Disclaimer: This article serves an educational purpose only and does not supersede any professional medical opinion. You are encouraged to consult a healthcare professional before buying a milk formula for your baby.
The World Health Organization (WHO) and UNICEF recommend that all infants are breastfed exclusively for the first 6 months of life, followed by an introduction of nutritionally-adequate and safe complementary (solid) foods at 6 months together with continued breastfeeding up to 2 years of age or beyond. This is because human breast milk is a good source of nutrients for infants. You may read more about the benefits of breastfeeding in our previous article here.
However, not all mothers are able to breastfeed. Many of them do not feel prepared or supported to feed the babies they want to. As a result, they may face judgement or feel guilty, which in turns impacts their emotional wellbeing at an especially challenging and vulnerable time. In such instances, healthcare professionals may suggest the mothers opt for a commercial milk formula for their baby instead.
An overview of the various infant milk formula in the market
Commercially prepared infant formula is available in three forms: ready to use, concentrated liquid and powder. The ready-to-use form is highly convenient as it does not require mixing with water, but it is also the most expensive one. The powdered infant milk formula is the cheapest and most common option for many households.
However, unlike concentrated liquid and ready-to-use formula, powdered infant milk formula does not undergo sterilization (subject to extremely high temperature to kill off the bacteria) and therefore can contain bacteria. Its reputation has been tainted when an Enterobacter sakazakii infection associated with the use of powdered infant formula happened in the United States. As a result, powdered milk formula is not recommended to preterm infants or those with weak immunity.
The choice of a suitable infant milk formula can be guided by the following factors:
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Whether the infant is full-term or preterm
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Whether the infant has lactose intolerance
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Whether the infant has cow’s milk protein allergy (CMPA)
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Financial capability of the parents
These factors will be discussed as we go through each milk formula.
Cow’s milk-based formula
Term infants should take cow’s milk based formula unless the family prefers a vegan diet for the infants. The majority of available infant milk formulas are made with cow’s milk that has been artificially modified to resemble human breast milk. Variations in different formulations of cow’s milk formula include the amount of protein, source of fat and source of carbohydrate. Casein and whey are two protein sources available in both cow’s milk and human breast milk, however in a different ratio. Many manufacturers of cow’s milk formula change the original whey-to-casein ratio in cow’s milk (18:82) to mimic the ratio in human breast milk (range from 48:52 to 60:40), so that it is easier to digest by the baby. The major source of carbohydrate in cow’s milk-based formula is lactose. If your baby cannot tolerate lactose, a lactose-free formula can be tried instead.
Lactose-free formula
Lactose-free formula is recommended to infants with lactose intolerance or those who experience stomach discomfort when taking conventional milk. Lactose intolerance happens primarily due to a deficiency of primary lactase, which leads to reduced ability to digest dairy foods. Some of the symptoms of lactose intolerance may include abdominal distension, flatulence/gas, abdominal cramping, and ultimately diarrhea (loose stool).
The original lactose present in conventional cow’s milk formula is replaced with maltodextrins and corn syrup solids. Such formulas may be less irritating to the baby’s digestive system.
Do note that lactose intolerance in infants is different from cow’s milk protein allergy (CMPA), which requires a hypoallergenic milk formula instead of lactose-free formula. Both lactose intolerance and CMPA share similar symptoms with timing difference: lactose intolerance usually happens in later stages of life, while CMPA takes place in the first few months of the infant’s life. You are advised to bring the infant to see a doctor for more accurate diagnosis.
Hypoallergenic milk formulas
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These are the formulas suitable for infants with diagnosed CMPA. In these formulas, the cow’s milk protein has been partially or fully broken down (hydrolyzed) so that it can be absorbed by infants with cow’s milk protein allergy. Extensively hydrolyzed formula (EHFs), a type of hypoallergenic milk formula, is derived from bovine casein or whey, and can be tolerated by 95% of infants who are allergic to cow’s milk.
However, hypoallergenic milk formula is very expensive (at least 3 times more expensive than conventional formula) and has an unpalatable taste.
Previously, there have been claims that hypoallergenic milk formulas help to prevent risk of atopic diseases (asthma, eczema, allergic rhinitis, food allergy) among infants. The American Academy of Paediatrics has since refuted this claim as there is a lack of supportive evidence.
Soy-based formulas
Soy-based formula is recommended to lactose intolerant infants, infants with galactosaemia and when a vegan diet is preferred. Soy-based formulas do not contain cow’s milk protein or lactose; instead, they contain soy as the primary protein source. But this does not make them a suitable formula for infants with CMPA, as half of these infants may still develop allergy to soy protein when given soy-based formula.
Soy-based formula contains phytoestrogens, a group of compounds highly similar to the human’s estrogen in the body. As the infants go through developmental stages that are sensitive to estrogens, there have been concerns that infants fed with soy-based formula may experience negative health impacts later in life, such as vaginal changes and menstrual pain in females. Also, because soya-based formula contains glucose, so it is more likely to harm a baby's teeth. Only use soya-based formula if it has been recommended or prescribed by a healthcare professional.
Other formulas
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Amino acid-based formula. This is recommended to infants with CMPA who failed to tolerate EHFs. They are also very expensive.
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Rice-thickened formula. This can be recommended to babies who experience reflux issues.
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Formula with prebiotics. Prebiotics are non-digestible components that stimulate the growth of ‘good’ bacteria in the infant’s digestive system. There has been one study that showed that such formula may reduce risk of eczema among babies, more evidence is required to establish the benefits of such formula.
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Formula with probiotics. Probiotics are ‘good’ bacteria (e.g. lactobacilli) that colonises the human’s digestive system. There is a lack of evidence that supports the use of such formulas as well.
Takeaway
Selecting the appropriate formula for an infant can be challenging. Fret not, as you can always consult a doctor or pharmacist on such choices. You are also encouraged to feedback your baby’s negative response towards a certain milk formula to your healthcare professional so that appropriate action can be taken.
Reference:
Pharmacists’ guide to infant formulas for term infants - available from: https://doi.org/10.1331/JAPhA.2011.09125
