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

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

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

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.

The Guide to Infant Formulas: Part 1. What’s in formula, anyway?

The Pediatric Insider

© 2013 Roy Benaroch, MD

There used to be only a handful of infant formulas. The ordinary kind, made from cow’s milk; plus ones made from soy protein. There have also been extensively hydrolysed products with broken-down proteins available for babies with protein allergies. That was it. Three choices for bottle-feeding.

Not any more. There are dozens of formulas, each one claiming to address some kind of need—there are choices that “soothe”, or other ones that provide “comfort”. There’s even one specifically for supplementing. There are the top-tier name brands, then a cheaper name brand (with multiple choices), and the store brands. Which is best? Which one should you choose if you’d like to give your baby formula?

We at The Pediatric Insider are here to help. Presenting The Guide to Infant Formulas, untainted by commercial interests, with all of the marketing stripped away.

So what’s in that stuff, anyway? Commercial formula manufacturers all claim to make a product that’s closest to human milk—but by law, most of the nutrient components of these products are all the same. The net content of almost all of the significant nutrients has to fit within a narrow range dictated by the FDA, including the content of the macronutrients fat, protein, and carbohydrates. There are also vitamins, minerals, and nucleotides in specific amounts. Though the sources of these nutrients can vary, and there is a little bit of wiggle room, the bottom line for all of these formulas is that in almost every important respect, the nutrient quality and quantity is the same.

All the manufacturers can do is to tinker about at the margins, adding a little of this, a dash of that. All of the important decisions about what’s in there have already been made.

About the sources of these nutrients: there are some differences, though for most babies it doesn’t matter. For instance, most baby formulas get their proteins from cow’s milk, which contains both whey and casein proteins. The different companies use different proportions of whey and casein, or sometimes claim to break these proteins down into smaller fragments that are (they say) easier to digest. Some use only the whey portion. But there is no good evidence that any of these differences will make any difference to any babies—and certainly not your baby.

Some formulas are based on soy proteins rather than cow’s milk. This may be a selling point especially for vegans, but for most babies it makes no difference. Milk protein allergy does occur, but many babies who are allergic to cow’s milk protein are also allergic to soy, so switching from one to the other makes little sense.

The fat and carbohydrate sources can be different. Some manufacturers use palm-derived oils, or oils from other sources; some use lactose (which is abundantly present in human milk as well), and others use sugars more similar to cane sugar, or use a broken-down form of sugar. Again, the nutrient quality of these is the same. Some like to market their products as lactose-free (because so many parents are intolerant of lactose), but lactose intolerance is very, very rare in human babies. It really just doesn’t happen. These choices of carbohydrates are all about marketing, not about nutrition.

There are some formulas that are “extensively hydrolysed” to cut up the proteins into little bits. These are appropriate for babies with genuine milk protein allergy (which isn’t very common, and certainly isn’t a common cause of fussiness unless accompanied by other symptoms.) They’re expensive, but are crucial for those few babies who genuinely need them.

So fats, carbs, and proteins—very little important differences there, for most babies. What else can the formula companies add or change to distinguish their products from one another?

Many products now contain additives advertized to change the “intestinal flora”—that is, to help babies establish helpful, healthy bacteria in their guts. The additives include “probiotics—those are actual bacterial colonies that may or may not make their way to the colon—or “prebiotics”, which are compounds that provide nutrition for bacteria, or otherwise change the intestinal contents to be more supportive of healthy bacterial growth. An even newer word is “synbiotics”, which are a mix of probiotics and prebiotics. Though there is a lot of research on these going on, there’s currently very little to zero actual clinical evidence that these improve the health of babies when added to their formula. Available studies might show a change in the composition or quality of stool—but is that even important? We don’t know what kinds of pre- and probiotics are best, we don’t know the doses, we don’t know how they interact, and we certainly don’t know that routinely adding them to formula is a good thing. For what it’s worth, they seem harmless. But all of the marketing about the proportions and amounts and special kinds of pro- & pre- biotics is just that: marketing.

About ten years ago, formula manufacturers started adding long-chain fatty acids, often from chemical sources abbreviated “AHA” or “AA” or “DHA.” These compounds are found in varying amounts in human breast milk, and seem important for brain and eye development—though studies of their actual clinical benefits have not been impressive. We honestly don’t know the exact amounts of these nutrients that are ideal, especially because the amount in breast milk varies very much with mom’s diet. Still, it’s probably a good idea to have them in breast milk, and almost all available infant formulas in the US now contain them. Some claim to have more than others, but again, we don’t even know what the “best” amount is.

A few formulas have additives to help with spitting up. Typically, it’s a modified rice starch that makes the formula a little thicker, or one that thickens even more when in the acidic environment of the stomach. These are meant to be used instead of just adding rice cereal to the bottle—and there is an advantage over adding rice, because you don’t end up giving extra calories. But these products are seldom necessary. Spitting is normal, and all babies spit at least some. For most babies who spit up, the best solution is to feed less, or feed slower, and worry less about the spitting. Babies who genuinely have health problems because of regurgitation (such as poor growth or esophagitis or recurring pneumonias) need a thorough medical evaluation, not an “added rice” formula.

Next up: I’ll go through the products out there and tell you what you need to know. And then: my final recommendations!

Melamine is here

Melamine in infant formula, here in the USA?

Yup. Trace amounts of this, as well as many other industrial chemicals, are found throughout the food chain. Plasticizers, solvents, cleaners, all sorts of chemicals are used in the processing and packaging of food. And shortly, you’re going to hear all sorts of grandstanding by politicians eager to make a splash in the news. But before you get caught up in the coming hysteria, let’s hear the rest of the story…

Melamine is an industrial product used in cleaning food equipment and packaging. It can also be used deliberately by ruthless food manufacturers to “fool” chemical assays of protein content—that’s probably why it was added in large amounts to several sources of milk used to make infant formula and other foods in China. That story broke in August, 2008, shortly after the Olympics. To date, the Chinese government has acknowledged 3 deaths and 50,000 sickened children from exposure to melamine, though many observers think the totals could be far higher. Melamine causes illness by binding with other chemicals in the urine and forming kidney stones. The tainted products were also exported from China to several neighboring countries, though very little was brought to the United States (only a few candies and novelty foods, mostly sold in Chinese markets, have been shown to be contaminated in high concentrations from the Chinese milk.)

Formulas and other foods in China that made babies ill have been found to have 2,500 parts per million (ppm) of melamine. Keep that number in mind.

In the United States, regulations prohibit the use of melamine as a food additive, but do allow melamine-containing solutions to be used as cleaners of food processing equipment (that regulation was passed over 40 years ago.) The FDA has established a “safe concentration” for most foods of less than 2.5 ppm, 1000x less than the toxic levels seen in China. However, this “safe concentration” does not apply to infant formula—for formulas, no “lower safe limit” has ever been established.

The commercial assays available for manufacturers to test for melamine have a lower detection limit of 0.25 ppm. This includes the published method that the FDA suggests food manufacturers use to test their own products. However, chemical methods continue to improve, and lower limits of detection have become possible with new technology.

The FDA began testing infant formula shortly after the melamine story broke, using the most sensitive assays available. They’ve found that several infant formulas in the US have measurable concentrations of melamine, about 0.14 ppm. It’s not known (or least I couldn’t find) assays of the concentration of melamine in breast milk or drinking water—but my guess is that it will be more than zero.

This concentration in formula is far less than the established safety threshold for most foods, and far far far less than the concentration that has made kids sick in China. Only a few years ago, this concentration wouldn’t even have been detectable; it’s only improved chemistry that has allowed us to know it’s even there.

Paracelsus (1493-1541), a Swiss chemist, is often credited for his statement of the most basic tenet in toxicology: “The dose makes the poison.” In other words, any substance is a poison at a high enough dose (for example, water, salt, and vitamin C will all kill you if you ingest enough of these.) And there is no substance that is poisonous if taken at a low enough dose. Even deadly rattlesnake poison or the most lethal nerve gases have a threshold of toxicity, below which they’re harmless.

Several politicians have already seized on the melamine issue, insisting on a “zero-tolerance” policy. From a science point of view, that’s silly: ordinary foods always contain traces of deadly chemicals, including arsenic (a natural element) and cyanide (which is produced in small amounts in each one of your body’s cells every day.) As chemical assays improve, it becomes possible to detect the most minute amounts of anything—does that mean that the small amounts, which may always have been present, pose a danger? And if all of the infant formula is recalled, what, exactly, are we supposed to feed our babies once they’ve weaned?

The harm of a mass recall of formula—babies being fed some kind of home-brew concoction, or products that are very demonstrably unsafe for infants (like plain whole cow’s milk)—is far, far greater than any harm that might be posed by these infinitesimal amounts of melamine. Besides, there’s an even higher amount of melamine allowed in whatever parents might use as formula substitutes. That couldn’t be an improvement.

The melamine issue requires some clear thinking. Formula manufacturers should work to find the source of the minimal contamination—probably a cleaning solution that could be rinsed more thoroughly—and eliminate that source. Studies to look for possible long-term effects of food-source melamine should be undertaken, and reasonable steps to minimize contamination with melamine and other chemicals should be taken at every step of food processing and preparation. But there is no reason for any sort of formula recall, and no reason for anyone to panic.

sources: http://news.yahoo.com/s/ap/20081126/ap_on_he_me/infant_formula;

http://sbk.online.wsj.com/article/SB122764783105057435.html

Organic infant formula? One brand is a bad idea

As reported by the New York Times, parents thinking that Similac Organic Infant Formula is healthier than conventional formulas are in for a surprise. The company that makes it, Ross, decided to use cane sugar as a sweetener. This makes Similac Organic taste sweeter than other infant formulas, and much sweeter than human milk. It’s riskier for a baby’s teeth, and is very likely to lead to over-eating. Worse still, it may help imprint a desire for sweeter foods starting at a very young age.

As discussed in this post, I’m not a proponent of organic foods. They’re more expensive, and I’m not convinced that they’re healthier or better for children. In the case of this particular infant formula, parents are paying about 30% more for a product that’s very likely to be less healthful than non-organic alternatives. You can’t assume that organic = more healthful.

BPA in baby bottles: a genuine worry, or just a media scare?

Kristen asked, “Will you please explain the BPA concern in bottles? There is quite a bit of information about it, but I’m having a hard time determining if the bottles I use contain it or not since I don’t see any number on my bottles (Avent). Is a drop in system the best alternative while companies are determining which products are safe? Thanks for any information and help in finding the ‘correct’ bottle.”

As with many issues of toxins and exposures, no one knows with 100% certainty that the amount of BPA that a bottle-fed baby is exposed to will definitely never cause any health problems. I will say based on the available data and the best studies, BPA is almost certainly not something that’s going to harm your child. There are BPA-free alternatives if this is something that you find yourself continuing to worry about.

How much formula needed at 10 mos?

Katie posted: “My daughter’s 10 months old. She takes 4 bottles a day, about 20oz. I want to ease into the 1 year – weaning – thing. What is the minimum amount of formula I should give her? Can I go ahead and supplement with milk, or is it best to wait until she is 1 year old?”

By 10 months, your daughter should be eating solids at least three times a day, and solid meals should include a good variety of ordinary table foods that you share with her at family meals together. This can include almost any sorts of foods, except nuts, peanuts, and raw honey. All of these foods ought to be soft enough for her to “gum them.” Good examples are noodles, well-cooked veggies, beans, crumbly meat, cottage cheese—almost anything can be ripped apart so it’s soft enough for a 10 month old.