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Breast Milk and Infant Formulas. Lori S. Brizee MS, RD, CSP Clinical 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.

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breast milk and infant formulas

Breast Milk and Infant Formulas

Lori S. Brizee MS, RD, CSP

Clinical Dietitian

Children’s Hospital and Regional Medical Center

human milk and infant formulas
Human Milk and Infant Formulas:
  • Breast milk
  • Standard Infant Formulas
  • Premature Infant Formulas
  • Specialty Infant Formulas
  • Modular Additives
breast milk characteristics
Breast Milk Characteristics
  • First choice feeding for MOST infants
  • Immunologic factors
    • Protective against diarrhea causing infections and otitis in infants
  • Trophic to GI tract
    • Well tolerated by infants with short bowel
  • Fatty acids important to brain/visual development
breast milk vs standard milk based formulas
Breast Milk vs StandardMilk 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
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
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 baby7
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 feeding8
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
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.
formula brands
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
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 formulas13
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 formulas characteristics
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
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 formulas characteristics compared to milk based
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
protein hydrolysate 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 infant formula
Elemental Infant Formula
  • NeoCate (SHS)
    • Protein: Free Amino Acids
    • Fat: Long chain
    • Carbohydrate: Lactose Free
    • Indications for use: Food Allergy or intolerance to peptides or whole protein
premature infant breast milk additives and formulas
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 formulas general characteristics compared to standard
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 formulas
“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
Other Specialty Formulas
  • Portagen (Mead Johnson)
    • 85% fat MCT, 15% fat Corn oil
    • Used for infants with chylothorax
  • Similac PM 60/40(Ross)
    • Low in Ca, P, K+ and NA; 2:1 Ca:P ratio
    • Used for infants with Renal Failure
  • Formulas for Metabolic Disorders
    • Several condition specific products by Ross and Mead Johnson
products to augment energy and protein in breast milk
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
Finding Up to Date Information
  • Similac products
  • Enfamil products
  • Nestle products
  • generic products
    • lower cost formulas made by Wyeth

Neocate formulas

when baby is not growing
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 growing31
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 growing32
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
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
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
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