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

Oxford Handbook of Midwifery (151 page)

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Submerge the equipment, ensuring that no air bubbles are trapped in the bottles or teats.
Keep all the equipment under the water, using the plunger provided or a plate.
Leave in the solution for a minimum of 30min.
Discard the solution and make up fresh every 24h.
Use cooled, boiled water if you wish to rinse the equipment prior to use.
Sterilization using a steam or microwave sterilizer
Follow the manufacturer’s instructions.
Sterilizing in a microwave without a microwave sterilizer is not advisable.
Preparing a formula feed
The correct preparation of infant formula feeds is important to prevent such conditions as dehydration, constipation, and gastroenteritis. The Food Standards Agency and the DH
¹have produced new guidelines on the safe preparation of infant formulas to reduce the risk of gastroen- teritis. Powdered infant formula is not a sterile product and may contain bacterial contaminants.
Enterobacter sakazakii
and
Salmonella
are those of greatest concern. Both NICE and UNICEF UK recommend that all mothers who are artificially feeding their infants should be shown the correct method of preparing a formula feed prior to discharge from hospital.
^2,3
Methods of making up formula feeds
Scoop method
Individual feed sachets
Ready-to-feed cartons.
Scoop method
A fresh bottle should be made up for each feed. This is because bacteria multiply quickly at room temperature and may survive and
multiply slowly in some fridges, therefore storing formula milk can
increase the risk of gastroenteritis.
The feed should be made up with water of around 70°C as this will destroy most bacterial contaminants. This means boiling the kettle and leaving it to cool for no longer than 30min. Do
not
use bottled or artificially softened water.
Read the tin or pack to find out how much water and formula you require.
Clean a surface on which to prepare the feed. Wash your hands thoroughly with soap and water, and dry on a clean towel.
All equipment used for making up the feed must have been freshly sterilized.
If using a sterilizer, remove the lid, turn upside down and place the teat(s) and cap(s) in it. If using a chemical (cold water) sterilizer rinse with cool, boiled water (not tap water) if wished.
Remove the bottle rinse with cooled, boiled water (if wished) and stand on a clean, flat surface. Pour cool boiled water which should
CHAPTER 25
Artificial feeding
722
still be hot into the bottle, up to the required mark. This is better if undertaken at eye-level.
- Measure the exact amount of formula using the scoop provided. Level the formula in the scoop using the knife or spatula provided.
- Do
  not
  compress or compact the formula in the scoop.
- Add the formula to the water in the bottle
  never
  the other way round. In the UK all baby formulas use one scoop to 1oz (30mL) of water.
- Do
  not
  add anything else to the feed unless medically prescribed.
- Apply the top or teat and cover. Shake the bottle well until all the formula is dissolved.
- Cool the feed down to required temperature by holding the bottle with the cap in place, under cold running water.
- Check the temperature of the formula prior to feeding the baby, by dripping a little on to the inside of your wrist; it should be lukewarm but not hot.
- Discard any formula that has not been used within 2h, clean and re-sterilize the bottle.
  When it is not practical to make up feeds just before feeding
  It is best to make up feeds individually as required but this may not always be practical. Ready to use formula is the safest option but this is more expensive.
  Feeding the baby away from home
  It is safest to carry a measured amount of formula powder in a small, clean, dry container, a flask of hot water that has been boiled and an empty sterilized feeding bottle. The feed is then made up fresh as required. The water should still be hot when used and therefore the bottle will need to be cooled before giving to the baby.
  Making-up and transporting feeds for later use
  If the above advice is difficult to follow, e.g. if preparing and transporting feeds either to a nursery or child minder the following steps should be adopted.
  •
  Prepare feeds individually, not in one large container.
- Make the feeds up the day they are required not the night before. This
  reduces storage time therefore reduces the risk.
- Once prepared store at the back of a fridge at below 5°C.
- Ensure the feed has been in the fridge for at least 1h before transporting.
- Store for the minimum of time.
- Remove from the fridge just before leaving home and transport in a cool bag with ice packs.
- Use within 4h. If arriving at the destination in <4h, remove from the cool bag and store in the back of a fridge below 5°C.
- Never store reconstituted feeds for more than 24h.
- Re-warm before use.
  Re-warming stored feeds
- Only remove the feed from the fridge just before it is needed.
- Re-warm using a bottle-warmer, or placing in a container of warm water.
  MANAGEMENT OF ARTIFICIAL FEEDING
  723
Never
use a microwave to re-warm a feed.
Never
warm for more than 15min.
Shake the bottle to ensure even heating of the feed.
Check the temperature before feeding the baby.
Principles of artificial feeding
Feed the baby when he or she is hungry.
Let him or her take as little or as much as desired.
Ideally, the minimum of caregivers should feed the baby and he or she should not be passed from person to person for feeding.
Never
feed babies by ‘bottle propping’ and
never
leave them unattended when feeding from a bottle.
Make up feeds individually as required.
Test the temperature of the feed on the inside of your wrist before offering it to the baby.
Feeding times should be enjoyable and relaxed.
Hold the baby securely, and close to your body, in a similar position to that used in breastfeeding.
Maintain eye contact.
Ensure that the teat covers the baby’s tongue, and tip the bottle up sufficiently so that air is excluded from the teat.
The baby will suck and pause while retaining the teat in their mouth.
During the feed, when necessary, sit the baby in an upright position so he or she can bring up wind; this may be once or twice.
It is normal for babies to regurgitate small amounts (posseting).
If the baby is sucking but the feed does not appear to be reducing, check the teat for blockages.
The baby will stop feeding when he or she has had enough.
If the baby is draining the full amount offered, the amount should be increased.
Any feed left at the end of the feed should be discarded and should
never
be reheated.
1. Food Standards Agency/Department of Health (2007).
  Guidance for Health Professionals on Safe Preparation, Storage and Handling of Powered Infant Formula
  . London; FSA.
2. National Institute for Health and Clinical Excellence (2008).
  Improving the Nutrition of Pregnant and Breastfeeding Mothers in Low-income Households
  . London: NICE.
3. UNICEF (1998).
  Implementing the Ten Steps to Successful Breastfeeding
  . London: UNICEF.
  CHAPTER 25
  Artificial feeding
  724‌‌
  Problems associated with formula feeding
  Constipation
  It is the consistency, not the frequency, of bowel movements that should be considered when discussing constipation. Babies may go several days without a bowel movement, but if the stools are soft and yellow, then no treatment is required. Constipation results from reabsorption of water from the stools and stools present as hard, round pellets.
  Management
  - Check that the condition is constipation and not just infrequent stools.
  - Ensure that the feeds are being prepared correctly, i.e. the water is being placed in the bottle prior to the formula, the powder in the scoop is not being compressed, and extra scoopfuls are not being added.
  - Offer the baby cooled, boiled water between feeds. There should be
    no
    additives to the water, e.g. brown sugar or orange juice.
  - Try an alternative make of formula; not all formulas suit all babies.
  - If the above strategies do not work, seek a medical opinion.
    Posseting
    It is normal for a baby to regurgitate a small amount of milk following a feed. Reassure the mother that it is normal and take no action unless it becomes persistent or projectile vomiting, in which case medical aid should be sought immediately.
    This page intentionally left blank
    CHAPTER 25
    Artificial feeding
    726‌‌
    Disadvantages associated with formula feeding
    The following disadvantages for the formula-fed infant have been identified.
    ¹Formula milk is deficient in:
  - Some nutrient compounds (e.g. epidermal growth factors)
  - Cells (e.g. leucocytes, macrophages) which are important in protecting the infant from a wide variety of pathogens
  - Antibodies, antibacterial, and antiviral factors (e.g. lgA, IgG, IgM, lactoferrin)
  - Hormones (e.g. prolactin, thyroid hormones)
  - Enzymes (e.g. mammary amylase, milk lipase, lysozyme)
  - Prostaglandins.
    These deficiencies are important to the infant’s immunological and hor- monal responses, as well as neonatal development and cell maturation.
    The formula-fed infant may be further compromised by:
  - The presence of cow’s milk or soya proteins
  - Possibility of errors during manufacture, including incorrect manufacture, bacterial contamination, foreign bodies, etc.
    ²
  - Addition of new ingredients on an uncertain scientific basis
  - Frequent errors in the preparation of feeds, which alter their concentration
    ³
  - Variability of the mineral and trace element content in the water used to reconstitute feeds.
    Formulas may be contaminated with bacteria and/or pathogens:
  - During manufacture
  - While preparing feeds at home with unclean utensils and/or contaminated water.
Examples of specific types of formulas
This is not a comprehensive list of all Infant formulas. There may be other specific types of formulas that have not been included as brand names change frequently due to constant research and re-branding by formula companies.
Examples of whey- and casein-dominant formulas (Table 25.1)
Table 25.1
Examples of whey- and casein-dominant formulas
Whey-dominant formula Casein-dominant formula
(60% whey, 40% casein) (80% casein, 20% whey)
Aptamil First
^®Aptamil Extra Hungry
^®
Cow and Gate First Milk
^®Cow and Gate for Hungrier Babies
^®Heinz Nurture Newborn
^®Heinz Nurture Hungry baby
^®
SMA First Infant Milk: Stage 1
^®SMA Extra Hungry
^®
HIPP Organic First Infant Milk
^®HIPP Organic Second Infant Milk
^®
DISADVANTAGES ASSOCIATED WITH FORMULA FEEDING
727
Examples of soya infant formulas