Formula feeding education, or lack thereof

Reading through my Google alerts, I almost squealed with excitement when I saw a link entitled “Health Tip: Preparing Baby Formula” from none other than U.S. News and World Report. A major news outlet! Formula feeding education! Squee!

Well, turns out the article was less “squee” and more “eh”.

According to the esteemed publication, the formula-related health tip that was so vital that it necessitated being “called out” (publishing world lingo for highlighting a fact or quote) was the following:

Wash Your Hands.

The rest of the tips have to do with general hygiene- cleaning surfaces, sterilizing bottles, etc. I’m probably being unnecessarily snarky, because this is important information; it is important to keep things as clean and sterile as possible when making up an infant’s bottle. They also throw in one useful tip about keeping boiled water covered while cooling (great advice). But most of this is certainly not new information, and in many ways, I think it’s a waste of newsprint.

Why? First, I expect most parents know they are supposed to wash their hands and clean their bottles. What they may not know is why. There is no mention of the risk of bacterial infection here, so it just comes of sounding like vague, somewhat stodgy advice, like something your mother-in-law tells you in that tone. (You know the one.) The kind of advice that gets filed in the “I know I should do it, but come on, what’s the harm” portion of your conscience, alongside “floss twice a day” and “never jaywalk” (unless you are in Los Angeles. Then you probably take the jaywalking thing seriously, as the LAPD will ticket your ass for crossing where you shouldn’t). I think an acknowledgement that these precautions will help you avoid potentially deadly bacterial infections would make the advice seem a tad more topical.

But also, this is standard food prep protocol. There are other intricacies to formula feeding that may not be as intuitive- safety precautions like mixing the proper amounts of water to formula; not diluting the formula; using the right type of water; discarding formula after specific amounts of time; opting for ready-to-feed for newborns. Or what about other tips which might help avoid other formula-related health problems? Like a run down of the different types of formulas so that parents can choose the right type for their babies. Advice for understanding hunger cues. A bit of education on growth spurts; what’s normal when it comes to formula-fed babies and spit-up and elimination (both pee and poop); a quick description of how to feed a baby holding the bottle at a good angle?

I get that this was merely a half-column filler, not an 800-word feature. I understand that U.S. News & World Report isn’t in the business of imparting feeding advice to parents (and in fact, the article in question was syndicated, from Health Day) . And I seriously do appreciate the effort to give a bit of valuable info to formula feeding parents. Yet, I can’t help but wish that this half-column was put to better use. A short paragraph on when (and just as importantly, why) formula should be discarded would have been infinitely more interesting and useful.

There are a few reasons why formula feeding education is as hard to come by as a good house under half a million in the greater Los Angeles area (I’m bitter about real estate at the moment). Many people think it’s unnecessary; formula feeding is seen as the “easy way out”, and assumed to be as simple as scoop and shake. Some breastfeeding advocates believe that prenatal formula education/preparation is counterproductive to breastfeeding promotion – the theory being that if you discuss it, it will be taken as an endorsement, when formula should only be used in an all-else-has-failed scenario. (The World Health Organization’s “WHO Code” basically forbids health workers from even uttering the words “infant formula” until it becomes clear that there is no other option.)

What is puzzling to me about this situation is that breastfeeding, while definitely a lost art in our bottle-heavy society, does have an intuitive aspect to it. Or at least it is portrayed that way – something so natural, so instinctual, shouldn’t require training. Assistance, yes. Support, most definitely. Protection, you bet your bottom dollar. But instruction/education? That seems rather – well, quite literally, counterintuitive.

Formula feeding, on the other hand, is something which has always been a man-made, lab created, medically-approved (at least up until recent events) form of infant feeding. It does require instruction; you don’t see our primate cousins giving birth and popping open a can of Similac (although I am quite sure they could be trained to do so, considering how smart they are. I’ve seen Rise of the Planet of the Apes. Scared the bejesus out of me). Yet parents leave their prenatal classes and hospital stays with plenty of info on birthing and baby care and breastfeeding, but little to no instruction on how to make a damn bottle.

The vast majority of babies will have some formula in their first year. Heck, by the time they are 6 months old, it’s a safe bet to assume most of them are partially, if not exclusively, formula fed. We can’t sell infant feeding as the number one predictor of infant health and development and simultaneously ignore the primary way our nation’s babies are being fed.  It’s bogus, and irresponsible.

This is not to imply that parents are putting their babies in dire jeopardy because they leave a bottle out too long, or forget to scrub their hands like Lady MacBeth before mixing formula. Heck, I committed almost every formula feeding sin and my kids are pretty normal. (Except for Fearlette’s suspicious fear of police helicopters, but I blame that on her past life.) But until we ensure that parents are properly educated on formula feeding – something that could be done with one quality, AAP-endorsed pamphlet, or a few minutes of discussion in a hospital baby care class – we can’t possibly get a clear idea of the real risks of formula feeding (I bet we’d see an even smaller difference in breastfed versus formula fed if all formula feeding parents were doing it correctly), or feel confident that all of our babies are getting the best version of whatever feeding method their parents have chosen.

For now, I’d suggest checking out Bottle Babies – a great non-profit organization run by some friends of mine. They’ve put together some excellent, research-based information on a myriad of bottle-related issues. Or feel free to click on the link to the FFF Quick-and-Dirty Guide. And I hate to say it, but for the moment, the formula companies are probably the best resource for formula feeding parents. At least they give a crap about their customer base, even if this is rooted in a desire for customer loyalty and a fear of litigation.

And, ya know, remember to wash your hands.

The FFF Quick-and-Dirty Guide to Formula Feeding: Recognizing Sensitivity, Intolerance or Allergy to Formula

Those of you who haven’t been following this blog since the beginning may not know this, but my son Fearless Child (FC) has a dairy allergy, which went undiagnosed for the first few months of his life. Having his insides assaulted on a daily basis made him grumpy – so grumpy that he screamed bloody murder for about 20 hours a day. And yet it took us over a month of elimination diets, doctor visits, and late-night consultations with Dr. Google to figure out what was going on. This was partly because FC’s symptoms were slightly atypical, but more so because as new parents, we were utterly confused as to what was “normal” newborn behavior and what necessitated medical intervention.

There’s a good deal of information on dairy intolerance in babies on the Web, but not much specifically geared towards bottle-feeding parents. This is unfortunate, as those of us feeding our kids in this manner actually have a really simple way of figuring out if food issues are at play – and yet so many of us struggle for months, feeling increasingly frustrated and hopeless with our inability to comfort or feed our children adequately.

I always hesitate to offer what might be construed as medical advice, since there’s far too many hacks out there doing just that. So before I continue with this post, let me reiterate: I am not a doctor. I haven’t even played one on t.v. (Does anyone still get that reference? Or does it make me sound old?)  The following information is what I have culled from my own research, talking to pediatricians and pediatric GIs, and from my own experience as the mother of two kids with feeding issues.

Oh, and one more note: I am going to use the terms “intolerance”, “sensitivity”, and “allergy” interchangeably here, even though these three things are entirely different. This is because until you see a physician, you won’t know which of the three you are dealing with. My purpose with this post is to help you realize when something is amiss, and to assist you in navigating a medical system which often ignores the power of parental intuition and knowledge of one’s own child. You’ll have to see an actual MD to get a true diagnosis… and I don’t meant Dr. Google.

 

Behavioral Symptoms of Formula Intolerance or Allergy in Young Babies

Newborns are complicated creatures. Some are calm and sweet (this is the kind of baby everyone else seems to get at least once, but apparently my and my husband’s genetics do not morph in a manner conducive to a docile temperament), others are generally chill except for a bout of colic between weeks 2-8, and others are fussy all.the.time. This last group is the one that we need to worry about. Typically, a calm, contented baby is a well-fed and happy one. This is not to say that food allergies will not strike later in life, once solids are introduced, but a newborn who is sensitive to something in formula will usually express discomfort in a pretty vocal way. Watch out for:

- Extreme fussiness. Colic is defined as crying for a period of 1-3 hours, at least 3 days a week, typically in the evening. A baby who is sensitive to formula will cry constantly, throughout the day. They can sometimes be comforted, but only by extreme measures like continuous movement (we had to bounce FC so vigorously that once, while shopping for a new car, a man came up to us in horror and told us we should stop shaking our baby; a friend’s dairy intolerant breastfed baby was only comfortable while being vibrated in his bouncer – all night long), specific holds (the Harvey Karp /Happiest Baby hold is magical for babies with tummy issues). The difference between a “normal” fussy baby and one with potential allergy or intolerance is that they have 2 settings: sleep and screaming. The fussiness is the default, rather than the exception.

- Trouble sleeping. While many young babies sleep erratically, they usually sleep a lot cumulatively.  A newborn with a formula intolerance will often be too uncomfortable to sleep.

- Trouble eating. This one gets tricky, because other issues can cause trouble with feedings – sensory issues, reflux, dislike of the type of bottle or nipple you are using… but one common symptom in babies experiencing formula intolerance is fussiness around eating. They may pull away from the bottle and scream; or eat only small amounts at a time. Reflux can also be associated with formula intolerance, so spitting up an excessive amount after every feeding (especially if there is curdled formula or blood in the spit up) might signal a problem. Some babies might develop an aversion to eating, associating the formula with pain, and refuse the bottle altogether. Others may “comfort feed” and want to eat constantly (more on this later).

- Inability to connect or bond. Again, this can signal a far more serious issue, but it should be noted that babies who are in constant pain have a rough time chillaxing enough to focus on their parents or begin engaging in social interactions. I’ve had numerous parents tell me that they had secretly worried their baby “had no soul” or “wasn’t all there” prior to diagnosing and solving a severe allergy or intolerance. If your baby is screaming constantly or is noticeably stiff, writhing, or doesn’t seem to be comforted by touch, see your doctor.

 

Physical Symptoms of Formula-Related Food Intolerance or Allergy

The physical manifestations of a formula intolerance are more straightforward, but they also tend to suggest a more serious problem (i.e., clinical allergy versus sensitivity). In terms of getting a diagnosis, they do make life easier, but they can also be scary when first encountered. These include:

- Weight loss, or extreme weight gain, from comfort feeding.  I’ve heard of more than a few cases where babies who are overeating are misdiagnosed with the excuse that “milk protein intolerance causes failure to thrive”. This is true; many kids will have aversions to formula or breastmilk caused by associations with pain, and refuse to eat; these conditions can also cause malabsorption, so the baby isn’t getting the necessary nutrients to grow. But some babies find the liquid comforting as it goes down (especially those who have reflux associated with the intolerance or allergy), or like the sucking action, and want to eat constantly. The offending food causes more distress, which then creates a need to comfort feed more… and suddenly you’ve got Jabba the Hut, Jr. on your hands. Their girth may cause doctors to dismiss discomfort and symptoms as “overeating”(which can certainly cause a whole list of problems, but my point is that sometimes, the overeating is a symptom, not a cause).

- Blood in the stool – this can appear looking like strawberry jelly (red) or like coffee grinds (black). If you see blood, drop everything and call your pediatrician.

- Mucous in the stool – this is a biggie, because often the blood will be invisible to the naked eye, but mucous is easy to spot. Mucous looks like stringy, gelatinous strands, usually white or clear in color.

- Rashes – these can appear in a variety of forms, and may be hard to differentiate from normal newborn skin issues like diaper rash or infant acne. Sometimes the rashes might look like hives, but they can be atypical. FC would get petechia-type red dots on his cheek, right next to his eye, and down his cheek. (This same reaction continued as he grew into toddlerhood, and was a great way for us to know we’d screwed up and allowed for accidental exposure). Other parents have told me that the rashes congregate near the joints, or as a red ring around the anus. All lovely and comforting things to see on your precious newborn, right?

- Vomiting up blood. Again, this merits a panicked call to the doctor. Stat.

Something you should also know is that milk protein allergies come in two forms: rapid onset (immediate reaction) or delayed onset (reaction within 7-10 days of ingesting milk). This may explain why some babies don’t start reacting to formula until a week or so after birth/switching over from breastfeeding. Rapid onset looks more like a “classic” food allergy – hives, wheezing, bloody diarrhea. The rapid onset form is far more dangerous, as allergies can worsen with every exposure, eventually leading to anaphylaxis, so if you see these sort of symptoms, do not pass go, do not collect $200, just dial your pediatrician.

Which brings me to….

Seeing Your Doctor

There are a lot of fabulous pediatricians out there. There are also some really crappy ones. And in the middle, there are doctors who have seen thousands of neurotic new parents who freak out at the first sign of slight fussiness in their babies, and also a slew of legitimately concerned parents dealing with the untreatable hell that is infant colic. Considering that in the majority of cases the babies they see are either healthy and just waking up to the world (it’s normal for a baby to be impossibly easy and sweet for the first few weeks and then wake up one day with an attitude. Think of it as good practice for the teen years), or are unfortunate victims of colic and just have to wait it out (excuse my tangent for a moment but I cannot for the life of me understand why no one has figured out this colic thing. Seriously? We can clone sheep and we can’t figure out why some babies cry inconsolably for exactly 3 hours at the same time every night??!), it is understandable that some pediatricians have dismissive or patronizing attitudes towards those complaining about fussy babies.

I have seen parents who do overreact to sudden onset of mild spitting up, fussiness, or constipation- it’s hard not to, considering the lack of sleep, the hormones, and the lure of the Internet (Dr. Google is an alarmist). But for the most part, every parent who has emailed me with a laundry list of weird symptoms and a general, foreboding sense that something is “not right” with their newborn, has later followed up to confirm diagnosis of an allergy or intolerance. I’m a big believer in mommy/daddy “gut” when it comes to your baby’s gut.

So, here’s what I would suggest: before you go in for your child’s appointment, write down a list of every symptom you have observed. If you’ve been noticing mucous or blood, collect a stool sample, and show your doctor the craziness that is coming out of your kid’s tush. If your doctor starts talking about colic, explain to him/her that you are well aware of what colic is, and colic does not explain the other symptoms you are noticing (you might also want to mention if your child’s crying doesn’t follow a colic-like pattern – meaning that it is not sustained crying for a specific period of time, but rather constant fussiness throughout the day).

It is also well within your rights to request allergy testing, but here’s the thing: with this sort of testing, only a clinical allergy will show up. If your baby has an intolerance or sensitivity, the testing will probably come back as inconclusive or “normal”. Additionally, there is some controversy on whether allergy testing in young infants is even accurate.

Luckily, there is another, non-invasive way to see if the formula you are using is the problem, which is what I like to call…

The Miracle Cure

I could write a Shakespearean sonnet for hypoallergenic formulas, and I’m sure the folks who like to think I’m paid off by formula companies will find fodder for this conspiracy theory in how often I hawk Alimentum on here. But I just love the stuff. And not just Alimentum. Nutramigen, and Neocate, and whatever comparable product is on the European/Asian markets. The stuff is stinky, expensive….and utterly lifesaving.

If you suspect that your baby has a milk protein sensitivity, and the symptoms are not severe enough to necessitate medical intervention, you might want to consider doing a 48-hour hypoallergenic challenge. This is a 4-step process:

1. Get thee to thy nearest drugstore/grocery store

2. Purchase a commercial hypoallergenic formula (please read my post on types of hypoallergenic formula to ensure that you are choosing a true hypoallergenic and not simply a “sensitive” brand)

3. Serve said formula to thy infant, and observe for the next day or two

4. Thou shalt be singing high praises to the heavens by yonder morning, otherwise the formula probably wasn’t the problem in the first place.

While milk and soy protein allergies are the most prevalent in young infants, there are some kids who are sensitive to corn or other ingredients in formula. And for children with severe milk protein allergy, a commercial hypoallergenic isn’t going to cut it – they will need an amino acid-based formula, which is available by prescription only. But for most babies suffering from mild to moderate sensitivities/intolerances, a hypoallergenic formula is truly a godsend. You should see a marked improvement within 2 days if the problem is food related and not due to some other underlying medical condition (cough*call doctor*cough) or- and I seriously hate to say this – if it’s just colic or fussiness, in which case you really do just need to give it time, and start drinking heavily to get through the next few months. Kidding. (Maybe…)

If you are dealing with colic or normal infant fussiness, the good news is that you can skip the following section, and not have to worry about a childhood without ice cream and birthday cake. But if the formula does make a dramatic difference, you may want to consider….

What the Future Holds

If the hypoallergenic works wonders, you can continue to use the formula and try re-introducing a normal or sensitive formula at about 6 months, once your baby’s system has developed a little more. If symptoms return, then you simply return to the hypoallergenic.

That said, hypos are quite costly, and if your child does have a true milk protein allergy, you might be able to get the formula covered by your insurance. You’ll need to see your pediatrician to get the right paperwork filled out in order to do this.

I’d also suggest that you do ask for a referral to an allergist and/or pediatric GI, just so you will have someone in your corner when you start solids. While most children outgrow a milk protein allergy or intolerance as they become toddlers, some take longer than others. It gets really difficult to figure out a delayed-reaction allergy once they start solids, because the exposure could have been anytime in the week or so prior to the reaction. Also, weaning off formula looks a bit different in a dairy intolerant/allergic child. Sometimes, pediatricians will want you to stay on formula a little longer since it’s harder for kids to get the nutrition they need when they can’t eat or drink dairy products. In other cases, using a milk substitute like soy (unless your child is sensitive to soy as well, which many milk protein intolerant kids are), rice, almond (as long as you’ve seen an allergist and been tested for nut allergies), oat. or hemp, can be a perfectly acceptable option. My kids have both thrived on unsweetened almond milk, which is fortified with so much stuff nowadays that the only thing milk trumps it on is protein content and fat (and we incorporate other foods into their diets that compensates for this).

You’ll get very good at reading labels, and creative with recipes, and become a master at surreptitiously pulling vegan cupcakes out of your diaper bag at birthday parties so your kid won’t feel left out. You’ll probably do “challenges” with your kid every so often to see if his or her body has decided to make friends (or at least frenemies) with dairy, and when that day comes, you may even get to see a face like this:

Fearless Child’s first time eating cake & ice cream at a friend’s birthday. And yes, I cried.
Until then, remember- you are the expert on your child. You are also your child’s best advocate. Formula can be changed at any time, so there is no reason to suffer stoically if you suspect an intolerance or allergy to the one you are using now.
Great Links/Sources
http://kidshealth.org/parent/medical/allergies/milk_allergy.html
http://www.allergy.org.au/patients/food-allergy/cows-milk-dairy-allergy
http://foodallergies.about.com/od/dairy/a/babymilkallergy.htm
http://adc.bmj.com/content/92/10/902.full.pdf
http://www.kidswithfoodallergies.org/resourcespre.php?id=140&
http://www.medscape.org/viewarticle/563463

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 FFF Quick-and-Dirty Guide to Formula Feeding: How much and how often should you feed your formula-fed baby?

There are a ton of charts and calculators online claiming to help you figure out how much you should be feeding your baby. Unfortunately, they are all missing one fundamental message: your baby is an individual. He probably doesn’t adhere to static feeding rules any more than you do. For instance, I tend to eat barely anything during the day, but I chow down like a Sumo wrestler at night. Although this runs contrary to all advice given by nutritionists (I think the breakfast like a king, lunch like a pauper, dinner like a peasant concept is pretty well-accepted across the board), this seems to work for my body and my metabolism. Likewise, there are some kids who eat more, some who eat less, some who eat a ton and then throw it all up because they have god-awful reflux, and some who comfort eat due to stomach distress. The latter two might need some medical help (or a formula switch) to remedy their issues, but my point is that not all babies play by the Baby Rulebook.

I hesitate to give a formal “guide” on how much you should feed your baby, because I believe that for the most part, parental instinct is superior to over-generalized prescriptives. But I know there’s a need for non-judgmental practical advice, so here goes.

Before talking amounts, let’s just go over some basics:

1. You cannot overfeed a newborn. You cannot make a newborn fat. Yes, I know there have been recent studies linking rapid weight gain in infants to later obesity, but come on, people… how many scrawny people do you know who were chubbilicious babies, and vice versa? Newborns do not have the brain power to binge eat. They eat when they are hungry (there is one exception to this, which I will talk about in a second, so bear with me), and when they are full, they will pull away from the bottle or, when they are teeny tiny, they may just unlatch. I’ve heard the warnings about formula feeding parents forcing their kids to finish the last few ounces while the poor babies flail and choke helplessly, but the fact is, any baby who is strong enough to to do the “breast crawl” or handle breastfeeding can make it pretty clear when they are done with a bottle. Just watch your baby – if she pulls away or suddenly doesn’t seem interested in eating, that means she’s done. Doesn’t matter that the feeding guide that came with your formula says she should be eating 3 oz in a sitting; if she acts finished after 1.7 oz, that’s all she needs at the moment. On the other hand, if she downs the 3oz you prepared and is still screaming at you or sucking desperately at the nipple, offer her another few ounces (this is where a formula pitcher or even just a salad-dressing mixer comes in handy – if you make like 10 oz at a time, you can offer smaller amounts off the bat and give only an ounce or tow more at a time, so as to avoid wasting formula.

2. As for knowing when to feed your baby, that’s a matter of learning his hunger cues. All babies have them; the most common ones are “rooting” (moving his head from side to side or opening his mouth wide like a guppy, especially when you touch his cheek or chin); shoving his hands in his mouth; sucking on whatever is in reach; crying (this is what many baby sites deem as a “too-late” hunger cue, implying that if it gets this far you must have been negligent in some way); fussing; or my favorite, sticking out his tongue.

3. As your baby gets older, hunger cues aren’t always so easy to read – babies lose the rooting reflex at a point, and sometimes it can be hard to tell what’s hunger-related fussiness versus plain old fussiness. This is where it’s easy to fall into the trap of giving a bottle for comfort and not hunger. It’s unfair, because one wonderful perk of breastfeeding is that you can pop a baby on the breast at the first cry and no one thinks anything of it; do the same with a bottle and you’ll be warned against obesity and blamed for your child’s emotional eating problem in 20 years. Fun times. Professionally, I know the right thing to say is that giving a bottle to calm a baby is probably not the best idea – in fact, I kind of think giving the breast to calm a baby would have many of the same negatives. But personally, as an ardent supporter of Path of Least Resistance Parenting, let’s just say I would never fault someone for giving a comfort bottle when their baby is screaming bloody murder in the car or whatever. Sometimes, you just need to calm the kid down, and if other things aren’t working… well, do what you need to do. As long as it isn’t a daily habit, I wouldn’t worry too much about it.

4. Okay, remember I mentioned there was an exception to the stuff I’ve been saying? That exception is if the baby has an underlying GI or health issue which may make eating challenging in any number of ways. For example, if your baby has an allergy or intolerance to formula, or severe reflux, the “classic” presentation is that she will refuse the bottle altogether, and show signs of failure to thrive. But sometimes this can manifest in what’s known as comfort feeding. Imagine that you’re a baby, and your stomach is constantly hurting or your esophagus feels like fire. And then imagine that when cool, smooth liquid is running down your throat, and you have that lovely sucking motion going on…. not all babies are going to make the association that it’s eating which is causing all the pain to begin with.

Reflux is tricky too, because some kids may eat a ton and throw up the majority of it; it might appear that they are over-eating, but really they’re keeping down the bare minimum of daily calories. Confusing matters further, kids who do eat too much for their little bellies will simply spit up the extraneous amounts; some might assume this is reflux – and a vicious cycle can begin. But I’ll tell you a little story: my Fearlette was consuming about 32 oz of thickened formula (fed in frequent, small amounts) a day. About 15 oz of that was getting regurgitated on a daily basis. She was the scrawniest baby you’ve ever seen, sometimes scarily so. But to read the “how much should they be eating” charts, you’d think I was doing everything wrong.

Bottom line? There are exceptions to every rule. I’ll say it again – every child is an individual. It’s far more helpful to focus on getting to know your kid- her quirks, her cues, her special needs – rather than knowing what the experts say you “should” be doing.

I know you’ve probably skimmed to the end of this novella and are probably wishing I’d get to the point – FFF, just shut up and tell me how much and how often should I feed my baby, dammit – so here you go. The basic rule of thumb for formula feeding:

For every pound your baby weighs, s/he should be eating approximately 2.5 oz of formula. So if she is 10 lbs, that’s 25oz per day. Most kids top off at 32 oz; the general consensus is that anything between 16-32 oz per day is in the realm of “normal” (god, I hate that word). In terms of how often, most sites/experts advise every 2-4 hours in the beginning, with longer stretches at night as the baby grows. Again using our 10-pounder as an example, this might mean five 5-oz bottles per day. But some kids are snackers, so this could also mean feeding a baby every 2-3 hours with 2-oz bottles. Just depends on the kid.

Let’s assume you have the most textbook child on the planet, though; in this case, your best bet would probably be to distribute those 25 oz primarily in daytime hours, assuming the 10- pounder is at least 8 weeks old and can go longer stretches at night. You might do a 5oz bottle at 9am; 12pm, 3pm, 6pm, and then top him off with 3 oz around 9pm to help him go through the night, with probably another 2oz around 5am. Figure out the schedule that works best for your baby; my point is just that many kids will only be able to handle a specific amount at a time, and at certain times they may want more than others. Many breastfed babies do what is called “cluster feeding”, meaning they have numerous short nursing sessions all clumped together in a short time period. Formula fed babies can do this too (obviously), by drinking smaller amounts every hour or so. (If she usually takes a 4oz bottle every 3 hours, you can do a 3-oz bottle an hour before bedtime and then another 2 right before she goes down.) Some claim that this allows babies to sleep longer stretches at night; kind of the equivalent of carbo-loading before a marathon. I did find with both my kids that if they did some cluster feeding around bedtime, they slept better. Could have been a fluke though.

During growth spurts, you may find that your typical amount isn’t enough. I think that as long as you have spent time getting to know your baby’s hunger cues, you can feel pretty safe just feeding on demand. But also keep in mind that kids can get might ornery during these growth spurts, so it is possible that they will cry a lot and it won’t necessarily mean they are hungry. Do whatever it is you do to comfort them, and if it doesn’t work, let them eat. Babies don’t play mind-games: if something else is wrong, your baby will probably keep freaking out despite your sacrificial offering of Enfamil. If she’s hungry, she’ll eat and hopefully sleep… well, you know.

Like a baby.

Whatever the hell that means.

The FFF Quick-and-Dirty Guide to Formula Feeding: Mixing bottles

Hola, FFFs. And holla, because here is the quick-and-dirty guide to formula feeding I’ve been promising for ages! Actually, this is just Part One, but I will be posting new parts every so often until the entire guide is finished – at which point I will make it available via a tab on the right-hand side of the blog. Sound good?

I hope that this guide will offer some simple, accurate info for prospective (and current) formula feeders, without the subtle guilt-mongering prevalent in most formula feeding info. I figure the least we deserve is some evidence-based advice that doesn’t come via the formula companies.

Since many readers of this blog are experienced, educated formula feeders, I’m sure they will be able to elaborate on what I write in this guide. Be sure to read the comment threads, as I hope that there will be even more helpful hints and tips offered by the FFF community.

And as always, if you have any specific questions, please feel free to email me at formulafeeders@gmail.com and I will try and find the answer for you.

Happy formula feeding, lovely ones!

- The FFF

******************
The FFF Quick-and-Dirty Guide to Formula Feeding:
Mixing Bottles

Mixing up a bottle of powdered formula isn’t rocket science, but it can be trickier than one might assume. First, always read the back of the can, because brands vary – some say to use an unpacked level scoop, others require a “packed” scoop. It’s important to have the proper ratio of formula and water because the wrong ratios can lead to stomach upset, which might make you think your baby is “intolerant” of the formula you’re using, when really it’s just that you’ve been using too much powder.

Finished reading the directions on your can? Cool. On to the next steps – and please note that I’ve broken this down into two categories, for newborns and babies older than three months. More precautions are necessary when your baby is a fragile newborn, since even the most insignificant illness can have a big impact on a human that tiny.You’ll notice that the instructions for older babies are much shorter. Like everything else about parenting, as the kid gets older, things get easier. If you can afford it, for the first month, use Ready-to-Feed formula rather than powdered. It’s safer (no chance of contamination from water, and less chance of contamination from your hands as all you have to do is pour it into a bottle or, in the case of those little nurser bottles some companies make, attach a pre-sterilized nipple. Easy-peasy, but pricey, so this is really just a short-term solution – but well worth it in the early days when the last thing you want to be worrying about is mixing formula the wrong way at 3am.)

Mixing Formula for Newborns

  • Measure the water. In terms of water, if you are mixing formula for a baby under three months old, the water source is pretty important. This is because if the water is contaminated with any bacteria, your baby can get sick. You know all those “facts” you hear about how formula fed babies get more gastrointestinal diseases? Most likely, it’s the water and not the formula which is causing these problems. (By the way, I’m sure you don’t need me to tell you this, but always wash your hands before you open the can and before you make up any formula. Duh, right?) Your best bet is distilled, bottled water (not all bottled waters are purified enough to reduce the chance of bacteria, and the distilling process helps gets rid of the little buggers), or simply boil a batch of water on your stove, let it cool, and keep it in the fridge. As long as you live in a community with a good water source, you’ll be able to use tap water (or tap water that’s been run through a home filtering system like a Brita pitcher) when your baby is a bit older.Pour the same amount of water into the bottle that you want to make of formula. So for example, if you are making a 4-oz bottle, pour 4 oz of water into the bottle.

(A little note about the “nursery water” that they sell at many grocery stores – this is usually fortified with fluoride, which may or may not be a good thing. Check out this post for more info.)

  • Measure the formula. Again, check if you’re supposed to use an unpacked or packed level scoop. Always use the scoop that the formula company provides, because they vary. The ratio for all formulas is one scoop to 2 oz of water (the exception to this is prescription Neocate, which uses a ratio of one formula scoop to one oz – thanks to FFF Perfesser for alerting me to this), so if you are making a 4-oz bottled, you’ll use 2 scoops; a 6-oz bottle, 3 scoops, and so on. Now, if you want to make an odd number of oz, things get trickier. You can eyeball a half-scoop, but this is obviously not an exact science, and I wouldn’t recommend it for a newborn. Instead, I’d suggest making more formula than you need, and pouring the remainder into another bottle which you can refrigerate and use at the next feeding. So for example, to make a 3-oz bottle, just make 6 oz of formula (6 oz of water/3 scoops of formula), shake up the bottle, and then pour 3 oz into another clean bottle to save for later. Cap that extra bottle and stick it in the fridge, and serve the other 3 oz immediately to your baby. When the time comes for the next feeding, warm the refrigerated bottle to room temp, and serve.
  • Insert any rings/discs that your bottle needs (for example, Avent bottles have little circular rings that need to be inserted before putting on the nipple; Dr. Brown’s use a whole elaborate contraption, and Born Free use a two-part disc. Other bottles don’t need anything but the nipple. I’ll leave figuring out the particular mechanics of your bottle of choice to the manufacturer’s website, because those things confuse the hell out of me. Took me like 3 weeks to figure out how to get the Dr. Brown’s system to work…) and then attach the nipple.
  • Mix or shake. Once everything is attached correctly, cap the bottle (or just place your finger over the hole in the nipple) and shake it vigorously. Then place the bottle on a flat surface and let it settle before serving. Check the nipple to make sure there are no clumps of formula stuck up in there, because it happens. A lot. Your other option is to use a formula mixer. Some folks swear by the little hand-held ones; they are supposed to mix the formula more smoothly and prevent air bubbles from forming. Personally, they didn’t work for me; the formula seemed more clumpy than when I shook the bottles by hand. I preferred using a formula pitcher, or even a salad dressing mixer (a heck of a lot cheaper than the commercial formula pitchers, and they do the trick). With these, you mix batches of formula and then pour the desired amount into bottles. Now, some warn against using these, as it is recommended that you make each bottle separately right before feeding. This is done, once again, to protect against bacterial contamination. Bacteria breeds the longer it is left out, so the theory is that if you have formula lying around – even in the fridge – it gives the bacteria a chance to grow and multiply. But if you are using pre-boiled or distilled water refrigerate the formula immediately and use it within a few hours, your chance of this happening is pretty tiny. You can also be extra-cautious and mix only the amount of formula that you need in the pitcher. One more caveat to using a separate pitcher/mixer – make sure you clean it after every use. And I’ll say it again – duh, right?
  • Make sure you feed your baby the bottle within 2 hours of mixing it up, unless you refrigerate it for later use. I used to be skeptical of this rule, but I’ve recently changed my mind. Just to clarify (thank to FFF Becky05 for this one), if you refrigerate the bottle, it stays good for 24 hours. But at room temp, you need to use it within 120 minutes, and once your babe has put it’s mouth to the nipple, it’s only good for 2 hours regardless of whether you stick it back in the fridge (although I still stick to my original belief that for an older baby, nursing a bottle for a little longer than 2 hours probably won’t hurt him/her, with a newborn, it’s better safe than sorry.)

 

Mixing formula for an older baby (3+ months)

  • Pour the water. At this point, you can use whatever water you personally drink. Bottled or tap (as long as it is from a safe water source – check with your city’s health department if you’re not sure) or filtered.
  • Scoop the formula. If you’ve recently switched formulas, double check that you are using the right amount – packed or unpacked – and make sure to use the scooper provided by the manufacturer. A hint for those of you as absent-minded as me – don’t try and have a conversation while mixing formula. You may find you suddenly have no idea if you’ve put in two scoops or three, at which point the whole batch might be ruined. It sucks. Pay attention and count aloud when you’re doing it. Seriously… or you’ll be crying over (unusable) milk.
  • Shake or mix. As long as there isn’t formula clumped in the nipple, you’re good to go. If you are worried about air bubbles, or your baby has an issue with excess gas, you can add a few of those infant gas drops (like Mylicon) to each bottle. But there’s really no need unless your baby is particularly gassy or spits up a lot. You can also just mix up the formula 15 minutes or so before a feed and let it settle – this will allow the air bubbles to subside.
  • Feel free to mix the day’s amount of formula in a formula pitcher (or even just a 32-oz Tupperware container), refrigerate, and use within 24 hours. If you’re using thickened feeds for a reflux baby, this is a total lifesaver – you can mix your batch to your baby’s specifications and not have to measure everything out for each bottle.

A few other hints:

  • For night time feedings: pre-measure water into bottles. Buy a formula dispenser, and measure out your formula into the dispenser. Bring all the stuff into your bedroom or master bath, and when you need to feed your baby in the middle of the night, all you need to do is pour the formula from the dispenser into the bottle. No fumbling around or measuring half-asleep.
  • The formula dispenser is also a great tool for outings. They have 3 little compartments, so you can measure out the amount of scoops you need for each bottle; bring bottles filled with water, and this way you don’t need to bring a cooler or anything when you’re out and about.
  • These instructions make it look like formula feeding is a massive undertaking. I promise you, it’s not. But I also strongly believe that most of the “dangers” of formula that are so widely discussed are due to improper formula handling. The older babies get, the lower the risk for major problems with bacteria and dehydration, and you can get more lax about things. But most of this stuff becomes pretty rote, anyway. Using ready-to-feed formula takes a lot of the stress out in the beginning, and as things get more chill in general, the less scary everything becomes. Just like breastfeeding has a learning curve, there’s a learning curve with formula feeding. You’ll get good at it and figure out what works best for you. As long as you have safe water, clean bottles, and accurately measured formula, you’ll be fine.

 

   Suzanne Barston (me) on KidsInTheHouse.com:

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