Breastfeeding is the biologically normal method of infant feeding and has many health protective and health enhancing advantages over formula feeding. Except in very rare situations (such as galactosaemia or maternal HIV infection) all ‘infants should be exclusively breastfed for the first six months of life’ as recommended by the WHO. Thereafter, infants should continue to be breastfed in combination with suitably nutritious complementary foods until two years of age and beyond.^1,2

Breastfeeding supports optimum growth, development and better future health for infants and their mothers.

Breastfeeding support and guidance

Although breastfeeding initiation rates are increasing in Ireland, they remain low by international standards at 56%.³ Breastfeeding duration rates are not collected at national level but research studies indicate a steady decline in breastfeeding rates following discharge from maternity hospitals. National data suggests that 81% of women who ceased to breastfeed by three to four months would have liked to breastfeed for longer.⁴

Mothers need to be supported to commence and continue exclusive breastfeeding in line with best practice recommendations. Many first-time mothers lack confidence in their ability to breastfeed, which is often compounded by recommendations from healthcare professionals to begin formula top ups. 

Introducing formula top ups, particularly in the early stages, has a negative impact on the mother’s milk supply due to the ‘supply on demand’ mechanism of breastfeeding, and should be avoided. Instead, mothers should be supported and allowed time to learn the skill of breastfeeding. They should be given practical information on correct attachment, provided with the knowledge and confidence to know that breastfeeding is going well, and referred to community-based breastfeeding support groups. 

Information-giving and support around breastfeeding should begin prenatally or earlier, as antenatal intention to breastfeed is the strongest predictor of breastfeeding initiation. In addition to the health benefits, once the skill of breastfeeding is learned it becomes a much more convenient and economical way of feeding and helps foster a greater emotional bond between mother and baby.

Formula feeding

Formula feeding is associated with higher health risks compared to breastfeeding. Exclusive formula feeding costs an estimated extra €12 million a year in healthcare costs for the treatment of infections in infancy alone.³ As well as an increased risk of infections in infancy, research shows increasing trends of atopy, obesity and diabetes mellitus among formula-fed infants.^5,6,7

Despite this, many mothers in Ireland choose not to breastfeed or discontinue breastfeeding before 12 months old. For these, as well as those rare circumstances where breastfeeding is not possible, a suitable infant formula is required in order to meet the infant’s full nutritional needs. 

Support for formula feeding

There are many different types of formulas available and this continues to expand. Many formula-fed infants experience various gastrointestinal symptoms (such as reflux, infantile colic, diarrhoea and constipation), which often results in multiple formula changes due to the perception that symptoms reflect a formula intolerance. Occasionally, a formula change is indicated but often parents mistake what are normal infant behaviours as manifestations of intolerance to their formula and unnecessarily switch brands or formula type. 

Healthcare professionals should know the different types of formulas available to enable them to provide advice to mothers who have made an informed choice not to breastfeed or to stop breastfeeding.

Which type of formula is suitable?

For most non-breastfed babies, a standard infant formula based on cows’ milk protein, which has been significantly modified to make it suitable for infants, should be used until 12 months old. 

There are two main milk proteins: whey and casein. Whey dominant formulas most closely match breast milk in protein composition and as whey is easily digested, whey-dominant formulas are preferred. 

First infant formulas

First infant formulas, which are suitable from birth, are whey-dominant. All formula-fed babies should stay on a first infant formula until changing to full fat cows’ milk at 12 months of age, unless otherwise advised by a doctor or dietitian. Examples include SMA Gold, Cow & Gate First Infant Milk, Aptamil 1.

Second infant formulas

Second infant formulas are often described as suitable for ‘hungrier babies’. There is little nutritional difference between first and second infant formulas but due to their protein composition, which is mostly casein, second infant formulas empty more slowly from the stomach, supposedly keeping infants feeling full for longer. 

There is no evidence that babies settle better or sleep longer when fed this type of formula, and they could potentially worsen symptoms of reflux in infants due to the delayed gastric-emptying effect. Examples include SMA Extra Hungry Infant Milk, Cow & Gate Infant Milk for Hungrier Babies, Aptamil Extra Hungry.

Follow-on formulas

Follow-on formulas are suitable for infants aged six to 12 months. They are casein-based and are higher in protein and calcium that standard infant formulas. Provided the weaning diet is nutritionally dense, follow on formula use is not needed. Research has found no clear benefit for their use over first infant formula. Examples include SMA Follow-On, Cow & Gate Follow-On, Aptamil Follow-On.

Anti-reflux formula

Anti-reflux formula can be useful in the management of physiological regurgitation or reflux in an otherwise healthy infant. Examples include Enfamil AR and SMA staydown. These formulas have an added ingredient (rice or corn starch, or carob bean gum), which causes the formula to thicken upon reaching stomach acid thereby helping to reduce regurgitation. However, these formulas cannot be used in conjunction with acid-suppressing medications or thickeners, which are often prescribed for infants with regurgitation. 

Half of all infants will experience some simple reflux, and where there are no other complications, reassurance and practical suggestions to manage reflux is often all that is required rather than a change in formula.

Partially-hydrolysed formulas

Partially-hydrolysed formulas, also known as 'comfort formulas', are composed of proteins that are partially broken down or hydrolysed. They are marketed as 'easier to digest' for infants with 'sensitive digestive systems' and manufacturers claim that these formulas can help improve colic, constipation and reflux. Examples include Aptamil Comfort, SMA Comfort and Cow & Gate Comfort. 

A recent large randomised control trial in healthy formula-fed infants found no difference in tolerance of standard infant formula versus partially-hydrolysed protein formulas.⁸ The National Institute for Health and Clinical Excellence (NICE) believes there is insufficient evidence to suggest that infant formulas, based on partially hydrolysed cows’ milk protein, can help prevent allergies.⁹

Lactose-free formula

Lactose-free formula is free of the milk sugar lactose and is recommended for the management of lactose intolerance. Primary lactose intolerance, an extremely rare genetic condition, requires lifelong strict lactose exclusion from birth. The much more commonly seen secondary lactose intolerance is usually transient, occurring after a GI insult, and lactose can usually be reintroduced gradually following a six to eight week low-lactose or lactose-free diet. 

Lactose-free formula still contains milk protein and is unsuitable for the management of cows’ milk protein allergy. Examples are Enfamil O-LAC and SMA LF.

Extensively hydrolysed formulas

Extensively hydrolysed formulas contain protein that has been extensively broken down into very small chain peptides and are recommended for the first-line management of most formula-fed infants with cows’ milk protein allergy. Examples suitable from birth include Aptamil Pepti 1 and Nutramigen 1. 

Examples suitable from six months include Aptamil Pepti 2 and Nutramigen 2. These should only be used under medical/dietetic supervision. 

There is some evidence that extensively hydrolysed formulas reduce the risk of atopic dermatitis compared with a standard cows’ milk protein-based formula.¹⁰ Breastfeeding remains the best form of nutrition for infants who are at increased risk of atopy.

Amino acid formulas

Amino acid formulas are required for the management of cows’ milk protein allergy in infants intolerant to extensively hydrolysed formula, and as first-line management for infants with suspected severe cows’ milk protein allergy. This includes infants with faltering growth, severe atopic eczema, history of anaphylactic reaction, or history of reaction to cows’ milk protein through breast milk. 

Examples of amino acid formula include Neocate and Nutramigen AA. These formulas should only be used under medical or dietetic supervision.

Soy-based formulas

Soy-based formulas are free from cows’ milk protein and lactose, and have been shown to meet the nutritional needs of the term infant. They also meet the standards set by current legislation on acceptable protein sources in infant formula.¹¹ The concern with soy protein-based formula is the presence of isoflavones, which may influence fertility, immune function and thyroid disease. 

Use of soy-based formula should therefore be limited, particularly under six months of age, to infants with galactosaemia or primary lactase deficiency. Soy-based infant formula is not recommended for the management of cows’ milk protein allergy due to a high risk of cross-reactivity between cows’ milk and soya allergies. An example of a soy-based infant formula is SMA Wysoy.

Goats’ milk based formula

Goats’ milk-based formulas were, until recently, not considered suitable as a source of nutrition for infants under 12 months of age under any circumstances. Although there remains no clinical indications for goats’ milk based formula, the European Food Safety Authority (EFSA) has recently concluded that “goats’ milk can be suitable as a protein source for infant and follow-on formula”.¹²

Goats’ milk-based formulas are not suitable for the management of cows’ milk protein allergy due to cross-reactivity between cows’ milk and goats’ milk allergies. An example of a goats’ milk based formula is Nanny Care Goat Milk.

Organic infant formula

Organic infant formulas are cows’ milk-based formula manufactured with all production aspects certified as organic. In order to claim that a food is organic it must be produced without conventional pesticides, chemical fertilisers, antibiotics or growth hormones. As the composition of all infant formula is strictly regulated, both organic and non-organic formulas do not exceed government safety thresholds for these residues. There is no evidence that organic foods are more nutritious than non-organic foods. An example of organic infant formula is Hipp Organic.

Note: For further information, see the 2011 Food Safety Authority of Ireland Scientific Recommendations for a National Infant Feeding Policy (2nd edition)

References

1. World Health Organisation, 2011 Statement. Available at: http://www.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/inind.html
2. Department of Health and Children, 2005. Breastfeeding in Ireland. A five-year strategic action plan - National Committee on Breastfeeding. Available at: http://www.dohc.ie/publications/Breastfeed_actionplan_2005.html
3. Joint ESRI/HSE National Office of Health Promotion Conference 1-10-12 Breastfeeding in Ireland 2012: Consequences and Policy Response. Available at: https://www.esri.ie/news_events/latest_press_releases/breastfeeding_in_ireland_/index.xml
4. Begley et al. (2008) The national infant feeding survey. Health Service Executive: Dublin
5. Dell & To (2001) Breastfeeding and asthma in young children. Archives of Pediatrics & Adolescent Medicine; 155:1261–1265.
6. Berdanier (2001) Diabetes mellitus: Is there a connection with infant-feeding practices? Nutrition Today; 36(5):241–248.
7. Gillman et al. (2001) Risk of overweight among adolescents who were breastfed as infants. Journal of the American Medical Association.285(19):2461–2467.
8. Berseth et al (2009) Tolerance of a standard intact protein formula versus a partially hydrolysed formula in healthy term infants. Nutrition Journal: 8, 27.
9. National Institute for Health and Clinical Excellence (2008) Maternal and Child Nutrition. Public Health Guidance 11. Available at: www.nice.org.uk/nicemedia/pdf/PH011quickrefguide.pdf
10. American Academy of Paediatrics (2005) Position Statement: Breastfeeding and the use of Human Milk. Pediatrics, 115(2) 496-506.
11. Commission Directive 2006/141/EC on infant formulae and follow on formulae amending directive 1999/21/EC
12. European Food Safety Authority (2012) Scientific Opinion on the suitability of goat milk protein as a source of protein in infant formulae and in follow on formulae. EFSA Journal 2012;10(3):2603