Journal of Nutrition Animal Diets/Enrichment Products...

Home Help [Feedback] [For Subscribers] [Archive] [Search] [Contents]
 QUICK SEARCH:   [advanced]


     


This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Purchase Article
Right arrow View Shopping Cart
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Fomon, S. J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Fomon, S. J.
(Journal of Nutrition. 2001;131:409S-420S.)
© 2001 The American Society for Nutritional Sciences


Supplement

Infant Feeding in the 20th Century: Formula and Beikost1

Samuel J. Fomon

Department of Pediatrics, College of Medicine, University of Iowa, Iowa City, IA 52242


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
The early years of the 20th century were notable for improvements in general sanitation, dairying practices and milk handling. Most infants were breast-fed, often with some formula feeding as well. Availability of the home icebox permitted safe storage of milk and infant formula, and by the 1920s, feeding of orange juice and cod liver oil greatly decreased the incidence of scurvy and rickets. Use of evaporated milk for formula preparation decreased bacterial contamination and curd tension of infant formulas. From 1930 through the 1960s, breast-feeding declined and cow’s milk and beikost were introduced into the diet at earlier and earlier ages. Although commercially prepared formulas, including iron-fortified formulas replaced home-prepared formulas, few infants were breast-fed or formula fed after 4–6 mo of age. Iron deficiency was prevalent. From 1970 through 1999, a resurgence of breast-feeding was associated with a prolongation of formula feeding and an increase in usage of iron-fortified formulas. By the end of the century, formula feeding of older infants had largely replaced feeding of fresh cow’s milk and the prevalence of iron deficiency had greatly decreased.


KEY WORDS: • infant feeding • breast-feeding • infant formula • beikost


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
In 1948 when I began my pediatric residency, I had little awareness of the history of infant feeding during the first half of the 20th century. Since then, I have collected small bits of information in relation to specific interests at the time. As a research fellow in renal physiology, I studied osmotic diuresis and reviewed the literature on renal solute load, including the reports concerning infants. In the 1950s, when I was involved with Charlie May in metabolic balance studies with normal infants, I reviewed the older reports on intakes and excretion of protein, fat and some of the major minerals. However, despite all the effort I invested over the years in trying to define desirable characteristics of infant formulas, I did not attempt an interpretive review of the history of infant feeding; even in my 1993 book (Fomon 1993Citation ), I relied primarily on reviews by other authors for events that occurred before about 1950. Thus, the thoughts presented here as they relate to the first half of the 20th century require some indulgence of the readers. I am on firmer ground during the second half of the century.

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 infants—areas 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 1993Citation ). 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 cow’s milk had been defined. Even at the beginning of the 20th century, it was generally appreciated that infant formulas based on cow’s milk required the addition of water and carbohydrate. A number of commercially prepared formulas were patented. Liebig’s food for infants, marketed in 1867 as a liquid and subsequently as a powder, consisted of wheat flour, cow’s milk, malt flour and potassium bicarbonate (Forsyth 1910–1911Citation , Smith 1885Citation ). Other formulas were introduced in rapid succession; by 1883, 27 brands of patented infant foods were available (Bracken 1953Citation ). However, relatively few infants were fed commercially prepared formulas.


    The years 1900–1930
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
In 1900, general sanitation and dairying practices, although better than in the past, were still quite primitive by current standards. Seamless rubber nipples, which could be fitted over the necks of feeding bottles had become available but were apparently not widely used (Brennemann 1912Citation ); thus, cleaning of bottles and nipples was generally unsatisfactory. Means for safe storage of formula in the home were not generally available, and adulteration of milk was common. The possibility that inadequate intakes of vitamins or of trace minerals could lead to disease had not been considered. As stated by Langworthy in 1898 (McCollum 1957Citation ), it was generally believed that "Foods have a dual purpose: Building and repair. Energy for heat and work. Foods consist of the nutrients protein fat and carbohydrates and various mineral salts."

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)Citation ]. A survey of a number of urban centers in 1912–1919 indicated that at 12 mo of age, 13% of infants were exclusively breast-fed and 45% were partially breast-fed (Yankauer 1994Citation ).

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 1911Citation ). 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 1898Citation ).

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 1907Citation ). 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 1935Citation ) and Walker-Gordon Laboratories, which used this milk, were in operation in many cities in the early 1900s (Friedenwald and Ruhrah 1905Citation , Morse 1935Citation ). 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 7–10% fat). Because the tough curd formation associated with feeding cow’s 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 1958Citation ) 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 1912Citation ), and safe storage of milk in many homes had become possible because of the availability of the kitchen icebox (Fig. 1Citation ). The important contribution on the energy requirements of infants (Rubner and Heubner 1899Citation ) 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 1912Citation ). 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. 1934Citation ) were no >53 kcal/dL, whereas formulas made from whole milk with added Karo syrup (Marriott and Davidson 1923Citation ) or from evaporated milk diluted 1:1 with water and the addition of Karo syrup (Marriott 1927Citation ) provided nearly 100 kcal/dL.



View larger version (10K):
[in this window]
[in a new window]
 
Figure 1. Changes in infant feeding and nutrition from 1900 to 1930: major improvements in sanitation, dairying practices and milk handling occurred from 1900 to 1912; sterilizable rubber nipples and the home icebox became widely available by 1912; beginning in the early 1920s, feeding of orange juice and cod liver oil resulted in decrease in the prevalence of scurvy and rickets, and use of boiled or evaporated milk in formula preparation from the mid-1920s resulted in infant formulas with lower curd tension and less bacterial contamination.

 

    Vitamins
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
As reviewed by McCollum (1957)Citation , a number of animal studies in the late 1800s and early 1900s had demonstrated that, despite the scientific consensus of the time, diets containing protein, fat, carbohydrate and mineral salts were inadequate to support life. An enlightened view was presented by Hopkins (1906)Citation : "The animal body is adjusted to live either on plant tissues or on other animals, and these contain countless substances other than proteins, carbohydrates and fats. Physiologic evolution, I believe, has made some of these well nigh as essential as are the basal constituents of the diet." In 1912, Funk (1912)Citation suggested that beriberi, scurvy, pellagra and possibly rickets were caused by deficiency in the diet of special substances for which he proposed the name, "vitamines."

Scurvy.

Although scurvy of the adult had been recognized as early as 1734 [citation of Bachstrom by Stewart and Guthrie (1953)Citation ], 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 1957Citation ). 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 1963Citation ). In 1920, Mellanby (1920)Citation demonstrated that a fat-soluble substance could prevent rickets in puppies; in 1922, McCollum and co-workers (1957)Citation 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
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
By the mid-1920s, when it was known that infantile scurvy could be prevented by daily feeding of fruit juices, the prejudice against use of boiled milk in infant formulas disappeared and formula feeding became much more successful. To modify curd tension, lactic acid was commonly used. The use of lactic acid rather than lime water for modifying curd tension may have occurred because of the advantage of acidified over alkalinized formulas in inhibiting bacterial growth.

Evaporated milk was first marketed by Gail Borden in 1858 (Wharton 1941Citation ); 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 1929Citation , Marriott 1927Citation , Marriott and Schoenthal 1929Citation ). 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 1937aCitation ), thus contributing to the reduction in curd tension.


    Beikost
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
Although cereal was commonly included as a constituent of infant formulas in the early 1900s, the purpose of its inclusion was the reduction of curd tension, not as an energy source. With the use of evaporated milk for infant formulas, cereal was no longer needed. On the basis of her review of the literature, Adams (1959)Citation stated that until the 1920s, the usual feeding pattern in the United States was introduction of sieved vegetable soup by the end of y 1, potato at ~18 mo and other vegetables not until 2 y of age or later. She pointed out that in Holt’s 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. 1934Citation ).


    The years 1930–1970
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
Various developments in infant feeding and nutrition from 1930–1970 are indicated in Figure 2Citation . Although data on the percentage of infants who were breast-fed in the United States from 1930 to 1950 are less satisfactory than later data, there is no question that the trend was downward. Data from the National Fertility Study (Hirschman and Hendershot 1979Citation , Hirschman and Butler 1981Citation ), indicate that from 1931 to 1935, >70% of first-born infants and a somewhat lesser percentage of second-born infants were initially breast-fed and 40% of infants were breast-fed for at least 6 mo. By 1946–1950, initial breast-feeding of first-born infants had decreased to 50% and only 20% were breast-fed for at least 6 mo. A survey of hospitals carried out in 1945 (Bain 1948Citation ) indicated that 69% of infants discharged <=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 1979Citation , Hirschman and Butler 1981Citation ). During the 1950s and 1960s, the trend in breast-feeding was steadily downward, and by the early 1970s, only ~25% of infants were breast-fed at age 1 wk and only 14% between 2 and 3 mo of age (Fig. 3Citation ).



View larger version (13K):
[in this window]
[in a new window]
 
Figure 2. Changes in infant feeding and nutrition from 1930 to 1970: breast feeding declined, whereas beikost and fresh cow’s milk were introduced at earlier and earlier ages. The first federal regulations concerning infant formulas went into effect in 1941 and, beginning in 1950, commercially prepared formulas began to replace home-prepared formulas. Iron-fortified formulas were introduced in 1959.

 


View larger version (12K):
[in this window]
[in a new window]
 
Figure 3. Exclusively and partially breast-fed infants as percentage of all infants in 1971, 1991 and 1998. Data for 1971 from Martinez and Krieger (1985)Citation and for 1991 from personal communication from Ross Mothers’ Survey (Greenbaum, S., 1992, Ross Products Division, Columbus, OH). A smoothed curve is presented for 1998 based on data from personal communications from Boettcher, J. A. (1999, Mead Johnson Nutritionals, Evansville, IN) and the Ross Mothers’ Survey (Ryan, A., 2000; Ross Products Division, Columbus, OH).

 

    Home-prepared infant formulas
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
From the 1930s or early 1940s, most formulas fed to infants in the United States were prepared by mixing evaporated milk or fresh cow’s milk with water and adding carbohydrate. A typical evaporated milk formula, as prepared in 1949, when I was a pediatric resident, included 1 can (13 fl oz) of evaporated milk, 19 fl oz of water, and ~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 cow’s 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 cow’s 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 1999Citation ); 2) the low content of iron in the formulas together with the high intake of inhibitors of iron absorption (Fomon 1993Citation ) 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. 1990Citation ); 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 1956–1960, 713 infants and children were admitted to these hospitals because of scurvy (Committee on Nutrition 1962Citation ).


    Commercially prepared formulas
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
Milk-based formulas.

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 cow’s milk than in human milk, believing that these were responsible for the poor tolerance of infants to butterfat (Gerstenberger et al. 1915Citation ). 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 cow’s 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. 4Citation ). By 1960, concentrated liquid formulas had largely replaced powdered formulas (Fig. 4)Citation . 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 1966Citation , Committee on Nutrition 1971Citation ). By the late 1960s, <10% of infants were fed home-prepared formulas (Fig. 5Citation ).



View larger version (15K):
[in this window]
[in a new window]
 
Figure 4. Commercially prepared formula sales by type from 1950 to 1998: powder, concentrated liquid (133 kcal/dL) and ready-to-feed (67 kcal/dL). Data through 1987 based on Ross Mothers’ Survey, personal communication from Martinez, G. A. (1989, Ross Products Division, Columbus, OH); subsequent data based on personal communication from Boettcher, J. A. (2000, Mead Johnson Nutritionals, Evansville, IN).

 


View larger version (14K):
[in this window]
[in a new window]
 
Figure 5. Percentage of 2- to 3-mo-old infants receiving various forms of feeding from 1958 to 1970: feeding of commercially prepared formulas (prepared) increased and feeding of formulas based on evaporated milk (EM) decreased. Relatively few infants were breast-fed and few young infants were fed cow’s milk (CM). Data based on Ross Mothers’ Survey, personal communication from Martinez, G. A (1989, Ross Products Division, Columbus, OH).

 
From at least the 1930s (Powers 1935Citation ) until the 1950s, the protein concentration of human milk was believed to be greater than is now known to be the case, and many pediatricians believed that cow’s milk protein was so inferior to human milk protein for meeting the needs of infants that infants fed formulas required a considerably greater intake of protein than did breast-fed infants. Protein content of a number of widely used formulas ranged from 3.3 to 4.0 g/100 kcal and several formulas recommended for use in management of infants with diarrhea provided 5.7–6.3 g/100 kcal (Fomon 1967Citation ). During the late 1950s and early 1960s, most of the leading commercially prepared formulas fell into one of two classes. One class (e.g., Lactum, Mead Johnson) consisted of formulas similar to home-prepared evaporated milk formulas but with added vitamins; the other class (e.g., Similac and SMA) were of lower protein content and contained a mixture of vegetable and oleo oils with added vitamins and minerals. The gradual takeover of the market by the latter formulas seems not to have been based on considerations of nutrient requirements or renal solute load, but on the unpleasant odor of regurgitated butterfat after its partial digestion and on the impression that formulas similar to the home-prepared evaporated milk formulas led to constipation.

As early as 1923, James Gamble had gained at least some understanding of renal excretion of solutes (Abt 1965Citation ), 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. 1950Citation , Darrow et al. 1954Citation , Pratt et al. 1948Citation ), 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. 1998Citation ). 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 1967Citation ). 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. 1988Citation , Oski 1980Citation ) did not seem to change the prejudice against iron-fortified formulas.

Recognizing that human milk has a preponderance of whey proteins, whereas cow’s 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 cow’s 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 cow’s milk and became commercially available in 1929 (Abt 1965Citation ). 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 1993Citation ). In addition, goitrogens present in soy flour were responsible for development of goiters in infants fed a soy flour–based 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 1993Citation ).

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 flour–based formulas. Isolated soy protein–based 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 infant’s 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 flour–based products, and a few cases of vitamin K deficiency were reported before the products were fortified with vitamin K (Fomon 1993Citation ). 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
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
The United States was among the last of the major industrialized countries to implement federal regulations concerning safety of infant formulas (Miller 1989Citation ). It was not until 1938 that the new Food and Drug Act included reference to foods for special dietary purposes, including infant formulas. In 1941, the FDA declared that a food sold for use by infants should include a label declaration for moisture, energy, protein, fat, available carbohydrates, fiber, calcium, phosphorus, iron and vitamins A, B-1, C and D.

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 1993Citation ). 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 1989Citation ). 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)Citation was used as a basis for public hearings in 1968–1969, and the final regulation, published in 1971 (FDA 1971Citation ) 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 1965Citation ) 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 1993Citation ). 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 1993Citation ). 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 5Citation . 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.


    Cow’s milk
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
Comprehensive data on the percentage of infants fed cow’s milk at various ages in the 1940s through the 1960s are not available, but Harris and Chan (1969)Citation in a limited survey found that 60% of infants were fed whole milk by 4 mo of age. The percentage may not have been quite as high for the entire country. In 1971, >30% of infants from 3 to 4 mo of age, >40% of infants from 4 to 5 mo of age and ~60% of infants from 5 to 6 mo of age were fed cow’s milk (Fig. 6Citation ). On the basis of data from various sources, I estimated that in 1975 (Fomon 1975Citation ), 58% of 5- to 6-mo-old infants were fed cow’s milk.



View larger version (13K):
[in this window]
[in a new window]
 
Figure 6. Infants fed cow’s milk (no breast-feeding, no formula feeding) as percentage of all infants in 1971, 1980 and 1991. Data for 1971 and 1980 from Martinez et al. (1981)Citation ; data for 1991 based on personal communication from Ross Mothers’ Survey (Greenbaum, S., 1992, Ross Products Division, Columbus, OH).

 
Because it was not yet appreciated that feeding of homogenized, pasteurized cow’s milk to young infants could predispose to dehydration during illness and to development of iron deficiency, there seemed therefore little reason not to change at an early age from feeding formula to feeding fresh cow’s milk. Cow’s milk was considerably less expensive than infant formula, required no mixing and was a staple item in the home. Moreover, many parents probably considered that the ability of an infant to tolerate at a young age a diet more closely approaching that of older children was an index of infant development and maturity.


    Beikost
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
Following the trend of the previous two decades, the recommended age for introduction of beikost continued to decrease from 1930 to the early 1970s. In 1935, Marriott (1935)Citation suggested mo 5 or 6 as an appropriate age for introduction of solid foods, and in 1937 the American Medical Association (Council on Foods 1937bCitation ) stated that pediatricians favored feeding of strained fruits and vegetables at ~4–6 mo of age. Beal (1957)Citation reported that in an upper socioeconomic group in Denver, strained foods were offered to the infant at increasingly early ages during the years 1946 through 1955, and this seemed to be a general trend. Among pediatricians responding to a survey in 1954, feeding of solids was recommended before 8 wk of age by 66% and before 3 mo of age by 88% (Butler and Wolman 1954Citation ). Most extreme were the recommendations of Sackett (1953)Citation , who promoted feeding of cereal at 2–3 d of age, strained vegetables at 10 d and strained fruits at 17 d. In 1963, Epps and Jolley (1963)Citation reported that when infants were seen for a first health visit at 1–2 mo of age in the Child Health Clinics of the District of Columbia, 83% were already receiving beikost. On the basis of a survey in Rochester, Minnesota, in the late 1960s, Harris and Chan (1969)Citation reported that nearly 80% of infants were being fed cereal by 1 mo of age. In 1975, I estimated that 5- to 6-mo-old infants obtained 40% of energy intake from beikost (Fomon 1975Citation ). Such a diet can be calculated to be generous in protein and carbohydrate and relatively low in fat (Fomon et al. 1990Citation ). Because few infants were fed iron-fortified formulas (or any formulas) after 5 or 6 mo of age, beikost contributed most of the dietary iron for most infants, and dry powdered cereals fortified with iron were the major contributors.

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 1976bCitation ). On the basis of a report by Rios et al. (1975)Citation 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 infant’s need for iron. Therefore, most physicians saw no objection to feeding cow’s 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 1971aCitation ) 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 1971bCitation ). 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 1987Citation ). 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
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
In 1954, soon after I arrived in Iowa as an assistant professor in the Department of Pediatrics, the chairman of the department, Charles D. May, was asked by the executive director of the AAP to serve as chairman of a new committee of the Academy, the Committee on Nutrition, which had been established by the Executive Board of the Academy on April 1, 1954 (Executive Board 1956Citation ). In those days, the AAP operated in a much less formal mode than was to be the case in later years, and May was given complete freedom in choosing members, mostly from pediatric departments, to serve on the committee. A liaison group of scientists and administrators was also established with individuals from governmental agencies, including the FDA and the infant food industry. With the aid of suggestions from May, the Executive Board of the Academy in 1956 outlined the scope of the Committee activities as follows: "This Committee shall concern itself with standards for nutritional requirements, optimal practices and the interpretation of current knowledge as these affect infants, children and adolescents."

The first report of the Committee, "Ethics and etiquette in advertising" (Committee on Nutrition 1956Citation ) was written by May. The second report, "Water requirement in relation to osmolar load as it applies to infant feeding" (Committee on Nutrition 1957Citation ), I prepared at May’s 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 (1957–1960) and I was the third chairman (1960–1962). 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 1970–1999
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
 
Infant feeding in the United States during the last 30 y of the 20th century was marked by increases in breast-feeding and formula feeding and a decrease in feeding of cow’s milk (Fig. 7Citation ). The increase in breast-feeding in industrialized countries in the 1970s was worldwide, and the reasons for the increase after several decades of decline are not easy to identify. The movement toward increased breast-feeding seemed to arise from the general public rather than from health professionals, and may have been in part associated with negative publicity directed against the formula industry. The formula industry was accused of interfering with breast-feeding in lesser industrialized countries by its aggressive marketing of infant formulas (Joseph 1981Citation , McComas 1988Citation ). In the 1970s in the United States, the National Council of Churches’ Interfaith Center on Corporate Responsibility and the Infant Formula Action Coalition mounted an effective public awareness campaign. Likely in response to this new climate, the infant formula manufacturers increased their efforts to promote breast-feeding.



View larger version (14K):
[in this window]
[in a new window]
 
Figure 7. Changes in infant feeding and nutrition from 1970 to 2000: breast-feeding increased, although the duration of breast-feeding was generally <6 mo and was commonly accompanied by formula feeding. The change from breast- or formula feeding to feeding of cow’s milk occurred at progressively later ages. The women, infants and children (WIC) program included a larger and larger percentage of infants from low income families and contributed to increased breast-feeding and use of iron-fortified formulas in this group. The American Academy of Pediatrics (AAP) Committee on Nutrition provided guidance to the Food and Drug Administration (FDA) on the nutrient content of infant formulas and issued policy statements on infant feeding, including one that contributed to the later introduction of cow’s milk. Federal regulations on infant formulas included the Infant Formula Act of 1980 and a new regulation in 1985 on nutrient content of infant formulas.

 

    Federal regulations regarding infant formulas
 TOP
 ABSTRACT
 INTRODUCTION
 The years 1900-1930
 Vitamins
 Other developments before 1930
 Beikost
 The years 1930-1970
 Home-prepared infant formulas
 Commercially prepared formulas
 Governmental regulations...
 Cow’s milk
 Beikost
 American Academy Committee on...
 The years 1970-1999
 Federal regulations regarding...
 Formation and growth of...
 Infant formulas
 Cow’s milk
 Beikost
 What may lie ahead
 REFERENCES
&