Tag Archives: infant formulas

February 2015 (just)

Have just uploaded February 2015 newsletter – with 4.5 hours of February to go….

NICE on gastro-oesophageal reflux disease, how to recognise speech delay, more viral exanthems, resus cards and information on forthcoming allergy courses.  Do leave comments below:

Sick and tired – the truth about infantile reflux

Sick and tired – the truth about infantile reflux

By Dr Tom Waterfield

We have all had that difficult conversation regarding “reflux” when a tired parent has come to us with their “sicky child” and an unshakeable belief that their baby has gastro-oesophageal reflux disease. There is often enormous pressure to provide a solution but how do we decide which children need treatment and what treatments should we use? In view of the recent concerns regarding the use of Domperidone I have chosen to review the current evidence base for the management of this common problem.


The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) produced a useful guideline document in 20091. This concise 50 page document discusses the evidence base for all aspects of gastro-oesophageal reflux and some of the key points are outlined below.



1)      Physiological Gastro-oesophageal reflux (GER) is common; around 50% of healthy infants will display symptoms of GER. These “happy spitters” will be gaining weight and healthy1.

2)      Faltering growth is unlikely to be due to GERD and alternate diagnosis such as cow’s milk protein allergy should be considered1.


1)      The Gold-Standard investigation to make a positive diagnosis of GERD is an impedance study. This has largely replaced the pH study. In this study the changes in the electrical impedance (ie, resistance) between multiple electrodes located along an oesophageal catheter are used to measure reflux. Unlike a pH study the impedance study will also be able to detect non-acidic reflux1.


2)      In the majority of cases there will be no role for any other diagnostic test for GERD1


1)      Reassurance

Try to avoid treating simple GER. Reassurance is often all that is required. Before starting any treatment have a frank discussion regarding the risks and benefits1.


2)      Positioning “Tummy Time”

There is evidence that lying prone improves GERD when compared with lying supine or semi-erect. It is however, not recommended that children sleep prone due to the associated risk of sudden infantile death (SIDS). A sensible compromise might involve allowing the child to lie prone when awake and supervised by the parent. Semi-supine positions (such as sitting in a car seat) are not recommended and may exacerbate reflux symptoms1.


3)      Thickened Feeds

Commercially available thickened feeds (anti-reflux feeds) are safe and relatively effective at reducing visible regurgitation1.


4)      Buffering agents and Alginates

There is very little evidence to support the use of alginates (e.g. Gaviscon Infant) in the treatment of GERD although their use is likely to be safe1.


5)      H2RAs and PPIs (Unlicensed treatments)

Antacid treatment with Histamine 2 Receptor Antagonsists (HR2As) is effective at healing proven oesophagitis in adults but there is very little data to support their use in infancy. H2RAs such as Ranitidine are relatively safe but their effectiveness is unproven and there are high rates of tachyphylaxis thereby limiting their usefulness in the long term1.


Proton Pump Inhibitors (PPIs) such as Lansoprazole and Omeprazole do not demonstrate tachyphylaxis and can be used for longer term acid suppression. Despite this however, randomised placebo controlled studies have failed to demonstrate a benefit of (PPIs) over placebo when treating GERD in infants1.


Some studies have suggested that long term acid suppression with PPIs and H2RAs can lead to increased rates of pneumonia and gastroenteritis1.


6)      Prokinetics (unlicensed)

ESPGHAN and NASPGHAN advise against the use of all prokinetic agents including Erythromycin and Domperidone. There is no reliable evidence to support their effectiveness at treating GERD in infants and there have been concerns raised over the potentially cardiotoxic effects of Domperidone2.



Reflux is very common with half of infants having some symptoms. In the majority of cases reassurance is all that is required. If symptoms are severe and persistent and an alternate diagnosis is unlikely then consider thickened feeds and “tummy time” as a first line treatment. If this is unsuccessful then consider antacids but be aware that the evidence base for these treatments is limited and they are being used off license. Prokinetics play no part in managing GERD in infants and Domperidone use may be cardiotoxic2.



1)      Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition(NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN)Journal of Pediatric Gastroenterology and Nutrition. 49:498–547 # 2009

2)      Domperidone: limited benefits with significant risk for sudden cardiac death. Hondeghem LM.J CardiovascPharmacol. 2013 Mar;61(3):218-25.


Feeding disorders

Fussy eating is one of the most common things that parents present with to both primary and secondary care.  My colleague, Ann Duthie, has kindly allowed me to paraphrase a recent talk she gave to the department on this subject.  I hope you find the structure as sensible, helpful and reassuring as we did.

FEEDING DISORDERS IN CHILDREN encompass the behaviour of those who have difficulty consuming adequate nutrition by mouth (impaired feeding), those who eat too much and those who eat the wrong thing (pica).  We have not covered here eating disorders such as anorexia or bulimia.

Common presentations include:

  • Dysphagia
  • Food refusal
  • Self feeding inadequacy
  • Excessive meal duration
  • Choking, gagging, vomiting
  • Inappropriate mealtime behaviours
  • Food selectivity by type and texture


Normal feeding development is as follows:

  • Up to 6 mths – breast/bottle fed milk
  • 6-12 mths – solids introduced and increased in variety & volume.  Milk intake begins to decrease.
  • At 1 yr – teeth; family diet; ½ pt milk/day; change in attitude to food; active and wt gain slows
  • 15 mths – hold spoon, messy feeding, use feeding cup

The child moves from a state of total dependency on parents for food to one in which he/she can exert control & independence to determine what is
eaten, when and how.  Some parents struggle to adapt to this:

  • Messy
  • Feeding cues can be missed
  • Parental fear that insufficient food will be taken, child will lose weight
  • Parents own food preferences
  • Rejection of a food and assumption that child will never like it
  • Time pressures

The health professional must look for an organic cause of food refusal:

Organ system GI disorder Mechanism
Mouth Carious teeth
Structural with oral
Reluctance to swallow
Pharynx Tonsils
Pain, obstruction
Choke, gag
Oesophagus Reflux oesophagitis
Cows milk allergy
Pain, burning
Stomach Motility disorder Reduced appetite,
Colon Constipation Pain, discomfort, reduced

Children with neurodevelopmental problems or autism may have additional factors affecting their feeding behaviours.

There are 5 key elements to the assessment:

  • How is the problem manifested?
  • Is the child suffering from any disease?
  • Have child’s growth & development been affected?
  • What is the emotional climate like during mealtimes?
  • Are there any great stress factors in the family?


Red flags to look out for include:

  • Swallowing difficulty with cough, choke or gag
  • Vomiting/abdominal pain/arching/grimacing/eye watering
  • Recurrent chest infections
  • Stridor on feeding
  • Snoring with sleep apnoeas
  • Constipation

The history is, as always in medicine, of paramount importance and needs to be fairly detailed:

  • Birth History
  • Previous illness (inc. h/o vomiting, respiratory symptoms) & hospitalisations
  • Developmental progress
  • Chronology of feeding problem
    – Diet since birth
  • – Changes of milk formulae
    – Introduction of solids
  • Current diet (typical day)
  • What happens at meal times?
  • Family & Social history

Height and weight must be measured and plotted on an age appropriate growth chart and corrected for prematurity if less than 2 years of age.  Refer children with red flags or significant faltering growth to secondary services.

  • Management of the well child in primary care:
  • Reduce milk intake if necessary (maximum of 500mls total in 24 hours)
  • Encourage family foods
  • Meal time management (see NHS Lothian’s dietetic advice)
  • Aim: Improve infants comfort at meal times, relieve parental fears and improve parent-infant relationship


The multidisciplinary approach:

  • Health Visitor – can assess child within home situation
  • Dietician
  • – Nutritional assessment and feeding advice
  • – Calorie enrichment
  • – Calorie supplementation
  • – Enteral feeds (very occasionally)
  • Speech & Language therapist
  • – Direct assessment of feeding & advice in home situation
  • – Parent-child interaction
  • – Is swallow safe?
  • – Toddler feeding groups (eg. Waltham Forest’s “Ooey Gooey” group at Wood Street)

Summary points:

  • Feeding disorders in children are common
  • Occur in healthy children but assessment should be made for organic causes
  • – GI tract problems
  • – Developmental delay
  • – Autistic spectrum disorder
  • Watch out for obligate milk drinkers
  • Meal time management is crucial
  • Involve Health Visitor


Further resources:

Weaning your premature baby.  Free download from Leicestershire Dietetic Service 2011

Help! My child won’t eat and My child still won’t eat.  British Dietetic Association.  Available to buy in packs from http://www.ndr-uk.org/

My Child Won’t Eat by C Gonzalez                    – these are both books and the links are to www.amazon.co.uk

New Toddler Taming by C Green

Vitamin D guidance at last!

Take a look at this not-definitive-but-nevertheless-sensible guideline on Vitamin D deficiency in both adults and children which Barts and the London published in January 2011:  http://www.icms.qmul.ac.uk/chs/Docs/42772.pdf.  Please note that it is NOT a national guideline and the authors acknowledge that more research is needed in this area and that variations in practice are common, even across London.

The Paediatric Pearls newsletters are checked every month by my consultant colleagues.  We have been keen to put something together for GPs on vitamin D for a few months now but are struggling with the lack of evidence and consensus in this area.  Some of the comments I have received back from my colleagues concerning this guideline include:

  • A cut off of 80nmol/l is too high as the lower limit of normal.  Most hospitals (including Whipps) use 50nmol/l because symptoms do not tend to be evident until that level.
  • The paediatric clinical guideline currently in use at the Royal London Hospital is not quite the same as their Clinical Effectiveness Guideline in that it advocates lower doses of vitamin D therapy (than the BNFc) for a longer period of time.  The advantage of this is that no monitoring of calcium levels is required.
  • Liquid ergo or colecalciferol are difficult to get hold of nationally and some patients find it hard to find a community pharmacist who will supply it.  There is a shortage of it at the moment and it is expensive.  It would make practical sense therefore to just treat the deficient ones (<25nmol/l) rather than the asymptomatic insufficient patients (25 to 50nmol/l).  This is in practice what the majority of us do, ensuring that the insufficient (and even sometimes the asymptomatic deficient group) ones get vitamin supplementation (400IU/day).
  • “Symptomatic” includes general aches and pains and does not just refer to hypocalcaemic tetany or rickets. 
  • Healthy Start vitamins are available again now and are a better long term option than Abidec or Dalivit as they are free to young mothers and their children and to people on benefits, see http://www.healthystart.nhs.uk/.  They should be available at all health centres at low cost (if the family does not qualify for healthy start vouchers) to all breastfeeding babies and then for the over ones when they have moved on to cows’ milk.
  • We all agree that children with rickets and bone deformities secondary to vitamin D deficiency should be seen in secondary care as they require a greater degree of monitoring, especially their calcium levels, when first started on high doses of colecalciferol.  There is also a risk of cardiomyopathy in this group.
  • The Clinical Effectiveness Guideline from the Barts and the London group states that 90% of South Asian people in their region (mainly Tower Hamlets in east London) are vitamin D deficient.  We don’t yet seem to have found an answer as to why there are not even more cases of rickets or hypocalcaemic tetany in that region then. 

I suspect, as usual, the answer to the vitamin D conundrum is not quite as straight forward as this guideline makes out.  Do leave comments below.

This is the 2011 Barts Health Vitamin D guidance, with thanks to pharmacist Nanna Christiansen for allowing me to upload it to this site.  Please note that the doses here are not the same as the BNFc.  There is a wide range of doses which you can prescribe for Vitamin D deficiency and insufficiency and no national agreement on what constitutes either deficiency or insufficiency.

Faltering growth

I am teaching our local GPVTS trainees this week on faltering growth, food allergy and coeliac disease.  As usual, I have learnt more from preparing their presentation than they are going to learn in the hour it will take me to present it!  I have found a great GP training website set up by a GP in the north of the UK with similar altruistic aims to me.  Have a look at what he has to say on faltering growth at http://www.gp-training.net/training/tutorials/clinical/paediatrics/pgrowth2.htm

I have put together an algorithm for managing cows’ milk protein allergy and a table on various different infant formulas which you are welcome to download or comment on.

I used to work in Poole Hospital, Dorset and was pleased to find this patient information leaflet from the dieticians there on tips for families where a child is refusing to eat: http://www.poole.nhs.uk/documents/leaflets/nutrition/My%20Child%20Wont%20Eat.pdf.  It is based on the leaflet “Help, my child won’t eat” which is put together by the Paediatric Group of the British Dietetic Association but not obviously available on-line.