Infant nutrition

Feeding a baby is a frequent parental concern regardless of whether it is the first or fifth child. Many parents (and health professionals) feel infants should ‘take what it says on the side of the tin’ or do exactly what the book says. However, rather than expecting children to eat by the ‘rules’, infants and young children base their eating on the body’s natural processes: hunger and drive to survive, appetite and the need for pleasure. Parents need to take leadership with feeding and let the child be self-directing at every stage.¹

Choosing to breast or bottle feed

Breast is best for infants and their mothers. There is no doubt from a health perspective and with the right support and education most mothers can breastfeed successfully. Local public health nurses as well as Cuidiu and La LeLeche league are invaluable supports to help mothers establish and maintain breast feeding. 

However, when a mother chooses combination or solely to formula feed here begins the ‘which feed is best?’ The Food Safety Authority of Ireland recommends a whey-based
protein formula as the preferable bottle feeding choice as it reflects the protein ratios in breast milk, ie. casein: whey ratio 40:60.² Hungrier infant milks have a casein: whey ratio 80:20, most similar to cow’s milk. 

Be calm and organised

Parents receive very little instruction on the ways to feed infants and young children but even less on the importance of the environment for feeding, the sensory preparation of the infant, the sensory preparation of the feeder, the sensory aspects of the meal and the sensory information the infant may need in transitioning to the next activity of the day. 

A harried, stressed feeder in a loud, busy environment generally will not make for good infant feeding. 

Positioning is key to a baby’s ability to feed properly. Regardless of whether infants are breast or bottle fed, ensuring the following can help feeding go smoothly:³

• Keep the baby’s head in alignment with the body (keeping the head, neck, and body in a straight line)
• Do not allow the baby’s head and neck to extend backwards as hyperextension of the head and neck can cause wide jaw movement, excessive tongue protrusion, tongue mounding and biting down for stability  
• Keep the baby’s ear above the mouth, so that fluid does not enter the Eustachian tubes, by holding the baby at a 45 degree angle or more
• For infants who are bottle fed use an appropriate teat size. Parents need a bottle teat that suits the baby’s mouth. If the baby has a small mouth then a short teat is needed. Teats that are too long can make it difficult for a baby to latch on. The shape of the teat is also important as some babies feed better with an orthodontic teat
• Keep the baby more upright and the bottle more horizontal to reduce the effects of gravity. 

Always check these basics – you would be surprised how often they are the source of minor feeding problems and can be easily remedied.

Timing, tempo, frequency and amount 

Generally infants are very good at letting parents know when they are hungry but many parents (and health professionals also) are not always good at reading their cues for when they are not! 

When it comes to how often an infant should feed and how much they should take – one size does not fit all. Appropriate weight gain is crucial and babies should not be over or underweight – but how much is right?⁴

As a guide, target weight gains in the first year of life should be: 

Term infants will generally double their weight by four months and triple it in the first year of life. 

Breastfed infants are seldom overweight as they stop eating when they are full. They will sometimes eat large meals and other times snack. Breastfeeding usually takes about 15 minutes or less per breast with newborn infants feeding about every two hours. Breast milk production adjusts to the infant’s needs when it is going well – hence the need to make sure mum is eating, drinking and resting. 

Bottle-fed infants are easy to overfeed. A baby’s stomach is small and I am constantly reminding parents to use the size of their infant’s fist as a guide to how much it can take. That ‘extra ounce’ to help the baby sleep is often the cause of the gastro-oesophageal reflux, discomfort and large spit-ups that concern parents and often result in over-feeding. 

Both breast and bottle-fed infants need to self-regulate the amount they drink according to their own needs. It is important that all babies decide how much and how often they wish to feed unless they demonstrate signs of poor growth and/or dehydration. The amount every infant drinks is individual depending on age, growth rate, activity level and stomach size. In clinical terms, healthy infants need about 150ml/kg of a standard formula to achieve adequate growth until the introduction of solid food. The latest national guidelines (FSAI) recommend the introduction of solid foods at about six months of age (24 weeks) but not before 17 weeks and not to be delayed beyond six months, but the exact timing to begin this process should be driven by the unique needs of the individual infant.⁵ Critically important is being able to read an infant’s cues and monitoring them closely for safe feeding while supporting them through the developmental process of learning to eat, no matter what age. 

Generally, bottle-feeding infants take the following amounts: 

These are guideline amounts/day and I always tell parents that it is better to feed an infant smaller more frequent feeds than over-feed at one meal. Once infants are introduced to solid foods these requirements can and do change significantly. If an infant’s intake falls below 20oz (600ml/day) then they are at risk of nutrient deficiencies, as well as constipation and dehydration, depending on what they are eating. Infants generally do not need extra fluids unless advised, during periods of warm weather or to help with constipation. 

Burps, hiccups and spit ups

Wind affects all babies to some extent as they usually swallow air while feeding. Young babies naturally fuss and get cranky when they swallow air during feeds. Although this occurs in both breastfed and bottle-fed infants, it’s seen more often with the bottle. When feeds are taken too slowly or too quickly, the amount of air swallowed may increase. A baby suffering from wind may stop feeding and cry, or squirm or have a pained expression on their face.⁶

Babies vary in how often they need to be winded during feeding.³ Some babies have very little wind and may only need to be winded at the end of a feed, or not at all, while others need to be winded quite regularly, eg. after every 2oz of feed or at any stage during the feed when they become uncomfortable. Babies also differ in how easily they bring up their wind. Some babies will bring it up within a minute or two in a nice satisfying burp, but others take longer.

A good strategy is to burp (wind) infants frequently, even if they show no discomfort. The pause and the change of position alone will slow gulping and reduce the amount of air taken in. If bottle-feeding, burp after every 2-3oz (60-90ml) or when breastfeeding between switching breasts. Some breastfed babies don’t swallow very much air, and therefore they may not need to wind frequently. 

Winding or burping properly is critical and different ways work for different infants, eg. against the body, sitting up, or face-down on the lap. Don’t spend longer than a few minutes at the end of a feed trying to get a baby’s wind up. The baby may well settle to sleep without bringing up any wind.  Sometimes a baby will pass flatus rather than burping.

In general, breastfed babies have fewer problems with wind than those on bottle feeds because they can control the flow of milk at the breast. However, in the first few weeks of life, breastfed babies may not be able to make a good lip seal and they swallow air during sucking. Also, if a breast-fed baby is a fast feeder, or the milk flow is particularly quick, wind may be a problem.

Hiccups 

All babies hiccup from time to time. If hiccups occur during a feed, changing position, trying to burp, or helping to relax can help. Wait until the hiccups are gone to resume feeding. If they don’t disappear on their own in five to 10 minutes, try to resume feeding for a few minutes. If your baby gets hiccups often, try to feed him when he’s calm and before he’s extremely hungry.

Spit-ups

Spitting up is another common occurrence during infancy. Sometimes spitting up means the baby has eaten more than an infant’s stomach can hold; sometimes infants spit up while burping or drooling. Although it may be a bit messy, it’s usually no cause for concern. It almost never involves choking, coughing, discomfort, or danger to the child, even if it occurs while the infant is sleeping. 

Reflux occurs when small quantities of formula or breast milk are vomited soon after feeding. Vomits are usually effortless and the amount of milk lost is not large. This is known as simple gastro-oesophageal reflux (GOR) and is a very common problem affecting up to 50% of babies. If a baby is gaining weight and is otherwise well, there is usually nothing to worry about. Most babies grow out of this problem during the first year. It often shows signs of improvement once they start on solids. Even a small or very mild reflux can cause a baby to spit up milk because the infant oesophagus is quite short compared to older children and adults. Babies with reflux may not vomit after every feed. It is common for reflux to occur after some feeds but not others. There may be no pattern to the reflux.

Reflux can be managed by:

• Reducing the infant’s wind. Infants with reflux may find being winded against the shoulder the most comfortable
• Discouraging infants from drinking too quickly
• Avoiding large feeds
• Sitting infants up nice and straight during feed
• Not letting infants lie flat for at least 20 minutes after a feed. It may also be helpful to raise the cot mattress a little by placing one or two rolled-up beach towels underneath the head of the mattress 
• Don’t move or jiggle infants immediately after a feed
• Avoiding tight waist bands.

If these measures fail to reduce reflux but the infant is growing well and is otherwise happy then the best course of action is to do nothing else. Spitting up and reflux are often more problematic for parents than infants. However, if reflux is causing problems, ie. if the baby needs several changes of clothes in a day and/or social outings are difficult, offering the baby a thickened formula may help. A thicker liquid settles more easily in the stomach and is harder for the baby to bring back up. There are three ways to thicken infant feeds:⁴

1. Change the formula to a pre-thickened formula

In order to maximise the effect of a pre-thickened formula, they should not be used in conjunction with an antacid medication eg. ranitidine or omeprazole. They should not be used either with Gaviscon Infant or thickening agents such as C&G Instant Carobel. It is important that parents follow the instructions on the box for making up these formulas.

2. Add a feed-thickening agent to the normal formula or give it as a paste before breastfeeding

An alternative to pre-thickened formulas is the addition of a thickening agent to regular formula or breast milk. C&G Instant Carobel is a white powder containing carob bean gum and maltodextrin and comes packaged in a box similar to powdered spoon feeds. A small sterile plastic scoop is provided in the box separate from the powder. Loose stools can occur in a minority of infants and the product should be withdrawn in these cases.

For breastfed babies it should be made up to form a gel. The gel is made by mixing one level scoop of Instant Carobel with 15ml of cooled boiled water and stir well. Leave for three to four minutes to thicken. Stir again. The gel should be freshly prepared before every feed in a sterilised container. It can also be made with expressed breast milk. The infant can be offered one to two teaspoons of the gel from a spoon or clean finger before the breast feed and again during the feed. 

3. Add a surface agent to the normal formula or give it as a paste before breastfeeding

Gaviscon Infant contains sodium alginate and magnesium alginate. It works by forming a surface gel over the milk preventing it from going back up the oesophagus. It also helps to protect the delicate lining of the oesophagus from the stomach acid.

For breastfed babies, Gaviscon Infant can be mixed to a paste as per the manufacturer’s instructions and offered from a spoon or feeding bottle after each breast feed. Gaviscon Infant can be added to the formula as per the manufacturer’s instruction just before feeding. Many parents ‘dump’ a sachet of Gaviscon Infant into the bottle resulting in the product not working as it should. Ensure parents follow the instructions on the box as it is a medicine and should not be given more than six times in 24 hours. Using more than this can cause issues such as constipation and it should be remembered that each sachet contains 21mg sodium. It is safe to use Gaviscon Infant for a prolonged period of time if needed, but under supervision.

Note: Instant Carobel and Gaviscon Infant should not be used together or with pre-thickened or comfort formulas.

Once infants are able to sit unsupported, reflux usually starts to improve. 

Colic

Colic can affect up to 30% of infants between three and 13 weeks of age – a few diehard screamers persist to five months.⁸ It affects breastfed and formula-fed infants equally. A baby with colic has spells of unexplained irritability, agitation, fussing or crying. Crying is an infant’s way of communicating that they are tired, hungry, over-stimulated or simply want to release tension. However, a baby with infant colic cannot be comforted during crying episodes. The cause of colic is unclear, but it is widely thought that painful contractions of the gut due to a build-up of wind (often from crying or feeding too quickly) may be a cause. Over-stimulation is another possible reason, hence the importance of getting the basics of infant feeding right!  

A diagnosis of colic is usually made when no other problem can be found and the baby is otherwise well and growing normally. Colic always improves on its own regardless of what is tried. Encourage parents to massage their baby if sorting the basics hasn’t helped. Gentle massaging of an infant’s tummy in a circular clockwise motion about an hour before they are likely to start crying – but not just after a feed – is often effective. 

There are a number of treatments for colic available including Infacol and Dentinox. Gripe water is no longer available in Ireland but continues to be sold in the UK and Northern Ireland. However, none of the above has been scientifically proven to help in infant colic. Some parents have found them beneficial and as there is no evidence that they cause any harm they are worth considering. Some comfort formulas are effective in reducing episodes of colic.

Cow’s milk allergy

While no way exhaustive – the following list highlights common manifestations of CMA₉;

* (usually with at least 1 other GI symptom) 

In infants with suspected cow’s milk protein allergy (CMPA) a trial of a hypoallergenic formula for two weeks is warranted. For the bulk of infants a trial of an extensive hydrolysed formula is the first choice – with elemental formulas for the firstline in infants failing to thrive or who have had anaphylactic reactions to cow’s milk infant formula. For mothers who are breastfeeding a trial of a milk-free diet is advised and where an infant fails to tolerate breast milk elemental formula is recommended. 

If the infant responds to the exclusion of milk from their diet they should be maintained on a milk-free diet for six months or until their first birthday. Removing foods from the diet significantly increases the risk of nutritional deficiencies so it should only be done under medical supervision and with advice from a dietitian. 

Solid food readiness

Infants should be weaned when they are ready and not before then. Seventeen weeks is the earliest time that complementary food can be introduced, but it is necessary that the infant be physically and developmentally ready.⁵ Breast milk/infant formula is only nutritionally complete for the first six months of life. Usually infants are ready to feed when they can hold their head up high constantly for longer periods, sit up (albeit with propping and support) at about six months of age, and can open their mouth wide showing interest in food and watching others eat. 

Constipation

Breastfed infant stools have a distinctive, sweet smell. They are a mustardy or bright yellow colour and have a loose runny texture. The baby might produce two to three of these stools a day or they may only go once a week once breastfeeding is established. Constipation in any breastfed infant is a red flag – it may be that the infant is not getting enough milk but generally these infants will not be gaining weight as expected and investigation is warranted. 

Bottle-fed infant stools will be bulkier than breastfed ones and will smell a little like adult ones. The colour will be dark green and they should pass a stool every two to three days to avoid becoming constipated. A common cause of constipation in bottle-fed infants is over concentrated formulas. Ensure formula is made up as advised. The simple addition of a bottle of cooled boiled water (1-2oz or 30-60ml) between feeds can improve this. Constipation is common in infants on some prethickened formulas.

Infant stools will vary but diarrhoea, constipation or blood-streaking are not normal for any baby to have continuously. If they occur just once, they might be symptoms of something quite simple. Any kind of small tummy bug, medication or teething can cause diarrhoea and this should clear up without treatment within 24 hours. Streaks of blood can sometimes appear in infant stools if they’ve got constipation, or a breastfeeding mother has had cracked nipples, but any infant with frequent or increasing blood in the stool warrants medical review. Most of the time this blood in the stool is secondary to a cow’s milk protein intolerance and placing the breastfeeding mother on a milk-free diet or the child on a hypoallergenic formula will treat the problem. Any infant with an suspected milk allergy is best referred to a dietitian for management in this critical stage of infant growth. 

A feeding problem, no matter how small, will worry a parent, with many presenting to primary care givers such as GPs for assistance. Many parents find that between the internet, their family and different health professionals they have no idea who to listen to! Simple, practical advice is critical. Dietitians with experience in infant feeding (both hospital and community-based) are helpful resources and always happy to help where further advice is needed. 

References

1. www.ellynsatterinstitute.org/other/fdsatter.php

2. FSAI. Recommendations for a national infant feeding policy. 1999. 

3. Bahr D. Everything from bottles and breathing to health speech development. ISBN 13:978-1-935567-20-2. 

4. Vanessa Shaw. Clinical Paediatric Dietetics, 4th Ed. ISBN: 978-0-470-65998-4. 

5. FSAI.  Best Practice for Infant Feeding in Ireland - A Guide for Healthcare Professionals. 2013

6. Bennett C, Underdown A, Barlow J. Massage for promoting mental and physical health in typically developing infants under the age of six months. Cochrane Database Syst Rev. 2013 Apr 30;4. 

7. Vandenplas Y. Management of paediatric GERD. Nat Rev Gastroenterol Hepatol. 2014 Mar;11(3):147-57.  

8. Shamir R, St James-Roberts I, Di Lorenzo C et al. Infant crying, colic, and gastrointestinal discomfort in early childhood: a review of the evidence and most plausible mechanisms. J Pediatr Gastroenterol Nutr 2013 Dec;57 Suppl 1:S1-45.  

9. Fiocchi A et al. World Allergy Organization (WAO) Special Committee on Food Allergy. Pediatr Allergy Immunol. 2010 Jul;21 Suppl 21:1-125.  

10. Bekkali N, Hamers SL, Reitsma JB et al. Infant stool form scale: development and results. J Pediatr. 2009 Apr;154(4):521-526.e1.