Weaning onto cow’s milk: why are the recommendations different for formula feeders and breastfeeders?

I always wonder about the term “toddler”. When does a baby become a toddler, and when does a kid cease to be one? I assume the term came from the propensity of the early childhood set to toddling, since most babies don’t perfect their gait until close to two years of age. But two year olds are still considered toddlers, right? Am I the only one who is confused about this? Or the only one who wastes time even thinking about it?

Confusing label as it may be, there is one thing that is clear when it comes to toddlers: they no longer need infant formula. Once our kids hit the magic 12 month mark, we can throw out those $5 formula checks and do a little dance of joy. If you’re doing extended bottle feeding, you can fill the bottle with cow’s milk or a milk substitute of your choice- any of these options will be a welcome change to your bank account. Some parents choose to switch to a toddler formula (especially if their child is a super picky eater, or has been diagnosed as failure to thrive or with another feeding or nutritional issue), and for those of us with kids cursed by the dreaded dairy allergy, we might be forced to remain on hypoallergenic infant formula for awhile longer to make up for the lack of fat and protein most kids get from cow’s milk (the substitutes do a bang-up job of providing calcium, vitamin D and a myriad of other nutrients these days, but they can’t compete with the fat and protein profile produced by the dairy industry). But for the vast majority of formula feeding parents, the first year birthday party is made up of presents, cake, and a ceremonial dumping of Enfamil down the kitchen sink.

And yet, as FFF Abigail pointed out on the Facebook page today, breastfeeding moms are encouraged to nurse for two years by WHO, UNICEF, the AAFP, and other major medical organizations. One would therefore assume that there would be a nutritional or medical reason for this recommendation; since formula has been created to fill in for breastmilk, wouldn’t it stand to reason that the toddler nutritional needs that necessitate breastmilk would also benefit from formula over plain old cow’s milk?

In some ways, the answer is pretty simple: the reason we don’t use cow’s milk prior to a year of age is because our systems aren’t developed enough to process it. By the age of one, human digestive organs are capable of handling dairy, and cow’s milk provides a good amount of the protein, fat, and vitamin content that young kids need to thrive. Obviously, breastmilk does as well – and it has the added advantage of being made specifically for human babies. Breastfeeding moms can keep nursing, and provide a good source of protein and fat; in this case, there is no need to include cow’s milk or a milk substitute into a toddler’s diet. (This is not to say that breastmilk should replace solids or a diverse range of foods for kids over 6 months- from the research I’ve seen, there is a strong case that breastmilk, formula or regular milk should always be part of a toddler’s diet, not all of it.)

It’s easy to see why someone might be confused about this, though. The American Academy of Family Physicians does not really explain why a baby should be breastfed for two years; WHO and UNICEF lean heavily on arguments about lack of sufficient nutrition and risks of bacterial contamination in the developing world, which are not all that relevant in resource-rich nations – although I do suppose one could argue that Americans living in abject poverty may reap some of the same benefits, given the difficulty of obtaining quality nutrition. If you search “benefits of breastfeeding past one year”, the Google Gods will hand you vague blog posts based on opinion rather than fact, which make bizarre and unfounded claims about the more “supple skin” and “shiny hair” of the breastfed toddler. There are some citation-based claims about how the immunological benefits of breastfeeding continue into toddlerhood; comments from well-known breastfeeding advocates about how beneficial extended nursing is, without much research to back it up; and articles which explain a dose-response effect of breastmilk (meaning that the longer a woman breastfeeds, the better the effect), but most studies do not look at Western, nursing children over a year old in terms of health outcomes.

I am not trying to belittle extended breastfeeding in any way, or to suggest that there aren’t plenty of advantages to breastmilk later in childhood (as I said before, it is a far more appropriate drink than cow’s milk, from a biological and evolutionary perspective).  I am a strong proponent of nursing as long as it feels right to you and your child. But I also think it’s fair to ask the question: if the nutritional benefits reaped from a 2-year nursing relationship are so vital that WHO views 2 years of nursing as ideal, even in the developed world, wouldn’t that necessitate some sort of substitute or supplement for those who aren’t meeting that recommendation? We’ve been told that toddler formula is just a ploy of the formula companies, so something doesn’t seem quite kosher here. (Ha! Like how I said kosher? And we’re talking about milk?)

I fear that these organizations are confusing people with their recommendations, as they are turning what should be a personal decision into a monitored, medicalized act. Using risk-based rhetoric to support every breastfeeding recommendation they make has the negative side effect (among many others) of making us expect such reasoning. So, when these organizations encourage us to breastfeed for two years, we assume there is a risk to not doing so. I can’t find a significant body of research on this subject, and when even the most ardent lactivist sites are relying on claims about toddler beauty to support the superiority of longer-term nursing, it makes me wonder if maybe there aren’t enough proven benefits to justify the WHO recommendations. 

There may in fact be numerous and vital health benefits to nursing through the second year of life; I don’t doubt that there are emotional ones, because I believe that there are emotional benefits to gently and intuitively responding to your child’s individual needs. But if babies truly need some nutritional aspect of breastmilk beyond the immunological properties (which, while certainly a nice feature, are probably not going to make a significant difference if kids are in daycare or have an older sibling – i.e., exposed to germs –  according to this study), then there very well might be a basis for all those follow-on formula ads, which would make me feel like a dumbass for scoffing at them and screaming that they were a dumb marketing ploy). Or at the very least, pediatricians should be recommending a supplement of some sort to add to dairy/almond/soy/rice/hemp/flaxseed/coconut milk.

Going back to the original question, I don’t think that there is any medical or nutritional reason to remain on formula longer than a year, provided the child has a somewhat well-rounded diet and is growing well. Then again, I’m not a huge proponent of cow’s milk in general, and I’m certainly not a medical professional, so my opinion means squat anyway. But considering the scarcity of good studies on breastfeeding past year one, I’m not sure the AAFP or WHO’s opinion should mean all that much in this case, either.

Bottom line? Breastfeed as long as you want, but do it because it feels right to you and your child; breastmilk has tremendous nutritional value and there sure as hell isn’t a reason to stop if you don’t want to. Just don’t feel like you are sacrificing your child’s health if you do decide to wean at a year, because from a nutritional, health, and risk standpoint, it appears you have as much right to throw your frozen breastmilk down the drain as your formula feeding sister has to pitch the formula, and vice versa.

Two excellent reviews of this subject:

Science of Mom- Breastfeeding Beyond a Year – Why is the AAFP stretching the truth about the benefits?

Good Enough Mum: Breastfeeding for Longer Than a Year – myths, facts, and what the research really shows 

 

Suzanne Barston is a blogger and author of BOTTLED UP. Fearless Formula Feeder is a blog – and community – dedicated to infant feeding choice, and committed to providing non-judgmental support for all new parents. It exists to protect women from misleading or misrepresented “facts”; essentialist ideals about what mothers should think, feel, or do; government and health authorities who form policy statements based on ambivalent research; and the insidious beast known as Internetus Trolliamus, Mommy Blog Varietal.

Suzanne Barston – who has written posts on Fearless Formula Feeder.


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8 thoughts on “Weaning onto cow’s milk: why are the recommendations different for formula feeders and breastfeeders?

  1. I was having this discussion in my head the other day. We supplemented Sophie a lot longer than most kids (to age 4) but she was Failure to Thrive and formula packed in a lot more nutrition per oz than anything we could physically keep in her. I remember her baby group turning 1 and the huge drive to get cow’s milk into the kids (and a few subsequent eczema encounters from it) but no one really knew *why* they were doing it when formula was doing such a great job. Milk isn’t cheap either when you consider how much some toddlers consume.

    Isn’t there a risk of cow’s milk induced anemia in kids over 1? Or is that not an issue if the toddler is eating a well rounded diet?

    I’m really quite interested now.

    • Jen, what I’ve read/been told is that toddlers who are used to a largely liquid diet may find it easier to guzzle down milk and get their nutrients from it rather than to eat a range of solid foods, and this has an opportunity cost – i.e. you won’t eat enough foods rich in iron and in vitamins. Too much cow’s milk in a child’s diet can be tricky. For us, this was an important reason to continue with formula a few months past the first birthday – child was pretty fussy with solids and simply didn’t consume enough calories from them and really howled if we tried to cut back to only 2-3 bottles a day (I almost laughed at the old-school elderly male pediatrician who scolded me, saying “He should be eating three square meals a day by now” – and wanted to welcome him to our house to just try to get those square meals down a toddler who wouldn’t even sit). It depends on your child I think, and how much time/energy you have to pick a fight on bottle vs solids. I had a spouse travelling for weeks on end, classes to teach and re-sleep training to worry about so I continued with the darned formula.

  2. I agree to an extent. Long post, sorry if I drone on and on.

    In Canada, the mothers are told to give cow’s milk from 9 months on. Why? Because there are no studies to support that 12 months is any different than 10 months as far as anemia risks go, and I’m told that they think a breastfeeding mom will feel discouraged if she goes to 9 months then finds that she has to use formula. Personally, I don’t think there IS a magic age. 12 months, 10 months, 16 months, it doesn’t matter as much as watching the baby and how they react to the cow’s milk. If your baby is drinking more than 16-24oz in a day (the 16oz is a recommendation by wary pediatricians who saw anemia when babies drank more than that, so it’s not exactly a certain number here, some babies may not tolerate 24oz of cow’s milk in a day…) then hold off until they are eating enough that they are drinking less than that. If you give your baby cow’s milk and they had diarrhea or constipation, then back off and give them less, if they won’t tolerate less then back off and wait a month. Most important is having iron screening tests done to see if their iron levels are maintaining or slowly decreasing (often the problem is undiagnosed until the baby is anemic, which is silly. We can catch this long before then, when we notice the levels are dropping for that particular child.)

    Then there’s the amount of milk a baby drinks in a serving. Some doctors are wary, recommending parents break up an 8 oz bottle to 2-4oz bottles, others say only to give in a sippy cup because that will slow down how much they drink. The common rational of thinking is that a baby who drinks too much and is not ready and will react to the protein that causes intestinal bleeding, will have a greater reaction if they guzzle down 8oz as opposed to 4oz, then a break with other foods or drink, then another 4oz. If the baby is on the cusp of being ready and can tolerate 2oz-4oz bottles of milk in a day, then giving them too much at once may cause a reaction and that can lead to anemia if repeated over a period of time. I honestly believe that is the rational behind the “only give cow’s milk in a sippy cup” that I hear from doctors and health professionals, just wanting to slow down the consumption so hopefully the intestines can handle it.

    Anemia is most common in babies from 9 months until about 24 months old, at which point it seems everyone is ready to switch to cow’s milk so the risk disappears, though the risk continues until 3 years old. This is because of many kids simply not eating a wide variety of high-iron sources, and cow’s milk interfering with that absorption of iron (as well as the possible intestinal problems for those closer to a year old.) For the record, this is why toddler formulas tend to say that they’re for children up to 3 years old. After that, the risk of anemia is pretty much gone and the benefits of a formula is no longer necessary.

    http://www.ncbi.nlm.nih.gov/pubmed/17583621 (This was a small study. However, the conclusion was that, over a 4 month period of time, toddlers (aged 1-3) drinking iron fortified formulas are at less risk for anemia.)

    http://www.aafp.org/afp/2002/1001/p1217.html (Note, in this they state a suggestion that for babies who are stopped breastfeeding at a year old that the mother should use iron-fortified formula, not cow’s milk, until 24 months old, but say that the reason they are not adopting that suggestion is because for some parents that may not be feasible. Not that it’s not wise or supported by observations and such, just that some parents may not be able to afford it. This to me is the main reason why they say formula feeding moms should introduce cow’s milk at a year old. Because they think formula feeding moms won’t be able to afford more formula, the programs to provide formula are already stretched thin, and the baby will get cow’s milk ANYWAY, so rather than the best scenario of continuing an iron fortified formula until 24 months they put limits on it.)

    http://www.nlm.nih.gov/medlineplus/ency/article/007134.htm (talking about how 1-3 year olds are the most commonly afflicted by anemia, and how that’s because toddlers 1-3 are less likely to eat enough iron rich foods, and more likely to drink too much cow’s milk which can interfere with absorption of iron as well as other difficulties.)

    http://www.askdrsears.com/topics/feeding-infants-toddlers/bottle-feeding/switching-formula-cows-milk (Blood doctor stating that introducing cow’s milk slowly in the second year with tests to make sure anemia is not a risk rather than just switching them at a year old.)

    http://health.nytimes.com/health/guides/disease/anemia/risk-factors.html (Talking about how using the bottle for longer than a year increases the risk of anemia in the 9-18 month crowd. That would fit with when mothers put cow’s milk in the bottle instead of in sippy cups.)

    http://www.healthlinkbc.ca/kb/content/special/hw97699.html (Canada’s recommendation of babies weaned to bottles before 9-12 months needing formula, but after 9 months they can switch them to cow’s milk.)

    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2580047/ (not sure where to put this, but for some reason I found it an interesting read about the risks of anemia and different living situations and why it can affect children in developed and undeveloped countries. Breastfed babies absorb iron better than cow’s milk fed babies, and the risk numbers for other countries shows why WHO would recommend breastfeeding to 2 to try and help that situation. We’re not in those countries though, our own anemia levels is something like 9%.)

    Basically… I agree that for some it’s fine to switch at a year old, both from breastfeeding to cow’s milk as well as from formula feeding to cow’s milk. However, parents need to be aware of the warning signs, and be willing to take steps back and to limit amounts just to be on the safe side well into the second year, as well as making sure their baby is eating iron-rich foods in amounts that will maintain their iron stores, ideally with a couple of tests to see if the baby’s iron levels are slowly going down after the introduction of milk. If a parent doesn’t WANT to worry about all that then an iron fortified formula will protect from anemia and isn’t going to harm their baby any more than if a mom decided to breastfeed for that second year. After the second year, even the most wary doctors believe all babies are ready for cow’s milk (unless there’s a lifetime issue going on.)

    As far as hurting the pocketbook… most of the toddler formulas are cheaper than the infant formulas were. Big formula companies are willing to send coupons to help pick up the slack as well. I found that the first few months after the first birthday, about 4 months, was the hardest as my kids didn’t slack much on their consumption (for my kids at that time, both were drinking about 32oz a day.) But at 16 months both of them dropped drastically to 16-24oz a day. By 18-20 months they were usually having 8-16oz a day, and then dropped off to nothing before they reached 2 (except my son who still wants a formula bottle when he’s sick.) The thing is, the cost became negligible (maybe $20-40 a month, usually 20 though) after 16 months. There were times I bought 4-5 cans of name-brand formula for $5 a piece when I’d catch a sale and had coupons. We are poor, but this wasn’t a hardship for us.

  3. I read your link to the Good Enough Mum article, which supported what I have been taught: Passive immunity that a baby gets from the mother mostly occurs prenatally via placenta and passive immunity through breastmilk wanes between 3 and 6mos after baby is born. There is no evidence that passive immunity is happening or important if it is, after early infancy. Toddlers’ immune systems are capable of handling the variety of colds and stomach bugs that plagues them (especially if they go to daycare or preschool). There is evidence (no citation at present, will have more time to look later, but according to our pediatrician) having colds, etc early on means that later on, they will be less sick. It does seem to be true that children starting school after daycare are sick less frequently than children starting school after being home with Mom or other caregiver for 5yrs. Breastmilk plays no role there, simply proximity with other humans leads to the spread of viruses, and exposure to viruses leads to antibodies (made in the child’s body with no help from Mom).

    My pet peeve with the whole BF v. FF thing is how many people misunderstand what passive immunity is and how it works.

    • Amy, your information is out of date, the immunological benefits of breastfeeding continue as long as the child breastfeeds. I recommend you read the Textbook of Human Lactation, Hale T. and Hartmann P.

  4. I had this discussion with my doctor at our one year appointment last month. My husband and I wanted to switch our child to toddler formula since she isn’t the best eater. But he claimed cow’s milk would be just as good and would cost us less. A month later we are doing 50/50. This is such a good point in the different recommendations for the various worlds of infant (and toddler) feeding.

  5. I think WHO’s reasoning is to help families without access to clean water. Mom’s body is a great water filter. The second benefit is delayed ovulation. It’s not a perfect system, but many women don’t ovulate while bfing (I’m not one of them). It’s to the baby’s benefit to be the only baby for as long as possible. And the mother needs the time to rest and regain her health between pregnancies.
    Neither of those benefits have much to do with hair or immune systems, nor are they unsupplementable in the first world. Nothing but tap water and contaceptives here, my friends.

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