Tuesday, November 23, 2010

Best position for baby to sleep

I have had an influx of parents asking what I recommend to be the best position for their child to sleep in.

Now, of course, when you search this on google, anyone would find the advice on the 'back to sleep' campaign that was created in 1994 to help avoid Sudden Infant Death Syndrome (SIDS). But what about best for the back, spine and skull?

In adults, we see a lot of back and neck pain that can easily be related to sleeping in the prone (on the front) position. This is because of the lower back having to arch, and the neck being turned to one side. So, naturally, it makes sense that this is the same case in children. Sleeping on the front is not advised, with the back in mind. Consequently, sleeping on the back or side can be seen as a good position for the developing spine.

Lying on the side?
Interestingly lying on the side position has shown in a few studies to increase the likelihood of SIDS, but the research is still divided. The main understanding is that the risk of SIDS is significantly reduced by lying on either the side or back. The American Academy of Paediatrics has advised that if the child is sleeping on the side, the arm on the 'dependent' downside arm should be put in front of the child and out at a 90 degree angle. This aims to decrease the likelihood of the infant rolling onto the front - which is what the research seems to show is the risk to sleeping on the side - rolling onto the front and creating breathing problems.

In my opinion, sleeping on the side is fine, but everytime the child is placed back into the cot/bed, then they should be placed on the opposite side. This avoids preference of head position and turning. Keeping stimulus equal from side to side is important for the child's neurological development.

Sleeping on the back is obviously recommended, but this has created an increase in positional plagiocephaly (flattening of the skull) over the years of its recommendation. This is a benign condition and the head will normalise once the child has begun to sit. But this can also be balanced out by giving the child enough tummy time - when awake.

Shall I use the wedge support?
The use of supporting wedges to help the child stay, particularly on the side position, has not been shown to be of any value. The AAP Task Force does not recommend their use. They suggest that for a child to sleep on their side, put the dependent arm out and support the back of the child against the side of the cot.
The child sleeping on their back does not need any support.

Should healthy babies ever be placed on their front?
It is vital for the development of the strength of the neck, shoulder girdle and back for the child to be placed on the front. However, this must be done when the child is awake, and in a happy alert state. The younger the child, the more they will probably complain. This is not that it may be particularly uncomfortable - its just hard work! The head is heavy and its hard to keep it up all the time! 'Tummy time' is very important, but it doesn't have to be for such long periods of time - even a minute at a time if it has to be.

Recommended reading
http://www.nichd.nih.gov/sids/sids_qa.cfm - Questions and Answers on the 'back to sleep' campaign from the Task Force by the American Academy of Pediatrics

Thursday, October 7, 2010

Which Infant Formula?

Of course we all suggest that breastmilk is best when feeding a newborn child, but what happens when you cannot breastfeed or express milk and now you have to look at the infant formula market? Which formula is better for your baby?

The latest information from the American Academy of Paediatrics (2009) suggests that certain formulas should be used for certain types of child. It is important to note any familial allergies, current symptoms of fussiness, reflux, gas and type of stool (soft, hard runny, bubbly) when taking into consideration each type of infant formula. The AAP suggests that all children under 12 months should be breastfed or be fed using an iron-fortified infant formula. They suggest that the child older than 12 months should be given whole milk, not skimmed or semi-skimmed.

The typical infant formula that is suggested to be the routine in all babies is the Standard milk-based formula. These formulas have been derived from cows-milk protein and changed to be similar to breast-milk. Lactose and minerals from the cow's milk, as well as vegetable oils, minerals, and vitamins are also in the formula. The American Academy of Paediatrics suggests that the majority of children will do well on this formula. They advise that fussiness and colic symptoms are typically not related to the infant formula, and it is not necessary to switch to a different formula in such cases.

Commonly, from my experience, it is usually the action of changing the infant formula that tends to be the issue than the actual formula itself. It seems to take the child’s digestive system approximately a week to normalise after the change of a formula, which during this time will commonly entail a shift between loose stools through to hard through to soft again. It is usually 2 or 3 days into the change that the parents see that ‘oh no, the child is constipated now’ with the harder stools and then go and change the formula yet again...creating another cycle of issues. If you are not sure whether this is the right formula for the child, wait for a week. Unless you get frothy, extremely pungent stools, which in this case, it’s probably lactose intolerance and best to ask the advice of your medical practitioner.

If your child has been diagnosed with galactosemia, or congenital lactase deficiency, then the soy based formulas are suggested. These formulas are derived from soy and do not contain lactose. They are also designed for the family who does not want their child to consume animal-derived protein. For the baby who may be allergic to cow’s milk it is not always that they will not be allergic to soy as well. Soy based formulas have not been shown to be helpful for milk allergies or colic. Most of the time soy based formulas are used as an alternative, due to the high expense of the hypoallergenic formulas. Research suggests that the evidence is still out there on the effect of the phyto-oestrogen content of the soy products. These increase the isoflavone serum levels (in the blood) which when administered directly to animals can cause decrease in fertility. However,clinically relevant adverse effects of soy formulas in infants are not reported. 

Hypoallergenic formulas are designed for the true allergy to milk protein baby, or wheezes, or skin rashes from allergies. They contain extensively hydrolysed proteins that are less likely to stimulate antibody production in the child, hence aiming to decrease the allergic reaction to the formula.

Lactose-free formulas are ones that are specifically for congenital or primary lactase deficiencies, or galactosemia children. Please take note that lactase deficiency can only be diagnosed when the child is over 12 months old using special tests.
A child who has an illness with diarrhoea does not necessarily need a lactose-free formula. Though, a temporary lactase deficiency can arise after an acute bout of gastroenteritis, soy and lactose-free formulas shorten the bout of diarrhoea, but do not change the overall recovery or weight gain in the following 2-week period.

Anti-Reflux formulas are thickened with rice starch and are designed to be used for the reflux child who is not gaining weight or who is very uncomfortable. They are shown to decrease vomiting/regurgitation, but have not been shown to affect growth or development.

There are also special premature and low birth weight formulas that are designed for the premie. These contain extra calories and minerals to aid the child who needs to put on weight.

Interestingly, the formulas designed for Toddlers who are picky eaters, have not been shown to be any better than whole milk and multivitamins.


O'Connor NR (2009). Infant formula. Am Fam Physician.79:565-570.

Vandenplas Y (2010). Soy infant formula: is it that bad? Acta Paediatrica. Sept 22.

Thursday, March 11, 2010

Breastfeeding and Maternal Diet

Breastfeeding and mothers nutrition
When looking at the maternal diet whilst breastfeeding I came across little documented evidence that confirms what to and what not to eat whilst breast feeding to avoid any ‘colicky’ symptoms in the child. Surprising given all the ‘old wives tales’ about you can’t eat this or that whilst breast feeding.

So, for the sake of all those rumours and hours of chatting mothers saying the ‘not so evidence-based’ anecdotes, I decided to put it all on my blog so others cannot be soooo confused!

In the early research days in an article by Evans et al., found that a number of foods, particularly chocolate and fruit, did seem to cause an increase in colicky symptoms, but cow’s milk showed no significant change in symptoms.  R. W. Evans, R. A. Allardyce, D. M. Fergusson, Brent Taylor (1981). Maternal diet and infantile colic in breast fed infants. The Lancet  317 (8234): 1340-2
However, another earlier article had written that their evidence showed that it was worthwhile for breast feeding mothers to exclude cow’s milk in their diet to avoid colicky symptoms. But, looking at the ages ranges in the experiment, it was highly likely that the colicky symptoms disappeared as a matter of time anyway. Jakobsson I, Lindberg T. (1978). Cow's milk as a cause of infantile colic in breast-fed infants. The Lancet  312  (8087) 437-439
Two of the most in-depth studies in 1995 and 1996 however, did seem to show a little more promise in identifying the ‘cursed’ foods. The study by Hill et al., (1996) took out all the previously said allergens in a diet and gave mothers a diet that was artificial colour-free, preservative-free, and additive-free and also randomized some to an active low allergen diet (milk-, egg-, wheat-, nut-free). 
For those that would like to know, the diet only allowed:
Rice, buckwheat, apple, pear, water, watery tea, watery coffee, potato, pumpkin, zucchini, marrow, lettuce, carrot, cauliflower, squash, lamb, beef, chicken, veal, turkey, fish, milk-free margarine, safflower oil, honey, sugar, salt and pepper.
Hill et al concluded that “a period of dietary modification with low allergen diet should be considered to avoid colicky symptoms”. Hill D J et al. (1995). A low allergen diet is a significant intervention in infantile colic: Results of a community-based study. J Allergy and Clinical Immunology 96 (6) 886-892
Lust et al. In 1996 came up with the research that colic was significant with the consumption of: Cabbage, cauliflower, broccoli, cow’s milk, onion and chocolate. They said that the occurrence of colicky symptoms may depend less on how often these item are consumed than whether they were consumed at all. Lust K D et al. (1996). Maternal intake of cruciferous vegetables and other food and colic symptoms in exclusively breast-fed infants.  J Am Diet Assoc  96 (1): 46-48

As to the reason why these foodstuffs cause the colicky symptoms the jury is still out. Some have come to say that the cruciferous veggies have a certain chemical that could irritate the intestines and cause gas, and others suggest that cow’s milk intolerance is immunologically mediated. Whether this is just a transient protein intolerance that improves after 6 weeks of age, in regards to the cow’s milk protein, is also still to be argued.