Use Of Infant Formula Research Articles

Synthesis of Infant Formula Fat Analogs Enriched with DHA from Extra Virgin Olive Oil and Tripalmitin

AbstractStructured lipids (SLs) containing palmitic, oleic, and docosahexaenoic acids for possible use in infant formulas were synthesized by enzymatic acidolysis reactions. The substrates used were tripalmitin, extra virgin olive oil free fatty acids (EVOOFFA), and docosahexaenoic acid single cell oil free fatty acids (DHASCOFFA) in 1:1:1, 1:2:1, 1:3:2, 1:4:2, and 1:5:1 molar ratios. Reactions were carried out at 65 °C for 24 h using Lipozyme® TL IM lipase. The products were analyzed for total and positional fatty acids by GC‐FID, triacylglycerol (TAG) molecular species by HPLC‐ELSD, and thermal behavior by DSC. The SLs, SL132, SL142, and SL151 had desirable fatty acid distribution for infant formula use with nearly 60 mol% palmitic acid at the sn‐2 position and oleic acid predominantly at the sn‐1,3 positions. The total DHA content of SL132, SL142, and SL151 were 7.54, 6.72, and 5.89 mol%, respectively. The major TAG molecular species in the SLs were PPP, OPO, and PPO. The melting completion temperature of SL132 was 37.1, 35.2 °C in SL142, and 32.9 °C in SL151. The SLs synthesized in this study have potential use in infant formulas.

Production of human fat milk analogue containing α-linolenic acid by solvent-free enzymatic interesterification

Human milk fat (HMF) analogue was synthesized by lipase-catalysed interesterification of tripalmitin with extra virgin olive oil, and flaxseed oil in a solvent-free media. Lipozyme® TL IM, immobilized sn-1,3 specific lipase, was used as biocatalysts. Substrate molar ratio, reaction temperature and reaction time were used to model and to optimize the reaction conditions via response surface methodology. Good quadratic models were obtained for the incorporation of palmitic acid and α-linolenic acid. At the optimal conditions generated from the model, the palmitic acid and α-linolenic acid contents of the product were found to be 25.2 g/100 g and 15.9 g/100 g, respectively. The chemical properties (free fatty acid, iodine value, and saponification value), sn-2 positional fatty acid composition, and sterol composition of the final structured lipid (SL) were determined. Furthermore, the oxidative stability of the SL and the SLs with antioxidants (BHT, gallic acid, and rosemary extract) was evaluated. The peroxide and thiobarbituric acid reactive substances (TBARS) values of the SLs showed they had antioxidant activity on the SL. The HMF analogue synthesized in this study may have potential use in infant formulas to provide omega-3 fatty acids (α-linolenic acid).

Production and Characterization of DHA and GLA‐Enriched Structured Lipid from Palm Olein for Infant Formula Use

AbstractPalm olein was modified via lipase‐catalyzed acidolysis reaction to obtain fatty acid composition and positional distribution similar to human milk fat. In the reaction, a free fatty acid mix containing 23.23 % docosahexaenoic (DHA), 31.42 % gamma‐linolenic (GLA), and 15.12 % palmitic acid was employed. The DHA and GLA were incorporated into the structured lipid (SL) product to improve its nutritional value. Response surface methodology (RSM) was used to investigate the effects of reaction time and substrate mole ratio (palm olein to a free fatty acid mix) on the amount of palmitic acid at the sn‐2 position of SL triacyglycerols (TAG), and on the total DHA and GLA incorporation. Gram‐scale production of SL was performed using the conditions predicted by RSM to maximize the content of palmitic acid at the sn‐2 position. Verification of the predictions from RSM confirmed its practical utility. The resulting SL had 35.11 % palmitic acid at the sn‐2 position, with 3.75 % DHA and 5.03 % GLA. Differential scanning calorimetry and HPLC analyses of the TAG revealed changes in their polymorphic profiles and TAG molecular species of SL compared to palm olein. The SL from this study can potentially be used in infant formula formulations.

Promoting breastfeediang in the Wirral: A hearts and minds approach

Breastfeeding has many health benefits for both infants and mothers and offers cost savings over the use of infant formula. However, despite an increase in breastfeeding in the UK since 1990, rates of breastfeeding initiation remain among the lowest in Europe. An initiative was undertaken to increase breastfeeding in the Wirral, an area with one of the lowest rates of breastfeeding in England.

Japanese mothers' breastfeeding knowledge and attitudes assessed by the Iowa Infant Feeding Attitudes Scale.

This study describes Japanese mothers' knowledge and attitudes towards breastfeeding using the Iowa Infant Feeding Attitudes Scale (IIFAS). A cross-sectional survey of 1,612 mothers was conducted in Japan in 2007. The participants were recruited at the free health checks conducted for infants at 18 months of age. The survey was self-administered using the Japanese version of the IIFAS. Descriptive statistics were used to summarise sample characteristics and IIFAS score followed by multiple logistic regression to identify association between total IIFAS score and breastfeeding duration. While the IIFAS showed that the majority recognized some benefits of breastfeeding, their overall knowledge and attitudes towards breastfeeding were neutral and more positive towards the use of infant formula. It is important to provide accurate prenatal education that focuses on methods and long-term benefits of infant feeding to mothers, family and health professionals.

Soy Infant Formula may be Associated with Autistic Behaviors.

The effects of soy-based infant formulas on childhood development are not well understood. This exploratory study evaluates the severity of autistic behaviors in association with the use of soy-based infant formula in a population of high-functioning autistic children. Medical record data were analyzed from the Simons Foundation Autism Research Initiative Simplex Collection, which included data on infant formula use and autism diagnostic scores for 1,949 autistic children. We found exploratory associations between the use of soy-based infant formula and several autistic behaviors as assessed by line-item analysis of the Aberrant Behavior Checklist, Autism Diagnostic Interview-Revised and Autism Diagnostic Observation Schedule. This study provides preliminary data that the use of soy-based infant formula may be associated with specific autistic behaviors.

Infant feeding practices and breastfeeding duration in Japan: A review.

The Japanese health system places great emphasis on healthy development. However, the prevalence of Exclusive Breastfeeding at one month postpartum between 1980 and 2005 has remained unchanged, fluctuating between 42% and 49%. At the same time, the Any Breastfeeding prevalence has gradually increased from about 80% to 95%. In 2010, the latest national breastfeeding report showed that ‘exclusive’ and ‘any’ breastfeeding rates have improved. However, as the World Health Organization (WHO) definition of breastfeeding practices was not used in this study or in other national surveys, it is difficult to interpret these latest results. While the Japanese government has launched several promotion projects, there have been few studies and reviews of risk factors that influence breastfeeding duration. The objectives of this review were to summarise the factors that have influenced the duration of breastfeeding in Japan to provide information relevant to breastfeeding promotion programs. A search of electronic databases in Japanese and English was undertaken up to 2011. The inclusion criteria for this review were studies that focused on infant feeding practices and targeted Japanese mothers, fathers, or health professionals, but excluded mothers’ friends and peer groups. In total, 12 articles were selected for the final analysis. Smoking status, low birth weight of infants and maternal perceptions of insufficient breast milk supply were negative influences on breastfeeding duration, while support from husbands/partners is associated with continued breastfeeding. Some factors that have been found to be associated with breastfeeding in other countries, including maternal age, family income, maternal educational levels, and living with grandparents of infants have not been confirmed in Japan. While the national breastfeeding rates were higher than other countries of similar health status, inconsistent knowledge of breastfeeding benefits and inappropriate hospital practices remain in Japan may be associated with increased the use of infant formula and reduced breastfeeding duration. Most of the studies reviewed were cross-sectional in design, with only a limited number of cohort studies. Also many published studies used small sample sizes. Cohort studies of infant feeding practices with larger sample sizes are required to monitor trends in rates and risk factors for breastfeeding outcomes.

Probiotics, prebiotics infant formula use in preterm or low birth weight infants: a systematic review.

BackgroundPrevious reviews (2005 to 2009) on preterm infants given probiotics or prebiotics with breast milk or mixed feeds focused on prevention of Necrotizing Enterocolitis, sepsis and diarrhea. This review assessed if probiotics, prebiotics led to improved growth and clinical outcomes in formula fed preterm infants.MethodsCochrane methodology was followed using randomized controlled trials (RCTs) which compared preterm formula containing probiotic(s) or prebiotic(s) to conventional preterm formula in preterm infants. The mean difference (MD) and corresponding 95% confidence intervals (CI) were reported for continuous outcomes, risk ratio (RR) and corresponding 95% CI for dichotomous outcomes. Heterogeneity was assessed by visual inspection of forest plots and a chi2 test. An I2 test assessed inconsistencies across studies. I2> 50% represented substantial heterogeneity.ResultsFour probiotics studies (N=212), 4 prebiotics studies (N=126) were included. Probiotics: There were no significant differences in weight gain (MD 1.96, 95% CI: -2.64 to 6.56, 2 studies, n=34) or in maximal enteral feed (MD 35.20, 95% CI: -7.61 to 78.02, 2 studies, n=34), number of stools per day increased significantly in probiotic group (MD 1.60, 95% CI: 1.20 to 2.00, 1 study, n=20). Prebiotics: Galacto-oligosaccharide / Fructo-oligosaccharide (GOS/FOS) yielded no significant difference in weight gain (MD 0.04, 95% CI: -2.65 to 2.73, 2 studies, n=50), GOS/FOS yielded no significant differences in length gain (MD 0.01, 95% CI: -0.03 to 0.04, 2 studies, n=50). There were no significant differences in head growth (MD −0.01, 95% CI: -0.02 to 0.00, 2 studies, n=76) or age at full enteral feed (MD −0.79, 95% CI: -2.20 to 0.61, 2 studies, n=86). Stool frequency increased significantly in prebiotic group (MD 0.80, 95% CI: 0.48 to 1.1, 2 studies, n=86). GOS/FOS and FOS yielded higher bifidobacteria counts in prebiotics group (MD 2.10, 95% CI: 0.96 to 3.24, n=27) and (MD 0.48, 95% CI: 0.28 to 0.68, n=56).ConclusionsThere is not enough evidence to state that supplementation with probiotics or prebiotics results in improved growth and clinical outcomes in exclusively formula fed preterm infants.

Práticas alimentares no primeiro ano de vida e fatores associados em amostra representativa da cidade de Porto Alegre, Rio Grande do Sul

OBJETIVO: Investigar a adequação das práticas alimentares no primeiro ano de vida e seus fatores associados na cidade de Porto Alegre (RS). MÉTODOS: Este estudo transversal foi realizado durante a Campanha Nacional de Imunização no ano de 2008. Utilizou-se amostragem por conglomerados em dois estágios e foram avaliadas 1.099 crianças menores de um ano de idade, em 31 postos de vacinação. A coleta de dados consistiu da aplicação de questionário estruturado sobre características maternas, uso de chupeta, consumo de leite materno, de leites artificiais, chá, água, alimentos complementares e de alimentos de baixo valor nutricional pelas crianças. Para estimar a associação entre variáveis maternas, uso de chupeta e práticas alimentares, foram utilizadas análises de regressão logística. RESULTADOS: A prevalência de aleitamento materno exclusivo foi de 47,1% entre as crianças com até quatro meses de vida e de 21,4% entre as crianças entre quatro e seis meses. A frequência de aleitamento materno exclusivo foi maior entre as crianças que não usavam chupeta, que não eram primogênitas e cujas mães não trabalhavam fora de casa ou estavam em licença maternidade. Melhores práticas de alimentação complementar foram observadas em crianças cujas mães tinham maior nível de escolaridade e trabalhavam fora de casa. CONCLUSÃO: Este estudo mostrou a existência de fatores de risco para a interrupção precoce do aleitamento materno exclusivo e o consumo de alimentos inadequados aos lactentes.

Milk and Social Media

The advent of social networking sites and other online communities presents new opportunities and challenges for the promotion, protection, and support of breastfeeding. This study examines the presence of infant formula marketing on popular US social media sites, using the World Health Organization International Code of Marketing of Breast-milk Substitutes (the Code) as a framework. We examined to what extent each of 11 infant formula brands that are widely available in the US had established a social media presence in popular social media venues likely to be visited by expectant parents and families with young children. We then examined current marketing practices, using the Code as a basis for ethical marketing. Infant formula manufacturers have established a social media presence primarily through Facebook pages, interactive features on their own Web sites, mobile apps for new and expecting parents, YouTube videos, sponsored reviews on parenting blogs, and other financial relationships with parenting blogs. Violations of the Code as well as promotional practices unforeseen by the Code were identified. These practices included enabling user-generated content that promotes the use of infant formula, financial relationships between manufacturers and bloggers, and creation of mobile apps for use by parents. An additional concern identified for Code enforcement is lack of transparency in social media-based marketing. The use of social media for formula marketing may demand new strategies for monitoring and enforcing the Code in light of emerging challenges, including suggested content for upcoming consideration for World Health Assembly resolutions.

Determinants of infant formula use and relation with growth in the first 4 months

The wide variety of infant formula available on the market can be confusing for parents and physicians. We aimed to determine associations between predominant type of formula used from birth to 4 months and parental and child characteristics and type of physician consulted, and then to describe relations between type of formula used and growth. Our analyses included 1349 infants from the EDEN mother-child cohort. Infant's feeding mode and type of formula used were assessed at 4 months by maternal self-report. Infant's weight and height from birth to 4 months, measured in routine follow-up, were documented by health professionals in the infant's personal health record. Anthropometric z-scores were calculated by using World Health Organization growth standards. Multinomial logistic regression was used to identify factors associated with the type of formula predominantly used; relations with growth were analysed by linear regressions. Partially hydrolysed formulas were more likely to be used by primiparous women (P < 0.001), those breastfeeding longer (P < 0.001) and for infants with family history of allergies (P = 0.002). Thickened formulas were more often used by mothers returning to employment in the first 4 months (P = 0.05) and breastfeeding shortly (P < 0.001). No significant relation was found between infant's growth and type of formula (P > 0.20). Infants breastfed shorter showed higher weight-for-age (P < 0.001) and length-for-age (P = 0.001) z-score changes between birth and 4 months. The use of a specific type of infant formula seems to be mainly related to parental characteristics. Infant's growth in the first 4 months is related to other factors than to the type of formula used.

Breastfeeding &amp; obesity: WIC policy changes increase breastfeeding rates and reduce obesity at age four

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides nutritious food and nutrition and breastfeeding education to low‐income pregnant and postpartum women, and children up to age 5. About half of all infants in the US receive services from the WIC Program. The objectives of this research are to (1) examine the impact of the 2009 changes to the WIC food packages on the rate and duration of exclusive breastfeeding among California WIC participants and (2) assess the impact of breastfeeding on childhood obesity rates at age four. ANOVA was used to analyze administrative data on 180,000+ infants in California to demonstrate impacts of policy changes on breastfeeding rates. Multiple logistic regression was used to examine the association between breastfeeding behavior and obesity rates at age four on a sample of 80,000 children served by WIC from birth to age four. Rates of fully breastfeeding increased by 86% and rates of infant formula use decreased significantly following the changes to the WIC food packages. Duration of breastfeeding to 2 and 6 months also increased significantly in the months following the policy change. Breastfeeding initiation was associated with a 26% reduction in childhood obesity at age four, and breastfeeding duration to six months conferred additional reductions in obesity rates of almost twice that amount for some sub groups. These data provide strong support for the impact of policy changes on WIC breastfeeding rates as well as the impact of breastfeeding on rates of childhood obesity among the low‐income population served by WIC. Funding was provided by the USDA FNS through a grant for WIC administered by the CA DPH.

Compliance Status of Product Labels to the International Code on Marketing of Breast Milk Substitutes

The aim of this study was to determine the compliance status of product labels regarding Article 9 of the International Code on Marketing of Breast-milk Substitutes (the Code) in Denizli province, Turkey. A cross-sectional study design was employed to determine the compliance status. The product labels were obtained from a convenience sample of five supermarkets, one store and 5 pharmacies in the City centre and district of Honaz. Using a data collection form prepared by previously published studies, data were collected between July 26, 2010 and August 06, 2010. Data collection form included 13 criteria. In addition, we checked the boxes for the availability of a Turkish written label. Forty product labels of 7 companies were reached and evaluated. These products consisted of 83.0% of the products marketed by these companies in Turkey. Thirty seven (92.5%) of the labels violated Article 9 of the Code in terms of one or more criteria. Thirty four (85.0%) of the labels had photos or pictures idealizing the use of infant formula. Nine (22.5%) had a photo, a picture or any representation of an infant, and five (12.5%) had text which idealize the use of infant formula or discouraging breastfeeding. Eight (20%) did not state that breastfeeding is the best. Four (10%) had a term such as 'similar to breast milk or human milk'. In conclusion, the majority of the product labels of breast milk substitutes marketed in our country violate the Code. It is appropriate that the Turkish Ministry of Health, medical organizations, companies, and NGOs work more actively to increase awareness of this issue.

Enrichment of palm olein with long chain polyunsaturated fatty acids by enzymatic acidolysis

Long-chain polyunsaturated fatty acids (LCPUFA) such as docosahexaenoic (DHA) and arachidonic (ARA) acids have great benefits for the development and maintenance of human brain functions. The production of structured lipid (SL) by acidolysis of palm olein with a free fatty acid mixture obtained from DHASCO® and ARASCO®, catalyzed by Novozym 435® in hexane was optimized by response surface methodology (RSM). Three independent factors chosen were substrate mole ratio of total free fatty acids to palm olein (6–18 mol/mol), reaction temperature (55–65 °C), and reaction time (12–24 h). Good quadratic models were obtained for the incorporation of DHA + ARA (response 1) and their incorporation at the sn-2 position (response 2) by multiple regression and backward elimination. The models were verified by carrying out acidolysis reaction at several random combinations of the independent factors. The optimal condition generated from the models resulted in 25.25 g/100 g total incorporation of DHA + ARA and 17.20 g/100 g DHA + ARA incorporation at the sn-2 position. The fatty acid composition of SL was comparable to that of human milk fat. The SL produced in this study has potential for use in infant formulas as well as in nutraceutical applications for pregnant women.

Association between infant formula feeding and dental fluorosis and caries in Australian children

The objective of this study was to evaluate associations between patterns of infant formula feeding and dental fluorosis and caries in a representative sample of Australian children. A population-based study gathered information on fluoride exposure in early childhood. Information on infant formula feeding and fluoridation status was used to group children: three groups in nonfluoridated areas (formula nonuser, user for ≤6 months, and user for 6+ months) and four groups in fluoridated areas (nonuser, user with nonfluoridated water, user with fluoridated water for ≤6 months, and user with fluoridated water for 6+ months). Children aged 8-13 years were examined for fluorosis using the Thylstrup and Fejerskov (TF) Index. Primary tooth caries experience recorded at age 8-9 years was extracted from clinical records. Fluorosis cases were defined as having TF 1+ on maxillary incisors. Fluorosis prevalence and primary caries experience were compared across formula user groups in multivariable regression models adjusting for other factors. Total sample was 588 children. Children in fluoridated areas had higher prevalence of very mild to mild fluorosis, but lower caries experience than those in nonfluoridated areas. Among children in nonfluoridated areas, formula users for 6+ months had significantly higher prevalence of fluorosis compared with nonusers. There was no significant difference in fluorosis prevalence among the formula users in fluoridated areas. Among children in fluoridated areas, formula users with nontap water had higher caries experience. Infant formula use was associated with higher prevalence of fluorosis in nonfluoridated areas but not in fluoridated areas. Type of water used for reconstituting infant formula in fluoridated areas was associated with caries experience.

NTP‐CERHR expert panel report on the developmental toxicity of soy infant formula

NTP‐CERHR expert panel report on the developmental toxicity of soy infant formula

A review of the progress in enzymatic concentration and microencapsulation of omega-3 rich oil from fish and microbial sources

Technology continues to evolve for the concentration and stabilisation of omega-3 fatty acids for delivery into food and beverage products. The use of lipases for selective concentration of EPA and DHA, or for re-esterification reactions, is important in the production of omega-3 concentrates. Enzymatic strategies require robust enzymes that can be immobilised and multiply re-used. Novel and mild processing methods are particularly important for providing oils with good sensory properties, which are required for successful use as functional food ingredients. Although in some cases good quality oils can be used directly in some foods, such as margarine, many foods require that microencapsulated and stabilised omega-3 oils be used. This is particularly important when the oils are preconcentrated. There are a number of industrially used microencapsulation methods, but the most widely used are complex coacervates and spray dried emulsions. Fish oil is still the most widely used source of long-chain omega-3 fatty acids for addition to food, although algal oil is the primary source of DHA for infant formula use in North America. Algal oil is still significantly more expensive than fish oil for most applications, although many groups are improving both the cost and quality of omega-3 oil from algal sources. In particular, Thraustochytrid and Schizochytrid strains are a promising source of both DHA and EPA, and with further improvement could be used to provide varying ratios of these omega-3 fats. In this short review we will describe some of the current research in omega-3 fat concentration and microencapsulation, with particular emphasis on the use of lipases for concentration and complex coacervation for microencapsulation.

Efficacy of Phototherapy for Newborns with Hyperbilirubinemia

Use of instrumental variables is gaining popularity as a method of controlling for confounding by indication in observational studies of treatments. To illustrate how unmeasured instrument-level treatment substitution can distort effect size estimates using as an example an instrumental variable analysis of phototherapy for neonatal jaundice. Retrospective cohort study. Northern California Kaiser Permanente Hospitals. The authors studied 20,731 newborns ≥ 2000 g and ≥ 35 weeks' gestation born 1995-2004 with a "qualifying" total serum bilirubin (TSB) level within 3 mg/dL of the 2004 American Academy of Pediatrics (AAP) phototherapy threshold who did not have a positive direct antiglobulin test. The intervention was inpatient phototherapy within 8 hours of the qualifying TSB. The outcome was a TSB level exceeding the AAP exchange transfusion threshold <48 hours from the qualifying TSB. The instrumental variable was a measure of the frequency of phototherapy use at the newborn's birth hospital. The unmeasured substituted treatment was supplementation with infant formula, assessed by chart review in a sample from the same cohort. In total, 128 infants (0.62%) exceeded the exchange transfusion threshold. Logistic and propensity analyses yielded crude odds ratios of ~0.5 for phototherapy efficacy, decreasing to ~0.2 with control for confounding by indication. Instrumental variable analyses suggested much greater phototherapy efficacy (e.g., odds ratios of 0.02-0.05). However, chart reviews revealed greater use of infant formula (which also lowers bilirubin levels) in hospitals that used more phototherapy (r = 0.56; P = 0.02), an association not present at the individual level (r = 0.13). Instrumental variable analyses may provide biased estimates of treatment efficacy if there are cointerventions or confounders associated with treatment at the level of the instrument, although even when these associations may not exist in individuals.

Evaluation of bioequivalency and toxicological effects of three sources of arachidonic acid (ARA) in domestic piglets

Arachidonic acid (ARA) and docosahexaenoic acid (DHA) are routinely added to infant formula to support growth and development. We evaluated the bioequivalence and safety of three ARA-rich oils for potential use in infant formula using the neonatal pig model. The primary outcome for bioequivalence was brain accretion of ARA and DHA. Days 3–22 of age, domestic pigs were fed one of three formulas, each containing ARA at ∼0.64% and DHA at ∼0.34% total fatty acids (FA). Control diet ARA was provided by ARASCO® and all diets had DHA from DHASCO® (Martek Biosciences Corp., Columbia, MD). The experimental diets a1 and a2 provided ARA from Refined Arachidonic acid-rich Oil (RAO; Cargill, Inc., Wuhan, China) and SUNTGA40S (Nissui, Nippon Suisan Kaisha, Ltd., Tokyo, Japan), respectively. Formula intake and growth were similar across all diets, and ARA was bioequivalent across treatments in the brain, retina, heart, liver and day 21 RBC. DHA levels in the brain, retina and heart were unaffected by diet. Liver sections, clinical chemistry, and hematological parameters were normal. We conclude that RAO and SUNTGA40S, when added to formula to supply ∼0.64% ARA are safe and nutritionally bioequivalent to ARASCO in domestic piglets.

Infant formula, tea, and water supplementation of latino infants at 4-6 weeks postpartum.

The American Academy of Pediatrics recommends exclusive breastfeeding until 6 months-of-age. The authors examined prevalence and risk factors for use of infant formulas, water, and teas at 4-6 weeks in Latino infants in the San Francisco Bay Area, a group at high risk for future obesity. They recruited a cohort of pregnant Latina women (N = 201). Infant dietary recall and postpartum depressive symptoms were assessed at 4-6 weeks. The authors found that 105 women (53.1%) were feeding infant formulas and 48 (25.4%) were supplementing with tea or water. Of those providing water or tea, 60.0% were providing daily supplementation. In multivariate analyses, risk for infant supplementation with water or tea was associated with postpartum depressive symptoms (relative risk, 1.8; 95% confidence interval, 1.1-3.0), cesarean delivery (relative risk, 1.9; 95% confidence interval, 1.3-2.9), and infant formula use (relative risk, 1.3; 95% confidence interval, 1.1-1.6). Early supplementation with water or teas and infant formulas should be discouraged in Latinos, given the high frequency observed in this population.