1. Which Infant Formula?

2. Feed Choices FeedExamplesEnergy Kcal/100ml Protein g/100ml Indications Breastmilk661.31 st choice EBM can be used as tube feed Standard Infant Formula SMA Gold Cow & Gate Premium Farleys First Aptamil First 661.4Whey based Casein based feeds e.g. SMA White, C&G Plus. High Energy Infant Formula SMA High Energy Infatrini 91 100 2.0 2.6 Fluid restriction, Higher energy requirements.

3. Specialised Formulas FeedProtein SourceFat SourceIndications Nutramigen (Mead Johnson) Hydrolysed Casein LCTMalabsorption of whole protein with/without disaccharide intolerance Pregestimil (Mead Johnson) Hydrolysed Casein 55% MCTAs above plus fat malabsorption Pepti Junior (Cow & Gate) Hydrolysed Whey 50% MCTAs above plus fat malabsorption Pepti (Cow & Gate) Hydrolysed Whey LCTCHO – 40% lactose Cows Milk intolerance Nan H.A. (Nestle) Partially hydrolysed whey LCTAtopic allergy prophylaxis Neocate (SHS) Free amino acidsLCTSevere malabsorption/ multiple allergy

4. COT report on phytoestrogens March 2003 ‘the Working Group note the advice by the Department of Health based on 1996 COT advice. This stated that breast and cows’ milk formulae are the preferred sources of nutrition for infants. However, women who have been advised by their doctor or other health professionals to feed their baby soy-based infant formulae should continue to do so. In the light of new data presented in this report, which was unavailable in 1996, the Working Group recommend that the current advice be amended to state that soy based infant formulae to be fed to infants only when clinically indicated. The Working Group note that similar advice has been issued in other countries (e.g. NZ, Australia)

5. Soya Formula Risks an infant receiving soya based infant formulae as a sole source of nutrition between the ages of 4-6 months will consume approx. 4mg isoflavins/kg bodywt/day Studies show upto 36% of infants given soya formulas for the management of Cows’ Milk Protein Allergy manifest symptoms of soya protein allergy. Recent concerns of an increased peanut allergy in infants fed soya based infant formula give further support to delaying exposure to soya

6. CMO Statement on Soya Based Formula. jan.2004 Soya based formulas should not be the first choice for the management of infants with proven cows’ milk sensitivity Soya based formulas should only be used in exceptional circumstances Infants with cows’ milk allergy/intolerance who refuse extensively hydrolysed/elemental formula Vegan mothers Galactosaemia Hydrolysed formulas should be used as first choice

7. Protein breakdown of formula PotentialProtein BreakdownHydrolytic Stages of an Antigenicity antigenic protein molecule High Intact protein Incomplete proteins (partially digested) Large peptides Small peptides Low Amino acids

8. Amino Acid Formula Only true ‘allergen free’ formula Hydrolysate intolerance occurs Atopy presenting during exclusive breast feeding (especially when FTT) improves on a.a. formula Multiple food allergy or hydrolysate/breast milk intolerance.

9. Genetic Predisposition Allergy risk in family No allergies 1 Parent with Allergy 2 Parents with Allergy Percentage of new borns 70%25%5% Probability of later allergies in their children 15%20 – 40%50 – 80% Absolute number of infants with probable allergy 1183

10. Beneficial Effects of Breast Feeding Sarrinen and Kayosaari 95 Greatest protection against atopic disease – exclusive BF 1 -6 months Joint statement of ESPACI and ESPGHAN (Arch. Dis Child. 96) ‘exclusive breast feeding during the first 4 -6 months of life might greatly reduce the incidence of allergic manifestations and is strongly recommended.’

11. Evidence for use of eHF as allergy prophylaxis Oldeaus 97 155 infants with FH allergy No cows milk 9/12, fish/egg/citrus 12/12, weaning 4/12 At weaning – pHF, eHF, CMF Atopic symptoms at 18/12 = 81% (CMF) 66%(pHF), 51%(eHF)

12. Evidence for use of pHF as allergy prophylaxis Chandra 97 288 high risk infants CMF, SF, pHF Cumulative incidence of atopy (eczema, wheeze, rhinitis, otitus media, vomiting, diarrhoea, colic) % culmulative allergy = pHF 7% CMF 36% SF 37% BF 20%

13. Strategies for Reducing Allergy Development Risk in Babies Family history of allergy No history - Low risk 1 or both parents with allergy - High risk PregnancyConsume a healthy, balanced diet during pregnancy, containing foods from all 5 food groups. Restricting maternal diet in pregnancy is not advised. As for low risk. However mothers may wish to avoid peanut and peanut containing foods.

14. Strategies for Reducing Allergy Development Risk in Babies Family history of allergy No history - Low risk 1 or both parents with allergy - High risk First 6 months of life Exclusive breast feeding is the first choice Where formula milk is used, a cows, milk formula is recommended. Mothers can also used a partially hydrolysed formula Exclusive breast feeding is the first choice Where formula is used, partially hydrolysed whey or extensively hydrolysed casein –based milks are recommended. Infants at highest risk who are not breast fed should be given extensively hydrolysed formula Do not use other milks, including soya, goat or standard cows milk formulas or off-the-shelf non formula milks from these sources.

15. Strategies for Reducing Allergy Development Risk in Babies Family history of allergy No history - Low risk 1 or both parents with allergy - High risk WeaningWeaning should not start before or beyond 6 months, definitely not before 17 weeks. Follow expert guidelines on the introduction of different textures and variety into the diet Don’t delay introducing the major allergenic foods (e.g. milk, egg, wheat, etc.) beyound 6 months of age. Planned introduction of major allergenic foods to be done one at a time, at 3 – 5 day intervals. By 12 months, all major allergenic foods that are normally suitable for a child of this age should have been introduced (excluding peanut)

16. Dietary Guidelines for Allergy Prevention Muraro et al Pediatr Allergy Immunol 2004 Mothers should aim to breast feed exclusively for 6 months (but at least 4 months) If mothers cannot breast feed or choose not to, they should use an extensively hydrolysed formula until 4 months of age. Partially hydrolysed whey formula may have an effect in terms of allergy prevention, although seems less than the effects of eHF.

17. Allergy Prevention Palatability Cost/presribability Ethnic acceptance (pork enzyme) Motivation of mother Conflicting advice from health professionals/relatives/friends Infant ailments attributed to special formula

18. Benefits of Healthy Gut Flora Infants with a healthy gut flora (i.e. one dominated by beneficial bacteria, such as Bifidobacterium and/or Lactobaccillus) have reduced risk of infection, disease and later development of food allergy. Decreased prevalence of eczema in high risk infants given probiotics/lactobacillus. Certain species of gut bacteria down regulate inflammation

19. Immunological Factors: Non Breast Milk Sources LCPs and Nucleotides are added to all standard whey based formulas – important in the development of inflammatory chemicals and development of the infants adaptive immune response. Prebiotics (in the form of oligosaccharides) Promotes the development of microbial flora similar to that of breast-fed infants (namely, one that is bifidobacteria-dominant)

20. Other Infant Formulas Soya formula – Wysoy, Infasoy Low lactose formula – SMA LF, Omneocomfort (C&G), Enfamil Lactofree. Thickened formula – SMA Staydown, Enfamil AR, Omneocomfort