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FDA Consumer Reprint--Breast Milk or Formula: Making the Right Choice for Your Baby
Breast Milk or Formula: Making the Right Choice for
Your Baby
Source: Rebecca D. Williams and Isadora Stehlin, Publication No. (FDA) 98-2309
New parents want to give their babies the very best. When it comes to nutrition, the
best first food for babies is breast milk.
More than two decades of research have established that breast milk is perfectly suited
to nourish infants and protect them from illness. Breast-fed infants have lower rates of
hospital admissions, ear infections, diarrhea, rashes, allergies, and other medical
problems than bottle-fed babies.
"There are 4,000 species of mammals, and they all make a different milk. Human
milk is made for human infants, and it meets all their specific nutrient needs," says
Ruth Lawrence, M.D., professor of pediatrics and obstetrics at the University of Rochester
School of Medicine in Rochester, N.Y., and spokeswoman for the American Academy of
Pediatrics.
Health experts say increased breast-feeding rates would save consumers money, spent
both on infant formula and in health-care dollars. It could save lives as well.
"We've known for years that the death rates in Third World countries are lower
among breast-fed babies," says Lawrence. "Breast-fed babies are healthier and
have fewer infections than formula-fed babies."
Although breast-feeding is still the best nourishment for infants, infant formula is a
close enough second that babies not only survive but thrive.
Commercially prepared formulas are regulated by the Food and Drug Administration.
The nutritional adequacy of commercially prepared formula is also ensured by the
agency's nutrient requirements and its safety by strict quality control procedures that
require manufacturers to analyze each batch of formula for required nutrients, to test
samples for stability during the shelf life of the product, to code containers to identify
the batch, and to make all records available to FDA investigators.
The composition of infant formula is similar to breast milk, but it isn't a perfect
match, because the exact chemical makeup of breast milk is still unknown.
Human milk is very complex, and scientists are still trying to unravel and understand
what makes it such a good source of nutrition for rapidly growing and developing infants.
More than half the calories in breast milk come from fat, and the same is true for
today's infant formulas. This may be alarming to many American adults watching their
intake of fat and cholesterol, especially when sources of saturated fats, such as coconut
oil, are used in formulas. (In adults, high intakes of saturated fats tend to increase
blood cholesterol levels more than other fats or oils.) But the low-fat diet recommended
for adults doesn't apply to infants.
The reason is that infants have a high energy requirement, and they have a restricted
volume of food that they can ingest. The way to meet these energy requirements in a
restricted amount of food is to have a high amount of fat.
While greater knowledge about human milk has helped scientists improve infant formula,
it has become "increasingly apparent that infant formula can never duplicate human
milk," wrote John D. Benson, Ph.D, and Mark L. Masor, Ph.D., in the March 1994 issue
of Endocrine Regulations. "Human milk contains living cells, hormones, active
enzymes, immunoglobulins and compounds with unique structures that cannot be replicated in
infant formula."
Benson and Masor, both of whom are pediatric nutrition researchers at infant formula
manufacturer Abbott Laboratories, believe creating formula that duplicates human milk is
impossible. "A better goal is to match the performance of the breastfed infant,"
they wrote. Performance is measured by the infant's growth, absorption of nutrients,
gastrointestinal tolerance, and reactions in blood.
Human Milk for Human Infants
The primary benefit of breast milk is nutritional. Human milk contains just the right
amount of fatty acids, lactose, water, and amino acids for human digestion, brain
development, and growth.
Cow's milk contains a different type of protein than breast milk. This is good for
calves, but human infants can have difficulty digesting it. Bottle-fed infants tend to be
fatter than breast-fed infants, but not necessarily healthier.
Breast-fed babies have fewer illnesses because human milk transfers to the infant a
mother's antibodies to disease. About 80 percent of the cells in breast milk are
macrophages, cells that kill bacteria, fungi and viruses. Breast-fed babies are protected,
in varying degrees, from a number of illnesses, including pneumonia, botulism, bronchitis,
staphylococcal infections, influenza, ear infections, and German measles. Furthermore,
mothers produce antibodies to whatever disease is present in their environment, making
their milk custom-designed to fight the diseases their babies are exposed to as well.
A breast-fed baby's digestive tract contains large amounts of Lactobacillus bifidus,
beneficial bacteria that prevent the growth of harmful organisms. Human milk straight from
the breast is always sterile, never contaminated by polluted water or dirty bottles, which
can also lead to diarrhea in the infant.
Human milk contains at least 100 ingredients not found in formula. No babies are
allergic to their mother's milk, although they may have a reaction to something the mother
eats. If she eliminates it from her diet, the problem resolves itself.
Sucking at the breast promotes good jaw development as well. It's harder work to get
milk out of a breast than a bottle, and the exercise strengthens the jaws and encourages
the growth of straight, healthy teeth. The baby at the breast also can control the flow of
milk by sucking and stopping. With a bottle, the baby must constantly suck or react to the
pressure of the nipple placed in the mouth.
Nursing may have psychological benefits for the infant as well, creating an early
emotional attachment between mother and child. At birth, infants see only 12 to 15 inches,
the distance between a nursing baby and its mother's face. Studies have found that infants
as young as 1 week prefer the smell of their own mother's milk. When nursing pads soaked
with breast milk are placed in their cribs, they turn their faces toward the one that
smells familiar.
Many psychologists believe the nursing baby enjoys a sense of security from the warmth
and presence of the mother, especially when there is skin-to-skin contact during feeding.
Parents of bottle-fed babies may be tempted to prop bottles in the baby's mouth, with no
human contact during feeding. But a nursing mother must cuddle her infant closely many
times during the day. Nursing becomes more than a way to feed a baby; it's a source of
warmth and comfort.
Benefits to Mothers
Breast-feeding is good for new mothers as well as for their babies. There are no
bottles to sterilize and no formula to buy, measure and mix. It may be easier for a
nursing mother to lose the pounds of pregnancy as well, since nursing uses up extra
calories. Lactation also stimulates the uterus to contract back to its original size.
A nursing mother is forced to get needed rest. She must sit down, put her feet up, and
relax every few hours to nurse. Nursing at night is easy as well. No one has to stumble to
the refrigerator for a bottle and warm it while the baby cries. If she's lying down, a
mother can doze while she nurses.
Nursing is also nature's contraceptive--although not a very reliable one. Frequent
nursing suppresses ovulation, making it less likely for a nursing mother to menstruate,
ovulate, or get pregnant. There are no guarantees, however. Mothers who don't want more
children right away should use contraception even while nursing. Women who are
breast-feeding can use barrier methods of birth control, such as condoms and diaphragms.
Hormone-containing methods are not first choice. These include injections (such as
Depo-Provera), implants (such as Norplant), and birth control pills. A woman who
breast-feeds should consult her doctor about which type of contraception is appropriate
for her until the baby is weaned.
Breast-feeding is economical also. Even though a nursing mother works up a big appetite
and consumes extra calories, the extra food for her is less expensive than buying formula
for the baby. Nursing saves money while providing the best nourishment possible.
When Formula Is Necessary
There are very few medical reasons why a mother shouldn't breast-feed, according to
Lawrence.
Most common illnesses, such as colds, flu, skin infections, or diarrhea, cannot be
passed through breast milk. In fact, if a mother has an illness, her breast milk will
contain antibodies to it that will help protect her baby from those same illnesses.
A few viruses can pass through breast milk, however. HIV, the virus that causes AIDS,
is one of them. Women who are HIV positive should not breast-feed.
A few other illnesses--such as herpes, hepatitis, and beta streptococcus
infections--can also be transmitted through breast milk. But that doesn't always mean a
mother with those diseases shouldn't breast-feed, Lawrence says.
"Each case must be evaluated on an individual basis with the woman's doctor,"
she says.
Breast cancer is not passed through breast milk. Women who have had breast cancer can
usually breast-feed from the unaffected breast. Studies have shown, however, that
breast-feeding a child reduces a woman's chance of developing breast cancer later.
Silicone breast implants usually do not interfere with a woman's ability to nurse, but
if the implants leak, there is some concern that the silicone may harm the baby. Some
small studies have suggested a link between breast-feeding with implants and later
development of problems with the child's esophagus. Further studies are needed in this
area. But if a woman with implants wants to breast-feed, she should first discuss the
potential benefits and risks with her child's doctor.
Tough but Worthwhile
For all its health benefits, breast-feeding isn't always easy. In the early weeks, it
can be painful. A woman's nipples may become sore or cracked. She may experience
engorgement more than a bottle-feeding mother, when the breasts become so full of milk
they're hard and painful. Some nursing women also develop clogged milk ducts, which can
lead to mastitis, a painful infection of the breast. While most nursing problems can be
solved with home remedies, mastitis requires prompt medical care.
Women who plan to go back to work soon after birth will have to plan carefully if they
want to breast-feed. If her job allows, a new mother can pump her breast milk several
times during the day and refrigerate or freeze it for the baby to take in a bottle later.
Some women alternate nursing at night and on weekends with daytime bottles of formula.
In either case, a nursing mother is physically tied to her baby more than a
bottle-feeding mother. The baby needs her for nourishment, and she needs to nurse
regularly to avoid getting uncomfortably full breasts. But instead of feeling it's a
chore, nursing mothers often cite this close relationship as one of the greatest joys of
nursing.
If a woman is unsure whether she wants to nurse, she can try it for a few weeks and
switch if she doesn't like it. It's very difficult to switch to breast-feeding after
bottle-feeding is begun.
If she plans to breast-feed, a new mother should learn as much as possible about it
before the baby is born. Obstetricians, pediatricians, childbirth instructors, nurses, and
midwives can all offer information about nursing. But perhaps the best ongoing support for
a nursing mother is someone who has successfully nursed a baby.
La Leche League, an international support organization for nursing mothers, has
chapters in many cities that meet regularly to discuss breast-feeding problems and offer
support.
Most La Leche League chapters allow women to come to a few meetings without charge.
League leaders offer advice by phone as well. To find a convenient La Leche League
chapter, call 1-800-LA-LECHE (1-800-525-3243) or contact the organization's world wide web
site at http://www.lalecheleague.org/.
Formula Choices
If the mother cannot or chooses not to breast-feed, normal, full-term infants should
get a conventional cow's-milk-based formula, according to John N. Udall Jr., M.D., chief
of nutrition and gastroenterology at Children's Hospital of New Orleans. However, adverse
reactions to the protein in cow's milk formula or symptoms of lactose intolerance (lactose
is the carbohydrate in cow's milk) may require switching to another type of formula, he
says.
Symptoms that may indicate an adverse reaction to cow's milk protein include vomiting,
diarrhea, abdominal pain, and rash. With lactose intolerance, the most common symptoms are
excessive gas, abdominal distension and pain, and diarrhea. Since some of the symptoms
overlap, a stool test may be necessary to determine the culprit. Usually, lactose
intolerance will produce acidic stools that contain glucose. If the protein is the
problem, stools will be nonacidic and have flecks of blood.
The main alternative to cow's milk formula is soy formula.
The carbohydrates in most soy formulas are sucrose and corn syrup, which are easily
digested and absorbed by infants. However, soy is not as good a protein source as cow's
milk. Also, babies don't absorb some minerals, such as calcium, as efficiently from soy
formulas. Therefore, according to the American Academy of Pediatrics, "Healthy
full-term infants should be given soy formula only when medically necessary."
For a child who can't tolerate cow's milk protein, William J. Klish, M.D., a Baylor
College of Medicine pediatrician and former chairman of the American Academy of Pediatrics
Committee on Nutrition recommends the use of hydrolyzed-protein formula. Although
hydrolyzed-protein formulas are made from cow's milk, the protein has been broken up into
its component parts. Essentially, it's been predigested, which decreases the likelihood of
an allergic reaction.
Iron
The infant formulas currently available in the United States are either
"iron-fortified"--with approximately 12 milligrams of iron per liter--or
"low iron"--with approximately 2 milligrams of iron per liter.
"There should not be a low-iron formula on the market for the average child
because a low-iron formula is a nutritionally deficient formula," says Klish.
"It doesn't provide enough iron to maintain proper blood cell counts or proper
hemoglobin." (Hemoglobin is a blood protein that carries oxygen from the lungs to the
tissues, and carbon dioxide from the tissues to the lungs.)
In addition, studies have shown that school children who had good iron status as
infants because they were fed iron-fortified formula performed better on standardized
developmental tests than children with poor iron status. However, FDA has permitted
marketing of low-iron formulas because some pediatricians prefer to use them.
Why is there low-iron formula on the market? "In the past there have been a lot of
symptoms that have been attributed to iron, including abdominal discomfort, constipation,
diarrhea, colic, and irritability," says Klish. "Also there was some concern
about too much iron interfering with the immune system. All of those concerns and
questions have been laid to rest with appropriate studies."
Another reason for originally producing low-iron formulas was that human milk contains
low amounts of iron--less than a milligram per liter. However, it is now understood that
an infant absorbs virtually 100 percent of the iron from human milk, but considerably less
from infant formula.
Cooking Lessons
Both milk and soy formulas are available in powder, liquid concentrate, or
ready-to-feed forms. The choice should depend on whatever the parents find convenient and
can afford.
Whatever form is chosen, proper preparation and refrigeration are essential. Opened
cans of ready-to-feed and liquid concentrate must be refrigerated and used within the time
specified on the can. Once the powder is mixed with water, it should also be refrigerated
if it is not used right away. The exact amount of water recommended on the label must be
used. Under-diluted formula can cause problems for the infant's organs and digestive
system. Over-diluted formula will not provide adequate nutrition, and the baby may fail to
thrive and grow.
In the past, the American Academy of Pediatrics felt that municipal water supplies were
safe enough without boiling the water before mixing with the formula. But because of the
contamination of Milwaukee's water with the parasite Cryptosporidium in 1993, "the
whole business of boiling water has come up again," says Klish. "The academy is
now again recommending boiling water for infant formulas."
Klish advises heating the water until it reaches a rolling boil, continue to boil for
one to two minutes, and then let it cool. "That should take care of all the bacteria
and parasites that might be in the water," he explains.
The American Academy of Pediatrics does not have any recommendations about bottled
water. Klish says bottled water is fine, but it still needs to be boiled. "There's no
reason to think that bottled water is any safer than city water," he says.
Bottled water must meet specific FDA quality standards for contaminants. These are set
in response to requirements that the Environmental Protection Agency has established for
tap water.
A regulation published in the Nov. 13, 1995, Federal Register sets standard definitions
for different types of bottled waters, helping resolve possible confusion about what
different terms mean.
The regulation also requires accurate labeling of bottled waters marketed for infants.
If a product is labeled "sterile," it must be processed to meet FDA's
requirements for commercial sterility. Otherwise, the labeling must indicate that it is
not sterile and should be used as directed by a physician or according to infant formula
preparation instructions.
What about sterilizing the bottles and nipples? "Dishwashers tend to sterilize
bottles and nipples fairly well," says Klish. They can also be sterilized by placing
them in a pan of boiling water for five minutes.
Warming the formula before feeding isn't necessary for proper nutrition, but most
infants prefer the formula at least at room temperature. The best way to warm a bottle of
formula is by placing the bottle in a pot of water and heating the pot on the stove.
Don't Try This at Home
Homemade formulas should not be used. Homemade formulas based on cow's milk don't meet
all of an infant's nutritional needs, and cow's milk protein that has not been cooked or
processed is difficult for an infant to digest. In addition, the high protein and
electrolyte (salt) content of cow's milk may put a strain on an infant's immature kidneys.
Substituting evaporated milk for whole milk may make the homemade formula easier to digest
because of the effect of processing on the protein, but the formula is still nutritionally
inadequate and still may stress the kidneys.
Today's infant formula is a very controlled, high-tech product that can't be duplicated
at home, says Udall.
Rebecca D. Williams is a writer in Oak Ridge, Tenn. Isadora Stehlin is a member
of FDA's public affairs staff.
Tips for Breast-Feeding Success
It's helpful for a woman who wants to breast-feed to learn as much about it as possible
before delivery, while she is not exhausted from caring for an infant around-the-clock.
The following tips can help foster successful nursing:
- Get an early start: Nursing should begin within an hour after delivery
if possible, when the infant is awake and the sucking instinct is strong. Even though the
mother won't be producing milk yet, her breasts contain colostrum, a thin fluid that
contains antibodies to disease.
- Proper positioning: The baby's mouth should be wide open, with the
nipple as far back into his or her mouth as possible. This minimizes soreness for the
mother. A nurse, midwife, or other knowledgeable person can help her find a comfortable
nursing position.
- Nurse on demand: Newborns need to nurse frequently, about every two
hours, and not on any strict schedule. This will stimulate the mother's breasts to produce
plenty of milk. Later, the baby can settle into a more predictable routine. But because
breast milk is more easily digested than formula, breast-fed babies often eat more
frequently than bottle-fed babies.
- No supplements: Nursing babies don't need sugar water or formula
supplements. These may interfere with their appetite for nursing, and that can lead to a
diminished milk supply. The more the baby nurses, the more milk the mother will produce.
- Delay artificial nipples: It's best to wait a week or two before
introducing a pacifier, so that the baby doesn't get confused. Artificial nipples require
a different sucking action than real ones. Sucking at a bottle could also confuse some
babies in the early days. They, too, are learning how to breast-feed.
- Air dry: In the early postpartum period or until her nipples toughen,
the mother should air dry them after each nursing to prevent them from cracking, which can
lead to infection. If her nipples do crack, the mother can coat them with breast milk or
other natural moisturizers to help them heal. Vitamin E oil and lanolin are commonly used,
although some babies may have allergic reactions to them. Proper positioning at the breast
can help prevent sore nipples. If the mother's very sore, the baby may not have the nipple
far enough back in his or her mouth.
- Watch for infection: Symptoms of breast infection include fever and
painful lumps and redness in the breast. These require immediate medical attention.
- Expect engorgement: A new mother usually produces lots of milk, making
her breasts big, hard and painful for a few days. To relieve this engorgement, she should
feed the baby frequently and on demand until her body adjusts and produces only what the
baby needs. In the meantime, the mother can take over-the-counter pain relievers, apply
warm, wet compresses to her breasts, and take warm baths to relieve the pain.
- Eat right, get rest: To produce plenty of good milk, the nursing mother
needs a balanced diet that includes 500 extra calories a day and six to eight glasses of
fluid. She should also rest as much as possible to prevent breast infections, which are
aggravated by fatigue.
--R.D.W.
Medicines and Nursing Mothers
Most medications have not been tested in nursing women, so no one knows exactly how a
given drug will affect a breast-fed child. Since very few problems have been reported,
however, most over-the-counter and prescription drugs, taken in moderation and only when
necessary, are considered safe.
Even mothers who must take daily medication for conditions such as epilepsy, diabetes,
or high blood pressure can usually breast-feed. They should first check with the child's
pediatrician, however. To minimize the baby's exposure, the mother can take the drug just
after nursing or before the child sleeps. In the January 1994 issue of Pediatrics, the
American Academy of Pediatrics included the following in a list of drugs that are usually
compatible with breast-feeding:
- acetaminophen
- many antibiotics
- anti-epileptics (although one, Primidone, should be given with caution)
- most antihistamines
- alcohol in moderation (large amounts of alcohol can cause drowsiness, weakness, and
abnormal weight gain in an infant)
- most antihypertensives
- aspirin (should be used with caution)
- caffeine (moderate amounts in drinks or food)
- codeine
- decongestants
- ibuprofen
- insulin
- quinine
- thyroid medications
Drugs That Are Not Safe While Nursing
Some drugs can be taken by a nursing mother if she stops breast-feeding for a few days
or weeks. She can pump her milk and discard it during this time to keep up her supply,
while the baby drinks previously frozen milk or formula.
Radioactive drugs used for some diagnostic tests like Gallium-69, Iodine-125,
Iodine-131, or Technetium-99m can be taken if the woman stops nursing temporarily.
Drugs that should never be taken while breast-feeding include:
Bromocriptine (Parlodel): A drug for Parkinson's disease, it also decreases a woman's
milk supply.
Most Chemotherapy Drugs for Cancer: Since they kill cells in the mother's body, they
may harm the baby as well.
Ergotamine (for migraine headaches): Causes vomiting, diarrhea, convulsions in infants.
Lithium (for manic-depressive illness): Excreted in human milk.
Methotrexate (for arthritis): Can suppress the baby's immune system.
Drugs of Abuse: Some drugs, such as cocaine and PCP, can intoxicate the baby. Others,
such as amphetamines, heroin and marijuana, can cause a variety of symptoms, including
irritability, poor sleeping patterns, tremors, and vomiting. Babies become addicted to
these drugs.
Tobacco Smoke: Nursing mothers should avoid smoking. Nicotine can cause vomiting,
diarrhea and restlessness for the baby, as well as decreased milk production for the
mother. Maternal smoking or passive smoke may increase the risk of sudden infant death
syndrome and may increase respiratory and ear infections.
Whole Milk for First Birthday
The American Academy of Pediatrics recommends that babies be breast-fed for at least 12
months and thereafter for as long as mutually desired. The only acceptable alternative to
breast milk is infant formula iron fortified and solid foods can be introduced gradually
when the baby is 6 months old, but a baby should drink breast milk or formula, not regular
cow's milk, for a full year.
"There aren't any rules about when to stop breast-feeding," says Ruth
Lawrence, M.D., professor of pediatrics and obstetrics at the University of Rochester
School of Medicine in Rochester, N.Y., and spokeswoman for the academy. "As long as
the baby is eating age-appropriate solid foods, a mother may nurse a couple of years if
she wishes. A baby needs breast milk for the first year of life, and then as long as
desired after that." Formula, however, should not be continued after the first
birthday. That's the time to introduce milk. For all babies the milk, however, should be
whole milk. Low-fat and skim milk do not have enough fat and calories to supply the
nutritional needs of a 1-year-old, explains John Udall, chief of nutrition and
gastroenterology at Children's Hospital of New Orleans. At that age, "the child is
growing so quickly, and the fat is so important for brain and central nervous system
development," he says. "The recommendation that our daily intake of fat should
compose less than 30 percent of our caloric intake does not apply to children under 2
years of age."
New on the market are special toddler formulas that claim to be better than milk. The
formulas are good nutritionally, says Udall, but they're not necessary. "A
well-balanced diet with milk and juices would be just as good in a healthy, normally
active, normally growing child," says Udall.
William Klish, former chairman of the American Academy of Pediatrics Committee on
Nutrition, says that if a child needs to take a vitamin supplement, the toddler formula,
fortified with a full range of vitamins and minerals, including iron, can serve that
purpose. In addition, the toddler formulas don't need refrigeration, making them a
convenient choice for snacks away from home.
--I.S.
Publication No. (FDA) 98-2309
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