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Finding a Formula

Q. My sister gave up breastfeeding after only a few weeks, and she had to switch formulas several times to find one that agreed with her baby. One of my vegetarian friends feeds her infant soy formula, while my neighbor's baby drinks a special hypoallergenic preparation. I've also noticed lactose-free formula on the supermarket shelf --the choices are overwhelming! How can I figure out which kind is right for my baby?

A.
Although the American Academy of Pediatrics (AAP) recommends that mothers breastfeed their babies for at least 12 months, many women choose not to breastfeed at all, encounter problems with it, or quit early for personal reasons. In these situations, infant formula is the only appropriate substitute for breast milk during the first year of a child's life.

Since commercial formula first became available more than 70 years ago, it has continually undergone modifications and improvements so that it provides the calories and nutrients a baby needs in as close an approximation to breast milk as possible. Formula preparations do differ, however: While the Food and Drug Administration regulates nutrient content, each manufacturer adds its own ingredients and uses its own processing methods. While I can't endorse a specific brand, I can give you an overview of the different types of formula that are available so that you -- together with your baby's doctor -- can choose one that's best for your child.

The Basics

No matter which type of formula you select, make sure it is labelled "with iron" or "iron-fortified." The AAP recommends that all infant formulas contain extra iron. Iron deficiency, which can cause anemia and impair mental and motor development, is markedly reduced in formula-fed infants who drink iron-fortified formula. Unfortunately, anecdotal reports that supplemental iron causes digestive problems such as constipation, spitting up, or colic lead some parents to choose low-iron formulas. However, research studies fail to show that iron-fortified formulas are directly related to these conditions.

Ordinarily, standard cow's milk formula, with its long history of safe use and extensive testing, is the first choice if breastfeeding is eschewed or halted early. Since regular, whole cow's milk is not recommended for babies under a year of age (it contains little iron, is relatively high in protein and minerals and low in essential fatty acids, and can even cause intestinal blood loss), basic infant formula is derived from cow's milk that has been modified to make it more similar to breast milk and more agreeable to an infant's digestive system.

But because some babies do not tolerate regular cow's milk formula, various alternatives have been developed. Unfortunately, many parents do not understand the indications for using these alternative formulas, and switches are often made without a clear rationale. Before deciding to change your infant's formula, speak with your baby's doctor, who can help you make a suitable selection that will be well tolerated by your child.

The Alternatives

One type of cow's milk formula with a special modification is lactose-free formula. It was created to feed babies who suffer from lactose sensitivity or a deficiency of lactase, the digestive enzyme needed to break down the milk sugar lactose, a component of standard formula. Such babies can become fussy, gassy, or experience diarrhea when drinking regular cow's milk formula. Lactose-free formula simply replaces lactose with a more tolerable carbohydrate.

Soy formula, which uses soy protein in place of cow's milk protein (and is also lactose-free), has been available for several decades. It is very popular, and doctors recommend it for a variety of symptoms. Most commonly it is suggested for infants whose fussiness, gas, loose stools, spitting up, or vomiting is believed to be caused by an allergy to cow's milk protein. A soy formula may also be prescribed for infants who have eczema due to a food allergy, trouble digesting lactose, or are recovering from a bout of diarrhea, since the condition can temporarily deplete the lactase enzyme. Some vegetarian parents, like your friend, may prefer to feed their infant a soy formula. Although many breastfeeding mothers choose a soy formula to supplement their infants because they believe it to be healthier, the AAP acknowledges no advantage of soy over cow's milk formula in this instance.

Many infants with symptoms of cow's milk allergy also react adversely to soy. These babies may do best on a hypoallergenic (or protein hydrolysate) formula that has been developed for infants with severe food allergies, problems digesting protein, or colic due to suspected cow's milk protein sensitivity. Since the protein in these formulas is broken down extensively (or predigested) so that it does not provoke an allergic response, hypoallergenic formulas are also recommended for babies at high risk for developing allergies due to a strong family history of them. Most hypoallergenic formulas are also lactose-free and contain fats that have been broken down to facilitate their digestion by babies with fat malabsorption. These specialized formulas can be incredibly helpful for certain babies, but they are more expensive than others and are sometimes not very tasty.

Follow-up and "toddler" formulas are marketed for older babies. These formulas contain extra protein, calcium, and iron for children who may not receive adequate amounts from the food they eat. However, if your child eats a well-rounded diet and drinks regular formula through age 1, this type of formula is probably not necessary.

Special Circumstances

Other formulas have been developed for infants with conditions that require extra care. For example, one manufacturer makes a cow's milk formula that is pre-thickened with rice starch to reduce regurgitation in infants who spit up more frequently than others. Another makes a soy formula with added soy fiber, which is believed to shorten the duration of diarrhea in toddlers and infants over 6 months. Thankfully, formula manufacturers also make highly specialized formulas for the small number of infants and toddlers born with inherited metabolic disorders that require highly unusual feeding regimens, such as phenylketonuria (PKU).

Special formulas are also available for feeding very small, hospitalized premature infants under a doctor's care. Often they are used to supplement breast milk, giving a tiny preemie that extra boost of nutrients needed to promote speedy growth and development. Premature infant formulas generally contain additional calories, protein, vitamins, minerals (like calcium), and easily digestible fats and carbohydrates. Preterm discharge formulas are now available to provide a higher level of nutrients to improve the growth of very premature infants after they leave the hospital.

I hope this primer will help you sort through the maze of formula options you've encountered. Once you and your doctor have made a choice, through, don't forget that feedings aren't just about nutrition. They are also an ideal time for intimate social interaction between you and your infant. You can encourage this closeness by holding your baby close to you in a semi-upright position, making eye contact, and speaking softly to him while he eats. Just because you're not breastfeeding doesn't mean you can't share a special bond with your baby during this time.

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