each product to use and how often,
eczema. In children with frequent flare ups, when and how to step treatment up or down,
symptoms may be kept at bay by using topical and how to recognise infected eczema.
Faltering growth
Most babies lose weight after birth and then start regaining it at around two
weeks of age. However, faltering growth (or failure to thrive) is when a baby
does not gain weight at the expected rate
B reastfed babies tend to
gain more weight in the
first two months than
formula-fed babies – a trend that
reverses after this age.
A baby’s development –
particularly their brain “A baby’s
development – may be development –
affected if their particularly their
growth falters, which brain development
is why it’s vital that the – may be affected
problem is recognised if their growth
as quickly as possible. falters”
51
CHAPTER 4 SPECIALIST MILKS
How it’s recognised • Are having infant formula For formula-fed babies, special
milks may be prescribed. In all
Every baby’s weight should be milk that has been prepared cases, growth will need to be
regularly checked against growth incorrectly (e.g. it is too dilute). monitored carefully to ensure
charts or centiles. These compare it returns to normal as quickly
the baby’s weight, length and When weaning starts, infants as possible and also to prevent
head circumference with babies may not get enough calories undesirable excess weight gain.
of the same age and sex. and nutrients, particularly if they
Faltering growth is diagnosed: have too much fibre in their diet, Formula milks
which can fill them up.
• If a baby loses more than Infant formula milks for faltering
Persistent reflux, vomiting and growth are nutritionally
10 per cent of its birthweight cows’ milk protein allergy can complete, energy-dense formulas
or fails to regain its birthweight lead to faltering growth. There (e.g. SMA High Energy). They can
by day 14 are also medical conditions where be used for medically identified
food is not absorbed properly increased energy and nutrient
• If a baby’s weight slips two (e.g. coeliac disease), which can requirements, such as faltering
cause poor weight gain in babies. growth, disease-related
centiles or if it is consistently low malnutrition and malabsorption.
for two months. Treatment
These specialist formula milks
Causes Faltering growth needs to be can be used as the sole source
diagnosed by a GP or health of nutrition in babies from birth,
There are many reasons for visitor, who will recommend in older babies to complement
faltering growth, with feeding appropriate treatments or referral weaning, or mixed with foods
problems being the most to a paediatric dietitian. for babies up to 18 months. The
common. A baby may not be formulas have a protein:energy
taking in enough calories for For breastfed babies, the mother ratio close to that recommended
their development if they: may need to increase her calorie for catch-up growth and are
and nutrient intake and get help gentle on immature kidneys.
• Are not fed often enough with her breastfeeding technique.
• Have a problem feeding and
don’t get enough milk during
each feed
• Fall asleep before they’ve
had enough
Pre-term/low
birthweight babies
The phrase ‘pre-term’ applies to babies born before
37 weeks of pregnancy. Pre-term babies have minimal
body reserves of nutrients and immature body systems
A significant proportion Appropriate nutrition for pre-term both for new tissue development
of a baby’s weight gain babies is important to enable and for catch-up growth.
occurs between weeks growth at the same rate as a baby
36 and 40 of pregnancy. in the womb. Pre-term babies Pre-term babies will usually be in
Therefore pre-term babies, who have minimal body reserves of hospital and may need to be fed
are born before this stage of nutrients, and immature body intravenously (total parenteral
pregnancy, tend to have a lower systems (e.g. a lack of digestive nutrition – TPN) or via a tube
birthweight and will fall into one enzymes). This means they have (enteral nutrition) because babies
of the categories in the table on increased requirements for energy, born at less than 34 weeks are
page 53. protein, vitamins and minerals – unable to suck properly.
52
CHAPTER 4 SPECIALIST MILKS
Terminology Description which reduces the risk of
bacterial contamination, they
are for hospital use only.
Low birthweight (LBW) Birthweight < 2.5kg (5.5lbs) Post-discharge formulas
Very low birthweight Birthweight between 1kg
(VLBW) (2.2lbs) and 1.5kg (3.3lbs) There are no definitive guidelines
Extremely low Birthweight < 1kg (2.2lbs) on when a pre-term formula
birthweight (ELBW) should be discontinued. When
pre-term babies go home from
Breast milk fortifiers Suitable formulas hospital, they may still weigh less
than average full-term babies, so
Breast milk is the preferred form When breast milk cannot be will need to continue rapid
of feeding for pre-term babies used, an infant formula milk that growth.
because it provides nutritional, has been designed to meet the
immunological, gastrointestinal, needs of pre-term infants can be Formula-fed babies may switch
physiological and developmental used (e.g. SMA Pro Gold Prem 1, to a post-discharge formula such
benefits. It has been shown to Cow & Gate Nutriprem 1). These as Cow & Gate Nutriprem 2 or
have an impact on the long-term meet the latest guidelines on SMA Pro Gold Prem 2. These
health and development of pre- pre-term nutrition and contain provide additional nutrients for
term babies. Mums are the energy and nutrients pre-term infants and bridge the
encouraged to express their milk required by pre-term babies in a gap between specialist formulas
as soon as possible if they are not smaller volume than breast milk. and full-term infant formula
able to breastfeed, so the milk Available in ready-to-use bottles, milks. Available on prescription,
can be used for enteral feeding. they can be used until six months
corrected age.
Many pre-term babies – When to refer to the pharmacist
especially those who have a very
or extremely low birthweight – This chapter has covered basic information about the use of specialist
cannot tolerate large quantities milks. As these are used for specific conditions, it is likely that parents
of breast milk and may not will have already seen their GP or health visitor. However, you should
receive the nutrients they need. confirm this. Customers who ask for advice about the use of specialist
Breast milk fortifiers (e.g. SMA milks should be referred to the pharmacist or pharmacy technician.
Breast Milk Fortifier, Cow & Gate
Nutriprem Human Milk Fortifier) Foods for special medical purposes should only be used under medical
are powder supplements that supervision after full consideration of the feeding options, including
can be added to expressed or breastfeeding. They are suitable for use as the sole source of nutrition
donor breast milk to provide for infants from birth, and/or as part of a balanced diet from six to 12
calories, vitamins, minerals and months. Refer to labels for details.
protein. These are for hospital
use only.
CHAPTER 4 SPECIALIST MILKS
Ask the experts i
If a baby requires a specialist milk, parents may
have more questions than usual. Here’s what
our experts advise for these common queries
Q Which specialist milks are available Q What are the main differences
on prescription? between an allergy and intolerance?
And how does the treatment and advice
A Geraldine Goodman, community dietitian, differ accordingly?
Dietetic Department, Cumberland Infirmary,
says: “For babies with cows’ milk protein allergy A Registered nutritionist Dr Glenys Jones
there is a range of alternative hypoallergenic says: “Food allergies are thankfully
formulas available on prescription. Extensively rare, but occur when the body produces an
hydrolysed formulas contain proteins that have immune response to a food or ingredient.
been broken down into smaller segments and Therefore the offending food or foods need
these formulas are suitable for many babies to be avoided. These can produce symptoms
with an allergy. from itchy skin through to severe breathing
problems and anaphylaxis.
“For babies who do not tolerate these, it may
be necessary to use an amino acid formula. “Food intolerances are more common, and
Soya based formulas are not suitable as a first- arise due to factors such as insufficient enzyme
line choice in babies with cows’ milk protein production or reactions to compounds, such as
allergy.” histamine, that are naturally present in foods.
The response can take several hours or days to
Q If a parent wants additional develop, with symptoms including headaches,
information about specialist milks, diarrhoea and stomach pains. In many cases
what sources of help can I signpost people can continue to consume the food
them to? in reduced amounts before symptoms occur.
A Registered nutritionist Charlotte “The advice I would give in both cases is,
Stirling-Reed BSc (Hons) MSc, says: “NHS in the first instance, to get the parent to
Choices website (nhs.uk) is the best source speak to the doctor to determine whether
of information for mums on this topic. This a food allergy or intolerance exists. Then,
includes information on different formula milks moving forward, get a referral or support
and on cows’ milk intolerance. The First Steps from a dietitian to help with ensuring that
Nutrition Trust has also produced a document the parents have the correct advice to make
for HCPs on infant feeding milks in the UK.” sure the child has a well-balanced diet that
meets the needs of growth and development.
Tanya Thomas, BSc (Hons) RD freelance Remember, if an allergy or intolerance is
paediatric dietitian, adds: “There is a wealth diagnosed and alternative milks/formulas
of information on the internet. Many baby milk are needed, it can take a little while for
manufacturers provide information on their infants and children to get used to these,
products and the British Dietetic Association so do give these time. A dietitian can support
provides impartial advice on printable fact parents on encouraging take up or suggesting
sheets.” alternatives.”
54
CHAPTER 4 SPECIALIST MILKS
Training & CPD REFLECT PLAN
The following practice points and questions can be EVALUATE CCYPCDLE
used by individual members of the pharmacy team
and/or by the pharmacist for team training ACT
1 When a baby has across. Consider asking them: Once you know that a family has
a feeding problem, these issues, it is much easier to
whether it’s difficulty • How was the problem be a listening ear and provide the
latching on to the breast or necessary support.
getting used to a bottle, or a diagnosed? Have they seen
longer-term problem such as a GP about it? 2 Consider the following
colic, reflux or an allergy, it can scenarios and the
be very distressing for parents. • What did they feel like when advice that you could
offer. Consider what support is
Those who have a baby with the problem was diagnosed? available locally and where you
any of these problems will Were they thankful for the might signpost parents to. Also,
often feel anxious, isolated knowledge or did they worry what potential signs and
and in need of support. The about how they would cope? symptoms do you think you
pharmacy team is ideally placed would refer, and to whom?
to provide support, so it’s • How do they cope on a day-
important that you gain an • The parent of a three-month-
understanding of the anxieties to-day basis? Is their sleep
parents face when their baby disturbed? How does that affect old daughter who has moderate
has feeding problems, as well the parents’ performance at eczema
as how they cope and what work?
you can do to help. • A mum with a three-month-
• Has there been an effect on
Identify a parent you know who old baby affected by cows’ milk
has a baby with, say, colic, an family relationships? allergy
allergy or infant eczema. These
are likely to be the most common • How has the baby been since • A dad of a one-month-old
problems that you will come
he or she was diagnosed? baby who is experiencing
symptoms of reflux
• Has the parent been given
• A mum of a two-week-old
helpful advice and support?
In particular, ask the parent what baby with colic who looks
they would value from you and thoroughly exhausted.
your pharmacy in terms of
support. They may get a specialist
formula from the pharmacy, but
is there other equipment they
need?
CHAPTER 4 SPECIALIST MILKS
YOUR CPD Multiple choice questions
Pharmacists and technicians 1. W hich of the following advice statements would NOT be
– don’t forget to record your
CPD at: uptodate.org.uk suitable for a breastfeeding mum of a four-week-old baby
Reflection affected by colic?
• What specialist milks are a. She could try removing caffeine and spicy food from her
prescribed by local GPs
and/or stocked in your diet n
pharmacy?
• Are you confident to b. Wind the baby both during and after the feed n
discuss the uses of these
milks? c. Try topping up with a specifically designed formula feed n
Planning d. Reassure her that it should resolve by three to four months
• How will you research of age n
relevant support groups?
• Consider the available 2. W hat is the most suitable advice to give to the mum of n
resources and identify a three-month-old formula-fed baby who is affected by n
whether or not you need reflux? n
more information. n
a. Try feeding the baby less frequently, with larger feeds
Action b. Try omeprazole solution
c. Try soya milk
• Discuss specialist milks d. Try a thickened formula feed
with your team
• Ensure that you give 3. W hich if the following is NOT a red-flag symptom in a
appropriate advice on
feeding problems three-month-old baby with suspected gastroenteritis?
• Exercise caution with
parents who may have a. Stomach cramps n
diagnosed their baby’s
feeding problem without b. Neck stiffness n
asking a GP or health visitor
• Ensure your staff know c. A temperature of 38.5ºC n
the difference between
lactose intolerance and d. Abdominal distension n
cows’ milk protein allergy
and when to refer to you.
Evaluation 4. W hat key advice would you give to a pregnant woman who
• Look out for examples has eczema, and is worried that her baby will be affected?
of when you have applied
your learning in practice. a. She should use hypoallergenic bedding in the baby’s cot n
Want to complete b. A milk such as SMA H.A. Infant milk can be used from one
this test online?
Visit: tmmagazine.co.uk month of age n
c. Breastfeeding provides the best protection against allergy
development n
d. Signs of eczema will appear when the baby is around five
months old n
5. When discussing her baby’s feeding, a mother is n
concerned about her two-month-old’s diarrhoea and n
eczema. She is using a combination of breastfeeding
and bottle-feeding, giving one bottle in the evening. n
What could be an issue, and what advice is the most n
appropriate?
a. It could be a cows’ milk allergy, she should try an amino-
acid based formula milk
b. It could be lactose intolerance, try a lactose-free formula
c. It could be a reaction to foods she is eating passing into
the milk, try altering her diet by removing dairy products,
to see if that helps
d. It could be a cows’ milk allergy, refer her to the GP for
a diagnosis
56
INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY
BREASTFEEDING IS BEST FOR BABIES
Introducing new NEW
ADVANCED
FORMULA
SMA® PRO Anti-Reflux
Unique combination of easily
digestible starch and 100% whey,
partially hydrolysed protein
New, easier preparation
2015 NICE guidelines recommend
trial of a thickened formula in
formula-fed infants with GOR1*†
Available from June 2017,
in retail only
For babies currently using SMA Staydown®, this
product can be used in its place. SMA Staydown
will remain available on prescription for a further
few months.
Learn more about the SMA® Nutrition Specialist Range at Supporting you
to support parents
www.smahcp.co.uk
www.smahcp.ie
SMA Careline UK: 0800 0 81 81 80
ROI: 1800 931 832
IMPORTANT NOTICE: Breast milk is best for babies and breastfeeding should continue for as long as possible.
This product must be used under medical supervision. SMA PRO Anti-Reflux is a special formula intended
for the dietary management of bottle-fed babies when significant reflux (regurgitation) is a problem. It is
suitable as the sole source of nutrition up to 6 months of age, and in conjunction with solid food up to 12 months
of age. If the baby’s reflux does not improve within 2 weeks of starting SMA PRO Anti-Reflux, or if the baby
fails to thrive, the family doctor should be consulted.
Reference:
1. National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease in children and young people. NICE, 2015.
*GOR: Gastroesophageal reflux †As part of a stepped care approach
®Registered trademark SMA® Nutrition UK and Ireland NWHS003 ZTC1765/04/17
CHAPTER 4 SPECIALIST MILKS
COLIC & CONSTIPATION
Aptamil Comfort Nutricia Early Life Nutrition
For the dietary management Features Nutrition information:
of colic and constipation.
3 P artially hydrolysed proteins Per 100ml prepared feed:
3 Structured vegetable fat
3 Reduced lactose Energy 275kJ
3 U nique blend of galacto-
(66kcal)
and fructo-oligosaccharides
3 Contains LCPs (AA/DHA) Fat 3.4g
3 Contains nucleotides
3 Easy to digest Saturates 1.5g
3 Nutritionally complete
Unsaturates 1.9g
Suitable for:
LCPs 0.020g
3 B abies from birth to one year
with colic and/or constipation Arachidonic acid (AA) 0.011g
Available as: Docosahexaenoic acid (DHA) 0.006g
3 9 00g powder (PIP code: 328-7273) Carbohydrate 7.2g
Sugars 3.3g
Lactose 2.7g
Fibre 0.6g
Protein 1.5g
Whey 1.5g
(100%)
Salt 0.05g
Food for Special Medical Purposes. Should be used on the advice of a healthcare professional such as a pharmacist or pharmacy technician.
Cow & Gate Comfort Nutricia Early Life Nutrition
For the dietary management Features Nutrition information:
of colic and constipation.
3 Easy to digest Per 100ml prepared feed:
3 Reduced lactose
3 C ontains LCPs and Energy 275kJ
oligosaccharides (66kcal)
3 Contains nucleotides
3 P artially hydrolysed proteins Fat 3.4g
Suitable for: Saturates 1.5g
3 B abies from birth to one year Unsaturates 1.9g
with colic and/or constipation
LCPs 0.020g
Available as:
Arachidonic acid (AA) 0.011g
3 9 00g powder (PIP code:
310-5756) Docosahexaenoic acid (DHA) 0.006g
Carbohydrate 7.2g
Sugars 3.3g
Lactose 2.7g
Fibre 0.6g
Protein 1.5g
Whey 1.5g
Food for Special Medical Purposes. Should be used on the advice of a healthcare (100%)
professional such as a pharmacist or pharmacy technician.
Salt 0.05g
HiPP Combiotic Comfort HiPP UK
For the dietary management Features Available as:
of colic and constipation. 3 N utritionally complete formula
3 800g powder
3 Reduced lactose
3 Hydrolysed protein
3 S pecial fat blend Nutrition information:
Per 100ml prepared feed:
3 C ontains omega-3 and 6 LCPs
(AA and DHA) Energy 280kJ
3 C ontains a source of prebiotic (67kcal)
oligosaccharides Fat 3.5g
Saturates 1.6g
Suitable for: Unsaturates 1.9g
3 B abies from birth onwards LCPs 16mg
as a sole source of nutrition
Carbohydrate 7.1g
3 U se as part of a varied weaning
diet from six months Sugars 3.0g
N.B. Not suitable for parenteral Lactose 2.7g
use or for babies who are allergic
to cows’ milk Fibre 0.3g
Food for Special Medical Purposes. Protein 1.6g
Should be used under medical
supervision. Whey 100%
Salt 0.06g
58
CHAPTER 4 SPECIALIST MILKS
COLIC & CONSTIPATION/REFLUX
SMA Comfort Easy to Digest Infant Milk SMA Nutrition
Easy to digest milk, Features Available as:
designed to be gentle
on babies’ tummies. 3 Nutritionally complete 3 8 00g powder (PIP code:
3 Partially hydrolysed 100% 370-8625)
whey protein Nutrition information:
3 F at blend enriched with
Per 100ml prepared feed:
SN-2 palmitate
3 Reduced lactose Energy 280kJ
3 O mega-3 and 6 LCPs
3 Contains nucleotides (67kcal)
3 E asy to digest
3 N o need to use fast flow teat Fat 3.6g
3 A vailable on Healthy Start
Saturates 1.6g
Scheme
Unsaturates 2g
Suitable for:
Beta-palmitate 340mg
3 B abies from birth
3 Vegetarians LCPs 19.4mg
3 Halal
Arachidonic acid (AA) 12.3mg
Docosahexaenoic acid (DHA) 7.1mg
Carbohydrate 7.1g
Sugars 4.5g
Lactose 3.9g
Protein 1.6g
Whey 100%
Aptamil Anti-Reflux Nutricia Early Life Nutrition
For the dietary management Features Nutrition information:
of reflux and regurgitation.
3 F ormulated with carob bean Per 100ml prepared feed:
gum for greater viscosity in
the stomach Energy 275kJ
3 Contains LCPs and nucleotides (66kcal)
3 Nutritionally complete
3 Thickened formula Fat 3.5g
Saturates 1.5g
Unsaturates 2.0g
Suitable for: LCPs 0.021g
3 B abies from birth to one year Arachidonic acid (AA) 0.012g
with frequent reflux and
regurgitation Docosahexaenoic acid (DHA) 0.007g
Carbohydrate 6.8g
Sugars 6.1g
Lactose 6.0g
Available as: Fibre 0.4g
3 9 00g powder (PIP code: Protein 1.6g
376-3232)
Whey 0.3g
Casein 1.3g
Food for Special Medical Purposes. Should be used on the advice of a healthcare Salt 0.06g
professional such as a pharmacist or pharmacy technician.
Cow & Gate Anti-Reflux Nutricia Early Life Nutrition
For the dietary management Features Nutrition information:
of reflux and regurgitation.
3 Thickened formula Per 100ml prepared feed:
3 Contains LCPs and nucleotides
3 Nutritionally complete Energy 275kJ
Suitable for: (66kcal)
3 B abies from birth to one year Fat 3.5g
with frequent reflux and
regurgitation Saturates 1.5g
Available as: Unsaturates 2g
3 9 00g powder (PIP code: LCPs 0.021g
376-4990)
Arachidonic acid (AA) 0.012g
Docosahexaenoic acid (DHA) 0.007g
Carbohydrate 6.8g
Sugars 6.1g
Lactose 6g
Fibre 0.4g
Protein 1.6g
Whey 0.3g
Casein 1.3g
Food for Special Medical Purposes. Should be used on the advice of a healthcare Salt 0.06g
professional such as a pharmacist or pharmacy technician.
59
CHAPTER 4 SPECIALIST MILKS
REFLUX
Cow & Gate Instant Carobel Nutricia Early Life Nutrition
For use as a gelling or Features Nutrition information:
thickening agent for the
dietary management of 3 Milk-free Per 100g powder:
reflux or regurgitation. 3 Gluten-free
3 Lactose-free Energy 1345kJ
3 C an be spoon fed as a paste
(318kcal)
or directly added to liquids
Fat 0.3g
Suitable for:
Carbohydrate 66.2g
3 Infants, children and adults
3 B reastfed and bottle-fed Sugars 6g
infants Lactose 0g
Available as: Fibre 25.1g
3 1 35g powder (PIP code: Protein 0g
246-9450)
Salt 0.015g
Food for Special Medical Purposes. Should be
used on the advice of a healthcare professional
such as a pharmacist or pharmacy technician.
HiPP Organic Combiotic Anti-Reflux HiPP UK
For the dietary management Features Available as:
of reflux and regurgitation.
3 Nutritionally complete 3 800g powder
Food for Special Medical Purposes. Should formula
only be used under medical supervision. Nutrition information:
3 T hickened milk formula –
thickened with carob bean Per 100ml prepared feed:
gum
Energy 279kJ
3 Certified organic
3 C ontains omega-3 and 6 LCPs (67kcal)
(AA and DHA) Fat 3.5g
Suitable for: Saturates 1.1g
3 B abies from birth onwards Unsaturates 2.4g
as a sole source of nutrition
LCPs 16mg
3 U se as part of a varied
weaning diet from six months Carbohydrate 7.1g
N.B. Not suitable for parenteral Sugars 6.3g
use or for babies who are
allergic to cows’ milk Lactose 6.2g
Protein 1.4g
Whey:Casein 60:40
Salt 0.05g
SMA PRO Anti-Reflux SMA Nutrition
For the dietary Features Available:
management of reflux
and regurgitation. 3 Dual action. Unique 3 F rom June 2017 in retail
combination of starch 3 Current SMA Staydown
and 100% whey, partially will remain available on
hydrolysed protein prescription for a few more
3 C ontains easily digestible months (PIP code: 286-7588).
potato starch Nutrition information:
3 T he only 100% whey anti-
Per 100ml prepared feed:
reflux formula in the UK
and Ireland Energy 280kJ
3 Lowest protein anti-reflux
formula in UK and Ireland, (67kcal)
with 1.3g of protein/100ml
3 New easier preparation Fat 3.4g
3 Nutritionally complete
3 Thicker formula, may require Saturates 1g
fast flow teat
Unsaturates 2.4g
Suitable for:
Carbohydrate 7.8g
3 B abies from birth with reflux,
who bring back their feeds Sugars 5.1g
Lactose 5.1g
Starch 2.7g
Protein 1.3g
Whey 1.3g
(100%)
Food for Special Medical Purposes. Should be used on the advice of a healthcare professional such as a pharmacist or pharmacy technician.
60
CHAPTER 4 SPECIALIST MILKS
REDUCTION OF RISK TO ALLERGY/
ALLERGIES & INTOLERANCE
SMA H.A. Infant Milk SMA Nutrition
For babies with a family Features Nutrition information:
history of allergy.
3 Clinically proven to reduce Per 100ml prepared feed:
A healthcare professional should the risk of eczema by over
be consulted before use. 50% in babies with a family Energy 280kJ
history of allergy (one or more
parents or sibling) (67kcal)
3 Nutritionally complete
3 Use from first formula feed Fat 3.4g
3 Omega-3 and 6 LCPs (AA and DHA)
3 Easy to digest Saturates 1.0g
Suitable for: Unsaturates 2.4g
3 Babies from birth LCPs 16mg
Available as: Arachidonic acid (AA) 8mg
3 8 00g powder (PIP code: 378-5912) Docosahexaenoic acid (DHA) 8mg
Carbohydrate 7.8g
Sugars 7.8g
Lactose 7.8g
Protein 1.3g
Whey 1.3g
SMA H.A. Infant Milk should NOT be used if a baby has already been diagnosed with allergy to cows’ milk proteins or is suspected of already
having an allergy to cows’ milk proteins. SMA H.A. Infant Milk should be used as the first formula feed, before babies have been exposed to
intact cows’ milk proteins.
Aptamil Lactose Free Nutricia Early Life Nutrition
For the dietary management Features Nutrition information:
of lactose intolerance.
3 F ree from lactose and sucrose Per 100ml prepared feed:
3 Contains LCPs
3 C ontains nucleotides Energy 275kJ
3 Enriched with iron
(66kcal)
Suitable for:
Fat 3.5g
3 B abies from birth
Saturates 1.4g
Available as:
Unsaturates 2.1g
3 400g powder (PIP code:
386-7439) LCPs 0.021g
Arachidonic acid (AA) 0.012g
Docosahexaenoic acid (DHA) 0.007g
Carbohydrate 7.3g
Sugars 1.1g
Lactose <0.006g
Fibre 0g
Protein 1.3g
Casein 1.3g
Food for Special Medical Purposes. Should be used on the advice of a healthcare (100%)
professional such as a pharmacist or pharmacy technician.
Salt 0.04g
Aptamil Pepti 1 Nutricia Early Life Nutrition
For the dietary management Features Nutrition information:
of cows’ milk allergy.
3 Extensively hydrolysed Per 100ml prepared feed:
Food for Special Medical Purposes. whey-based formula
To be used under medical supervision. Energy 280kJ
N.B. Now listed as Aptamil Pepti 1 on 3 Nutritionally complete
EMIS and other prescribing systems 3 C ontains galacto- and (67kcal)
(previously Milupa Aptamil Pepti 1).
fructo-oligosaccharides Fat 3.5g
3 Contains LCPs (AA and DHA)
3 Contains nucleotides Saturates 1.6g
Suitable for: Unsaturates 1.9g
3 Babies from birth with cows’ LCPs 0.027g
milk allergy
Arachidonic acid (AA) 0.012g
Available as:
Docosahexaenoic acid (DHA) 0.011g
3 4 00g (PIP code: 346-5689)
and 800g powder (PIP code: Carbohydrate 7.0g
391-8976)
Sugars 3.4g
Lactose 2.9g
Fibre 0.6g
Protein 1.6g
Whey 1.6g
(100%)
Salt 0.05g
61
CHAPTER 4 SPECIALIST MILKS
ALLERGIES & INTOLERANCE
Aptamil Pepti 2 Nutricia Early Life Nutrition
For the dietary management Features Nutrition information:
of cows’ milk allergy.
3 E xtensively hydrolysed Per 100ml prepared feed:
whey-based formula
Energy 285kJ
3 C omplements a cows’ milk-free
weaning diet from six months (68kcal)
3 C ontains galacto- and Fat 3.1g
fructo-oligosaccharides
Saturates 1.4g
3 C ontains LCPs (AA and DHA)
3 Contains nucleotides Unsaturates 1.7g
3 Enriched with calcium and iron
LCPs 0.021g
Arachidonic acid (AA) 0.009g
Docosahexaenoic acid (DHA) 0.009g
Suitable for: Carbohydrate 8.1g
3 Infants from six months with Sugars 3.6g
cows’ milk allergy
Lactose 2.9g
Fibre 0.6g
Food for Special Medical Purposes. Available as: Protein 1.6g
To be used under medical supervision.
N.B. Now listed as Aptamil Pepti 2 on EMIS 3 4 00g (PIP code: 391-8950) Whey 1.6g
and other prescribing systems (previously and 800g (PIP code: 391-8968)
Milupa Aptamil Pepti 2). powder (100%)
Salt 0.06g
Neocate LCP Nutricia Advanced Medical Nutrition
A hypoallergenic amino Features Nutrition information:
acid-based formula for
infants with CMA, MFPA 3 100% free amino acids Per 100ml prepared feed:
or those who require an 3 Considered non-allergenic
amino acid-based formula. 3 Contains LCPs and nucleotides Energy 279kJ
3 Halal and Kosher certified
(67kcal)
Suitable for:
Fat 3.4g
3 Babies from birth onwards
with cows’ milk allergy Saturates 1.2g
(CMA), multiple food protein
allergies (MFPA), or another Monounsaturates 1.3g
condition where an amino
acid-based formula is required Polyunsaturates 0.66g
Available as: Carbohydrate 7.2g
3 4 00g tin (PIP code: 329-0301) Sugars 0.65g
Fibre 0g
Protein 1.8g
Food for Special Medical Purposes.
Must be used under medical supervision.
Neocate Spoon Nutricia Advanced Medical Nutrition
A unique hypoallergenic Features Available as:
spoonable product
designed to supplement 3 1 00% free amino acids 3 Box of 15x37g sachets
the nutritional intake of 3 Unique spoonable consistency (PIP code: 365-7244)
infants with CMA or MFPA. 3 Added calcium, phosphorous
Nutrition information:
and iron
3 C an be mixed with other Per serving:
foods Energy 733kJ
3 Kosher certified
(175kcal)
Suitable for:
Fat 7g
3 Babies from weaning (six
months) and young children Saturates 2.6g
who have cows’ milk allergy
(CMA), multiple food protein Monounsaturates 2.8g
allergy (MFPA), or another
condition where an amino Polyunsaturates 1.3g
acid-based formula is required
Carbohydrate 24.9g
Sugars 4.6g
Fibre 0g
Protein 3g
Food for Special Medical Purposes.
Must be used under medical supervision.
62
CHAPTER 4 SPECIALIST MILKS
ALLERGIES & INTOLERANCE
Neocate Junior* Nutricia Advanced Medical Nutrition
A hypoallergenic formula Features Available as:
for children over the age of
one year with CMA, MFPA, 3 100% free amino acids 3 4 00g tin (PIP codes:
or those who require an 3 T ailored nutrition Unflavoured 404-2545 /
amino acid-based formula. 3 S ingle solution for oral Strawberry 404-2560 / Vanilla
404-2552)
Food for Special Medical Purposes. or tube feeding
Must be used under medical supervision. 3 F lexible concentration Nutrition information:
3 Available in unflavoured,
Per 100ml prepared feed:
strawberry or vanilla flavours
3 Halal certified Energy 420kJ
Suitable for: (100kcal)
3 C hildren over the age of one Fat 4.6g
year with cows’ milk allergy
(CMA), multiple food protein Saturates 2.0g
allergy (MFPA), or other
conditions where an amino Monounsaturates 1.6g
acid-based formula is required
Polyunsaturates 0.8g
Carbohydrate 12g
Sugars 1.1g
Fibre 0g
Protein 2.8g
Neocate Active* Nutricia Advanced Medical Nutrition
A hypoallergenic formula Features Available as:
for children over the age of
one year with CMA, MFPA, 3 1 00% free amino acids 3 B ox of 15x63g sachets
or those who require an 3 Two sachets meets iron (PIP codes: Unflavoured 326-
amino acid-based formula. 3886 / Blackcurrant 326-3878)
and calcium requirements
Food for Special Medical Purposes. (reference nutrient intake) Nutrition information:
Must be used under medical supervision. 3 Available in unflavoured
or blackcurrant flavours Per 100ml prepared feed:
3 Kosher certified
3 U se as an oral feed Energy 418kJ
Suitable for: (100kcal)
3 Children over the age of one Fat 4.8g
year with cows’ milk allergy
(CMA), multiple food protein Saturates 1.8g
allergy (MFPA), or another
condition where an amino Monounsaturates 1.9g
acid-based formula is required
Polyunsaturates 0.9g
Carbohydrate 11.3g
Sugars 1.0g
Fibre 0g
Protein 2.8g
Neocate Advance* Nutricia Advanced Medical Nutrition
A hypoallergenic formula Features Available as:
suitable as a sole source
of nutrition in children 3 1 00% free amino acids 3 B ox of Unflavoured 10x100g
with CMA or MFPA or 3 35% medium chain sachets (PIP code: 264-1298)
those who require an
amino acid-based formula. triglycerides (MCT) 3 B ox of Banana-Vanilla 15x50g
3 A vailable in unflavoured sachets (PIP code: 290-5727)
Food for Special Medical Purposes.
Must be used under medical supervision. or banana-vanilla flavours Nutrition information:
3 Halal and Kosher certified
3 Use as an oral or tube feed Per 100ml prepared feed:
Suitable for: Energy 420kJ
3 Sole source of nutrition for (100kcal)
children from one to 10 years
with cows’ milk allergy (CMA), Fat 3.5g
multiple food protein allergy
(MFPA), or other conditions Saturates 1.3g
where an amino-acid based
formula is indicated Monounsaturates 1.5g
Polyunsaturates 0.5g
MCT 35%
Carbohydrate 14.6g
Sugars 1.3g
Fibre 0g
Protein 2.5g
63 *N.B. Neocate Junior will replace Neocate Active and
Neocate Advance over a period of 12 months, from
April 2017 to April 2018.
CHAPTER 4 SPECIALIST MILKS
ALLERGIES & INTOLERANCE
Cow & Gate Pepti-Junior Nutricia Early Life Nutrition
For the dietary Features Nutrition information:
management of
malabsorption. 3 E xtensively hydrolysed Per 100ml prepared feed:
whey-based formula
Energy 275kJ
3 50% medium chain
triglycerides (MCT) (66kcal)
3 Low osmolality Fat 3.5g
Suitable for: Saturates 1.9g
3 Babies from birth with Unsaturates 1.6g
malabsorption
LCPs 0.016g
Available:
Arachidonic acid (AA) 0.007g
3 As 450g powder (PIP code:
049-0714) Docosahexaenoic acid (DHA) 0.007g
3 On prescription MCT 1.6g
Carbohydrate 6.8g
Sugars 1g
Lactose 0.06g
Fibre 0g
Protein 1.8g
Food for Special Medical Purposes. To be used under medical supervision. Salt 0.05g
SMA Alfamino Nestle Health Science
An amino acid formula for Features Available as:
the dietary management of
complex cows’ milk allergy 3 Hypoallergenic 100% amino 3 400g powder (PIP code: 385-6416)
and/or multiple food acid-based formula suitable
allergies. for all cases of CMA Nutrition information:
3 Nutritionally complete Per 100ml prepared feed:
3 Nutritional profile for
Energy 293KJ
a better taste1,2
3 With DHA and AA (70Kcal)
3 Added MCT and a low
osmolality* to support Fat 3.4g
disorders of digestion3,4
Saturates 1.3g
Suitable for:
Monounsaturates 1.3g
3 Complete nutritional support
from birth or supplementary Polyunsaturates 0.63g
feeding from six months and
up to three years LCPs 14mg
Arachidonic acid (AA) 7mg
Docosahexaenoic acid (DHA) 7mg
MCT 0.84g
Carbohydrate 7.9g
Sugars 0.56g
Protein 1.9g
Food for Special Medical Purposes. Must be used under medical supervision. Salt = Na (g) x 2.5 0.063g
SMA Althéra Nestle Health Science
An extensively hydrolysed Features Nutrition information:
whey-based formula for the 3 The most extensively Per 100ml prepared feed:
hydrolysed formula in the UK
dietary management of mild for greater hypoallergenicity5,6 Energy 280KJ
to moderate cows’ milk allergy 3 Nutritionally complete
and/or multiple food allergies. 3 N utritional profile for a better (67Kcal)
Fat 3.4g
taste7,8 Saturates 1.3g
3 With DHA and AA Monounsaturates 1.3g
Polyunsaturates 0.57g
Suitable for: LCPs 14.8mg
3 Complete nutritional support Arachidonic acid (AA) 7.4mg
Docosahexaenoic acid (DHA) 7.4mg
from birth or supplementary Carbohydrate 7.3g
feeding from six months and Sugars 4g
up to three years Lactose 3.8g
Available as: Protein 1.7g
Salt = Na (g) x 2.5 0.05g
3 450g powder (PIP code: 378-7413)
Food for Special Medical Purposes. Must be used under medical supervision.
64
CHAPTER 4 SPECIALIST MILKS
ALLERGIES & INTOLERANCE / PRETERM
SMA LF Lactose Free Formula SMA Nutrition
For babies with lactose Features Nutrition information:
intolerance. 3 Specially tailored, nutritionally Per 100ml prepared feed:
complete, lactose-free formula
Food for Special Medical Purposes. Should 3 Contains omega-3 and 6 LCPs Energy 281kJ
be used on the advice of a healthcare 3 Contains nucleotides
professional such as a pharmacist or 3 Fortified with iron to support (67kcal)
pharmacy technician.
normal cognitive development Fat 3.6g
3 T he only whey dominant LF
Saturates 1.4g
available in UK and Ireland**
Unsaturates 2g
LCPs 19.4mg
Arachidonic acid (AA) 12.3mg
Suitable for: Docosahexaenoic acid (DHA) 7.1mg
3 B abies from birth with a primary Carbohydrate 7.2g
or secondary lactose intolerance Sugars 2.6g
Lactose <0.007g
3 V egetarians and Halal Protein 1.5g
Available: Whey 0.9g
Casein 0.6g
3 A s 430g powder (PIP code: 240-4127) **As per Department of Health guidelines.
3 On prescription
SMA Wysoy Soya Infant Formula SMA Nutrition
The only soya-based infant Features Nutrition information:
formula for babies with
cows’ milk protein allergy, 3 A lternative protein source Per 100ml prepared feed:
galactosaemia, and to cows’ milk protein
galactokinase Energy 281kJ
deficiency. 3 N utritionally complete
3 Good palatability (67kcal)
A healthcare 3 L actose-free and sucrose-free
professional 3 Omega-3 and 6 LCPs Fat 3.6g
should be
consulted Suitable for: Saturates 1.4g
before use.
3 Vegetarians Unsaturates 2g
3 H alal
LCPs 19.4mg
Available:
Arachidonic acid (AA) 12.3mg
3 A s 860g powder (PIP code:
022-2489) Docosahexaenoic acid (DHA) 7.1mg
3 On prescription Carbohydrate 6.9g
Sugars 2.5g
Lactose 0g
Protein 1.8g
Department of Health advice: Soya formulas should not be used as a first line for infants with proven cows’ milk allergy, lactose intolerance,
galactokinase deficiency and galactosaemia. Soya-based formulas may pose health risks for babies under six months of age because they
contain phytoestrogens. Soya can be used in exceptional circumstances to ensure adequate nutrition where alternatives are unacceptable.
Cow & Gate Nutriprem 2 Nutricia Early Life Nutrition
For the dietary management Features Nutrition information:
of preterm and low
birthweight babies when 3 Nutritionally tailored formula Per 100ml prepared feed:†
discharged from hospital. 3 N utrient rich to support
Energy 315kJ
Food for Special Medical Purposes. catch-up growth until six
Must be used under medical supervision. months corrected age (75kcal)
3 Contains GOS/FOS, LCPs
and nucleotides Fat 4g
Suitable for: Saturates 1.7g
3 For the dietary management Unsaturates 2.3g
of preterm and low
birthweight babies when LCPs 0.034g
discharged from hospital.
Arachidonic acid (AA) 0.017g
Available:
Docosahexaenoic acid (DHA) 0.013g
3 900g powder (PIP code:
272-4409) and 200ml liquid Carbohydrate 7.5g
(PIP code: 312-6752)
Sugars 6.3g
3 On prescription
Lactose 5.9g
Fibre 0.6g
Protein 2g
Whey 1.2g
(60%)
Casein 0.8g
(40%)
Salt 0.07g
65 †All nutrition information is based on the powder format.
There may be slight variations in the ready-to-feed formats.
CHAPTER 4 SPECIALIST MILKS
PRETERM / HIGH ENERGY
SMA PRO Gold Prem 2 Post-discharge Formula SMA Nutrition
For preterm and low Features Available:
birthweight babies when
discharged from hospital. 3 Contains higher protein than 3 A s 400g powder (PIP code:
a standard formula to help 345-3297) and 200ml liquid
promote catch-up growth (PIP code: 371-0530)
3 100% whey, partially 3 On prescription
hydrolysed protein
Nutrition information:
3 Contains fat blend enriched
with SN-2 palmitate Per 100ml prepared feed:†
3 L owest osmolality of all UK Energy 305kJ
and Ireland post-discharge
formulas – 290 mOsmol/kg (73kcal)
H2O9
Fat 3.8g
Suitable for:
Saturates 1g
3 P reterm and low birthweight
infants up to six months Unsaturates 2.8g
corrected age, for use on
discharge from hospital LCPs 28.8mg
Arachidonic acid (AA) 14.4mg
Docosahexaenoic acid (DHA) 14.4mg
Carbohydrate 7.7g
Sugars 5.5g
Lactose 5.3g
Protein 2g
Food for Special Medical Purposes. Should be used on the advice of a healthcare Whey 2g
professional such as a pharmacist or pharmacy technician.
(100%)
SMA PRO High Energy SMA Nutrition
For infants and young Features Nutrition information:
children with medically
identified increased 3 Nutritionally complete, Per 100ml ready-to-use feed:
energy and nutritional nutrient-dense formula
requirements. 3 100% whey, partially Energy 414kJ
hydrolysed protein
3 Contains a fat blend enriched (99kcal)
with SN-2 palmitate
3 Clinically proven to be well Fat 5.4g
tolerated10
3 Contains omega-3 and 6 LCPs Saturates 1.8g
Suitable for: Unsaturates 3.6g
3 Infants and young children LCPs 40mg
from birth to 18 months with
medically identified increased Arachidonic acid (AA) 20mg
energy and nutrient needs
Docosahexaenoic acid (DHA) 20mg
Available:
Carbohydrate 10g
3 A s 200ml carton (PIP code:
253-3693) Sugars 6.5g
3 On prescription Lactose 6.4g
Protein 2.6g
Whey 2.6g
(100%)
Food for Special Medical Purposes. Should
be used on the advice of a healthcare
professional such as a pharmacist or
pharmacy technician.
References:
1. Alfamino versus Neocate LCP. Independent benchmark testing (data on file)
2. Alfamino versus Puramino. Independent benchmark testing (data on file)
3. Bach, AC. & Babayan, VK. (1982). AM J Clin Nutr, 36: 950-962
4. Shaw, V & Lawsom, M. (2007). Clinical Paedeatric Dietetics, 3rd eds V. Shaw & M. Lawson, 3-20.
Oxford: Blackwell Publishing
5. Luyt. D et al. Clinical & Experimental Allergy 2014. 44: 642-672
6. Rapp et al. Clin Transl Allergy 2013; 3 (suppl 3):132
7. Althéra versus Nutramigen. Independent benchmark testing (data on file)
8. Althéra versus Similac Alimentum. Independent benchmark testing (data on file)
9. Data is correct as per SMA PRO Gold Prem 2 and Cow & Gate Nutriprem 2 datacards (August 2016)
10. Lama More RA et al. Poster presentation at LASPGHAN 26-29 March 2014.
* Low osmolality compared with Neocate LCP & Puramino as per data cards (April 2017).
†All nutrition information is based on the powder format. 66
There may be slight variations in the ready-to-feed formats.
95% of Paediatricians* reported an improvement in common infant
feeding problems with a formula like Cow & Gate Comfort1
Evidence shows these partially-hydrolysed formula milks containing oligosaccharides
(GOS/FOS) improve the symptoms of colic in bottle-fed babies.1,2 So if a bottle-fed
baby’s colic is more than mum can manage with practical tips alone, put digestive
care first with Cow & Gate Comfort.
Learn more about the evidence-based management of colic at in-practice.co.uk
*Out of 96 paediatricians Comfort for babies, relief for mums
References: 1. Savino F et al. Acta Pediatr Suppl 2003; 441: 86–90.
2. Savino F et al. Eur J Clin Nutr 2006; 60: 1304–1310.
CHAPTER 5 6-12 MONTHS
Babies aged After reading this
6-12 months chapter, you will have a
better understanding of:
From the age of six months, babies’
nutritional requirements change to meet • Follow-on milks for
their bodies’ growing
demands. Solid food babies aged 6-12 months
starts to play
a role and • How follow-on milks differ
follow-on
milks can from infant formula milks
help to and cows’ milk.
bridge any
dietary gaps
H ealthy babies will Follow-on milks met by follow-on milk
approximately triple
their birthweight by Follow-on milks can be given to • Key vitamins and minerals (e.g.
babies from six months of age to vitamins A, C, D, E, calcium and
zinc) are included because they
12 months of age, but to do this complement a healthy weaning are important for healthy
development at this age
they need to consume energy- diet. At this age, follow-on milks
• Many also contain
rich and nutrient-dense foods can be used as the main drink
oligosaccharides and nucleotides
that are high in fat and low in and when preparing foods for the development of a healthy
gut and immune system.
fibre so that they don’t feel full containing milk. They contain a
IMPORTANT
too quickly. higher level of some key nutrients
Follow-on milks are intended
than infant formula milks, such to complement a weaning
diet and should not be used
The Department of as iron and vitamin D, to as the only source of nutrition.
However, as milk is still an
Health recommends help meet the needs important source of nutrition
at this stage in a baby’s
that full fat cows’ “From six of infants at this age development, follow-on milks
milk should not be months of age, on a weaning diet. can act as a nutritional ‘safety
given to babies as parents should be net’ – reassuring parents if
a drink until 12 encouraging their Follow-on milks babies seem fussy or go
months of age baby to drink from are manufactured through a difficult eating stage.
because of its low a lidded cup or by modifying
iron and high cows’ milk:
sodium and protein beaker”
• The whey:casein
content; however, it ratio is altered
can be used in food
• Iron is added because
recipes. Infant formula milk and a baby’s stores of iron will have
follow-on milk are therefore the reduced by about six months
only appropriate alternatives to of age, when weaning is first
breast milk for bottle-fed babies started. A significant proportion
before 12 months. of a baby’s iron needs can be
68
CHAPTER 5 6-12 MONTHS
Top tips for introducing a cup
• A lidded beaker without a valve is best. Valves, like bottles, require babies to suck – the habit
we are trying to break by introducing a cup
• When drinks are offered in a cup, all bottles should be kept out of the baby’s sight
• Initially, it’s best to offer the cup with one meal in the day when the baby is not tired
• Ensure the baby is seated upright, at a table or in a highchair, before offering a cup so that
they are in a good drinking position
• Once they are used to one cup a day, others can gradually be introduced
• The bottle that the baby is most reliant on (often the one at bedtime) should be replaced last.
Preparing feeds bacteria and is still a potential free-flow cup without a valve as
source of infection for babies this will help the baby learn to sip
As with infant formula milk, in this age group, bottles and rather than suck, which is better
follow-on milk should be made teats should continue to be for the teeth.
up as it is required, rather than sterilised until the baby’s first
in batches. This is because of birthday. Comfort sucking on sweetened
possible bacterial growth in the drinks is the biggest cause of
milk during storage. It is Once a baby is using a cup, this tooth decay in young children.
therefore important that parents doesn’t need to be sterilised, but When using a bottle or trainer
follow the instructions on how to simply requires careful washing cup, nothing other than infant
make up a feed, as covered in in hot, soapy water before being formula milk, breast milk or water
Chapter 2 (page 19). rinsed thoroughly in clean, should be put into it.
running water. Alternatively, it
You should also remind parents can be washed in a dishwasher. Advise parents that they may
of how important it is to use need to try a few cups before
boiled water that has only been Moving from bottle to cup finding one that suits their baby.
allowed to cool for 30 minutes. By 12 months of age, babies
This will ensure that it is at the From six months of age, parents should have stopped using
required minimum temperature should encourage their baby to bottles with teats.
of 70°C. drink from an open cup or a
Keep sterilising! Example on-pack feeding guide*
Since milk provides ideal 1 scoop = approximately 4.5g powder
conditions for the growth of
VITAMIN Amount of water Number of
SUPPLEMENTS scoops of powder
The Department of Health ml fl. oz (approx)
recommends giving
vitamins A, C and D 150 5 5
180 6 6
•to Bbraebaisetsmreilckeiavsinthge: ir main 210 7 7
d•r iLnekssatfhtearns5ix0m0moln(tahspint)
*Powder weights vary by brand, so always check the instructions on pack.
of infant formula milk or
follow-on milk per day N.B. All babies are different, but customers should try to ensure that
from six to 12 months. once weaning is established, babies of six to 12 months should have
Vitamin drops are available 500ml (a pint) of follow-on milk a day, either as a drink, on cereals
as part of the Healthy Start or mixed with food.
scheme (see page 29).
Mix one scoop of powder with 30ml (approx. 1fl. oz.) of water.
69
CHAPTER 5 6-12 MONTHS
Ask the experts i
At six months old, babies’ diets change to
become less reliant on milk. So how do the
experts advise pharmacy teams help parents
at this transitional phase?
Q What is the best way to persuade Q If a nine-month-old baby is eating
a baby to start drinking from a cup? three meals a day, how much milk
should he be drinking?
A Tanya Thomas, BSc (Hons) RD freelance
paediatric dietitian, says: “Introduce a A Dr Emma Derbyshire, independent
cup from around six months of age onwards. nutrition consultant and founder of
Encourage an open cup or a free-flow cup Nutritional Insight Ltd, says: “Three bottles
without a valve so that baby learns to sip of about 150-200ml each time, in the morning,
rather than suck – this is better for their teeth. before or after their nap, and before bed.”
It is sometimes a good idea to try using the cup
in the day rather than the night time at first. Registered nutritionist Charlotte Stirling-Reed
It may take several attempts to introduce a cup. BSc (Hons) MSc, adds: “This will vary from
Parents and carers need to persevere and may baby to baby. Once a baby is established with
need support. They should also be prepared solid foods and feeding well, parents will find
for some mess!” that their baby doesn’t need so much milk
and will normally start taking less milk at each
Q How do follow-on milks differ feed or even drop a milk feed altogether. It’s
from cows’ milk? important that parents look for signs that their
baby has had enough milk during a feed such
A “Follow-on milks can be as turning their head away, clamping their
given from six months,” mouth shut or stopping before the end of a
says Boots UK nutritionist,
Vicky Pennington. “They feed. Responsive feeding is important
contain higher levels of key for parents to try and
nutrients such as vitamin recognise their baby’s
D and iron than cows’ signs of fullness and
milk. In comparison, to ensure they don’t
babies cannot be overfeed. The best
given cows’ milk way to check that
until they are at a baby is getting
least 12 months old enough in
because it’s too low the way of
in iron and too high energy is to
in salt. Follow-on milks get them
are milk drinks and are weighed
not a substitute for breast fairly
milk for babies under six regularly
months of age.” with the
health
visitors.”
70
CHAPTER 5 6-12 MONTHS
Training & CPD REFLECT PLAN
The following practice points and questions can be EVALUATE CCYPCDLE
used by individual members of the pharmacy team
and/or by the pharmacist for team training ACT
Practice points want to be sure that your additional vitamins and minerals?
pharmacy offers a good choice. Are you aware of the differences
1 Between the ages of Have a look at the cups and between all of the supplements?
six and 12 months, beakers you stock in the
milk will remain a pharmacy. Study wholesaler • Are you confident about the
significant source of nutrition pages and see if you could
for babies, although they will improve your range. advice you give to parents about
be eating some solid food as vitamins?
well. Two important issues at 2 Growing babies and
this stage are: the type of milk children don’t always 3 Consider the following
that is appropriate for this get the vitamins they scenarios and think
age group (i.e. breast milk, need, especially if their diet is about the advice that
infant formula and follow-on not healthy and varied. This
milk); and the need to get a is why the Department of you would offer.
baby used to a beaker or cup. Health recommends vitamin
A, C and D supplements for all • A mother of an eight-month-
• Have a look at the infant children from the ages of six old baby is looking at the follow-
months to five years.
formula milks you stock and on milks. she wants to know
compare their nutrient levels with • Which suitable supplements
those in follow-on milks. What how these milks are different
are the key differences? Could do you stock?
you explain these differences and to cows’ milk and why she can’t
why they exist to a mum who has • Do you know which vitamins
planned to stop breastfeeding give her baby cows’ milk
and is returning to work? they contain and the correct
dosage for children of different • A mum of a 10-month-old
• Getting a baby to drink from ages? baby wants to know what
a cup can be difficult, so you • Do you stock supplements for vitamins she should be giving her
young children which contain baby. Think about:
•• WWhhaatt
questions you would ask
advice you would give if
she is feeding her baby follow-on
milk
• What advice you would give
if she is breastfeeding.
CHAPTER 5 6-12 MONTHS
YOUR CPD Multiple choice questions
Pharmacists and technicians 1. WA hfaictheorfatshkes forlloywouinr gadsvtaictee.mHeisntnsinaeb-omuotnftohl-lolwd-soonnmisilks
– don’t forget to record your
CPD at: uptodate.org.uk iws eFaAnLiSnEg?and is now eating three meals a day. He is not
Reflection a. Tsuhreeyhcoawn bmeuucshemd ialks ahne isnhfoaunltd’sbmeahianvdinrign.kWahnadt wadhveince
• Are you confident in your pwroeupladriynogufgoiovdes?containing milk n
k•nAorwe lyeodugecoonfffidoellnotwi-noynour
mknilokws?leWdgheatoifs ftohleloirwp-loance ba. TOhneey2o0f0temnl cboonttlaein– oinligthoesaecvchenarinidgesbeafnodrenubceldeotides for n
imniilnksf?ant feeding? What is
the nutritional difference b. tThweod2e0v0emlolpbmoettnlteso–f aonheeainlththyegmutoarnidngimamndunoenseystem n
b• eAtrweeyeonufcoollnofwid-eonntminilks
ayonudrinafdavnictefoarbmouutlavmitailmksi?n c. Taht ebyedcotinmtaein lower levels of iron and vitamin D than n
•suAprpeleymouenctosnffoidr ecnhtildinreynour
aodvevirctehaebaoguet oviftasimx imnonths? c. iTnhfraenet 2fo00rmmul lbaomttillekss– one in the morning, one before/ n
supplements for children
o•vWerhtahtefuargteheorftsriaxining do d. Tahfteeyr snhaoputldimbeeagnidveonnteobceofmorpelebmedent a healthy n
myoounnthese?d to complete on
follow-on milks? d. wFoeuarn2in0g0mdilebtottles – one in the morning, one before n
Planning lunch, one mid-afternoon and one at bedtime n
Planning
2. HThoewwdaoteesr fuoslelodwto-omn amkielkadfiofflelorwto-ocnowmsil’kmfeilekd? should be:
• Consider further
resources to enhance a. HBoigilheedralenvdeulsseodf iwrohnenancdolvditamin D nn
y•oRuervkienwowthleedkgneowledge
•leHveolws owf iylloyuoruteeanmsu re your b. HAitgahetermlepverlsatoufresoodfiu6m0ºC nn
staff put their knowledge
i•nHtoowprawcitlilcyeo?u ensure your c. OBoliigleodsaacnchdaurisdeedsiamnmdenduiaclteeolytides are removed nn
staff put their knowledge
d. LBoowileedr laenvdelas lolofwireodn taoncdovoiltafomrin30Dm inutes nn
iAnctotiopnractice?
3. W hich of the following infants, according to Department
•tAhAcestfkiooyllnoouwr-sotnafmf tiloksloyookuat
3. WofhHicehalothf gthueidfeolilnloews,iwngoustldatNeOmTennteseadbtoourtecinetivroedvuitcainmgin
stock and ensure they are
f•aWmhiliachr wfoitllhowth-eomn milks saucpuppleims eFAntLsSoEf? vitamins A, C and D?
•doIseysoyuorutrepahmarcmonafciydsetnotck?
in explaining the role of a. AInisteiavlelyn-omffoenrtthh-eolbdewakheor hwaisthbroenaestmmeialkl washtehneitrhme abianby
f•oWllohwat-oandvmicileksw?ould
•yoIsuygoiuver toenamvitcaomnifnident disrninokt tired nn
wsuhpepnleamdevnistins?g parents on
the use of vitamins in b. TAh1e0b-mototnletht-hoaldt twhheobahbasy tihs rmeeosmt erealisaanntdondrsinhkosualdrobuend
infants and young children?
2re0p0lmacleodf ffiorslltow-on milk a day nn
Evaluation
Evaluation c. A sliidx-dmedonbteha-okeldr whitohohuats astvaartlveed iws beaensting who has n
tq•a••ahpehnnxuarIHMaasadyveatcmteeartvvhitvkieppiehicetenseulearyego.aytymosoWntduncoihnnaiofoffiiensodsftuh?eeleclalloeroodnonewanwtfsynrifwfon-tyaioidluoieneynnedur?ydgnmaotinnilytkos d. Paaroreunntds 3sh0o0umldl fionltlorowd-uocnemaiclkupa fdraoym six months of age nn
further training needs?
• Are you aware of other d. A n eight-month-old who has two meals and has around
healthcare professionals
who can help mums with 500ml of follow-on milk a day n
feeding and when you can
refer to them? 4. The Department of Health recommends vitamin A,
WWaanntt ttooccoommpplleettee 4. AC manudmDassukpspfolermyeonutrsatdovbicaebaiebsowuthgoe: tting her baby
tthhiiss tteessttoonnlilninee??
VViissiitt: :tmtmmmaaggaazzininee.c.coo.u.ukk a. tDoridnrkinleksfsrtohmana5c0u0pm. Wl ahdaat yadovfiicnefaisnNt OfoTrmsuuiltaable?
a. Amiclukpfrsohmouslidx btoe 1in2trmodounctehds at around six months of age nn
b. AHacvuepbwreitahstamvialklveasisthbeeisrtmain drink after six months n
c. Tohf eagbeaby should be seated upright, so that they are n
c. iDnriankgoleosds tdhrainnki5n0g0mpol saitdioany of follow-on milk from six n
d. Atoli1d2dmedonbtehasker without a valve is best nn
d. All of the above n
5. In relation to bottles with teats, which statement is TRUE?
a. By around 12 months of age, babies should have
5. sWtohpicphedofutshinegfothlleomwing statements is FALSE? n
ba. BOontcteleas abnadbyteisatussidnogna’t cnuepedit sdtoereislisniontgnaefetedr ttohebebaby
isstesrixilimseodnths old nn
cb.. TWohgeent ubsainbgiesa ubsoetdtlteoodritfrfaeirneenrt cfulapv,onuorst,hdinilgutoetdhefrutihtan
jiunifcaentcafnorbmeuglaivmenilkin, bthreeairstbmotitlkleo r water should be used nn
dc.. WFoalltoewr s-ohnoumldilkonshlyobueldgbiveemn aindea ucuppi,nnboattcinheasbottle n
d. Awiftrheea-ftleoawt, cfuropmwsitixhomuotnathvsalovfeaisgebetter for a n
baby’s teeth n
7721
RELIEVE REDUCE REASSURE
cows’ milk allergy incidence of with superior
symptoms1 with atopic dermatitis palatability4,5
up to five years3
97% efficacy2
Aptamil Pepti for the effective management of
cows’ milk allergy, without compromise
Unique blend GOS/FOS oligosaccharides to help reduce long-term allergy risk3 Pepti 1 Pepti 2
Extensively hydrolysed formula with a composition nutritionally closer to
400g & 800g 400g & 800g
breastmilk, encouraging normal growth and development6
Palatable for baby4,5, as convenient to prepare as standard infant formulas
For more information call 0800 996 1234 or visit: aptamilprofessional.co.uk
References: 1. Verwimp JJ et al. Eur J Clin Nutr. 1995;49 (Suppl1):S39-S48 2. Giampietro PG et al. Pediatr Allergy
Immunol. 2001;12:83-86. 3. Arslanoglu S et al. J Biol Regul Homeost Agents. 2012;26:49-59. 4. Pedrosa M et
al. J Investig Allergol Clin Immunol. 2006; 16(6):351-6. 5. Venter C. Cows milk protein allergy and other food
hypersensitivities in infants. [Online] Available at: https://www.jfhc.co.uk/Cows_milk_protein_allergy_and_other_
food_hypersensitivities_in_infants_20679.aspx [Accessed January 2016]. 6.VandenplasYet al. J PediatrGastroenterol
Nutr. 1993;17(1):92-96.
IMPORTANT NOTICE: Aptamil Pepti 1 & 2 should only be used under medical supervision, after full consideration of
the feeding options available including breastfeeding. Aptamil Pepti 1 is suitable foruse as the sole source of nutrition
for infants from birth to 6 months of age. Aptamil Pepti 2 is suitable for babies over 6 months as part of a mixed diet,
and as a principle source of nourishment with other foods.
Date of prep: April 2016 / AS9511
CHAPTER 5 6-12 MONTHS
Aptamil Follow On Milk 2 Nutricia Early Life Nutrition
Follow-on milk nutritionally Features Pronutra+, Aptamil’s Nutrition information:
tailored to complement
weaning. 3 Contains Per 100ml prepared feed:†
unique blend of ingredients
3 A ptamil’s patented blend Energy 285kJ
of galacto- and fructo- (68kcal)
oligosaccharides Fat 3.0g
3 Iron to support normal Saturates 1.2g
cognitive development Unsaturates 1.8g
3 E nriched with vitamins LCPs 0.020g
A, C and D Arachidonic acid (AA) 0.009g
Docosahexaenoic acid (DHA) 0.009g
Suitable for: Carbohydrate 8.6g
3 B abies from six months Sugars 6.5g
Available as: Lactose 6.1g
3 9 00g powder (PIP code: Fibre 0.6g
310-5905)
Protein 1.4g
3 2 00ml (PIP code: 269-9072)
and 1 litre ready-to-feed Whey 0.7g
(50%)
Casein 0.7g
(50%)
Salt 0.06g
Vitamin A 66µg RE
Vitamin C 9.9mg
Vitamin D3 1.4µg
Iron 1mg
Aptamil Profutura Follow On Milk 2 Nutricia Early Life Nutrition
Follow-on milk nutritionally Features Nutrition information:
tailored to complement
weaning. 3 A ptamil’s patented blend Per 100ml prepared feed:†
of galacto- and fructo-
oligosaccharides Energy 285kJ
3 C ontains omega-3 LCP (DHA) (68kcal)
to support normal visual
development of infants up Fat 2.9g
to 12 months. The benefit
can be obtained from a daily Saturates 1.4g
intake of 100mg DHA
Unsaturates 1.5g
3 S ource of iodine which
contributes to the normal LCPs 0.03g
growth of children
Arachidonic acid (AA) 0.011g
Suitable for:
Docosahexaenoic acid (DHA) 0.011g
3 B abies from six months
EFAs 0.427g
Available as:
Linoleic acid (LA) 0.363g
3 8 00g powder (PIP code:
400-7712) Alpha linolenic acid (ALA) 0.064g
3 2 00ml ready-to-use (PIP code: Phospholipids 0.06g
404-7007)
Carbohydrate 8.8g
Sugars 8.7g
Lactose 8.4g
Fibre 0.6g
Protein 1.4g
Whey 0.7g
(50%)
Casein 0.7g
(50%)
Salt 0.05g
GOS/FOS 0.8g
Iron 1mg
†All nutrition information is based on the powder format. 74
There may be slight variations in the ready-to-feed formats.
CHAPTER 5 6-12 MONTHS
Cow & Gate Follow On Milk 2 Nutricia Early Life Nutrition
Follow-on milk nutritionally Features Nutrition information:
tailored to complement
weaning. 3 Contains oligosaccharides Per 100ml prepared feed:†
3 C ontains iron to support
Energy 285kJ
normal cognitive
development (68kcal)
3 C ontains vitamin D and
calcium for normal bone Fat 3.0g
development
3 Nutritionally tailored to Saturates 1.3g
complement a weaning diet
Unsaturates 1.7g
Suitable for:
Carbohydrate 8.6g
3 B abies from six months
Sugars 8.5g
Available as:
Lactose 8.3g
3 9 00g powder (PIP code:
310-5863) Fibre 0.6g
3 2 00ml (PIP code: 251-1442) Protein 1.4g
and 1 litre ready-to-use
Whey 0.4g
(21%)
Casein 1.6g
(79%)
Salt 0.04g
Vitamin D 1.5μg
Iron 1mg
Calcium 68mg
HiPP Organic Combiotic Follow-On Milk 2 HiPP UK
Follow-on milk to Features Nutrition information:
complement weaning.
3 Certified organic Per 100ml prepared feed:†
3 Contains a source of prebiotic
oligosaccharides Energy 292kJ
3 Contains omega-3 (ALA)
3 Enriched with iron (70kcal)
Suitable for: Fat 3.5g
3 Babies from six months Saturates 1.2g
Available as: Unsaturates 2.3g
3 800g powder Linoleic acid (omega-6) 0.6g
3 250ml ready to feed
α-linolenic acid (omega-3) 0.07g
Carbohydrate 7.8g
Sugars 7.6g
Lactose 7.4g
Protein 1.5g
Whey 0.6g
(40%)
Casein 0.9g
(60%)
HiPP Organic Good Night Milk HiPP UK
Follow-on milk to Features Nutrition information:
complement baby’s
bedtime routine. 3 Specially formulated Per 100ml prepared feed:
bedtime milk
Energy 292kJ
3 W ith added organic cereals
3 Gluten-free (70kcal)
Suitable for: Fat 3.5g
3 Babies from six months Saturates 1.2g
Available as: Unsaturates 2.3g
3 350g powder Linoleic acid (omega-6) 0.6g
α-linolenic acid (omega-3) 0.07g
Carbohydrate 8.0g
Sugars (Lactose) 5.0g
Starch 2.8g
Protein 1.6g
Whey 0.3g
(20%)
Casein 1.3g
(80%)
75 †All nutrition information is based on the powder format.
There may be slight variations in the ready-to-feed formats.
CHAPTER 5 6-12 MONTHS
SMA PRO Follow-on Milk SMA Nutrition
Nutritionally tailored Features Available as:
follow-on milk to
complement the 3 T he lowest protein follow-on 3 400g (PIP code: 394-9120)
weaning diet. milk in the UK and Ireland at and 800g (PIP code: 347-3915)
1.3g/100ml powder
3 S MA Nutrition’s most 3 200ml (PIP code: 395-0151)
advanced formula yet, made and 1 litre (PIP code: 370-
with an exclusive protein 8484) ready-to-use liquid milk
process
Nutrition information:
3 F ortified with iron to help
support normal cognitive Per 100ml prepared feed:†
development
Energy 278kJ
3 O mega-3 and 6 LCPs
3 G OS/FOS. Powder only (67kcal)
3 W ith Nutri-Steps – SMA
Fat 3.2g
Nutrition’s unique blend
of ingredients Saturates 1.3g
3 H elps to build a nutritional
foundation for life Unsaturates 1.9g
Suitable for: LCPs 17.6mg
3 B abies from six months Arachidonic acid (AA) 8.8mg
3 Halal
Docosahexaenoic acid (DHA) 8.8mg
Carbohydrate 7.9g
Sugars 5.5g
Lactose 5.3g
Fibre (GOS/FOS) 0.4g
Protein 1.3g
Whey 0.66g
(50%)
Casein 0.66g
(50%)
Follow-on milk is only for babies from six months as part of a mixed diet and should not be
used as a breast milk substitute before six months. The decision to start weaning or to use
follow-on milks before six months should be made only on the advice of a doctor, midwife,
health visitor, public health nurse, dietitian, pharmacist or pharmacy technician, based on
babies’ individual needs.
†All nutrition information is based on the powder format.
76There may be slight variations in the ready-to-feed formats.
CHAPTER 6 12 MONTHS +
Toddlers aged After reading this chapter,
12 months + you will have a better
understanding of:
At 12 months, toddlers will be getting used
to solid food, and milk will start to become less • The nutritional
essential in meeting their dietary needs, taking
a more complementary role instead needs of toddlers aged
1•2 Tmheonntuhtsriatniodnoalvebrenefits
of toddler and growing up
f•o rHmouwlathmeislkesmilks can
complement a healthy,
balanced diet.
F rom 12 months onwards, servings of milk and dairy foods, VITAMIN D
toddlers are walking, such as cheese or yoghurt.
talking and interacting. It’s recommended that
As they start to eat family meals, The Department of Health children aged one to four
it’s easy to assume that their recommends the following years should have a daily
dietary requirements are simply regarding the introduction 10mcg vitamin D supplement
those of ‘mini adults’. This is not of cows’ milk: all year round.
the case. They are still growing
and developing rapidly so require • Full-fat cows’ milk can be As a precaution, all babies
more energy and nutrients than under one year should have
adults in relation to their size. introduced from one year of age a daily 8.5-10mcg vitamin
D supplement to make sure
From a child’s first birthday, • Semi-skimmed milk can be they get enough.
milk should begin to play a less
important role when it comes to introduced after two years of However, babies who have
meeting an infant’s dietary age, as long as the diet is varied more than 500ml (about a
requirements. However, toddlers and balanced and the child is pint) of infant formula a
aged one to three years still growing well day don’t need a vitamin
need at least two to three daily D supplement as formula
• Skimmed milk or 1% fat milk is already fortified.
should not be introduced before For more information, see:
five years of age because it nhs.uk/Conditions/pregnancy-
cannot provide enough nutrients and-baby/Pages/vitamins-for-
for growth before this age. children.aspx.
At 12 months of age, children To reduce the volume of milk
should not be drinking more consumed, parents can:
than one pint (500ml) of
milk a day (cows’, • Offer water instead
formula or toddler/
growing up milk) of milk for some drinks
as excessive
amounts can: • Restrict milk consumption
• Leave little to after meals
room or appetite • Feed from a cup, not a bottle
for other foods • Reduce the amount of milk in
• Lead to the cup or use a smaller cup.
excessive energy
(calorie) intake,
which may lead to
children becoming
overweight
or obese.
77
CHAPTER 6 12 MONTHS +
Toddler/growing up milks
Even with the most careful planning, some toddler diets may still fail
to provide sufficient levels of the key nutrients – which is where toddler/
growing up milks can help*
C ompared to cows’ milk, Fussy eaters Remember to always advise
toddler/growing up milks parents to check the pack for
contain: Toddlers are notorious for being details of how the milk should be
fussy eaters. Their likes and prepared. Some products require
• Much higher levels of iron dislikes can be a barrier to water that has been boiled and
achieving a nutritionally balanced cooled to 70ºC, while others are
and vitamin D. Vitamin D is diet. However, these phases are prepared with cooler water.
needed for normal growth and quite normal and usually only last
bone development, but infants a short time. Parents should Many toddler/growing up
and young children in the UK are therefore consider their child’s milks are available in ready-to-
only getting 27 per cent of their dietary intake over the course of use bottles or cartons which do
daily vitamin D needs, according a week, rather than daily, to get not require any preparation
to the 2011 National Diet and a more accurate picture. before use.
Nutrition Survey
See Chapter 7 for more tips and Brands offer slightly different
• A significant proportion of advice. Any concerned parents advice regarding how long
should be referred to the products can be stored or used
key vitamins and minerals, such pharmacist or a health visitor once opened or prepared – look
as vitamins A and C or GP, if necessary. at products in-store to familiarise
yourself with the guidelines.
• Increased essential fatty acids How to prepare milks
• Some brands also contain After a toddler’s first birthday, all
As before, milks should still be liquids should be from a beaker
prebiotic oligosaccharides and made up as required and not in or cup and toddlers should be
LCPs. batches because milk powder is fully weaned off bottles, so
not sterile and can contain sterilising will no longer be
Cows’ milk can be given in harmful bacteria (see Chapter 2). necessary. If a parent does
combination with toddler milks. however use a bottle beyond
For example, cows’ milk could be 12 months of age, it is best to
used in cooking and toddler milk continue sterilising.
given as a drink.
When to refer
Example on-pack feeding guide**
Refer parents with the following
1 scoop = approximately 4.5g powder concerns to the pharmacist for
further advice:
ml Amount of wfal. toerz (approx) scooNpusmobfeproowfder
• Toddlers not eating a healthy,
150 5 5
180 6 6 balanced diet
210 7 7
• Children drinking too much
N.B. After 12 months, it is recommended that children have a
minimum of 300ml milk a day (or two dairy servings). Mix one or too little milk
scoop of powder with 30ml (approximately 1fl. oz) of water.
• Feeding problems (e.g. child is
**Powder weights vary by brand, so always check the instructions on pack.
not gaining weight, has reflux or
unusual symptoms)
• Children with signs of allergies
to certain foods.
78 *Using toddler/growing up milk is an option
for parents – it is not essential.
CHAPTER 6 12 MONTHS +
Ask the experts i
It can be difficult to get the right balance between food and milk in a
toddler’s diet. Here’s how our experts would answer these common queries
Q What feeding problems might a baby Q If a 12-month-old baby does not
have at 12 months plus? have a good appetite, should they be
given more toddler/growing up milk to
A Geraldine Goodman, community dietitian, compensate?
Dietetic Department, Cumberland Infirmary,
says: “As they get older it is perfectly normal for A “Toddlers can lose their appetite for a
babies/toddlers to start to refuse to eat or even number of reasons – for example, if they
taste new foods. Providing they eat foods from are tired, feeling pressured to eat food they
the four main food groups, even if it is always don’t want or are constipated,” says Sarah
the same favourites, parents don’t need to worry. Mills, nutritionist at Danone Nutricia Early
They should gradually introduce other foods or Life Nutrition. “Making mealtimes relaxed,
go back to the foods their child didn’t like before enjoyable and consistent can help. Growing up
and try them again. They should also try to eat or toddler milks are made from cows’ milk that
meals together, if possible. Never force a baby to has been adapted and fortified with vitamins
eat – if a food is rejected it should be taken away and minerals, and can be included as part of a
without comment. Parents should try to stay toddler’s varied, balanced diet. Fortified milks
calm, however frustrating.” are not a substitute for a healthy, balanced
diet, and it is important that toddlers are not
Q How much cows’ milk should given more milk than they need, as it can
a toddler be drinking? reduce their appetite.”
A Registered nutritionist Charlotte Stirling- Q Does a toddler who is drinking
Reed BSc (Hons) MSc, says: “Cows’ milk is toddler/growing up milk also need
not recommended to be offered as a drink to vitamin supplements?
babies under one year of age; however, after six
months, it can be added to foods. Once babies A “It is recommended that all toddlers
get to one year of age they no longer need in the UK should take a supplement
formula milk, and can start drinking full fat cows’ containing vitamins A, C and D,” explains
milk, but they also need less milk every day. The Sarah. “Supplements should provide 10mcg
NHS recommends that between one and three
years of age children only need to have around of vitamin D. The levels
350mg of calcium a day. About 300ml of milk of these vitamins in
(just over half a pint) would provide this.” growing up or toddler
milks can vary, so
Tanya Thomas, BSc (Hons) RD freelance parents should always
paediatric dietitian, adds: “Toddlers check the label and
should have no more than 600ml the quantity that
of milk a day, which is roughly a their toddler is
pint. Toddlers who drink more drinking to see
than a pint of milk tend to be whether they
too full to eat an adequate will need to
toddler diet and may miss out offer their child
on the essential nutrients that supplements
are not present in milk.” as well.”
79
CHAPTER 6 12 MONTHS +
Training & CPD REFLECT
The following practice points and questions can EVALUATE CCYPCDLE PLAN
be used by individual members of the pharmacy
team and/or by the pharmacist for team training ACT
Practice points write down the brands you stock 2 Consider the
and any differences between following scenarios
1 Once a baby reaches them. Do this exercise as a team. and think about the
the age of 12 months, You may be able to think of more advice that you would offer.
it can be confusing to features that you would like to
know which milk to give them add to the table. • What advice would you give
and how much. Can a mum
continue to breastfeed? What When completed, consider to a mum who doesn’t know
about follow-on milk and laminating it and putting it what milk to give her one-year-
toddler or growing up milk? on the wall in the pharmacy old son. Some of her friends have
When can cows’ milk be given or perhaps keeping it in your suggested she gives him almond
and which type is suitable? resource folder. The aim of this milk but she’s not sure why
What about goat’s milk or a exercise is to revise what you
non-dairy milk, such as soya, have learned about the suitability • A dad is worried his child is
almond, oat or rice milk? of different milks at different
stages of a child’s life. being too fussy. What advice
Get a piece of paper and create would you give about helping
a table detailing the milks that are him to ensure his daughter is
suitable or not suitable for infants getting the right amount of
aged under 12 months and for nutrients
children aged one to five years.
• A mum is worried that her
For milks that are suitable,
identify guideline quantities, key 18-month-old is putting on too
nutritional characteristics of the much weight. What would you
milk, and the place of the milk in advise her? What reference
the child’s diet and how it can be materials might she access?
used. If a milk
is available in
pharmacy,
CHAPTER 6 12 MONTHS +
YOUR CPD Multiple choice questions
Pharmacists and technicians 1. W hich of the following infants’ nutritional intakes would
– don’t forget to record your
CPD at: uptodate.org.uk you NOT be concerned about?
Reflection a. An 18-month-old who has three pints of full-fat milk a day n
• Do you and the team b. A two-year-old who has three pints of semi-skimmed
feel confident when
recommending milks for milk a day n
children over 12 months
of age? c. A two-year-old who has meals and about a pint of semi-
• When would you refer
someone to their GP or skimmed milk a day n
health visitor?
d. An 18-month-old who will only eat a very limited range
Planning
of foods n
• Plan when to
complete your training 2. Which statement is FALSE about a toddler who n
• Plan what training is drinking too much milk?
needs to be delivered to n
other members of your a. They will not get enough calcium n
team. b. They might consume too many calories, putting them n
Action at risk of obesity
c. It might reduce their appetite for food
• Review the range of d. They should be offered water instead
growing up/toddler
milks and vitamins 3. How much calcium does a two-year-old need daily? n
stocked in your a. 350mg n
pharmacy b. 150mg n
• Undertake additional c. 50mg n
training if necessary. d. 25mg
n
Evaluation 4. W hich of the following nutrients are found in toddler/ n
n
• How was your practice growing up milks compared to cows’ milk? n
improved as a result of a. Key vitamins and minerals
completing the training? b. Increased fatty acids
c. Higher levels of iron and vitamin D
d. All of the above
5. Approximately how much milk (as a minimum) should n
a 14-month-old infant be having each day? n
n
a. 50ml n
b. 100ml
c. 300ml
d. 600ml
Want to complete 81
this test online?
Visit: tmmagazine.co.uk
CHAPTER 6 12 MONTHS +
Aptamil Growing Up Milk 3 Nutricia Early Life Nutrition
Fortified milk drink for Features Pronutra+, Aptamil’s Nutrition information:
toddlers aged one to
two years. 3 Contains Per 100ml prepared feed:†
unique blend of ingredients
3 Contains Aptamil’s unique Energy 275kJ
blend of galacto- and fructo- (65kcal)
oligosaccharides Fat 2.6g
3 Enriched with iron Saturates 0.6g
3 Contains DHA/EPA (omega-3) LCPs 0.020g
3 E nriched with calcium and Docosahexaenoic acid (DHA) 0.012g
vitamin D Eicosapentaenoic acid (EPA) 0.008g
Carbohydrate 8.5g
Suitable for: Sugars 6.7g
3 Toddlers aged one to two years Fibre 0.8g
Protein 1.5g
Available as: Salt 0.07g
3 900g powder (PIP code: GOS/FOS 1.2g
352-2810)
3 2 00ml (PIP code: 315-8086) Vitamin D3 3.1µg
and 1 litre ready-to-use Calcium 120mg
Iron 1.2mg
Aptamil Growing Up Milk 4 Nutricia Early Life Nutrition
Fortified milk drink for Features Nutrition information:
toddlers aged two to
three years. 3 Contains Pronutra+, Aptamil’s Per 100ml prepared feed:†
unique blend of ingredients
Energy 210kJ
3 Contains Aptamil’s unique
blend of oligosaccharides (50kcal)
3 Enriched with iron
3 Contains DHA/EPA (omega-3) Fat 1.9g
3 Enriched with calcium and
vitamin D Saturates 0.5g
3 Semi-skimmed version
LCPs 0.020g
Suitable for:
Docosahexaenoic acid (DHA) 0.012g
3 T oddlers aged two to three years
Eicosapentaenoic acid (EPA) 0.008g
Available as:
Carbohydrate 6.5g
3 8 00g powder (PIP code:
364-5744) Sugars 5.1g
3 2 00ml and 1 litre ready-to-use Fibre 0.8g
Protein 1.3g
Salt 0.05g
GOS/FOS 1.2g
Vitamin D3 3.1µg
Calcium 120mg
Iron 1.2mg
Aptamil Profutura Growing Up Milk 3 Nutricia Early Life Nutrition
Fortified milk drink for structure of fats within breast Saturates 0.7g
toddlers aged one to milk
two years. 3 H igh in vitamin D and is a source LCPs 0.027g
Features
3 C ontains phospholipid-bound of calcium, vitamins A and C Arachidonic acid (AA) 0.001g
LCPs inspired by the complex Docosahexaenoic acid (DHA) 0.016g
Suitable for: Eicosapentaenoic acid (EPA) 0.010g
3 Toddlers from one to two years Carbohydrate 8.4g
Sugars 6.6g
Available as: Fibre 0.8g
3 8 00g powder (PIP code: Protein 1.6g
400-7720)
Salt 0.07g
GOS/FOS 1.2g
Nutrition information: Vitamin A 60µg RE
Per 100ml prepared feed:† Vitamin C 15mg
Vitamin D3 2.9µg
Energy 275kJ Calcium 124mg
(65kcal) Iron 1.2mg
Fat 2.6g Iodine 20µg
†All nutrition information is based on the powder format.
82There may be slight variations in the ready-to-feed formats.
CHAPTER 6 12 MONTHS +
Cow & Gate Growing Up Milk 3 Nutricia Early Life Nutrition
Fortified milk drink for Features Nutrition information:
toddlers aged one to
two years. 3 E nriched with vitamin D Per 100ml prepared feed:†
and calcium for normal
bone development Energy 275kJ
3 E nriched with iron to (65kcal)
support normal cognitive
development Fat 2.6g
Suitable for: Saturates 0.6g
3 T oddlers aged one to two Carbohydrate 8.5g
years
Sugars 6.7g
Available as:
Fibre 0.8g
3 9 00g powder (PIP code:
332-9760) Protein 1.5g
3 2 00ml (PIP code: 315-8078) Salt 0.07g
and 1 litre ready-to-use
GOS/FOS 1.2g
Vitamin D3 3.1µg
Calcium 120mg
Iron 1.2mg
Cow & Gate Growing Up Milk 4 Nutricia Early Life Nutrition
Fortified milk drink for Features Nutrition information:
toddlers aged two to
three years. 3 E nriched with vitamin D Per 100ml prepared feed:†
and calcium for normal
bone development Energy 210kJ
3 E nriched with iron to (50kcal)
support normal cognitive
development Fat 1.9g
3 Semi-skimmed version Saturates 0.4g
Suitable for: Carbohydrate 6.5g
3 Toddlers aged two to three Sugars 5.8g
years
Fibre 0.9g
Available as:
Protein 1.3g
3 8 00g powder (PIP code:
364-5967) Salt 0.05g
3 2 00ml and 1 litre ready-to-use GOS/FOS 1.2g
Vitamin D3 2.9µg
Calcium 120mg
Iron 1.2mg
HiPP Organic Combiotic Growing Up Milk 3 HiPP UK
Gentle, satisfying organic Features Nutrition information:
growing up milk for active
toddlers. 3 Certified organic Per 100ml prepared feed:†
3 Contains a source of prebiotic
oligosaccharides Energy 275kJ
3 Contains omega-3 (ALA)
3 Enriched with iron (66kcal)
Suitable for: Fat 3.0g
3 Babies from 12 months Saturates 1.0g
onwards
Unsaturates 2.0g
Available as:
Linoleic acid (omega-6) 0.5g
3 600g powder
3 250ml ready to feed α-linolenic acid (omega-3) 0.06g
Carbohydrate 8.0g
Sugars 7.8g
Lactose 7.6g
Protein 1.4g
Whey 0.3g
(20%)
Casein 1.1g
(80%)
83 †All nutrition information is based on the powder format.
There may be slight variations in the ready-to-feed formats.
CHAPTER 6 12 MONTHS +
HiPP Combiotic Growing Up Milk 4 HiPP UK
Growing up milk to Features Nutrition information:
complement the diet of
active toddlers from two 3 Contains a source of prebiotic Per 100ml prepared feed:
years onwards. oligosaccharides
3 Contains vitamin D – supports Energy 200kJ
bone and teeth development
and the immune system (48kcal)
3 With iodine to help support
normal growth and Fat 2.2g
development
3 Contains omega-3 (ALA) Saturates 0.7g
Suitable for: Unsaturates 1.5g
3 Toddlers from two years Linoleic acid (omega-6) 0.4g
of age onwards
α-linolenic acid (omega-3) 0.05g
Available as:
Carbohydrate 5.0g
3 600g powder
Sugars 5.0g
Lactose 4.8g
Fibre 0.6g
Protein 1.7g
Whey 0.3g
(20%)
Casein 1.4g
(80%)
SMA PRO Toddler Milk SMA Nutrition
Toddler milk is nutritionally development of bones. Available as:
balanced for toddlers aged Vitamin D also contributes
one to three years. to the normal function of the 3 4 00g (PIP code: 394-9112)
Features immune system in children and 800g (PIP code: 347-4012)
3 S MA Nutrition’s most 3 A daily serving of 2x200ml powder
provides 108% of a toddler’s
advanced formula with vitamin D reference intake1 3 200ml (PIP code: 355-8939)
increased vitamin D 3 F ortified with iron, which and 1 litre (PIP code: 385-
(compared to previous helps support normal 9972) ready-to-feed liquid milk
SMA Toddler Milk) cognitive development
3 V itamin D and calcium 3 Iodine to help support Nutrition information:
to support normal normal growth
growth and 3 Omega-3 and 6 LCPs Per 100ml prepared feed:†
3 With Nutri-Steps – SMA
Nutrition’s unique blend Energy 267kJ
of ingredients
3 H elps to build a nutritional (64kcal)
foundation for life
Fat 3.3g
Suitable for:
Saturates 1.3g
3 Toddlers from one to three
years Unsaturates 2.0g
3 Vegetarians (powder only)
3 Halal LCPs 9.1mg
Arachidonic acid (AA) 5.3mg
Docosahexaenoic acid (DHA) 3.8mg
Carbohydrate 7.0g
Sugars 7.0g
Lactose 7.0g
Protein 1.5g
Whey 0.3g
(20%)
Casein 1.2g
(80%)
Reference:
1. EC (European Commission) (2006). Directive 2006/141/EC on infant formulae and follow-on formulae
and amending Directive 1999/21/ EC. European Commission.
†All nutrition information is based on the powder format.
84There may be slight variations in the ready-to-feed formats.
CategoryHub
Infant Feeding
supported by SMA® Nutrition
Pharmacists and technicians
are now able to access training,
information resource
articles and sponsored
SMA® Nutrition
content about infant
feeding in one place
• Complete the SMA Nutrition sponsored CPD training modules
• Use the SMA Nutrition 5-Stage Plan to achieve an effective
infant feeding service within your pharmacy
• Keep up to date with latest research
• Access the Pharmacy Guide to Infant Feeding
• Become an SMA Nutrition Infant Feeding Champion*
Find the Infant Feeding Category Hub at any of the following CIG sites:
www.pharmacymagazine.co.uk | www.tmmagazine.co.uk | www.p3pharmacy.co.uk
*Champions will receive training resources, for example, modules on specialist milks and infant feeding and allergy
risk. All SMA Nutrition sponsored training modules are available on the Infant Feeding Category Hub.
ZTC1380a 04/2016 ®Registered Trademark
Infant formula milk (Whey dominant) Infant formula milk (Casein dominant)
Aptamil First Aptamil Cow & Gate HiPP Organic SMA PRO First Aptamil Cow & Gate HiPP Organic SMA Extra
Infant Milk 1 Profutura First Infant Combiotic Infant Milk Hungry Milk Infant Milk Combiotic Hungry Infant
First Infant Milk 1 First Infant for Hungrier Hungry Infant Milk
Milk 1 Milk 1 Babies Milk
Nutrient per 100ml
prepared feed
Energy (kJ/kcal)
INFANT FORMULA MILKS COMPARED
86
275kJ (66kcal) 275kJ (66kcal) 275kJ (66kcal) 277kJ (66kcal) 280kJ (67kcal) 275kJ (66kcal) 275kJ (66kcal) 281kJ (67kcal) 280kJ (67kcal)
Fat 3.4g 3.4g 3.4g 3.5g 3.6g 3.1g 3.1g 3.5g 3.6g
Saturates 1.5g 1.6g 1.5g 1.2g 1.5g 1.4g 1.4g 1.1g 1.6g
Unsaturates 1.9g 1.8g 1.9g 2.3g 2.1g 1.7g 1.7g 2.4g 2.0g
LCPs 0.024g 0.026g 0.015g 0.020g 0.017g 0.023g 0.014g 0.014g 0.019g
Carbohydrate 7.3g 7.3g 7.3g 7.3g 7.1g 7.7g 7.7g 7.3g 7.0g
Sugars 7.3g 7.2g 7.3g 7.2g 7.1g 7.6g 7.6g 7.2g 7.0g
Lactose 7.0g 7.0g 7.0g 7.1g 7.1g 7.4g 7.4g 7.1g 7.0g
Protein 1.3g 1.3g 1.3g 1.25g 1.25g 1.6g 1.6g 1.6g 1.6g
Whey 0.8g (62%) 0.8g (62%) 0.8g (62%) 0.75g (60%) 0.88g (70%) 0.3g (19%) 0.3g (19%) 0.3g (20%) 0.3g (20%)
Casein 0.5g (38%) 0.5g (38%) 0.5g (38%) 0.5g (40%) 0.37 (30%) 1.3g (81%) 1.3g (81%) 1.3g (80%) 1.3g (80%)
H* H* H* O H H* H* O V*/H
V egetarian (V), Organic (O)
or Halal approved (H)
All nutrition information is based on the powder format. There may be slight variations in the ready-to-feed formats. *Powder only.
Breastfeeding is best for babies. Infant formula is suitable from birth when babies are not breastfed. It is recommended that all formula milks be
used on the advice of a doctor, midwife, health visitor, public health nurse, dietitian, pharmacist or other professional responsible for maternal and child care.
Follow-on milk Toddler/growing up milks
Aptamil Aptamil Cow & Gate HiPP Organic SMA PRO Aptamil Aptamil Cow & Gate HiPP Organic SMA PRO
Follow On Profutura Follow On Combiotic Follow-On Growing Up Profutura Growing Up Combiotic Toddler
Milk 2 Follow On Milk 2 Follow-On Milk Milk 3 Growing Up Milk 3 Growing Up Milk
Milk 2 Milk 2 Milk 3 Milk 3
Nutrient per 100ml
prepared feed
Energy (kJ/kcal)
FOLLOW-ON AND TODDLER MILKS COMPARED
87
285kJ (68kcal) 285kJ (68kcal) 285kJ (68kcal) 292kJ (70kcal) 278kJ (67kcal) 275kJ (65kcal) 275kJ (65(kcal) 275kJ (65kcal) 275kJ (66kcal) 267kJ (64kcal)
Fat 3.0g 2.9g 3.0g 3.5g 3.2g 2.6g 2.6g 2.6g 3.0g 3.3g
Saturates 1.2g 1.4g 1.3g 1.2g 1.3g 0.6g 0.7g 0.6g 1.0g 1.3g
Unsaturates 1.8g 1.5g 1.7g 2.3g 1.9g 2.0g 2.0g
LCPs 0.020g 0.03g 0.017g 0.020g 0.027g 0.009g
Carbohydrate 8.6g 8.8g 8.6g 7.8g 7.9g 8.5g 8.4g 8.5g 8.0g 7.0g
Sugars 6.5g 8.7g 8.5g 7.6g 5.5g 6.7g 6.6g 6.7g 7.8g 7.0g
Lactose 6.1g 8.4g 8.3g 7.4g 5.3g 7.6g 7.0g
Protein 1.4g 1.4g 1.4g 1.5g 1.3g 1.5g 1.6g 1.5g 1.4g 1.5g
Whey 0.7g (50%) 0.7g (50%) 0.4g (21%) 0.6g (40%) 0.66g (50%) 0.3g (20%) 0.3g (20%)
Casein 0.7g (50%) 0.7g (50%) 1.6g (79%) 0.9g (60%) 0.66g (50%) 1.1g (80%) 1.2g (80%)
Iron 1.0mg 1.0mg 1.0mg 1.0mg 1.0mg 1.2mg 1.2mg 1.2mg 1.2mg 1.2mg
Vitamin D 1.4mcg 1.3mcg 1.5mcg 1.2mcg 1.2mcg 3.1mcg 2.9mcg 3.1mcg 1.3mcg 1.9mcg
Vo regHeatlaarliaanpp(Vro),veOdrg(aHn)ic (O) H* H* H* O H H* H H* O V*/H
All nutritional information is based on the powder format. There may be slight variations in the ready-to-feed formats. *Powder only.
Breastfeeding is best for babies. Infant formula is suitable from birth when babies are not breastfed. It is recommended that all formula milks be
used on the advice of a doctor, midwife, health visitor, public health nurse, dietitian, pharmacist or other professional responsible for maternal and child care.
CHAPTER 7 WEANING
Weaning
At around six months of age, babies start
the natural process of learning to eat
solid food. While weaning is an exciting
milestone to reach, it’s not
without its challenges After reading this Do’s and don’ts
chapter, you will have a
A s babies grow and better understanding of: Most ingredients are safe for
develop, solid food babies, but advise parents:
becomes an important • How to start the weaning
part of their diet. This process p•••r oHTAch oehewsessattlaotghheyesdlpoiefftuwfsoesyar naeinantgienrfsa. nt • Not to add salt to food as it
of introducing food is called
weaning. The Department of How to start is bad for babies’ kidneys. Avoid
Health recommends that babies stock cubes and gravy too as
start weaning at six months. Weaning is an exciting new these are often high in salt
While all babies are different experience. It’s a gradual learning
and some may be ready to wean process for babies and can • Not to add sugar to babies’
earlier than six months of age, provide a great opportunity for
parents should not begin the the family to sit down together food. However, natural sugars
process before 17 weeks because and for the baby to learn from
babies’ kidneys and digestive their parents. SUITABLE
systems, along with their motor FIRST FOODS
skills, are not sufficiently The first aim is to simply get the
developed to cope with solid baby used to the feeling of food F•r oMmasshixemd oonr tphusr:éed cooked
food and it could also increase and different tastes in his/her vegetables (e.g. potato,
the risk of infections and mouth, which may take practice.
allergies. Equally, parents It is also important to offer carrot, parsnip, broccoli)
shouldn’t start weaning their babies a wide variety of tastes
baby later than 26 weeks, as it to help educate their palates and or baby rice made up with
may lead to the baby struggling help them become good little
to accept lumpier foods later on. eaters in the future. b•r eMaasts/hfoedrmfruulait milk, then
(e.g. ripe
Telltale signs that signal a baby Starting the weaning process
is ready to wean include the with vegetables teaches babies banana, cooked apple/pear).
baby being able to: that not all foods are sweet and
it can increase their liking and N•e Fxutlsl-tfeaptsd: airy products
• Stay in a sitting position and the amount of vegetables eaten (e.g. yoghurt, custard)
for years to come.
hold their head steady w• iBthlennodeadddoerdpusurégeadr cooked
If a baby spits out a new taste meat, fish or pulses can be
• Co-ordinate eyes, hands and at first, parents should keep
trying – the more times babies introduced after the above
mouth so that they can look at try a new taste, the more likely
food, pick it up and put it in their they will be to accept it (even foods – making sure bones
mouth by themselves if it does take a few attempts!).
are removed and without
• Swallow food. (Babies who are
adding salt, gravy or sauce.
not ready will push their food
back out with their tongue.)
Babies will rarely show these
signs in combination before
six months of age.
88
CHAPTER 7 WEANING
from mashed fruit or breast/ Top tips for starting weaning
formula milk are fine
Parents can try the following:
• Avoid honey until the age of
• Choose a time of day when they are relaxed and baby is alert
12 months. Occasionally, honey • Try giving the baby food during or after a milk feed so
contains bacteria that can
produce toxins in a baby’s that the baby is not hungry and doesn’t get frustrated when
intestines, leading to infant expecting the breast or a bottle
botulism, which is a very serious
illness. Honey is also a sugar, so • To begin with, offer a couple of teaspoonfuls of food once
avoiding it helps to prevent tooth
decay a day. Try starting with puréed vegetables, then progress to
fruit or cereal mixed with milk (see ‘Suitable first foods’ on
• Avoid wheat, gluten, nuts page 88)
(including peanuts), soya, meat, • Allow plenty of time, and prepare to get messy
fish, dairy and other potential • Wait for the baby to open their mouth before spoon-
allergens until six months of age
as they may cause allergies or feeding. If the baby doesn’t seem to like a particular food,
make the baby ill don’t force it – just try again another day
• Don’t give whole peanuts or • Gradually increase the amount of food and offer food twice
nuts to children under five years and then three times a day. The aim will eventually be to get
old because they could choke on babies eating three meals a day – breakfast, lunch and dinner –
them with healthy snacks in between
• Don’t choose low fat foods. Fat • Once the baby has learned to eat puréed foods, start giving
is an important source of calories food with soft lumps. Even babies without any teeth can learn
and certain vitamins for babies to chew soft food
and young children. It’s better for
infants between the ages of six • Let the baby learn and get used to individual tastes before
months and two years to have
full-fat milk, yoghurt and cheese mixing foods (particularly fruit and vegetables)
• Not to give shark, swordfish or • Remember to keep introducing the baby
marlin. The amount of mercury in to a wide range of healthy tastes and
these fish can affect textures by trying new foods – this
a baby’s growing nervous system way they are more likely to keep
eating them as they grow up.
• Always check the labels of It can take 10 or more attempts
before a baby accepts a new
cooking sauces, soups, breakfast food, so keep trying
cereals, etc., as they may contain
high levels of salt, sugar or • Be positive and praise the
artificial sweeteners.
baby for trying new foods.
The process of weaning
Baby’s age Skills babies are naturally learning Texture of food
From six • Take food from a spoon • Smooth purées of fruit and
months • Move food from the front to the back vegetables
of the mouth for swallowing. • Progress to soft mashed food.
Seven to nine • Move lumps of food around the • Mashed food with soft lumps
months mouth and chew • Soft finger foods (e.g. cooked
• Use fingers to feed themselves vegetables and soft, peeled fruit).
10-12 months • Sip drinks from a cup.
• Chew minced and chopped food • Harder finger foods (e.g. toast,
• Try to use a spoon to feed biscuits and harder vegetables)
themselves. • Minced and chopped tailored family
meals.
89
CHAPTER 7 WEANING
Homemade versus homemade and ready-made food. Healthy homemade food can get
ready-made A huge variety of ready-made babies used to the type of food
foods are available, from cereals the family eats. When making
Choosing to give babies home- to savoury meals as well as baby food, it is a good idea to
made or ready-made food is desserts and snacks. All products make up batches to provide
often a big decision for parents. will have a suitable age range on several portions of the same meal
Some research has suggested the packaging, as follows: that can be refrigerated or frozen
that mums feel a sense of guilt for future use.
when buying ready-made baby • From four to six months
foods. In addition, the research When preparing food for the
found that mums often buy baby Products have a smooth texture freezer, it’s important to cool the
foods out of convenience, as a and are suitable for babies just food down quickly by placing it in
distress purchase or ‘just in case’. starting to wean. Some are made an airtight container and holding
While convenience when out and with one ingredient so babies can under a cold running tap, stirring
about is a key benefit of ready- get used to individual tastes. the contents occasionally. This
made food, it can also help to should be done within one to
offer variety and introduce little • From six months plus two hours. Food stored in a
ones to new tastes and fridge should be used within two
ingredients. Products have a slightly thicker days and if kept in a freezer, it
texture, and will start to will need to be used within
To reassure parents, advise them introduce babies to basic proteins three months. Food should be
that ready-made baby foods are such as cheese and to more thoroughly re-heated (only once)
specifically designed to meet the complex tastes. Parents can also to ensure that it is piping hot all
nutritional requirements of start to introduce meat. the way through, and then left
infants and young children. They to cool before feeding the baby.
are carefully prepared to ensure • Seven to nine months plus
they provide the right balance of Did you know?
nutrients in appropriate amounts Products have a mashed texture.
and use high quality, baby grade Soft, cooked meat such as Eating food from a spoon or
ingredients to do so. Parents can chicken, and mashed fish can fingers requires a different
check the labels of infant foods be introduced, as well as pasta, mouth action to that used
to make sure they’re happy with noodles and rice. These foods when drinking free-flowing
the ingredients. have different flavours to help milk, and may aid speech
develop babies’ palates. development.
When it comes to advising
parents, there is no right answer – • 10 to 12 months plus
the decision will be whichever
works best for the parents, which Products contain small, soft
will usually be a combination of chunks and lumps to develop
babies’ chewing skills.
• 12 months plus
Products contain much larger
lumps of food to further develop
the child’s ability to chew.
Flavours are more adventurous
and closer to family meals.
90
CHAPTER 7 WEANING
Tackling fussy eating between meals. Limit them to a day, they’ll hate something, but
milk drink and some fruit slices a month later, they may love it.
It can take a while for babies or a small cracker with a slice of
to get used to a new taste or cheese, for example When to refer to the
texture, but if parents are worried pharmacist
that their baby is becoming a • It’s best not to use food as
fussy eater, you can suggest the The following customers should
following tips: a reward, especially for eating be referred to the pharmacist:
vegetables. Your child may start
• Eat the same meals and foods to think of sweets as nice and • Parents with babies younger
vegetables as nasty
as a family that you want the than six months who are thinking
baby to eat – seeing the family • Children sometimes get thirst about weaning
enjoy the food will encourage
the baby to do the same and hunger mixed up. They • Those having problems with
might say they’re thirsty when
• Give small portions and praise really they’re hungry and vice weaning
versa
the baby for eating, even if they • Parents whose babies are
only manage a little • Make mealtimes enjoyable,
having feeding problems
• If the baby rejects the food, fun and social, and not just about (e.g. their baby is not gaining
eating weight, is refusing milk or food,
don’t force them to eat it. Just or has any unusual symptoms)
take the food away without • If the parent knows other
comment. Try to stay calm, even • Parents who think their baby
if it’s very frustrating children of the same age who
are good eaters, ask them round may be allergic to certain foods
• Don’t leave meals until the for tea. A good example can or who want their baby to follow
work well a vegetarian/vegan diet.
baby is too hungry or tired N.B. If parents mention any
to eat • Sometimes a child will eat symptoms or behaviour in
a baby that seem unusual or start
• The baby may be a slow eater, for someone else, such as a alarm bells ringing, refer them to
grandparent, without any fuss the pharmacist/GP.
so be patient
• Children’s tastes change. One
• Don’t give too many snacks
91
CHAPTER 7 WEANING
Ask the experts i
Weaning can be a challenging process for
parents who want to ensure their toddler is
getting the best nutrition. Here’s how our experts
would answer these common weaning queries
Q What are the signs that a baby is not Q What foods should not
getting the right diet or enough to eat be given to a baby during
while they are weaning? the weaning process?
A ”If a baby is not getting enough to eat, A Boots UK nutritionist Vicky Pennington says
he/she will start to fall below their normal that babies should not be given:
growth line (centile) on the growth chart,”
says Geraldine Goodman, community dietitian, • Before six months: cows’ milk, eggs, wheat,
Dietetic Department, Cumberland Infirmary.
“Babies not getting the right balance of foods in gluten, nuts, peanuts, seeds, fish, shellfish, liver,
their diet are unlikely to show obvious signs for soft or unpasteurised cheese
a while and so it is important to make sure that
your baby is having foods from each of the main • Added sugar, salt or stock cubes
food groups, including: meat, fish, pulses and • Honey before one year of age
eggs; potato, rice, pasta, yam, bread and cereals; • Whole nuts until the age of five
fruit and vegetables; milk, yoghurt, cheese and • Raw or undercooked eggs
custard. If a parent is concerned that their baby • Low fat or low calorie foods
is not growing properly, they should discuss this • Too many high fibre foods, or foods with
with their health visitor or GP.”
added bran, which fill a baby up. Also, too much
Q Why is it best to start the weaning fibre interferes with absorption of important
process with vegetables? minerals such as iron
A “Vegetables are great sources of nutrients • Shark, swordfish, marlin (the mercury in them
and are easy, safe foods to offer to babies
as their first foods. They are cheap, easy to can affect the nervous system) or raw shellfish
prepare and also very versatile as they can be
mashed, puréed or offered as soft finger foods,” • Tea, coffee, fizzy drinks or squash.
says registered nutritionist Charlotte Stirling-
Reed, BSc (Hons) MSc. “As babies are born with Q When a baby starts eating solids, how
a preference for sweet foods, they don’t often will his bowel movements change?
need encouragement to enjoy eating fruit. What are the signs that something might
However, vegetables have a variety of different be wrong?
tastes – some bitter, some sour – so it is a good
idea to start getting baby used to these different A “The stools tend to get firmer and darker
flavours right away. Familiarity is key to babies’ and may become less frequent. The
acceptance of new foods, so it’s important to appearance of the stools will depend on what
encourage parents to continue offering a variety has been eaten,” explains freelance paediatric
of different tastes, textures and flavours to baby dietitian Tanya Thomas, BSc (Hons) RD. “Signs
during complementary feeding.” that something is wrong may be straining,
pain, infrequency or difficulty passing a stool.
These may indicate constipation, which can
occur at weaning with the change in solid
intake. If stools are very loose or frequent, this
may indicate an intolerance to some part of the
weaning diet.”
92
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The m ment they’re ready for weaning
CHAPTER 7 WEANING
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 anxious one, as it may coincide • What was it like for parents to
with a mum returning to work
1 At six months, babies outside the home, new child care give their baby solid food for the
should be introduced arrangements and exhaustion as first time? Was it fun?
to solid food. This can the baby becomes more lively and
be a time of great enjoyment demanding. While a pharmacy • What foods did they try at
for parents as they and their may not be the first port of
babies explore new tastes and call for parents wanting advice first?
textures together. But it can about weaning, the pharmacy
also be a time when parents team should be knowledgeable • Which foods did the baby like?
need plenty of patience. The and be able to refer any feeding • Which foods did they not like?
main thing for parents to problems to other healthcare
remember is that it is more professionals, if necessary. 2 Consider the following
important for the baby to get scenarios and think
used to the idea of eating If possible, identify a customer about the advice that
than how much he or she who is looking at baby foods or you would offer.
eats. The baby will still be perhaps follow-on milk in the
getting most of their nutrition pharmacy. Explain to them that • The parent of a five-month-
from breast milk or formula you would like to talk to them
milk so there is no pressure about their experiences when old baby has discussed weaning
for the baby to eat three weaning their baby. Be sensitive with her health visitor and is
meals a day. in your approach as parents don’t going to start in the next few
want to feel threatened that they weeks. She is not sure what
The weaning period is a time are not being good parents! foods to start with, and what
when the pharmacy team can the differences are between
offer support to parents who Alternatively, use the pharmacy the ready-made baby foods for
may find this experience quite an team’s experience to help. Try to different stages of weaning.
find out: She also wants to know what
“baby-led weaning” is.
• A mum of a six-month-old
is ready to start weaning. Her
family is all vegetarian and she
wants her child to be too.
94
CHAPTER 7 WEANING
YOUR CPD Multiple choice questions
Pharmacists and technicians 1. The latest age that a baby should be weaned is: n
– don’t forget to record your a. 17 weeks of age n
CPD at: uptodate.org.uk b. 22 weeks of age n
c. 26 weeks of age n
Reflection d. 32 weeks of age
• Are you confident 2. W hich of the following is a suitable first food for n
in your knowledge of a five-month-old? n
weaning? n
• Does your team a. Yoghurt and honey n
know how much milk b. Puréed butternut squash
and what types can be c. Puréed potato and chicken
consumed by babies d. Mashed lentils
during the weaning
stages? 3. W hich of the following are top tips when starting
• Where else might
you look for further weaning?
information?
a. Start offering food three times a day, after milk n
Planning
b. Give fruit and vegetables puréed together to get the
• Plan what training you
and your team need baby used to a variety of flavours n
• Consider whether
you have appropriate c. Wait until the baby is really hungry before offering food n
information on weaning
available in the d. Offer a couple of teaspoons once a day n
pharmacy
• Is there help and 4. W hich of the following statements is TRUE? n
information available a. A one-year-old should be given reduced fat yoghurt n
for parents? b. Soya shouldn’t be given until after six months of age n
c. Fish such as swordfish is a good source of omega-3 n
Action d. Reduced fat daiy products are a suitable first food
• Complete the training 5. What are the advantages of ready-made weaning food?
• Carry out and practice
different customer a. They are prepared to give the right balance of nutrients n
scenarios with team
members so you are all b. The packaging makes it clear which products are suitable
confident in the advice
that you are offering. for the different stages of weaning n
Evaluation c. They are convenient when out for the day n
• How have you helped d. All of the above n
parents who are
weaning their infants?
• Have you signposted
to other members of the
healthcare team?
Want to complete 95
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THE PHARMACY GUIDE TO INFANT FEEDING
MANUFACTURERS’ INDEX
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NUTRITION
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01225 711688 / neocate.co.uk SMA Althéra
Specialist SMA NUTRITION
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Neocate Advance 0800 0818 180 / smahcp.co.uk
Neocate Junior
Neocate LCP 0-6 months
Neocate Spoon SMA PRO First Infant Milk
SMA Extra Hungry Infant Milk
NUTRICIA EARLY LIFE NUTRITION 6-12 months
Newmarket House, Newmarket Avenue, SMA PRO Follow-on Milk
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Wiltshire BA14 0XQ SMA PRO Toddler Milk
0800 996 1234 / eln.nutricia.co.uk / Specialist
cowandgate.co.uk SMA Comfort Easy to Digest Infant Milk
SMA H.A. Infant Milk
0-6 months SMA LF Lactose Free Formula
Aptamil First Infant Milk 1 SMA PRO Anti-Reflux
Aptamil Hungry Milk SMA PRO Gold Prem 2 Post-discharge Formula
Aptamil Profutura First Infant Milk 1 SMA PRO High Energy
Cow & Gate First Infant Milk 1 SMA Wysoy Soya Infant Formula
No part of this publication may be reproduced without the written permission of the publishers. The publisher
accepts no responsibility for any statements made in signed contributions or in those reproduced from any other source, nor for
claims made in information on products or ranges featured. Published under licence by Communications International Group
Ltd, © 2017 Groupe Eurocom Ltd, Linen Hall, 162-168 Regent Street, London W1B 5TB. Tel: 020 7434 1530. Email: [email protected]
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ISBN 978-1-911393-18-4
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The complete guide to nutrition
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