Infant Feeding Difficulties Clinic (IFDC) & Infant Feeding Allergy Clinic (IFAC)

For symptoms suggestive of reflux:

• Back arching/pulling up legs/extreme discomfort
• Extreme crying for >3-4 hrs/day for at least a week
• Oral aversion: refusing feeds or taking small amount
• Poor sleep (i.e. difficult to settle, not keen to lay on back, crying out in pain)
• Regurgitation & at least one of the above symptoms
• Coughing/hiccupping/wheezing/hoarse

First line advice: to follow prior to referral:

1. 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
2. Formula fed: ensure feeding is responsive: feed to around 150ml/kg/day (1oz = 28ml) & try small frequent feeds

If no improvement:

4. Breast Fed: Start a two week trial of Gaviscon Infant or Cow & Gate Instant Carobel. For Carobel give as a paste before feeding 3 scoops to 2oz EBM 
   Formula Fed: Start a two week trial of Carobel as follows:
   Start at:  ½ scoop of carobel for every 90mls/3oz of feed. If there is no improvement, then increase to 1 scoop – 1 ½ scoops per 90ml/3oz of feed. See separate information sheet on carobel.
5. If no improvement to symptoms: Refer immediately to IFDC. Consider commence dispersible Omeprazole at 1mg/kg o.d (with minimum dose of 5mg). It is good practice to provide Omeprazole advice sheet https://www.medicinesforchildren.org.uk/omeprazole-gastro-oesophageal-reflux-disease-gord

For symptoms suggestive of CMPA:

• Regurgitation with no signs of reflux
• Loose stools +/- blood/mucus
• Constipation
• Discomfort after feeding
• Painful wind
• Skin rashes
• Eczema/dry skin
• Hives/swelling/immediate flare ups of eczema/rashes*

1. Breastfed infants refer to specialist breastfeeding service via specialistbreastfeedingclinic@nhs.scot
2. Formula fed: Commence 3 week trial of Extensively Hydrolysed Formula (e.g. SMA Althera with Carobel (as above). Request 8 tins only on prescription and not for repeat script at this stage. AFTER 3 WKS RE-CHALLENGE back to standard formula*. Trial & re-challenge sheets are available from the dietitian.
3. If symptoms resolve on EHF & reoccur on re-challenge: continue with EHF & immediately refer to IFAC via paediatric dietetics paediatricdietitians@highland.gov.uk

*DO NOT RE-CHALLENGE:  if IgE mediated CMPA is suspected i.e. Hives/swelling/immediate flare ups of eczema /rashes. Start EHF and refer immediately to dietetics