Breastmilk is the optimum source of nutrition for babies under 1 year and mothers should be supported and encouraged wherever possible to breastfeed or give expressed breastmilk. However, despite relatively high levels of breastfeeding initiation, rates of exclusive breastfeeding in the UK decline significantly from 6 weeks postbirth, with less than 1% of babies exclusively breastfed at 6 months. It is essential that midwives are able to give clear, supportive evidence-based advice to those parents who make the decision to give their baby formula milk.
Most infant formulas are derived from cows’ milk that has been dehydrated and treated to make it suitable for very young infants. This is usually then fortified with a variety of vitamins, minerals and other ingredients in an attempt to mimic the constituents of breastmilk. A small percentage of babies may be allergic to the proteins in cows’-milk formula and may require soya-based milk available on prescription. Some formulas are made with goats’ milk but these should not be given to babies with cows’-milk allergy.
Under the terms of the WHO International Code of Marketing of Breastmilk Substitutes, advertising and promotion of formula milk is strictly controlled.
Parents should be reassured that, except in cases of diagnosed cows’-milk-protein allergy, all first infant formulas will be suitable for babies under 6 months old and there is no evidence to support the suggestion that any one brand is ‘better’ than another. Furthermore, there is no evidence to suggest that after the age of 6 months babies require those milks marketed as ‘follow-on’ or ‘growing-up’ milks. Parents should be advised that there is no need to move on from first infant formulas until the age of 1, when ordinary cows’ milk may be introduced.
Sterilisation of all equipment is essential and parents should be taught how to sterilise bottles and prepare feeds, even when using readymade formula (Figure 44.1; Boxes 44.1 and 44.2). Busy and tired parents may be tempted to make up an entire day’s formula feeds at one time, storing them in the fridge to heat up as needed. However, this significantly increases the risk of bacteria breeding in the milk and so they should be advised to make up each individual feed as required.
Babies should be kept sitting as upright as possible for a bottle feed. Their body and head should be in line to enable easy sucking and swallowing, and their head should be well supported. Babies should never be left ‘propped up’ on a pillow or similar to feed, as this increases the chance of choking. To avoid the baby taking in air whilst feeding, the bottle should always be held at an angle that ensures the teat is full of milk. The baby may not wish to take the same amount of milk each time, or may be slower or faster to feed at different times; this is normal and parents are encouraged to be responsive to their baby’s individual needs at every feed. Babies should never be forced to finish a bottle, and leftover milk should be discarded straight after the feed. Formula-fed infants may need breaks during feeds and may require gentle ‘winding’ during or after the feed.
Evidence is clear that a strong maternal–infant bond in the first days and weeks of life can help to promote secure emotional attachment and brain development in the infant. This evidence has often been based on observations of breastfeeding mothers; however, parents who have chosen to formula feed should also be encouraged to regard feeds as an opportunity to develop this close attachment with their baby and learn to respond to their needs. Skin-to-skin contact whilst bottlefeeding should be promoted as a way to keep babies warm, secure and to help develop a loving connection through the increase in oxytocin levels in both mother and baby (Figure 44.2). Equally, parents should be encouraged to maintain eye contact whilst giving formula, stroking, cuddling and talking to their babies as they feed. The UNICEF Baby Friendly Initiative suggests that parents try to give the majority of feeds themselves in order to increase this connection during these important early months.
- Feeds should be made up as required and not stored.
- Ensure that all equipment is correctly sterilised.
- Wash hands and work surfaces with hot soapy water.
- Boil fresh tap water in a clean kettle and allow to cool slightly (not more than 30 minutes cooling time). Do not use water that has already been boiled.
- Bottled, mineral or artificially softened water should not be used as it may contain levels of minerals that are unsuitable for an infant.
- Always follow the manufacturer’s instructions when making up feeds to ensure the correct amount of water and powder for the age of the baby.
- Fill the bottle with the appropriate amount of slightly cooled boiled water.
- Add the required amount of formula as per manufacturer’s instructions. Always level off the amount of formula in the powder scoop to avoid overfilling the scoop.
- Never add extra formula powder, sugar, cereals etc. to the feed.
- Replace the teat and cover and gently shake the bottle to ensure the powder is fully mixed with the water.
- Do not touch the teat.
- Ensure the feed is at an appropriate temperature. Cool the feed down by running under the cold tap if necessary. Never heat up a feed in a microwave as this can cause ‘hot spots’, scalding and burns.
- Test the temperature of the feed before giving to the baby. The easiest way is by dropping a little on the inside of the wrist. It should feel warm, not hot or cold.
- Discard any unused milk after feeding.