Formula Feeding Part 1: Choosing Which Infant Formula To Purchase
The value of feeding human milk for virtually all infants cannot be overstated. However, the overwhelming majority of infants in the United States will receive some infant formula during the first year of life and often parents are given little objective guidance in how to make a formula choice. Parents have questions both about how to select an infant formula and how to prepare it. Let’s start in this blog post with the selection issues. In the interests of full disclosure, I have in the past conducted nutritional research funded by several infant formula manufacturers but currently have no financial connection with any infant formula manufacturer either via formula company-funded research activity or other consultancy. In choosing an infant formula, parents would like to be sure that the formula meets the nutrient needs of their infant for growth and development. Parents are also concerned that the formula will be well-tolerated, and will not provoke or worsen allergies or any other health problems. Finally, infant formula is expensive and parents do not wish to pay for a product that is higher in cost without fully documented benefits justifying the expense. For most healthy full-term infants, a standard infant formula that is derived from cow milk will meet these requirements. Although not mandated by professional organizations, some families may choose to use a ready-to-feed liquid formula, especially during the first month of life. This is because although the risk of infection from powdered formula or from water added to formulas or other aspects of preparing the formula is extremely low, most of the risk of an infection associated with formula-feeding in full-term healthy infants occurs during the first month of life. Using a ready-to-feed liquid formula in the first month of life adds an extra level of reassurance and avoidance of any formula preparation that some families may prefer. I want to emphasize that using ready-to-feed liquid formulas in the first month of life is not a requirement or recommendation of dietary agencies and these formulas are more expensive, but it is simpler and avoids issues of preparing formula. Specialized formulas exist that are partially or completely adapted such that the cow milk protein in them is “broken down”. This is often done to avoid concerns about an allergic response. In general, formulas in which the protein is very “broken down” (fully hydrolyzed) are more expensive and should only be used on the advice of a pediatrician. Some brands have what is called partially hydrolyzed protein. The benefit to this for healthy babies is debated, but most infants do not require a formula in which the proteins have been hydrolyzed. In the presence of a strong family history of cow milk protein allergy, which is not the same as lactose intolerance, discussions about the best formula should be done with the baby’s pediatric care provider. Low lactose formulas exist but are not generally needed as few babies are actually lactose intolerant. Other formulas are designed for fussy babies, those who spit, and those born on Fridays. Well, I’m just kidding about the last one of these but it SEEMS like there are a million specialized formulas. The evidence for a benefit to formulas with thickeners or soy protein is not strong and mostly they can be avoided. However, there are a few babies who might benefit, usually after clearly having trouble with the routine formulas. Again, this should best be done after discussion with a pediatric care provider. We have a few things we don’t recommend. First, we don’t recommend unpasteurized milk of any form for infants. Here’s what the FDA says about raw milk: "Raw Milk Misconceptions and the Dangers of Raw Milk Consumption". Second, we don’t recommend adding whole cow’s milk to the diet of infants in the first year of life. Whole cow milk doesn't have the best forms of protein or enough iron for infants. Finally, we don’t recommend using any milk, such as almond milk or goat’s milk that is not specifically approved by the FDA for infant nutrition. Some of these have gained popularity recently, but the nutrient contents do not always meet FDA guidelines for infants and there is little evidence for a benefit to them in infant feeding. I realize that others, including some pediatric experts recommend these, but I believe that they are not good choices for infant nutrition. Parents may notice a large difference in prices between different brands of formulas and claims of benefits to certain formulas due to specific added components. Caution should be used when reading that a formula is “close” to human milk. This term has no real meaning. No infant formula is close to human milk and that isn’t the goal anyway. The goal is to have a baby that grows and develops most closely like a human milk fed baby and that is a complex goal given the differences in content and absorption of nutrients between formulas and human milk. Families should not use advertisements of “close to mother’s milk” or similar wording as the reason to select a particular brand or type of infant formula. In general, if seeking to choose a cow milk-based formula based on price, families can be reassured that all formulas labeled and marketed as infant formulas meet federal standards for infant nutrition. If in doubt, check with a pediatrician, but be sure to find out why they wish you to use a more expensive product if a similar less expensive one is available. That is what I recommend to families when asked. More expensive does not necessarily mean better, so be sure there is a reason for picking “more expensive”.
Dr. Steven Abrams, Neonatologist