Download Infant Feeding Formula Policy

Policy statement on Prescribing of Infant Milks (and including Formulary Milks)
Breastfeeding should be strongly encouraged as providing the safest, most nutritionally adequate
form of feeding for most infants. A change from breast milk to formula milk should not be
initiated if the mother is happy to continue breast feeding. Consider supplementing breast
feeding with formula milks if necessary.
Mid-Essex Clinical Commissioning Group only commissions primary care prescribing of infant
formula milks on a restricted basis in accordance with the following policy.
Where breast feeding is not in place, parents should purchase appropriate infant formula milks.
For those qualifying for ‘Healthy Start’ support (http://www.healthystart.nhs.uk/healthy-startvouchers/do-i-qualify/), vouchers may be spent on infant formula milk that is based on cows’ milk
and says on the packaging that it can be used from birth. This therefore includes lactose-free
milks which are derived from cow’s milk.
For infants who appear unsettled, colicky etc. there are a range of commercially available milks
designed to be easier to digest which parents are able to purchase but should not be prescribed.
Similarly, infants presenting with reflux symptoms should be advised that there are commercial
products to purchase but they are not recommended for prescribing within NHS Mid Essex.
Soya-based infant formula was originally developed for babies who can't have infant formula
based on cows' milk because, for example, they have a milk allergy. Other types of formula that
are more suitable for these babies are now available. Soya-based infant formula must not be
given to infants under 6 months of age due to the phyto-oestrogen content. It also contains
glucose, and glucose is more harmful to babies’ and small children’s teeth than the lactose in
infant formula made with cows' milk. Prescribing of soya milks by GPs is not supported for all
ages.
Infants may develop lactose intolerance; for example secondary to an infectious gastrointestinal
illness. Symptoms include: abdominal bloating, wind, increased (explosive) and loose, green
stools. Lactose intolerance should be suspected in infants who have had symptoms that persist
for more than 2 weeks. Diagnosis is the resolution of symptoms, usually within 48 hours, once
lactose is removed from the diet. Lactose free infant formulas can be bought at a similar cost to
standard infant formula. Prescribing of lactose free infant formulas by GPs is not supported.
Pre-term infants will have had their formula commenced in hospital. It is started for babies born
before 34 weeks gestation and is continued until the child reaches their 6 months corrected age.
At this age children should then be moved onto standard infant formula. Infant milks for pre-term
infants can be bought at a similar cost to standard infant formula. Prescribing of special formula
milks for pre-term infants by GPs is not supported.
In certain conditions some foods have characteristics of drugs and the Advisory Committee on
Borderline Substances advises as to the circumstances in which such substances may be regarded
as drugs. The Advisory Committee's recommendations are listed in the Drug Tariff. .
Prescriptions, where issued, must be in accordance with the Committee's advice and endorsed
"ACBS".
Approved by: Mid Essex Area Prescribing Committee
Chairman: Dr Alan Jackson
Date; January 2014
Review date: January 2016
Prescribing of all infant feeds in children must meet ACBS criteria and will only be supported
until the infant is 1 year of age, unless a shorter or longer period is indicated within this policy or
there are exceptional clinical circumstances. If NHS prescribing of infant milks is appropriate, a
sufficient quantity to support all the nutritional needs of the child must be prescribed; it is not
appropriate to expect parents to purchase some. If special formula milks are required after this
age, parents are then expected to purchase these milks. Please note that Neocate Active® and
Neocate Advance® are not indicated in children under 1 year of age and therefore prescribing is
not supported unless there are exceptional clinical circumstances.
Cows’ Milk Protein Allergy (CMPA)- Extensively hydrolysed formula for infants with a suspected
cows’ milk protein allergy (CMPA) will be used first line. e.g. Nutramigen® Lipil 1 or 2 or Aptamil
Pepti®1 or 2. Prescription of CMPA-hydrolysed formula milks may be initiated by GPs but must
not be continued without a referral and confirmation of diagnosis from a paediatrician or
paediatric gastro-enterologist or dietician. Prescriptions will initially be for a 2 week trial period
(for tolerance); however it may take 4-6 weeks for symptoms to resolve. Infants who do not
tolerate one formula may tolerate another. Therefore it is worth prescribing only 1 or 2 tins
initially and if not tolerated or taken after perseverance, try another comparable formula.
Amino Acid formula should only be prescribed when hydrolysed formulas do not resolve
symptoms or when there is evidence of severe/multiple allergy. These are highly specialised
products and CMPA-Amino Acid formula milks e.g. Neocate® LCP, Nutramigen® AA must only be
initiated by secondary/tertiary care second line. GPs should only initiate if hydrolysed formula
has not been tolerated after a reasonable trial and if they have made a formal referral to a
paediatrician and it is not clinically appropriate to wait for a specialist recommendation. GPs
should only accept continued prescribing of these products after benefit has been demonstrated
and in line with an agreed treatment plan.
Faltering growth-prescribing of high energy formula milks is indicated when the weight of an
infant falls below the bottom centile (0.4th) or crosses 2 centiles downwards on a growth chart. It
is important to rule out possible disease-related/ medical and social causes for the faltering
growth. High energy formula milks must only be initiated in secondary care after assessment by a
paediatrician to rule out medical causes. Before referral to secondary care ensure parents/carers
are offered food first advice on suitable high calorie foods if the infant is weaned.
All infants on a high energy formula must have growth (weight and length/height) monitoring to
ensure catch up growth and appropriate discontinuation of formula to minimise excessive weight
gain. Stop high energy formula at 18months of age or if patient over 8kg - If concerns with weight
refer to Paediatric Dietitian.
The volumes of feed to prescribe for infants
The guidelines below are a guide only for infants from 6 months of age. Individual requirements
may vary and GPs should prescribe sufficient to meet the dietary needs of the child. Please bear in
mind requirements will gradually reduce after weaning depending on how much solid food is
being taken. By 1 year of age, the milk requirement should be decreasing and prescribing of infant
formulas must cease unless there are clinically exceptional circumstances. For infants under 6
months of age the volume prescribed should be roughly the same as the volume of milk they are
currently taking (NOTE: most commonly used shop bought formulas are in 900g tins). As a guide,
for a child taking 150ml/kg/day a 400g tin should last 3.5 days (therefore 8x400g tins a month;
4x900g tins a month).
Approved by: Mid Essex Area Prescribing Committee
Chairman: Dr Alan Jackson
Date; January 2014
Review date: January 2016
Mid Essex FORMULARY for Infant formula milk products
Please note the nutritional reference value for calcium in a child < 1 yr is 525mg /day (1 to 3 yrs 350mg), formula
may not provide a sufficient daily dose and supplementation may need to be considered
♦Infant formulas to be considered for GP initiation where there is a clear and definite reaction to milk and whilst
awaiting a secondary care referral. Any improvement should be seen within 1-2 weeks.
Use 1st line
Secondary/Tertiary care
Use 2nd line only if 1st
Purchase only
initiation
only
treatment unsuccessful
N.B: DO NOT PLACE THESE PRODUCTS ON A PATIENTS REPEAT PRESCRIPTION LIST. A review of growth and
quantities prescribed should occur regularly.
Extensively hydrolysed Infant Formula-Use in Cows’ Milk Protein Allergy (CMPA)
The taste of hydrolysed formulae is unpleasant and it has a bitter smell therefore compliance can be improved by using
a bottle, closed cup or a straw. Younger infants take hydrolysed formulas more readily than older infants. Introduction
of a new formula to babies who do not have a severe reaction is best done by mixing it with their current formula and
gradually changing over. For breast fed babies whose mothers wish to change, this may be achieved by mixing with
expressed breast milk, given by someone other than the mother until the infant is used to it. Infants who refuse
Nutramigen (first line choice) may tolerate Aptamil-Pepti, however infants who have a systemic reaction to
Nutramigen are unlikely to tolerate alternative extensively hydrolysed formula and will need an Amino Acid formula.
It is therefore worth prescribing only 1 or 2 tins initially to ensure acceptance of the product. Continue formula until
child has grown out of allergy or they are 2 years old. Do not advise sheep or goats milk due to cross reactivity. Beyond
2 years calcium enriched soya milk can be used as an alternative source of milk .
Product
Criteria for Stopping
Number of tins per
Indicated Age
month-guide only
Range
1st Line
*Continue formula until infant has grown out
From birth to 6
♦Nutramigen® Lipil 1 of allergy or they are 2 years old. Local policy
months
Mead Johnson
supports prescribing of such milks on the NHS
until the child is one year old, following which 7x400G
1st Line
From 6 months
if
this
is
still
needed,
the
milk
should
be
Nutramigen®Lipil-2
to 2 yrs*
purchased.
Mead Johnson
At 6 months change prescription to
♦Aptamil-Pepti ® 1*
From birth to 6
Nutramigen®Lipil 2 unless a dietician has
Aptamil
months
♦Aptamil-Pepti® 2** advised otherwise. The same for Apatmil3x900g
From 6 months
Pepti
®
1
and
2.
Aptamil
to 2 yrs*
These children should be reviewed every 6
♦Pepti-Junior
6x450G
From birth until 2
months as paediatric allergy will often
Cow & Gate
yrs*
resolve. They will require secondary/tertiary
care input to establish this. Refer to NICE
guidelines (2011) for which children should be
challenged with cows’ milk in secondary care
setting
** Aptamil Pepti contains lactose, so will not be tolerated by all infants with CMPA, some infants may have a degree of
lactose intolerance particularly if gut symptoms are present. Infants may accept this when Nutramigen has been
refused. If infants have suffered a reaction to Nutramigen however Aptamil Pepti® is also unlikely to be suitable.Amino Acid Formula –GPs may only initiate if hydrolysed formula not tolerated after reasonable trial and if they have made a formal
referral to a paediatrician, and it is not clinically appropriate to wait for a specialist recommendation.
Specialist Initiation
♦Neocate LCP
SHS
Specialist Initiation
Nutramigen AA
Mead Johnson
These formulas are stopped when the infant
has grown out of the allergy. They will require
secondary/tertiary care input to establish this.
7x400G
Birth until infant
has grown out of
allergy (up to 12m)
7x400G
Birth until infant
has grown out of
allergy (up to 12m)
Faltering growth
High Energy Formula milks are indicated when the weight of an infant falls below the bottom centile (0.4th) or crosses
2 centiles downwards on a growth chart. It is important to rule out possible disease-related/ medical and social causes
for the faltering growth. Specialist initiation
1st line
Before commencing a high energy formula
68x250ml
From birth to 18
SMA High Energy
ensure parents/carers are offered food first
months or 8 kg
Ready to feed
advice on suitable high calorie foods if the
infant is weaned. Any infant being considered 168x100ml or
Infatrini ready to
From birth to 18
for
a
high
calorie
formula
should
be
referred
feed
86 x 200ml
months or 8 kg
to a paediatrician to rule out medical causes.
Nutricia
NOTE: All infants on a high energy formula will 140x120ml
Similac High Energy
From birth to 18
need growth (weight and length/height)
Abbott
months or 8 kg
monitoring to ensure catch up growth and
appropriate discontinuation of formula to
minimise excessive weight gain
Metabolic Disorders - follow specialist unit recommendation
Tertiary Care recommendation – prescribe initially as per recommendation then confirm with paediatrician/dietitian
as to possibility of changing to formulary milks
The following types of infant formula milks (and some examples of these milks) are not recommended for
prescribing on the NHS as they may be purchased at a similar price to standard formula milks.
Product
Prescribing on the NHS not recommended
Number of tins per
Indicated Age
month-guide only
Range
Lactose Free Formula
SMA LF
Lactose free infant formulas can be bought at 6x430G
From birth to 2
SMA
a similar cost to standard infant formula and
yrs
therefore prescribing on the NHS is not
Enfamil Lactofree
7x400G
From birth to 2
supported.
Mead Johnson
yrs
Other Specialised Formula
Pre-term infants
These children will have had their formula commenced in hospital. It is started for babies born before 34 weeks
gestation. For advice on vitamin supplementation please see East of England Perinatal guidance
SMA Gold Prem 2
Pre-term infant formulas can be bought at a
<6 months
SMA
similar cost to standard infant formula and
corrected age
therefore
prescribing
on
the
NHS
is
not
Nutriprem 2
<6 months
supported.. Any infant discharged on these
Cow and Gate
corrected age
formula should have their growth (this
includes weight, length and head
circumference) monitored by the health
visitor. These formulas should be stopped if
there is excessive weight gain.
Approved by: Mid Essex Area Prescribing Committee
Chairman: Dr Alan Jackson
Date; January 2014
Review date: January 2016