Infant nutrition and breastfeeding

Infant nutrition includes the use of breast milk, infant formula, infant vitamin supplementation, and complementary feeding. Breast milk (i.e., from breastfeeding, self-expression, or donors) is the preferred source of infant nutrition for the first 6 months of life. Contraindications to breastfeeding are rare and include infant metabolic conditions (e.g., galactosemia) and, in lactating individuals, certain untreated infections and the use of toxic substances (e.g., recreational drug use, chemotherapy agents, radioactive agents). Iron-fortified infant formula is an appropriate alternative or supplement to breast milk if indications for formula are present. Exclusively or partially breastfed infants require vitamin D and iron supplementation. Complementary feeding is introduced at 6 months of age, while continuing to provide breast milk or infant formula until 12 months of age. Due to the many benefits of breastfeeding, prolonged breastfeeding is encouraged for ≥ 2 years if desired. To prevent early cessation of breastfeeding, provide regular assessment of breastfeeding and promptly manage any breastfeeding issues or complications. A risk-benefit analysis is recommended before prescribing medications to lactating individuals; most medications are not contraindicated during breastfeeding.

For children ≥ 1 year of age, see “Pediatric well-child anticipatory guidance” for nutritional guidance.

General principles ^[1][2][3][4]

• Counseling on infant nutrition should begin during prenatal care and continue during well-child visits. ^[5]
• While breast milk is preferred, formula is an acceptable alternative.
• Provide education and support for the caregiver's preferred feeding choice. ^[3]

Age < 6 months ^[1][2][3][4]

• Encourage exclusive breast milk for the first 6 months of life. ^[2][3][4][6]
• Iron-fortified infant formula may be used as an alternative or supplement.

Age 6–11 months ^[1][2][3][4]

• Continue breast milk (preferred) and/or iron-fortified infant formula until 12 months of age.
• Introduce complementary foods.
• Water is optional; limit most infants to ≤ 4 oz (120 mL) per day ^[7]
• Introduce a sippy cup.

At 12 months ^[1][2][3][4]

• Recommended beverages: breast milk, whole milk, and/or water
• Encourage continued breast milk ≥ 2 years of age, if desired. ^[3][8]
• Infant formulas or toddler formulas are not recommended. ^[9]
• See “Pediatric well-child anticipatory guidance” for further recommendations.

Discourage parents from offering foods and beverages that are not recommended for infants.

Infant feeding schedule ^[5][10][11]

• Infant feeding should be on demand and guided by infant hunger cues rather than at set times.
• Stop feeding when the infant shows signs of satiety.
• Infants who consume breast milk typically drink smaller amounts and more frequently than formula-fed infants. ^[11]

Do not wake infants for feeds once they are ≥ 1 month of age with good weight gain. ^[12]

Assessment of milk intake ^[1][14]

The following clinical signs apply to both formula-fed and breastfed infants.

Adequate milk intake in newborns

• 8–12 feeds per day
• Signs of infant satiety after feeds
• 6–8 wet diapers per day after the first 2 days
• Stools transition from black to green by day 3 and to a bright, seedy yellow by day 5
• Normal weight patterns ^[1]
  • An initial weight loss < 8% of birth weight
  • After days 3–4, gains 15–30 g/day

Inadequate milk intake in newborns

• No audible swallowing during feeds
• Infant hunger cues persist after feeds
• Lethargy
• Insufficient wet diapers for age (uric acid crystals may be in diaper) ^[15][16]
• Persistent black-green stools after days 3–5.
• Excessive weight loss in breastfed infants

Infant vitamin supplementation

• Vitamin D ^[3][17]
  • Exclusively or partially breastfed infants; : oral vitamin D from birth until meeting the recommended daily intake of vitamin D through diet ^{[17] [3][17]}
  • See “Prevention of vitamin D deficiency” for additional information.
• Iron ^[18][19]
  • Exclusively or partially breastfed infants: oral iron from 4 months of age until consuming the recommended daily intake of iron through diet ^[5][10][19]
  • Premature infants: oral iron from birth until consuming the recommended daily intake of iron through diet ^[19]
  • See “Prevention of iron deficiency in children” for additional information.
• Fluoride for infants ≥ 6 months of age if water supply is not fluoridated ^[10][20]

Exclusively or partially breastfed infants require vitamin D and iron supplementation until they can meet their daily requirements through their diet. ^[10]

In exclusively formula-fed infants, vitamin D and iron supplementation are generally not required unless there are underlying medical conditions (e.g., malabsorption, prematurity). ^[17][18][19]

Breast milk composition

Breast milk contains all the required nutrients (except vitamin D and vitamin K) for infants up to 6 months of age.

• Colostrum: the first milk produced during late pregnancy until 3–4 days postpartum; rich in proteins and immunoglobulins
• Mature milk is composed of:
  • Proteins, lactose and oligosaccharides, fats, minerals, trace elements, and vitamins
  • Proteins and cells that provide passive immunity in neonates
    • Immunoglobulins (secretory IgA), lactoferrin, lysozymes
    • Lymphocytes, macrophages
  • Bifidobacteria that contribute to the neonate's gastrointestinal flora

Refer breastfeeding parents who follow a vegan or vegetarian diet to a dietitian to evaluate for additional nutritional needs (e.g., vitamin B₁₂ supplementation). ^[10][21]

Storage and preparation of breast milk ^[10][22]

• Freshly expressed breast milk: Discard after ≥ 4 hours at room temperature or ≥ 4 days of refrigeration. ^[22]
• Frozen breast milk ^[22]
  • Discard after ≥ 2 hours at room temperature, ≥ 24 hours of refrigeration, or > 12 months in the freezer.
  • Use breast milk that has been frozen the longest first.
  • Thaw breast milk in the refrigerator overnight or with lukewarm water.
  • Never refreeze breast milk.
• Freshly expressed or frozen breast milk: Discard any remaining breast milk offered as a feed within 2 hours after the infant stops feeding.

Donor breast milk, which may be used for very low birth weight infants, should be pasteurized and come from a qualified milk bank. ^[3]

Avoid storing breast milk in the door of the refrigerator or freezer due to temperature fluctuations. ^[22]

Indications for infant formula ^[3][14]

• Parental desire
• Contraindications to breastfeeding
• Need for supplementation, e.g., ^[16]
  • Inadequate breast milk production
  • Signs of inadequate breast milk intake
  • Excessive weight loss in breastfed infants
  • Complications in the infant

Infant formula options ^[7][10][23]

• Iron-fortified infant formulas are an acceptable alternative to breast milk until 12 months of age. Formulations include powdered, concentrated, and ready-to-feed.
• Cow's milk infant formula is the standard initial formula for healthy, term infants.
• Medical indications for specialized formulas include
  • Allergies (e.g., cow milk protein allergy): hypoallergenic formulas
  • Prematurity: premature formulas
  • Galactosemia, lactose intolerance: soy-based formulas
• During formula shortages, see “Tips and Links” for recommendations from trusted societies.

Generic and brand commercial infant formulas are nutritionally equivalent.

Avoid homemade infant formulas due to the risk of nutritional deficiencies. ^[10]

Storage and preparation of infant formula ^[10][24][25]

• Use clean bottles and nipples; sterilization is not necessary for healthy, term infants. ^[26]
• Ensure water is safe to use for consumption.
• Follow package instructions for recommended measurements and preparation.
• Offer prepared formula immediately or keep refrigerated until the infant is ready to feed.
• If warming is desired, use lukewarm water and check the temperature before feeding.
• Discard prepared formula after
  • ≥ 1 hour after being offered as a feed
  • ≥ 2 hours at room temperature
  • ≥ 24 hours of refrigeration

Compared to breastfed infants, the stools of formula-fed infants are usually firmer, browner, and have a stronger odor due to differences in digestion and the composition of formula. The stool frequency of formula-fed infants varies greatly from several stools per day to one stool every 3 to 4 days.

Introducing complementary feeding ^[3][5][10]

• In addition to breast milk or formula, start offering foods at 6 months if the infant shows signs of complementary feeding readiness. ^[10][27]
• Recommend the following:
  • Foods rich in protein, iron, and zinc; iron-fortified infant cereal and pureed meats are good first sources of iron
  • A variety of foods that includes fruits, vegetables, and potentially allergenic foods (see “Food allergy prevention”) ^[27][28]
  • Avoidance of foods and beverages that are not recommended for infants
• Start with 0.5–1 oz (1–2 tbsp) of a single food once a day. ^[10]
  • Consider waiting 3–5 days before introducing another food to monitor for allergic reactions. ^[5][10]
  • Gradually increase the amount, variety, and texture of foods as tolerated.
• Avoid overfeeding.
  • Stop feeding when the infant shows signs of satiety.
  • As solid food intake increases, breast milk and/or formula intake will decrease.
  • See “Infant feeding schedule” for recommendations by age.

Delaying the introduction of allergenic foods (e.g., peanut products, eggs, wheat) is no longer recommended and may increase the risk of food allergies. ^[27][28]

Signs of complementary feeding readiness ^[10]

• Interest when food is presented, e.g., smiling, mouth opening, reaching for food.
• Developmental readiness
  • Good head and neck control
  • Sitting upright with minimal support
  • Exploring objects with the mouth
  • Reaching for desired objects
  • Resolution of the tongue thrust reflex

Infants with developmental delay may not be ready for solid foods at 6 months of age. ^[10]

Foods and beverages to avoid in infants ^[10][29]

• Foods
  • Honey
  • Unpasteurized dairy products, e.g., yogurt, cheese, milk
  • Uncooked meat
  • Sweetened products, e.g., syrups, chocolate
  • Salt, e.g., canned foods, processed meats
  • Fish high in mercury
• Beverages
  • Water: no water if < 6 months of age and generally limit to 4 oz/day between 6–11 months
  • Teas
  • Cow's milk (excluding infant formula) or alternative milk, e.g., goat's milk ^[7]
  • Drinks that are carbonated or sweetened (including artificial sweeteners)

Do not give honey to infants < 12 months of age due to the risk of infant botulism. ^[10][25]

Storage and preparation of complementary food ^[10][30]

Home-prepared food and commercially prepared infant food are acceptable. For commercially prepared food, follow the instructions on the container. For home-prepared food: ^[30]

• Cook foods according to FDA food safety standards. ^[31]
• Do not add sugar, salt, or excess fat.
• Ensure food is served safely to prevent choking hazards.
  • Mash or puree foods to the right consistency.
  • Remove bones from fish and meat before cooking.
  • Cut finger foods, especially round firm foods (e.g., grapes), into small cubes or thin slices. ^[30]
  • Remove seeds and pits.
• Discard food after:
  • Offering it as a feed (due to the risk of contamination)
  • 2 days of refrigeration
  • 3 months in the freezer

General principles ^[1][14]

• Recommend exclusive breastfeeding for all infants 6 months of age.
• Encourage continued breastfeeding ≥ 2 years of age, if desired.
• Consider waiting to introduce nipples (e.g., pacifiers, bottles) until breastfeeding is well-established. ^[32]
• Breastfeeding infants require infant vitamin supplementation.

Physiology of lactation

• Lactogenesis: the process of mammary epithelial cell differentiation and milk production in the mammary gland that begins mid pregnancy as a result of increased estrogen and progesterone levels
• Lactation is initiated by the delivery of the placenta → abrupt ↓ progesterone levels → ↑ prolactin → stimulation of milk secretion
• Maintaining lactation requires suckling, which stimulates the secretion of:
  • Prolactin; from the anterior pituitary: leads to stimulation of continued lactogenesis (milk production); and disruption of pulsatile GnRH secretion (causing lactational amenorrhea)
  • Oxytocin; from the posterior pituitary: leads to stimulation of milk ejection (letdown); and uterine contractions

Benefits of breastfeeding ^[1][3][33]

In addition to promoting infant-parent bonding, breastfeeding offers a range of benefits for both individuals.

• Benefits for the infant include reductions in
  • Infant mortality (e.g., sudden infant death syndrome)
  • Allergic conditions: asthma, atopic dermatitis
  • Infections: AOM, respiratory, gastrointestinal (e.g., pediatric gastroenteritis, necrotizing enterocolitis)
  • Inflammatory bowel disease
  • Metabolic conditions: obesity, type 2 diabetes
• Benefits for the lactating individual
  • Faster postpartum uterine involution and weight loss ^[34]
  • Spaced births for family planning (see “Lactational amenorrhea”)
  • Reduced costs ^[10][35]
  • Decreased risk of cancers (e.g., ovarian, endometrial, breast), hypertension, diabetes mellitus

Breast milk has antimicrobial, antiinflammatory, and immunoregulatory properties, which help the infant's immune system develop. ^[3][25]

Breast milk contains maternal immunoglobulins (especially IgA), which provide passive immunity to the infant. ^[10]

Contraindications to breastfeeding

Discourage the use of alcohol, marijuana, and tobacco while breastfeeding. ^[3]

Lactating individuals with opioid use disorder on stable treatment doses (i.e., methadone or buprenorphine) should be encouraged to breastfeed. ^[36]

LactMed (see “Tips and Links”) and FDA labels are good resources for evaluating medication safety while breastfeeding.

Approach ^[1][14]

• Provide anticipatory lactation counseling at hospital discharge.
• After delivery and at each postpartum and infant well-child visit, assess for:
  • Signs of a good latch
  • Signs of adequate milk intake in newborns
  • Breastfeeding issues and complications
• Offer lactation services to any lactating parent, especially if issues are identified. ^[33][41]

Regular assessment and support for breastfeeding parents may prevent complications and early weaning. ^[14]

Consider using a validated scoring system, e.g., LATCH score, to assess breastfeeding. ^[1]

Signs of a good latch ^[14]

• Pain-free latch for the lactating individual
• Deep latch with most of the areola and nipple in the infant's mouth
• The infant's mouth is open and the lips everted, with the chin and nose resting on the breast.
• Rhythmic sucking and audible swallowing in the infant
• Signs of infant satiety after feeds

• Breastfeeding issues and complications are common reasons for early cessation of breastfeeding.
• Anticipatory lactation counseling, assessment of breastfeeding, and referral to a lactation consultant can prevent or quickly address identified issues.

Encourage continued breastfeeding or breast milk expression while addressing breastfeeding issues or complications. ^[14]

Negative breastfeeding experiences increase the risk for postpartum depression and anxiety; screen and treat individuals accordingly. ^[14][45]