When preparing for childbirth, we all have questions about breastfeeding and formulas. Choosing a formula can be confusing. Whether we decide not to breastfeed or are weaning, one question remains – which formula to use? There are over 50 types of commercial infant formula (CIF).
When you research formulas, parents are impressed with the number available on the market and wonder which one is better than another. Today, there are hundreds of infant formulas sold in pharmacies or grocery stores. They can be expensive: for an infant, plan on spending between $85-$120 per month for a basic formula. Expect to pay more for more specialised formulas. These include lactose-free, added omegas or probiotics, thickened, added GOS (galactooligosaccharides, which helps feed the good bacteria in the intestinal flora), hydrolyzed (predigested), higher calories…
Without going into all the details of the different components found in formulas, all formulas for babies up to one year sold in Canada must meet Canadian food and drug standards. Formulas are assured to contain enough water, protein (whey, casein, amino acids, soy), carbohydrates (lactose, corn syrup extract, sucrose), fat (sunflower oil, safflower, soy and added DHA/ARA), vitamins and minerals to meet the needs of a young child, regardless of the brand you choose. However, you should know that private commercial preparations (house brands of companies such as Kirkland, President’s Choice, Equate or any other grocery or pharmacy banners) are not held to the same standards and inspections by the Canadian government.
Generally, there are no brands better than others as long as the nutritional value is the same, and your baby can tolerate the formula. The Canadian Pediatric Society suggests formulas with iron supplements up to one year to prevent infant anemia. Iron is also essential for brain and immune system development. The formula’s iron value must be at least 1mg/100 calories to be labelled enriched or rich in iron.
Vitamin D is also essential for the growth of a baby’s bones and teeth. There are two types of vitamin D. D-3, which is synthesised by the skin when exposed to the sun, and D-2, which is added to foods such as orange juice, milk, etc. This vitamin is also added to formulas. But latest health recommendations state that it’s best to give your baby a vitamin D supplement, both when breastfed or bottle-fed with formula, for the first year. Why? Because we know that in Canada, vitamin D synthesis from the sun’s rays is almost nonexistent for babies. When young, they are hidden from the sun, and later due to the application of high SPF sunscreen. Also, even if the formula already includes vitamin D, the quantity that needs to be consumed to get the proper dose is very high and difficult for babies to reach. Thus the need for a D-2 supplement.
Some parents ask me questions about aluminum content in formula recipes. Yes, it can be found in infant formulas. But studies seem to show that most formulas contain a level lower than the daily dose set by the World Health Organisation, no more than 2mg/kg body weight per week. Be careful of soy-based formulas, as they contain more aluminum than cowmilk-based formulas. Generally, there are no brands better than others as long as the nutritional value is the same, and your baby can tolerate the formula.
In the next part, we will describe the three main categories and some of their characteristics to help you understand their differences and make a better choice.
Three Main Formula Categories
There are three main categories of formulas:
- Cow milk protein-based formulas for everyday use for a healthy baby born at term;
- Soy-based milk used more in cases of galactosemia, lactose intolerance or vegan diets;
- Specialised formulas for premature or intolerant babies or babies with severe allergies. These formulas do not contain lactose.
Recently, “Certified Organic” formulas have entered the market. But for the moment nothing has proven that they have better nutritional value than other products. The final choice is up to parents. Organic or not, you always have to follow the manufacturer’s recommendations to minimize contamination, pesticides and undesirable substances.
Bovine Protein-based Milk (Cow Milk)
Many companies offer these kinds of formulas, which are all produced similarly. What is the most difficult thing for a young baby to digest in these formulas? It’s the casein (protein) molecules in the formula, compared to the amount of whey. Whey, unlike casein, is much better absorbed, as it is in breast milk. Some formulas are presented in a more standard casein/whey ratio, while others are intended to be partially hydrolyzed, i.e. the protein has been deconstructed (usually 10 times smaller on average) and the casein has been eliminated. In these formulas, 100% whey is favored, which in the end facilitates digestion, promotes soft stools in babies, and leads to better gastric emptying.
Even if companies state that they have added miracle products to the formula, the quality of formulas on the market seems comparable, without being equivalent. However, you should not shift from one formula to another with a very young baby given the immaturity of their system, which has not yet adapted to their milk.
Before suggesting specific milk for your baby, a health professional first needs to know a bit about their history since birth. Were they born at term? Do they have reflux? Do they have difficulty digesting even breast milk? Did they have colic earlier in their life? Were they constipated or did they have an anal fissure? Is there a family history of intolerance? Everything needs to be looked at before making a suggestion. For example, if the baby’s digestive system seems to be more fragile, we might suggest a milk that’s easier to digest right from the start, or even a formula that includes probiotics for a child with more colic, reflux or signs of constipation. If your baby was born at term, showed no reactions to breast milk and they are growing as expected, a cowmilk based formula will be suggested, and after 2-3 weeks of use, they will check to see if they react to it and will then make changes only as needed.
Soy-based Milk
Soybeans are a vegetable, so don’t have animal milk sugar (lactose) which, for some babies, causes discomfort. But soy-based milk should NEVER be given to babies unless recommended by a doctor. In fact, since you can also develop intolerance to soymilk, and there are also associated risks of nutritional deficiencies, you should get advice from an expert. Suggested for vegetarian diets or for cultural or religious reasons, and also in the case of galactosemia (carbohydrate metabolic disease). This milk can be continued up to the age of 2, if the baby does not consume cow’s milk after one year.
Therapeutic Milk
Therapeutic milk is much easier to digest if the baby’s system is immature or fragile. The bovine proteins can then be highly deconstructed, i.e., up to 50-60% of free amino acids (ex: Alimentum and Nutramigen) and there is also a recipe who exhibits complete decomposition at 100% acid free aminos (ex: Puramino and Neocate), which really helps the absorption in the baby’s intestine. All these specialized formulas are very low-lactose or lactose-free. If needed, the doctor can prescribe this kind of milk, for example, if your baby has clear signs of intolerance or severe allergies to regular formulas or in the presence of various syndromes. Beware of self-diagnosis, as in reality this milk is suitable for a minority of babies. This milk is costly, but in Quebec, you will be reimbursed for the full cost if the doctor filled out the form when prescribing it for a baby requiring only.
The above information is a good overview of the different formula categories, but there are dozens and dozens of different kinds of milk in each category. When in doubt, ask for help from a specialist. Perinatal health professionals can advise you about the best choice for your child.
Transitional or second stage formulas refer to those products that are adapted for children over 6 months of age. When a child is eating well from a variety of food groups at 6 or 7 months of age, a parent can decide to give them second stage milk up to 9-12 months (even 18 months for a light drinker), which contains more calcium and iron to complement the solid foods the baby eats. He can also continue the first stage formula he is taking without any problem if he eats everything very well. At 9 months of age (for a full-term and healthy baby), a baby can drink 3.25% milk if they eat well and are growing and developing well. If your baby has had intolerances/ allergies younger or more important reflux or very important colic, it is better at this time to continue the formula until 1 year old, before introducing 3.25% milk to give him every chance to mature even more his digestive system.
Pasteurized goat’s milk can also be presented to a baby from 9-12 months if he is healthy and he presents nothing special in terms of its development, but at the end, it does not offer more benefits to the baby than the 3.25%. 2% milk will not be recommended before the age of 2 years old, as well as soy, almond or rice drinks.
Types of Formulas
There are many types of formulas, which I define below:
- Ready-to-serve formula: easy to use. Open the container, pour in the bottle and heat. More expensive to buy (almost double the price of concentrated or powdered formula). Liquid infant formula is sterilized by heat treatment. With infants with immune disorders or low birth weight, ready-to-serve formula is the safest choice because the formula is stable and has fewer possibilities for error, since it is already diluted.
- Concentrated formula: also easy to use. Mix one part water with one part concentrate, but you need to boil the water up to four months to eliminate bacteria. You need to handle it more and follow the manufacturer’s instructions for the proper nutritional concentration. Beyond preparation, there are also guidelines for storage to avoid cross-contamination.
- Powdered formula: also requires more handling and, above all, great care when making the mixture. Powdered milk is not recommended for premature babies or those with health problems, such as heart problems, babies with weakened immune systems or those who are underweight, as powdered milk is not sterile (source: Health Canada). It is imperative to follow Health Canada’s recommendations on the preparation and handling of powdered infant formula, to prevent contamination with various bacteria.
How to prepare a bottle of formula?
- Clean the formula container before opening it;
- Use sterilised bottles and nipples until 4 months (boiling water and air-dried; dishwasher using high heat; other sterilisers; sterilisation bag for the microwave);
- Boil the water for at least 2-5 minutes;
- Let the water cool for at least 30 minutes (should be warm-cold, not too hot) before mixing the concentrate or powder;
- Refrigerate after mixing.
Current research does not indicate that probiotics added to infant formulas help prevent things such as bloating, colic, obesity, infections or constipation. But it seems that probiotics help eczema in babies considered high risk for cow milk protein intolerance.
Beware of milk thickened with rice starch sometimes recommended by health professionals for a baby with reflux. In a situation of very important reflux in a baby, it will be preferable to change the milk for a hydrolyzed formula at first, instead of thickened milk to help the baby who is having bad digestive problems. After the trial of a few weeks with the hydrolyzed formula, an addition of an antacid medication could be suggested by the doctor in situations of persistence of symptoms in the baby and/or growth disorder. Note that thickened milk can prevent the absorption of antacid medication, therefore, in this sense, thickened milk are contraindicated.
Those are our remarks about formulas. We hope it helps you make your choice.
Talk to your caregiver before choosing if you need help.
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Marie Fortier
The Baby Expert
Updated article : April, 2024.
