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Infant Formula NINA R Infant Formula NINA R. O’CONNOR, MD, Chestnut Hill Family Practice Residency, Philadelphia, Pennslyvania Although the American Academy of Pediatrics and the American Academy of Family Physicians recommend breast milk for optimal infant nutrition, many parents still choose formula as an acceptable alternative. The wide variety of available formulas is confusing to parents and physicians, but formulas can be classified according to three basic cri- teria: caloric density, carbohydrate source, and protein composition. Most infants require a term formula with iron. There is insufficient evidence to recommend supplementation with docosahexaenoic acid or arachidonic acid. Soy formulas are indicated for congenital lac- tase deficiency and galactosemia, but are not recommended for colic because of insufficient evidence of benefit. Hypoallergenic formulas calici with extensively hydrolyzed protein are effective for the treatment of S milk protein allergy and the prevention of atopic disease in high-risk ris D CH an infants. Antireflux formulas decrease emesis and regurgitation, but M I HE have not been shown to affect growth or development. Most infants N with reflux require no treatment. Family physicians can use these S. OPPE guidelines to counsel parents about infant formula, countering con- rt sumer advertising that is not evidence-based. (Am Fam Physician. 2009;79(7):565-570. Copyright © 2009 American Academy of Family Physicians.) ILLUSTRATION BY BE ▲ Patient informa- lthough the American Academy of is no evidence to recommend one brand tion: A handout on Family Physicians and the Ameri- over another; all formulas are nutritionally baby formula, written by the author of this can Academy of Pediatrics (AAP) interchangeable. article, is available promote breastfeeding as optimal All infants should receive iron-fortified at http://www.aafp. Ainfant nutrition, many parents still choose formula to prevent iron deficiency anemia.3,4 org/afp/20090401/565-s1. infant formula as an acceptable alternative.1,2 Low-iron formulas are commercially avail- The wide variety of available formulas can be able, and some parents choose these formu- This clinical content con- confusing and overwhelming for parents and las with the belief that iron causes stomach forms to AAFP criteria for physicians, and formula companies target upset. Family physicians should strongly evidence-based continuing both audiences with advertising campaigns. counsel parents to not use these products. medical education (EB CME). Family physicians can advise parents about Recently, formulas with long-chain poly- infant formula choices based on available unsaturated fatty acids have been heav- evidence. Additionally, family physicians ily marketed to promote eye and brain should identify the minority of infants who development. Arachidonic acid (AA) and would benefit from a specialized formula. docosahexaenoic acid (DHA) are the most All formulas are classified based on three common additives. These fatty acids are parameters: caloric density, carbohydrate found in breast milk, but not conventional source, and protein composition. Commer- formula, and are thought to be important in cially available infant formulas are presented the development of membrane constituents by these parameters in Table 1. in the central nervous system. Clinical trials of the effects of AA and DHA on cognitive, Term Formulas social, and motor development have been Most infants need a basic formula for term inconsistent. Although no harm has been infants. These formulas are modeled after demonstrated, most well-conducted ran- breast milk and contain 20 kcal per ounce. domized trials show no benefit. Thus, recent Their carbohydrate source is lactose, and Cochrane reviews conclude that supplemen- they contain cow’s-milk protein. There tation of formula with DHA and AA cannot April 1, 2009 ◆ Volume 79, Number 7 www.aafp.org/afp American Family Physician 565 Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2009 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References There is insufficient evidence to recommend supplementation of infant formula with A 5, 6 docosahexaenoic acid or arachidonic acid. Preterm and enriched formulas may improve short-term growth parameters in premature A 8 infants, but have not been shown to improve long-term growth or development. Hypoallergenic formula is effective for the treatment of milk protein allergy and the prevention B 10, 16, 25 of atopic disease. Antireflux formulas reduce daily emesis and regurgitation in infants, but have not been shown A 12, 26 to improve growth or development. Parental counseling is more effective than changing formula in the treatment of infant colic. B 30 A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp. org/afpsort.xml. Table 1. Comparison of Breast Milk and Available Infant Formulas Cost per ounce* Calories Protein Powdered Class Brand names (kcal per oz) Carbohydrate source source Indications formula† Ready-to-feed Breast milk — 20 Lactose Human milk Preferred for all infants — — Term formula Carnation Good Start; Enfamil with Iron; Similac 20 Lactose Cow’s milk Appropriate for most infants $0.14 $0.27 with Iron Term formula with Enfamil Lipil; Good Start DHA & ARA; Similac 20 Lactose Cow’s milk Marketed to promote eye and brain 0.16 0.30 DHA and AA Advance development Preterm formula Enfamil 24 Premature; Preemie SMA 24; Similac 24 24 Lactose Cow’s milk Less than 34 weeks’ gestation — 0.80 Special Care Weight less than 1,800 g (3 lb, 15 oz) Enriched formula Enfacare; Similac Neosure 22 Lactose Cow’s milk 34 to 36 weeks’ gestation 0.19 0.32 Weight 1,800 g (3 lb, 15 oz) or greater Soy formula Enfamil Prosobee; Good Start Soy; Similac Isomil 20 Corn-based Soy Congenital lactase deficiency, 0.16 0.30 galactosemia Lactose-free formula Enfamil Lactofree; Similac Sensitive 20 Corn-based Cow’s milk Congenital lactase deficiency, primary 0.16 0.30 lactase deficiency, galactosemia, gastroenteritis in at-risk infants Hypoallergenic Similac Alimentum; Enfamil Nutramigen; Enfamil 20 Corn or sucrose Extensively Milk protein allergy 0.25 0.37 formula Pregestimil hydrolyzed Nonallergenic Elecare; Neocate; Nutramigen AA 20 Corn or sucrose Amino acids Milk protein allergy 0.35 — formula Antireflux formula Enfamil AR; Similac Sensitive RS 20 Lactose, thickened with Cow’s milk Gastroesophageal reflux 0.18 0.31 rice starch Toddler formula Enfamil Next Step; Good Start 2; Similac Go and 20 Lactose Milk Nine to 24 months of age 0.15 0.25 Grow AA = arachidonic acid; DHA = docosahexaenoic acid. *—Calculated from average retail price. Most information comes from http://www.drugstore.com. †—After adding water. 566 American Family Physician www.aafp.org/afp Volume 79, Number 7 ◆ April 1, 2009 Infant Formula be recommended based on current evidence.5,6 Addition- mulas must be ordered in ready-to-feed bottles and are ally, these formulas cost more than formulas without the more expensive. above additives. It is currently the standard of care to prescribe these formulas for preterm infants. Cut-offs for weight and Preterm and Enriched Formulas gestational age are based on expert opinion, with varia- Preterm infants have higher protein and calorie require- tion between institutions. Infants are usually transi- ments. In addition, they need more calcium, magne- tioned from 24 to 22 kcal per ounce when they achieve sium, and phosphorus (minerals transferred in utero a weight of 1,800 g (3 lb, 15 oz) or 34 weeks’ gestational during the third trimester). These special requirements age.7 Hospital discharge is rare before 34 weeks, so led to the development of enriched and preterm formu- infants presenting for outpatient care are typically on las designed to facilitate “catch-up” growth. Preterm 22-kcal formula. There are no studies to guide timing formulas contain 24 kcal per ounce, whereas enriched for the discontinuation of enriched formula. Although formulas contain 22 kcal per ounce. Enriched formulas preterm and enriched formulas may improve short- are available in stores as liquid or powder. Preterm for- term growth parameters, they do not appear to affect longer-term growth or development at 18 months of age.8 Table 1. Comparison of Breast Milk and Available Infant Formulas Specialized Term Formulas Cost per ounce* Most infants tolerate standard formula, but family physicians should screen for the Calories Protein Powdered Class Brand names (kcal per oz) Carbohydrate source source Indications formula† Ready-to-feed minority of infants with feeding intolerance (Table 2).9,10 In these cases, family physicians Breast milk — 20 Lactose Human milk Preferred for all infants — — can guide parents toward appropriate spe- Term formula Carnation Good Start; Enfamil with Iron; Similac 20 Lactose Cow’s milk Appropriate for most infants $0.14 $0.27 cialized formulas (Figure 1).5,10-13 with Iron SOY FORMULAS Term formula with Enfamil Lipil; Good Start DHA & ARA; Similac 20 Lactose Cow’s milk Marketed to promote eye and brain 0.16 0.30 DHA and AA Advance development Despite limited indications for its use, soy formula accounts for almost 25 percent of Preterm formula Enfamil 24 Premature; Preemie SMA 24; Similac 24 24 Lactose Cow’s milk Less than 34 weeks’ gestation — 0.80 formula sales in the United States.11 These Special Care Weight less than 1,800 g (3 lb, 15 oz) formulas are made with corn-based carbo- Enriched formula Enfacare; Similac Neosure 22 Lactose Cow’s milk 34 to 36 weeks’ gestation 0.19 0.32 hydrate and soy protein, making them free Weight 1,800 g (3 lb, 15 oz) or greater of lactose and cow’s-milk protein.
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