Assuring Pediatric Nutrition in the Community

FREQUENTLY ASKED QUESTIONS:
General Nutrition - Infant feeding

Adding rice cereal to infant formula to increase energy density
Goat's milk as an infant formula

A pediatrician recommended adding rice cereal to an infant's bottle to increase the energy-density. As far as I know, infants should not be introduced to cereal until 4 months of age and/or they have the physical cues (holding head up, etc.). Does evidence show that this can cause developmental harm?

If rice cereal is added to infant formula, it increases energy density by adding mostly carbohydrate, with very little protein, vitamins or minerals (other than iron); this becomes a problem if the infant is not taking in enough formula to meet these nutrient needs. A more balanced way to increase the energy density of formula is to concentrate to 24 kcal/oz, by decreasing the water added to liquid concentrate or powdered formula. If energy needs are very high, further addition of carbohydrate and/or fat can be done to increase to as high as 30 kcal/oz (must make sure that protein and vitamin and mineral needs are being met with the formula, as carbohydrate and fat can also "dilute" nutrients).

If rice cereal is used to increase energy density, it may result in early satiety, defeating the purpose of increasing energy concentration. In a study by Shulman, et al, absorption of energy and protein from rice cereal mixed with formula was well tolerated, but did not result in increased net energy and nitrogen absorption in infants 16-40 days of age. Stool excretion (dry weight) increased more than fourfold when the diet of the infants was changed from formula alone to formula plus rice cereal. Thus cereal may be a very inefficient way to increase energy intake in infants.

When an infant is ready to start "semi-solids" (between 4 and 6 months of age), s/he should be fed with a spoon, to promote normal feeding development.

Rice cereal, mixed with formula has been used as a treatment for gastro-esophageal reflux for many years; however, this is a controversial practice. It has not been shown to decrease reflux, and has been associated with increased coughing after feedings.

Rice cereal is also used to thicken feeds for infants with swallowing disorders. This is efficacious in many cases; but there are still concerns about "diluted" nutrients, as well as adequate water intake.

References
Samour PQ, King-Helm K, Lang CE, eds. Handbook of Pediatric Nutrition, 2nd Edition. Gaithersburg, MD: Aspen Publishers, Inc. 1999; pp 82, 85, 93, 539-40

Nevin Follino N, ed. Pediatric Manual of Cinical Dietetics 2nd edition. Chicago: American Dietetic Association. 2003.

Shulman, Boutton, Klein. Impact of dietary cereal on nutrient absorption and fecal nitrogen loss in formula-fed infants. J Pediatr, 1991;118:39-43.

Bailey, Andres, Danek. Lack of efficacy of thickened feedings as treatment for gastroesophageal reflux. J Pediatr, 1987;110:187

Orenstein, Shalaby, Putnam. Thickened feedings as a cause of increased coughing when used as therapy for gastroesophageal relux in infants. J Pediatr, 1992;121:913.

We have a 7 month old who came to our clinic with reports of formula intolerance. For 2 weeks he has been on Meyenberg Goat Milk diluted 2 scoops/ 8 oz. water, 4 bottles/day. Three of these bottles include 3 oz. rice cereal. No added vitamin or mineral supplements. Solids include jar foods, apple juice, and variety of finger foods.

What are the goat's milk inadequacies for infants under 6 months of age? Are these concerns for nutrient inadequacies similar for infants 6-12 months? Is diluting goat's milk to half-strength appropriate for a 7 month old?

Resources indicate that the information on the composition of goat's milk is included in the formulary for informational purposes only and that goat's milk is not indicated for use in infancy. Here is some rationale:

1) Goat's milk is deficient in folic acid and vitamin B6.

2) Goat's milk is higher in protein than human milk (1.0 gm pro/100 ml) and infant formula (1.4 gm/100 ml). It actually has 3.6 gm pro/100 ml, which puts an infant at risk for dehydration and a higher renal solute load.

3) The reason many of the "recipes" for goat's milk for infants call for dilution (usually the recommendations are to dilute it to 2/3 strength, but in this case, it appears to be for half strength) is to decrease the renal solute load. When it is diluted, however, nutrients including energy, are diluted. With this comes the risk of hyponatremia or water intoxication, which can result in seizures. Dilution of goat's milk to half-strength supplies about 10 calories per ounce. This means to meet the energy needs (98 kcal x 8.25 kg, which is the 50th percentile for a 7 month old boy), 80 ounces per day of goat's milk would be required.

4) Goat's Milk Acidosis has been reported in the literature most likely secondary to the high protein level.

5) It may be appropriate to try a formula that has no intact protein, milk, casein or soy and gradually introduce individual foods rather than rely on goat's milk which is not recommended for infants.

References
Nevin Follino N, ed. Pediatric Manual of Clinical Dietetics, 2nd ed. Chicago: American Dietetic Association. 2003.

Texas Children's Hospital, Pediatric Nutrition Reference Guide

Foman S. Nutrition of Normal Infants, Mosby, 1993.