South Africa, like most other countries, has adopted the World Health Organisation’s policy with regard to the “promotion, protection and support of breastfeeding”.  It is therefore the responsibility of all health care professionals to promote and support breastfeeding.

A large proportion of the population are however opting for infant formula substitutes.  Many different milk formulae are available and it is essential that pharmacy staff are familiar with the choices, understand the use of milk substitutes at various stages of infant growth and be able to provide patients with advice on the correct preparation and appropriate sterilisation techniques when choosing to bottle-feed an infant. 

Breast or bottle

There may be a variety of reasons as to why a mother may not be able to or may not want to breast feed her baby, e.g. returning to work, illness or medication.  In these situations the use of commercially available formula feeds is very useful.  However, many new mothers are faced with the dilemma of whether to bottle-feed their children when the situation demands it.  There is a general feeling of inadequacy and guilt associated with the decision not to breastfeed.  If the choice has been made not to breastfeed, the client must be supported in her decision.

There is no doubt that breast milk is the ultimate food, i.e. it is always available, convenient and at the perfect temperature.  In addition breast milk is known to have nutritional and protective properties superior to those found in infant formulas. But, both breast and bottle-feeding have pros and cons.

Breast milk has been shown to impact positively on the baby’s mental development, provide increased immunity and reduce allergies and obesity in children.  In addition breast milk contains beneficial bacteria which aid the infant’s digestive system and help prevent diarrhoea while breastfeeding helps correct development of the jaw, tongue and teeth.  However not all mothers find breastfeeding easy or enjoyable, some may even find it painful.  In addition mothers on certain medication may not be allowed to breastfeed.

Some advantages

Bottle-feeding also has some advantages such as allowing parents to share the role of feeding and making it easier to leave the child with a minder, should the mother need to return to work.  Parents should be advised of the option to use expressed breast milk when returning to work.

Consultation

Parents should know that although they do not require a health care professional’s endorsement to bottle-feed their baby, it is advisable that one be consulted in order to ensure that the most suitable type of formula is chosen for the child.  The final decision may in fact rest with the infant themselves with respect to their appetite, digestive system and tastes.

Cow’s milk

It should be noted that cow’s milk, dairy blends, imitation dairy products, skim milk and evaporated milk are all regarded as unsuitable for the feeding of infants less than one year.  Many people ask the question “Why not use cow’s milk?”  One very important reason is related to the phosphorus content of cow’s milk.  Breast milk phosphorus content is very low, about 14mg/100ml, whereas cow’s milk has a phosphorus content of as much as 90 – 100mg/100ml.  This excess of phosphorus may affect an infant detrimentally by interfering with their calcium metabolism, bone mineralization and iron absorption.

In addition, cow, goat and soy milk lack a variety of nutrients found in breast milk, which is essential for physical and mental development.  These milks are also high in protein and sodium placing a strain on immature kidneys and increasing the risk of dehydration.  Infant formulas are modified forms of these milks which have been designed to be as similar to human milk as possible.  It may however be necessary to change an infant’s formula up to three times in order to adjust to the different growth stages in the first year of life.

Different types of infant formulas

Different commercially available formulas are generally offered for infants of differing age, i.e. certain formulas are suited to infants under the age of six months (starter formula) whereas others are more suited to older infants and are usually called ‘follow-on’ or ‘progress’ formulas.  These formulas differ in their composition to suit the maturity of the digestive system.  For example ‘follow on’ formulas used for infants six months and older contain more protein, iron, calcium and other essential nutrients necessary for healthy growth.  ‘Starter’ and ‘follow on’ formulas also differ in the type of protein used, i.e. whey or casein.  Feeds containing more whey than casein are closest to breast milk and are used as starter feeds for newborn or premature infants since they are easier to digest.   Casein is more slowly digested than whey and leaves the infant feeling fuller for longer.  Formulas that are higher in casein are useful for feeding healthy full term infants and satisfy ‘hungry’ babies.  The increased digestion time may however cause discomfort and constipation in some infants.  These formulas are also useful follow on formulas for routine feeding of infants older than six months.

Biologically acidified mild formulae may be useful in infants suffering from mild gastrointestinal disorders, e.g. colic, regurgitation, mild diarrhoea, constipation.

Lactose or soy

Another consideration when choosing an infant formula should be the presence or absence of lactose.  Lactose is a natural  sugar found in breast, cows and goats milk.  Some infants have trouble digesting lactose which results in bloating, diarrhoea and windiness.  This inability to adequately digest lactose may be short lived due to an ‘immature’ digestive system and may resolve itself as the child develops.  The alternatives to lactose containing formulas are soy milk formula or casein based lactose free formulas.   Infants who have suffered with digestive system infections may become temporarily ‘lactose intolerant’ and may benefit from using these lactose free formulas as well.

It should be noted that lactose intolerance is an inability to adequately digest lactose resulting in an increased level of ‘sugar’ in the bowel which then results in diarrhoea.  An allergy to lactose is however not the same thing and usually presents as a rash, eczema or asthma.  Allergies are difficult to identify and diagnosis is based on family history and clinical manifestations.  Significant improvement in the child after changing the feed would confirm the diagnosis.  Specialist hydrolysed protein formulas are available for infants who show allergies to all formulas and breast milk.

Specialised formulas

Specialised formulas are also available for infants with ‘reflux’.  Reflux in an infant is usually due to an immature digestive system which allows the regurgitation of acid from the stomach up into the infant’s oesophagus causing a burning sensation similar to ‘heart burn’.  The specialised reflux formulas are usually thicker formulas which stay in the stomach and are less likely to splash back into the oesophagus or mouth.  Reflux formulas are usually casein based and have lower fat levels as this tends to reduce the regurgitation.

Preparation of infant formula

The commercially available feeds provide detailed instructions on preparation.  It is important that feeds are prepared accurately.  The addition of generous scoops of powder when preparing formulae results in a feed with a higher energy density.  This places the infant at risk of dehydration and constipation.

It should be noted that all feeds should be discarded if not used within a twenty-four hour period, as bacterial contamination is likely.

Sterilisation

The risk of thrush and diarrhoea is greater in bottle fed babies and may be prevented by adequate cleaning and sterilisation.  Bottles may be sterilised by boiling bottles and caps for 5 – 10 minutes and teats for 3 minutes.  Bottles should be left inverted to drain and not dried.  Cold chemical sterilisation using commercially available solutions e.g. Milton™ is also an option.  Steam sterilisation in a microwave is a new method used with good results.

Conclusion

To know which formula is the best for a specific child depends on many factors.  Pharmacy staff should familiarise themselves with the pros and cons of each product and more importantly acquire training from the different manufacturers to ensure accurate recommendation.

IMC de Carvalho B.Soc.Sc. Hons.