Chapter 44

Principles of infant nutrition

Formula feeding

Learning outcomes

Having read this chapter, the reader should be able to:

• discuss the principles of correct powdered formula milk preparation and the dangers of incorrect preparation

• discuss in detail the advice and education that new parents need when choosing to formula feed

• summarize the role and responsibilities of the midwife.

When a baby is not being breastfed, the midwife has an important role in facilitating safe and effective infant nutrition using formula milk. This chapter considers the significance of correct powdered infant formula reconstitution both within and outside of the home, appropriate feeding technique and the midwife’s role and responsibilities. This chapter needs to be read in conjunction with Chapter 41 (breastfeeding) and Chapter 43 (sterilization/decontamination of feeding equipment).

Formula feeding

Time has passed since the World Health Organization (WHO 2007) gave new guidance regarding the safe preparation of powdered infant formula at home. Nevertheless, the UK 2010 Infant Feeding Survey (McAndrew et al 2012) suggested that only 49% of mothers in England using formula milk had prepared it correctly during that week. While this is an improvement, this still leaves a large number of babies receiving an inaccurately prepared formula feed. It is a requirement in Baby Friendly Accredited Care (UNICEF UK 2014a) that women who are using formula milk should be shown how to correctly prepare a feed postnatally before transfer home. All parents of new babies need to understand effective sterilization/decontamination of feeding equipment (Chapter 43). Redmond & Griffith (2009) state that for various reasons, the domestic kitchen is not a good place for safe food preparation and therefore healthcare practitioners should take seriously their role in educating parents in these matters.

What are the risks?

The digestive tract of newborn infants varies in its pH according to feeding method. The formula-fed infant has a more alkaline intestine and therefore has less protection against harmful microorganisms. The Department of Health are clear in their guidelines (DH 2012) that formula milk powder itself may contain microorganisms; consequently care should be taken in its reconstitution, the formula-fed baby being at a greater infection risk to begin with. Minchin (2000) and Inch (2013) both suggest that the production and manufacture of artificial milk has many unanswered questions – its composition, the role of genetically modified ingredients, the potential hazards in manufacture (and to the environment (Inch 2013)), to name but a few. Marchant & Rundall (2008) would agree, adding their concerns over misleading advertising claims as well. The health benefits to mothers and babies of breastfeeding are well documented, while the long-term consequences of a formula-fed population are not yet fully realized, but can be anticipated to show poorer health outcomes. Parents may also not appreciate the dangers of choking, overfeeding, or poor feeding technique, alongside feed preparation inside and outside of their home environment.

Formula milks

Powdered infant formula milks suitable for newborn babies are modified cow’s milk and are either whey or casein dominant. There are variations in the constituents of the milk according to manufacturers; some are suggested for vegetarians, for example. Parents can find guidance about formula milks from UNICEF UK (2010). However, it is clear (Crawley & Westland 2013) that, for whichever milk is chosen, it must be an age-suitable formula. Equally, where (often because of probiotic additives) the manufacturers suggest preparation at a lower water temperature, this advice should be disregarded (DH 2013). Powdered infant formula milk should be prepared with water at 70°C (or higher, but not boiling). Each packet of formula milk powder is supplied with a plastic scoop that is suitable for use with that packet only.

Equipment required

The following equipment is suggested:

• handwashing and drying facilities, clean towel where possible

• infant feeding bottles with tops, covers and teats (BPA free (Anon. 2011)). Wide-necked bottles are often easier to clean. The scale on the side should be clearly visible. Standard flow teats are acceptable (drip rate of 1 drop per second). The woman may make different choices later, according to her baby’s needs

• sterilizing equipment (Chapter 43)

• bottle and teat brushes (non-metallic), hot water and washing-up liquid

• plastic spatula or leveller if not integral in milk packet

• a safe water supply with kettle or means of boiling water, 1 L of water at least (Crawley & Westland 2013)

• age-appropriate powdered infant formula, within ‘use by’ guidance

• equipment for use out of the home, e.g. flask and container for milk powder, (possibly a cool bag, depending on the situation).

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