NHD PAEDIATRIC HUB FACT FILE

Infant Feeding

If you are new to paediatrics or simply a student commencing a paediatric placement, it’s important to understand infant feeding. Infants need breast milk or formula to provide the protein and energy they need to grow. The amount and type of food an infant eats changes as they grow. This is simply a brief guide to help you navigate this area.

What you need to know about breast milk

Breast milk is a living fluid produced by a mother's mammary glands, which provides essential nutrients for a baby's growth and development. It's the primary source of nutrition for newborns. It contains:

  • Water: About 87% of breast milk is water.

  • Fat: The fat content varies throughout the day and during a feeding.

  • Proteins

  • Carbohydrates

  • Minerals and vitamins

  • Hormones: Breast milk contains hormones that regulate metabolism and appetite.

  • Growth factors

  • Immunological factors: Breast milk contains factors that protect against infection and inflammation.

Breastmilk changes throughout a mother’s breastfeeding journey:

  • Colostrum: The first milk produced after pregnancy is thick and yellow, and rich in immune factors.

  • Transitional milk: This is a combination of colostrum and mature milk, which is produced from days 7 to 14 after giving birth.

  • Mature milk: Produced after about 10 to 15 days after giving birth, mature milk contains all the nutrients a baby needs .

The fat content of the breast milk also changes throughout the day and during feeds, which shows how adaptable it is as a source of nutrition. Breastfeeding also carries many advantages for babies outside of just growth.

Benefits of breastfeeding

Brain development

  • Breast milk contains DHA and ARA, which help a baby's brain and visual system develop. 

  • Breastfed babies may perform better on intelligence tests. 

Protection

  • Breast milk contains antibodies that help babies develop a strong immune system.

  • Breastfed babies have a lower risk of many illnesses, including asthma, obesity, type 1 diabetes, and SIDS.

  • Breastfed babies are less likely to have ear infections and stomach bugs.

Other benefits

  • Breastfeeding can support the mother-baby relationship.

  • Breastfeeding can be convenient for mothers.

  • Breastfeeding can be comforting for babies when travelling.

It can be difficult to measure what influences there are on the development and learning of children, as lots of factors influence this. However, some studies show that breastfed babies and societies where more babies are breastfed do better overall.

Let’s not forget that the mother also gets breastfeeding benefits. Women who breastfeed have a lower risk of breast cancer, ovarian cancer, osteoporosis, cardiovascular disease and obesity. 

Reccomendations

The World Health Organisation (WHO) recommends that babies are exclusively breastfed for the first six months of life and feeding is commenced within the first hour of life. Ways to know if breastfeeding is going well include:

Baby's feeding:

The baby is feeding for 5–40 minutes at each feeding, and takes long, rhythmic sucks. They seem calm and content and come off the breast on their own.

Baby's Growth:

The baby is growing along their current centile and gaining appropriate amounts of weight again

Baby's wet and dirty diapers:

The baby has at least six wet diapers and two-three yellow bowel movements every 24 hours.

Baby's skin:

Baby's skin colour is normal, and baby doesn't appear jaundiced.

The mother’s breasts:

Her breasts feel softer after feeding, and mum's nipples aren't painful or flattened.

Important note:

Always ensure that mum finds breastfeeding is going well for her!

What to do if the mother can’t breastfeed

Use a breast pump to extract milk, and store and feed it to the baby in a bottle. If a mother is struggling with her breastfeeding journey remember to signpost to areas of support as well:

  • National Breastfeeding Helpline

  • La Leche League GB

  • NCT Support Line

  • Look locally about what is available for mothers in your area


There are many different courses available for dietitians to help improve knowledge on different latching techniques, plus support that you can provide directly to a mother who is struggling. We would recommend you look into these via the BDA website or speak to your local midwife team to get some more exposure and experience!

Formula feeds

First Milk Formulas

First Milk Formulas are suitable from birth and there are two main types.

  1. Why dominant

  2. Casein dominant

There is no evidence about changing between whey or casein dominant formula or brands as they have similar calorie and protein amounts. Often there are slight composition differences between things like prebiotics, antioxidants and nucleotides. However, casein-based formulas are often recommended for hungrier babies although there is no scientific evidence behind this.

Typical Formula contain:

  • 67-69kcal/100ml

  • 1.4-1.9g protein/100mls

There are various different formula brands on the market and all have to meet a certain minimal content established by the UK Government Regulations. These regulations cover:

  1. Composition: Formula must meet the nutritional requirements and needs of a healthy infant

  2. Labelling: Labels must be clear and easy to understand and avoid confusion around infant and follow on formula

  3. Advertising: Advertising must be scientific and factual and cannot imply that bottle-feeding is better than breastfeeding

  4. Promotion: Manufacturers and distributors cannot offer free or discounted products to samples.

These help ensure that breastfeeding is protected, formulas are safe and appropriate to use and there is evidenced based information provided about infant feeding.

Follow On Formulas

These are usually suitable for infants from six months of age. If around 500mls is consumed within the day, this will maintain adequate vitamins and iron intake. Under this, and a supplement may need to be considered.

SACN (2023) recommends supplementing vitamin D and A for:

  • Breastfed infants from 6 months (or 1 month if there is doubt in mothers vitamin status during pregnancy)

  • Formula Fed infants over 6 months who are taking less than 500mls of formula per day

  • Children from 1-5 years of age living in Northern UK, Asian, African, Middle Eastern Origin and selective eaters.

Healthy Start

Mothers under 18 years or on benefits are eligible for vouchers to spend on milk, fresh and frozen vegetables. Infant formula and supplements.

Preparation

It’s important that feeds are made up appropriately and safely. Key points to remember are:

  1. Add 1 scoop of milk powder to 1oz/30 mls water or as per guidance on the tin

  2. Boiled coiled water should be used

  3. Always add powder to water (unless dietetically indicated otherwise)

  4. Scoops are not interchangeable between brands

  5. Scoops should be levelled

Weaning or complementary feeding

Weaning or complementary feeding is the process of gradually introducing solid foods to an infant whilst reintroducing their reliance on breastmilk or formula. The recommended age for a child to wean is 6 months of age. However, each child is individual but introducing solids should not be delayed!

Developmental signs of readiness to wean include:

  1. They can sit up with their head steady

  2. They can coordinate their eyes, hands and mouth to look at, pick up and put food to their mouth

  3. They can swallow foods rather than spit this back out.

Note that waking in the night for additional feeds is not a sign of hunger so should not be considered a sign.

Methods for introducing solids:

There are different methods used to introduce solids and there is no evidence to suggest that one way is better than another. The main methods include:

Baby-Led Weaning: This approach involves skipping purees and spoon-feeding but to let babies self-feed with finger foods from their first bites.

Spoon-Fed Weaning: This is more of a traditional approach where parents tend to hold spoon and bring this to the baby’s mouth. They are typically pureed and mashed foods but then finger foods are introduced around 9 months.

Combination of the two: This is a combination of spoon feeding and self-feeding with finger foods.

There is advantages and disadvantages of all the methods, and we would encourage you investigate these in more detail. However, each child will differ in what method is right for them. Furthermore, it’s a very personal decision for the family to make so therefore, it’s important that you encourage the family remain on track to help the baby’s progress.

At this time, the introduction of the allergens should occur.

Dietetic consultation

Are they growing? Tracking along their centiles? Gaining appropriate weight?

A rough guide to expected growth in a healthy baby following the 50th centile is:

Weight

Under 3 months

200g/week (30g/day)

3-6 months

150g/week

6-9 months

100g/week

12-24 months

75g/week

>24 months until puberty

2kg/year

Length

0-12 months

25cm/year

12-24 months

12cm/year

Height

>24 months until puberty

10cm/year

Head circumference

0-12 months

1cm/month

12-24 months

2cm/month

Remember to use the correct growth chart for the infants age and consider they are preterm or not as this will affect the growth chart used as well and you would not expect the same weight gain as above.

Children born at pre-term (32-36 weeks) should be corrected until 1 year

Children born very pre-term (<32 weeks) should be corrected until 2 years

  • Calculations for expected ideal weight for height (WFH) %

To do this you need to:

  1. Plot height centile (actual height)

  2. Read off the growth chart the weight that corresponds to same weight centile as the height centile

  3. Actual weight/expected weight

Clinical 

  • Born at term? Any complications at birth?

  • Any hospital admissions since birth?

  • Current diagnosis? Awaiting any investigation results?

  • History of reflux or vomiting?

  • Bowels and Urine output? (as a rough guide, >1 week, infants have over or equal to around 6 wet nappies a day and around 2 dirty nappies)

  • Any medications?

  • Family History of allergies?

  • Has the baby suffered from tongue tie? About 1 in 10 babies are thought to have tongue tie. For a majority, this is not problematic but small numbers can cause difficulty with breastfeeding.

Dietary assessment

It’s important to take a detailed look at feeding history in these children:

For infants and young children:

  • What are they currently feeding on?

  • If on formula, is this being made correctly?

  • Were they breast or bottle fed from birth?

  • Were they a good feeder from birth?

  • When were solids introduced? Were they good eater?

  • Did they progress well throughout the stages of weaning? (thinking about textures and food groups)

  • What method of weaning was used?

  • Have all the allergens been introduced?

  • How long do mealtimes last?

  • Any distractions used during mealtimes?

  • Vitamin and Mineral Supplement?

  • Remember to still check if they are having pre-bedtime or during night feeds!

  • What are their nutritional requirements?

Age

Feed intervals

Number of feeds

Feed volume (ml)

Fluid requirement (ml/kg)

1-2 weeks

3hrly

7-8

50-70

150

2-6 weeks

3-4hrly

6-7

75-110

150

2 months

4hrly

5-6

110-180

150

3 months

4hrly

5

170-220

150

6 months

Evenly spread in the day and sleep through night

4

220-240

150

12 months

Morning and bedtime feed (may have afternoon feed)

2-3

220-240

120

Environmental/ social:

  • Does mum have appropriate support around her?

  • Has she seen the midwives or health visitors regularly?

  • Are their supportive spaces for her to breastfeed if she needs to?

  • If having to return to work, has mum thought about how to help continue her breastfeeding journey?

Conclusion

As you can appreciate, this topic is so vast but with some additional reading, this Fact Sheet should provide you with the confidence to commence consultations for those children in the first year of life.

Compiled exclusively for NHD by...

Ellie-May is a Registered Dietitian working freelance and for the NHS.  She graduated with a first-class degree from the University of Coventry. She is currently working as a rotational Paediatric Dietitian and has recently completed a renal rotation. 

Ellie-May Evans, RD

References/ resources:

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