Infant feeding and milk formulas


Whether we eat for living or live for eating, food are prime concern. But the quality & quantity of food is equally important & should significantly promote development, health & welfare. Early childhood nutrition affects learning ability, work performance and the possible development of adult diseases such as hypertension, osteoporosis and cardiovascular disease. Although primary protein-energy malnutrition is uncommon in developed countries, undernutrition occurs. Thus, careful attention to the nutritional needs of children throughout life, but especially during the first year of life when brain growth is rapid, is necessary to permit children to develop to their full potential.

Caloric requirements for infants

  1. Caloric requirements for new-borns are approximately 90-100 kcal/kg/day. These calories are necessary to meet the normal energy needs for basal metabolism, growth and activity. Breast-fed infants consume about 7-10% fewer calories than their formula fed peers. RDA recommends no additional allowances if sufficient amount of human milk is ingested by a healthy infant from well nourished mother. It supplies all the essential nutrients and is a balanced diet for infant.
  2. Between 3 and 9 months of age, all infants consume 10% fewer calories than in the first 3 months or between 9 and 12 months of age.
  3. The protein requirement for a full term newborn is 2.2 g/kg/day and decreases to 1.6 g/kg/day during the second 6 months of life.
  4. Premature infants have higher caloric requirements, 120-150 kcal/kg/day. These high requirements are necessary to attain growth equivalent to intrauterine growth in the face of an immature gastrointestinal tract.
  5. The protein requirement for premature infants is 2.5-4.0 g/kg/day, which is necessary to promote synthesis of body tissue and postnatal growth. Even after hospital discharge, premature infants may require high caloric and protein intakes to achieve optimal growth.
  6. Infants fed exclusively on human and cows milk develop iron deficiency anemia, hence iron supplements may be needed.

Note: To approximate the composition of human milk, the diet of infants should contain 40-60% of total calories from carbohydrate, 7-11% of total calories from protein and 40-55% of total calories from fat. Commercial formulas based on cow's milk or soy protein contain this distribution of calories. Fat and cholesterol should not be restricted in infancy. This is in contrast to children older than age 2, who should have approximately 30% of total calories as fat.

Nutrition from Breastfeeding

Exclusive Breastfeeding is the ideal form of nutrition and sufficient to support optimal growth and development for approximately first six month of life. They don’t even need to give water since breast milk have enough fluid to keep the baby hydrated except during very hot weather or when baby have fever when they can receive extra fluids as water. Human milk is the standard by which all other forms of alternative feeding methods should be measured in regard to growth, health and development.

Contraindications to breastfeeding are:
  1. Galactosemia in infant
  2. Maternal human immunodeficiency virus
  3. Maternal consumption of drugs that can be found in human milk
  4. Mother has active untreated tuberculosis
  5. Breast cancer in the mother

During first few days after delivery mother produces thin yellowish fluid [COLOSTRUM] which is rich in proteins and antibodies that provide passive immunity to baby as baby immune system is not fully developed at birth. It also helps in growth of the digestive system and its proper functioning. Colostrum will gradually change to become milk in first 3-4 days when it will appear thin and watery and later thicker and creamier.

Characteristics of breast milk
  1. Has high lactose content, thus provides readily available energy for neonatal enzymes system.
  2. Vitamin E is present in high amount thus preventing anaemia by increasing erythrocyte life span.
  3. Has Ca:P ratio as 2:1 thus prevents Calcium deficiency tetany.
  4. Favourably changes the pH of intestinal flora and stools thus preventing bacterial diarrhoea.
  5. Transfers antibodies from mother to infant.
  6. Has cholesterol and taurine which are important for brain growth.
  7. Natural source of fatty acids which are important for visual development.

Advantages of Breastfeeding

  1. Breast milk provides complete nutrition and is easy for the baby to digest which in turn promotes child eating more often due to faster digestion.
  2. It helps to strengthen the child jaws.
  3. Breast feeding triggers biochemical reactions which allows for enzymes, hormone, growth factor and immunologic substances to help create effective defence to infectious disease for infants.
  4. Decreases the risk of allergies, diabetes, celiac diseases and SIDS.
  5. Breast-feeding has nutritional and immunologic benefits and decreased incidence of respiratory infections, otitis media and gastrointestinal infections.
  6. Cold and flu resistance is increased.
  7. There is decreased risk of obesity in adulthood and improve cognitive development.
  8. Breast milk has long chain polyunsaturated fatty acids which help with normal retinal and neural development.
  9. There are also economic benefits for the family, since the additional calories needed for lactating women cost less than infant formulas needed to sustain infants.
  10. In addition, breast-fed infants have less health care expenditure in the first year of life.
  11. Of all the benefits breastfeeding creates an emotional bonding between the infant and mother which is above everything else.

Note: Though breast milk is a complete diet, some supplementation may still be necessary for breast-fed infants. The vitamin D content of human milk is low (22 IU/L). Current AAP recommends daily vitamin D oral drops intake should be 200 IU per day for all infants from first two month of life and continued until daily consumption of vitamin D fortified food is enough. Fluoride supplementation for breast-fed infants remains controversial. Fluoride is not present in human milk and is recommended when drinking water is not fluoridated.

Why cow milk is not recommended for infants?

AAP[ American Academy of paediatrics] and ESPGHAN[ European Society of paediatric, Gastroenterology, Hepatology and Nutrition] does not recommends cow milk before 12 months of age. Cow milk can have certain harmful effects if given before 12 months of age. It can lead to:

  1. Iron deficiency anaemia: As cow milk has low concentration of iron its intake can lead to iron deficiency anaemia.
  2. Stress on kidneys: High level of protein and minerals present in cow milk can put stress on infants’ immature kidneys.
  3. Difficulty in digestion: Cow milk has high level of protein [three times the breast milk] and fat thus making it difficult to digest. Several distinct patterns of gastrointestinal disorders may result from ingestion of milk protein, one being allergic colitis, which typically presents in 1 to 2 month-old infant, with small volume, streaky bright red rectal bleeding associated with loose mucoid stool. Weight loss and other constitutional symptoms are not common. A second pattern, milk protein enteropathy, presents with symptoms of malabsorption and growth failure, usually in the first month of life. The prognosis for remission is excellent, with less than 1% of affected infants maintaining a lifelong intolerance.
  4. Allergy: Allergy to cow milk is difficult to precisely define. The incidence of true cow milk protein allergy is 1-5%. Perhaps an additional 3-5% of infants are cow milk sensitive. Symptoms attributable to cow milk sensitivity include skin rashes, recurrent upper respiratory infections and otitis media. Anaphylaxis to cow's milk protein can occur.

Low-fat cow milk should not be offered to children under age 2 years because of low caloric content, inadequate fat and high protein, mineral and electrolyte content, which leads to an increased renal solute load. Additionally, low-fat milk contains inadequate fat-soluble vitamins to meet the requirements of infants.

Formula milk

The alternative to breast milk is commercially prepared infant formula. Based on the protein content of infant formulas, there are three main groups:

  1. Cow milk protein
  2. Soy protein
  3. Hydrolysed casein protein.

There are many other specialized formulas available, such as amino acid-based formulas and formulas made specifically for certain inborn errors of metabolism which should not be given without paediatrician consultation.

Cow milk Formula

Cow milk formula is the most common human milk substitute and accounts for 80% of formula sold today. Cow milk is treated to make protein more digestible, more milk sugar [lactose] is added to make concentration equal to that of breast milk and butter fat is removed and replaced by vegetable oil or other fats that are easily digested by infants. Cow milk formulas contain whey and casein as protein, with added taurine to simulate the amino acid composition of breast milk.

Lactose-free cow milk formula is also available. This formula too contains vegetable oil as the fat source and may be used for infants with lactose or sucrose intolerance. Primary congenital lactase deficiency is extremely rare and secondary lactase deficiency may result from any injury to the gastrointestinal mucosa, such as with prolonged diarrhoea. Acute self-limited diarrheal disease in infants does not require a change to lactose-free formula. Iron fortified cow milk formula has dramatically reduced the chances of iron deficiency anaemia.

Formula Soy milk

Soy formulas are lactose free and contain methionine-fortified soy protein isolate and carbohydrate either glucose or sucrose different from milk based formulas. Soy protein-based formulas are used for infants with galactosemia and lactose intolerance. There are infants who appear to be sensitive to cow milk protein but do well on soy formula; however, 30-40% of infants who are allergic to cow milk is also allergic to soy protein and should be then given specialized formula like amino -based or elemental formula.

Formula Hydrolysed casein protein

Hydrolyzed formulas or pre-digested formula have protein casein which is already broken down to smaller proteins and can be easily digested. These formulas are recommended for infants allergic to intact cow milk protein and soy protein. The sources of carbohydrate and fat vary among products and should be evaluated when used for purposes other than protein allergy or sensitivity.

Note: Vitamin and mineral supplement are not needed in healthy full-term infants fed on commercially prepared formula. Only iron-fortified formula should be fed to infants, unless they have a hematologic disease for which repeated transfusions are necessary.

Probiotic formulas

Some formulas are fortified with friendly bacteria which are already normally present in high level in digestive system of breastfed babies. Those babies who are formula fed, it is required to promote a balance of bacteria in intestine and offset growth of unfriendly organisms that could cause infections. Thus probiotic fortified formulas can be recommended. Bifidobacterium and lactobacillus are most common types of probiotic strains used which can treat disorder like infectious diarrhoea and atopic dermatitis in children. These probiotic formulas should only be given if prescribed by paediatrician.

Solid foods and other foods

Introduction of solid foods is recommended at approximately 6 months of age when infants develop hand-eye coordination and the extrusion reflex disappears. The first solid foods should include iron-fortified infant cereal mixed with breastmilk or iron-fortified infant formula or juices. Initially, new baby foods should be added one at a time so signs of intolerance such as skin rashes, diarrhoea or wheezing etc. associated with the offending food can be ruled out.


  1. American Academy of Pediatrics Committee on Nutrition. Fluoride supplementation. Pediatrics 95:777, 1995. Current recommendations for when to start fluoride supplementation and how much to give.
  2. Baker R. “Human milk substitute. An American perspective”. Minerva Pediatr 55(40; 195-207; 2003
  3. Butte, N. Energy requirements of infants. Eur. J. Clin. Nutr. 50:S24“S36, 1996.
  4. Breastfeeding and the use of human milk. Paediatrics. 2012; 129(3); e827-e841.
  5. Fomon, S. Nutrition of Normal Infants (3rd ed.). St Louis: Mosby, 1993.
  6. Kelleher, D., and Duggan, C. Breast milk and breastfeeding in the 1990s. Curr. Opin. Pediatr. 11: 275-280, 1999.
  7. Lawrence, R., and Lawrence, R. Breastfeeding: A Guide for the Medical Profession (5th ed.). St. Louis: Mosby, 1998
  8. Riordan J, Countryman BA. Basics of breastfeeding. Part 1; infant feeding patterns past and present. JOHN Nurs 9(4);207-10;1980.
  9. Tigges, B. Infant formulas: Practical answers for common questions. Nurse Pract. 22:70, 73, 77-80, 1997.
  10. Tiwari S. Infant and young child feeding guidelines. 2010,47;995-1004.

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Dr. Mansi Jain

MDS (Pediatric and Preventive Dentistry) | Reader and Head of the Department (MN DAV Dental College and Hospital)

MN DAV Dental College, Solan

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