What is the best infant formula?

If you saw my most recent post in “Saying Grace,” you know that with both daughters I was one month short of having each exclusively breastfed up to one year.

Ultimately coming up short is not something most moms want to admit, especially those of us who consider ourselves breastmilk advocates and highly invested in pediatric health. However finding myself in this position, twice now, has led me to ask myself a question so many moms wonder:

What is the best infant formula for my baby?

 

Your job is to feed your child the best you can. If formula is the way your family needs to go for whatever reason, this post will help support you in thinking through that decision and ultimately, in deciding which option is most appropriate for your child’s needs and family’s situation.

Types of Infant Formula

For most parents and pediatricians, the conversation of “which formula to feed our baby” starts and ends with the type: Milk-based, soy-based, and partially or fully hydrolyzed formulas. Each of these is intended for infants with specific health needs and dietary tolerances.

Milk Based

Majority of the infant formula on the market is made from cow’s milk. This type of formula is the most well-researched and considered nutritionally adequate for majority of infants.

Soy Based

For infants with known or suspected cow’s milk protein allergies or lactose intolerance, soy formulas are the next suitable option. Being both readily-available and more affordable than the following options, soy formulas may be worth trying if your child needs to avoid cow’s milk based formulas. However research shows that, “Eight to 14% of infants with symptoms of cow's milk allergy will also react adversely to soy,” so children with milk and soy allergies may need a formula where the large protein is broken down, being either partially or extensively hydrolyzed.

Hydrolyzed

These formulas are either partially or extensively hydrolyzed to promote tolerance, depending on how much processing is required for an infant’s gut to adequately digest and absorb the given infant formula. Many of your partially hydrolyzed formulas are those that are marketed for improved comfort, gastrointestinal ease and reduced spit-up (such as Enfamil Gentlease and Gerber Good Start Gentle and Soothe). While some people may see their infant benefits from a partially hydrolyzed formula, these are not hypoallergenic. For this reason, most infants allergic to cow’s milk will react to the large pieces of milk protein in partially hydrolyzed formulas as well. For this reason, many infants with a milk-protein allergy will need an extensively hydrolyzed formula, such as Alimentum or Nutramigen. For infants who need a hypoallergenic formula, extensively hydrolyzed formula work for a reported 90% of infants with a cow’s milk allergy.
 

Elemental

Lastly, formulas such as Elecare or Neocate are the most elemental, or “pre-digested,” form of infant formula available. They offer complete nutrition to infants who are unable to tolerate even those that have been extensively hydrolyzed. If after evaluating this is the type of formula your child needs with your child’s pediatrician and/or pediatric registered dietitian, call your insurance to see what type of coverage may be available. Depending on your plan and child’s condition, some insurance companies may help to offset the out of pocket expenses for this formula.

A Visual of it All

Back when I worked at Texas Children’s Hospital, I remember we used to explain the different types of formulas to parents like this: 

Some parents may be inclined to quickly move down the pyramid, thinking the more pre-digested the formula the fewer issues their infant will have. However, it is important to remember that very few babies require this specialized of formula. Symptoms of occasional gas, fussiness, spit-up, and irritability are typically normal aspects of infant life. If you have concerns that your child is experiencing any of these excessively (i.e. constipation, diarrhea, blood or mucous in stools, vomiting, eczema, fatigue and weakness), they are struggling to gain weight on a given formula regimen, or they have other health issues that may be impacted by their infant formula, talk to your pediatrician and/or a pediatric registered dietitian nutritionist about what other options may be available for promoting tolerance. While some children may need to switch to a different formula, it is not recommended to change formulas frequently, especially without first seeking medical advice.

The main goal is to find one formula that fits your infant’s needs and your family’s lifestyle, and to stick with it solely or ideally as a supplement to breastfeeding until age one.

Most sites that came up when I googled, “what is the best formula,” left the conversation at this. Once you know what type of formula your child assumptively may need, you are apparently good to go. Head to the grocery store, but then be prepared to stand completely overwhelmed with options. Because as Today’s Dietitian puts it,

"There are so many things added now…Prebiotics, probiotics, lutein for eye and brain development, and increased levels of vitamin E…There are different protein sources, different ratios of casein to whey, partially hydrolyzed protein, extensively hydrolyzed protein, or even elemental formulas. There are formulas with 19, 22, or 24 kcal per ounce instead of 20. There are even human milk fortifiers, used to increase the nutrient content of breast milk for preemies.”

I am a pediatric dietitian and all these options make even my head spin.

So let's chat about some of the issues to consider when qualifying which infant formulas are best to meet your infant’s needs and family’s lifestyle.

My advice is to also consider the convenience, cost, and quality of the formula options at hand.

Consider Convenience

How long will you be offering your infant formula? The duration of how long you will give your infant formula may impact the means you are/are not willing to go through to access premium formula, how much you can afford to spend during that time frame, and other convenience factors such as the form of powder formula, concentrate, or ready to feed.

How will you purchase the formula? Be realistic with your and your family’s shopping habits. If you need an option your husband can pick up at any given store while you are at home with a newborn, consider which may be the most readily available. If you know you tend to shop a few different grocery stores each week, you may be able to shop around to see what infant formula options specialty stores carry. If you are open to ordering online and someone who tends to plan at least a few days to weeks in advance, you may be able to explore more domestic or international options than those available locally in stores.

How will you prepare the formula? For some families, powdered formula is not an issue. They get accustomed to measuring the water and then adding the powder, can maintain safe feeding practices using powder, and don’t have an issue preparing it this way. This is the ideal option as it provides you the greatest number of options for choosing an infant formula. If however, there may be a childcare situation with a busy working mom, an older caretaker, or a less mature babysitter that demands the convenience of already prepared, ready to feed infant formula, powdered may not be an everyday option. For such families, the convenience factor may be worth the peace of mind that the formula is being mixed properly every time, in exchange for the reassurance that they have selected the most premium product available (in powder).

 

Consider Cost

While I agree with the remarks from one food analyst of the Cornucopia Institute that not all organic formulas are made equal (as restated in a popular article on FoodBabe found here), I also don’t believe that means you have to buy the most expensive option either. Although breastmilk is by far the most economical option, we are forced to consider what our families can afford when it comes to including infant formula to our “food budget” as well.

Consider where you are most willing to spend your money. If you need a ready to feed formula, there will be an added cost for that when compared to the same product in powder. If you can sacrifice the convenience factor of ready to feed formula however for a higher quality product, you could invest such money on a superior powdered infant formula, such as many shared here. If you can’t afford ordering premium European formula options, consider which organic options available in the states may be more affordable options.

 

Consider Quality

This could be a whole post of its own, but for the sake of including key factors I believe parents need to consider as part of the “big picture” of formula feeding, I would be remiss to exclude the aspect of quality in this post.

From the types of milk protein to fatty acids added to sugar types used to sweeten infant formula, many parents feel like there are red flags everywhere when it comes to the ingredient lists on formula. Unfortunately, just purchasing any old infant formula with an organic label in the United States does not ensure you will get the highest standards either. Instead, what many parents discover are the disturbing the differences in the FDA’s United States standards compared to those from the European Union. Many purists in the formula world will recommend using a European formula option instead of even organic options available in the states. Such options include brands like Hippe and Holle.

While there are some key ingredients to keep a closer eye on that distinguish even organic U.S. formulas from those available in Europe, parents also need to use their discretion when ordering such formulas and the sources they get these from since European formulas are not regulated by the FDA.

A Note on Homemade Infant Formulas

This may need to be it's own post at some point, but for now I want to be sure to include a strong advisory against homemade infant formula. I believe in the power of real foods and advocate to optimize nutrition starting as early as possible. However, dietitians from all over the world are seeing homemade baby formula as an increasingly popular trend. Often seen as a "healthier alternative" to infant formula when breastmilk is not an option, parents assume real food, "clean" ingredients must then make a superior product to a manufactured powder. Unfortunately such claims by certain organizations (like Weston A. Price) are not well-substantiated by science. Additionally, too many people are unofficially publishing such homemade formula recipes without the rigor and scrutiny required to ensure these options are safe for infants. An alternative option may be to consider human milk sharing options such as “Human Milk 4 Human Babies” and “Eats on Feets."

In Summary

What all parents need to know is that infant formulas on the market are designed to provide baseline nutrition for all infants. While I don’t believe all products are created equal nor all formulas are on the same playing field, parents need to find a bit of peace in the fact that any formula technically “will do.” With this said, there are several other factors discussed above that impact your decision as to which formula is the best fit for your family, starting with the type. Furthermore, families need to consider other aspects including:

• Convenience
• Cost
• Quality