Infant Feeding Difficulties Clinic & Paediatric Infant Feeding Allergy Clinic (Paediatric Guidelines)

For red flag symptoms, see www.nice.org.uk/guidance/ng1 

Normalise behaviour in first instance

• Provide Crying and Your Baby leaflet (includes signposting to online resources)
• Refer to Health Visitor team for additional support
• Refer to Crying and Your Baby Webinar (Further info available from yvonne.sutherland5@nhs.scot)

Normalise regurgitation in first instance

• If only symptom is regurgitation, offer reassurance to parent that this can be normal for a baby to regurgitate.
• Feeding assessment may be required as per below. 

Assessment of GOR

Indicators of GOR include:

• Unexplained feeding difficulties (refusing to feed, gagging, choking)
• Faltering growth
• Chronic cough and or hoarseness
• Single episode of pneumonia

Feeding assessment: Formula fed

Ensure feeding is paced & responsive:

• Feed to around 150mL/kg/day (1oz = 28mL) & try small, frequent feeds.

Symptoms suggestive of GOR (See to NICE NG1): consider trial of thickener

• Start at: ½ scoop of Carobel for every 90mL/3oz of feed.
  If there is no improvement, then increase to 1 scoop to 1 ½ scoops per 90mL/3oz of feed.
• If there is no improvement after a 2 week trial then refer to IFDC via paediatric dietetics: paediatricdietitians@highland.gov.uk 

Feeding assessment: Breast fed

• Ensure a full breastfeeding assessment is carried out by an appropriately trained Health Care Professional, ensuring positioning and attachment has been assessed as effective
• If any concerns: Refer to specialist breastfeeding service via nhsh.specialistbreastfeedingclinic@nhs.scot

Symptoms suggestive of GOR (See to NICE NG1): consider trial of thickener

• Gaviscon Infant or Cow & Gate Instant Carobel.
  For Carobel give as a paste before feeding. 3 scoops to 2oz EBM
• If there is no improvement after a 2 week trial then refer to IFDC via paediatric dietetics: paediatricdietitians@highland.gov.uk 

Non-IgE CMPA

• See NICE CKS cows-milk-allergy-in-children/diagnosis/diagnosis/ 
• Non-IgE is a delayed reaction (2 to 72hrs)

Symptoms

• Pruritus / erythema / flushing / atopic eczema
• Regurgitation +/-reflux
• Gastrointestinal symptoms: Eg, loose / frequent stools (can be normal in breastfed infants), blood, mucus in stools, constipation, straining (even with soft stools), abdominal pain or discomfort colic / irritability, perianal redness
• Oral aversion
• Pallor / tiredness
• Faltering growth, with at least one GI symptom
• Respiratory symptoms (cough, wheeze, SOB) plus at least one symptom from above

Breast fed

• Refer to specialist Breastfeeding Service via nhsh.specialistbreastfeedingclinic@nhs.scot

Formula fed

If non-IgE mediated CMPA is suspected

• Start 3 week trial of an Extensively Hydrolysed Formula (EHF) (Eg, Aptamil Pepti Syneo).
• After 3 weeks: re-challenge back to standard formula.
• If symptoms resolve on EHF & reoccur on re-challenge: continue with EHF & immediately refer to IFAC via paediatric dietetics: paediatricdietitians@highland.gov.uk 

If IgE mediated CMPA is suspected. Eg: Hives / swelling:

• Start EHF and refer immediately to dietetics.
• DO NOT RE-CHALLENGE
• If symptoms do not resolve with EHF prior to seeing dietetics: Some infants don’t tolerate Carobel & symptoms can be similar to CMPA.
  If not tolerating EHF & also using Carobel, please stop Carobel first before move to Amino Acid Formula (AAF) Eg, Neocate Syneo)
• Dietetics to review.

See: NICE (NG1) for further info: Overview | Gastro-oesophageal reflux disease in children and young people: diagnosis and management | Guidance | NICE.

• Do NOT commence acid suppressing drugs, such as PPIs, where overt regurgitation is the only presenting symptom.
• A 4-week trial of a PPI may be considered when an infant has overt regurgitation plus 1 or more of the following:
  • Unexplained feeding difficulties (e.g. refusing feeds, gagging, choking)
  • Distressed behaviour
  • Faltering growth
• Assess response and consider referral to paediatrics if the symptoms do not resolve or recur after stopping the treatment.

• Unlicensed: There is no product licence for the medicine. 
• Off label: The medication is being used in a way that is different to the product’s licence, eg, used outside the licensed age range.
• Medicines that are unlicensed or are used off label place extra responsibility on the prescriber and pharmacist and the patient is to be informed of the licensed status.

Patient information

• Omeprazole for gastro-oesophageal reflux disease (GORD) – Medicines For Children (Click on the pdf link for a print version)
• Lansoprazole for gastro-oesophageal reflux disease (GORD) and ulcers – Medicines For Children (Click on the pdf link for a print version)
• Patient information leaflet: Difficulty swallowing PPI capsules /tablets 

• AAF - Amino Acid Formula
• CMPA - Cow’s milk protein allergy 
• EHF - Extensively Hydrolysed Formula
• GI - gastrointestinal
• GOR - gastro-oesophageal reflux 
• GORD - Gastro-oesophageal reflux disease
• SOB - shortness of breath