Formula feeding and complementary feeding — formative SAQs

SAQ 1 — Counselling a parent on safe formula feeding and starting solids (10 marks)

Prompt: A healthy 2-month-old formula-fed infant is reviewed in your general clinic. At the same visit the parent, who plans to return to work soon, asks how to make up feeds safely, how much to give, and when to start solids. Outline your advice. [1]

Model answer

• Formula choice: a standard first infant formula (stage 1) is nutritionally complete and appropriate from birth through to twelve months; there is no need to switch brands or move to a follow-on formula. [1]
• Safe preparation: boil fresh water and let it cool to no less than 70 degrees Celsius before adding powder, which kills any Cronobacter or Salmonella; add the exact number of level, unpacked scoops to the correct volume of water, never packing or adding extra scoops; use or refrigerate the feed immediately and discard unfinished feed. Over-concentration causes hypernatraemic dehydration and seizures, while under-concentration causes faltering growth and hyponatraemia. [7]
• Volume and responsive feeding: a working estimate in early infancy is about 150 mL per kg per day, always guided by appetite and growth rather than forced; hold the infant, keep the bottle horizontal to control flow, and never prop a bottle or put the infant to bed with one. [1]
• Timing of complementary feeding: begin at around six months when the infant shows developmental readiness (head control, supported sitting, interest in food, reduced tongue thrust); offer iron-rich first foods such as pureed red meat, lentils or iron-fortified cereal; introduce common allergens early and keep them regular; progress texture from puree to lumpy to family foods by twelve months. Emphasise that whole cow's milk as the main drink and honey are for after twelve months. [1]

SAQ 2 — The infant with iron deficiency anaemia from early cow's milk (10 marks)

Prompt: A 9-month-old presents with pallor and lethargy. Since six months the family have used whole cow's milk as the main drink. Haemoglobin is low and ferritin is low. Discuss the mechanism, the immediate and feeding management, and the safety-net. [10]

Model answer

• Mechanism: whole cow's milk as the main drink before twelve months is low in iron and provokes occult gastrointestinal blood loss in young infants, while its high renal solute load stresses the immature kidney; the result is iron deficiency anaemia, one of the commonest nutritional deficiencies of early childhood. [10]
• Immediate management: confirm with a full blood count and ferritin, and treat with an oral iron preparation at an appropriate weight-based dose with dietary review; advise that cow's milk as the main drink is stopped and replaced with a first infant formula or continued breastfeeding. [10]
• Feeding management: introduce or reinforce iron-rich complementary foods (red meat, lentils, beans, iron-fortified cereal) alongside a source of vitamin C to aid absorption; cow's milk is reintroduced only as the main drink after twelve months, with dairy kept as a food within a balanced weaning diet. Recheck haemoglobin after an appropriate interval to confirm response. [1]
• Safety-net: any infant with pallor, lethargy, poor feeding or further weight loss returns promptly for review; persistent anaemia despite correction of the diet warrants investigation for other causes of blood loss or malabsorption. [10]