Published online: 2021-09-23

THIEME
Review Article | Artigo de Revisão 61

Infant Formulas: A Long Story

Fórmulas infantis: uma longa estória
Mário Cícero Falcão1 Patrícia Zamberlan1

1 Child and Adolescent Institute, Hospital das Clínicas, Faculdade de Address for correspondence Mário Cícero Falcão, MD, PhD, Av Dr
Medicina, Universidade de São Paulo, São Paulo, SP, Brazil Eneas Carvalho Aguiar, 647, São Paulo, CEP: 05403-020, Brazil
(e-mail: [email protected]).
Int J Nutrol 2021;14(2):e61–e70.

Abstract The ideal feeding for infants is the breast milk because it has a balanced nutritional
composition, which includes all essential nutrients, in addition to many bioactive
factors that contribute to the growth and development of the child, as well as to the
maturation of the gastrointestinal tract. Among them are immunological factors,
antimicrobials and anti-inflammatory components, digestive enzymes, various types
of hormones, and growth factors. If human milk is not available, there is an indication of
infant formulas that should follow the recommendations of the Codex Alimentarius of
the Food and Agriculture Organization/World Health Organization (WHO). In a century
of history, infant formulas have gone from a simple combination of cow milk
(evaporated or condensed) and water to highly sophisticated products, elaborated
by very refined technological processes to produce lactose-free, antiregurgitation,
based on soy protein, hydrolyzed protein in various grades, and only amino acids
Keywords formulas. The major milestones in the modification of infant formulas were the
► breast feeding incorporation of nutrients/ingredients such as: iron, nucleotides, alpha lactalbumin,
► breast-milk long-chain polyunsaturated fatty acids, prebiotics, probiotics, postbiotics, oligosac-
substitutes charides similar to human milk, lactoferrin, and milk fat globule membrane. Many of
► bottle feeding these ingredients have shown benefits on the immunological system. Despite the
► infant formula technological advances, breast milk remains irreplaceable, being the gold standard for
► infant infant feeding.

Resumo A alimentação ideal do lactente é o leite materno, por possuir uma composição
nutricional equilibrada que inclui todos os nutrientes essenciais, além de muitos fatores
bioativos que contribuem para o crescimento e o desenvolvimento da criança, assim
Palavras-chave como para o amadurecimento de seu trato gastrintestinal. Entre eles, destacam-se
► aleitamento materno fatores imunológicos, antimicrobianos, anti-inflamatórios, enzimas digestivas, vários
► substitutos do leite tipos de hormônios e fatores de crescimento. Ante a impossibilidade do uso do leite
humano humano, existe a indicação de fórmulas infantis que devem seguir as recomendações
► alimentação artificial do Codex Alimentarius da Food and Agriculture Organization/Organização Mundial da
► fórmulas infantis Saúde (OMS). Em um século de história, as fórmulas infantis passaram de uma simples
► lactente combinação de leite de vaca (evaporado ou condensado) e água para produtos

received DOI https://doi.org/ © 2021. Associação Brasileira de Nutrologia. All rights reserved.
July 3, 2021 10.1055/s-0041-1735640. This is an open access article published by Thieme under the terms of the
accepted ISSN 1984-3011. Creative Commons Attribution-NonDerivative-NonCommercial-License,
July 15, 2021 permitting copying and reproduction so long as the original work is given
appropriate credit. Contents may not be used for commercial purposes, or
adapted, remixed, transformed or built upon. (https://creativecommons.org/
licenses/by-nc-nd/4.0/)
Thieme Revinter Publicações Ltda., Rua do Matoso 170, Rio de
Janeiro, RJ, CEP 20270-135, Brazil
62 Infant Formulas: A Long Story Falcão et al.

altamente sofisticados, elaborados por processos tecnológicos bastante refinados,

surgindo as fórmulas isentas de lactose, antirregurgitação, à base da proteína da soja,
com proteína hidrolisada em vários graus e somente de aminoácidos. Os grandes
marcos na modificação das fórmulas infantis foram as incorporações de
nutrientes/ingredientes tais como: ferro, nucleotídeos, alfa lactoalbumina, ácidos
graxos polinsaturados de cadeia longa, prebióticos, probióticos, pósbióticos, oligossa-
carídeos similares ao leite humano, lactoferrina e membrana do glóbulo de gordura.
Muitos destes ingredientes têm mostrado benefícios do ponto de vista imunológico.
Apesar dos avanços tecnológicos, o leite materno continua insubstituível, sendo o
padrão ouro para a alimentação de lactentes.

Introduction feeding the infant with breast milk, there is the indication of
infant formulas.
Knowledge of child nutrition is fundamental in the training
of health professionals, as it enables them to deal with
Brief History of Infant Milk Feeding
frequent situations in the clinical practice. Knowing and
understanding these processes, from food acceptance to Feeding infants who do not receive human milk has been a
the use of different nutrients, is a situation of great relevance problem for centuries. Wet nurses have already been used (a
in the care of the child. method that is currently not allowed), and cow and other
The adequacy of the diet to the needs of the child ensures mammalian animals milk, plus starch and sucrose, with high
their nutrition, a process to which all other vital functions morbidity for infants due to inadequate preparation techni-
are subordinated. Nutrition is one of the main determinants ques and to their composition (high protein content, low
of the health and wellbeing of the human being and assumes bioavailability of iron, excess saturated fatty acids, and high
special importance in early life. caloric density).3
Subordinates such as the incorporation of nutrients to the After comparations between the composition of cow and
body, growth and development, and fundamental character- human milks, several efforts were made to make cow milk
istics of the child are, consequently, highly dependent on the more similar to human milk, from the point of view of the
satisfaction of nutritional needs. composition of macronutrients (proteins, carbohydrates,
Human milk is considered the ideal food for the newborn and lipids).4
and infant. It is known that milk produced by healthy Thus, around 1920, commercial formulas began to be
mothers is sufficient to meet all nutritional needs during produced; however, these formulas were homemade prep-
the 1st 6 months of life, exclusively and up to  2 years old arations, using whole cow milk (evaporated or condensed),
together with complementary feeding.1 corn syrup, and water.3
Human milk has a balanced nutritional composition, These mixtures presented the same problems as fresh cow
which includes all essential nutrients, in addition to many milk, that is, very high protein content, inadequate lipid
conditionally essential and  45 different types of bioactive profile, with excess saturated fatty acids and very little
factors; many of these factors contribute to the growth and supply of essential fatty acids and extremely low in vitamins,
development of the infant, as well as to the maturation of the especially vitamin C, besides presenting a high load of renal
gastrointestinal tract. Among them, stand out antimicrobial solutes, which can lead to hypertonic dehydration and
factors, anti-inflammatory agents, digestive enzymes, vari- kidney injury.4
ous types of hormones, and growth factors.2 From 1950 on, safer and easier preparation infant formu-
The numerous benefits of breastfeeding for the infant las have been designed, with important changes in their
organism include hygienic, immunological, psychosocial, composition:4
and cognitive aspects, as well as those related to the prevention
1. Lower protein content and change in the ratio between
of future diseases. The economic advantages of breast milk due
whey protein and casein;
to its lower cost and contraceptive effect, as well as the benefits
2. Better lipid profile, with gradual decrease in the content of
of breastfeeding on the organism of the mother, should also be
saturated fatty acids of animal origin and added mixtures
considered. Human milk is undoubtedly the great example of
of vegetable oils;
immune nutrition, drastically decreasing infectious diseases,
3. Addition of lactose and other carbohydrates
mainly gastrointestinal and respiratory diseases.2
(maltodextrin);
Unfortunately, a good portion of infants, for various
4. Adjustments in micronutrient content.
reasons, do not receive breast milk, and, therefore, the
pediatrician has the task of prescribing the best alternative A few years later, acidified formulas emerged, which were
in this situation. In the absence or in the impossibility of obtained by adding lactic or citric acids to partially

International Journal of Nutrology Vol. 14 No. 2/2021 © 2021. Associação Brasileira de Nutrologia. All rights reserved.
 Table 1 Nutritional characteristics and indications of infant formula

Formula Kcal/mL Protein source Carbohydrate Fat source Fiber Indications

source source
Formula based on 0.6–0.7 Whey protein Lactose Vegetable oils FOS Indicated as routine feeding for children when
cow or goat milk Casein Maltodextrin Milk fat GOS breast milk is unavailable or insufficient
Fish oil
Soy-based formula 0.6–0.7 Isolated soy protein Maltodextrin Vegetable oils — Indicated for children with cow milk allergy older
with methionine Fish oil than 6 months, lactose intolerance,
galactosemia, glycogenosis type I
Lactose-free formula 0.6–0.7 Serum protein Maltodextrin Vegetable oils – Indicated for children with lactose intolerance,
Casein Fish oil galactosemia, glycogenosis type I
Antiregurgitation formula 0.6–0.7 Serum protein Lactose Vegetable oils — Suitable for children with GER
Casein Maltodextrin Milk fat
Corn starch Fish oil
Rice starch
Carob gum
Hydrolyzed formula 0.6–0.8 Hydrolyzed casein Lactose Vegetable oils — Indicated for children with cow milk soy allergy
Hydrolyzed whey protein Maltodextrin Fish oil (with or without diarrhea), and with
Starch Medium chain triglycerides malabsorption, such as short bowel syndrome,
cystic fibrosis or liver disease

International Journal of Nutrology

Amino acid formula 0.6–0.8 Free amino acids Maltodextrin Vegetable oils — Indicated for children who continue with
Starch Fish oil symptoms with the use of extensively hydrolyzed

Vol. 14
Medium chain triglycerides formulas; children with severe malabsorption
Hypercaloric formula 1.0 Serum protein Lactose Maltodextrin Vegetable oils FOS Indicated for newborns and infants with
Casein Milk fat GOS increased caloric needs or requiring fluid

No. 2/2021
Fish oil restriction. Can be used in children with
difficulty/ maintaining weight gain.

Abreviatório: FOS, hidro-oligocitemias; GOS, galacticocentricidade.

Infant Formulas: A Long Story
Falcão et al.

© 2021. Associação Brasileira de Nutrologia. All rights reserved.

63
64 Infant Formulas: A Long Story Falcão et al.

decremated cow milk. This process improved the digestibili- legislation and they must also meet the Codex Alimentarius
ty of cow milk and started the growth of enteropathogenic standards of the Food and Agriculture Organization/World
microorganisms due to their acidic pH.4 Health Organization (WHO), be nutritionally adequate and
Meanwhile, finding an acceptable alternative to breast safe, acceptable in taste and odor, and be readily available for
milk has proven to be a complicated quest that continues acquisition.6,7
today. The formula model is always human milk. For this model
to be at least partially achieved, it is necessary to reduce the
protein content and to suit the ratio of serum/casein proteins
Current View of Infant Formulas: Definition,
(in breast milk, it is 60:40, and in cow milk, it is 20:80). In
Classification, and Indications
addition, there should be a reduction in the content of fats
In the absence of human milk, infant formulas are the (saturated), addition of vegetable fats (unsaturated), and of
appropriate substitutes for infant nutrition. However, these essential fatty acids (linoleic and linolenic acids), as well as
formulas do not reproduce the composition of human milk lactose to make the intestinal pH more acidic, thus improving
for several reasons: the absorption of calcium, iron, minerals, trace elements, and
vitamins.8
1. Human milk contains hormones, growth factors (growth
Infant formulas should also contain a caloric density
hormone and insulin-like growth factor 1 [IGF-1]), anti-
between 67 and 70 Kcal/100 ml, so that, with the usual intake
bodies, enzymes (lysozymes) and living maternal cells
of 150 to 200 ml/Kg/d (100 to 135 Kcal/kg/d), there is ade-
(neutrophils, macrophages, T and B lymphocytes), pros-
quate weight gain (20 to 30 g/d). In general, they have a
taglandins, complement system fractions, and granulo-
higher concentrations of nutrients when compared with
cyte colony stimulating factors, which are virtually
those of human milk, in order to compensate the lower
impossible to be added to infant formulas;5
bioavailability.9
2. Human milk presents the bifidum factor (whey proteins
and kappa fractions of casein, short chain fatty acids, and
lactose) that stimulates the growth of bifidobacteria, Classification of Infant Formulas (►Table 1)
which are microorganisms present in the protective in-
Infant formulas are classified as:1
testinal microbiota;5
3. Formulas are mostly developed from cow milk and al-  Complete polymeric (intact macronutrients, especially
though the proportion of whey/casein proteins (60:40) of protein)
current formulas is similar to mature breast milk, these  Natural proteins (not used)
proteins, of animal origin, are distinct from human milk,  Purified casein-based proteins and/or whey proteins
besides having a different composition of amino acids;5 (cow or goat milk)
4. The bioavailability of various nutrients, mainly micro-  Nondairy proteins – soy and rice
nutrients, of infant formulas is lower than that of human  Complete oligomeric
milk;  Partially hydrolyzed
5. Human milk is consumed practically after its synthesis,  Extensively hydrolyzed
while the formulas require heat treatment to ensure  Amino acids
longer shelf life, with consequent structural change.
The complete formulas are those that provide adequate
Despite the issues described, infant formulas are con- daily amounts of all nutrients and can be used exclusively. In
stantly improved when new information, nutrients, ingre- polymeric formulas, macronutrients, especially protein, are
dients, and technologies become available. intact. Oligomeric formulas are chemically constituted and
There are three basic indications of infant formulas: composed of predigested nutrients, with partially hydro-
lyzed proteins, widely hydrolyzed (oligopeptides) or fully
1. As a substitute for human milk when it is contraindicated
hydrolyzed (amino acids).
(human immunodeficiency virus disease, some inborn
errors of metabolism, maternal chemotherapy, use of
illicit drugs); Start and Follow-up Formula
2. As a supplement for breastfed infants whose intake of
Start infant formula is the product, in liquid or powder form,
breast milk does not meet their needs;
used by prescription, especially manufactured to meet, by
3. As a substitute for human milk when the mother does not
itself, the nutritional needs of healthy infants during the 1st
produce milk or chooses not to breastfeed.
6 months of life (5 months and 29 days old). For this, they
Infant formulas are dairy products modified to obtain a present a nutritional composition similar to that of human
nutritional composition similar to that of human breast milk, milk, with a caloric density between 0.67 and 0.70 Kcal/ml;
defined as a powder or liquid product intended for the osmolality  300mOsm/Kg; amount of protein from 1.2 to
feeding of infants (0 to 36 months old), by prescription, in 1.4 g/100 ml; serum/casein protein ratio of 60:40 or 70:30;
total or partial replacement of human milk, to meet the addition of vegetable fat (for the supply of essential fatty
nutritional needs of this age group. These formulations must acids) and of long-chain polyunsaturated fatty acids of the
follow the nutritional specifications described in the current ω-6 and ω-3 series (docosahexaenoic and arachidonic acids);

International Journal of Nutrology Vol. 14 No. 2/2021 © 2021. Associação Brasileira de Nutrologia. All rights reserved.
 Infant Formulas: A Long Story Falcão et al. 65

addition of lactose (acidifies the intestinal environment Currently, there are lactose-free formulations, which have
improving calcium absorption), minerals, trace elements, been developed with the objective of meeting the nutritional
vitamins, and nutrients considered conditionally essential and diet therapeutic demands of newborns and infants with
such as taurine and carnitine. Some formulas contain par- lactose intolerance. Usually, the predominant carbohydrate
tially hydrolyzed proteins in their composition.9 is maltodextrin, which has high caloric density, with little
Follow-up infant formula is the product, in liquid or effect on osmolality, which reduces complications such as
powder form, used when indicated, for healthy infants diarrhea, malabsorption, and necrotizing enterocolitis. Pro-
from the 6 month of life up to 12 incomplete months of tein is whey and casein, and fats are composed of vegetable
age (11 months and 29 days), and for healthy children in the oils. Basically, lactose-free formulas have the same composi-
early childhood (12 months to 3 years of age), constituting tion as infant formulas based on cow milk. Long-chain
the main net element of a progressively diversified diet. They polyunsaturated fatty acids of the ω-6 and ω-3 series (doco-
have protein content similar to that of the start formulas, but sahexaenoic and arachidonic) should also preferably be
higher amounts of iron. Some follow-up formulas contain added.12,13
partially hydrolyzed proteins in their composition.9
Infant formulas (start and follow-up) based on goat milk
Antiregurgitation Formulas
have recently appeared as another safe and appropriate
alternative to feeding newborns, infants, and early childhood Gastroesophageal reflux (GER), which manifests in the form
children who cannot receive breast milk, either partially or of regurgitation, is common in newborns. It can be consid-
exclusively. Goat milk is known to be naturally easier to ered physiological during the neonatal period, and it is
digest because its protein profile provides the formation of a estimated that it occurs in about half of the children from
smoother curdle in the stomach, conferring better birth to 2 months of life.14
digestibility.10 Among the several factors that contribute to the high
incidence of GER and regurgitation among infants are im-
maturity of the lower esophageal sphincter, small size of the
Soy-based Formulas
stomach, short esophagus, and peristaltic dysfunction. How-
Soy-based formulas (isolated and purified soy protein) are ever, as the function of the sphincter, as well as the anatomy
lactose-free and should also be free of sucrose, and malto- and function of the esophagus, mature with age, these causes
dextrin is the predominant carbohydrate. Fats are derived of regurgitation tend to be resolved as the child develops.14
from vegetable oils and polyunsaturated long-chain fatty Gastroesophageal reflux may also be secondary to some
acids of the ω-6 and ω-3 series (docosahexaenoic and pathological conditions such as cow milk allergy and some
arachidonic) should preferably be added, as well as methio- specific abnormalities of gastrointestinal motility, when it is
nine to improve the biological quality of protein.11 then called GER disease.15
The American Academy of Pediatrics, through its Nutri- There are efficient and economical treatments to reduce
tion Committee, recommends the use of formulas based on the symptoms of GER and at the same time ensure that the
the isolated and purified soy protein in the following sit- child receives the amount of nutrients necessary for its
uations: galactosemia, lactase deficiency and allergy to IgE- growth and development. Since 1996, the European Society
mediated cow milk protein. This same committee does not of Gastroenterology, Hepatology and Pediatric Nutrition
recommend the use of these formulas in children < 6 months (ESPGHAN) has had standards for the management of the
old.11 condition, including reassurance of parents and dietary
management through thickened formulas.16
In general, antiregurgitation formulas have a composition
Lactose-free Formulas
similar to that of standard infant formulas, following the
Lactose intolerance is caused by a lactase deficiency, which regulation of the Codex Alimentarius. The main difference is
can be congenital or acquired. Secondary or transient defi- in the source of carbohydrates. Usually, the carbohydrate
ciency is the most common type of lactase deficiency and found in these formulas, in addition to lactose and malto-
originates from lesions suffered by brush cells of the intesti- dextrin, is pregelatinized rice or corn starch, which thickens
nal mucosa that lose the ability to produce the enzyme. This in contact with the acidic pH of the stomach, preventing
deficiency, most often a temporary condition, can occur after regurgitation, or carob gum, which is naturally already a
an intestinal infection by bacteria, viruses, protozoa and/or thickener. Polyunsaturated long-chain fatty acids of the ω-6
fungi.12 and ω-3 series should also be added.16
When there is clinical suspicion of a lactase deficiency,
the first step is the exclusion of lactose from the diet. This is
Hydrolyzed Formulas
of great important in infants, whose main food source is
milk. This clinical condition also implies the suspension of Hydrolyzed formulas have the protein subjected to a hydro-
human milk, which may be transient or definitive, and the lysis process, resulting in oligopeptides and amino acids,
introduction of a lactose-free infant formula or of a formula which are small molecules that trigger less immune re-
based on soy protein, since these formulas are also lactose- sponse. Therefore, they were developed for children unable
free.13 to digest the intact protein from milk (cow or goat) or who

International Journal of Nutrology Vol. 14 No. 2/2021 © 2021. Associação Brasileira de Nutrologia. All rights reserved.
66 Infant Formulas: A Long Story Falcão et al.

are allergic to it. They should contain a mixture of 40 to 50% than the amounts of nucleotides synthesized or salvaged,
peptides < 1,500 daltons and 40 to 50% of free amino acids.17 such as rapid growth, limited nutrient intake or disturbed
In the clinical practice, hydrolyzed formulas are usually endogenous synthesis and certain diseases.21
used in cases of cow milk or soy protein allergy, and in cases Nucleotides have numerous biological effects, most of
of malabsorption, either by gastrointestinal or hepatobiliary which have been demonstrated in experimental animal
disease, such as cystic fibrosis, short bowel syndrome, bile models. It has been shown that the intestinal tissues of
duct atresia, cholestasis, chronic or persistent diarrhea.18 animals fed nucleotide-supplemented diets have more mu-
They have a protein content ranging from 0.20 to 0.25g/ml cosal protein and DNA, higher villus height and disacchari-
and the protein source can be serum protein, casein or rice, dase activities, and better recovery after intestinal injury
always widely hydrolyzed.17 than those of animals fed nucleotide-free diets, and studies
In general, they are free of lactose and sucrose and the in infants indicate that dietary nucleotides may protect
carbohydrate source is a mixture of maltodextrin and modi- against diarrheal disease.21,22
fied complex starches. Regarding the immune system, several studies in infants
Lipids are a mixture of vegetable oils and medium chain indicate an effect of dietary nucleotides as higher serum
triglycerides, at  40%, in order to facilitate absorption. concentrations of Hemophilus influenzae type b and diphthe-
Polyunsaturated long-chain fatty acids of the ω-6 and ω-3 ria antibodies after immunization, greater natural killer cell
series should also be added.18 activity, and higher concentrations of immunoglobulin G
antibody to β-lactoglobulin.23

Amino Acid Formulas

Iron
Amino acid formulas are those that have in their protein
composition 100% free amino acids.16 They generally have Iron is an essential nutrient that is critically important for
the same characteristics as hydrolyzed formulas regarding normal growth and development, particularly of the brain.
other nutrients, and have specific clinical indications, such as Iron deficiency and iron-deficiency anemia are the most
severe cases of intestinal dysfunction or of food allergies.17 common nutritional deficiencies worldwide. They affect
Regarding cow milk protein allergy, amino acid formulas every age group but are a particular concern in infants and
are indicated for children in whom treatment with extensively young children, since they undergo rapid growth and
hydrolyzed formulas has not been successful, because the development.24
more extensive hydrolysis determines lower antigenicity.19 The American Academy of Pediatrics (AAP) Committee on
Nutrition stated more than a quarter century ago that “the
early use of fortified formula results in augmentation of iron
Incorporation of New Nutrients/Ingredients
stores which help prevent later development of iron defi-
into Infant Formulas
ciency”.25 The strategy to improve iron stores during the 1st
In the advancement of developments in human milk research year was a response to the high rates of iron deficiency before
and food engineering technology, several nutrients/ingre- the 1970s, when the rate of cow milk consumption during
dients have been incorporated into infant formulae: nucleo- the 1st year and the concordant rate of iron deficiency were
tides, iron, α-lactalbumin, long-chain polyunsaturated fatty unacceptably high. Since then, the formulas have been forti-
acids, prebiotics, oligosaccharides similar to human milk, fied with iron at levels that vary considerably globally due to
probiotics (not allowed in Brazil), postbiotics (not yet pre- the wide range of iron levels offered by expert recommen-
sented in Brazilian formulas), lactoferrin (not yet presented dations and by regulatory agencies.
in Brazilian formulas), and cow milk fat globule membrane. Knowledge about the factors that influence iron status
during the 1st year of life as well as the benefits and risks of
iron supplementation during the 1st year of life evolved over
Nucleotides
time, motivating an “Iron Expert Panel” to make recommen-
Human milk has a higher concentration of nucleotides (from dations for the appropriate level of iron in formulas designed
30 to > 70 mg/L), which are believed to be important for the for infants from 0 to 12 months old.26
growth and maturation of the gastrointestinal tract and in The panel members proposed the following recommen-
the development of neonatal immune function, besides iron dations for iron fortification intended for healthy term
absorption and carbohydrate, lipid, protein and nucleic acid infants, based on their expert opinion and available evi-
metabolism (because nucleotides are the structural units of dence: for healthy full-term infants from birth to 3 months
nucleic acids, RNA and DNA, and are essential compounds in old, iron stores accumulated during gestation are sufficient
the energy transfer systems).20 to support the requirements of the infant, and there is no
Nucleotides were first identified in human milk in 1960 need to provide iron in any form, including iron-fortified
and represent between 2 and 5% of the nonprotein nitrogen infant formula; some healthy full-term infants deplete their
in human milk. Synthesized de novo by the body utilizing endogenous iron stores and become iron deficient as early as
amino acid precursors or salvaged from degraded nucleic at 4 months old, and formulas based on cow or goat milk
acids, nucleotides can be considered essential nutrients in protein or protein hydrolysates designed for infants from 3
certain conditions in which the needs of the body are greater up to 6 months old should contain between 2 and 4 mg/L of

International Journal of Nutrology Vol. 14 No. 2/2021 © 2021. Associação Brasileira de Nutrologia. All rights reserved.
 Infant Formulas: A Long Story Falcão et al. 67

iron, and formulas based on soy protein should contain linolenic acid (LNA) by successive desaturation and elonga-
between 3 and 6 mg/L of iron. Since the iron stores present tion steps in the intestine, the liver, and the brain.31
at birth inevitably become depleted after between 5 and Originally, infant formulas were not supplemented with
6 months of age, the panel recommends that formulas (based LCPUFAs; they contained only LA and LNA. Over the past few
on cow or goat milk protein or on hydrolysate protein) years, some manufacturers, due to the recommendations of
designed for infants from 6 up to 12 months of age contain some international organizations such as the European
between 4 and 8 mg/L of iron, and that formulas based on soy Society for Paediatric Gastroenterology Hepatology and
protein should contain between 6 and 12 mg/L of iron (L).26 Nutrition (ESPGHAN) Nutrition Committee, have added
LCPUFAs to infant formulae.32
Recent reviews that aimed to assess whether supplemen-
α-Lactalbumin
tation of milk formula with LCPUFAs is both safe and benefi-
Originally, infant formulas were based on unmodified cow cial for full-term infants, while focusing on effects on visual
milk protein and, therefore, had a protein profile comprising function, neurodevelopment, and physical growth, conclud-
80% casein and 20% whey proteins.27 During all the years that ed that most of the included randomized controlled trials
infant formulas have been available, much research has been reported no beneficial effects of LCPUFAs supplementation
devoted to improving especially protein quality, resulting in on neurodevelopmental outcomes of formula-fed full-term
formulas with a protein profile closer to that of human milk infants and no consistent beneficial effects on visual
that have a high proportion of whey proteins, with the whey acuity.32,33
and casein protein fractions constituting  60 and 40% of the Regarding preterm newborns, the conclusions of the most
total, respectively, until the 100th day, when the ratio of whey recent reviews were similar, although the overall quality of
to casein declines to  50:50.28 evidence was considered low. The authors concluded that
In 1961, the first whey-dominant infant formula was infants enrolled in the trials were relatively mature and
developed and, since then, the proportion of α-lactalbumin healthy preterm infants, and the assessment schedule, meth-
has increased in products over time. The method of produc- odology, dose, and source of supplementation and fatty acid
ing whey-dominant formulae lowered the renal solute load composition of the control formula varied between
and protein concentration delivered to the infant.29 trials.33,34
α-Lactalbumin has an amino acid composition that is high However, intervention studies have shown that LCPUFAs
in essential amino acids and comparatively rich in trypto- supplementation has positive developmental outcomes that
phan, lysine, cysteine, and the branched-chain amino acids resemble trajectories seen in infants fed human milk regard-
leucine, isoleucine, and valine that may lead to improve- ing cognitive function, visual acuity, and immune response.
ments in intestinal health, immune responses, and growth, Infants that are fed formulas supplemented with LCPUFAs
as well as to increased absorption of essential trace elements have higher levels of DHA and AA in plasma or red blood cells
like iron and zinc. Therefore, this increase in the proportion compared with infants that are fed formulae that are not
of α-lactalbumin in infant formulae while reducing total supplemented. As such, all formulae for both term and
protein content is beneficial.30 preterm infants are currently supplemented with
Human milk proteins, along with the peptides released LCPUFAs.35,36
during digestion, exert physiological effects on gastrointesti-
nal function, including motility (glutamate and quinolinic acid,
Prebiotics
produced by tryptophan degradation, influence intestinal
motility and immune competence) and antimicrobial activity Prebiotics are nondigestible carbohydrates, primarily oligo-
(peptide fractions have been shown to resist digestion and saccharides that pass through the small intestine and stimu-
exert their antibacterial activity in the colon; some seem to late the growth of beneficial microorganisms, such as
stimulate the phagocytic activity of macrophages; others have bifidobacteria, in the lower intestine.37 They are found in
prebiotic activity by stimulating the growth of bifidobacteria). high concentrations in human milk and, thus, it seems to be
Thus, since α-lactalbumin stimulates the growth of beneficial imperative for product manufacturers to fortify infant for-
microorganisms, which reduce pH in the intestinal tract, it mulae with them. Products are most often supplemented
may enhance mineral absorption.28 with galacto-oligosaccharide, fructo-oligosaccharide or pol-
ydextrose, which can mimic the prebiotic effects of human
milk, which has been demonstrated to beneficially impact
Long-chain Polyunsaturated Fatty Acids
the gut microbiota composition and activity as well as the
The n-6 and n-3 series of long-chain polyunsaturated fatty immune system, showing a reduced risk of allergies and
acids (LCPUFAs) have an important role during gestation, infections.38,39
lactation, and infancy since they are constituents of cell
membrane phospholipids and precursors of eicosanoids.
Human Milk Oligosaccharides
Besides, they are considered essential for the maturation
of the developing brain, the retina and other organs.31 Human milk oligosaccharides (HMOs) are complex, nondiges-
Long-chain polyunsaturated fatty acids are biosynthe- tible carbohydrates that are the 3rd largest fraction in human
sized from essential fatty acids linoleic acid (LA) and milk (between 12 and 15 g/l). More than 200 HMOs have been

International Journal of Nutrology Vol. 14 No. 2/2021 © 2021. Associação Brasileira de Nutrologia. All rights reserved.
68 Infant Formulas: A Long Story Falcão et al.

Fig. 1 Infantile formula timeline. 38,51,52

discovered in human milk, where 2-fucosyllactose and lacto- (including those found in breast milk) are stabilized by a 3-
N-neotetraose are the most abundant.40 They were discovered layered membrane called milk fat globule membrane
> 60 years ago, but their biological roles and functions have (MFGM). which is highly structured and contains various
been studied more extensively only in recent years, especially components, such as specific proteins (mainly glycopro-
in the past 10 years.41 They are known to exert a beneficial teins), choline, sialic acid, polar lipids (phospholipids and
impact on the immune system of infants, primarily through glycosphingolipids), and no polar lipids (cholesterol
the promotion of a balanced gut microbiota. and cerebrosides). This membrane acts as an emulsifier
Human milk oligosaccharides are not digested by the and protects the globules from coalescence and enzymatic
infant. Thus, they arrive in the intestinal colon intact, where degradation.46
part of them is fermented by bacteria probiotics such as The milk fat globule membrane has been studied for the
bifidobacteria, while some HMOs bind to potentially patho- purpose of enhancing the efficacy of infant nutrition formu-
genic bacteria, such as Escherichia coli and Campylobacter lae. A recent review by Brink et al. examined MFGM and its
jejune, inhibiting their adhesion to the intestinal epithelium components regarding resistance to infections, cognitive
and, consequently, infections.41 Even without being digested, development, establishment of gut microbiota, and infant
a small number of HMOs is absorbed from the intestine and metabolism. The authors concluded that the addition of this
reaches the systemic circulation, acting on other systems and ingredient in infant formulae is safe and warranted because
organs. Thus, current evidence has suggested effects of HMOs the membrane fraction is an inherent component of all
that go beyond the intestinal ones acting directly on the mammalian milk, and its biological value is lost in infant
immune cells, for example.42 Certain acidic HMOs reduce the formulae due to the use of vegetable oils for fat. Furthermore,
expression of proinflammatory cytokines IL-1β and IL-6 in to date, clinical evidence support the beneficial effects of
macrophages stimulated by lipopolysaccharide and in other adding back this fraction on infant health and
immune cells, indicating that they alter the immune re- development.47
sponse.43 A clinical study with 200 infants showed that the Figure 1 shows the timeline of the evolution of infant
levels of studied immunological markers were similar be- formulae.
tween breastfed and breastfed infants who received infant
formula supplemented with 2’-FL.44
Final Considerations
Furthermore, some HMOs contain sialic acid, which is an
important structural component of the nervous system. It has Infant formulae are infant-specific foods and should only be
been observed that the sialic acid concentration in the brain of indicated in the absence and/or in the impossibility of using
exclusively breastfed infants is significantly larger than that in human milk.
the brains of infants fed infant formulas. Therefore, sialic acid In almost a century of history, we have left the condition of
present in HMOs can contribute to the neurological and using fresh cow milk in the composition of highly complex
cognitive advantages provided by breastfeeding the infant.45 formulas, always in accordance with the current legislation
and better meeting the nutritional needs of this age group,
besides being quite safe.
Cow Milk Fat Globule Membrane
Major milestones in the modification of the composition
The human milk fat globule is a heterogeneous structure of infant formulae were the incorporation of nucleotides,
varying in diameter, triglyceride content, membrane, and LCPUFAs, and prebiotics, among others, showing benefits to
fatty acid composition. The lipid droplets of milk fat globules the immunological status.

International Journal of Nutrology Vol. 14 No. 2/2021 © 2021. Associação Brasileira de Nutrologia. All rights reserved.
 Infant Formulas: A Long Story Falcão et al. 69

Despite advances in knowledge and technology, breast 18 Nocerino R, Pezzella V, Cosenza L, et al. The controversial role of
milk remains irreplaceable, being the gold standard for food allergy in infantile colic: evidence and clinical management.
infant feeding. Nutrients 2015;7(03):2015–2025
19 Meyer R, Groetch M, Venter C. When Should Infants with Cow’s
Milk Protein Allergy Use an Amino Acid Formula? A Practical
Funding Guide. J Allergy Clin Immunol Pract 2018;6(02):383–399
None. 20 Yu VY. Scientific rationale and benefits of nucleotide supplemen-
tation of infant formula. J Paediatr Child Health 2002;38(06):
543–549
Conflict of Interests 21 Lerner A, Shamir R. Nucleotides in infant nutrition: a must or an
The authors have no conflict of interests to declare. option. Isr Med Assoc J 2000;2(10):772–774
22 Walker WA. Exogenous nucleotides and gastrointestinal immu-
nity. Transplant Proc 1996;28(05):2438–2441
References 23 Pickering LK, Granoff DM, Erickson JR, et al. Modulation of the
1 Eriksen KG, Christensen SH, Lind MV, Michaelsen KF. Human milk immune system by human milk and infant formula containing
composition and infant growth. Curr Opin Clin Nutr Metab Care nucleotides. Pediatrics 1998;101(02):242–249
2018;21(03):200–206 24 Kleinman RE. Introduction: recommended iron levels for nutri-
2 Falcão MC. Dynamics of lipid composition of infant formulas and tional formulas for infants. J Pediatr 2015;167(4, Suppl)S1–S2
their clinical implications. BRASPEN J 2020;35(03):294–306 25 American Academy of Pediatrics. Committee on Nutrition. Iron
3 Marriot WM, Schoenthal L. An experimental study of the use of fortification of infant formulas. Pediatrics 1999;104(1 Pt
unsweetened evaporated milk for the preparation of infant 1):119–123
feeding formulas. Arch Pediatr 1929;46:135 26 Kleinman RE. Expert recommendations on iron fortification in
4 American Academy of Pediatrics. Proposed changes in Food and infants. J Pediatr 2015;167(4, Suppl)S48–S49
Drug Administration regulations concerning formula products 27 Layman DK, Lönnerdal B, Fernstrom JD. Applications for α-lactal-
and vitamin-mineral dietary supplements for infants. Pediatrics bumin in human nutrition. Nutr Rev 2018;76(06):444–460
1967;40(05):916–922 28 Krissansen GW. Emerging health properties of whey proteins and
5 Tuma Calil V, Falcão MC. Human milk composition: the ideal their clinical implications. J Am Coll Nutr 2007;26(06):713S–723S
nutrition for infants. Rev Med (São Paulo) 2003;82(1-4):1–10 29 Lien EL, Davis AM, Euler ARMulticenter Study Group. Growth and
6 Brasil. Ministério da Saúde, Secretaria de Vigilância Sanitária, RDC safety in term infants fed reduced-protein formula with added
n°43 de 19/09/2011. Dispõe sobre o regulamento técnico para bovine alpha-lactalbumin. J Pediatr Gastroenterol Nutr 2004;38
fórmulas infantis para lactentes. (acesso 27 junho 2021) em: (02):170–176
http://www.ibfan.org.br/site/wp-content/uploads/2014/06/Res- 30 Sandström O, Lönnerdal B, Graverholt G, Hernell O. Effects of
olucao_RDC_n_43_de_19_de_setembro_de_2011.pdf alpha-lactalbumin-enriched formula containing different con-
7 Brasil. Ministério da Saúde, Secretaria de Vigilância Sanitária, RDC n° centrations of glycomacropeptide on infant nutrition. Am J Clin
44 de 19/09/2011. Dispõe sobre o regulamento técnico para fórmulas Nutr 2008;87(04):921–928
infantis de seguimento para lactentes e crianças de primeira infância. 31 Gil A, Ramirez M, Gil M. Role of long-chain polyunsaturated fatty
(acesso 27 junho 2021) em: http://bvsms.saude.gov.br/bvs/saudele- acids in infant nutrition. Eur J Clin Nutr 2003;57(Suppl 1):S31–S34
gis/anvisa/2011/res0044_19_09_2011.html 32 Jasani B, Simmer K, Patole SK, Rao SC. Long chain polyunsaturated
8 Ahern GJ, Hennessy AA, Ryan CA, Ross RP, Stanton C. Advances in fatty acid supplementation in infants born at term. Cochrane
Infant Formula Science. Annu Rev Food Sci Technol 2019; Database Syst Rev 2017;3(03):CD000376
10:75–102 33 Verfuerden ML, Dib S, Jerrim J, Fewtrell M, Gilbert RE. Effect of
9 Milbrandt TP. Standard Infant Formula and Formula Feeding-Cow long-chain polyunsaturated fatty acids in infant formula on long-
Milk Protein Formulas. Pediatr Rev 2017;38(05):239–240 term cognitive function in childhood: A systematic review and
10 Park YW, Haenlein GFW, Wendorff WL Eds. Handbook of Milk of meta-analysis of randomised controlled trials. PLoS One 2020;15
Non-Bovine Mammals. 2nd Ed. Nova Jersey/EUA: Wiley-Black- (11):e0241800
well; 2017 34 Moon K, Rao SC, Schulzke SM, Patole SK, Simmer K. Longchain
11 Bhatia J, Greer FAmerican Academy of Pediatrics Committee on polyunsaturated fatty acid supplementation in preterm infants.
Nutrition. Use of soy protein-based formulas in infant feeding. Cochrane Database Syst Rev 2016;12(12):CD000375
Pediatrics 2008;121(05):1062–1068 35 Lien EL, Richard C, Hoffman DR. DHA and ARA addition to infant
12 Gaffey MF, Wazny K, Bassani DG, Bhutta ZA. Dietary management formula: Current status and future research directions. Prosta-
of childhood diarrhea in low- and middle-income countries: a glandins Leukot Essent Fatty Acids 2018;128:26–40
systematic review. BMC Public Health 2013;13(3, Suppl 3)S17 36 Richard C, Lewis ED, Field CJ. Evidence for the essentiality of
13 MacGillivray S, Fahey T, McGuire W. Lactose avoidance for young arachidonic and docosahexaenoic acid in the postnatal maternal
children with acute diarrhoea. Cochrane Database Syst Rev 2013; and infant diet for the development of the infant’s immune system
(10):CD005433 early in life. Appl Physiol Nutr Metab 2016;41(05):461–475
14 Vandenplas Y, Hauser B. An updated review on gastro-esophageal 37 Gibson GR, Hutkins R, Sanders ME, et al. Expert consensus docu-
reflux in pediatrics. Expert Rev Gastroenterol Hepatol 2015;9 ment: The International Scientific Association for Probiotics and
(12):1511–1521 Prebiotics (ISAPP) consensus statement on the definition and scope
15 Salvatore S, Savino F, Singendonk M, et al. Thickened infant of prebiotics. Nat Rev Gastroenterol Hepatol 2017;14(08):491–502
formula: What to know. Nutrition 2018;49:51–56 38 Vandenplas Y, De Greef E, Veereman G. Prebiotics in infant
16 Chao HC, Vandenplas Y. Comparison of the effect of a cornstarch formula. Gut Microbes 2014;5(06):681–687
thickened formula and strengthened regular formula on regurgi- 39 Oozeer R, van Limpt K, Ludwig T, et al. Intestinal microbiology in
tation, gastric emptying and weight gain in infantile regurgita- early life: specific prebiotics can have similar functionalities as
tion. Dis Esophagus 2007;20(02):155–160 human-milk oligosaccharides. Am J Clin Nutr 2013;98(02):
17 Borschel MW, Baggs GE, Oliver JS. Comparison of Growth of 561S–571S
Healthy Term Infants Fed Extensively Hydrolyzed Protein- and 40 Skolnick J, Chou C, Miklavcic J. Insights into novel infant milk
Amino Acid-Based Infant Formulas. Nutrients 2018;10(03):289 formula bioactive. Adv Nutr 2012;3(03):398S–405S

International Journal of Nutrology Vol. 14 No. 2/2021 © 2021. Associação Brasileira de Nutrologia. All rights reserved.
70 Infant Formulas: A Long Story Falcão et al.

41 Rudloff S, Kunz C. Milk oligosaccharides and metabolism in 45 Wang B. Molecular mechanism underlying sialic acid as an
infants. Adv Nutr 2012;3(03):398S–405S essential nutrient for brain development and cognition. Adv
42 Newburg DS, Ruiz-Palacios GM, Morrow AL. Human milk glycans Nutr 2012;3(03):465S–472S
protect infants against enteric pathogens. Annu Rev Nutr 2005; 46 Silva RCD, Colleran HL, Ibrahim SA. Milk fat globule membrane in
25:37–58 infant nutrition: a dairy industry perspective. J Dairy Res 2021;88
43 Bode L. The functional biology of human milk oligosaccharides. (01):105–116
Early Hum Dev 2015;91(11):619–622 47 Brink LR, Lönnerdal B. Milk fat globule membrane: the role of its
44 Goehring KC, Marriage BJ, Oliver JS, Wilder JA, Barrett EG, Buck various components in infant health and development. J Nutr
RH. Similar to those who are breastfed, infants fed a formula Biochem 2020;85:108465
containing 2′-Fucosyllactose have lower inflammatory cytokines
in a randomized controlled trial. J Nutr 2016;146(12):2559–2566

International Journal of Nutrology Vol. 14 No. 2/2021 © 2021. Associação Brasileira de Nutrologia. All rights reserved.