Choosing Baby Formula

This question comes up over and over again — what formula should I get?

Decision points

  • protein source
  • cost
  • ease of access
  • medical restrictions

In the US, infant formula is regulated by the FDA. In order to be marketed as infant formula, it must be in compliance with FDA regulations, which means it must meet certain nutritional requirements and have proven that it does so at the beginning and end of its shelf life.

Are there formulas for sale that are not FDA compliant? Yes, but they are labeled as “toddler formulas” instead of infant formulas. These include “Nature’s One Baby’s Only Toddler Formula” (which supposedly meets the requirements for an infant formula, despite illogical objections to getting certified as such) and “Kabrita Goat Milk Toddler Formula” (which seems to also meet criteria, but is slightly different than the allegedly-forthcoming infant formula version, which is not yet available in the US).

Are the EU requirements very different? No, they are mostly similar.

Cow or goat (or camel or soy)?

Goat milk formula manufacturers and fans frequently describe goat milk as gentler and easier to digest. Is that true?

“Unmodified goat’s milk is not suitable for infants because of the high protein and minerals content and of a low folate content. Goat’s milk has no clear nutritional advantage over cow’s milk and is not less allergenic. The European Food Safety Authority recently stated that proteins from goat’s milk can be suitable as a protein source for infant and follow-on formula, provided the final product complies with the compositional criteria laid down in Directive 2006/141/EC.” Turck, D. (2013). Cow’s milk and goat’s milk. World Review of Nutrition and Dietetics, 108, 56–62. https://doi.org/10.1159/000351485

Comparison of protein, calcium, phosphorus, sodium, and potassium of human, cow, and goat milk. Compiled from http://www.infantnutritioncouncil.com/resources/breastmilk-information/ and http://milkfacts.info. From: http://www.theboobgeek.com/blog/homemade-formula.html

These high levels of proteins and minerals can be damaging to a human infant’s kidneys.

Is goat milk closer to human milk? Maybe. Non-protein components, like nucleotides, may be closer to human milk. Prosser, C. G., Mclaren, R. D., Frost, D., Agnew, M., & Lowry, D. J. (2008). Composition of the non-protein nitrogen fraction of goat whole milk powder and goat milk-based infant and follow-on formulae. International Journal of Food Sciences and Nutrition, 59(2), 123–133. https://doi.org/10.1080/09637480701425585

Is it easier to digest?

“There were differences in the values of some amino acids and blood biomarkers between the formula-fed groups, but the mean values for biomarkers were within the normal reference range. There were no differences in the occurrence of serious adverse events, general health, and incidence of dermatitis or medically diagnosed food allergy. The incidence of parentally reported blood-stained stools was higher in the goat milk formula-fed group, although this was a secondary outcome and its importance is unclear. Goat milk formula provided growth and nutritional outcomes in infants that did not differ from those provided by a standard whey-based cow milk formula.”

Zhou, S. J., Sullivan, T., Gibson, R. A., Lönnerdal, B., Prosser, C. G., Lowry, D. J., & Makrides, M. (2014). Nutritional adequacy of goat milk infant formulas for term infants: a double-blind randomised controlled trial. The British Journal of Nutrition, 111(9), 1641–1651. https://doi.org/10.1017/S0007114513004212

Soy is not generally a recommended option. Babies who are sensitive to dairy are typically sensitive to soy as well.

Summary: don’t use straight up goat milk. Formula based on goat milk is unlikely to be very different than cow, but it is more expensive. There is no evidence that it is ‘gentler’ or “easier to digest” than formula based on cow milk.

Store Bought or Home Made?

Please don’t make your infant formula at home, unless you’re making it in your own body. Infant nutrition is complex. The recipes you find online are not vetted for nutritional adequacy, are very complex and time consuming to make, are expensive to make, and are potentially harmful, with too little of certain nutrients and potentially too much of others. If they are not complex, then they probably are not providing the complex set of nutrients required to grow and thrive.

Ease of Access

I think it’s important that it be easy to find formula to your baby. Scarcity is scary. When formula is difficult to get, it increases stress — we’re almost running out! we’ve run out! we can’t just go to the store to get it! — and leads some families to ration formula, which compromises baby’s nutrition and growth.

To me, this means formula you can buy in a store. Not that you can’t buy it online, but that this shouldn’t be the only way you can access food for your baby.

Home made formula definitely doesn’t qualify as easy to access. Neither does European import formula. Because European formula is not FDA compliant, it cannot be legally distributed in the US, which means that you’re essentially buying out of someone’s trunk of smuggled goods.

Landscape of US Formulas

Here is my understanding of the landscape of formula manufacturers in the US.

Similac and Enfamil are the biggest manufacturers.

Costco Kirkland Signature formula is Similac, “several innovations behind,” although it does have “2’-FL HMO prebiotic for immune support,” which is the big feature of Similac Pro-Advance, so I’m not sure which innovations it’s lacking. Similac for Supplementation doesn’t have that feature, since they assume that if baby is getting some breastmilk, they’re getting those components from the breastmilk.

Enfamil does not do private labeling. The only Enfamil products are those with the Enfamil name.

Most store brands, including Target (Up & Up), Walmart (Parent’s Choice), Kroger (Comforts), are made by Perrigo.

Plum, Honest, Happy Baby, Gerber, and Earth’s Best are presumably manufactured by their respective distributors, but who knows.

Non-GMO? Doesn’t matter to me, but if it matters to you, there are plenty of FDA-compliant non-GMO options.

Organic? Doesn’t matter to me, but if it matters to you, there are plenty of FDA-compliant organic options.

Corn Syrup?

Check out this press release from when Plum Organics launched their infant formula:

The only product of its kind on the market, Plum’s Organic Infant Formula is unique in that it uses organic lactose as its only carbohydrate rather than the industry standard of adding corn syrup solids.

https://www.prnewswire.com/news-releases/plum-organics-enters-earliest-feeding-category-with-organic-infant-formula-300232480.html

Huh. That sure makes it sound like it’s the only formula without corn syrup! So what exotic formula is this ingredient list from?

Surprise, it’s Costco Kirkland Signature Infant Formula with Iron.

Here’s the deal. Humans have relatively low protein, high carbohydrate, high fat milk. If you’re starting with an animal milk like cow milk, the protein is too high, the carbohydrates are too low, and the fat is too low. To make it appropriate for a human infant, you need to add carbs and fat.

There are different classes of formula.

  1. regular dairy formula
  2. special formulas, like “gentle protein,” “for sensitive tummies,” hypoallergenic, etc.

The regular dairy formulas almost all use lactose as the carbohydrate source.

The special formulas generally have lower lactose levels. But they still need carbohydrates, which need to come from somewhere. Generally that’s corn syrup, rice syrup, or glucose syrup (generally derived from corn). Fancy or not, organic or not, that’s the distinguishing feature. The first ingredient of Earth’s Best Organic Sensitivity Infant Formula with Iron is “organic glucose syrup solids.”

I don’t know of any regular dairy formulas that use sucrose as the carbohydrate source, but the blogs plugging the Euro formulas make it sound like those formulas are the only ones without sucrose. It’s not true.

Medical Restrictions

For babies with milk or soy protein intolerance (MSPI), it’s important to understand the special classes of formula. Remember that proteins are molecules built out of long chains of amino acids.

  1. gentle/sensitive – these proteins are broken down a bit (partially hydrolyzed), but are still generally recognizable by the body as being the offending animal protein. This class is mostly for marketing. The protein breakdown isn’t extensive enough for a baby with a real protein intolerance. These include Similac Pro-Sensitive, Enfamil GentleEase.
  2. fully or extensively hydrolyzed proteins like Alimentum or Nutramigen. These amino acid chains are broken down further and are generally not recognized as offensive by the body.
  3. amino acid formulas like Neocate or Elecare — the proteins are completely broken down into their amino acid building blocks

The more broken down the proteins, the more expensive the formula, the yuckier the taste (to the refined adult taste buds, anyway), and the quicker it moves through the baby’s digestive system. These formulas should be recommended or prescribed by a doctor before using.

A Tale of Two Formulas, Two Ways

Here’s a big table that looks at how two popular formulas in the US market and the EU market match up nutrient for nutrient.

Of note, the Euro formulas tend to have lower iron. That may be why they are perceived as better tolerated.

Also of note, the two Hipp and Holle formulas I looked at both fail to meet the EU requirements for a bunch of the B vitamins — riboflavin (B2), pyridoxine (B6), niacin (B3), and pantothenic acid (B5) — and Hipp doesn’t have enough thiamine (B1) either. It’s possible that my math isn’t right — even though I did three times — so if you have a correction for me, let me know.

Cost

Most fully formula-fed babies drink somewhere around 30 oz of formula per day, with a general range of 25-35 oz per day. Less at the beginning.

For folks wondering about costs between Euro imports and formula that’s easily purchased here in the US, here is a minimal comparison set:

Costco, man. Winner winner chicken dinner.

If I play the game — usually on Amazon, stacking big coupons with subscribe & save discounts — I can get Similac Pro Advance down to Kirkland Signature prices.

Both Similac and Enfamil also send formula checks, which are processed like real checks (instead of being processed as coupons). You can apparently use them at Costco, but I’ve never tried. Probably the best way to play the formula check game is to use the $5 checks on small things (like a 6-pack of ready-to-feed bottles to stash in your emergency kit in the car), and when you’ve used three checks, they send you one for $17. You can stack them with manufacturer coupons and Cartwheel.

Powder or Ready-to-Feed?

Most formulas are available as a powder, or pre-prepared liquid that is ready-to-feed. There used to be liquid concentrates available, which you would have to dilute, but they don’t seem to be available anymore.

Powdered formula is significantly cheaper than ready-to-feed formula. You must follow the instructions closely on how to prepare powdered formula. If you use too much or too little water, or too much or too little powder, the formula will have too much or too little nutrition and water. Either way, it’s bad for baby.

For babies under 3 months, it’s recommended to either use ready-to-feed formula, or to prepare powder with very hot water (at least 158°F/70°C). Powdered formula cannot be sterilized and there is a small risk of serious bacterial contamination, which might sicken very young babies. This risk is from the powdered formula itself, not from the water, so using clean water (which most of us have at home from our taps) or bottled or filtered water doesn’t eliminate the risk.

After preparing the formula with hot water, allow it to cool to a reasonable, non-scalding temperature before feeding it to baby.

You can prepare a full day’s worth of formula and refrigerate it — it’s fine in the fridge for 24 hours. The Dr Brown’s pitcher is a great way to mix formula without incorporating a lot of air/bubbles.

tl;dr

For an infant in the US with no medical restrictions, any regular, commercially available, FDA-complaint, infant formula based on cow dairy is fine. Store brand — whether Costco, Target, or whatever is easily available — is likely the most cost-effective.

Useful Info

Most formula is 19-20 kcal (calories) per ounce. (Neosure, which is for preemies, is 22 kcal per ounce.)

If you want to ballpark how much volume your baby needs, 150 mL per kilo will give you a very rough estimate.

Edits: this post was edited on 7/10/19 to remove references to FDA-approved formula, since the FDA doesn’t actually approve it, it just comes after you if you market a formula as an infant formula that doesn’t meet the requirements. Look forward to a post exploring this concept more fully. Oh look, here it is.

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