In the first instalment of a two-part article, Alf Nicholson discusses problems regularly encountered in relation to breastfeeding, bottle feeding and reflux
Parents frequently present to primary care with their infants who may have a number of issues related to feeding. Issues relate to whether breastfeeding is successful, whether weight gain is adequate, is this crying or vomiting normal, managing constipation, and how parents ensure a balanced diet in their strong-willed toddler.
This article is an attempt to explore these issues in some detail and to debunk a few myths along the way.
Healthy eating for infants and toddlers means eating a combination of age-appropriate foods that provide sufficient energy and nutrients to allow for growth and development and which also help to optimise health and reduce the risk of disease.
Exclusive breast-feeding for six months is the feeding option of choice in early infancy as it ensures protection against bacterial and viral infection in addition to its nutritional superiority. Sadly, fewer than 50% of Irish mothers initiate breastfeeding and a much smaller number continue exclusive breastfeeding for six months.
Infant formula is based on modified cow’s milk. Breast milk or formula should be the main milk drink for the first year of life and unmodified cow’s milk should not be used as the main milk drink before the age of one year.
Specialised formula should only be used under medical supervision. Formula is either whey dominant or casein dominant. Whey-dominant formula is designed to reflect the composition of breast milk and casein-dominant formula is similar to cow’s milk. Weaning the infant onto solids is not necessary before six months of age.
Breastfeeding is matched to the specific nutritional requirements of the growing infant and provides protection against infection. Colostrum is produced in the first five days and it contains large amounts of protein, IgA, immunoglobulins and lysozyme and provides immunity within minutes of birth.
The composition of breast milk is variable from mother to mother, time of the day and the length of time post-partum. Breast milk consists of whey proteins in a 60:40 ratio, fat and essential fatty acids and carbohydrate mainly in the form of lactose.
Breastfeeding is a learned skill and the establishment of successful breastfeeding cannot be assumed to occur easily for all women. Ideally, breastfeeding education should start in the antenatal period. Practical assistance is essential following birth in order to ensure the baby is feeding well prior to discharge home. Correct attachment and positioning are fundamental to breastfeeding success. What a mother learns in hospital about breastfeeding and the quality of that experience will affect her breastfeeding skills for a long time and will strongly influence how she feeds her future children.
Initially colostrum is produced. Colostrum is a thick and viscous and the infant ingests four to 14ml at each feed. Milk yield increases gradually over the first 36 hours and this is followed by a dramatic increase during the next 48-96 hours. Milk production will be initiated whether or not breastfeeding takes place. However, breastfeeding and milk removal are essential components for the continuation of lactation.
The optimal time to initiate breastfeeding is in the period immediately following delivery. The infant’s sucking reflex is at its most intense within the first two hours after birth. Correct positioning skills will minimise problems such as sore and cracked nipples, breast engorgement and mastitis.
Mild degrees of breast engorgement in the mother can be managed by ensuring that the infant feeds both effectively and frequently to aid breast emptying. Incorrect attachment of the infant to the breast and nipple may lead to cracked nipples and mastitis. If the degree of nipple trauma or breast tenderness makes breast-feeding too painful, milk should be expressed by hand or breast pump.
Prior to discharge home, mothers should be advised to feed their babies frequently, to keep their infant on the first breast until a feed is completed, not to time feeds, and to avoid the use of dummies and supplemental formula feeds. No specific intervention is required for bilateral inverted or retractile nipples. They should be told to seek help if their infant is producing scant urine, is lethargic or extremely fretful, if no swallowing is felt or heard or if there is extreme nipple soreness or breast engorgement that persists after the first week.
Where there is more than the usual weight loss (ie. more than 8% of birth weight), the infant should be carefully evaluated and may require review by a paediatrician. One may supplement with, ideally, expressed breast milk or, rarely, formula milk. Assessment of urea and electrolytes is essential as the most serious consequence of inadequate intake is hypernatraemic dehydration, which although rare is potentially life threatening. Significantly the infant may not appear dehydrated as normal skin turgor is maintained.
Enthusiastic support and monitoring of breastfeeding mothers is essential to promote continuation of breastfeeding following discharge from hospital.
Indicators that breast feeding is progressing well include:
Formula feeding Infants who are not breastfed should be fed infant formula for the first year of life. Brands are generally divided into whey – or casein dominant. Whey dominant formulae, which contain whey and casein in a ratio of 60:40, include Aptamil, Cow and Gate Premium, Farley’s First milk and SMA Gold.
Another type of infant formula available are known as second milks. These have a whey to casein ratio of 20:80 reflecting more the protein composition in full cream cow’s milk. These milks are marketed as being for the hungrier baby as casein is more difficult to digest creating a larger curd in the stomach and hence are not recommended for babies younger than six weeks old. They are seen are being more satisfying. These include Cow and Gate Plus, Farley’s Second, Milumil and SMA White.
The third milk group available is made up of ‘follow-on milks’. These again are made from modified cow’s milk and contain extra iron, minerals and vitamins and have been marketed for the older baby – over six months of age. These include Farley’s Follow on milk, SMA Progress, Cow and Gate Step Up and Milupa Forward. These milks are designed to discourage mothers from feeding unmodified cow’s milk to infants under the age of one. If the baby is content there is no reason why they should change from a first milk to a second milk. Frequent changes from one brand of formula milk to another is strongly discouraged as it carries a real possibility of error in preparation and is of questionable usefulness.
Specialised formulas are available for different conditions. Nutriprem 1 and 2 are reserved for preterm babies and have a higher caloric value. Nutriprem 1, containing 80 kcal per 100ml, and Nutriprem 2, containing 74 calories per 100ml, and a higher protein and fat content than formula feeds for full-term infants. High-energy formulas are available and provide almost 1 kcal per ml. SMA High Energy, providing 0.91 kcal per ml, is used in cases of failure to thrive where catch up growth is desirable.
Other formulas available include Enfamil AR and SMA Staydown. These are thickened feeds, which may be used if gastro- oesophageal reflux is present. These formulas are of normal consistency when constituted, but thicken on contact with the stomach acid. Infants with suspected cow’s milk protein allergy or other malabsorption syndromes may use formulas containing predigested proteins or medium chain fats. These include Nutramigen and Nutrilon Pepti. Other formulas include Enfamil Lactofree and SMA LF, which can be used in cases of lactose intolerance.
After the first few days, formula-fed infants take up to 100ml per kilo per day (one fluid once = 30ml) and may later settle on 100-120 ml per kilo per day. Fruit drinks should not be given in lieu of milk feeds or at bedtime. Tea, mineral water or fizzy drinks are not suitable drinks for infants. If parents choose to give their baby a drink between meals, cooled boiled water is preferred. Breast or formula milk should remain the main milk of choice for the first 12 months of life as cow’s milk is very low in iron.
Cup drinking should be introduced from after six to seven months of age and the limiting of bottle feeds should be commenced at this stage.
Weaning to solids
Weaning to solid foods should commence from six months of age. Recommended first foods include gluten-free cereals such as baby rice, mashed potato, pureed fruit with little or no added sugar and pureed vegetables. Pureed meat can be added later on once weaning is established.
First feeds should be pureed and be of a soft runny consistency, without lumps. Foods should be introduced one at a time, leaving a few days between the additions of each new food. One should use expressed breast milk, infant formula or cooled, boiled water to mix the foods.
Honey carries a small risk of botulism and is not recommended until after one year of age. Peanut butter may be included after six months of age unless there is a family history of nut allergy or severe atopic disease .
By seven to eight months a meal pattern of three meals in a 24-hour period should be achieved. A milk drink or milk dessert could be included after this. Breastfeeds, bottles of milk and drinks from cups should also be included. At this stage, infants can begin chewing soft lumps and then progress to mashed and chopped food. By 11-12 months of age, the infant will have progressed to eating the family meals that have been adapted to cater for their needs, ensuring low sodium levels etc.
Gastro-oesophageal reflux (GOR) occurs in up to 50% of normal healthy infants and involves the passage of gastric contents into the oesophagus with or without regurgitation and vomiting. It is a normal physiological process that occurs several times per day. Most reflux episodes last less than three minutes and occur in the period following feeds. GOR affects breastfed and formula fed infants equally. GOR gradually decreases with age so that by 12-15 months of age, only 5% of infants regurgitate. A small number of infants have gastro-oesophageal reflux disease (GORD) with significant oesophagitis and symptoms of forceful vomits, poor weight gain, inconsolable crying, back arching and feed refusal after starting.
Managing GOR in primary care
The website www.livingwithreflux.org includes very helpful parent leaflets that can be downloaded.
Alf Nicholson is a professor of paediatrics at the Children’s University Hospital Temple Street, Dublin
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