Choline Content of Term and Preterm Infant Formulae Compared to Expressed Breast Milk-How Do We Justify the Discrepancies?

Choline/phosphatidylcholine concentrations are tightly regulated in all organs and secretions. During rapid organ growth in the third trimester, choline requirement is particularly high. Adequate choline intake is 17-18 mg/kg/day in term infants, whereas ~50-60 mg/kg/day is required to achieve fetal plasma concentrations in preterm infants. Whereas free choline is supplied via the placenta, other choline carriers characterize enteral feeding. We therefore quantified the concentrations and types of choline carriers and choline-related components in various infant formulae and fortifiers compared to breast milk, and calculated the supply at full feeds (150 mL/kg/day) using tandem mass spectrometry. Choline concentration in formula ranged from values below to far above that of breastmilk. Humana 0-VLB (2015: 60.7 mg/150 mL; 2020: 27.3 mg/150 mL), Aptamil-Prematil (2020: 34.7 mg/150 mL), Aptamil-Prematil HA (2020: 37.6 mg/150 mL) for preterm infants with weights < 1800 g, and Humana 0 (2020: 41.6 mg/150 mL) for those > 1800 g, comprised the highest values in formulae studied. Formulae mostly were rich in free choline or phosphatidylcholine rather than glycerophosphocholine and phosphocholine (predominating in human milk). Most formulae (150 mL/kg/day) do not supply the amounts and physiologic components of choline required to achieve fetal plasma choline concentrations. A revision of choline content in formulae and breast milk fortifiers and a clear declaration of the choline components in formulae is required to enable informed choices.