Infant formula

What should I know about infant formula?

Commercial infant formula first appeared in the late 1800s. The 1900s saw a dramatic increase in infant formula feeding and now it is the more common method of feeding babies. There are four main types. Most healthy, full-term babies who need to be supplemented use regular infant formula, but some babies cannot tolerate this. Other options are low allergy, soy, and specialty infant formula. There is no evidence to recommend one brand over another. Infant formula comes in three different forms: ready-to-use, concentrated, and powdered. Whatever form mothers use, infant formula can be contaminated during manufacturing or preparation and storage.

A) The history of infant formula feeding

Corn syrup advertisement from a booklet given by a hospital to all new mothers. Corn syrup continues to be an ingredient in some infant formula. Best Wishes. Edmonton, Alberta, Canada: Royal Alexandra Hospital; 1957

1) Changes in infant formula: late 1800s to 2000s

Commercial infant formula (formula) was first manufactured around the end of the 1800s. Prior to this, babies who were not breastfed by their mothers were often breastfed by another woman, known as a wet nurse, or given animal milks or soft solids. In the later part of the 1800s, pasteurization made animal milk less lethal, but many babies continued to die until carbohydrates were added.

Some of the landmarks in commercial formula were as follows (IM 2004):

  • 1856: Condensed milk was produced.
  • 1867: Liebig's food for infants became available and contained wheat flour, cow's milk, malt flour, and potassium bicarbonate.
  • 1890s: Pasteurization of milk becomes popular.
  • 1915s: Formula contained cow’s milk, lactose, oleo oils, and vegetable oils (powdered form).
  • 1929: Soy formula (soy flour) was commercially available.
  • 1930s: Vitamin D was added to commercial milk products.
  • 1935: Protein content of formula considered.
  • 1959: Iron was added.
  • 1960s: The effect of formula on a baby’s kidneys was addressed.
  • 1960s: Formula was available as liquid concentrate.
  • 1960s : Soy power is replaced by soy protein isolate
  • 1960s: Commercial formulas gained increasing acceptance over homemade preparations.
  • 1980s: Taurine was added.
  • Late 1990s: Nucleotides were added (Collier 2009).
  • Late 1990s: Probiotics were added to some formulas.
  • Early 2000s: Long-chain polyunsaturated fatty-acids were added to some formulas.

2) Illness cause by infant formula.

In the early 1900s, some babies received homemade formula made of evaporated milk, water, and corn syrup or table sugar. These were lacking in vitamins C and D, resulting in the development of scurvy and rickets respectively. By the 1920s, the incidence of these diseases decreased through adding orange juice and cod liver oil to the baby's diet. Homemade formula was also low in iron, resulting in anemia.

Homemade formula became increasing popular and remained so until the late 1960s, when the use of iron-fortified commercial formula increased (Fomon 2001).

Homemade formula is now being promoted online. Its use is not recommended.

3) The reasons for decreasing breastfeeding rates

Breastfeeding rates decreased through the early and mid-20th century. 

Many factors drove this change from breastfeeding to formula feeding, including:

The dramatic increase in formula feeding led to increased illness in babies. Public health agencies then began to promote breastfeeding. However, formula use remains the more common method for the feeding of babies. Worldwide, only 40% of children under six months are exclusively breastfed at six months (WHO 2017).

C) Choosing an infant formula: types, brands, and forms

Babies can have different responses to different formula brands and choices and changes are mostly made by trial and error. Talk to your health-care providers about which formula type is appropriate for your baby.

1) Infant formula type

Most healthy, full-term babies who are not breastfed or given breast milk use regular formula based on cow’s milk and fortified with iron. This is also the formula most commonly used when babies need milk supplementation and the mother’s own breast milk and pasteurized donor human milk are not available. Regular infant formula can also be based on goat’s milk. Other types of formula are given to babies who cannot tolerate regular formula for a medical reason.

Standard formula has either 0.64 calories/millilitre (19 calories/U.S. fluid ounce) or 0.67 cal/ml (20 cal/oz). Ingredients vary between formula types, manufacturers, and countries. Even the same brand made at different times can have different ingredients (Furse 2019).

Cow’s milk is not a formula substitute for babies under one year of age. They should receive breast milk or formula. After this age, children can receive up to 500 ml (2 cups) of whole cow’s milk each day if they are not breastfed. There is no need for toddler milk. Goat's milk should not be given to babies.

2) Infant formula brand

Formula companies often make and advertise several types of formula, each with its own brand. Choosing one brand can be confusing. As formula is one of the most regulated foods in the world, there is no evidence to recommend one brand over another (Dipasquale 2019). However, each manufacturer has slightly different ingredients (O’Connor 2009; Wargo 2016). The important decision is around which type of formula to use and to then see how the baby tolerates it.

Brands can also be name-brands or store-brands, also known as generic brands.

There is no evidence to choose a more expensive brand over a cheaper one or to continue using the brand of formula you were given in hospital.

3) Infant formula form

You will need to choose one of three formula forms:

  • Ready-to-use
  • Concentrated
  • Powdered

These products vary in price, ease of use and risk of contamination. Each form is designed to provide enough nutrients for your baby to grow.

D) Iron-fortified infant formula

All babies should receive iron-fortified formula to prevent low levels of iron in the blood (anemia) (Eden 2000).

Most iron-fortified formula contains between 4 and 13 milligrams of iron per litre. Some babies are at higher risk of having low iron levels and may benefit from a formula with iron levels at the higher end of that range.

Babies at risk of low iron include those:

E) Adding rice to infant formula bottles

Adding rice or other cereals to formula to make babies sleep longer is an outdated practice and no longer recommended because there are no documented benefits and there are risks.

Some speciality formula has cereal added to thicken it and is used for infants with swallowing difficulties. Such babies should be under the care of a health-care provider.

References

Belamarich PF, Bochner RE, Racine AD. A Critical Review of the Marketing Claims of Infant Formula Products in the United States. Clin Pediatr (Phila). 2016 May;55(5):437-42
 
Collier R. Squabble over risks of probiotic infant formula. CMAJ. 2009 Aug 4;181(3-4):E46-7
 
Dipasquale V, Serra G, Corsello G, et al. Standard and Specialized Infant Formulas in Europe: Making, Marketing, and Health Outcomes. Nutr Clin Pract. 2019 Feb 11
 
Eden AN. Iron fortification of infant formulas. Pediatrics. 2000 Jun;105(6):1370-1
 
Fomon S. Infant feeding in the 20th century: formula and beikost. J Nutr. 2001 Feb;131(2):409S-20S
 
Furse S, Koulman A. The Lipid and Glyceride Profiles of Infant Formula Differ by Manufacturer, Region and Date Sold. Nutrients. 2019 May 20;11(5). pii: E1122
 
Institute of Medicine (US) Committee on the Evaluation of the Addition of Ingredients New to Infant Formula (IM). Infant Formula: Evaluating the Safety of New Ingredients. Washington (DC): National Academies Press (US); 2004. 3, Comparing Infant Formulas with Human Milk.
 
O'Connor NR. Infant formula. Am Fam Physician. 2009 Apr 1;79(7):565-70
 
Wargo WF. The History of Infant Formula: Quality, Safety, and Standard Methods. Journal of AOAC International 2016, 99 (1): 7-11
 
WHO/UNICEF. Global breastfeeding scorecard; tracking breastfeeding policies and programmes. Geneva: World Health Organization; 2017