infant formula infant formula infant formula, baby formula, or simply formula (american english); or baby milk or infant milk (british english), is a manufactured food designed and marketed for feeding to babies and infants under 12 months of age, usually prepared for bottle-feeding or cup-feeding from powder (mixed with water) or liquid (with or without additional water). the u.s. federal food, drug, and cosmetic act (ffdca) defines infant formula as "a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk". infant formula an infant being fed from a baby bottle manufacturers state that the composition of infant formula is designed to be roughly based on a human mother's milk at approximately one to three months postpartum; however, there are significant differences in the nutrient content of these products. the most commonly used infant formulas contain purified cow's milk whey and casein as a protein source, a blend of vegetable oils as a fat source, lactose as a carbohydrate source, a vitamin-mineral mix, and other ingredients depending on the manufacturer. in addition, there are infant formulas using soybean as a protein source in place of cow's milk (mostly in the united states and great britain) and formulas using protein hydrolysed into its component amino acids for infants who are allergic to other proteins. an upswing in breastfeeding in many countries has been accompanied by a deferment in the average age of introduction of baby foods (including cow's milk), resulting in both increased breastfeeding and increased use of infant formula between the ages of 3- and 12-months. a 2001 world health organization (who) report found that infant formula prepared in accordance with applicable codex alimentarius standards was a safe complementary food and a suitable breast milk substitute. in 2003, the who and unicef published their global strategy for infant and young child feeding, which restated that "processed-food products for...young children should, when sold or otherwise distributed, meet applicable standards recommended by the codex alimentarius commission", and also warned that "lack of breastfeeding—and especially lack of exclusive breastfeeding during the first half-year of life—are important risk factors for infant and childhood morbidity and mortality". in particular, the use of infant formula in less economically developed countries is linked to poorer health outcomes because of the prevalence of unsanitary preparation conditions, including lack of clean water and lack of sanitizing equipment. a formula-fed child living in unclean conditions is between 6 and 25 times more likely to die of diarrhea and four times more likely to die of pneumonia than a breastfed child. rarely, use of powdered infant formula (pif) has been associated with serious illness, and even death, due to infection with cronobacter sakazakii and other microorganisms that can be introduced to pif during its production. although c. sakazakii can cause illness in all age groups, infants are believed to be at greatest risk of infection. between 1958 and 2006, there have been several dozen reported cases of c. sakazakii infection worldwide. the who believes that such infections are under-reported. uses, risks and controversies the use and marketing of infant formula has come under scrutiny. breastfeeding, including exclusive breastfeeding for the first 6 months of life, is widely advocated as "ideal" for babies and infants, both by health authorities—and accordingly in ethical advertising of infant formula manufacturers. despite the recommendation that babies be exclusively breastfed for the first 6 months, less than 40% of infants below this age are exclusively breastfed worldwide. the overwhelming majority of american babies are not exclusively breastfed for this period—in 2005 under 12% of babies were breastfed exclusively for the first 6 months, with over 60% of babies of 2 months of age being fed formula, and approximately one in four breastfed infants having infant formula feeding within two days of birth. some studies have shown that use of formula can vary according to the parents' socio-economic status, ethnicity or other characteristics. for example, according to a research conducted in vancouver, canada, 82.9% of mothers breastfeed their babies at birth, but the number differed between caucasians (91.6%) and non-caucasians (56.8%), with the difference essentially attributed to marital status, education and family income. in the united states, mothers of lower socio-economic status have been found less likely to breastfeed, although this may be partly related to adverse effects of government nutrition supplementation programs that provide subsidies for infant formula. the use of hydrolysed cow milk baby formula versus standard milk baby formula does not appear to change the risk of allergies or autoimmune diseases. use of infant formula in some cases, breastfeeding is medically contraindicated. these include: mother's health: the mother is infected with hiv or has active tuberculosis. she is extremely ill or has had certain kinds of breast surgery, which may have removed or disconnected all milk-producing parts of the breast. she is taking any kind of drug that could harm the baby, including both prescription drugs such as cytotoxic chemotherapy for cancer treatments as well as illicit drugs. one of the main global risks posed by breast milk specifically is the transmission of hiv and other infectious diseases. breastfeeding by an hiv-infected mother poses a 5–20% chance of transmitting hiv to the baby. however, if a mother has hiv, she is more likely to transmit it to her child during the pregnancy or birth than during breastfeeding. a 2012 study conducted by researchers from the university of north carolina school of medicine showed reduced hiv-1 transmission in humanized mice, due to components in the breast milk. cytomegalovirus infection poses potentially dangerous consequences for pre-term babies. other risks include mother's infection with htlv-1 or htlv-2 (viruses that could cause t-cell leukemia in the baby), herpes simplex when lesions are present on the breasts, and chickenpox in the newborn when the disease manifested in the mother within a few days of birth. in some cases these risks can be mitigated by using heat-treated milk and nursing for a briefer time (e.g. 6 months, rather than 18–24 months), and can be avoided by using an uninfected woman's milk, as via a wet-nurse or milk bank, or by using infant formula and/or treated milk. in balancing the risks, such as cases where the mother is infected with hiv, a decision to use infant formula versus exclusive breastfeeding may be made based on alternatives that satisfy the “afass” (acceptable, feasible, affordable, sustainable and safe) principles. baby is unable to breastfeed: the child has a birth defect or inborn error of metabolism such as galactosemia that makes breastfeeding difficult or impossible. baby is considered at risk for malnutrition: in certain circumstances infants may be at risk for malnutrition, such as due to iron deficiency, vitamin deficiencies (e.g. vitamin d which may be less present in breast milk than needed at high latitudes where there is less sun exposure), or inadequate nutrition during transition to solid foods. risks can often be mitigated with improved diet and education of mothers and caregivers, including availability of macro and micronutrients. for example, in canada, marketed infant formulas are fortified with vitamin d, but health canada also recommends breastfed infants receive extra vitamin d in the form of a supplement. personal preferences, beliefs, and experiences: the mother may dislike breast-feeding or find it inconvenient. in addition, breastfeeding can be difficult for victims of rape or sexual abuse; for example, it may be a trigger for posttraumatic stress disorder. many families bottle feed to increase the father's role in parenting his child. mental health: the pressure to breastfeed in many cultures can be so much that the mother's mental health may take a sharp decline. this can have physical effects such as poor latching as well as milk depletion and a lack of connection to the child. in some cases it is better for the child to be formula fed so that a better bond can be made between mother and child rather than the ‘special bond’ that comes from breastfeeding being tainted by negative breastfeeding experiences. the pressure to breastfeed in many cultures can increase the likelihood of postpartum depression. absence of the mother: the child is adopted, orphaned, abandoned, or in the sole custody of a man or male same-sex couple. the mother is separated from her child by being in prison or a mental hospital. the mother has left the child in the care of another person for an extended period of time, such as while traveling or working abroad. food allergies: the mother eats foods that may provoke an allergic reaction in the infant. financial pressures: maternity leave is unpaid, insufficient, or lacking. the mother's employment interferes with breastfeeding. mothers who breastfeed may experience a loss of earning power. societal structure: breastfeeding may be forbidden, discouraged or difficult at the mother's job, school, place of worship or in other public places, or the mother may feel that breastfeeding in these places or around other people is immodest, unsanitary, or inappropriate. social pressures: family members, such as mother's husband or boyfriend, or friends or other members of society may encourage the use of infant formula. for example, they may believe that breastfeeding will decrease the mother's energy, health, or attractiveness. conversely, societal pressures to breastfeed can also lead to mental health issues. a sense of shame from not being able to or struggling to do so equalling being a failure has a connection to postpartum depression lack of training and education: the mother lacks education and training from medical providers or community members. lactation insufficiency: the mother is unable to produce sufficient milk. in studies that do not account for lactation failure with obvious causes (such as use of formula and/or breast pumps), chronic lactation insufficiency affects around 10-15% of women. for about 5-8% of women, milk coming in (i.e., lactogenesis ii) may not occur at all, and only drops are produced. alternatively, despite a healthy supply, the woman or her family may incorrectly believe that her breast milk is of low quality or in low supply. these women may choose infant formula either exclusively or as a supplement to breastfeeding. new research is showing that mothers who report problems with milk production have physical markers indicating low milk production, calling into question the assumption (called “perceived insufficient milk supply” or pims) that mothers are incorrect about the quantity of milk they are producing. fear of exposure to environmental contaminants: certain environmental pollutants, such as polychlorinated biphenyls, can bioaccumulate in the food chain and may be found in humans including mothers' breast milk. however studies have shown that the greatest risk period for adverse effects from environmental exposures is prenatally. other studies have further found that the levels of most persistent organohalogen compounds in human milk decreased significantly over the past three decades and equally did their exposure through breastfeeding. research on risks from chemical pollution is generally inconclusive in terms of outweighing the benefits of breastfeeding. studies supported by the who and others have found that neurological benefits of breast milk remain, regardless of dioxin exposure. in developing countries, environmental contaminants associated with increased health risks from use of infant formula, particularly diarrhea due to unclean water and lack of sterile conditions – both prerequisites to the safe use of formula – often outweigh any risks from breastfeeding. lack of other sources of breast milk: lack of wet nurses: wet nursing is illegal and stigmatized in some countries, and may not be available. it may also be socially unsupported, expensive, or health screening of wet nurses may not be available. the mother, her doctor, or family may not know that wet nursing is possible, or may believe that nursing by a relative or paid wet-nurse is unhygienic. lack of milk banks: human-milk banks may not be available, as few exist, and many countries cannot provide the necessary screening for diseases and refrigeration. health risks use of infant formula has been cited for association with numerous increased health risks. studies have found infants in developed countries who consume formula are at increased risk for acute otitis media, gastroenteritis, severe lower respiratory tract infections, atopic dermatitis, asthma, obesity, type 1 and 2 diabetes, sudden infant death syndrome (sids), eczema and necrotizing enterocolitis when compared to