Breastmilk is the optimal feeding for infants. When extra fortification is required, infant
formula can be added to breastmilk. If an infant is formula-fed, most products can be
concentrated to increase caloric density. It is important to monitor growth closely when
increasing caloric density. This guide accompanies the Oregon Pediatric Nutrition Practice
Group (OPNPG) formula selection listing of standard and special medical infant formulas.
Considerations for evaluating the etiology of poor growth:
 Is the infant’s growth plotted accurately on the proper World Health Organization
(WHO) growth chart?
 Is weight for length being assessed?
 How is the infant’s growth velocity?
 What are the hunger cues of the infant? Can parents identify hunger/fullness cues?
 Are sleep/awake cycles appropriate to stimulate hunger?
 Has mother’s milk supply been assessed?
 What is the frequency and duration of breastfeeding?
 What is the volume of intake for the infant? Is it sufficient?
 Is the formula prepared correctly?
 Has the infant been assessed for gastroesophageal reflux? Diarrhea? Malabasorption?
 Does the infant have oral/tactile hypersensitivity?
 Does the feeding position support adequate intake?
 How long do feedings last? Refer when feedings last longer than 30 minutes.
 Are solids replacing breastmilk/formula?
Products not recommended for infants less than 12 months of age:
 Cow’s milk
 Evaporated milk
 Goat’s milk
 Any pediatric formula intended for use over 1 year of age
 Soy beverage
 Instant breakfast drinks
 Leche Nido
 Rice, almond beverages or other milk substitutes
Health risks associated with the products listed above:
 Intestinal blood loss
 Improper bone mineralization
 Hypervitaminosis
 Improper nutrient composition
 Insufficient fluid intake due to caloric density
 Allergenic properties
 Increased risk of dehydration due to high renal solute load
These recommendations are general guidelines. They are not intended to be used for the
treatment of specific clinical conditions or without medical supervision.
Oregon Pediatric Nutrition Practice Group 2015 www.eatrightoregon.org Post-discharge
Premature
Formula
Standard and
Medical Infant Formula
Breastmilk
Recipes to increase caloric and nutrient density of breastmilk or formula
Fortification of breastmilk using:  Standard infant formulas: Routine, partially hydrolyzed or soy (use of
thickened formulas is contraindicated)
 Special medical infant formulas: Extensively hydrolyzed protein*, postdischarge premature
Breastmilk
3 oz
3 oz
3 oz
Powder (unpacked, level scoops)
½ teaspoon
1 teaspoon
2 teaspoons
Caloric density (kcal/oz)
22 kcal/oz
24 kcal/oz
27 kcal/oz
Concentration of standard or extensively hydrolyzed protein* infant
formulas:
 Concentrating thickened formulas above 24 kcal/oz is contraindicated
 Recipes can be doubled
Water
5.5 oz
5 oz
4.5 oz
Water
11 oz
9 oz
6.5 oz
Powder (unpacked, level scoops)
3 scoops
3 scoops
3 scoops
Concentrate
13 oz
13 oz
13 oz
Caloric density (kcal/oz)
22 kcal/oz
24 kcal/oz
27 kcal/oz
Caloric density (kcal/oz)
22 kcal/oz
24 kcal/oz
27 kcal/oz
Concentration of post-discharge premature formulas:
 Recipes can be doubled
Water
Powder (unpacked, level scoops)
Caloric density (kcal/oz)
2 oz
1 scoop
22 kcal/oz
3.5 oz
2 scoops
24 kcal/oz
5.5 oz
3 scoops
24 kcal/oz
8 oz
5 scoops
27 kcal/oz
95 ml
2 scoops
27 kcal/oz
*When concentrating breastmilk or formula using Nutramigen Enflora or Pregestimil use packed level scoops
Use caution when concentrating formula above 24 kcal/oz
High caloric levels increase the renal solute load of formula, increasing the risk for dehydration.
Other modifications used to reach higher caloric levels (e.g. fat or carbohydrate modulars) may
dilute the ratio of protein, vitamins and minerals per calorie. When concentrating formula above
24 kcal/oz, it is recommended that a pediatric dietitian evaluate nutritional adequacy and
monitor growth closely.
Oregon Pediatric Nutrition Practice Group 2015 www.eatrightoregon.org