Infant Feeding: Human Milk and Formula Joan C Zerzan MS RD CD

Feeding Recommendations Considerations Growth in infancy Physiology of infancy GI Renal Infant Development Nutrient requirements Programming Health and prevention

Feeding Recommendations Nutrient needs Programming Health, development, and prevention

Considerations Coordinated sucking and swallowing Gastric emptying Intestinal motility Secretions: salivary, gastric, pancreatic, hepatobiliary Enterocyte function in terms of enzyme synthesis, absorption, mucosal protection Metabolism of products of digestion and absorption Expulsion of undigested waste products

Physiology - GI Maturation

In utero Fetal GI tract is exposed to constant passage of fluid that contains a range of physiologically active factors: growth factors hormones enzymes immunoglobulins These play a role in mucosal differentiation and GI development as well as development of swallowing and intestinal motility

At Birth Gut of the newborn is faced with the formidable task of passing, digesting, and absorbing large quantities of intermittent boluses of milk Comparable feeds per body weight for adults would be 15 to 20 L

Gut Hormones Gastrointestinal peptides are found in venous cord blood at birth in levels similar to those of fasting adults In fetal distress a number of gut peptides are elevated which might account for passage of meconium With enteral feeding levels of gut hormones (motilin, neurotensin, GIP (gastric inhibitory peptide), gastrin, enteroglucagon, PP - pancreatic polypeptide, rise rapidly

Gut Hormones Influenced By: Choice of breast or formula feeds Enteric intake (induces epithelia hyperplasia and stimulates production of microvillous enzymes) Early enteral feeding (enteral feeding is strongly encouraged to promote GI function and differentiation)

Possible Roles for Gut Hormones in Early Infancy

Pancreas Pancreatic function is relatively deficient at birth and mature levels of pancreatic enzymes are not achieved until late infancy Pancreatic amylase activity increases after 4 to 6 months Lipase levels do not approach adult efficiency until about 6 months

Protein Digestion

Carbohydrate Digestion

Fat Digestion

Motility - Upper GI Esophageal motility is decreased in the newborn LES is primarily above the diaphragm LES pressure is less for first months Gastric Emptying may be delayed

Motility - Intestinal Intestinal motility is more disorganized Prolonged transit time in upper intestines may improve absorption of nutrients Rapid emptying of ileum and colon may reduce time for water and electrolyte absorption and increase risk of dehydration

Maturation in First Year LES tone increases after 6 months and is associated with less reflux in most infants Gastric acid and pepsin activity do not reach adult levels until 2 years Pancreatic amylase increases by 6 months Retention of lactase activity is typical until 3 to 5 years. Fat absorption does not approach adult efficiency until about 6 months Lipase reaches adult levels by 2 years.

Renal Limited ability to concentrate urine in first year due to immaturities of nephron and pituitary Potential Renal solute load determined by nitrogenous end products of protein metabolism, sodium, potassium, phosphorus, and chloride.

Potential Renal Solute Load

Renal solute load Samuel Foman J Pediatrics Jan 1999 134 # 1 (11-14) RSL is important consideration in maintaining water balance: In acute febrile illness Feeding energy dense formulas Altered renal concentrating ability Limited fluid intake

RSL Water balance RSL in diet Water in Water out Renal concentrating ability

Urine Concentrations Most normal adults are able to achieve urine concentrations of 1300 to 1400 mOsm/l Healthy newborns may be able to concentrate to 900-1100 mOsm/l, but isotonic urine of 280-310 mOsm/l is the goal In most cases this is not a concern, but may become one if infant has fever, high environmental temperatures, or diarrhea

Programming by Early Diet Nutrient composition in early diet may have long term effects on GI function and metabolism Animal models show that glucose and amino acid transport activities are programmed by composition of early diet Animals weaned onto high CHO diet have higher rates of glucose absorption as adults compared to those weaned on high protein diet

Allergies: Areas of Recent Interest Early introduction of dietary allergens and atopic response atopy is allergic reaction/especially associated with IgE antibody examples: atopic dermatitis (eczema), recurrent wheezing, food allergy, urticaria (hives) , rhinitis Prevention of adverse reactions in high risk children

Allergies: Infancy Increased risk of sensitization as antigens penetrate mucosa, react with antibodies or cells, provoking cellular response and release of mediators Immaturities that increase risk: gastric acid, enzymes microvillus membranes lysosomal functions of mucosal cells immune system, less sIgA in lumen

Allergies: IDDM Theory: sensitization and development of immune memory to food allergens may contribute to pathogenesis of IDDM in genetically susceptible individuals. Milk, wheat, soy have been implicated. Breastfeeding and delay in non-milk feedings may be beneficial. “There is little firm evidence of the significance of nutritional factors in the etiology of type 1 diabetes.” (Virtanen SM, Knip M. Am J Clin Nutr , 2003)

Feeding the Infant Choices: Human Milk Standard Infant Formula (Cow, Soy) Hypoallergenic (hydrolysates vs amino acid based Other specialty formulas Preterm Post discharge formulas for preterm infants

Infant Feeding: Historical Perspective Breast feeding Human Milk Substitutes Science, Medicine and Industry

“No two hemispheres of any learned professor’s brain are equal to two healthy mammary glands in the production of a satisfactory food for infants” - Oliver Wendell Holmes

Human Milk Complements Immaturities of these systems Promotes maturation Epithelial growth factors and hormones Digestive enzymes - lipases and amylase

Characteristics and Advantages of Human Milk Low renal solute load Immunologic, growth and trophic factors Decrease illness, infection, allergy Improved digestion and absorption Nutrient Composition: CHO, Protein, Fatty Acid, etc Cost Other

Breast milk Nutrient composition of breastmilk is remarkable for its variability, as the content of some of the nutrients change during lactation, throughout the bay, or differ among women, while the content of some nutrients remain relatively constant throughout lactation.

Human Milk Colostrum Higher concentration of protein and antibodies Transitions around days 3-5 Mature by day 10

Breastmilk and establishment of core microbiome Definition: Full collection of microbes that naturally exist within the body. Alterations or disruptions in core microbiome associated with chronic illness: Crohns disease, increased susceptability to infection, allergy, NEC, etc

Microbiome Beneficial effect for the host: Nutrient metabolism Tissue development Resistance to colonization with pathogens Maintenance of intestinal homeostasis Immunological activation and protection of GI integrity

Human milk and microbiome Core microbiome established soon after birth Core microbiome of breastfeeding infant similar to core microbiome of lactating mother Components of breastmilk supporting establishment of microbiome Prebiotics,probiotics

AAP: Breast milk and allergy 1.Breast milk is an optimal source of nutrition for infants through the first year of life or longer. Those breastfeeding infants who develop symptoms of food allergy may benefit from: a.maternal restriction of cow's milk, egg, fish, peanuts and tree nuts and if this is unsuccessful, b.use of a hypoallergenic (extensively hydrolyzed or if allergic symptoms persist, a free amino acid-based formula) as an alternative to breastfeeding.

Protein: Predominant protein of human milk is whey & predominant protein in cow’s milk is casein Casein: proteins of the curd (low solubility at pH 4.6) Whey: soluble proteins (remain soluble at pH 4.6) Ratio of casein to whey is between 40:60 and 30:70 in human milk and 82:18 in cow’s milk some formulas provide more whey proteins than others

Distribution of Kcals

Allergies: Breastmilk May be protective due to sIgA and mucosal growth factors Maternal avoidance diets in lactation remain speculative. May be useful for some highly motivated families with attention to maternal nutrient adequacy.

AAP: Breastfeeding and the Use of Human Milk, 1997 “Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth….It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired.”

AAP: Breastfeeding and the Use of Human Milk, 1997 Human milk is the preferred feeding for all infants Breastfeeding should begin as soon as possible after birth Newborns should be nursed 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes per breast. (Crying is a late indicator of hunger.)

AAP: Breastfeeding and the Use of Human Milk, 1997 Formal evaluation of breastfeeding by trained observers at 24-48 hours and again at 48 to 72 hours. No supplements should be given unless a medical indication exists. When discharged at <48 hours, should have FU visit at 2 to 4 days of age, assessment at 5 to 7 days, and be seen at one month.

AAP: Breastfeeding and the Use of Human Milk, 1997 “Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding preferably directly or by pumping the breasts.”

AAP statement on breastfeeding (continued) Supplements (water, glucose, formula) should be avoided (unless medically necessary). Pacifiers should also be avoided. Exclusive breastfeeding is ideal for the first 6 months. Breastfeeding should continue for at least 12 months.

AAP statement on breastfeeding (continued) In the first 6 months, water, juice and other foods are generally unnecessary. Vitamin D and iron may be needed. Fluoride should not be given during the first 6 months.

a.Breastfeeding mothers should continue breastfeeding for the first year of life or longer. During this time, for infants at risk, hypoallergenic formulas can be used to supplement breastfeeding. Mothers should eliminate peanuts and tree nuts (eg, almonds, walnuts, etc) and consider eliminating eggs, cow's milk, fish, and perhaps other foods from their diets while nursing. Solid foods should not be introduced into the diet of high-risk infants until 6 months of age, with dairy products delayed until 1 year, eggs until 2 years, and peanuts, nuts, and fish until 3 years of age.

Formula Human Milk Substitutes History Regulation Composition and indications

Formula Composition Breast Milk as “gold standard” Attempt to duplicate composition of breast milk ? Bioactivity, relationship, function of all factors present in breast milk ? Measure outcome: growth, composition, functional indices Examples: DHA/ARA, Prebiotics and Probiotics Evaluation: growth, composition, functional indices, other measures of safety and efficacy

Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants (2006) There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy compared to exclusive breast feeding. In high risk infants who are unable to be completely breast fed, there is limited evidence that prolonged feeding with a hydrolysed formula compared to a cow's milk formula reduces infant and childhood allergy and infant cow’s milk allergy. In view of methodological concerns and inconsistency of findings, further large, well designed trials comparing formulas containing partially hydrolysed whey, or extensively hydrolysed casein to cow's milk formulas are needed.

Human Milk Substitutes Early evidence of artificial feeding Majority of infants received breast milk Maternal BF Wet nurses Wealthy women Orphans, abandoned, “illegitimate” Prematurity or congenital deformities

Human Milk Substitutes Wet nurses Other mammalian milk (cow, goat, donkey, camel) Pablum: bread/flour, mixed with water “bread, water, flour, sugar and castille soap to aid digestion”

Human Milk Substitutes 1915 Gerstenberger developed first “complete infant formula” marketed as SMA (synthetic milk adapted) Base was defatted and diluted cow’s milk with beef tallow added to mimic the fat content of human milk

Human Milk Substitutes 1920-1950’s: evaporated or fresh cow’s milk, water and added CHO (prepared at home) 1950’s to present commercially prepared infant formulas have replaced home recipes

Science, Medicine, and Industry Infant Morbidity and Mortality Recognition of association with human milk substitutes, and infection Industrial development Storage Safety Food industry

Science, Medicine, and Industry Growth of child Health and welfare in early 20th century

Historical timeline 1900 Pasteurization of milk in US Association between bacteria and diarrhea 1912 U.S Children’s Bureau Public Health and Pediatricians efforts to improve infant/child health and decrease mortality 1920 Intro evaporated milk Cod liver oil prevents rickets Curd tension of milk altered Increased availability of refrigeration Vitamin C isolated Vitamin D prepared in pure form Improved sanitation

Historical timeline 1940 1960 Homogenized milk widely marketed Further advances in technology and packaging Commercially prepared infant formula becoming increasingly popular

Infant Formulas - History Cow’s milk is high in protein, low in CHO, results in large initial curd formation in gut if not heated before feeding Early Formulas from 1920-1950 majority of non-breastfed infants received evaporated milk formulas boiled or evaporated milk solved curd formation problems cho provided by corn syrup or other cho to decrease relative protein kcals

Soy Formulas First developed in 1930s with soy flour Early formulas produced diarrhea and excessive gas Now use soy protein isolate with added methionine

Infant Formula - History, cont. 50s and 60s commercial formulas replaced home preparation 1959: iron fortification introduced, but in 1971 only 25% of infants were fed Fe fortified formula Cow’s milk feedings started in middle of first year between 1950-1970s. In 1970 almost 70% of infants were receiving cow’s milk.

Regulation of Infant Formula FDA Infant Formula Act Manufacturers Voluntary monitoring AAP, National Academy of Sciences, other professional organizations Guidelines for composition and intake: (e.g. DRI’s) Guidelines for preparation and handling of formula/human milk in health care facilities

Regulation of Infant Formulas Infant Formula Act: The purpose of the infant formula act (1980) is to ensure the safety and nutrition of infant formulas – including minimum and in some cases maximum levels of specified nutrients. The act authorizes the FDA to establish appropriate regulations for 1) new formulas, 2) formulas entering the U.S. market, 3) major changes, revisions, or substitutions of macronutrients 4) formulas manufactured in new plants or processing lines, 5) addition of new constituents 6) use of new equipment or technology 7) packaging changes

Formula Regulation Regulation is by the Infant Formula Act of 1980, under FDA authority Nutrient composition guidelines for 29 nutrients established by AAP Committee on Nutrition and adopted as regs by FDA Nutrient Requirements for Infant Formulas. Federal Register 36, 23553-23556. 1985. 21 CFR Part 107.

Regulation of Infant Formulas Infant Formula Act: Manufacturing regulations Quality control Non specific testing requirements, case by case basis, growth outcomes Recall Procedures Nutrient content and labeling Panel convened 1998 and 2002 (recommended revisions including exemptions)

Infant Formula Act Institute of Medicine Food and Nutrition Board 3/2004 “Although the federal regulatory processes for evaluating the safety of food ingredients have worked well for conventional substances, they were not designed to ensure the needs and vulnerabilities of infants and are insufficient to ensure the safety of new types of ingredients proposed for infant formulas

Infant Formula Act “The current regulatory processed do not fully address the unique role of formula as a food source. Formula is the only infants’ food if they are not being breastfed. The processes used to regulate the safety of any new additions of formula should be tailored to these products distict role and the special needs and susceptibilities of infants”

Infant Formula Act Key limitation: lack of explicit guideleines for determining when and what safety data is needed…..(GRAS) Clarification is crucial given the increasing number of bioactive peptides and enzymens generated from unconventional sources or new technologies

Infant Formula Act: Points for discussion Addition of DHA and ARA to formulas Addition of prebiotics to formula Present in BM GRAS Vitamin/mineral content conforms to regulation ? testing

Standard Infant Formulas, Milk or Soy Based………..

Cow’s Milk Based Formula Commercial formula designed to approximate nutrients provided in human milk Some nutrients added at higher levels due to less complete digestion and absorption

Formula Brands Ross Mead Johnson Nestle Wyeth SHS Similac/Isomil/Alimentum Mead Johnson Enfamil/Prosobee/Enfacare Nestle Good Start Wyeth Generic in USA; Gold Brands; SMA SHS NeoCate, DuoCal

Milk Based Formulas Standard 0-12 months Similac with iron Enfamil with iron Good Start Essentials/Good Start Supreme Wyeth Generic Standard 0-12 mos with DHA/ARA Similac Advance with iron Enfamil Lipil with iron Good Start Supreme DHA/ARA Wyeth formulas

Milk Based Formulas Characteristics Blend of Whey and Casein Proteins (8.2-9.6 % total calories) Carbohydrate: lactose Fats: long chain Meet needs of healthy infant

Protein, cont. whey proteins of human and cow’s milk are different and have different amino acid profiles. Major whey proteins of human milk at a lactalbumin (high levels of essential aa) , immunoglobulins, and lactoferrin( enhances iron transportation) Cow’s milk has low levels of these proteins and high levels of b lactoglobulin Infants appear to thrive equally well with either whey or casein predominant formulas.

Cow’s Milk Based Formula: Fat & CHO Fat: butterfat of cow’s milk is replaced with vegetable fat sources to make the fatty acid profile of cow’s milk formulas more like those of human milk and to increase the proportion of essential fatty acids Cho: Lactose is the major carbohydrate in most cows’ milk based formulas.

Infant Formulas: AAP Cow’s milk based formula is recommended for the first 12 months if breast milk is not available

Soy Formulas Isomil/Isomil DF /Isomil Advance/Isomil Advance 2 Prosobee/Prosobee Lipil/Next Step Prosobee Good Start Essentials Soy/Good Start 2 Essentials Soy Wyeth All iron fortified

Soy Formulas Protein: soy protein isolate with added methionine Fat: vegetables oils Cho: usually corn based products

Soy Formulas Characteristics compared to Milk Based Higher protein (lower quality) Higher sodium, calcium, and phosphorus Carbohydrate: Corn syrup solids, sucrose, and/or maltodextrin; lactose free Fats: Long chain Meet needs of healthy infants

Possible Concerns about Soy Formulas: AAP 60% of infants with cowmilk protein induced enterocolitis will also be sensitive to soy protein - damaged mucosa allows increased uptake of antigen. Contains phytates and fiber oligosacharides so will inhibit absorption of minerals (additional Ca is added) Higher levels of osteopenia in preterm infants given soy formulas Phytoestrogens at levels that demonstrate physiologic activity in rodent models Higher aluminum levels

Health Consequences of Early Soy Consumption. Badger et al. J Nutr US soy formulas made with soy protein isolate (SPI+) SPI+ has several phytochemicals, including isoflavones Isoflavones are referred to as phytoestrogens Phytoestrogens bind to estrogen receptors & act as estrogen agonists, antagonists, or selective estrogen receptor modulators depending on tissue, cell type, hormonal status, age, etc.

Figure 1. Hypothetical serum concentrations profile of isoflavones from conception through weaning in typical Asians and Americans. The values represent the range of isoflavonoids reported by Adlercreutz et al. (6 ) for Japanese (dotted lines) or reported by Setchell et al. (3 ) for Americans fed soy infant formula (dashed line).

Should we be Concerned? - Badger et al. No human data support toxicity of soyfoods Soyfoods have a long history in Asia Millions of American infants have been fed soy formula over the past 3 decades Rat studies indicate a potential protective effect of soy in infancy for cancer

Soy formulas given to 25% of infants but needed by very few American Academy of Pediatrics Committee on Nutrition. Soy Protein-based Formulas: Recommendations for Use in Infant Feeding. Pediatrics 1998;101:148-153. Soy formulas given to 25% of infants but needed by very few Offers no advantage over cow milk protein based formula as a supplement for breastfed infants Provides appropriate nutrition for normal growth and development Indicated primarily in the case of vegetarian families and for the very small number of infants with galactosemia and hereditary lactase deficiency

Contraindications to Soy Formula: AAP preterm infants due to increased risk of inadequate bone mineralization infants with cow milk protein-induced enteropathy or enterocolitis most previously well infants with acute gastroenteritis prevention of colic or allergy.

Soy formula for prevention of allergy and food intolerance in infants (Cochrane, 2006) “Feeding with a soy formula cannot be recommended for prevention of allergy or food intolerance in infants at high risk of allergy or food intolerance. Further research may be warranted to determine the role of soy formulas for prevention of allergy or food intolerance in infants unable to be breast fed with a strong family history of allergy or cow's milk protein intolerance.”

Those infants with IgE-associated symptoms of allergy may benefit from a soy formula, either as the initial treatment or instituted after 6 months of age after the use of a hypoallergenic formula. The prevalence of concomitant is not as great between soy and cow's milk in these infants compared with those with non–IgE-associated syndromes such as enterocolitis, proctocolitis, malabsorption syndrome, or esophagitis. Benefits should be seen within 2 to 4 weeks and the formula continued until the infant is 1 year of age or older.

Breast-milk should remain the feed of choice for all babies. Cow’s milk protein avoidance and development of childhood wheeze in children with a family history of atopy (Cochrane, 2003) Breast-milk should remain the feed of choice for all babies. In infants with at least one first degree relative with atopy, hydrolysed formula for a minimum of four months combined with dietary restrictions and environment measures may reduce the risk of developing asthma or wheeze in the first year of life. There is insufficient evidence to suggest that soya-based milk formula has any benefit.

Predigested protein based infant formulas

Protein Hydrolysate Formulas Alimentum Advance Pregestimil/Pregestimil Lipil Nutramigen Lipil Protein Casein hyrolysate + free AA’s Fat (Alimentum and Pregestimil) Medium chain + Long chain triglycerides; (Nutramigen) Long chain triglycerides Carbohydrate: Lactose free

Hydrolysate Formulas Whey Hydrolysate Formula: Cow’s milk based formula in which the protein is provided as whey proteins that have been hydrolyzed to smaller protein fractions, primarily peptides. This formula may provoke an allergic response in infants with cow’s milk protein allergy. Casein Hydrolysate Formula: Infant formula based on hydrolyzed casein protein, produced by partially breaking down the casein into smaller peptide fragments and amino acids. `

AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000) Recommendations

AAP: Breast milk and allergy 1.Breast milk is an optimal source of nutrition for infants through the first year of life or longer. Those breastfeeding infants who develop symptoms of food allergy may benefit from: a.maternal restriction of cow's milk, egg, fish, peanuts and tree nuts and if this is unsuccessful, b.use of a hypoallergenic (extensively hydrolyzed or if allergic symptoms persist, a free amino acid-based formula) as an alternative to breastfeeding.

2.Formula-fed infants with confirmed cow's milk allergy may benefit from the use of a hypoallergenic or soy formula as described for the breastfed infant.

3.Infants at high risk for developing allergy, identified by a strong (biparental; parent, and sibling) family history of allergy may benefit from exclusive breastfeeding or a hypoallergenic formula or possibly a partial hydrolysate formula. Conclusive studies are not yet available to permit definitive recommendations. However, the following recommendations seem reasonable at this time:

AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000) Currently available, partially hydrolyzed formulas are not hypoallergenic.

AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000) Carefully conducted randomized controlled studies in infants from families with a history of allergy must be performed to support a formula claim for allergy prevention. Allergic responses must be established prospectively, evaluated with validated scoring systems, and confirmed by double-blind,placebo-controlled challenge. These studies should continue for at least 18 months and preferably for 60 to 72 months or longer where possible

Formulas containing hydrolysed protein for prevention of allergy and food intolerance in infants (2006) There is no evidence to support feeding with a hydrolysed formula for the prevention of allergy compared to exclusive breast feeding. In high risk infants who are unable to be completely breast fed, there is limited evidence that prolonged feeding with a hydrolysed formula compared to a cow's milk formula reduces infant and childhood allergy and infant cow’s milk allergy. In view of methodological concerns and inconsistency of findings, further large, well designed trials comparing formulas containing partially hydrolysed whey, or extensively hydrolysed casein to cow's milk formulas are needed.

Specialty Formulas Elemental - Neocate Premature Follow Up - Neosure, Enfamil 22 Other highly specialized for metabolic conditions

Elemental formula for infants

Elemental Infant Formula NeoCate (SHS) Protein: Free Amino Acids Fat: Long chain Carbohydrate: Lactose Free Indications for use: Food Allergy or intolerance to peptides or whole protein

Premature Infant Breast Milk Additives and Formulas Enfamil Human Milk Fortifier Similac Human Milk Fortifier Powdered breast milk additives Similac Natural Care Advance Liquid breast milk additive Similac Special Care Advance Enfamil Premature +/- Lipil

Premature Formulas General Characteristics compared to Standard Increased Protein,Vitamins & Minerals For infants born at <1.5kg up to 2000-2500gm Feeding of infants > 2500 gm risk of vitamin toxicities Premature formulas vary in nutrient content

Post Premature Infant formula

“Post” Premature Formulas NeoSure Advance EnfaCare Lipil Standard Dilution: 22 kcal/oz Protein: between standard and Premature Vitamins: Higher than standard,significantly lower than Premature Calcium and Phosphorus: between standard and Premature

Other Specialty Formulas Portagen (Mead Johnson) 85% fat MCT, 15% fat Corn oil Used for infants with chylothorax Similac PM 60/40 (Ross) Low in Ca, P, K+ and NA; 2:1 Ca:P ratio Used for infants with Renal Failure Formulas for Metabolic Disorders Several condition specific products by Ross and Mead Johnson

Indications Cow’s milk based Soy Protein Hydrolysates Preterm Formulas Health term infant Soy Vegetarian Galactosemia Protein Hydrolysates Protein intolerance/allergy other Preterm Formulas Post-discharge Preterm formulas Other Specialty Formulas Specific medical, metabolic indications

Know What You Are Feeding Caloric density, protein, fat and carbohydrate vitamin and mineral content. Osmolality: Renal Solute Load: Evaluate RSL in context of solute intake, fluid intake and output. Evidence Based Rationale Cost and availability

Finding Up to Date Information www.ross.com Similac products www.meadjohnson.com Enfamil products www.verybestbaby.com Nestle products www.wyethnutritionals.com generic products www.brightbeginnings.com lower cost formulas made by Wyeth www.shsna.com/html/Hypoallergenic.htm Neocate formulas

Addition of DHA & ARA 2001: FDA approves as GRAS 2002: Ross & Mead Johnson introduce products with DHA and ARA Cost: 15-20% above standard formulas

Formulas with DHA & ARA

Additional concerns/issues Appropriate infant feeding Cows milk, goats milk, homemade formulas safety Preparation miscellaneous

AAP: Cow’s Milk in Infancy Objections include: Cow’s milk poor source of iron GI blood loss may continue past 6 months Bovine milk protein and Ca inhibit Fe absorption Increased risk of hypernatremic dehydration with illness Limited essential fatty acids, vitamin C, zinc Excessive protein intake with low fat milks

Cows milk and goats milk Protein RSL Folic acid, iron, vitamin D pasteurization

Formula Safety Issues - 2002 Enterobacter Sakazakii in Intensive care units Powered formula is not sterile so should not be used with high risk infants FDA recommends mixing with boiling water but this may affect availability of vitamins & proteins and also cause clumping Irradiation proposed

Formula safety FDA recall list 2005-2006

Milk Feedings Cautionary Tales Cooper et al. Pediatrics 1995. Increased incidence of severe breastfeeding malnutrition and hypernatremia in a metropolitan area. Keating et al. AJDC 1991. Oral water intoxication in infants. Lucas et al. Arch Dis Child. 1992. Randomized trial of ready to fed compared with powdered formula.

Cooper, cont. 5 breastfed infants admitted to Children’s hospital in Cincinnati over 5 months period for breastfeeding malnutrition and dehydration age at readmission was 5 to 14 days mothers were between the ages of 28 and 38, had prepared for breastfeeding 3 had inverted nipples and reported latch-on problems before discharge 3 families had contact with health care providers before readmission including calls to PCP and home visit by PHN

Cooper, cont. at time of readmit none of presenting complaints related to s&s of dehydration, only one infant presented with feeding complaint wt. Loss at admission: 23%, range 14-32% Serum Na - mean 186 mmol/l, range 161-214 (136-143 is wnl) 3 infants had severe complications: multiple cerebral infarctions, left leg amputation secondary to iliac artery thrombus

Keating 24 cases of oral water intoxication in 3 years at Children’s Hospital and St. Louis Most were from very low income families and were offered water at home when formula ran out Authors suggest: provision of adequate formula and anticipatory guidance

Lucas 43 infants randomized to RTF or powdered formula Infants given powdered formula had increased body wt. And skinfold thickness at 3 and 6 mos.. Compared to RTF and breastfed Powdered formula - 6 of 19 were above the 90th percentile wt/ht, but only 1 of 19 RTF infants Authors suggest errors in reconstitution of formula

Formula Preparation Microwave Protocol (Sigman-Grant, 1992) Heat only 4 oz or more refrigerated formula with bottle top uncovered 4 oz bottles < 30 seconds 8 oz bottles < 45 seconds Invert 10 times before use Should be cool to the touch Always test drops of formula on tongue or top of hand

Bright Futures AAP/HRSA/MCHB http://www.brightfutures.org “Bright Futures is a practical development approach to providing health supervision for children of all ages from birth through adolescence.”

Newborn Visit: Breastfeeding Infant Guidance how to hold the baby and get him to latch on properly; feeding on cue 8-12 times a day for the first four to six weeks; feeding until the infant seems content. Newborn breastfed babies should have six to eight wet diapers per day, as well as several "mustardy" stools per day. Give the breastfeeding infant 400 I.U.'s of vitamin D daily if he is deeply pigmented or does not receive enough sunlight.

Newborn Visit: Breastfeeding Maternal care rest fluids relieving breast engorgement caring for nipples eating properly Follow-up support from the health professional by telephone, home visit, nurse visit, or early office visit.

Newborn Visit: Bottle-feeding type of formula, preparation feeding techniques, and equipment. Hold baby in semi-sitting position to feed. Do not use a microwave oven to heat formula. To avoid developing a habit that will harm your infant's teeth, do not put him to bed with a bottle or prop it in his mouth.

First Week Do not give the infant honey until after her first birthday to prevent infant botulism. To avoid developing a habit that will harm your infant's teeth, do not put her to bed with a bottle or prop it in her mouth.

One Month Delay the introduction of solid foods until the infant is four to six months of age. Do not put cereal in a bottle.

Four Months Continue to breastfeed or to use iron-fortified formula for the first year of the infant's life. This milk will continue to be his major source of nutrition. Begin introducing solid foods with a spoon when the infant is four to six months of age. Use a spoon to give him an iron-fortified, single-grain cereal such as rice.

Four Months, cont. If there are no adverse reactions, add a new pureed food to the infant's diet each week, beginning with fruits and vegetables. Always supervise the infant while he is eating. Give exclusively breastfeeding infants iron supplements. Continue to give the breastfeeding infant 400 I.U.'s of vitamin D daily if he is deeply pigmented or does not receive enough sunlight. Do not give the infant honey until after his first birthday to prevent infant botulism. .

Six Months, cont. Let the infant indicate when and how much she wants to eat. Serve solid food two or three times per day. Begin to offer a cup for water or juice. Limit juice to four to six ounces per day. Give iron supplements to infants who are exclusively breastfeeding.