The formula shuffle

This month, I will be addressing a very common pediatric phenomenon – the formula shuffle. It is rare for me to go a week in clinic without addressing a parent’s concern about what type of formula they should use (or switch to) in some way, and I suspect many of you have the same experience.

An important disclaimer: Human breast milk is, as we all know, the best source of nutrition for infants in their first year of life. Before we think about educating families about formula, we should always be sure we are educating them as early and often as possible about the benefits of breast-feeding. If a family is struggling with formula choice in the hospital after delivery, or even in the first week of life (if the mother is still producing milk), it is very appropriate to readdress the issue of breast-feeding with a reminder that breast milk is better tolerated than formula! That said, many families still choose formula and/or may not be able to breast-feed for some reason; the remainder of this column will focus on formula-fed infants, but look for a future column focusing on supporting breast-feeding.

For families who choose to formula-feed their infant, the choice of what to use is understandably important to them. What they select will be their infant’s main source of nutrition for a good part of their first year of life. Infants feed often enough that much of a new parent’s day (and night) revolves around feeding – and preparing the formula, and washing bottles, and going to the store to buy formula – another argument for "ready-to-feed" breast milk! Likewise, if something is not going well – an infant is colicky or not sleeping well or spitting up a lot – you can understand why the choice of formula seems a likely culprit. Certainly, the formula manufacturers have figured this out. The number of different formulas for parents to choose from is overwhelming, even when you know and understand the nutritional science!

While a detailed review of indications for using different types and categories of formulas is well beyond the word limit of this column, there are a few basic principles I live by:

• When are specialized formulas indicated? There are sometimes clear medical indications for a specialized formula, such as prematurity, milk-protein allergy, and galactosemia. Be sure you know these, and are clear on what formulas are recommended for use in these situations. For example, soy-based formulas are not recommended for use with milk-protein allergy because a large number of these infants will have cross-reactivity to the soy.

• What about switching for fussiness, spitting up, or allergies? Outside of these clear medical indications, there is not very good evidence that switching formulas is generally very helpful for treating such conditions as fussiness, spitting up, or mild eczema/allergies. That is not to say there is no evidence, but it is generally not very strong or compelling. There is some evidence that extensively or partially hydrolyzed formulas may be helpful in preventing symptoms in infants at high risk for allergic disease (but breast milk is still better). This is not to say that you should never recommend switching formula for a child who does not have a clear medical indication, but you should be clear and thoughtful about why you are doing it. I am also very transparent with parents about what evidence does and doesn’t exist for my recommendation. All that said, I find that many parents have already made the switch on their own, which leads me to my next point.

• Stick with it. In general, almost all formulas provide adequate nutrition. If an infant is tolerating a formula and the parents are happy, I recommend sticking with it unless there is reason not to do so. I do, however, discourage rapid changing of formulas. I find this causes frustration (and wastes money) for the family with little benefit. Often many of the symptoms of concern settle out after a few weeks (often just because of developmental maturity!), so I encourage a 2- to 3-week trial before making another change.

Store-brand formulas are generally equivalent to brand-name formulas, as long as you are sure they aren’t counterfeit formulas or sold outside of the U.S. regulatory system. My general opinion is that there is also no significant benefit to organic formulas, but no real harm either. There has been some controversy that the carbohydrates used in some organic formulas have a sweeter taste, which may be unacceptable to some families, so parents should be made aware of this. In the end, the decision to use an organic formula or not is a personal one.

Most importantly, I try to respect the parents’ concern and desire to do what is best for their child. I reassure them that we will work together until things improve, and that they invariably almost always do.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. 

This month, I will be addressing a very common pediatric phenomenon – the formula shuffle. It is rare for me to go a week in clinic without addressing a parent’s concern about what type of formula they should use (or switch to) in some way, and I suspect many of you have the same experience.

An important disclaimer: Human breast milk is, as we all know, the best source of nutrition for infants in their first year of life. Before we think about educating families about formula, we should always be sure we are educating them as early and often as possible about the benefits of breast-feeding. If a family is struggling with formula choice in the hospital after delivery, or even in the first week of life (if the mother is still producing milk), it is very appropriate to readdress the issue of breast-feeding with a reminder that breast milk is better tolerated than formula! That said, many families still choose formula and/or may not be able to breast-feed for some reason; the remainder of this column will focus on formula-fed infants, but look for a future column focusing on supporting breast-feeding.

For families who choose to formula-feed their infant, the choice of what to use is understandably important to them. What they select will be their infant’s main source of nutrition for a good part of their first year of life. Infants feed often enough that much of a new parent’s day (and night) revolves around feeding – and preparing the formula, and washing bottles, and going to the store to buy formula – another argument for "ready-to-feed" breast milk! Likewise, if something is not going well – an infant is colicky or not sleeping well or spitting up a lot – you can understand why the choice of formula seems a likely culprit. Certainly, the formula manufacturers have figured this out. The number of different formulas for parents to choose from is overwhelming, even when you know and understand the nutritional science!

While a detailed review of indications for using different types and categories of formulas is well beyond the word limit of this column, there are a few basic principles I live by:

• When are specialized formulas indicated? There are sometimes clear medical indications for a specialized formula, such as prematurity, milk-protein allergy, and galactosemia. Be sure you know these, and are clear on what formulas are recommended for use in these situations. For example, soy-based formulas are not recommended for use with milk-protein allergy because a large number of these infants will have cross-reactivity to the soy.

• What about switching for fussiness, spitting up, or allergies? Outside of these clear medical indications, there is not very good evidence that switching formulas is generally very helpful for treating such conditions as fussiness, spitting up, or mild eczema/allergies. That is not to say there is no evidence, but it is generally not very strong or compelling. There is some evidence that extensively or partially hydrolyzed formulas may be helpful in preventing symptoms in infants at high risk for allergic disease (but breast milk is still better). This is not to say that you should never recommend switching formula for a child who does not have a clear medical indication, but you should be clear and thoughtful about why you are doing it. I am also very transparent with parents about what evidence does and doesn’t exist for my recommendation. All that said, I find that many parents have already made the switch on their own, which leads me to my next point.

• Stick with it. In general, almost all formulas provide adequate nutrition. If an infant is tolerating a formula and the parents are happy, I recommend sticking with it unless there is reason not to do so. I do, however, discourage rapid changing of formulas. I find this causes frustration (and wastes money) for the family with little benefit. Often many of the symptoms of concern settle out after a few weeks (often just because of developmental maturity!), so I encourage a 2- to 3-week trial before making another change.

Store-brand formulas are generally equivalent to brand-name formulas, as long as you are sure they aren’t counterfeit formulas or sold outside of the U.S. regulatory system. My general opinion is that there is also no significant benefit to organic formulas, but no real harm either. There has been some controversy that the carbohydrates used in some organic formulas have a sweeter taste, which may be unacceptable to some families, so parents should be made aware of this. In the end, the decision to use an organic formula or not is a personal one.

Most importantly, I try to respect the parents’ concern and desire to do what is best for their child. I reassure them that we will work together until things improve, and that they invariably almost always do.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington. 

This month, I will be addressing a very common pediatric phenomenon – the formula shuffle. It is rare for me to go a week in clinic without addressing a parent’s concern about what type of formula they should use (or switch to) in some way, and I suspect many of you have the same experience.

An important disclaimer: Human breast milk is, as we all know, the best source of nutrition for infants in their first year of life. Before we think about educating families about formula, we should always be sure we are educating them as early and often as possible about the benefits of breast-feeding. If a family is struggling with formula choice in the hospital after delivery, or even in the first week of life (if the mother is still producing milk), it is very appropriate to readdress the issue of breast-feeding with a reminder that breast milk is better tolerated than formula! That said, many families still choose formula and/or may not be able to breast-feed for some reason; the remainder of this column will focus on formula-fed infants, but look for a future column focusing on supporting breast-feeding.

For families who choose to formula-feed their infant, the choice of what to use is understandably important to them. What they select will be their infant’s main source of nutrition for a good part of their first year of life. Infants feed often enough that much of a new parent’s day (and night) revolves around feeding – and preparing the formula, and washing bottles, and going to the store to buy formula – another argument for "ready-to-feed" breast milk! Likewise, if something is not going well – an infant is colicky or not sleeping well or spitting up a lot – you can understand why the choice of formula seems a likely culprit. Certainly, the formula manufacturers have figured this out. The number of different formulas for parents to choose from is overwhelming, even when you know and understand the nutritional science!

While a detailed review of indications for using different types and categories of formulas is well beyond the word limit of this column, there are a few basic principles I live by:

• When are specialized formulas indicated? There are sometimes clear medical indications for a specialized formula, such as prematurity, milk-protein allergy, and galactosemia. Be sure you know these, and are clear on what formulas are recommended for use in these situations. For example, soy-based formulas are not recommended for use with milk-protein allergy because a large number of these infants will have cross-reactivity to the soy.

• What about switching for fussiness, spitting up, or allergies? Outside of these clear medical indications, there is not very good evidence that switching formulas is generally very helpful for treating such conditions as fussiness, spitting up, or mild eczema/allergies. That is not to say there is no evidence, but it is generally not very strong or compelling. There is some evidence that extensively or partially hydrolyzed formulas may be helpful in preventing symptoms in infants at high risk for allergic disease (but breast milk is still better). This is not to say that you should never recommend switching formula for a child who does not have a clear medical indication, but you should be clear and thoughtful about why you are doing it. I am also very transparent with parents about what evidence does and doesn’t exist for my recommendation. All that said, I find that many parents have already made the switch on their own, which leads me to my next point.

• Stick with it. In general, almost all formulas provide adequate nutrition. If an infant is tolerating a formula and the parents are happy, I recommend sticking with it unless there is reason not to do so. I do, however, discourage rapid changing of formulas. I find this causes frustration (and wastes money) for the family with little benefit. Often many of the symptoms of concern settle out after a few weeks (often just because of developmental maturity!), so I encourage a 2- to 3-week trial before making another change.

Store-brand formulas are generally equivalent to brand-name formulas, as long as you are sure they aren’t counterfeit formulas or sold outside of the U.S. regulatory system. My general opinion is that there is also no significant benefit to organic formulas, but no real harm either. There has been some controversy that the carbohydrates used in some organic formulas have a sweeter taste, which may be unacceptable to some families, so parents should be made aware of this. In the end, the decision to use an organic formula or not is a personal one.

Most importantly, I try to respect the parents’ concern and desire to do what is best for their child. I reassure them that we will work together until things improve, and that they invariably almost always do.

Dr. Beers is an assistant professor of pediatrics at Children’s National Medical Center and the George Washington University Medical Center, Washington.