ReferencesAzevedo, Ana Regina Ramos, Alves, Valdecyr Herdy, Souz.docx

References
Azevedo, Ana Regina Ramos, Alves, Valdecyr Herdy, Souza,
Rosangela de Mattos Pereira de, Rodrigues, Diego Pereira,
Branco, Maria Bertilla Lutterbach Riker, & Cruz, Amanda
Fernandes do Nascimento da. (2015). Clinical management of
breastfeeding: knowledge of nurses. Escola Anna Nery, 19(3),
439-445.
Fonseca-Machado, M. D., Monteiro, J. C., Viduedo, A. D.,
Haas, V. J., Alves, L. C., & Gomes-Sponholz, F. (2013). The
paradox of nursing practice on breastfeeding promotion: what
they say and what they do. Journal of Nursing Education and
Practice,3(11). doi:10.5430/jnep.v3n11p141
Jiang, H., Li, M., Yang, D., Wen, M., Hunter, C., He, G. &
Qian, X. (2012). Awareness, Intention, and Needs Regarding
Breastfeeding: Findings from First-Time Mothers in Shanghai,
China. Breastfeed Med, 7(6), 526–534. doi:
10.1089/bfm.2011.0124 Comment by Author: Capitalization
formatting error
Kozhimannil, K.B., Jou, J., Attanasio L.B., Joarnt, L.K. &
McGovern, P. (2014) Medically complex pregnancies and early
breastfeeding behaviors: A retrospective analysis. PLoS
ONE.9:279. doi: 10.1371/journal.pone.0104820.[Cross Ref]
Martin, C.R., Ling, P. & Blackburn, G.L. (2016). Review of
Infant Feeding: Key Features of Breast Milk and Infant
Formula. Nutrients. 8(5): 279. doi:10.3390/nu8050279
Comment by Author: Capitalization formatting error
Motee, A., Ramasawmy, D., Pugo-Gunsam, P. & Jeewon, R.
(2013). An Assessment of the Breastfeeding Practices and
Infant Feeding Pattern among Mothers in Mauritius. J Nutr
Metab. 243852. doi: 10.1155/2013/243852 Comment by
Author: Capitalization formatting error
Rosangela De Mattos Pereira De Souza, Alves, V. H.,
Rodrigues, D. P., Branco, M. B., Lopes, F. D., & Maria Teresa
Rosa De Souza Barbosa. (2015). Nursing strategies in the

clinical management of breastfeeding: a descriptive and
exploratory study. Online Brazilian Journal of Nursing,14(1).
doi:10.5935/1676-4285.20154612
Vijayalakshmi, P., Susheela, T. & Mythili, D. (2015).
Knowledge, attitudes, and breastfeeding practices of postnatal
mothers: A cross-sectional survey. Int J Health Sci (Qassim).
9(4): 364–374.
Running Head: LITERATURE REVIEW
1
LITERATURE REVIEW
7
Literature Review
Daysha Polk
Grand Canyon University NRS 490
January 21st, 2018

Literature Review
Introduction Comment by Author: Remember, you do not
need to say Introduction, just start the first paragraph AS the
introduction as it is understood to be ust that.
The PICOT’s objective was to discover whether nurses who
possessed skills and knowledge in breastfeeding could
encourage and effectively increase the practice of breastfeeding
among post-partum women relative to those nurses without
knowledge and skills in breastfeeding. This literature review
builds on this object; it looks at current research and studies
conducted that try to pursue similar aims. Specifically, the
literature review endeavors to determine the known and the
unknown relative to the PICOT. The work will make a
comparison of research questions from multitude sources versus
those outlined in the PICOT. Further, the work will compare
the sample population used in researches done in other works.
Limitations that occurred in other studies relative to those in the
PICOT will be underlined. Comment by Author: Incorrect
punctuation. Use a comma after the word object and join the
two clauses with the conjunction and. Comment by Author:
This should be from a multitude of sources Comment by
Author: Where are literature sources outlined in your PICOT
question? Comment by Author: There are no underlined sources
in this paper, I think you need a different word here.
Comparison of Research Questions Comment by Author:
Heading should be in bold Comment by Author: You were
supposed to compare the research questions of the articles, not
the research questions of the article to your PICOT.
The research question in the PICOT was ‘In mothers who
choose breastfeeding, will education by nurses who possess
knowledge within the practice, compared to nurses without this
knowledge increase the practice of breastfeeding at time of
patient discharge?’. The above research question compares to
Azevedo et al.’s (2015) whose research objective was to assess

the knowledge possessed by nursing professionals regarding
clinical management of breastfeeding to ascertain the
advantages of breastfeeding on the health of women and
children. In a study by Vijayalakshmi, Susheela, & Mythili
(2015), the aim of the research was to study the attitude and
knowledge towards infant feeding and breastfeeding practices
among Indian mothers. Similar to Vijayalakshmi, Susheela, &
Mythili (2015), Jiang (2012) explored the guidelines and
information of breastfeeding in China by WHO. Kozhimannil et
al. (2014) measured the relationship between a complex
pregnancy, early infant breastfeeding, and the available hospital
support and intentions. Rosangela et al.’s (2015) objective was
to determine the approaches used by nursing professionals
concerning the clinical administration of breastfeeding and
further conduct analysis on the tactics used by nurses in
carrying out breastfeeding clinical management. Like
Rosangela et al. (2015), Martin et al.’s (2016) study strived to
apprise the dietary knowledge and facts about infant formula
and breast milk from birth to age of 12 months during which
substitute of nutrients was necessary. Motee et al.’s (2013)
research was carried out in Mauritius where the authors’
objective was to underline enough evidence to recommend
exclusive breastfeeding of infants continuously for 6 months.
In the study by Fonseca-Machado et al. (2013), the objective
was to underline breastfeeding-related performance of
professionals in nursing from a perspective of wellness
promotion.
Comparison of Sample Populations Comment by Author:
Heading should be in bold
Azevedo et al. (2015) utilized a sample population of 59, which
was almost half those enrolled by Vijayalakshmi, Susheela, and
Mythili (2015). In Vijayalakshmi, Susheela, & Mythili (2015),
138 mothers were enrolled in the study of which only 122 were
included in the final study population. In the study by Jiang
(2012), a total of 653 women at between 5 and 22 gestational
weeks were recruited into the sample population. The sample

population in Kozhimannil et al.’s (2014) study, comprised of
2400 women who gave birth at an American hospital. Rosangela
et al.’s (2015) sample population was 107 nurses working at an
obstetric center in Rio De Janeiro, Brazil. Motee et al. (2013)
utilized sample population comprised of 500 mothers aged
between 18 and 45 years.
Comparison of the Limitations of the Studies Comment by
Author: Heading should be in bold
In the study by Azevedo et al. (2015), the absence of
audiovisual materials in health care units presented a limitation
in the study as these facilitate counseling of breastfeeding
mother. In Vijayalakshmi, Susheela, & Mythili’s (2015) study,
the main limitation arose from the fact that all participants were
at the six months postpartum. The sample size was also tiny
making it difficult to generalize the findings. The study by
Jiang (2012) also had its limitations. Firstly, since the design
of the study was cross-sectional, no fundamental relationships
could be determined assertively relative to the conclusions in
the study. Secondly, the study consisted of a population sample
of highly educated mothers. As such, the study had a selection
bias which limited its generalization. Additionally, the study
did not analyze whether the awareness of breastfeeding could be
converted to future breastfeeding.
Conclusion Comment by Author: Heading should be in bold
Current literature indicates that breastfeeding does indeed offer
several advantages to both the mother and the infant. On
average, studies reviewed suggested that about 80% of the
infants were breastfed exclusively for the first six months of
their lives. Studies reviewed additionally indicate that after the
first six months of exclusive breastfeeding, most mothers tended
to wean their babies. Effectively, the literature reviewed
denoted that the level of breastfeeding was fairly high.
Nevertheless, in some countries, there was a low awareness on
how to breastfeed effectively especially among first-time

mothers. An emphasis on the health advantages of
breastfeeding and which comply with those espoused by WHO
should thus be encouraged if higher levels of breastfeeding
prevalence are to be achieved. Further, specific apprehensions
regarding difficulties mothers encounter during breastfeeding
must be addressed. Difficulties such as discrimination against
breastfeeding in public, and no designated breastfeeding areas.
There is also need to review the national course of action on
maternal leave. Further, places of work must be redesigned
such that they are conducive for breastfeeding. Comment by
Author: Sentence is fragmented and incomplete Comment by
Author: This should be a need
References
Azevedo, Ana Regina Ramos, Alves, Valdecyr Herdy, Souza,
Rosangela de Mattos Pereira de, Rodrigues, Diego Pereira,

Branco, Maria Bertilla Lutterbach Riker, & Cruz, Amanda
Fernandes do Nascimento da. (2015). Clinical management of
breastfeeding: knowledge of nurses. Escola Anna Nery, 19(3),
439-445.
Fonseca-Machado, M. D., Monteiro, J. C., Viduedo, A. D.,
Haas, V. J., Alves, L. C., & Gomes-Sponholz, F. (2013). The
paradox of nursing practice on breastfeeding promotion: what
they say and what they do. Journal of Nursing Education and
Practice,3(11). doi:10.5430/jnep.v3n11p141
Jiang, H., Li, M., Yang, D., Wen, M., Hunter, C., He, G. &
Qian, X. (2012). Awareness, Intention, and Needs Regarding
Breastfeeding: Findings from First-Time Mothers in Shanghai,
China. Breastfeed Med, 7(6), 526–534. doi:
10.1089/bfm.2011.0124 Comment by Author: Capitalization
formatting error
Kozhimannil, K.B., Jou, J., Attanasio L.B., Joarnt, L.K. &
McGovern, P. (2014) Medically complex pregnancies and early
breastfeeding behaviors: A retrospective analysis. PLoS
ONE.9:279. doi: 10.1371/journal.pone.0104820.[Cross Ref]
Martin, C.R., Ling, P. & Blackburn, G.L. (2016). Review of
Infant Feeding: Key Features of Breast Milk and Infant
Formula. Nutrients. 8(5): 279. doi:10.3390/nu8050279
Comment by Author: Capitalization formatting error
Motee, A., Ramasawmy, D., Pugo-Gunsam, P. & Jeewon, R.
(2013). An Assessment of the Breastfeeding Practices and
Infant Feeding Pattern among Mothers in Mauritius. J Nutr
Metab. 243852. doi: 10.1155/2013/243852 Comment by
Author: Capitalization formatting error
Rosangela De Mattos Pereira De Souza, Alves, V. H.,
Rodrigues, D. P., Branco, M. B., Lopes, F. D., & Maria Teresa
Rosa De Souza Barbosa. (2015). Nursing strategies in the
clinical management of breastfeeding: a descriptive and
exploratory study. Online Brazilian Journal of Nursing,14(1).
doi:10.5935/1676-4285.20154612
Vijayalakshmi, P., Susheela, T. & Mythili, D. (2015).
Knowledge, attitudes, and breastfeeding practices of postnatal

mothers: A cross-sectional survey. Int J Health Sci (Qassim).
9(4): 364–374.
Hindawi Publishing Corporation
Journal of Nutrition and Metabolism
Volume 2013, Article ID 243852, 8 pages
http://dx.doi.org/10.1155/2013/243852
Research Article
An Assessment of the Breastfeeding Practices and
Infant Feeding Pattern among Mothers in Mauritius
Ashmika Motee,1 Deerajen Ramasawmy,2 Prity Pugo-Gunsam,3
and Rajesh Jeewon1
1 Department of Health Science, Faculty of Science, University
of Mauritius, Reduit, Mauritius
2 Faculty of Law and Management, University of Mauritius,
Reduit, Mauritius
3 Department of Bioscience, Faculty of Science, University of
Mauritius, Reduit, Mauritius
Correspondence should be addressed to Rajesh Jeewon;
[email protected]
Received 30 March 2013; Revised 8 June 2013; Accepted 9 June
2013
Academic Editor: Johannes B. van Goudoever
Copyright © 2013 Ashmika Motee et al.This is an open access
article distributed under the Creative CommonsAttribution
License,

which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Proper breastfeeding practices are effective ways for reducing
childhoodmorbidity andmortality.While manymothers
understand
the importance of breastfeeding, others are less knowledgeable
on the benefits of breastfeeding and weaning. The aim in here is
to
assess breastfeeding pattern, infant formula feeding pattern, and
weaning introduction in Mauritius and to investigate the factors
that influence infant nutrition. 500 mothers were interviewed
using a questionnaire which was designed to elicit information
on
infant feeding practices. Statistical analyses were done using
SPSS (version 13.0), whereby chi-square tests were used to
evaluate
relationships between different selected variables. The
prevalence of breastfeeding practice in Mauritius has risen from
72% in 1991
to 93.4% as found in this study, while only 17.9% breastfed
their children exclusively for the first 6 months, and themean
duration of
EBF (exclusive breastfeeding) is 2.10 months. Complementary
feeding was more commonly initiated around 4–6 months
(75.2%).
Despite the fact that 60.6% of mothers initiate breastfeeding
and 26.1% of mothers are found to breastfeed up to 2 years, the
practice
of EBF for the first 6 months is low (17.9%). Factors found to
influence infant feeding practices are type of delivery, parity,
alcohol
consumption, occupation, education, and breast problems.
1. Introduction

Adequate nutrition during infancy and early childhood is
essential to ensure the growth, health, and development of
children to their full potential [1]. It has been recognized
worldwide that breastfeeding is beneficial for both themother
and child, as breast milk is considered the best source of
nutrition for an infant [2].
The World Health Organization (WHO) recommends
that infants be exclusively breastfed for the first six months,
followed by breastfeeding along with complementary foods
for up to two years of age or beyond [3]. Exclusive breastfeed-
ing can be defined as a practice whereby the infants receive
only breast milk and not even water, other liquids, tea, herbal
preparations, or food during the first six months of life, with
the exception of vitamins,mineral supplements, ormedicines
[4].Themajor advantage of exclusive breastfeeding from 4 to
6 months includes reduced morbidity due to gastrointestinal
infection [5]. However, many researchers are questioning
if there is sufficient evidence to confidently recommend
exclusive breastfeeding for 6 months for infants in developed
countries due to the fact that breast milk may not meet the
full energy requirements of the average infant at 6 months of
age [6]. Nevertheless, there is scanty data that give estimation
about the proportion of exclusively breastfed infants at risk of
specific nutritional deficiencies.
Several studies have shown that mothers find it difficult
to meet personal goals and to adhere to the expert recom-
mendations for continued and exclusive breastfeeding despite
increased rate of initiation [7]. Some of the major factors
that affect exclusivity and duration of breastfeeding include
breast problems such as sore nipples or mother’s perceptions
that she is producing inadequate milk [4, 8, 9]; societal
barriers such as employment and length of maternity leave
[9]; inadequate breastfeeding knowledge [8]; lack of familial

and societal support; lack of guidance and encouragement
from health care professionals [2, 9]. These factors in turn
promote the early use of breast milk substitute.
2 Journal of Nutrition and Metabolism
When breast milk or infant formula no longer supplies
infants with required energy and nutrients to sustain normal
growth and optimal health and development, complementary
feeding should be introduced [10]. According to the WHO
recommendations, the appropriate age at which solids should
be introduced is around 6 months [11] owing to the immatu-
rity of the gastrointestinal tract and the renal system as well
as on the neurophysiological status of the infant [12]. Factors
that influence the weaning process include infant feeding
problems such as refusal to eat, colic, and vomiting among
others [13]. These factors represent challenges for mothers
and in turn may either directly or indirectly influence the
feeding pattern. Hence, understanding the factors affecting
infant nutrition inMauritius can help in developing strategies
to promote breastfeeding and overcoming problems faced by
mothers and children.
Predictors of breastfeeding and weaning practices vary
between and within countries. Urban or rural difference, age,
breast problems, societal barriers, insufficient support from
family, knowledge about good breastfeeding practices, mode
of delivery, health system practices, and community beliefs
have all been found to influence breastfeeding in different
areas of developing countries [4, 8, 9]. Information on the
prevalence and factors influencing infant feeding practices
is limited in Mauritius and dates back to 1996 [14]. This
present study aims to determine infant feeding pattern and
its predictors among Mauritian mothers with the following

objectives: (1) to elucidate breastfeeding practices, in terms
of initiation, exclusivity, and termination, and the factors
influencing them; (2) to determine the time when weaning
starts, the challengesmet bymothers, and the type of weaning
adopted.
2. Methods
2.1. Study Design and Data Collection. A survey-based study
was conducted on a group of 500 mothers in 2011 (from
August 2011 to January 2012) to elicit information about
infant feeding practices by the use of a properly designed
questionnaire given to mothers in Area Health Centres
(AHCs) and Community Health Centres (CHCs) both in
rural and urban areas of the island. Research has been granted
approval by the University Research Ethics Committee, and
prior consents were obtained from all participants.
2.1.1. Questionnaire Design. The questionnaire consisted pri-
marily of a closed format including dichotomous questions
(e.g., yes/no) and multiple response for ease of completion
and analysis. The resulting questionnaire consisted of 46
close-ended questions, all categorized in 4 sections as follows.
(i) Section A: the first section elicited information on
the participants in terms of age, place of residence,
marital status, type of family, parity, lifestyle fac-
tors (smoking and alcohol consumption), education,
occupation, income, religion, and age of baby.
(ii) Section B: this section was sought to understand the
main factors encouragingmothers to breastfeed, their
awareness on colostrum, the practice of exclusive
breastfeeding, the termination of breastfeeding, as
well as themain problems encountered during breast-

feeding.
(iii) Section C: multiple response questions were mainly
used in this section to determine more information
on the uptake of infant formula.
(iv) Section D: it consists of dichotomous and multiple
response questions to find out more details on the
weaning process.
2.1.2. Subjects. A sample of the female population consisting
of mothers aged 18–45 years was considered since they are
adults and are mature enough to participate in the study. In
addition, the sampling was based on the following inclusion
and exclusion criteria.
(i) Inclusion Criteria. Mothers who already delivered their
baby and those with a child who is below 5 years old were
considered in this survey.
(ii) Exclusion Criteria. Pregnant women or mothers having a
child with any kind of malformations. Mothers with children
who are above 5 years old.
2.2. Statistical Analysis. Questionnaire responses were col-
lected and analysed using SPSS (version 13.0). Chi-square
tests were used to evaluate relationships between different
selected variables (e.g., to find association between breast-
feeding initiation and mode of delivery; association between
breastfeeding duration and parity, alcohol consumption,
education, and occupation of respondents).The critical value
for significance was set at � < 0.05 for all analyses.
3. Results
3.1. Breastfeeding Practices. A total of 500 respondents com-

pleted the questionnaire of which 216 were from urban
areas and 284 were from rural areas, with 53% mothers
having completed at least secondary level education. Equal
representation of mothers from rural and urban areas was
achieved through a quota sampling technique based on place
of residence [15].The age of the participants ranged from 18 to
45 years old whereby the majority of the participants (38.4%)
belonged to the age group 25–31 years andmost of themwere
married (92.6%) living in a nuclear family (58.6%). A total of
93.4% of the mothers acknowledged that they breastfed their
infants of which 64.7% stated that they were self-motivated to
opt for the natural way of feeding their infant since they were
aware of the health benefits of breast milk and claimed that
“breast milk is best.”
3.2. Initiation of Breastfeeding. Additionally, 60.6% of the
participants initiated breastfeeding the same day after deliv-
ery, while 39.4% started to nurse their baby 24 hours after
delivery. Chi-square (�2) test confirmed that the timing of
breastfeeding initiationwas significantly associated withmode
of delivery (�2 = 212,� < 0.001). It should be noted that there
were a greater number of mothers, that is, 294 participants
Journal of Nutrition and Metabolism 3
Table 1: Reasons for not adhering to the WHO recommendations
of exclusive breastfeeding for the first six months.
Reasons Frequency
� %
Introduction of water 116 30.1
Resumption of work 105 27.3
Milk insufficiency 87 22.6

Mother’s desire 50 13.0
Baby too demanding/not satisfied 42 10.9
Unwillingness of the child to suckle 37 9.6
Medical complications 15 3.9
Had to take medication 11 2.9
Lack of time 5 1.3
Too painful 3 0.8
0
5
10
15
20
25
30
35
34.3
19.9
27.9
17.9
M
ot
he
rs

(%
)
Number of months
Duration of EBF
<1 1-2 3-4 5-6
Figure 1: Duration of exclusive breastfeeding.
(58.8%) delivered their infants by the normal vaginal method
compared to 206 mothers (41.2%) who delivered by the
caesarean method. It has been observed that 42.6% who had
a normal vaginal delivery initiated breastfeeding immediately
or withinminutes after birth compared to 23.9% of those who
had a caesarean type of delivery.
3.3. The Practice of Exclusive Breastfeeding. Although 35.7%
of the participants had adequate knowledge on the defini-
tion/meaning of EBF, the practice was relatively low com-
pared to the WHO recommendation, whereby only 17.9% of
the women gave their infants only breast milk during the first
six months.
The main deterrent of EBF is the early introduction of
water (Table 1) and infant formula (Table 3). It is worth noting
thatmothers stated during the survey that they started to give
water around 2 months. Other major barriers to EBF include
employment (27.3%) followed by milk insufficiency (22.6%)
as reported by the respondents.
These factors in turn led to a very short mean duration
of EBF that is 2.10 months. Figure 1 depicts the number of
months that mothers have exclusively breastfed their infants.

The majority of the women practiced exclusive breastfeeding
for less than one month (34.3%), while only 17.9% of them
breastfed their child exclusively for around 5-6 months.
0 20 40 60
Others
Sickness
Child reluctant to suckle
Soreness of nipple
Back pain
Fatigue
Breast engorgement
None
1.3
2.8
4.1
5.7
23.2
24.9
25.1
33.3
46.2
Mothers (%)
M
ai

n
pr
ob
le
m
s
1.3
2.8
4.1
5.7
23.2
24.9
25.1
33.3
Pain due to caesarean
section
Figure 2: Main problems encountered during the breastfeeding
process.
3.4. Factors Influencing Breastfeeding Duration. Themajority
of the mothers completely terminate breastfeeding around
19–24months (26.0%);�2 test confirms that there are associa-
tions between the duration of breastfeeding and parity, alcohol
consumption, education, and occupation of the respondents,
while age group, residence, type of family, and type of delivery
were not statistically significant (� > 0.05). These data are
shown in Table 2.
It has been found that more primiparous mothers would

stop nursing their infants around 19–24 months (34.5%)
compared to multiparous mothers (19.9%), and cessation of
breastfeeding beyond 24 months is more prevalent among
participants who never drink alcoholic beverages. As far as
education is concerned, it has been seen that irrespective of
the level of schooling attained, mothers usually stop breast-
feeding their infants within 24 months. In addition, even
if women are employed as professionals (28.3%) or are
housewives (26.3%), they are more likely to discontinue
breastfeeding within 24 months.
During the breastfeeding process, many mothers com-
plained about the problems they encountered. It can be
seen from Figure 2 that the majority of the respondents
(46.2%) did not face any problems while breastfeeding, but
among those having difficulties, breast engorgement was
most prevalent (33.3%) followed by fatigue (25.1%), back pain
(24.9%), and soreness of nipple (23.2%), while pain due to
caesarian section, reluctance of infant to suckle, or sickness
were minor problems that mothers faced.
With respect to the introduction and use of infant
formula, results indicate that more participants (37.9%) start
to use breast milk substitute within one month after deliv-
ery, whereby 33.9% of participants who use infant formula
highlighted milk insufficiency as being the major reason to
bottle feed, while 32.5% reported that they had to resume
work; thus, they opted for formula feeding as shown in
Table 3.
Though themajority of themothers reported that they did
not have any problems with the breast milk substitute, that
is, they never had to change the type of formula milk used
(80.8%), some reported that baby constipated (5.9%) and fell
sick (4.3%) with the infant formula, respectively.

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8
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ife
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42
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55
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3
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7.8
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3.
6

Table 3: Reasons for opting infant formula.
Reasons Frequency
� %
Milk insufficiency 127 33.9
Resumption of work 122 32.5
Unwillingness of the child to suckle 55 14.7
Mother’s desire 51 13.6
Other’s 44 11.7
Medical complications 29 7.7
Doctor’s recommendation 8 2.1
Aesthetic reason 1 0.3
3.5. Weaning Introduction. Complementary feeding was
more commonly initiated around 4–6 months (75.2%) and
partial weaning (when baby is breastfed once or twice per day
while receiving complementary foods)was themost common
type of weaning practiced by mothers (62.8%). During
complementary feeding, both home-made and commercially
available foods (cereals, ready-made pots) are given to the
infants (69.2%). It has been found that weaning started with
mashed vegetables or fruits (66.9%) and the main reasons are
due to the freshness of home-made food and it is also more
hygienic (93.5%). Additionally, 86.4% of the participants
reported that the nutritional quality of home-made food is
superior to that of commercial food, while 84.9% of the
women stated that food prepared at home provides room
for more choices for a balanced meal. With regard to the
commercially available baby foods, it was noted that mothers
prefer cereals (34.1%) to ready-made pots (7.80%). It has

also been found that 68.7% of mothers did not encounter
any difficulty with their infants during the weaning period.
Moreover, the other respondents (21.7%) highlighted that
their children were unwilling to take solid foods, while 19.6%
of them reported that their infants prefer drinking to food.
4. Discussion
A higher standard of living coupled with a higher education
level in Mauritius during the last 20 years has resulted in
more women in the working sector. However, this has not
dramatically decreased breastfeeding practice as it has been
noted that the prevalence of breastfeeding in Mauritius has
risen from 72% in 1991 [14] to 93.4% as found in this study.
This may reflect the success of health promotion campaigns
reiterating that “breast is best” or “breast milk is beneficial for
babies and mothers” which account for the fact that mothers
were self-motivated to breastfeed. Findings of this study are
consistent with the one conducted in Northern Ireland [16]
which reported that mothers were encouraged to breastfeed
only because they know that “breast is best” or owing to the
benefits of breast milk.
4.1. Initiation of Breastfeeding. Although WHO’s, Global
and National Infant, and Young Child Feeding Guidelines
recommend that all newborns should start breastfeeding
immediately (within the first hour after delivery), the current
study showed that very few participants (27.2%) started
to breastfeed immediately/within minutes after delivery or
within one hour after birth compared to 39.4% mothers who
initiated breastfeeding later than 1 hour within the same day.
Additionally, caesarian delivery in Mauritius is on the rise. It
has been noted that 206 respondents delivered by caesarian
section of which 76.1% began to breastfeed their infants after
24 hours of birth. The delayed initiation of breastfeeding was

most probably related to (1) the physical condition of the
mother after delivery [17], whereby some mothers claimed
that theywere not feelingwell enough to be able to breastfeed;
(2) painful conditions associated with caesarian section; (3)
the absence of their infants who were kept in nursery.
Similarly, other studies also noted that the rate of breast-
feeding initiationwithin 1 hourwas low and the principal bar-
rier to the initiation and even continuation of breastfeeding
is due to the operative obstetrical intervention [17–19]. It has
also been reported that after the caesarean section, mothers
and infants are separated for a long period of time owing
to anesthesia, baby being kept in nursery, or mother being
sedated for pain and unable to feed [19, 20]. This ultimately
leads to poor maternal milk surge.
4.2. Exclusive Breastfeeding. It has been found that although
knowledge on EBF for the first 6 months as per WHO
recommendation (35.7%) was relatively high, only about half
(17.9%) actually practiced it. The mean duration of exclusive
breastfeeding inMauritius is only 2.10months, whereby there
are 17.9% ofmothers who practiced EBF for the first 6months
unlike in other developing countries such as East Asia/Pacific
which have the highest rate of exclusive breastfeeding (43.0%)
followed by Eastern/Southern Africa (41.0%) (UNICEF, the
United Nations Children’s Fund) [21]. Therefore, it can be
argued that mothers failed to adhere strictly to the WHO
recommendation of EBF for the first 6 months owing to
the introduction of water and infant formula much before 6
months.
The main determinants of EBF include resumption of
work followed by milk insufficiency. Usually, female workers
in Mauritius are allowed 12 weeks of maternity leave which
equals to approximately 3 months (SSPTW, Social Security
Programs Throughout The World) [22]. Under these cir-

cumstances, mothers are prompted to resort to the supple-
mentation of infant formula before 3 months so that their
infants familiarize to bottle feeding during their absence.This
finding is consistent with other studies which highlighted
employment and milk insufficiency as the major barriers
to EBF [2, 8, 23–25], while another research pointed out
that mothers stop EBF as they perceive that their infants
feel hungry and unsatisfied with breast milk only [8]. They
ultimately resort to supplement with infant formula.
Nevertheless, it has been argued that the exclusivity of
breastfeeding is affected when mothers experience problems
with the infant latching-on or sucking and they do not get
assistance from some clinicians who do not feel intrepid in
their skills to support breastfeeding and may have limited
time to address the matter during preventive visits [26].
Additionally, 26.0% of the respondents cease breastfeeding
within 2 years, while there are notably some mothers who
breastfeed above 2 years.This implies that despite the fact that
themajority of the participants adoptmixed feeding, they still
adhere to the WHO recommendation which involves con-
tinued breastfeeding up to 2 years or beyond [1]. This study
reveals that factors including parity, alcohol consumption,
education, and occupation are associatedwith the termination
of breastfeeding.
4.3. Factors Associated with the Duration of Breastfeeding
4.3.1. Parity and Alcohol Consumption. There are a greater
number of women from the lower parity who terminate
breastfeeding within 2 years as compared to their counter-

parts. Primiparous women are less knowledgeable and skilful
in breastfeeding [25]; hence, they will usually seek assistance,
advice, and help from health care professionals who generally
promote breastfeeding. Furthermore, first time mothers are
more likely to consider health promotion messages or be
exposed to them in different ways [27]. On the other side,
higher parity leads to short birth intervals, hence, minimal
time available for breastfeeding [28]. In contrast to previous
reviews, primiparity was associated with reduced risk for
breastfeeding duration [29], while other studies done in
the United Kingdom [30] and in Bangladesh [31] affirmed
that breastfeeding duration increases with increasing parity
whichmight be related to previous breastfeeding experiences.
Nevertheless, in another study [32], it was asserted that parity
had no significant influence on duration of breastfeeding.
There is an association between the frequency of intake of
alcoholic beverages and duration of breastfeeding. Mothers
who never or seldom take alcoholic drinks are more apt to
breastfeed longer than thosewho consume themoccasionally.
This might be because those who consume alcohol on a
regular basis avoid breastfeeding owing to the fact that
alcohol readily crosses into breast milk by simple diffusion,
attaining levels approximately equal to that in the maternal
blood stream [33].
This finding agrees with those observed in other studies
carried out in Australia [34] and in Greece [35] which stated
that mothers stop breastfeeding their infants earlier because
exposing the child to small amounts of alcohol through breast
milk disrupts infant sleeping patterns.
4.3.2. Education and Occupation. It was noted that the level
of education did not have any influence on breastfeeding
duration andMauritianmothers usually breastfeed at least for
12 months.

In contrast to this study, it has been found in a previous
research conducted in Philippines [28] that education plays a
significant role in determining the duration of breastfeeding.
Increasing level of education also implies adoption ofmodern
ideas while gradually leading to the dereliction of traditional
practices regarding child care, thus, a decrease in the rate of
breastfeeding.
With regard to occupation of the mothers, it has been
observed that regardless of the fact that the participants
are housewives or employed as professionals, they would
normally stop nursing their infants within 2 years. Gener-
ally, housewives have unlimited time available to feed their
infants while on the other hand, despite the fact that the
participants work as professionals, they still breastfeed as
long as housewives do. One most probable reason for this is
that even though they work, they express their breast milk
eithermanually or with pumps so that somebody else can still
feed the baby or they are usually given flexible time at work
to maintain breastfeeding. Another study in Malaysia [36]
reported that facility atworkplace similar inMauritius such as
allowing mothers a flexible time to express breast milk helps
in maintaining lactation. This issue of breast milk expression
needs to be addressed in future studies. Conversely, other
investigators observed that women having professional jobs
especially in urban areas stop breastfeeding earlier than the
recommended duration because they have reduced access
to their children whereas those involved in traditional work
have more time and maintain longer periods of lactation
[28].
4.4. Breastfeeding Challenges. Although a greater part of
the participants do not experience any difficulties while
nursing their infants, there were still a significant number

of the respondents who complain about breast engorgement,
fatigue, back pain, and soreness of nipple. Breast engorge-
ment usually occurs when milk gets accumulated in the
breast, while sore nipples arise because of the baby sucking
the nipple area of the breast only [37]. Generally, nursing
mothers breastfeed their children frequently during the day
(each 2 hours) which leads to fatigue and back pain. This
research affirmed that these difficulties result in a negative
experience with breastfeedingwhich is followed by a decrease
in mothers’ confidence to wet-nurse their infants, hence,
causing early cessation of breastfeeding [38]. These results
are consistent with recent studies demonstrating that many
women encounter problems such as crackednipples, lowmilk
supply, and breast engorgement [24, 26, 37–41].
4.5. Infant Formula Feeding. Early termination of breast-
feeding also implies early use of breast milk substitute and
as pointed out above, factors such as work, milk insuffi-
ciency, and breastfeeding difficulties are the major reasons
for adopting formula feeding. Among the few participants
who encountered minor feeding problems with the formula
milk reported constipation and sickness such as vomiting,
diarrhoea, colic, and regurgitation as themost common ones.
The risk of constipation among formula-fed children is quite
common and this has also been found in Italy [42], whereby
the authors reported that there is a prolonged gastrointestinal
transit in formula-fed infants and the stool consistency is hard
compared to breastfed infants.
4.6. Weaning Introduction. Complementary foods are gen-
erally introduced between 4 and 6 months and partial
weaning is the most common type of weaning adopted
by mothers. Generally, women who terminate breastfeeding
within 2 years are more likely to adopt partial weaning
because it involves nursing the infant as well as introducing
complementary foods [43], while those who stop nursing

their infants within 6 months adopt mother-led weaning.
Conversely, mother-led weaning occurs when the mother
feels the need to introduce complementary foods. Since, there
is limited research on the type ofweaning adopted bymothers
during infant feeding practices, the results obtained in the
present study are more suggestive than affirmative.
Results herein corroborate those carried out in Switzer-
land [12] which demonstrate that a greater number of women
start to wean their infants with mashed vegetables or fruits
followed by cereals. The main reason as pointed out by
the participants in this study is that home-made food is
more fresh, nutritious, and hygienic unlike commercially
available cereal or baby foods. Gradually, baby cereals or
commercial purees are also used alongside home-made foods
and more women prefer cereals (34.1%) to ready-made pots
(7.80%) because they believe that commercial purees contain
additives, high sugar content and salt content, compared to
cereals. To date, there are no published data on the type
of weaning food (home-made versus commercially available
food).
A fewmothers experience difficulties during complemen-
tary feeding which include unwillingness of the child to eat
while exerting preferences to drink rather than eating. The
minority of the participants affirmed that they encountered
problems such as allergic reactions and health problems with
the infant including vomiting, colic, and diarrhoea which
may arise due to the feeding practices adopted by mothers
[44]. Other possible barriers during complementary feeding
found in other studies unlike the present study include food

refusal, selective, picky or fussy eating, eating slowly, being
less interested in food, and having a small appetite [44].
5. Conclusion and Limitations
This study shows that the prevalence of breastfeeding has
increased over the past 20 years in Mauritius. The WHO
guidelines advise to breastfeed exclusively until 6 months
of age. Despite a high breastfeeding initiation rate of 61%,
only 18% succeed to give exclusive breastfeeding until 5-
6 months. The mean duration of exclusive breastfeeding is
2 months, with adding water as the main reason for not
continuing exclusiveness. Awareness of the health benefits
of breastfeeding was noted in 65%, a percentage that may
be increased by further breastfeeding education and support.
The major barriers to breastfeeding practices in this study in
terms of initiation, exclusivity, and duration are (1) type of
delivery; (2) parity; (3) alcohol consumption; (4) occupation
and education; (5) breast problems,mainlymilk insufficiency.
These factors encourage early use of formulamilk. On the
other hand, complementary foods are normally introduced
around 4 to 6 months and mothers usually start with home-
made food because of its freshness and for hygienic reasons.
However, there are very few mothers who encountered
difficulties during the weaning process as compared during
breastfeeding practices such as refusal to eat followed by
vomiting, colic, allergic reactions, and diarrhea which were
rare.
There are two major limitations in our study. Future
studies along the same line should target children of 3 years
as it has been suggested by Khassawneh that this will reduce
the risk of recall bias [45].
To calculate the sampling size, the female population in

the reproductive ages was considered. However, this data is
not representative of the number of mothers aged between 18
and 45 years.
Acknowledgments
The authors declare that they have no conflict of interests.
It is to be noted that SPSS that was used for carrying out
the statistical analysis was purchased by the University of
Mauritius. AshmikaMotee and Rajesh Jeewon carried out the
study design. Ashmika Motee carried out the data collection.
Ashmika Motee and Deerajen Ramasawmy carried out the
statistical analysis. Ashmika Motee, Pugo-Gunsam Prity, and
Rajesh Jeewon carried out the preparation of the paper. All
authors critically reviewed the paper and approved the final
version submitted for publication. The authors thank the
Department of Health Sciences of the University ofMauritius
and their special gratitude goes to the nursing staff at the Area
Health Care Centres and Community Health Centres for
their assistance and valuable information. A word of thanks
goes also to the mothers who gave their valuable time and
participated in the survey.
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nutrients
Review
Review of Infant Feeding: Key Features of Breast

Milk and Infant Formula
Camilia R. Martin 1, Pei-Ra Ling 2 and George L. Blackburn
2,*
1 Department of Neonatology and Division of Translational
Research, Beth Israel Deaconess Medical Center,
Harvard Medical School, Boston, MA 02215, USA;
[email protected]
2 Department of Surgery, Feihe Nutrition Laboratory, Beth
Israel Deaconess Medical Center,
Harvard Medical School, Boston, MA 02215, USA;
[email protected]
* Correspondence: [email protected]; Tel.: +617-667-2604; Fax:
+617-667-2608
Received: 14 March 2016; Accepted: 26 April 2016; Published:
11 May 2016
Abstract: Mothers’ own milk is the best source of nutrition for
nearly all infants. Beyond somatic
growth, breast milk as a biologic fluid has a variety of other
benefits, including modulation of
postnatal intestinal function, immune ontogeny, and brain
development. Although breastfeeding is
highly recommended, breastfeeding may not always be possible,
suitable or solely adequate. Infant
formula is an industrially produced substitute for infant
consumption. Infant formula attempts
to mimic the nutritional composition of breast milk as closely as
possible, and is based on cow’s
milk or soymilk. A number of alternatives to cow’s milk-based
formula also exist. In this article,
we review the nutritional information of breast milk and infant
formulas for better understanding of
the importance of breastfeeding and the uses of infant formula
from birth to 12 months of age when a

substitute form of nutrition is required.
Keywords: breast milk; infant formula; cow’s milk allergy;
cow’s milk alternatives
1. Introduction
Mothers’ own milk is considered to be the best source of infant
nutrition [1]. Extensive evidence
has shown that breast milk contains a variety of bioactive
agents that modify the function of the
gastrointestinal tract and the immune system, as well as in brain
development. Thus, breast milk is
widely recognized as a biological fluid required for optimal
infant growth and development. Recently,
studies have further suggested that breast milk mitigates infant
programming of late metabolic diseases,
particularly protecting against obesity and type 2 diabetes [2].
The World Health Organization recommends that infants should
be exclusively breastfed for
the first six month of life [3]. The American Academy of
Pediatrics also recommends breastfeeding
for at least 12 months [4]. Recently, the Academy of Nutrition
and Dietetics reaffirms and updates
their mission that exclusive breastfeeding provides optimal
nutrition and health protection for the
first six months of life, and that breastfeeding with
complementary foods from six months until
at least 12 months of age is the ideal feeding pattern for infants
[1]. In addition to its nutritional
advantage, breastfeeding is convenient and inexpensive, and
also is a bonding experience for the
mother and infant.
The decision to breastfeed is highly personal and is often

influenced by many factors [5]. Under
certain situations, breastfeeding might not be possible,
unsuitable or inadequate, which warrants an
interruption or cessation in breastfeeding. Globally, only 38%
of infants are exclusively breastfed.
In the United States, only 75% of infants initiate breastfeeding
from birth; however, by the age of three
months, 67%, or 2.7 million, of them rely on infant formula for
some portion of their nutrition [6].
Among new mothers, the six-month “any breastfeeding” rate for
the total U.S. population is 43%,
with only 13% meeting the recommendation to breastfeed
exclusively for six months [4].
Nutrients 2016, 8, 279; doi:10.3390/nu8050279
www.mdpi.com/journal/nutrients
http://www.mdpi.com/journal/nutrients
http://www.mdpi.com
http://www.mdpi.com/journal/nutrients
Nutrients 2016, 8, 279 2 of 11
Infant formula is intended as an effective substitute for infant
feeding [7,8]. Although production
of an identical product to breast milk is not feasible, every
effort has been taken to mimic the nutrition
profile of human breast milk for normal infant growth and
development. Cow milk or soymilk
are most commonly used as the base, with supplemental
ingredients added to better approximate
the composition to human breast milk and to attain health
benefits, including iron, nucleotides and
compositions of fat blends. The fatty acids of arachidonic acid
(AA) and docosahexenoic acid (DHA)

are added. Probiotics and compounds, produced by genetic
engineering, are either added or currently
being considered for addition to formula.
During the first six months of infant life, providing optimal
nutrition is critical as the consequences
of inadequate nutrition can be very severe. The purpose of this
article is to review nutritional
information on breast milk and infant formulas to reinforce the
importance of breastfeeding, while also
understanding the uses of infant formula.
2. Human Breast Milk
Human breast milk contains carbohydrates, protein, fat,
vitamins, minerals, digestive enzymes
and hormones. In addition to these nutrients, it is rich in
immune cells, including macrophages, stem
cells, and numerous other bioactive molecules. Some of these
bioactive molecules are protein-derived
and lipid-derived, while others are protein-derived and
indigestible, such as oligosaccharides.
Human milk oligosaccharides (HMOs) possess anti-infective
properties against pathogens in the
infant gastrointestinal tract, such as Salmonella, Listeria, and
Campylobacter, by flooding the infant
gastrointestinal tract with decoys that bind the pathogens and
keep them off the intestinal wall [9].
Oligosaccharides also play a vital role in the development of a
diverse and balanced microbiota,
essential for appropriate innate and adaptive immune responses,
and help colonize up to 90% of the
infant biome [10].
2.1. Composition of Human Breast Milk

Human breast milk is a complex matrix with a general
composition of 87% water, 3.8% fat, 1.0%
protein, and 7% lactose. The fat and lactose, respectively,
provide 50% and 40% of the total energy
of the milk [11]. However, the composition of human breast
milk is dynamic and changes over time,
adapting itself to the changing needs of the growing child. For
instance, during each nursing session,
the milk that is expressed first (foremilk) is thinner with a
higher content of lactose, which satisfies
a baby’s thirst, and following the foremilk, hindmilk, is
creamier with a much higher content of fat
for the baby’s needs. Variations are also present with the stage
of nursing (age of infant), maternal
diet, maternal health, and environmental exposure. During early
lactation, the protein content in
human milk ranges from 1.4–1.6 g/100 mL, to 0.8–1.0 g/100 mL
after three to four months of lactation,
to 0.7–0.8 g/100 mL after six months [11,12]. The fat content
varies significantly with maternal diet
and is also positively related to weight gain during pregnancy.
Remarkably, it has been observed that
a mother’s breast milk is almost always adequate in essential
nutrients for her term infant’s growth
and development, even when her own nutrition is inadequate.
Although the mean concentrations of
protein, sodium, chloride and potassium in early preterm milk
are adequate to meet the estimated
requirements for preterm infants, specific nutritional
supplementation is required for mother’s milk
delivered to preterm infants [13,14].
In contrast to protein and fat, lactose content is fairly constant
in mature milk (after 21 days
postpartum). The stable concentration of lactose is important in
maintaining a constant osmotic

pressure in human milk. Lactose also aids the absorption of
minerals and calcium. In breast milk,
many carbohydrate-based bioactive compounds, such
oligosaccharides, are attached to lactose. If the
small intestine does not produce enough of an enzyme (lactase)
to digest these sugar complexes,
lactose malabsorption and intolerance syndromes can be
observed. Lactase deficiency malabsorption
and disease are extremely rare in the exclusively breastfed
infant.
Nutrients 2016, 8, 279 3 of 11
2.2. Protein in Human Breast Milk
There are two classes of protein in breast milk: Casein and
whey. Casein becomes clots or curds
in the stomach; while whey remains as a liquid and is easier to
digest. Depending on the stage
of milk, 80% to 50% of protein in breast milk is whey [11]. The
whey/casein ratio in human milk
fluctuates between 70/30 and 80/20 in early lactation and
decreases to 50/50 in late lactation [15].
This proportion is significantly greater compared to the milk of
other mammals. In cow’s milk, whey
proteins represent only 18% of milk protein. Traditionally,
infant formulas are high in casein, making
them harder to digest compared to human breast milk. Because
the amino acid profiles of casein and
whey proteins are different, the overall amino acid profile of
human milk varies depending on the
stage of lactation. Glutamine, the most abundant free amino
acid, is nearly 20 times higher in mature
milk than its lowest value in colostrum [16]. Glutamine is

important for providing ketoglutaric acid for
the citric acid cycle, possibly acting as a neurotransmitter in the
brain, and serving as a major energy
substrate for intestinal cells [17].
The main whey proteins are alpha-lactalbumin, lactaferrin and
secretory IgA. Other proteins
include lysozyme, folate-binding protein, bifidus factor, casein,
lipase and amylase, alpha1-antitrypsin
and antichymotrypsin, and haptocorrin [11]. After ingestion,
these proteins are broken down rapidly
to free amino acids for absorption and utilization. Most of these
proteins also have bioactive functions
and non-nutritive functions [18]. For instance, alpha-
lactalbumin is essential for lactose synthesis and
binding of Ca and Zn ions. Casein assists to form masses with
calcium and phosphorus. Lactoferrin
and lysozyme prevent the spread of potentially pathogenic
bacteria, preventing illnesses in infants.
The IgA antibody destroys bacteria and protects the mucosal
surface of the gut.
2.3. Fats in Human Breast Milk
Fats are the most important composition of breast milk,
supplying energy and helping the
development of the central nervous system. Moreover, milk fat
is a carrier of taste and aroma.
In general, human breast milk fat content ranges from 3.5% to
4.5% during lactation. The main lipid
fraction are triglycerides, which account for about 95% of total
lipids. Near half of milk fatty acids are
saturated fatty acids, with 23% palmitic acid (C16:0) in total
fatty acids [11]. The monounsaturated fatty
acid, oleic acid (18:1w9), is in the highest percentage (36%) in
milk. Human breast milk also contains

two essential fatty acids, linoleic acid (C18:2w6) at 15% and
alpha-linolenic acid (C18:3w3) at 0.35% [11].
These two essential fatty acids are, respectively, converted to
arachidonic acid (AA, C20:4w6) and
eicosapentaenoic acid (EPA, C20:5w3), the latter of which is
further converted to docosahexaenoic acid
(DHA, 22:6w3). AA, EPA and DHA are important for regulating
growth, inflammatory responses,
immune function, vision, cognitive development and motor
systems in newborns.
Long chain polyunsaturated fatty acids are transferred from
mother to fetus in the third trimester
through the placenta, and to infants through breast milk after
birth [19]. During the last trimester and
neonatal period, brain tissue is rapidly synthesized. Cell
differentiation and development of active
synapses in the brain need specific requirements of DHA and
AA. Eighty percent of brain DHA is
acquired from the 26th week of gestation until birth. Notably,
the synthesis of AA and DHA from
linoleic acid (18:2w6) and alpha-linolenic acid (18:3w3) is
limited in the fetus and neonate due to the
premature enzyme activity. Thus, the required amounts of AA
and DHA must come from the mother
during pregnancy, or as breast milk after birth. One study has
showed that the fat content and the
percentage of all polyunsaturated fatty acids in breast milk
increase significantly between the sixth
week and sixth month of lactation [20]. There is evidence that
slowly turning-over maternal body pools
of AA are the major source of milk AA [21]. The AA
concentration in breast milk is dose-dependently
associated with the consumption of AA-rich foods in lactating
mothers [22]. Breast milk EPA and
DHA concentrations are also closely linked to maternal dietary

EPA and DHA intake [23]. Human
milk from lactating women consuming vegan or vegetarian diets
has <0.1% DHA, compared to mean
levels of 0.2%–0.4% DHA in the United States and ě0.8% DHA
in China, where DHA intakes from fish
or other sources are high [24]. It is suggested that intakes of
~300 mg of DHA per day are necessary to
Nutrients 2016, 8, 279 4 of 11
achieve human milk levels of 0.3%–0.35% of DHA [25].
However, the effects of human milk fatty acids
on neurodevelopment is complex, particularly because
neurodevelopment is assessed after the period
of the first six month of exclusive human milk feeding.
In premature birth, the transmission of these fatty acids is
interrupted from the placenta to the
fetus during the critical last trimester. Studies also showed that
decreased postnatal docosahexaenoic
and arachidonic acid blood levels in premature infants are
associated with neonatal morbidities [26].
Thus, after birth, the preterm infant is dependent on an adequate
diet for sufficient fatty acid levels.
Adding DHA and AA to preterm-infant formulas led to initial
beneficial effects on visual acuity, visual
attention and cognitive development compared with infant
receiving no supplementation [27].
2.4. Vitamins, Minerals and Other Bioactive Components in
Breast Milk
Human breast milk contains adequate amounts of most vitamins
to support normal infant

growth, except for vitamins D and K. Infants who are
exclusively breastfeeding receive below
the minimum recommended intake of vitamin D, and much
lower than the recommended dietary
intake. These infants are at the risk for vitamin D deficiency,
inadequate bone mineralization and
conditions such as rickets. However, the overall risk of vitamin
D deficiency in breastfed infants is also
correlated with overall sun exposure with increasing risk in
climates with a lower sun index. Maternal
supplementation with 400–2000 IU (International Unit). of
vitamin D/day can increase the levels of
vitamin D in breast milk, but only a higher dose (2000 IU)
achieves satisfactory levels of 25-OH-D in
the infant [11]. Normal vitamin D stores present at birth are
depleted within eight weeks. Sunlight
exposure and vitamin D supplementation are recommended for
breastfed infant. Formula-fed infants
often have higher serum concentration of vitamin D metabolites
than breastfed-infants. Vitamin K is
essential to the protein involved in blood coagulation. However,
only limited amounts of vitamin K is
transferred from the placenta to fetus. Thus, a newborn infant
often has an extremely low concentration
of vitamin K, and is at risk of developing hemorrhagic disease.
After birth, vitamin K supplementation
is recommended.
In human breast milk, minerals contribute to a variety of
physiological functions, forming essential
parts of many enzymes and are of biological important to
molecules and structures. The contents
of minerals are comparable between human milk and bovine
milk. Over the decades, many other
bioactive components have been identified in human milk,
including hormones, growth factors and

immunological factors.
3. Human Milk Options—Milk Donors and Milk Banks
The World Health Organization and the American Academy of
Pediatrics recommends
pasteurized human donor milk for preterm infants when a
mother’s own milk is unavailable [28].
Donor milk undergoes a pasteurization process, which reduces
many of the normal commensal
microbes, as well as significantly reducing or obliterating live
immune cells, bioactive proteins,
and enzymes, collectively limiting some of the health benefit
compared to a mother’s own milk.
Research efforts to optimize donor breast milk are ongoing.
Before using donor breast milk, the mother
should consult with their baby’s health care providers.
4. Infant Formulas
Infant formula is intended as an effective substitute to breast
milk and is formulated to mimic the
nutritional composition of breast milk. The recently updated
FDA (Food and Drug Administration)
rule on current Good Manufacturing Practices for infant
formula, 21 CFR 106.96 [6], requires, among
other things, that formulas satisfy the quality factors of normal
physical growth and a sufficient
biological quality of protein component (adequate amounts of
protein in a form that can be used by
infants). Infant formula is only for the health of infants without
unusual medical or dietary problems.
The manufacturing process is highly regulated and monitored to
meet national and international
quality criteria [29,30].

Nutrients 2016, 8, 279 5 of 11
4.1. The Infant Formula Market
The United Nations estimates that the world’s current
population of 7.2 billion will grow by one
billion over the next 12 years, reaching 9.6 billion by 2050 [31].
This increase will drive the global
demand for infant milk formula, especially innovative products
that use ingredients such as prebiotics
and specific milk protein fractions [31]. Over the next five
years, the $50 billion infant formula market is
expected to be the fastest-growing packaged food category,
achieving gains in excess of 7% a year [32].
Some industry experts predict an even higher annual growth of
8%–9% [32]. According to analyst
Diana Cowland, the rapid expansion of infant formulas is set to
continue with a compounded annual
growth rate of 11%, with demand driven by Asia, and more
particularly, China [33].
Infant formulas are available in three forms: (1) powder: The
least expensive form of infant
formula that must be mixed with water before feeding; (2)
liquid: Concentrated liquid that must
be mixed with an equal amount of water; and (3) ready-to-feed:
The most expensive form of infant
formula that requires no mixing.
4.2. Guidelines for Manufacturing of Infant Formula
Infant formulas must include proper amounts of water,
carbohydrate, protein, fat, vitamins and
minerals. The composition of infant formula is strictly

regulated, and each manufacturer must follow
established guidelines set by government agencies. For instance,
all the major components added
to formula (protein, lipids, carbohydrates) have a range of
minimum and maximum values for their
effectiveness. These components must have established a
history of safe use [34]. The required range
of each nutrient must be maintained throughout the shelf life of
the product [35]. For amino acids,
only L forms of amino acid are allowed to be added, while D
forms are not permitted because they may
cause D-lactic acidosis [36]. Fructose should be avoided due to
fructose intolerance. Hydrogenated
fats and oils are also not allowed. Ionizing radiation of the
formula product is not permitted because it
could cause product deterioration [35]. Infant formula prepared
ready for consumption should contain
no less than 60 kcal (250 kJ) and no more than 70 kcal (295 kJ)
of energy per 100 mL (CAC, 1981) [11].
Furthermore, product reformulation must be based on medical
and nutritional findings. The committee
of the “Evaluation of the addition of Ingredients New to Infant
Formula” has recommended that
“manufacturers must demonstrate that the formula containing
the new ingredient is capable of
sustaining physical growth and development over 120 days
when formula is likely to be the sole
source of infant nutrition” [7].
In the United States, the Food and Drug Administration (FDA)
defines that adding new
ingredients to infant formula should have “reasonable certainty
of no harm” as the safety standard [7].
The World Health Organization (WHO) has noted that
unmodified cow’s milk should never be
fed to infants, and that unmodified goat’s milk is also not

recommended for infants. With the
WHO guidelines, federal and local agencies of different
countries control and monitor infant formula
regulations, including requirements for quality and
manufacturing practices in their own countries.
From a manufacturers perspective, it is in their best interest to
continuously improve their products to
be as close as possible to human breast milk.
4.3. Classes of Infant Formula Products
There are three major classes of infant formulas: Cow-milk
based formula, soy-based formula
and specialized formula. They vary in nutrition, calories, taste,
digestion, and cost. Specific kinds of
formulas are available to meet a variety of needs. Some cow’s
milk substitutes are amino acid based or
contain extensively hydrolyzed whey or casein proteins. Some
are rice-based formula.
4.4. Cow Milk-Based Formula
Bovine milk is the basis for most infant formula. However,
bovine milk contains higher levels
of fat, minerals and protein compared to human breast milk.
Therefore, cow milk must be skimmed
Nutrients 2016, 8, 279 6 of 11
and diluted to more closely resemble human breast milk
composition [34,35]. Cow-milk-based infant
formula contains added vegetable oils, vitamins, minerals and
iron for consumption by most healthy
full term infants.

According to the American Academy of Pediatrics [37],
children under one year of age should
not be fed raw, unmodified, or unpasteurized cow’s milk as a
replacement for human milk or infant
formula. Additionally, unmodified milk does not provide
enough vitamin E, iron or essential fatty
acids. Moreover, infants’ systems cannot handle the high levels
of protein, sodium, and potassium of
unmodified cow milk. Formulas with a protein content 2–2.5
g/100 mL and a protein/energy ratio
<3 g/100 kcal are used for normal infants, while with higher
protein content (2.9 g/100 mL) and higher
protein/energy ratio (3.5 g/100 kcal) are for a very low birth
weight or preterm infants [38]. Recent
studies showed that high protein content in infant formula is
associated with excess weight gain in
infancy, which can lead to a 20% risk of obesity later in life
[39].
Cow’s milk is one of the first foods introduced into an infant’s
diet and one of the most common
causes of food allergy [40]. Usually, clinical reactions start
very early in life, after breastfeeding has
stopped and cow’s milk is introduced into the diet; symptoms
rarely appear during lactation.
The clinical manifestations of cow milk allergy vary widely in
type and severity. It may be
defined as a reproducible adverse reaction to one or more milk
proteins (usually caseins or whey
beta-lactoglobulin) mediated by at least one immune mechanism
[41]. The prevalence of cow milk
allergy varies across studies, as well as across diagnostic
criteria and infant diets. It presents in the first
year of life, with an estimated population prevalence of between

2% and 3% [41], or as high as 7% [42].
However, the results from recent cohort studies and from a
randomized trial of early introduction
of allergenic foods in the diet of breast-fed infant have shown
that the incidence for IgE-mediated
cow milk allergy could be as low as 0.5% [43–45]. Because
there is no definition for differentiating
IgE-mediated and non-lgE-mediated cow milk allergy, and the
clinical symptoms of both overlap
significantly, it is possible that, at least, some non-IgE mediated
allergy cases may have been included
in IgE-mediated cow milk allergy in previous reports.
Symptoms of cow milk allergy may be immediate or delayed.
IgE-associated mechanisms are
responsible for approximately 60% of cow milk-induced adverse
reactions. These typically appear
immediately or within 1 to 2 h after ingestion, and tend to affect
the skin, respiratory system,
and gastrointestinal tract. In severe cases, cow milk allergy can
also cause systemic anaphylactic
reactions [40].
Non-IgE-associated symptoms are characterized by delayed
onset of approximately 2 h to several
days after cow milk consumption. The period of 2 h helps to
exclude the non-IgE-associated or
no-allergic reactions. The non-lgE-associated clinical symptoms
mainly affect the gastrointestinal
system, and include enterocolitis, proctocolitis, enteropathy,
and eosinophilic esophagitis [46].
Non-lgE-mediated gastrointestinal food-induced allergic
disorders have a favorable prognosis and
majority symptoms dissolve within one to five years [47].
4.5. Soy-Based Formulas

Formulas made from soy proteins are effective options for
infants with galactosemia or congenital
lactase deficiency. They help with colic and milk allergies,
however, rarely, infants who are allergic
to cow’s milk may also be allergic to soymilk [33]. Soy
products should not be used in infants under
six months of age with food allergy [46]. Because
phytoestrogens are present in soy-based formula,
the uses of soy-based formulas are limited by the concern of
potential harm for the infant, although
this remains controversial [48,49].
4.6. Hypoallergenic Formulas
Protein hydrolysate formulas are meant for infants and babies
who are unable to tolerate cow milk
or soy-based formulas. They contain protein that has been
hydrolyzed—partially or extensively—into
Nutrients 2016, 8, 279 7 of 11
smaller sizes than those found in cow or soy-based products.
For infants who have a protein allergy,
extensively hydrolyzed formulas are a satisfactory alternative.
4.7. Amino Acid Formulas
Amino acid formulas are another option for infants who have
severe cow milk allergy with
reactions to or refusal to ingest appropriate amounts of
extensively hydrolyzed formula. They provide
protein in the form of free amino acids with no peptides.

5. Non-Bovine Milk Sources
Elimination of all cow milk products without appropriately
modified and fortified substitutions
can lead to malnutrition and/or specific nutrient deficiencies at
a time when infants and children are
growing. Infant milk formulas from different animals (goat,
ewe, mare, donkey, or camel), or formulas
based on lamb or chicken, have been widely marketed as
substitutes for cow milk in the management
of cow milk allergy in infants and children. However, other
animal-milk-based formulas are currently
not acceptable in many places because there are no robust
randomized clinical trials.
6. Probiotics and Prebiotics
The high concentration and structural diversity of human milk
oligaosaccharides are unique to
humans. Without probiotics and prebiotics supplementation, the
gut microbiota of formula-fed infants
is generally not dominated by the Bifidobacterium species
[50,51]. Studies have shown that breastfed
newborn carry a more stable and uniform population of
oligaosaccharides compared with formula-fed
newborns [52]. Adding probiotics to formula represents a key
strategy to reduce the incidence and
severity of diarrhea in infants [53].
Domestic animal milk contains a large variety of complex
oligosaccharides. Sialylated
oligosaccharides account for approximately 80%–90% of the
total pool from milk of all domestic
animals [54]. Milk of grazing cows contains higher
concentrations of sialic acid compared to
non-grazing cows [55]. Cow’s milk might be a useful source of

a variety of sialylated oligosaccharides
for use as additives in infant formula. It is now also possible to
supplement commercial infant formula
with synthesized oligosaccharides that are chemically identical
to human milk oligosaccharides [56].
Most probiotic strains added to formula have been isolated from
food or fecal infant microbiota.
Although the use of probiotics is now extending from research
to recommendations, rigorous scientific
effort is still required to validate specific strains with
antiallergenic potential for preventive and
therapeutic applications.
Evidence on the use of Lactobacillus reuteri for the treatment of
infantile colic is mixed.
Sung et al. [57] found that L. reuteri DSM 17938 was of no
benefit in a community sample of breast- and
formula-fed infants with colic. This outcome differed from
those of smaller trials in select populations,
but did not support a general recommendation for the use of
probiotics to treat colic. Conversely,
a prospective, randomized, blinded, controlled trial in 138
infants showed that L. reuteri had a protective
effect. The treatment group showed a lower number of pediatric
consultations related to infant colic
than the control group (p < 0.0001). It also reduced the use of
pain relieving agents and of infant
formula [58]. Such new treatments as probiotics have been
proposed to treat infantile colic, but only a
few strains have been tested. Further investigations are needed
to provide evidence-based guidelines.
The impact of early pre- and probiotic intervention on preterm
infants’ well-being, crying, growth,
and microbiological programming were conduced in 94 infants

(gestational age 32 to 36 weeks and
birth weight >1500 g) who were randomized to receive
prebiotics (a mixture of galacto-oligosaccharide
and polydextrose 1:1), probiotics (Lactobacillus rhamnosus
GG), or placebo during the first two months
of life and follow-up lasted one year [59]. The results showed
that among excessive criers (29% of
the infants), there was significantly less crying in the pre- and
probiotic groups than in the placebo
group (19% vs. 19% vs. 47%, respectively; p = 0.02). The
placebo group had a higher percentage of
Clostridium histolyticum bacteria in their stools than the
probiotic group did (13.9% vs. 8.9%, respectively;
Nutrients 2016, 8, 279 8 of 11
p = 0.05). Another study on safe and simple strategies to
prevent viral respiratory tract infections
between 3 and 60 days of life has demonstrated that prebiotics
or probiotics had significantly less
(p < 0.001 and p = 0.022) viral respiratory tract infections
compared with those receiving placebo [60].
Additionally, the incidence of rhinovirus-induced episodes,
which comprised 80% of all respiratory
tract infections, was significantly lower in the prebiotic (p =
0.003) and probiotic (p = 0.051) groups
than in the placebo group.
7. Fatty Acids and Milk Fats from Different Mammalian Species
The lipid portion of human milk is the major source of energy
for growing infants and provides
approximately 45% to 55% of total energy. The lipid
compositions of mammalian milks (cow, buffalo,

donkey, sheep, and camel) were compared with that of human
milk on fatty acid profiles and
triacylglycerol (TAG), phospholipid, and phospholipid fatty
acid compositions, as well as melting and
crystallization profiles [59]. The results showed that these milk
fats, especially sheep milk fat, had high
degrees of similarity to human milk fat in total fatty acid
composition. However, other chemical
aspects had less similarity. This outcome indicates that these
milk fats do not meet the requirements of
human milk fat substitutes, but large amounts of these
commercialized mammalian milk fats are good
raw materials for infant formula production. Milk fat globule
membranes are a fraction that has been
previously excluded from infant formulas, but its components
are active and prevent infection [61].
Milk fat globule membrane supplementation of infant formula
also narrows the gap in cognitive
development between breastfed and formula fed infants [62].
8. Bioactive Proteins
Novel dairy fractions from bovine milk have been isolated and
are now commercially available.
Many of these components are proteins, such as α-lactalbumin,
lactoferrin, osteopontin, and milk fat
globule membrane proteins. When adding bioactive proteins to
infant formulas, it is important to
reduce the total protein content of formula. The amino acid
composition of formula is also important;
serum concentrations of essential amino acids should not be
lower than those in breastfed infants.
For example, α-Lactalbumin, often the first limiting amino acid
in infant formulas, is digested into
smaller peptides with antimicrobial and prebiotic activities and
has an immunostimulatory effect.

It also enhances mineral absorption. Osteopontin is a heavily
phosphorylated and glycosylated
protein that modulates immune function and stimulates Th1/Th2
switching. It might also affect bone
mineralization and growth, and facilitate the biological function
of lactoferrin.
9. Conclusions
Breast milk is the best nutrition for infant growth and
development, and is also rich in antibodies
that provide the first source of adaptive immunity in a
newborn’s intestinal tract. In preterm or
low birth weight newborns, a mother’s own milk is the first
choice for preterm infants; when it is
unavailable, donor breast milk is considered as the next best
choice. For healthy newborns whose
mothers are unable to provide sufficient breast milk, the current
option of choice is infant formula.
Acknowledgments: The authors extend their appreciation to Rita
Buckley for research, writing, and editing
services provided in the development of this manuscript.
Author Contributions: The sole author had responsibility for all
parts of the manuscript. All authors have read
and approved the manuscript.
Conflicts of Interest: The authors declare no conflict of interest.
Nutrients 2016, 8, 279 9 of 11
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