We discuss formula feeding, including types of formula, preparation, and safety. We are joined by Kelly Mazzarella, DO, Assistant Professor of Neonatal-Perinatal Medicine at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern newborn nursery.
Dr. Neeta Goli:
Welcome back to the podcast. Today, we'll be discussing formula feeding. This will be a special social distancing edition of the podcast brought to you by the COVID pandemic. So we're joined remotely today by Dr. Kelly Mazzarella, Assistant Professor of Pediatrics here at UT Southwestern in the newborn nursery.
Dr. Kelly Mazzarella:
Hey, this is Kelly.
Dr. Neeta Goli:
Dr. Mazzarella, thanks for joining us today.
Dr. Kelly Mazzarella:
Oh, it's a pleasure to be with you guys. Thank you for having me.
Dr. Neeta Goli:
Absolutely. So, some families will provide their babies with formula supplementation or will formula feed their babies all together. While we support and encourage breastfeeding, it is also very important for us to know how to answer our family's questions about formula. So in this episode, we'll talk about some of the most common questions families might have for you. Let's get started. So the most common question I usually get is what kind of formula should I buy for my baby?
Dr. Kelly Mazzarella:
Yeah, I agree. I think that that is the most common question that I'll get from families as well. The big thing is you don't need a name brand. Generic formula will suffice for infants. Cost is a big consideration. I'm actually a member of a Similac reward program, so they have coupons that they offer through that. You just sign up online. So I'm a big couponer so I'll tend to do that, but other families might not want to do that. And so going with the generic brand, as I'll mention later when I talk about price range, is a perfectly good option as well.
Dr. Kelly Mazzarella:
The FDA requires infant formulas meet certain standards for nutrition, and this is where we can actually say a generic versus a brand name really doesn't matter. So no one formula is better than the other when we're just discussing the standard formulas that are out there. And the FDA helps us in regards to that. For most of the newborns that we see, term newborns, there really is no advantage to that name brand over generic formula.
Dr. Kelly Mazzarella:
So let's talk about the types of formulas that are out there. The three big categories include cow's milk based, soy, and hydrolyzed formulas. Now cow's milk-based formulas costs anywhere between $25-$35. That was for Similac when I did a quick search. For generic, it's about $20 a can. Most are iron fortified. It's super important for development, and most have vitamin D. It's super important for bone growth, as I'm sure as you know. And some have probiotics, some have fatty acids like DHA and ARA. With probiotics, we need to do more research on this, but they can have some protective benefits with infectious diarrhea, eczema, colic, allergies. Like I said, we need to do more research on this, but they can have those protective benefits.
Dr. Kelly Mazzarella:
Now with DHA and ARA, that's thought to help with brain and eye development. So cow's milk-based formula is what we usually will have our infants on in the nursery and most infants have, or we recommend for most infants in general. Now, soy-based formula is really only needed for instance, with galactosemia or primary lactase deficiency. Both are on the rarer side, and so you might not see this, but that's really when soy is indicated. And so galactosemia, we actually will pick up on newborn screen. I've seen that a handful of times. Primary lactase deficiency, like I said, soy is definitely indicated, but extremely rare.
Dr. Kelly Mazzarella:
And next we have our hydrolyzed based formulas. And this is for infants with higher risk for developing allergies or concerns for milk, soy, protein allergy or intolerance. Now these babies will have bloody stools, moderate to severe eczema, severe colic, or failure to thrive even. And they'll require this formula in order to help them with that. Essentially it's just broken down milk protein. And how much have they been broken down, partially or completely? So our hydrolyzed formulas are Nutramigen and Alimentum, and they go for anywhere between 40 to $52. An amino acid based formula is a completely broken down milk protein, and examples of this would be Neocate, EleCare, or Puramino. And that would go for anywhere between 45 to $150, just depending on how much you get. You can see that this is pretty expensive.
Dr. Kelly Mazzarella:
And just as a side note, even if these babies have issues in infancy, they can go on to drink cow's milk or whole milk at around the 15 to 18 month mark and not have complications at that point. Most of those babies who actually have this problem, I like to consult pediatric gastroenterology for their assistance and monitoring. Once again, most of our babies that we see in our nursery will do well on cow's milk based formulas. And I think that hopefully answers your question, Neeta.
Dr. Neeta Goli:
Absolutely. That was a really great review of all the formulas that are available for families. Now, you mentioned that a lot of those formulas can be quite expensive and costs can add up. So for some of our families who have food insecurity, which means they're unable to afford enough food to feed their family for the past six months or the past year, for those families, what kind of resources do we have to offer them in terms of formula?
Dr. Kelly Mazzarella:
That's a great question. So WIC is such a great resource for families who can't necessarily afford formula or enough formula. So mainly WIC is for families with lower incomes or limited incomes. And they provide a certain allotment of powdered formula cans based on the age of the infant. When you are a newborn, they get about nine cans per month. After three months from like four to five months old, they get 10 cans a month. For infants who are greater than six months, they get seven cans a month, and that's when they start eating your table foods, and so they don't need it. I guess you would probably just need about the same amount of cans from that point on to 12 months. And if a family runs out of formula, they may be able to access formulas from local food pantries. And then oftentimes if that's not possible, lots of pediatricians end up having samples at their office, so that's another resource for them as well.
Dr. Neeta Goli:
Okay. And then I know you addressed this a little bit when discussing the different types of formula, but especially more in the outpatient clinic than in the newborn nursery specifically, but sometimes parents will say that they are lactose intolerant or some of their other children are lactose intolerant and they'll ask if they need to use a soy protein based formula for their baby for their newborn.
Dr. Kelly Mazzarella:
Just because an adult has lactose intolerance doesn't mean that their infant is going to have that. And lots of times, that is just a process of age. It's an acquired deficiency of lactase. And so you'll see that in your adolescents and in your adults, that you don't really see that in your newborn population. And so those babies can still trial cow's milk-based formula first and foremost, and that's totally what I would recommend.
Dr. Neeta Goli:
Absolutely. I agree. And then another common question I get sometimes more in the warmer months is parents will ask, what if my baby's thirsty? Can I give her water or can I water down the formula or breast milk?
Dr. Kelly Mazzarella:
Yeah, I get that a lot too. And I always just say, no, you do not need to do that. Unless the baby is a little bit older, I would say six months on, you can do some introducing of water, but their main source of nutrition should be breast milk or formula. And so if the baby's thirsty, just do exactly that, breastfeed or bottle feed. Babies do not need free water. We never should dilute breast milk, no dilution of formula. I want families to follow the directions on the can to a T. So one of the big things is just adding formula to the bottle that already has water measured in it. That's something that can change the amount of water that's in there actually. And all in all, what we're really getting at here is that if a baby gets too much water, there can be electrolyte derangement, specifically hyponatremia that we worry about in a baby. And that can cause seizures. So we don't want that to happen to our babies. And really if the baby's thirsty, stay the course with breastfeeding or bottle feeding.
Dr. Neeta Goli:
Okay. And then you mentioned at six months or so it's okay to introduce water. How do you usually counsel families to go about that?
Dr. Kelly Mazzarella:
Yeah, I think that starting around the six month mark, we can start introducing our complementary foods. And I think that's a good time to introduce having water around in a sippy cup. It's trying to give the baby an idea of the feel of water, the lack of taste to water, I guess you can say. So it just exposes them a little bit, but certainly not in huge amounts and not to the point where we're worried about getting that hyponatremia and causing any seizure activity.
Dr. Neeta Goli:
Okay. And then if we get back to our newborns in the nursery, how do you tell families to prepare formula? I know you mentioned you like them to follow the directions on the can to a T.
Dr. Kelly Mazzarella:
Yeah. So for every two ounces of water, add one scoop of powder. Like I said before, don't dilute. And once again, if, if formula is diluted, which some food insecure families tend to do, if they're running low on formula, there's a risk for those seizures like I mentioned. It's okay to use tap water, but if there are concerns about how the quality of water is, so you can use bottled water as well, but there's no need to buy distilled water or nursery water. And I mentioned this before, but sometimes this can be confusing and it can change the concentration of the formula. So once again, you add water to the container first, you measure water, and then you add the powder, and then you shake it up. So the exact recommendations vary between the AAP, our American Academy of Pediatrics, the CDC, and the WHO in regards to water temperature.
Dr. Kelly Mazzarella:
So here's what the AAP recommends: so you can boil water for about a minute and just bring it down to room temperature, let it sit for about 30 minutes. Obviously it's going to be a little bit cooler then. Then you can add your powder. You can also make the formula with just plain old, room temperature water. You don't necessarily have to boil it unless you're concerned about the quality of the water, and then feed without warming or refrigerating. Just, you have to make sure that the liquid is not hot prior to giving to infant.
Dr. Neeta Goli:
And then for families, if they need to check the temperature of the milk, they can always put a little bit on the inside of their wrist and make sure that it doesn't feel too hot.
Dr. Kelly Mazzarella:
Exactly.
Dr. Neeta Goli:
And then once they do make the formula, how long can they keep it?
Dr. Kelly Mazzarella:
I think this is a really important question. Because sometimes like families, even in the hospital, they'll leave the bottle out and want to reuse it again. And that's a no no, unless it meets certain criteria. So if we're at room temperature and you open the bottle, that formula needs to be used within about two hours. Once prepared, you can store it for 24 hours in the fridge. If we offer it to the baby and expose it to the baby's oral flora, that needs to be discarded, if you haven't used all of it in an hour.
Dr. Kelly Mazzarella:
But here's a side note. Formula is not sterile boiling water prior to adding formula, does not sterilize that formula per se. And this is just like fun facts or little tidbit. Cronobacter sakazakii is a rare contaminant in powdered formula. This is actually more pertinent for our low birth weight babies, or our really, really young babies or our premature babies. Cronobacter doesn't survive temperatures greater than 45 to 47 degrees Celsius. So you can actually end up boiling water and then adding the formula to that, so it could potentially kill that bacteria. And that's so that our low birth weight babies or premature babies wouldn't be at risk for that bacteria, which can cause issues obviously with infections.
Dr. Neeta Goli:
So that's a great little tidbit to know, especially for our preemies or low birth weight babies, like you mentioned. But yeah, I agree, so for most of our healthy term neonates, like you mentioned it is okay if parents want to make the formula with just regular room temperature water.
Dr. Kelly Mazzarella:
Yep.
Dr. Neeta Goli:
So once the formula is made, how do parents know how often babies need to eat and how much?
Dr. Kelly Mazzarella:
Good question. So, the number one thing we think about here is just following cues for hunger. Just like for breastfed babies, we look for rooting, smacking lips, and then of course crying would be that last sign that a baby is getting hungry. Over the first few days, we recommend just a slow ramp up to two to three ounces per feed, every three to four hours. So this is definitely different than breastfed babies. Breastfed babies are kind of just on demand, usually every two to three hours, right? So when you're working in the nursery, you'll also see that we have kind of a guideline or a poster for moms and dads to understand how tiny their baby's bellies are in the first couple of days of life and how that steadily increases. But you can imagine a small belly, the size of a cherry does not acclimate well to huge volumes, like two to three ounces a feed. They're just going to vomit all that stuff back up or reflux all that stuff back up.
Dr. Kelly Mazzarella:
So, small frequent feeds initially. And then a slow ramp up to two to three ounces over the first couple of days of life. And then the first few weeks of life, we really get into a better pattern with that every three to four hours. I always tell my families, you need to wake your baby to feed. Especially during that timeframe. First few days, first few weeks, even up to the first one to two months. It's important for their growth. By the end of the first month, the infant will likely take about four ounces of feed every three to four hours, so ultimately like 24 to 32 ounces a day. At around six months, they'll take six to eight ounces, every four to six hours. The big thing here is we need to keep in mind that every baby is different. I was talking about on demand for breastfed babies, still a baby will let you know when they're hungry. And if they don't, we need to be woken up to feed.
Dr. Kelly Mazzarella:
And every baby's different and it might not fit the mold that I mentioned, or I was just discussing. So how do we know that a baby's doing well with the feeding schedule that the parents are using? The best thing to do is just make sure and encourage our families to follow up with our well baby visits. And with every well baby visit we get to see those growth curves, and hopefully we're seeing happy little growth curves. That was one of my favorite parts about working as an outpatient pediatrician is just seeing a baby grow. And so really that's what we can hang our hat on is these growth curves, just making sure that our babies are growing well.
Dr. Neeta Goli:
And I think that's such an important point about the care needing to be individualized based on the baby, because again, there's science and algorithms and medicine, but ultimately there is also an art to it as well. So yeah, so important to have that follow up with the pediatrician. Personally, I usually tell families as far as waking babies up for feeds that if baby is a few weeks old and they are above their birth weight, that they don't have to necessarily wake the baby up for feeds. But yes, that that decision should absolutely be made with the family's pediatrician, looking at the growth chart, making sure everything's going the right direction.
Dr. Kelly Mazzarella:
Yep. And just a few extra little tips here. When parents are feeding baby, holding the infant nice and close during a feed will help establish that bonding that we kind of see with breastfed babies. It makes them feel secure. We don't recommend propping bottles. This is a choking risk. You can warm with a bottle warmer, but never microwave a bottle. And of course, we mentioned this before. If warming a bottle, you test the temperature prior to use. You can just use your wrist to test the temperature. Intermittent burping during feeds is helpful too. And then we'll discuss this a little bit later, but paced bottle feeding is also important.
Dr. Neeta Goli:
Okay. And then actually let's get into that. So what special considerations do you have for babies who are breastfeeding and supplementing with the bottle?
Dr. Kelly Mazzarella:
So whether you express breast milk or formula feeding bottle feeding can sometimes confuse infants when they're doing a mixture of all those things together. So when getting nutrition from a bottle, infants don't necessarily have to work as much. I almost think of it like if you're at the soda machine, at the movies or at the gas station and you're getting soda, like you press a button and it just flows. An infant can suck and the nutrition flows when they're getting it from a bottle. But when you're breastfeeding infants, they might have to work a little bit more to get a letdown to happen, and that let down is when that milk starts flowing. So in other words, they have to suck more for longer and work harder. So I encourage moms who are breastfeeding to hand express prior to putting babies to the breast, to take away some of that work.
Dr. Kelly Mazzarella:
Another way to think about feeding is like having a conversation. I think that's one of the best ways I've heard a lactation consultant talk about breastfeeding, is having a conversation. So it's like taking breaks from a dialogue to let someone else talk, and that's a normal way to hold a conversation. Breastfeeding should mimic this. Feeding should mimic this. And this is what I was talking about before, paced bottle feeding. So the pace of breastfeeding is similar to this conversation. The infants will suck and then take periodic breaks as they're feeding. So to help a baby who is both breast and bottle feeding, and to prevent bottle preference or prevent the baby from developing a bottle preference, paced bottle feeding is recommended in helping to make that conversation that we're talking about.
Dr. Kelly Mazzarella:
So you can actually get onto YouTube and type in paced bottle feeding and lots of good videos should pop up for you so you get a better idea of it, but typically we're using a size zero nipple and then we'll take periodic breaks from the bottle. Whether you're just taking the nipple out of the mouth or you're burping the baby, you're basically interrupting that flow so you can have that conversation with the baby. I mentioned using a size zero nipple. Lots of bottles that are sold in stores come with that size one nipple. So that means that there's an increased flow or an easier flow from that nipple. Using a size zero nipples is just, it's a slower flow.
Dr. Neeta Goli:
Okay. I think that's great for families to know. Again, especially for those babies who are supplementing to keep them from getting that flow preference. So, Kelly, thanks so much for all this practical hands on information today. This has been really useful. I'm hopeful our listeners will feel more confident now when their families ask them all these questions about formula. To end today's episode, what tips do you have for our listeners to succeed while taking care of newborns?
Dr. Kelly Mazzarella:
Thank you so much for having me. I love being on. I think a good takeaway from this podcast that we're having today is, and something that I actually used to give you guys some good information, was healthychildren.org. I love that website. Healthy children.org. It's backed by the American Academy of Pediatrics. It has a lot of good, nerdy pediatric information. But whether you're a med student or you're a resident, it has good information that can carry you through throughout the rest of your life. It's actually good for parents to know too. So I oftentimes will talk about it when I am going through my teachings with families and I even use it for my child, so I totally recommend it for you guys out there who are listening.
Dr. Neeta Goli:
I agree. I love healthychildren.org. It's a great resource. So Kelly, thanks so much for joining us today. This has been great.
Dr. Kelly Mazzarella:
Oh, thank you so much for having me Neeta, I really appreciate it.
Dr. Neeta Goli:
Appreciate it. Have a good one, bye.
Dr. Kelly Mazzarella:
Thanks. You too, bye.
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwesternat.edu. As a reminder, this content is educational and is not meant to be used as medical advice, views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.