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.
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Bottle Feeding Breastfed Babies

 

by Tanya Lieberman, IBCLC, with Amy Peterson, IBCLC

We’re very pleased to share an interview about bottles and breastfed babies today. We asked Amy Peterson, IBCLC, co-author of Balancing Breast and Bottle: Reaching your Breastfeeding Goals, to answer our questions.

For those of you who combine bottles with breastfeeding – whether you’re pumping at work, supplementing, or use a bottle for occasional separations – bottle and nipple selection can be confusing. For those of you whose babies refuse bottles, it can be very frustrating!

We hope that the information she shares below is helpful. Amy offers more information on bottlefeeding breastfed babies on her website.

Many bottles are advertised as “easing the transition from breast to bottle” and back again. What do you think of these claims? Are they independently verified?

These claims are very misleading. Just as every mother’s breast has a unique shape and flow, every baby has a unique suck/swallow cycle. What works well for one baby might be terrible for another. Parents need to observe their own baby sucking on a bottle nipple and analyze if the latch and swallow look similar to that on the breast. In our book, we use a tool called the SIMPLE Method that guides parents step-by-step on how to choose a bottle nipple for their own baby’s unique latch.

We are not aware if such advertising claims have been verified. However, we do know that this type of marketing is in violation of the International Code of Breastmilk Substitutes. This international health policy document, adopted by many countries excluding the U.S., is designed to protect families from underhanded marketing ploys such as words or pictures idealizing artificial feeding. Comparing a bottle to breastfeeding—even if it contains breastmilk—is idealizing that brand.

In our professional experience of helping babies combine breast and bottle-feeding, we have found that the nipples which claim to be best for breastfed babies are often the worst choice. The bottle nipples that are best for breastfed babies have a gradual transition from tip to base.

You and your co-author tested 37 bottles. What were the features you were comparing, and what did you learn about the range of bottles that you’d most want parents of breastfed babies to know?

We tested two different aspects of bottle nipples. First, we measured dripping by looking at the number of drips and the size of each drip. Then we hooked up bottles to a hospital grade breast pump to determine how fast bottles flow. After performing these tests, we compared the results to see if bottle dripping and flow rate were related.

The results were surprising. First of all, about half of the nipples, regardless of a non-“no drip” label stopped dripping within five seconds of tipping them upside-down. That was important for us because many bottle companies claim their nipples are “no drip,” implying that bottles that don’t drip are a better choice. To rule out the importance of dripping, we did further testing.

Second, we measured the size of the drip for those bottles that did drip. The most important thing we found was dripping does not equal a higher amount of liquid. Bottles that appeared to drip a lot often had less volume. Frequently it is assumed that a fast dripping bottle has a large amount in the drip. We discovered that a bottle may drip frequently, but with a low output. So, it is impossible to judge the size of the drip with the naked eye. Stated another way, the number of drips doesn’t mean more liquid is coming out.

As for flow, the term “slow” is not standard. To determine flow, we hooked up bottles to a hospital grade breast pump and measured the amount of liquid collected after 20 cycles. We found there was a wide range of “slow.” For example, the fastest nipple was eleven times faster than the slowest nipple. Following testing, we ranked nipples from slowest to fastest in Appendix C of Balancing Breast and Bottle. This is important because if a nipple flows too quickly, a baby’s suck will become disorganized. Likewise, a nipple might be too slow for some babies. A parent needs to watch their baby’s response to bottle-feeding rather than relying on package labeling. If a parent thinks the bottle is flowing too fast, try a different nipple in the package, and/or try a different brand.

The most fascinating results came from comparing the data of these two tests (drip and flow). Dripping is different than flow; they are not related. Most breastfeeding books suggest turning a bottle over to see how fast it drips in an effort to select a bottle with a slow flow. This suggestion is not accurate. We tested a nipple that dripped an average of 56 times when tipped over, but had a slow flow. Then, we looked at a no-drip nipple and much to our surprise, found it flowed 10.6 times faster. Big difference! Dripping is not related to flow.

Parents are often advised to begin breastfed babies on “slow flow nipples,” but even nipples advertised as “slow flow” can seem very fast. Are there any that are as slow as you think is appropriate?

As mentioned earlier, the term “slow” is not standardized. Nonetheless, it is important to begin with a slow nipple. If a nipple flows too quickly, a baby’s suck will become disorganized. For breastfeeding babies, it is best to choose a flow that mimics mom’s flow. For this reason, it is hard to say one or two brands are “best” since flow varies from mother to mother. Likewise, a nipple might be too slow for some babies. This is why we ranked the bottles and listed them in our book.

It is also important to remember that flow is only one aspect of choosing a bottle. If the baby’s mouth placement is wrong, regardless of the flow, baby will bring bad habits to the breast and still be in danger of early weaning.

For parents who are struggling to get their breastfed babies to take bottles, and who are exploring different bottles, what should they be looking for?

Moms need to consider the nipple shape and their baby’s mouth placement on the nipple. Ideally, the nipple chosen will gradually flare from the nipple length to the nipple base. This shape allows the tip of the nipple to reach far back into the baby’s mouth as the breast does, and then helps the baby to feed with the mouth open. Quite often a “narrow neck” nipple has a shape that reaches far into the baby’s mouth and allows for gradual widening of the baby’s lips.

A shape that often does not work well is a wide neck nipple where the nipple length meets the nipple base at a right angle. This nipple shape promotes what we call “straw” sucking, where the baby’s mouth closes around the length of the nipple and doesn’t open for the base. When babies “straw” suck on a bottle nipple, we often see gaps in the corners of the baby’s mouth which leads to leaking milk, gulping air, etc. This is quite different than breastfeeding.

One bottle feeding method is called “paced feeding.” Can you describe it and explain why it might be helpful to a breastfed baby? What are some signs that a baby is becoming overwhelmed while bottle feeding?

Paced feeding refers to helping a baby eat more slowly from the bottle. Pacing became popular in 2002, before flow had been studied. The idea behind pacing is that by helping the baby rest briefly during bottle-feeding, moms can more closely mimic how the baby naturally feeds at the breast. When a baby breastfeeds, the mother has several let-downs during the feeding. Between let-downs, the baby’s sucking slows and baby can rest briefly. If a baby is feeding from a fast flow “slow flow” nipple, the suck/swallow will be disorganized. Pacing helps the baby have rest periods while bottle feeding that naturally occur at the breast. Now that we know flow can be controlled by choosing an appropriate nipple, we have another technique in our bag of tricks to help babies be more coordinated when feeding from a bottle.

It is important to note that most babies can pace themselves once they master bottle-feeding with the right nipple. How do you pace? First, listen for swallowing while the baby is breastfeeding, noting when the baby naturally pauses and rests. Then apply the same rhythm to bottle-feeding. Also of importance is positioning. With bottle-feeding, support the baby in a more upright position because the flow of some bottles increases when the baby is laying back to feed (another element we tested).

Do all breastfed babies require pacing? No, in fact, imposing pacing can disrupt the natural feeding rhythm of a baby and cause harm when over used. Babies who are “good” feeders, meaning they have a normal, rhythmic suck/burst cycle, do not need pacing. It has been our experience that once a baby has mastered bottle feeding, it is no longer necessary for the parent to impose pacing.

Some signs of a poor bottle-feed include gulping, catch-up breaths, fast feeds, leaking milk from the sides of the mouth or down the chin, baby who has a furrowed brow looking very concerned, and a baby who pulls away from the bottle. For these babies, nipple shape and flow need to be double checked, and this becomes a good time to use pacing. Pacing also is an excellent technique for NICU and other high risk babies that are having feeding difficulties.

Lastly, we would like every caregiver who uses a bottle to know that dripping bottles given before a baby begins sucking usually cause the baby to pull back or flat out refuse the bottle. Caregivers need to be sure the nipple is not dripping when the bottle is offered to the baby. Allow the bottle to stop dripping or keep the milk tipped down in the bottom of the bottle. This topic is further explored on our website.

 

 

 Tanya Lieberman is a lactation consultant (IBCLC) who has helped nursing moms  in hospital and pediatric settings.  She writes and produces podcasts for several  breastfeeding websites, including  Motherwear,  Motherlove Herbal Company, and  the Best for Babes Foundation.  Tanya recently authored Spanish for Breastfeeding Support, a guide to help lactation consultants support Spanish-  speaking moms.  Prior to becoming a lactation consultant she was senior  education policy staff to the California legislature and Governor, and served as a  UN civilian peacekeeper.  Tanya is passionate about supporting nursing moms, and especially to eliminating the barriers so many moms face in meeting their breastfeeding goals. She lives in Massachusetts with her husband, her 8 year old son and her 1 year old daughter.

 

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Nipple confusion, bottles, and alternative feeding options

On January 17, 2012 in the United States, Medela, best known for their pumps, launched their latest “feeding innovation”, the Calma.  The Calma is a bottle that seeks to eliminate nipple confusion and flow preference by making a bottle fed baby work for its milk, similar to how your little one must compress and suck at your breast to get milk out.  According to Medela, this “supports an easy transition from the breast to the teat and back.”

As a registered International board certified lactation consultant, I am very skeptical of these claims.

I have often heard that nipple confusion is a myth, foisted on mothers to keep them stuck to their brand new babies, to keep them from leaving the house, to subjugate us all.  This is simply not true.  Nipple confusion happens.  I have seen numerous cases of it in my practice.  Babies become nipple confused for three reasons – flow preference, difference in movements, and difference in feel.  Medela has the right idea on part of the equation.  Babies that are given a lot of bottles in the early period can decide that it’s not that fun to work a breast when this plastic thingy is way easier.  Most bottles, even the slowest flowing, flow faster than milk from a breast.  However, your baby also moves their mouth differently to get the milk from a bottle than from a breast.  The jaw and tongue movements are not even close to the same, and trying to transfer the movements from one to another can frustrate and upset your baby.  After all, if your baby is new, this whole eating thing is new, too.  Why complicate it?  There’s a bonus too: a baby nursing at the breast will develop their mouth in a way that will help with prettier smiles and better speech, too!

The third part of the equation is the different feel.  If you are giving your baby a softer breast and a harder silicone, they may very well like the way that a bottle feels more – especially since that silicone is, again, delivering milk faster and the mouth movements are different.   Medela hasn’t really done anything to cure that.  I’ve seen and felt the Calma, and, I assure you, it will not be mistaken for breast tissue anytime soon.

The easiest way to prevent nipple confusion is by waiting to introduce a bottle until four to six weeks (three to four at the earliest) and to simply offer the breast more than the bottle.  Some families have other situations, though, that don’t make the whole four to six week thing possible.  So what is a modern mom to do?  For many of us, it is not feasible to never give milk from anywhere but the breast.  We have work, and school, and other children, and obligations, and, man, sometimes Mommy just needs a day (or an hour or two) off.   But babies still have to eat during that time!  And what if your baby has issues with latching at the breast, or you are inducing a supply, or you need to do some supplementing?

Luckily, being a modern mom means that we have some awesome options available to us.  There is spoon feeding, where you can hand express colostrum or milk directly into a spoon and give it to your baby.  This works best in the beginning, when your baby isn’t taking in much milk yet – it would be a fairly long process for a family feeding an older infant.  To spoon feed, you simply use a clean spoon, hold the baby in an upright position (like sitting) and put the spoon at the lower lip, giving small amounts and letting the baby go at their own pace.  A spoonful can be considered a full feeding if you are dealing with a newborn.

Cup feeding is another option.  Cups are widely available, cheap, and easy to use.  Your infant won’t take the cup from your hands and drink like a big kid, of course, but will instead lap at the milk kind of like a baby animal might.  There are special cups sold for cup feeding, but it might be easier and cheaper to just use a shot glass.  With cup feeding, like spoon feeding, you’ll hold the baby supported and upright.  You’ll put the cup to the lips and tilt slightly so that the baby can easily lap at the milk (not so it’s pouring into his or her mouth.)  Allow the baby to eat at his or her own pace.  It may take a while, but that is ok!  Babies shouldn’t be gulping down their feeds – when they do, they often overeat, which can hurt their tummies and set a bad precedence of wanting more than they need.

You can also use what’s called a supplemental nursing system, or SNS.  SNSs are generally a bottle type thing hooked to a long tube.  You put the milk in the bottle part, and then you can do one of two things with the tube.  First, you can use it on the breast, either by sticking it in a nipple shield (which you should only use if followed by a lactation consultant for sizing and to negate any potential complications that might arise) or by taping the end near the nipple so that the baby gets an extra boost of liquid while nursing.  This can be really helpful if you’re relactating or increasing a milk supply, if your baby needs to be supplemented but is nursing well, or if you have a preemie or baby with suck issues that maybe doesn’t milk the breast as effectively as they should be.  You can also use a SNS to finger feed your baby.  With that, you attach the tube to your finger, and the baby sucks the finger to get the milk.  A lactation consultant can even help you use this method to train or retrain your baby to suck properly.  SNS systems can be hard to clean, so please carefully read the instructions and check with a health care provider for any extra precautions you should take if you have a preemie or immune compromised baby.

If you have an older baby (4 months or so) that’s just now getting around to taking milk in another way, you can try forgoing bottles altogether and working on cup training or using sippy cups.  Sometimes the difference is interesting enough for an older baby who has rejected bottles.  As with any of the other methods, the goal is to allow your baby to learn and go at their own pace.  Be prepared for this to be a messier endeavor with an older baby who is starting to show some independence.  You will probably have to help them to hold and tilt the cup – they may not be content with the idea of you holding it all yourself, and you may have some spills in the process.

But what if none of these methods work for you?  Maybe your care provider is balking, or you are annoyed and uncomfortable with one or all of the methods, and you really, really just want to use a bottle.  In that case, instead of purchasing the reportedly $15 a piece Calma, I would try Fleur at Nurtured Child’s method of baby-led bottlefeeding.  In fact, any time you are bottlefeeding, you should use this method.  It is the ideal way to feed a baby from a bottle and encourage any care-takers that will be feeding your baby with a bottle to utilize this method as well.  In choosing a bottle, there is no really good evidence that I have seen showing that a certain bottle or nipple is better than another for breastfeeding.  There are a lot of nipples that are supposed to be similar to your breast in look and feel, but in my time in the bottle aisle, I never saw any that made me go, “That looks EXACTLY like my boob.  That one, right there, with the wide base and medium sized nipple!!”  My kids never really liked the wide bottomed nipples, although they are often touted as being awesome for breastfeeding babies.  When it all boils down to it, most of that is hype.  When selecting a bottle, select the one you think might work that is in your budget.

If you are giving milk due to a breastfeeding problem, be sure to discuss methods and supplements with a medical professional with good lactation training.  Ask a lot of questions.  If supplements are ordered, get a LOT of information on them.  Why do you need to supplement?  How long does your medical professional want you to supplement?  How much should you supplement?  How often should you supplement?  Can you use your own expressed breast milk?  What is the plan of action for weaning from supplementing?  If your baby isn’t nursing well at the breast, you will likely need to do some pumping along with the supplementing to keep your supply healthy while you work through the problem.  Find out how often you need to pump and how you should store your breastmilk – especially if your baby is hospitalized and you are transporting it.

There are other feeding options for more serious problems, such as cleft lip/palate as well. That type of situation needs to be followed very closely by a lactation professional and physician to ensure that the baby’s unique situation is being addressed.

If you are going to be separated from your baby for another reason – work, school, or just going out – remember to think of your magic number.  This is the number of times your baby breastfeeds in a normal day (and, yes, that can vary.  Just take an average.)  You want to be sure that you are replicating that amount of times by a combination of pumping and nursing.  This will help to keep your milk supply plentiful.

In the end, there is no product on the market that can magically be just like your breast and provide your baby the exact same experience.  Luckily, there are many options for your baby and your family that will help you to achieve your breastfeeding goals.

 

 
 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.
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