Tuesday 26 th September 2017 Dr Rukhsana Hussain
Introduction Breast milk is the optimal milk for infants and should be promoted and encouraged where possible. If infant formula is required, it is important that it is both tolerated and cost-effective. First line recommendations in the following summary are based on cost only. Prescribers should switch to an alternative formula if an infant has problems with tolerance.
How much should I prescribe? Prescribe only 1 or 2 tins initially to assess tolerance and palatability A guide for a 28 day supply: Age Quantity Under 6 months 10 x 400g tins or 5 x900g tins 6-9 months 8 x 400g tins or 4 x 900g tins 9-12 months 6 x 400g tins or 3 x 900g tins Over 12 months 6 x 400g tins or 3 x 900g tins
Cow s milk protein allergy (CMPA) First line: Extensive Hydrolysed Formula (EHF) In order of cost effectiveness: 1. Similec Alimentum (birth - 2 years) 2. Althera (birth 12 months) 3. Aptamil Pepti 1 (birth 6 months) Aptamil Pepti 2 (6 months - 2 years) 4. Nutramigen Lipil 1 (birth 6 months) Nutramigen Lipil 2 (6 months 2 years)
Second line: Amino Acid Formula (AAF) Nutramigen AA and Neocate LCP should normally be started in secondary care unless a child has an anaphylactic reaction to cow s milk. Children with potential anaphylaxis should be treated with AAF as an initial treatment with immediate referral to secondary care Lactose-free formulae are not suitable for those with CMPA
Soya formula (Infasoy or SMA Wysoy) should not be routinely used for patients with CMPA. It should not be prescribed at all for those less than 6 months due to high phyto-oestrogen content and only be advised in patients over 6 months who have not tolerated the first or second line formula suggested. Parents should be advised to purchase it as it costs similar to cow s milk.
Review the need for prescribing if the : Child is over 2 years age Formula has been prescribed for over a year Quantities prescribed are more than they should be for the age of the child Child can now tolerate milk-based products Children with multiple allergies may need prescription beyond the age of 2 years. This should always be done at the suggestion of the paediatric dietitian.
Gastro-Oesophageal Reflux disease (GORD) Rule out overfeeding Average requirement for babies up to 6 months age is 150ml/kg/day spread over 6-7 feeds. Consider a 2 week trial of thickened feeds using a thickening agent such as Gaviscon added to the usual milk. Infant Gaviscon contains sodium and shouldn t be given more than 6 times in 24 hours. Recommend OTC anti-reflux formula initially (if thickener doesn t work) e.g. Cow & Gate Anti-Reflux or Aptamil Anti-Reflux
If prescribing thickening formula then: First line: SMA Staydown (contains corn starch) Second line: Enfamil AR (contains rice starch) Alert parents/carers that thickening feeds need to be made up with fridge-cooled pre-boiled water. Do not prescribe thickening formula with Ranitidine or PPIs or Gaviscon since they need stomach acids to thicken and reduce reflux.
Review at one month. If symptoms not improved then refer to secondary care. In those who respond to treatment, monitor growth and symptoms regularly. GORD usually spontaneously resolves between 12-15 months, therefore, cessation of treatment can be trialled after 12 months. Once vomiting resolves return to standard formula.
Secondary Lactose intolerance Symptoms usually occur after an infectious GI illness and include symptoms of : Abdominal bloating Increased wind Loose green stools Suspect lactose intolerance if an infant has had the above symptoms for over 2 weeks. Resolution of symptoms within 48 hours of withdrawal of lactose from the diet confirms the diagnosis.
Treatment is a low lactose/lactose free formula: SMA LF or Enfanil O-Lac with Lipil. Lactose free infant formula has similar costs to standard formula so prescribers should consider the need to prescribe. Review at 2 weeks. If no better consider an alternate diagnosis. If improved, continue lactose-free formula for 4-8 weeks then slowly re-introduce standard formula or milk into the diet.
Faltering Growth Diagnosis is made when an infant falls below 0.4 th centile or crosses 2 centiles downwards on a growth chart. Refer secondary care without delay. BUT high energy formula can be initiated in primary care in the short term whilst awaiting specialist review. First line: SMA High Energy Second line: Infatrini or Similec High Energy (all suitable up to 18 months age or 8 kg)
Key points in prescribing infant formulae Encourage and promote breastfeeding where possible. Breast milk is best for baby. Check that formulae prescribed are appropriate for the age of the infant and are prescribed in suitable quantities. Prescribe cost-effectively and small amounts initially to test for tolerance. Ensure regular reviews of the need for specialist infant formula.
Consider the possibility of secondary lactose intolerance in infants with abdominal bloating, increased wind and persistent loose green stools after an infectious GI illness. Do not prescribe lactose-free formula for infants with CMPA. Do not routinely prescribe Soya formula and definitely not to those under 6 months. Do not prescribe thickening formula with antacids as they need stomach acids to work!
References South West Yorkshire Area Prescribing Committee Prescribing Specialist Infant Formula in Primary Care guidance April 2017