An overview to making an educated choice about formula

Star and I worked together on this post as a result of seeing a need to answer some questions and provide information on infant formula.  I believe that breastfeeding advocates and educators often provide only “formula is bad” kind of information that isn’t helpful for the parent that seriously needs to consider formula options for their child.  This article is intended to be a resource for those that will be using formula and would like information as they go about making their decision and for those that want to offer genuinely supportive support to all families, regardless of the feeding method employed.  There will be further information on formula available soon but for now, we hope this is helpful for those that need it.  It is my hope that breastfeeding advocates and educators will be able to provide quality information on formula when necessary and do so in a supportive manner.  Let’s truly support families and be a safe source of information on infant nutrition, free of judgment and profit-making agendas.  If you are a breastfeeding mom that needs to supplement with formula or switch entirely over to formula, be sure to consult not only with your child’s doctor but also an IBCLC in making your formula choice.  ~Jessica 

What are the questions and why do we need to look at them

Babies and breastmilk go together perfectly.  Breastmilk is the optimal, normal standard of infant nutrition, and I love the fact that I am in a profession where I can help mothers to achieve their goals where breastfeeding is concerned.  While I am a hugely passionate breastfeeding advocate I am not anti-formula.  Something that seems to confuse some people but it boils down to respecting the fact that we all make choices in feeding our babies, and sometimes formulas are a part of that choice.  Formula feeding moms love their babies just as much as breastfeeding moms do and want their babies to grow and thrive.  During some hiccups in my own breastfeeding relationships, I used commercial infant formulas as a supplement and I am thoroughly unashamed of that fact.  However, formula can be such a dirty word in infant feeding communities, and there’s a lot of confusion over it.  What kinds are there?  Which formulas are better than others?  Should I use commercially made formulas or make my own?  And how do we mix them?

 

The different types of formula

First of all, let’s address the varieties of formula.  There are three major types that are available: cow’s milk based formulas, soy formulas, and protein hydrolysate formulas.  Cow’s milk is the least expensive and most common.  They are nutritionally appropriate for most babies and engineered to be as close as possible to breastmilk recognizing they can not completely replicate all that is breastmilk.  However, some babies may not do well on these.  Some common reasons for not using cow’s milk formulas are allergies to the protein in the cow’s milk or the family’s desire to avoid animal products for their babies.

The next variety of formula is soy.  Soy formulas are not recommended for preemies.  They do not contain animal proteins, so they are useful in some medical situations or if a baby has issues with those proteins.  They can also be used by families who adhere to a lifestyle that avoids animal products.  A review by the AAP in 2008 found very few medical reasons to utilize soy formula.  There are also concerns that soy could interfere with the thyroid, immune system, or the reproductive system.  Those concerns have not yet been proven to be warranted, although the AAP did advocate for further testing.  Bottom line?  Unless your baby needs soy formula or you have some family reason that you are choosing to avoid animal products, it is probably not necessary.

The last of the three major commercial varieties is the protein hydrolysate formula.  These are also called hypoallergenic formulas.  Really, these will generally be ordered by a doctor to combat an issue like allergies to both the soy and the cow’s milk formulas.  Most people aren’t buying these over the counter because they’re just such an amazing choice.  They’re typically very expensive and needed only in specific cases.

 

Standards and regulations

Formula is held to certain standards of nutrition by the FDA.  (Note: this is different than being approved or regulated by the FDA.  However, there are standards of nutrition that must be met or the FDA will take action.)  Therefore, there is typically not significant difference between generic and name brand formulas of the same type.  There are pretty negligible differences between organic and nonorganic formulas, too.  Basically, with organic formulas, there is a certain standard for the production of the ingredients in the formulas.  Organic formulas have not been proven to be better for babies.  They are sometimes sweetened with organic cane sugar, which can make them taste sweeter.  This might be a problem – babies could develop a taste for sweeter foods or overeat due to the taste – but these are theories that have not been proven with peer reviewed research.

Homemade formulas are touted by many people and websites, but they are not something that I would ever recommend to a client or anyone else, for that matter.  There absolutely are risks associated with feeding an infant commercial formula, but there are even more risks to non-commercial formula.  No health body that I’m aware of recommends homemade formulas.  With commercial formula, you are getting something that is built to have the most optimal nutrition possible when breastmilk is not an option.  With homemade formula, there are a plethora of risks, running from nutritional imbalances to severe infections from pathogens in the ingredients.  In the days before commercialized formula, babies had to be supplemented with other things to keep away conditions like scurvy and there were deaths due to babies ingesting contaminated products.  Do it yourself is awesome for cleaning products or baby food or many other things.  It’s not good for your baby, though.  This is particularly true in a young baby with an immature gut, or digestive tract where the risk of illness from contaminated formula is even higher.  This post takes a thorough look at goat’s milk and homemade formula as alternatives for infant nutrition if you’d like more information.

 

Preparation and safe handling

Preparation of commercialized formula can be a problem, too. We often think that women in developing countries where there is unsafe water or not enough money to purchase the correct quantity of formulas are the ones at risk of incorrect preparation.  Of course, that does happen.  But we also see preparation issues in developed countries, too.  We may not hear about them as often but they certainly occur.

The only kind of formula that is sterile and can pretty much be put in a bottle, heated, and be good to go is ready to feed liquid formula.  Some health organizations recommend that babies under 3 months be fed only ready to feed for this reason.  However, most people use powdered infant formula.  Powdered infant formula is not sterile.  If you have a baby with immune system issues, or an ill baby, it is preferable to use ready to feed.  Using powdered formula in the right way can really help to make it safer.  You want to prepare formula on a clean surface, with freshly washed hands, and put it in clean, sterile equipment.  The World Health Organization recommends that you use water that has been boiled and then allowed to cool for no more than 30 minutes.  You should mix this water with the powdered formula (the EXACT AMOUNT called for on the can.  There are generally scoops with the formulas, and you should use the correct amount of level scoops) and then cool it to a suitable temperature by running the feeding implement (bottle, cup, whatever) under cool/cold water or placing it in cool or cold water.  It should be fed to the baby right away and leftovers should be discarded.  For more information, see the WHO guidelines for the safe preparation, storage, and handling of powdered infant formula.

 

Social issues and real support

Now that we’ve talked about types and preparation – and if I didn’t cover something that you have a burning desire to know about, please, comment or message myself or Jessica and I will find it out for you – let me step on a soapbox for a minute.  We know that breastmilk is optimal nutrition and that formula is recommended by the World Health Organization as the 4th best option for infant nutrition (following milk from the mother’s breast, expressed milk from the mother, and donated milk from another lactating woman).  But we simply cannot go on acting like formula is a poisonous, horrible thing that only uneducated, mean parents feed to their poor defenseless babies.  Some of the horrible comments that I have seen about formula and formula feeding mothers lately are ridiculous.  Would it be awesome if all babies everywhere could get breastmilk, either from their mothers or from donated milk?  Sure.  Is that likely to happen in the not too distant future?  No.  (Look here and here for information on being a donor or if you need donated milk for your baby.)  If we can meet moms where they are and provide the information they are seeking without judgment, we can be a trusted source for education and support and moms won’t have to turn to the formula companies as their primary origin of information.

I am the first person to step up and say that formula should be better regulated, that marketing should be reined in, that we deserve the best possible product for the smallest and most defenseless of our citizens.  But those are issues with the formula companies or manufacturing, not issues with mothers who can’t or won’t breastfeed.  Every mother I have ever met has a wide variety of factors and reasons that came into play when she chose how to feed her baby.  Discounting those things or casting blame or shame on her for them quite frankly sucks.   A real advocate supports women in general and knows that not everyone will make the same choice as her.

 

 
 Star Rodriguiz, IBCLC, is a breastfeeding peer counselor for a WIC in the Midwest and has just started her private practice as an IBCLC (her Facebook page is here, go “like” for great support).  She also sits on the  breastfeeding task force in her town, is helping her  community’s Early Head Start redefine  their breastfeeding support, and is the  driving force behind a local breastfeeding campaign.  In  the remainder of her free  time, she chases around her nursling and preschooler.
Share

Comments

  1. Thank you for not being too afraid to post this! Some moms will need this information, and you’ve provided it in a safe place. Way to go, Leaky Boobs!

  2. This is great! I have never used formula for my children, but if I needed to feed my own or another child with formula honestly I would not have the faintest clue how to go about doing it safely and responsibly. So thank you for the info!

    I have questions, still. What about concentrated formula? Are there issues with BPA in the ready-to-serve formula – is it worth getting it in the glass bottles?

    How about DHA, and the way it is manufactured? To DHA, or not to DHA?

    What is with those formula mixing pitchers, since a days’ worth of feeds can not be safely made and refrigerated as formula was once prepared?

    Is it safe to measure out formula in advance, and then wait to mix with water at the time baby is ready to be fed?

    What about using bottled water vs. tap water, flouridated vs. non flouridated?

    Formula is complicated to me.

  3. First of all, THANK you for this article. I’m a dedicated exclusive pumper for my daughter who has a genetic disorder and a cleft palate. Hoping to go to breast after the cleft palate repair this summer. It’s a super challenge to keep up a milk supply while exclusively pumping and we have to supplement with formula on occasion. She’s also been through periods where we had to fortify her breastmilk with formula powder to make her gain weight faster – it’s kept her from a gtube. It’s been hard to find a good comparison of formula out there, especially one from the perspective of breastfeeding mothers. LOVE IT. I’m struggling to keep up with her most recent growth spurt and so we’re going out tomorrow to get a can of formula to make sure that she doesn’t miss a feed because of supply issues. She can’t afford it with surgery coming!

    I’m a committed vegan, have been for 12 years. You should know that there are NO VEGAN FORMULAS. All formula, even soy, is at least caseinated (casein is a milk protein that’s used in a lot of things.) This was a hard concession for us but one that we felt necessary for our daughter’s health.

    Wanted to let you know, because you mention the issue of families wanting to avoid animal products in your article and that soy is an alternative. For strict vegans, it’s not.

  4. Hi, this post is great and I totally agree with you, but it seems to be more aimed at breastfeeding advocates rather than families seeking information about formula.

    The major thing that I think is missing is regarding how bottles are given to babies (regardless of what they contain but especially if it is something other than breastmilk.) I work with families with young babies, and I see babies in strollers with bottles propped int their mouths, babies lying flat on their backs with bottle shoved in etc. It makes me sad because all babies deserve to be cuddled and feeding time can be so intimate and a lovely sharing time with Mum even with a bottle, eye contact and feeling safe are just as important to the formula fed baby, quite apart from the risks of ear infections etc.

    You don’t clearly outline the risks of improperly preparing formula, nor address the issue of feeding baby while out and about. Sterilizing feeding equipment is also important, and “preparation issues” doesn’t really explain the problem.

    Also Goats milk formula is widely available in New Zealand, is there evidence that it is better than Cows Milk Formula?

    M.

    • Merewyn, thank you for the points you make. This piece isn’t intended to be a comprehensive guide on formula feeding, merely an overview on selecting a formula. As I stated in the piece, we are planning to release more informational resources on the topic of formula feeding but it takes time. I agree, how to bottle feed is very important as are the risks of improperly preparing formula which is why we linked to the WHO guidelines for formula preparation. Thanks for taking the time to comment and share your thoughts! ~Jessica

  5. “We know that breastmilk is optimal nutrition and that formula is recommended by the World Health Organization as the 4th best option for infant nutrition (following milk from the mother’s breast, expressed milk from the mother, and donated milk from another lactating woman). ”

    Actually, it doesn’t; this is one of those internet urban myths.

    This is actually what the WHO says: “18. The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered un- suitable for her infant. For those few health situations where in- fants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.” Direct breastfeeding by the mother is stated to be the optimal choice, but the rest are presented as being simply alternatives, among which the parents may choose. Full document available here:
    http://whqlibdoc.who.int/publications/2003/9241562218.pdf

    As for the WHO guidelines on preparing formula; most of what you said here about hygiene and proper measuring was spot on, but seriously…boiling water up and waiting for it to cool down….? This is completely and utterly impractical for the average formula feeding parent of the average baby. The WHO guidelines make sense if you are preparing formula en masse in, say, an orphanage or refugee camp in a developing country; they are hardly necessary in places like the US. I advise being very wary of approaches to formula that attempt to reduce all risk to zero no matter how high the price is in terms of cost, convenience and everything else; if such logic were to be applied to breastfeeding, then milk banking would be out (even the “official” kind, let alone informal networks), and we breastfeeding mothers would not be able to take a single medication while breastfeeding unless it had been proven to be safe through double-blind testing (which can’t be done because it wouldn’t an ethical test), or any alcohol.

    That said, there was plenty of other good information here, especially the parts about homemade formulas. I too cringe when I hear of people feeding young babies on strange concoctions they have brewed up in their kitchen. There is a huge potential for things to go wrong here.

  6. Dutchblonde says:

    I enjoyed being blissfully ignorant regarding formula. When people were like “oh you are pumpin past 6 months” I’d say “I am lazy. I can’t figure out which formula I should give her”.

    Thanks for the article. I appreciate the intent. Maybe it will not encourage ff.

  7. I have to say I really appreciated this post. I am an RN, LLL volunteer and staunch breastfeeding advocate & you’re right I know nothing of formula! Kinda embarrassing when you think about it (although I’m also a wee bit proud) It definitely makes sense to learn about formula, especially since I’m applying for LLL Leadership & many moms have to supplement – I can see it being a major turn off to have a breastfeeding helper be there for you in every way except for when your problems are severe enough to warrant formula then they give a shrug – you’d likely run away! Even though I don’t support rampant use of formula for no reason, it makes sense to at least know. Knowledge never hurt anyone in the long run.

  8. I have only read the opening paragraph so far. I am preparing to start supplementing with formula. It is difficult to find information on how to make the transition. Because I have tried to bf so much for as long as possible I feel like I am letting her down to swap to formula and that formula is bad. It is nice to have the reminder formula is not bad and she will still be beautiful and healthy and smart.
    Thanks

  9. Jennifer says:

    I am really glad this information is here. I wish I could have read it back when I supplemented my daughter. I was definitely in the category of feeling like a piece of crap for having to supplement, even though through medical conditions I wasn’t making enough milk.

    I also wanted to add that eventually through a combination of determination and finally prescription drugs, I was able to make enough milk for my little one. She only had to drink the nasty stuff for about 3 months while I worked diligently to build up my supply.

  10. Apollina Whitney says:

    No one who uses formula boils the water first. I use bottled distilled water because we have very high fluoride levels in our tap water and I don’t want my daughter to get stains on her teeth, but my (lactivist) pediatrician said it’s fine to use tap water. Boiling doesn’t remove fluoride, anyway.

    It’s really not that difficult to prepare a bottle: pour water into bottle, add powder, shake. It takes 30 seconds. At night you give the bottles a quick wash just like you would the rest of the family’s dishes. Sterilization isn’t necessary (per not only my ped but every childcare book I’ve read) because unless your baby is in an incubator, nothing about him is sterile. Your boob is not sterile, either. If you really want to be overzealous about it, you can get a microwave steam sterilizer: pop everything in, microwave for five minutes, sterile. I think lactivists try to make formula preparation sound like this long, drawn-out process to discourage people from doing it.

    • Apollina Whitney says:

      Also, formula CAN be prepared in advance. Powder is good for 24 hours once prepared and concentrate is good for 48. When you’re out it’s easiest to use powder because it doesn’t require refrigeration until mixed, so you can just get those little individual-serving powder packets and keep some in your purse/diaper bag.

      • So the WHO is making this up because…? There have been known and well documented cases of contamination of formula that made infants, particularly newborns, very ill because of the tap water. Personally, I’d rather follow both the AAP and the WHO’s suggestion and boil it than regret my infant getting ill from something I could have easily prevented. It has nothing to do with wanting to make formula feeding sound harder but rather everything to do with caring about the safety of children. ~Jessica

        • It’s not the water that’s the problem, it’s the possibility of bacteria in the powdered formula. When you add water to the formula powder if the water isn’t over 70C there is the chance that E. Sakazakii or salmonella or another bacteria may multiple. E. Sakazakii can and does kill infants – even in the US unfortunately http://siouxcityjournal.com/news/local/a1/article_8d4f5e4d-7e74-5603-8709-77ce9f0b8be9.html – and this bacteria has been known to have killed babies since 1961 when 2 babies died in the UK (details here – http://wwwnc.cdc.gov/eid/article/9/10/pdfs/03-0218.pdf).

          That’s why the WHO, the UK government bodies the Dept. of Health, the National Health Service, UNICEF’s Baby Friendly Hospital Initiative all recommend making up each feed as needed with 70C or hotter water and discarding the feed after 2 hours. A less safe alternative (but not as risky as making up feeds with room temp tap water) is to make up the feeds with 70C water then flash cooling and refridgerating for no more than 24 hours.

      • In some parts of the US, tap water can actually be unsafe still. Those with wells often don’t have their wells tested frequently, so contamination by bacteria can be a concern there as well. The boiling suggestion makes sense in these circumstances if not using pre-sterilized bottled water. The USA isn’t pure, clean, and thoroughly advanced everywhere, after all! *chuckle* We didn’t even have plumbing sometimes when I was growing up. 😉

  11. My pediatrician said using bottled water to prepare formula was fine. She didn’t say I needed to use boiled water. I have asked some other moms also and they said they just used bottled water. There seems to be a lot of conflicting information on this matter.