Breast Milk and

Infant Formulas

Lori S. Brizee MS, RD, CSPClinical 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 tractWell 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

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 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 AcidsFat: Long chainCarbohydrate: Lactose FreeIndications 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 oilUsed for infants with chylothorax

Similac PM 60/40 (Ross)Low in Ca, P, K+ and NA; 2:1 Ca:P ratioUsed for infants with Renal Failure

Formulas for Metabolic DisordersSeveral condition specific products by Ross

and Mead Johnson

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 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