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Department of Pediatrics, College of Medicine, University of Iowa, Iowa City, IA 52242
| ABSTRACT |
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KEY WORDS: infant feeding breast-feeding infant formula beikost
| INTRODUCTION |
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Among the most important advances in infant nutrition and feeding during the latter half of the 20th century were the increase in breast-feeding and the nutrition and feeding of preterm infantsareas to be covered in other presentations in this symposium. Although important advances were also made in feeding of infants with chronic disease, my presentation is restricted to nutrition and feeding of normal term infants.
A number of changes in public health during the latter half of the 19th
century contributed to more successful formula feeding of infants in
the early part of the 20th century (Fomon 1993
). Most
important of these were improvements in general sanitation, disposal of
garbage and, at least in some cities, chlorination of water. Handling
and storage of milk improved. The biochemical differences between the
major components of human milk and cows milk had been defined. Even
at the beginning of the 20th century, it was generally appreciated that
infant formulas based on cows milk required the addition of water and
carbohydrate. A number of commercially prepared formulas were patented.
Liebigs food for infants, marketed in 1867 as a liquid and
subsequently as a powder, consisted of wheat flour, cows milk, malt
flour and potassium bicarbonate (Forsyth 19101911
, Smith 1885
). Other formulas were introduced in rapid succession;
by 1883, 27 brands of patented infant foods were available
(Bracken 1953
). However, relatively few infants were fed
commercially prepared formulas.
| The years 19001930 |
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Although reliable data on the prevalence of breast-feeding during
the early years of the 20th century are not available, comments in the
literature suggest that most infants were breast-fed throughout
most of y 1 of life, many of them also being fed some formula [see,
e.g., Friedenwald and Ruhrah (1905)
]. A survey of a
number of urban centers in 19121919 indicated that at 12 mo of age,
13% of infants were exclusively breast-fed and 45% were partially
breast-fed (Yankauer 1994
).
There is reason to believe that formula feeding in the early 1900s was
less successful in the United States than in Europe. In Europe, at
least in Germany, milk was almost uniformly boiled for use in infant
formulas, whereas in the United States, raw milk was most commonly used
(Brennemann 1911
). The strong prejudice against the use
of heat-treated milk was based on the observation that scurvy
occurred primarily in infants fed sterilized, condensed or pasteurized
milk (American Pediatric Society 1898
).
The early years of the 20th century were notable in the United States
for the adoption by many physicians of a complex sequence of changes in
formula composition, the "percentage method" or "American
method" of formula feeding (Rotch 1907
). The aim was
to provide a formula with a composition close to that of human milk but
taking into account the digestive capability of the individual infant.
Nevertheless, the major emphasis was on the ratios of protein, fat and
carbohydrate and not on energy density; formulas commonly ranged from
<50 kcal/dL to >80 kcal/dL. Formula preparation was so complex that
it was commonly performed in commercial laboratories dedicated to this
purpose. With the endorsement of Rotch, the Walker-Gordon Farm had
been established in 1891 for the production of clean milk (Morse 1935
) and Walker-Gordon Laboratories, which used this milk,
were in operation in many cities in the early 1900s (Friedenwald and Ruhrah 1905
, Morse 1935
). In retrospect,
although the system of formula preparation was unnecessarily complex,
the formulas prepared by the Walker-Gordon Laboratories were made
with care, were unlikely to be seriously contaminated with pathogens
and were therefore generally more satisfactory than formulas made in
the home. For all its prominence in the literature, this "American
Method" of formula prescription was not widely used in rural areas
nor by less affluent families in urban areas. Thus, the majority of
formula-fed infants received formulas made in the home from whole
milk or "top milk" (i.e., milk with 710% fat). Because the tough
curd formation associated with feeding cows milk protein presented a
greater problem to the infant than the digestion of butterfat, the use
of "top milk" resulted in more digestible formulas.
By 1912, clean milk was generally available in New York City
(Rosen 1958
) and it seems likely that similar
improvements in dairying practices and milk handling had occurred in
much of the United States. Rubber nipples that could be readily cleaned
had come into widespread use (Brennemann 1912
), and safe
storage of milk in many homes had become possible because of the
availability of the kitchen icebox (Fig. 1
). The important contribution on the energy requirements of infants
(Rubner and Heubner 1899
) had gained general recognition
and at least some physicians recommended an energy intake of 100
kcal/(kg · d) during the first few months of life and somewhat
lesser intakes per unit of body weight subsequently (Brennemann 1912
). Nevertheless, even in the 1920s, formulas varied
considerably in energy density. Those fed from 1924 to 1929 to infants
under the care of the Infant Welfare Society of Chicago (Grulee et al. 1934
) were no >53 kcal/dL, whereas formulas made from
whole milk with added Karo syrup (Marriott and Davidson 1923
) or from evaporated milk diluted 1:1 with water and the
addition of Karo syrup (Marriott 1927
) provided nearly
100 kcal/dL.
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| Vitamins |
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Scurvy.
Although scurvy of the adult had been recognized as early as 1734
[citation of Bachstrom by Stewart and Guthrie (1953)
],
the relation between infantile scurvy and scurvy of the adult was slow
to be recognized. It was largely through the efforts of Hess that it
became customary in the 1920s to supplement the diets of infants with
fruit or vegetable juices (McCollum 1957
). The
prevalence of infantile scurvy then decreased substantially.
Rickets.
As urban living in the United States increased during the late 1800s
and early 1900s, infantile rickets increased. The Russian pediatrician,
Schabad, in a series of reports published between 1908 and 1912,
demonstrated that cod liver oil was effective in curing and preventing
rickets (Holt 1963
). In 1920, Mellanby (1920)
demonstrated that a fat-soluble substance could
prevent rickets in puppies; in 1922, McCollum and co-workers (1957)
demonstrated that the fat-soluble substance was not
vitamin A. Use of cod liver oil as a prophylactic measure against
rickets became widespread in the United States by the mid-1920s.
| Other developments before 1930 |
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Evaporated milk was first marketed by Gail Borden in 1858
(Wharton 1941
); beginning in 1885, it was sold in
hermetically sealed cans sterilized by heat. However, because of fear
of producing scurvy, it was not used in infant feeding until the 1920s,
when its use was promoted by several of the leading pediatricians of
the time (Brenneman 1929
, Marriott 1927
,
Marriott and Schoenthal 1929
). Evaporated milk was
relatively inexpensive, could be stored at room temperature and was
free of bacterial contamination until the can was opened. The processes
of evaporation, homogenization and heat treatment resulted in physical
changes in the milk, with an increased percentage of casein adsorbed to
the surface of the fat globules (Council on Foods 1937a
), thus contributing to the reduction in curd tension.
| Beikost |
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18 mo and other vegetables not until 2 y of age or
later. She pointed out that in Holts The Diseases of Infancy
and Childhood, the recommended age for introduction of green
vegetables in the 1911 edition was 36 mo, but that by the 1929 edition,
the age had decreased to 9 mo. However, it is evident that earlier
introduction of beikost was common at least in some areas. Infants
under the care of the Infant Welfare Society of Chicago between 1924
and 1929 received cereal at 5 mo of age and a vegetable at 6 mo of age
(Grulee et al. 1934| The years 19301970 |
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7 d after birth were breast-fed and 60% of
infants discharged >7 d after birth were breast-fed. The data of
Bain regarding percentage of infants initially breast-fed are based
on a review of discharge records and therefore are likely to be more
accurate than the recall data of Hirschman and co-workers
(Hirschman and Hendershot 1979
25% of infants were breast-fed at age 1 wk and only 14%
between 2 and 3 mo of age (Fig. 3
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| Home-prepared infant formulas |
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1 oz of
carbohydrate, usually in the form of corn syrup (Karo) or sucrose. Such
a formula provided
67 kcal/dL, with 15% of energy from protein,
42% from carbohydrate and 43% from fat. Home-prepared formulas
were sometimes made with cows milk (usually pasteurized and
homogenized) rather than with evaporated milk. These formulas provided
about the same distribution of energy from protein, fat and
carbohydrate as did the evaporated milk formulas. Most evaporated milk
and most pasteurized, homogenized whole cows milk were fortified with
vitamin D. Orange juice was given as a source of vitamin C.
Improved general sanitation, safe supplies of water and milk, and
better understanding of both microbiology and nutrient requirements
resulted in a high degree of success with formula feeding, and it was
the opinion of most physicians and the general public that formula
feeding was about as safe and satisfactory as breast-feeding.
However, the infant formulas in general use in the 1950s were
associated with a number of problems unappreciated by physicians and
parents, including the following: 1) the high potential
renal solute load placed the infants, especially young infants, at risk
of developing hypernatremic dehydration during illness (Fomon and Ziegler 1999
); 2) the low content of iron in the
formulas together with the high intake of inhibitors of iron absorption
(Fomon 1993
) were responsible for a high prevalence of
iron deficiency and, in the case of whole-milk formulas, probably
with the added problem in some infants of increased intestinal blood
loss (Ziegler et al. 1990
); 3) intakes of
essential fatty acids were low. In addition, scurvy continued to be
seen. A survey of 226 teaching hospitals in the United States indicated
that during the years 19561960, 713 infants and children were
admitted to these hospitals because of scurvy (Committee on Nutrition 1962
).
| Commercially prepared formulas |
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From the late 1800s, a number of commercially prepared formulas were
available in the form of powders that merely required the addition of
water before being ready to feed to infants. Many of these formulas had
been developed in an attempt to mimic the chemical composition of human
milk, and several researchers had focused their attention on the
greater percentages of low-molecular-weight fatty acids in cows milk
than in human milk, believing that these were responsible for the poor
tolerance of infants to butterfat (Gerstenberger et al. 1915
). Thus, even in the early 1900s, formulas free of
butterfat had been marketed. The cost of powdered formulas was
appreciably greater than that of formulas made from evaporated milk or
whole cows milk, and usage of commercially prepared formulas was
rather low. However, beginning in 1951, when concentrated liquid
formulas (133 kcal/dL) were introduced, considerations of convenience
began to supersede considerations of cost, and the popularity of
commercially prepared formulas increased dramatically
(Fig. 4
). By 1960, concentrated liquid formulas had largely replaced powdered
formulas (Fig. 4)
. The change from home-prepared formulas to
commercially prepared formulas was accelerated by the introduction in
1959 of iron-fortified formulas and the vigorous promotion of these
formulas by the formula industry and by pediatricians (Andelman and Sered 1966
, Committee on Nutrition 1971
). By
the late 1960s, <10% of infants were fed home-prepared formulas
(Fig. 5
).
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As early as 1923, James Gamble had gained at least some understanding
of renal excretion of solutes (Abt 1965
), but it was not
until the 1950s that the relation of renal solute load to water balance
in infants received serious consideration (Cooke et al. 1950
, Darrow et al. 1954
, Pratt et al. 1948
), and not until the 1960s that renal solute load began to
be considered in the design of infant formulas. However, even at the
end of the century, infant formula regulations permitted the marketing
of formulas with undesirably high potential renal solute load. In 1998,
an Expert Panel recommended to the Food and Drug Administration (FDA)
that infant formulas provide a potential renal solute load (i.e.,
solutes of dietary origin that would require renal excretion if none
were diverted into growth and none were lost through nonrenal routes)
no >33 mosm/100 kcal (Raiten et al. 1998
). Although the
FDA took no immediate action on this recommendation, the upper limit of
33 mosm/100 kcal is well above that of formulas marketed during the
last 20 y of the 20th century. However, most of the formulas fed
in the first half of the 20th century exceeded this maximum and
undoubtedly contributed to the prevalence of hypernatremic dehydration.
An iron-fortified formula was introduced in the United States in
1959; by the mid 1960s, most manufacturers offered the same base
formula with or without substantial iron fortification (Fomon 1967
). Many parents and physicians were reluctant to use
iron-fortified formulas because they believed that feeding such
formulas was responsible for constipation, fussiness and intestinal
disturbances in the infants. Studies that failed to confirm such
adverse effects (Nelson et al. 1988
, Oski 1980
) did not seem to change the prejudice against
iron-fortified formulas.
Recognizing that human milk has a preponderance of whey proteins, whereas cows milk has a preponderance of caseins, a milk-based formula with a whey/casein ratio similar to that of human milk was introduced in the United States in 1962 and by the mid 1990s, whey-predominant formulas became the rule. Nevertheless, the whey proteins of cows milk are quite different from those of human milk; even today, rather meager evidence exists that a milk-based formula with added whey proteins results in a product that is superior to a milk-based formula without the additional whey proteins.
Nonmilk-based formulas.
A formula based on soy flour was developed by Hill as a feeding for
infants allergic to cows milk and became commercially available in
1929 (Abt 1965
). Formulas prepared from soy flour were
pale tan in color and had a nutty odor. Parents complained that the
formulas produced loose, somewhat malodorous stools, and resulted in
staining of the reusable cloth diapers that were in general use.
Excoriation of the diaper area was common. The stool characteristics
resulted primarily from the presence of considerable amounts of fiber
in the soy flour. In addition to soy-based formulas, a
meat-based formula and a casein hydrolysate formula were marketed.
Several of these special formulas were not fortified with vitamins when
initially marketed, apparently because pediatric allergists believed
that the vitamin mixes used for vitamin fortification of formulas might
include allergens. In the 1950s and 1960s, a number of vitamin
deficiencies were described (Fomon 1993
). In addition,
goitrogens present in soy flour were responsible for development of
goiters in infants fed a soy flourbased formula unfortified with
iodine. A few cases of vitamin K deficiency were reported in the 1940s
in infants fed a meat-base infant formula (protein from beef heart)
or a casein hydrolysate formula before these formulas were fortified
with vitamin K (Fomon 1993
).
Formulas prepared with isolated soy protein became commercially
available in the United States in the mid-1960s and within 10 y
almost completely replaced soy flourbased formulas. Isolated soy
proteinbased formulas are similar in color to milk-based formulas
and are nearly odorless. Because most of the fiber is removed during
the protein isolation process, the infants stools are generally
similar to those of infants fed milk-based formulas. However, the
process employed in isolation of the protein resulted in elimination of
most of the vitamin K that had been naturally present in the soy
flourbased products, and a few cases of vitamin K deficiency were
reported before the products were fortified with vitamin K
(Fomon 1993
). Development of nutrient deficiencies in
infants fed milk-free formulas was responsible in part for the
development of a series of federal regulatory actions on nutrient
content of infant formulas.
| Governmental regulations concerning infant formulas |
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In 1952 and 1953, an alteration in the method of heat treatment of
concentrated liquid SMA resulted in a decrease in vitamin B-6 content,
and clinical manifestations of vitamin B-6 deficiency developed in a
number of infants (Fomon 1993
). As a result of this
experience, the FDA in 1962 published a proposed revision of the 1941
regulations. A revised final regulation published in 1966 included the
requirement for minimal levels of 11 vitamins and minerals; because of
controversy over the regulations, however, it was not put into effect
(Miller 1989
). Instead, the FDA asked the Committee on
Nutrition of the American Academy of Pediatrics (AAP) to recommend
levels of nutrients in infant formulas. The report of the
Committee on Nutrition (1967)
was used as a basis for
public hearings in 19681969, and the final regulation, published in
1971 (FDA 1971
) included minimum requirements for
protein, fat, linoleic acid and 17 vitamins and minerals.
Commercial formula services and the development of ready-to-feed formulas.
Throughout the first half of the 20th century, hospitals maintained
formula laboratories to prepare formulas for newborns and other
formula-fed infants. This activity required special equipment, was
labor intensive and presented formidable problems in quality control.
In the early 1950s, commercial formula services began operating in a
number of metropolitan areas in the United States (Committee on Nutrition 1965
) and many hospitals elected to use these
services rather than to continue their own activities in formula
preparation. By the early 1960s, considerable discussion centered about
the cost effectiveness of purchasing ready-to-use formulas from outside
sources rather than preparing them intramurally (Fomon 1993
). It was evident that use of a commercial formula service
influenced the choice of stock formula selected by a hospital. For
example, if an evaporated milk formula was offered at $0.09/bottle
while a commercially prepared formula was offered at $0.12/bottle (the approximate purchase price in the early 1960s), the less expensive
formula was likely to be chosen. Manufacturers of various prepared
formulas were therefore motivated to develop competing feeding systems.
In 1963, the Mead Johnson Company introduced the Beneflex system of
feeding in which bulk quantities of any infant formula manufactured by
that company could be transferred aseptically to feeders suitable to
the needs of individual infants (Fomon 1993
). Soon
afterward, the formula manufacturers were able to offer sterile
ready-to-feed formulas in disposable bottles with disposable or
reusable nipples. These were first used in hospitals but were
subsequently made available to the general public. An indication of the
rapid rise in sales of ready-to-feed formulas during the late 1960s and
early 1970s may be seen from Figure 5
. The data in the figure apply to consumer sales and do not include
hospital usage. Early in 1965, approximately equal numbers of hospitals
in the United States used ready-to-feed formulas supplied by
manufacturers and formulas supplied by locally operated commercial
formula services. By 1970, nearly all of the locally based commercial
formula services had ceased to exist, few hospitals prepared their own
formulas intramurally and most newborn nurseries used commercially
prepared, ready-to-feed formulas.
| Cows milk |
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60% of infants from 5 to 6 mo of age were fed cows milk
(Fig. 6
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| Beikost |
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46 mo of age. Beal (1957)
In the 1940s and 1950s, infant cereals were fortified with sodium iron
pyrophosphate or other insoluble iron compounds of low bioavailability;
beginning in 1972, the cereals were fortified with electrolytic iron
powder (Committee on Nutrition 1976b
). On the basis of a
report by Rios et al. (1975)
that electrolytic iron
powder was as well absorbed by infants as was ferrous sulfate, it was
generally assumed that regular feeding of iron-fortified cereals
could meet the infants need for iron. Therefore, most physicians saw
no objection to feeding cows milk.
Throughout the 1960s, salt, monosodium glutamate, sugar and modified
food starches were included in the preparation of many commercially
available strained and junior foods. Salt, monosodium glutamate and
sugar were presumably added to satisfy the preferences of adult taste
panels, and the modified food starches were used to achieve and
maintain the desired physical appearance, consistency and texture of
the products. The manufacturers voluntarily discontinued the use of
monosodium glutamate in 1969. In 1970, a subcommittee of the Food
Protection Committee, Food and Nutrition Board, National Academy of
Sciences/NRC recommended an upper limit of 0.25% for salt added to
commercially prepared infant foods (Filer 1971a
) and
concluded that, when used in accordance with federal regulations, there
was no toxicologic basis for excluding modified food starches from the
diets of infants (Filer 1971b
). Over the next few years,
the manufacturers adjusted their formulations to decrease the
concentration of salt in infant foods. The downward trend in addition
of salt was accompanied by a downward trend in addition of sugar. By
1977, the addition of salt had been discontinued, and sugar was added
to fewer products and in smaller amounts than previously. The decrease
in addition of sugar resulted in a considerable decrease in the energy
density of some products, e.g., strained fruits provided an average of
82 kcal/100 g in 1972 and only 54 kcal/100 g in 1984 (Anderson and Ziegler 1987
). By the late 1970s, all manufacturers had
reduced the number of beikost items to which modified food starches
were added, and had discontinued use of all but a few types of modified
starches.
| American Academy Committee on Nutrition |
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The first report of the Committee, "Ethics and etiquette in
advertising" (Committee on Nutrition 1956
) was written
by May. The second report, "Water requirement in relation to osmolar
load as it applies to infant feeding" (Committee on Nutrition 1957
), I prepared at Mays request. Fortunately, the report
did not acknowledge that I was the author because I had included
calcium and magnesium as components of the renal osmolar load. It was
the first of a series of gradually improving statements that I, and
later Ziegler and I, published on the topic. The second chairman of the
Committee was Charles U. Lowe (19571960) and I was the third chairman
(19601962). During those early years, the reports of the Committee
were primarily educational and did not include policy statements. It
was not until the mid 1960s that the Committee finally gained
nutritional prominence through its assistance to the FDA in defining
nutritional requirements for infant formulas and in setting policy for
nutritional practices relating to infants, children and adolescents.
During the last quarter of the 20th century, the Committee on Nutrition
exerted an enormous influence on child nutrition, most notably on
aspects of infant feeding.
| The years 19701999 |
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| Federal regulations regarding infant formulas |
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A task force of the AAP submitted revised recommendations on nutrient
content of infant formulas to the FDA in 1983 (Forbes and Woodruff 1985
). The final rule, published 2 years later
FDA (1985)
, specified minimum concentrations of 29
nutrients and maximum concentrations of 9 of these nutrients. In 1998,
an Expert Panel made recommendations for revision of the Code of
Federal Regulations (CFR) as it applied to the nutrient content of
infant formulas (Raiton et al. 1998
). This Expert Panel
suggested a number of revisions of the upper and lower limits for
nutrients already specified in the CFR, recommended an upper limit for
potential renal solute load, a change in the assessment of protein
quality and the addition of upper limits for most nutrients. As the
20th century ended, the FDA had taken no action on these
recommendations.
| Formation and growth of the WIC program |
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| Infant formulas |
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14% were still breast-fed
between 2 and 3 mo of age (Fig. 3)
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Until the 1980s, only Wyeth Laboratories marketed a
whey-predominant, milk-based formula in the United States.
Whey-predominant formulas were introduced by other companies in the
1980s and 1990s and by the mid 1990s, nearly all milk-based
formulas contained added whey proteins. From the time of introduction
of isolated soy proteinbased formulas in the mid-1960s until the end
of the 20th century, these formulas were much more widely used in the
United States than in most other countries. Although data that separate
isolated soy proteinbased formulas from several other special
formulas are not available, it seems likely that in 1991 >20% of
formula-fed infants were fed isolated soy proteinbased formulas
(Fomon 1993
). More recent data are not available. The
speculation that generous intakes of isoflavones from soy-based
products might exert adverse effects on infant development
(Setchell et al. 1997
) appears to have been taken more
seriously in other countries than in the United States.
Iron deficiency.
Iron deficiency in infancy in the United States has always been most
prevalent among infants in low income families, presumably at least in
part because these infants are inclined to be of lower birth weight and
therefore, as a group, begin life with lower iron stores than infants
from higher income families. In the 1950s and 1960s, as already
mentioned, most infants were fed cows milk beginning at 46 mo of
age and this practice extended into the early 1970s. Although national
survey data for infants are not available, three surveys of 12- to
36-mo-old children conducted between 1968 and 1980 (Owen et al. 1974
, Pilch and Senti 1984
, Singer et al. 1982
) demonstrated that iron deficiency was relatively common.
In the 19761980 national survey, slightly >10% of children from 1
to 2 y of age were anemic (hemoglobin concentration < 110
g/L) and the great majority of these children were iron deficient
(Pilch and Senti 1984
). In the 19881994 survey, only
3% of children from 1 to 2 y of age demonstrated
iron-deficiency anemia (Looker et al. 1997
). I
concluded in 1987 (Fomon 1987b
) and still believe it
most likely that the origin of the iron deficiency in these children
was during y 1 of life, when absorption of dietary iron was
insufficient to meet the infants needs.
Although sales of iron-fortified formulas increased progressively
from 40% of all formula sales in 1971 to 64% in 1975, 72% in 1980
and 79.5% in 1985 (Fomon 1987b
), this increase exerted
only a modest effect on prevention of iron deficiency until, in the
1980s, formula feeding began to be extended well beyond 6 mo of age.
Figure 9
presents data on the percentage of formula-fed infants receiving
iron-fortified formulas at various ages in 1971, 1980 and 1991. I
have been unsuccessful in obtaining data for 1998 or 1999, but there is
little question that the percentage of infants fed iron-fortified
formulas was quite high in the last few years of the 20th century. Much
of the increase in number of infants fed iron-fortified formulas
from 1971 to 1991 can be accounted for by the increased enrollment in
WIC, because it is evident that many of these infants would otherwise
have been fed cows milk. In 1992, the Committee on Nutrition (1992)
published a forthright recommendation that all
nonbreast-fed infants be fed iron-fortified formulas until 12
mo of age, and this statement probably exerted a major influence on
pediatricians caring for infants not enrolled in WIC.
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Beginning about 1970, use of concentrated liquid formulas declined,
whereas use of powdered and ready-to-feed formulas increased
(Fig. 4)
. By the early 1970s, the physical properties of formula
powders had been improved to the extent that they were much more
readily suspended in water. The increased use of powdered formulas
after 1971 coincided with the increase in breast-feeding. Powdered
formulas are commonly used to make up an occasional formula feeding for
breast-fed infants and many mothers may have continued to use
powdered formulas after cessation of breast-feeding.
| Cows milk |
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In the 1960s and early 1970s, a number of physicians recommended the
feeding of skim milk to infants beginning at 46 mo of age, presumably
motivated by the desire to treat real or imagined obesity or to prevent
development of obesity or atherosclerosis (Fomon 1974
).
We carried out a study (Fomon et al. 1977
) in which
infants were fed from 4 to 6 mo of age a skim milk modified by the
addition of a small amount of safflower oil and fat-soluble
vitamins, and demonstrated that the infants consumed enormous
quantities of the milk and of beikost, gained in length at a normal
rate but gained in weight at a slower rate than did normal infants.
Most impressive was the loss of skinfold thickness, suggesting that the
infants were using body fat stores to make up for the energy deficit of
the diet. We speculated that persistence with such a diet was likely to
be seriously detrimental to the infants. The Maternal and Child Health
Service distributed reprints of our report widely to child health
clinics but whether this had any effect on the practice is difficult to
determine. In any case, with the increase in breast-feeding and
associated changes in attitude toward infant feeding in the 1970s, the
practice of feeding milk with decreased fat content became uncommon.
In 1981, we found evidence that fresh pasteurized cows milk provoked
blood loss in apparently normal infants (Fomon et al. 1981
) and, largely on the basis of this report and a subsequent
one (Ziegler et al. 1990
), the Committee on Nutrition (1992)
recommended that infants who were not
breast-fed should be given iron-fortified formulas rather than
fresh cows milk throughout y 1 of life. Actually, provocation of
gastrointestinal blood loss may not be as important in the development
of iron deficiency in infants fed fresh cows milk as is the presence
in cows milk of large amounts of bovine proteins and calcium, which
are known to be potent inhibitors of nonheme iron absorption
(Cook et al. 1991
, Hallberg et al. 1991
,
Hurrell et al. 1989b
). As early as 1968, a question had
been raised about the bioavailability of electrolytic iron powder of
intermediate particle size (Elwood et al. 1968
), the
iron used to fortify dry infant cereals, and in the 1980s, several
authors (Fomon 1987a
, Hurrell 1984
,
Hurrell et al. 1989a
) concluded that this iron was
probably of low bioavailability.
| Beikost |
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Infant cereal is generally the first beikost item offered to infants,
and the age at which it is introduced is therefore an indication of the
age of introduction of beikost. Changes in the age of introduction of
cereal from 1976 to 1991 are shown in Figure 10
, which is based on a survey carried out from 1976 to 1980
(Sarrett et al. 1983
) and unpublished data from 1991
(Boettcher, J. A., personal communication). The unpublished data
also include age of introduction of cereal in 1999, and these values
are remarkably similar to those for 1991. Thus, by the end of the
century, fewer infants were being fed beikost at 12 mo of age than
had been the case in the mid 1970s, but even at the end of the century,
most infants were being fed beikost before 4 mo of age.
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Delay in introduction of beikost until
4 mo of age may have some
long-term health benefit. In 1979, my colleagues and I speculated
that early introduction of beikost might contribute to establishing
habits of overeating (Fomon et al. 1979
), and this
possibility has been discussed subsequently (Committee on Nutrition 1980
, Fomon 1993
). The argument may be
summarized as follows: Among the more important goals of nutritional
management during infancy is the establishment of sound eating habits,
including the habit of eating in moderation. Establishment of such
habits may require that the infant be encouraged to discontinue eating
at the earliest sign of willingness to do so. The infants willingness
to discontinue eating can be readily detected by an alert individual
who is feeding the infant by breast or bottle and can also be readily
detected during feeding by spoon, but only after the infant is able to
sit with support and has fairly good control of head and neck muscles.
This stage of neuromuscular development is reached in most infants by
4 mo of age.
| What may lie ahead |
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| FOOTNOTES |
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2 Abbreviations used: AAP, American Academy of
Pediatrics; CFR, Code of Federal Regulations; FDA, Food and Drug
Administration; WIC, program for women, infants and children. ![]()
3 Early history of the WIC program was obtained
from the web page, www.usda.gov. ![]()
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