0021-7557/10/86-03/179

Jornal de Pediatria
Copyright © 2010 by Sociedade Brasileira de Pediatria
Review Article

The history of infant nutrition

Silvia Diez Castilho,1 Antônio de Azevedo Barros Filho2

Abstract

Objective: To retrace the history of infant nutrition with the objective of better understanding breastfeeding.
Sources of data: Bibliographic searches were run on MEDLINE, LILACS, SciELO, and the Internet. Encyclopedias,
scientific textbooks and books for the general public, in addition to literature, art and history, were also used.
Texts on child care from several different periods were consulted, in addition to the history of medicine and recent
scientific articles on infant nutrition.
Summary of the findings: During the preindustrial period, customs varied little and the likelihood of survival
was linked to breastfeeding or its substitution by a wetnurse’s milk. Where this was not possible, infants were
given animal milk, pre-chewed foods or paps that were poor in nutrients and contaminated, which caused high
mortality rates. There was nothing that could successfully substitute breastfeeding and the survival of the species
was dependent on breastfeeding. Once the industrial revolution had started, women who had been accustomed
to breastfeeding went to work in factories, stimulating the search for alternative infant nutrition. Consumption of
animal milk and formulae (diluted, flour-based, powdered milk) and premature introduction of complementary
foods compromised children’s health. The feminist movement and the contraceptive pill caused a fall in birth rates.
Manufacturers in search of profits developed modified formulae and invested in advertising. Society reacted with
breastfeeding support movements.
Conclusions: Nowadays, the advantages of breastmilk are recognized and exclusive breastfeeding is
recommended up to 6 months, to be supplemented with other foods from this age on and continued until at least
2 years of age. Infant nutrition, whether natural or artificial, has always been determined and conditioned by the
social value attributed to breastfeeding.

J Pediatr (Rio J). 2010;86(3):179-188: Breastfeeding, weaning, /history.

Introduction
As mammals, human beings have always depended practice as natural as breastfeeding nowadays needs to be
on breastmilk for survival. However, throughout history encouraged in a variety of ways and protected by law.
breastfeeding has been molded by cultural values, many
of which are today considered to be harmful to the practice
and, consequently, to children’s health. An understanding Synthesis
of how and why societies gave support to certain beliefs If one were to be asked what food is usually given to
and customs which were, in many cases, recommended infants who are not breastfed, the immediate reply would
by physicians, can be useful to the health professionals of be non-human milk. However, if we roll back the clock to
today who work to promote breastfeeding. prehistoric times we will soon see that this has not always
The objective of this article is to retrace, in a succinct been the correct answer. There was a time when humans
manner, the advances and retreats in the process of feeding hunted and gathered the food they needed to survive.1,2
infants during their first years of life that have meant that a Thus, if a mother could not breastfeed, then her child was

1. Doutora, Pediatria. Professora, Faculdade de Medicina, Pontifícia Universidade Católica de Campinas (PUC-Campinas), Campinas, SP, Brazil.
2. Doutor, Pediatria. Professor associado, Departamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas,
SP, Brazil.
No conflicts of interest declared concerning the publication of this article.
Suggested citation: Castilho SD, Barros Filho AA. The history of infant nutrition. J Pediatr (Rio J). 2010;86(3):179-188.
Manuscript submitted Aug 03 2009, accepted for publication Sep 30 2009.
doi:10.2223/JPED.1984

179
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condemned to death unless another woman took her place. Hippocrates indicated that solid foods should be
At that time it is probable that breastfeeding continued introduced as soon as children cut their first teeth.8 Aristotle
until the child was able to find its own food. Even during discusses milk (both human and animal) and its qualities in
the Neolithic period, when humans began to find practical Historia animalium stating that “milk is composed of whey
solutions to everyday problems, planting and harvesting and curds,” “milk that is rich in curds is more nutritious,”
and raising livestock, it still took a long time before animals but “the healthiest milk for children is that with the lowest
were milked.1-3 As domestic herds formed, many children quantity of curds.”9 He advised mothers not to breastfeed
survived as a result of being fed on animal milk, given in a previous child when pregnant, “because the colostrum
vessels or directly from the udder.3-5 produced before the seventh month is inappropriate,
The story of Moses, as told in the Old Testament becoming appropriate only after the child is born.” He was
(Exodus 1:15 to 2:10), describes the way that Hebrews against giving children wine, which was a common habit
and Egyptians sought wetnurses to guarantee the survival at the time, because it “encourages the appearance of
of children separated from their mothers.6 Another Biblical convulsions, and red is worse than white, particularly if
reference gives an idea of how long children were breastfed. undiluted.”10 Little more is known about other foods given
In 1000 BC Samuel was taken to live with Eli when he was 3 to non-breastfed children during this period. However,
years old, after he had been weaned (I Samuel 1:22-24).6 Fildes comments that they probably survived on milk with
Teachings in the Talmud that date from 200 BC encouraged honey, milk with cereals, pre-chewed food or by suckling
mothers to breastfeed for 2 years and emphasized that the from animals.4
procedure was important “to preserve life.”4 The first Roman texts to discuss childcare were written
Despite cultural differences, the people of Mesopotamia, by Soranus and Galen, who were Greek physicians practicing
Egypt and Hebron cared for their children in a similar in Rome during the start of the Christian era.11 Table 1
way, which remained constant for millennia.2,4 They summarizes the main points of their dietary guidance for
considered children to be divine gifts. After the Egyptians infants.2,4
were dominated by the Romans, the Greco-Roman culture Although these were the recommendations, vessels
dominated and children lost their value in that culture too. found in children’s tombs suggest that the poorer classes
Families would make contracts with wetnurses who would were often weaned during the neonatal period.4
take children to their own homes and only return them years During the same period, philosophers and moralists
later. This custom spread throughout the Greek colonies and argued against the use of wetnurses. Pliny, Plutarch and
the Roman Empire and was introduced into Europe in that Tacitus understood that, in addition to milk being the best
period. Descriptions indicate that some babies were given food for infants, the act of breastfeeding helps to strengthen
milk and eggs before being weaned from the breast; fruit emotional bonds “avoiding future problems.”2 Mothers should
and vegetables were only introduced after weaning.4 When only be relieved of this duty if they were ill or wished to
a wetnurse was not available, children were suckled directly become pregnant.4 According to Badinter,12 Plutarch started
from animals’ udders or given milk using vessels.7 the first moral movement in favor of breastfeeding.
The western world’s childcare customs have their roots Physicians were less demanding than moralists when it
in Greco-Roman and Arab medical knowledge. came to breastfeeding. However, since they believed that

Table 1 - Soranus’ and Galen’s dietary prescriptions for infants

Soranus Galen
Prescription (circa 70-130 AD) (circa 130-200 AD)

First food Honey + cow’s milk Honey

Start of breastfeeding Wetnurse on 2nd day, mother on 20th day
Breastfeeder (mother or wetnurse) Mother, wetnurse (only if necessary) Mother
Technique Don’t give colostrum
Quantity Frequently
Introduction of foods After 40th day; preferably after 6 months After first tooth
Complementary foods Cereal, bread + milk or wine, porridge, eggs; not pre-chewed Bread, vegetables, meat, milk
Wine Diluted Contraindicated
Weaning 18-24 months, gradual 3 years
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by suckling the child would absorb characteristics from the During the Renaissance (thirteenth to seventeenth
nursing female, they recommended that when choosing centuries), the ideal of humanism and the invention of the
wetnurses both their qualities as a milk provider and as a printing press stimulated the publication of books. Among the
woman should be taken into account, including age, health, medical texts of the time were four treatises on Pediatrics,
height, temperament and morals.2,4 known as the Paediatric Incunabula.2,14 The authors of
these books follow the recommendations of Avicenna;
The knowledge of ancient Greece arrived in the Arab
they recommended breastfeeding (mother or wetnurse),
world in the ninth century BC. The most important authors
but the colostrum was not valued. The advance was that
of Islamic medical texts were not, in truth, Arabs, but
books began to appear written in languages other than
Persians. Notable among them was Avicenna, author of
Latin, increasing access to information. The first drawings
the Canon of Medicine.2,4,11,13
of infants being fed with vessels similar to babies’ bottles
Avicenna believed that the state of health and the appeared in Versehung von Lieb (1429).4,15
characteristics of the nursing mother influenced the
The Renaissance and the Reformation were responsible
health of the baby. If she were to become ill, she should
for changes in customs.11 Handbooks for midwives appeared.
be substituted by another woman. If the milk was thick
Discussion about breastfeeding continued, but the scarcity
or unpleasant smelling the recommendation was that it
of data on alternative feeding should not be interpreted as
should be expressed, exposed to fresh air and then given
meaning the practice was rarely employed.4
to the child in “vessels or horns with artificial teats.”4,13
Avicenna recommended that children be breastfed for as Concepts about infant nutrition began to change after

long as possible, because “it is the most appropriate food publication of The Accomplisht Midwife (1668).2 In this

for growth and development.”13 Avicenna’s conduct is work, Mauriceau led the way with new ideas about caring
for newborn infants based on empiricism, which began to
summarized in Table 2.
influence thinking, and the theories of Avicenna, Soranus
In that era a good meal comprised meat, grain, sweets and Galen, which until then had dominated the medical
and wine. Other foods were considered medications or recommendations, were sidelined.4,11 The principal change
preservatives. Fresh fruit was only good for those carrying was in relation to nutrition for infants whose mothers did not
out hard work, and vegetables were considered to have an have milk to feed them. Paps and other substitutes began
effect on febrile diseases.13 Diets were very poor and did not to be more accepted than using wetnurses. The interest in
provide sufficient nutrients, not for children weaned after 2 the infant had given way to the mother-child pair and, later,
or 3 years and even less so for those weaned early. the focus moved to the wellbeing of the mother.
The medical texts of the Middle Ages reflect the thinking The value accorded to colostrum began to change after
of Soranus and Galen and also that of Avicenna, since the publication of Essay Upon Nursing and the Management of
Canon of Medicine was translated into Latin and was used Children by Cadogan in 1748.2,4 Initially, the colostrum was
in European Universities until the seventeenth century credited with having cleansing properties that helped to
AD.11,13 Works of art, stories, poems, letters, records found eliminate meconium, but soon its influence on prevention
in orphanages and other documents that have survived also of certain diseases, both of the mother (milk fever) and
provide information about the diet and childcare received of the infant (gastrointestinal infections).4 Cadogan also
by children during the period. believed in the importance of the “emotional bond” that

Table 2 - Avicenna’s dietary prescriptions for infants

Avicenna
Prescription (980-1036 AD)

First food Honey

Start of breastfeeding Day 1, wetnurse
Breastfeeder (mother or wetnurse) Mother
Technique Don’t give colostrum
Quantity 2-3 times a day
Introduction of foods When child starts to request it
Complementary foods First pre-chewed bread; then bread + wine, honey or milk
Wine Diluted
Weaning 2 years
182 Jornal de Pediatria - Vol. 86, No. 3, 2010 Feeding infants - Castilho SD & Barros Filho AA

is established “when a mother breastfeeds her child from worsened with a significant impact on child health, since
its first hours of life.” He condemned the habit of giving animal milk and meat stocks were gradually substituted by
newborn infants butter with sugar or paps while breastmilk water. Other ingredients, such as eggs, egg yolks, butter
has not yet become “mature milk.”2 He also advised against and fats, important sources of vitamins A and D, proteins,
wetnurses and introducing complementary feeding before calcium and iron, also ceased to be included in recipes.4
6 months. He believed that boiling animal milk altered its Children began to suffer from rickets, kidney stones and
properties, making it bad for the health.4 As a result, he scurvy. Contamination of utensils and food, often prepared
recommended that when it was used in paps it should be in advance and reheated countless times, also increased the
added after the other ingredients had been cooked. incidence of tuberculosis, brucellosis and gastrointestinal
Data indicate that between 1675 and 1750 there was infections.4,17
a gradual fall in infant mortality in England. According to Data show that medical recommendations are not
Hollingsworth16 apud Fides,4 this reduction was due to always followed. At the start of the eighteenth century,
changing habits with relation to giving infants colostrum. families persisted in many practices that were condemned
by physicians.4 The habit of offering pre-chewed food has
In 1749, a demographic study showed that infant
existed for centuries, indeed, both Soranus and Galen
mortality had decreased in Sweden during the eighteenth
mentioned it.2,4,11 Possibly because it was a common custom,
century. This advance was attributed to the work of physicians
people did not believe it could damage the health.
and midwives to convince mothers to breastfeed.15 If, at the
start of the century, half of all children died during their first The introduction of complementary foods, which
year of life, 40 years later this rate had been halved. happened between 7 and 9 months in the sixteenth century,
moved forward to the second or fourth month during the
Infant feeding habits truly changed when it was observed
next two centuries. Little is known about the frequency and
that children in Foundling Hospitals (1741) who were fed
quantities offered, but it is notable that, as the wellbeing
with animal milk (goats and mules) or who were given
of mothers began to be prioritized (Cadogan), on-demand
substitute foods were less likely to survive than children
breastfeeding was substituted by four to six feeds per day,
breastfed by their mothers.4 This relationship was confirmed
probably making it necessary to introduce other foods.15,18
after “infirmaries” were set up (1747), in which mothers
Only at the end of the eighteenth century did the first texts
spent the first few days after delivery breastfeeding their
appear commenting on the excessive quantity of food
children from their first hours of life onwards.2
given to children and recommending breastfeeding with
During the sixteenth and seventeenth centuries, it no fixed times.4
was more common for Protestant mothers to breastfeed
The Industrial Revolution began in England in the
than for Catholic mothers. However, between the end of
eighteenth century and influenced thousand-year-old
the seventeenth century and the start of the eighteenth,
practices of infant feeding as poor rural women, who had
the number of women hiring wetnurses began to increase
breastfed their own children and those of more privileged
once more.15 The practice became so common that
classes, moved to the cities.17 In an age when no method
agencies appeared that recruited wetnurses and conducted
had yet been discovered to preserve milk, other foods were
negotiations between the two parties. Mothers who did not
introduced ever earlier and more often. Mortality rates
wish to breastfeed would explain their decision as being
increased and the State, interested in manual labor and
due to adverse effects on their health and appearance,
troops, invested in the search for solutions to reduce the
difficulties due to flat or inverted nipples (caused by the
high infant mortality rates. These changes began in the
tight clothing they wore) and their husbands’ attitudes to
eighteenth century and bore fruit in the next century (Table
the idea that breastfeeding women could not have sex,12,15
3).17 Urbanization changed the way that families lived; they
because the Catholic church prohibited carnal relations
began to depend on monetary power, since in cities they
during lactation.4,12
could not plant or raise livestock for subsistence. Living
During this period, mothers who did not breastfeed conditions were poor, with people living in slums where they
started to prefer paps and bread sops rather than wetnurses. were crowded together in small quarters with little hygiene.
The first references to this type of diet are from before the Exploitation of labor through low wages obliged women to
fifteenth century. Recipes consisted of a liquid ingredient go to work. Children left at home or in institutions needed to
(milk, beer, wine, vegetable or meat stock, water), a cereal be fed somehow. There were no more wetnurses, or money
(rice, wheat or corn flour, bread) and additives (sugar, to pay them with. Ignorance of techniques for preserving
honey, herbs or spices, eggs, meat).2,4 milk, whether during transportation from rural areas to
Up to the sixteenth century, the nutritional value of these the cities or during storage at home, further compromised
paps was reasonable, with only vitamin C deficiency obvious, infants’ nutrition.
resulting from inadequate intake of fruit and vegetables.4 At the end of the nineteenth century, authors were
From the seventeenth century on, their nutritional content already pointing out the high malnutrition and mortality
Feeding infants - Castilho SD & Barros Filho AA Jornal de Pediatria - Vol. 86, No. 3, 2010 183

rates related to the reduction in the number of children The stimulus to seek alternatives came when women
being breastfed and the increase in the use of animal realized that, even being paid lower wages than men,
milk. Jelliffe & Jelliffe17 mention that “in 1863, 60% of they could earn more money working in factories than as
breastfed children in Manchester were well-nourished at wetnurses.20
9 months compared with just 10% of those given milk The argument in favor of animal milk was reinforced
in a bottle.” According to Radbill,19 feeding with paps or after 1838 when Simon discovered that cow’s milk contains
non-human milk caused 100% of mortality during the more protein and less carbohydrate than human milk.18,20
first week of life. Survival increased when alternative As time passed it was realized that CM was indigestible
foods were introduced after the first month, but, even because it formed more curds than breastmilk.21 Physicians
so, mortality was greater than 50%.20 began to blame deaths on “intoxication” by milk protein

Table 3 - Significant events in the history of infant nutrition since the Industrial Revolution

Date Event

1838 Simon: “CM contains more protein than BM.”

1856 Gail Borden: condensed milk.

1867 Leibig: First commercial formula (wheat flour + malt + potassium bicarbonate); powder to be added to diluted milk.

1872 Warning: condensed milk (high energy and low fat content).

1874 First complete artificial formula (powdered milk + wheat flour + malt + sugar); powdered milk to be mixed with water.
Too expensive for the majority.

1880 Chlorinated water.

1883 Myenberg: evaporated milk. Advantage: no sugar, more fat, sterile, more digestible.

1885 Meigs (United States) and Biedert (Germany) revealed the exact composition of BM.

1890 Pasteurization of milk. Many people were opposed.

1895 Rotch: “mathematical formulae” based on proportions for preparing milk at home. Impractical for the majority, so
formulae were made up and sold in bottles (ready-to-use milk).
Electricity made it possible to use refrigeration to conserve milk. Advertising of formulae + pasteurization + refrigeration;
reduced breastfeeding and increased intake of CM and formulae. The first milks produced to imitate the composition
of BM.

1912 Funk: linked beriberi, scurvy, pellagra and rickets to vitamin deficiencies. Energy requirements recommendation.

1920 Recommendation: supplement feeding with juice and cod liver oil. Tendency to move to solids earlier.

1929 Soy formula for children allergic to CM. (Isolated protein formula was only produced in 1960.)

1940 Evaporated or pasteurized milk fortified with vitamin D; children were given juice to guarantee a source of vitamin C

After the Second World War: advertising and increased birth rate bring profits.

1960 Feminism + contraceptive pill reduce birth rate. Industry expands to the Third World. Baby foods containing monosodium
glutamate, sugar and starch to improve texture and appearance. Constant changes to formulae (lactic acid, lactose,
fat, minerals, vitamins) to meet needs of infants.

1962 Formula ingredients regulated.

1970 Breastfeeding support movement formed. CM introduced ever later. Recognition of allergy, diarrhea and iron deficiency
anemia. Formula with Fe or CM with fortified cereal for non-breastfed children.

1990 Innocenti Declaration, Baby Friendly Hospital Initiative, Ten Steps for Successful Breastfeeding, regulation of advertising
of teats, bottles and formulae.

1993 WHO: the difference in growth of breastfed children.

1997-2003 WHO Multicenter Growth Reference Study. New Growth Charts WHO-2006.
Growth charts for the twenty-first century.

Twenty-first century Recommendation: EBM up to 6 months, then BM + complementary foods at least until 2 years.

BM = breastmilk; CM = cow’s milk ; EBM = exclusive breastmilk; WHO = World Health Organization.
184 Jornal de Pediatria - Vol. 86, No. 3, 2010 Feeding infants - Castilho SD & Barros Filho AA

or on excessive electrolytes.20 This knowledge led them to these formulae made them inaccessible to the majority of
prescribe diluting milk before giving it to infants. Mortality the population.21
rates dropped, but it was soon found that children were Water began to be chlorinated in the first world in around
not thriving.18 Physicians then began to recommend, on an 1880, producing favorable conditions for the preparation
empirical basis, adding sugar and cream to the diluted milk.20 of powdered milk.24 However, the process was slow to
The discovery that this procedure led to children surviving reach other countries, so that preparing milk from powder
and developing well was a watershed in the argument in continued to pose a risk to child health because the powder
favor of cow’s milk, which began to dominate from the end was mixed with contaminated water.
of the nineteenth century.18
As the nutritional requirements of children were
Between 1850 and 1910, scientific advances in the
discovered, pediatrics became established as a specialty.
field of bacteriology led to improvements in health and
Pediatricians were made responsible for preparing milk
nutrition.17 The process of pasteurization, suggested by
(in laboratories), which was supplied in “ready-to-use”
Appert in 1795, was confirmed by Pasteur’s discovery
bottles,17 and for providing guidance on how to prepare
(1864) that keeping wine at high temperatures eliminated
“homemade formulae.”21 These formulae were based on
the bacteria that turned it to vinegar.5,21 The process was
percentage proportions, to reduce the quantity of casein
only employed to stop milk from going sour after 1890.2
in the milk, using the method developed by Biedert and
Many physicians, however, were opposed to the method
perfected by Rotch.2,5 The objective of the method was
because they believed it reduced the nutritional value of
to approximate the composition of cow’s milk as close
the milk, which was indeed confirmed later when it was
as possible to that of human milk (dilution, adding sugar
found that pasteurized milk was low in vitamins C and D.
or honey and cream)21 in terms of protein, sugar and fat
Pasteurization only became routine practice in the United
content, but ended up reduced to a mathematical exercise
States after 1915.21
that was impractical for the majority of people.2,5,17 This
Another alternative emerged in 1856 when Gail Borden prescription predominated from 1890 to 1915 because
discovered a method for making condensed milk.18,20,21 many believed that flour-based formulae were nutritionally
The milk was heated to high temperatures (removing half inadequate for children’s needs.21
of the water content) and large quantities of sugar were
In 1883, Myenberg discovered a method for producing
added. The resulting milk was sterile and could be stored
evaporated milk.18,20 This product did not contain sugar
because its hyperosmolarity prevented bacterial growth.
in excess nor did it lack fat, like condensed milk.18,20
It was initially used to feed soldiers in the American Civil
The manufacturing process consists of evaporating 60%
War (1861-1865) and was only later indicated as a food for
of the water content from milk and then heating it to
children.21 Many physicians were opposed to the practice
200 °C in sealed cans.20,21 The procedure changes the
because of the high energy density and because they
properties of the milk, making it more digestible because
observed that infants were not thriving because of the low
it reduces curd formation and also offering the advantage
fat content of the milk.18
of sterilizing it.21
The first commercial infant formula was developed by
Another important discovery was made simultaneously
Leibig (1867).5,20-22 It rapidly became popular in Europe.
in the United States and in Germany, when Meigs and
Leibig did not dare to challenge the prevailing idea that
Biedert revealed the exact composition of breastmilk (1885),
breastmilk was the “best food for infants,” but claimed he
confirming the low percentage of protein (1.1 g/100 mL;
had managed to produce a combination of ingredients that
40% casein and 60% whey protein), when compared with
resulted in a “flour,” which, when added to milk, resulted
cow’s milk (3.5 g/100 mL; 82% casein and 18% whey
in a food “identical” to breastmilk. The formula contained
protein).5,17,18
wheat flour, malt and potassium bicarbonate and was to be
mixed with preheated milk.5,21 Countless imitations soon In parallel with these developments in the food industry,
followed23,24 and some physicians began to recommend that glass feeding bottles and rubber teats were patented
using formula was a better choice than a wetnurse.25 (1845).18,21 These innovations helped to encourage the

A few years later (1874) saw the first “complete artificial use of breastmilk substitutes. Until then, substitutes had

formula for feeding infants,” since it no longer needed to been fed to children in horns, pewter or porcelain vessels or

be mixed with milk because it contained powdered milk, spoons.4 Aiming to reach mothers and the medical profession,

wheat flour, malt and sugar.21 Advertising claimed this manufacturers began to promote evaporated milk.18

was the “best food for children,” because cow’s milk can With the discovery of electricity and the advent of
cause gastrointestinal diseases in the heat and all that was refrigeration and because of frustration with the complexity
necessary to prepare the new formula was to “just mix of the formulae written by Rotch, physicians started to prefer
the powder with water.”25 Although they were available on evaporated milk or commercial formulae (powdered or
both the United States market and in Europe, the price of “ready-to-drink” liquids). Countless patents were registered
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from 1898 onwards.21,23,24 These factors, associated with formation because of the production process, it was no
promotional campaigns, contributed to the decline of longer necessary to add cereals.24
breastfeeding.2,18 Between 1912 and 1919, a study indicated As mothers breastfed less, solids were introduced ever
that just 13% of 1-year-old infants living in urban centers earlier. If the 1911 edition of Diseases of Infancy and
in the United States were fed breastmilk exclusively, while Childhood (Holt) recommended that vegetables should be
45% were given breastmilk and formula.26 Another study introduced after 3 years, the 1929 edition indicated doing
compared data from 1911 and 1967 and found that, if at so at 9 months.2 Other studies also demonstrated this
the start of the century 58% of 1-year-old infants in the tendency. In 1920, strained vegetables were introduced
United States were breastfed, 50 years later only 25% at the end of the first year, root vegetables at 18 months
were on exclusive breastfeeding when discharged from and other foods only after 2 years.29 In the 1950s, fruit
maternity.17 and vegetables were prescribed from 4 months onwards
At that time the dilution method (homemade formulae) and, by the next decade, 83% of 1 month old children
was the most popular in Europe and in the United States.24 seen in the District of Columbia were already eating some
Whereas the Germans used boiled milk, in the United Sates form of semi-liquid or solid food.30 In research conducted
milk was used in natura because of the observation that in Los Angeles in 1976, Hollen observed that one third of
certain diseases, such as scurvy, predominantly affected physicians indicated introducing solids within 6 weeks and
children fed on sterilized, pasteurized or condensed milk.24 almost two thirds before 3 months.31 At the same time,
In 1912, Funk suggested that beriberi, scurvy, pellagra animal milk was being introduced earlier and earlier and the
and rickets were caused by a lack of vitamins in the diet. prevalence of breastfeeding reduced even further between
This discovery led to the recommendation that diets be 1930 and 1970.17,24 Very often, commercial formulae were
supplemented with fruit juice and cod liver oil.24 From then used for a few months only, because of their high cost when
on, boiled milk was no longer a threat to health, and the compared with cow’s milk.24
use of diluted formulae became popular. In the 1940s, homemade formulae in the United States
Continuing to search for a good substitute for breastmilk, were made by mixing evaporated milk or pasteurized cow’s
the industry began to invest in producing modified milks milk with water and corn syrup or sucrose. Rickets and
(industrial formulae) in order to “humanize them,” i.e., scurvy were no longer feared because all processed milk
to approximate their composition to the characteristics was fortified with vitamin D and children were given juice
of breastmilk.21,24 Emphasis was put on the proportions to guarantee a source of vitamin C. Physicians believed
of protein, fat and carbohydrates and not on the energy that using formula was just as safe and satisfactory as
provided. With recognition of calorie requirements came breastfeeding.24
the recommendation of a daily intake of 100 kcal/kg Since the start of the century laboratories invested in
during the first months of life.24 Even so, between 1925 developing modified milks. There were so many options
and 1930 modified milks still varied considerably in terms on the market that even physicians found it difficult to
of energy density. choose the most appropriate formula for a given child.
In 1909, Ruhräh produced the first formula made from In search of increased profits, which had been hurt by
Soy, but it only became commercially available (United falling birth rates are caused by the Second World War,
States) after 1929, when Hill proposed it as an alternative manufacturers began “perverse” promotion of breastmilk
option for children who are allergic to cow’s milk.2,24,27 substitutes.18 After the war, sales increased in response to
Many parents complained about the color of this milk and the advertising campaigns and because of the baby boom.
said that it made their children’s feces foul smelling and The formulae that predominated between 1950 and 1960
stained their clothes, causing more frequent rashes. These were similar to evaporated milk, but with added vitamins,
effects were due to the large quantity of fiber contained or were low in protein and had vegetable oil and vitamins
in soy milk.24 In the 1950s it began to be noticed that and minerals added.
children fed on soy formulae had vitamin deficiencies.24,28 In the 1960s birth rates began to fall again as a result
Formulae were not fortified, however, because scientists of the contraceptive pill and the feminist movement.
believed that vitamins could trigger or exacerbate allergy. Breasts, which hitherto had had functional connotations,
Only in the mid-1960s did formulae appear made from gained esthetic and sexual roles.17 Feeding bottles were
isolated soy protein-based formulae, which were similar in adopted as a symbol of women’s liberation. The food
color to milk-based formulae and nearly odorless, leading industry diversified its products even further, increased
to increased toleration.28 advertising and expanded into the Third World.18 The
Since Leibig developed the first flour-based formula, compositions of formulae were changed (lactic acid, lactose,
cereals had always been added to milk with the objective fat, minerals, vitamins) to adapt them to new knowledge
of reducing curd formation and improving digestibility. about nutrition and to gain sales by offering advantages
When evaporated milk was invented, with reduced curd over other similar products or by reducing cost.17,28,32 The
186 Jornal de Pediatria - Vol. 86, No. 3, 2010 Feeding infants - Castilho SD & Barros Filho AA

term “humanized milk” gave way to “adapted milk.”17 All The world breastfeeding support movement began
of these changes contributed to the fall in breastfeeding in the 1970s, but it is difficult to identify the causes that
rates, the predominance of artificial feeding and the early triggered the change in prevailing mentality.24 The reasons
introduction of supplementary foods. appear to be rooted in society, which accused the industry
Until then, infant formulae available commercially of interfering in breastfeeding using aggressive advertising
were in powder form and based on whole cow’s milk. After campaigns.36
1951, concentrated liquid formulae began to appear in the Powdered formulae currently dominate the market for
United States and Canada. They dominated the market breastmilk substitutes practically all over the world. They
until the mid-1960s when ready-to-feed formulae were consolidated public preferences as they became more and
launched that no longer needed added water and had a more soluble.24,28
casein/whey protein ratio similar to human milk.28,33 The As breastfeeding returns to popularity, a tendency is
market for these products was restricted to North America, observed to introduce cow’s milk ever later, since after
since, with few exceptions, they were not made available weaning mothers are choosing powdered formulae.24 In
in other countries. addition to the practicality, the choice is also probably
Infant formulae have constantly changed since the partly the result of studies that have linked cow’s milk to
mid-20th-century in attempts to meet as closely as anemia. However, the use of fortified formulae had a modest
possible the needs of infants.34 Technological advances effect on the prevalence of iron deficiency anemia when it
made it possible to produce products that helped to was restricted to the first few months.37 As a result of this
reduce malnutrition, compensate for digestive and observation it was recommended that fortified formulae
absorptive deficiencies and deal with allergy problems were used at least until the end of the first year of life, or
and gastroesophageal reflux. where this is not possible, that fortified cereals be added
Breastmilk is the best possible food for an infant, but to cow’s milk.28,38,39
faced with a situation in which breastfeeding is not possible In 1979, Fomon et al.38 suggested that premature
(work, retrovirus infection, innate errors of metabolism, introduction of supplementary foods before 4 months
weight deficit) a formula should be chosen that is adequate contributed to forming unhealthy habits, with increased
for the age group, since formulae change depending on incidence of overweight and obesity. These authors
requirements. These formulae are more expensive than considered that this was probably because at this age
unmodified cows milk, whether powdered or liquid, and children are not yet able to refuse food when satisfied by
are very often inaccessible to low-income families.34 closing their mouths and turning their faces away.
Notwithstanding, it is known that unmodified cows milk is The return to popularity of breastfeeding also influenced
unsuitable for infants less than 1 year old because of the the time when complementary foods were introduced,
high concentration of protein, the incorrect casein to whey delaying it.28 If in 1976, 60% of children in the United States
protein ratio, and high levels of sodium, chloride, potassium were already eating solid foods at 1 month, by the start of
and phosphorus, insufficient carbohydrate, low quantities the 1990s this rate was below 10%.24 Unfortunately, the
of essential fatty acids (linoleic and linolenic), of vitamins same was not true of juices, since sales increased from 9.7%
(C, D and E) and of iron, zinc, copper and selenium.34,35 in 1971 to 16.7% in 1984,40 which was unjustifiable, since
These differences from the ideal composition compromise both breastmilk and formulate contained vitamin C.
digestion and absorption, lead to inadequate weight gain, The prevalence of breastfeeding reached its low point
overload the kidneys, contribute to obesity, predispose to in 1972 when data show that just 22% of newborn infants
diarrhea and dental caries and do not meet requirements in the United States were breastfed when discharged from
for essential fatty acids, vitamins or trace elements. In hospital.41 This rate they inclined, reaching 34% in 1975
addition to these risks, premature exposure to cow’s milk and 59.7% in 1984.42 Among the factors responsible for
can lead to hypersensitivity to milk protein, predisposing to this increase are the Natural Childbirth Movement (1960),
allergy, infection and anemia, because of intestinal micro- which questioned the medical model of delivery, claiming
hemorrhages. that it negatively impacted on the mother-child bond and
At the same time as infant formulae diversified, the on breastfeeding, and the Baby Friendly Hospital Initiative,
industry evolved in terms of both sweet and savory baby launched by the World Health Organization (WHO) and the
foods. Countless options appeared. In the 1960s, many United Nations Children’s Fund (UNICEF), to promote, protect
substances such as monosodium glutamate, sugar and and support breastfeeding (Innocenti Declaration) through
starch began to be added to paps with the intention of the Ten Steps to Successful Breastfeeding (1990).40
improving their appearance, density and texture, adjusting In this context, these entities took action to prohibit
them to the adult palate.28 Over time, this practice was advertising of baby milk, bottles, teats and pacifiers (1980-
regulated and the quantities of salt and sugar added to 90). Under pressure, the industry adopted the following
manufactured baby foods was reduced. slogan in advertising “breastmilk is the best food for infants,”
Feeding infants - Castilho SD & Barros Filho AA Jornal de Pediatria - Vol. 86, No. 3, 2010 187

emphasizing that its products should only be used when so, for example in the current fight to increase maternity
breastfeeding was not possible.18,28 leave from 4 to 6 months.
In 1993, the WHO observed that healthy breastfed
children had a different pattern of growth from that illustrated
by the National Center for Health Statistics growth charts Conclusions

(NCHS, 1977). This demonstrated the need to construct Infant nutrition, whether natural or artificial, has always
growth curves for breastfed children and use them as the been determined and conditioned by the social value
target growth profile. Therefore, between 1997 and 2003, attributed to breastfeeding. Over time, women breastfed
data were collected from children of six different ethnic less and less, particularly after the industrial revolution.
groups to construct international reference curves. The Initial discoveries resulted in high infant mortality rates,
study that led to the New Growth Charts (WHO, 2006) which were not in the interests of the State. Necessity
showed that, in contrast with what had been claimed, stimulated the search for alternatives which furthered
children from different ethnic groups had similar growth if the decline of breastfeeding and led to a peak in
given satisfactory conditions.43 artificial feeding. Current knowledge about the benefits

Studies undertaken during the last 25 years have of breastfeeding have led to laws being passed regulating

further highlighted the importance of breastfeeding, the breastmilk substitute advertising and guaranteeing the

role of vitamins and mineral salts in nutrition and the right to maternity leave, with the objective of increasing

importance of the energy density of foods.44-46 Advances in breastfeeding prevalence rates and ensuring that children

the fields of nutrology, immunology and psychology have have the best possible growth and development.

helped to consolidate the position of breastfeeding.43

In common with the WHO,46,47 the Pan American
Health Organization (PAHO)47 and the Brazilian Society
of Pediatrics (Sociedade Brasileira de Pediatria, SBP)35 References
currently recommend feeding infants only on breastmilk 1. Flandrin JL, Montanari M. História da alimentação. Tradução
de Luciano Vieira Machado e Guilherme JF Teixeira. São Paulo:
until 6 months, with no water or teas, and recommend Estação Liberdade; 1998. 885p.
introducing complementary foods (cereals, root vegetables, 2. Colon AR, Colon PA. Nurturing children: a history of pediatrics.
pulses, meat, greens, vegetables and fruit) from 6 months Westport: Greenwood Press, 1999. 329p.
onwards (3 times a day for breastfed children and 5 times 3. Middleton C, editor. A aurora da humanidade, 2nd ed. Rio de
Janeiro: Abril Livros Ltda.; 1993. 176p. (Phillip E, editor. Time-
a day children who have already been weaned).35,47,48
Life Books. Boyle C, editor. História em Revista).
Consistency should be thickened gradually, sugar avoided
4. Fildes, VA. Breasts, bottles and babies: a history of infant feeding.
and salt used sparingly. Home cooked food should be Edinburgh: Edinburgh University Press; 1986. 462p.
preferred to manufactured foods, which vary little and 5. Greenberg MH. Neonatal Feeding. In: Smith GF, Vidyasagar D.
contain additives, preservatives and antimicrobials that Historical Review and Recent Advances in Neonatal and Perinatal
Medicine. Mead Johnson Nutritional Division, 1980. (website).
are prejudicial to the health. It is recommended that [Link] Access:
coffee, soft drinks, tinned food, fried food and delicacies 31/03/2008.
be avoided, that children’s tolerance be respected and 6. A Bíblia Sagrada: Antigo e Novo Testamento. Trad. João Ferreira
that children be encouraged to drink liquids from cups or de Almeida. Edição revista e atualizada no Brasil. São Paulo:
Sociedade Bíblica do Brasil; 1969. 309p.
months once supplementary foods have been introduced.
7. Castilho SD, Barros Filho AA, Cocetti M. Evolução histórica dos
These foods, known as transitional foods (which are utensílios empregados para alimentar lactentes não amamentados.
prepared especially for children) should be of a pasty (website). [Link]
artigos/artigo_int.php?id_artigo=1477. Access: 02/04/2008.
consistency until children can manage food in pieces.
8. Hippocrates, volume II: prognostic. Tradução de Jones WH. Boston:
The recommendation is that by the end of the first year Loeb Classical Library, Harvard University Press; 1985. 416p.
the infant should be eating the same food as the rest 9. Aristotele. Historia animalium, book III, 20 (I2v) e 21 (I4r).
of the family. The phase of introducing supplementary Eletronic Text Center. University of Virginia Library. (website).
foods is a potential risk period because of the possibility [Link]
xml&images=images/modeng&data=/texts/english/modeng/pa
of contamination. Breastfeeding should be encouraged at rsed&tag=public&part=3&division=div2. Access: 10/04/2008.
least until 2 years of age. 10. Aristotele. Historia animalium, book VII, 5 e 12. Eletronic Text Center.
University of Virginia Library. (website). [Link]
Science advances rapidly and health professionals
edu/etcbin/toccer-new2?id=[Link]&images=images/
must keep themselves constantly up-to-date. Although the modeng&data=/texts/english/modeng/parsed&tag=public&part
prevalence of breastfeeding is improving in Brazil, it is still =7&division=div2. Access: 10/04/2008.

well below the ideal48 and health professionals must work 11. Magner, LN. A history of medicine. 2nd ed. Boca Raton: Taylor &
Francis Group, 2005. 611p.
in conjunction with the state to improve these figures, not
12. Badinter, E. Um amor conquistado: o mito do amor materno.
merely by advising mothers to breastfeed but by seeking Tradução de Waltensir Dutra. Rio de Janeiro: Nova Fronteira;
to provide them with the conditions in which they can do 1985. 370p.
188 Jornal de Pediatria - Vol. 86, No. 3, 2010 Feeding infants - Castilho SD & Barros Filho AA

13. Ibn Sina, Abu Ali al-Husayn ibn Abd Allah. The Canon of Medicine 34. Weffort VR, Lamounier JÁ. (Org.). Nutrição em pediatria: da
(al-qanun fi’l tibb). Adaptado por Laleh Bakhtiar da tradução de neonatologia à adolescência. Barueri, SP: Manole, 2009. 661p.
O Cameron Gruner e Mazar H Shah. Chicago: Great Books of the
35. Sociedade Brasileira de Pediatria. Manual de orientação para a
Islamic World, Inc. 1999. 710p.
alimentação do lactente, do pré-escolar, do escolar, do adolescente
14. Demaitre L. The idea of childhood and child care in medical writings e na escola. Departamento Científico de Nutrologia. 2nd ed. São
of the Middle Ages. J Psychohist. 1977;4:461-90. Paulo; 2008. 120p.
15. Larsson E and contributors. The influence of oral habits on 36. Joseph SC. The anatomy of the infant formula controversy. Am
developing dentition and their treatment: clinical and historical J Dis Child. 1981;135:889-92.
perspectives. Editor Dr Samir Bishara 2nd ed. Iowa City, Iowa;
37. Fomon SJ. Reflections on infant feeding in 1970s and 1980s. Am
2003. 55p.
J Clin Nutr. 1987;46:171-82.
16. Hollingsworth TH. (1957). A demographic study of the British
38. Fomon SJ, Filer LJ Jr, Anderson TA, Ziegler EE. Recommendations
Ducal families in Glass, D.V.& Eversley, D.E.C. Population in
for feeding normal infants. Pediatrics. 1979;63:52-9.
history. Essays in historical demography, London (1974).
39. Ziegler EE, Fomon SJ, Nelson SE, Rebouche CJ, Edwards BB, Rogers
17. Jelliffe DB, Jelliffe EF. Human milk in the modern world
RR, et al. Cow milk feeding in infancy: further observations on blood
– psychosocial, nutritional, and economic significance. Oxford:
loss from the gastrointestinal tract. J Pediatr. 1990;116:11‑8.
Oxford University Press, 1978. 500p.
40. Anderson TA, Ziegler EE. Recent trends in weaning in the United
18. Rea MF. Substitutos do leite materno: passado e presente. Rev
States. Nestlé Nutr Workshop Ser. New York: Raven Press.
Saude Publica. 1990;24:241-9.
1987;10:153-68.
19. Radbill SX. Infant feeding through ages. Clin Pediatr (Phila).
41. Eckhardt KW, Hendershot GE. Analysis of the reversal in
1981;20:613-21.
breast feeding trends in the early 1970s. Public Health Rep.
20. Barness LA. History of infant feeding practices. Am J Clin Nutr. 1984;99:410‑5.
1987;46:168-70.
42. Martinez GA, Krieger FW. 1984 milk-feeding patterns in the United
21. Schuman AJ. A concise history of infant formula (twist and turns States. Pediatrics. 1985;76:1004-8.
included). Contemp Padiatr. 2003;20:91-103.
43. Onis M, Graza C, Onyango AW, Martorell R. WHO Child Growth
22. Nichols B. Symposium: accomplishments in child nutrition during Standards. Acta Paediatr. 2006;95:5-101.
the 20th century. Introduction. J Nutr. 2001;131:398S-400S.
44. WHO/UNICEF. Global strategy for infant and young child feeding.
23. Victoria Advertising – Victorian Baby Food. (website). http:// Geneva: World Health Organization; 2003. 140p.
[Link]/[Link]. Access:
45. WHO/Programme of Nutrition. Report of a technical consultation
09/02/2009.
(1995. Mountpellier, France). Complementary feeding of infants
24. Fomon S. Infant feeding in the 20th century: formula and beikost. and young children. Geneva: World Health Organization; 1998.
J Nutr. 2001;131:409S-20S. 48p.
25. Levenstein H. Revolution at the table: the transformation of the 46. Giuliani ERJ, Victora CG. Normas alimentares para crianças
American diet. New York: Oxford University Press, 1988. 275p. brasileiras menores de dois anos. Embasamento científico.
OMS/OPAS. (website). [Link]
26. Yankauer A. A classic study of infant mortality – 1911-1915.
[Link]. Access: 24/02/2009.
Pediatrics. 1994;94:874-7.
47. Cardoso AL, Lopes LA, Taddei JA. (Org.). Tópicos atuais em
27. Bhatia J, Green F; American Academy of Pediatrics Committee
nutrologia pediátrica. São Paulo: Editora Atheneu; 2004. 184p.
on Nutrition. Use of soy protein-based formulas in infant feeding.
Pediatrics. 2008;121:1062-8. 48. Ministério da Saúde. Secretaria de Políticas de Saúde. Área de Saúde
da Criança. Pesquisa de Prevalância de Aleitamento Materno nas
28. Fomon SJ. Nutrition of Normal Infants. Saint Louis, MO: Mosby-
capitais Brasileiras e Distrito Federal PPAM-CDF, 1999. (website).
Year Book, Inc., 1993. 475p.
Disponível em: [Link]
29. Adams SF. Use of vegetables in infant feeding though the ages. arqs/[Link]. Access: 08/06/2009.
J Am Diet Assoc. 1959;35:692-703.
30. Epps RP, Jolley MP. Unsupervised early feeding of solids to infants.
Med Ann Dist Columbia. 1963;32:493-5.
31. Hollen BK. Attitudes and practices of physicians concerning breast-
feeding and its management. J Trop Pediatr Environ Child Health.
1976;22:288-93. Correspondence:
32. Campos LA, Feitosa AR, Pinho LG, Melo MC. Fórmulas para Silvia Diez Castilho
lactentes: repercusões na qualidade da nutrição e saúde infantil. Av. Princesa D’Oeste, 1144/171
CEP 13100-040 - Campinas, SP - Brazil
Rev Pediatr. 2008;9:59-65.
Tel.: +55 (19) 3295.4237, +55 (19) 8168.8472
33. Adelman MB, Sered BR. Utilization of iron by term infants. A study Fax: +55 (19) 3242.5035
of 1,048 infants from a low socioeconomic population. Am J Dis E-mail: sdiezcast@[Link], sdiezcast@[Link]
Child. 1966;111:45-55.