Posted tagged ‘bottle feeding’

Breastfeeding increases the risk of newborn readmission. Now what do we do?

January 9, 2019

The Pediatric Insider

© 2019 Roy Benaroch, MD

An August 2018 paper in Academic Pediatrics found an unsettling conclusion: breast-fed newborns have about double the risk of needing to be hospitalized in their first month of life, compared to babies who were formula-fed. The numbers are solid, and they jibe with the real-life experience of many pediatricians, including me. So what should we do about it?

The study itself looked at about 150,000 healthy, normal newborns born in Northern California hospitals from 2009 to 2013. The study authors were able to collect data on how these babies were fed in the few days following birth from hospital records (dividing them into groups of all-breast, all-formula, and a mixed group that did some of both.) They were then able to track these babies over the first month of their lives to see which ones ended up hospitalized for any reason. Most of the hospitalizations were related to dehydration and jaundice, which are closely linked to inadequate feeding.

The good news is that relatively few of these babies ended up back in the hospital – whether bottle-fed, breast-fed, or both, most babies did great. But babies who were breast-fed were much more likely than formula-feeders to end up underfed and hospitalized. Among vaginal deliveries, the risk of rehospitalization was 2.1% for bottle-fed babies versus 4.3% for breast-fed babies (the risk for mixed feeders was in between.) That’s about double the risk. Mathematically, the “number needed to harm” was 45. That is, for every 45 babies exclusively breast fed, one extra baby would end up in the hospital. Not good.

Among Caesarian births, the differential was less, with an increased risk of hospitalization of 2.1% (breast) versus 1.5% (formula). Both of these numbers are lower than the risk of rehospitalization for vaginal deliveries, probably because c-section babies already spend an extra day or two in the hospital. This provides more time for good feeding to be established (whether breast, bottle, or both.)

Does this mean we should discourage breast feeding? Of course not. Most breast-fed babies do great, and there are some health advantages of breastfeeding. But we need to be honest with ourselves, and honest with moms who are trying to do the best thing for their babies. Nursing isn’t perfect. It’s not a perfect food*, and it’s not a perfect method. There are pros and cons to both nursing and formula feeding, and parents (and babies) deserve an honest appraisal.

Nursing moms also need support. That includes “technical support” (ie “How to do it”) but also emotional and medical support – which should include time for rest, and an honest evaluation of how both moms and babies are doing. There is a role for formula, both for moms who choose to use it and for situations where babies aren’t getting enough to eat. Families, pediatricians, nurses, and lactation specialists all need to work together, without guilt or finger-pointing, to help keep babies and moms healthy.

*Human breast milk is an inadequate source of vitamin D from birth, and an inadequate source of iron by 4-6 months of life.

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Bottle and formula feeding questions and answers

February 2, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

 

What’s the best way to warm up the bottle?

Cool formula can be warmed up safely by dunking the bottle in warm water. This method isn’t quick, but it works and it’s safe. There are also “bottle warmers” you can buy that surround the bottle with gentle warmth from all sides—though I am not sure they work any quicker than using warm water in the sink.

Bottle and formula manufacturers caution against using a microwave to heat a bottle. There is a possibility of creating “hot spots” either in the formula or on the nipple, with small areas becoming hot enough to burn.

 

Is it necessary to warm up a baby’s bottle?

No, it’s not necessary—but it’s traditional, and some babies get used to warm formula and don’t like it chilled. As babies get closer to weaning off the bottle at 12 months, many families back off the warming for convenience, and those babies do fine. There is no harm in trying cool or lukewarm formula to see if your baby likes it.

 

Should I use tap or bottled or boiled water to mix the bottles?

Ordinary city municipal tap water is fine. Tap water is very highly regulated, and is monitored far more closely than bottled water for purity. There is no reason to waste your money on bottled water or special nursery water. It is also unnecessary to boil tap water—it’s very clean right out of the tap. Heart surgeons wash their hands in that stuff, you know. And babies’ mouths (and mom’s breasts) are loaded with germs. Sterility is not necessary for feeding humans.

If your water supply comes from a well or cistern, check with your local water authorities for guidance on using that water for formula.

 

Do I need to boil or sterilize bottles and nipples?

No, running them through an ordinary dishwashing cycle or handwashing them is sufficient. Clean is good, sterile isn’t necessary.

 

How do I mix formula?

Always follow the instructions on the package, using the scoop that came with the product. Typically you’ll first measure the correct amount of water, then add the leveled scoops of powder. The exact proportions will be on the packaging. Mixed formula should be kept refrigerated and used within 24 hours. Once the package of powder has been opened, keep it in a cool dry place and discard any unused powder in one month.

 

What should I do with leftover formula if by baby doesn’t finish the bottle?

Throw it away. Once formula has been re-heated OR once a baby has taken any from the bottle, the formula should be considered contaminated and used within one hour, or discarded. Do not re-refrigerate warmed or partially-consumed formula.

 

Is there a kind of nipple or bottle system that’s best?

I don’t think so. There are many varieties, and some are marketed quite heavily with promises to reduce colic, or promises that they’re more like breast feeding. All of that is advertising hype. I suggest you purchase simple, cost-effective bottles and nipples.

Once choice you’ll have to make is to use traditional bottles versus the kind with the drop-in, disposable bags. While neither has any advantage for your baby, the drop-ins may save some trouble with fewer bottles to wash—in return for more plastic bags to throw away. Either style works well for most families.

 

Are generic or store-brand formulas any good?

They’re as good as name brand, commercial formulas. With name brands, you’re not getting a better or more-nutritious product—you’re just paying for fancier packaging and marketing hype.

 

Maybe I should just make my own formula. I found a recipe on the internet!

No, no, no, no. Do not make your own formula. It is not safe, it is not nutritious, and it is dangerous. Homemade cookies? Good. Homemade formula? Bad.

 

What about BPA and chemicals in plastic bottles?

In 2008 Congress banned BPA and several related compounds from baby products, based on sketchy and indirect evidence of potential harm. Still, it seemed prudent to avoid the chemical, as there were still unanswered questions about long term exposures. Since then, there’s now new concerns being raised about chemicals that have replaced BPA.

I say: there’s always something to worry about. And when things are really safe (ahem, vaccines), the modern media feeds into our own worries, especially about purity and food and children. I don’t think there’s any reliable evidence that parents need to worry about plastics used in baby bottles or spoons or anything else. But if you’re concerned, use glass bottles.

 

 

Homemade infant formula is not a good idea

September 15, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Miranda wrote in with a topic suggestion—she wanted to know about homemade infant formula. She had noticed a lot of people suggesting it. What’s the deal?

Speaking about nutrition and human babies, it makes sense to start with this: human breast milk, from mom, is the best food for babies. But even that is an over-simplification. It turns out that in the modern world, human breast milk is often deficient in vitamin D, and maybe iron, too. I know I’m going to get some heat over this, but it’s true: even human breast milk isn’t “perfect.” It’s close, but if we’re going to be honest, even straight-up mom’s milk isn’t “ideal” for babies.

So what’s the best alternative? The contestants: human breast milk, which we’ll just call “human milk.” Commercial infant formula, which we’ll call “science milk.” This is the stuff that’s been studied for years, and is lab-designed to give babies the exact nutrition they need to thrive. Then there’s home-mixed infant formula, which we’ll call “homemade milk”, usually prepared based on an internet recipe.  What kind of “grade” should we give our three competitors, based on an objective assessment of their composition?

The number one “ingredient”, so to speak, is water. Clean, pure, safe water. Human milk, fresh from the breast, is free of harmful contaminants and infectious germs. Science milk is made under sterile conditions, and the liquid versions are pasteurized—as long as they’re stored correctly, there’s essentially no risk of infections spreading. Homemade milk? Who knows. I doubt anyone at home is sterilizing all of their surfaces to the extent done in a commercial lab. And some of the homemade milk recipes call for unpasteurized, “raw” milk—which can be loaded with animal colon bacteria as has been linked to all sorts of colorful infections. Winners: human milk and science milk (tie); loser: homemade milk.

Then there’s protein. There’s too much protein of the wrong kind in most mammal milks (including cow and goat), so science milk relies on modified mammal milk or soy to get the right amounts of the right kind of proteins. The wrong proteins can cause intestinal and kidney damage. One homemade milk recipe I found used blenderized livers as a protein source, which is even more dangerous. Human milk, protein-wise, is perfect. Winner: human milk, with science milk a close second. Loser: homemade milk.

The carbohydrate in all mammal’s milks is mostly lactose. Goats, humans, cows—our milk is all lactose-based. Science formulas sometimes substitute other carbs, largely to take advantage of the fear of lactose intolerance (which doesn’t occur in human newborns.) There’s no known downside to this, though it’s kind of silly. Winner: tie! Lipids (fats) are pretty much the same across the board, or near-enough so.

Sodium: ordinary milk from other mammals (goats and cows and presumably kangaroos, though I honestly don’t know about them) has far, far too much sodium. To properly reduce this, homemade formulas have to dilute that out somehow. Winners: human and science formulas.

Other micronutrients: there are a lot of these, of course—iodine and vitamin C and vitamin D and iron. And these really are important. Iron deficiency in infancy can contribute to permanent cognitive problems. You really do want to make sure that Junior is getting all of these vitamins and minerals in the exact proportions needed. The micronutrient content of human milk has been extensively studied, and science formula does a great job in either copying that, or even improving on that (re: iron and vitamin D.) Winner, science formula, by a nose; human milk is a very close second. Homemade formula are based on dozens or maybe hundreds of recipes, and no one has systematically figured out which if any actually deliver the micronutrients that are needed.

 Here’s a funny, true story from my residency: an 8 month old baby was admitted to the pediatric intensive care unit, near death. (Wait, it gets funnier.) He was very, very anemic—I remember noticing when drawing blood from his nearly lifeless body that the blood itself was kind of watery and runny. He also had neurologic problems and his vital organs had shut down. It turns out that his father was traveling hours a day, back and forth, to a farm to pick up fresh goat’s milk to feed him (because his parents had heard that goat’s milk was healthy!) Since goat’s milk is entirely deficient in one of the B vitamins (folate), the child’s blood marrow pretty much shut down. And there were a whole bunch of other health consequences related to other nutrient deficiencies and protein overload. After a few weeks in the ICU the baby survived. Isn’t that a funny story? No, of course it isn’t. It isn’t funny at all.

Ease of use and preparation: human milk wins, here, of course—though it has to be said, not always. Some women really do have a hard time nursing. It’s not always the easiest choice. Fortunately, we have another reasonably easy alternative: science milk. Mix the powder with water in the right proportion, and you’ve got pretty much exactly what your baby needs. The worst choice, here, would be homemade milk: it’s complicated and fiddly, has a lot of ingredients to get wrong, and it still may not even provide the nutrition your baby needs.

Homemade infant formula is a terrible idea. There is no way for parents to make something as pure and complete as either human milk or commercial infant formula (science milk.) There’s no evidence whatsoever that it even might be safer or better in any tangible way. This is one case where homemade is not the way to go. If you’re not breastfeeding, you should use commercial infant formula. Do not trust your baby’s health on your chemistry skills and recipes from the internet.

Breastfeeding and post-partum depression: A possible cure, a possible cause

September 3, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

An August, 2014 British study comes to two seemingly opposite conclusions: in some women, breastfeeding can protect against depression; while in other women breastfeeding seems to increase the risk of depression. It all depends on what mom’s intentions had been.

The study is complicated, and has a lot of tables—but they’ve kindly made it open-access, so you can read it yourself in detail (click the Download PDF button after the link, above.) Briefly, researchers looked at about 14,000 births, and tracked measures of mental health during pregnancy and periodically afterwards. They also tracked whether women tried or didn’t try to breastfeed, and how long breastfeeding continued. And, they kept track of what women had said their intentions to breastfeed had been prior to delivery. Results were corrected for things like socioeconomic factors and the health of the baby, since we know those have a big effect on the risk of post-partum depression.

The women who didn’t intend to breastfeed, and didn’t end up breastfeeding, were used as the comparison group, and the relative risks of post-partum depression were determined. What they found was fascinating:

Among women who intended to breastfeed, and who did in fact successfully breast feed, the risk of depression was cut in half. This effect was strongest for longer-duration nursing. The authors postulate that the beneficial effect of nursing in this group was conveyed by hormonal factors released during nursing.

Unfortunately, those positive hormonal factors were not seen in all women. Among women who had planned to breastfeed, but were in fact unable to nurse sucessfully, the risk of depression more than doubled. Most women who try to nurse find nursing a successful experience, but women who don’t meet their own expectations seem especially vulnerable to depression.

And: among women who didn’t plan to breastfeed, but did in fact end up breastfeeding anyway, the risk of depression was also increased. Perhaps these women, who hadn’t wanted or planned to nurse, felt bullied or coerced into nursing?

The obstetric and pediatric communities are fully in support of breastfeeding, which offers medical and psychological advantages to most women and their babies. But we need to acknowledge that nursing can be difficult, and that women who don’t nurse are still capable, good moms—they don’t need scorn or dirty looks when they use baby formula. It’s a shame that moms who are providing love, nurturing, and good nutrition though a bottle may be at higher risk of depression. We can do better than this.

The Guide to Infant Formulas: Part 5. The Final Recommendations

September 12, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Choices for bottle feeding are truly overwhelming. There are at least 20 different formulas out there—and I’m not even counting the special medical formulas for specific medical indications. Which one is the best for your baby?

The best “formula”, of course, is human milk. It’s cheap, it’s nutritionally super-good, and for many women it’s very convenient and easy. But it’s not for everyone. Some families like to supplement, or some families choose to bottle feed; some moms try their best but for whatever reason exclusive breastfeeding doesn’t work out. That is not a disaster, not by any means. We’ve got very good and nutritious formulas to use. Being a mom is tough enough—we don’t need to give anyone a hard time about not nursing.

So, when choosing a formula, what’s the best one to choose? Drum roll, please….

#1 for almost all bottle-fed babies

I’m giving the nod to one of any of the generic, store-brand, cow’s milk based products. They’re all fine. Save a few bucks for the college fund, or (even better) hire a babysitter with the extra $$ you would have spent on name-brand formula and go out to dinner without your baby. You deserve it.

Runner up: It’s a tie! All other ordinary cow’s milk formulas go here! Yay!

#1 if you’re avoiding cow’s milk for personal reasons

 

Any generic soy-based product, yay! The runner-up is any of the other soy products. You probably saw that coming.

#1 for fussy babies

 

It’s probably not the formula, you know. And it’s probably not a medical problem at all. Some babies are just kind of anxious or fussy, and need more holding and soothing. I like this guy’s approach. But if you’d like to try a formula change, feel free to try either a soy formula (which has different proteins) or one of the partially hydrolyzed products like Enfamil Gentlease, Similac Total Comfort, or any Gerber Good Start product. Don’t bother with any formula for lactose intolerance—I promise, that is not the problem.

#1 for babies with real protein allergy

These are babies with bloody stools or persistent vomiting or other health problems, and they ought to be monitored by a physician. Appropriate formulas for these babies are Similac Alimentum or Enfamil Nutramigen. Those formulas have very little role for any other babies, but are essential for babies with true allergy.

#1 for babies who spit up

If you really need to treat spit up (and usually you don’t), ask your pediatrician or family doc about adding rice cereal to the bottles—it’s cheap and easy and can reduce spitting. Or, you could try one of the “spit up” formulas (generic, or EnfamilAR or Similac Spit Up.) But I rarely recommend them.

Now I’ll take a few questions from the audience:

Do we really have to stick with one formula? What if I have coupons?

Most babies don’t care if you switch around. Save money, use samples and coupons. The taste might be a little different, but it’s not such a bad thing for babies to have to get used to different meals not tasting exactly alike.

Can I mix formula on my own, from scratch?

In the old days, before the wide availability of commercial formulas, people used to mix up baby formula with evaporated milk, added vitamins, and added carbohydrates or fats. Don’t mess around with any of that now—formulas are complex emulsions of many ingredients, and your baby will do much better on commercial varieties. Do not try this at home.

What about those follow-up formulas for babies after age one?

Traditionally, babies move to milk as a beverage at around age one, and stop drinking formulas. Often that’s a good age for nursing babies to wean. Really, there’s seldom any need for any specific “formula” other than a varied diet. Toddler formula is an unnecessary expense.

Are you expecting a Pulitzer for this series on infant formulas?

Not expecting, no. But it would look nice here next to my computer. Thanks for contacting the Pulitzer committee to suggest it!

The Guide to Infant Formulas

Part 1: What’s in formula?

Part 2: The Similac Products

Part 3: Enfamil and friends

Part 4: Gerber and the Generics

Part 5: The final recommendations

The Guide to Infant Formulas: Part 4. Gerber and the Generics

September 4, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Abbot’s Similac and Mead Johnson’s Enfamil are the big players, but they’re not the only formula choices out there.

What used to be called “Nestle Good Start” is now part of the Gerber Good Start line of formulas, which are often priced just a little less than those of the two better-known formula companies.

Good Start, whether from Nestle or Gerber, has always had a slight difference from the flagship products from Similac and Enfamil: it uses partially broken down elements, which they market as “comfort proteins”. They say this is easier to digest. Their products are similar in that way and in that claim to the partially hydrolyzed Similac Total Comfort or Enfamil Gentlease—and similarly lack any good data supporting this “easy digesting” claim. Still, like all formulas, it’s nutritionally complete to the best of our knowledge.

Like the other companies, Gerber has lately jumped on the “market segmentation” bandwagon, coming out with multiple similar products to grab market share. But their products are even less dissimilar from each other. There’s Gerber Good Start Protect, which I think is their flagship. “Protect” here refers to their probiotic mix of bacteria, which per their literature “may support the protective barrier in the digestive tract.”

There’s also Good Start Soothe, which has reduced lactose—but isn’t lactose free. So it’s treating a condition that doesn’t exist (lactose intolerance in human babies) with a treatment that would be ineffective. It of course has those probiotics and things, too.

Then there’s Good Start Gentle which is based on only the whey portion of cow’s milk protein, partially hydrolyzed like other Good Start products. So you get to choose, with Good Start: Gentle, or Protect. Or Soothe. Can’t have them all!!

One more Good Start product, this one with an intuitive name: Soy. That’s right, a soy based product, with partially broken-down soy proteins that may or may not be better in some vague way. These Gerber products are all nutritionally equivalent.

The Gerber line is priced a tad lower than the Enfamil or Similac lines, but is still more expensive than generic baby formulas. Those generics, like all formulas, are tightly regulated by the FDA, and offer essentially identical nutrition.  There are generics marketed as “Premium” or “Advantage” that are similar to the flagships; there are generics often labeled as “gentle” which are similar to the partially hydrolyzed formulas Gentlease, Total Comfort, and the Gerber Line. There’s a generic lactose-free labeled “sensitive” and “tender” which seems similar to Gerber’s “gentle,” with 100% whey. Soy, organic, or even with added rice starch—the generic versions are out there, though sometimes they’re named differently. Between the generics and Gerber, that’s at least 10 more varieties of infant formula to choose from.

One formula you won’t find: “Low Iron.” There used to be Low-Iron formulas around, because iron was blamed for fussiness and constipation—despite there never having been any evidence that in the doses found in formulas, iron was causing these symptoms. What we did know what that low iron formulas were nutritionally inadequate. Iron is essential for normal brain development, and restricting iron from babies is not a good idea. The formula manufacturers quietly increased the iron in their low iron formulas several years ago, and a few years later phased them out entirely. Good.

We’ve covered a lot of formulas, and a lot of detail. So what’s the bottom line? What’s the best formula for you baby? See you next time!

The Guide to Infant Formulas: Part 3. Enfamil products

August 30, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

There certainly are a lot of choices when it comes to infant formula, aren’t there? Last time we saw all of the colorful ones offered by Abbot. Let’s see what else it out there.

The other big manufacturer of infant formulas is Mead-Johnson, with their Enfamil line. Enfa, I guess like enfant, which I think is a baby elephant; -mil meaning, I don’t know what. I couldn’t find anything about where that name comes from on their site. What I did find, unlike Abbot’s Similac site, are lots of photos of cute babies.

Enfamil introduced a new twist: staging different formulas for different-aged babies. They claim that human breast milk varies as a baby grows, which is true; and they claim that their newborn-oriented product has a protein mix that more-closely matches that of moms who are nursing newborns (as opposed to older babies). The catch here is that there’s a lot of variability among women. That ratio of the protein mix varies quite a bit, and isn’t really the same among women; when it starts to change is variable, too. Plus, there’s no actual clinical evidence that somehow more-closely matching the whey-casein ratio makes any difference, especially because it can’t be matched individually to each mom. But in any case, that’s the shtick, and that’s what makes the Enfamil line at least a little unique.

Enfamil’s flagship product for littler babies is “Enfamil Newborn”, which of course has a similar blend of DHA and prebiotics as everyone else. They also say it has a “tailored” level of vitamin D for its target age – 0 to 3 months – though the AAP recommends the same 400 IU/day for babies of all ages.

Moving past of their newborn-specific formula, the next “flagship” product is Enfamil PREMIUM Infant (that’s their capitals, not mine.) This is product says it’s tailored for babies 0-12 months, which overlaps their other product tailored differently for 0-3 months, but perhaps they used a different tailor. In any case, Enfamil Infant (I’m not typing PREMIUM every time) is a fine cow’s-milk based formula for babies. It’s got all of the stuff we’ve been talking about.

Enfamil, of course, can’t just stop there. They’ve got a product with partially hydrolyzed proteins (similar to Good Start and Similac Total Comfort) called “Enfamil Gentlease”. That’s named maybe after the word “Gentle”, or less-likely the word “Lease”. Though I like the name, as I’ve said before there’s no clinical evidence that these partially hydrolyzed formulas are an improvement, but they’re certainly nutritionally equivalent to ordinary formulas.

Enfamil has a spit-up formula, similar to Similac for Spit Up, called EnfamilAR. I can’t tell if AR means “added rice” or “anti-reflux,” but they claim it reduces spit up by “over 50%”. That sounds suspiciously like the 54% that Similac for Spit Up claimed, though the number is less specific. Advice for Enfamil people: use exact numbers, they look more “sciency.” In any case, Sim for Spit Up and EnfAR seem about the same in every important way.

Enfamil’s soy-based product is Enfamil ProSobee, and their extensively hydrolyzed product is Nutramigen. There’s very limited need for these. They also have a formula for preemies, and a whole host of metabolic and other formulas for specific medical needs that are very rarely needed—but kudos to them for developing and selling them. For babies that need special formulas, Mead-Johnson has come through.

So: Mead-Johnson’s Enfamil line has your basic milk and soy and hydrolysate formulas, plus a slightly-different-in-an-unimportant-way Newborn formula, plus a few bonus versions. We’ll call it 6 formulas, plus the 7 from the Similac line. Are thirteen enough choices already? Of course not! Next up: the “minor” company and the generics.