1. Mónica Riojas, MD LSU Pediatrics
Infant Formula
Mónica Riojas, MD
LSU Pediatrics

2. Principles of Infant Feeding
Energy Requirements: kcal/kg/d
0-12 mo:
1-3 yr:
4-6 yr:
7-10 yr:
15+ yr:

3. Principles of Infant Feedings
Formula fed infants feed every 3-4 hrs.
Feedings/day
0-3 Months:
4-6 Months:
6-8 Months:
9-12 Months:
By 4 mo, the baby is being introduced to solids, these are bottles only. Infants c feeding difficulties eat more freq. or more volume. 3

4. Principles of Infant Feeding
Average Volume of Milk per Feeding
1st wk: oz
2-4 wks: oz
1-2 mo: oz
3-4 mo: oz
5-6 mo : oz
By 12 mo of age, the average child should be taking an average of 24 oz/d.

5. INFANT STOMACH CAPACITY

6. Infant Formula Indications
As substitute for human milk in infants for whom BF is medically contraindicated.
As supplement for BF infants who do not gain weight adequately.
As a substitute or supplement for human milk whose mother chooses not to BF or not to do it exclusively.

7. Distribution of Kcals Breastmilk Formula % Protein 6 9 % Fat 52 48
% Carbohydrate 42

8. Question
Which of the following statements about infant nutrition is true?
Human milk contains more casein than infant formulas.
Infants who receive increased whey protein have been shown to grow better than those who receive primarily casein.
Iron is absorbed better from cow milk formulas than from human milk.
Lactose-free formulas result in decreased absorption of calcium.
There are no apparent negative effects from the addition of DHA and ARA to formulas.

9. Differences Between Types of Milk
Breastmilk
Standard Cow Formula
Cow Milk
Calories
20 kcal/oz
19 kcal/oz
Protein
0.9 g/dL
1.4 g/dL
3.5 g/dL
Minerals (Ca, P, Fe)
Lower
Higher
Iron Absorption
Better
Worse
Terrible
Vit. ABC
Same
Vit. DEK
Renal Solute
Whey:Casein Protein Ratio
70:30
Varies, but not better than human milk
20:80

10. Benefits of Whey Protein
Promotes more rapid gastric emptying.
Consists of soluble proteins that are easily digested.
Lines the GI tract and plays a role in host defense.

11. Question Is iron supplementation required at birth?No
When should you start iron supplementation?
All babies (including breastfed) should receive supplementation in their food (iron-fortified cereal) by 6 months of age.
In FT infants, iron stores become depleted by 4-6 months of age.

12. Dietary Recommendations
IRON
Pre-term: 2 mg/kg/d at 1-12 mo
Full-term: 1 mg/kg/d at 4-6 mo
Iron Fortified Formula: 12 mg/L
Cow’s milk has 0.5mg/L of iron.

13. Dietary Recommendations
VITAMIN D
400 IU/d
Who should receive Vitamin D?
All BF infants, unless they are weaned to at least 1000 ml/d (33 oz) of Vit. D fortified formula.
Formula fed infants ingesting ≤ 1000 ml/d of Vit. D fortified formula.
Children/adolescents who get no sun light, ≤ 1 L of Vit. D fortified milk, no MVI.

14. Infant Formulas
Premature Formulas
Standard Formulas
Special Formulas

16. Standard Formulas COMPOSITION Protein Whey (β lacto-globulin) & Casein
Whey predominant (60:40), Casein predominant (20:80), or 100% whey
Fat
Vegetable oils
Coconut: Saturated, short & MCFA
Palm oil: Saturated & LCFA
Safflower, corn & soy: LCFA, DHA & ARA
Carbohydrate
Lactose

17. Standard Infant Formulas
Provide 20 cal/oz
PRESENTATIONS:
Powder
Concentrated Liquid
Ready to Feed

18. Preparation of Infant Formula
POWDER
Add 1 scoop powder to 2 oz of water
CONCENTRATED LIQUID
Mix 1 oz concentrated liquid and 1 oz water
13 oz can
READY TO FEED
Hospital use: 2 and 3 oz bottles
32 oz container
Expensive
Careful reconst. Important forexact concentration. Powder increase volumen

19. Preparation of Infant Formula
What type of water should be mixed with the formula?
Tap: safe, may boil x 1 min.
Distilled water with fluoride.
Well: boil 10 min. Give fluoride.
Warm, cold or room temperature.

20. Cow Milk/Standard Formulas
Designed to meet the nutritional needs of the term and near-term infant.
Enfamil Premium Newborn & Infant
Similac Advance
Store Brands
SMA withdraw from SE area 20

21. Cow Milk/Standard Formulas
Enfamil NB has Vit D 400 IU in 27 oz, SA has lutein good for eye health doesn’t contain palmein oil=improved calcium absorption

22. New Infant Formula Features
Prebiotics
Nondigestible short-chain carbohydrates that stimulate growth and function of specific species of bacteria.
Increases concentration of lactobacillus and bifidobacterium.
Used to treat chronic diarrhea.
Beneficial to atopic children.
Probiotics
Live microorganisms that survive digestion and colonize the colon.
Organic
No pesticides or synthetic fertilizer used.
No hormones or antibiotics used.

23. Premature Infant Formulas
For LBW and Premature Infants
Increased energy requirement: 120 kcal/kg/d
Preterm formulas should always be discontinued before hospital discharge.
Increased intake with age → excess intake of vitamins/minerals
Show stomach size 23

24. Composition of Premature Infant Formula
20, 22, 24 kcal/oz
Increased protein: whey predominant
60% whey:40% casein
Breastmilk - 70% whey:30% casein
Increased calcium & phosphorus
Contain AA: cysteine and taurine
Lactose + glucose polymers
MCT
Increased Vitamins & Minerals
Higher caloric density, more readily absorbed lipids, greater protein content, AA deficient in preemies and important for brain development, 24

25. Premature Infant Formulas
Enfamil Premature 20 cal
Enfamil Premature 24 cal
Similac Special Care Advance 20 cal
Similac Special Care Advance 24 cal
Good Start Premature 24 cal

26. Premature Infant Formulas

27. Transitional Formulas
22 kcal/oz
INDICATIONS
Infants 34 WGA or 1,800-2,000 g
How long should infants be on transitional formulas?
6 to 9 months of age

28. Transitional Formulas
Enfamil Enfacare
Similac Expert Care Neosure

29. Transition Formula

30. Question
What type of milk would you recommend a breastfeeding infant that develops “rash and hives” while eating yogurt and cream cheese, and tolerates foods such as eggs and bread without any problems?
Trial of Soy Milk–Based Formula
If no improvement switch to an extensively hydrolyzed or AA-based formula
Milk protein allergy, IgE mediated reaction

31. Soy Protein Formulas Lactose Free
Contain higher concentrations of protein, AA, calcium, phosphorus, zinc and iron.
Primary Carbohydrate
Glucose polymers from corn syrup solids or maltodextrin

32. Soy Protein Formulas INDICATIONS Galactosemia
Congenital Lactase Deficiency
Post-diarrhea lactose intolerance
Strict vegetarian family

33. Soy Protein Formulas NOT RECOMMENDED FOR
Preterm infants with BW ≤ 1800 g.
Do not meet requirements for calcium and phosphorus.
Prevention of colic or allergy
Infants with cow milk protein-induced enterocolitis (non-IgE allergic enterocolitis)
30% of infants with milk protein allergy also have soy protein allergy.

34. Soy Protein Formulas Enfamil ProSobee Similac Sensitive
Store Brand Soy Infant Formula

35. Soy Protein-Based Formulas

36. Modified Cow Milk Protein or Soy-Based Formulas
Carbohydrate
Reduced lactose or lactose-free carbohydrate blends
Protein
Partially hydrolyzed whey and soy proteins
Other
Thickeners (rice cereal)
Soy fiber
Prebiotics

37. Modified Cow Milk Protein or Soy-Based Formulas
INDICATIONS
Infants recovering from diarrhea
Infants with colic
Infants with GER
NOT for infants with galactosemia
NOT for cow milk formula intolerance

38. Special Indications GER Enfamil AR Similac Sensitive for Spit up
Diarrhea and fussiness
Similac Expert Care for Diarrhea
Enfamil Gentlease
Similac Sensitive Fussiness and Gas
Specialty-metabolic formulas
Similac PM 60/40

39. Modified Cow or Soy Milk-Based Formulas
Gentleease: milk based powder with iron, partially broken down proteins

40. Modified Cow or Soy Milk-Based Formulas

41. Modified Cow or Soy Milk-Based Formulas

42. Modified Cow or Soy Milk-Based Formulas

43. Question
A mother brings her 1 month old infant to clinic because of a 1 week history of “bloody streaks in stool” and fussiness. Mom was breastfeeding for the first 3 weeks of life, then switched to a cow milk-based formula 1 week ago. What formula should you recommend?
Protein Hydrolysate Formula
Child has milk protein intolerance, non-IgE mediated. Usually begins at 2 weeks of age-2 mo.

44. Extensively Hydrolyzed Formulas
Made for infants who are unable to digest or tolerate formulas containing intact cow milk protein.
Lactose free
Protein
Extensively hydrolyzed casein
Partially hydrolyzed whey
Carbohydrate
Glucose polymers and/or sucrose
Fat Content
Vegetable oils
LCT/MCT from safflower and soy

45. Extensively Hydrolyzed Formulas
INDICATIONS
Cow milk and soy protein allergy
Malabsorption syndromes
Cystic fibrosis
Biliary Atresia
Short gut syndrome
Pancreatic insufficiency
Protein calorie malnutrition
Autoimmune diseases/immunodeficiency syndromes

46. Question
Hydrolysate formulas are MOST often used in the management of:
Celiac disease
Cow milk protein allergy
Cystic fibrosis
GER
Lactose intolerance

47. Extensively Hydrolyzed Formulas
Nutramigen
Pregestemil
Similac Expert Care Alimentum

48. Extensively Hydrolyzed Formulas

49. Amino Acid Based Formulas
Intolerance to intact or hydrolyzed protein.
Protein
Free Amino Acids
Carbohydrate
Glucose polymers

50. Amino Acid Based Formulas
INDICATIONS
Cow Milk Protein Allergy
Eosinophilic GI disorders
Atopic diseases
Severe food allergy
Asthma
Eczema

51. Amino Acid Based Formulas
Neocate
Elecare
Nutramigen AA

52. Amino Acid Based Formulas

53. Other Formulas Follow-up Formulas From 9 months of age - toddlers
Increased protein, minerals and iron.
No advantage for infants eating adequate amounts of formula and solid foods.

54. Follow-up Formulas Enfamil Enfagrow Premium Enfagrow Premium Soy
Similac
Similac Go and Grow
Good Start
Good Start 2 Essentials
Good Start 2 Essentials Soy

55. Follow-up Formulas

56. Question
A 4 month old male is at clinic for his well child check. On questioning of his diet, mom states he drinks whole milk, orange juice, ravioli, and cheetos puffs. How do you counsel on appropriate dietary recommendations for his age?

57. Cow’s Milk Introduce until 12 months of age!!!! Low iron content.
May increase fecal blood loss in some infants.
May cause hypocalcemia.
High protein and electrolyte content → high renal solute.
Lower caloric content (19 cal/oz)

58. Principles of Infant Feeding
Number of Meals a Day
0-3 mo: bottles
4-6 mo: 5 bottles + 1 solid meal
6-8 mo: 4 bottles + 2 solid meals
9-12 mo: 3 bottles + 3 solid meals

59. Infant Nutrition: Solid foods
Cereal
Strained Vegetable
Strained Meats
Strained fruits
Table Food
Juices and desserts
Vitamins and Minerals

60. Solid Foods Introduce at 4-6 months age Has good head control
No extrusion reflex
Sits with support
Has doubled birth weight
Seems hungry after 32 oz milk

61. Question
What is the MOST likely outcome of introducing solid foods at an age of ≤ 3 months?
Accelerates the development of oral motor skills
Helps the infant sleep through the night
Increases the risk of food allergies
Increases the risk of GER
Increases the risk of GI infections

62. Solid Food Introduce rice cereal first. Advance to single vegetables.
Add one food at a time.
Feed same for 3-5 days.
Combination dinners last.

63. Infant Nutrition 0-4 mo: 100% total calories from milk
6-8 mo: 65% calories from milk
33% calories from solids.
9-12 mo: 50/50 milk and solids

64. Solid foods Strained Food Stage 1 Foods: 2.5 oz jar, 4-5 mo

65. Infant Nutrition
CEREALS
Rice cereal
Oatmeal
Barley
Mixed

66. Infant Nutrition CEREALS First solid introduced at 4-6 months of age
Iron Fortified
Provides 15 calories per Tbsp
Full serving: 4 Tbsp + 4 oz formula or breastmilk
DO NOT ADD IN BOTTLE!!!!!!!!
Thickened feedings for severe GER

67. Rice Cereal

68. Introduction of Solids
Recommendations
At 4 months
Breakfast: Rice Cereal (4 tbsp cereal/4oz formula)
Lunch: Stage 1 veggies/fruits
Same vegetable for 3-5 days, then switch to new veggie

70. Introduction of Solids
At 6 months
Breakfast: Cereal
Lunch: Stage 2 foods
Introduction of meats
Mixed veggies or dinners
Dinner: Stage 2 foods

71. Introduction of Solids
At 9 months
Stage 3 and finger foods.

72. A Typical 6 mo Infant Diet
Morning: Cereal Mid-morning: Formula Noon: Vegetable Mid-afternoon: Formula Late afternoon: Dinner Bed-time: Bottle