How to Cope when your child says NOPE!

This paper I wrote about picky eating habits among toddlers. I just finished it today! I hope you like it and learn some new strategies when your child just will not eat!

Picky Eating, Zinc, and Developing Food Appreciation in Toddlers

Amy Tobey

FCSC 430 George Fox University

My sister Sarah is very precious to me, someone whom I look up to and admire for her courage, tenacity, and willingness to go the extra mile for those she loves. She has her share of difficulties in life though. One of them is that her son, now four, is a very picky eater. I’ve watched him refuse to eat almost everything except sugar. His little brother who is two, on the other hand, sometimes eats so much so fast he makes himself sick. He really likes food. I know the problem that my sister has faced with her four year old has affected the way she deals with food in general as well as her quality of life. How common is this problem? What are the underlying causes of picky eating? And is there anything a parent, like my sister, can do to help coax their little one to eat a wider variety of foods?

According to Lisa Fields of WebMD, “one in five preschoolers is a picky eater (2010).” The causes of eating problems are as varied as the children who have them. According to Effective Parenting for the Hard-to-Manage Child,

            “The child may have problems sucking, chewing, and swallowing, making the process of   eating difficult and exasperating for both parent and child. Some children are so     hypersensitive to touch on their faces and in their mouths that certain food textures are             aversive. There are also children who simply refuse to eat, hate sitting at the table, or     have no desire for food.” (DeGangi and Kendall, 2008, p.47)

Problems can occur as early as the first introductions of food in the form of breast milk for those children who have sensory issues, making them hypersensitive to touch, especially in and around the mouth area (DeGangi and Kendall, 2008). This problem, known as tactile hypersensitives may cause the child physical pain when feeding, resulting in gagging, pulling away from food sources, and rejecting food of certain textures altogether (DeGangi and Kendall, 2008).  This problem can persist when solid foods are introduced to young children.

             “A common problem arising from oral tactile hypersensitivities is rejection of different     food textures. This usually emerges around 9 months of age when table foods are offered.       Some infants develop a preference for food with a firm, smooth texture, such as crackers    or crunchy cereal. When this occurs, the infant is usually seeking deep pressure to the    mouth by selecting foods that allow him to bite. Foods with uneven textures, such as             applesauce with sliced bananas, are often rejected.” (DeGangi and Kendall, 2008, p. 51)

Children who refuse to eat often do so because they are learning to assert their will (Fields, 2010). The caregiver may be not paying attention to the child’s cues that he is full, or may feed a passive child too much food (DeGangi and Kendall, 2008). Children then become upset at their caregiver and express their need to be independent and care for themselves through food intake or refusing to eat (DeGangi and Kendall, 2008). If the behavior persists to the point of causing failure to thrive, the child will need to be evaluated by a multidisciplinary team to determine underlying causes of food rejection and help develop a plan for parents to overcome this disruption in nutrition (DeGangi and Kendall, 2008). This analysis of the child is especially important because an eating problem can often be the first sign of a chronic condition (Brown, 2011). “Examples of such conditions include gastroesophageal reflux, asthma (pulmonary problems in general), developmental delay, cerebral palsy, attention deficit hyperactivity disorder, and autism (Brown, 2011, Kindle location 11191).”

There are also children who become confused by their body signals. “Many infants and children with feeding problems cannot tell when they are hungry or full. Some children may confuse being hungry or full with the need to eliminate. Problems of this type are common in children who have poor processing of the sensory receptors in the gut and colon (DeGangi and Kendall, 2008, p. 49).” Children have not had their bodies as long as adults, and learning how to handle them can at times be a frustrating process.

Most children, however, are very aware of when they are hungry and not. If a child has too many snacks and drinks before meal time, he may never be hungry enough to eat anything that is served for dinner (Fields, 2010). Also, parents who force their child to clean their plate or use food as a reward can derail this whole self-regulating ability of the child instead teaching the child to overeat or under eat (Brown, 2011).

While children can self-regulate how much food, they learn what kinds of foods to eat (Brown, 2011). This can cause a problem when children are put on a special diet or show food preferences, especially when it comes to meeting a child’s need for zinc (Brown, 2011). “Zinc is found in foods of animal origin. Plant sources of zinc include legumes, nuts, and whole grains (Brown, 2011, Kindle location 10828).” Zinc is an important nutrient in the overall development of the child, yet low intake of zinc was found in most toddlers between the ages of 12 and 18 months by the Feeding Infants and Toddlers Study 2002 (Brown, 2011).

            “Zn, the most abundant intracellular trace element, is involved in a multitude of diverse    catalytic, structural, and regulatory functions. For example, Zn is found in numerous             enzymes, is a component of biomembranes, is thought to be necessary for RNA, DNA, and ribosome stabilization, is involved in the binding of a number of transcription factors,       stabilizes some hormone-receptor complexes, and may have a regulatory role in tubulin             polymerization.” (Keen and King, 1999, p.228)

According to King and Kleen, clinical manifestations of  severe human zinc deficiency include growth retardation, delayed sexual maturation and impotence, hypogondism and hypospermia, alopecia, acoorificial skin lesions, other epithelial lesions (including glossitis, alopecia, and nail dystrophy), immune deficiencies, behavioral disturbances, night blindness, impared taste, delayed healing of wounds, burns, and decubitus ulcers, impaired appetite and food intake, and eye lesions. (1999) Keen and King tell us,

            “If it is accepted that impared growth velocity is the primary clinical feature of mild Zn    deficiency, several studies in Denver, Colorodo, provide convincing evidence. Apparently healthy children with low height-for-age percentiles were selected for a            double-blind, controlled trial of Zn supplementation…In all studies of these growth-           retarded children, Zn supplementation increased the mean height increment and height-    for-age percentile increment compared with   those of placebo controls.” (Keen and King   199, p. 230)

Environmental factors also have a huge effect on children’s eating patterns. If parents argue at the table, the television is on during meal time, or parents are dieting or picky themselves, children will sometimes refuse to eat (Fields, 2010). Children do not wish to be put in unpleasant situations with caregivers, can become distracted by the television, and watch parents’ eating habits to see what is acceptable and what is not at the table (Fields, 2010).

At this point, the parent of the picky eater may be beside themselves with the problem. Understanding it is useless unless strategies exist to help get parents through the difficult spots until the child begins to eat more regularly. Fortunately, there are things parents can do to help their child when it comes to establishing positive eating patterns. According to UCSF Benioff Children’s Hospital, the first step is to share responsibility when it comes to meal time (2011). Their website tells us, “As a parent, you have responsibilities for feeding your child. Your child also has responsibilities. You control what, where and when food is provided. Your child decides whether or not to eat the food, and how much to eat (UCSF Benioff Children’s Hospital, 2011).” By setting this standard, mealtime becomes less of a battle ground and more of a learning experience.

UCSF Benioff Children’s Hospital also urges parents to offer age appropriate food, avoid being a short order cook, respect eating quirks, and make meals pleasant (2011). Also, giving a toddler small portions and letting him ask for more is a better strategy than loading a plate with more food than the child can eat, establish eating patterns that allow the child to eat throughout the day without loading up on sugary beverages and empty foods, and setting enough time between feeding periods to allow the child to become hungry (Brown, 2011). The American Academy of Pediatrics recommends the child be given two cups of milk and four to six ounces of fruit juice, with water being utilized as a “thirst quencher” the rest of the time (Brown, 2011).

Other strategies to help the picky eater include:

            “Use treatment techniques…to desensitize the mouth. Desensitize the child to one food at            a time so as not to overwhelm him. If he eats only “white” foods, introduce a new white          food such as rice cakes. If there is aversion to smell, put a competing, pleasant smell in             the environment to override the smell aversion of the food. For example, burn a pleasant     smelling cinnamon- or peach-scented candle during meals. Begin with firm food textures   like crackers, steamed vegetables, or a piece of turkey. Expand the food repertoire,            beginning with smooth, soft textures like yogurts and applesauce before introducing uneven textures (banana chunks in yogurt).” (DeGangi and Kendall, 2008, p. 59)

Effective Parenting for the Hard-to-Manage Child also includes a Tool Sheet on pages 248 and 249 to help the caregiver establish proper eating habits for their child, a valuable resource for parents who have tried everything they know how to get their child to eat a varied diet, that I have included as an appendix in this paper (2008).

Dealing with a picky eater can be a frustrating power struggle that is often made worse by parents’ attempts to get their child to just eat something. It’s important to remember that a parent is not alone in this problem, that most children grow out of this stage, and that there are techniques that parents can implement to make meal time pleasant for everyone involved. And, as my sister Sarah can attest to, some things do get better with age. He four year old is starting to eat regular meals and is learning to appreciate a variety of foods. Picky eating is just another challenge that is a part of parenting.

Appendix: Tool 18. Food Rules

1.      Establish a schedule for mealtimes. If your child doesn’t eat a meal, avoid the temptation to try again in another hour. Stay with the schedule. There should be three main meals and two scheduled snacks (in the middle of the morning and afternoon). No extra snacks should be served, even if your child did not eat at one of the meals or snacks. This way your child will start to feel hunger and satiety and understand that when he eats, it satisfies his hunger. When it’s time for the next meal, talk about feeling hungry. After eating, talk about being full.

2.      Don’t worry about how much he eats at mealtime. When it’s clear that your child is finished, take away the food and, if your child cannot play unsupervised on the floor, try giving him something to play so you might be able to finish your own meal.

3.      Begin with food that your child can eat on his own, such as pieces of banana.

4.      Always eat something with your child. This socializes the mealtime and keeps him interested in eating too. Be careful not to diet when your child is in this program. He will get the message that you are avoiding foods to lose weight and will model your behavior.

5.      All meals are in the high chair or other appropriate seating. Ne eating should occur while your child roams the house or is in other places (i.e., bathtub, car seat, ect.).

6.      Take plates, food, cups, etc. away if they get thrown. Give one warning, saying clearly “No throwing!” If the throwing continues, end the meal.

7.      Let your child self-feed whenever possible. For younger children who cannot spoon feed, you can put out a small dish for baby to use while you feed him. Focus on foods that let your child self-feed and that are easy to manage in the hands or by spoon. For example, sticky foods such as applesauce or pureed bananas are easier than more liquid foods. Finger foods should be julienne strips of steamed vegetables or pieces of fruit or cheese that can be easily managed in the hand and mouth.

8.      Limit mealtime to 30 minutes. Terminate the meal sooner if your child refuses to eat, throws food, plays with food, or engages in other disruptive behavior. If your child is not eating, remove the food after 10 to 15 minutes

9.      Separate mealtime from playtime. Do not allow toys to be available at the high chair or dinner table. Do not entertain or play games during mealtimes. Don’t use games to feed and don’t use food to play with.

10.  Don’t praise for eating and chewing. Deal with eating in neutral manner. It is unnatural to praise someone for chewing and swallowing food.

11.  Don’t play games with food or sneak food into your child’s mouth.

12.  Withhold expressions of disapproval and frustration if your child doesn’t eat.

13.  Offer solid foods first then follow this with liquids. Drinking liquids will fill the stomach so that the child will not be hungry for solids.

14.  Hunger is your ally and will motivate your child to eat. Do not offer anything between meals, including bottles of milk or juice. The child may drink water if he is thirsty.

15.  Do the “special play time” (child-centered activity) before or after mealtime to give your child attention in positive ways.

16.  Emphasize mealtimes as a social, family gathering time. In this way, the focus is on socialization rather than worrying about how much your child is eating. Be sure the television is off.

17.  All caregivers need to agree to the program or it won’t work!

References

Brown, Amy (2011). Nutrition Through the Life Cycle, 4^th Edition. Belmont, CA: Wadsworth.

DeGangi, Georgia A. and Kendall, Anne (2008). Effective Parenting for the Hard-to-Mange Child: A Sills Based Book. NY: Routledge, Taylor & Francis Group, LLC.

Fields, Lisa (June 6, 2011). What You Didn’t Know About Picky Eaters: Why your child is a picky eater and what to do about it. WebMD.com. Retrieved February 22, 2012, from http://www.webmd.com/parenting/features/feeding-a-picky-eater?page=2&print=true

Keen, Carl L. and King, Janet C (1999). Zinc. In  Maurice E. Shils, M.D., Sc.D., James A Olson, Ph.D., Moshe Shike, M.D., and A. Catharine Ross, Ph.D. (Eds.), Modern Nutrition in Health and Disease: Ninth Edition (pp. 223-240). Baltimore: Lippincott Williams & Wilkins.

UCSF Benioff Children’s Hospital (September 27, 2011). Picky Eaters. UCSFBenioffChildrens.org. Retrieved February 22, 2012, from http://www.ucsfbenioffchildrens.org/education/picky_eaters/index.html

What's the Difference Between Breast Milk and Formula Anyway?

So, I did this paper a while back, and just realized I did not post it. I learned a lot from the research, and I hope it passes on some helpful information to you too as you decide what to feed your baby. Remember, it is your child and your choice. Enjoy!

Composition of Breast Milk and Commercial Formulas

Amy Tobey

FCSC 430 George Fox University

Composition of Breast Milk and Commercial Formulas

While many consider breast milk to be the only option when it comes to feeding their newborn infant, I wanted to see what the differences were between what women produce naturally and what is being produced for them by manufacturers. What are the benefits of breastfeeding, and what are the benefits of a formula based diet? How do the nutrients provided by each compare? And is one just as good as the other, or is human milk still the best thing we can give to our newly born under normal circumstances?

Endorsed by multiple public health organizations, breast milk has long been hailed as the best food source for infants (Institute of Medicine, Committee on the Evaluation of the Addition of Ingredients New to Infant Formula Staff, 2004). “Human milk is unquestionably the gold standard for infant nutrition. Ideally, the healthy, term infant experiences direct, exclusive breastfeeding; the milk itself and the act of feeding provide many advantages…” (Biancuzzo, 2003, p. 431) Because of the over 200 components in breast milk, and the diversity of the human body, nutrients and calories in the milk vary greatly and can be linked with time of day, mother’s diet, how much time the feeding has taken, and how often the baby gets fed (Dewar, 2008).

It is important to note that the body changes the composition of the milk throughout lactation (Dewar, 2008). “Mature breast milk looks very different from colostrum, the milk produced in the first few days after birth. According to Guthrie (1989), each 100 mL of colostrum yields approximately: 58 calories, 5.3 g carbohydrates, 2.9 g fat, and 3.7 g protein.” (Dewar, 2008) The high beta carotene content in colostrum gives it a yellow hue (Dewar, 2008). Vitamin E and zinc are also very concentrated in mother’s milk at this time (Dewar, 2008). Throughout the first week, the fat and lactose content of the milk goes up while the protein, vitamin, and mineral content go down (Dewar, 2008). These changes continue until the milk reaches the mature state at 21 days after conception (Dewar, 2008).

One study of British moms showed their milk to be composed of 70 calories, 89.97 grams of water, 7.4 grams of carbohydrates primarily in the form of lactose, 4.2 grams of fat, and 1.3 grams of protein (Dewar, 2008).

The majority of the calories of breast milk come from fat, but this fat varies throughout the course of the day, as well as each feeding (Dewar, 2008). “The fat content of human milk increases during a single nursing session. As a full breast empties, the milk it produces becomes more fatty.” (Dewar, 2008) The more often a baby is fed, the higher the fat content of milk the breast will produce and the less likely the baby will suffer from vitamin deficiencies (Dewar, 2008). Long chain fatty acids may help in brain development, and one, docosahexanoic acid (DHA), helps to make the myelin sheath that insulates nerve fibers  (Dewar, 2008). Cholesterol is another important element of fat important for brain maturation that can only be found in breast milk as formulas have yet to include it (Dewar 2008).

Anyone who has experienced a baby spitting up dinner knows that milk separates in their little stomach.  Milk has two proteins responsible for this, casein (which turn into curds) and whey (Dewar 2008). 60% of the proteins in breast milk are whey while most infant formulas are high in curds making it harder to digest them (Dewar, 2008). Proteins not only serve to build muscles and bones, but also protect against pathogens as is the case with immunoglobulin A, a protein that defends against repertory issues, intestinal parasites, and bacteria (Dewar, 2008).

Breast milk also contains cholesterol, calcium, sodium, phosphorus, vitamin C, magnesium, zinc, pantothenic acid, iron, nicotinic acid, iodine, vitamin A and copper in addition to other vitamins and minerals, hormones, and agents to fight disease (Dewar, 2008). Clearly, breast milk is the perfect food for infants.

Busy mothers who want to take advantage of this high nutrient food are presented with a bit of a challenge. Although pumping  breast milk is an option for the busy mother who wants to give her child the best nutritional start possible, some nutrients do leave the breast milk with storage.“Milk that is not promptly fed to infants may be altered. First, storage can diminish some of the components of the milk. Even if milk is not exposed to extremes in temperature, exposing it to light results, within three hours, in a 50% reduction in riboflavin content and 70% loss of vitamin A. Second, pathogens may enter stored milk.” (Biancuzzo, 2003 p. 432) Clearly, it’s not ideal, but it will do in a pinch. Breast milk is best served straight from the mom to the baby with no stops in between.

While breast milk is a wonderful source of nutrients, even this may not be enough for a premature baby. The smallest of babies often times cannot get all the nourishment they need from their moms. In this case, a helping hand is required. “…Very-low-birth-weight (VLBW) infants will need to have mother’s milk “modified” in some way; for example, the infant may need expressed milk with an added fortifier. The fortifier may be added to either fresh or previously stored milk... Generally, fortifiers are indicated when the infant’s birth weight is less than 1500 g… When VLBW infants can tolerate human milk at greater than 100 ml/kg/day, supplementation using a human milk fortifier is started.” (Biancuzzo, 2003, p.432) In these cases, formulas work together with breast milk to keep the most vulnerable babies alive.

Unlike VLBW’s, most healthy full term babies will not need any vitamin supplements to enjoy the full benefits of their mother’s milk (Biancuzzo, 2003). However, supplementation may be necessary in the following instances. To prevent hemorrhaging in infants, a vitamin K supplement is administered at birth to all infants (Biancuzzo, 2003). Vitamin D deficiency is rare in breastfed infants, but can occur if the mother is not getting enough vitamin D herself and keeps the baby from exposure to the sun (Biancuzzo, 2003). Supplements of vitamin D currently are only available mixed with vitamin A and vitamin C in the form of drops (Biancuzzo, 2003). Vitamin B-12 deficiencies may occur in breastfed infants whose mothers are strict vegetarians, and vitamin B-1 deficiencies can also occur in babies whose moms are malnourished, especially in developing countries (Biancuzzo, 2003). Finally, 6% to 20% of breastfed babies are at risk for low iron stores after the first four months of breastfeeding (Biancuzzo, 2003). Although breast milk is generally lower in iron concentration than traditional formula, the iron in it is more bioavailable making the little go a long way (Biancuzzo, 2003).

Breast milk can be enhanced in overall proteins, vitamins, and fatty acids by taking prenatal vitamins, eating proteins, limiting saturated fats, eating fish, breastfeeding when the baby is asking for milk, and making sure each breast has been emptied before switching (Dewar, 2008). Also, there are some risks involved with breastfeeding. Aside from nutrient deficits already discussed, infants are at risk of being exposed to toxins from their mother’s milk including legal and illegal drugs, infectious pathogens, and AIDS (Institute of Medicine, Committee on the Evaluation of the Addition of Ingredients New to Infant Formula Staff, 2004).

Formula has been hailed as a more viable source than cow’s milk for infants in regards to its nutrient balance, and promotion of growth and development in infants (Institute of Medicine, Committee on the Evaluation of the Addition of Ingredients New to Infant Formula Staff, 2004). “Infant formulas do not duplicate the components of breast milk exactly;...the exact composition of breast milk has not yet been fully established. Rather the goal of infant formula is to match the function of breast milk in regard to meeting the infant’s nutritional needs… There is no set, immutable recipe for infant formulas. With the passage of time, new technologies immerge and new ingredients gain credibility.” (Pray, 2010)

Formula manufacturers change their recipes when prompted by science to do so to make their product more closely conform to the properties of breast milk (Institute of Medicine, Committee on the Evaluation of the Addition of Ingredients New to Infant Formula Staff, 2004). They do this by adding new ingredients, but this can be more complicated than one might guess (Institute of Medicine, Committee on the Evaluation of the Addition of Ingredients New to Infant Formula Staff, 2004). “In the simplest example, nutrients that are present in both milks may be present in different ratios. For many nutrients that do not interact chemically or compete for enzymatic or receptor binding sites, the relative amounts many not be important. However, in situations where there is competition for enzymes or receptor binding sites in the intestine, the relative proportions may have biological significance.” (Institute of Medicine, Committee on the Evaluation of the Addition of Ingredients New to Infant Formula Staff, 2004)

So what is infant formula made of and how does it meet the nutritional needs of the infant? Infant formulas come in liquids that are ready to use and powders that must be diluted with water or reconstituted in preparation for a feeding (Pray, 2010). Formulas are made of water, carbohydrates fat, protein, vitamins, minerals, and other ingredients (Pray, 2010). “FDA requirements specify minimum amounts of 29 separate nutrients and the allowable maximum amounts for 9 of the nutrients. Manufacturers usually set nutrient amounts that safely exceed the FDA minimums (without exceeding the maximum levels) and this practice allows the formula to meet its label claims up to its expiration date.” (Pray, 2010)

Water, carbohydrate, proteins and fats are essential nutrient sources for all humans. Formulas are 85% water regardless of whether they are ready to use or must have water added (Pray, 2010).  If too much water is added, the baby can end up with water intoxication, and too little water can result in diarrhea, dehydration, renal failure, gangrene of the legs, and coma (Pray, 2010). In light of this, it is important to prepare formulas according to the manufacturers specifications. Water should also be boiled for at least a minute before using in formula to make sure it is sterile (Pray, 2010). “Carbohydrates are a major source of energy for an infant’s brain, muscles, and other tissues. Lactose is the standard carbohydrate in milk-based formulas and lactose-free formulas contain such carbohydrates as glucose polymers, sucrose, corn syrup solids, tapioca starch, and modified cornstarch.” (Pray, 2010) Protein is present in milk based formulas as casein and whey while soy isolate is preferred for infants with special medical needs (Pray, 2010). Fat is given to babies on formula in the form of corn oil, soy oil, safflower oil, and coconut oils (Pray, 2010) However, there is some debate on the quality of the fat being received via formula. “Human milk fat is more bioavailable than the vegetable oils found in infant formulas.” (Institute of Medicine, Committee on the Evaluation of the Addition of Ingredients New to Infant Formula Staff, 2004)

There are other elements included in formulas as well. Vitamins and minerals are generally supplied according to what is recommended for a healthy baby and should not be supplemented unless the caregiver is instructed to do so by a medical physician (Pray, 2010). Prebiotics and probiotics are sometimes added to support good digestive health (Pray, 2010). “Carnitine must be added to all infant formulas to aid in fat oxidation. It is found naturally in formulas prepared from human milk and cow’s milk but must be added to soy-derived formulas…Nucleotides are found in breast milk , and are the fundamental building  blocks of ribonucleic acid (RNA) and deoxyribonucleic acid (DNA), as well as adenosine-5’-triphosphate (ATP). Their addition to infant formula may aid in the proper development of the gastrointestinal tract and enhance overall immune function.” (Pray, 2010)

Formula is harder for infants to digest than breast milk and therefore allows for longer periods between feedings (Pray, 2010). In addition to this, formulas are built so that all nutrients are included in their composition, eliminating the need for further supplementation (Pray, 2010). The FDA has strict standards for the formulas on the shelves in the US, and all manufacturers must meet these standards in order to have a piece of the market share in this country (Pray, 2010).

So, all the jargon aside, how do breast milk and formulas really compare when we are looking at the overall nutritional composition? A cow’s milk based formula is 8 to 9% protein, 41-43% carbohydrate, and 45-50% fat according to babyfoodchart.com’s nutrient composition of formula chart. The same website states that breast milk contains 6% protein, 40-45% carbohydrate, and 50% fat. The wonder of breast milk is that it changes with the child’s nutritional needs. The mother’s body senses what the baby needs and then produces that for the child. A formula cannot adapt like that because it’s not a living organism. It comes in a can. So, while both will feed a child and provide nutrition for the growth of the baby, the quality of food that comes from breast milk cannot be matched by a formula.

References

Biancuzzo, Marie (2003). Breastfeeding the Newborn: Clinical Strategies for Nurses. St. Louis, MO: Mosby.

Dewar, Ph.D. Gwen (2008). Nutrients and calories in breast milk. Parenting Science. Retrieved February 6, 2012, from http://parentingscience.com/calories-in-breast-milk.html

Institute of Medicine (U.S.), Committee on Evaluation of the Additional Ingredients New to Infant Formula Staff (Contributor) (2004). Infant Formula: Evaluating the Safety of New Ingredients.Washington D.C.: National Academic Press. doi: http://site.ebrary.com/lib/georgefox/Doc?id=10060399&ppg=63

Pray, PhD, DPh, W. Steven (March 15, 2010). Infant Formulas: Safe Alternatives to Breast Milk in Many Situations. USPharmacist.com. Retrieved February 6, 2012, from http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/106527/