The FFF Quick-and-Dirty Guide to Formula Feeding: Differences between formulas and bottles

I’ve promised quick and dirty, and instead I’ve delivered Ivory soap-flaked novellas, haven’t I?

Sorry about that. This “chapter” will be as short and to-the-point as I’m capable of.

Two issues I want to cover here: how to pick the right formula, and how to choose the right bottle, for your child. First the easy one….

1. Do different bottles really make a difference?

I’ve raised two primarily bottle-fed babies and yet standing in the bottle aisle still makes my head spin. There are just so many darn choices, and all of them are so… different. I am a sucker for a cool-looking design, so I went for a rather space-age looking set with my younger daughter. Come to find out that space age also means drippy and aggravating.

It really boggles the mind. Anti-colic, anti-gas, with vents and without, glass or BPA-free plastic… But just like there is no one-size-fits-all method of infant feeding, there’s no one-size-fits-all bottle. Even the one that gets the best reviews online may end up being wrong for your particular baby. That’s why it’s hard to say which bottles are the “best”; there was one interesting study conducted by one company which appeared to suggest that their bottles maintain vitamins and antioxidants better than others, but then again, nearly every big-name company claims to be “clinically proven” to lead to less colic or gas. I’d love to see a large-scale, independent study on what bottles really do offer the best health-related benefits, but I’m not aware of any at the moment.

But while we can’t say one is “best” across the board, bottles certainly do differ. Some babies prefer the shapes of certain nipples better, for example (and in fact if you are either combo-feeding or switching from the breast, studies suggest that babies prefer a nipple shape which resembles the mother’s own nipple – this is valuable info for parents of babies who do not transition well). Baby bottles also differ in how much air gets allowed into the bottle by the mechanics of the nipple (this is where all those discs, vents, rings, etc. come into play), which can definitely affect gassy or refluxy babies, at least according to moms I’ve talked to. (For the record, nothing helped my severely refluxy baby, and we tried every bottle on the market. I have a feeling these things make a difference for kids with mild reflux or who are getting gas/discomfort from feeding postures, awkward latches and so forth, but I’m not convinced a bottle can really “cure” a baby with clinical GERD.)

Other than that, bottles differ in how easy they are to clean. The more parts they have, the more aggravated you’ll be at the end of the day when you have 6 bottles to wash and just want to go watch Grey’s Anatomy.

Best advice? Don’t commit to any brand too soon. Before your baby is born, read the reviews online, and choose one to start with. ONLY BUY ONE OR TWO. Don’t make the same mistake I made with the space-age ones and fork out $50 for the 6-bottle set. (Most babies will like whatever they are first exposed to, so if you go for the cheapest BPA-free ones, more power to you.) If your baby likes the bottle you chose, go buy more. If not, try and figure out what he doesn’t like about it. Is the flow too fast? (If so, you may want to see if the company makes a slower nipple; that may solve the problem). Too big? Is the nipple too big for your baby’s mouth? Does it seem like he is swallowing a lot of air, or gulping? Or is the problem on your end – is it an awkward shape for you to hold, or is it drippy?

Sounds lame, but whatever your issue is, Google it. I guarantee you’ll stumble across Babycenter or Facebook threads discussing that very problem, complete with numerous rants and raves about bottles that address your specific concern. Buy one of the bottles you see recommended a lot, and hope for the best. It may take a few tries to find the one that works for you.

You may also want to check out my post on changing nipples and formulas as your baby grows.

2. What are the differences between formulas? Aren’t all formulas the same?

There’s this mythology out there that all formulas are the same. They are not.

Yes, all commercial formulas must meet certain nutritional standards, so all of them will nourish your child. Generics are fine, and there is no reason to pay full price for a name brand if you can get the same result from the cheaper version. But there are indeed differences between brands and types which, although sometimes small, can make a significant difference, especially to a sensitive child.

There are several categories of formula. The first are standard milk-based formulas. Within this category, some manufacturers have different formulas designed for age range – the differences in these is usually that the proteins are a little easier to digest in the newborn version, and there may be more or less of certain vitamins for different age ranges. There are also thickened formulas for reflux, which are just normal, milk-based formulas with added rice starch to help the liquid stay down; and organic versions, which typically use an organic milk source. Not all ingredients in these formulas are organic, however.

While still milk-based, the next category is comprised of “gentle” formulas marketed for babies with sensitive tummies. Depending on the brand, some are made with partially broken down proteins which are easier to digest. Recent studies have suggested that babies fed formulas with these types of protein – called partially hydrolyzed proteins – fare better in a few key ways.So they might be worth considering. You want to look for the words ‘partially hydrolyzed whey or casein” on the label – these are types of milk protein.

Next up, there’s soy formula. There is some question on whether giving babies so much soy protein is a good thing, so these are usually only recommended if a baby is truly lactose intolerant, or allergic to milk protein, or if the parents are vegan. My personal view is that like anything, these should be assessed with a risk/benefit analysis – if you can find another type of formula that works for your baby, it’s probably not worth the (incremental) risk of having her consume too much soy. But remember- this is a small, small risk, so if there are other immense benefits to using soy (for example, your child can’t tolerate milk-based formulas and you can’t afford the hypoallergenics), you can still choose it with confidence.

Then, we have hypoallergenic formulas which are made with completely hydrolyzed milk protein – meaning it’s broken down so much that even babies allergic to milk protein can tolerate it– or a prescription version for severely food allergic babies, made from amino acids rather than milk or soy proteins. These are seriously life-saving for babies with severe allergies or food intolerances, but they are quite expensive and smell pretty nasty (especially when you drip them all over your car. Not that I’d know from experience or anything…) so these should only be used if you really need them. They are also marketed for “colic symptoms”; unless the “colic” is caused by a food intolerance which is exacerbated by regular formula, they probably won’t do all that much for you. Then again, since no one really knows the cause of colic, I could be dead wrong about this. If colic is some sort of gastrointestinal issue, then a hypoallergenic (or “hydrolysate”) formula could feasibly make life easier for a stressed-out baby gastro system. It’s worth a shot. Usually, if these formulas are going to help, you’ll know withing 24-48 hours of trying them. It’s often a quick and dramatic change for the better.

Lastly there are specialty formulas – some for premature infants or infants who are having trouble gaining/maintaining weight (sometimes doctors will have parents use regular formulas and just mix up different ratios of formula to water or add other elements to make them more nutrient dense – which should ONLY be done with a doctor’s supervision), and lactose-free formulas for kids who are lactose-intolerant. Most children are reacting to the milk protein and not the lactose (although certainly not all – lactose intolerance does indeed occur in babies, it’s just not as common as milk protein allergy) and will not do any better on these formulas; they will need a hypoallergenic formula to make them more comfortable.

3. What’s the difference between ready-to-feed, concentrated, and powdered formula?

Formula can come in three forms: powder, ready-to-feed, and concentrated.

The most common and economical option is the powdered formula, where you mix specific amounts of powder with (safe) water to make the formula.

Ready-to-feed is exactly what it sounds like – the formula is ready to go as is, so all you need to do is pour it from the container into the bottle, or some companies make “nurser” bottles, where you just attach a nipple directly to the bottle the formula comes in. These are often used for newborns, due to their ease and safety – if there is no water or mixing involved, there is less chance for human error or contamination. I think if you can afford to use them, they are the best bet for the first few weeks. There’s a lot less to worry about when you’re using these, and what new parent couldn’t use a little break from all the worry?

The last kind of formula, concentrated, isn’t all that common these days, but it is kind of like condensed soup – it comes in liquid form, and you need to add water to make it drinkable.

There are actually some differences in the formula itself when in different forms – some sensitive or refluxy babies do better with ready-to-feed, for example, because it isn’t clumpy and tends to be smoother and creamier in consistency than the powdered version. Also, most powdered formulas contain anti-caking agents – often corn-derived – that certain babies might be sensitive to. But for most babies, the powdered version will work just fine, and it is certainly the most economical option.

Bottom line: formulas and bottles do differ by type, brand, etc. This doesn’t mean one is necessarily better than the other, but there are fundamental differences, so if you are having feeding problems, don’t despair. It may be a case of trial-and-error (and if you’re like me, there may be a lot of error) but eventually you will find a feeding system that makes the heavens open and the sun shine down. Well, maybe not that good, but at the very least, you’ll find a system that allows your baby to be comfortable and fed.

The 2-Hour Rule: Is a bottle safe when it’s been left out too long?

On a message board I frequent, a mother recently asked how many of us obey the “don’t feed formula left out over 2 hours” rule. While most people responded that they did abide by this recommendation, a conversation ensued about why we we’d all been told to do this. The answers varied, from vague concepts about bacteria spreading in room temperature bottles, to warnings that the nutrient content of the formula would decrease as time went on.

This all got me wondering: what is the reason we’re told to be so careful about not letting our babies consume “old” formula? For a snacker like Fearlette is – especially one on $30-a-can Alimentum – this rule is a real drag. My sick little theory was that this rule is all b.s., a combined ploy of the formula manufacturers and breastfeeding pushers who want to make it more costly and aggravating to formula feed. So I started researching… and I found plenty of studies on how formula feeding moms don’t follow safe practices, and articles about how unsafe formula handling can kill babies… but no concrete facts, statistics, or studies about just how room-temperature formula becomes an instrument of morbidity.

Go figure, right?

Anyway, let me share with you the information I could find. An Infant Formula Council document warns that the longer formula is left at room temperature, the more likely it is to become contaminated with a bacteria called Enterobacter sakazakii, which can indeed be lethal for premature infants or those with compromised immune systems for other reasons:

A microorganism of particular concern, and which can survive in powdered infant formula, is Enterobacter sakazakii (E. sakazakii). E. sakazakii is an opportunistic pathogen that poses little risk to healthy, term infants. However, in certain highly vulnerable infants this microorganism can cause serious infection that can present severe and life­threatening conditions, including meningitis. This most commonly occurs in low birth weight and immuno­compromised infants, in whom isolated outbreaks of E. sakazakii infections have been reported in a few hospital settings. Some of these cases have been linked to the improper preparation and storage of reconstituted powdered infant formula. For example, blenders used to reconstitute formula have been shown to harbor bacteria. Because reconstituted powdered infant formula is rich in nutrients and is not sterile, it provides a good medium for microbial growth under certain conditions. For example, prolonged periods of storage or administration of prepared powdered infant formula at room temperature will increase the bacterial load. Thus, proper handling and use of powdered infant formula in the health care setting is an important patient safety issue.

The AAP also warns about the dangers of improper formula handling:

In the United States, infant formulas are available in 3 types: ready-to-feed, liquid concentrate, and powdered. Liquid concentrates and powders require appropriate dilution with clean water. Adding too much water may lead to inadequate intake of calories and nutrients, whereas adding too little water may lead to dehydration, diarrhea, and excessive intake of calories. The safety of liquid concentrate and powdered formulas can be compromised if they are diluted with water of poor quality.1 Unlike ready-to-feed and liquid concentrates, powdered formulas are not sterile when purchased and could contain bacteria. To reduce the risk of infant illness caused by bacteria in powdered formula,3 the World Health Organization urges caregivers to use water no less than 158°F when reconstituting powdered formula.4

I checked the references of both these articles – which were coming from two different organizations with dramatically different biases (the AAP one was written, in part, by an IBCLC) – and it was insanely frustrating, They used other articles as backup for these theories that also offered no stark data. I couldn’t find any documentation of cases where children got sick from formula left out of the fridge too long, or suffered long-term health effects because their parents let them drink a bottle they’d been snacking on for 2 hours and 15 minutes.

In terms of preventing contamination Enterobacter sakazakii (ES), a rather stubborn bacteria which does indeed confer risks to infant formula, I did find a long chain of good studies which examined how this bug can survive even under refrigeration, and can cling to surfaces which makes it a real threat in NICU units. Apparently, the longer formula is left out, the more likely it is to become contaminated. But again… no concrete evidence.

Here is what I would like to know (and gold stars for anyone who can find a study which answers these questions):

1. Many of the studies on ES recommend using breast milk or ready-t0-feed formula, since ES has been found in cans of powdered formula…but then they also discuss other ways the bacteria can spread, like through feeding tubes, etc. Couldn’t this bacteria theoretically infect a baby in the NICU fed through one of these tubes with human milk or RTF formula? If so, shouldn’t this be added to the warning? According to this study, ES can thrive in breastmilk; also, although we are innundated with the message that “formula is not sterile” and therefore unsafe…. neither is expressed breastmilk, for the exact same reasons. I don’t see much information on dangerous bacteria being passed to the millions of women who pump their breastmilk daily, and I think it’s worth mentioning.

2. Have there been any documented cases of an infant becoming sick after consuming formula left out more than 2 hours? Why is the 2 hours the limit? I’m looking specifically for a study which examined harmful bacteria growth on a sample of formula over time…

Now, none of this is to say that formula-related dangers don’t exist. I personally know a few parents who’ve experienced health crises due to improper formula usage, which is why I think formula education is incredibly important. It makes complete sense that we should wash our hands prior to making a bottle, or use safe water (there are PLENTY of documented cases in developing nations of babies dying from formula made with contaminated water). But the no-bottles-after-2-hours rule, in areas with clean water or in cases where purified water is being used, just seems to have a startling absence of evidence to back it up.

It seems that this recommendation is based on pure hypotheticals – bacteria could feasibly grow in formula, and two hours seems like a decent cut-off point. But where is the evidence? If we’re seriously concerned about our babies’ safety, shouldn’t we be demanding some real statistics on this potential threat?

Interestingly, while researching this post, I came across a study done by the company which makes Dr. Brown’s bottles. The study looked at how the type of bottle can effect the nutrient decomposition of both breastmilk and formula:

The study measured the level of loss of vitamins A, C and E during baby bottle feedings. The results suggest that the amount of air within a baby bottle, the bottle’s design, and the impact on vitamin levels warrant closer examination….The bottle study was designed to investigate changes in nutrient levels that might occur during a typical bottle feeding time of 20 minutes, using both expressed human milk and infant formula, in both vented bottles and unvented bottles…

As milk is removed from the bottle by the infant, the milk is replaced by ambient air. Nutrient loss is likely caused by the oxidation of nutrients that takes place as air is introduced into the liquid. The amount of air moving through the milk and into the bottle depends on the bottle type, bottle shape, and bottle size.

The lead researcher on this study also mentioned that storage of both human and formula milk could effect the nutrient levels. She offered the following tips for bottle-feeding moms:

Select bottles that minimize air traveling through the bottle.

• Look for little to no bubbles forming in the milk as the baby feeds.

• Use breastmilk that is as fresh as possible.

• Use small bottles that minimize the amount of air at the top of the milk.

• When using infant formula, make it fresh for every feeding.

• Feed babies with small, frequent feedings.

Although this study was funded by the makers of the same bottle which fared the best in the study (Dr. Brown’s), I still think it’s a superb example of the type of research we should be focusing on. It tells us a specific effect of a specific behavior, and offers suggestions to counteract the negative results of the study. Good, useful, empowering information.

I’m certainly not in the business of giving recommendations, and as I’ve said a million times before, I am not a doctor, nor do I play one on tv. But here’s my personal take on it: I’d be pretty careful about the 2-hour rule if your baby is under 6 months old or immuno-compromised in any way. But after that… I don’t know. The fact is, once your kid is on solids, they are going to be at risk for foodborne illness from all sorts of products, not just infant formula. I haven’t found any research that makes me believe Fearlette is at risk because I let her snack on the same bottle for 3 hours rather than 2.

Not that I’d do that. We’re talking hypotheticals here, remember?

Hitting the bottle

We are having a heck of a time weaning Fearless Child (FC) off the bottle.

I thought I was making progress. We started him on sippy and straw cups around 7 months, and he figured them out pretty quickly. He even runs around the house swigging imaginary coffee from his tiny toy coffee cups (and yes, kids are indeed little sponges, and you can guess where he learned that behavior. He also has to help me “make” the coffee every morning or he throws a fit… just training him young…). I never would have imagined that at 15 months, the kid would be hooked on the bottle to the extent that he clearly is. And I don’t know what to do about it.

Actually, I take that back. I do know what to do about it – there are a ton of great bottle weaning resources online – it’s more that I am having a philosophical crisis about it. I feel pressure to get him onto sippies exclusively; all his friends are on them, and I’m starting to get sideways glances at the playground when I pull out the bottle (not that this is anything new, of course, but now that there’s water in the bottles, the stares are for an entirely different reason). So, sometimes in the morning, when FC starts whining for his morning fix (usually 6 oz water with 1 oz of organic, 100% apple juice for flavor), I’ll hand him the magic elixer in his sippy cup. Just to see what will happen. 

This is what happens:  the two men in my life start screaming bloody murder at me, before I’ve even had that vital first cup of coffee (it’s hard to get my toddler to make it for me when he’s so upset. Kidding. But I kind of wish I weren’t. Wouldn’t it be so rad if the kiddo could pad downstairs in his Dr. Dentons and brew me up some French Roast before I even showered?) The smaller of the two guys throws the sippy on the floor as soon as he realizes that it is a poor imposter for his beloved bottle; the taller of my boys starts yelling that I’m torturing the kid for no reason – “He wants a bottle! Give him the freaking bottle!”

Can you see why I choose the path of least resistance?  Worse case scenario, I figure, is that FC will have a hard time getting a date when he drinks Chardonnay out of a Born Free. 

In all seriousness though… I do understand the importance of weaning to a cup for dental reasons. But it does seem unfair that what my child depends on for comfort has to be taken away so soon. If I were breastfeeding, the medical authorities would be encouraging me to continue, right? They wouldn’t insist that I pump my milk into a sippy cup. And yes, I understand this is an issue with the delivery system – having a bottle constantly in one’s mouth can have a negative impact on speech, diet and tooth decay; toddlers can’t walk around with a breast in their mouth all day. Makes sense. However, just like breastfed kids nurse for both nutrition and comfort, my son finds solace in a silicone nipple. 

According to La Leche League, “Toddlers have a huge world to explore, and breastfeeding provides them (and their mothers!) with some quiet time in their busy, waking hours.” Well, what about my toddler? He loves being cuddled while he sucks away on his bottle. The kid is so independent, which I love… but those moments where he’s in my arms, drinking languidly, in the same way he has since infancy… I don’t know. It’s hard for both of us to let that go.

So tell me, FFFs – how did you wean off the bottle? Am I alone in feeling sad and a bit angry over the reality of this transition?

Choosing the right bottle for your baby: Milking your options

Okay, ladies… time to take a break from the controversy and talk shop. Formula feeding support isn’t just about analyzing studies or fighting off our detractors, after all. And like so many other aspects of parenting, no one really talks about the idiosyncrasies of bottle feeding. One peak inside a Babies-R-Us tells the tale: row upon row of bottles, nipples, warmers, and other accoutrements… and if you’re like me and found yourself unexpectedly formula feeding after nursing didn’t work out, getting set up for your new feeding situation can be more than a bit stressful.

I had half-heartedly zapped a Born Free “starter kit” onto my registry when I was about seven months pregnant, thinking that this addition was merely insurance. At some point I was going to try and pump so that my husband could take a feeding or two, right? The starter pack would certainly suffice… bottles were bottles after all, and they were BPA free, said so right on the label… it was a safe choice. I liked the packaging. Done and done.

Flash to several months later, when my kid couldn’t latch, and suddenly I had to cash in that insurance policy, big time. I ripped open the Born Free package… and felt my eyes cross. What were these little plastic disks about? And those things that looked like puzzle pieces? I have issues with spacial relations on a good day, let alone one when I was going on half an hour of sleep, with a screaming, hungry baby and a complex about having to feed him from a bottle in the first place.

I figured out the system eventually, but then it became apparent that we were going to need more than the four bottles that came in the pack. So, off to BRU we went; back to the Wall of Possibilities (see, if I make it sound like something Harry Potter-esque it seems cooler, right?) to get some more supplies. My husband went to grab some more Born Frees, staying all brand loyal and crap, but I restrained him.

“WAIT!” I cried, desperately trying to sooth our colicky baby (who was still suffering from a milk allergy, although we didn’t know it at the time). “Look at all our choices… maybe we’re using the wrong bottle! Maybe he’s just gassy! This one says it’s best for colic and gas…Ooooo, and this one is made from PVC…how freaking cool is that?”

And thus began our journey into bottle madness. I think we must have gone through about 20 brands of bottles (and later, sippy cups) before ending up exactly where we started. Born Free was my baby’s bottle of choice; he hated the Dr. Brown’s, was indifferent to Playtex, and wouldn’t even touch the Nuby. The little Medela ones that came with my breast pump kit were okay for a bit, but they were just so flimsy looking; I gravitated towards the high-tech looking delivery systems: the more parts the better. (I regretted this preference every time I went to wash the dishes, but what can you do? For the record though, to this day I don’t understand why those little disks need the hard plastic and soft plastic parts. Couldn’t they make it simpler on us? Plus, I was always losing the little buggers down the disposal and mutilating them, and the company does not sell the disks separately, forcing you to buy a whole new set of bottles… total racket, if you ask me.) I started collecting overpriced baby bottles like other women collect overpriced shoes. You know – the kind you never actually use, but look really great lined up in your closet?

I’ve since found that most moms get super committed to their brand of bottle. And babies do too. My kid can spot a Born Free from a mile away, and yet he has no interest in the baby with the Playtex drop-in right next to him. It’s tough to recommend a bottle to a new mom; it’s kind of like telling someone which breed of dog to get. I happen to love the smoosh-faced breeds (hence our proud ownership of beloved Japanese Chin), but my mom thinks it’s not a dog if it doesn’t have a snout.  There’s no accounting for taste, or the preferences of infants, which apparently, at least in my son’s case, can be developed before they even know how to focus their eyes. My suggestion? If you can liquidate your savings account, buy one of each brand, and try them all until your junior gourmet chooses his favorite. In this economy, though, that might not be a rational way to go; instead, I’d recommend thinking about the following:

1. How much you can withstand dishpan hands: The bottles with a lot of parts (Born Free, Dr. Browns) are highly recommended, but with the caveat that they are a pain in the touchas to clean. Little bits of grime get stuck in the crevices of the disks and you’ll find yourself grumbling at your in-laws’ kind attempts to wash up for you, after the eighth time you discover gross chunks of leftover formula collected on the sides of the plastic. But if you are a bit OCD and enjoy washing dishes, then go for it – I honestly think my kid did have less gas with the Born Free bottles.

2. How environmentally friendly you are: Playtex Drop-Ins are by the far the easiest system (and a lifesaver in those first few weeks of parenthood when washing a dish seems as doable as climbing the Himalayas barefoot), but those liners are not too “green”. A year into a bottle-fed baby’s life, and you’ll have be the proud owner of a plastic liner landfill.

3. How intimidated you get by the Mammary Mafia: When I first switched to formula, I’d only use Medela bottles outside of the house, since they are the preferred choice of pumping moms. I figured people would assume there was breastmilk in my bottle and leave me alone. Sad, but true. Medela’s got the monopoly on pumps and pump parts, so if you’re in the formula closet (not that I am condoning this, by any means, but I also know how it feels to be a new mom in a primarily breastfeeding community, and we all need to get through the day), Medela is a good “beard”.

4. How “trendy” you are: It’s hard to accessorize a newborn. Those little headbands and caps only go so far. What better way to show your offspring’s good taste than a stylish glass Weego or high-tech, self-heating Yoomi? You gotta feed the kid; might as well make a statement while you’re doing it.

That’s my two cents on bottles. I’d love to hear from the peanut gallery…. which is your brand of choice? Do you think the bottle can really make a difference with gas and spit up? Talk to me, FFFs….

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