Around half of all babies will experience some kind of feeding problem during their first year. Parents are hungry for advice on how to solve problems, and pharmacy staff are well placed to offer help

For new parents, feeding their baby effectively is a prime concern and when problems arise they can spoil those precious early months of parenthood if they aren’t addressed quickly. Up to 50 per cent of babies experience some kind of feeding issue in their first year, with half of all babies under three months affected by reflux alone.

Feeding problems can be hard to diagnose and resolve, with GPs and midwives not always readily available to discuss what might help. Pharmacy staff are ideally placed to help parents work through infant feeding worries, from giving information about different types of formula milk and suggesting OTC remedies to signposting breastfeeding mums to specialist lactation consultants and support groups.

While there are many OTC remedies available to relieve symptoms, many experts are instead favouring a nutrition-led approach to solving feeding problems, for both breast and bottle-fed babies. Here we look at the most common feeding issues you’ll come across in the pharmacy and give the latest expert advice on how to advise parents and when to refer to the pharmacist.

Colic

Up to one in five babies are affected by colic and it usually begins within the first few weeks, normally resolving by the time the baby is three to four months old. Colic is classified as excessive, frequent crying in an otherwise healthy and well-fed baby. The main symptoms are:

  • Intense, persistent crying in the late afternoon or evening, lasting several hours
  • A red, flushed face
  • Clenching fists and drawing the knees up to the tummy or arching the back
  • Baby continues to feed and gain weight normally.

What causes colic?

The exact cause of colic is unclear, but theories include:

  • An immature digestive system leading to indigestion and trapped wind
  • Temporary sensitivity to proteins and sugars in breast and formula milk
  • Taking in too much air during a feed.

Infant feeding expert and author Clare Byam-Cook says it’s important to rule out hunger before treating a baby’s crying as colic. “A huge percentage of babies don’t have colic at all, but are hungry and not getting enough milk. This is more common in breastfed babies.”

“Firstly, suggest mums try feeding baby some expressed breast milk (as much as he or she wants) in a bottle after a normal breastfeed. If baby drinks the extra milk happily and instantly becomes more settled, it’s not colic. If baby refuses the extra milk and continues to be distressed, it’s likely to be a digestive problem such as wind, colic or reflux.”

For breastfed babies, Clare has this advice for pharmacy teams to pass on to mums: “If it is colic, look at your diet and try leaving out things like spicy foods or citrus fruits, which can upset a baby’s digestion. But don’t cut out dairy as you need calcium when breastfeeding – always see your GP or health visitor if you think it may be a cows’ milk allergy.”

For bottle-fed babies, she advises: “Try adding anti-colic drops with baby’s feed. If that doesn't help, try a different brand of formula milk to see if that suits him or her better. If this doesn’t help, see your GP or health visitor for advice about switching to a specialist formula milk.”

She adds: “If it’s true colic, baby will usually grow out of it by about three months. If baby is still suffering, it may be cows’ milk allergy or a reflux problem, so seek further advice.”

A healthcare professional can recommend a specialist milk. These contain partially hydrolysed whey protein to make them easier to digest and have a thicker consistency to reduce air swallowing, as well as a reduced lactose level to aid digestion.

Self-help tips

Offer parents the following self-help advice:

  • Hold baby close during a crying bout
  • Hold baby in different positions (e.g. over a shoulder or with baby’s tummy on the parent’s lap)
  • Avoid caffeine and spicy foods
  • Use a fast-flow teat when using a bottle – if holes are too small, baby may swallow too much air
  • Sit baby upright during feeding and always burp after a feed
  • Rock baby, take them for a walk in a pram or a drive in a car
  • White noise in the background can be soothing
  • Try a warm bath
  • Contact a support network such as CRY-sis.

Reflux

“Reflux happens when a baby has a weak valve at the top of the stomach. It tends to occur more in bottle-fed babies, as they will often be drinking larger feeds than breastfed babies and therefore placing more strain on the valve,” says Clare.

“Some babies suffer from reflux within days after birth, others develop it after five or six weeks. Although most babies with reflux have problems with every feed, it is not unusual for a baby to be fine with some feeds and not others.”

New guidance from the National Institute for Health and Care Excellence (NICE) recommends:

  • Breastfeeding mums should consult a healthcare professional who can look at breastfeeding technique
  • If baby is formula-fed, mums should consult a healthcare professional to review baby’s feeding history and then reduce the volume of milk if it’s excessive for the baby’s weight. A trial of smaller, frequent feeds can be given, followed by a trial of thickened formula milk.

Specialist milks for reflux are casein dominant, so take longer to digest and are thicker so less likely to be brought up. Feed thickeners can also be added to expressed breast milk or given as a paste before or during a feed, or added to formula milk. “Always refer parents to a healthcare professional [such as a pharmacist or pharmacy technician] for advice if reflux is suspected,” says Clare.

A GP can prescribe medication and/or a healthcare professional can recommend special formula milks. Suggest parents also try the following:

  • Wind baby throughout feed
  • Avoid over-feeding
  • Check teat holes are not too large
  • Hold baby upright for a while after feeding. Avoid active play right after a feed.

Signs it may be more serious

If reflux happens frequently or baby projectile vomits, refuses feeds or isn’t gaining weight, it could be a sign of a more serious condition such as GORD (gastro-oesophageal reflux disease). This long-term form of reflux happens in babies because their oesophagus is shorter and narrower. In these cases, parents should be advised to see a GP.

Allergy or intolerance?

Cows’ milk allergy (CMA) is caused by the body’s immune system over-reacting to the protein in cows’ milk as if it were a foreign substance. The subsequent times the baby has cows’ milk, the antibodies produced by their body will trigger the various symptoms. An intolerance (e.g. to lactose) can cause a reaction, but doesn’t involve the immune system.

Main symptoms of CMA:

  • Skin rashes/hives
  • Diarrhoea
  • Vomiting  
  • Stomach cramps, constipation and bloating
  • Difficulty breathing
  • Colic
  • Eczema.

Main signs of a lactose intolerance:

  • Diarrhoea
  • Poor weight gain or even weight loss
  • Stomach cramps, wind and bloating
  • Mild colic.

Cows’ milk allergy

Half of all children in the UK are now affected by allergy, with five to eight per cent of babies and young children affected by a food allergy – cows’ milk and egg are the most common. A family history of atopic disease makes cows’ milk allergy (CMA) more likely. One child in five in the UK has eczema, and most cases develop before the age of one.

Food allergies are associated with eczema – studies have found that babies who suffer with severe eczema, especially before three months of age, are more likely to develop food allergy. “A family history of atopy and early exposure to cows’ milk formula increase the risk of an allergy,” says Amena Warner, nurse advisor at Allergy UK.

“Look out for signs including reflux, constant crying, constipation, diarrhoea and blood in stools. This can happen in both bottle and breastfed babies. Eczema or urticaria are often early warning signs of cows’ milk allergy.”

Amena adds: “CMA can also give immediate symptoms of a red, raised rash, eczema, swelling of the lips or eyes and distressing breathing symptoms. This needs prompt medical attention and treatment.

“Breastfeeding is always recommended as first-line prevention of CMA. Colostrum [the first part of breast milk] passes antibodies to baby to strengthen the immune system. However, breastfed babies can still develop CMA and then you need to look at mum’s diet and exclude cows’ milk, under the advice of a dietitian.”

An extensively hydrolysed formula or amino acid formula may be recommended by a healthcare professional.

Constipation

Babies vary in how frequently they pass a bowel motion, so parents need to recognise what’s normal for their child. Signs a baby might be constipated include:

  • Crying and pain when doing a poo
  • Dry, hard poo that they have trouble passing
  • Fewer than three bowel motions a week
  • Foul smelling wind or poo
  • A hard tummy
  • Loss of appetite.

A number of factors can cause constipation, including dehydration; a change in diet when starting to eat solid food; a lack of fibre in the diet; emotional causes (e.g. starting nursery or a new sibling arriving); medication side effects, and not being very active. Suggest parents try the following tips to help ease symptoms:

  • Offer baby extra water between feeds
  • Take extra care making up feeds – they should never be too diluted or overconcentrated
  • Massage baby’s abdomen and move their legs in a clockwise ‘cycling’ motion
  • to help stimulate the bowels
  • If weaned, include more fruit and vegetables in their diet.

Giving advice on specialist formula milks

Only healthcare professionals (e.g. doctors, midwives, pharmacists and pharmacy technicians) can recommend first milks and specialist milks. Medicines counter assistants can initiate conversations and gather information from parents, but should then refer to a pharmacist or pharmacy technician. Babies should ideally be exclusively breastfed for the first six months.

Diarrhoea

Formula-fed babies have a higher risk of getting diarrhoea than breastfed babies and this is often due to poor hygiene when making up feeds or storing feeds incorrectly. Top tips to pass on to the parents of bottle-fed babies include:

  • Make up bottle feeds one at a time, not in batches
  • Use freshly boiled drinking water from the tap. Leave the water to cool in the kettle for no longer than 30 minutes
  • Don’t use bottled water for making up feeds
  • Throw away any milk that the baby doesn’t drink within two hours of making up the feed
  • All feeding equipment (bottles, teats, etc) must be sterilised before use, for every feed.

A viral or bacterial infection can also cause diarrhoea. Keeping baby hydrated is key with tummy bugs and diarrhoea so advise parents to continue offering the same feeds as normal and offer older babies frequent sips of water. The infection is normally self-limiting and will clear up within a few days.

Many experts are favouring a nutrition-led approach to solving feeding problems

Originally Published by Training Matters

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