Whilst these guidelines advise on the appropriate choice of specialist infant formula, breast milk remains the optimal choice for infants. This should be promoted and encouraged where it is clinically safe to do so.
Definition and Diagnosis
- Weight loss of up to 10% of birth weight is common in the early days of life. Birth weight is usually regained before 3 weeks of age as feeding is established.
- Faltering growth after the early days of life is characterised by a slower rate of weight gain than expected for age, sex, and current weight.
- It is not possible to detect faltering growth without using appropriate growth charts.
- A detailed clinical and feeding history should be taken to look for evidence of dehydration or possible medical causes for faltering growth.
- The length of an infant should be measured and monitored to assess linear growth and growth potential.
Using UK WHO Growth Charts to detect faltering growth:
- If birth weight of infant is less than the 9th centile: threshold for concern is a fall in 1 or more weight centile spaces.
- If birth weight is 9th to 91st centile: threshold for concern is a fall in 2 or more weight centile spaces.
- If birth weight is more than 91st centile: threshold for concern is a fall in 3 or more weight centile spaces.
- For any birth weight: threshold for concern includes if current weight is below the 2nd centile for age.
Onward Referral
Consider referral to secondary care for paediatrician assessment and or referral to paediatric dietitians.
A high energy formula may be recommended following assessment.
Review and Discontinuation of Prescription
All infants on high energy formula will need their growth (weight and length) monitored to ensure catch up growth is achieved.
Once catch-up growth has been achieved the formula should be discontinued to minimise excessive weight gain. Review recent correspondence from the paediatric dietitian.
Choice of formula
High energy formula – not to be routinely initiated in primary care.
Preferred High Energy Formula
SMA® High Energy
200ml carton or 90ml bottle. Birth to 18 months or up to 8kg in body weight.
Other High Energy Formula
To be prescribed if preferred formula not appropriate or not tolerated, as recommended by a dietitian:
Infatrini®
125ml, 200ml or 500ml bottle. Birth to 18 months or up to 9kg in body weight.
Similac® High Energy
60ml or 200ml bottle. Birth to 18 months or up to 8kg in body weight.
High Energy Formula with Medium Chain Triglycerides (MCT)
Formula with at least 50% MCT to be started in secondary care or by specialist dietitian for infants with malabsorption and or maldigestion.
Infatrini® Peptisorb
125ml, 200ml or 500ml bottle. Birth to 18 months or up to 9kg in body weight.
Quantity to prescribe
For liquid high energy formula:
Review recent correspondence from paediatrician or paediatric dietitian. If it is necessary to prescribe a high energy formula prior to paediatrician or dietitian assessment; prescribe an equivalent volume of formula to the child’s usual intake. Consider prescribing a 2 week supply only until tolerance and compliance are established.
Breastfeeding
Supplementary feeding with a high energy infant formula in a breastfed infant may help with weight gain, but often results in cessation of breastfeeding. Therefore:
- Support mothers to continue breastfeeding
- Advise expressing breast milk to promote milk supply
- Advise to feed the infant with any available breast milk before giving any infant formula
References and resources
NICE Guideline NG75: Faltering growth: recognition and management of faltering growth in children.