By Suzanne Barston
This is not a post about breast versus bottle. This is not a post that is making any claims about the relative safety or efficacy of infant formula, nor is it a post that has anything to do with mommy wars, emotions, politics, or any other volatile subjects.
This is simply a post for those who find themselves supplementing or exclusively using infant formula, for whatever reason, not that your reason is any of my darn business.
Regardless of the reasons why (and again, I repeat: this is not a post about infant feeding politics), most parents are not given adequate instruction on how to formula feed safely. Many of us just measure out some powder from whatever brand gave us a free sample, shake the bottle, and hope for the best. And statistically, your baby will probably be fine even if the only formula feeding education you receive is from the back of the can. But no parent wants to play the statistics game, and you (and your child) deserve to know how to formula feed in the healthiest and most instinctual way. So, here are a few tips that will hopefully turn you from confused bottle shaker to confident, expert formula feeder.
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 usually just normal, milk-based formulas with added rice starch to help the liquid stay down; and organic baby formula versions, which typically use an organic milk source. (Not all ingredients in these formulas are necessarily organic, however, so make sure to read the labels carefully if that matters to you. Also note: Many parents rave about the Nature’s One formula, which is the only one to use brown rice syrup as a sweetener. They do not market their formula as an infant formula because they do not want to discourage breastfeeding, however it IS suitable for babies under 6 months. The company will verify this if you call them.)
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. You want to look for the words ‘partially hydrolyzed whey or casein” on the label – these are types of milk protein. If you have a family history of allergies or food intolerances, these might be a better choice for you. I also tend to recommend these for newborns simply because they are easier on their tiny GI systems. (Tip: You can always start on a partially-hydrolyzed formula and gradually switch to a “regular” formula after a few months, as long as your baby tolerates this).
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 within 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.
Homemade formulas have also started to gain popularity. The American Academy of Pediatrics and numerous other medical associations have warned against using these homemade concoctions, mostly because there is so much potential for human error. Bacterial contamination is the biggest concern with formula feeding in the developed world; this is why the World Health Organization and countries like Canada and Australia have urged parents to boil water before preparing formula (which we will get to in a second). If you’re mixing your own formula using animal milk (goat’s milk, often unpasteurized, is a popular base for homemade formula), there is ample opportunity for one of the ingredients to become contaminated. Not to mention that babies need a particular balance of fat, carbohydrate, sugar, and vitamins. It’s easy to understand why people don’t trust corporations, but you may want to consider seeking out donor milk before endeavoring to make your own formula, if you are dead-set against the commercial kind.
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.
How much should I be feeding my 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.
The best thing you can do is learn your baby’s 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. Newborns should always feed on demand, so learn the hunger cues, and feed as often as you need do. Just make a few ounces of formula at a time; you can always make more, and this way you won’t waste anything if your baby only takes a few sips and slips into one of those glorious newborn naps.
Unfortunately, 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. So as a basic guide, 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.
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 formula.
Mixology 101: How to Safely Prepare a Bottle
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. Please note: 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. 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.)
1. 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. (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?)
In recent years, the rules have changes a bit when it comes to formula water. Now, more and more health organizations are recommending that parents use boiled water instead of tap water. In some countries, they even recommend that you add the water while it’s still extremely hot to the powder, so that it kills any potential bacteria hiding in the bottle or the formula itself. Statistically, the chances that you will get a can of contaminated formula is very slim, and as long as you are using good sterilization and cleaning practices (cleaning all parts of your bottles and nipples thoroughly between uses with hot, soapy water, or better yet, running them through the dishwasher “sterilize” cycle ; making sure to sterilize them every evening during the newborn stage and every couple of days thereafter), I think this method can do more harm than good. The AAP hasn’t changed it’s advice on this one, yet, so for now, just boil whatever water you are using and let it cool. (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 with your pediatrician.)
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.
2. 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 most formulas is one scoop to 2 oz of water (there are exception to this, like prescription Neocate, which uses a ratio of one formula scoop to one –double check the instructions on your can), 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.
3. 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.
4. Shake it up. 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.
5. Feed your baby. Experts advise making 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.
Regardless, please make sure you feed your baby the bottle within 2 hours of mixing it up, unless you refrigerate it for later use. To clarify – 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.
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. As time goes one, you’ll get good at it – and feeding time will become a time full of love and connection, rather than feeling like a high school science experiment.