Breast Milk Substitutes - Types, Indications, Selection, and Storage

Introduction:

Breastfeeding is vital for a child’s growth and development. Exclusive breastfeeding should be provided to infants until six months of age. It is the healthiest way to feed an infant in their initial days after birth. Breast milk contains antibodies and other components that protect children when their immune system is underdeveloped. In addition, breast milk is considered life-saving in many neonatal infections.

The World health organization (WHO) and UNICEF emphasized maintaining breastfeeding and promoting breastfeeding wherever it was declining. Therefore, it is recommended for all mothers to continue breastfeeding for up to six months and continue breastfeeding and introduce some solid food items later. It also encourages breastfeeding until the mother and the baby desire it.

Breast milk substitutes could serve the nutritional needs of infants when breast milk is unavailable. However, studies claim that breastfeeding mothers either decrease the number of breast milk feedings or cease breastfeeding when other kinds of milk are introduced into the infant's diet.

What Are Breast Milk Substitutes?

According to the World health organization (WHO), breast milk substitutes include milk specially marketed for feeding infants and young children up to three years. Whether or not suitable, it could be any food (solid or liquid) present in the market that can be used as a partial or total replacement for breastmilk.

The World health assembly adopted the international code of marketing of breast-milk substitutes1 for protecting and promoting breastfeeding. It is focused on ensuring the appropriate marketing and distribution of breast-milk substitutes. It indicates that infant formula was only one type of breast milk substitute and the code was not able to specify any age range for products.

However, in 2016 the WHO established guidance 2 to clarify that breast milk substitutes could be any milk or products that could replace the milk. It could be fortified soy milk, either in liquid or powdered form, available in the market, especially for feeding infants and young children up to the age of three years.

When Is Breast Milk Substitute Indicated for an Infant?

The world health organization recommends that mothers initiate breastfeeding during the first hour after birth. After that, it should be continued until six months, which can then be modified along with the introduction of other solid or liquid foods into the diet. The infant must receive adequate nutrition that fulfills their growing needs. However, exclusive breastfeeding is not possible for some moms under certain circumstances.

Some of the commonly reported situational concerns that require breast milk substitutes are:

• Infants and young children who have lost their moms at birth or when their mother is unavailable for a more extended period.

• When donor human breast milk is unavailable for feeding the infant.

• There is a medical condition when breastfeeding is prohibited (e.g., medical conditions when the mother is not allowed to breastfeed either temporarily or permanently).

• Sometimes as a temporary measure, while the mothers are being supported for transition to exclusive breastfeeding, infants under six months of age are mixed-fed, including breastfeeding and breast milk substitutes.

What Are the Infant Conditions Which Warrant Breast Milk Substitutes?

• Infants who are not supposed to receive breast milk or any other milk except specialized formula.

• Infants with classic galactosemia: a special galactose-free formula is needed.

• Infants with maple syrup urine disease: a special formula free of leucine, isoleucine and valine is needed.

• Infants with phenylketonuria: a special phenylalanine-free formula is needed (some breastfeeding is possible, under careful monitoring).

What Are the UNICEF Guidelines for the Selection of Appropriate Breast Milk Substitutes?

UNICEF demands that the provision of breast milk substitutes should adequately meet the quantity and quality of the infants who are dependent on artificial feeding. It also prioritizes the needs of infants aged 0 to 6 months of age if the resources are limited.

The guidelines for breast milk substitutes for infants should include the following:

• All breast milk substitutes (BMS) used must comply with the Codex Alimentarius Standards.

• Marketed products containing generic labeling followed by branded products are preferred.

• The container should be labeled in a local language. However, in situations when this is impossible, stickers should be prepared in a language that the targeted population can easily understand.

• The powdered infant formula (PIF) preparation should follow the WHO guidance.

What Are the Storage Guidelines for Breast Milk Substitutes?

Breast milk substitutes must follow the manufacturer’s guidelines for storing the containers. It is best to keep RUIF (ready-to-use infant formula) and PIF away from direct sunlight. It should be placed in a secure and supervised area. Storage instructions of room temperature must be followed. It can resist temperatures up to 40°C as well as below 0°C. It is a high-value product and is often subject to theft for use or resale. Therefore, it should be taken into consideration that it is kept out of sight to avoid being interpreted as a promotion for artificial feeding.

Which Is the Most Appropriate Breast Milk Substitute for Infants and Young Children?

Infants and young children older than six months for whom breastfeeding is unavailable can use RUIF if available and affordable. RUIF is a product that can be used directly for infant feeding once the container is opened. In addition, it is a sterile product until it is opened, which does not require reconstitution with water, unlike PIF. Therefore, it is the safest option for feeding this vulnerable age group. However, PIF may be considered in a particular case. The other alternative could be fat milk that has undergone ultra-heat treatment (UHT) can also be used for this age group of infants. It is comparatively cheaper.

Some other known breast milk alternatives are:

• Whole fat milk.

• Pasteurized full-cream milk from a cow, goat, sheep, camel, or buffalo.

• Ultra-high-temperature liquid milk.

• Fermented liquid milk.

• Yogurt.

All these alternatives are safer than the powdered infant formula as it is a non-sterile product requiring unsafe preparations.

Conclusion:

As per World health organization (WHO) recommendations, the international code aims to save breastfeeding by inhibiting inappropriate marketing and distribution of breast-milk substitutes. Continued breastfeeding for up to two years is beneficial for both the mother and the infant. It can save lives, so it is crucial to include a follow-up formula. Studies report that follow-up formula can replace breast milk intake and therefore acts as a breast-milk substitute. Sanitization guidelines must be followed to avoid any complications in an infant.