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Feeding problems in infants Module 186: February 2013
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Child health
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From colic to reflux to cows’ milk allergies, many common infant feeding problems arise in the first
year and GPs are at the frontline of parents’ questions and need to offer advice and reassurance
(This module was facilitated by Prof Alf Nicholson)
Parents frequently present to their GP with their
infant under one, who may have a number of issues related
to feeding. Common issues that present in general practice
include questions about whether breastfeeding is successful, whether weight gain is adequate, is crying or vomiting
normal, managing constipation and how parents can 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.
Overview
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 breastfeeding for six months is the
feeding option of choice for 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 formulae are based on modified cow’s milk. Breast
milk or infant-based 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. All specialised formula should only be used under
medical supervision. Infant 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.
Breastfeeding
Breastfeeding is matched to the specific nutritional
requirements of the growing infant and provides protection
against infection. The colostrum is the milk 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 thick and
viscous and the infant ingests 4-14ml 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 breastfeeding 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. Mothers 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
DISTANCE LEARNING Feeding problems in infants
Table 1
A guide to feed intake
Age
Feed
intervals
No of feeds
per 24 hours
Feed volumes
per single feed
1-2 weeks
3 hourly
7-8
50-70ml (2oz)
2-6 weeks
4 hourly
6-7
75-100ml
(3oz)
2 months
4 hourly
5-6
120-180ml
(4-6oz)
3 months
4 hourly
5
180-220ml
(6-7oz)
6 months
4 hourly
4-5
210-240ml
(7-8oz)
is extreme nipple soreness or breast engorgement that persists after the first week.
Where there is more than the usual weight loss (ie. over
8% of birth weight), the infant should be carefully evaluated and may require review by a paediatrician. One may
supplement with expressed breast milk ideally or formula
milk (rarely). 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
breastfeeding is progressing well include:
• Adequate weight gain with a return to birth weight by
10-14 days of age and thereafter 170-200g per week
weight gain during the first three months of life
• More than five wet nappies per day
• Infant latches on well with entire nipple and almost all of
the areola covered by the infant’s mouth
• Milk is seen in the infant’s mouth with brief pauses in
the sucking and swallowing motion being observed and
heard.
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. There are different types of
infant formula. The first group are whey dominant formulae, which contain whey casein ratio 60:40. These milks
include Aptamil First Milk, Cow & Gate First Infant Milk,
and SMA First Milk.
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 less than six weeks. They are seen as being more
satisfying. These include Aptamil Hungry Milk, Cow & Gate
Infant Milk for Hungrier Babies and SMA Extra Hungry.
The third milk group available is follow-on milks. These
are made from modified cows’ milk and contain extra iron,
minerals and vitamins. These are for the older baby over
FORUM February 2013
six months of age. They include Aptamil Follow On milk,
Cow & Gate Follow-on Milk and SMA Follow-on Milk. These
milks are designed to discourage mothers from feeding
unmodified cows’ 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 form
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.
After the first few days, formula-fed infants take up to
100ml per kilo per day (1 fluid ounce = 30ml) and may later
settle on 100-120ml 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
you choose to give your baby a drink between meals, cooled
boiled water is preferred to sweetened drinks, tea, etc.
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 6-7
months of age and the limiting of bottlefeeds should be commenced at this stage (see Table 1 – a guide to feed intake).
Specialised formulas
Specialised formulas are available for different conditions. Cow & Gate Nutriprem One and Two are reserved for
preterm babies and have a higher caloric value. Nutriprem
One contains 80kcal per 100ml and Nutriprem Two contains 74kcal per 100ml and a higher protein and fat content
than formula feeds for term infants. High-energy formulas
are available and provide almost 1kcal per ml. SMA High
Energy providing 0.91kcal 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 formulae containing predigested proteins or medium
chain fats. These include Nutramigen, Cow & Gate PeptiJunior and Aptamil Pepti 1 and 2. Other formulae include
Enfamil O-Lac and SMA LF, which can be used in cases
of lactose intolerance. Cow and Gate Comfort and Aptamil
Comfort can be used from birth to one year to reduce colic,
constipation and posseting
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. Peanut butter may be included
after six months of age unless there is a family history of
DISTANCE LEARNING Feeding problems in infants
nut allergy or severe atopic disease.
By 7-8 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, the infant
will have progressed to eating the family meals .
Gastro-oesophageal reflux
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 a 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. Useful growth charts
can be found at www.rcpch.ac.uk and are available on
www.healthforallchildren.co.uk
Guidance for managing GOR in primary care
• Keep the baby upright for at least 30 minutes after a
feed
• Raise head of the cot to a 30 degree angle
• Avoid use of car seats immediately after feeding
• A void clothing or nappies that are tight around the
abdomen
• Check volume of feeds and avoid over-feeding
• Feed thickening with carob bean gum and maltodextrin
(Cow & Gate Instant Carobel) – one scoop per 150ml and
allow to stand for 3-4 minutes after adding
• P re-thickened feeds (Enfamil AR or SMA Staydown)
thicken on contact with stomach acid. Prepare using previously boiled water that has been chilled and vigorously
roll bottle between hands.
• Antacids such as Gaviscon contain sodium and magnesium alginate and form a surface gel over the milk
– Gaviscon should not be used with feed thickeners or
pre-thickened formulae. Trial of Gaviscon best reserved
for breastfed infants
• Use of H2 receptor antagonists such as ranitidine only if
unresponsive to simple measures as above
• Barium swallow is not recommended for GOR.
The website www.livingwithreflux.org includes very helpful
parent leaflets that can be downloaded.
Excessive crying in early infancy
While it is often difficult to determine when an infant
should be considered to have colic, the most widely used
definition is that proposed by Wessel and colleagues. This
is known as the ‘rule of threes’. An infant should be considered to have colic if he/she cries for more than three
hours per day for more than three days per week for three
weeks. However, this definition has its limitations in that
FORUM February 2013
the actual duration of crying may be difficult to quantify
and very few parents are prepared to wait three weeks until
an official announcement proclaiming that their infant has
colic is made.
It is important to note that most cases of colic cannot
be accounted for by pre-existing maternal personality characteristics, postnatal depression or non-optimal caregiving.
Because of inexperience, first-time mothers may bring their
crying infants to medical attention more often, but there
is no difference in the amount of crying in first-born and
subsequent infants.
Thus most cases of colic are unlikely to be due to
problems in either the mother or infant. Differences in caregiving (such as the amount of contact, the frequency and
type of feeding) may modify both the duration and pattern
of crying.
Which treatable conditions may underlie excessive infant
crying?
Infection
Always enquire about a history of recent fever as the presence of fever in an under three-month old may indicate
the possibility of a serious bacterial infection (urinary tract
infection, septicaemia or meningitis).
Feeding issues
There is an important link between feeding problems and
excessive crying. Refusal to feed and excessive crying are
not related to gastro-oesophageal reflux (GOR). Difficulties with breastfeeding (such as problems of attachment or
positioning) may put susceptible infants at risk of increased
crying and aversive feeding behaviours. Functional lactose
overload occurs when breastfeeds do not contain enough
fat, resulting in rapid milk transit through the intestine.
Undigested lactose ferments in the colon with resulting
explosive or frothy stools, excessive crying and a desire to
feed very often.
Cow’s milk protein allergy (CMP)
Some infants with excessive crying have CMP allergy.
Pointers towards CMP allergy as a cause of excessive crying
include those infants with ‘high-pitched’ crying, infants who
regularly arch their backs during crying bouts and when the
crying pattern does not fit a pattern of evening clustering.
A late onset of increased crying in the third month of life or
following a switch from breast to formula milk may implicate CMP allergy.
Managing colic in primary care
As a family doctor, the starting point in managing colic is
to take the problem seriously and to ensure that feeding is
adequate and appropriate for the infant. A detailed examination of the infant is important.
Most breastfed infants in the first few weeks to months
of life need 8-12 feeds a day with at least one breastfeed
between midnight and 6am. Babies may seek cluster feeds
whereby they take to the breast every 30-60 minutes for a
period, most commonly in the evening. It is advisable for
mothers of crying infants to respond in a relaxed manner
to pre-cry cues with an offer of a breastfeed, before the
baby becomes even more distressed and difficult to soothe.
This is an exhausting schedule for even the most committed mother! Cue-based care from birth, combined with an
DISTANCE LEARNING Feeding problems in infants
average of 10 hours of physical contact (whether awake,
feeding or sleeping) in a 24-hour period is associated with
50% less crying in early infancy
Spend time reassuring and explaining the problem to parents and do not be afraid to advise admission to hospital if
necessary to alleviate a very stressful situation at home.
There is a group of infants with colic that are classified
as ‘Wessel’s plus’ and these infants fulfil Wessel’s criteria
for colic but in addition have other cues that cause concern. These infants tend to display clenched fists, flexed
legs, back arching, distended abdomens, regurgitation with
crying and a pained face when crying. In this Wessel’s plus
group (especially if there is associated diarrhoea and/or
vomiting), a trial of elimination of cow’s milk protein (either
from the mother’s diet if breastfeeding, or from the infant’s
diet by changing to a CMP-free formula (Aptamil Pepti or
Nutramigen) may be indicated.
10-step guide for managing colic in primary care
Crying and fussing do reduce significantly after three
months of age and this relates to the maturing central nervous system of the infant and coincides with a changing role
for the cry signal – from expressive crying to communicative
crying. Therefore, the most important aspect of the management of colic is to reduce psychological pressure on the
caregivers, especially the mother. This is best achieved by
using the following principles:
• Acknowledge the reality of the parents’ concern, regardless of the amount of crying
• Take a thorough history (including perinatal and feeding
history) and perform a thorough physical examination of
the infant
• Encourage parents to experiment with relaxed cue-based
care, sleeping in the same room as the infant, with increased
physical contact (including skin-to-skin contact).
Dietary management
Ensure correct breastfeeding technique (if breastfed),
trial of probiotics (Lactobacillus reuteri) for 10 days and
then a trial of maternal dairy-free diet for two weeks. If
formula-fed, ensure correct feeding technique and winding. If parents are at their wits end, implement a trial of
ICGP LIBRARY
& information service
Some suggestions for additional resources:
GUIDELINES
• FSAI (2011) Best Practice for Infant Feeding in Ireland – a guide for healthcare
professionals www.fsai.ie/news_centre/press_releases/infant_feeding_19112012.html
• NICE Guideline CG116 (2011) Diagnosis and assessment of food allergy in
children and young people in primary care and community settings
http://guidance.nice.org.uk/CG116
• NICE Guideline CG99 (2010) Diagnosis and management of idiopathic childhood constipation in primary and secondary care
http://guidance.nice.org.uk/CG99
GENERAL
• Breastfeeding.ie: www.breastfeeding.ie/
• Growth Monitoring – WHO-UK Growth Charts for Ireland:
www.hse.ie/eng/services/healthpromotion/growthmonitoring/
• WHO – Promoting proper feeding for infants and young children:
www.who.int/nutrition/topics/infantfeeding/en/index.html
extensively hydrolysed formula for two weeks.
It is helpful to assess the supports for the mother and
to see that these support persons (eg. grandparents) are
also educated about the best way to perceive and handle
crying.
• Ask the mother to keep a diary of crying
• Ask your practice nurse or public health nurse to support
the family and regularly weigh the infant
• Arrange for regular ‘respite’ periods for the mother, if
possible
• Safe swaddling and infant massage may help for some
mothers and babies
• In severe cases, especially if the increased crying is occurring in the context of a fragile or otherwise challenged
family, refer for a paediatric opinion and perhaps consider
admission to take the heat out of the situation.
Studies point to excessive crying being a condition of in
the first three months in normal infants. All young infants
display crying which peaks at 4-6 weeks of age. As doctors
we should firstly never ignore or downplay parental concern regarding colic and the infant with excessive crying
should be regularly monitored. Drug therapy is ineffective
and dietary changes are rarely indicated.
Resources for parents
• www.purplecrying.info – Informs parents about infant
crying. Advice is given in both text and video
• www.zerothree.org – Includes an interactive baby map,
a podcast about infant crying and a number of relevant
articles pertaining to excessive crying
• www.mothersmatter.co.nz – Provides information for families about post-natal depression, managing infant crying
and coping with negative feelings towards the new arrival.
Constipation in infancy
Stool frequency and consistency varies enormously in
early infancy. For breastfed infants, stools are often runny,
mustard to orange in colour with white flecks and occur
after every feed. Formula-fed infants have stools that are
passed one to three times per day to once every two to three
days. These stools are grayish-green in colour depending on
the type of formula used.
Constipated stools are firm, dry or pellet-like in consistency and cause significant distress to the infant. The main
causes of constipation in infancy are inadequate fluid intake
(most common by far), incorrect feed preparation, frequent
formula changes and cow’s milk protein allergy (rarely).
Advice for management of simple constipation
• Ensure adequate formula intake
• Offer 30-60ml of cooled boiled water once or twice per
day between feeds
• From two months of age, offer 30-60ml of dilute apple or
pear juice (15ml juice and 45ml water) twice a day
• If no response, start 5-10ml of lactulose daily if constipation is severe and fails to respond to dietary measures
• Avoid use of suppositories if possible.
Professor Alf Nicholson, professor of paediatrics, Children’s
University Hospital, Temple St, Dublin
References on request
FORUM February 2013