Infant Formula
Hetty Cunningham, MD
December 2007
Learning Objectives:
- Understand different types of formula their indications and usage
- Learn about formula use in infants with milk protein allergy.
Primary References:
1. Hall RT, Carroll RE. Infant feeding. Pediatrics in Review. 2000;21(6): 191-200.
2. Soy Protein-based Formulas: Recommendations for Use in Infant Feeding. Pediatrics 1998;101;148-153
Secondary References:
1. Hypoallergenic Infant Formulas. Pediatrics 2000;106;346-349
2. Ripkin Formula Intolerance, Pediatr. Rev. 1997;18;191
3. Garrison MM, Christakis, DA. A Systematic Review of Treatments for Infant Colic. Pediatrics. Vol. 106 No. 1 Supplement July 2000, pp. 184-190
Formula cases:
Case I
1a. The mother of a breastfeeding mother would like to supplement with formula and she is asking you which would be the best formula to use soy or cow’s milk based.
Answer 1a: Infant formula basic nutritional components standards developed by the AAP Committee on Nutrition, and regulations of the FDA are based on these standards. Infants need 90-115 kcal/kg/d in the first 6 months. 8-12% of these calories should be provided by protein and 30-50% by fat.
There is a popular view in the media that soy is less allergenic and more “natural” than cow’s milk formula. The data does not support this and in fact the AAP recommendation is that, while soy formula is safe and effective, cow’s milk formula should be used unless there is a reason to use soy: i.e. vegan family, galactosemia, hereditary or acquired lactose insufficiency. Soy formula should not be used in premature infants.
1b. Mother has heard about the lipil formulas and DHA supplementation in formula. She would like to know whether it is worth paying extra money for these formulas.
Answer 1b: There are a number of new formulas available – many of them aimed at making formula more like breastmilk. Supplementation with DHA and ARA is one such development. These long-chain polyunsaturated fatty acids are found in human milk; they play a role in brain and visual development. Although it makes sense that these would be beneficial especially for premature infants, there are no data that support this theory. (Examples are: Enfamil Lipil, Similac Advance, and Nestle Good Start Supreme DHA & ARA; and now there are soy formulas and premature formulas with DHA and ARA)
1c: Mom asks what are those other formulas on the shelves at Wal-Mart? They seem to go on and on…
Answer 1c:
1. Follow-up formulas: Similac 2, Enfamil Next Step and Nestle Good Start Supreme 2. They generally have more calcium and iron than regular infant formula, again no data to support their use over standard formula.
1. Enfamil AR (added rice), which is marketed for infants with reflux
2. Premature formulas, such as Similac Special Care and Enfamil Premature.
3. Lactofree and Similac Lactose free
4. Elemental formulas are also lactose free and are made with hydrolysate proteins, which are easy to digest for infants with protein allergies. Types of elemental formulas include Nutramigen, Pregestamil and Alimentum.
5. Probiotic containing formula is new as of this year. (Nestle Good Start Natural Cultures)
6. Low Iron formula: There is no indication for low-iron formula, which has 6 times less iron than standard formula. Although some parents feel that the iron in standard formula is constipating, this has not been shown. Further, infants need a healthy supply of iron to avoid iron deficiency anemia.
1d: Mother reads only French, Woloff, and German and thus cannot read the instructions on the back of the formula container. How would you instruct mother to mix powdered formula? Concentrated liquid formula?
Answer 1d: Because of infant’s decreased ability to regulate fluid and electrolyte shifts it is crucial that formula be mixed correctly.
i. Powdered formula: 1 scoop for every 2 oz of water
ii. Concentrated canned formula: 1 can of formula to 1 can of water
1e: What water should she use?
Answer 1e: Tap water is fine and very safe in NYC, but many people don’t feel comfortable with this. Bottled, filtered, or boiled water is fine. If the family lives in an area where boiling is recommended, bring to a rolling boil and then boil for 2 minutes. If there is a suspicion of lead piping, only cold water should be used and the water should be run for 2 minutes before using.
At 6 months of age, babies need fluoride supplementation. Boiled tap water and most filters do not remove fluoride from the water. Reverse osmosis filters do remove fluoride from the water. Fluoride can also be prescribed in liquid form.
2. You are seeing a 6 month old premature baby who has been fed with Neosure. The baby is growing very well and the mother is wondering when she can switch to regular formula since her insurance company “Cheepie HMO” is giving her a hard time about paying for it.
- Premature babies have significantly greater protein and caloric needs than term infants. They need 120-130 kcal/kg/day and 2.5-3 gm/kg/d of formula protein. Premature formulas have these additional requirements, and are recommended for the first year of life.
- Soy formula should not be fed to premature infants due to increased aluminum concentration (~100X the aluminum of human milk.) There is increased deposition in bone and CNS and osteopenia has been documented in low birth weight and preemies.
Case II: Consider the following 3 cases: In which would you consider a formula change, to what and why?
1. A mother of a 2 month old presents to your office. She reports that the child is spitting up a lot (not projectile) and she would like to change the formula. The child otherwise seems to be thriving. Also the child has atopic dermatitis and constipation.
2. You are seeing a 2 month old in your office mother reports that the child is very fussy and cries in pain frequently throughout the day. Mother’s neighbor recommended changing the formula to soy and mom is now is asking you for a letter for WIC.
3. You are seeing a 2 month old who is cranky, spit up a lot, has flecks of blood in the stool and has dropped 2 percentiles in the past month.
i. Would you substitute with a soy formula?
ii. Could you substitute with a lactose-free formula?
Milk protein allergy – 2 types:
A: IgE –mediated. Symptoms may be gastrointestinal (constipation, vomiting), cutaneous (eczema), respiratory (wheezing), and generalized (urticaria or anaphylaxis).
For a child with documented IgE mediated allergy to cow mild protein have a 10% cross reactivity to soy protein, and anaphylaxis to soy is rare, thus a trial of soy is indicated in these cases, especially after 6 months of age.
B. Non- IgE mediated. These disorders include enterocolitis, enteritis, and malabsorption with villous atrophy most commonly, also, pulmonary hemosiderosis, eosinophilic proctocolitis, and esophagitis. Sx usually start between 1 week and 3 months of age. Examination for protein-specific IgE, RAST or skin prick tests are usually negative. Infants usually present with vomiting, diarrhea, bloody stools, malabsorption, FTT, usually in response to cow’s milk or soy-based formulas. Symptoms may not occur until several hours after the protein ingestion.
1. Up to 60% of infants with cow’s milk protein induced enteritis or enterocolitis will have cross reactivity with soy, so not recommended.
2. When should milk protein be reintroduced? At 1 year of age can trial. 70-80% of milk and soy hypersensitivity resolve by age 4y. Formula Intolerece, Ripkin Pediatr. Rev. 1997;18;191
Answer Case #1
Dx GER:
- r/o overfeeding
- In general, infants with simple GER will not benefit from a formula change.
- However, in an infant with clinically significant atopic dermatis and/or constipation, IgE-mediated milk-protein allergy should be considered, and the infant might benefit from a trial of a different formula. (A soy formula could be tried and if unsuccessful, the child might be one of the 10% of children who have cross-reactivity. Depending on the severity and economic feasibility, a hydrolyzed formula would not be unreasonable.)
Answer Case #2:
Dx: Colic
Some infant may experience only extreme fussiness or colic as their only symptom of milk-protein allergy. So although the majority of infants will not respond to a hypoallergenic formula, those with severe colic may benefit from a 2 week trial.
Answer Case #3:
Dx: Non-IgE mediated milk protein induced enteritis.
i. Would you substitute with a soy formula?
Answer: No, b/c up to 60% of cow milk protein induced enterocolitis will be equally sensitive to soy protein.
ii. Could you substitute with a lactose free formula?
Answer: This process is an allergy mediated by the immune system as opposed to lactose intolerance, which is transient or permanent deficiency of lactase – the enzyme which breaks down lactose into glucose and galactose.
**Goat’s milk: not recommended – high cross reactivity with cow, and high incidence of Folate deficiency and megaloblastic anemia. Goat’s milk.—use with care. Low in folate, iron and vitamins A,C,D.
Case III:
The mother of a 3 day old presents to your office with persistent vomiting and diarrhea. The child has lost 20% of her birth weight, and she has a weak cry and poor perfusion. What would you do?
A sepsis w/u reveals a UTI and the child is admitted for antibiotics. After 24 hours, her urine culture grows E-Coli. On antibiotics the child’s color and energy improves moderately, however she continues to have vomiting and diarrhea.
The medical student if there is any significance to the positive clinitest result on her urinalysis.
This child has galactosemia -- Galactosemia is a disorder of galactose metabolism. Three inherited disorders of galactose metabolism have been described. They are all transmitted by autosomal recessive inheritance.
Vomiting usually presents within days of starting cow’s milk formula or breast milk. FTT is most common presenting complaint. Jaundice presents in the first few weeks and is initially unconjugated. There is high neonatal mortality from E-coli UTI. Lactose in milk containing formula is broken down into glucose and galactose. The treatment is soy formula and avoidance of lactose and galactose containing products.
The clinical manifestations in infants are due to toxic effects of prolonged exposure to galactose.
Case IV:
TODDLER CASES LINK
