Infant Feeding

Robert T. Hall and Robin E. Carroll

Pediatr. Rev. 2000;21;191-200
DOI: 10.1542/pir.21-6-191

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/cgi/content/full/21/6/191

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2000 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601. Online ISSN: 1526-3347.

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 ARTICLE

Infant Feeding
Robert T. Hall, MD,* and Robin E. Carroll, MS, RD†
immunity is enhanced in this
OBJECTIVES system.
After completing this article, readers should be able to: Lipids provide approximately
50% of the caloric content of human
1. Delineate the optimum nutrition for infants through the first year of milk. Lipids are contained in milk
life. fat globules, and absorption is
2. Describe the formulas that can be used as adequate substitutes for enhanced by bile salt-stimulated
term infants whose mothers cannot or choose not to breastfeed lipase. The fatty acid content of
through the first year of life.
human milk is high in palmitic,
3. Explain the place of low-iron-containing formulas in infant feeding.
4. Explain the differences and implications of growth velocity in oleic, linoleic, and alpha-linolenic
formula-fed and breastfed infants. acids. Arachidonic acid (AA) and
5. Explain the implications of adding solid foods to the diets of breastfed docosahexaenoic acid (DHA), deriv-
and formula-fed infants. atives of linoleic and alpha-linolenic
acids, respectively, are found in
human but not in bovine milk. They
are related specifically to the com-
Breastfeeding and there are consistently improved
position of neural and retinal tissue,
The American Academy of Pediat- scores on tests of cognitive develop-
and deficiencies of these very long-
rics (AAP) has recommended exclu- ment directly correlated with the
chain polyunsaturated fatty acids
sive breastfeeding during the first duration of breastfeeding. However,
have been shown to be associated
6 months of life and continuation of it is clear that other factors associ-
with decreased neural, developmen-
breastfeeding for the second ated with breastfeeding enhance tal, and visual function in experi-
6 months as optimum nutrition in infant development, including mater- mental animal models.3 These very
infancy.1 There are multiple reasons nal socioeconomic status, the Home long-chain polyunsaturated fatty
for this recommendation. First, Inventory (a measure of the ade- acids have not been determined to
human milk is the optimum nutrient quacy of the home environment), be essential in term infants because
for term and near-term infants with maternal educational level, and of formation from their precursors,
respect to protein, fat, and carbohy- maternal intelligence quotient (IQ).2 but the question remains unanswered
drate composition. Second, the anti- for preterm and very low-birth-
infective properties of human milk weight (VLBW) infants.
reduce the incidence of acute ill- COMPOSITION OF HUMAN MILK Lactose is the major carbohydrate
nesses such as infectious diarrhea, The protein content of human milk in human milk. It is hydrolyzed in
pathogenic bacterial fecal flora, is approximately 70% whey and the small intestine into glucose and
necrotizing enterocolitis, otitis 30% casein, which differs from that galactose by lactase. This enzyme
media, lower respiratory tract infec- of bovine milk (18% whey, 82% appears somewhat late in the devel-
tions, and urinary tract infections in casein). The whey proteins are resis- oping fetal intestine, and some lac-
infants. Third, it has been suggested tant to acid precipitation and are tose, even in term infants, enters the
that the incidence of immune- digested more easily, which pro- distal small bowel where it ferments,
mediated diseases such as diabetes motes gastric emptying. The whey permitting proliferation of predomi-
mellitus, Crohn disease, eczema, protein fraction provides lower con- nantly acidophilic bacterial flora
asthma, and allergic gastroenteritis is centrations of phenylalanine, (lactobacilli). These bacteria produce
lower among breastfed infants. tyrosine, and methionine and higher an acid medium that suppresses
Fourth, psychological and long-term concentrations of taurine than does growth of more pathogenic organ-
cognitive advantages have been casein. The major component of
observed in breastfed infants com- whey protein is alpha-lactalbumin.
pared with formula-fed infants. It is Lactoferrin, lysozyme, and secretory
believed that mother-infant bonding ABBREVIATIONS
immunoglobulin A are specific
is enhanced during breastfeeding, AA: arachidonic acid
whey proteins involved in host
AAP: American Academy of
defense. Oligosaccharides, nucleo- Pediatrics
tides, growth factors, and cellular DHA: docosahexaenoic acid
*Professor of Pediatrics; Chief, Division of components of human milk also
Human Development. ELBW: extremely low-birthweight
enhance the infant’s immune system.
† Ig: immunoglobulin
Assistant Professor of Pediatrics, University The mother may produce specific
of Missouri Kansas City School of Medicine, LCPUFAs: long-chain polyunsaturated
antibodies that are excreted in her fatty acids
Children’s Mercy Hospital, Kansas City,
MO. milk as secretory immunoglobulin NCHS: National Center for Health
Dr Hall and Ms Carroll receive grant A (IgA) (intramammary-immune Statistics
support from Wyeth, Ross Nutritionals, and system) when exposed to foreign VLBW: very low-birthweight
Mead-Johnson Companies. antigens. Therefore, specific passive

Pediatrics in Review Vol. 21 No. 6 June 2000 191

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 NUTRITION
Infant Feeding
isms and promotes absorption of
calcium and phosphorus.
Human milk also contains miner-
als, vitamins, and micronutrients in
concentrations sufficient to achieve
optimum growth in the term and
near-term infant. No supplementa-
tion is required until 4 to 6 months
of age when iron (approximately
1 mg/kg per day) should be added
to the diet, preferably in the form of
iron-fortified cereal. Vitamin D sup-
plementation also may be necessary
in term infants at approximately 4 to
6 months of age if they are dark-
skinned or exposed to low levels of
sunlight. Vitamin D supplementation
of 400 IU/d is recommended for
these breastfed infants and may be
provided in the form of multiple
vitamin preparations for infants who
are exclusively breastfed. Fluoride
supplementation is recommended
“Lactose is the major carbohydrate in human milk . . .
some lactose . . . enters the distal small bowel where it
ferments, permitting proliferation of . . . bacterial flora
. . . that produce an acid medium . . . that promotes
absorption of calcium and phosphorus.”
from 6 months to 3 years of age in
breastfed and formula-fed infants if
the water supply contains less than
0.3 ppm fluoride.4 Other minerals
and micronutrients contained in
human milk are adequate for normal
growth and nutrition, although rates
of growth in breastfed infants are
lower than in formula-fed infants in
the second 6 months of life. Solid
foods commonly are introduced
beginning at 4 to 6 months of age,
but such additions do not change the
growth velocity of breastfed infants.
SUCCESSFUL BREASTFEEDING
Successful breastfeeding of the new-
born infant is a complex process and
frequently requires support and
encouragement. Recommendations
of the AAP, the United Nations
Children’s Fund, and the World
Health Organization have been
designed to promote breastfeeding.
Important among these recommen-
dations are discussion of feeding
plans with the mother prior to deliv-
ery and education about the details
of breastfeeding during prenatal
classes. Instruction and discussion
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should continue during hospitaliza-
tion and thereafter. Breasts should
be examined prenatally to identify
problems such as inverted nipples.
Breastfeeding should begin as soon
as possible after delivery, preferably
in the first hour. Infants should
room-in with their mothers and be
encouraged to breastfeed at least
8 to 12 times per day. If the breast-
feeding is incomplete or ineffective,
the mother should initiate a regimen
of expressing her milk. Supplemen-
tary feedings of water, glucose
water, or formula generally are not
necessary for healthy infants and
may be counterproductive.
CONSEQUENCES OF LACTATION
FAILURE
Early hospital discharge (⬍48 h)
and prematurity constitute risk fac-
tors for lactation failure that can
result in excessive jaundice and
dehydration. Infants should be
examined within 2 days of hospital
discharge to assess breastfeeding
and initiate appropriate intervention
strategies as necessary. Mothers and
caregivers should understand that
excessive jaundice is the result of
inadequate human milk intake dur-
ing the first week of life, necessitat-
ing increased frequency of breast-
feeding. This may be provided best
by employing a feeding tube
attached to the breast, gastric tube,
or supplemental bottle feedings with
human milk or formula. Jaundice
due to human milk is uncommon. It
usually begins and peaks after the
first week of life, whereas breast-
feeding jaundice that is associated
with decreased intake and increased
enteropathic circulation occurs pre-
dominantly during the first week of
life. Bilirubin levels in breastfed
infants may peak normally at 306 to
340 mcmol/L (18 to 20 mg/dL).
Such levels do not require photo-
therapy or discontinuation of breast-
feeding unless there are other asso-
ciated conditions (eg, hemolysis,
Pediatrics in Review
inborn errors of metabolism,
infection).
STORAGE OF HUMAN MILK
Expressed human milk that will be
fed within 48 hours of collection
can be refrigerated; that which is not
to be fed within 48 hours should be
frozen. Milk expressions should be
packaged and frozen separately and
preferably labeled with the name
and date if the infant is to be cared
for in a child care center. Frozen
milk should be thawed in warm
water. Microwave warming should
be avoided.
Formula Feeding for Term
and Near-term Infants
Cow milk formulas and soy milk
formulas are adequate substitutes for
term and near-term infants who are
not breastfeeding during the first
12 months of life.5 All of the
infant’s nutritional needs may be
met with iron-fortified formulas fed
during the first 4 to 6 months, and
these formulas provide a major
source of nutrition for the second
6 months of life.
Indications for the use of infant
formulas are: 1) as substitute or sup-
plement feedings for mothers who
do not or cannot provide human
milk for their infants; 2) infants who
have certain inborn errors of metab-
olism or other conditions causing
intolerance to human milk (eg,
galactosemia and tyrosinemia);
3) infants whose mothers have cer-
tain infections caused by organisms
known to be transmitted in human
milk (eg, human immunodeficiency
virus and, under rare circumstances,
cytomegalovirus, herpes simplex
virus, and bacteria); 4) infants
whose mothers are undergoing can-
cer chemotherapy or are receiving
certain other drugs, foods, medica-
tions, or environmental agents that
are excreted into human milk.6 For-
mula supplementation also should be
considered if the infant fails to gain
weight following optimal encourage-
ment and therapy for breastfeeding.
FORMULA COMPOSITION
Cow milk infant formulas vary in
composition but generally have been
altered to optimize nutrient intake.
Vol. 21 No. 6 June 2000
 NUTRITION
Infant Feeding

Protein in cow milk formula varies
in concentration from approximately
1.4 to 1.6 g/dL, which is approxi-
mately 40% greater than that in
human milk (Table 1). Although the
composition varies in ratios of whey
to casein, the bovine whey-dominant
formulas produce amino acid pat-
terns that differ from those seen
with human milk whey protein. The
predominant whey protein in cow
milk is beta-lactoglobulin. Infants
fed bovine whey-predominant for-
mula have increased serum levels of
threonine, phenylamine, valine, and
methionine compared with breastfed
infants. There are no known adverse
effects of these differing amino acid
patterns in otherwise normal infants.
The fat content of cow milk for-
mulas constitutes approximately 50%
of their energy. The butterfat of cow
milk formula is replaced largely with
vegetable oils that enhance digestibil-
ity and absorption. Fat blends vary
among formulas, but generally they
provide a mixture of highly digestible
short-chain fatty acids (coconut
oil), long-chain polyunsaturated
fatty acids (LCPUFAs) (palm oil),
and polyunsaturated fatty acids
(soy, corn, and safflower oils). The
essential fatty acids, linoleic and
alpha-linolenic acids, are added in
concentrations sufficient to provide
adequate substrate for their long-
chain polyunsaturated derivatives,
AA and DHA, respectively. How-
ever, there is debate over whether
the very long-chain polyunsatu-
rated fatty acids, AA, and DHA
that are present in human milk

TABLE 1. Human Milk and Commerical Formulas for Term Infants

NUTRIENT COMPOSITION PER LITER
RDA
0 TO HUMAN ENFAMIL姞 SIMILAC姞 CARNATION姞
12 MO MILK WITH IRON WITH IRON GOOD START
Energy (kcal) 98 to 108 680 676 676 676
kcal/kg
Protein (g) 13 to 14 10.5 14.2 14.0 16.2
Source
Whey (% total) 70 60 18 100
Casein (% total) 30 40 82 0
Fat (g) 39 35.8 36.5 34.5
Source
Polyunsaturated (%) 14 29 37 32
Monounsaturated (%) 42 16 17 26
Saturated (%) 44 55 46 43
Predominant oil Human milk Palm olein, soy, Soy, coconut, Palm olein, soy,
fat coconut, safflower coconut,
sunflower safflower
Carbohydrate (g)
Source
Lactose 73 74 73 74
Minerals
Calcium (mg) 400 to 600 280 528 527 433
Phosphorus (mg) 300 to 500 140 358 284 243
Magnesium (mg) 40 to 60 35 54 41 45
Iron (mg) 6 to 10 0.3 12.2 12.2 10.1
Zinc (mg) 5.0 1.2 6.8 5.1 5.1
Copper (mcg) 400 to 700 252 507 610 541
Iodine (mcg) 40 to 50 110 68 41 54
Sodium (mEq) 5 to 9 8 8 8 7
Potassium (mEq) 13 to 18 14 19 18 17
Chloride (mEq) 5 to 9 12 12 12 11
Renal solute load (mOsm) — 91 131 127 136
Osmolality (mOsm/kg H2O) — 286 300 300 265
Fat-soluble Vitamins
A (IU) 1,240 2,230 2,027 2,027 2,027
D (IU) 300 to 400 21 405 405 405
E (IU) 3 to 4 3 14 20 14
K (mcg) 5 to 10 2 54 54 55

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 NUTRITION
Infant Feeding
should be added to term infant
formulas.
Lactose is the major carbohydrate
in standard cow milk-based formulas,
although some formulas contain starch
or other complex carbohydrates. Lac-
tose intolerance appears to be uncom-
mon in the first year of life, but there
is a growing market for nonlactose-
containing formulas for infants who
have nonspecific symptoms of bloat-
ing, gaseous distention, vomiting, spit-
up, and nonspecific diarrhea. With the
exception of galactosemia and second-
ary lactase deficiency following small
intestinal injury (usually following
gastroenteritis), there are very few
indications for a lactose-free formula
in infancy.
“Mineral and vitamin content of standard cow and soy
milk formulas is adequate to meet the nutritional needs
of infants in the first year of life except for fluoride. . . .”
Iron is an important component
of cow milk formulas and is present
in a concentration of 12 mg/L. Low-
iron-containing formulas continue to
be marketed because of a perception
that iron causes constipation and
other feeding problems. Data are
inadequate to support this percep-
tion, and the AAP has recommended
that all cow milk formula-fed infants
receive iron-fortified formula.7
Mineral and vitamin content of
standard cow and soy milk formulas
is adequate to meet the nutritional
needs of infants in the first year of life
except for fluoride, which should be
added after 6 months of age if the
fluoride concentration in the water
supply is less than 0.3 ppm.4 Formula
intake should be ad libidum and ade-
quate to support weight gains of
approximately 25 to 30 g/d for the
first 3 months, 15 to 20 g/d for the
second 3 months, and 10 to 15 g/d
between 6 and 12 months of age. For-
mula intake generally ranges from
5 to 7 oz/kg per day in the first 3
months and remains at 26 to 32 oz/d
thereafter through the first year of life.
Solid feedings provide additional
caloric intake for formula-fed infants
after 4 to 6 months of age and result
in greater weight gains than in breast-
fed infants, perhaps because breastfed
infants decrease their intake of human
milk when introduced to solid foods.
Formula-fed infants generally continue
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to consume the same volume of milk
in spite of additional caloric intake
from solids and have accentuated
weight gain velocity.
Soy formulas and lactose-free cow
milk formulas support the growth of
normal term infants through the first
year of life. They may be used in lieu
of cow milk formula. Use of these
formulas reportedly comprises nearly
25% of the formula market, although
this far exceeds the estimated inci-
dence of cow milk protein and lactose
intolerance for which they are
employed. Phytate in soy formula in
addition to the absence of lactose
diminishes calcium absorption,
although adequate bone mineralization
has been demonstrated in term infants
receiving these formulas. Because
premature and enriched formulas are
available for preterm infants, there is
no indication for the use of soy or
lactose-free formulas in preterm
infants who have no demonstrated
intolerance.
FORMULA MIXING
Boiling Water
Most municipal water supplies are
safe, and boiling water infrequently
is recommended to prepare infant
formulas. However, families using
well water or pond water or who
live in areas where flooding is a
problem should boil the water used
to prepare formula.
Lead Exposure
Lead exposure is still a common
problem in the United States that
affects all ethnic and socioeconomic
groups. Infants can be exposed to
lead if contaminated tap water is
used to prepare their formula. Older
homes may contain lead pipes, and
some newer homes are at risk
because the pipes may have been
soldered with lead. To reduce the
possibility of lead contamination in
tap water, mothers should be
instructed to use only cold water,
run the water for 2 minutes before
using it, and avoid boiling water
Pediatrics in Review
excessively, which can increase the
concentration of lead.
Fluid Requirements
Infants are particularly vulnerable to
fluid imbalances. Compared with
adults, infants have a larger surface
area-to-body weight ratio and a
higher percentage of body water and
are unable to communicate thirst. In
general, infants who weigh 0.5 to
3 kg require 120 mL/kg per day of
fluid, and those who weigh 3 to
10 kg require 100 mL/kg per day.
Infants weighing 10 to 20 kg require
1,000 mL plus 50 mL/kg per day for
each kilogram above 10 kg. Inappro-
priate mixing of infant formulas
may lead to dehydration, overhydra-
tion, and weight loss.
Nutritional Needs of Preterm
Infants
The preterm infant who is born at
34 weeks’ gestation and weighs less
than 2,000 g and perhaps is as large
as 2,500 g and as old as 36 weeks’
gestation has special nutritional
needs. Specific data on the 34- to
36-week-gestation infant are sparse.
Special nutritional supplementation
of these infants may shorten the
time of recovery from deficiencies
of abbreviated intrauterine accretion
and those accrued from inadequate
nutritional intake during early neo-
natal life.
Clearly, the VLBW infant
(⬍1,500 g birthweight and
⬍32 weeks’ gestation) has extraor-
dinary nutritional needs and special
requirements for intake that can be
met only with fortified human milk
and preterm infant formulas. The
energy intake required for growth of
the VLBW infant is approximately
100 to 120 kcal/kg per day or
greater to achieve a weight gain of
15 g/kg per day. Protein intakes nec-
essary to achieve this growth are
3.5 to 4 g/kg per day. Preterm infant
formulas are whey-predominant
(albeit bovine whey), which pro-
duces plasma amino acid levels
close to those of breastfed infants
(Table 2).
Fat should constitute approxi-
mately 50% of the energy intake.
The fat content of human milk is
fairly constant from early lactation
Vol. 21 No. 6 June 2000
 NUTRITION
Infant Feeding

TABLE 2. Fortified Human Milk and Formulas for Preterm Infants

HUMAN PREMATURE INFANT NUTRIENT ENRICHED
MILK ⴙ HUMAN FORMULA FORMULA
POWDERED MILK ⴙ
FORTIFIER LIQUID SIMILAC 24
1 PKG/ FORTIFIER SPECIAL ENFAMIL 24
25 ML 50/50 CARE姞 PREMATURE姞 NEOSURE姞 ENFACARE姞
Energy (kcal) 788 739 806 806 746 751
Protein (g) 20 18 22 24 19 21
Source Human milk, Human milk, Nonfat milk, Nonfat milk, Nonfat milk, Nonfat milk,
whey nonfat whey whey whey whey
protein, milk, protein protein protein protein
casein whey
protein
Fat (g) 38.8 41.4 43.8 41.1 41 40
Source Human milk Human milk, MCT, soy, MCT, soy, Soy, safflower, Sunflower,
MCT, soy, coconut coconut coconut, soy,
coconut MCT coconut,
MCT
Carbohydrate (g) 91 76 86 90 77 80
Source Lactose, Lactose, Lactose, Lactose, corn Lactose, corn Lactose, corn
corn syrup corn syrup corn syrup solids syrup solids syrup
solids solids syrup solids
solids
Minerals
Calcium (mg) 1,116 971 1,452 1,331 784 902
Phosphorus (mg) 561 531 806 669 463 496
Magnesium (mg) 40 64 97 55 67 60
Iron (mg) 1.2 2.1 14.5 (3)* 14.5 (2)* 13.4 13.5
*Low-iron
Zinc (mg) 10.2 7.8 12.1 12.1 9 9
Copper (mcg) 1,229 1,330 2,016 1,008 896 902
Iodine (mcg) 104 78 48 202 112 113
Sodium (mEq) 13.4 12.9 15.1 13.7 10.7 11.4
Potassium (mEq) 17.2 20.6 26.6 21.2 27.1 20.2
Chloride (mEq) 19.9 17 18.4 19.3 15.8 16.5
Renal solute (mOsm) 186 170 211 214 179 184
Osmolality (mOsm/ 410 285 280 310 250 250
kg/H2O)
Fat-soluble vitamins
A (IU) 13,015 6,990 10,081 10,081 3,433 3,381
D (IU) 2,056 615 1,210 2,177 522 601
E (IU) 55 22 33 51 27 30
K (mcg) 45 49 97 65 82 60
MCT ⴝ medium-chain triglycerides

to mature milk, and it is well
absorbed. Preterm infant formulas
contain a mixture of medium-chain
triglycerides and vegetable oils con-
taining polyunsaturated long-chain
triglycerides that also are well
absorbed. However, preterm infant
formulas do not contain very long-
chain polyunsaturated fatty acids
(AA and DHA). Although these very
long-chain polyunsaturated fatty acids
are important constituents of the brain
and retina, data are not yet conclusive
to determine whether adequate lev-
els are produced from their precur-
sors linoleic and alpha-linolenic
acids in preterm infants. This is an
area of intense investigation.
Carbohydrate requirements for
the VLBW infant are estimated to
be 40% to 50% of calories or
approximately 10 to 14 g/kg per
day. Human milk has fairly constant
levels of lactose from early to late
gestation, which may result in undi-
gested lactose in the distal bowel
because of inadequate lactase activ-

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 NUTRITION
Infant Feeding
ity. Although this may cause a fer-
mentative diarrhea, human milk is
well tolerated in most clinical set-
tings. However, preterm infant for-
mulas frequently contain 50% carbo-
hydrate with glucose polymers to
avoid problems of osmotic diarrhea
and lactose intolerance. These spe-
cial formulas generally have been
well tolerated because of high glu-
cosidase activity in the small intesti-
nal mucosa of the preterm infant.
Mineral absorption with these for-
mulas has not been impaired.
“Iron intake represents a special nutritional need for the
VLBW infant. Human milk contains very low quantities
of iron, and formulas for preterm infants are available
with or without iron supplementation. . . . iron in the
form of ferrous sulfate should be provided . . . to the
formula-fed growing preterm infant.”
Mineral requirements of the
VLBW infant are higher than for
larger preterm infants. Sodium and
potassium requirements are esti-
mated to be 2.5 to 3.5 mEq/kg per
day and even higher in extremely
low-birthweight (ELBW) infants
(⬍1,000 g birthweight). Calcium,
phosphorus, and magnesium require-
ments are related inversely to gesta-
tional age in the VLBW infant on a
per-kilogram basis. This is due in
large part to the extremely high
accretion rates generally achieved in
the last trimester of pregnancy.
Mature human milk is clearly inade-
quate to meet these needs, and pre-
term infant formulas contain 100 to
180 mg/100 kcal of calcium and
50 to 70 mg/100 kcal of phosphorus
in an attempt to achieve intrauterine
accretion rates. Fortification of
human milk to these levels has been
demonstrated to be adequate to
achieve bone mineralization and
intrauterine accretion within the nor-
mal range for term infants.
Human milk fortifiers are avail-
able in powdered and liquid form in
the United States. When added to
human milk (1 pack per 25 mL), the
powdered fortifier is sufficient to
achieve an energy content of
24 kcal/oz and is similar in compo-
sition to a 24 kcal/oz preterm infant
formula. However, fat absorption is
less when employing the currently
available powdered fortifier com-
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pared with premature formula,
necessitating intakes of approxi-
mately 180 mL/kg per day of forti-
fied human milk compared with
intakes of approximately 150 mL/kg
per day of premature formula to
achieve similar weight gain. New
powdered fortifiers are being evalu-
ated, which appear to overcome
problems of fat malabsorption while
maintaining adequate absorption of
calcium, phosphorus, and magne-
sium. Although fat absorption is
better (90%) with the commercially
available liquid fortifier, dilution of
the liquid fortifier with human milk
diminishes the content of human
milk fat. The result of using liquid
fortifiers is dilution of both human
milk and the fortifier in concentra-
tions proportionate to the mixture.
Iron intake represents a special
nutritional need of the VLBW
infant. Human milk contains very
low quantities of iron, and formulas
for preterm infants are available
with or without iron supplementa-
tion. It is clear that iron in the form
of ferrous sulfate should be provided
in quantities of 2 to 4 mg/kg per
day to the formula-fed growing pre-
term infant. Infants receiving eryth-
ropoietin may require iron supple-
mentation of 6 mg/kg per day or
greater.
Enriched formulas (Similac Neo-
Sure威 and Enfamil Enfacare威) have
been designed for the growing pre-
term infant who has achieved a
weight of at least 1,800 g (approxi-
mately 34 weeks’ postconceptual
age). These formulas generally pro-
vide 22 kcal/oz and are midway in
composition between fortified
human milk or preterm infant for-
mula and mature human milk or
cow milk formula (Table 2). The
enhanced protein and caloric density
of these formulas has been shown to
achieve increased growth in weight,
length, and even head circumference
in the VLBW infant. Unfortunately,
Pediatrics in Review
data are not available to recommend
precisely either the time of initiation
or discontinuation of enriched for-
mula. However, data to date suggest
that initiation at 1,800 g weight or
34 weeks’ postconceptual age and
continuation to a postconceptual age
of 52 to 56 weeks (3 to 4 mo) is
associated with enhanced growth
compared with infants receiving cow
milk formula or human milk. Bone
mineralization also is enhanced in
infants receiving enriched formula.
Clinical studies are underway to
evaluate the optimum duration for
continuation of enriched formula in
VLBW infants.
Meeting the nutritional needs of
VLBW infants who are breastfeed-
ing following hospital discharge has
been evaluated incompletely. Data
suggest that growth and bone miner-
alization are significantly lower in
these infants than those fed standard
cow milk formula or enriched for-
mula. Therefore, supplementation
with 8 oz/d of enriched formula or
fortified human milk may be pru-
dent. Assessment of nutritional ade-
quacy by obtaining serum calcium,
phosphorus, alkaline phosphatase,
urea nitrogen, and transthyretin (pre-
albumin) levels at 4 to 6 weeks
postdischarge is recommended.
Phosphorus levels less than
1.49 mmol/L (4.5 mg/dL) suggest
the need for additional supplementa-
tion of calcium and phosphorus.
Urea nitrogen less than 1.79 mmol/L
(5 mg/dL) or transthyretin less than
10 mg/dL indicates the need for
additional protein.
Special Infant Formulas
(Table 3)
Soy protein formulas are lactose-free
and may be used for infants who
have lactase deficiency or galac-
tosemia. Short-term use may be
indicated for infants who have post-
diarrheal lactose intolerance,
although infants generally should be
rechallenged with lactose in these
circumstances because lactase defi-
ciency is transient. Soy formulas
also have been employed in infants
who are perceived to have intoler-
ance to cow milk formula for a vari-
ety of reasons. Infants who have
IgE-mediated cow milk protein
intolerance may benefit from soy
Vol. 21 No. 6 June 2000
 TABLE 3. Commonly Employed Special Formulas
NUTRIENT COMPOSITION PER LITER
SOY FORMULAS LACTOSE-FREE PROTEIN HYDROLYSATE
SIMILAC

Pediatrics in Review
ISOMIL姞 PROSOBEE姞 ALSOY姞 LACTOSE FREE姞 LACTOFREE姞 ALIMENTUM姞 NUTRAMIGEN姞 PREGESTIMIL姞

Energy (kcal) 676 676 676 676 676 676 676 676

Protein (g) 17 17 19 14 14 19 19 19
Source Soy protein and Soy protein and Soy protein and Milk protein isolate Milk protein isolate Casein hydrolysate Casein hydrolysate Casein
methionine methionine methionine hydrolysate

Fat (g) 37 36 33 36 36 38 34 38
Source Safflower, Palm olein, soy, coconut, Palm olein, soy, Soy and coconut Palm olein, soy, coconut, Safflower, MCT, and Palm olein, soy, coconut, MCT, soy, corn,
coconut, and and sunflower coconut, and and sunflower soy and sunflower and safflower
soy safflower

Vol. 21 No. 6 June 2000

Carbohydrate (g) 70 72 75 72 74 69 74 69
Source Corn syrup Corn syrup solids Corn, malto- Corn syrup solids, Corn syrup solids Sucrose and modified Corn syrup solids and Corn syrup solids,
solids, dextrin, sucrose sucrose tapioca starch modified cornstarch dextrose,
sucrose modified
cornstarch

Minerals
Calcium (mg) 709 709 709 568 554 709 635 777
Phosphorus (mg) 507 561 412 378 372 507 426 507
Magnesium (mg) 51 74 74 41 54 51 74 74
Iron (mg) 12 12 12 12 12 12 12 12
Zinc (mg) 5 8 6 5 7 5 7 7
Copper (mcg) 507 507 811 608 507 507 507 507
Iodine (mcg) 101 101 54 61 101 101 101 101
Sodium (mEq) 13 11 10 9 9 13 14 14
Potassium (mEq) 19 21 20 19 19 20 19 19
Chloride (mEq) 12 15 14 12 13 15 16 16

Renal solute 154 161 164 134 134 171 171 174
(mOsm)

Osmolality 230 200 200 230 200 370 320 320

(mOsm/kg/H2O)

Fat-soluble
vitamins
A (IU) 2,027 2,027 2,095 2,027 2,027 2,027 2,027 2,568
D (IU) 405 405 426 405 405 304 405 405

Downloaded from http://pedsinreview.aappublications.org. Provided by Pakistan:AAP Sponsored on March 1, 2011

E (IU) 20 14 20 20 14 20 14 27
K (mg) 74 54 53 54 54 101 54 81
NUTRITION
Infant Feeding

MCT ⴝ medium-chain triglycerides

197
 NUTRITION
Infant Feeding
formula, although many of these
infants also may have soy milk
intolerance for nonspecific reasons
that frequently is manifested by
loose stools, spitting up, vomiting,
and irritability.
Lactose-free cow milk formulas
are enjoying an increased market for
infants who are perceived to have
lactose intolerance characterized by
bloating, gaseousness, vomiting,
colic, and diarrhea. It is not clear
that this market exuberance is justi-
fied by true lactose intolerance.
Rechallenging affected infants with
cow milk formula may avoid the
false impression of lactose or cow
milk protein intolerance that fre-
quently is perceived by the parents,
thereby creating a pattern of avoid-
ing milk products.
“The ability to digest and absorb proteins, fats, and
carbohydrates is sufficiently mature by 4 to 6 months of
age to tolerate cereal, pureed fruits, vegetables, and
meats.”
Protein hydrolysate formulas are
more appropriate for the infant who
is intolerant to intact milk protein.
The protein in these formulas is
extensively hydrolyzed, resulting in
peptides that do not elicit an immu-
nologic response in most infants. In
addition, the fat content of some of
the protein hydrolysate formulas
contains medium-chain triglycerides
to facilitate the absorption of fat.
Therefore, these formulas are suit-
able for conditions of chronic mal-
absorption (eg, cystic fibrosis, short
gut syndrome, biliary atresia, and
other forms of cholestasis). Most
protein hydrolysate formulas also
are free of lactose, and carbohydrate
is provided in varying forms of corn
syrup solids, modified corn starch,
sucrose, or dextrose. This may facil-
itate the efficacy of these formulas
in patients who have chronic malab-
sorption syndromes. Beyond hydro-
lysates, there is a place for the use
of L-amino acid formulas for infants
who have protein-induced intestinal
disease.
A wide variety of other special
infant formulas have specific but
uncommon medical indications,
including a low-solute formula
(Similac PM 60/40威) used for
infants who have renal or cardiovas-
198
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cular dysfunction. The sodium,
potassium, chloride, calcium, phos-
phorus, and iron concentrations of
these formulas are low, necessitating
very careful use and evaluation.
These formulas are not suitable for
use in the growing healthy infant
who has no specific indications.
A variety of amino acid-based for-
mulas specifically designed for
infants who have inborn errors of
metabolism also are available.
Follow-up or toddler formulas also
are commercially available (Pedia-
Sure威 and EleCare威). In general,
these formulas have higher protein
concentrations than cow milk for-
mula and are more consistent with
protein levels in cow milk. The fat
and carbohydrate concentrations are
also higher, resulting in a caloric
density of 1,000 kcal/L. These for-
mulas are designed as a nutritional
supplement or total feeding for
young children who have “failure to
thrive” from a variety of underlying
etiologies, such as chronic cardio-
pulmonary or neurologic disorders.
They are not suitable for infants
younger than 1 year of age or for
the otherwise growing healthy older
infant.
Introducing Solid Feedings
Timing of the introduction of solid
feeding depends on neurologic and
gastrointestinal maturation of the
infant. The infant should be able to
sit and to coordinate masticating and
swallowing nonliquid foods. The
ability to digest and absorb proteins,
fats, and carbohydrates is suffi-
ciently mature by 4 to 6 months of
age to tolerate cereal, puréed fruits,
vegetables, and meats. Renal matu-
ration generally is sufficient to toler-
ate increased renal solute.
There is considerable variation
among infants in achieving these
neuromaturational requirements.
Generally, the extrusion reflex has
resolved between 4 and 6 months of
age, and the ability to swallow non-
liquid foods is established. Infants
Pediatrics in Review
typically begin to indicate readiness
for oral feedings by opening their
mouths and leaning forward in the
sitting position. Similarly, they can
indicate satiety or lack of readiness
by turning away. Mothers should be
instructed to follow these cues to
avoid overfeeding or creating con-
flict over oral feeding. Introducing
solids prior to 4 to 6 months of age
may be inappropriate. There is no
scientific evidence to support the
claim that solids (cereal in the bot-
tle) will help an infant sleep longer
at night.
Families may need assistance in
setting realistic goals for introducing
solids. The decision to introduce
solid foods into the diet of any
infant should be individualized and
based on the infant’s developmental
ability. Feedings prior to this devel-
opmental stage may represent a type
of forced feeding and can be dan-
gerous. Infants may aspirate food if
they do not have the necessary oral-
motor skills.
It is important to continue breast-
feeding or formula feeding through
the first year of life. Although it
formerly was believed that caloric
intake would increase significantly
with the onset of solid feedings, evi-
dence suggests that consumption of
human milk will decrease, and the
addition of solid foods is not associ-
ated with increased weight gain in
breastfed infants.8
Single-ingredient foods generally
should be introduced first, with no
more than one started at weekly
intervals to permit identification of
any intolerance. Infant cereals are a
good first choice, with dry cereal
diluted 1:6 by weight with human
milk or infant formula. This pro-
vides a caloric density of
108 kcal/dL.
The introduction of puréed fruits,
vegetables, and meats may be
guided by individual taste and pref-
erence. Juices may be introduced
when the infant can drink from a
cup, but they should not replace
milk or formula. These products are
high in carbohydrates and may
decrease consumption of protein-
containing liquids if given exces-
sively. Quantities greater than 8 oz/d
may result in diarrhea and have the
potential for producing caries if
Vol. 21 No. 6 June 2000

infants are exposed to them for sus-
tained periods throughout the day
from a bottle. Extra water generally
need not be consumed except in
instances of excessive losses, such
as diarrhea or excessive perspiration.
The caloric density of commer-
cially prepared baby foods varies
considerably and is a factor in
caloric intake. For example, 100 g
strained fruit contains 40 to 50 kcal,
strained vegetables contain 30 to
65 kcal, meat contains 95 to
100 kcal, egg yolk contains
195 kcal, and desserts contain 70 to
90 kcal. Although breastfeeding
infants will decrease their intake of
human milk when solid foods are
added to the diet, formula-fed
infants may be encouraged by par-
ents to continue the same volume of
intake, which can result in greater
caloric consumption and the poten-
tial for excessive weight gains.
Finely chopped foods may be
introduced at 10 to 12 months of
age, but parents must be watchful
for potential aspiration of food parti-
cles. Peanuts, raw fruit, popcorn,
and hotdogs should not be fed to
children younger than 2 years of
age. Salt intake varies considerably
from product to product and manu-
facturer to manufacturer. Some cau-
tion should be exercised to avoid
both deficient and excessive intake,
although earlier concerns about salt
avoidance to prevent hypertension
have not been borne out by long-
term studies.
Assessment of Growth and
Nutritional Status
Assessment of growth and nutrition
of the infant is fundamental to nutri-
tional care. Although simple in its
fundamentals, such assessment is
complex in discerning disorders
from norms, particularly because
there are widely divergent normal
values for different populations and
nutrient intakes.
Growth is assessed primarily by
comparing values for weight, length,
weight-to-length ratios, and head
circumference against National Cen-
ter for Health Statistics (NCHS)
growth standards for boys and girls.
However, several shortcomings are
evident from these measurements
Pediatrics in Review Vol. 21 No. 6 June 2000
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alone. Growth velocity is a more
sensitive index than weight or length
obtained at a specific time. It is a
measure of changes in the parameter
over time and should be employed
when assessing the nutritional status
of infants. For example, weight gain
should approximate 10 to 15 g/kg
per day in the first month of life,
7 to 10 g/kg per day from 2 to
3 months of age, and 5 to 7 g/kg per
day from 3 to 6 months of age.
Height velocity and weight-to-length
ratios or ponderal index (weight [g]
⫼ length [cm3] x 100) are excellent
measures of stature. Body mass
index (weight [g] ⫼ height [m2]) is
useful after 2 years of age. Recum-
bent length should be employed in
infants younger than 2 years of age,
having the infant lie supine on a flat
surface and using a length board
fitted against the soles of the feet
and the crown of the head.
A second potential shortcoming
of using NCHS growth curves is
misinterpretation of growth in
breastfed infants. Comparison of
weight by using this reference stan-
dard suggests that breastfed infants
are falling below normal growth
standards at 4 to 6 months of age
and beyond, when their growth
velocity tapers compared with that
of formula-fed infants.9 In fact, the
growth velocity of formula-fed
infants may be accelerated in the
second 6 months, raising concern
about overweight and subsequent
obesity. Weight-to-length ratios
should be observed carefully during
this time. However, data to date
indicate neither that the larger
weight and possibly length of
formula-fed infants nor the lower
weight and possibly length of
breastfed infants persists beyond the
second year of life. Separate growth
charts for formula-fed and breastfed
infants are being developed and
should be available for use within
3 years. It is important in the inter-
val not to discourage breastfeeding
after 4 to 6 months of age because
such infants are demonstrating
decreased weight and length velocity
compared with formula-fed infants.
The Z score is another useful
marker of infant nutrition. This is a
calculation of the variance of the
parameter measured with normal
NUTRITION
Infant Feeding
values. It is calculated as a function
of observed value - median value ⫼
median value. A 3% or 97% devia-
tion is ⫾1.88 standard deviations
from the median.
Failure to achieve normal growth
rates or growth velocity suggests the
need to assess nutritional intake,
which traditionally is performed by
24-hour intake recall assessment.
A 3-day prospective nutrient intake
may be indicated after 6 months of
age, when intake may vary from day
to day. Reference standards for
nutrient composition of infant foods
are readily available. Breastfeeding
cannot be assessed accurately from
historical information, and it may
require accurate weights before and
after breastfeeding to determine the
quantity of intake. There is no evi-
dence that quality of milk is signifi-
cantly altered by maternal nutritional
status, although nutrient content var-
ies considerably throughout the day,
and hind milk is known to provide
greater fat (energy) intake than that
present in early lactation.
REFERENCES
1. American Academy of Pediatrics Work
Group on Breastfeeding. Breastfeeding
and the use of human milk. Pediatrics.
1997;100:1035–1039
2. Jacobson SW, Chiodo LM, Jacobson JL.
Breastfeeding effects on intelligence in 4-
and 11-year old children. Pediatrics.
1999;103:e71. http://www.pediatrics.org/
cgi/content/full/103/5/e71
3. Neuringer M, Connor WE. n-3 Fatty
acids in the brain and retina. Evidence
for their essentiality. Nutr Rev.
1986;44:285–294
4. American Academy of Pediatrics Com-
mittee on Nutrition. Fluoride supplemen-
tation for children: interim policy recom-
mendations. Pediatrics. 1995;95:777
5. American Academy of Pediatrics Com-
mittee on Nutrition. Soy protein-based
formulas: recommendations for use in
infant feeding. Pediatrics. 1998;101:
148 –153
6. American Academy of Pediatrics Commit-
tee on Drugs. The transfer of drugs and
chemicals into human milk. Pediatrics.
1994;93:137–150
7. American Academy of Pediatrics Com-
mittee on Nutrition. Iron-fortified infant
formulas. Pediatrics. 1989;84:1114 –1115
8. Dewey KG. Growth characteristics of
breast-fed compared to formula fed
infants. Biol Neonate. 1998;74:94 –105
9. Dewey KG, Peerson JM, Brown KH, et al.
Growth of breast-fed infants deviates from
current reference data: a pooled analysis of
United States, Canadian, and European data
sets. Pediatrics. 1995;96:495–503
199
 NUTRITION
Infant Feeding
PIR QUIZ
Quiz also available online at
www.pedsinreview.org.
5. The whey protein content of human
milk is closest to:
A. 10%.
B. 30%.
C. 50%.
D. 70%.
E. 90%.
6. Which of the following statements
about supplementing the diets of term
breastfed infants exposed to adequate
sunlight is most accurate?
A. Iron and vitamin D should be
added at 2 to 3 months after birth.
B. Iron and vitamin D should be
added at 4 to 6 months after birth.
C. Iron should be added at 2 to
3 months after birth.
D. Iron should be added at 4 to
6 months after birth.
E. No supplementation is required as
long as breastfeeding proceeds.
200
Downloaded from http://pedsinreview.aappublications.org. Provided by Pakistan:AAP Sponsored on March 1, 2011
7. Which of the following statements
concerning the introduction of solid
feedings in breastfed and formula-fed
infants is most accurate?
A. Introduction can begin at 3
months in breastfed infants and at
4 to 6 months in formula-fed
infants.
B. Introduction can begin at 3
months in formula-fed infants and
at 4 to 6 months in breastfed
infants.
C. Introduction can begin at 4 to 6
months in formula-fed infants and
6 to 8 months in breastfed infants.
D. Introduction can begin at 3
months, with breastfeeding or
formula feeding continuing
through the first year.
E. Introduction can begin when the
infant is sitting erect and demon-
strating interest, with breastfeeding
or formula feeding continuing
throughout the first year.
Pediatrics in Review
8. According to available weight and
length data, which of the following
statements about the growth velocity
of infants is most accurate?
A. No difference in growth velocity
is discernable between breastfed
and formula-fed infants either
after 4 to 6 months of age or after
2 years of age.
B. The growth velocity of breastfed
infants appears to be less than that
of formula-fed infants at 4 to 6
months of age, and the differences
persist beyond age 2 years.
C. The growth velocity of breastfed
infants appears to be less than that
of formula-fed infants at 4 to 6
months of age, but differences do
not persist beyond age 2 years.
D. The growth velocity of
formula-fed infants appears to be
less than that of breastfed infants
at 4 to 6 months of age, and the
differences persist beyond age 2
years.
E. The growth velocity of formula-
fed infants appears to be less than
that of breastfed infants at 4 to 6
months of age, but differences do
not persist beyond age 2 years.
Vol. 21 No. 6 June 2000
 Infant Feeding
Robert T. Hall and Robin E. Carroll
Pediatr. Rev. 2000;21;191-200
DOI: 10.1542/pir.21-6-191

Updated Information including high-resolution figures, can be found at:

& Services http://pedsinreview.aappublications.org/cgi/content/full/21/6/191

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