A user’s guide to the confusing world of milk

The Pediatric Insider

© 2013 Roy Benaroch, MD

Emily Z. wrote in about a recent study linking lower-fat milk with obesity. She also wondered about omega-3 fortified milk—could it be worth the money? Emily wants to know, “How did the dairy section of the store get so complicated?”

Milk sure has gotten complicated. You’ve got, of course, milk—the white stuff that comes out of cows—in different varieties of fat content, and lactose-free versions, too. And now soy milk, and rice milk, and almond milk, and hemp milk. And organic milk. Fortified with omega-3 acids, like DHA and ARA! And don’t forget goat milk, which has natural goaty goodness. AAAAAA!! How can you decide?

First, let me suggest a definition to start with: milk is a beverage that’s high in protein, and has other nutritional stuff in there too. It’s a great food for mammal babies like our own, and for about the last 8,000 years humans have domesticated animals to continue to drink milk and eat dairy products well past infancy.

Is milk necessary at all? For babies, yes—they can’t really eat other things. Rarely does one see a one-month-old thriving on Doritos Locos Tacos. By about 9 months of age, human babies are starting to get a significant chunk of their calories from solids, and by 12-15 could probably do just fine without any milk at all. Some will just refuse it. Still, milk is an easy and tasty source of protein and calcium, so it’s traditionally a part of a child’s diet for many years.

What’s with all of the milk variants, then? Are they better than ordinary cow milk?

Ordinary, full-fat milk has about 4% milkfat in the USA. It used to be thought that infants needed that high milkfat, but a 2008 AAP statement corrected that misimpression, and their most recent statement on cardiovascular health reiterated that for families with heart health or obesity concerns (that should be all of us), low fat milk is appropriate starting at age 1. A recent study from the BMJ, reviewed here, questions that wisdom by linking lower fat milk with increased weight—but that’s probably an example of logical reverse causality. Families with high weights and weight concerns choose lower fat milk, explaining the association. In other words, it’s not the milk that causes the excess weight, but the excess weight concerns that cause the choice of lowfat milk.

There’s overwhelming evidence that too many US kids get too many calories. To me, it makes sense to choose lowfat or skim milk products as soon as babies wean from mother’s milk or formula at 12 months. We’ll have to see if better evidence appears to put that in question.

When should other kinds of milk be considered?

Rice milk – this isn’t milk. It’s high-carb, and low-protein. Drink it instead of apple juice, if you want. But it isn’t a milk substitute at all.

Soy and almond milk – good for those who want to avoid cow’s milk, or for those allergic to cow’s milk. There may be some cross reactivity with soy especially, so beware. All non-mammal milk is lactose free.

Organic milk – I don’t think it’s worth the extra cost. The main concern seems to be the use of supplemental cow growth hormone by many conventional dairies to increase milk supply. There’s zero convincing evidence that this is harmful to humans, and zero biologic plausibility that it could cause trouble for our kids. To me, my main objection is that it may be unhealthy or cruel for the cows.

Raw milk – ew. Stay away from unpasteurized things loaded with nasty microorganisms, OK?

Lactose-free milk – great for those with lactose intolerance. That means babies and young children almost never need it. Lactose intolerance is essentially non-existent in newborn humans and other mammals, because human milk is loaded with lactose. It develops later in life, typically in teens or young adults.

Hemp milk – honestly, I have no idea what this is for. Sounds groovy.

Goat milk –expensive! It’s deficient in micronutrients like folate, and has no advantage over cheap and readily available cow’s milk. Still, it’s got that goat cache.

Omega-3 fortified milk – Omega-3s are so-called essential fatty acids that are part of brain and retina tissue. Children probably need some, and we really don’t know how much is ideal or sufficient. Conditions of omega-3 deficiency are difficult to identify, and may not even exist. Still, it’s probably a good idea to eat fish once in a while, or try an omega-3 supplement of some kind. I don’t know why it ought to be added to milk in particular. I wonder if they’ll make a Nestle Quik Fish Flavor?

Confusing? You bet. I pretty much just drink conventional skim. Though sometimes, a nice Café au Lait hits the spot. Mmmmm.

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13 Comments on “A user’s guide to the confusing world of milk”

  1. sheri flink Says:

    Dr. Roy, you are so darn practical I just love it!!!!! So happy I found you as my kid’s pediatrician.

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  2. Susan Says:

    I have a friend who has loads of trouble with breastfeeding. She decided with her most recent baby to try goats milk as a substitute for formula. She has access to a local farm where she can get clean pasturized milk on the cheap (way cheaper than tub after tub of powdered formula). Is there any essential nutrients that should be added to her diet? The baby seems perfectly healthy and hasn’t had any digestive problems, other than kind of smelling like a baby goat.

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  3. Dr. Roy Says:

    Goats milk is absolutely inappropriate as a substitute for infant formula. It is deficient in several essential micronutrients, and the protein content is also not good for young babies. Babies less than one year should consume either mother’s milk or a commercial infant formula mixed per manufacturer’s directions.

    True story: as a resident, I helped take care of an infant in the ICU whose parents somehow became convinced that goat’s milk was superior to infant formula. No joke, this baby almost died, and will likely suffer from the consequences of his parents’ food faddism for the rest of his life. I realize the tone of my post was kind of jokey, but this is no joke at all. Infant < 1 year? Don't play around with kooky substitutes. Momma's milk is best, infant formula is a good substitute, anything else is playing with your child's health.

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  4. Susan Says:

    Thanks, will spread the word!

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  5. Any particular Omega 3 supplementing guidelines that you recommend? Fish oil vs. plant-based sources, supplements vs. actual fish. Adults can swallow fish oil pills, but that’s not easy for little kids. I tried the Gummy vitamin version once with my kids and it tasted and smelled terrible. Hard to cover up the fishy taste/smell. Full disclosure though, I hate fish!

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  6. Dr. Roy Says:

    Ah,but Emily, if don’t you use those huge fish-oil capsules, you’ll miss out on the wonderful experience of burping concentrated essence of sardine for an hour! The burp of health!

    I don’t mind the fishy capsules, but I agree they may not be everyone’s first choice.

    As with other vitamins, a chemical is a chemical. It doesn’t matter if your vitamin C comes from rose hips or sweet potato or a pill, and it doesn’t matter if your omega-3 source is from flaxseed or fish or plankton.

    One good omega-3 option for kids– and I have no industry affiliation with these people, or any other manufacturer– is “Gummi Fish”, which taste good and have no fishy flavor. (BTW Gummi Fish are not the same as Swedish Fish, which are kind of nasty proto-Gummi things which taste like furniture from Ikea. Coincidence? I think not.)

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  7. Scott Says:

    Also traditionally doctors have said that the fat was necessary for brain development. But the Special Turku Coronary Risk Factor Intervention Project (STRIP) study put infants on low cholesterol low fat diet with 1.5% milk with no difference in neurological outcomes.

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  8. Thanks for the insights! Unfortunately I know exactly what you mean about the burps!

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  9. Renee Says:

    “Cafe-au-lait hits the spot”. Hah! Cafe-au-lait and spot in the same sentence… Intended pun?

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  10. Dr. Roy Says:

    Renee, it was a long way to go for a neurofibromatosis pun, but it was worth it!!

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  11. Jessie Says:

    Please don’t assume all babies wean from mother’s milk at age 1! Breast milk healthiest and cheapest, whether your kid is 3 months old or 3 years old 🙂

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  12. FocusKick Says:

    This is comical, but oddly an all too frequently occurring situation in our neighborhood grocery stores nowadays. While I personally know a number of people with certain food allergies that make drinking “regular ol’milk” a challenge, I still believe that most of the confusion can simply be attributed to marketing gimmicks. For example, I’m fairly certain that hemp-milk won’t cause much harm if that’s an individual’s preference, but I’m equally fairly certain that the lasting impact may simply be a slightly lighter wallet over time. Personally, I just stick with skim milk. Nice post. Thanks for sharing. 🙂

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  13. CATT Says:

    What a disgusting crock of lies, this article is. I have been drinking raw milk for 45 years, drank it during my 4 pregnancies and when my children were weaned from my own “raw” milk, they drank raw goat or cows milk. Raw milk is far superior in all ways to pasteurized homogenized milk. Pasteurized milk is nothing more than rotten processed junk food with no nutritional benefits at all, since it’s been cooked. Not to mention loaded with antibiotics, growth hormones and all kinds of filth.

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