Few things are as important in the development of human life as ensuring adequate nutrition during the first months and years after birth. The nutrition an infant receives, particularly up to the first year of life, will have lifelong effects on the growth and developmental abilities of the child as well as susceptibility to future medical illnesses.1
Given this, parents and pediatricians alike are rightly focused on providing infants with the best nutrition possible. Without question, optimal feeding for most normal, healthy term infants comes from breast milk, and organizations such as the American Academy of Pediatrics (AAP) strongly recommend it for most, if not all, infants.
However, for some infants, breast milk may not be the best option because of specific conditions that either temporarily or categorically make the infant intolerant to the breast milk. In addition, there may be personal or medical reasons why a mother may choose not to breastfeed.
In these situations, how to choose the best formula among the many available can be daunting. In a presentation at the 2017 AAP National Conference titled “So many infant formulas: How is a pediatrician to choose?,” Jatinder Bhatia, MD, FAAP, professor and chief, Division of Neonatology, Medical College of Georgia, Augusta University, Augusta, Georgia, helped pediatricians wade through the many options available. He provided a brief primer on the types of infant formulas available, how to decide on which one to choose, as well as issues related to switching formulas and transitioning from formulas/breast milk to whole foods.2
However, he opened his talk with a reminder that breastfeeding remains the best option for most infants. “Breastfeeding should be the norm,” he emphasized. “If breastfeeding cannot or should not be done, then we consider infant formula appropriate for the infant.”
How to choose a formula
Cow’s milk-based formulas
The standard choice of formula for most infants who are not breastfed is a cow’s milk-based (bovine) formula with iron (Table 1). These formulas account for up to 80% of formulas sold.3 Bhatia emphasized that all currently available bovine-based formulas meet the energy and nutrient requirements for healthy term infants during the first 4 to 6 months of life. After age 6 months, these formulas are used to complement the increased variety of foods introduced to infants around this age.
Bhatia, in line with recommendations by the AAP, recommended one of these formulas for any infant who is not exclusively or only partially breastfed from birth to 1 year of life.
One issue that is still unknown with these formulas, according to Bhatia, is the true beneficial effect of the addition of prebiotics and probiotics that more recent cow’s milk-based formulas (as well as other formulas) have introduced as a way to prevent allergic conditions in infants. A meta-analysis that looked at whether formulas supplemented with prebiotics could prevent allergy found some evidence of a beneficial effect on the prevention of eczema. However, the study concluded that further investigation is needed to assess whether there is a benefit on other allergic diseases including asthma, as well as for which infants these formulas are best suited.4
Regardless of whether breast milk or formula milk is used, Bhatia emphasized that milk should continue to be a major part of an infant’s diet through the transition to solid foods.
1. Gamble Y, Bunyapen C, Bhatia J. Feeding the term infant. In: Berdanier CD, Dwyer J, Feldman EB (eds). Handbook of Nutrition and Food. 2nd ed. Boca Raton, FL: CRC Press; 2007:271-284.
2. Bhatia J. So many infant formulas: How is a pediatrician to choose? (F4004) Presented at: American Academy of Pediatrics National Conference and Exhibition; September 19, 2017; Chicago, IL.
2. American Academy of Pediatrics. Choosing a formula. HealthyChildren.org. Available at: https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Choosing-a-Formula.aspx. Updated November 21, 2015. Accessed April 11, 2018.
3. Osborn DA, Sinn JK. Prebiotics in infants for prevention of allergy. Cochrane Database Syst Rev. 2013;(3):CD006474.
4. Alexander DD, Cabana MD. Partially hydrolyzed 100% whey protein infant formula and reduced risk of atopic dermatitis: a meta-analysis. J Pediatr Gastroenterol Nutr. 2010;50(4):422-430.