InfantFeedingGuidelines

02339 infant feeding guide 20/6/06 3:59 pm Page 1
Infant Feeding
Guidelines
March 2006
02 I n fa n t Fe e d i n g G u i d e l i n e s
I n fa n t Fe e d i n g G u i d e l i n e s 03
EHSSB Infant Feeding Guidelines
A multidisciplinary working group originally wrote the EHSSB Infant Feeding Guidelines in
1991. The document was revised in 1996 (1) to take account of the 1994 COMA report on
“Weaning and the Weaning Diet” (10). Further developments in good practice and advice
from the Department of Health have since taken place and the guidelines required further
revision.
The preparation and publication of this update of the guidelines has been coordinated by
the Community Nutrition and Dietetic Service on behalf of the EHSSB.
The draft document was widely distributed for comment. We would like to take this
opportunity to thank all the individuals who took the time to send their comments and
helped to shape this final version of the EHSSB Infant Feeding Guidelines 2006 (see
appendix 3).
M rs G e r a l d i n e B l e a k n ey
Head of Health Promotion Commissioning, EHSSB
Department of Public Health Medicine and Nursing
EHSSB
March 2006
Contents Page
1 Introduction 09
2 Aim and objectives 10
2.1 Aim 10
2.2 Objectives 10
3 Diet in pregnancy and lactation 11
3.1 Preconceptual Nutrition 11
3.2 Diet in pregnancy 12
3.3 Diet in lactation 13
3.4 Medicines in pregnancy and lactation 13
4 Breastfeeding 14
4.1 Health benefits of breastfeeding 14
4.2 Anti-infective properties of breastmilk 15
4.3 Composition of breastmilk 15
5 Promotion of breastfeeding 16
5.1 Antenatal education 16
5.2 Delivery period 17
5.2.1 Vitamin K 17
5.3 Postnatal period 18
5.4 Neonatal jaundice 20
5.5 Diabetes mellitus 20
6 Maintenance of breastfeeding 21
6.1 Duration of feed 21
6.2 Baby-led feeding or demand feeding 21
6.3 Complementary feeds 21
6.4 Faltering growth 21
6.5 Night feeding 22
6.6 Special circumstances 22
6.7 Breastfeeding and returning to work 23
6.8 Pre-term babies 23
6.9 Allergies/food intolerance 23
6.10 Breastfeeding and HIV 23
6.11 Contraception 24
6.12 Alcohol 24
7 Use of “dummies” 25
8 Formula feeding 26
8.1 Frequency of feeds 26
8.2 Volume of feeds 26
8.3 Over feeding 26
8.4 Underfeeding 27
8.5 Monitoring 27
8.6 Hazards of bottle feeding 27
8.6.1 Contamination 27
8.6.2 Heating bottles in a microwave 28
8.6.3 Bottled water 28
8.6.4 Ready to feed preparations 28
8.6.5 Bottle caries 29
9 Infant formulae 30
9.1 First baby formulae 30
9.2 Follow-on milks 30
9.3 Soya formulae 31
9.4 Lactose free formulae 32
9.5 Extensively hydrolysed formulae 32
9.6 Partially hydrolysed formulae 32
9.7 Elemental formula 33
9.8 Low birth weight/pre-term formulae 33
9.9 Breastmilk fortifiers 33
9.10 Anti-reflux formulae 33
9.11 Organic formulae 33
9.12 Goat’s milk formulae 33
10 Milks 34
10.1 Cow's milk 34
10.2 Soya drinks 34
10.3 Goat and sheep's milk 34
10.4 Summary of use of different milks/formulae 35
11 Fluids 36
12 Colic 36
13 Reflux 36
14 Constipation 37
14.1 Treatment of constipation 37
15 Diarrhoea 38
16 Weaning 39
16.1 Preparation of weaning foods 39
16.2 How to wean 40
16.3 Weaning before six months 41
16.4 Summary of suitable foods and drinks 42
16.5 Comparison of home prepared with commercial baby foods 43
17 Nuts/hard particles 44
18 Allergy or food intolerance 44
19 Cow's milk/lactose intolerance 45
20 Food additives 46
21 Inborn errors of metabolism 46
22 Vitamins and minerals 47
22.1 Vitamins A, D and C 47
22.2 Iron 47
23 At risk groups 49
23.1 Low income 49
23.2 Vegetarian/vegan diets 49
23.2.1 Infant feeding for vegetarians 49
23.2.2 Weaning for vegetarians 50
23.3 Ethnic Minority Groups 50
23.4 Monitoring growth 51
23.5 Acquired lactase deficiency 51
24 Fluoride 52
24.1 Dental health guidelines 52
24.2 Fluoride supplement guidelines 53
25 Paediatric medicines 54
26 International code on the marketing of breastmilk substitutes (WHO 1981) 55
Appendix 1 56
Appendix 2 57
Appendix 3 58
References 60
Useful contacts and addresses 62
Useful resources 64
Other useful websites 64
1 Introduction
Nutrition in the early years of life is a major determinant of growth and development in
childhood and it also influences adult health. The Eastern Health and Social Services Board
(EHSSB) Infant Feeding Guidelines should be seen as a positive step towards maximising
the nutritional health of children. The core purpose of these guidelines is to promote sound
infant feeding practice and enable health professionals to give clear, consistent evidence
based advice to parents and carers. These guidelines have been updated from those
produced in 1996 (1), to incorporate guidance from the Department of Health, the Food
Standards Agency and the World Health Organisation (WHO). For the purpose of this
document an infant is a child who has not attained the age of one year.
It is very important to encourage and support mothers to breastfeed for immunological and
nutritional reasons as well as convenience and pleasure. If parents do decide to bottle feed
their child, it is imperative that they are supported in their decision and are given accurate
and consistent information on the preparation and use of modified infant formulae.
In 2005, Northern Ireland was again included in the Office of National Statistics (ONS)
Infant Feeding Survey (2), however the data from this survey will not be available until 2007.
The comparative data for breastfeeding rates in England, Wales, Scotland and Northern
Ireland from the previous two surveys are presented in Appendix 1.
The Department of Health and Social Services (DHSS) set targets for breastfeeding in
Northern Ireland for the period 1997-2002. These targets, to be achieved by 2002, were as
follows:
• To increase to 50% the percentage of mothers breastfeeding during the first two or
three days after birth.
• To increase to 35% the percentage of mothers breastfeeding at 6 weeks.
It is apparent from the data in appendix 1 that these were challenging targets and despite
very positive progress during the last decade they were not achieved.
The percentage of EHSSB residents breastfeeding their babies at time of discharge from
hospital, and how it has changed since 1993, is detailed in Appendix 2.
2 Aim and Objectives
2.1 Aim
To improve the nutritional health of children under one year of age by providing clear and
consistent information and advice on infant feeding in the EHSSB area.
2.2 Objectives
1. To provide clear and consistent guidelines on infant feeding, which are scientifically
sound and evidence based.
2. To promote an increase in the prevalence and duration of breastfeeding.
3. To draw attention to factors which may be causing confusion and to clarify these.
4. To dispel the many myths which surround the area of infant feeding.
3 Diet in Pregnancy and Lactation
3.1 Preconceptual nutrition
Diet is an important consideration for both men and women wishing to conceive. Lower
socio-economic groups are particularly at risk at this time and would benefit from sound
preconceptual information. Efforts should be concentrated on achieving acceptable body
weight for height, eating a varied diet with a good intake of all essential nutrients and
restricting or preferably excluding alcohol whilst trying to conceive. It is also wise to avoid
foods that are not advised during pregnancy so that these foods are not inadvertently
consumed in the early weeks before a woman is aware that she is pregnant. Ideally
changes should be made three to four months prior to conception. Further advice is
provided in the Eastern Area Communication Resource and Information Service (CRIS)
publication “Preparing for Pregnancy - healthy living healthy baby”.
In 1992, the Department of Health published recommendations for the prevention of neural
tube defects. They recommended that to prevent first occurrence of neural tube defects all
women should take an extra 0.4 milligrams (400 micrograms) of folic acid as a daily
medicinal or food supplement prior to conception and until the twelfth week of pregnancy.
They should also be encouraged to eat foods rich in folate e.g. green leafy vegetables,
pulse vegetables (peas, beans, and lentils) and folic acid fortified breakfast cereals.
Women who have not been supplementing their folate/folic acid intakes and suspect they
may be pregnant should start supplementation at once and continue until the twelfth week
of pregnancy.
A daily dose of 5 milligrams (5000 micrograms) of folic acid should be taken:
• by women with a history of a previous child with neural tube defect;

• where there is a family history of neural tube defects;
• by women receiving treatment for epilepsy who wish to become or who are at risk of
becoming pregnant.
3.2 Diet in pregnancy
Pregnant women should be given information on the principles of healthy eating,

encouraged to eat to appetite and to avoid excesses. In this way an adequate intake of
nutrients can normally be achieved without supplements in all but some “at risk groups”
(e.g. adolescents, low income, immigrants, vegans, underweight, recent pregnancy). Where
a woman, or her partner, has a personal or family history of allergy, eczema or hay fever
she should avoid peanuts whilst pregnant or breastfeeding. It is important to make women
aware of the risks of drinking alcohol and smoking to the unborn baby. Advice regarding
avoiding unpasteurised raw egg, mould ripened soft cheeses, blue cheeses, liver and
products containing liver (e.g. pâté), raw shellfish, undercooked or poorly reheated foods
still stands. More recently advice has been issued on limiting consumption of fish high in
methyl mercury as high levels of mercury can harm the developing nervous system. The
advice is to avoid eating shark, swordfish and marlin and limit the amount of tuna eaten to
two tuna steaks per week (140g cooked weight or 170g raw weight) or four medium cans
of tuna per week (140g drained weight).
Excessive intakes of caffeine should also be avoided as this has been linked to low birth
weight and miscarriage. Caffeine intakes should not exceed 300mg per day (for example
100mg caffeine is equivalent to 1 mug of instant coffee or 1 cup of brewed tea or 2.5 cans
of cola or 2 x 50g bars of chocolate).
Vitamin and mineral supplements are generally not advised, especially those containing
Vitamin A. This advice should be continued throughout pregnancy. There is some concern
about reduced intakes of Vitamin D and the re-emergence of rickets in the UK. Free vitamin
supplements are available from Maternity and Child Health Clinics for those on Income
Support and Job Seekers Allowance.
The Food Standards Agency publication “Eating While You are Pregnant” and the CRIS
publication “Good Food for Mums to Be” give more detailed advice on these important food
safety and hygiene issues.
3.3 Diet in lactation
For most women, increased quantities of a varied diet should provide their nutritional
requirements. Strict weight reduction diets should be discouraged. An adequate fluid intake
is essential to establish and maintain lactation. Fluid intake should be increased according
to thirst. It is not necessary to encourage breastfeeding women to drink large quantities of
liquid. Excessive intake of alcohol should be avoided; an occasional social drink is not
believed to be harmful (see section 6.12).
There is no reason to advise a lactating mother to OMIT certain foods from her diet just
because she is breastfeeding (the exception to this is nuts - see section 3.2.). It is perfectly
normal for breastfed infants to have loose stools particularly from the third to the fifth day
of life as this is related to the mother's influx of milk and not any dietary factor. However,
some foods may “upset” individual infants. True food intolerance is rare, however, if dairy
foods are suspected then they should only be eliminated from the diet for a two week trial.
If a food is excluded for a long period of time, specialist dietary advice may be required to
ensure that the mother has a nutritionally adequate intake. Referral to a Registered Dietitian
may be made via the General Practitioner.
3.4 Medicines in pregnancy and lactation
Medicines may pass across the placenta and also into breastmilk. The ingestion of
medicines should be avoided when possible during pregnancy, although very few
medicines are completely contra-indicated during lactation. If medicines are necessary,
advice should be sought from a doctor or community pharmacist on those suitable for
mothers who are breastfeeding before any are taken. A useful source of information is
“Medications and Mothers Milk” (Hales 2004).
4 Breastfeeding
Mother's milk is the ideal food for the young infant. It has nutritional and anti-infective
qualities which cannot be reproduced in an infant formula. Breastmilk is easily digested and
absorbed and provides complete nutrition for the first six months of life. Regarding the
optimal duration of breastfeeding the World Health Organisation recommends that
breastfeeding, with suitable complementary foods, can be continued until two years of age
or beyond (3).
A l l m o t h e r s s h o u l d b e g i v e n a c c u r a t e a n d t i m e l y i n fo r m a t i o n t o e n a b l e t h e m t o m a k e
a n i n fo r m e d c h o i c e a b o u t h o w t h e y w i l l f e e d t h e i r b a b i e s . H e a l t h c a r e s t a f f s h o u l d
s u p p o r t a l l wo m e n i n t h e i r c h o s e n m e t h o d o f i n f a n t f e e d i n g .
4.1 Health benefits of breastfeeding
The health benefits of breastfeeding are now recognised to extend beyond benefits to the
infant. Benefits to both mother and child are maximised if the infant is exclusively breastfed
for several months, these continue even after breastfeeding has ceased.
Benefits to the infant:
- Reduces the risk of gastroenteritis, middle ear, respiratory and urinary tract infections.
- Optimum neurological development.
- Reduces the risk of necrotising enterocolitis.
- Exclusive breastfeeding offers some protection against the development of atopic
disorders and other allergies. Where there is a strong family history of eczema,
asthma or cow's milk protein intolerance, breastfeeding should be encouraged.
H e a l t h b e n e f i t s l a s t i n g i n t o ch i l d h o o d :
Reduced risk of:
- Diseases of the respiratory system.

- Allergic disorders.
- Type 1 Diabetes.
- Raised systolic blood pressure.
- Childhood obesity.
There is also increasing evidence of long-term protection against cardio-vascular disease.
Benefits to the mother:
- Enhanced post partum weight loss.

- Delayed return of fertility (see section 6.11).
- Reduced risk of ovarian and breast cancers.
- Reduced risk of postmenopausal osteoporotic hip fracture.
4.2 Anti-infective properties of breastmilk
a. Colostrum is the milk produced in the first few days after birth. Apart from
providing nutrients and fluid required by the infant, like mature breastmilk,
colostrum supplies immunoglobulins.
b. The transfer of lymphocytes and macrophage cells from breastmilk enhances
the infant's gut defences.
c. Other anti-infective agents in breastmilk are the iron binding protein lactoferrin
and the enzyme lysozyme.
d. Breastmilk also contains viral fragments, which help enhance the effectiveness
of vaccines.
4.3 Composition of breastmilk
a. Protein in breastmilk is rich in lactalbumin (whey) and low in casein (curd)

compared with cow's milk. The amino acid content is more suited to the needs
of the infant.
b. The fat content is rich in essential fatty acids particularly the long chain
polyunsaturated fatty acids. Breastmilk contains lipase, which aids fat
absorption.
c. The principal carbohydrate in breastmilk is the disaccharide lactose, which is
also present in cow's milk.
d. Breastmilk provides the infant with his/her vitamin, mineral and trace element
requirements.
5 Promotion of Breastfeeding
Parents should be enabled to make an informed choice about infant feeding and, when
possible, all pregnant women should be provided with a one-to-one discussion on the
benefits of breastfeeding.
However, it is now recognised as best practice not to ask women their feeding intention
antenatally as this has the potential to discriminate between breast and formula feeding
mothers and to categorise a mother who may later choose to breastfeed as a formula milk
feeder. If a woman decides after delivery not to breastfeed she should be supported to
bottle feed safely and successfully.
5.1 Antenatal education
Antenatal/Parentcraft classes should cover and discuss the following points:
a. The pros and cons of both breastfeeding and bottle feeding, including the health
benefits of breastfeeding and the differences between breastmilk and formula
milk.
b. Simple explanation of the anatomy and physiology of lactation as well as factors
that control lactation.
c. Basic hygiene.
d. Factors which affect breastfeeding e.g. cultural, social, environmental, role of the
father, using dummies, teats, etc.
e. Management of breastfeeding, including skin-to-skin contact, positioning and
attachment, rooming in and bed sharing.
f. Clothing for breastfeeding e.g. bra type, pull up tops and other “baby friendly
fashion”.
g. Management of common experiences/difficulties that may occur.
h. Diet, rest, self care.
i. The role and location of local voluntary breastfeeding support groups and peer
support workers.
Women who do not attend classes should be offered the same information and given the
opportunity to discuss infant feeding on a one-to-one basis.
5.2 Delivery period
All mothers should be given their babies to hold for an unlimited period with skin-to-skin
contact within 30 minutes of delivery (or within 30 minutes of the mother being able to
respond in the case of Caesarian Section). They should be encouraged to initiate the first
breastfeed as soon as the baby is receptive (4).
5.2.1 Vitamin K
Vitamin K is of importance in the prevention of Haemorrhagic Disease of the newborn.

Regional guidance on the use of vitamin K in newborn babies was issued by the Chief
Medical Officer and Chief Nursing Officer in 1998 as follows:
• “We recommend that all newborn babies should receive an appropriate vitamin K
regime to prevent the rare but serious and sometimes fatal disorder of VKDB [Vitamin
K Deficiency Bleeding].
• All should be offered one of the available regimes after an informed discussion with
parents in the antenatal period.
Could vitamin K be harmful?
• A joint Medicines Control Agency, Committee of Safety of Medicines and Department

of Health expert group has concluded that overall, the available data do not support
an increased risk of cancer caused by vitamin K but due to limitations of the data it is
not possible to exclude a small increase in leukaemia.
How c a n v i t a m i n K b e g i v e n ?
• Either by intramuscular (i.m.) injection or using an oral regime. Parents should be fully
informed about benefits and possible disadvantages of the regimes and be involved
in the decision about the one chosen.
• i.m. Vitamin K effectively prevents VKDB in virtually all babies following a single dose
given at birth, using Konakion (Roche) in a dosage of 1 mg.
• Oral regimes for additional doses of vitamin K can also be effective, but doses must
be repeated. Arrangements must be in place to ensure that all recommended oral
doses are given at the appropriate ages. Doses of vitamin K given at and shortly after
birth should suffice for formula fed babies who then continue to receive vitamin K
because it is added to formula milk. Breastmilk is the ideal nutrition for babies and,
as for formula fed, breastfeeding babies need to receive additional vitamin K” (15).
I t i s e s s e n t i a l t h a t a l l s t a f f a r e aw a r e o f t h e i m p l i c a t i o n s o f t h i s g u i d a n c e i n t h e i r ow n
l o c a l i t y.
5.3 Postnatal period
a) Mother and infant should remain together and only be separated where the
health of either the mother or the baby prevents them being cared for together.
b) All mothers of i l l o r p r e - t e r m b a b i e s should be provided with information about
the health benefits of breastmilk. Mothers should be encouraged to express milk
as soon as possible, within six hours of delivery if possible. Early suckling or
expressing is important for stimulating lactation and aiding successful
breastfeeding. Mothers should be encouraged to express milk 6-8 times a day
and at least once at night. For practical details see booklet “Breastfeeding your
ill or premature baby” Health Promotion Agency (HPA) and “Advice for Mothers
Breastfeeding Premature Babies” and “Breastfeeding if Your Baby Needs Special
Care” (National Childbirth Trust).
c) Correct positioning and attachment of the baby on the breast is essential for
effective feeding and to prevent nipple damage. Any experience of pain or other
discomfort is abnormal and professional advice should be given.
C o r r e c t p o s i t i o n i n g o f t h e b a by :
• Baby turned towards the mother (“tummy to mummy”).

• Held close.
• Head and body in line (not twisted).
• Baby held nose to nipple.
• Baby should be moved to the breast (nn o t breast to baby).
S i g n s o f g o o d a t t a ch m e n t a n d m i l k t r a n s fe r :
• Baby's chin touching breast and the nose is free.

• If visible, more aerola seen at baby's nose and top lip.
• Mouth wide open, bottom lip curved outwards.
• Cheeks round - not dimpled or sucked in.
• Sustained rhythmic suck/swallow pattern with occasional pauses.
• Audible swallowing.
• Mouth moist.
• Feeding is comfortable.
• Breasts softer after feed than before.
• Baby satisfied after feeding.
• Regular soaked nappies.
d) All mothers should be shown how to express by hand and be given written
instructions.
e) Feeding on demand should be encouraged to establish a good milk supply. It is
vital that mothers should learn to recognise their baby's feeding cues and
respond to these. Signs of hunger include increased alertness, activity,
mouthing, rooting or crying.
f) Complementary feeds must not be offered unless clinically indicated or with fully
informed maternal consent. Complementary feeds lower demand and
consequently reduce milk supply. If a breastfed baby requires supplementation,
expressed breastmilk should be given via a cup or syringe (for amounts less than
5mls) and not a bottle to avoid confusion between the nipple and teat.
g) The healthy, term baby is not at risk of developing h y p o g ly c a e m i a as a result of
simple underfeeding. If signs of hypoglycaemia are detected, an underlying
condition should be suspected. At risk infants include premature and/or small for
gestational age infants, those who suffered intrapartum asphyxia or who are sick
or born to mothers with diabetes. “For newborns at risk, breastmilk is the safest
and nutritionally most appropriate food” (6).
h) The mother should eat a well balanced diet, which should be provided without
restrictions. The need for a higher energy intake should be recognised and
catered for, fluids should be increased according to thirst (see sections 3.2 and
3.3 on diet in pregnancy and lactation for advice on nuts).
i) Breasts and nipples should be checked routinely and any problems treated.
j) Test weighing should be discouraged. It is an ineffective method of assessing the
adequacy of lactation.
k) The use of dummies should be discouraged as this can confuse the infant and
reduce milk supply.
l) Details of local and national breastfeeding support contacts should be given
before discharge from hospital.
5.4 Neonatal jaundice
Breastfeeding should be continued unless there is a medical contra-indication i.e. excess

levels of bilirubin. “A breastfed baby who has signs of jaundice should be actively
encouraged to breastfeed frequently, and woken to feed if necessary” (5). Frequent
breastfeeds lead to an increased excretion of bilirubin in the first three days of life. Correct
positioning and attachment should be checked by observing a breastfeed. Mothers of
sleepy babies should be encouraged to feed their babies frequently (8 -12 times in 24
hours). “Breastfed babies should not be routinely supplemented with formula, water or
dextrose water for the treatment of jaundice” (5).
5.5 Diabetes mellitus
Mothers with diabetes mellitus should be advised to eat extra carbohydrate when
breastfeeding. In general approximately 50g extra carbohydrate should be taken over the
course of the day. Careful monitoring of blood sugars will help determine individual
requirements for extra carbohydrate. Mothers should be advised to eat before feeding the
baby, to prevent hypoglycaemia. A snack before the night-time feed may be required.
6 Maintenance of Breastfeeding
6.1 Duration of feed
There are no set rules as to how long a feed should take. Some babies will feed at a higher
rate for a short time and others at a slow rate for a longer time. If feeds are routinely taking
a long time, mothers may need further help with positioning and attachment. A mother
should be encouraged to allow her baby to finish the first breast before offering the second
and re-assured that it does not matter if her baby only wants to feed from one breast at an
individual feed. If she starts with the second breast at the next feed there should be no long-
term imbalance in milk production. She should be similarly reassured that if the baby
requires both breasts at a feed, this is equally acceptable, and that the baby may shift from
one pattern of feeding to another.
6.2 Baby-led feeding or demand feeding
Baby-led (demand) feeding should be encouraged for all breastfed babies unless clinically
contra-indicated. The expected pattern of feeding at different stages and variation between
babies should be explained to mothers. They should be encouraged to waken their baby for
feeding if their breasts are overfull and to recognise signs of waking and willingness to feed
in their baby. Unrestricted breastfeeding helps prevent engorgement, increases milk supply,
stabilises neonatal serum glucose levels and increases initial weight gain.
6.3 Complementary feeds
Milk formulae should not be given routinely to treat poor lactation. There are very few
women who do not produce sufficient milk. Giving complementary feeds of formula milk
leads to less suckling, compromises the milk supply further and causes nipple versus teat
confusion.
6.4 Faltering growth
If an infant is displaying faltering growth, a history of breastfeeding should be taken. A

breastfeed should be observed and position and attachment assessed. In addition, the
number of feeds and frequency of wet/soiled nappies per day should also be assessed. If
the problem persists referral should be made to a lactation consultant or breastfeeding
counsellor as well as a medical practitioner.
There are five major causes of faltering growth, these are:
• Inadequate intake.
• Increased losses.
• Failure to absorb.
• Failure to utilize.
• Increased requirements.
Normal weight gain for a breastfed infant is 150 -210g/week in the first four months. Birth
weight should be regained by 10 - 14 days old.
Early positive intervention makes this problem easier to solve without affecting the mother's
confidence in her ability to breastfeed and without resorting to formula feeding.
The Department of Health and WHO both recommend exclusive breastfeeding for the first
six months of life with no other foods or fluids being given (7,3). Expressed breastmilk can
be given from a cup, spoon or syringe. The use of formula milk, even when breastfeeding
is well established, should not be encouraged. Formula milk can sensitise a vulnerable
baby to allergy or diabetes, increase the risk of infection due to changes in the gut, lower
milk supply and undermine a mother's confidence or encourage the development of nipple/
teat confusion.
6.5 Night feeding
Babies should be breastfed on demand throughout 24 hours. Prolactin levels (which

stimulate milk supply and depress fertility) are high at night and infant formula should not
be given instead of a breastfeed.
6.6 Special circumstances
Where the infant's medical condition prevents breastfeeding, the mother should be
encouraged and supported to express and store breastmilk until the infant recovers. See
National Childbirth Trust leaflet on “How to Express and Store Breastmilk”, UNICEF Baby
Friendly Initiative leaflet “Breastfeeding Your Baby” and the HPA leaflet “Off to a Good Start”
and the United Kingdom Association of Milk Banks Leaflet on “Collection and storage of
breastmilk in the neonatal unit”.
6.7 Breastfeeding and returning to work
A mother who is planning to return to work should be encouraged to develop a plan for how
she is going to manage feeding her baby. She may want to introduce bottle feeding to her
infant. This should be initiated only when breastfeeding is well established and the infant
then given a small volume of expressed breastmilk. Cup feeding, as an alternative to bottle
feeding should be encouraged. Prior to returning to work mothers should be advised how
to express, store and use breastmilk (see La Leche League or National Childbirth Trust
leaflets on how to express and store breastmilk) or how to gradually introduce infant formula
feeds if that is the mother's wish.
6.8 Pre-term babies
Ideally all pre-term babies should be fed breastmilk (see section 6.6). The anti-infective
properties of breastmilk (section 4.2) are particularly beneficial to this group and breastmilk
exerts a favourable effect on the neuro-development and gut integrity of pre-term babies.
Where appropriate, the use of donor expressed breastmilk should be considered (see
section on Sources of Useful Information).
6.9 Allergies/food intolerance
The Department of Health recommends that weaning for all infants be delayed until six
months (26 weeks). Early introduction of solids can lead to an increased risk of food allergy
or intolerance. By delaying weaning to six months, the risk of developing food allergies or
intolerance is reduced. This advice is particularly relevant where there is a strong family
history of atopic disease. If the exclusion of common allergens is considered necessary the
General Practitioner should refer the mother to a Registered Dietitian for specific dietary
advice.
6.10 Breastfeeding and HIV
HIV may be transmitted via breastmilk. In the United Kingdom, women known to be HIV
positive and those at a high risk who have not been serologically tested are advised not to
provide their own milk for their infants (10). HIV is destroyed by pasteurisation of milk. There
is some evidence that infants of seropositive mothers who breastfeed exclusively do not
appear to be at risk of acquiring HIV. However, mixed feeding (breastfeeding in combination
with other feeding) carries a significant risk of the infant acquiring HIV infection.
6.11 Contraception
Breastfeeding is a useful contraceptive method but is only effective while:

• the baby is exclusively breastfed.
• the baby continues to feed at night.
• the mother has not resumed menstruation.
Oral contraceptives may be prescribed by a physician. The combined pill is not suitable for
use when breastfeeding because it can reduce the milk supply; the progesterone only pill
is suitable at this time. Other barrier forms of contraception do not interfere with breastmilk
supply.
6.12 Alcohol
Although alcohol does transfer across into breastmilk, occasional or light drinking (defined
as one or fewer drinks per day) has not been found to be harmful to breastfed babies.
Mothers who drink more than this may find that the letdown reflex is affected and milk intake
by the baby is reduced. Other problems that may occur with moderate to heavy alcohol
consumption include the infant's motor development being affected and weight gain may be
reduced.
Parents who have been drinking alcohol, who smoke, or have taken drugs/medication
should avoid co-sleeping with their baby.
Further information about alcohol and breastfeeding can be found on the La Leche League
website, www.lalecheleague.org
7 Use of “Dummies”
The use of a “dummy” is not to be encouraged but it would be preferable to sucking a finger
or cloth. The dummy, often called a “soother”, may act as a comforter. It is better that he/she
is given an orthodontic dummy which may be removed as early as possible and in the child
who is developing normally, this should be no later than 9 months. If a dummy is necessary
the following guidelines should be followed:
• Strict standards of hygiene should be maintained. When not in use the dummy should
be kept in a steriliser.
• Never dip the dummy in honey, syrup or sugar.
• The dummy should be removed from the child as soon as he/she has settled,
excessive use may impair speech development.
• A baby should not be allowed to sleep with a dummy in his/her mouth. However “if a
baby has become accustomed to using a pacifier while sleeping, it should not be
stopped suddenly during the first 26 weeks” (5).
8 Formula Feeding
“Appropriate feeding practices are of fundamental importance for the survival, growth,
development and nutrition of infants and children everywhere” (7).
8.1 Frequency of feeds
As for breastfed infants, infants fed on manufactured formula milks should be fed ON
DEMAND. Parents should be advised that infants will require frequent feeds, usually every
3 - 4 hours over a 24 hour period (averaging 6 - 8 feeds daily), to ensure adequate volumes
and nutritional intake are achieved. As the infant gets older they may feed less frequently
if tolerating larger feed volumes. A useful guide to the frequency of feeds is to avoid any
gap of more than 5 hours between daytime feeds and more than 8 hours at night. If an
infant demands to be fed more than every 2-3 hours he/she may require extra fluids. Freshly
boiled cooled water without added sugar may be offered in this situation.
8.2 Volume of feeds
In general, an infant's fluid, energy and protein requirements will be satisfied by an intake
of 150ml/kg body weight per 24 hours, (2.5 fl.oz/lb) of infant formula from birth until 6
months of age. Infants achieving these volumes of infant formula will ensure adequate
nutritional intake for age. From 7 - 12 months fluid intake usually reduces to 120 ml per kg
body weight as solids are increased. Infant formula volumes will gradually decrease in view
of increased weaning foods. A minimum of 500 ml formula should be encouraged daily (per
24 hours) to ensure appropriate vitamins and minerals are provided (see section 22.1).
8.3 Overfeeding
Infants who receive correctly prepared infant formula are unlikely to be overfed. Formula
must be prepared according to manufacturer's instructions and the measuring scoop
provided should be used. Feeds should be made up by first measuring out the cooled boiled
water and then adding the correct number of level scoops to the fluid. Extra formula powder
should not be added as this will result in an over concentrated feed. Instruction in proper
measurement technique should be given antenatally and reinforced postnatally. It is of
paramount importance that solids are never added to bottle feeds. Check volumes as per
section 8.2.
8.4 Underfeeding
Infants who are fed with diluted feeds are at a greater risk of being undernourished. Infants
who have faltering growth must be identified, their feeding pattern and volume of formula
taken should be assessed. If necessary the baby should be referred for medical
investigation promptly (see section 6.4).
8.5 Monitoring
The best way of monitoring an infant's growth is to record his/her weight gain and length
during the first year of life. Percentile charts should be used regularly by Health Visitors to
record weight gain/loss in the Personal Child Health Record (“red book”). When pre-term
babies are monitored on percentile charts an allowance should be made for their
prematurity. Significant deviations from the infant's percentile charts should be referred
without delay for medical investigation.
8.6 Hazards of bottle feeding
8.6.1 Contamination
Bottle fed infants may develop gastroenteritis from contaminated formula feeds. Feeds may
be contaminated by a variety of methods, including using bottles and utensils that are either
not properly washed or sterilised or not making feeds up correctly. The European Food
Safety Authority (EFSA) (8) has now issued advice which has been adopted by the
Department of Health on the safety of making up bottle feeds. This is due to the risk of
contamination of infant formulae with Salmonella and Enterobacter Sakazakii.
Contamination of formula with these bacteria can occur during the production of powdered
infant formula. These bacteria can grow in the reconstituted product if it is stored above 5ºC
for a sufficient time and multiply very rapidly at room temperatures.
The most recent advice is:
• “Good hygienic measures are essential to avoid contamination (e.g. wash hands,
ensure cleanliness of kitchen and equipment…).
• Prepare powdered infant formula for each meal.
• Use “sanitised” containers to reconstitute the formula (e.g. use clean bottles, ideally
sterilised in boiling water).

• Always reconstitute formulae in hot water (>70ºC) or water that has been boiled and
cooled, avoiding recontamination.
• Cool the reconstituted formula rapidly to room temperature.
• Use the reconstituted formula immediately.
• After feeding discard any remaining formula.” (8)
EFSA recommend that guidelines for preparation, handling, storage and use of infant
formula in the home and in hospitals are developed. The Health Promotion Agency is
currently preparing a leaflet on bottle feeding incorporating this new advice.
Health professionals involved in teaching parents to prepare bottle feeds should emphasise
the importance of using proper techniques when sterilising utensils and equipment required
in the preparation of feeds. In practical terms mothers who require a feed for later are
advised to keep boiled water in a sealed flask and the measured amount of formula in a
separate sterilised container and make up fresh formula milk as it is needed. Alternatively,
sterile ready to feed cartons of formula may be used.
8.6.2 Heating bottles in a microwave
An infant's feed should not be warmed in a microwave oven. Very hot fluid at the centre of
the bottle may be missed and may scald the baby.
8.6.3 Bottled water
A l l water used to make up infant formula feeds or for giving as a drink of water to infants
less then six months of age should be boiled and cooled. There is no advantage under
normal circumstances to using bottled water. Most non-carbonated, bottled waters are
suitable for use with infants, however bottled waters labelled “ N a t u r a l m i n e r a l w a t e r ” a n d
e f fer v e s c e n t w a t e rs a r e n o t s u i t a ble fo r u s e w i t h i n f a n t s due to their higher sodium
content.
8.6.4 Ready to feed preparations
Adequate hygienic procedures must be followed when opening and transferring from the
carton to the bottle. Opened cartons stored in the fridge should be discarded after 24
hours.
8.6.5 Bottle caries
This occurs in infants or toddlers who are given a feeding bottle for extended periods of time
during the day or at night. Although lactose is relatively non-cariogenic, it will cause tooth
decay if it is left in contact with the teeth for long periods of time. Infants should not be put
to bed with feeding bottles. If this is not possible then a bottle containing water should be
used. Advice to use a cup from six months of age should be reinforced.
9 Infant Formulae
9.1 First baby formulae
There are two main types of infant formula, whey based and casein based. Whey based
formulae are more similar to breastmilk than casein based formulae. Whey based
formulae are recommended as they are easier to digest than casein based formulae and
have a lower renal solute load.
Examples of infant formulae available
Whey b a s e d Casein based
Cow and Gate Premium Cow and Gate Plus
Farley's First Milk Farley's Second Milk
Milupa Aptamil First Milupa Aptamil Extra and Milumil
SMA Gold SMA White
Changing to a casein-based formula is common practice in order to “satisfy” a hungry baby.

There is no scientific evidence to support this practice and it should be discouraged. The
frequency and volume of feeds should be altered first. However, changing from whey to
casein milk is preferable to the early introduction of solids.
9.2 Follow-on milks
Follow-on milks are not recommended for use as a replacement for breastmilk or infant
formula before six months of age. They are aimed at infants and children where there are
concerns over the dietary intake of iron, but for the majority of infants and children they are
not necessary. Breastfeeding should not be stopped in favour of using a follow-on milk.
“Continued use of iron enriched infant formula or follow on milk as a main drink after the
first year should be considered if there are concerns about the adequacy of iron in the diet”
(10).
Examples of follow-on milks are:
• Aptamil Forward (Milupa).

• Follow-on milk (Farley's).
• Progress (SMA).
• Step-up (Cow and Gate Nutricia).
9.3 Soya formulae
Soya formulae are no longer recognised as an appropriate first line treatment for lactose
intolerance (section 9.4) or cow's milk protein intolerance (see section 9.5). Infants at risk
of cow's milk protein allergy may also be sensitive to soya protein, particularly if the cow's
milk protein intolerance has been manifested in gastrointestinal symptoms. The Chief
Medical Officer stated in 2004 that soya-based formulae “should only be used in
exceptional circumstances to ensure adequate nutrition. For example they may be given to
infants of vegan parents who are not breastfeeding or infants who find alternatives
unacceptable” (9).
There are also concerns in relation to the long term effects of using soya based formulae
in infancy. These relate to a significant increase in prolonged and painful menstruation in
adult women fed soya formulae and changes in the number of Leydig cells in the testes and
suppression of testosterone rise in neonatal marmosets partially fed soya formula (9).
The Paediatric Group of the British Dietetic Association have issued a Position Statement
on the use of Soya Protein for Infants (9). It recommends “that the use of soya protein as
first line treatment should be discouraged …. particularly in the first six months of life - to
avoid sensitisation to soya protein and exposure to phytoestrogens while organ systems
remain at their most vulnerable. This includes soya infant formula and soya products such
as desserts, etc.
When a soya-based infant formula is used, parents should be informed of current findings
relating to phytoestrogens and health and on the clinical need for soya. Any parent choosing
to refuse soya for their infant should be supported in their decision. More research is
needed into whether any adverse effects are dose related” (9).
If a soya formula is to be used, infants should be fed on demand and it should be

remembered that the lactose has been substituted with glucose or sucrose. It therefore
carries a risk to dental health and parents should be advised to safeguard dental health. A
cup should be introduced at six months and by one year bottlefeeding should be
discontinued. Soya formula between meals or at bedtime is not recommended.
Soya formula remains the preferred option for the management for Galactosaemia.
N u t r i t i o n a l l y c o m p l e t e s oy a fo r mu l a e i n cl u d e :
• Farley's Soya formula (Farley's).

• Infasoy (Cow & Gate).
• Isomil (Abbott).
• Prosobee (Mead Johnson).
• Wysoy (SMA Nutrition).
9.4 Lactose-free formulae (prescription only)
Infant formulae which have been developed specifically for lactose intolerance are SMA
Lactose Free (SMA Nutrition) and Enfamil Lactofree (Mead Johnson).
9.5 Extensively hydrolysed formulae (prescription only)
Formulae appropriate for the treatment of cow's milk protein intolerance (CMPI) are
extensively hydrolysed formulae which include: Nutramigen 1 (Mead Johnson), Nutramigen
2 (for greater than 6 months of age) (Mead Johnson), Pepti (Cow & Gate), Pepti-junior
(Cow & Gate), and Pregestimil (Mead Johnson).
9.6 Partially hydrolysed formulae (non-prescribable)
These products are marketed for the treatment of “colic and mild gastro oesophageal
reflux”. There is no strong clinical evidence to support the use of these feeds and they may
in fact “mask” other conditions which need diagnosis and where other more appropriate
dietary management is indicated e.g. CMPI, lactose intolerance or reflux. Examples include:
Omneo Comfort 1 (Cow & Gate), Omneo Comfort 2 (Cow & Gate), Nan HA 1 (Nestle) and
Nan HA 2 (Nestle).
9.7 Elemental formula (hypoallergenic prescription only)
The elemental formula Neocate (SHS International) may be required or trialled if the child
has a family history of multiple food protein intolerances and remains unsettled on
hydrolysed formula.
9.8 Low birth weight/pre-term formulae (prescription only)
Ideally all pre-term infants should be fed breastmilk, however this may need to be
supplemented. Pre-term formulae are intended only for pre-term or low birth weight infants
and should only be used on medical recommendation. They provide more energy, protein
and minerals per unit volume than whey based formulae. They are not suitable for infants
with faltering growth. These milks are only available as “ready to feed” formulae and are
mainly for hospital use, although they may be continued in the community under review by
a Registered Paediatric Dietitian and/or Paediatrician.
9.9 Breastmilk fortifiers (Neonatal units, prescription only)
Breastmilk fortifiers are available to increase the nutritional content of expressed

breastmilk, however it should be remembered that these products are derived from cow's
milk.
9.10 Anti-reflux formulae
Enfamil AR (Mead Johnson) and SMA Staydown (SMA Nutrition) may be an appropriate
choice for reflux management when addition of a thickener (section 13) is not appropriate
or where non compliance is likely.
9.11 Organic formulae
These are available from birth to 12 months and are nutritionally complete. Usual weaning
practice should be adopted (section 16).
9.12 Goat's milk infant formulae
These are not recommended. Infant formulae and follow on milks made from goat's milk
are not approved for use within Europe (see section 10.3).
10 Milks
10.1 Cow's Milk
1. Breastmilk or infant formula should be continued until 1 year of age.

2. Small quantities of whole cow's milk may be used to mix solid foods from six
months of age, however, whole cow's milk should not be used as a main drink
until after 1 year of age.
3. The use of a minimum of 350mls of whole cow's milk daily is recommended from
1 year of age, however the intake of large volumes i.e. more than 600mls (1 pint)
should be discouraged as this will decrease the appetite for other foods.
4. Semi-skimmed milk may be given to healthy children over 2 years who are eating
a good variety of foods and when it is already in general use within the home.
5. Skimmed milk should not be given to children under 5 years because of its low
energy and vitamin A and D content.
6. Pasteurised cow's milk does not need to be boiled once it is kept covered and
refrigerated and does not require dilution before use.
10.2 Soya drinks
Soya drinks (previously known as “soya milk”), which are not infant formulae, should not be
used during weaning. If used after one year of age particular attention should be given to
ensure adequate vitamin and mineral intake, especially calcium intake. Particular care
should be taken to safeguard dental health owing to the high sugar content of some soya
drinks. Unsweetened varieties are available.
10.3 Goat and sheep's milk
These milks are totally unsuitable for infants under 1 year of age because they have a very
high protein and salt content. They are also deficient in vitamins A, D, C, B12, folate and
iron and are not always pasteurised. “Although these milks may be perceived as less
allergenic or else providing special nourishment, none of these claims have been
substantiated. Goat and sheep's milk should not be given to infants but may be given from
the age of one year so long as precautions against mineral and vitamin deficiencies are
taken”, the milk must be pasteurised or boiled (10). Infant formulae and follow-on milks
made from goat's milk are not approved for use within Europe.
10.4 Summary of use of different milks/formulae
Milk types A g e when used Special points
Breast. 0 - 2 years, sole form of May be continued for

nutrition for first 6 months. longer if wished (3).
Formula milk. 0 - 1 year, sole form of May be continued for

nutrition for first 6 months. longer if considered necessary.
Follow-on milk. From 6 months - 1 year. May be continued for longer

if considered necessary.
Whole cow's milk. From 6 months. May be used to make up solid food
but n o t a s a m a i n d r i n k.
From 1 year. As a main drink.
Semi-skimmed milk. 2 years +. Provided dietary intake is

otherwise adequate.
Skimmed milk. 5 years +. Provided dietary intake is

otherwise adequate.
Low lactose formulae. 0 - l year. May be continued for longer

if considered necessary.
Partially hydrolysed Not recommended. Not considered suitable for use in

formulae. lactose intolerance or cow's milk
protein intolerance.
Extensively From birth. Preferred formulae for children

hydrolysed formulae. with food allergies.
Soya formulae. Not recommended. It contains sugar and presents

If used - not before a risk to dental health.
6 months.
Soya drink. 1 year +. Particular attention needs to be given

to ensure an adequate vitamin and
mineral intake. These may contain
sugar and present a risk to dental
health. Low sugar varieties are
available.
Goat/Sheep's milk. 1 year +. N o t recommended, but if used after

1 year must be pasteurised or
boiled. Attention to ensure
adequate vitamin and mineral intake
is required.
11 Fluids
Breastmilk, formula, follow-on milk or water should constitute the majority of the total drinks
given to the infant until 1 year of age. Under 6 months of age water should be boiled and
cooled. For further information on other drinks including tea, soft drinks and fruit juices see
section 16.4 “Summary of Suitable Foods”. A cup can be introduced from 6 months of age
and feeding from a bottle should be discouraged by 1 year of age. (10)
12 “Colic”
“Colic” is common, harmless but distressing and occurs particularly in the first 3 months of
life. Sympathetic treatment is required; milk type should not be changed routinely.
Occasionally an alteration in the maternal diet, if breastfeeding, may be worth a trial. See
diet and lactation section 3.3. Gripe Water, herbal drinks containing sugar, local “remedies”
or medicines are not recommended. In formula fed babies, the use of an extensively
hydrolysed formula may be considered for treating colic but only under medical guidance
(5). It is recommended that this is accompanied by a referral to a Registered Dietitian.
13 Reflux
Oesophageal reflux may be alleviated by the use of a gel before breastfeeds or the addition
of a thickener to formula or expressed breastmilk e.g. Carobel or Nestargel. A gastric-
thickening feed which thickens on contact with stomach acid after feeding may also be used
e.g. SMA Staydown (SMA Nutrition) or Enfamil AR (Mead Johnson). These formulae
should not be used in conjunction with anti reflux medication e.g. Losec as they will not
thicken when stomach acids have been neutralised. They are indicated where the use of a
thickener is not appropriate or where non compliance is likely. Infant gaviscon may also be
used. Specialised advice should be sought in dealing with reflux if it is persistent or
problematic.
14 Constipation
a. Constipation may be defined as difficulty in passing hard stools and not the
passing of stools less frequently than “normal” for that individual. Bottle fed
infants are much more likely to suffer from constipation than those who are
breastfed, however constipation is a rare event in all newborns and infants.
b. The stools of breastfed babies may vary considerably in texture, colour and
frequency. In the child who is thriving this variation should cause no alarm.
Sometimes a breastfed baby will not pass any stools for several days, this should
not cause any concern.
c. Constipation may occasionally occur during the early stages of weaning in
breastfed babies and care should be taken to prevent this by maintaining regular
breastfeeding.
d. Any cause of dehydration may produce constipation in babies e.g. over
concentrated bottle feeds, excess sweating caused by fever, excessive clothing
or exposure to high temperatures.
e. The older child who is eating a low fibre diet may also suffer constipation.
14.1 Treatment of constipation
a. Check that bottle feeds are made up correctly according to the manufacturer's
instructions.
b. Give cooled boiled water or well diluted unsweetened pure fruit juice (diluted to
1 part fruit juice to 10 parts water) between feeds. The addition of sugar, glucose
or honey to water/feed is not recommended.
c. Give the following high fibre foods to infants over 6 months- Weetabix,
wholemeal bread, fresh fruit and vegetables. NB Pure bran mu s t n o t b e g i v e n
t o c h i l d r e n u n d e r 5 y ears .
d. If a child does not respond to this treatment medical advice should be sought.
15 Diarrhoea
a. Diarrhoea may be defined as a change in bowel habit for the individual child
resulting in substantially more frequent and/or looser stools. Medical advice
should be sought for an infant with these symptoms.
b. In bottle fed infants, mild to moderate cases may be treated at home by stopping
formula and giving appropriate prescribable oral rehydration solutions (ORS)
e.g. Dioralyte, Dextrolyte or Rehydrate. Infants who are not weaned should
recommence on full strength lactose containing formula as soon as possible
following rehydration with ORS (which is normally given over 4 hours).
c. Breastfed infants should continue to breastfeed through the rehydration and
maintenance phases of their acute gastroenteritis illness.
d. Sugary drinks e.g. cola drinks and “home made” salt/sugar solutions should not
be used, as they are unsuitable for rehydration therapy.
e. If the diarrhoea does not respond to treatment, further medical advice should be
sought.
f. If an infant is vomiting as well as having diarrhoea, the danger of dehydration is
greatly increased and urgent medical attention should be sought.
16 Weaning
The Department of Health and WHO recommends that weaning begins from the age of six
months (26 weeks) (7,3). From this age infants need more iron and other nutrients than
breastmilk or infant formula alone can supply. From six months, babies:
• Are able to actively move the upper lip down to clean the spoon.
• Chew.
• Use the tongue to move food from the front to the back of the mouth.
• Are curious about other tastes and textures.
• Develop eye-hand co-ordination.
Older babies more readily accept a diet with varied textures, tastes and amounts.
Early introduction of solids may predispose the infant to age-related gastrointestinal

disease during the first six months of life due to the human gut being functionally immature
at birth. If parents choose to introduce solids earlier than this they should be advised n o t
to do so b e fore 17 weeks. Early weaning requires additional advice (see section 16.3).
NOTE: Food should always be offered from a shallow spoon and never added to bottles.
This produces an overconcentrated feed, which may lead to hyperosmolar states. The
thickened feed may also block the teat of the bottle. Thickened feeds can also increase the
risk of choking and can cause acute thirst. In addition, the infant needs to learn how to take
food from a spoon. Infants should never be left alone when eating, as they may choke or
inhale small hard pieces of food.
For further advice on weaning refer to the leaflet “Weaning Made Easy”, HPA.
16.1 Preparation of weaning foods
Family foods may be cooked in bulk, without added salt or sugar, and frozen in individual
portions. These should be allowed to defrost thoroughly, then be reheated to boiling and
allowed to cool before feeding.
Commercial baby foods should be transferred into a bowl before feeding. Only the quantity
of food required should be heated and the remainder should be stored according to the
manufacturer's instructions.
16.2 How to wean
Start with baby rice, smooth or well mashed cooked vegetable (e.g. carrot, parsnip, potato,
turnip, etc.), smooth or well mashed banana, stewed apple, tinned fruit (in fruit juice),
natural/plain yoghurt (whole milk varieties if possible), unsweetened custard.
One or two teaspoons of semi-solid food should be offered at first. The use of small shallow
plastic spoons and special feeding bowls is recommended. After six months of age
equipment does not need to be sterilized. As the baby learns to take food from a spoon the
amount and number of spoon feeds will need to be increased. This should be guided by
the baby's appetite and interest in eating.
New foods d o n o t have to be introduced one at a time, at three or four day intervals, unless
there is a history of atopy in the family.
At this stage breastfeeding on demand or at least 500 - 600mls infant formula should
continue to be used until at least one year of age. Cow's milk may be used to mix foods but
should not be used as a main drink until after one year of age.
A c u p c a n a l s o b e i n t ro d u c e d a t t h i s s t a g e
F o o d s t o av o i d :
• Salt - including stock cubes - babies’ kidneys are not fully developed at six months of age
and high amounts of salt/salty foods can be harmful.
• Sugar - encourages a sweet tooth and can lead to dental decay.
• Honey - avoid in the first year of life as honey can contain the botulinum bacteria. After
the age of one year the infant gut matures and the bacteria is no longer able to grow. It
is important to remember that honey is a sugar and can lead to dental decay.
• Nuts - children under 5 should avoid whole nuts. For most children products containing
nuts are safe, however where there is a family history of allergy or atopic disease, nuts
should be completely avoided until the age of three years.
After a couple of weeks the texture can be increased to include a few soft lumps and the
variety of foods increased. In particular foods containing iron, e.g. beef, lamb, pork, egg
yolk, green vegetables, beans, lentils and fortified breakfast cereals, should be included
regularly.
By sev e n m o n t h s food can be mashed with a fork and babies should be having three
spoon feeds a day.
By n i n e m o n t h s the infant can progress to chopped foods and by one year should be
eating family meals and drinking from a cup. Feeding from a bottle should be discouraged.
(10)
16.3 Weaning before six months
If parents decide that they wish to wean their baby earlier, they should be advised not to
wean before 17 weeks. Babies should still continue to receive breastmilk on demand or at
least 600mls infant formula. At this stage a number of foods need to be avoided due to the
risk of developing allergies.
F o o d s t o b e a v o i d e d b e fo r e s i x m o n t h s :
Gluten containing foods - e.g. wheat flour, bread, wheat containing breakfast cereals, rusks,
pasta.
Nuts and seeds - including peanut butter and other nut spreads.
Eggs.
Cow's milk - this also includes using milk to mix into foods.
Fish and shellfish.
Citrus fruits - including fruit juices.
Soft and unpastuerised cheeses.
Salt - including stock cubes.
Sugar.
Honey.
All feeding equipment needs to be sterilized for babies less than six months old.
Suitable first foods at this stage include baby rice, pureed potato, carrot, parsnip, turnip,
pureed banana, and unsweetened stewed fruit.
Start with a teaspoon of a suitable food mixed with breastmilk or infant formula to a thin
consistency. As the baby gets used to taking food from a spoon the variety of food can be
increased (taking into account the list above). Again, foods should be of a pureed
consistency and food should be thoroughly cooked.
Gradually increase the amount of food offered and the number of spoon feeds. The texture
and variety of food should also be increased. It is important to always ensure suitable iron
rich foods are included as this happens. The variety available to be offered is dependent
on the baby's age.
Pre-term Infants
Advising parents when to wean an infant born prematurely can present difficulties. Current
advice is to begin weaning around the equivalent age of 6 months post delivery. Breastmilk
or infant formula should be the only nourishment prior to this. However there will be
individual variation and when required, expert advice can be sought from the Paediatrician
who can make a referral to a Registered Paediatric Dietitian.
16.4 Summary of suitable foods and drinks
Milk
Breast, formula or follow-on milk should be continued until 1 year of age and longer if
considered necessary. Cow's milk products, such as custard and plain unsweetened
yoghurt, (whole milk varieties if possible) or whole cow's milk for mixing food may be
introduced after 6 months.
Egg s
Well-cooked eggs may be introduced from 6 months.
Fluids
Water should be boiled and cooled until the baby is 6 months old. Baby juices and herbal
drinks are not needed, but if given they should be used sparingly, and only at meal times
from a feeding cup to protect dental health.
• Colas, s q u a s h e s , f i z z y d r i n k s a n d “ d i e t ” d r i n k s are unsuitable for infants.

• Tea (with or without sugar) should not be given to infants as a main drink. The tannin
in tea binds with iron and other minerals and if sugar is added, it is a risk to dental
health.
• U n sw e e t e n e d o r a n g e o r o t h e r f r u i t j u i c e may sometimes be given to infants as a
source of vitamin C to assist iron absorption, particularly in the case of vegetarians.
This juice should be diluted to a level of 1:10, given from a cup at meal times and
never in a bottle at bedtime.
16.5 Comparison of home prepared with commercial baby foods
The majority of the infant's food should come from family meals. In general, home prepared
weaning foods have many advantages over commercial baby foods (see table below).
Health professionals should take the opportunity at antenatal and baby clinics to advise on
the adaptation of family food for weaning. Advice on the use of appropriate commercial
foods should also be given, e.g. more use of savoury meals and fruit purees rather than
puddings. “If parents are giving predominantly manufactured foods, it is important that the
home prepared foods should also be given to accustom the infant to the greater ranges of
flavour and texture that they provide.” (10)
C o m p a r i s o n o f h o m e p r e p a r e d a n d c o m m e rc i a l b a by fo o d s
H o m e p r e p a r e d fo o d s C o m m e rc i a l b a by fo o d s
• Cheap. • Expensive.
• More control over ingredients. • Fixed ingredients - may not be desirable

e.g. sugar, gluten.
• Infant becomes accustomed • Infants may reject family foods.

to family foods.
• May be produced in bulk and • Large contents of tin/jar may be

frozen in small amounts. wasted in early stages of weaning.
• Texture of food may be varied to • Hard lumps of “junior” or “stage 2” foods

suit various stages of weaning. may be rejected by infants.
• Unknown nutritional content • Known nutritional content. However parent

e.g. food may be overcooked. has no quality control over the process.
• Not always convenient • Convenient. Useful when away from

e.g. inadequate home cooking home, travelling, etc.
facilities, poor family diet, etc.
17 Nuts/Hard particles
The consumption of nuts, crisps or other hard particles should be discouraged in infants
and young children. These may be inhaled rather than swallowed and cause choking and
suffocation. Children under the age of 5 years should not be given whole nuts to eat.
18 Allergy or food intolerance
Where there is a family history of atopy disease or gluten enteropathy, mothers should be
advised to breastfeed for at least six months and weaning before 6 months should
particularly be discouraged. If parents choose to wean early, the introduction of foods
traditionally regarded as allergenic i.e. cow's milk protein, eggs, nuts, wheat and shellfish,
should be delayed until after six months at the earliest (see section 16.2 for details of how
to wean).
If infant formula is required, an amino acid or extensively hydrolysed formula may be

prescribed following medical advice, e.g. Pregestimil (Mead Johnson), Nutramigen (Mead
Johnston), Prejomin (Milupa), Pepti Junior (Cow & Gate) Pepti (Cow & Gate). Ordinary soya
drinks are inadequate in energy, vitamins and minerals for infant feeding (see 9.3 and 10.2).
Weaning foods most suitable for potentially allergic infants are milk free baby rice (mixed
with expressed breastmilk, appropriate formula or cooled boiled water), pureed fruit and
pureed vegetables.
As weaning progresses, one new food should be introduced weekly, and this food should
be given daily for that week to assess whether it has caused any side effects.
The most common allergens are: fresh cow's milk; egg; wheat; nuts; citrus fruits. These
should not be introduced in the diet until after 8 months of age. Vitamin supplements should
be given from the age of 1 to 5 years, particularly in those at risk of nutritional deficiency.
The range of foods given should be gradually increased until the child is having a full and
varied diet by the age of approximately 1 year.
In the case of an infant with suspected food allergy/intolerance, it is important that a firm
diagnosis is made. The public often attempt self-diagnosis and treatment of food allergic
disease when medical and dietetic advice is not available or forthcoming. The dietary
treatments undertaken may often be unnecessary and indeed potentially harmful. The use
of soya formula should not be recommended.
Withdrawal and reintroduction of the suspected food or foods should be shown to promote
the disappearance and re-appearance of symptoms. If an allergic reaction has been severe,
reintroduction of the foods, often called “challenge”, should be carried out under medical
supervision. Withdrawal of the food causing the problems may increase the sensitivity of the
individual to that food; therefore in the case of a child with acute anaphylactic type
reactions, challenge may be deferred for several years or indeed may not be carried out at
all.
If a child requires an exclusion diet it is vital that a Registered Dietitian gives the parents
specific advice in order to ensure adequate nutrition.
19 Cow's milk/lactose intolerance
True cow's milk/lactose intolerance is uncommon and is usually transient. If it is suspected,

a milk free diet should be prescribed by a medical practitioner and trialled for six weeks. At
weaning, dietary advice should be given by a Registered Dietitian. If symptoms of vomiting
and diarrhoea and/or eczema persist, further medical advice should be sought. These
infants should be referred to a community or hospital Paediatrician for further investigation.
20 Food additives
These are substances added to foods to improve their appearance, texture or keeping
qualities. Total removal of food additives is neither practicable nor achievable and indeed
some food additives improve the nutritional value of a food item. The consumption of excess
additives is not recommended and this can be achieved by using family foods and
unprocessed foods as often as possible and limiting confectionery, sweets and soft drinks
which contain a lot of additives.
A small number of children have been found to be intolerant to certain food additives. If food
additive intolerance is suspected it is essential that the diet of the child does not become
nutritionally inadequate due to over zealous and often unnecessary dietary restriction
imposed by parents or advisers. Such children should receive dietary advice from a
Registered Dietitian.
21 Inborn errors of metabolism
Children with inborn errors of metabolism such as Phenylketonuria and Galactosaemia will
require life long adherence to special diets. These children require specialised medical and
dietary advice and monitoring.
22 Vitamins and minerals

22.1 Vitamins A, D, and C
“Breastfed infants under six months of age do not need vitamin supplementation provided
the mother had an adequate vitamin status during pregnancy”. “From six months of age,
infants receiving breastmilk as their main drink should be given supplements of vitamins A
and D” (10). If there are doubts about the nutritional status of the mother during pregnancy,
vitamin supplements may be given to the baby from one month of age. The vitamin
supplements used should be sugar free.
“Bottle fed infants who are consuming 500ml infant formula or follow-on milk a day do not
need vitamin supplementation because these manufactured products are fortified with
vitamins” (10).
Vitamin A and D supplements should be given to a child from 1 year of age. These
supplements should be continued until 5 years of age unless the child's diet contains plenty
of vitamin A and D rich foods and the child has moderate exposure to sunlight. Infants and
children should not be placed in direct sunlight, where they would be at risk of sunburn.
Vitamin A and D supplements should be particularly encouraged until 5 years of age in

children from traditional Asian or Islamic communities, children born with poor stores of
vitamin D including pre-term babies and children who are poor eaters.
Vitamin drops are available, the recommended dose is 5 drops (0.14ml) per day.
This will supply:
Vitamin A 200 micrograms

C 20 micrograms
D 7 micrograms
22.2 Iron
Babies born at term have accumulated an iron store; pre-term babies do not have these
iron stores and are particularly vulnerable to deficiency during the first year. Breast or
formula milk supplies all a healthy term infant's nutritional needs for the first six months of
life. Thereafter iron intakes need to be increased to meet the increasing demands of the
growing infant. Iron deficiency is the most common nutritional disorder during early
childhood in the UK. Iron deficiency can cause apathy, reduced exercise capacity and poor
appetite. Iron deficiency anaemia in toddlers is also associated with psychomotor delay.
Pre v e n t i o n o f i ro n d e f i c i e n c y
After six months, the amount of iron from breastmilk or formula cannot meet increasing
needs; therefore adequate intakes of iron as well as other minerals must be provided from
other dietary sources.
• Dietary advice around the time of weaning is particularly important. Good sources of
iron include red meat, liver, cooked lentils and beans (pulses), green vegetables, iron
fortified cereals and egg.
• Foods containing haem iron e.g. red meat, liver and meat products should be
introduced by 6-8 months unless the infant is being weaned on a meat free diet.
• Adequate Vitamin C should be ensured with meals to assist iron absorption from
foods containing non-haem iron e.g. cereals, pulses and green vegetables. This is
particularly important if the diet is meat free.
• Foods which are poor sources of iron, such as cow's milk, should not be consumed
as main foods until a mixed diet is well established and likely to provide adequate
bioavailable iron from other sources. Breastmilk, infant formula or follow-on milk are
therefore recommended in preference to cow's milk as the main drink before 12
months of age.
• The absorption of iron from breastmilk is greater if breastfeeds are given separately
from solid foods.
• If there are concerns about the adequacy of iron in the child's diet after 12 months,
continued use of iron enriched infant formula or follow-on milk as a main drink should
be considered.
• Drinks, which are known to inhibit iron absorption such as tea and coffee, should be
avoided.
23 At Risk Groups
23.1 Low income
Low income families have less money to spend on food than more affluent families. The
Health Promotion Agency survey “Eating for Health?” (11), found that those from manual
groups and low income households were more likely to be confused about what healthy
eating is and say that healthy eating is too expensive. Those from low income households
tended to have the lowest intakes of fruit, vegetables, higher intakes of potatoes and white
bread and processed meat products than higher income homes. As a result the infants in
these families may also have inadequate nutrient intakes. These families should be strongly
encouraged to avail of free milk (or avail of the Healthy Start scheme when it becomes
available) and to use vitamin supplements for infants.
23.2 Vegetarian/Vegan diets
There are various categories of vegetarians, who exclude different foods. Lacto ovo
vegetarians do not eat meat but take milk and eggs. Ovo vegetarians will eat eggs but not
milk or meat. Vegans exclude all meat and animal derived products e.g. milk, eggs, honey.
23.2.1 Infant feeding for vegetarians
Breastfeeding should be recommended. If the parents choose not to breastfeed one of the
following formulae should be chosen:
F o r mu l a e s u i t a b l e fo r v e g e t a r i a n s
Milk based S oy a b a s e d *
SMA Gold and White except 250mls Farley's Soya Formula.
ready made cartons.
Milupa Organic range. Infasoy.
Isomil.
Prosobee.
Wysoy.
* See section 9.3

23.2.2 Weaning for vegetarians
Breastmilk or a suitable infant formula is recommended to be used for 2 years and up to

five years in vegan children. A cup should be introduced from six months. If a soya formula
is being used it is important to safeguard dental health owing to the sugar content. Care
should be taken to ensure that a nutritionally adequate diet is provided. Children being
weaned on to a vegan diet will require supplements of vitamin B12 and riboflavin. Where
there are doubts about the adequacy of intakes, the child should be referred to a Registered
Dietitian for dietary assessment and advice. Examples of suitable weaning foods are given
in the HPA leaflet “Weaning made Easy”.
23.3 Ethnic minority groups
Some religious or ethnic minority groups are at an increased risk of nutritional problems due
to cultural or religious beliefs.
Hindus and Sikhs generally exclude pork and all types of carnivorous animals and Jews
exclude pork, rabbit, shellfish and eels. Some groups tend to eat very hot or highly spiced
foods, which are not easily digested by infants. Chinese people tend to exclude dairy
produce.
Similarly to vegetarians/vegans, ethnic minority groups should be encouraged to breastfeed

their babies or if this is not possible, to use an appropriate recommended formula.
Some cultures traditionally add solids to bottle feeds, this practice should be strongly
discouraged for the reasons outlined earlier.
Weaning should be commenced at the normal time and not later than 8 months in order to
prevent faltering growth or anaemia. It is important to build on the traditions and customs of
the specific ethnic group.
Many savoury baby products contain meat, which has not been killed by the halal method
and these products are unacceptable to Muslims. Rice with the addition of family food items
should be encouraged rather than a dependence on manufactured puddings and desserts.
Vitamin supplements should be given until the age of 5 years. The ethnic minority groups
who dress modestly tend to have a greater incidence of rickets and the need for an
adequate intake of vitamin D and calcium is even greater. If not breastfeeding, infant
formula rather than cow's milk should be given until 1 year of age, since it is fortified with
vitamins and minerals.
There have been recent increases in the numbers of immigrants, many of whom either do
not speak English or it is not their first language. They may be on low incomes and face
particular difficulties feeding their babies. Special attention should be given to these families
to ensure that information is provided in a suitable format to enable them to feed their
babies safely.
23.4 Monitoring growth
The racial background of the child should be taken into consideration when using height
and weight centile charts for children from ethnic minority groups. Standard charts for
children in the UK do not take the totally different stature of some racial groups into
consideration. Parental height also influences growth potential and should be considered.
23.5 Acquired lactase deficiency
This is a condition, which occurs quite commonly in Asians and some Africans. After infancy
the level of lactase decreases and thus the ability to digest cow's milk or cow's milk products
lessens. The child may be able to tolerate up to 250mls of milk but quantities greater than
this will promote diarrhoea. In cases such as these symptoms will most commonly appear
in the 1-5 year group, a lactose tolerance test should be carried out and, if positive, low
lactose formula should be given instead of cow's milk.
24 Fluoride
When water supplies already contain fluoride at a concentration of 1 part per million (ppm)
then considerable life-long resistance to dental decay has been demonstrated. In the
absence of fluoride at this level a similar effect can be achieved by either:
• Adjusting the fluoride content of water supplies to the optimal level of 1ppm
(water fluoridation).
• Twice daily brushing with a fluoride toothpaste.
• Prescribing fluoride dietary supplements for individuals who are considered to
be at high risk of tooth decay.
At present there is no water fluoridation in Northern Ireland and all water supplies contain
fluoride below the level of 0.2ppm. Twice daily toothbrushing with a fluoride toothpaste is
currently considered to be the most effective alternative method of preventing tooth decay.
24.1 Dental health guidelines
• As soon as the first tooth erupts, brushing with a small, soft toothbrush and a
smear of fluoride toothpaste is recommended.
• Children under 7 years and considered at low risk of dental caries, or who are
already receiving fluoride supplements, can be advised to use a toothpaste with
no more than 600ppm of fluoride. Those considered to be at higher risk should
use a standard toothpaste (1,000 - 1,500ppm). A pea-sized amount of
toothpaste is recommended.
• After brushing, spit out excess toothpaste rather than rinsing, to gain maximum
effect from the fluoride.
• Toothbrushing should normally be supervised for children under 7 years.
“Fluoride dietary supplements may be considered for those for whom the consequences of
decay pose a hazard to general health or for whom dental treatment would be difficult
because of their medical or physical condition” (12). At risk categories include children with
heart disease, cardiac defects, systemic disorders and those with special needs. They also
include evidence of past caries activity, history of high caries in siblings, social deprivation
and dietary indicators such as the use of infant formula which contain high levels of
cariogenic sugars.
24.2 Fluoride supplement guidelines

• Advice on fluoride supplements should be given by dentists based on individual

need.
• Health visitors, pharmacists, doctors and other health professionals are
encouraged to advise parents of at-risk children to contact a dentist for advice.
• If fluoride supplements are being used, tooth brushing should take place at a
different time for maximum effectiveness and reduced risk of fluorosis.
• The British Society of Paediatric Dentistry (BSPD) guidelines on fluoride
supplement dosage, where the water has less than 0.3ppm of fluoride are as
follows (13):
F l u o r i d e s u p p l e m e n t s - r e c o m m e n d e d d o s ag e
A ge m g F l u o r i d e / d ay
6 months - 3 years 0.25
3 years - 6 years 0.5
6 years + 1.00
BSPD 1996
25 Paediatric medicines
In the past the majority of medicines were sweetened to make them more appealing to
children. The sugar in medicines may promote tooth decay. Many drug companies have now
replaced the sugar with non-cariogenic sweeteners.
Where available the use of sugar free medicine is desirable, therefore it is important to
check if a medicine contains sugar before prescribing or recommending its use. Liquid
formulations of medicine should be used whenever possible as many solid-dose forms are
not intended to be crushed. It may be inappropriate to add medicines to food because of
the effect of the food on the medicine. Cooled boiled water is a more suitable vehicle and
allows the medicine to be given on an empty stomach, where this is a requirement.
26 International Code on the Marketing of Breastmilk Substitutes (WHO

1981)
The aim of this code is to “contribute to the provision of safe and adequate nutrition for
infants, by the protection and promotion of breastfeeding, and by ensuring the proper use
of breastmilk substitutes, when these are necessary, on the basis of adequate information
and through appropriate marketing and distribution” (14). Those concerned with maternal
and infant nutrition should make themselves familiar with their responsibilities under this
code, particularly the information specified in Article 4.2. This states:
“Informational and educational materials, whether written, audio or visual, dealing with the
feeding of infants and intended to reach pregnant women and mothers of infants and young
children, should include clear information on all the following points:
1. The benefits and superiority of breastfeeding;

2. Maternal nutrition, and the preparation for and maintenance of breastfeeding;
3. The negative effect on breastfeeding of introducing partial bottle feeding;
4. The difficulty of reversing the decision not to breastfeed;
and
5. Where needed, the proper use of infant formula, whether manufactured
industrially or home prepared.
When such materials contain information about the use of infant formula, they should
include the social and financial implications of its use; the health hazards of unnecessary
or improper use of infant formula and other breastmilk substitutes. Such materials should
not use any pictures or text which may idealise the use of breastmilk substitutes.”
It is important that health professionals do not inadvertently promote and endorse formula
to mothers by carrying/using sponsored diaries, stationery, calendars and pens.
Appendix 1
Incidence, prevalence and duration of breastfeeding in the United Kingdom

1995 and 2000
A g e o f B a by E n g l a n d / Wales Scotland N Ireland United Kingdom

(%) (%) (%) (%)
1995 2000 1995 2000 1995 2000 1995 2000
Birth 68 71 55 63 45 54 66 69
1 week 58 57 46 50 35 37 56 55
2 weeks 54 54 44 47 32 34 53 52
6 weeks 44 43 36 40 25 26 42 42
4 months 28 29 24 30 12 14 27 28
(17 weeks)
6 months 22 22 19 24 8 10 21 21
(26 weeks)
8 months 16 17 14 18 6 7 15 16
(35 weeks)
9 months 14 14 13 15 5 7 14 13
(39 weeks)
S o u rc e : O.N.S. I n f a n t F e e d i n g S u r vey 1995 and 2000
As outlined above, the incidence, prevalence and the duration of breastfeeding in Northern
Ireland remain lower than in the other countries studied in the 2000 ONS survey.
Appendix 2
Breastfeeding rates at discharge from hospital - EHSSB residents (1993 and

2004) by Trust within which the mother lives
Tr u s t A r e a 1993 (%) 2004 (%)
Down and Lisburn Trust 29.8 41.9
North and West Belfast 15.8 23.6
South and East Belfast 38.6 48.9
Ulster Community and Hospitals Trust 35.1 45.5
S o u rc e : C h i l d H e a l t h S y s t e m s , EHSSB
For further information on breastfeeding in the EHSSB area see

www.publichealthmatters.com
References
Appendix 3
Comments and advice were gratefully received during the consultation on the draft revised
Infant Feeding Guidelines. The following contributions are gratefully acknowledged.
Thanks to:
Community Dietitians, North and West Belfast HSS Trust -

Miss Claire Alldritt
Mrs Alison Armstrong
Miss Kirsty Forsythe (nutrition student)
Miss Grainne McMacken
Mrs Ashleigh Macaskill
Mrs Wendy Nesbitt
Ms Liz Taylor
Dr Carol Beattie, Consultant in Public Health Medicine, EHSSB

Dr Angela Bell, Consultant Paediatrician, UCHT
Mrs Geraldine Bleakney, Head of Health Promotion Commissioning, EHSSB
Mrs Zoe Boreland, Acting Principle Midwife, Down and Lisburn HSS Trust
Dr Borghild Breistein, Clinical Director of Dental Services, North and West Belfast HSS
Trust
Mrs Janet Calvert, Regional Breastfeeding Co-ordinator, HPANI
Dr Carol Campbell, Community Paediatrician, Foyle HSS Trust
Mrs Carmel Duffy, Deputy Programme Director, UNICEF UK Baby Friendly Initiative
Ms Valerie Jackson, Director of Nursing, Primary Care & Quality, UCHT
Dr Martin Kerr, Community Pharmacy Development Pharmacist, EHSSB
Miss Arlene Long, Paediatric Dietitian, Ulster Hospital
Mr Will Maxwell, Director of Dental Services, EHSSB
Mrs Phil Morrow, Nurse Lecturer, QUB
Mrs Marion McAroe, Child Health Services Manager, South and East Belfast HSS Trust
Miss Christine McCabe, Paediatric Dietitian, RBHSC
Mrs Kim McCabe, Primary care Co-ordinator, North and West Belfast HSS Trust
Ms Helen McCarthy, Lecturer (Dietetics), University of Ulster
Mrs Jayne McClenaghan, Breastfeeding Co-ordinator, South and East Belfast HSS Trust
Mrs Ann McCrea, Health Visitor, Irvinestown Milk Bank
Ms Helen McIlroy, Breastfeeding Co-ordinator, Royal Jubilee Maternity Hospital
Dr Alan McMillan, Associate Specialist Child Health, North and West Belfast HSS Trust
Dr Helen McMillen, Senior Clinical Medical Officer, South and East Belfast HSS Trust
Mrs Justine Prosser, Chief Dietitian, Downe Hospital
Miss Patti Speedy, Senior Health Promotion Officer (Dental), EHSSB
Dr Moira Stewart, Consultant Paediatrician, North and West Belfast HSS Trust/Senior
Lecturer in Child Health, QUB
Mrs Lynda Vladeanu, Health Promoting Hospitals Co-ordinator, Down and Lisburn HSS
Trust
Mrs Deirdre Webb, Assistant Director of Nursing, EHSSB
Thanks to Miss Claire McClean for typing the document.

1. Eastern Health and Social Services Board (1996) Infant feeding Guidelines. Belfast:
Health Promotion Unit, Eastern Health and Social Services Board.
2. Office of National Statistics (2002) Infant Feeding Survey 2000. H.M. Stationery
Office.
3. World Health Organisation (2003) Global Strategy for Infant and Child Feeding.
www.wh.int/nut/documentss/gs_infant_feeding_text_eng.pdf
4. UNICEF UK Baby Friendly Initiative (2005) www.babyfriendly.org.uk
5. National Institute for Clinical Excellence (2005) Guidance on Postnatal Care: Routine
Postnatal Care of Women and their Babies (draft) National Collaborating Centre for
Primary Care.
6. World Health Organisation (1997) Hypoglycaemia of the Newborn - Review of the

Literature. www.who.int/reproductive-health/docs/hypoglycaemia_newborn.htm
7. Department of Health (2003) Infant Feeding Recommendations. London: Department

of Health.
8. European Food Safety Authority (2004) Opinion adopted by the BIOHAZ Panel related
to the microbiological risks in infant formulae and follow-on formulae. The EFSA
Journal 113, 1-34.
9. Paediatric Group of the British Dietetic Association (2004) Position Statement on the
Use of Soya Protein for Infants. British Dietetic Association.
10. Committee of Medical Aspects of Food Policy (1994) Weaning and the Weaning Diet.
Report on Health and Social Subjects No. 45. H.M. Stationery Office.
11. Health Promotion Agency for (2001) Eating for Health? Belfast: Health Promotion
Agency.
12. Levine RS & Stillman-Lowe CR (2004) The Scientific Basis of Oral Health. London:
BDJ Books.
13. Holt RD, Nunn JH, Rock WP & Page J (1996) British Society of Paediatric Dentistry:
A Policy Document on Fluoride Dietary Supplements and Fluoride Toothpastes for
Children. International Journal of Paediatric Dentistry 6, 139-142.
14. World Health Organisation (1981) International Code of Marketing of Breast-Milk

Substitutes. www.who.int/nut/documents/code_english.PDF
15. Department of Health and Social Services (Northern Ireland). HSS (MD) 12/98.
Useful Contacts and Addresses

Hospital Breastfeeding/Infant Feeding Advisors in EHSSB Area
Lagan Valley Maternity Unit, Lisburn.

Tel: 028 9266 5141
Mater Infirmorum Hospital

Tel: 028 9074 1211
Royal Jubilee Maternity Service

Tel: 028 9024 0503
Ulster Hospital, Dundonald

Tel: 028 9048 4511
La Leche League
Mrs Sarah McCann
Volunteer Breastfeeding Counsellor
La Leche League
29 Downshire Gardens
Carrickfergus
BT37 7LW
Tel: 028 93362387
www.lalecheleague.org
National Childbirth Trust

Mrs Catherine George
19 Farmley Crescent
Glengormely, Co. Antrim
Tel: 028 9058 7949
www.nctms.co.uk/res
NIMBA
Northern Ireland Mother and Baby Action

Breast Pump Loan Service
Hope House
54 Scotch Quarter
Carrickfergus, BT38 7DP
Tel: 028 9332 9933
www.nimba.org.uk
Regional Breastfeeding Strategy Coordinator

Mrs Janet Calvert
Health Promotion Agency for Northern Ireland
18 Ormeau Avenue
Belfast, BT2 8HS
Tel: 028 9031 1611
www.healthpromotionagency.org.uk
Royal College of Midwives

NI Board
58 Howard Street
Belfast, BT1 6PH
Tel: 028 9024 1531
www.rcm.org.uk
TAMBA
Twins and Multiple Births Association
216 Belmont Road
Belfast
Tel: 028 9023 9050
www.tamba.org.uk
Regional Milk Bank Coordinator

Mrs Ann McCrea
Unit 2 Mill Street
Irvinestown, Co Fermanagh
Tel: 028 6862 8333
Useful Resources
• Breastfeeding, if your baby needs special care (leaflet) - National Childbirth Trust.
• Breastfeeding Your Baby (leaflet) - UNICEF Baby Friendly Initiative.
• Collection and Storage of Breastmilk in the Neonatal Unit - UK Association of Milk
Banks.
• Eating While You Are Pregnant (leaflet) - Food Standards Agency.
• Feeding Your Baby (leaflet) - Health Promotion Agency.
• Good Food for Mums To Be (leaflet) - Eastern Area CRIS.
• Hales TW (2004) Medications and Mothers Milk. ISBN 0-9636219-8-X.
• How to express and store breastmilk (leaflet) - National Childbirth Trust.
• Nutrition and Dental Health Guidelines, EHSSB.
• Off to a Good Start (leaflet) - Health Promotion Agency.
• Preparing for Pregnancy - Healthy Living, Healthy Baby (leaflet) - Eastern Area CRIS.
• Renfrew, Fisher & Arms (1990) (book) Bestfeeding - Getting breastfeeding right for
you. ISBN 0-89087-571-5.
• Royal College of Midwives - Successful Breastfeeding. ISBN 0-89087-571-5.
Other Useful Websites
Breastfed Babies.org
www.breastfedbabies.org
Department of Health
www.dh.gov.uk
Public Health Matters

www.publichealthmatters.com
Scientific Advisory Committee on Nutrition

www.sacn.gov.uk
World Health Organisation

www.who.int/en
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02339 infant feeding guide 20/6/06 3:59 pm Page 1

EHSSB Infant Feeding Guidelines

2 Aim and Objectives

3 Diet in Pregnancy and Lactation

3.1 Preconceptual nutrition

A daily dose of 5 milligrams (5000 micrograms) of folic acid should be taken:

• by women with a history of a previous child with neural tube defect;

3.2 Diet in pregnancy

Pregnant women should be given information on the principles of healthy eating,

3.3 Diet in lactation

3.4 Medicines in pregnancy and lactation

4.1 Health benefits of breastfeeding

Benefits to the infant:

- Diseases of the respiratory system.

There is also increasing evidence of long-term protection against cardio-vascular disease.

Benefits to the mother:

- Enhanced post partum weight loss.

4.2 Anti-infective properties of breastmilk

4.3 Composition of breastmilk

a. Protein in breastmilk is rich in lactalbumin (whey) and low in casein (curd)

5.1 Antenatal education

Antenatal/Parentcraft classes should cover and discuss the following points:

5.2 Delivery period

Vitamin K is of importance in the prevention of Haemorrhagic Disease of the newborn.

Could vitamin K be harmful?

• A joint Medicines Control Agency, Committee of Safety of Medicines and Department

5.3 Postnatal period

• Baby turned towards the mother (“tummy to mummy”).

• Baby's chin touching breast and the nose is free.

5.4 Neonatal jaundice

Breastfeeding should be continued unless there is a medical contra-indication i.e. excess

5.5 Diabetes mellitus

6.1 Duration of feed

6.2 Baby-led feeding or demand feeding

6.3 Complementary feeds

6.4 Faltering growth

If an infant is displaying faltering growth, a history of breastfeeding should be taken. A

There are five major causes of faltering growth, these are:

6.5 Night feeding

Babies should be breastfed on demand throughout 24 hours. Prolactin levels (which

6.6 Special circumstances

6.7 Breastfeeding and returning to work

6.8 Pre-term babies

6.9 Allergies/food intolerance

6.10 Breastfeeding and HIV

Breastfeeding is a useful contraceptive method but is only effective while:

8.1 Frequency of feeds

8.2 Volume of feeds

8.6 Hazards of bottle feeding

The most recent advice is:

sterilised in boiling water).

8.6.2 Heating bottles in a microwave

8.6.3 Bottled water

8.6.4 Ready to feed preparations

9.1 First baby formulae

Examples of infant formulae available

Whey b a s e d Casein based

Cow and Gate Premium Cow and Gate Plus

Farley's First Milk Farley's Second Milk