Infant feeding: formula

The purpose of this guideline is to provide guidance about infant feeding with formula at Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH).

Breastfeeding is the most appropriate method of feeding most newborn infants (Rationale 1). The following resource can support staff in assisting mothers with breastfeeding:

  • 'Off to the best start' leaflet produced by UNICEF should be given to all breastfeeding mothers. It contains pictures and advice about positioning and attachment.
  • Whilst actively supporting mothers to breastfeed where possible, it is acknowledged that this method of feeding may not be feasible for some mothers. This guideline highlights the alternative products that are available and proffers advice as to the best alternative way to feed babies.

Feeding the newborn baby

Facilities must be provided for mothers to feed their babies in privacy and comfort (Rationale 2).  
 
Babies who are too ill or too immature to suckle may have their mother’s expressed breast milk fed via an orogastric or nasogastric tube.
 
Breastfeeding may be difficult to establish in sick infants; babies who are not breastfed require an approved infant formula (Rationale 3).

Formula feeding for babies

Babies who are not breastfed and who do not require a special therapeutic feed should be given a sterile ready-to-feed (RTF) infant formula.
 
Infant formulas must not be made on the wards under any circumstances (Rationale 4).
 
The approved RTF whey-based infant formulas available at GOSH for term babies are: Aptamil Profutura 1TM, Cow & Gate 1 TM, SMA Pro 1 TM (Rationale 5).
 
The approved RTF pre-term formula available at GOSH for premature babies is: SMA Pro Gold Prem 1™ and must not be given to term babies (Rationale 6).
 
Standard infant formulas are whey dominant and parents are offered a range of commercial formulas within this category (Rationale 7). Some mothers may choose to use casein-based infant formulas in the belief that their baby will sleep longer if they are more satisfied with their feed (Rationale 8). These are not available at GOSH as there is no evidence to support their use in a clinical setting and their use is not supported at GOSH.
 
RTF formula milks are available on the wards via a top-up system (see Appendix 1).
 
RTF formula milks should be stored in a cool dry place; they do not need to be refrigerated (Rationale 9).
 
Some babies will need special therapeutic feeds according to their underlying disorder. Contact your ward dietitian who will assess the baby’s requirements and arrange for feeds to be provided by the Special Feeds Unit (SFU) (Rationale 10)
 
Special therapeutic feeds from the Special Feeds Unit must be stored in a locked dedicated milk refrigerator at ward level. No other foods, fluids, drugs should be stored in the milk refrigerator (Rationale 11).

Feed volumes required

Fluid requirement from about one week of age to six months of age for a term baby, receiving all of its nutrition from a feed, is about 150ml/kg. Each baby will have its own individual requirements and so it is best to let them feed on demand (Rationale 12a).
 
Babies should be weighed weekly or more frequently if indicated and their weight plotted on the appropriate centile chart (Rationale 12b). (see Clinical guideline: Measuring a child’s weight).
 
Extra fluid may be needed if the ward is very hot, or if the baby is pyrexial or has extra fluid losses due to e.g. vomiting, diarrhoea. RTF bottles of water are available on the ward (Appendix 1)(Rationale 13).
 
Newborn babies will need to feed two to three-hourly during the day and night; this will graduate to four-hourly feeds at around six weeks of age for most babies. Between six and 16 weeks, the baby may sleep longer during the night and a night feed may be dropped 
 
Premature babies have very different fluid requirements - discuss with your ward dietitian (Rationale 15).
 
Please note: All pre-registration student nurses and healthcare assistants must have all feeds double checked by a registered nurse prior to administration.

Preparing the feed

Hands should be washed according to Trust hand hygiene guidelines (Rationale 16).
 
The bottle of feed (whether RTF formula or special therapeutic feed from the Special Feeds Unit) may be warmed under warm running tap water, taking care that the water does not run over the bottle cap (Rationale 17: 18).
 
Alternatively, the bottle may be placed in a jug of warm water, taking care that the water level is not higher than the bottle cap (Rationale 18). Do not warm for more than 15 minutes.
 
Never microwave the feeding bottle (Rationale 19).
 
When opening a RTF bottle of formula, make sure that the button in the centre of the lid pops up and check its use by date (Rationale 20).
 
When opening a bottle of special feed from the Special Feeds Unit:
  • Make sure the tamper proof seal is in place. 
  • Check the patient’s name and number on the bottle, and that it has not passed its use by date (Rationale 21)
Place the teat on the bottle. 
 
  • Term babies should have the standard teats. These teats are single use only and must be disposed of at the end feed; they must not be sterilised on the ward (Rationale 22).
  • Pre-term babies should have a premature teat. Please note: the fast flow delivered by these teats may not be suitable for every pre-term baby. These teats are single use only and must be disposed of at the end of the feed; they must not be sterilised on the ward (Rationale 23).
  • If the baby has their own teat system then use this e.g. Haberman teat. Please note:  re-usable teats must be decontaminated in microwave sterilising bags available from the ward in accordance with the manufacturer’s instructions (Rationale 23).
Check the temperature of the feed before giving it to the baby, by shaking a few drops of feed onto the inside of your wrist (Rationale 24).

Feeding the baby

Make sure that both you and the baby are comfortable.
 
Loosen or remove some of the baby’s clothing if necessary (Rationale 25).
 
Hold the baby securely (Rationale 26).
 
Only remove the bottle cap and screw on the teat immediately prior to feeding the baby (Rationale 27).
 
Ensure the teat is in the correct position – the indentation by the collar goes under the baby’s nose (Rationale 28).
 
Make eye contact; talk to the baby and don’t be distracted (Rationale 29).
 
Observe the baby for signs of discomfort, e.g. wind, and help them to ease any discomfort (Rationale 30).
If the baby is old enough to hold the bottle, let them hold it with you (Rationale 31).
 
Babies feed at different rates and most will complete a bottle feed in about 20 minutes. Don’t prolong the feed beyond 30 minutes (Rationale 32).
 
Never leave a baby alone with a bottle (Rationale 33).
 
Once the feed has been warmed and the teat attached, it must be used within one hour.  Any unused feed must be discarded (Rationale 34).

Vitamin supplements

A daily vitamin D supplement should be given to all breast-fed infants and all infants having less than 500ml of formula (Rationale 35).
 
Please note: Sick babies (including premature babies) and children may have different vitamin requirements depending on their underlying condition. Check with your ward dietitian (Rationale 36).

Rationale

Rationale 1: The benefits of human milk for normal growth and development and associated long-term benefits are well documented (American Academy of Paediatrics 2012; Angelsen et al 2001; Arenz et al 2004; Bartok et al. 2009; Cesar et al 1999; Fewtrell 2004; Horta et al. 2013; Jones et al 2000; Kramer et al 2001; Ladomenou et al 2010; Marild et al 2004; Quigley et al 2009; Sadauskaite-Kuehne et al 2004; Wilson et al 1998). To promote successful breastfeeding (Broadfoot et al 2005). Sick and premature infants may benefit from the immunological advantages of receiving breast milk (Kelleher & Lonnerdal 2001; Groer and Walker 1996; Mathur et al 1990). The suck-swallow-breathe reflex is not fully developed before 34 weeks gestation and may be delayed in infants with certain clinical disorders and premature babies (Arvedson and Brodsky 2002).
Rationale 2:  To ensure successful and confident breastfeeding 
Rationale 3:  To ensure nutritional adequacy.
Rationale 4:  To prevent potential contamination if feeds were to be prepared in the ward environment. To comply with infection control guidance.
Rationale 5: Whey-based infant formulas have a profile closer to that of breast milk.
Rationale 6: Term formulas do not meet the increased nutritional requirements of premature babies. The levels of some nutrients in preterm formulas are too high for term infants.
Rationale 7: To comply with patient choice (Department of Health 2004).
Rationale 8: There is no evidence to suggest that casein-based formulas ‘satisfy the hungry baby’.
Rationale 9: According to manufacturer’s instructions.
Rationale 10: To ensure that the correct feed is supplied and nutritional adequacy is guaranteed. To ensure feeds are made in a safe environment.
Rationale 11: To comply with infection control and security guidance.
Rationale 12a: Newborn babies gradually increase their intake from about 20ml/kg on the first day of life to 150ml/kg by seven days. To provide nutritional adequacy and meet fluid requirements. To prevent under or over-feeding.
Rationale 12b: As an indicator of nutritional adequacy.
Rationale 13: To maintain fluid balance. To provide extra fluid.
Rationale 14: To satisfy the baby’s natural feeding pattern.
Rationale 15: To ensure adequate nutrition and hydration.
Rationale 16: To prevent cross-infection.
Rationale 17: Warming feeds for term infants is not necessary, but most infants show a preference for warmed feeds, possibly due to the body temperature of breast milk.
Rationale 18: To ensure that non-sterile water on the surface of the bottle does not enter when the cap is removed. To prevent proliferation of any micro-organisms that may be present in non-sterile feeds.
Rationale 19: Hot spots may remain in the milk and burn the baby’s mouth. Heat sensitive vitamins will be destroyed (World Health Organisation 2007).
Rationale 20: Indicates that the feed is sterile, and has not been previously opened, ensures the feed is in date and the feed is therefore safe to use.
Rationale 21: Indicates the feed has not been previously opened and is therefore safe to use. To ensure that the correct feed is being given and that it is in date.
Rationale 22: To comply with infection control guidance. To ensure that the baby is fed from a teat most suited to their developmental stage.
Rationale 23: To comply with infection control guidance. To ensure that the baby is fed from a teat most suited to their needs.
Rationale 24: To check that the feed isn’t too hot.
Rationale 25: To enhance the feeding experience. To prevent overheating.
Rationale 26: To calm the baby (Murray and Andrews 2000).
Rationale 27: To prevent any potential microbiological contamination.
Rationale 28: So that the baby can suck properly.
Rationale 29: To comfort the baby (Murray and Andrews 2000).
Rationale 30: So the baby can continue to feed in comfort.
Rationale 31: To promote self-feeding in the future.
Rationale 32: The baby will become tired and bored.
Rationale 33: To prevent choking.
Rationale 34: To prevent any potential microbiological overgrowth (Robbins and Becker 2005)
Rationale 35: To comply with recommendations. (Scientific Advisory Committee on Nutrition 2016).
Rationale 36: To ensure that the correct supplements are given.

References

American Academy of Paediatrics (2012) Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 129 (3): e827-e841.

Angelsen NK, Vik T, Jacobsen G, Bakketeig LS (2001) Breast feeding and cognitive development at age 1 and 5 years. Arch Dis Child 85 (3): 183-8.

Arenz S, Ruckerl R, Koletzko B, von Kries R (2004) Breast-feeding and childhood obesity -a systematic review. Int J Obes Relat Metab Disord 28 (10): 1247-56.

Arvedson JC, Brodsky L (2002) Pediatric Swallowing and Feeding Assessment and Management, 2nd Ed. San Diego, Singular Publishing Group

Bartok C, Ventura A (2009) Mechanisms underlying the association between breastfeeding and obesity. Inter J Pediatr Obes  4 (4): 196-204. 

Broadfoot M, Britten J, Tappin DM, MacKenzie JM (2005) The Baby Friendly Hospital Initiative and breast feeding rates in Scotland. Arch Dis Child Fetal Neonatal Ed 90 (2): F114-6.

Cesar JA, Victora CG, Barros FC, Santos IS, Flores JA (1999) Impact of breast feeding on admission for pneumonia during postneonatal period in Brazil: nested case-control study. BMJ 318 (7194): 1316-20.

Department of Health (2004) National Service Framework for Children, Young People and Maternity Services. London, Department of Health.

Fewtrell, M.S. (2004) The long-term benefits of having been breastfed. Current Paediatrics 14 : .97-103. http://www.the long-term benefits of having been breast-fed.com  [last accessed 22/09/17]

Groer M, Walker WA (1996) What is the role of preterm breast milk supplementation in the host defenses of preterm infants? Science vs. fiction. Adv Pediatr 43: 335-58.

Horta BL, Victoria CG (2013) Long-term effects of breastfeeding: a systematic review. WHO, Geneva.

Jones G, Riley M, Dwyer T (2000) Breastfeeding in early life and bone mass in prepubertal children: a longitudinal study. Osteoporos Int 11 (2): 146-52.

Kelleher SL & Lonnerdal B (2001). Immunological activities associated with milk. Adv Nutr Res. 2001;10(39-65)

Kramer MS, Chalmers B, Hodnett ED, Sevkovskaya Z, Dzikovich I, Shapiro S, Collet JP, Vanilovich I, Mezen I, Ducruet T, Shishko G, Zubovich V, Mknuik D, Gluchanina E, Dombrovskiy V, Ustinovitch A, Kot T, Bogdanovich N, Ovchinikova L, Helsing E, PROBIT Study Group (Promotion of Breastfeeding Intervention Trial) (2001) Promotion of Breastfeeding Intervention Trial (PROBIT): a randomized trial in the Republic of Belarus. JAMA 285 (4): 413-20.

Ladomenou F, Moschandreas J, Kofatos A, Tselentis Y, Galanakis E (2010) Protective effect of exclusive breastfeeding against infections during infancy: a prospective study. Arch Dis Child 95: 1004-1008.

Marild S, Hansson S, Jodal U, Oden A, Svedberg K (2004) Protective effect of breastfeeding against urinary tract infection. Acta Paediatr 93 (2): 164-8.

Mathur NB, Dwarkadas AM, Sharma VK, Saha K, Jain N (1990) Anti-infective factors in preterm human colostrum. Acta Paediatr Scand 79 (11): 1039-44.

Murray L, Andrews L (2000) The Social Baby. Understanding Babies Communication from Birth . Richmond, CP Publishing.

Quigley M A, Kelly YJ, Sacker A  (2009) Infant feeding, solid foods and hospitalisation in the first 8 months after birth. Arch Dis Child 94: 148-150.

Robbins ST, Becker LT (2005) Infant Feeding: Guidelines for Preparation of formula and Breastmilk in Healthcare Facilities. USA, American Dietetic Association.

Sadauskaite-Kuehne V, Ludvigsson J, Padaiga Z, Jasinskiene E, Samuelsson U (2004) Longer breastfeeding is an independent protective factor against development of type 1 diabetes mellitus in childhood. Diabetes Metab Res Rev 20 (2): 150-7. 

Scientific Advisory Committee on Nutrition. (2016)  Vitamin D and health Available at: www.gov.uk/government/SACN_Vitamin_D_and_Health_report.pdf  [lasted accessed 22/09/17]

Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW (1998) Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ  316 (7124): 21-5.

World Health Organisation (2007):  Guidelines on the Safe preparation, storage and handling of powdered infant formula 

Appendices

Appendix 1

The following sterile, RTF formulas are available via the ward top-up system. Any queries should be made to the Materials Management team on extension 8593
 

Whey-based formulas

  • Aptamil Profutura 1™ (70ml bottle) ABC009 - in packs of 24
  • Cow & Gate First Infant Milk 1™ (70ml bottle) ABT058 - in packs of 24
  • SMA Pro First™ (70ml bottle) ABT069 - in packs of 32

Pre-term formula

  • SMA Pro Gold Prem 1™ (70ml bottles) ABT065

Water

  • Cow & Gate™ Distilled Sterile Water™ (90ml bottle) ABT740 - in packs of 20

Document control information

Lead Author(s)

Philippa Wright, Head of Dietetics, Dietetics

Additional Author(s)

Úna McCrann, Clinical Nurse Specialist, CAMHS

Document owner(s)

Philippa Wright, Head of Dietetics, Dietetics

Approved by

Guideline Approval Group

Reviewing and Versioning

First introduced: 
18 January 2007
Date approved: 
22 September 2017
Review schedule: 
Three years
Next review: 
22 September 2020
Document version: 
4.0
Previous version: 
3.0