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Choosing the Best Formula

Rebecca D. Williams


If the mother cannot or chooses not to breast-feed, normal, full-term infants should get a conventional cow's-milk-based formula, according to John N. Udall Jr., M.D., chief of nutrition and gastroenterology at Children's Hospital of New Orleans. However, adverse reactions to the protein in cow's milk formula, or symptoms of lactose intolerance (lactose is the carbohydrate in cow's milk) may require switching to another type of formula, he says.

Symptoms that may indicate an adverse reaction to cow's milk protein include vomiting, diarrhea, abdominal pain, and rash. With lactose intolerance, the most common symptoms are excessive gas, abdominal distension and pain, and diarrhea. Since some of the symptoms overlap, a stool test may be necessary to determine the culprit. Usually, lactose intolerance will produce acidic stools that contain glucose. If the protein is the problem, stools will be nonacidic and have flecks of blood.

The main alternative to cow's milk formula is soy formula.

The carbohydrates in most soy formulas are sucrose and corn syrup, which are easily digested and absorbed by infants. However, soy is not as good a protein source as cow's milk. Also, babies don't absorb some minerals, such as calcium, as efficiently from soy formulas. Therefore, according to the American Academy of Pediatrics, "Healthy full-term infants should be given soy formula only when medically necessary."

For a child who can't tolerate cow's milk protein, William J. Klish, M.D., a Baylor College of Medicine pediatrician and former chairman of the American Academy of Pediatrics Committee on Nutrition recommends the use of hydrolyzed-protein formula. Although hydrolyzed-protein formulas are made from cow's milk, the protein has been broken up into its component parts. Essentially, it's been predigested, which decreases the likelihood of an allergic reaction.


The infant formulas currently available in the United States are either "iron-fortified"--with approximately 12 milligrams of iron per liter--or "low iron"--with approximately 2 milligrams of iron per liter.

"There should not be a low-iron formula on the market for the average child, because a low-iron formula is a nutritionally deficient formula," says Klish. "It doesn't provide enough iron to maintain proper blood cell counts or proper hemoglobin." (Hemoglobin is a blood protein that carries oxygen from the lungs to the tissues, and carbon dioxide from the tissues to the lungs.)

In addition, studies have shown that school children who had good iron status as infants (because they were fed iron-fortified formula) performed better on standardized developmental tests than children with poor iron status. However, FDA has permitted marketing of low-iron formulas, because some pediatricians prefer to use them.

Why is there low-iron formula on the market? "In the past there have been a lot of symptoms that have been attributed to iron, including abdominal discomfort, constipation, diarrhea, colic, and irritability," says Klish. "Also, there was some concern about too much iron interfering with the immune system. All of those concerns and questions have been laid to rest with appropriate studies."

Another reason for originally producing low-iron formulas was that human milk contains low amounts of iron--less than a milligram per liter. However, it is now understood that an infant absorbs virtually 100 percent of the iron from human milk, but considerably less from infant formula.

Rebecca D. Williams is a writer in Oak Ridge, Tenn. Isadora Stehlin is a member of FDA's public affairs staff.

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