Types of Milk Formulas and

Their Uses

PRESENTED BY
RAWA MUHSIN
ALI

SUPERVISED BY
DR JAMAL AHMAD RASHID
 Best food for babies

AAP recommendation

4-6 mo 1 yr

exclusive breastfeeding + regular foods ±

breastfeeding weaning breastfeeding
 What is milk?

87% water and 13% solids

 fats (including essential fatty acids—linoleic, linolenic,
arachidonic)
 proteins (especially caseins and whey proteins)
 carbohydrates (lactose, composed of glucose and galactose)
 minerals and vitamins

Fresh milk has a pH of 6.7-6.5

 > 6.7 → mastitis
 < 6.5 → colostrum or bacterial activity
Breast vs Bottle
Breast vs Bottle
More whey → more easily digested
and promotes more rapid gastric
emptying
Lactoferrin and immunoglobulin
(specifically secretory IgA) → host
defense
VLCPUFAs, ARA, and DHA → visual
function and neurodevelopment
More lipase → superior fat
absorption
Unabsorbed lactose → softer stool,
more nonpathogenic fecal flora, and
improved absorption of minerals
Oligosaccharides that mimic
bacterial antigen ligands →
preventing bacterial attachment to
host mucosa
Minerals are more bioavailable
(since bound to digestible proteins)
Breast vs Bottle
 Breast is best?

Advantages to baby
 ready, proper temperature, fresh, clean (Enterobacter sakazakii)

 ↓ incidence or severity of diarrhea, intestinal bleeding, occult melena, colic,

necrotizing enterocolitis
 ↓ incidence or severity of respiratory illnesses, otitis media, UTI,
bacteremia, bacterial meningitis, infant botulism

 ↓ incidence of obesity and overweight, type 1 DM, celiac disease, Crohn

disease, lymphoma, leukemia, food allergy, eczema

 ↓ hospitalizations and infant mortality

 psychological (close and comfortable relationship with the mother)
 Breast is best?

Advantages to mother
 psychological (sense of accomplishment and being essential)
 decreased risk of postpartum hemorrhage
 longer period of amenorrhea
 reduced risk of ovarian and premenopausal breast cancers
 possible reduced risk of osteoporosis

Advantages to society
 reduced health care costs
 reduced employee absenteeism
Breast is best
 When breast is not best

Transmission of infections
 HIV, HTLV type 1, CMV, rubella virus, hepatitis B virus
(but not C), and HSV (direct contact)

Transmission of drugs and allergens

 Metronidazole, sulfonamides, antithyroid, lithium, drugs
of abuse, radioactive dyes, anticancer agents, isoniazid

Transmission of contaminants (cigarettes,

alcohol)

Metabolic diseases in the baby

 Nutritional issues with breastfeeding

Fluoride
 deficient if not sufficient in water supply (≤0.3 ppm)
 give 10 μg daily in first 6 months; thereafter, give as in adults
Vitamin D
 if maternal intake deficient or limited infant sunlight exposure
 give 10 μg daily
Iron
 low amount but well-absorbed, sufficient for first 6 months
 beyond 6 months give iron-fortified food or iron preparation
Vitamin K
 give 1 mg parenterally at birth to prevent hemorrhagic disease
Formula feeding
 Indications for bottle feeding

Complementary
 insufficient breast milk
 replaces some breast feeds (e.g. working mother)

Substitutive
 replaces breast completely
 absent milk secretion, chronically ill mother, personal choice
Energy requirements
 Formula preparations

powder concentrated ready-to-feed

All provide 20 kcal/1 oz or 0.67 kcal/mL (similar to

breast milk)
 Bottle feeding how-to

Number and interval of feeds

 from ≥ 8/day after birth to 3-4/day at 1 year
 duration of each feed: 5-25 min
 interval between feeds: 3-5 hours
 around-the-clock feeding in first 2-3 months
Concentration of milk
 water:milk ratio = 7:1
 small scoop (4 gm): 30 ml water per scoop
 large scoop (8 gm): 60 ml water per scoop
 concentrated formula is intended to be diluted 1:1 with water
 Bottle feeding how-to

Amount of milk per feed

 weight method: 140-200 ml/kg/day
 age method: 10 ml increase every day, then week, then month

Age Average quantity per feed

1st and 2nd weeks 2 – 3 oz (60 – 90 mL)
3 weeks – 2 months 4 – 5 oz (120 – 150 mL)
2 – 3 months 5 – 6 oz (150 – 180 mL)
3 – 4 months 6 – 7 oz (180 – 210 mL)
5 – 12 months 7 – 8 oz (210 – 240 mL)
 Bottle feeding how-to

Position: same as for breastfeeding

Bottle propping to be avoided (risk of aspiration and
otitis media, less contact and security)

Regurgitation (spitting) more common in bottle

feeders than breast milk feeders

Bottle: small size of nipple holes

Temperature: does not matter
Bottle feeding how-to
 Adequacy of feeding

Infant is satisfied after each feed (vs crying

vigorously or sucking on a fist)

Sleeps 2-4 hr between feedings (vs sleeping 1-2 hrs)

Wetting between four and six diapers each day

Gains weight adequately

Types of formulas

COW MILK-BASED
SOY
HYDROLYSATE
AMINO ACID
OTHERS

METABOLIC
 Cow’s milk protein-based formulas

Protein concentration 1.45 to 1.6 g/dL vs ~1 g/dL

in breast milk

Whey:casein ratio is 18:82 to 60:40 (or even 100%

whey)

The predominant whey protein is β-globulin in

bovine milk and α-lactalbumin in human milk.

No clinically significant difference demonstrated

 Cow’s milk protein-based formulas

Fat source is plant or plant and animal mixture

All infant formulas supplemented with LCPUFAs,
DHA, and ARA
 ARA and DHA concentrations in human milk vary by
geographic region and maternal diet.
 DHA and ARA supplementation has positive effects on visual
acuity and neurocognitive development.
 No consistent beneficial effect of LCPUFAs supplementation
Carbohydrate type in cow formula is lactose;
formulas for older infants might contain starch and
other complex carbohydrates
Cow’s milk protein-based formulas
 Cow milk protein allergy

IgE-Mediated IgE- or Non–IgE- Non–IgE-Mediated

Mediated
Urticaria Atopic dermatitis Contact dermatitis
Angioedema Asthma Food-induced pulmonary
hemosiderosis
Rhinoconjunctivitis Eosinophilic esophagitis Food-induced
enterocolitis
Acute bronchospasm Eosinophilic gastritis Food-induced
proctocolitis
Oral allergy syndrome Eosinophilic Food-induced
gastroenteritis enteropathy
Gastrointestinal Gastroesophageal reflux
anaphylaxis disease
 Cow milk protein allergy

Avoidance and replacement by another formula

Acute IgE-mediated reactions treated by epinephrine

Future treatment possibilities

 Oral immunotherapy
 Sublingual immunotherapy
 Epicutaneous immunotherapy
 Subcutaneous immunotherapy

Most will outgrow the allergy with age

 Soy formulas

Protein is a soy isolate supplemented with l-

methionine, l-carnitine, and taurine to provide a
protein content of 1.65-1.9 g/dL
It is free of cow milk protein

Fats are similar to those of cow’s milk

Carbohydrates are glucose oligomers and

sometimes sucrose, but not lactose
 Soy formulas

Indications for use

 Hereditary lactase deficiency or secondary lactose intolerance (e.g.
after gastroenteritis)
 Galactosemia
 Vegetarian diet
 ??? Cow milk protein allergy (enteropathy or enterocolitis)

No proven benefit in infantile colic, fussiness, or atopic

disease
Should not be given to LBW preterm infants
Problem of phytoestrogens???
Soy formulas
 Protein hydrolysate formulas

Proteins can be partially hydrolyzed (MW < 5000

d) or extensively hydrolyzed (MW < 3000 d) casein

Fats similar to those in cow milk formula, and can

include MCTs

Carbohydrates are corn maltodextrin or syrup

solids, and do not contain lactose
 Protein hydrolysate formulas

Indications for use

 Cow milk protein intolerance
 Soy protein intolerance
 Lactose intolerance and galactosemia
 Malabsorption due to cystic fibrosis, short gut syndrome,
cholestasis, mucosal atrophy or injury, and prolonged diarrhea

Can be protective against atopic disease (especially

extensively hydrolyzed formulas)
Not all hydrolysate formulas are created equal!
Protein hydrolysate formulas
 Amino acid formulas

No proteins, only amino acids (mixture of essential

and non-essential amino acids)

Indications:
 dairy protein allergy not responding to hydrolysate formulas
 intestinal transplant

Effect on prevention of atopic disease not studied

Amino acid formulas
Comparison of formulas
 Premature formulas

Best milk for premature infants is breast milk + human milk

fortifiers (which boost caloric content to 24 kcal/oz and nutrient
content)
 fortifiers contains protein, carbohydrate, calcium, phosphorus, magnesium,
sodium, zinc, copper, and multivitamins.

If not sufficient, fortified donor milk recommended

If not feasible, premature formulas can be given until they reach 44
weeks post-conceptive age

Transition formulas (standard at 22 kcal/oz) are intermediate in

protein and micronutrients to promote growth postdischarge
Premature formulas
 Other formulas

Fat modified
 high MCT, useful for chylous effusions and severe
steatorrhea
 Lipisorb, Portagen, Tolerex
Prethickened
 for dysphagia, mild GER
 Enfamil AR
Carbohydrate intolerance
 all monosaccharides and disaccharides removed;
dextrose and fructose additives can then be titrated
to tolerance
 3232A, Ross Carbohydrate Free
 Other formulas

Standard milk protein-based

 Ages 1 to 10, given as tube feeds or oral
supplements
 Nutren Junior, PediaSure, Kindercal

Food-based
 made with beef protein, fruits, and vegetables-
contains lactose fortified with vitamins/minerals
 Compleat Pediatric
 Bovine milk

Avoid bovine milk (whole, partial fat, and skimmed cow’s milk) before
at least 1 yr of age because these infants ingest:
↑ protein (3 x)
↑ sodium (half)
↑ phosphorus
↓ linoleic acid (half)
↓ iron (two thirds)
↑ intestinal blood loss

Why this discussion important?

Use of skimmed milk recommended between 12-24 months of age in

those at risk of overweight or obesity.
 Homemade formula

Use only evaporated milk (not condensed milk)

All utensils should be sterilized by boiling in
water for 5 to 10 min (rubber nipples for no
more than 5 minutes)
Quart (32 oz) bottle are easiest to use
1 can (13 oz) of evaporated milk + tap water + 2
tablespoons of cane sugar
Stir well and terminally heat
This will make enough formula for 1 day of the
infant’s needs. Each supply must be made no
more than 1 day at a time.
 Metabolic formulas

Maple syrup urine disease

 aminoacidopathy of defective breakdown of branched-chain
amino acids leucine, isoleucine, and valine
 BCAD 1 and 2
 Metabolic formulas

Phenylketonuria
 defective breakdown of phenylalanine
 Phenyl-Free®1, 2, 2HP
 Metabolic formulas

Tyrosinemia
 inability to metabolize fumarylacetoacetatic acid
 TYROS 1 and 2
 Metabolic formulas

Homocystinuria
 defective methionine metabolism
 HCY 1 and 2
 Metabolic formulas

Glutaric acidemia
 inability to metabolize lysine, hydroxylysine, and tryptophan
 GA
Isovaleric acidemia
 defective leucine metabolism
 LMD
Propionic and methylmalonic acidemias
 defective propionic or methylmalonic acid metabolism
 OA 1 and 2
Urea cycle disorders
 various enzyme defects in urea cycle
 WND® 1 and 2
Miscellaneous amino acid disorders
 PFD Toddler and 2
Metabolic formulas
 Vignette

A mother brings her 2-week-old full-term girl to your office with concern for blood
in her stools. The infant is formula fed and has become increasingly fussy with
feeds. The infant has otherwise been without fever, vomiting, change in appetite.

You consider the differential diagnosis for neonatal hematochezia, which includes
swallowed maternal blood, anal fissure, necrotizing enterocolitis, and milk protein
allergy. After initial evaluation, you decide that milk protein allergy is most likely
cause for the hematochezia and recommend that they switch to which of the
following formulas?

a. Soy
b. Lactose free
c. Hydrolyzed
d. Amino acid
e. Fat modified
 References

Nelson Textbook of Pediatrics, 19th Edition

Nelson Essentials of Pediatrics, 6th Edition
Pediatrics for Medical Students, 3rd Edition
Illustrated Textbook of Pediatrics, 4th Edition
Oski’s Pediatric Certification and Recertification Board
Review
Pediatric Clinical Diagnosis, 6th Edition
Atlas of Metabolic Diseases, 2nd Edition
Atlas of Pediatric Physical Diagnosis, 5th Edition
The internet, journal articles, and UpToDate
Done