Bottle Feeding With Safety and Love - Part One

While human milk is certainly best for human babies, there may be a medical reason for needing to feed your baby formula. Or perhaps your life-style required you to both breast- and bottle feed your baby, dubbed "combo feeding." If you regard feeding as a time to interact with your baby, not just deliver food, and if you understand the subtle differences among formulas, together with your baby's doctor you can, using the following information, make the right choice of the right formula and style of feeding for your baby.

Formula Facts
The more you know about how infant formulas are made and marketed, the better equipped you will be to make an informed choice.

How formulas are made.
Using human milk as the nutritional gold standard, formula manufacturers follow a basic recipe that combines proteins, fats, carbohydrates, vitamins, minerals, and water in similar proportions to those found in human milk. The basic nutritional building blocks of proteins, fats, and carbohydrates are taken from cow's milk, soybeans, or other vegetable (corn syrup or sugar cane) sources. Commercially made vitamins, minerals, and other nutrients are then added to the milk-based or soy-based formula.

How formulas are marketed.
Once upon a time parents relied only on their baby's doctor to choose the right formula. It was generally felt that advertising infant formulas directly to the consumer was unethical. Both the American Academy of Pediatrics and the World Health Organization have strongly discouraged marketing formulas directly to parents and bypassing the baby's health care provider. Unfortunately, this nutritional code of ethics is not followed by all formula companies.

How formulas are regulated.
Don't be confused by the parade of formula cans on the supermarket shelves. You'll notice that the amounts of all the nutrients in each brand are about the same. That's because by law they have to be. The Infant Formula Act mandates that the FDA tightly regulate infant formula manufacturers so that all formulas contain all the nutrients that babies need. In fact, the FDA so tightly regulates infant formulas that all formulas are nutritionally equivalent. A formula manufacturer cannot make any nutritional changes in their formula without FDA approval.

How formulas differ.
Although the nutritional content of infant formulas is tightly regulated, formulas differ in three ways: packaging, digestibility, and cost.

Packaging: Commercial formulas are packaged in three forms:
* powdered formula, with directions for how much water to add
* liquid concentrate, to be mixed half-and-half with water.
* ready-to-feed liquid, to be put directly into the bottle

Your choice of packaging is mainly a question of time and economics. Powdered formulas are the least expensive but the most time-consuming to prepare; ready-to-feed formulas are the most expensive but the easiest to use, especially while traveling or when you are too busy to prepare formula.

Digestibility: With different food sources and processing methods, formulas can be more or less allergenic and easier or harder to digest. While all formula makers claim superiority when it comes to intestinal tolerance, your baby's individual digestive system will be the final judge.

Cost: Because the FDA so tightly regulates formula composition, parents don't need to worry that a less expensive formula is nutritionally inferior to a pricier one. Formulas from the "big four" (Enfamil, Similac, Carnation, and store brands) are nutritionally equivalent, though they may differ in cost. If your baby needs a special hypoallergenic formula, expect to pay considerably more.

Types of Formula
Reading the labels on formula cans may leave you feeling like you need a Ph.D. in biochemistry to make an intelligent choice. There are three basic, categories of infant formulas: milk-based formulas (also known as standard infant formulas), soy-based formulas, and hypoallergenic formulas.

Milk-Based Formulas.
These formulas use cow's milk as the food source of the protein and sugar (lactose). Cow's milk-based formulas enjoy a much longer history of experience and research and are well tolerated by most infants. Unless recommended otherwise by your baby's doctor, use a standard milk-based formula. Around 70 percent of formula-fed American babies consume this type of formula.

Soy-Based Formulas.
As an alternative for infants who are allergic to or cannot tolerate milk-based formulas, soy formulas use soy-beans as their protein source. Around 25 percent of formula-fed American babies consume some form of soy formula because it is touted to be less allergenic than milk-based formulas. However, the opinion of the Committee on Nutrition of the American Academy of Pediatrics that soy formulas should not be used as the starter formula for most infants for the following reasons:

* 30-50 percent of infants who are allergic to cow's milk protein are also allergic to soy protein.

* Where there is a family history of allergies, formula-feeding parents are sometimes advised to begin feeding their baby a soy formula in hopes of preventing later allergies. Research does not support this practice. Starting a newborn on a soy formula does not decrease the later incidence of allergy. Nor does the use of soy formula lower the risk of infant colic. For these reasons, the American Academy of Pediatrics' Committee on Nutrition recommends against the use of soy-protein formulas in the routine management of colic or routinely in potentially allergic infants. Instead of soy, hypoallergenic formulas (see below) are recommended.

* Giving an infant soy at a young age, when the intestines are more permeable to allergens, may predispose the child to soy allergies later on, even as an adult. He may then find himself unable to tolerate many foods, since soy is present in a wide range of foods, often as a hidden filler.

* The wisdom of using lactose-free formulas, as most soy formula labels now boast, is questionable. Lactose is the sugar in human milk, as it is in the milk of all other mammals. Why tamper with nature's oldest nutritional experiment? Lactose enhances calcium absorption and helps colonize babies' intestines with favorable bacteria. The substitute sugar in some soy formulas is corn syrup, itself a potential allergen.

* Most soy formulas contain more minerals than the infant needs -- adding extra work for little kidneys and possibly shaping tiny tastes to prefer salty foods.

* The bioavailability of the added iron and zinc in soy formulas may be less than in other formulas.

* The Committee on Nutrition of the American Academy of Pediatrics recommends that soy formula be reserved for term infants only and that it not e used for preterm or small-for-date infants.

At present, soy formula is used for:

* Infants who are lactose deficient, a digestive problem which is uncommon in babies, or who have a rare disease in which they cannot metabolize lactose.

* Some infants who are intolerant of cow's milk-based formula.

If you believe your babe is allergic to cow's milk formulas, always consult your physician before switching to a soy formula.

Hypoallergenic Formulas.
The terms "hypoallergenic" and "hydrolyzed protein" on the formula label mean that the potentially allergenic protein has been predigested, tha6t is, broken up into tinier proteins that are theoretically less allergenic. Infants who are allergic to protein in milk-based formulas may better tolerate these formulas -- but at a price. The proven hypoallergenic formulas (Nutramigen, Pregestimil, Alimentum, and Neocate) are more expensive. Another disadvantage in some of these formulas is the absence of lactose as a carbohydrate source and the substitution of corn syrup and modified cornstarch. A third problem is their unpalatable taste.

Choosing a Formula
You're staring at the dazzling array of formula choices on the supermarket shelves, understandably confused by which formula to choose. Here's how to make the right choice for your baby:

* Consult your baby's doctor before selecting a formula for your baby. If you have a formula preference based upon experience with a previous formula-fed baby, share it with your doctor.

* Begin your baby on a milk-based formula unless advised otherwise by your doctor. If your doctor gives you a choice of several formulas, purchase a small amount of each or ask for a sample of each. Try each formula o see which one is best tolerated and most eagerly accepted by your baby.

* If one of your children was allergic to milk-based formula, don't assume subsequent children are also allergic to it. Try a milk-based formula first.

* Use an iron-fortified formula unless your doctor advises otherwise. Formulas that are labeled "low iron" contain insufficient iron, and there is no reason to use them. Iron-fortified formulas contain the amount of iron recommended by the American Academy of Pediatrics and other organizations. Because the iron in formula is not absorbed as much as the iron in breast milk, expect your formula-fed infant's stools to be greenish (since iron is green). In this case, green stools are of no significance. Some parents feel that iron-fortified formulas upset their baby more than formulas without iron, but controlled studies comparing formulas with and without added iron showed no difference in gastrointestinal upsets.

* Choose a DHA- and ARA (or AA)-enriched formula. Beginning in February 2002, docosahexaenoic acid (DHA) and arachidonic acid (ARA), the brain-building fats that are found in breast milk, were added to some infant formulas made in the United States. These fats, which are so important for optimal development of the central nervous system, have for many years been added to infant formulas in over sixty other countries. Multiple studies have shown that infants fed a DHA- and ARA-enriched infant formula enjoyed increased visual and central nervous system development compared with infants fed a formula without these added fats. Since many researchers attribute the intellectual advantage that breastfeeding babies enjoy to the fact that breast milk contains lots of these omega-3 fats, it stands to reason that formula-fed infants should receive DHA- and ARA-enriched formula. Look for "DHA/ARA-enriched," or a similar notice, on the label.

Comparison Between Human Milk and Formula
Fat: Provides calories for growth, needed for brain development
Human milk:
* High in cholesterol (used for building nerve tissue)
* Contains the brain-building omea-3 fatty acids DHA and ARA
* Easily digested because human milk contains the enzyme lipase
* Level changes during feeding in response to baby's sucking; levels declines as baby gets older
Infant formula:
* No cholesterol; contains vegetable fat
* Some brands now include DHA and ARA
* No lipase; fat not completely absorbed -- fat ends up in baby's stools
* Fat level remains constant during feeding, doesn't adjust to infants changing needs
Comment:
A growing body of evidence shows that longer periods of breastfeeding may protect against high blood pressure and high cholesterol in later childhood and adulthood. High cholesterol levels in human milk may prepare infants to handle cholesterol better after weaning. The better intellectual skills observed in breastfed infants may be attributed to DHA and other fatty acids in human milk, which contribute to brain development.

Protein: Provides amino acids for tissue growth; other proteins have special functions.
Human Milk:
* Contains mainly why protein, which is easy to digest
* Non-allergenic; babies aren't allergic to human milk protein
* Some proteins help baby fight infection; see "Immune Factor," below
* Contains the ideal balance of types of amino acids for brain growth, tissue development, and body building
* Contains sleep-inducing proteins
Infant formula:
* Many contain mostly casein protein, which forms a rubbery curd in baby's tummy
* Protein comes from cow's milk and may cause allergies; soy formulas may also cause allergies
* Offers no special immune protection
* Higher levels of protein are hard on baby's kidneys
* Amino acid profile, which is different from human milk's, may affect tissue development
* Does not contain as many sleep-inducing proteins
Comment:
Formula has more protein than human milk, but more is not always a good thing.

Carbohydrates: Needed for brain development; sweet flavor that infants love
Human Milk:
* Rich in lactose
* High levels of lactose promote the growth of lactobacillus bifidus in the infant gut, responsible for better-smelling stools and resistance to gastrointestinal infections.
Infant formula:
* Because cow's milk does not contain as much lactose as human milk, lactose and corn syrup are added to infant formula
* Less gut-friendly
Comment:
Animal species with bigger brains have more lactose in their milk.

Vitamins and Minerals: Needed for growth and physiologic processes
Human Milk:
* High levels of bioavailability, especially for zinc, calcium, and iron
* 50-75 percent of the iron in human milk is used by baby
* The right balance of different vitamins and minerals ensures that all are well absorbed
Infant formula:
* Extra amounts of vitamins and minerals are added to formula to compensate for poor absorption
* Iron-fortified formula contains either levels of iron, but only 5-10 percent is absorbed by baby
* The complexities of how vitamins and minerals in human milk work together are not completely understood; infant formula may not contain the right balance of these nutrients.
Comment:
Vitamin and mineral levels in infant formula are based on those in human milk, with an added margin of safety. Infant formula may contain more of many vitamins and minerals, but they may not be as available to baby as they are in human milk, Too much of one nutrient may make it harder for baby to use another nutrient.

Immune Factors: Protect baby from infection until his own immune system matures
Human Milk:
* Living white blood cells in human milk destroy bacteria in baby's intestines
* Immunoglobulin's protect baby against specific germs in the environment; other immunoglobulin's line baby's digestive tract and prevent foreign proteins from getting through and causing allergies
* Lactoferrin, lysozyme, and other specialized proteins prevent bacteria and viruses from multiplying in baby's gut
Infant formula:
* No live cells in infant formula
* Immunoglobulin's come from cows -- no t the kind humans need; most are destroyed in processing
* Minimal amounts of specialized proteins (or none at all) in formula
Comment:
Mother manufactures antibodies to the germs to which she and baby are exposed. Baby gets these through mother's milk. Baby is protected by mother's more mature immune system.

Enzymes and Hormones
Human Milk:
* Contains digestive enzymes which help baby use the nutrients in human milk
* Contains many hormones that my contribute to infant growth and development
Infant formula:
* Enzymes from cow's milk are destroyed in heat processing
* Hormones from cow's milk are destroyed in heat processing
Comment:
Science is just beginning to investigate the role of the many enzymes, hormones, and growth factors in human milk, Working together in complex ways, these substances may account for differences in the health and development of breastfed and formula-fed babies.

Effects of Breastfeeding on Mother
Human milk:
* Lowers risk of breast and ovarian cancer
* Lactation hormones aid in relaxation, help mother bond with baby
* Easier weight loss
* Exclusive breastfeeding provides protection from pregnancy for several months
* Saves money
* Healthier baby is easier to care for
Infant formula:
* Risk of breast and ovarian cancer not lowered
* Caregivers other than mother can feed baby, though time must be spent preparing formulas, cleaning bottles, etc.
* Fertility returns sooner
* Costs $1,200 a year or more
* Formula-fed babies visit the doctor more often in the first year
Comment:
When mothers are struggling with breastfeeding in the first days after birth, it may seem simpler to switch to formula. Yet the benefits of breastfeeding for both mother and baby are long-lasting. Even if it is difficult at the beginning, the rewards will come. Human milk for human babies -- it makes sense!

Switching Formulas
During the early months you may joining the formula parade, experimenting with different formulas before choosing the one that baby enjoys the mot and that is least upsetting. Sometimes it's a matter of taste. Sometimes it's a matter of preparation: Your baby may show a preference for the liquid or powdered form of the same formula. Here are the signs that your baby may be allergic to or intolerant of a particular formula:

* bouts of crying after feeding
* vomiting immediately after nearly every feeding
* persistent diarrhea or constipation
* colic with a distended, tense, painful abdomen after feeding
* generally irritable behavior and/or frequent night waking
* a red, rough sandpaper like rash, especially on the face and/or around the anus
* frequent colds and/or ear infection

If your child persistently has one or more of these features, change the formula in consultation with your doctor.

There will be more articles on infants, breast or bottle feeding and other related topics to follow. So please keep an eye out for more of my articles.