CENTER ON HUMAN DEVELOPMENT AND DISABILITY, UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON

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1 Nutrition for children with special health care needs Volume 26, No. 3 Human Milk and Pediatric Update Jo Ann Tatum Hattner, MPH,RD Nutritionist San Francisco, California INTRODUCTION In this edition you will read about human milk and pediatric formula. This issue s primary focus is to provide highlights from the session, Update on the Pediatric Guide, presented at the 19th National Conference on Advances in Perinatal and Pediatric Nutrition held July 2010 at Stanford University, Stanford, California. The 2010 formula guide additions and changes reflect the manufacturer s emphasis on digestibility, gut microflora, immune enhancement and protection, and the use of surrogates for human milk oligosaccharides. The 2010 Guide is included at the end as a supplement to this edition. Pediatric formulas continue to be marketed with brand names and registered trademarks which are descriptive of the product s individual characteristics or intended use. However, there is confusion in the marketplace both by the consumer and the professional as to which formula to use for what. The formula composition guide (6-page supplement) and this brief discussion along with the glossary on page 4 are tools for you to use in sorting through the maze. However, there are continual changes in products so the pediatric nutrition professional must often check with the manufacturers, read product labels, and/or visit web sites to stay knowledgeable of new branding, new additions, and the scientific documentation of their use. Human Milk and BreastFeeding Human milk is species-specific and scientific literature supports that it is the supreme feeding for infants. Optimal nutrients for growth and development are provided in breast milk and breast fed infants have less susceptibility to infectious disease with fewer illnesses such as diarrhea, otitis media, and pneumonia. The act of breast feeding promotes intimate contact and bonding while the mother herself benefits with a more rapid weight loss and possible protection from cancers of the breast and ovaries. EDITOR S NOTE This issue was to be our Sept/Oct issue but due to various health issues with earlier authors Ms. Hattner agreed for her article to be published as the May/June issue since she completed it by our editorial timeline. I want to thank her for her willingness to let us publish her work earlier to meet our needs. This is also the first issue for Nutrition Focus to offer 2 CE credits for reading the article and completing the quiz. Details about this opportunity are available at: Thank you, Sharon Feucht, Editor Oliver Wendell Holmes is credited with the quote: No two hemispheres of any learned professor s brain are equal to two healthy mammary glands in the production of a satisfactory food for infants. Yet researchers continue to identify components of human milk that may eventually be provided in formula feedings. An example of this is the fascinating research presently being conducted on human milk whose focus is the non-digestible carbohydrates: the human milk oligosaccharides (HMOs). Approximately 200 from pooled human milk samples have been identified and analyzed by mass spectrometry-based tools. 1 The role of these oligosaccharides in human milk was at first not understood. In fact, early researchers questioned why human milk would contain non-digestible components thought to be unusable by the newborn infant. Later, researchers provided one explanation when they found that these small oligosaccharides were fueling beneficial bacteria in the newborn s gut. These short-chain oligosaccharides are selectively nourishing strains of bifidobacterium and aiding in the maturation of the newborn s gut. Presently being investigated are the number and structure of the HMOs, as well as their function and clinical efficacy. 2 manufacturers are adding non-digestible carbohydrates from sources other than human milk to infant formula supported by studies documenting normal growth and stools similar to breast fed infants. The search contin- CENTER ON HUMAN DEVELOPMENT AND DISABILITY, UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON

2 ues for components, which can be added to formulas, with the goals of duplicating the composition of human milk and providing outcomes similar to the breast fed infant. 3 BreastFeeding Rates The Feeding Infants and Toddlers Study (FITS) published in 2008 is a cross sectional survey of a large representative sample (3,273) of United States children from birth to 4 years of age. Infant feeding practices were compared to 2002 data. Breast feeding trends, when compared to the 2002 study, demonstrated a longer duration in the 2008 sample beginning with infants being ever breast fed. The percentage of infants currently breastfeeding was significantly higher in the months age group and the month age group. The month group was higher than 2002 but not significantly higher. 4,5 Feeding Infants and Toddlers Study (FITS) Ever breast fed 76.2% ± -1.1% 79.5% ± 1.5 % months 26.2% ± 2.2% 42.5% ± 1.5 % months 26.9% ± 1.8% 37.3% ± 5.4% months 20.9% ± 1.9% 36.7% ± 5.0% The Centers for Disease Control Breast Feeding Report Card for 2010 reported that 75% of US mothers breast feed their newborns and 45% are still breast feeding at 6 months. They also report the rate of exclusive breast feeding which is defined in the CDC report as the baby receiving only breast milk and not other foods or liquids. Exclusive breast feeding rates are only 33% at 3 months and 13.3% at 6 months. Exclusive breast feeding is thought to enhance the likelihood of continued breast feeding. The CDC interprets these findings as most mothers in the U.S. want to breast feed and are trying to do so, however, many mothers may not be getting the breastfeeding support they need. 6 Breast Feeding Promotion and Support The US Surgeon General has responded to this concern by issuing a Call to Action to support breast feeding just this year, in The Call to Action calls for a societywide approach to support mothers and babies who are breastfeeding and to eliminate obstacles to breastfeeding. The document identifies specific targets with a total of 20 recommended actions which address how families, communities, health care professionals and employers can support breastfeeding. The targets include: Mothers and their families Communities Health Care Employment Research and Surveillance Public Health Infrastructure The Affordable Care Act enacted in 2010 supports breast feeding moms who work outside the home. As part of the Act employers are required to offer mothers reasonable break time to express milk in a private setting while at work. This requires programs to educate employers and assist with implementation which is discussed in the Call to Action document. 7 This publication is available at Of note is that a new ruling by the Internal Revenue Service allows mothers who are breast feeding to use their tax free spending accounts for the first year breastfeeding supplies including the purchase of pumps and storage containers. The new policy is a reversal of a previous decision and states: Lactation expenses. Expenses paid for breast pumps and supplies that assist lactation qualify as deductible medical expenses. 8 Pediatric Infant Safety Infant formula provides a nutritionally adequate and safe alternative for feeding infants. Infant formula is considered a single food which means it has to be nutritionally complete. The US Infant Act developed in 1980, established adequacy and minimum standards for nutrient composition of infant formula. The act was amended in 1986 with broader regulation and enforcement by the FDA. There are many new additives to infant formula since the 1980s. In 1998, the Life Sciences Research Office of the American Society of Nutrition released its report, a state of the art analysis of the scientific literature on the nutritional needs of infants. The report was published in the Journal of Nutrition. Their conclusions included a strong recommendation for evaluating new additions to infant formulas; these extensive recommendations for evaluation are included in their report. 9 Preparation Guidelines Ready-to-feed formulas are recommended for newborn feedings because they are commercially sterile. The use of powdered formula requires specific preparation guidelines. The 2011 Infant Feedings: Guidelines for preparation of formula and breastmilk in health care facilities provides instructions for preparation. 10 Nutrition Focus Vol. 26 #3 2

3 Pediatric Composition Guide The 2010 guide is a tool for comparing formulas. The guide was compiled in July 2010 with the assistance of the manufacturers listed under information sources. The individual manufacturers provided the formula name and nutrient data for their products. Contact websites and phone numbers are provided. Author s Note: The formula guide included in this publication may not relate recent discontinuations, or changes in name or composition that have occurred since July name changes reflect interest in digestive health, including colic, spitting up, ease of digestion, and stool composition. They also reflect the development of a healthy immune response, decreasing the incidence of allergy, as well as eye and brain development. Today the trend is to use the single branded name to cover the entire family of formulas with subtle differences of individual family members which may include those with probiotics, prebiotics or both, rice, various types of proteins, ARA (arachidonic acid) and DHA (docosahexaenoic acid), lactose free and organic. New descriptors change frequently, which adds to consumer confusion. Even dietetic professionals may have difficulty keeping knowledgeable regarding new formulas and/or name changes. When using the guide it is important to understand how it is designed. The formulas for infant feeding are categorized by their protein source. This structure was established early in the development of the guide which was designed by the author for ease of use in comparing products for use in caring for infants and children treated in the Pediatric Gastroenterology Clinic (GI) at Stanford. Tolerance to various sources of protein is always a consideration when treating children with chronic GI conditions or transient damage to the GI tract. New Additions Prebiotics Starter infant formulas now contain prebiotics. You can find the specific prebiotic listed as a new addition to the carbohydrate column where you can compare the prebiotic source and the amount contained in g/dl. For example: Similac Advance Early Shield GOS 0.4 g/dl Abbott s statement reads Similac Advance has the prebiotic GOS, which is proven well tolerated in clinical studies. GOS is an abbreviation for galacto-oligosaccharide a shortchain carbohydrate which feeds bacteria in the proximal large intestine. Mead Johnson Enfamil Premium Natural Defense with Dual Prebiotics GOS 0.2g/dl and Polydextrose 0.2g/dl. Mead Johnson positions their Dual Prebiotic Blend as designed to promote the growth of beneficial bacteria throughout the large intestine. GOS feeds bacteria in the proximal large intestine. Polydextrose is a resistant oligosaccharide extracted from inulin and soybean which feeds bacteria throughout the large intestine. As discussed earlier, prebiotics added to formulas provide a substitute for human milk oligosaccharides. They survive digestion in the stomach and feed beneficial bacteria throughout the large intestine resulting in softer, looser stool patterns similar to breast fed infants. Their fermentation results in a more acidic environment and the production of short-chained fatty acids. However, these additions are not sourced from human milk. Prebiotic Safety A systematic review of randomized controlled trials on prebiotic supplementation in full-term neonates was conducted by Rao et al. 11 They looked at a study selection of 11 of 24 studies with 1459 neonates who were given two weeks of formula with prebiotics and controls without prebiotics. Outcome measures included stool colony counts, ph, consistency, frequency, symptoms of intolerance, and anthropometry. Results for the infants receiving prebiotics: 6 trials reported significant increases and 2 reported a trend toward increases in bifidobacteria counts. Significant reduction in stool ph Slightly better weight gain than controls Softer and more frequent stools (more like breast fed) 1 trial reported diarrhea, irritability and eczema The supplemented group characteristics included higher colony counts of bifidobacteria in addition to higher lactobacilli counts, lower pathogen counts, and more acidic stools which were softer and more frequent. Larger population-based trials with continued long-term follow-up are needed to ascertain if the short term benefits relate to improved general health and reduced morbidities. 11 Note: The glossary on page 4 contains listings of the commonly used prebiotics in formula. Probiotics In this edition of the guide more formulas contain probiotics. Probiotics are added to formulas to alter the infant s microbiota to resemble the profile of the breast fed infant. Breast fed infants have more Lactobacillus and Bifidobacteria than infants fed traditional formula. The probiotic added by the manufacturer is listed with the name. For example: Starter : Gerber Good Start Protect Plus (B. Lactis) Nutrition Focus Vol. 26 #3 3

4 For a further understanding of this probiotic and its addition to formula, a discussion of Bifidobacterium lactis follows. The inclusive nomenclature: B. lactis also B. animalis subspecies lactis, B. bifidum, strain Bb12. This explains why you may see it written differently on products and in the literature. There have been more than 15 clinical trials involving 30 countries over the last 15 years with 1,800 infants, of which half received B. lactis. Although contained in formulas in Europe and Asia, it took many years for the FDA to give GRAS (Generally Regarded as Safe) status for use in infant formula. Characteristics of B. lactis include: Survives intestinal digestion Appears in the stool Produces acids: acetate and lactate Constitutes most of the breastfed infant s microflora Gerber s statement regarding their formula with B. lactis states: The probiotics in breastmilk, including bifidobacteria, help strengthen the developing immune system. But when moms can t or choose not to breast feed, bifodobacteria supplementation can help. Safety of Probiotics Two recent articles address the use and safety of probiotics in pediatric formula. The first is published by the American Academy of Pediatrics, Committee on Nutrition, in the Journal of Pediatrics with lead authors Dan Thomas and Frank Greer. 12 The report reviews the clinical applications of both prebiotics and probiotics. It provides guidance on the usefulness and benefits of prebiotics and probiotics in pediatric care. Numerous topics are addressed including the use of probiotics in acute infectious diarrhea and in antibiotic-associated diarrhea, for which they conclude that probiotics can reduce the incidence and duration of diarrhea. For the treatment and prevention of atopic disease they find the results of studies encouraging. Their discussion on safety concludes with to date the products seem to be safe for healthy infants and children. However, they do include a warning statement for practitioners that probiotics should not be given to children who are chronically or seriously ill until the safety of administration has been established. and in the summary they state that important questions remain including the optimal duration of probiotic administration as well as the GLOSSARY Bacteria Single cell microscopic living organisms with different species in the intestine alone. Bowel transit time The amount of time it takes for ingested food to travel through your GI tract and pass out as stool. Fructo-oligosaccharide (FOS) A naturally occurring fructan sugar which passes undigested to the large intestine where it is extensively fermented by colonic bacteria. Galacto-oligosaccharide (GOS) a short-chained carbohydrate which feeds bacteria in the proximal large intestine. GOS can be synthesized from cow s milk lactose by fermentation. Gut Site of digestion, absorption, immune function, and elimination. Inulin A natural prebiotic fiber, found in over 36,000 plants worldwide. It is extracted for use in commercial foods primarily from chicory root. Lactose intolerance The inability to digest lactose, the natural sugar of milk. Symptoms may include bloating, gas, diarrhea, and discomfort. Microbes Any minute form of life. Microflora Bacteria and other microorganisms that inhabit an area, (e.g., the intestinal tract). Microbiota A term used by researchers to replace microflora. Microorganisms Microscopic living organisms. Milk allergy Hypersensitivity to milk protein. Oligofructose A short chain of fructose molecules, a nondigestible fermentable carbohydrate. Oligosaccharide Non-digestible (resist hydrolysis by salivary and intestinal digestive enzymes) fermentable carbohydrate a short chain of sugar molecules. Olig means few and saccharide means sugar. Pathogenic bacteria Disease causing bacteria which can cause both damage to the gut tissue and infections. PHGG Partially hydrolyzed guar gum. Polydextrose A resistant oligosaccharide extracted from inulin and soybean which feeds bacteria throughout the large intestine. Prebio A combination of inulin and oligofructose. Prebiotics A selectively fermented ingredient that results in specific changes in the composition and/or activity of the gastrointestinal microbiota, thus conferring benefit(s) upon host health. Source: Glenn Gibson Probiotics Live microorganisms which, when consumed in adequate amounts, confer a health benefit on the host. scfos Short-chain fructo-oligosaccharides, a specific prebiotic fiber with a unique structure. Adapted from: Gut Insight: probiotics and prebiotics for digestive health and wellbeing. Jo Ann Hattner with Susan Anderes Nutrition Focus Vol. 26 #3 4

5 preferred microbial dose and species. They also call for centralized oversight to ensure probiotic organism safety, identity and genetic stability. 12 The second article, a Position Paper published by the European Society Pediatric Gastroenterology, Hepatology and Nutrition, Committee on Nutrition published in Journal of Pediatric Gastroenterology and Nutrition is a more extensive investigation of probiotic strains, their clinical applications and review of studies. 13 They are in agreement with the American Academy of Pediatrics Committee on Nutrition supported by their statement: For healthy infants the available scientific data suggest that the administration of currently evaluated probioticsupplemented formula to healthy infants does not raise safety concerns with regards to growth and adverse effects. 13 They conclude that supplemented infant and follow-up formulas may be associated with some clinical benefits, but they also emphasized that there is a lack of data for long term effects. Both papers agreed on their use for reduction of GI infections and reduced risk of antibiotic use. Editor s Note - In a previous issue of Nutrition Focus, Hattner addressed Digestive Health: Probiotics and Prebiotics for Children. Vol 24 No.3 May/June Components: Protein, Carbohydrate and Fat Sources Within the first section of the Composition Guide, Cow s Milk Based, you will find there are differences in the protein, carbohydrate and fat sources. For a better understanding, each manufacturer s web site should have information about their protein, carbohydrate and fat sources and should include clinical papers documenting their benefits. Comparing the source and composition is valuable when making a clinical decision regarding the appropriate choice. The labeling and marketing terms provide some insight as well, for example, terms such as Gentlease or Comfort Proteins refer to ease of digestibility and emptying time as well as stool consistency. Both Enfamil Gentlease and Good Start Gentle Plus also have less lactose than some of the other starter formulas. The use of Restful and Sensitive RS which has recently been changed to for spit up relates to the use of rice starch which thickens in the stomach to provide feedings of greater viscosity and less spit up. It replaces the former practice of mothers adding rice cereal to the formula to thicken a baby s feeding. However, you need to read carefully beyond the labels as it can be confusing, for example private label Sensitivity refers to its lactose free composition as does Sensitive by Abbott. A good rule for formula selection, compare ingredients and read scientific papers which studied their use. A recent development related to protein is that for the first time FDA has acknowledged the current scientific evidence supports a Qualified Health Claim for an infant formula (Gerber Good Start Gentle and Good Start Protect). A health claim characterizes the relationship between a substance and a disease, and it is the first time FDA authorizes a disease related claim for a routine use infant formula. In this case, the foundation of this claim is the risk reduction of atopic dermatitis (the most common allergic manifestation in infants) associated with the use of 100% partially hydrolyzed whey protein found in these formulas, compared to other routine formulas which use intact cow milk proteins. 14 See the website: Food/LabelingNutrition/LabelClaims/QualifiedHealth- Claims/ucm htm One of the shorter permissible versions is: Breastfeeding is the best way to nourish infants. Little scientific evidence suggests that, for healthy infants who are not exclusively breastfed and who have a family history of allergy, feeding a 100% whey protein partially hydrolyzed infant formula from birth up to 4 months of age instead of a formula containing intact cow s milk proteins may reduce the risk of developing atopic dermatitis throughout the 1st year of life. Partially hydrolyzed formulas should not be fed to infants who are allergic to milk or to infants with existing milk allergy symptoms. If you suspect your baby is already allergic to milk, or if your baby is on a special formula for the treatment of allergy, your baby s care and feeding choices should be under a doctor s supervision. Specialty s Amino Acid Based Nutramigen with Enflora LGG is positioned for the management of cow s milk protein allergy (CMPA). This is supported by the belief that extensively hydrolyzed protein, which is the protein source in Nutramigen, are less allergenic and that Lactobacillus GG (LGG), promotes gut barrier function and colonizes the gut with beneficial microflora. One study involved 26 formula fed infants with presumptive allergic colitis randomly assigned to an extensively hydrolyzed casein formula (EHCF) with LGG or EHCF without LGG. The results of the study demonstrated that the addition of LGG to the EHCF formula significantly improved the recovery of the inflamed mucosa as indicated by decrease in fecal calprotectin (a marker of intestinal inflammation) measurements after one month. The authors comment that this may be related to enhancing the intestinal mucosa s barrier function. 15 Nutrition Focus Vol. 26 #3 5

6 For Special Feeding Problems Enfaport is a new formula for special feeding developed by Mead Johnson. Enfaport is designed for use in infants with chylothorax or LCHAD deficiency with high levels of MCT at 84% of fat and with all essential fatty acids. Note: Chylothorax refers to the presence of lymphatic fluid in the pleural space secondary to leakage from the thoracic duct or one of its main tributaries. 16 Long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) deficiency is a rare condition that prevents the body from converting certain fats to energy, particularly during periods without food (fasting). Feeding Beyond One Year of Age More organic formulas are now available as PBM expanded to include the first organic beverage offering for children over 1 year; The Smart Organic Choice with the name Pedia Smart which they compare to PediaSure. Nature s One has a new Baby s Only Lactose Free Toddler formula and a new oral electrolyte solution Pedia- Vance made with organic fruit juice. In addition, some of the formulas reflect offerings previously only in the infant section but now are also offered in the over one year for example those with probiotics and prebiotics. The Future The idea of manipulating the gut microbiota in early life is appealing using pre- and probiotics to decrease the risk, prevent, or treat diseases, even those that occur later in life. Prebiotics and probiotics will remain in the forefront. Nomenclature may change with more explicit definitions based on biomedical research. Research may explore if we come closer to duplicating or even using human milk components as additions for presently we can only mimic their role. Pregnancy and lactation may be a focus for the future use of probiotics and prebiotics resulting in newborns who receive optimal colonization from their mothers during the birthing process and through their breast milk. Whether or not it is the baby or the mother who is targeted as the recipient of probiotics and prebiotics, there will be increased oversight and monitoring of these additions. These substances may require greater study and more clinical trials before they may be added as additions to food or beverages intended for pregnant or lactating women, infants, and children. The author wishes to express her appreciation to Susan Anderes for her assistance with library research. The glossary in this issue originally appeared in Gut Insight. 17 REFERENCES 1. Zivkovic AM, German JB, Lebrilla CB, Mills DA. Human milk glycobiome and its impact on the infant gastrointestinal microbiota. Proc Natl Acad Sci U S A. Mar ;108 Suppl 1: Niñonuevo MR, Lebrilla CB. Mass spectrometric methods for analysis of oligosaccharides in human milk. Nutr Rev. 2009;67:S216-S Ziegler E, Vanderhoof JA, Petschow B, et al. Term infants fed formula supplemented with selected blends of prebiotics grow normally and have soft stools similar to those reported for breast-fed infants. J Pediatr Gastroenterol Nutr. Mar 2007;44(3): Siega-Riz AM, Deming DM, Reidy C, Fox M, Condon E, Briefel RR. Food Consumption Patterns of Infants and Toddlers: Where Are We Now? J Am Diet Assoc. 2010;110(12):S38-S Buchanan-Adams R. Using FITS to Understand Consumption Patterns in a Critical Period for the Development of Childhood Obesity. Building Blocks. 2011;34 (2): Centers for Disease Control. Division of Nutrition PAaO, National Center for Chronic Disease Prevention and Health Promotion. Breastfeeding Data and Statistics. 2011; gov/breastfeeding/data/. Accessed April 28, 2011, Office of the Surgeon General. The Surgeon General s Call to Action to Support Breastfeeding. 2011; 8. Internal Revenue Service. Medical and Dental Expenses. 2010; p502.pdf. 9. Assessment of nutrient requirements for infant formulas. J Nutr. Nov 1998;128(11 Suppl):i-iv, 2059S-2293S. 10. Robbins ST, Meyers R. Infant Feedings: Guidelines for Preparation of Human Milk and in Health Care Facilities. 2nd ed. Chicago: American Dietetic Association; Rao S, Srinivasjois R, Patole S. Prebiotic supplementation in full-term neonates: a systematic review of randomized controlled trials. Arch Pediatr Adolesc Med. Aug 2009;163(8): Thomas DW, Greer FR. Probiotics and prebiotics in pediatrics. Pediatrics. Dec 2010;126(6): Braegger C, Chmielewska A, Decsi T, et al. Supplementation of infant formula with probiotics and/or prebiotics: a systematic review and comment by the ESPGHAN committee on nutrition. J Pediatr Gastroenterol Nutr. Feb 2011;52(2): Schneeman BO. 100% Whey-Protein Partially Hydrolyzed Infant and Reduced Risk of Atopic Dermatitis. 2011; HealthClaims/ucm htm. Accessed May 31, Baldassarre ME, Laforgia N, Fanelli M, Laneve A, Grosso R, Lifschitz C. Lactobacillus GG improves recovery in infants with blood in the stools and presumptive allergic colitis compared with extensively hydrolyzed formula alone. J Pediatr. Mar 2010;156(3): ozar R. Chylothorax. Medscape Reference. Online: article/ overview. Accessed May 3, Hattner JAT, Anderes S. Gut Insight: probiotics and prebiotics for digestive health and well-being San Francisco: Hattner Nutrition; NUTRITION FOCUS is published six times per year by the Nutrition Section at the Center on Human Development and Disability, University of Washington Annual subscription rate is $45.00 and must be prepaid to the University of Washington. Credit card payments can be made online. Or, mail your payment, complete address and phone number to the editor. Some printed back issues are available, and online archives are available to all current subscribers. To share resources and comments please contact the Editor: Sharon Feucht, MA, RD, CD, Nutrition Focus, CHDD-University of Washington, Box , Seattle, WA Phone: FAX: sfeucht@uw.edu Current subscription or renewal questions should be addressed to the Nutrition Focus Subscription Manager, Nancy Saunders. Contact her at CHDD-University of Washington, Box , Seattle, WA Phone: FAX: charbeha@uw.edu View our web page: Nutrition Focus Vol. 26 #3 6

7 Continuing Education Opportunity We are pleased to present an opportunity for continuing education, beginning with this issue. Login to LIN to access the quiz related to this issue. You must correctly answer 80% of the questions to pass. Questions are included below for your convenience. Cost is $20 (subscribers) or $40 (non-subscribers) for 2 CPEU. 1. According to the article, FITS data indicate that breastfeeding rates have: a. stayed the same b. decreased between 2002 and 2008 c. increased between 2002 and 2008, but only among infants older than 8.9 months of age d. increased between 2002 and 2008, especially for infants who were ever breastfed and infants in the month and month age groups 2. The CDC Breast Feeding Report Card for 2010 reported that: a. Exclusive breastfeeding rates have declined since 2002 b. 33% of US mothers breast feed their newborns and 13.3% are still breastfeeding at 6 months c. 69% of US mothers breast feed their newborns and 25% are still breastfeeding at 6 months d. 75% of US mothers breast feed their newborns and 45% are still breastfeeding at 6 months 3. The osmolality of human milk is estimated to be: a. 170 b. 235 c. 300 d The amount of protein in human milk: a. is higher than cow s milk-based formulas b. is lower than cow s milk-based formulas c. is the same as cow s milk-based formulas d. depends on maternal diet 5. Which of the following is NOT a prebiotic: a. Inulin b. Maltodextrin c. Galacto-oligosaccharide d. None of the above; they are all prebiotics 7. Two recent articles published by the American Academy of Pediatrics and the European Society of Pediatric Gastroetnterology, Hepatology, and Nutrition address use and safety of probiotics in pediatric formula. They conclude that probiotics in infant formula: a. should be used to treat and prevent atopic disease b. should only be used for short periods of time, because long-term use has not been studied c. appears to be safe for most healthy infants and may confer clinical benefits d. appears to be safe and should be promoted for all infants who are not breastfed 8. For the first time, the FDA has authorized a disease-related claim for a routine use infant formula, by allowing the following: a. use of Gentlease and Comfort Proteins for treatment of colic b. the terms Restful and Sensitive RS to indicate rice starch s role in decreasing gastroesohpageal reflux c. promotion of Gerber Good Start Gentle and Good Start Protect to reduce risk of atopic dermatitis, compared to other routine formulas with intact cow milk proteins d. none of the above; the FDA does not allow diseaserelated claims on infant formula labels 9. A good rule for formula selection includes each of the following steps, EXCEPT: a. compare ingredients b. read scientific papers which studied their use c. use the name of the formula to determine appropriate use d. visit manufacturer s websites for information about protein, carbohydrate, and fat sources of specific formulas 10. Probiotics are added to formulas: a. to provide fuel for the microbiota b. to decrease lactic and acetic acid production c. to provide a substitute for human milk oligosaccharides d. to alter the infant s microbiota to resemble the profile of a breastfed infant 6. True or false: Use of prebiotics leads to softer, looser stool patterns. a. True; because of this, additional fiber should be provided to prevent diarrhea b. True; fermentation of prebiotics leads to a more acidic environment and production of short-chain fatty acids in the large intestine c. False; in several studies, prebiotics lead to decreased bifidobacteria, but higher lactobacilli counts d. False; the oligosaccharides are digested in the stomach, so have no effect on the large intestine Nutrition Focus Vol. 26 #3 7

8 2010 Composition Guide SUPPLEMENT TO HUMAN MIL AND PEDIATRIC FORMULA UPDATE IN NUTRITION FOCUS NEWSLETTER JULY/AUGUST 2011 This table is a supplement to the article Human Milk and Pediatric Update in the July/August 2011 Nutrition Focus Newsletter. Ms. Hattner and Dr. John erner* compiled this table in July 2010 with information current at that time. However, manufacturers do change product formulations and introduce new products. On page 6 of this guide you will find the information sources used for this table which include the manufacturer s web sites and telephone numbers to contact them for additional information. In this editor s experience, the manufacturers readily respond to questions about formula content, preparation, storage and more. In addition, if formula concentration is being considered the manufacturers can provide the specific guidelines. We encourage you to contact them if you have detailed questions. My thanks to Ms. Hattner for her willingness to continue to provide this information for the NUTRITION FOCUS subscribers for use in their work with families and their children. Ms. Hattner s work first appeared in the Jan/Feb 1994 NUTRITION FOCUS. The table composed two pages at that time; 6 pages are provided today. Note that human milk is listed below, at the beginning of the table, so that other feedings can be compared to this uniquely superior milk. The values in the table represent information for liquid formulas unless otherwise indicated. The products are listed in the resource table by type and include the following information for the purpose of comparison: Product s brand name and manufacturer Caloric content per ounce Source of protein, fat and carbohydrate Amount of sodium, potassium, calcium and phosphorus Sharon Feucht, MA, RD, CD Editor *The Center for Pediatric Gastrointestinal Diseases and Nutrition, Lucile Packard Children s Hospital, Standford University Medical Center Human Milk Human Milk Source gm/ Source gm/ Source gm/ Mature Human Milk 1 20 Human Milk 1.0 Human Milk 4.4 Lactose Bright Beginnings with Lipids (pwd) Enfamil PREMIUM TM Natural Defense TM Dual Prebiotics Enfamil AR Enfamil Restfull Enfamil Gentlease Gerber Good Start Gentle PLUS Concentrate 20 Demineralized Whey, Skim Milk (liq) Skim Milk, Whey Protein Concentrate (pwd) COW S MIL BASED FORMULAS Source gm/ Source gm/ Source gm/ 1.5 Palm, High Oleic Safflower or Sunflower, Coconut, Soybean Oils, DHA 1.4 Palm Olein, Soy, Coconut, 20 Nonfat Milk 1.7 Palm Olein, Soy, Coconut, 20 Partially Hydrolyzed Nonfat Milk and Whey Protein concentrate (pwd), Partially Hydrolyzed Milk Protein (liq) 20 Enzymatically Hydrolyzed Reduced Minerals Whey 1.6 Palm Olien, Soy, Coconut, 1.5 Palm Olein, Soy, Coconut,, 3.6 Lactose Lactose, GOS 0.2g/, Polydextrose 0.2g/ 3.4 Lactose, Rice Starch, Maltodextrin 3.6 Corn Syrup Solids, Lactose (pwd), Corn Syrup Solids, Lactose, Rice Starch (liq) 3.4 Lactose, Maltodextrin, GOS 0.4 g/ (liq) 230 (pwd) (liq) 230 (pwd) CENTER ON HUMAN DEVELOPMENT AND DISABILITY, UNIVERSITY OF WASHINGTON, SEATTLE, WASHINGTON

9 Gerber Good Start Protect PLUS (B.lactis) Private Label Added Rice Milk- Based with Lipids 20 Enzymatically Hydrolyzed Reduced Minerals Whey Hydrolysate COW S MIL BASED FORMULAS - continued Source gm/ Source gm/ Source gm/ 1.5 Palm Olein, Soy, Coconut,, 1.7 Vegetable Oils, Palm Olein, DHA 3.4 Lactose, Maltodextrin Rich Starch, Maltodextrin, Lactose Private Label Gentle with Lipids (pwd) Private Label Lactose Free Milk-Based with Lipids (pwd) Private Label Milk-Based Prebiotic with Lipids (pwd) Private Label Organic with Lipids (pwd) Private Label Sensitivity Milk-Based (PBM Products) Similac Advance EarlyShield Similac Organic Similac Sensitive Similac Sensitive RS Hydrolysate Hydrolysate Hydrolysate 1.5 Coconut, Soy, High Oleic Safflower, High Oleic Sunflower, Palm Oils, DHA 3.5 Lactose, Corn Syrup Solids Palm Olein, DHA 3.6 Corn Syrup Solids Vegetable Oils, Palm Olein, DHA 20 Organic Whey Concentrate 1.5 Organic Vegetable Oils, Palm, High Oleic Safflower or Sunflower, Coconut, Soy, DHA Hydrolysate Concentrate Similac PM 60/40 20 Whey Protein Concentrate, Sodium Caseinate 3.6 Lactose, Corn Syrup Solids, GOS 0.4g/ Organic Lactose Palm Olein, DHA 3.7 Corn Syrup, High Oleic Safflower, Coconut, Soy Oils, M. alpina & C. cohnii Oils (ARA & DHA) 20 Organic Nonfat Milk 1.4 Organic Oils (High Oleic Sunflower, Soy, Coconut) M. alpina & C. cohnii Oils (ARA & DHA) 20 Milk Protein Isolate 1.4 High Oleic Safflower, Soy, Coconut Oils, M. alpina & C. cohnii Oils (ARA & DHA) 20 Milk Protein Isolate 1.4 High Oleic Safflower, Soy, Coconut Oils, M. alpina & C. cohnii Oils (ARA & DHA) 1.5 High Oleic Safflower, Soy & Coconut Oils 3.7 Lactose, GOS 0.4 g/ Organic Corn Maltodextrin, Organic Lactose, Organic Sugar 3.7 Corn Maltodextrin, 3.7 Corn Syrup, Rice Starch, Lactose Enfamil 24 Reduced Minerals Whey, Nonfat Milk NUTRIENT DENSE COW S MIL BASED FORMULAS Source gm/ Source gm/ Source gm/ 1.7 Palm Olein, Soy, Coconut, 4.3 Lactose Bright Beginnings Soy with lipids (pwd) 20 Soy Protein Isolate with SOY BASED FORMULAS Source gm/ Source gm/ Source gm/ 1.8 Palm, High Oleic Safflower or Sunflower, Coconut, Soybean Oils DHA &ARA 3.6 Corn Syrup Solids, Supplement to Nutrition Focus Vol. 26 #3 2

10 Gerber Good Start Soy PLUS TM Similac Isomil Advance Similac Isomil DF Enfamil ProSobee 20 Partially Hydrolyzed Soy Protein Isolate with 20 Soy Protein Isolate with 20 Soy Protein Isolate with 20 Soy Protein Isolate with 1.7 Palm Olein, Soy, Coconut, 1.7 High Oleic Safflower, Soy, Coconut Oils, M. alpina & C. cohnii Oils (ARA & DHA) 3.4 Corn, Maltodextrin, 3.7 Corn Syrup Solids, 1.8 Soy, Coconut Oils 3.7 Corn Syrup Solids,, Soy Fiber 1.7 Palm Olein, Soy, Coconut, Corn Syrup Solids (liq) 180 ((pwd)) Alimentum Powder Alimentum Liquid Nutramigen With Enflora LGG Powder Nutramigen Liquid Pregestimil Powder Pregestimil Liquid Pregestimil Liquid 20 Casein Hydrolysate with added Amino Acids 20 Casein Hydrolysate, L-cystine, L-tyrosine, L-tryptophan 20 Casein Hydrolysate with added Amino Acids 20 Casein Hydrolysate with added Amino Acids 20 Casein Hydrolysate with added Amino Acids 20 Casein Hydrolysate with added Amino Acids 24 Casein Hydrolysate with added Amino Acids CASEIN HYDROLYSATE FORMULAS Source gm/ Source gm/ Source gm/ 1.9 High Oleic Safflower, MCT (33%), Soy Oils, M. alpina & C. cohnii Oils (ARA & DHA) 1.9 High Oleic Safflower, MCT (33%), Soy Oils, M. alpina & C. cohnii Oils (ARA & DHA) 1.9 Palm Olein, Soy, Coconut, 1.9 Palm Olein, Soy, Coconut, 1.9 MCT (55%), Soy, Corn, High Oleic Safflower Oil, 1.9 MCT (55%), Soy, High Oleic Safflower Oil, Single Cell Oils Rich in DHA 2.3 MCT (55%), Soy, High Oleic Safflower Oil, Single Cell Oils Rich in DHA 3.7 Maltodextrin, , Modified Tapioca Starch 3.6 Corn Syrup Solids, Modified Corn Starch From Protein Sources, Citrates 3.6 Corn Syrup, Modified Corn Starch 3.8 Corn Syrup Solids, Modified Corn Starch 3.8 Corn Syrup Solids, Modified Corn Starch 4.5 Corn Syrup Solids, Modified Corn Starch (2 fl oz) 260 (other liquids) Neocate Infant Neocate Infant w/dha EleCare, unflavored EleCare, unflavored w/dha Nutramigen AA TM (Mead Johnson) AMINO ACID BASE FORMULAS Source gm/ Source gm/ Source gm/ 20 L-Amino Acids 2.1 High Oleic Sunflower, Refined Vegetable Oil (Coconut, Soy) MCT (5%) 20 L-Amino Acids 2.1 High Oleic Sunflower, Refined Vegetable Oil (Coconut, Soy) MCT (33%), DHA 20 Free L-Amino Acids 2.1 High Oleic Safflower, MCT (33%),Soy Oils 20 Free L-Amino Acids 2.1 High Oleic Safflower, MCT (33%), Soy Oils, M. alpina & C. cohnii Oils (ARA & DHA) 20 Amino Acids 1.9 Palm Olein, Soy, Coconut, 3.0 Corn Syrup Solids Corn Syrup Solids Corn Syrup Solids Corn Syrup Solids Corn Syrup Solids, Tapioca Starch Supplement to Nutrition Focus Vol. 24 #3 3

11 Enfaport TM 30 Caseinate, Sodium Caseinate FOR SPECIAL FEEDING PROBLEMS Source gm/ Source gm/ Source gm/ 3.6 MCT (84%), Soy Oils, 5.5 Corn Syrup Solids /Milk FOR FEEDING BEYOND ONE YEAR OF AGE Source gm/ Source gm/ Source gm/ Whole Cow s Milk 20 Cow s Milk 3.3 Cow s Milk 3.7 Lactose Baby s Only Organic Dairy Toddler (Nature s One) Baby s Only Organic Lactose Free Toddler (Nature s One) Baby s Only Organic Soy Toddler (Nature s One) Enfagrow TM PREMIUM TM Next Step Milk-based Powder months Enfagrow TM Soy Next Step Powder months Enfagrow TM Gentlease Next Step Powder months Gerber Good Start 2 Gentle PLUS 9 24 months Gerber Good Start 2 Protect PLUS (B.lactis) 9 24 months Gerber Good Start 2 Soy PLUS 9 24 months Private Label Older Infants (9-12 mos) Similac Go & Grow Milk- Based Similac Go & Grow Soy-Based 20 Certified Organic Nonfat Milk 20 Certified Organic Milk Protein Concentrate 20 Certified Organic Soy Protein Concentrate 20 Nonfat Milk, Milk protein Isolate (liq) Nonfat Milk (pwd) 20 Soy protein Isolate with 20 Partially Hydrolyzed Nonfat Milk and Whey Protein Concentrate 20 Enzymatically Hydrolyzed Reduced Mineral Whey 20 Enzymatically Hydrolyzed Reduced Mineral Whey 20 Partially Hydrolyzed Soy Protein Isolate with 1.7 Certified Organic High Oleic Sunflower, Soybean, Coconut Oils 1.4 Certified Organic High Oleic Sunflower, Soybean, Coconut Oils 1.9 Certified Organic High Oleic Sunflower, Soybean, Coconut Oils 1.8 Palm Olein, Soy, Coconut, 2.2 Palm Olein, Soy, Coconut, 1.8 Palm Olein, Soy, Coconut, 1.5 Palm Olein, Soy, Coconut, 1.5 Palm Olein, Soy, Coconut, 1.8 Palm Olein, Soy, Coconut, 20 Nonfat Milk 1.8 Vegetable Oils, Palm Olein, DHA 20 Nonfat Milk 2.0 High Oleic Safflower, Soy, Coconut Oils, M. alpina & C. cohnii Oils (ARA & DHA) 20 Soy Protein Isolate, 1.7 High Oleic Safflower, Soy, Coconut Oils, M. alpina & C. cohnii Oils (ARA & DHA) 3.5 Certified Organic Brown Rice Syrup, Naturally Occurring Organic Lactose 3.6 Certified Organic Brown Rice Syrup 3.5 Certified Organic Brown Rice Syrup 3.6 Lactose, Corn Syrup Solids Corn Syrup Solids Corn Syrup Solids, Lactose 3.4 Lactose, Maltodextrin GOS 0.4 g/ Lactose, Maltodextrin Corn, Maltodextrin, Corn Syrup, Lactose Lactose, GOS 0.4g/ Corn Syrup Solids, /Milk BOOST id Essentials (Flavored) BOOST id Essentials Sodium and Caseinates, Whey Protein Concentrate 44 Sodium and Caseinates, Whey Protein Concentrate NUTRIENT DENSE FOR FEEDING BEYOND ONE YEAR OF AGE Source gm/ Source gm/ Source gm/ 3.0 High Oleic Sunflower Oil, Soy Bean Oil, MCT (21%) Soy Lecithin 4.2 Soy Bean Oil, High Oleic Sunflower Oil, MCT (10%), Soy Lecithin 3.8 Sugar, Maltodextrin Maltodextrin, Sugar Supplement to Nutrition Focus Vol. 26 #3 4

12 BOOST id Essentials 1.5 w/fiber Compleat Pediatric Blenderized Enfagrow TM PREMIUM TM Vanilla months Enfagrow TM PREMIUM TM Chocolate months Monogen Nutren Junior Vanilla Flavored Nutren Junior With Fiber Vanilla (Nestlé ) PediaSmart Complete Organic Nutrition (Nature s One) PediaSure Enteral PediaSure Enteral w/fiber and scfos PediaSure PediaSure w/fiber Portagen Powder (Mead Johnson) Private Label Pediatric Drink Liquid Private Label Pediatric Drink w/fiber Liquid Private Label Soy Pediatric Drink *Chocolate Flavor does not contain the ingredient 44 Sodium and Caseinates, Whey Protein Concentrate 30 Chicken, Sodium Caseinate, Pea Puree 24 Whole and Skim Milk Powder 21 Whole and Skim Milk Powder 4.2 Soybean Oil, High Oleic Sunflower Oil, MCT (10%), Soy Lecithin 3.8 Canola Oil, MCT Oil (20%), Soy Lecithin 3.2 High Oleic Sunflower, Marine Oil DHA 2.7 High Oleic Sunflower, Marine Oil DHA 7.5 Maltodextrin, Sugar, PHGG, Soy Fiber 3.9 Cranberry Juice, Corn Syrup Solids, Partially Hydrolyzed Guar Gum, Vegetables and Fruits 3.8 Lactose,, Maltodextrin, Corn Starch Vanilla flavor, GOS 0.2g/ 2.3, Lactose, Maltodextrin and Starch GOS 0.2g/ N/A N/A 30 Whey Protein Concentrate 2.7 MCT (90%), Walnut Oil 2.8 Dried Glucose Syrup Milk Protein Concentrate, Whey Protein Concentrate 30 Milk Protein Concentrate, Whey Protein Concentrate 30 Certified Organic Milk Protein Concentrate 3.0 Soybean Oil, Canola Oil, MCT (25%) Soy Lecithin 3.0 Soybean Oil, Canola Oil, MCT (21%) Soy Lecithin 2.9 Certified Organic High Oleic Sunflower, Soybean, Coconut Oils 30 Milk Protein Concentrate 3.0 High-Oleic Safflower, Soy, MCT (15%) Oils 30 Milk Protein Concentrate 3.0 High Oleic Safflower, Soy, MCT (15%) Oils 30 Milk Protein Concentrate, Whey Protein Concentrate*, Soy Protein Isolate 30 Milk Protein Concentrate, Soy Protein Isolate 3.0 High Oleic Safflower, Soy, MCT (15%) Oils 3.0 High Oleic Safflower, Soy, MCT (15%) Oils 5.0 Maltodextrin, Maltodextrin,, Pea Fiber, Oligofructose, Inulin 3.8 Certified Organic Rice Oligodextrin, Evaporated Cane Juice 4.0 Corn Maltodextrin, 4.0 Corn Maltodextrin,, Blend of Soluble &Insoluble Fibers, scfos 0.3g/ 3.8, Corn Maltodextrin, scfos 0.4g/ 3.8, Corn Maltodextrin, Soy Fiber, scfos 0.4g/ (Chocolate) Sodium Caseinate 3.5 MCT (87%), Corn Oils 4.7 Corn Syrup Solids, Sugar Sodium Caseinate Whey 3.0 High Oleic Safflower, Soy, MCT (20%) 5.0 Corn Syrup,, scfos 0.5g/ 30 Sodium Caseinate Whey 3.0 High Oleic Safflower, Soy 5.0 Corn Syrup,, Soy Fiber, scfos 0.6g/ 30 Soy Protein Isolate with 3.0 High Oleic Safflower, Soy, MCT (20%) 5.0, Maltodextrin, scfos 0.5g/ /Milk EleCare Vanilla Neocate One + Powder E028 Splash Neocate Junior Unflavored Neocate Junior Flavored SPECIALIZED PEDIATRIC NUTRITION PRODUCTS MODIFIED PROTEIN BASED FORMULAS Source gm/ Source gm/ Source gm/ 30 Free L-Amino Acids 3.1 High Oleic Safflower, MCT (33%), Soy Oils 30 L-Amino Acids 2.5 MCT (35%), Canola, High Oleic Safflower Oils 30 L-Amino Acids 2.5 MCT (35%), Canola, High Oleic Safflower Oils 30 L-Amino Acids 3.3 MCT (35%), Canola Oil, 30 L-Amino Acids 3.5 MCT (35%), Canola Oil, 4.9 Corn Syrup Solids Corn Syrup Solids Maltodextrin, Corn Syrup Solids Corn Syrup Solids Tropical 680 Chocolate 700 Supplement to Nutrition Focus Vol. 24 #3 5

13 Neocate Junior with Prebiotics Unflavored Pepdite Junior Unflavored Pepdite Junior Banana Flavored Peptamen Junior Unflavored (Nestlé ) Peptamen Junior Vanilla or Chocolate or Strawberry Peptamen Junior w/prebio1 Vanilla Peptamen Junior Fiber Vanilla Peptamen Junior 1.5 Vital jr. Vivonex Pediatric 30 L-Amino Acids 3.5 MCT (35%), Canola Oil, 30 Hydrolyzed Protein (Pork and Soy), L-Amino Acids 30 Hydrolyzed Protein (Pork and Soy), L-Amino Acids 30 Enzymatically Hydrolyzed Whey 30 Enzymatically Hydrolyzed Whey 30 Enzymatically Hydrolyzed Whey 30 Enzymatically Hydrolyzed Whey 44 Enzymatically Hydrolyzed Whey Protein 30 Whey Protein Hydrolysate, Sodium Caseinate 3.1 MCT (35%), Canola Oil, 3.1 MCT (35%), Canola Oil, 3.0 MCT (60%), Soybean Oil, Canola Oil, Soy Lecithin 3.0 MCT (60%), Soybean Oil, Canola Oil, Soy Lecithin 3.0 MCT (60%), Soybean Oil, Canola Oil, Soy Lecithin 3.0 MCT (60%), Soybean Oil, Canola Oil, Soy Lecithin 4.5 MCT (60%), Soybean Oil, Canola Oil, Tuna Oil 3.0 Structured Lipid (Interestified Canola and MCTs) MCT (50%), and Canola Oils 4.7 Corn Syrup Solids, FOS and Inulin 0.4g/ Corn Syrup Solids Corn Syrup Solids Maltodextrin, Corn Starch Maltodextrin,, Corn Starch 3.8 Maltodextrin,, Corn Starch, Oligofructose, Inulin 3.8 Maltodextrin,, Corn Starch, Pea Fiber, Oligofructose, Inulin 6.8 Maltodextrin, Corn Starch, Oligofructose, Inulin 4.1 Corn Maltodextrin,, scfos 0.3g/ 24 L-Amino Acids 2.4 MCT (68%), Soybean Oil 2.4 Maltodextrin, Modified Starch NITROGEN-FREE ENERGY SOURCES PRODUCT FAT SOURCE CHO SOURCE Duocal 4.9/gm Corn, Coconut, MCT Oils Hydrolyzed Cornstarch Microlipid 4.5/ml Safflower Oil None MCT Oil 7.7/ml 8.3/gm Fractionated Coconut Oil None Polycal 3.8/gm None Maltodextrin Polycose (pwd) 3.8/gm None Glucose Polymers Safflower Oil 8.8/gm Safflower None SOLUTION Enfamil Enfalyte Pedialyte Unflavored PediaVance (Made with Organic Fruit Juice) (Nature s One) ORAL ELECTROLYTE SOLUTIONS Carbohydrate Source 3.5 Rice Syrup Solids, Citrates gm/ Na Dextrose Organic Dextrose & Organic Fructose INFORMATIONAL SOURCES: Abbott Nutrition Abbott Laboratories, Columbus, Ohio Agricultural Research Service, USDA, Washington D.C. Mead Johnson Nutrition, Evansville, Indiana (800) Nature s One, Inc Cotter Street, Lewis Center, OH ( ) Nestlé Infant Nutrition, Florham Park, NJ (800) Nestlé Nutrition, Florham Park, NJ (800) Nutricia North America, Nutrition Services (800) PBM Products, LLC, Gordonsville, VA (800) Prolacta Bioscience, Monrovia, CA Compiled 7/2010 J. Hattner RD, J. erner MD PROTEIN SUPPLEMENTS PRODUCT PROTEIN SOURCE PROTEIN Beneprotein 3.4/gm Whey Protein Isolate 6.0 gm/scoop Complete Amino Acid Mix 3.3/gm Amino Acids 0.8 gm/gm Powder Supplement to Nutrition Focus Vol. 26 #3 6