1. Infant Milk Formula Update: What, when and why? Sally-Ann Denton Chief Community and Paediatric Dietitian Portsmouth Hospitals NHS Trust September 2010

2. Overview Standard formulas –Main differences –When to use –considerations Specialised formulas –Indications & contraindications for use

3. QUIZ

4. Standard Formulas Breast milk best (WHO) Infant formulas based on modified cows milk with additions to bring as close to breast milk as possible. First milks whey dominant (as is breast milk) Often labelled number ‘1’ Casein dominant milks sometimes called second milks (numbered as ‘2’ ) Marketed for hungrier baby– no evidence that will satisfy baby better /delay weaning NB SMA hungrier baby milk no number

5. Standard Milk Formulas Recent Advances Always aiming to be closer to breast milk : additions to mimic beneficial effects Prebiotics added to some formulas – can help with immunity (promote colonisation of the GI tract by probiotics), prevent GI infections and diarrhoea, soften stools and may prevent atopic dermatitis Nucleotides – involved in cellular immunity important in tissues with rapid turnover e.g. GI tract & immune system in infants LCPs – help with brain & eye development - source often fish oils Antioxidants – e.g. beta carotene and selenium

6. Protein – SMA First Infant Milk (and some others) contain 1.3 g/100ml cf 1.4g/100ml Others 1.3-1.4g/100ml Extra hungry milks 1.6g/100ml Lower levels of protein in formula may slow infants weight gain so that it is closer to that of breast fed babies and reduce risk of later obesity SMA ↑ α –lactalbumin and ↓β- lactoglobulin

7. Organic Milks Don’t always contain additions e.g. Hipp Organic - no nucleotides added Organic ≠ vegetarian

8. Follow On Formulas Suitable from 6 months onwards Compared to cow’s milk: less protein,higher Fe and Vit C Compared to first milks : higher Fe & Zn therefore MUST NOT BE GIVEN if baby < 6 months Some higher protein content N.B SMA Follow on now labelled as 2 – can be confusing Not necessary but can be helpful for older infants and toddlers if diet poor

9. Toddler Milks From 1 year upwards Not usually necessary but can be helpful for toddlers with poor diets Often display number ‘4’ – but SMA Toddler milk = ‘3’ NB cost may be an issue

10. Goodnight Follow On Milks

11. Aptamil Comfort For minor GI problems – not prescribable Contains partially hydrolysed whey protein, prebiotics,modified fat and thickeners Manufacturers suggest may help colic/ minor digestive problems but evidence weak

12. Specialist Milks Different composition to standard milks: –Protein- whole – but ? different source - extensively hydrolysed - elemental (amino acids) –Fat - LCT - MCT –Carbohydrate- lactose - glucose –Viscosity

13. Pre thickened formulas Enfamil AR and SMA Stay down Available OTC and prescribable for G.O.R. Contain starches that thicken in the stomach Normal consistency in bottle but thickens upon contact with stomach acid Contain whole milk protein and lactose and are therefore unsuitable for treating CMPI

14. Lactose Intolerance Usually secondary and therefore transient (post-infective e.g. to rotavirus) Treat with lactose free formula: e.g. Enfamil O-Lac or SMA LF plus a milk free diet Usually recovers 2 to 4 weeks after infection Primary, congenital lactase deficiency very rare. Some patients from East and South-East Asia and Africa may suffer from primary hypolactasia (typically age 3yrs + ) Still contain casein and whey proteins - NOT SUITABLE FOR COWS MILK ALLERGY

15. Infants> 1 year of age can use whole milk supermarket lacto free milk – cheaper Lactase drops to add to formula/ breast milk also an option for transient lactose intolerance

16. Cow’s Milk Protein Hypersensitivity Describes IgE mediated allergy and non-IgE mediated allergy (intolerance) Manifests itself through variety of symptoms, mild to severe including anaphylaxis, urticaria, GOR, FTT, diarrhoea, constipation, severe atopic eczema Treatment: appropriate formula and milk free solids N.B: babies with hypersensitivity to cow’s milk protein may still be thriving on presentation

17. Cow’s Milk Protein Allergy Babies < 6 months: use extensively hydrolysed formula (EHF) e.g. Nutramigen1, Pregestimil, Pepti junior (whey based +MCT oil), Aptamil Pepti ( whey based +lactose) Soya formula not recommended as first line treatment : –high phytoestrogen content –potential risk to long term reproductive health (from animal studies) –Except in Galactosaemia > 6 months: soya formula safe (lower dose of phytoestrogens per kg body weight) Or use extensively hydrolysed formula e.g. Nutramigen 2

18. Amino Acid Based Formulas Based on artificial amino acid mix e.g. Neocate LCP Nutramigen AA Use if: –anaphylaxis / breathing difficulties with whole protein formula –growth failure –No improvement in breast fed infant with mother on milk free diet –blood in stools –no clinical response with hydrolysed formula (to which 90% babies respond to) –refusal of hydrolysed formula

19. Use Of EHF and Amino Acid Formulas Prescribe for as long as needed. Dietetic supervision important to ensure nutritional adequacy of diet – refer early Calcium and Vitamins needed if formula intake inadequate Don’t normally challenge before 1 year of age 50% infants outgrow cows milk protein hypersensititvity by 1 year and 80% by age 2-3

20. Cows Milk Allergy in Breastfed Infants In breast-fed babies: –Place mum on a strict milk free diet (avoiding obvious dairy and traces of dairy products) –Ensure that she receives calcium supplementation (1000mg/day eg Calcichew b.d. or Sandocal 1000 o.d.)

21. Unsuitable Milks Goats milk / goats formula unsuitable Rice milk must not be given to <5’s inorganic arsenic levels potentially harmful Supermarket soya milk low fat and low in protein not nutritionally complete Other nut milks low in protein not nutritionally complete Oat milk low energy and low protein not nutritionally complete

22. High Energy Milks Contain whole cow’s milk based protein and lactose Used in faltering growth Nutritionally complete and RTF High protein: energy ratio to promote catch up growth Infatrini (Nutricia) 100Kcal/100ml for 0-12 mths / up to 8kg body weight SMA High Energy 91kcal /100ml for infants up to 18 mths of age Similac (Abbott) 101 kcal /100ml for 0-18 mths (8kg) (standard formula: 68 kcal per 100 ml)

23. Quiz Answers How did you do?