Breast Milk and Infant Formulas Lori S. Brizee MS, RD, CSP Clinical Dietitian Children’s Hospital and Regional Medical Center

Human Milk and Infant Formulas: Breast milk Standard Infant Formulas Premature Infant Formulas Specialty Infant Formulas Modular Additives

Breast Milk Characteristics First choice feeding for MOST infants Immunologic factors Protective against diarrhea causing infections and otitis in infants Trophic to GI tract Well tolerated by infants with short bowel Fatty acids important to brain/visual development

Breast Milk vs Standard Milk Based Formulas Energy: slightly higher Protein: Lower, but higher quality (whey and casein) Renal Solute load: Lower Carbohydrate: Mainly lactose Fats: Long chain; DHA/AA (lipases increase absorption)

Common Challenges with Breast Feeding Baby sided problems Illness preventing/interfering with early feeding Anatomic malformations Sleepy baby Thrush

Common Challenges with Breast Feeding Sleepy Baby Sleep cycles REM sleep-----deep sleep (15 min +/-) ----wake (quiet alert) If cannot wake, in deep sleep, try again in 15+/- minutes Watch for hunger cues e.g., sucking on hands

Common Challenges with Breast Feeding Sleepy Baby Waking techniques Hold by armpits and dangle Put feet on hard surface Spin around Last resort: stroke palate with finger until sucking, then take finger out and put nipple in.

Common Challenges with Breast Feeding Mom sided problems Low milk supply Frequent feeding, pump after feeding Medications: Reglan, Domperidone Fenugreek Sore Nipples Clogged ducts Mastitis Yeast Infection

Breast Feeding: Is baby getting enough? Regain birthweight by 1 week Newborn to 2 months gain > 1 ounce per day Newborn to 4-6 weeks: 2-10 bowel movements per day Bowel movements are better clue than wet diapers.

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

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/without iron Enfamil with Good Start Essentials/Good Start Supreme Wyeth Generic Standard 0-12 mos with DHA/ARA Similac Advance with iron Enfamil Lipil with/without iron Good Start Supreme DHA/ARA Wyeth formulas

Milk Based Formulas Older Infant and toddler formulas Similac 2 Advance (9-24 mos) Enfamil Next Step Lipil (9-24 mos) Good Start 2 Essentials (4 to24 mos) Wyeth Generic “follow on formulas” Increased Calcium Increased protein (Good Start and Enfamil) Intended to compliment nutrients in solid milk

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

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 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

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

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

Modular Products to Increase Energy/Protein

Modular Products to increase Energy or Protein

Products to Augment Energy and Protein in Breast Milk Human Milk Fortifiers For Premature infants less than 2000-2500gm only Standard Infant Formula Powder 1 teaspoon to 100mL = 24kcal/oz+/- Do Not Add CHO or Fat w/o protein: Final product is TOO LOW in protein

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

When Baby is Not Growing Normal Weight gain and linear growth Guo et al J Pediatrics 1991 Assess Feeding Number feedings/day Feeding environment BF: baby “empties” breasts each feeding Formula: volume per feeding Vomiting? Diarrhea? Medical issues that increase needs/decrease intake?

When Baby is Not Growing Increase number of feedings/day If baby <6 months d/c solids, increase breast milk or formula Monitor weight weekly If no improvement in 1 week consider increasing caloric concentration of breast milk or formula to 24 kcal/oz.

When Baby is Not Growing In cases of increased need due to medical condition or fluid limit, may need to go higher than 24 kcal/oz In all cases monitor closely watch for Signs of dehydration (baby may take less volume of concentrated feed) Vomiting Diarrhea

Increasing Caloric Density of Formula Concentrate formula (decrease water added): Calculate kcals desired (e.g. 30 oz of 24 kcal/oz formula = 720kcal) Divide kcals by kcal/oz of liquid or scoop of powder (e.g. 720 kcal divided by 40 kcal/oz liquid conc. = 18 oz liquid conc. Formula). Add water to make final volume (12 oz water + 18 oz liquid conc. Formula = 30 oz 24kcal/oz formula)

Using Modulars to Increase Calories Example: Making 30 oz of 30 kcal per oz formula (30oz X 30kcal/oz = 900 kcal) Start with 24 kcal/oz formula: 24kcal/oz X 30oz = 720 kcal 900kcal - 720 kcal = 180 kcal from modulars Use Polycose and Micro lipid to make up additional kcals (approximately 90 kcal of each)

Using Modulars to Increase Calories continued Polycose 23 kcal/TBSP 90 kcal /23kcal/TBSP =3.9TBSP (use 4 TBSP X 23 kcal = 92 kcal; still need 88 kcal) Microlipid 4.5 kcal/mL 88 kcal/4.5 kcal/mL =19.55 mL (use 20 mL X 4.5 kcal = 90 kcal) Final calculation: 720kcal + 92 kcal + 90 kcal = 902 kcal/30oz =30.07 kcal/oz

Know What You Are Feeding Caloric density, protein, fat and carbohydrate vitamin and mineral content. Osmolality: goal is for <400mOsm/kg H2O; can slowly go up to 700 Meds/modulars increase osmolality Renal Solute Load: goal is for less than 300mOsm/l (all infant and pediatric meet this recommendation when concentrated up to 30 kcal/oz.) Addition of protein will increase Renal Solute Load