Breastfeeding is the preferred form of infant nutrition. Formula is associated with:
- Higher infant mortality (6–10 times)
- Increased incidence and severity of diarrhoea, pneumonia, otitis media, Hib, meningitis, atopy, type 1 diabetes, leukaemia, and obesity in adulthood.
Even partial breastfeeding is better than exclusive formula feeding. For example, the risk of diarrhoea is 25x higher in formula-fed infants but only 8.4x higher in partially breastfed infants.
WHO guidelines therefore recommend exclusive breastfeeding for the first 6 months with no other fluids, even water (though they may have medicines and vitamin supplements). Breastmilk is nutritionally adequate and safe until 6 months, when complementary feeds should start. Even after starting solids, women should be encouraged to continue breastfeeding until 2 years.
What’s in breastmilk?
- About 3.5 g fat per 100 mL, with increased fat in the hindmilk. It has the long chain polyunsaturated fatty acids docosahexaenoic acid (DHA) and arachidonic acid (ARA).
- Carbohydrate, as 7 g lactose per 100 mL
- Protein,0.9 g per 100 mL. The casein in breastmilk is easily digested and the whey is alphalactalbumin.
- Vitamins and minerals. It is important to ensure that the mother is not deficient, especially in iodine, and infants still need exposure to sunlight for vitamin D. The iron levels will be fine for the first 6 months if the mother’s levels are adequate. Zinc levels fall after 4–5 months.
- components that promote immunity including: secretory IgA; oligosaccharides that promote bifidobacteria and lactobacilli (probiotic bacteria), which in turn inhibit the binding of bacterial / viral pathogens to gut epithelial cells; the proteins lactoferrin and lactadherin; lysozyme; and leukocytes including neutrophils, monocytes, and CD8 T lymphocytes.
Formula, on the other hand,
- Is not sterile
- Carries a risk of infection if not prepared appropriately
- Has good nutrient quality is but cannot replicate the anti-infective qualities of breastmilk.
Breastmilk is not enough if there is:
- Poor weight gain
- Excessive irritability
- Explosive, bloody stools
- Maternal illness
- Maternal psychosocial issues that interfere with feeding.
If formula is needed, the choice will depend on a number of factors, including the full history of breastfeeding, the problems and concerns, any family history of allergies or atopy, and previous formulas used.
The current available standard infant formulas are:
- Stage 1
- Stage 2
- Probiotics (Nan)
- Prebiotics (Aptamil)
- Gold – long chain fatty acids (omega 3/6)
- Colic (Novalac)
- Overnight / hungry baby (Novalac, SMA)
- Organic (Bellamy’s)
Source: Dr Annemarie Christie, Healthed Annual Women’s and Children’s Health Update, Adelaide
Practice tip: How safe are your passwords?
Strong passwords are essential – but what characterises a “strong” password?
Ideally, choose a minimum of nine alpha numeric characters, with no sequential numbers or letters. It should include capitals and lower case letters and at least one symbol (eg jB3dwK*9s).
This would take a super computer decades to crack.
Nevertheless, due to the threats of keyloggers and social engineering attacks, you should change your password EVERY month.
Source: Detective Superintendent Brian Hay, Healthed Annual Women’s Health Update, Melbourne 2013
Clinical tip: Ins and outs of denosumab
Denosumab is a fully human monoclonal antibody that binds to RANKL (receptor activator of nuclear factor-kB ligand) – RANKL binds to RANK and stimulates osteoclast differentiation, activation, and survival.
- Blocks the interaction of RANKL with RANK and therefore inhibits bone resorption
- Decreases the risk of vertebral fracture by 70% in postmenopausal women
- Is not contraindicated in chronic kidney disease (the adverse event profile is similar to placebo)
- Is fully reversible, so that no inhibition is present 6 months after administration.
However, it requires close compliance.
Denosumab is administered subcutaneously 60 mg every 6 months.
Source: Dr Neil Hearnden, Healthed Annual Women’s Health Update, Melbourne 2013
Clinical tip: Causes Of Androgen Deficiency
The cause of androgen insufficiency can be divided into:
- Normal aging – symptomatic pre/postmenopausal women with low bioavailable testosterone
- Ovarian insufficiency – uni/bilateral oophorectomy, premature menopause, chemotherapy or radiotherapy
- Adrenal insufficiency – adrenal failure/surgery
- Iatrogenic: exogenous oral oestrogen or chronic glucocorticosteroid therapy
Source: Dr Henry Burger, Healthed Annual Women’s Health Update, Melbourne 2013
Latest news: Management of paediatric gastro-oesophageal reflux
Physiological reflux is a normal phenomenon that occurs in most infants and involves recurrent vomiting or regurgitation. The diagnosis is based on the history and exam and no testing is usually necessary.
GORD, however, involves oesophagitis and the diagnosis is suspected when weight loss or poor weight gain occurs. Other clues include abdominal pain, back arching, and extra-oesophageal problems such as respiratory symptoms.
Endoscopy is recommended in children who do not respond to conservative measures or at the start of treatment to rule out other diagnoses.
Both reflux and GORD are treated with lifestyle modifications in the first instance, including for infants changing the type of feed, frequency of feeds, position during feeds, and/or the mother’s diet, and for older children losing weight loss and dietary changes.
All medications have side effects. For infants with GORD, options include H1 antagonists such as ranitidine and PPIs like omeprazole. There is insufficient evidence is insufficient to support the use of prokinetic agents such as metoclopramide.
Source: Pediatrics 2013;131:e1684