ClinicalCommunity Pharmacy

From Baby to Classroom

"Is my baby getting enough milk?”

“Is my baby getting enough milk?” Explore first of all why this question is being asked. It can help to reassure that for the first month, while milk supply is being established, feeding 8-12 times daily is quite normal. It may also be reassuring to mention that feeds will become less frequent, and often shorter, as the baby gets older, which can be welcome news to a tired new mum.

Also, breastfeeding takes time, and while it is difficult to define what is ‘normal’ because every baby is different, newborns can nurse for up to 15-20 minutes on each side (though sometimes less), so it can help to ask the mother how long she is feeding for before changing sides.

Breastmilk starts off as quite watery foremilk to satisfy thirst, before changing in consistency to thicker hindmilk, with a higher fat content that satisfies hunger for longer. This means that changing sides too soon can mean the baby only getting the foremilk, so they may get hungry again much sooner than would otherwise be the case.

That said, many health professionals advocate watching the baby instead of the clock. A satisfied baby will come off the breast when they have had enough. If they have had 6-8 wet nappies and are settled and content between feeds and gaining weight, then it is very likely that they are getting enough milk. If a mother is still worried, she should speak with her midwife if within the first 14 days or health visitor after that, who will be able
to provide 1-1 advice and assess technique etc.

Formula feeding

Bottle-feeding is currently the most common method of infant feeding. Formula milks are mostly based on modified cow’s milk (although some are based on soya, or goat’s milk), with additives e.g. vegetable oils, vitamins, minerals and fatty acids.

The two main types of protein in breastmilk are whey and casein. Whey is more easily digested and is the type of protein contained in the liquid part of milk when it curdles. 60% of breastmilk protein is made up of whey protein.
Casein is the type of protein in the solid part of curdled milk and makes up the remaining 40% of breastmilk. Casein protein remain in the stomach for longer, and hence are slower to digest. Cow’s milk is 80% casein and 20% whey. The whey: casein ratio in ‘first’ infant milks is more closely aligned to that of human breastmilk (60:40), which makes these formulae generally easier to digest, especially for new-born babies.

Hungry milks have a higher percentage of casein than standard first milk. Casein takes longer to digest so it can help babies feel fuller for longer. These milks are used to help to delay the onset of early weaning.

Follow-on milks
The main difference between follow- on milks and first infant / hungry milks is that they have a higher iron content. Babies are born with a natural store of iron which begins to deplete around 6 months. As babies are usually beginning to wean at 6 months there are only taking very small amounts of food and may not be eating enough iron rich food at this stage. Parents can choose to move to a follow-on milk at 6 months which contains higher levels of iron that standard first milks.

These milks are for babies over 6 months, and as such they may be advertised direct to the public.

Cow’s Milk Protein Allergy (CMPA)
Cow’s milk protein allergy affects approx. 2-7.5% of babies, although NICE states that up to 15% show symptoms of an adverse reaction to it. CMPA can induce both acute IgE immunoglobulin-mediated reactions (within 2 hours) e.g. rash or urticaria, wheeze, vomiting, and also non IgEmediated reactions which are more delayed, e.g. mild-moderate eczema, reflux.

Management of the allergy necessitates the complete removal of CMP from a baby’s diet. For the breastfed infant, this means that the mother must follow a strict milk-free diet, and because of this, she also needs to take supplements containing 1000mg calcium and 10 micrograms of vitamin D daily. Bottle-fed infants need a formula
which contains no cow’s milk, and there are two main options available to achieve this:

Extensively Hydrolysed Formula (eHF)
In these milks the protein causing the allergy is broken up into smaller fragments (peptides) that are less likely to illicit an immune response. Aptamil Pepti and SMA Althera are whey-based eHF milks and Nutramigen and Similac Alimentum are casein-based ones. 90% of babies with CMPA can tolerate these formulae. If a baby is still showing symptoms after 2-6 weeks on an eHF formula, they may be switched onto an amino acid formula.

Amino Acid formula (AAF)
These are for the remaining 10% of babies whose symptoms do not resolve on an eHF, and who require the peptides to be broken up further, into amino acids. AAFs are quite expensive and are more likely to be needed for babies who have multiple allergies or a family history of CMP. Examples include Neocate LCP, Nutramigen Puramino and SMA Alfamino.

CMPA usually resolves over time, and in most cases has completely resolved by 3-5 years. Guidance on how to gradually introduce food with increasing amounts of CMP in a controlled manner is laid out in the Milk Ladder4, and this process is managed by a paediatric dietician. Parents should introduce cow’s milk back into their child’s diet under medical advice.

Lactose intolerance
This is usually transient and often follows an episode of gastroenteritis, during which there is a reduction in lactase activity for a period lasting from a few days up to a few weeks. True lactase deficiency is extremely rare. Unlike CMPA, symptoms are usually limited to the gastrointestinal tract, e.g. diarrhoea, abdominal pain, flatulence and bloating.

The 3 main types of lactose intolerance are:
Congenital – an extremely rare condition where babies are born with a genetic defect resulting in the absence of the lactose enzyme.
Primary – a genetically inherited condition uncommon before 2-3 years of age, normally becoming apparent after 5 years of age.
Secondary – a temporary, more common, condition caused by damage to the gut (where lactase is produced) e.g. following gastroenteritis. Usually resolves after a few weeks once the gut heals. If a baby has been diagnosed with temporary lactose intolerance breastfeeding mothers should be encouraged to speak to a healthcare professional about a lactose free diet. Babies who are bottle fed are usually recommended to move to a lactose free milk for 6-8 weeks. After this time the damage to the baby’s gut has usually resolved and they can move back to their usual milk.

Milks for colic and constipation
Types of milk are commonly known as comfort milks and are a specialised formula for the dietary management of colic and constipation. They should only be used under medical supervision. They are nutritionally complete
from birth to 6 months and can be used as part of a weaning diet from 6 months.

Dealing with Colic
Pharmacists play a unique role in the assistance of families coping with colic. They are easily accessible to parents and may often be the first healthcare professional to turn to for advice on an inconsolable infant.

There are several points of advice, including:
• Advise parents that colic is not curable, but inform them of some popular soothing techniques that may help
• Make them aware of the fact that colic occurs in both breastfed and formula-fed babies, and the cause is unknown
• Reassure them that colic is temporary and is usually gone by the time the infant is 3 months old
• Ask open-ended questions related to how the parents are coping

Changes as simple as choosing the right baby bottle can help avoid the swallowing of air and thereby, put a stop to wind related colic in babies.

There are many baby bottles on the market claiming to be ‘anti-colic’, yet it is important to recognise, that not all ‘anticolic’ bottles are the same and understand the physics behind the bottle mechanics.

In conventional feeding bottles, negative pressure is generated both in the oral cavity and in the bottle, when fluid is removed by sucking. Consequently, the negative pressure retained inside the bottle causes the infant to suck excessively.

Back to School
Back to school this year is going to feel very different from previous years as we navigate the Coronavirus Pandemic. Hygiene is always high up the parent shopping list, this year it will be even more important.

Headlice are spread from head to head contact, the eggs (nits) are usually laid at the nape of the neck or behind the ears. Once an infestation is confirmed (and we only recommend treating confirmed cases) a suitable product can be selected for your customer. The longer a treatment is in contact with the hair, the more effective it seems to be.
Treatment times range from 10 mins to 12 hours overnight. If a child suffers from asthma or eczema, some of the lice treatments can aggravate these conditions so it is important to choose the right one.

Understanding a person’s preference, medical and drug history, the product’s active ingredient, how the active
ingredient works, how the product should be used and if anything has been tried previously will allow pharmacists and pharmacy staff to recommend and help parents choose the right head lice product.

Mechanical removal involves systematically combing the whole head of wet hair with a detection comb to remove the lice. The comb must be cleaned after each pass through the hair to remove lice and eggs, which is best done by wiping it on clean white paper or cloth.

The process must be repeated every few days for two weeks. Products containing dimeticone or isopropyl myristate kill the lice through physical action. Dimeticone coats the surfaces of head lice and suffocates them, while isopropyl myristate dehydrates head lice by dissolving their external wax coating. The advantages of these
products are that they are easy to apply, they have few side-effects, are odourless or have only a faint perfume, and the head lice are unlikely to become resistant to them.

The life cycle of the creature is around 21 days so treating again after a week will catch any newly hatched lice but hit them before they become mature enough to reproduce. We recommend using the same treatment – only change if there is a complete failure. This common condition happens to even the most hygienic families, so assure parents that they have not failed in any way if an infestation affects their child.

Worms (Threadworms)
As with head lice, this condition may be considered highly embarrassing, although it is usually harmless and not serious. Usually the first sign that parents notice is the child scratching his or her bottom. Sometimes parents will see thread like objects in faeces, eggs can sometimes be seen around the opening of the anus. This condition is easily treated with an over the counter product, with a second dose used after two weeks. Liquid and tablets are available for treatment from 2 years old. It’s recommended to treat the whole household as infection can be present without symptoms. After treatment, step up the hand hygiene, cut fingernails short, wear underwear at night, and ensure the bottom is washed daily.

Omega 3 Fish Oil
Half of the fat in the brain contains one of the Omega 3 fatty acids, docosahexaenoic acid (DHA). So we know that it plays a crucial role in brain development. Some studies also show that there is a positive effect on concentration levels. They’re found in oily fish like salmon, sardines and mackerel but these are not popular food choices with children. We recommend a supplement to ensure children are getting all the benefits of Omega 3.

More back to school top tips:
• Focus on nutrition – a healthy balanced diet will help boost immunity, help concentration and fight fatigue
• Be alert to early changes of behaviour during term time that could flag potential bullying issues
• Get an eye check organised, there’s lots of visual demands on a school goer – devices, books, whiteboards, etc. An optician will also check for general eye health
• Apart from diet and exercise, sleep has a huge impact on performance at school. Around ten hours is right up to age 13

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