The right formula

baby drinking from bottle

Motherhood is a minefield of conflicting advice. As such, pharmacists play a key support role, particularly when it comes to infant feeding

The World Health Organisation (WHO) recommends mothers worldwide to exclusively breastfeed infants for the child’s first six months to achieve optimal growth, development and health. After which time, babies should be given nutritious complementary foods and continue breastfeeding up to the age of two years or beyond.

However, the ‘Australian National Breastfeeding Strategy: 2018 and Beyond’ states, ‘While the majority of Australian women intend to breastfeed their baby and 96 per cent initiate breastfeeding after birth, only a small proportion (15–25%) continue exclusive breast-feeding to around six months.

There are many reasons why a mother might choose to formula feed; and this may be done alone or in combination with breastfeeding.

Ultimately, a mother’s informed decision not to breastfeed, or not to exclusively breastfeed, should be respected and supported by healthcare professionals.

After all, there are a number of barriers to breastfeeding including:

  • poor family and social support;
  • embarrassment about feeding in public;
  • lactation problems; and
  • returning to work.

Choosing an appropriate formula

If a mother chooses to feed her child formula, it’s important to offer support and advice for the optimum health of the baby.

All infant formulas available in Australia are regulated by the Australia New Zealand Food Standards Code and contain adequate nutrients for infants. However, there are several different types of infant formulas—from cow’s milk and hydrolysed varieties to soy-based and lactose-free formulas. Not to mention anti-regurgitation and gold formulas.

With so many types and brands of formulas available, selecting a suitable infant formula can be confusing for parents and caregivers. Pharmacists and their staff play an essential role in helping people understand their choices.

Terry White Chemists pharmacist Chris Campbell says, “Making sure quality advice is available on baby formula is important. We have a huge role in ensuring parents have access to the right care, whatever their circumstances.

“We find a lot of men enter the pharmacy with some trepidation and, in many cases, with limited knowledge around infant feeding. They have often been sent off by mum with very clear instructions—‘find the best formula at the pharmacy’. Choice, without informed advice, can be overwhelming,” Mr Campbell says.

In the study ‘Infant formula feeding practices and the role of advice and support’, Jessica Appleton and her team of researchers discovered that choice of formula was mostly based on parents’ assessment of its suitability for their infant.

However, a variety of factors influenced the initial choice of formula including:

  • made in Australia;
  • labelled organic;
  • previous experience;
  • availability of the brand; and
  • advice from fellow parents and healthcare professionals.

While some parents also considered the information on the nutritional panel and the ingredients list, others were a little baffled by this information.

According to Mater Mothers’ Hospital, key factors when choosing an appropriate baby formula include:

  • cow’s milk-based formula is suitable for the first 12 months;
  • specialist formulas such as soy-based should only be used on the advice of a medical practitioner;
  • only infant formula suitable from birth should be used for babies;
  • follow-on formula is not suitable for infants under six-months of age; and
  • changing to cow’s milk is appropriate at 12-months of age.

Specialist infant formula
According to infant feeding guidelines, cow’s milk-based formula is suitable for most healthy full-term infants and is recommended over formulas made from soybeans, goat’s milk or modified lactose formula.

Honor Penprase, managing partner at Capital Chemist Wanniassa, ACT, advises, “For the majority of babies, a cow’s milk formula will be appropriate. Goat-milk formula is not suitable for babies who have an allergy to cow’s milk formula, because the proteins in both are very similar.”

She adds, “soy formulas are not recommended for babies under six months. Additionally, if a baby has a cow’s milk intolerance soy may not be suitable because approximately six in 10 babies who are sensitive to cow’s milk are also sensitive to soy.”

In some instances of infants with nutritional deficiencies or intolerances, specialist formulas can be used on the advice of a doctor.

Possible alternatives might include hypo-allergenic formulas, hydrolysed formulas where the protein has been thoroughly broken down, and lactose-free formulas.

Pharmacists and their staff can add great value to the area of specialist infant formula. For those mothers who are unable to breastfeed because their baby is lactose intolerant, for example, finding the right formula can be a tiring and stressful process.

Advising parents and caregivers on the different specialist formulas and the alternatives to cow’s milk is a vital service that is not only highly valuable to parents, but also sets the pharmacy apart from the supermarket.

baby formula in tin

Preparing and storing infant formula
The majority of parents surveyed by Appleton said they prepared the bottle of formula according to the instructions on the tin, including using the enclosed scoop to measure out the correct amount of formula.

However, if the wrong powder-to-water ratio is used, this can cause illness or lead to deficiencies. Advising parents on preparing and storing infant formula correctly can help reduce the risk of illness and help support the health of the child.

Key steps in preparing infant formula include:

Thoroughly washing hands with soap and warm water and cleaning work surfaces prior to preparing formula.

Using boiling water. In addition Mater recommends that the safest way of making formula is one bottle at a time, in the bottle. This reduces the potential for contamination and the possibility of error when counting scoops of formula.

Never, for any reason, adding any more scoops of formula than specified on the tin, unless specifically instructed by a qualified healthcare practitioner. Also, never dilute formula by adding more water than specified.

Pouring the required amount of prepared water into a clean feeding bottle. Note: The WHO states that the water should be no cooler than 70 degrees celsius, so it should not be left for more than 30-minutes after boiling.

Always using the scoop provided in the tin of formula and adding the exact amount of formula to the water in the bottle (not the other way around).

Returning the dry scoop back to the tin after use. Do not wash as this may introduce inadvertent moisture collection contamination if not adequately dried.

Mixing the formula thoroughly by shaking the bottle.

Cooling the bottle to a suitable feeding temperature by running the bottle under cold water or putting it in a container of cold or iced water.

Checking the temperature of the formula by dispensing a drop onto the inside of the wrist.

Finally, ensuring any formula that has not been consumed within two hours after preparation is thrown away.

Formula feeding—support and advice
According to Appleton et al, when it comes to how much and how often to feed, there are a number of factors that influence parents’ decision. The amount of formula given to the child may depend on routine, the baby’s cues, for example cries of hunger, or based solely on the advice on the formula tin, which specifies volume and frequency of feeds depending on the child’s weight.

Yet Appleton’s study revealed that parents also adopt other external sources of advice on how much and how often to feed their baby. ‘Informal’ sources of advice included other mothers, the internet, family and friends. While midwives, maternal and child health nurses, doctors, paediatricians and pharmacists were considered by parents to be ‘formal’ sources of advice.

Many parents in the study said they would have liked to receive more advice from health professionals, which includes pharmacists.

A common question raised was whether it was okay for the infant to drink less than the recommended amount on the formula tin. According to information provided by Mater, there are several variations in the amount of formula and the number of bottles consumed by individual babies over a 24-hour period. As such, information provided on formula tins is a guide only and does not necessarily suit every baby.

‘Plenty of wet nappies, consistent (but not excessive) weight gain and a thriving, active baby indicate that all is well.’

One of the study participants said, “It would have been very helpful to have professionals have some sort of information on hand when they find out that you are formula feeding, to make sure that you are making it up correctly, giving the right amount and what types of formula are out there that are beneficial.”

The study highlighted how important it is for health professionals to provide a positive experience when being asked about infant feeding, including using formula.

Being sympathetic to individual situations and supporting mothers in their choice is paramount to building trust and encouraging more mums to be proactive in seeking professional advice and support.

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