Formula Feeding

Question 1

Why is it important to monitor growth?

Answer 1

• reinforcing healthy growth patterns
• nutrition and health evaluation tool
• initiate further assessment in case of unusual growth patterns
• “teachable moments” with caregivers
• context for regular contact with primary health care services and public health

Question 2

What does growth equate to?

Answer 2

Health

Question 3

What growth charts can be used to monitor growth?

Answer 3

• centre for disease control (CDC)
• World Health Organization (WHO)

Question 4

What do growth charts for birth to 2 years assess?

Answer 4

• Weight for age
• Length for age
• Head circumference for age
• Weight for length

Question 5

Assessing growth as a reference

Answer 5

Seen with the CDC
- how infants/children growing within a population
- growth assessed relative to others within the population

Question 6

Assessing growth as a standard

Answer 6

WHO based off this
- optimal growth in infants/children
- growth assessed relative to optimal
- identify inadequate or excessive growth

Question 7

How were CDC growth charts developed?

Answer 7

Looked at growth when obegenic already a problem
- reference group is a large number of infants in the USA
- includes breastfed and formula fed
- indicates how infants growing compared to other infants

Question 8

How where WHO growth standards developed

Answer 8

Standards based on optimal growth
- international growth charts
- longitudinal follow-up of children in six countries: Brazil, Ghana, India, Norway, Oman, USA
- selective in which infants included in dataset

Question 9

WHO standards between BF and FF

Answer 9

Breastfed infants have a different growth pattern than formula fed infants
- slower rate of gain first year compared to formula fed

Question 10

What growth chart does Canada use?

Answer 10

Based on WHO - Developed by Dietitians of Canada, Canadian Paediatric Society, others
- WHO 2006 Child Growth Standard birth to 5 years
- WHO Growth Reference 2007 5 to 19 years

Question 11

What are key growth changes for healthy development of infant?

Answer 11

• 5-95th percentile “normal”
• Double birth weight by 3-6 months
• Triple birthweight by 1 year

Question 12

History of infant formula

Answer 12

• Mid 1800s: first commercially available infant formula: wheat flour, malt, potassium bicarbonate
• Late 1800s: attempts to make more similar to breastmilk composition (ie use of lactose)
• 1960: use of isolated proteins
• 1962: composition regulated and heavily marketed that woman werent making enough
• 1980s-1990s: emphasis on breastmilk is best; regulations on the marketing of infant formula

Question 13

What is the International Code of Marketing of Breast-milk Substitutes

Answer 13

From WHO in 1981 Health professionals must provide information about:
* the importance of breastfeeding
* the costs of formula feeding
* the difficulty of reversing the decision
* counsel those who have made a fully informed choice not to breastfeed on the use of breastmilk substitutes

Question 14

When is formula recommended?

Answer 14

Circumstances where mothers are unable/unwilling to breastfeed

Question 15

What can breastmilk be replaced with?

Answer 15

• pasteurized breastmilk from screened donors or commercial formulas
• iron-fortified formula until 9-12 months

Question 16

Inappropriate breastmilk substitutes

Answer 16

• Non-human milk
• Diluted formula
• Homemade formulas
• Evaporated milk
• Powdered milk
• Coffee whitener
• Rice or soy beverages

Question 17

Why should infants not be given other animal milks?

Answer 17

Infant formulas are modified to resemble breastmilk composition as much as possible and is regulated. Unmodified animal milk is poorly suited to infant’s needs
* milk produced by humans is perfectly suited for humans

Question 18

Human milk compared to cow milk

Answer 18

• Althought PRO, Ca, P, and Fe are low they are highly bioavailable
• protein sources differ drastically

Question 19

What is a benefit of infant formula?

Answer 19

complete infant food – no supplementation required

Question 20

What are the categories of infant formula?

Answer 20

Categorized by protein source:
* Cow milk protein
* Soy protein
* Non-intact protein (partially hydrolyzed/elemental)

Question 21

What are the common characteristics of breastmilk versus formula?

Answer 21

Almost all infant formulas are quantitatively nearly identical in nutrients – formulation to mimic nutrient availability in breastfed infants
* Energy: ~67-70 kcal/d
* Protein: 9-13%
* Fat: 45-50%
* CHO: 39-45%

Question 22

Availability of cow milk based formulas

Answer 22

most commonly available and least expensive usually the “default” formula
* common brands: Enfamil, Similac, Bonamil, Good Start, many others
* most available as powders, concentrate, ready-to-feed; time and place for each of them

Question 23

Content of cow milk based fromulas

Answer 23

• protein: intact protein from cow’s milk - whey:casein ration variable, some contain 100% whey
• carbohydrate: lactose
• lipid: primarily vegetable oils (coconut, palm, soybean, sunflower, safflower)
• additional contents in some formulas: AA, DHA, nucleotides, probiotics

Question 24

Availability of soy based formulas

Answer 24

formulas with plant source protein which are readily available and often similar price to cow’s milk based
* common brands: Isomil, Prosobee, Soyulac, Alsoy
* most available in powder, concentrate, ready-to-feed

Question 25

Content of soy based formula

Answer 25

* **protein**: intact soy protein with additional methionine (limiting aa in soy) * **carbohydrate**: corn (dextrin-easily digested), sucrose in some * **lipid**: vegetable oils (coconut, palm, soybean, sunflower, safflower) * **additional contents in some formulas**: AA and DHA, nucleotides, probiotics

Question 26

What are indications for using soy formula?

Answer 26

* vegans * galactosemia * congenital lactase deficiency

Question 27

Why should soy formula not be used for cows milk allergy?

Answer 27

15-40% allergic to both cow’s milk and soy protein * higher risk for peanut allergy

Question 28

Partially Hydrolyzed formula

Answer 28

Cow milk and soy protein formulas with proteins partially hydrolyzed * no evidence of benefit for infants since gut is pretty much functional already and able to break down the proteins * might contain some intact proteins

Question 29

Lactose- Free Formulas

Answer 29

Lactose-free cow milk protein formula with glucose polymers instead of lactose * no evidence of benefit for infants

Question 30

Hydrolyzed/ elemental formulas

Answer 30

hydrolyzed such that every component is elemental * common brands: Nutramigen, Pregestimil, Alimentum, Neocate * very expensive, 2-4 x cost of standard * most only available in powdered form

Question 31

What are indications for using hydrolyzed/elemental formulas?

Answer 31

specialized formulas for use under medical supervision * allergy: especially now milk protein * Malabsorption: protein, fat or carbohydrates

Question 32

content of hydrolyzed/elemental formula

Answer 32

* **protein**: peptides, amino acids * **carbohydrate**: corn (dextrin), sucrose, monosaccharides * **lipid**: same as other formulas, some containing medium chain (fat malabsorption)

Question 33

Other potential formulas

Answer 33

* thickened formulas (rice starch) * follow-up formulas * preterm formulas with higher energy density (typically under medical supervision)