The only acceptable alternative to human breast milk (via breastfeeding [chestfeeding] or consumption of expressed breast milk) during the first year is infant formula, which contains the necessary nutrients to support infant development and is digestible by infants. Water can cause hyponatremia and undernutrition in infants and whole cow’s milk is not nutritionally complete and may cause occult intestinal bleeding (1). Advantages of formula-feeding include the ability to quantify the amount of nourishment and the ability of family members to participate more in feedings. But all other factors being equal, these advantages are outweighed by the clear health benefits of breastfeeding (2).
Commercial infant formulas are available as powders, concentrated liquids, and prediluted (ready-to-feed) liquids; each contains vitamins, and most are supplemented with iron (iron-free formulas are not recommended) (3, 4). Powdered formula should be prepared with fluoridated water after the emergence of primary teeth; or, oral fluoride drops should be given when fluoridated water is unavailable or when using prediluted liquid formula, which is prepared with nonfluoridated water (5).
Choice of formula is based on infant need. Cow’s milk–based formula is the standard choice unless spitting up, diarrhea (with or without blood), rash (hives), or poor weight gain suggests sensitivity to cow’s milk protein or true lactase deficiency (extremely rare in neonates) (6); then, a change in formula may be recommended. All soy formulas in the United States are lactose free, but some infants allergic to cow’s milk protein may also be allergic to soy protein; then, a hydrolyzed formula is indicated. Hydrolyzed formulas are derived from cow’s milk, but the proteins are broken down into smaller chains, making them less allergenic. True elemental formulas made from free amino acids are available for the few infants who have allergic reactions to hydrolyzed formula.
Bottle-fed infants are fed on demand, but because formula is digested more slowly than breast milk, they typically can go longer between feedings, initially every 3 to 4 hours. Initial volumes of 15 to 60 mL (0.5 to 2 ounces) can be increased gradually during the first week of life up to 90 mL (3 ounces) about 6 times/day, which supplies approximately 120 kcal/kg/day for a 3-kg infant.
(See also Nutrition in Infants.)
Formula-feeding references
1. Fernandes SM, de Morais MB, Amancio OM. Intestinal blood loss as an aggravating factor of iron deficiency in infants aged 9 to 12 months fed whole cow's milk. J Clin Gastroenterol. 2008;42(2):152-156. doi:10.1097/01.mcg.0000248007.62773.3a
2. Meek JY, Noble L; Section on Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988
3. Domellöf M, Braegger C, Campoy C, et al. Iron requirements of infants and toddlers. J Pediatr Gastroenterol Nutr. 2014;58(1):119-129. doi:10.1097/MPG.0000000000000206
4. Iron fortification of infant formulas. American Academy of Pediatrics. Committee on Nutrition. Pediatrics. 1999;104(1 Pt 1):119-123.
5. Clark MB, Keels MA, Slayton RL; SECTION ON ORAL HEALTH. Fluoride Use in Caries Prevention in the Primary Care Setting. Pediatrics. 2020;146(6):e2020034637. doi:10.1542/peds.2020-034637
6. de Leusse C, Roman C, Roquelaure B, Fabre A. Estimating the prevalence of congenital disaccharidase deficiencies using allele frequencies from gnomAD. Arch Pediatr. 2022;29(8):599-603. doi:10.1016/j.arcped.2022.08.005
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