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

“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

Characteristics and Advantages of Human Milk Low renal solute load Immunologic, growth and trophic factors

Decrease illness, infection, allergy Improved digestion and absorbtion Nutrient Composition: CHO, Protein, Fatty

Acid, etc Cost Other

Infant Feeding: Historical Perspective Breast feeding Human Milk

Substitutes Science, Medicine

and Industry

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 Homogenized milk

widely marketed

1960 Further advances in

technology and packaging

Commercially prepared infant formula becoming increasingly popular

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

Regulation of Infant Formulas Infant Formula Act:

Manufacturing regulations Quality control

Non specific testing requirements, case by case basis, growth outcomes

Recall Proceedures Nutrient content and labeling Panel convened 1998 and 2002

(recommended revisions including exemptions)

Formula Composition

Breast Milk as “gold standard” Attempt to duplicate composition of

breastmilk ? Bioactivity, relationship, function of

all factors present in breast milk ? Measure outcome: growth,

composition, functional indices

Approaches to Estimating Nutrient Requirements

Direct experimental evidence ie protein and amino acids

extrapolation from experimental evidence relating to human subjects of other age groups or animal models

ie thiamin--related to energy intake .3-.5 mg/1000 kcal Breast milk as gold standard

ie average [ ] X usual intake Metabolic balance studies

ie protein, Ca, Mg, Cu, Zn (may be overestimate) Clinical Observation

ie formula manufacturing errors B6, Cl Factorial approach

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

Feeding the Infant

Considerations Infant (needs, tolerance,

acceptance, safety) Indications Family preferences Cost availability

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

Formula Brands Ross

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 FormulasCharacteristics

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 FormulasCharacteristics 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 FormulasGeneral 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 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

Modification of Infant Formulas

Cost and Availability Potential mixing errors Impact on absorbtion, utilization

and interaction of nutrients Evidence Based Requires detailed assessment to

determine need

Modular Products to Increase

Energy/Protein

Modular Products to increase Energy or Protein

Carbohydrate Fat Protein

Polycose (Ross)

MicroLipid (Mead Johnson)

ProMod (Ross)

Moducal (Mead Johnson)

Safflower Oil Casec (Mead Johnson)

Super Soluble DuoCal (SHS)

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 Evaluate growth rates (weight, length,

OFC) in addition to absolute size

(percentiles), body composition,

weight/length

Guo et al J Pediatrics 1991

When Baby is Not Growing

Assess Feeding Number feedings/day

Feeding environment

BF: baby “empties” breasts each feeding

Formula: volume per feeding

Feeding observation

When Baby is Not Growing

Medical status, illness, vomiting, output

Development and behavior

Psychosocial

Diet Frequency

Amount

Preparation

content

When Baby is not growing

Weighing Risks and Benefits

Identify Problem Address Problem Formula Changes

or modifications Risk vs benefit Cost Availability Addresses

problem

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