Ref.

29

CHAPTER 4: INFANT FORMULA FEEDING

This chapter reviews commonly used types A variety of infant formulas are available for
of infant formula; recommended amounts to healthy, full-term infants who are not breastfed
feed formula-fed infants in the first year; tips or partially breastfed. These include cow’s milk
on bottle feeding; guidelines on the selection, or soy-based infant formulas (iron-fortified),
preparation, and storage of infant formula; hypoallergenic infant formulas, and other infant
traveling with infant formula; warming bottles; formulas designed to meet the nutritional needs
and infant formula use when there is limited of infants with a variety of dietary needs (e.g.,
access to common kitchen appliances. Additional lactose-free or Kosher).
information is provided regarding milks and
other food products inappropriate for infants. Milk-Based Infant Formula
Counseling points related to the information
presented in this chapter are found in Chapter 8, The most common infant formulas consumed by
pages 161–167. infants are made from modified cow’s milk with
added carbohydrate (usually lactose), vegetable
This chapter does not address the infant formula oils, and vitamins and minerals. Casein is the
needs and feeding protocols for premature and predominant protein in cow’s milk. Since the
low-birth-weight infants or infants with medical primary protein in breast milk is whey protein,
conditions requiring exempt infant formulas (see rather than casein, some milk-based infant
page 83 for more information regarding exempt formulas have been altered to contain more whey.
infant formulas). Since nutritional management Despite that alteration, the protein in infant
of these infants may be complicated by treatment formula is significantly different from that in
for existing medical conditions, consult with and breast milk because of their different amino acid
follow the recommendations of the infant’s health and protein composition. In milk-based infant
care provider when counseling caregivers. formulas, about 9 percent of the kilocalories
are provided by protein, 48–50 percent by fat,
and 40–45 percent by carbohydrate. These
Types of Infant Formulas infant formulas are lower in fat and higher in
Breast milk is the optimal source of nutrition for carbohydrate, protein, and minerals than breast
the infant but, when breast milk is not available, milk.
iron-fortified infant formula is an appropriate
alternative for the infant’s first year of life. Infant Iron-Fortified Infant Formula
formula is “a food which purports to be or is The American Academy of Pediatrics (AAP)
represented for special dietary use solely as a recommends that iron-fortified cow’s milk-based
food for infants by reason of its simulation of infant formula is the most appropriate milk
human milk or its suitability as a complete or feeding from birth to 12 months for infants who
partial substitute for human milk.”1 The Food, are not breastfed or who are partially breastfed.3
Drug, and Cosmetic Act mandates that all infant
formulas marketed in the United States provide Use of an iron-fortified infant formula ensures
the same nutrition for healthy, full-term infants.1 that formula-fed infants receive an adequate
Because infant formulas are often the only source amount of iron, an important nutrient during
of nutrition for infants, the Food and Drug the first year. Standard iron-fortified infant
Administration (FDA) monitors infant formula formulas are fortified with approximately 10 to 12
manufacturers very closely to assure the product milligrams of iron, in the form of ferrous sulfate,
provides the appropriate nutrition for all infants.2 per quart. Research shows that providing iron-
fortified infant formula and cereal for the first
12 months of life, as done in the WIC and CSF

INFANT NUTRITION AND FEEDING 81

 Programs, has been successful in reducing iron infant formulas are fortified with similar amounts
deficiency.4, 5, 6 Iron deficiency is associated with of iron as milk-based iron-fortified infant
poor cognitive performance and development in formulas.
infants. See pages 24–25 for more information
regarding iron deficiency. The AAP has stated that soy-based infant
formulas are safe and effective alternatives to
Low-Iron Infant Formula cow’s milk-based infant formulas, but have no
In 1997, the AAP Committee on Nutrition advantage over them.
recommended that the manufacture of infant
formula containing less than 4 milligrams of Soy-based infant formulas may be indicated in the
iron per quart be discontinued.3 Some of the following situations: 10
most commonly used milk-based infant formulas ▘▘ Infants with galactosemia (a rare metabolic
are also available with reduced iron content. disorder) or hereditary lactase deficiency
These low-iron infant formulas now contain ▘▘ Infants whose parents are seeking a vegetarian
approximately 5 milligrams of iron per quart of diet for their full-term infant or
formula.7 ▘▘ Infants with documented IgE-mediated
allergy to cow’s milk protein.
There are no known medical conditions for
which the use of iron-fortified infant formula is The use of soy-based infant formulas has no proven
contraindicated. Some caregivers request low- benefit in the following situations: 10
iron infant formula for their infants because
▘▘ Healthy infants with acute gastroenteritis
they believe that the iron in the infant formula
in whom lactose intolerance has not been
causes gastrointestinal problems, such as colic,
documented
constipation, diarrhea, or vomiting. However,
▘▘ Infants with colic
studies have demonstrated that gastrointestinal
▘▘ Prevention of allergy in healthy or high-risk
problems are no more frequent in infants
infants and
consuming iron-fortified than low-iron infant
▘▘ Infants with documented cow’s milk protein-
formula.8, 9
induced enteropathy or enterocolitis.
As noted above, for the partially or non-breastfed
infant, iron-fortified infant formula is the formula
Hypoallergenic Infant Formula
of choice to assure that an infant’s iron needs are A number of infant formulas have been
met. developed and marketed for infants with
allergies or intolerances to milk or soy-based
Soy-Based Infant Formula infant formulas or those with a family history
of allergies. Infant formulas manufactured and
Soy-based infant formulas were developed for
labeled for infants with allergies vary in the degree
infants who cannot tolerate infant formula made
to which the allergy-causing protein has been
from cow’s milk. These infant formulas contain
modified. They may contain partially hydrolyzed
soy protein isolate made from soybean solids
protein, extensively hydrolyzed protein, or free
as the protein source, vegetable oils as the fat
amino acids. Extensively hydrolyzed and free
source, added carbohydrate (usually sucrose and/
amino acid-based infant formulas have been
or corn syrup solids), and vitamins and minerals.
demonstrated to be tolerated by at least 90
Soy-based infant formulas are fortified with the
percent of infants with documented allergies.11
essential amino acid methionine, which is found
Currently available partially hydrolyzed infant
in very low quantities in soybeans. In these infant
formulas are not hypoallergenic and should
formulas, 10 to 11 percent of the kilocalories are
not be used to treat infants with documented
provided by protein, 45 to 49 percent by fat, and
allergies.11
41 to 43 percent by carbohydrate. All soy-based

82 INFANT NUTRITION AND FEEDING

The prevalence of milk protein allergy in infancy Lactose-Free Infant Formula
is low, at 2 to 3 percent. However, food allergies
may present in three ways:11 Lactose is the major carbohydrate in cow’s milk-
based infant formulas. Lactose intolerance may
▘▘ Immunoglobulin E (IgE)-associated reactions, lead to excess gas, diarrhea, or fussiness. A very
such as runny nose, wheezing, eczema, small number of infants produce insufficient
vomiting, and difficulty breathing; amounts of lactase, the enzyme needed to break
▘▘ Non-IgE-associated reactions including down lactose.12 Congenital lactase deficiency is
diarrhea, malabsorption, colitis, or extremely rare. Premature infants may have lower
esophagitis; and levels of lactase than term infants, proportional to
▘▘ Extreme irritability or colic. their degree of prematurity, since lactase activity
develops during the last trimester of pregnancy.
All suspected cases of food allergy should be referred Lactose intolerance may develop in later
to a qualified health care professional for further childhood (>2 years of age in some susceptible
diagnosis and treatment. populations) or adulthood, but very few term
infants have true lactose intolerance. Transient
The AAP recommends that the use of lactose intolerance may occur following acute
hypoallergenic infant formulas should be limited diarrhea, but enzyme activity is restored quickly
to infants with well-defined clinical indications.11 and switching to lactose-free infant formulas is
If hypersensitivity is diagnosed, a physician may usually not necessary.
change the infant formula prescribed. The AAP
states that formula-fed infants with confirmed Several cow’s milk-based infant formulas are
cow’s milk allergy may benefit from the use of now available for infants with documented
hypoallergenic (extensively hydrolyzed or, if lactose intolerance. In addition, soy-based infant
symptoms persist, a free amino acid-based infant formulas are lactose-free and may be used for
formula) or soy-based infant formula.12 Soy- infants with documented lactose intolerance.
based infant formula may be used for infants with
IgE-associated symptoms. Improvement is usually Exempt Infant Formula
seen in 2 to 4 weeks; however, the infant formula An exempt infant formula is one that is
should be continued until at least 12 months of represented and labeled for use by infants who
age. Hypoallergenic infant formulas made from have inborn errors of metabolism or low birth
extensively hydrolyzed protein or free amino acids weight, or who otherwise have unusual medical
may be used for infants with non-IgE-associated or dietary problems.13 There are many varieties
symptoms or those with a strong family history of specially designed infant formulas developed
of allergy. Hypoallergenic infant formulas are for infants with special medical conditions.
significantly more expensive than either milk- For the most up-to-date information on infant
based or soy-based infant formulas. In addition, formula composition and new products, refer to
their taste is altered significantly during hydrolysis pharmaceutical company product information
of the protein and they may not be well accepted materials or contact the manufacturer. For more
by some infants. information regarding exempt infant formulas
access FDA’s Web site at http://www.cfsan.fda.
gov/~dms/inf-exmp.html.

INFANT NUTRITION AND FEEDING 83

 WIC Formula Database on the WIC Works Resource in the brain and retina. Research demonstrating
Center Website better cognitive function in breastfed infants
http://www.nal.usda.gov/wicworks has led some to support the addition of ARA
and DHA to infant formula. This issue remains
The Food and Nutrition Service (FNS),
controversial; the FDA’s Life Sciences Research
Department of Agriculture (USDA)
Office Expert Panel on Assessment of Nutrient
developed an electronic database of infant
Requirements of Term Infant Formulas does not
formulas, exempt infant formulas, and
recommend either a minimum or maximum
medical foods that have been determined
content of ARA and DHA in infant formula.16
eligible for use in the Special Supplemental
FDA expects post-market surveillance to be
Nutrition Program for Women, Infants,
conducted by infant formula manufacturers
and Children (WIC). Manufacturers
because previous studies on the effects of fatty
benefit by having information about their
acids in infant formulas on the growth and
WIC-eligible formulas readily available to
development of infants were based on short-term
all WIC State agencies and approximately
studies. Additionally, ARA and DHA were not
10,000 WIC clinic sites throughout the
ingredients in infant formula in the United States
country. In turn, WIC agencies have access
before early 2002. FDA treats the evaluation of
to an up-to-date formula database that
the safety of ARA and DHA as new ingredients
will assist them in meeting the needs of
in infant formula as a judgment dependent on
participants.
scientific data as well as time.17 The AAP has
taken no official position on their addition.15
Most infant formula manufacturers currently
Long-Chain Polyunsaturated Fatty offer products containing added ARA and DHA.
Acids and Other Infant Formula
Additives Nucleotides, Prebiotics, and Probiotics
Nucleotides are metabolically important
In recent years, infant formula manufacturers
compounds that are the building blocks of
have begun to examine the benefits of adding
ribonucleic acid (RNA), deoxyribonucleic acid
a variety of nutrients and biological factors to
(DNA), and adenosine triphosphate (ATP),
infant formula to mimic the composition and
and are present in breast milk.18 It is thought
quality of breast milk.14 These include long-
that they may enhance immune function
chain polyunsaturated fatty acids, nucleotides,
and development of the gastrointestinal tract
prebiotics and probiotics.
and may be beneficial when added to infant
formula.19 Prebiotics are nutrients that support
Arachidonic Acid (ARA) and Docosahexaenoic the growth of “good” bacteria in the intestine,
Acid (DHA) while probiotics are these nonpathogenic bacteria,
Long-chain polyunsaturated fatty acids include including Bifidobacteria and Lactobacilli. Since
the essential fatty acids, linoleic acid (abbreviated these organisms are present in the intestines of
18:2 n-6 or LA), and α-linolenic acid (18:3 n-3 breastfed infants and may protect from infection
or ALA) along with their derivatives, arachidonic by other pathogenic bacteria, researchers are
acid (20:4 n-6 or ARA) and docosahexaenoic acid studying the effect of adding them to infant
(22:6 n-3 or DHA). Since formula-fed infants formula. Although infant formula manufacturers
have been observed to have lower plasma levels are beginning to add these compounds to infant
of ARA and DHA, interest has arisen about the formula, more research is needed to confirm the
formula-fed infant’s ability to synthesize these benefits of adding nucleotides, prebiotics, and
fatty acids.15 ARA and DHA are major fatty acids probiotics to infant formula.20

84 INFANT NUTRITION AND FEEDING

Other Milks and Other Products sufficient to correct iron-deficiency anemia.25
▘▘ Stress on the kidneys – Cow’s milk is
This section provides information on different difficult for a young infant’s immature
milk and other products that are not appropriate kidneys to process because of its concentrated
substitutes for infant formula for infants, less than protein, sodium, potassium, and chloride and
12 months old, in the WIC and CSF Programs. resulting high renal solute load (see page 30
for more information regarding renal solute
Whole Cow’s Milk load). The renal solute load of infants fed
The AAP Committee on Nutrition recommends whole cow’s milk is two to three times higher
that whole cow’s milk not be fed to infants during than that of formula-fed infants.26 Even older
the first year of life.21 Breast milk or iron-fortified infants may have a problem with the load of
infant formula is recommended instead of cow’s milk these nutrients on the kidneys and be at
for a number of nutritional and medical reasons. greater risk for developing dehydration.27 The
possibility of developing dehydration as a
Whole cow’s milk is not recommended for infants for result of a high renal solute load is greatest
the following reasons: 20 during: an acute illness when intake is lower,
▘▘ Inappropriate nutrient content – Research especially if there is fever; when the diet is
indicates that it is difficult for infants to calorie dense, that is, high in calories but low
consume a balanced diet, with adequate in volume of food/fluid; and when renal
nutrients, when whole cow’s milk replaces concentrating ability is decreased, as in
breast milk or iron-fortified infant formula.21 chronic renal disease and diabetes.28
Infants fed whole cow’s milk have low intakes ▘▘ Hypersensitivity (allergic) reactions –
of iron, linoleic acid (an essential fatty acid), Cow’s milk contains proteins that may
and vitamin E and excessive intakes of cause hypersensitivity (allergic) reactions
sodium, potassium, chloride, and protein. in the young infant due to his immature
These nutrient intakes are not optimal and gastrointestinal tract.
may alter an infant’s nutritional status, with Given these concerns about cow’s milk, the
the most dramatic effect on iron status. recommended choices to use in meeting an
Infants over 6 months old require good infant’s nutritional needs are breast milk and iron-
sources of iron in their diets; there is very fortified infant formulas (for those not breastfed
little iron in whole cow’s milk. The or partially breastfed). Encourage caregivers to
composition of whole cow’s milk (i.e., high breastfeed or keep their infants on iron-fortified
calcium, high phosphorus, and low vitamin infant formula until 12 months old.
C) may inhibit an infant’s ability to absorb
iron from different complementary foods, Low-Fat or Skim Cow’s Milk
including iron-fortified infant cereals.
▘▘ Microscopic gastrointestinal bleeding and Pediatric nutrition authorities agree that skim
blood loss – Cow’s milk has been shown to milk (fresh liquid, reconstituted nonfat dry
cause microscopic bleeding and blood loss milk powder, or evaporated skimmed milk)
from an infant’s immature gastrointestinal or low-fat milk (1 or 2 percent low-fat milk)
tract when fed to infants in the first 6 months should not be fed to infants.20, 21, 29 These milks
of life22 and to a lesser extent between 6 and contain insufficient quantities of fat (including
12 months.23 These problems disappear at linoleic acid), iron, vitamin E, and vitamin C;
about 12 months.24 This bleeding promotes and excessive protein, sodium, potassium, and
the development of iron deficiency anemia. chloride. The amount of protein and minerals
Studies show that iron deficiency in early in low-fat and skim milk is even higher than in
childhood may lead to long-term changes in whole cow’s milk; these milks place a strain on
learning and behavior that might not be an infant’s kidneys in the same way as does whole
reversed even with iron supplementation cow’s milk.

INFANT NUTRITION AND FEEDING 85

 Fat, as found in sufficient amounts in breast Goat’s Milk
milk and infant formula, is needed to meet an
infant’s energy needs for growth and for proper Goat’s milk is not recommended for infants.29
development of the nervous system. Increased Goat’s milk contains inadequate quantities of
publicity of the association between high-fat iron, folate, vitamins C and D, thiamin, niacin,
diets and heart disease has led some caregivers to vitamin B6, and pantothenic acid to meet an
believe that they should feed their infants skim or infant’s nutritional needs. Some brands of goat’s
low-fat milk to prevent obesity or atherosclerosis milk are fortified with vitamin D and folate, but
later in life. However, feeding skim or low-fat other brands may not be fortified. This milk also
milk to infants and children up to age 2, in an has a higher renal solute load compared to cow’s
attempt to prevent heart disease from developing milk and can place stress on an infant’s kidneys.
later in life, is not considered appropriate.30 This milk has been found to cause a dangerous
According to the AAP, consumption of skim or condition called metabolic acidosis when fed to
low-fat milk is not recommended in the first infants in the first month of life.
2 years of life because of the high protein and
electrolyte content and low caloric density of Soy-Based (Soy Milks) and Rice-Based (Rice
these milks.30 Milk) Beverages
Beverages made from soy, rice, or other grains
Evaporated Cow’s Milk or nuts are not equivalent to infant formulas or
Homemade formulas made from evaporated milk breast milk and are not appropriate for infant
are not recommended in the first 12 months of consumption.31 Although most are fortified with
life.29 Evaporated whole milk is whole cow’s milk vitamins A, D, and B12, riboflavin, calcium, and
from which approximately 60 percent of the water zinc, these beverages lack appropriate amounts
has been removed. This milk is fortified with of kilocalories, protein, and fat needed by infants
vitamin D but remains low in the same nutrients for adequate growth.31 Use of these milks can be
as whole cow’s milk and low in folate if the milk is dangerous to an infant’s health. Marasmus and
boiled. Evaporated milk can also be made from malnutrition have been reported in infants fed
skim cow’s milk. Before the development of infant these beverages as the whole or major source of
formulas, evaporated whole milk was used to nutrition.31
make a homemade infant formula which was
thought to be easier for an infant’s kidneys and Sweetened Beverages Fed From a Bottle
digestive system to handle than plain whole cow’s Infants should never be given sweetened beverages
milk. However, the disadvantages of evaporated (e.g., soda, fruit drinks, powdered beverages,
milk formulas are now considered similar to those sweetened teas) because they are associated with a
of whole cow’s milk. higher risk for developing early childhood caries
and childhood obesity. These beverages lack
Sweetened Condensed Milk appropriate amounts of kilocalories, protein, and
Sweetened condensed milk is not an appropriate other key nutrients and displace breast milk or
food or beverage for infants.29 This milk infant formula in the infant’s diet.32,33 See page
product has a high sugar concentration and 114 for more information regarding sweetened
similar disadvantages to whole cow’s milk. It is beverages.
made by adding sugar to whole cow’s milk and
then evaporating water from the milk. When
undiluted, this milk contains seven times the
carbohydrate content of evaporated whole milk.

86 INFANT NUTRITION AND FEEDING

Feeding Infant Formula in the First Year Signs of Fullness
The amount of infant formula needed by an Encourage the caregiver to feed the infant until
infant over a 24-hour period will vary depending he or she indicates fullness. Signs of fullness
on the infant’s age, size, level of activity, metabolic include:
rate, medical conditions, and other source(s) of ▘▘ Sealing the lips together
nutrition (breast milk and/or complementary ▘▘ A decrease in sucking
food). Infants have the ability to regulate their ▘▘ Spitting out the nipple and
food intake relative to their nutritional needs. In ▘▘ Turning away from the breast or bottle.
doing so, they express signs of hunger and satiety
and expect their caregiver to respond to these Some infants may eat less than the portions
cues. Thus, unless medically indicated otherwise, offered if they are not hungry. A caregiver should
infants should be fed on demand, i.e., fed when never force an infant to finish what is in the
they indicate their hunger, and not forced to bottle. Infants are the best judge of how much
follow a strict feeding schedule, nor to finish a they need. They may want to eat less if they are
bottle when no longer hungry. Infants placed on not feeling well and may want more if they are in
strict feeding schedules in the early months of life a growth spurt.35
stand a greater chance of being either overfed or
If you perceive that a caregiver is frustrated or
underfed.
having difficulty coping with an infant’s fussiness or
crying, refer him or her to a health care provider for
Hunger and Satiety Cues further assessment and assistance.
Infants, especially newborns, may not be
consistent or follow a timed schedule as to when Feeding Frequency and Amount
and how often they want to eat. A healthy infant
eventually establishes an individual pattern Newborn formula-fed infants are generally fed
according to his or her growth requirements. It is infant formula as often as exclusively breastfed
normal for infants to have fussy times; an infant infants are fed for a total of 8 to 12 feedings
may cry and just want to be held, to suck, or within 24 hours. These young infants need to
need to be changed; or may not be hungry. Thus, be fed small amounts of infant formula often
encourage caregivers to watch for and respond throughout the day and night because their
appropriately to the infant’s cues of hunger and stomachs cannot hold a large quantity. If a
satiety or fullness. Caregivers should look for the newborn infant sleeps longer than 4 hours at a
following common signals of hunger and fullness time, the infant should be awakened and offered
in their infants.34 a bottle. See page 59 for more information
regarding the sleepy infant.
Signs of Hunger
From birth to 6 months of age, infants grow
An infant who is hungry may: rapidly and will gradually increase the amounts
▘▘ Wake and toss of infant formula they can consume at each
▘▘ Suck on a fist feeding, the time between each feeding, and the
▘▘ Cry or fuss or total amount of infant formula consumed in 24
▘▘ Appear like he or she is going to cry. hours. Encourage parents or caregivers to prepare
2 ounces of infant formula every 2 to 3 hours at
Caregivers should respond to the early signs of first. More should be prepared if the infant seems
hunger and not wait until the infant is upset and hungry, especially as the infant grows.36
crying from hunger.
The partially breastfed infant will consume less
infant formula than given in these examples,

INFANT NUTRITION AND FEEDING 87

 depending on the frequency of breastfeeding. Formula Feeding Tips
At 6 months old, infants begin to shift from
dependence on breast milk or infant formula as Caregivers can help their formula-fed infants
the primary nutrient source to dependence on have a positive feeding experience by feeding in a
a mixed diet including complementary foods. relaxing setting. Encourage caregivers to:
Thus, the consumption of breast milk or infant
formula tends to decrease as the consumption of ▘▘ Find a comfortable place in the home for
complementary foods increases. feeding;
▘▘ Interact with the infant in a calm and relaxed
Sleepy or Placid Infant manner in preparation for and during feeding
(e.g., by cuddling and talking gently to the
An exception to using the demand feeding infant); and
approach is for a young infant who is sleepy or ▘▘ Show the infant lots of love, attention, and
placid. Some infants may either fall asleep after cuddling in addition to feeding - reassure
feeding on a bottle for a short time, may not be them that doing so will decrease fussiness and
easy to wake for feeding every 2 to 3 hours, or will not “spoil” the infant.
do not show signs of hunger normally. To assure
that such infants obtain sufficient nourishment, Guidelines on Feeding From a Bottle
it is advisable for mothers to wait no more
than 4 hours (or sooner if the infant’s health To make bottle feeding safe and comfortable for
care provider indicates) between feedings until infants, encourage caregivers to do the following:
the infant’s first well check up (between 2 and
4 weeks old). At that time, the infant’s health ▘▘ Wash their hands with soap and water before
care provider should be consulted to determine feeding.
whether to recommend continuation of that ▘▘ Hold the infant in their arms or lap during
practice based on the infant’s weight gain. the feeding (with the infant in a semi-upright
position with the head tilted slightly forward,
To wake a sleepy infant, a mother can try these slightly higher than the rest of the body, and
methods: supported by the person feeding the infant).
The infant should be able to look at the
▘▘ Stroking the infant’s cheek with the nipple caregiver’s face. If an infant’s head is tilted
▘▘ Holding the infant in an upright position back or lying flat down, the liquid could enter
(sitting or standing) while supporting the chin the infant’s windpipe and cause choking.
with one hand, several times ▘▘ Hold the bottle still and at an angle so that
▘▘ Rubbing or stroking the infant’s hands and the end of the bottle near the nipple is filled
feet with infant formula and not air. This reduces
▘▘ Unwrapping or loosening blankets the amount of air swallowed by the infant.
▘▘ Giving the infant a gentle massage ▘▘ Stroke the infant’s cheek gently with the
▘▘ Undressing or changing the infant’s clothing nipple to stimulate the “rooting” reflex. This
or diaper or will cause the infant to open his or her mouth
▘▘ Playing with and talking to the infant. to initiate feeding.
▘▘ Ensure that the infant formula flows from
Feeding throughout the night is not usually the bottle properly by checking if the nipple
necessary for the older infant with a normal hole is an appropriate size (if the bottle is
growth rate. Refer an infant, whose caregiver held upside down, the falling drops should
complains of the infant’s sleepiness or lack of follow each other closely and not make a
hunger signs, to a health care provider for further stream). The nipple ring on the bottle should
assessment. be adjusted so that air can get into the bottle
(otherwise the nipple may collapse).

88 INFANT NUTRITION AND FEEDING

▘▘ Burp the infant at any natural break in or at ▘▘ Infants may overfeed; or
the end of a feeding to eliminate swallowed ▘▘ Infants do not receive human contact, which
air from the stomach. Try to avoid stopping is important to make them feel secure and
to burp an infant after every couple of ounces loved.
because this can be disruptive to the feeding.
An infant can be burped by gently patting It is not advisable to give infants a bottle (whether
or rubbing the infant’s back while he or she propped or not) while the infant is lying down at
is held against the front of the caregiver’s nap or bedtime31 or while the infant is lying or
shoulder and chest or held and supported sitting in an infant car seat, carrier, stroller, infant
in a sitting position in the caregiver’s lap. swing, or walker. In addition to possibly causing
Burping at natural breaks during feeding choking and ear infections, these practices can
helps to slow the feeding, thereby lessening lead to dental problems if there is milk, fruit
the amount of air swallowed, and may help juice, or a sweetened beverage in the bottle. See
to reduce gastroesophageal reflux and colic pages 132–133 regarding early childhood caries.
in some infants (see pages 139–140 for more
information regarding reflux and colic). A Selection, Preparation, and Storage of
small amount of spitting up is common in
formula-fed infants. The breaks in feeding are Infant Formula
also good times for the caregiver to socialize To assure that infant formula is safe for
with (e.g., talk gently and smile at) her infant. consumption, the infant formula must be
properly selected, prepared, and stored and
Throughout infancy, it is especially important bottles must be properly sanitized.
that formula-fed infants be fed in a position that
both minimizes their chances of choking and Selecting Cans of Infant Formula
allows them physical and eye contact with their
caregivers. When an infant is held closely and can Encourage caregivers to take these steps when
establish eye contact with the caregiver, bonding selecting and using cans of infant formula:
between the two is enhanced. Older infants may
prefer to hold the bottle themselves while in the ▘▘ Check the infant formula’s expiration date
caregiver’s arms or lap or while sitting in a high on the label, lid, or bottom of the can. If the
chair or similar chair. See Figure 5 on page 90 for expiration date has passed, then the infant
more tips for feeding an infant with a bottle. formula has expired and should not be used.
▘▘ Do not select cans of infant formula that have
See pages 123–124 for information regarding
dents, leaks, bulges, puffed ends, pinched tops
weaning an infant from the bottle.
or bottoms, or rust spots. These characteristics
indicate that the product quality may be
Propping the Bottle Is Not Recommended diminished and the product is unsafe.
It is never appropriate to prop a bottle to feed an ▘▘ Store cans of infant formula in a cool, indoor
infant by placing a bottle supported by a pillow place – not in vehicles, garages, or outdoors.
or something similar in the infant’s mouth.

Caregivers should avoid propping the bottle because:

▘▘ Liquid in the bottle can accidentally flow into
the lungs and cause choking;
▘▘ Infants tend to contract ear infections because
fluid enters the middle ear and cannot drain
properly;

INFANT NUTRITION AND FEEDING 89

 Figure 5: Tips on Feeding With a Bottle Feeding the Infant:
▘▘ Feed the infant when he indicates hunger.
Respond to the early signs of hunger. Do not
wait until the infant is upset or crying.
▘▘ Gently and slowly position the infant to
prepare for a feeding.
▘▘ Feed the infant in a smooth and continuous
fashion. Follow the infant’s lead on when
to feed, how long to feed, and how much
to feed. Avoid disrupting the feeding with
unnecessary burping, wiping, juggling, and
Preparing and Storing Bottles: arranging.
▘▘ Always hold the infant during feedings.
▘▘ Ensure that bottles and accessories are clean
Propping the bottle is never appropriate.
and sanitary.
Propping a bottle may cause ear infections
▘▘ Do not allow bottles of breast milk or infant and choking. It also deprives the infant of
formula to stand at room temperature to important human contact.
prevent spoilage. Refrigerate prepared bottles
▘▘ Hold the infant’s head a little higher than the
until ready to use.
rest of the body to prevent milk from backing
▘▘ For those infants who prefer a warm bottle, up in the ear and causing an ear infection.
hold the bottle under running warm (not hot)
▘▘ Do not offer the bottle at nap time or let an
water immediately before feeding.
infant carry a bottle around. Allowing an
▘▘ Shake a bottle of breast milk before feeding infant to sleep with a bottle may lead to tooth
because breast milk separates when it is decay.
stored.
▘▘ Wait for the infant to stop eating before
▘▘ Never use a microwave oven to heat bottles burping. Burp by gently patting or rubbing
of breast milk or infant formula. They may the infant’s back while the infant is resting on
explode or the milk may get too hot. Since your shoulder or sitting on your lap.
the liquid heats unevenly, it can be much
▘▘ Continue to feed the infant until he or she
hotter than it feels. Microwave heating can
indicates being full. Signs of fullness include
destroy special substances in breast milk.
sealing the lips, spitting out the nipple, and
▘▘ Do not put cereal or other foods in a bottle. turning away from the breast or bottle.
This practice replaces breast milk or infant
▘▘ Never force an infant to finish what is in the
formula with food that may not be needed
bottle. Infants are the best judge of how much
by the infant, teaches the infant to eat
they need.
complementary foods (solids) incorrectly, and
increases the infant’s risk for choking. ▘▘ An older infant may be fed a bottle while
sitting in a high chair.
▘▘ Throw out unused breast milk or infant
formula left in a bottle and wash the bottle ▘▘ Before opening a can of infant formula,
with soap and hot water immediately. Clean wash the can lid with soap and water to
and sterilize bottles and accessories before remove bacteria, dust, insect parts, and
reusing them. other substances that could contaminate the
infant formula when opened. Rinse soap off
thoroughly with water so that soap does not
get into the infant formula.

90 INFANT NUTRITION AND FEEDING

Sterilizing Water and Bottles boiling destroys certain nutrients (e.g.,
folate and other water-soluble vitamins).
Infants 3 months of age and younger are more
likely to contract illnesses from micro-organisms
in bottles and nipples that are improperly
Preparing Infant Formula
cleaned, cleaned in contaminated water, or filled Powdered infant formula is prepared by mixing
with contaminated water. Therefore, for infants one unpacked level scoop of dry powder to 2
less than 3 months old, glass or hard plastic ounces of sterile water. Concentrated infant
bottles and bottle parts (nipples, caps, rings) formula is prepared by adding equal parts
should first be thoroughly cleaned using soap, of water to concentrated liquid. Ready-to-
hot water, and bottle and nipple brushes, and feed infant formula is ready for the infant to
then either be sterilized in boiling water for 5 consume. These preparations will yield an
minutes, as indicated in Figures 6a, 6b, and 6c, infant formula that is approximately 20 calories
pages 93–95, or washed in a properly functioning per ounce. See Figures 6a, 6b, and 6c on
dishwasher machine. If disposable plastic bottle pages 93–95 for a checklist of instructions for
liners are used, the bags should be discarded after preparing ready-to-feed, liquid concentrated,
one use and the nipples, rings, and caps sterilized or powdered iron-fortified infant formula.
in boiling water or washed in a dishwasher
until the infant is at least 3 months old. After 3 General guidelines for infant formula preparation
months, unless otherwise indicated by a health are provided; however, the caregiver should
care provider, bottles should be thoroughly always follow the manufacturer’s instructions
washed using soap and hot water and bottle for preparation. Although infant formula cans
and nipple brushes or cleaned in a dishwasher. include written instructions for preparation,
caregivers may not be able to read or understand
As a precaution, it is generally recommended to those instructions. If they are unable to read
boil the water used for infant formula preparation English but can read another language, printed
during the first 3 months of life.29 Caregivers instructions should be provided in their
should consult their health care providers own language. Infant formula preparation
regarding whether the water used for preparing instructions designed in picture format can be
infant formula or for feeding should be boiled for used for low-literacy or illiterate participants.
the infant older than 3 months. If a caregiver is
in doubt about the safety of the water supply or It is very important to prepare infant formula
if there are reports in the community about the properly. Increasing the water-to-formula ratio is
water supply being contaminated, he should find never recommended because it will yield a lower-
an alternate source of clean water and consult calorie formula, which will not meet the infant’s
his health care provider as soon as possible. calorie requirements. Decreasing the water-to-
formula ratio may be recommended for infants
Caregivers can boil water to make infant formula who are failing to thrive, but it should only be
by bringing the water to a rolling boil, boiling it done when recommended by the infant’s health
for 1–2 minutes, and then letting it cool.20, 37 See care provider. Infants consuming incorrectly
pages 35–39 regarding the use of different types reconstituted infant formula may develop serious
of water, including well water, and water safety. health problems. Under-diluted infant formula
(containing too little water) puts an excessive
The terminal sterilization of infant formula, burden on an infant’s kidneys and digestive
which involves filling clean bottles with system and may lead to dehydration. This
properly diluted infant formula first and problem becomes worse if the infant has increased
then boiling all the formula-containing fluid needs due to fever or infection. Over-diluted
bottles in water, is not recommended because infant formula (containing too much water)
may contribute to growth problems, nutrient

INFANT NUTRITION AND FEEDING 91

 deficiencies, and water intoxication. See pages Store bottles of prepared infant formula in a
28–29 for more information regarding water properly functioning refrigerator until ready to
needs for infants. If the caregiver has any questions use. Bacterial growth is reduced when infant
or concerns about infant formula preparation, refer formula is kept in a refrigerator at temperatures
him or her to their infant’s health care provider. at 40 degrees Fahrenheit or below. (Use a special
thermometer to test if the refrigerator is at the
Special Concerns appropriate temperature.) Caregivers should
Infant formula is a safe and effective always consult their health care provider and
alternative for infant nutrition when follow the manufacturer’s label instructions for
breastfeeding is impossible or impractical. infant formula storage procedures. In general, it is
However, healthcare professionals should recommended that caregivers:
be aware that powdered infant formulas ▘▘ Use refrigerated bottles of concentrated or
are not commercially sterile products. ready-to-feed infant formula within 48 hours
Powdered infant formulas are heat-treated of preparation or
during processing, but unlike liquid infant ▘▘ Use refrigerated bottles of powdered infant
formula products they are not subjected formula within 24 hours of preparation.
to high temperatures for sufficient time to ▘▘ Opened cans of concentrated or ready-to-feed
make the final product commercially sterile. infant formula should be covered, refrigerated,
A concern about possible Enterobacter and used within 48 hours. Freezing infant
sakazakii (E. sakazakii) infections led the formula is not recommended.
Food and Drug Administration to issue an ▘▘ Powdered infant formula should be tightly
alert to healthcare professionals in April covered and stored in a cool, dry place and
2002. For more information see http:// used within a month after opening.
www.cfsan.fda.gov/~dms/inf-ltr3.html. ▘▘ Discard any infant formula remaining after a
E. sakazakii is a microorganism belonging feeding. The mixture of infant formula with
to the family of the Enterobacteriaceae saliva provides an ideal breeding ground for
which may cause sepsis, meningitis, or disease-causing micro-organisms.
necrotizing enterocolitis among infected ▘▘ Infant formula that is removed from
infants. According to the FDA, “clusters of refrigeration should be used within 1 hour or
E. sakazakii infections have been reported discarded.39
in a variety of locations over the past ▘▘ Before reusing any bottles or their parts, they
several years among infants fed milk-based should be cleaned and sanitized as described
powdered infant formula products from under “Sterilizing Water and Bottles” on page
various manufacturers…The literature 91.
suggests that premature infants and those
with underlying medical conditions may be Traveling With Infant Formula
at highest risk for developing E. sakazakii When traveling, caregivers can take along a can
infection.”38 of powdered infant formula and separate water
in clean bottles (or sterilized bottles for infants
under 3 months old). Then, the infant formula
can be mixed up to make single bottles when
Storing Infant Formula needed. Alternately, single servings of ready-
Prepared infant formula is a highly perishable to-feed infant formula can be used. It is not
food that must be stored properly for safe recommended to travel with bottles of prepared
consumption. infant formula held at room temperature.
The following guidelines are recommended to
prevent spoilage of infant formula:

92 INFANT NUTRITION AND FEEDING

Figure 6a:
Preparation Checklist for Standard Ready-to-Feed Iron-Fortified
Infant Formula (using glass or hard plastic bottles)

1 Wash your hands, arms, and 7 Pour the amount of ready-to-

under your nails, very well feed formula for one feeding
with soap and warm water. into a clean bottle. Do not
Rinse thoroughly. Clean and add water or any other liquid.
sanitize your workspace.

2 Wash bottles and nipples,

8 Attach nipple and cap and
using bottle and nipple SHAKE WELL. Feed prepared
brushes, and caps, rings, formula immediately.
and preparation utensils
in hot soapy water before
using. Rinse thoroughly.

9 If more than one bottle is

3 Squeeze clean water prepared, put a clean nipple
through nipple holes to be right side up on each bottle
sure they are open. and cover with a nipple cap.
Baby Jane Baby Tony Label each bottle with the
8/12/98
2:30 p.m.
8/11/98
4:30 p.m. baby’s name and the date
and time that it
was prepared.

4 Put the bottles, nipples, caps, and rings in a pot 10 Refrigerate until feeding time. Use within
and cover with water. Put the pot over heat, bring 48 hours. Do not leave formula
to a boil, and boil for 5 minutes. Remove at room temperature. To warm
with sanitized tongs, allow the items to bottle, hold under running
cool, and air dry. warm water. Do not
microwave bottles. If
formula is left in the can,
aby Gabe
cover and refrigerate open
B
8/14/98
B
4:30 p.m. aby Tony
Baby Jose
Baby Jane
8/2/98
8:30 a.m. 8/12/98
10:30 a.m.
can until needed. Use
Baby Eva
within 48 hours.
8/12/98
2:30 p.m. 8/19/98

5
12:00 p.m.

Wash the top of the can

with soap and water and
rinse well to remove dirt.
Wash the can opener with
soap and hot water.

11 Throw out unused formula

left in bottle after feeding
or which has been
6 SHAKE CAN WELL and then
unrefrigerated for 1 hour
or more. Store unopened
open the can. cans in a cool, dry indoor
pantry shelf. Use before the
expiration date.

INFANT NUTRITION AND FEEDING 93

 Figure 6b:
Preparation Checklist for Standard Liquid Concentrated Iron-Fortified Infant Formula
(using glass or hard plastic bottles)
1 Wash your hands, arms, and 7 SHAKE CAN WELL and then
under your nails, very well open the can.
with soap and warm water.
Rinse thoroughly. Clean and
sanitize your workspace.

Wash bottles and nipples, 8 Pour needed amount of

formula into a clean bottle
2 using bottle and nipple
brushes, and caps, rings, and
using ounce markings to
measure formula and add
preparation utensils in hot an equal amount of cooled
soapy water before using. boiled water. Thus, if 4 oz. of
Rinse thoroughly. formula is poured into the
bottle, 4 ounces of water
should also be added.

3 Squeeze clean water through 9 Attach nipple and ring to

the bottle and SHAKE WELL.
nipple holes to be sure they Feed prepared formula
are open. immediately. If formula is
left in the can, cover and
refrigerate can until needed.
Use within 48 hours.

4 Put the bottles, nipples, caps, 10 If more than one bottle is

prepared, put a clean nipple
and rings in a pot and cover
with water. Put the pot over right side up on each bottle
heat, bring to a boil, and boil and cover with a nipple
for 5 minutes. Remove with
Baby Jane
8/12/98
Baby Tony
8/11/98 cap. Label each bottle with
sanitized tongs, allow the
2:30 p.m. 4:30 p.m.
the baby’s name and the
items to cool, and air dry. date and time that it was
prepared.

5 For formula, bring water to a very bubbly boil. Keep boiling

it for a minute or two, then let it cool. Use this water to
Refrigerate until feeding
time. Use within 48 hours.
mix the formula. Use water from a source approved by Do not leave formula at
the local health department. If tap water is Baby Gabe room temperature. To
used for boiling, collect only cold tap water 8/14/98
4:30 p.m. Baby Tony
8/2/98 Baby Jose warm bottle, hold under
allowed to run for Baby Jane
8/12/98
8:30 a.m.
Baby Eva
8/12/98
10:30 a.m.
running warm water.
2 minutes first. 2:30 p.m. 8/19/98

Do not microwave
12:00 p.m.

bottles.

6 Wash the top of the can with

soap and water and rinse well
12 Throw out unused formula left
in bottle after feeding or which
to remove dirt. Wash the can has been unrefrigerated for 1
opener with soap and hot hour or more. Store unopened
water. cans in a cool, dry indoor
pantry shelf. Use before the
expiration date.

94 INFANT NUTRITION AND FEEDING

Figure 6c:
Preparation Checklist for Standard Powdered Iron-Fortified
Infant Formula (using glass or hard plastic bottles)

1 Wash your hands, arms, and under your 8 Attach nipple and ring to the bottle and
nails, very well with soap and warm
SHAKE WELL. Feed prepared formula
water. Rinse thoroughly. Clean and
immediately.
sanitize your workspace.

2 Wash bottles and nipples, using bottle 9 If more than one bottle is prepared,
and nipple brushes, and caps, rings, and put a clean nipple right side up on
preparation utensils in hot soapy water each bottle and cover with a nipple
before using. Rinse thoroughly. Baby Jane Baby Tony cap. Label each bottle with the baby’s
name and the date and time that it was
8/12/98 8/11/98
2:30 p.m. 4:30 p.m.

prepared.

3 Squeeze clean water through nipple

holes to be sure they are open.
10 Refrigerate until feeding time.
Use within 24 hours. Do not leave
formula at room temperature.
4 Put the bottles, nipples, caps, and rings Baby Gabe
To warm bottle, hold under
running warm water. Do not
in a pot and cover with water. Put the 8/14/98
4:30 p.m. Baby Tony

microwave bottles.
8/2/98 Baby Jose
8/12/98
pot over heat, bring to a boil, and boil
Baby Jane 8:30 a.m.
8/12/98 Baby Eva 10:30 a.m.
2:30 p.m. 8/19/98

for 5 minutes. Remove with sanitized

12:00 p.m.

tongs, allow the items to cool, and air

dry.

5 For formula, bring water to a very bubbly boil.

Keep it boiling for a minute or two, then let it cool.
11 Throw out unused formula left in
bottle after feeding or which has been
Use this water to mix the formula. Use water from unrefrigerated for 1 hour or more.
a source approved by the local health
department. If tap water is used for
boiling, collect only cold tap water
allowed to run for 2 minutes first.

6 Remove plastic lid; wash lid with soap 12 Make sure that no water or other liquid
and clean water and dry it. Write date gets into the can of powder. Cover
on outside of plastic lid. Wash the top of opened can tightly and store in a cool
the can with soap and water, rinse well, dry place (not in the refrigerator). Use
and dry. Wash the can opener with soap within 4 weeks after opening to assure
and hot water. Open the can and remove freshness.
scoop. Make sure that the scoop is
totally dry before scooping out powdered
formula. Only use the scoop that comes
with the formula can.

13 To be used again, the scoop should be

washed with soap and hot water, rinsed
thoroughly, and allowed to air dry.
7 For each 2 ounces of cooled boiled water
added to a clean bottle, carefully add 1
When making formula again, the scoop
should be totally dry before using it
level scoop of powdered formula. Thus, to scoop powder out of the can. Store
if 8 ounces of water is poured unopened cans in a cool, dry indoor
into the bottle, 4 level scoops of pantry shelf. Use before the expiration
formula should be added. date.

INFANT NUTRITION AND FEEDING 95

 Warming Infant Formula ▘▘ Follow instructions for properly sanitizing
The following guidelines are recommended to warm bottles and water (see pages 91 and Figure 6c,
refrigerated infant formula: page 95).
▘▘ Prepare one bottle at a time, if powdered
▘▘ For infants who prefer a warmed bottle, warm infant formula is used; fill it with the
the bottle immediately before serving. approximate amount of infant formula that
▘▘ A safe method of warming a bottle is to hold the infant can consume at one feeding. Make
it under running warm tap water. Shake the sure to scoop the powder out of the can using
bottle before testing the temperature. Always a clean, dry scoop when preparing infant
test the temperature before feeding to make formula. Make sure no liquid enters the can
sure that it is not too hot or cold (test by because it will facilitate the growth of bacteria
squirting a couple of drops onto the back of and spoilage of the infant formula. See Figure
your hand). 6c, page 95, for more detailed instructions.
▘▘ Warm only as much infant formula as you ▘▘ Use infant formula immediately after it
think will be needed for a feeding. is prepared or after a ready-to-feed can or
▘▘ Never use a microwave oven to warm infant nursette is opened.
formula because this practice is dangerous. ▘▘ Discard any infant formula left over after a
Liquid in a bottle may become very hot when feeding or infant formula that has been sitting
heated in a microwave oven and remain hot at room temperature for more than 1 hour.39
afterwards even though the bottle feels cool.
Infants have been seriously burned while If there is no access to a stove or dishwasher:
being fed liquids warmed in microwave ovens.
Covered bottles, especially vacuum-sealed ▘▘ Nursette bottles are the ideal packaging of
and metal-capped bottles of ready-to-feed infant formula to use for infants less than
infant formula, can explode when heated in a 3 months old when a stove or a diswasher
microwave oven. (for sterilizing bottles and their parts and
boiling the water) is not available.
Guidelines for Using Infant Formula
When There Is Limited Access to Common Guidelines for Using Infant Formula After a
Kitchen Appliances Natural Disaster or Power Outage
The following guidelines regarding use of The Centers for Disease Control and Prevention
standard milk- and soy-based infant formulas are (CDC) recommends the following after a natural
recommended for caregivers with limited access disaster or power outage:40
to a refrigerator or stove (or when their own
appliances are not functioning properly; e.g., a ▘▘ Use ready-to-feed infant formula if possible.
caregiver’s refrigerator is not working and not ▘▘ Use bottled water to prepare powdered or
keeping foods at or below 40 degrees Fahrenheit). liquid concentrated infant formula.
▘▘ If bottled water is not available, use boiled
If there is no access to a refrigerator: water. Use treated water (treated with chlorine
or iodine to disinfect it per manufacturers
▘▘ Use powdered infant formula instead of directions) to prepare infant formula only if
32 ounce ready-to-feed cans or 13 ounce bottled or boiled water is not available.
concentrated cans. The latter two are designed
for the preparation of multiple bottles of
infant formula at one time and require use of
a refrigerator for storage. Alternately, ready-
to-feed infant formula in 8 ounce servings can
be used.

96 INFANT NUTRITION AND FEEDING

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100 INFANT NUTRITION AND FEEDING