This area of the website contains links to expert information on formula feeding your baby, plus issues that are relevant to this stage.
 A Formula For Feeding
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 Words by Leanne Cooper
We all know breast is best for babies but unfortunately not all mothers can breastfeed. Here childhood nutritionist Leanne Cooper offers parents advice on the alternative
(as published in My Child Magazine).
If you have ever tried to be more informed about infant formula, you may have found information somewhat sparse. You are not alone, and in fact this is a widespread issue. Policy preventing formula companies from pushing infant formula (by advertising or promotion to healthcare professionals) has had its reasoning: as consumers we are all aware of the huge effect that marketing can have on public health and the perceptions of buyers. Indeed there is a huge need for information in this area - commonly, even healthcare professionals are left to seek out training in complementary feeding.
By virtue of the importance of feeding and nourishing your growing baby it is essential that parents and caregivers who are using infant formula have easy access to resources and support. Interestingly, the World Health Organisation's Code of Marketing of Breastmilk Substitutes states that while clear advice should be provided about the advantages of breastfeeding, there should be no disadvantage to those who do not breastfeed and information should be available regarding suitable options.
So let's lift the lid and take a closer look at some of the issues which parents raise when using formula. Specialised formula, however, for premature infants or babies in hospital is not discussed, as these bubs need individualised feeding and care.
Who is running the show?
Food Standards Australia New Zealand (FSANZ) tightly controls the manufacture of infant formula. You can find full details on the guidelines manufacturers must follow on foodstandards.gov.au (listed under Standard 2.9.1 - Infant Formula Products ).
Formula manufacturers must adhere to regulations regarding a wide array of factors, including but not limited to:
- protein (which must be within a set range) and the source of the protein (for example soy, cows' milk, rice, etc)
- energy and fat content (which must be within a set range)
- the number and quantity of vitamins, minerals and ingredients thought to be biologically active, such as fish oils and probiotics
- clear information about serving size and preparation
- the maximum level of aluminium
- the appropriate infant age for the formula
- the font size (yes, the font size is prescribed - thank goodness for those of us who don't take our glasses shopping)
- carbohydrates, albeit indirectly as a result of the moderation of the nutrients given above
- the ratio of essential fatty acids (LA and ALA)
- the ratio of omega-6 to omega-3 fish oil fatty acids (EPA and DHA).
There are, however, a handful of vitamins and minerals that FSANZ give only a guideline on the maximum level. This includes vitamin C and some B vitamins, though many of the minerals are indirectly controlled via the ratio prescriptions of vitamins and minerals. In addition to this, the level of amino acids and proteins is monitored to prevent excessive load on babies' kidneys; proteins are large molecules that have the capacity to be heavyweights when it comes to manoeuvring about the body. Naturally, the use of additives is also strongly regulated.
In addition, specific warnings about adhering to the preparation guidelines are also required, and you may never have noticed but all formula containers or packets must also have the following clearly marked: Breast milk is best for babies. Before you decide to use this product, consult your doctor or health worker for advice. The claims relating to the ingredients that manufacturers use are also strictly controlled, though companies can apply to include claims about specific vitamins, minerals and biologically active compounds in regards to infant and child health. You might find it interesting to know what manufacturers aren't allowed to do and say, for example you will not see:
- pictures of babies
- use of words relating to humanised or "maternalised "
- claims that formula is suitable for all infants.
Marketing of infant formula is also governed by the Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement . And, there are many more regulations, so you can see just how strictly regulated formula is, and for good reason when we are talking about the nutrition and health of our babies.
What is formula?
The starting product for formula is most commonly cows' milk, specifically the protein component that is made of two main proteins: casein (also known as curds, which coagulate or clump together to form cheese) and whey (the remaining watery part that separates from the curd). A formula can be either casein or whey dominant - the latter is the most common. Other starting points can be soy or goats' milk, which don't contain whey or casein.
Currently there are over 20 different formulas for healthy full-term infants of various ages (from newborn to follow-on formula and, more recently, toddler varieties). Selecting the ideal formula for baby can be a daunting task for parents, and naturally feeding your child is an emotive subject; just the tin alone can be scary. Subtle claims of scientifically superior composition, most desirable makeup and optimal nutritional features for growth and development can leave you feeling confused. The following is designed to demystify some of these issues.
Babies, allergies & formula
Food intolerances are often confused with food allergies. Understanding the difference is important because they are often dealt with quite differently. For example, food intolerances don't involve an immune reaction by the body and so can't be classed as an allergy. Common food intolerances include lactose (milk sugar), naturally occurring substances in foods such as salicylates and reactions to preservatives, colourings and additives. The symptoms and signs of adverse reactions can occur singularly or in combination, with the severity of the reaction depending on the child and the amount of the offending agent that has been eaten (at times there may be a cumulative effect).
Food allergy refers to an immune response to a whole food protein or similar large molecule, for example from a food. In the case of a food allergy our body reacts to food proteins by treating it as an antigen (foreign body), which causes a release of chemicals such as histamine, antibodies and other immune substances. Such allergic responses always involve antibodies produced by the immune system, which give rise to signs and symptoms that may not always be obvious.
Recommendations to reduce or prevent allergy or food intolerance
Agencies such as the Australasian Society of Clinical Immunology and Allergy recommend women, where possible, to exclusively breastfeed for six months, or use expressed breastmilk as the next best option when breastfeeding is not possible. However, if complementary feeding has begun then it is suggested that infants be given hydrolysed formula (HF). There are two types of HF, partially hydrolysed formula (PHF) which can be freely purchased in stores and chemists and extra-hydrolysed formula (EHF) which requires a prescription from a GP or similar. In Australia EHF is subsided if your baby has a confirmed allergy to both cows' milk and soy milk.
Partially hydrolysed formula (HA)
As we know, most infant formula is either modified cows'-milk based, and - not being native to the infant's digestive system like breastmilk - the proteins can be treated as foreign bodies. PHF, denoted on formula tins as HA, contains protein that is broken up so that the complex protein molecules are easier to process and are less likely to be a threat to the baby's defences.
HA formulas are often recommended for babies who experience colic or reflux. They don't form curds in the stomach like casein-based formulas may, and it appears HA formulas are digested in a similar fashion to breastmilk and consequently sits better with babies. Some infant formula companies are applying to lower the protein content of their infant formula closer to breastmilk; to date, only one HA-type infant formula has such approval. Research on this type of formula appears to suggest that it reduces the amount of metabolic processes required by baby to digest the protein, and that it aids digestion and reduces constipation, allergies and stress on organs, such as still-developing kidneys.
Lactose intolerant bubs
Lactase is an enzyme that is naturally produced in the small cells that line the intestinal canal. For this reason, any condition that affects the health and integrity of these cells can impair lactase production. We all have different levels of lactase production and, therefore, different abilities to cope with lactose.
Food, including formula, entering the intestinal tract is broken down into smaller units that can then pass into the inner workings of the body for use. To digest food we need a huge array of enzymes and occasionally some may be low or even missing; lactase is a good example of this. When lactase is low, or in rare extreme cases not present, the body's ability to break lactose into smaller sugars (glucose and galactose) is impeded. The undigested lactose continues to pass along the intestinal tract and as it moves bacteria works on it, causing a fermenting process that results in gas forming and water being drawn into the area. It is this process that leads to some of the symptoms of lactose intolerance, including bloating, flatulence, diarrhoea and tummy pains.
Our production of lactase drops off markedly over our first four years. However, in some cultures where pastoral activity such as dairy farming has a long history, there appears to have been a genetic adaption that inhibits the slowing of lactase production. Interestingly, lactose intolerance genes are not dominant genes.
Those with mild lactose intolerance can, it seems, "up-regulate" the enzymes involved in lactose digestion via continual small exposure to lactose. Basically, over time we can gain a tolerance to a certain level of lactose. Having said this, like so many things in nutrition, you can still have lactose intolerance and not show any symptoms.
If you suspect that your baby is having difficulty with the lactose in a standard formula you can have a simple breath check done (from three months of age, ask your GP for details) and if it is confirmed, talk to your healthcare professional about either a lactose-free or low-lactose formula. Keep in mind that removing lactose altogether may reduce your baby's opportunity to adapt to a level of lactose. In the case of milk, it may be better to try a low-lactose infant formula and, when on solids, low-lactose foods in baby's diet to allow their body to practise making lactase. In severe cases a lactose-free formula may be recommended.
Keep in mind that any formula noted as lactose-free must have 'no detectable lactose' present. Soy-based formulas, being plant based, are free from lactose, whereas low-lactose formula must have no greater than 0.3g of lactose per 100ml of formula. When a formula product uses these terms they are also required to provide information on the quantities of lactose and galactose (animal breastmilk sugar) per 100ml.
Constipation
Constipation tends to be more common in bubs fed with formula. This is because the protein in formula is a little harder to digest and can cause water to be drawn out of the intestinal canal to help the kidneys process these proteins. Wherever fluid is lost from the intestinal canal this can increase the likelihood of constipation as it causes the faecal matter to become dry and consequently hard to pass. Keep in mind that just because a bub turns red and grunts and groans when passing a stool doesn't mean they are constipated. Constipation refers to dry, hard-to-pass stools. Even babies who pass stools only every few days aren't necessarily constipated. However, if your baby is on formula and has a change in bowel habits check the following:
- Scoop sizes for different formulas can differ - so always check the instructions on how to make up any formula.
- Ensure the ratio of formula to water. Make sure the scoop is not tightly packed and measure the water first. You can always call the manufacturer's hotline to check on this.
- Is it right for your bub? Some formulas don't suit all babies. Research suggests that formulas with probiotics can soften stools and also that the protein composition of a formula can affect constipation.
What if my baby doesn't finish the bottle?
It is commonly accepted that feeding on demand for breastfeeding is most ideal, and bottle-feeding with formula is no different. Naturally, there will be a great deal of variation from one baby to another in terms of both the amount taken at a feed and the number of feeds per day. Demand feeding allows your baby to use their innate abilities to self-regulate, which has been shown to be positive for later eating habits. Don't force your baby to finish a bottle. Instead, assuming baby is healthy, follow their lead.
While the information on formula packaging is a rough guide, babies should have plenty of wet nappies (at least six to eight per day), grow in a consistent fashion and be contented, active and thrive. If your baby is growing at a consistent rate then you can be reasonably sure that what is going in is meeting their needs.
Points to remember when using a bottle
- Guides for formula intake are not one size fits all. Instead, use your baby as your guide.
- Always check the temperature of the formula on the inside of your wrist.
- Constantly hold your baby while feeding to avoid spluttering, choking, ear infections and tooth decay.
- Enjoy feeding times, and foster eye contact while nursing your baby.
- Never allow baby to fall asleep with a bottle, as this can cause severe tooth decay - called bottle decay.
Recommending an infant formula
This is not a simple task. Formulas with LCPs, betacarotene, nucleotides or probiotics in them may be more expensive. Keep in mind that you should not feel guilty if you aren't able to afford these types of formulas, and remember that the strict control over the manufacture of infant formulas means that they are all reasonably similar. Also, the evidence that these additions provide any real long-term benefits is still unclear. Infant development and growth is very complicated, involving the interaction of a vast array of different factors that act in synergy with each other. Such additions, even if they are helpful, are only a few of the compounds found in breastmilk that affect the development of a baby, and a great many babies in the past have done very well without them. Ultimately, the best formula is the one that suits your baby. This may mean a few trials and errors but fitting the formula to the baby is ideal.
Why is cows' milk not suitable for babies?
There are many reasons why cows' milk or anything other than breastmilk or infant formula are not suitable as a baby's source of nutrition. In regards to cows' milk, it not only has the wrong quantity of protein (two and a half times more than breastmilk) but its protein quality is not suitable, it is generally 80 percent casein dominant and hence hard to digest. In addition, the type of fat in cows' milk is not easy for babies to absorb (breastmilk has just over 50 percent fat). In addition, cows' milk can cause intestinal bleeding, and the calcium level can further compromise iron levels. And lastly, many nutrients have levels too low for a baby's needs including vitamin A, D, C, E and iron.
Filtered vs tap water
You may have been alerted to some recent concern regarding the use of bottled water for making up formula. Again, current research doesn't support this concern, so cooled boiled water or bottled water both remain safe.
Nothing is too small to check
If you are at all concerned about your baby's feeding, growth or health don't hesitate to see your GP or child health nurse. Small changes in a baby can have a big impact on their health due to their rapid rate of growth, metabolic processes, still-developing body organs and large body surface area. If in doubt, check it out! .
The information provided is not meant to replace medical advice. The information given is aimed at supporting parents and carers who have already chosen to formula feed and does not seek to recommend formula feeding over breastfeeding. The World Health Organisation recommends: All infants should be exclusively breastfed from birth to about six months of age, and at least for the first four months of life.
Average formula requirements for infants and toddlers
Age |
Amount per kg of body weight daily |
Day 1 |
30ml |
Day 2 |
60ml |
Day 3 |
690ml |
Day 4 |
120ml |
Day 5 to 3 months |
150ml Some (especially premature) babies may need 180-200ml |
3 to 6 months |
120ml |
6 to 12 months |
90-100ml |
1 to 2 years |
90ml |
Modern formulas & technical terminology
You will find that almost any parent or caregiver who has trawled the infant formula aisle of a supermarket, trying to compare one brand with another, will be familiar with that sense of being completely bamboozled by the jargon. Infant formulas are continually being improved in efforts to replicate breastmilk. The use of terminology on products is increasingly common and the terms are getting longer. The following is a brief summary of some of the more common technical terms used by manufacturers of infant formulas.
AR = anti-regurgitation
Selected formulas include a small amount of thickening agents from rice starch, carob bean flour or processed cornstarch in place of some of the lactose (milk sugar). Formula, with added thickening agents is thought to help bubs who tend to "posset" or regurgitate often or in large volume after feeding. Always chat to a healthcare professional if your baby is having any difficulty with feeding and get good advice about the best road to take before trialing specialised formula.
LCPs = long-chain polyunsaturated fatty acids
A number of formulas contain added long chain polyunsaturated fatty acids (PUFAs), also shown as LCPs on formula, such as docosahexaenoic acid (more commonly known as DHA - the health-giving fatty acid found in fish) and arachidonic fatty acids. These fatty acids, along with their cousins alpha linolenic and linoleic acid, are found in breastmilk and are important for baby's brain and eye development, as well as being implicated in anti-inflammatory responses to allergens and the like. PUFAs accumulate in babies' brains in the last trimester of pregnancy and in the first month of life, and it is thought that infants are less able to produce such PUFAs themselves. Studies have shown that formula-fed babies can have less LCPs in their brains and blood than breastfed babies. However, a number of studies have shown that infants fed on formula with added PUFAs have better visual function as toddlers than those fed on formulas without PUFAs. Keep in mind that these are just a handful of studies and trends can change, and of course eyesight is a function that involves a great many factors. There is also research that appears to show that infants consuming formula with LCPs have softer bowel movements than those fed with ordinary formulas.
What does the term gold mean?
You may have noticed the use of the term gold on some infant formula tins; this refers to the inclusion of omega 3 oils (DHA and EPA, found in fish such as salmon), also shown as LCPUFAs (long-chain polyunsaturated fatty acids) or LCPs. LCPs are important in motor, eye and brain development and given a baby's rapid rate of growth they perform a vital function.
Nucleotides
Sounds like a very powerful word! Nucleotides are small parts of our genetic material; they are involved in energy production and the use of protein, fat and carbohydrates by the body. Nucleotides are found in most living cells as they are the structural units of DNA and RNA (genetic material). The nucleotides in our food are complexes that get broken down during digestion to compounds such as nucleosides. Nucleosides are what our intestinal cells prefer and can absorb. While our bodies can make nucleotides, it takes a lot of energy, and there may be times - such as during rapid growth - where production may not match requirements. Additionally, it is thought that infants aren't able to make nucleotides as efficiently. The benefit of nucleotides in formula is thought to include:
- assisting rapidly dividing cells in the intestinal tract
- immune support
- improved iron uptake
- support for healthy intestinal bacteria
- softer stools
- improved cholesterol levels.
Probiotics
The intestinal canal, which has an array of bacteria, forms a vital part of our immune function: probiotics are bacteria that grow in our gut and strongly influence bowel health. Breastfed babies tend to have healthy bowel flora, mainly bifidobacteria (over 90 percent) that protects against infections and keeps their motions soft. Interestingly, infants born via Caesarean can have very low levels of healthy intestinal bacteria. So if you had a Caesarean and are formula feeding, one with probiotics may be beneficial. Formula-fed babies still have bacteria in their bowel but not as much bifidobacteria. There is also some research suggesting that bubs on formula that contains Bifidus B have less febrile temperatures and experience less diarrhoea.
Formulas with probiotics appear to change a baby's bowel flora to be closer to that of a breastfed baby. Studies show that probiotic formulas may soften bowel motions, assist in preventing nappy rash and offer some protection against gastroenteritis. Lastly, probiotics may assist in preventing allergies, in particular infantile eczema.
Betacarotene
Betacarotene is found mainly in dark green and yellow fruit and vegetables, for example carrots, and in breastmilk (being very high in the early milk during the first week after birth). Our body changes much of the betacarotene we eat into vitamin A, to be used for the healthy growth of body cells. The betacarotene that remains unchanged is used directly as an antioxidant, which helps prevent cell damage and, possibly, cancer in older people. While vitamin A levels are sufficient in all formulas, many do not have betacarotene. However, it is interesting that evidence to date does not support any health benefit for babies having betacarotene as well as vitamin A in their formula.
Types of formula
1 Dairy-based formulas
So now we know that the protein part of milk consists of two types - casein and whey - let's look at breastmilk to see the ratios of these two proteins. In the beginning, breastmilk is whey dominant, with the ratio of whey to casein changing over the stages of lactation. In colostrum, on day one, the whey to casein ratio is 90:10; in mature milk, from day two to three onwards, the ratio is closer to 60:40 (whey:casein); and after eight months the ratio is balanced equally at 50:50. It is these ratios that are used in some infant formula makeup, with the aim to get formula as close to breastmilk as humanly possible.
Whey-dominant formulas are primarily based on whey protein in milk. These formulas have the bonus of being easier for infants under four months to digest than casein-dominant formulas.
Casein-dominant formulas use, largely, curd from dairy milk. While often less expensive, casein-dominant formulas are generally better suited to older infants due to the difficulty younger babies have in digesting casein. Casein is the protein in milk that has been linked to dairy-based allergies in such babies.
2 Soy-based formulas
Soy differs from the usual cows' milk-based infant formulas in two ways: firstly, it doesn't contain cows' milk proteins and secondly - being a plant - it doesn't contain lactose. In some circumstances soy-based formula may be recommended, for example for infants with galactosaemia.
While soy-based formulas do not contain lactose, much of the research on lactose intolerances suggests that using a partially hydrolysed cows' milk-based formula has better outcomes.
How is soy formula made?
The basis of soy formulas is soybean extract, and they can be used from birth onwards. Harvested soybeans are processed to remove the outer layer (hull) and create a pulp, and then they are further processed to oil and flakes. The flakes of soybeans can be made into soy flour or soy-protein isolate, and it's the latter that both formula and some types of soy milk are made from. Because plant forms of protein are generally considered incomplete, in that they are missing an essential amino acid (one that the body can't make), the soy-protein isolate is supplemented with additional amino acids to ensure nutritional bases are covered.
The Australian College of Paediatrics has raised concern over contaminants in soy such as aluminium (used in the extraction process) and also phytoestrogens (plant estrogens found naturally in soybeans) in formula. Many agencies, when reviewing the available literature on soy-based formulas, suggest that while there don't appear to be any adverse effects from using soy, there are greater benefits from the use of modified cows'-milk-based formula.
What about the plant estrogens?
There has been concern raised over the use of soy formula for babies, specifically in relation to phytoestrogens. Phytoestrogens have been shown to have a weak estrogenic (estrogen-like) effect. Debate has raised the issue of how this may affect a baby's reproductive organs. However, current evidence suggests that there is no issue for babies who are fed on soy formula in terms of the plant estrogens found in soybeans. In fact there doesn't appear to be any effect from soy formula on the reproductive organs of babies.
Soy & allergies
While soy-based formulas provide nutrition for normal growth and development, there are some important factors to consider when deciding on their use. Firstly, if the choice to use soy over dairy is due to a family history of allergies it must be noted that up to 50 percent of babies who are allergic to cows' milk protein will also react to soy protein. In fact, if a child is allergic to dairy they are highly likely to also be allergic to soy and/or goats' milk. Soy-based formulas don't prevent allergies. There are also concerns that babies fed on soy may have slightly lower immunity. Soy protein can cause intolerance reactions, with up to 40 percent of infants intolerant to cows' milk also developing soy protein intolerance. For these reasons, using soy to protect against the development of allergies isn't generally recommended. In most cases it's better to use a special low-allergy infant formula such as hydrolysed infant formula. Keep in mind before you make any judgment call about allergies or reactions you should gain a medical diagnosis and advice.
Note: According to the National Health and Medical Research Council, soy-based formulas are not suitable for preterm infants due to the difficulty in digesting the components of soy.
3 Goat's milk-based formulas
Interestingly, goats' milk straight from the goat is said to be the closest in composition to human breastmilk, though "closest" doesn't mean it is in fact similar. Many people use this information to suggest that goat's milk therefore has superior nutritional qualities to other types of milk but this is not true. Once again, goats' milk-based formulas, like soy, have been used for infants who don't respond well on dairy or soy-based formula or who have a family history of lactose intolerance. Special mention must be made that fresh goats' milk is not recommended for infant feeding as it is low in essential nutrients including vitamins A, D, C, B1, B6, B12 and B9, the latter two being integral to neural development. As a drink it may be offered from 12 months onwards.
Do I need to swap to a stage two?
It is probably best if you do. You should follow the guidelines that manufacturers provide and use an age-appropriate formula. As babies grow, their nutrient requirements change and so too does their energy requirement as they become more mobile. Many nutrient needs increase with age, though iodine is one exception. So the move to the appropriate stage (follow-on formula) at the right age helps to ensure your baby gets a range of nutrients at the most ideal level for their growth and development.
Leanne Cooper wrote What Do I Feed My Baby? (Cadence Health, $22.50). Visit sneakys.com.au for tip sheets and more information.
Published by My Child Magazine.
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