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Authors: Janet Medforth,Sue Battersby,Maggie Evans,Beverley Marsh,Angela Walker

Oxford Handbook of Midwifery (149 page)

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No advertising or promotion of these products in hospital, shops, or to the general public.
No free samples of breast milk substitutes to be given to mothers or members of their families.
No free gifts relating to the products within the scope of the code to be given to the mothers.
No promotion of products in healthcare facilities.
No gifts or personal samples to be given to health workers, nor any free or subsidized supplies to hospitals or maternity wards.
No words or pictures idealizing bottle feeding, including pictures of infants on product labels.
All information on infant feeding, including product labels, should explain the benefits of breastfeeding and the costs and hazards associated with bottle feeding.
Information provided by manufacturers to health care workers should include only scientific and factual material, and should not create or imply that bottle feeding is equivalent or superior to breastfeeding.
Unsuitable products (i.e. sweetened condensed milk) should not be promoted for babies.
All products should be of a high quality and should take into account the climate and storage conditions of the country where they are to be used.
Healthcare workers should encourage and protect the practice of breastfeeding.
1. Inch S (2009). Infant Feeding. In: Fraser DM, Cooper MA (eds).
  Myles: Textbook for Midwives.
  Chapter 41. Edinburgh: Churchill Livingstone.
2. World Health Organization (1981).
  International Code of Marketing Breast Milk Substitutes
  . Geneva: WHO
3. UNICEF UK Baby Friendly Initiative (2008).
  Three-day Course in Breastfeeding Management: Participant’s Handbook
  . London: UNICEF.
  CHAPTER 25
  Artificial feeding
  712‌‌
  Selecting an appropriate substitute
  All artificial milks are highly processed, factory-produced products. Under UK law it is an offence to sell any infant formula as being suitable from birth unless it conforms to the compositional and other criteria set out in the Infant Formula and Follow-on Formula Regulations 1995.
  - Health professionals must not recommend one brand of formula over another.
  - There is no scientific basis for recommending one brand over another.
  - There is no reason for a mother to remain with one brand.
  - All common baby milks suitable for home use are supplied in dried powder form so they can be stored and transported without risk of deterioration.
  - Many manufacturers also supply individual feed sachets and ready-to- feed cartons. These are handy to use but tend to be more expensive.
  - The DH recommends that soya formula should only be used for babies who are intolerant of cow’s milk or lactose, and only with medical guidance.
  - For babies and infants who are intolerant of standard formulas, alternative formulas, such as hydrolysate and amino-acid-based formulas, are medically prescribed.
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    CHAPTER 25
    Artificial feeding
    714‌‌
    Types of formula milks
    Whey and casein are proteins found in milk. Formulas are modified to vary the ratio of these proteins. There are two main types, whey-dominant and casein-dominant formulas.
    Whey-dominant formulas
  - Whey is the dominant protein in human milk.
  - Whey-based formulas have been modified so that the whey:casein ratio (60:40) is closer to that of human milk.
  - These formulas are more easily digested, which affects gastric emptying times and leads to feeding patterns similar to those of breastfed babies.
  - These formulas are suitable for use from birth to 1 year.
    Casein-dominant formulas
  - Casein is the dominant protein in cow’s milk.
  - Casein-dominant formulas have been modified so that the whey:casein ratio is 20:80 and is nearer to the type found in cow’s milk.
  - These formulas are not comparable to breast milk.
  - Such feeds form large, relatively indigestible curds in the stomach, which are intended to make the infant feel full for longer. However, there is little evidence to support this.
    ¹
  - They are advertised for the hungrier bottle-fed baby and can be used from birth to 1 year.
  - There may be an even greater metabolic demand on the infant when these formulas are given.
    ²
  - Babies who are settled and gaining weight on whey-dominant formulas will not need casein-dominant formulas.
    Additional ingredients
    Whey- and casein-dominant formulas may also have additional ingredi- ents, for example long-chain fatty acids (LCPs), nucleotides, B-carotene, and selenium. The ingredients and their sources vary from one brand to another.
    LCPs
  - Occur naturally in breast milk.
  - Aid brain, eye, and, CNS development.
  - Are added to formulas in the form of fish oils or egg yolk.
    Research into both the long- and short-term effects of adding LCPs to formulas is continuing.
    ß-carotene
  - Occurs naturally in breast milk.
  - Can be metabolized by the baby to produce vitamin A.
    Nucleotides
  - Nucleotides are present in breast milk.
  - Assist with development of the baby’s immune system.
  - Aid adsorption of other nutrients from breast milk.
    Selenium
  - An antioxidant found in breast milk.
TYPES OF FORMULA MILKS
715
Specially modified formula
Several formula manufactures have recently introduced specially modi- fied formulas which they claim aids digestion and helps reduce some of the common problems associated with formula feeding, e.g. constipation, colic. These products are available over the counter but their efficacy needs further research.
Follow-on milks
These milks are made from slightly modified cow’s milk and they have added vitamin D and iron.
They are
not
to be given to infants <6 months old.
^3,4
The large amounts of iron may make some babies constipated.
Full-fat cow’s milk has low levels of iron and vitamin D and should
not
be used as a main drink for an infant under 1 year of age. However, it can be used for preparing baby weaning foods from 4–6 months of age.
If an infant tolerates a well-balanced and varied diet, full-fat cow’s milk can be used from the age of 1 year.
Good night milks
‘Good night milks’ have added starch and rice flakes, and are represented as helping to settle babies at bedtime and are promoted for use as a bedtime liquid feed from a bottle or feeding cup.
The Scientific Advisory Committee on Nutrition
⁵has identified no scientific evidence that demonstrates ‘good night’ milk products offer any advantage over the use of currently available infant formulas.
Concern expressed that their promotion will encourage parents to believe that it is desirable for a baby to sleep longer at an age when healthy infants show considerable variation in normal sleeping patterns.
There is a potential risk that mothers may consider the product suitable for ‘settling’ their infant more than once a day and use these products on occasions additional to bedtime.
An even greater concern is that they may be used to ‘settle’ infants <6 months. Such unintended use would be contrary to advice that gluten-
containing products should not be given to infants <6 months of age.
⁵
Thickened formulas