Definition:

This guideline covers common questions asked about formula and bottlefeeding, including:

1. Types of formulas
2. Switching formulas and milk allergies
3. Powdered versus liquid formulas
4. Whole cow's milk, 2 percent and skim milk
5. Vitamins and iron
6. Water to mix with the formula
7. Extra water
8. Amounts: How much per feeding?
9. Schedules or frequency of feedings
10. Length of feedings
11. Night feedings: How to eliminate?
12. Formula temperature
13. Formula storage
14. Cereals and other solids
15. Burping
16. Baby bottle tooth decay
17. Traveling
18. Nipples and bottles
19. Normal stools
20. Breast discomfort

Other topics on baby feeding include poor formula intake, and decreased drinking fluids intake.

Call your doctor now (night or day) if:

• Your child looks or acts very sick.
• Age of less than 1 month old and looks or acts sick.
• Signs of dehydration (no urine in more than eight hours, sunken soft spot and very dry mouth).
• Too weak to suck.
• Age of less than 1 month old and refuses to bottlefeed for more than eight hours.

Call your doctor within 24 hours (during regular office hours) if:

• You think your child needs to be seen.
• Doesn't seem to be gaining enough weight.

Call your doctor during office hours if:

• You have other questions or concerns.

Parent care at home if:

• Bottlefeeding question about healthy child and you don't think your child needs to be seen.

Bottle (formula) feeding advice (Topics 1-20):

1. Types of formulas: 

• Milk-protein formulas, soy-protein formulas, and hydrolysate formulas. 
• Soy formulas don't contain lactose or milk protein. 
• Currently, 20 percent of infants in the U.S.are fed soy formula, often without valid reason. 
• Hydrolysate formulas are indicated for children who are sensitive to both milk protein and soy protein.

2. Switching formulas and milk allergies: 

• Switching from one milk-based formula to another milk-based formula is not helpful for any symptom. It is also not harmful.
• Switching from milk formula to soy formula is helpful for cow's milk allergy (which occurs in 1 to 2 percent of infants), during severe diarrhea and vegetarianism.
• Switching formulas for excessive crying, spitting up or gas is rarely helpful.
• Don't switch formulas without discussing it with your child's doctor.

3. Powdered versus liquid formulas: 

• Formulas come in three forms: powder, concentrated liquid and ready-to-feed liquid. Concentrated formulas are mixed 1:1 with water. 
• Ready-to-feed formulas do not need any additional water. 
• Powdered formulas are mixed 2 oz. (60 ml) of water per each level scoop of powder. 
• Powdered formula is the least expensive and ready-to-feed formula is the most expensive. 
• Powdered formula is the most convenient to supplement breastfeeding. 
• Ready-to-feed formula is the most convenient for traveling.

4. Whole cow's milk, 2 percent and skim milk: 

• Whole cow's milk should not be given to babies before 12 months of age due to an increased risk of iron deficiency anemia and allergies.
• Skim milk or 2 percent milk should not be given to children before 2 years of age because the fat content of whole milk (3.5 percent) is needed for rapid brain growth.

5. Vitamins and iron: 

• Use a formula that is iron fortified in all infants to prevent iron deficiency anemia. 
• The amount of iron in iron-fortified formulas is too small to cause any symptoms, including constipation and diarrhea. 
• Iron-fortified formulas contain all vitamin and mineral requirements except for fluoride. 
• Vitamin supplements are therefore not needed for infants taking formula. 
• From 6 months to 16 years of age, some children need fluoride supplements. (prescription item) to prevent dental caries. EXCEPTION: Present in water supply of most cities. If prescription needed, discuss with your doctor during office hours.

6. Water to mix with the formula: 

• Most city water supplies are safe for making one bottle at a time. Run the cold tap water for one minute. Don't use warm tap water (reason: to avoid potential lead exposure). Heat cold water to desired temperature. Add this to powder or formula concentrate. 
• EXCEPTIONS: untested well water, city water with recent contamination or your child has decreased immunity. F
• or these situations, use distilled water, bottled water, or filtered tap water. 
• Another option is to use city water or well water that has been boiled for 10 minutes (plus one minute per each 1,000 feet or 305 meters of elevation). 
• Bottled water is more expensive than distilled water. 
• For preparing a batch of formula, distilled, bottled or boiled water is required.

7. Extra water: Babies do not routinely need extra water because they get plenty in formula. 

• Excessive water can cause seizures from water intoxication. 
• Can offer some water if weather is very hot. 
• Don't give more than 4 ounces of extra water per day during the first six months of life.
• EXCEPTION: Don't give any water during the first month. 
• After starting solid foods, infants need more water.

8. Amounts - how much per feeding: 

• The average amount of formula (in ounces) that babies take per feeding usually equals the baby's weight (in pounds) divided in half (or equal to the weight in kg). 
• The average ounces of formula the baby takes in 24 hours is the baby's weight in pounds multiplied by 2 (or kg multiplied by 4). 
• A baby's appetite varies throughout the day. If the infant stops feeding or loses interest, the feeding should be stopped.
• If your baby is healthy and not hungry at several feedings, increase the feeding interval. The maximal amount of formula recommended per day is 32 ounces (1 liter).
• Overfeeding can cause vomiting, diarrhea or excessive weight gain. 
• If your baby needs more than 32 ounces (1 liter) and is not overweight, start solids. 
• Discard any formula left in bottle at end of each feeding Reason: It's contaminated.

9. Frequency of feedings (schedules): Babies mainly need to be fed when they are hungry. If they are fussy and more than two hours have passed since the last feeding, they usually need to be fed. The following are some guidelines: 

• From birth to 3 months of age, feed every two to three hours. 
• From 3 to 9 months of age, feed every three to four hours. 
• Infants usually set their own schedule by 1 to 2 months of age.

10. Length of feedings: 

• Feedings shouldn't take more than 20 minutes. 
• If the feeding is prolonged, check the nipple to be sure it isn't clogged. 
• A clean nipple should drip about one drop per second when bottle of formula is turned upside-down.

11. Night feedings - how to eliminate: 

• Most newborns need to be fed at least twice each night.
• By 3 to 4 months of age, most formula-fed babies give up middle-of-the-night feedings. 
• The following tips can help your baby sleep for longer intervals during the night: 
•  Keep daytime feeding intervals to at least two hours. Gradually stretch them to 3 hours.
• If your baby naps for more than three consecutive hours during the day, awaken him for a feeding. 
• Place your baby in the crib drowsy but awake. Don't bottle feed or rock until asleep.
• Make middle-of-the-night feedings brief and boring compared to daytime feedings. Don't turn on the lights, don't talk to your child, and feed him rather quickly.

12. Formula temperature: 

• Most infants prefer formula at body temperature. 
• In the summertime, some infants prefer formula that's cooler. 
• In the wintertime, some prefer warm formula. 
• The best temperature is the one your infant prefers. 
• There's no health risk involved except to make sure the formula is not so warm that it might burn the baby's mouth.

13. Formula storage: 

• Prepared formula should be stored in refrigerator and must be used within 48 hours. 
• Open cans of formula should be kept in refrigerator, covered and used within 48 hours. 
• Prepared formula left at room temperature for more than one hour should be discarded. 
• Leftover used formula should always be discarded because it's contaminated.

14. Cereals and other solids: 

• Bottle-fed infants should be started on solids (cereal or fruit) between 4 and 6 months. 
• Starting before 4 months is unnecessary and has the disadvantage of making feedings messier and longer. Early solids can also cause gagging. 
• Solids don't increase sleeping through the night for bottle-fed infants. 
• Delaying solids past 9 months of age runs the risk that your infant will refuse solids.

15. Burping: It is not harmful if a baby doesn't burp. 

• Burping is unnecessary. It doesn't decrease crying. 
• It does decrease spitting up. 
• Burping can be done twice per feeding, once midway and once at the end. 
• If your baby does not burp after one minute of patting, it can be discontinued.

16. Baby bottle tooth decay: 

• Some older infants and toddlers have learned to expect their bottle at naptime and bedtime.
• Severe tooth decay can be caused by falling asleep with a bottle of milk or juice. 
• Prevent this bad habit by not using the bottle as a pacifier or security object. 
• If you cannot discontinue the bottle, fill it with water instead of formula or milk.

17. Traveling: 

• Use prepackaged bottles of ready-to-feed formula (most expensive). 
• Or mix formula ahead of travel and carry in a cold insulated container. 
• Or use powdered formula.
• Put the required number of scoops in a bottle. Carry clean water in a separate bottle. Mix prior to each feeding.

18. Nipples and Bottles:

• Any commercial nipple/bottle is fine. 
• It is not necessary to sterilize bottles or nipples if they are washed with soap and water and thoroughly rinsed. 
• It is okay to wash bottles and nipples in the dishwasher.

19. Formula-Fed Stools, Normal: 

• Formula-fed babies pass one to eight stools per day during the first week, then one to four per day until 2 months of age.
• The stools are yellow in color and like peanut butter in consistency. 
• After 2 months of age, most infants pass one or two stools per day or one every other day, and they have a soft but solid consistency.

20. Breast Discomfort in Bottle-Feeding Mothers:  Your breasts will make milk for several days even though you chose not to breastfeed.  Breastmilk comes in on day 2 or 3 and swollen breasts can be painful for a few days.  Here is what to do:Ibuprofen.  Take 400 mg of ibuprofen 3 times per day to reduce pain and swelling.  There’s no special prescription medicine for this.

• Ice.  Apply a cold pack or ice bag wrapped in a wet cloth to your breasts for 20 minutes as often as needed.  This will reduce milk production.  Do not apply heat because it will increase milk production.
• Pumping.  For moderate pain, hand express or pump off a little breastmilk to reduce your pain.  While pumping breastmilk can increase milk production, doing this to take the edge off your discomfort is not detrimental.
• Wear a supportive bra (eg sports bra) 24 hours a day.
• Binding.  Binding the breasts by wearing a tight bra or elastic wrap is no longer recommended.  It can increase the risk of breast infections (mastitis).

 Parent Care for Pediatric Symptoms. Copyright © 2005. Barton D. Schmitt, MD, FAAP