Dr Donna Cosgrove MPSI writes about the importance of appropriate infant nutrition, including weaning and allergy issues, and what the pharmacist can do to help
Infancy is a period of rapid physical growth, cognitive development and social development. Nutritional requirements change significantly during the first year of life. Adequate nutrition is required to support physical growth, neurological development and immune function.
Infant nutrition can be an area of uncertainty for many parents and carers. Community pharmacies are highly accessible and often serve as a first point of contact for parents and carers with concerns regarding infant nutrition. Pharmacists are therefore well placed to provide practical and evidence-based guidance to promote infant nutrition during the first year of life. This article will explore key aspects of infant nutrition commonly encountered in community pharmacy, including breastfeeding, formula feeding, vitamin supplementation, weaning and food allergies.
Breastfeeding
Breastfeeding is recommended as the optimal source of nutrition during early infancy. Where possible, breastfeeding is recommended for the first six months, with complementary foods introduced thereafter while breastfeeding continues. It provides the nutrients required by healthy term infants during early infancy, while also providing immunological protection through the transfer of maternal antibodies.
Maternal benefits include a reduced risk of certain chronic health conditions. Pharmacists can provide general breastfeeding advice and appropriate signposting, while recognising when referral to specialist breastfeeding support is required. Some mothers may choose to express breast milk, combine breastfeeding with formula feeding, or use formula exclusively. These decisions should be approached without judgement and practical, evidence-based guidance.
Adequate nutrition is also important for breastfeeding mothers. A varied, balanced diet is recommended, with adequate fluid intake. Medication safety during breastfeeding is another common area of enquiry, with pharmacists well placed to advise on appropriate medicine use during breastfeeding. Routine multivitamin supplementation is not generally necessary for breastfeeding mothers, but individual supplementation may be indicated in certain cases. However, ensuring appropriate vitamin D supplementation for the infant is particularly important.
Vitamin D3 Supplementation
Vitamin D3 is required for normal bone and teeth development, helping to prevent rickets. Infants should not be deliberately exposed to direct sunlight, and supplementation is therefore recommended for infants who meet the relevant criteria.
HSE guidance recommends that breastfed babies receive 5 micrograms (200IU) of vitamin D3 daily from birth to 12 months. This is also recommended for infants receiving less than 300mL of infant formula daily. Those receiving more than 300mL of formula daily do not require additional vitamin D3, as infant formula is fortified with vitamin D3.
Supplementation is required throughout the first year for infants meeting the relevant criteria, regardless of season or maternal supplementation. The recommended dose is 5 micrograms (200IU) daily, but the number of drops or volume required may vary between products. Some infants may have additional nutritional requirements and require specific supplementation under medical supervision.
Formula Feeding
Infant formula provides an appropriate alternative source of nutrition in cases where breastfeeding is not possible, is not chosen, or supplementation is required. It can typically be used from birth and continued until 12 months of age. There is no nutritional advantage to choosing one standard first infant formula brand over another; standard first infant formulas are nutritionally regulated and meet infants’ nutritional requirements. First infant formula is available as ready-to-feed liquid or powdered formula.
Preparation of powdered formula is important, as incorrect preparation technique or poor hygiene can cause serious illness. The manufacturer’s instructions should be followed, using the correct quantity of powder and cooled boiled water. Feeding equipment should be cleaned and sterilised appropriately, and unused milk should not be kept for later feeds.
Preparation of powdered formula is important, as incorrect preparation technique or poor hygiene can cause serious illness
Several specialised formulas are marketed for feeding problems. These products should generally only be used following appropriate assessment and professional advice. Guidelines do not recommend the use of follow-on formula as it has no additional benefit. First infant formula can be continued until 12 months.
The distinction between infant formula and other milks is important. Cow’s milk should not be given as the main drink before 12 months of age as it does not provide all the nutrients required by infants. However, it can be incorporated into foods during weaning from around six months. Sheep’s milk, goat’s milk, condensed milk, oat milk, almond milk and rice milk are not recommended as a main drink for infants under 12 months. Soy formula should not be used in infants under six months unless under medical supervision, due to concerns regarding exposure to phytoestrogens in infancy.
Weaning
At approximately six months, complementary foods should be introduced. It is important to note that as complementary foods are introduced, breast milk or infant formula remains an important part of the diet. This process is known as weaning and is important, because infants’ energy and nutrient requirements can no longer be met by milk alone.
Weaning should begin when the infant is developmentally ready, typically between 17 and 26 weeks (around four-to-six months). Weaning before 17 weeks can risk displacing essential nutrients supplied by breast or formula milk. Waiting until after 26 weeks is not recommended, as an infant’s energy needs are no longer met by breast milk or formula, and the body’s iron stores have been used up.
The infant should show signs of developmental readiness, including being able to sit with support and control their head, showing co-ordination to pick up and place food in the mouth, and swallowing food rather than spitting it out.
Vegetables, fruit and potatoes are particularly useful in the initial phases of weaning. Cereals, eggs, pulses, dairy food, meat and fish can also be included as part of a varied diet. Iron is particularly important because infants’ requirements increase as they grow and their stores acquired before birth decline.
Sources of iron include meat, fish, eggs, beans, lentils and iron-fortified cereals, while vitamin C sources, such as berries, citrus fruits, broccoli and peppers, can improve the absorption of iron. Oily fish, including salmon, trout, mackerel and sardines, are an excellent source of omega-3 fatty acids, which are important for normal brain and eye development. Water can be offered with meals, while sugary drinks should be avoided. Salt and sugar should not be added to food. Honey should not be given to infants under 12 months due to the risk of botulism.
Foods may initially be offered as smooth or mashed textures, progressing to more lumpy and varied textures. Finger foods, baby-led weaning, spoon feeding and a combination of approaches can be introduced. Infants should always be supervised while eating due to the risk of choking. If an infant is not showing signs of readiness for weaning by around seven months, parents should discuss this with their GP or public health nurse. Premature infants may have different nutritional requirements and timing of complementary feeding, and parents should be advised to follow the individualised guidance provided by their healthcare team.
Food Allergy
Weaning is an excellent opportunity to introduce common food allergens. Common food allergens should be introduced around the time complementary feeding begins, usually from around six months, once the infant is developmentally ready. These foods include egg, dairy, peanuts, tree nuts, fish, wheat and sesame.
Delayed introduction of foods may increase the risk of developing an allergy. These should be introduced in safe forms appropriate to the infant’s developmental stage. When introducing an allergenic food for the first time, it should be offered in a small amount and the infant monitored for signs of an allergic reaction. Once tolerated, the food should continue to be included regularly in the infant’s diet.
Immediate allergic reactions can occur within minutes or up to approximately two hours after eating. Symptoms may include a sudden rash, swelling of the lips or face, vomiting and, in severe cases, breathing difficulties or anaphylaxis. Breathing difficulties, swelling of the tongue or throat, or symptoms suggestive of anaphylaxis require immediate emergency medical attention. Delayed allergic reactions can develop several hours after eating and may present with gastrointestinal symptoms such as vomiting, diarrhoea, or blood in the stool.
Immediate allergic reactions can occur within minutes or up to approximately two hours after eating
Eczema is not a food allergy, although infants with moderate-to-severe eczema may have an increased risk of food allergy. Foods should not be removed from the diet because of suspected allergy without appropriate professional advice.
Nutritional Problems
A number of feeding and nutritional difficulties may arise during infancy. In certain cases, referral to the GP or specialist may be required; however, not every feeding problem represents a nutritional deficiency or requires a change of formula or diet. Constipation can occur during weaning as dietary variety and fluid intake may change. Encouraging an appropriate variety of fruit, vegetables and other fibre-containing foods may relieve symptoms, while persistent or significant symptoms require referral.
Reflux and regurgitation are common in infants and often resolve as the child develops, particularly where the infant is otherwise well and growing appropriately. Similarly, a transient reduction in food intake during illness is less concerning than persistent poor food intake or delayed development. The overall clinical picture should be considered. However, poor weight gain, persistent feeding refusal, recurrent vomiting or diarrhoea, persistent abdominal distension, blood in the stool, suspected allergy and dehydration are all causes for referral.
Pharmacist’s Role
Community pharmacists are well placed to provide practical advice on supplementation, formula preparation, breastfeeding, complementary feeding and food allergy while recognising symptoms that require referral.
Breast milk or infant formula provides the foundation during early infancy, while complementary foods introduce the wider range of nutrients required for healthy growth and development. Counselling about infant nutrition should be supportive and non-judgemental. Breastfeeding, formula feeding or a combination of the two may be used for a variety of personal or medical reasons.
Pharmacists have an important role in providing evidence-based information, supporting informed decisions and recognising when referral is needed. Advice can include counselling on appropriate supplementation, explaining formula preparation, providing breastfeeding support and advising on weaning. Pharmacists can collaborate with other members of the multidisciplinary team to support parents and carers with questions about their infant’s nutritional requirements.
References available upon request
