Category: 6. Formula Feeding

​Many parents ask why they can’t feed their baby regular cow’s milk instead of breastmilk or formula. There are two main reasons: Infants cannot digest cow’s milk as completely or easily as they digest breastmilk or baby formula. And, more importantly, cow’s milk does not contain enough of certain nutrients that babies under a year old need.
During the current baby formula shortage, it may be OK for some babies over 6 months of age to have cow’s milk for a short period of time if no formula is available. If you aren’t able to find baby formula in stock anywhere, talk with your pediatrician.

Beyond digestion

Cow’s milk contains high concentrations of protein and minerals, which can stress a newborn’s immature kidneys and cause severe illness at times of heat stress, fever, or diarrhea. In addition, cow’s milk lacks the proper amounts of iron, vitamin C, and other nutrients that infants need. It may even cause iron-deficiency anemia in some babies, since cow’s milk protein can irritate the lining of the stomach and intestine, leading to loss of blood in the stools. Cow’s milk also does not contain the healthiest types of fat for growing babies. For these reasons, your baby should not receive any cow’s milk (or other non-human milk or milk substitute) until they are about 12 months of age unless no alternative is available.

Once your baby turns a year old

Once your baby is past one year old, you may give them pasteurized whole cow’s milk or reduced-fat (2%) milk, provided they have a balanced diet of solid foods (cereals, vegetables, fruits and meats). But limit their intake of milk to 2 cups (about 16 ounces) per day or less. More than 24 ounces a day has been associated with iron deficiency if toddlers aren’t getting enough other healthy iron-rich foods. If your baby is not yet eating a broad range of solid foods, talk to your pediatrician about the best nutrition for them.

At this age, children still need a higher fat content, which is why whole vitamin D-fortified milk is recommended for most infants after one year of age. If your child is or is at risk for overweight, or if there is a family history of obesity, high blood pressure or heart disease, your pediatrician may recommend 2% (reduced-fat) milk.

Age 2 and up

Do not give your baby 1% (low-fat) or nonfat (skimmed) milk before their second birthday, as it does not contain enough fat for brain development. After two years of age, you should discuss your child’s nutritional needs with your pediatrician. However, many children at this age can transition to lower-fat milk if that is what your family uses.

“Probiotics” (meaning “for life”) is a word you may see when shopping for infant formula and supplements. Some formulas are fortified with these probiotics, which are types of live bacteria. Doctors may also recommend probiotic drops or powders for breastfed infants. These are “good” or “friendly” bacteria already present at high levels in the digestive system of breastfed babies.

In formula-fed babies, probiotics in formulas promote a balance of bacteria in your baby’s intestines, and offset the growth of “unfriendly” organisms that could cause infections and inflammation.

Increasingly, parents can find probiotic supplements outside of formula, including for breastfed infants. Research on the benefits of probiotics is ongoing, with some pediatricians embracing their use for infants delivered by C-section or those whose mothers are given antibiotics during labor.

Possible health benefits of probiotics

The most common types of probiotics are strains of bifidobacteria and lactobacilli. Some research has shown these probiotics may prevent or treat disorders such as infectious diarrhea​ and atopic dermatitis (eczema) in children. Other possible health benefits are being studied as well, including the possibility of reduced risk of food-related allergies and asthma, prevention of urinary tract infections, and relief of symptoms of infant colic​.

More research is needed

With many of these health conditions, the evidence confirming any positive effects of probiotic use is limited and more research is needed. At this time, benefits appear to occur only as long as probiotics are being taken. Once your baby stops consuming probiotic-fortified formula, intestinal bacteria levels return to previous levels. This is different from in breastfed infants, where the bacteria in the gut resulting from breastfeeding​ are more resilient and set the stage for healthier outcomes. 

Remember

Before giving your child infant formula fortified with probiotics, discuss the issue with your pediatrician

Infants need a specific balance of nutrients—not too much or too little of anything—to grow and be healthy. Human breastmilk contains everything in exactly the right amounts, and infant formula can provide excellent nutrition when families can’t or choose not to breastfeed. But, keep in mind:

It’s important for your baby’s health to stick with products that meet federal standards, prepared according to directions on the label.

Risks of homemade baby formula recipes

Although recipes for homemade formulas circulating on the internet may seem healthy, less expensive or an answer to the baby formula shortage, they are risky. Homemade formula may not be safe or meet your baby’s nutritional needs. The U.S. Food & Drug Administration (FDA) reports that some babies fed homemade formula have been hospitalized for hypocalcemia (low calcium), for example.

Some formula-feeding tips from the American Academy of Pediatrics:If you feed your baby formula, make sure to always:Choose a formula product that has been reviewed by and meets FDA minimum nutritional and safety requirementsPrepare it according to directions on the label, unless you are given different instructions by your pediatrician because of a special medical need your baby has.What’s important NOT to do:Do not make a homemade formula from ingredients at the store, such as powdered cow milk or raw milk and sugar.Do not feed your infant under 1 year old cow milk or other milk substitutes from the dairy section of the grocery store, such as almond or soy beverages (sometimes labeled as milk).Do not use imported formulas from other countries that are not reviewed by the FDA.Do not water down formulas by adding more water when mixing powdered formula or adding extra water to ready-to-serve, non-concentrated liquid formula.

Why can’t I make my own formula or use regular milk or milk substitutes from the dairy aisle?

Although feeding babies regular milk or making homemade formula was common decades ago, it is not a safe or recommended practice. In the United States, laws and other government rules make sure that all infant formula sold in stores meets very strict rules about their ingredients, to make sure it supports healthy growth and development.

The FDA also oversees how approved formulas are made and stored. The government inspects both the formulas and the manufacturing facilities regularly to be sure the rules are followed to avoid contamination and spoilage.

Formula mixtures made from online or other resources may not have vital components, such as enough iron or vitamins for a baby. Or, they may have too much salt or other nutrients that your baby’s kidneys and liver cannot handle in large amounts.

In addition, regular dairy products like cow milk or alternatives such as soy, hemp, or almond milk are not designed with the right amount of very important nutrition sources including protein, iron, calcium, and vitamins that a baby needs. Even if it seems like they have enough from the label, the chemical forms of the nutrition may not be easily absorbed by the baby’s body. Or, certain ingredients may affect each other (such as calcium and phosphorus) in ways that is not ideal for things like bone growth.

Why are a baby’s nutritional needs so specific?

The first year of life is a key time for your baby’s brain and body to grow. If your baby doesn’t get enough of the important parts of infant formula—even for a few days or weeks—they can suffer long-term effects on their abilities grow strong and do well in school. Lack of these nutrients can lead to severe health problems and even death. Homemade formulas may also lead to risks of contamination, causing infections or may even cause serious problems with high or low levels of minerals like calcium or electrolytes such as sodium.

The chemicals on the infant formula label seem scary. How do I know these are safe for my baby?

The label lists the names for specific chemical forms of ingredients like calcium and iron. These are forms considered safe to feed a baby. Every formula that is reviewed by the FDA has been shown to lead to good infant growth.

Is it OK to buy formulas online that are imported from other countries and supposedly better for babies?

No. These formulas have not gone through FDA review and are not always safely shipped or stored correctly. They are often very expensive and do not offer any benefits for babies that have been shown in research. Despite what you might read or see online, there is no scientific evidence that imported formulas are better for babies than what is on your grocery shelf in the formula aisle.

Can I stretch the formula by adding a bit more water than the instructions say?

No. Although this might seem like a harmless way to help save money, FDA-approved infant formula is designed for just the correct amount of nutrition as described by the label. Adding extra water decreases and dilutes the nutrients and may cause serious growth problems or imbalances in vital nutrients like salt that can lead to serious health problems.

Can you use toddler formula for babies under 12 months old?

No, this is not a good idea, because the nutritional needs of a small infant is not the same as it is for a toddler. Also, toddler formula doesn’t have to be FDA reviewed like infant formulas is. Look at the label on the formula and make sure it says that it is designed for infants. If you have any questions, ask your pharmacist or pediatrician to help you make sure that you are choosing the best formula for your baby.

What should I do if I can’t afford formula?

• Special Supplemental Nutrition Program for Women, Infants and Children (WIC): Mothers who qualify based on income can enroll in WIC to receive vouchers for formula.
• Supplemental Nutrition Assistance Program (SNAP): You can use your SNAP Electronic Benefits Transfer card (formerly called food stamps) to buy formula. If you are enrolled in WIC, you also might qualify for SNAP.
• Temporary Assistance for Needy Families (TANF): This program offers temporary cash assistance to qualified families.

Where can I get help if I do not qualify for benefits?

• Feeding America is a nonprofit network of 200 food banks. Many provide free baby food, infant formula, diapers and other supplies.
• Dial 2-1-1 to be connected to a community resource specialist who can help you find local resources. The number can be dialed from almost anywhere in the U.S. 

Parents and pediatricians today are not as concerned with sterilizing bottles and water as they were a generation ago, but many are now having second thoughts in light of recent reports of contaminated city water supplies and increased concern over food safety.

• For starters, always wash your hands before handling baby bottles or feeding your baby.
• If you use disposable plastic bottle liners and ready-to-use formula, you still need to make sure the nipples are clean. Scrub them in hot, soapy water, then rinse to get rid of all traces of soap; some experts recommend boiling them for 5 minutes.
• Always wash and thoroughly rinse and dry the top of the formula can before you open it; make sure the can opener, mixing cups, jars, spoons, and other equipment are clean.

Glass Bottles & Formula Safety

If you use regular glass bottles and concentrated or powdered formula, you must make sure that the bottles and water added to the formula are germ free. You don’t need to boil the bottles; you can put them, along with mixing cups and other equipment used to prepare formula, in a dishwasher that uses heated water and has a hot drying cycle. Or you can wash the bottles in hot, soapy water and rinse thoroughly. This alone should kill most germs.

Mixing with Water 

Water for mixing infant formula must be from a safe water source as defined by the state or local health department. If you are concerned or uncertain about the safety of tap water, you may use bottled water or bring cold tap water to a rolling boil for 1 minute (no longer), then cool the water to room temperature for no more than 30 minutes before it is used. Warmed water should be tested in advance to make sure it is not too hot for the baby. The easiest way to test the temperature is to shake a few drops on the inside of your wrist. Otherwise, a bottle can be prepared by adding powdered formula and room-temperature water from the tap just before feeding. Bottles made in this way from powdered formula can be ready for feeding because no additional refrigeration or warming would be required.

Storing Prepared Formula

• Prepared formula must be discarded within 1 hour after serving a baby.
• Prepared formula that has not been given to a baby may be stored in the refrigerator for 24 hours to prevent bacterial contamination.
• An open container of ready-to-feed, concentrated formula, or formula prepared from concentrated formula, should be covered, refrigerated, and discarded after 48 hours if not used.

Infant formula comes in three forms: powder formula, concentrated liquid formula and ready-to-feed (non-concentrated) formula. If you use infant formula for your baby, no matter which form, be sure to follow directions closely. Formula that is diluted with too much water, for example, can cause serious health and development problems for your baby. It’s also important to use clean water for a safe source free of bacteria or other microorganisms that may cause disease, and low in certain minerals and contaminants that may be harmful. Read on to learn more.

When to add water & how much to use

Non-concentrated, ready-to-feed formula

Do not add any water non-concentrated, ready-to-feed formula. Remember, diluting it can be dangerous for your child (see below).

Concentrated liquid formula & powder formula

Use water to prepare concentrated liquid formula and powder formula, but only as directed. Use a safe water source as defined by your state or local government. Unless there is a known contamination of your local water source, you can use tap water to prepare concentrated liquid or powdered formula. In general, though, it is best to primarily use safe tap water that is fluoridated and occasionally use some non-fluoridated bottled water.

Why watering down formula is dangerous

News reports have found parents diluting formula to try and save money or feeding water in addition to breast milk or formula. This can lead to a dangerous condition called water intoxication.

Babies in the first 6 months after birth do not need water or other liquids such as juices in addition to formula or breast milk, unless specifically advised by a pediatrician. Adding extra water to formula or giving juices reduces the about of nutrients baby will receive. This can slow growth and development. Extra water also disturbs electrolyte and mineral balances such as calcium, sodium and potassium which can lead to major health problems including seizures. So always mix formula as directed by the manufacturer unless specifically guided to change these instructions for infants with special health needs.

If you’re using formula but having trouble affording it check with your pediatrician, local health department, food pantry or social service agency.

How to mix powder formula & water to prepare a bottle

The Center for Disease Control and Prevention (CDC) provides detailed instruction on preparing infant formula. Also look for instructions on the formula can labels, and from other reliable sources including state WIC agencies. There are a few key points to remember:

1. Water first, then powder. Always add the powder to the water that is in the bottle, not the other way around.
2. Boil the water when needed. For infants under 3 months of age, those who were born prematurely and those who have a weakened immune system, hot water should be used to prepare formula to kill any microbes. To do this, boil the water and let it cool for about 5 minutes. Then, add it to a clean bottle and add the formula based on the instructions on the container.
3. Cool formula to body temperature. If you are going to use the formula you prepared immediately, be sure to cool the formula to body temperature before feeding your baby. Run the prepared, capped bottle under cool water or place it into an ice bath.
4. Test the formula temperature to make sure it is not too hot before feeding it to your baby (see below).

How to test the temperature of you baby’s bottle

Test warmed water in advance to make sure it is not too hot for your baby. The easiest way to test the temperature is to shake a few drops on the inside of your wrist. Otherwise, a bottle can be prepared by adding powdered formula and room temperature water from the tap just before feeding. Bottles made in this way from powdered formula can be ready for feeding, as no additional refrigeration or warming would be needed.

How long is the bottle of formula good for after making it?

• Prepared formula must be discarded within 1 hour after feeding it from the bottle to your baby.
• Prepared formula that has not been fed to your baby may be stored in the refrigerator for 24 hours to prevent bacterial contamination.
• An open container of ready-to-feed formula, concentrated formula, or formula prepared from concentrated liquid formula, should be covered, refrigerated and discarded after 48 hours if not used.

Buying formula is a significant expense of parenthood. If you are so inclined, here is a little list of ways you might save a bit along the way.

• Do the math. We realize that it’s not always easy, fun, or feasible, but it can be quite worthwhile to take the time and figure out how much you’re paying per ounce. You may be surprised by what you find by comparing prices between brands as well as by comparing types and sizes. Once you’ve looked at the label and figured out how many total prepared ounces you’ll be getting in any given can or container, divide the price by the total number of prepared ounces. Depending on the retailer, the price per ounce may already be calculated and listed for your convenience right next to the total price posted on the display shelf.
• Stock up. To do this, you’ll first want to make sure that your baby is perfectly content with the formula he’s getting. Then take advantage of any sales and coupons you may spot along the way. You’ll want to remember to check the expiration date printed on the cans before stocking up. While many will have expiration dates well more than a year, you won’t want to get stuck with a bunch of cans whose time will be up before you can use them. 
• Save receipts. Early on it’s more difficult to know for sure that the formula you buy now is going to be the formula you buy forever after (i.e., through the end of the first year). While you’re still settling in over the next several weeks, we suggest tucking your receipts–for formula and all your other new-baby purchases–away somewhere for safekeeping and easy retrieval.

Infant formulas generally come as ready-to-feed liquid, concentrated liquid and powder. Which type is going to work best for you is likely to depend on how much formula you plan to use, where you plan to use it and how much you want to spend.

Start thinking in ounces

Bottle-feeding your baby will require you to think in ounces and adopt it as your standard unit of measurement.

Here are the basic measurements you’ll need for formula success:

• 1 ounce = 30 cc (cubic centimeters) = 30 mL (milliliters)
• 8 fluid ounces = 1 cup
• 32 fluid ounces = 1 quart

Formula prep by form

• Powder. The simple concept here is that you add powder to premeasured water and shake a lot. In what we can only assume was an enlightened attempt to eliminate room for mixing errors, most powdered formula is mixed according to the same recipe: 1 scoop of powder to every 2 fluid ounces of water. Powdered formula comes in cans containing enough powder to make anywhere from 90 ounces to more than 200 ounces of prepared formula. It is certainly your most economical choice, and quite frankly works perfectly well for most babies. You can decide whether to mix it up as you go or prepare a full day’s worth at a time and refrigerate it for up to 24 hours.
• Liquid concentrate. This is the “just add water as directed and shake” formula option. Mixing and measuring is again quite straightforward, because all brands of concentrate call for equal amounts of water and concentrate. If you intend to end up with a total of 4 fluid ounces of prepared formula, you’ll need to mix 2 fluid ounces of concentrate with 2 fluid ounces of water. Of course, many people choose to mix an entire can of concentrate (13 fluid ounces) with an equal amount of water. The resulting 26 fluid ounces of now-ready-to-feed formula can be covered and put in the refrigerator to be used over the next 48 hours. While some parents find concentrate to be easier, neater, and/or more convenient than powder, it is a convenience for which you will pay more.
• Ready-to-feed. This is your no-mixing, no-measuring, no-mess option. Typically sold in 2-,6-or 8-fluid-ounce containers (with anywhere from 4 to 24 to a pack) or 1-quart (32-fluid-ounce) containers/cans, the use of ready-to-feed formula is hopefully self-explanatory—what you see is what you give. While the fairly small “Ready-to-Feed” caption isn’t always prominently displayed on the label, you’d be hard pressed to miss the distinguishing price tag. While buying ready-to-feed formula inevitably costs the most, it leaves almost no room for error (assuming you don’t mistake it for concentrate and dilute it with water). Unopened ready-to-feed formula can be conveniently stored at room temperature. Once opened, unused portions can be covered and then refrigerated for up to 48 hours.

To maintain safety standards, U.S. law and the Food and Drug Administration (FDA) govern the contents and safe production and distribution of all infant formulas.

When shopping for infant formula, you’ll find several basic types.

Cow’s milk–based baby formulas

Cow’s milk–based formulas account for about 80% of the formula sold. Although cow’s milk is the basis for such formulas, the milk has been changed dramatically to make it safe for infants. It is treated by heating and other methods to make the protein more digestible. More milk sugar (lactose) is added to make the concentration equal to that found in breast milk, and the butterfat is removed and replaced with vegetable oils and other fats that infants can more easily digest and are better for infant growth.

Iron-fortified baby formula

Cow’s milk-based baby formulas have additional iron added. These iron-fortified formulas have dramatically reduced the rate of iron-deficiency anemia in infancy in recent decades.

Some infants do not have enough natural reserves of iron, a mineral necessary for normal human growth and development. For that reason, the American Academy of Pediatrics (AAP) currently recommends that iron-fortified formula be used for all infants who are not breastfed, or who are only partially breastfed, from birth to one year of age.

Additional iron is available in many foods (including baby food), especially in meats, egg yolks, and iron-fortified cereals. Low-iron formulas should not be used. Some mothers worry about iron causing constipation, but the amount of iron in infant formula does not contribute to constipation. Most formulas also have docosahexaenoic acid (DHA) and arachidonic acid (ARA) added to them, fatty acids, believed to be important for the development of a baby’s brain and eyes.

Probiotics

Some formulas also are fortified with probiotics, which are types of “friendly” bacteria. Others are now fortified with prebiotics, in the form of manufactured oligosaccharides, in an attempt to mimic the natural human milk oligosaccharides, which are substances that promote healthy intestinal lining.

Extensively hydrolyzed baby formula

Another type of formula is extensively hydrolyzed formula, which often is called “predigested,” since the protein content has already been broken down into smaller proteins that can be digested more easily. Ask your pediatrician to recommend a brand of hypoallergenic formula if one is needed for allergies or other conditions. However, these extensively hydrolyzed formulas tend to be costlier than regular formulas.

Soy formulas for babies

Soy formulas contain a protein (soy) and carbohydrate (either glucose or sucrose) different from milk-based formulas. They are sometimes recommended for babies unable to digest lactose, the main carbohydrate in cow’s milk formula, although simple lactose-free cow milk–based formula is also available.

Lactose intolerance

Many infants have brief periods when they cannot digest lactose, particularly following bouts of diarrhea, which can damage the digestive enzymes in the lining of the intestines. But this is usually only a temporary problem and does not require a change in your baby’s diet. It is extremely rare for babies to have a significant problem digesting and absorbing lactose (although it tends to occur in older children and adults). While lactose-free formulas are fine sources of nutrition, check with your pediatrician before starting your baby on a lactose-free formula, since whatever problem they may be having is likely due to something else.

Milk allergy

With a true milk allergy causing colic, failure to thrive, and even bloody diarrhea, the allergy is to the protein in the cow’s milk formula. In this case soy formulas may seem like a good alternative. However, up to half the infants who have milk allergy are also sensitive to soy protein, and thus must be given specialized formula (such as amino-based or elemental) or breast milk.

Vegetarian & vegan concerns

Some strict vegetarian and vegan parents choose to use soy formula because it contains no animal products. Remember that breastfeeding is the best option for vegetarian families. And while some parents believe a soy formula might prevent or ease the symptoms of colic or fussiness, there is no evidence to support this.

Galactosemia

The AAP believes that there are few circumstances in which soy formula should be chosen instead of cow’s milk–based formula. However, one of these situations is in infants with a rare disorder called galactosemia; children with this condition have an intolerance to galactose, one of the two sugars in lactose. These babies cannot tolerate breast milk and must be fed a lactose-free formula. All states include a test for galactosemia in routine newborn screening after birth.

Specialized baby formulas

There are specialized formulas for infants with specific disorders or diseases, including for premature babies. If your pediatrician recommends a specialized formula for your infant, follow their guidance about feeding requirements (amounts, scheduling, special preparations), since these may be quite different from regular formulas.

• ​In the first week after birth, babies should be eating no more than about 1 to 2 ounces (30 to 60 ml) per feed.
  
• During the first month, babies gradually eat more until they take 3 to 4 ounces (90 to 120 ml) per feed, amounting to 32 ounces per day. Formula-fed babies typically feed on a more regular schedule, such as every 3 or 4 hours. Breastfed babies usually take smaller, more frequent feedings than formula-fed infants.

If your baby sleeps longer than 4 to 5 hours during the first few weeks after birth and starts missing feedings, wake them up and offer a bottle.

• By the end of the first month: Your baby will be up to at least 3 to 4 ounces (120 mL) per feeding, with a fairly predictable schedule of feedings about every 3 to 4 hours.
• By 6 months: Your baby will consume 6 to 8 ounces (180–240 mL) at each of 4 or 5 feedings in 24 hours.

Formula feeding based on body weight

On average, your baby should take in about 2½ ounces (75 mL) of infant formula a day for every pound (453 g) of body weight. But they probably will regulate their intake from day to day to meet their own specific needs, so let them tell you when they’ve had enough. If they become fidgety or easily distracted during a feeding, they’re probably finished. If they drain the bottle and continues smacking their lips, they might still be hungry.

There are high and low limits, however. If your baby consistently seems to want more or less than this, discuss it with your pediatrician. Your baby should usually drink no more than an average of about 32 ounces (960 mL) of formula in 24 hours. Some babies have higher needs for sucking and may just want to suck on a pacifier after feeding.

On-demand feeding

Initially it is best to feed your formula-fed newborn a bottle on demand, or whenever they cry with hunger. As time passes, your baby will begin to develop a fairly regular timetable of their own. As you become familiar with their signals and needs, you’ll be able to schedule their feedings around their routine.

Eating & sleeping patterns

Between 2 and 4 months of age (or when the baby weighs more than 12 lb. [5.4 kg]), most formula-fed babies no longer need a middle-of-the-night feedings. They’re consuming more during the day, and their sleeping patterns have become more regular (although this varies considerably from baby to baby). Their stomach capacity has increased, too, which means they may go longer between daytime feedings—occasionally up to 4 or 5 hours at a time.

If your baby still seems to feed very frequently or consume larger amounts, try distracting them with play or with a pacifier. Sometimes patterns of obesity begin during infancy, so it is important not to overfeed your baby.

Getting to know your baby’s feeding needs

The most important thing to remember, whether you breastfeed or bottlefeed, is that your baby’s feeding needs are unique. No book―or website―can tell you precisely how much or how often they need to be fed or exactly how you should handle them during feedings. You will discover these things for yourself as you and your baby get to know each other.

When needed, infant formulas can provide excellent nutrition for your baby. But with so many commercially prepared infant formulas available, it’s easy for new parents to quickly become overwhelmed. In this series of articles, learn more about what to look for in a baby formula, and most importantly, how to prepare and store your baby’s formula safely.