SCIENCE INSPIRED BY NATURE Specially Tailored …...SCIENCE INSPIRED BY NATURE Practical guidance...

S C I E N C E I N S P I R E D B Y N A T U R E

Practical guidance

Specially Tailored support for a range of feeding issues

INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLYBREASTFEEDING IS BEST FOR BABIES

This chart is intended for bottle-fed babies, as a guide only and is not a diagnostic tool.

YES

YES YES

NO

NONO

START HERE

Is the baby full term?

Is the preterm baby receiving breast milk exclusively?Is there a family history of allergy?

Does the baby have special nutritional needs?

SMA H.A.®

Infant MilkFrom birth

SMA®

Breast MilkFortifierFrom birthIn hospital

SMA® Extra Hungry

Infant MilkFrom birth

SMA® Comfort

Easy to DigestInfant Milk

From birth

SMA® PRO RangeFirst, Follow-on & Growing Up Milks From birth, 6 months &

12 months

SMA® Organic RangeFirst, Follow-on & Growing Up Milks From birth, 6 months &

12 months

For hungrier babies

For babies with mild digestive

discomfort

SMA Gold Prem® 2Post Discharge

Formula90 ml in hospital,

200 ml for use at home

Prescribable (UK only)

SMA Gold Prem® 2Post Discharge

FormulaFor use at home

Prescribable (UK only)

SMAGold Prem® 1

Low BirthweightFormulaFrom birthIn hospital

NO YES

SMA High Energy®

From birthPrescribable(UK & ROI)

SMA® Anti-Reflux

From birthPrescribable

(UK only)

SMA LF®

Lactose FreeFrom birth

Prescribable(UK & ROI)

For babies with high energy

needs

For babies withsignificant

reflux

For babies intolerant to

lactose/sucrose

SMA® Wysoy®

Soya Infant FormulaFrom birth

Prescribable(UK & ROI)

For cows’ milk intolerant babies

FOR MEDICALLY DIAGNOSED SPECIAL NUTRITIONAL NEEDS


PAG

E 28

PAG

E 24

PAG

E 14

PAG

E 2

0

PAG

E 32

LITTLE STEPS® RangeFirst, Follow-on & Growing Up MilksFrom birth, 6 months &

12 months

SMA® ADVANCED Range First, Follow-on & Growing Up Milks

From birth, 6 months& 12 months

SMA® Specials Range | 32 | SMA® Specials Range

INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY

The aim of this booklet is to describe some of the common feeding issues experienced by infants, and to help you reassure parents by offering practical guidance.

The advice contained within this booklet is based upon the latest guidance from NICE and the Department of Health, where appropriate.

Feeding issues and protein intakeUnderstanding feeding issues ......................................................................... 6Importance of partially hydrolysed protein ....................................................... 8Role of whey dominance ................................................................................ 9

Reflux and regurgitationWhat is reflux and regurgitation? .................................................................... 10Starch thickener + NICE guidelines ................................................................. 12SMA® Anti-Reflux .......................................................................................... 14Comparison chart ......................................................................................... 15Preparation: instructions and comparison ......................................................... 16

Mild digestive discomfortSigns and symptoms ...................................................................................... 18Diagnosis criteria .......................................................................................... 19SMA® Comfort Easy to Digest Infant Milk ......................................................... 20Comparison chart ......................................................................................... 21

Lactose intoleranceWhat is lactose intolerance? .......................................................................... 22Types of lactose intolerance ........................................................................... 23SMA LF ® Lactose Free Infant Milk .................................................................... 24Comparison chart ......................................................................................... 25

Cows’ milk allergy or intoleranceAllergy vs intolerance? .................................................................................. 26Soya as a protein alternative .......................................................................... 27SMA® Wysoy® Soya Infant Formula ................................................................. 28

Allergy in infantsFamily history ............................................................................................... 30Supporting infants at risk of allergy ................................................................. 31SMA H.A.® Infant Milk ................................................................................... 32What do the guidelines say? .......................................................................... 33

Contents

NICE: National Institute for Health and Care Excellence.

BREASTFEEDING IS BEST FOR BABIES

4 | SMA® Specials Range SMA® Specials Range | 5

BREASTFEEDING IS BEST FOR BABIES INFORMATION FOR HEALTHCARE PROFESSIONAL USE ONLY

Feeding issues are a common part of life for young infants1

Research shows that Functional gastrointestinal disorders (FGIDs) occur in up to 55% of all infants in the first 6 months of life.1

Infant feeding issues are very common

INFANTS WHO HAVE FEEDING ISSUES

THE MOST COMMON FGIDs ARE:2

OVER HALF

REFLUX & REGURGITATION30%COLIC20%

Feeding Issues

This is due to a baby’s digestive system still being immature when born. • FGIDs include a number of symptoms that affect the

gastrointestinal tract in otherwise healthy infants3

• These symptoms are often frequent, age dependent, and related to the ongoing physiological development of the gut that occurs naturally after birth

• Although they usually resolve as the infant matures, they can cause considerable distress and anxiety for the parents as well as the infant

• As well as FGIDs, feeding issues also encompass lactose intolerance and cows’ milk protein allergy (CMPA), both of which have a defined organic cause

• The prevalence of lactose intolerance varies according to cause and ethnicity.4 CMPA affects between 1.8%-7.5% of infants in the first year of life.5

CONSTIPATION15%


0

15

20

25

30

35

40

Type of milk

% re

mai

ning

in st

omac

h

Breast Milk

100% whey, partially hydrolysed formula

Intact whey-predominant formula

Intact casein-predominant formula

18%

16%

26%

39%*


What is partially hydrolysed protein and why is it important?Infants who have a FGID may benefit from partially hydrolysed protein in a formula.

Partially hydrolysed means the protein is broken up into smaller pieces that are easier for the infant to digest.

• Breast milk contains enzymes that hydrolyse proteins6

• Gastrointestinal symptoms such as constipation, fussiness, colic or spitting up are very common at an early age1

• Some trials have demonstrated the efficacy of partially hydrolysed formula in the community when CMPA was not considered to be the cause of the infant’s colic symptom2

Partially hydrolysed formula may offer some advantage over intact protein in the dietary management of common functional gastrointestinal symptoms.2

Partially hydrolysed, 100% whey protein encourages easy digestion Breast milk contains partially hydrolysed proteins for easier digestion and absorption.7 Partially hydrolysed formulas have been shown to accelerate gastric emptying, making the formula easy for infants to digest.8

After 120 minutes only 16% of 100% whey, partially hydrolysed formula remains in the stomach compared with 26% of intact whey-predominant formula and 39% of intact casein-predominant formula.8

Both the UK and Ireland Department of Health recognise that whey protein is easier to digest.9,10

* p<0.05 versus 100% whey, partially hydrolysed formula and breast milk.FGID: Functional gastrointestinal disorder.

Plasmin

HydrolysisBig protein molecule Small, more easily digested peptides


16%

39%*

0

15

20

25

30

35

40

Type of milk%

rem

aini

ng in

stom

ach

100% whey, partially hydrolysed formula

Intact casein-predominant formula

Oesophagus

Duodenum

Lower oesophageal spincter (valve)

Pyloricspincter (valve)

Stomach


What is infant reflux and regurgitation? Gastro-oesophageal reflux (GOR) is an involuntary passage of gastric contents from the stomach into the oesophagus. Reflux is a normal physiological process in otherwise healthy infants and is a common FGID in an infant’s first year.11

• When reflux is high enough to be seen, it is known as regurgitation2,3

• Regurgitation or reflux occur daily in about 50% of infants under 3 months of age2

• This is primarily due to the functional immaturity of the stomach inlet11

In some cases, reflux may lead to complications and/or troublesome symptoms, which require further medical investigation and treatment – this is when gastro-oesophageal reflux disease (GORD) occurs.2,11

WHEY-BASED INFANT FORMULAS:

• Are more easily digested than those which are casein-based7

• Contain an adequate supply of essential amino acids and higher protein quality, closer to that of breast milk12

The importance of whey protein for infants with feeding issues Breast milk is whey-dominant during the first 6 months of life.7 Reflux and

regurgitation

FGID: Functional gastrointestinal disorder. * p<0.05 versus 100% whey, partially hydrolysed formula.

Rate of gastric emptying after 120 minutes, according to the type of milk8



The effect of a starch thickener on symptoms of refluxStarch thickener reduces the frequency of regurgitation in infants.13

• Starch is an appropriate thickener for infants with reflux and regurgitation, as it is digestible by the infant

• Starch-thickened formulas have shown efficacy in reducing the number of daily regurgitation episodes13

What the NICE guidelines sayIn 2015, NICE recommended the following measures for managing formula-fed infants with frequent regurgitation associated with marked distress:11

• Offer parental reassurance

• Review feeding history, suggest smaller, more frequent feeds (while maintaining appropriate daily milk volume intakes)

• Trial of a thickened formula

If a thickened formula does not work, stop the thickened formula and offer alginate therapy for a trial period of 1–2 weeks.

NICE: National Institute for Health and Care Excellence.

NICE Guideline on gastro-oesophageal reflux11

• Regurgitation of foods is a normal and common occurrence in infants

• Does not usually require investigation

• Reassure and advise parents and carers

• Look out for ‘red flags’ that may indicate a need to refer, e.g. blood in stool, fever

• In formula-fed infants with frequent regurgitation associated with marked distress, use a stepped-care approach: – Review feeding history– Reduce food volumes only if excessive for the infant’s weight– Trial of smaller, more frequent feeds (while maintaining appropriate total

daily amount of milk)– Trial of thickened formula– If above is unsuccessful, stop the thickened formula and offer alginate

therapy for a trial period of 1–2 weeks



REDUCES FREQUENCY OF REGURGITATION13 Starch-thickened formulas have shown efficacy in reducing the number of daily regurgitation episodes13

THICKENED FORMULA 2015 NICE guidelines recommend trial of a thickened formula in formula-fed infants with GOR11

SPECIALLY TAILORED Unique combination of easily digestible starch and 100% whey, partially hydrolysed protein, to help manage reflux and regurgitation13-14.

SMA® Anti-Reflux

NS: Not stated.GOR: Gastro-oesophageal reflux.NICE: National Institute for Health and Care Excellence.

How does SMA® Anti-Reflux compare?

SMA® Anti-Reflux14

Aptamil Anti-Reflux 15

Cow & Gate Anti-Reflux16

HiPP Anti-Reflux 17

Enfamil A.R. (‘Anti-Reflux’) 18

Whey:casein 100:0 40:60 40:60 60:40 NS

Type of protein Partially hydrolysed Intact Intact Intact Intact

Protein content (g/100 ml) 1.3 1.3 1.3 1.4 1.72

Type of thickener Potato starch Carob bean gum Carob bean gum Carob bean gum Rice starch

Vegetarian

Halal



SMA® Anti-Reflux14

Aptamil Anti-Reflux15

Cow & Gate Anti-Reflux16

HiPP Anti-Reflux17

Step 1

Step 2

Allow to cool for no more than 30 minutes.

Leave kettle to cool for no longer than 45 mins. Measure the required amount of water into a sterilised bottle. Be careful of scalding.

Measure the required amount of boiled water into a large sterilised bottle. Seal bottle and allow to cool for 45 minutes.

Leave to cool for no longer than 30 minutes.

Step 3

Place the sterilised teat and cap on the bottle. Cool bottle under cold running water or in a bowl or jug of cold water until lukewarm, do not immerse the teat.

Using the scoop provided level off the powder with the built in leveller. Do not press/heap the powder.

Using the scoop provided, level the powder with the built-in leveller. Do not press/heap the powder.

Measure the required amount of water into a sterilised bottle, following the feeding guide on the pack. Using the scoop provided, add the correct number of scoops of powder – one level scoop of powder for each fluid ounce of water (approx. 30 ml). Level off the powder with the back of a clean dry knife, but don’t press the powder down into the scoop.

Step 4

Using only the scoop provided, add the correct number of scoops of powder (see feeding guide), levelling off each scoop with the back of a clean, dry knife. Store the scoop in suspension inside the can and replace lid.

Add one scoop per 30ml (1 fl oz) of boiled and cooled water. Add the correct number of scoops to the water. Adding too many or too few scoops can be harmful.

Place the sterilised teat and cap on the bottle.

Hold the bottle horizontally and shake from left to right for 10 seconds, then hold it vertically and shake from top to bottom for 10 seconds. The time between adding the scoops and shaking the bottle should be as short as possible.

Add one scoop to every 30ml (1 fl oz) of boiled cooled water. Add the correct number of scoops to the water. Adding too many or too few scoops can be harmful.

Replace seal on bottle and roll the bottle upright between the palms of hands – roll it strongly for 5 seconds. The time between adding the scoops and rolling the bottle should be as short as possible.

Place the sterilised teat and cap on the bottle and shake well until all the powder has dissolved (approx. 15 seconds).

Step 5

Shake bottle well until powder has fully dissolved.Test temperature by shaking a few drops on to the inside of your wrist – milk should be lukewarm.SMA Anti-Reflux should usually not thicken after it has been prepared.**

Leave the bottle to stand for 5 minutes to allow it to thicken. Turn the bottle upside down just before feeding. Check temperature of feed. Feed immediately.

Shake the bottle for 20 seconds and then leave to stand for 7 minutes to allow it to thicken. Turn the bottle upside down just before feeding and test the temperature on your wrist.

Cool the milk to drinking temperature (approx 37°C) by holding the bottle under cold running water. ALWAYS test the temperature of the milk before feeding by dripping a bit onto the inside of your wrist; the milk should feel warm, not hot.

SMA® Anti-Reflux is easy to prepare

Reconstitute SMA® Anti-Reflux as per pack instructions for baby’s age and shake bottle.

Thicker formula, may require a fast flow teat.

1 Pull the safety seal and open the lid. The scoop is provided under the lid. Lift the tab, pull on the foil seal, carefully and safely remove the seal and dispose of it.

2 Wash hands well. Wash and sterilise all utensils according to manufacturer’s instructions.

3 Boil 1 litre of tap water. Allow to cool for no more than 30 minutes. Measure the required amount of water (see feeding guide) into a sterilised bottle, carefully – the water is hot. Do not use artificially softened or repeatedly boiled water.

4 Place the sterilised teat and cap on the bottle. Cool bottle under cold running water or in a bowl or jug of cold water until lukewarm, do not immerse the teat.

5 Using only the scoop provided, add the correct number of scoops of powder (see feeding guide), levelling off each scoop with the back of a clean, dry knife. Store the scoop in suspension inside the can and replace lid.

6 Shake bottle well until powder has fully dissolved. Test temperature by shaking a few drops on to the inside of your wrist – milk should be lukewarm.

Comparison of AR formulas*

* The preparation instructions have been taken from label and website information (accessed February 2020).SMA Anti-Reflux, because of use of potato starch, usually thickens when the powder is dissolved in water.

** If prepared according to preparation instructions, it should not thicken after the bottle has been prepared.

Wash hands and sterilise all utensils according to the manufacturer’s instructions.

Boil 1 litre of freshly run water. Do not use artificially softened or repeatedly boiled water.



Mild digestive disorders are common in an infant’s first weeks or months• At this time an infant’s digestive system is still developing

• Mild digestive disorders can present as colic-like symptoms, constipation, wind or crying after a feed

• Tummy troubles can be difficult for both infant and parents/caregivers

• About 20% of infants are reported by caregivers to have the prolonged periods of crying known as colic20

• The prevalence of constipation in the first year of life is 2.9%3

Rome IV diagnostic criteria3

Diagnostic criteria for infant colic3

Diagnostic criteria for functional constipation3

For clinical purposes, must include all

of the following:

• An infant who is <5 months of age

when symptoms start and stop

• Recurrent and prolonged periods of infant

crying, fussing or irritability reported

by caregivers that occur without obvious

cause and cannot be prevented or

resolved by caregivers

• No evidence of infant failure to thrive,

fever or illness

Must include 1 month of at least two of

the following in infants up to 4 years of age:

• Two or fewer defecations per week

• History of excessive stool retention

• History of painful or hard

bowel movements

• History of large diameter stools

• Presence of large faecal mass

in the rectum

Mild digestive discom

fort



EASY TO DIGEST Contains partially hydrolysed, 100% whey protein which is easier to digest than intact protein molecules8.

NUTRITIONALLY COMPLETE Contains all essential nutrients to support babies’ nutritional needs.

SPECIALLY TAILORED Contains an SN-2-enriched fat blend20 and reduced lactose to help manage mild digestive discomfort21.

SMA® Comfort Easy to Digest Infant Milk

How does SMA® Comfort compare?

SMA® Comfort Easy to Digest 22

Aptamil Comfort 23

Cow & Gate Comfort 24

HiPP Comfort 25

Whey:casein 100:0 100:0 100:0 100:0

Type of protein Partially hydrolysed

Partially hydrolysed



Protein content (g/100 ml) 1.6 1.5 1.5 1.25

No added thickener

Lactose (g/100 ml) 3.9 2.7 2.7 2.7

Contains SN-2

Vegetarian

Halal


Normal Lactose Digestion

Lactose

Lactase

Glucose

Galactose

Lactose intolerant

Small intestine

Largeintestine

Lactose

No/Insufficient Lactase

Water

Bacteria ferment

Acids and gases

Irritation caused


What is lactose intolerance?In infants who are unable to metabolise lactose, undigested lactose stays in the intestine, where it can cause diarrhoea, abdominal distension, nausea, bloating and wind:4,26

• These symptoms can be distressing for both infant and parents/caregivers

• Infants fed lactose-free formulas have shown comparable growth and key nutrient absorption to those fed formula containing lactose27,28

• Studies have also shown that infants with diarrhoea fed a lactose-free formula recovered in significantly less time than those fed a formula containing lactose29-31

Types of lactose intolerancePrimary lactose intolerance is the most common cause of lactose intolerance worldwide with prevalence related to ethnicity.4

Secondary lactose intolerance is common but a temporary cause of diarrhoea.4

• Secondary lactose intolerance often occurs because of damage to the intestinal brush border – the site of lactase production

• Secondary lactose intolerance may also develop in some children with gut-related symptoms associated with non-IgE-mediated CMPA, which resolves following exclusion of cows’ milk protein

• Temporary lactose intolerance is due to immaturity of the small intestine

• Usually improves as affected babies get older and their gut fully develops

Congenital lactose intolerance is a rare condition where newborn babies produce very little or no lactase as a result of an inherited genetic fault that runs in families.

Developmental lactose intolerance can be a problem with preterm babies born before the 34th week.4

Lactose intolerance



MANAGES SYMPTOMS OF LACTOSE INTOLERANCE For use in conditions where dietary lactose is contraindicated32

NUTRITIONALLY COMPLETE Contains all essential nutrients to support babies’ nutritional needs.

SPECIALLY TAILORED The only whey-dominant lactose-free formula available in the UK and Ireland, to help manage symptoms of lactose intolerance33-35

SMA LF® Lactose Free Infant milk

LCPs: Long-chain polyunsaturates.NS: Not Stated

How does SMA LF® Lactose Free Infant milk compare?

SMA LF®

Lactose Free 33Aptamil

Lactose Free 34Enfamil O-Lac 35

Whey:casein 60:40 0:100 20:80

Lactose content (g/100 ml) <0.0067 <0.007 NS

Iron (mg/100 ml) 0.7 0.71 1.1

Vitamin D (µg/100ml) 1.5 1.4 1.01

Vegetarian NS

Halal NS



What’s the difference between cows’ milk allergy and lactose intolerance? In some infants, cows’ milk can cause the following problems (both of which have a defined organic cause but are otherwise unrelated):

• Cows’ milk protein allergy (CMPA)

• Lactose intoleranceThere is often confusion between an allergy and an intolerance, both of which can affect breast- and formula-fed infants.

A food allergy occurs when the immune system reacts to a usually harmless food protein. This immune response leads to the release of substances, such as histamine, resulting in allergic symptoms, such as gut, skin and respiratory symptoms:

• A common food allergy is CMPA which affects approximately 1.8%-7.5% of infants in the first year of life

Contrastingly, a food intolerance does not involve the immune system, and may be enzymatic or pharmacological:

• Lactose intolerance is one example of an enzymatic food intolerance that occurs in infants causing gastrointestinal symptoms such as diarrhoea and bloating

Protein is vital for infants’ growthWhen infants are intolerant to cows’ milk protein, an alternative must be found.Under 6 monthsTo ensure infants receive adequate protein, it is acknowledged that there is a clinical need for soya formulas for infants under 6 months in the following:36,37

• Infants with CMPA or intolerance who refuse extensively hydrolysed or elemental formulas

• Infants whose parents want to offer a vegan diet. Vegan parents/caregivers who are unable to breastfeed or choose not to do so

• Infants with galactosaemia, galactokinase deficiency and lactose or sucrose intolerance

From 6 months• The BDA and FSAI state that soya infant milk may be used

for babies from 6 months with CMPA and/or lactose intolerance when soya is being used/considered for the weaning diet36-37

Cows’ milk

intolerance

* Child has been shown to have no soya allergy. BDA: British Dietetic Association. FSAI: Food Safety Authority of Ireland.



The only soya-based infant formula in the UK and Ireland.*

A nutritionally complete formula.38

Suitable for vegetarians.

SMA® Wysoy® Soya Infant Formula SMA® Wysoy® Suitability

Suitable for:SMA® Wysoy® Soya Infant Formula

is a nutritionally complete, soya protein-based infant formula that is suitable from birth onwards.

It can be used as the sole source of nutrition for infants up to 6 months of age and used as the milk part of

a mixed weaning diet. SMA® Wysoy® is lactose free, cows’ milk free and is suitable for vegetarians.

It is prescribable for milk protein intolerance,

lactose and sucrose intolerance, galactosaemia and galactokinase deficiency.

Not suitable for:1. Soya protein intolerance/allergy.

2. The inborn error of metabolism; phenylketonuria.

For suitability in vegan diets, please contact our SMA Careline.

*As of July 2015.


Whole protein Unfolds the protein Cuts the protein

1. Heat treatment

2. Specific enzymatic hydrolysis


Supporting infants at risk of allergy

One in three babies has a family history of allergy39

• Allergies are increasing – with a three-fold increase in the prevalence of atopic eczema over 15 years40

• 60–80% of babies with two parents with allergy will develop allergies41

• Supporting infants at risk of allergy – if exclusive breastfeeding is not possible, formulas that have been clinically proven to reduce the risk of allergy are recommended41

Supporting infants at risk of allergy

• SMA H.A.® Infant Milk uses a unique two step process to reduce the level of allergenicity in the protein: a heat treatment and a two stage enzymatic hydrolysis (a process which imitates natural digestion)

• This unique process cuts the proteins in exactly the right place to reduce allergenicity while retaining some larger protein strands to help train the immune system42

Family history

of allergy



In SMA H.A.®, cows’ milk proteins have been broken up into smaller pieces, which reduces the risk of infants developing an allergic response.

Partially hydrolysed whey protein formula containing 1.3 g protein per 100 ml.

SMA H.A.® Infant Milk reduces the risk of developing eczema by over 50% in the first year of life;43 it is easy to digest and available on the Healthy Start scheme (UK only).

SMA H.A.® Infant Milk

Important:• SMA H.A.® Infant Milk should NOT be used if a baby

has already been diagnosed with allergy to cows’ milk protein or is suspected of already having an allergy to cows’ milk protein

• Use from first formula feed

SMA H.A.® is an infant milk clinically proven to reduce the risk of developing eczema in infants with a family history of allergy.43

Supporting infants at risk of allergyWhat do the guidelines say?

EAACI Food Allergy and Anaphylaxis Guidelines (2014)41

“If breastfeeding is insufficient or not possible for the first 4 months, infants at high risk can be recommended a hypoallergenic formula with documented preventive effect for the first 4 months of life”

ESPGHAN (2014)44

“In high-risk infants, when breast-feeding is not possible, hydrolysates of documented safety and efficacy have an indication in infant feeding up to the age 4 to 6 months.”



References: 1. Iacono G et al. Dig Liv Dis 2005; 37(6): 432–438. 2. Vandenplas Y et al. JPGN 2015 (61); 5: 531–537. 3. Benninga M et al. Gastroenterology 2016; 150: 1443–1455. 4. Heyman MB. Pediatrics 2006; 118(3): 1279–1286. 5. NICE (2019). Clinical Knowledge Summaries: Cows’ milk protein allergy in children. Available at https://cks.nice.org.uk/cows-milk-protein-allergy-in-children#!topicsummary (accessed February 2020). 6. Armaforte E et al. International Dairy Journal 2010; 20: 715–723. 7. Martin CR et al. Nutrients 2016; 8(5): 279. 8. Billeaud C et al. Eur J Clin Nutr 1990; 44: 577–583. 9. NHS (2019). Types of formula milk. Available at https://www.nhs.uk/conditions/pregnancy-and-baby/types-of-infant-formula/ (accessed February 2020). 10. DoH (2006) https://www.hse.ie/eng/services/publications/children/unit-7-food-and-nutrition.pdf (accessed February 2020). 11. NICE (2015). Gastro-oesophageal reflux disease in children and young people. Available at https://www.nice.org.uk/guidance/ng1 (accessed February 2020). 12. Sidnell A et al. British Nutrition Foundation Nutrition Bulletin 2009; 34: 395–400. 13. Indrio F, et al. Effect of a Partially Hydrolysed Whey Infant Formula Supplemented with Starch and Lactobacillus reuteri DSM 17938 on Regurgitation and Gastric Motility. Nutrients 2017, 9, 1181. 14. SMA® Anti-Reflux data card. Available at https://www.smahcp.co.uk/formula-milk/anti-reflux-formula (accessed February 2020). 15. Aptamil Anti-Reflux datacard (June 2018). Available at https://eln.nutricia.co.uk/range/specialist-milks/ (accessed February 2020). 16. Cow & Gate Anti-reflux datacard. Available at https://eln.nutricia.co.uk/range/specialist-milks/ (accessed February 2020). 17. Hipp Organic anti-reflux datacard. Available at https://www.hipp4hcps.co.uk/resources/helpsheets/data-sheets/ (accessed February 2020). 18. Enfamil AR datacard. Available at https://hcp.nutramigen.co.uk/files/6614/6304/6719/Filofax_Insert_UK_June_2015_8.pdf (accessed February 2020). 19. St James-Roberts I et al. Early Dev Parent 1995; 4: 177–189. 20. Yao M et al. J Pediatr Gastroentrol Nutr 2010; 50(Suppl 2): PO-N-444. 21. Infante D et al. World J Gastroenterol 2011; 17: 2104–2108. 22. SMA® Comfort Easy to Digest Infant Milk datacard. Available at https://www.smahcp.co.uk/formula-milk/comfort-infant-milk (accessed February 2020). 23. Aptamil Comfort datacard. Available at https://eln.nutricia.co.uk/product-info/aptamil-comfort-from-birth-2/ (accessed February 2020). 24. Cow & Gate Comfort datacard. Available at https://eln.nutricia.co.uk/product-info/cow-gate-comfort-from-birth-2/ (accessed February 2020). 25. Hipp Organic Comfort Milk datacard. Available at https://www.hipp4hcps.co.uk/resources/helpsheets/data-sheets/ (accessed February 2020). 26. Thomas B, Bishop J (eds.) Manual of Dietetic Practice. Fourth Edition. Oxford: Blackwell Publishing 2007: 458–459. 27. Moya M et al. Acta Paediatr 1999; 88: 1211–1215. 28. Heubi J et al. J Am Diet Assoc 2000; 100: 212–217. 29. Saneian H et al. Iran J Pediatr 2012; 22: 82–86. 30. Xu JH et al. Contemp Pediatr 2009; 11: 532–536. 31. Vandenplas Y et al. Nutrition 2013; 29: 184–194. 32. NHS (2019). Lactose Intolerance. Available at https://www.nhs.uk/conditions/lactose-intolerance/ (accessed: January 2020). 33. SMA® LF® Lactose Free Infant Milk datacard. Available at https://www.smahcp.co.uk/formula-milk/lactose-free-formula (accessed February 2020). 34. Aptamil Lactose Free datacard. Available at: https://www.eln.nutricia.co.uk/media/4354/datacard_aptamil_ lactose_free.pdf (accessed December 2018). 35. Mead Johnson, Enfamil 0-Lac, information from Mead Johnson customer careline, 2016. 36. British Dietetic Association. Paediatric Group Position Statement Use of Infant Formulas based on Soy Protein for Infants. BDA, April 2019. 37. Food Safety Authority of Ireland, Best Practice for Infant Feeding in Ireland (2012). Available at https://www.lenus.ie/handle/10147/252765 (accessed February 2020). 38. SMA® Wysoy® Soya Infant Formula datacard. Available at https://www.smahcp.co.uk/formula-milk/soya-infant-formula (accessed February 2020). 39. Bergmann RL et al. Clin Exp Allergy 1997; 27: 725–760. 40. Eichenfield LF et al. Pediatrics 2003; 111: 608–616. 41. Muraro A et al. EAACI Food Allergy and Anaphylaxis Guidelines. Primary prevention of food allergy. Allergy 2014; 69(5): 590–601. 42. Jost R et al. Bibl Nutr Dieta 1991; 48: 127–137. 43. von Berg A et al. J Allergy Clin Immunol 2008; 121: 1442–1447.

IMPORTANT NOTICE: The World Health Organisation (WHO) has recommended that pregnant women and new mothers be informed on the benefits and superiority of breastfeeding – in particular the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for, and maintenance of, lactation, with special emphasis on the importance of a well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle-feeding or other foods and drinks should be discouraged since it will have a negative effect on breastfeeding. Similarly, mothers should be warned of the difficulty of reversing a decision not to breast-feed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision: for example, if a baby is exclusively bottle-fed, more than one can (400 g) per week will be needed, so the family circumstances and costs should be kept in mind. Mothers should be reminded that breast milk is not only the best, but also the most economical food for babies. If a decision to use an infant formula is taken, it is important to give instructions on correct preparation methods, emphasising that unboiled water, unsterilised bottles or incorrect dilution can all lead to illness. SMA® Wysoy® milk-free formula is intended to meet the nutritional needs of babies and children who are intolerant to cows’ milk protein, lactose or sucrose. Soya infant formulae are not recommended for preterm babies or those with kidney problems, where medical guidance should always be sought. SMA® PRO Follow-on Milk and SMA® Organic Follow-on Milk are only suitable for babies over 6 months as part of a mixed diet. They should not be used as a substitute for breast milk during the first 6 months of life. The decision to start weaning or to use a follow-on milk before 6 months, should be made only on the advice of a doctor, midwife, health visitor, public health nurse, dietitian or pharmacist, based on baby’s individual needs. SMA® PRO Growing up Milk is suitable for young children from 1-3 years, as part of a healthy balanced diet and it is not a breast milk substitute. SMA® Organic Growing up Milk is suitable for young children from the 12th month, as part of a healthy balanced diet and it is not a breast milk substitute. The following products must be used under medical supervision. SMA® Anti-Reflux is a special formula intended for the dietary management of bottle-fed babies when significant reflux (regurgitation) is a problem. It is suitable as the sole source of nutrition up to 6 months of age, and in conjunction with solid food up to 12 months of age. If the baby’s reflux does not improve within 2 weeks of starting SMA® Anti-Reflux, or if the baby fails to thrive, the family doctor should be consulted. SMA LF® is a lactose-free milk based formula for babies and young children who are intolerant to lactose or sucrose, or who are experiencing symptoms such as diarrhoea, tummy ache or wind caused by temporary lactose intolerance. It is suitable as the sole source of nutrition up to 6 months of age, and in conjunction with solid food up to 18 months of age. SMA High Energy® is a milk based formula for the dietary management of babies and young children with medically determined high energy requirements as identified by a healthcare professional. It is suitable as the sole source of nutrition up to 6 months of age, and in conjunction with solid food up to 18 months of age. SMA High Energy® is not intended for use with preterm babies, for whom fortified breast milk or a low birthweight formula such as SMA Gold Prem® 1 is more appropriate. SMA® Breast Milk Fortifier is a nutritional supplement designed to be added to expressed breast milk for the dietary management of feeding preterm low birthweight babies. SMA Gold Prem® 1 is a special formula intended for the dietary management of preterm low birthweight babies who are not solely fed breast milk. It is suitable for use as the sole source of nutrition for preterm babies from birth. SMA Gold Prem® 1 is not intended for use with older preterm babies, for whom a special catch-up formula such as SMA Gold Prem® 2 is more appropriate. SMA Gold Prem® 2 is a special catch-up formula intended for the dietary management of preterm low birthweight babies who are not solely fed breast milk. It is a nutritionally complete formula for use on discharge from hospital or when a low birthweight formula is no longer appropriate. It is suitable for use as the sole source of nutrition up to 6 months corrected age. SMA Gold Prem® 2 is not intended for use with newborn preterm babies, for whom fortified breast milk or a low birthweight formula such as SMA Gold Prem® 1 is more appropriate.

NWP089; CHLWP022; FRJNP008; IRFI1P002; NWH200-1; IRGMAP005; FRJNP008; NLNW031; DSHL003-1; DENWHS016; DSS005-1; DEDWHL008; DSHL001-2; DSH204; DSH001; NW102; LE136; JN070; NW101; LE135 ;JN069NWHP315F; NWHP315G; NWHP315H


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SMA® Nutrition’s Specialist formula range: Individually tailored to meet the challenges of specific infant feeding issues

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SCIENCE INSPIRED BY NATURE Specially Tailored …...SCIENCE INSPIRED BY NATURE Practical guidance...

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