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

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

3. 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

4. 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)

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

6. 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

7. 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.

8. 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

9. 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.

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

11. 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

12. 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

13. 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

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

15. 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

16. 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

17. Predigested protein based infant formulas

18. 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

19. Elemental formula for infants

20. 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

21. 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

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

23. Post Premature Infant formula

24. “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

25. 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

26. Modular Products to Increase Energy/Protein

27. Modular Products to increase Energy or Protein

28. Products to Augment Energy and Protein in Breast Milk
Human Milk Fortifiers
For Premature infants less than gm 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

29. Finding Up to Date Information
Similac products
Enfamil products
Nestle products
generic products
lower cost formulas made by Wyeth
Neocate formulas

30. 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?

31. 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.

32. 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

33. 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)

34. 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 kcal = 180 kcal from modulars
Use Polycose and Micro lipid to make up additional kcals (approximately 90 kcal of each)

35. 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

36. 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