Breast milk is best, but for those babies who won’t or don’t breastfeed there are formula alternatives. Here’s a primer on infant formulas and how to decide which option is appropriate for the individual child.
Jatinder Bhatia, MD, FAAP
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.
Specialty infant formulas
For the minority of infants who cannot tolerate cow’s milk, choice of other types of formulas is based on the particular condition the infant has that precludes him or her from receiving either breast milk or cow’s milk-based formulas (Table 2). Specific conditions that Bhatia highlighted in his presentation were allergies, metabolic diseases (ie, galactosemia and phenylketonuria), infectious diseases (eg, tuberculosis, hepatitis, and human immunodeficiency virus [HIV]), malabsorption, and intestinal failure.
“There are very few babies, a small percentage, that actually need all the other types of non–cow milk-based formulae,” said Bhatia.
One of the most common reasons for choosing a non–cow milk-based formula is for infants with an allergy to lactase or to prevent allergies. As shown in Table 2, soy protein-based formulas are recommended for infants with galactosemia (a condition in which they cannot tolerate lactose) or those with hereditary lactase deficiency. Soy protein-based formula also can be used in infants in families who are vegetarian. However, Bhatia emphasized that soy-based formula should not be given as a routine formula unless indicated for these relatively rare conditions.
To prevent allergies from developing, evidence points to the benefits of a hydrolyzed formula to reduce the incidence of atopic dermatitis (but not asthma or other allergies) (Table 2).5 Infants born into a family with a history of allergies, specifically atopic dermatitis, are good candidates for this type of formula.
Infants who cannot tolerate hydrolyzed protein formulas, and have an allergy to the protein in cow’s milk along with multiple food intolerance, are good candidates for amino acid-based formulas. However, Bhatia emphasized that these formulas are not intended to be used to prevent an allergy but only for the small percentage of infants (about 5%) who have an intolerance to hydrolyzed protein formulas and cow’s milk-based formula.
Other infants for whom amino acid-based formulas may be warranted are those who cannot absorb nutrients for some reason or do not have a sufficient gut to absorb nutrients, such as infants who have undergone surgery. However, Bhatia again emphasized that this is a relatively rare situation.
For infants with other conditions, such as infections or issues with malabsorption, for which a non–cow’s-milk formula may seem indicated, Bhatia discussed specific issues to keep in mind when considering a switch from a cow’s milk-based formula to a specialty formula. In some infants, only a temporary switch to a non–cow’s milk-based formula will be needed, while in others no switch at all is needed.
Infants presenting with specific symptoms, such as diarrhea and colic, are often switched formulas based on the assumption that the symptoms are caused by the formula. For most of these infants, said Bhatia, switching formulas is needed only temporarily to help a transient problem or is not needed at all.
For example, infants may present with diarrhea caused by a transient intolerance to sugar. For these infants, it is reasonable to switch to another formula with reduced lactose until the symptoms resolve and then switch them back to the original formula.
“Most babies can be managed like this,” said Bhatia. However, he emphasized that babies with other symptoms, such as blood in their stools, will need specialty formulas.
For infants with an infection, such as HIV or active tuberculosis, switching to a formula is also warranted until the infection clears. Once cleared, the infant can be switched back to breast milk.
Bhatia cautions, however, that symptoms of diarrhea and colic often are only temporary and not due to the formula used. “For most babies with transient diarrhea and colic, switching formulas is not needed,” he said, encouraging pediatricians and parents to “wait it out.”
He urges pediatricians and parents to do some “homework” to understand better why an infant may have diarrhea or colic. One major cause of these symptoms in infants, he said, is the introduction of new foods into the diet. This occurs often between the ages of 4 to 12 months when infants are transitioning to solid foods while still using breast milk or formula as complementary nutrition.
“Just by switching formulas, the pediatrician and parent may miss something easy that is going on that is responsible for the symptom like diarrhea or colic,” he said.
Figure 1 provides an algorithm developed by Bhatia to help guide pediatricians on the feeding of term infants and the transition to solid food.
Breast milk is recommended as providing the best nutrition for most term infants. For infants for whom breast milk is not tolerated or in situations where formula is preferred, a variety of formulas are commercially available based on specific need. Most infants are fed cow’s milk-based formulas, all of which meet the energy and nutrient requirements for healthy term infants during the first 4 to 6 months of life. For the relatively few infants who require specialty formulas, soy-based and hydrolyzed formulas are available, each indicated for specific situations only and not recommended as a routine feeding alternative for otherwise healthy term infants. Amino acid-based formulas are also available for specific indications.
For infants who experience transient intolerance to breast milk or cow’s milk-based formula, switching to a different formula until symptoms such as diarrhea or colic clear is a reasonable option. For many situations, switching is not needed as the symptoms may be due to something other than the formula (ie, introduction of new foods). Pediatricians and parents can take a wait-and-see approach to better understand what may underlie a symptom such as diarrhea or colic to ensure the underlying cause is accurately identified and not simply masked over by switching formulas.
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.