FORMULA FEEDING/

ARTIFICIAL FEEDING/

BREAST MILK SUBSTITUTES

INTRODUCTIONFormula feedings are used as substitutes for breast milk for

infants whose mothers choose not to or cannot breastfeed or

as supplements for breastfeeding.

Formula-fed infants often gain weight more rapidly than breastfed

infants, especially after the first 3 to 4 months of life.

But there is no evidence that any one of the many brands is

superior to any other.

ACCEPTABLE MEDICAL REASONS FOR USE

OF BREAST MILK SUBTITUTES

Malaysian Dietary Guideline by Ministry Of Health (Updated 2010) -

http://www.moh.gov.my/images/gallery/Garispanduan/diet/introduction.pdf

Infants

Can’t receive breast milk or any other milk except specialized formula:

1.Classis galactosemia: galactose-free formula

2.Maple syrup urine disease: formula free of leucine, isoleucine and valine

3. Phenylketonuria: phenylketonuria-freeformula

Need substitutes in addition to breast milk for a limited period:

1. Very low birth weight infants - less than 1500g

2. Very preterm infants- less than 32 weeks gestational age

3. Newborn infants who are at risk of hypoglycaemia

4. Infants younger than six months, in spite of frequent and effective suckling and in the absence of illness, show persistent downward growth curve

Maternal

Need to avoid breastfeeding:

HIV infection: if replacement feeding is acceptable, feasible, affordable and safe (AFASS)

Need to avoid breastfeeding temporarily:

1.Severe illness that prevent a mother from caring for her infant, for example sepsis

2.Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the mother’s breast and the infant’s mouth should be avoided until all active lesions have resolved.

Maternal medication:

• Sedating psychotherapeutic drugs, anti-epileptic drugs and opioids may cause side effects such as drowsiness and respiratory depression and are better avoided if a safer alternative is available.

• Radioactive iodine-131 is better avoided given that safer alternatives are available – a mother can resume breastfeeding about two months after receiving this substance

• Excessive use of topical iodine can result in thyroid suppression or electrolyte abnormalities in the breastfed infant and should be avoided.

• Cyctotoxic chemotherapy requires mother stops breastfeeding during theraphy

Mother who can continue breastfeeding although health problems may be of

concern:

Breast abscess: breastfeeding should continue on the unaffected breast;

feeding from the affected breast can resume once treatment has started

Hepatitis B: Infants should be given hepatitis B vaccine, within the first 48

hours or as soon as possible thereafter

Hepatitis C

Mastitis: If breastfeeding is very painful, milk must be removed by expression

to prevent progression of the condition

Tuberculosis: Mother and baby should be managed according to national

tuberculosis guidelines

Substance use: Mother should be encouraged not to use these substances and

given opportunities and support to abstain.

Pasteurised Cow’s Milk Many babies have been on ordinary pasteurised or sterilized cow’s milk.

Pasteurised cow’s milk may be given from 1 year of age

Disadvantages of unmodified cow’s milk;

1. Contain more protein More curd protein or casein, and these thick curds being

less easy to digest have caused bowel obstruction.

2. Contain more fat and phosphate Particularly from 5 to 15 days of age, this

may lead to hypocalcaemia with subsequent fitting.

3. Relatively high sodium Leads to hypernatraemia, which may cause fits and

brain damage

4. Some infants are allergic to cow’s milk protein React to feeding with perioral

rashes and oedema or by vomiting or passing frequent loose stools.

5. Deficient in vitamins A, C and D and iron.

COW’S MILK FORMULA

Cow milks currently available have been modified to make their mineral content and renal solute load comparable with that of mature human milk.

Cow’s milk formula are composed of

1. Skimmed Cow’s Milk with electrolyte-depleted whey or casein (protein)

2. Fat mixture of vegetable oils, commonly including soy, palm, coconut, corn.

3. Carbohydrate Lactose (lactose-free cow’s milk-based formulas are available.

Cow’s Milk-Based Formulas Unmodified cow’s milk is unsuitable for feeding in infancy

Contains too much protein and electrolytes and inadequate iron and vitamins.

No vitamin or mineral supplements are needed with such formulas.

Other than possibly fluoride after 6 months

The alternative to human milk is iron-fortified formula which permits

adequate growth of most infants

Human milk fortifiers with breast milk

1. To boost the caloric and nutrient content

2. For use with premature infants when adequate growth cannot be achieved with human milk

alone.

Soy Formulas

Soy protein-based formulas provide a safe alternative to

cow’s milk-based formulas when intolerance occurs from

immune reactions to cow’s milk proteins.

However, soy protein formulas do not prevent the

development of allergic disorders in later life.

A soy formula should not be used below 6 months of age

as it has a high aluminium content and contains

phytoestrogens (plant substances that mimic the effects

of endogenous oestrogens).

Comparison Of Human Milk, Cow’s Milk

and Infant Formula (Per 100 ml)

Mature Breast

Milk

Cow’s Milk Infant Formula

(Modified cow’s

milk)

Energy (kcal) 62 67 60-65

Protein (g) 1.3 3.5 1.5-1.9

Carbohydrate (g) 6.7 4.9 7.0-8.6

Casein:whey 40:60 63:37 40:60 to 63:37

Fat (g) 3.0 3.6 2.6-3.8

Sodium (mmol) 0.65 2.3 0.65-1.1

Calcium (mmol) 0.88 3.0 0.88-2.1

Phosphorus (mmol) 0.46 3.2 0.9-1.8

Iron (µmol) 1.36 0.9 8-12.5

Infant Feedings & Standard & Specialized Formulas

Formula Category Example Formulas Features and Typical Uses

Human milk • Gold standard

• Expressed milk can be delivered by

gavage or nasogastric tube

Cow’s milk-based

(with lactose)

Enfamil

Similac

Carnation Good Strat

Standard substitute for breast milk

Cow’s milk-based

(without lactose)

LactoFree

Similac Lactose Free

Useful for transient lactase deficiency

or lactose intolerance

Soy protein-

based/lactose-free

ProSobee

Isomil

• Alternative to milk-protein based

formulas

• Not recommended for premature

infants

Premature formula;

cow’s milk (reduced

lactose)

Similac Special Care

Enfamil Premature

• Indicated for premature and LBW

infants

• Fat is 50% MCT, higher in many

micronutrients

Why Are Bottle Feeding and Milk Powder

Not Recommended?

Infant formula is easily contaminated

In case of wrong infant formula preparation, child will become malnourished

and affect the growth and development

Weaker bond between the mother and baby

Child susceptible to:

A. More frequent infections – cough, common cold, fever and diarrhea

B. Constipation – infant formula is not as easy digested compared with

breast milk

C. Obesity – because of overfeeding

Why Are Bottle Feeding and Milk Powder

Not Recommended?

For mothers:

More difficult to lose weight after delivery

Higher risk of breast and ovary cancer

Poor spacing if not on contraception

By approximately 6 months, complementary feeding of semisolid foods is

suggested.

After 6 months of age, breast milk becomes increasingly nutritionally

inadequate as a sole feed, as it does not provide sufficient energy, vitamin

or iron.

By this age, an exclusively breastfed infant requires additional sources of

several nutrients, including protein, iron and zinc.

Although the growth rate of the infant is decreasing, energy needs for

activity increase.

COMPLEMENTARY FOODS AND WEANING

COMPLEMENTARY FOODS AND WEANING

It is done gradually, initially with small quantities of pureed

fruit, root vegetables, or rice.

To help identify possible allergies or food intolerances that may

arise when new foods are added to the diet, single-grain cereals

(rice, oatmeal, barley) are recommended as starting cereals.

Foods with high allergic potential that should be avoided during

infancy, (especially for infants with a strong family history of food

allergy)

include fish, peanuts, tree nuts, dairy products, and eggs.

a. If juice is given, it should be started only

after 6 month of age, be given in a cup (as

opposed to a bottle), and limited to 4 oz

daily.

b.Foods high in salt and sugar should also be

avoided

c. Honey (risk of infant botulism) should not

be given before 1 year of age.

Reference

Paediatrics Lecture Notes (9th edition) by Simon J.Newell and Jonathan

C.Darling

Essential Paediatrics (4th edition) by David Hull and Derek I. Johnson

Malaysian Dietary Guideline by Ministry Of Health (Updated 2010) -

http://www.moh.gov.my/images/gallery/Garispanduan/diet/introduction.pdf

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