Formula Feeding 101

Formula Feeding 101

It doesn’t matter what your personal views on breast/formula feeding is, the fact is that we are exceedingly lucky to live in a time where we have a safe, nutritional alternative to breast feeding that babies can and do thrive on. Even half a century ago the options for feeding infants beyond the breast were limited, and did not offer the safety and nourishment that modern day formula does. Seeking out alternatives to breast feeding is certainly not a new phenomenon, as long as there have been babies there have been mother’s looking for ways to feed them. I won’t get too far into the history of infant feeding but there is some really fascinating reading out there if you are interested.

But let’s talk about formula feeding and how to do it right. Because as wonderful as modern formula is, you still have to follow some basic guidelines to ensure you are giving you baby what he needs, and safely. Note – I am not a doctor, and your doctor (preferably a paediatrician) is always your best resource for any baby questions. So when in doubt please talk to your doctor! But there are some general guidelines for using formula that apply to most babies and some of them you might not know.

Types of Formula

Formula generally comes in three different formats:

  1. Ready to feed
  2. Liquid concentrate
  3. Powdered formula

All three formats are equal as far as nutrition. The only difference is in how they are prepared. The ready to feed formula, as the name implies, is (almost) ready to feed straight from the bottle or can without the addition of water. This makes it maybe the most convenient of the formulas and is a good choice if you might not have access to clean water (especially if you are travelling) but it is by far the most expensive way to buy formula. Liquid concentrate formula does require diluting it with water although it does tend to be easier to mix than the powdered formula. Powdered formula is probably the most common type of formula that parents buy because it does tend to be the most affordable. It does require a little more mixing but otherwise it’s pretty easy to prepare.

How to Choose

As mentioned above, all three types of formula contain the same nutrition so in most cases deciding which to use is simply a matter of preference and/or convenience. One note – in some cases your doctor may recommend starting out with ready to feed or liquid concentrate formula if you have a preterm infant or a baby with certain health issues.1  The reason is that powdered formula is not sterile. Now don’t let the words “not sterile” frighten you. Powdered formula that is prepared correctly is absolutely safe for healthy babies but there are some cases where you need to be extra cautious and liquid formulas may be recommended by your doctor.

Low Iron, Soy and all the Other Choices

When you look at the shelves of baby formula it can seem quite daunting to know which ones to choose, even after you have decided on which format (ready, concentrate, powder) you still have some decisions to make. There are a lot of brands and even each brand has a lot of different formulas. Where do you start?

Well let’s start with the low iron option. In most cases this is not what you need. Babies need iron 2 , in fact it is essential to healthy brain development, and regular formulas have the proper amount for healthy infants. The #1 reason that some parents decide to try low iron formula is because they believe it will prevent or ease digestive issues, especially constipation. That point is widely disputed. So, unless your doctor suggests it, you probably don’t need to use formula with low iron.

Soy formula became quite popular in the late 90s and early 2000s but by 2009 the sales (in the US) had dropped by 50% from what they were in 1999. Why the change? Well more and more studies starting coming out questioning the safety of soy based infant formula. And the verdict is – well we don’t really have one. One of the main concerns about soy based formula is the presence of  phytoestrogens in soy and what long term effects they may have on infants fed a soy based diet . The reasons that parents turn to soy formula typically include – wanting to provide a vegan diet, perceived or real lactose intolerance in baby, and perceived or real dairy allergy in baby. Because the use of soy formula was climbing – and at a rate that could not be accounted for cultural and legitimate health reasons, that prompted several health agencies to look further into the safety of using soy formula. The most recent recommendations, in general terms, are that soy formula is not recommended for pre term babies or infants that have no health issues that switching to soy formula would help. However, based on available human data, no overt harm has been proven with the use of currently available soy-based infant formulas as the sole source of nutrition for infants. This is definitely one of those things you will want to consult with your paediatrician about if you are considering using a soy formula.

What about Protein hydrolysate formula? This type of formula has been around for a while now and contains protien that have been broken down into smaller sizes than what are in regular or soy formula. This type of formula was developed for babies who cannot tolerate cow’s milk and/or soy formula. There are a couple of drawbacks to protein hydrolysate formulas – they tend to taste terrible, and they can be pretty expensive. When soy formula because readily available many parent’s who’s infants couldn’t tolerate cow’s milk but could tolerate soy made the switch to soy for those reasons.

One other type of formula I’d like to touch on is formula that contains probiotics. The addition of probiotics to infant formula is relatively new so the research on it is still very limited. So far it appears that there is little risk in using these formulas in generally healthy infants but  there are safety concerns in infants  who are immunocompromised, chronically debilitated, or seriously ill with indwelling medical devices. 4  Whether or not there is any real benefit to using formula with probiotics is really still up in the air as well but there is very small amounts of research that suggest it may be helpful for colic symptoms but, on the other hand, there is research suggesting it doesn’t. Bottom line – there is not nearly enough research yet to say that probiotics are useful to the average infant but in most cases they do appear to be safe so if you don’t mind spending the extra money, and your paediatrician approves, there is no compelling case against using these formulas.

Formula Brands

There are quite a few brands that make infant formula. There are also a lot of store brand formula on the shelves. They all must pass guidelines for safety and nutrition to get on the shelves. Which ever brand you choose is just fine for your baby.

Preparing Formula

Always refer to the directions on your bottle/can of formula when preparing, especially when it comes to the amount of water you need to use (if any). Not all formulas use the same ratio and it’s essential that you use the correct one. And, unless your paediatrician tells you otherwise, never make the formula weaker or stronger than the directions state. 

Unless you have safety issues with your tap water, it is not necessary to use bottled water to prepare formula (again unless a doctor tells you otherwise) and most health professionals advise against using distilled water for making formula. Distilled water is not just “boiled” water but also has all the minerals found in regular, healthy water removed. There are instances where your doctor may suggest you alternate using regular tap water with distilled or other non fluoridated water if your tap water contains a lot of fluoride and you are concerned about fluorosis. Fluorosis is not something you need to worry too much about – Fluorosis is a cosmetic condition that affects the teeth. It’s caused by overexposure to fluoride during the first eight years of life. In most cases it is quite mild and can leave white spots that are generally only noticed by a dentist or hygienist. 5  If your water supply contains added fluoride (or you’re uncertain) run it by your doctor or dentist if you have any concerns. Note that most ready to use formula does not contain fluoride (and is not mixed with water) and if you are also breast feeding and supplementing with formula there should be little concern about flourosis. Proper supervision with fluoride containing toothpaste and mouth rinses with young children is important to preventing fluorosis.

Now here’s a question that comes up very frequently when we are talking about preparing formula – do you boil the water used to mix formula?  There is no one answer to this question. There are a few variables at play here including the age and health of the infant, the quality of the water, and what type of formula you are using. Obviously if you are using ready to feed formula you don’t need to worry about this at all. What if you are using concentrated liquid formula? After extensive reading the general consensus for preparing concentrated liquid formula is:

  • If using tap water turn on the cold faucet and let the water run for two minutes before using the water.
  • In a pot or kettle bring water (even bottled water) to a boil for a solid two minutes.
  • Let the water cool and then use as directed on the can of formula

The majority of the guidelines I found suggested that you preboil your water for concentrated liquid formula until your baby is four months old.

Now let’s talk about water and powdered formula because things are little different here. From my experience and observations people tend to prepare powdered formula the same way they would prepare the concentrated formula, especially when it comes to preboiling the water. BUT there is a major difference between these two types of formulas. Liquid formulas (both ready to serve and concentrated) are sterile. Powdered formula is not. The guidelines for preparing powdered formula vary from source to source although almost all of them agree that for pre term, low weight of infants under 2 months of age you should do the following:

  • If using tap water turn on the cold faucet and let the water run for two minutes before using the water.
  • In a pot or kettle bring water (even bottled water) to a boil for a solid two minutes.
  • Let the water cool to no less than 70 degrees Celsius and then use as directed on the package of formula

How long (that is the age of your infant) you need to follow the no less than 70 degree rules depends on which guidelines you are reading. Health Canada 6 says pre term, low weight and under two months but WHO does not but an age limit in their guidelines. And to complicate matters just a bit – if you are using a powdered formula with probiotics like Nestle Good Start Probiotic the instructions warn you that using water at a temperature above 38 degrees Celsius will “compromise” the probiotics in the formula.  So this is something you want to consider when choosing your formula, especially in the first months of baby’s life.

Sterilizing

Once upon a time we were told you have to sterilize all the parts of baby bottles before each use. But most reputable sources today agree that for healthy babies you only need to sterilize bottles and nipples before the first use. After that just make sure you clean them well in hot soapy water and rinse them well between uses.

Warming Formula

Do you need to warm formula before giving it to baby? The short answer is no you don’t have to. There is no safety issues in giving your baby a cold bottle from the fridge or not warming ready to serve formula. However, you might find your baby has a preference and I think most of us just naturally think we should warm up the formula, especially if it’s been in the fridge. The best way to warm up formula is to run it under hot water or set the bottle in a container of hot water for a few minutes. A good bottle warmer can be used as well ( I loved mine). It’s recommended NOT to use a microwave to warm a bottle. Whichever method you use be sure to shake the bottle well and test it on the inside of your wrist before feeding baby.

Of course if you prepared your powdered formula using the no lower than 70 degree rule and want to feed it right away you need to cool it down. To do so just do the opposite of above and place the bottle in a container of cool water or under running cold water.

Storing Prepared Formula

If you are using ready to serve formula, depending on how much baby is eating, you may use the whole can in one feeding. But for newborns you probably will get a couple of servings from one can or bottle. Try not to put more in the bottle then you think you will use in one feeding (you can always add more) or it will just go to waste. Pour the rest into a clean bottle or jar and store in the fridge for up to 48 hours. If you are using concentrated liquid formula store any unused quantities in the fridge for up to 48 hours. When it comes to powdered formula WHOs official recommendation is to only mix up what you need for each feed. However, that is not always practical. So if you do mix up a larger quantity you can store any unused portion in clean, unused bottles or a container (like a jar) in the fridge for up to 24 hours. No matter what type of formula you use it is recommended that any formula left over in a used bottle be discarded after an hour. Do not put it back in the fridge to use later.

How Much?

How much formula your baby needs doesn’t have a black and white answer. Every baby and every baby’s needs are unique. But here’s a  broad idea of what to expect your formula fed baby to eat:

  • Up to one month – 2-4 ounces every four hours
  • 1-2 months – 5-6 6 ounces every five to six hours
  • 3-5 months – 6-7 ounces every five to six hours

Once your baby is six months (or if you start to introduce solids sooner) their formula requirements will slowly diminish but it will still be their main source of nourishment. Typically you can expect older babies to consume the following:

  • 6-7 months about 30 ounces per day in four to six feedings
  • 7-9 months about 30-32 ounces in three to five feedings
  • 10 – 12 months about 24-30 ounces in three to four feedings

Again this is a very general guideline and if you have any questions or concerns please talk to your paediatrician.

Bottles and Nipples

Baby bottles are a huge market. They come in all kinds of sizes and shapes, plastic (although they are all BPA free now) and glass. Choosing which one to use is purely a matter of preference. If you don’t know which brand or type to use your best bet is to ask friends with babies (if they use bottles) what their baby seems to like. That’s not a guarantee yours will love it but it’s a great place to start. When it comes to nipples they come in two materials – latex and silicone. Both are safe to use. Latex nipples are generally a beige color and are softer and more pliable than silicone which some babies prefer. The only real downside to latex nipples is they don’t last as long as silicone so you will have to replace them more often. Silicone nipples are usually clear (sometimes colored) and are firmer than latex. They are more heat resistant and will last longer than latex. If you try one and baby doesn’t take to it then maybe trying switching to the other material. Nipples also come in different shapes. The main shapes are the traditional round, dome shape or the orthodontic ones that are flatter on one side. Again, which you use is just a matter of what baby prefers. Just make sure whichever nipples you buy fit the bottle properly! Now the last consideration in choosing nipples is the flow. Most come in three flows – slow, medium and fast. Generally you will start with a slow flow nipple for newborns and gradually work your way up. Never try to increase the flow yourself by making the whole in the nipple bigger! You can easily damage the nipple that way. Whichever nipple you go with make sure to inspect them on a regular basis to make sure they are in good shape. If you notice any tearing or obvious signs of wear, throw them out.

The Basics

Whether you breast feed or bottle feed, this can be a wonderful time to bond with your baby so try not to stress too much and enjoy this precious time. And remember, when in doubt talk to your doctor!

Do read the directions for mixing carefully
Don't mix your formula weaker or stronger than the directions state
Do preboil water for mixing formula and follow the no less than 70 rule for newborns, premies and other babies at risk
Don't use distilled water (expect as discussed above)
Don't reuse formula in a bottle that baby has fed from for more than an hour
Don't add things like rice cereal to bottles unless your paediatrician has specifically recommended it
Do store liquid or prepared powdered formula in the fridge and only for the recommended time
Do inspect cans of liquid formula for dents or bulges
Do look carefully at cans of powdered formula before buying. Unforntunately tampering (buying formula, replacing it with something else and returning to the store) does happen
Do clean the lids of liquid formula thoroughly before opening
Do inspect nipples on a regular basis
Do check expiry dates on formula and toss if you haven't used it all before it's expired
Do hold your baby when bottle feeding
Do follow your paediatrician's recommendations for feeding

 

1 – WHO – How to Prepare Powdered Infant Formula in Care Settings 

2 – American Academy of Pediatrics – Iron Fortification of Infant Forumulas

3 – Canadian Paediatric Association – Concerns for the use of soy-based formulas in infant nutrition

4 – American Academy of Pediatrics – Probiotics and Prebiotics in Pediatrics

5 – CDC – Infant Formula and Fluorosis

6 – Health Canada -Recommendations for the Preparation and Handling of Powdered Infant Formula

This article has 2 comments

  1. Great article filled with lots information meant to inform and not pass judgement. As parents, we all know that there's enough of that going around.

    Whether we give our babies a bottle or breast, you're right that we are so lucky to have great choices.

    Besos Sarah.

    My recent post Donate to the @BostonPizzaFdn and Get 5 FREE Kids Meals! #BPKidsCards

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