Formula feedings and breast milk substitutes are used for infants whose mothers cannot or choose not to breastfeed. There are acceptable medical reasons for using breast milk substitutes, such as galactosemia or very low birth weight. Cow's milk formula is modified from cow's milk to make its mineral content and protein more similar to human breast milk. Soy formulas provide an alternative for cow's milk protein intolerance. By around 6 months, complementary foods are needed to provide additional nutrients beyond what is in breast milk alone. Food introductions should be gradual and avoid potential allergens initially.

1. FORMULA FEEDING/
ARTIFICIAL FEEDING/
BREAST MILK SUBSTITUTES

2. INTRODUCTION
Formula feedings are used as substitutes for breast milk for
infants whose mothers choose not to or cannot breastfeed or
as supplements for breastfeeding.
 Formula-fed infants often gain weight more rapidly than breastfed
infants, especially after the first 3 to 4 months of life.
 But there is no evidence that any one of the many brands is
superior to any other.

3. ACCEPTABLE MEDICAL REASONS FOR USE
OF BREAST MILK SUBTITUTES
 Malaysian Dietary Guideline by Ministry Of Health (Updated 2010) -
http://www.moh.gov.my/images/gallery/Garispanduan/diet/introduction.pdf

4. Infants
Can’t receive breast milk or any
other milk except specialized
formula:
1.Classis galactosemia: galactose-free formula
2.Maple syrup urine disease: formula free of
leucine, isoleucine and valine
3. Phenylketonuria: phenylketonuria-
freeformula
Need substitutes in addition to breast
milk for a limited period:
1. Very low birth weight infants - less than 1500g
2. Very preterm infants- less than 32 weeks
gestational age
3. Newborn infants who are at risk of hypoglycaemia
4. Infants younger than six months, in spite of frequent
and effective suckling and in the absence of illness,
show persistent downward growth curve
Maternal
Need to avoid breastfeeding:
HIV infection: if replacement feeding is acceptable,
feasible, affordable and safe (AFASS)
Need to avoid breastfeeding temporarily:
1.Severe illness that prevent a mother from caring for her infant, for example sepsis
2.Herpes simplex virus type 1 (HSV-1): direct contact between lesions on the mother’s
breast and the infant’s mouth should be avoided until all active lesions have resolved.
Maternal medication:
• Sedating psychotherapeutic drugs, anti-epileptic drugs and opioids may cause side
effects such as drowsiness and respiratory depression and are better avoided if a safer
alternative is available.
• Radioactive iodine-131 is better avoided given that safer alternatives are available – a
mother can resume breastfeeding about two months after receiving this substance
• Excessive use of topical iodine can result in thyroid suppression or electrolyte
abnormalities in the breastfed infant and should be avoided.
• Cyctotoxic chemotherapy requires mother stops breastfeeding during theraphy

5. Mother who can continue breastfeeding although health problems may be of
concern:
 Breast abscess: breastfeeding should continue on the unaffected breast;
feeding from the affected breast can resume once treatment has started
 Hepatitis B: Infants should be given hepatitis B vaccine, within the first 48
hours or as soon as possible thereafter
 Hepatitis C
 Mastitis: If breastfeeding is very painful, milk must be removed by expression
to prevent progression of the condition
 Tuberculosis: Mother and baby should be managed according to national
tuberculosis guidelines
 Substance use: Mother should be encouraged not to use these substances and
given opportunities and support to abstain.

6. Pasteurised Cow’s Milk
 Many babies have been on ordinary pasteurised or sterilized cow’s milk.
 Pasteurised cow’s milk may be given from 1 year of age
Disadvantages of unmodified cow’s milk;
1. Contain more protein  More curd protein or casein, and these thick curds being
less easy to digest have caused bowel obstruction.
2. Contain more fat and phosphate  Particularly from 5 to 15 days of age, this
may lead to hypocalcaemia with subsequent fitting.
3. Relatively high sodium  Leads to hypernatraemia, which may cause fits and
brain damage
4. Some infants are allergic to cow’s milk protein  React to feeding with perioral
rashes and oedema or by vomiting or passing frequent loose stools.
5. Deficient in vitamins A, C and D and iron.

7. COW’S MILK FORMULA
Cow milks currently available have been modified to make
their mineral content and renal solute load comparable
with that of mature human milk.
 Cow’s milk formula are composed of
1. Skimmed Cow’s Milk with electrolyte-depleted whey or
casein (protein)
2. Fat  mixture of vegetable oils, commonly including
soy, palm, coconut, corn.
3. Carbohydrate  Lactose (lactose-free cow’s milk-based
formulas are available.

8. Cow’s Milk-Based Formulas
 Unmodified cow’s milk is unsuitable for feeding in infancy
 Contains too much protein and electrolytes and inadequate iron and vitamins.
 No vitamin or mineral supplements are needed with such formulas.
 Other than possibly fluoride after 6 months
 The alternative to human milk is iron-fortified formula which permits
adequate growth of most infants
Human milk fortifiers with breast milk 
1. To boost the caloric and nutrient content
2. For use with premature infants when adequate growth cannot be achieved with human milk
alone.

9. Soy Formulas
 Soy protein-based formulas provide a safe alternative to
cow’s milk-based formulas when intolerance occurs from
immune reactions to cow’s milk proteins.
 However, soy protein formulas do not prevent the
development of allergic disorders in later life.
 A soy formula should not be used below 6 months of age
as it has a high aluminium content and contains
phytoestrogens (plant substances that mimic the effects
of endogenous oestrogens).

10. Comparison Of Human Milk, Cow’s Milk
and Infant Formula (Per 100 ml)
Mature Breast
Milk
Cow’s Milk Infant Formula
(Modified cow’s
milk)
Energy (kcal) 62 67 60-65
Protein (g) 1.3 3.5 1.5-1.9
Carbohydrate (g) 6.7 4.9 7.0-8.6
Casein:whey 40:60 63:37 40:60 to 63:37
Fat (g) 3.0 3.6 2.6-3.8
Sodium (mmol) 0.65 2.3 0.65-1.1
Calcium (mmol) 0.88 3.0 0.88-2.1
Phosphorus (mmol) 0.46 3.2 0.9-1.8
Iron (µmol) 1.36 0.9 8-12.5

11. Infant Feedings & Standard & Specialized Formulas
Formula Category Example Formulas Features and Typical Uses
Human milk • Gold standard
• Expressed milk can be delivered by
gavage or nasogastric tube
Cow’s milk-based
(with lactose)
Enfamil
Similac
Carnation Good Strat
Standard substitute for breast milk
Cow’s milk-based
(without lactose)
LactoFree
Similac Lactose Free
Useful for transient lactase deficiency
or lactose intolerance
Soy protein-
based/lactose-free
ProSobee
Isomil
• Alternative to milk-protein based
formulas
• Not recommended for premature
infants
Premature formula;
cow’s milk (reduced
lactose)
Similac Special Care
Enfamil Premature
• Indicated for premature and LBW
infants
• Fat is 50% MCT, higher in many
micronutrients

12. Why Are Bottle Feeding and Milk Powder
Not Recommended?
 Infant formula is easily contaminated
 In case of wrong infant formula preparation, child will become malnourished
and affect the growth and development
 Weaker bond between the mother and baby
 Child susceptible to:
A. More frequent infections – cough, common cold, fever and diarrhea
B. Constipation – infant formula is not as easy digested compared with
breast milk
C. Obesity – because of overfeeding

13. Why Are Bottle Feeding and Milk Powder
Not Recommended?
For mothers:
More difficult to lose weight after delivery
Higher risk of breast and ovary cancer
Poor spacing if not on contraception

14.  By approximately 6 months, complementary feeding of semisolid foods is
suggested.
 After 6 months of age, breast milk becomes increasingly nutritionally
inadequate as a sole feed, as it does not provide sufficient energy, vitamin
or iron.
 By this age, an exclusively breastfed infant requires additional sources of
several nutrients, including protein, iron and zinc.
Although the growth rate of the infant is decreasing, energy needs for
activity increase.
COMPLEMENTARY FOODS AND WEANING

15. COMPLEMENTARY FOODS AND WEANING
It is done gradually, initially with small quantities of pureed
fruit, root vegetables, or rice.
 To help identify possible allergies or food intolerances that may
arise when new foods are added to the diet, single-grain cereals
(rice, oatmeal, barley) are recommended as starting cereals.
 Foods with high allergic potential that should be avoided during
infancy, (especially for infants with a strong family history of food
allergy)
 include fish, peanuts, tree nuts, dairy products, and eggs.

16. a. If juice is given, it should be started only
after 6 month of age, be given in a cup (as
opposed to a bottle), and limited to 4 oz
daily.
b.Foods high in salt and sugar should also be
avoided
c. Honey (risk of infant botulism) should not
be given before 1 year of age.

17. Reference
 Paediatrics Lecture Notes (9th edition) by Simon J.Newell and Jonathan
C.Darling
 Essential Paediatrics (4th edition) by David Hull and Derek I. Johnson
 Malaysian Dietary Guideline by Ministry Of Health (Updated 2010) -
http://www.moh.gov.my/images/gallery/Garispanduan/diet/introduction.pdf

18. THANK YOU