Infant Feeding: Human Milk and Formula Joan C Zerzan MS RD CD

1. Infant Feeding: Human Milk and Formula Joan C Zerzan MS RD CD

2. “No two hemispheres of any learned professor’s brain are equal to two healthy mammary glands in the production of a satisfactory food for infants” - Oliver Wendell Holmes

3. Human Milk • Colostrum • Higher concentration of protein and antibodies • Transitions around days 3-5 • Mature by day 10

4. Distribution of Kcals

5. Protein: Predominant protein of human milk is whey & predominant protein in cow’s milk is casein • Casein: proteins of the curd (low solubility at pH 4.6) • Whey: soluble proteins (remain soluble at pH 4.6) • Ratio of casein to whey is between 40:60 and 30:70 in human milk and 82:18 in cow’s milk • some formulas provide more whey proteins than others

6. Characteristics and Advantages of Human Milk • Low renal solute load • Immunologic, growth and trophic factors • Decrease illness, infection, allergy • Improved digestion and absorbtion • Nutrient Composition: CHO, Protein, Fatty Acid, etc • Cost • Other

7. Breastmilk and establishment of core microbiome • Definition: Full collection of microbes that naturally exist within the body. • Alterations or disruptions in core microbiome associated with chronic illness: Crohns disease, increased susceptability to infection, allergy, NEC, etc

8. Microbiome • Beneficial effect for the host: • Nutrient metabolism • Tissue development • Resistance to colonization with pathogens • Maintenance of intestinal homeostasis • Immunological activation and protection of GI integrity

9. Human milk and microbiome • Core microbiome established soon after birth • Core microbiome of breastfeeding infant similar to core microbiome of lactating mother • Components of breastmilk supporting establishment of microbiome • Prebiotics,probiotics

10. Allergies: Breastmilk • May be protective due to sIgA and mucosal growth factors • Maternal avoidance diets in lactation remain speculative. May be useful for some highly motivated families with attention to maternal nutrient adequacy.

11. AAP: Breastfeeding and the Use of Human Milk, 1997 • “Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth….It is recommended that breastfeeding continue for at least 12 months, and thereafter for as long as mutually desired.”

12. AAP: Breastfeeding and the Use of Human Milk, 1997 • Human milk is the preferred feeding for all infants • Breastfeeding should begin as soon as possible after birth • Newborns should be nursed 8 to 12 times every 24 hours until satiety, usually 10 to 15 minutes per breast. (Crying is a late indicator of hunger.)

13. AAP: Breastfeeding and the Use of Human Milk, 1997 • “Should hospitalization of the breastfeeding mother or infant be necessary, every effort should be made to maintain breastfeeding preferably directly or by pumping the breasts.”

14. AAP: Breastfeeding and the Use of Human Milk, 1997 • Formal evaluation of breastfeeding by trained observers at 24-48 hours and again at 48 to 72 hours. • No supplements should be given unless a medical indication exists. • When discharged at <48 hours, should have FU visit at 2 to 4 days of age, assessment at 5 to 7 days, and be seen at one month.

15. AAP statement on breastfeeding (continued) • Supplements (water, glucose, formula) should be avoided (unless medically necessary). Pacifiers should also be avoided. • Exclusive breastfeeding is ideal for the first 6 months. Breastfeeding should continue for at least 12 months.

16. AAP statement on breastfeeding (continued) • In the first 6 months, water, juice and other foods are generally unnecessary. Vitamin D and iron may be needed. Fluoride should not be given during the first 6 months.

17. AAP: Breast milk and allergy • 1.Breast milk is an optimal source of nutrition for infants through the first year of life or longer. Those breastfeeding infants who develop symptoms of food allergy may benefit from: • a.maternal restriction of cow's milk, egg, fish, peanuts and tree nuts and if this is unsuccessful, • b.use of a hypoallergenic (extensively hydrolyzed or if allergic symptoms persist, a free amino acid-based formula) as an alternative to breastfeeding.

18. Breast feeding and allergy a.Breastfeeding mothers should continue breastfeeding for the first year of life or longer. During this time, for infants at risk, hypoallergenic formulas can be used to supplement breastfeeding. Mothers should eliminate peanuts and tree nuts (eg, almonds, walnuts, etc) and consider eliminating eggs, cow's milk, fish, and perhaps other foods from their diets while nursing. Solid foods should not be introduced into the diet of high-risk infants until 6 months of age, with dairy products delayed until 1 year, eggs until 2 years, and peanuts, nuts, and fish until 3 years of age.

19. Infant Feeding: Historical Perspective • Breast feeding • Human Milk Substitutes • Science, Medicine and Industry

20. Human Milk Substitutes • Early evidence of artificial feeding • Majority of infants received breast milk • Maternal BF • Wet nurses • Wealthy women • Orphans, abandoned, “illegitimate” • Prematurity or congenital deformities

21. Human Milk Substitutes • Wet nurses • Other mammalian milk (cow, goat, donkey, camel) • Pablum: bread/flour, mixed with water • “bread, water, flour, sugar and castille soap to aid digestion”

22. 1900 Pasteurization of milk in US Association between bacteria and diarrhea 1912 U.S Children’s Bureau Public Health and Pediatricians efforts to improve infant/child health and decrease mortality 1920 Intro evaporated milk Cod liver oil prevents rickets Curd tension of milk altered Increased availability of refrigeration Vitamin C isolated Vitamin D prepared in pure form Improved sanitation Historical timeline

23. 1940 Homogenized milk widely marketed 1960 Further advances in technology and packaging Commercially prepared infant formula becoming increasingly popular Historical timeline

24. Human Milk Substitutes • 1915 Gerstenberger developed first “complete infant formula” marketed as SMA (synthetic milk adapted) • Base was defatted and diluted cow’s milk with beef tallow added to mimic the fat content of human milk

25. Infant Formulas - History • Cow’s milk is high in protein, low in CHO, results in large initial curd formation in gut if not heated before feeding • Early Formulas • from 1920-1950 majority of non-breastfed infants received evaporated milk formulas boiled or evaporated milk solved curd formation problems • cho provided by corn syrup or other cho to decrease relative protein kcals

26. Infant Formula - History, cont. • 50s and 60s commercial formulas replaced home preparation • 1959: iron fortification introduced, but in 1971 only 25% of infants were fed Fe fortified formula • Cow’s milk feedings started in middle of first year between 1950-1970s. In 1970 almost 70% of infants were receiving cow’s milk.

27. Infant Formula

28. Formula Composition • Breast Milk as “gold standard” • Attempt to duplicate composition of breastmilk • ? Bioactivity, relationship, function of all factors present in breast milk • ? Measure outcome: growth, composition, functional indices

29. Formula Brands • Ross • Similac/Isomil/Alimentum • Mead Johnson • Enfamil/Prosobee/Enfacare • Nestle • Good Start • Wyeth • Generic in USA; Gold Brands; SMA • SHS • NeoCate, DuoCal

30. Infant Formula: Categories • Term vs. Preterm • Standard Infant Formula • Cows Milk Based • Soy Formula • Specialty Formulas • Hypoallergenic: Peptide hydrolysates, amino acid based • Metabolic Products • other

31. Standard Infant Formulas, Milk or Soy Based………..

32. Milk Based Formulas • Standard 0-12 months • Similac with iron • Enfamil with iron • Good Start Essentials/Good Start Supreme • Wyeth Generic • Standard 0-12 mos with DHA/ARA • Similac Advance with iron • Enfamil Lipil with iron • Good Start Supreme DHA/ARA • Wyeth formulas

33. 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

34. Standard Infant Formula • DHA/ARA • Prebiotics/Probiotics • Fiber • Organic • Other • Advance, Lipil, Gentlease, Restful, Sensitive, Early Shield, Triple Guard….etc, etc

35. Infant Formulas: AAP • Cow’s milk based formula is recommended for the first 12 months if breast milk is not available

36. Soy Formulas • First developed in 1930s with soy flour • Early formulas produced diarrhea and excessive gas • Now use soy protein isolate with added methionine

37. 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

38. 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

39. American Academy of Pediatrics Committee on Nutrition. Soy Protein-based Formulas: Recommendations for Use in Infant Feeding. Pediatrics 1998;101:148-153. • Soy formulas given to 25% of infants but needed by very few • Offers no advantage over cow milk protein based formula as a supplement for breastfed infants • Provides appropriate nutrition for normal growth and development • Indicated primarily in the case of vegetarian families and for the very small number of infants with galactosemia and hereditary lactase deficiency

40. Possible Concerns about Soy Formulas: AAP • 60% of infants with cowmilk protein induced enterocolitis will also be sensitive to soy protein - damaged mucosa allows increased uptake of antigen. • Contains phytates and fiber oligosacharides so will inhibit absorption of minerals (additional Ca is added) • Higher levels of osteopenia in preterm infants given soy formulas • Phytoestrogens at levels that demonstrate physiologic activity in rodent models • Higher aluminum levels

41. Figure 1. Hypothetical serum concentrations profile of isoflavones from conception through weaning in typical Asians and Americans. The values represent the range of isoflavonoids reported by Adlercreutz et al. (6 ) for Japanese (dotted lines) or reported by Setchell et al. (3 ) for Americans fed soy infant formula (dashed line).

42. Health Consequences of Early Soy Consumption. Badger et al. J Nutr. 2002 • US soy formulas made with soy protein isolate (SPI+) • SPI+ has several phytochemicals, including isoflavones • Isoflavones are referred to as phytoestrogens • Phytoestrogens bind to estrogen receptors & act as estrogen agonists, antagonists, or selective estrogen receptor modulators depending on tissue, cell type, hormonal status, age, etc.

43. Should we be Concerned? - Badger et al. • No human data support toxicity of soyfoods • Soyfoods have a long history in Asia • Millions of American infants have been fed soy formula over the past 3 decades • Rat studies indicate a potential protective effect of soy in infancy for cancer

44. Soy formula for prevention of allergy and food intolerance in infants (Cochrane, 2006) • “Feeding with a soy formula cannot be recommended for prevention of allergy or food intolerance in infants at high risk of allergy or food intolerance. Further research may be warranted to determine the role of soy formulas for prevention of allergy or food intolerance in infants unable to be breast fed with a strong family history of allergy or cow's milk protein intolerance.”

45. Contraindications to Soy Formula: AAP • preterm infants due to increased risk of inadequate bone mineralization • infants with cow milk protein-induced enteropathy or enterocolitis • most previously well infants with acute gastroenteritis • prevention of colic or allergy.

46. Predigested protein based infant formulas

47. 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

48. Hydrolysate Formulas • Whey Hydrolysate Formula: Cow’s milk based formula in which the protein is provided as whey proteins that have been hydrolyzed to smaller protein fractions, primarily peptides. This formula may provoke an allergic response in infants with cow’s milk protein allergy. • Casein Hydrolysate Formula: Infant formula based on hydrolyzed casein protein, produced by partially breaking down the casein into smaller peptide fragments and amino acids. `

49. AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000) Recommendations

50. AAP Policy Statement Re: Hypoallergenic Infant Formulas (August, 2000) • Currently available, partially hydrolyzed formulas are not hypoallergenic.