Parents frequently present to their GP with their infant under one, who may have a number of issues related to feeding. Common issues that present in general practice include questions about whether breastfeeding is successful, whether weight gain is adequate, is crying or vomiting normal, managing constipation and how parents can ensure a balanced diet in their strong-willed toddler. This article is an attempt to explore these issues in some detail and to debunk a few myths along the way.

Overview

Healthy eating for infants and toddlers means eating a combination of age-appropriate foods that provide sufficient energy and nutrients to allow for growth and development and which also help to optimise health and reduce the risk of disease. Exclusive breastfeeding for six months is the feeding option of choice for early infancy as it ensures protection against bacterial and viral infection in addition to its nutritional superiority. Sadly, fewer than 50% of Irish mothers initiate breastfeeding and a much smaller number continue exclusive breastfeeding for six months. 

Infant formulae are based on modified cow’s milk. Breast milk or infant-based formula should be the main milk drink for the first year of life and unmodified cow’s milk should not be used as the main milk drink before the age of one year. All specialised formula should only be used under medical supervision. Infant formula is either whey dominant or casein dominant. Whey dominant formula is designed to reflect the composition of breast milk and casein dominant formula is similar to cow’s milk. Weaning the infant onto solids is not necessary before six months.  

Breastfeeding

Breastfeeding is matched to the specific nutritional requirements of the growing infant and provides protection against infection. The colostrum is the milk produced in the first five days and it contains large amounts of protein, IgA, immunoglobulins and lysozyme and provides immunity within minutes of birth. The composition of breast milk is variable from mother to mother, time of the day and the length of time post-partum. Breast milk consists of whey proteins in a 60:40 ratio, fat and essential fatty acids and carbohydrate mainly in the form of lactose. 

Breastfeeding is a learned skill and the establishment of successful breastfeeding cannot be assumed to occur easily for all women. Ideally, breastfeeding education should start in the antenatal period. Practical assistance is essential following birth in order to ensure the baby is feeding well prior to discharge home. Correct attachment and positioning are fundamental to breastfeeding success. What a mother learns in hospital about breastfeeding, and the quality of that experience, will affect her breastfeeding skills for a long time and will strongly influence how she feeds her future children. 

Initially colostrum is produced. Colostrum is thick and viscous and the infant ingests 4-14ml at each feed. Milk yield increases gradually over the first 36 hours and this is followed by a dramatic increase during the next 48-96 hours. Milk production will be initiated whether or not breastfeeding takes place. However, breastfeeding and milk removal are essential components for the continuation of lactation. 

The optimal time to initiate breastfeeding is in the period immediately following delivery. The infant’s sucking reflex is at its most intense within the first two hours after birth. Correct positioning skills will minimise problems such as sore and cracked nipples, breast engorgement and mastitis. 

Mild degrees of breast engorgement in the mother can be managed by ensuring that the infant feeds both effectively and frequently to aid breast emptying. Incorrect attachment of the infant to the breast and nipple may lead to cracked nipples and mastitis. If the degree of nipple trauma or breast tenderness makes breastfeeding too painful, milk should be expressed by hand or breast pump.

Prior to discharge home, mothers should be advised to feed their babies frequently, to keep their infant on the first breast until a feed is completed, not to time feeds and to avoid the use of dummies and supplemental formula feeds. No specific intervention is required for bilateral inverted or retractile nipples. Mothers should be told to seek help if their infant is producing scant urine, is lethargic or extremely fretful, if no swallowing is felt or heard, or if there is extreme nipple soreness or breast engorgement that persists after the first week. 

Where there is more than the usual weight loss (ie. over 8% of birth weight), the infant should be carefully evaluated and may require review by a paediatrician. One may supplement with expressed breast milk ideally or formula milk (rarely). Assessment of urea and electrolytes is essential as the most serious consequence of inadequate intake is hypernatraemic dehydration which although rare is potentially life-threatening. Significantly, the infant may not appear dehydrated as normal skin turgor is maintained.

Enthusiastic support and monitoring of breastfeeding mothers is essential to promote continuation of breast-feeding following discharge from hospital. Indicators that breastfeeding is progressing well include:

• Adequate weight gain with a return to birth weight by 10-14 days of age and thereafter 170-200g per week weight gain during the first three months of life
• More than five wet nappies per day
• Infant latches on well with entire nipple and almost all of the areola covered by the infant’s mouth 
• Milk is seen in the infant’s mouth with brief pauses in the sucking and swallowing motion being observed and heard. 

Formula feeding

Infants who are not breastfed should be fed infant formula for the first year of life. Brands are generally divided into whey or casein dominant. There are different types of infant formula. The first group are whey dominant formulae, which contain whey casein ratio 60:40. These milks include Aptamil First Milk, Cow & Gate First Infant Milk, and SMA First Milk. 

Another type of infant formula available are known as second milks, these have a whey to casein ratio of 20:80 reflecting more the protein composition in full cream cow’s milk. These milks are marketed as being for the hungrier baby as casein is more difficult to digest creating a larger curd in the stomach and hence are not recommended for babies less than six weeks. They are seen as being more satisfying. These include Aptamil Hungry Milk, Cow & Gate Infant Milk for Hungrier Babies and SMA Extra Hungry. 

The third milk group available is follow-on milks. These are made from modified cows’ milk and contain extra iron, minerals and vitamins. These are for the older baby over six months of age. They include Aptamil Follow On milk, Cow & Gate Follow-on Milk and SMA Follow-on Milk. These milks are designed to discourage mothers from feeding unmodified cows’ milk to infants under the age of one. If the baby is content there is no reason why they should change from a first milk to a second milk. Frequent changes form one brand of formula milk to another is strongly discouraged as it carries a real possibility of error in preparation and is of questionable usefulness.

After the first few days, formula-fed infants take up to 100ml per kilo per day (1 fluid ounce = 30ml) and may later settle on 100-120ml per kilo per day. Fruit drinks should not be given in lieu of milk feeds or at bedtime. Tea, mineral, water or fizzy drinks are not suitable drinks for infants. If you choose to give your baby a drink between meals, cooled boiled water is preferred to sweetened drinks, tea, etc. 

Breast or formula milk should remain the main milk of choice for the first 12 months of life as cow’s milk is very low in iron. Cup drinking should be introduced from after 6-7 months of age and the limiting of bottlefeeds should be commenced at this stage.

Specialised formulas

Specialised formulas are available for different conditions. Cow & Gate Nutriprem One and Two are reserved for preterm babies and have a higher caloric value. Nutriprem One contains 80kcal per 100ml and Nutriprem Two contains 74kcal per 100ml and a higher protein and fat content than formula feeds for term infants. High-energy formulas are available and provide almost 1kcal per ml. SMA High Energy providing 0.91kcal per ml is used in cases of failure to thrive where catch-up growth is desirable.  

Other formulas available include Enfamil AR and SMA Staydown. These are thickened feeds, which may be used if gastro-oesophageal reflux is present. These formulas are of normal consistency when constituted but thicken on contact with the stomach acid. Infants with suspected cow’s milk protein allergy or other malabsorption syndromes may use formulae containing predigested proteins or medium chain fats. These include Nutramigen, Cow & Gate Pepti-Junior and Aptamil Pepti 1 and 2. Other formulae include Enfamil O-Lac and SMA LF, which can be used in cases of lactose intolerance. Cow and Gate Comfort and Aptamil Comfort can be used from birth to one year to reduce colic, constipation and posseting

Weaning to solids

Weaning to solid foods should commence from six months of age. Recommended first foods include gluten-free cereals such as baby rice, mashed potato, pureed fruit with little or no added sugar and pureed vegetables. Pureed meat can be added later on, once weaning is established.

First feeds should be pureed and be of a soft runny consistency, without lumps. Foods should be introduced one at a time, leaving a few days between the additions of each new food. One should use expressed breast milk, infant formula or cooled, boiled water to mix the foods.

Honey carries a small risk of botulism and is not recommended until after one year. Peanut butter may be included after six months of age unless there is a family history of nut allergy or severe atopic disease. 

By 7-8 months, a meal pattern of three meals in a 24-hour period should be achieved. A milk drink or milk dessert could be included after this. Breastfeeds, bottles of milk and drinks from cups should also be included. At this stage, infants can begin chewing soft lumps and then progress to mashed and chopped food. By 11-12 months, the infant will have progressed to eating the family meals . 

Gastro-oesophageal reflux

Gastro-oesophageal reflux (GOR) occurs in up to 50% of normal healthy infants and involves the passage of gastric contents into the oesophagus, with or without regurgitation and vomiting. It is a normal physiological process that occurs several times a day. Most reflux episodes last less than three minutes and occur in the period following feeds. GOR affects breastfed and formula-fed infants equally. 

GOR gradually decreases with age so that by 12-15 months of age, only 5% of infants regurgitate. A small number of infants have gastro-oesophageal reflux disease (GORD) with significant oesophagitis and symptoms of forceful vomits, poor weight gain, inconsolable crying, back arching and feed refusal. Useful growth charts can be found at www.rcpch.ac.uk and are available on www.healthforallchildren.co.uk

Guidance for managing GOR in primary care

• Keep the baby upright for at least 30 minutes after a feed
• Raise head of the cot to a 30 degree angle
• Avoid use of car seats immediately after feeding
• Avoid clothing or nappies that are tight around the abdomen
• Check volume of feeds and avoid over-feeding
• Feed thickening with carob bean gum and maltodextrin (Cow & Gate Instant Carobel) – one scoop per 150ml and allow to stand for 3-4 minutes after adding 
• Pre-thickened feeds (Enfamil AR or SMA Staydown) thicken on contact with stomach acid. Prepare using previously boiled water that has been chilled and vigorously roll bottle between hands.
• Antacids such as Gaviscon contain sodium and magnesium alginate and form a surface gel over the milk – Gaviscon should not be used with feed thickeners or pre-thickened formulae. Trial of Gaviscon best reserved for breastfed infants
• Use of H2 receptor antagonists such as ranitidine only if unresponsive to simple measures as above
• Barium swallow is not recommended for GOR.

The website www.livingwithreflux.org includes very helpful parent leaflets that can be downloaded. 

Excessive crying in early infancy

While it is often difficult to determine when an infant should be considered to have colic, the most widely used definition is that proposed by Wessel and colleagues. This is known as the ‘rule of threes’. An infant should be considered to have colic if he/she cries for more than three hours per day for more than three days per week for three weeks. However, this definition has its limitations in that the actual duration of crying may be difficult to quantify and very few parents are prepared to wait three weeks until an official announcement proclaiming that their infant has colic is made.

It is important to note that most cases of colic cannot be accounted for by pre-existing maternal personality characteristics, postnatal depression or non-optimal caregiving.  Because of inexperience, first-time mothers may bring their crying infants to medical attention more often, but there is no difference in the amount of crying in first-born and subsequent infants. 

Thus most cases of colic are unlikely to be due to problems in either the mother or infant. Differences in caregiving (such as the amount of contact, the frequency and type of feeding) may modify both the duration and pattern of crying.

Which treatable conditions may underlie excessive infant crying?

Infection

Always enquire about a history of recent fever as the presence of fever in an under three-month old may indicate the possibility of a serious bacterial infection (urinary tract infection, septicaemia or meningitis). 

Feeding issues 

There is an important link between feeding problems and excessive crying. Refusal to feed and excessive crying are not related to gastro-oesophageal reflux (GOR). Difficulties with breastfeeding (such as problems of attachment or positioning) may put susceptible infants at risk of increased crying and aversive feeding behaviours. Functional lactose overload occurs when breastfeeds do not contain enough fat, resulting in rapid milk transit through the intestine. Undigested lactose ferments in the colon with resulting explosive or frothy stools, excessive crying and a desire to feed very often.

Cow’s milk protein allergy (CMP)

Some infants with excessive crying have CMP allergy. Pointers towards CMP allergy as a cause of excessive crying include those infants with ‘high-pitched’ crying, infants who regularly arch their backs during crying bouts and when the crying pattern does not fit a pattern of evening clustering. A late onset of increased crying in the third month of life or following a switch from breast to formula milk may implicate CMP allergy. 

Managing colic in primary care

As a family doctor, the starting point in managing colic is to take the problem seriously and to ensure that feeding is adequate and appropriate for the infant. A detailed examination of the infant is important. 

Most breastfed infants in the first few weeks to months of life need 8-12 feeds a day with at least one breastfeed between midnight and 6am. Babies may seek cluster feeds whereby they take to the breast every 30-60 minutes for a period, most commonly in the evening. It is advisable for mothers of crying infants to respond in a relaxed manner to pre-cry cues with an offer of a breastfeed, before the baby becomes even more distressed and difficult to soothe. This is an exhausting schedule for even the most committed mother! Cue-based care from birth, combined with an average of 10 hours of physical contact (whether awake, feeding or sleeping) in a 24-hour period is associated with 50% less crying in early infancy 

Spend time reassuring and explaining the problem to parents and do not be afraid to advise admission to hospital if necessary to alleviate a very stressful situation at home.

There is a group of infants with colic that are classified as ‘Wessel’s plus’ and these infants fulfil Wessel’s criteria for colic but in addition have other cues that cause concern. These infants tend to display clenched fists, flexed legs, back arching, distended abdomens, regurgitation with crying and a pained face when crying. In this Wessel’s plus group (especially if there is associated diarrhoea and/or vomiting), a trial of elimination of cow’s milk protein (either from the mother’s diet if breastfeeding, or from the infant’s diet by changing to a CMP-free formula (Aptamil Pepti or Nutramigen) may be indicated.

10-step guide for managing colic in primary care

Crying and fussing do reduce significantly after three months of age and this relates to the maturing central nervous system of the infant and coincides with a changing role for the cry signal – from expressive crying to communicative crying. Therefore, the most important aspect of the management of colic is to reduce psychological pressure on the caregivers, especially the mother. This is best achieved by using the following principles:

• Acknowledge the reality of the parents’ concern, regardless of the amount of crying 
• Take a thorough history (including perinatal and feeding history) and perform a thorough physical examination of the infant
• Encourage parents to experiment with relaxed cue-based care, sleeping in the same room as the infant, with increased physical contact (including skin-to-skin contact).

Dietary management

Ensure correct breastfeeding technique (if breastfed), trial of probiotics (Lactobacillus reuteri) for 10 days and then a trial of maternal dairy-free diet for two weeks. If formula-fed, ensure correct feeding technique and winding. If parents are at their wits end, implement a trial of extensively hydrolysed formula for two weeks.  

It is helpful to assess the supports for the mother and to see that these support persons (eg. grandparents) are also educated about the best way to perceive and handle crying.

• Ask the mother to keep a diary of crying
• Ask your practice nurse or public health nurse to support the family and regularly weigh the infant
• Arrange for regular ‘respite’ periods for the mother, if possible
• Safe swaddling and infant massage may help for some mothers and babies

In severe cases, especially if the increased crying is occurring in the context of a fragile or otherwise challenged family, refer for a paediatric opinion and perhaps consider admission to take the heat out of the situation.

Studies point to excessive crying being a condition of in the first three months in normal infants. All young infants display crying which peaks at 4-6 weeks of age. As doctors we should firstly never ignore or downplay parental concern regarding colic and the infant with excessive crying should be regularly monitored. Drug therapy is ineffective and dietary changes are rarely indicated.

Resources for parents

• www.purplecrying.info – Informs parents about infant crying. Advice is given in both text and video
• www.zerothree.org – Includes an interactive baby map, a podcast about infant crying and a number of relevant articles pertaining to excessive crying 
• www.mothersmatter.co.nz – Provides information for families about post-natal depression, managing infant crying and coping with negative feelings towards the new arrival.

Constipation in infancy

Stool frequency and consistency varies enormously in early infancy. For breastfed infants, stools are often runny, mustard to orange in colour with white flecks and occur after every feed. Formula-fed infants have stools that are passed one to three times per day to once every two to three days. These stools are grayish-green in colour depending on the type of formula used. 

Constipated stools are firm, dry or pellet-like in consistency and cause significant distress to the infant. The main causes of constipation in infancy are inadequate fluid intake (most common by far), incorrect feed preparation, frequent formula changes and cow’s milk protein allergy (rarely).

Advice for management of simple constipation

• Ensure adequate formula intake 
• Offer 30-60ml of cooled boiled water once or twice per day between feeds
• From two months of age, offer 30-60ml of dilute apple or pear juice (15ml juice and 45ml water) twice a day
• If no response, start 5-10ml of lactulose daily if constipation is severe and fails to respond to dietary measures
• Avoid use of suppositories if possible.