What no one tells you about formula feeding

I’ll try to overwhelm you with information in a good way here. (Image credit Tanya Little via Flickr Creative Commons.)

Bottlefeeding babies, usually with formula, is, for all intents and purposes, the cultural norm in the United States. For whatever reasons, most American babies are not exclusively breastfed by the time they are 28 days old. Many breastfeeding moms are upset about the lack of support for breastfeeding, and rightly so. But families who use formula are also upset about a lack of support for their feeding method. Possibly because feeding formula is the cultural norm, and possibly because mainstream parenting tends to love the schedule and watch the numbers, there is not a lot of support or information about feeding babies formula and bottlefeeding in a respectful way.

Here’s my attempt to address some of the questions families may have about formula and bottles.

What type of formula should my baby eat?

Formula comes in a few forms: Ready-to-feed (which is just like it sounds), liquid concentrate (which is mixed with water before use), and powdered (the most common). It can be based on either cow’s milk, soy, or goat’s milk. These bases have been altered in various ways for different circumstances, and have different types of fortification. It can be confusing to know which to pick.

Generally speaking, families should talk to their child’s doctor about the best formula for their babies. However, keep in mind that pharmaceutical companies do forge relationships with care providers in order to encourage them to recommend one brand over others, and for most babies who are full term and healthy, a “standard” formula will do. All artificial baby milk does need to adhere to certain nutritional standards. All of it, when properly reconstituted, will provide specific amounts of calories, fat, and nutrients. Store brand formulas, which can be significantly less expensive than name-brand versions, are held to these same requirements.

Ready-to-feed formula should be used for any infant who may not be able to handle the potential risks of contaminants in powdered formula or the water used to reconstitute it, such as those infants born early or those who are immunocompromised. Ready-to-feed formula, while more expensive, is more convenient, as well, and you know it’s always properly constituted. Premature infants should, ideally, be receiving human milk from a milk bank and only fortifiers made from human milk, because there are risks of formula feeding for these babies that go way beyond potential contaminants. Necrotizing enterocolitis is a real, huge, potentially fatal concern for fragile infants, a concern that is greatly reduced when only human milk is given.

It also needs to be noted that there are risks of formula feeding for both babies and mothers, and that human milk banks and peer-to-peer milk sharing may be an option you wish to consider.

What are the different types? Should I be choosing low iron, soy, or hypoallergenic formula?

If your baby has a health or dietary concern that may necessitate a special kind of formula, this is something that should be discussed with your doctor. Soy formula is generally only used when a baby has a milk protein allergy or lactose intolerance (a very rare condition for an infant). There is some concern about whether large amounts of soy consumption can mess with a baby’s hormones, but research specific to infant formula is lacking and what we have is inconclusive. Most formula has a high iron content because the type of iron used in formula is not as readily absorbed as the iron in breastmilk, but it can cause constipation in some babies; if your baby is chronically constipated, a low-iron formula may help (but, again, talk to your doctor). Babies whose stomachs aren’t fond of standard formula may benefit from partially hydrolyzed formula, but hypoallergenic formula, given its expense and not-so-great smell, is meant for those babies who absolutely need it due to severe allergies.

Do I need to buy special water to make formula?

While Nursery® water—which is distilled, purified water with or without added fluoride—has been available for years, it’s nothing necessary unless you’re seeking fluoride supplementation for your baby or wish to control the amount of fluoride in your baby’s formula. Most municipal water supplies are fluoridated, but they may be fluoridated to different levels. The CDC has some discussion about fluoride and formula, as there is some concern that excess amounts of fluoride can lead to fluorosis in children, which is characterized by white streaks in tooth enamel. Bottled water should be used, obviously, when drinking water is not safe.

What’s the proper way to prepare formula?

Anyone who has had a baby will notice that everyone seems to have a different opinion on how to do everything. Formula preparation is absolutely no exception. has some information on food safety in terms of feeding babies, along with links to the NIH, FDA, and WHO recommendations for formula preparation. Whatever formula you’re using should also have instructions on how to mix it properly.

In terms of water temperature and the storage of prepared formula, I recommend that you read the information that we have from various public health authorities and figure out what you are comfortable with. Let’s be honest: We don’t all follow every recommendation for every public health issue, and we make our own choices. While it may be the official recommendation from the WHO to use boiled water cooled to 70 degrees C (158 degrees F) to mix with powdered infant formula, most parents are using tap or bottled water. (The reasoning for this particular temperature is that boiling will kill off pathogens in the water, and cooling it to 70 degrees C strikes a balance between destroying potential contaminants in powdered formula while preserving vitamin C, which denatures at high temperatures.) Using tap or bottled water without heating is not the “right” way to do it, and boiling every time is obviously time consuming; you will figure out the right way for your circumstances and hopefully it will be an informed choice.

Even more crucial than water temperature may be ensuring that you’re using the correct concentration of powdered (or liquid) formula to water. Pay close attention to how you’re scooping and adding to water; adding water to powdered formula gives you a different concentration than if you’re adding powdered formula to a certain amount of water. Consider, too, that scoops need to stay with their particular cans of formula, as scoop size or the formulation of the product may change without it being obvious (and it does change from brand to brand or type to type). The concentration can be changed by whether you’re using a leveled or heaping scoop. Over time, your baby is probably getting the right concentration of nutrients even without scientific measuring methods being used, but this is still something of which you should be aware.

One safety concern I would like to point out is that powdered formula is not sterile; that is why it is not recommended for very young or sick babies. It can also become contaminated from things like setting the scoop on the counter and putting it back in the can. The high-iron environment is rather hospitable to bacteria, so try to be mindful of what might get into that can as you’re working through it.

What about homemade formula? 

Homemade formula deserves a post of its own. In a nutshell, homemade formula is not a safe option, particularly for babies who are under 6 months of age and have not yet started complementary foods. It is also a very expensive option. Consider this: The time, effort, and money put toward sourcing the ingredients and making homemade baby formula could be spent on finding donor human milk instead.

What bottle should I use?

The short answer is: Use the bottle your baby likes. Every baby is different, and, although bottle manufacturers would love to try to convince you otherwise, no one bottle will fit every baby’s mouth or habits, and absolutely no bottle can truly mimic the breast. Babies should be “latched” onto a bottle very similarly to how they latch onto a breast—with “fish lips,” with enough nipple in their mouth that they stay on securely but no so much that they may be gagged, and able to drink at a comfortable pace. Use a flow level that suits your baby’s needs, not your baby’s age.

Practically speaking, you probably won’t need the most expensive bottles and you may need to try a few different types before you find one that works. I suggest starting inexpensively and working your way up if needed. Surprisingly—or maybe not—some of the bottles that are most happily taken by babies are the least expensive ones.

Where does “feeding with respect” come in?

Feeding with respect has nothing to do with what you feed a baby (aside from feeding age-appropriate food), but how. Every parent and care provider that offers bottles should learn how to use paced bottle feeding. This is a way of watching a baby’s cues to ensure a baby is getting enough but not being overfed. Babies shouldn’t be forced to finish bottles, no matter how expensive the formula was or how hard you worked to pump that milk. Babies should also be held while eating, with their bottles held for them by a person—no propping. Take the time to make feeding your baby an enjoyable experience for you both.

Here’s a video about paced bottle feeding:

Where can I go for more information and support?

Believe it or not, you can ask a lactation consultant or counselor for help with bottlefeeding, regardless of what is in the bottle. We think about how to feed infants more than anyone else, and, as a result, end up with a good understanding of feeding methods other than just feeding human milk from a human breast. If you’re nervous about whether or not you will get support or a lecture—ask. “Will you be able to offer support with bottlefeeding? Can you offer support if I use formula?” Yes, there are some breastfeeding support people who are adamantly anti-formula, but the vast majority of us want to support individual moms and families more than anything else. At the very least, in my opinion, we should all be able to direct families to resources that suit their needs.

Amy Peterson is one IBCLC who offers a lot of support for bottlefeeding, and she and her co-author, Mindy Harmer, a speech and language pathologist, have done a ton of independent research into what makes a great nipple, bottle, and pacifier. Their insight is valuable for the caregivers of any bottlefed baby.

It would be remiss of me to avoid mentioning Suzanne Barston, The Fearless Formula Feeder, even if I feel that she doesn’t give lactation professionals or activists enough credit. She is still fostering a unique community for people who use a wide variety of feeding methods for a wide variety of reasons, and I appreciate that she doesn’t entirely throw breastfeeding under the bus in order to help others.

What did I miss? Throw your questions at me if you have them. I am happy to provide evidence-based support about breast, bottle, or both. My primary goal, always, is to help families reach their breastfeeding goals, but all families need support and sound advice. And since not everyone’s breastfeeding goal involves breastfeeding until age one or later, it is important for the health, safety, and sanity of parents to have information on safe and respectful formula and bottlefeeding.