formula 09
DESCRIPTION
Formula 09TRANSCRIPT
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Infant Feeding: Human Milk and Formula Joan C Zerzan MS RD CD
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“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
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Human Milk Colostrum
Higher concentration of protein and antibodies
Transitions around days 3-5 Mature by day 10
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Distribution of KcalsBreastmilk Formula
% Protein 6 9
% Fat 52 48
% Carbohydrate 42 42
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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
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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
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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
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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
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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
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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.
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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.”
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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.)
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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.”
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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.
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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.
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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.
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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.
AAP: Breast milk and allergy
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Breast feeding and allergya.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.
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Infant Feeding: Historical Perspective Breast feeding Human Milk
Substitutes Science, Medicine
and Industry
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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
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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”
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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
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Historical timeline
1940 Homogenized milk
widely marketed
1960 Further advances in
technology and packaging
Commercially prepared infant formula becoming increasingly popular
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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
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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
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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.
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INFANT FORMULA
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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
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Formula Brands Ross
Similac/Isomil/Alimentum Mead Johnson
Enfamil/Prosobee/Enfacare Nestle
Good Start Wyeth
Generic in USA; Gold Brands; SMA SHS
NeoCate, DuoCal
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Infant Formula: Categories Term vs. Preterm Standard Infant Formula
Cows Milk Based Soy Formula
Specialty Formulas Hypoallergenic: Peptide hydrolysates, amino acid
based Metabolic Products other
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Standard Infant Formulas, Milk or Soy Based………..
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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
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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
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Standard Infant Formula DHA/ARA Prebiotics/Probiotics Fiber Organic Other
Advance, Lipil, Gentlease, Restful, Sensitive, Early Shield, Triple Guard….etc, etc
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Infant Formulas: AAP Cow’s milk based formula is
recommended for the first 12 months if breast milk is not available
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Soy Formulas First developed in 1930s with soy
flour Early formulas produced diarrhea
and excessive gas Now use soy protein isolate with
added methionine
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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
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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
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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
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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
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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).
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Health Consequences of Early Soy Consumption. Badger et al. J Nutr. 2002
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.
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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
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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.”
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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.
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Predigested protein based infant formulas
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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
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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. `
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AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000)
Recommendations
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AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000) Currently available, partially
hydrolyzed formulas are not hypoallergenic.
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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.
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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
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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.
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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:
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Elemental formula for infants
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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
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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
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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
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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
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Post Premature Infant formula
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“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
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Feeding the Infant Considerations
Infant (needs, tolerance, acceptance, safety)
Indications Family preferences Cost availability
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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
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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
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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
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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.
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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
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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)
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Formula safety FDA recall list 2005-2006
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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
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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
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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
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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.htmNeocate formulas
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Additional concerns/issues
Inappropriate infant feeding Cows milk, goats milk, homemade
formulas safety Preparation miscellaneous
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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
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Cows milk and goats milk Protein RSL Folic acid, iron, vitamin D pasteurization
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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.
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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
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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
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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
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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
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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
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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
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Breast Milk: Environmental contamination Lozoff et al Higher Blood Lead
Levels with Longer Duration of Breastfeeding J. Pediatr 2009:159:663-667
Gundacker, et al Lead and Mercury in Breast milk Pediatrics 2002 110:873-8
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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.”
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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.
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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.
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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.
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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.
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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.
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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.
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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. .
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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.
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Ben Age: 4 day old. Term breastfed
male Birth weight 3.2 kg Current weight: 2.8 kg Maternal concern: milk supply
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Kali 3 month old female, referred for FTT Weight gain over the past month 3 g/d Weight decreased from 70th percentile
at birth, to 10th percentile “colicky” Formula: Soy formula