Breast Milk Versus Formula

I decided to delve into this controversial debate about breast milk versus baby formula. I thought this might be an interesting blog post for a couple of reason. First of all it had been in the media quite frequently after President Trump tweeted "The failing NY Times Fake News story today about breast feeding must be called out. The U.S. strongly supports breast feeding but we don’t believe women should be denied access to formula. Many women need this option because of malnutrition and poverty." 


So if you are wondering about this article that President Trump said was Fake News you can find it HERE.  I would encourage you to read through it and see what your thought are. The main accusation against the United States is the reported situation as follows ... "American officials sought to water down the resolution by removing language that called on governments to “protect, promote and support breast-feeding” and another passage that called on policymakers to restrict the promotion of food products that many experts say can have deleterious effects on young children." That might not have been that big of an issue, but when other countries didn't come to back the United States' proposed changes then things got more heated. "When that failed, they turned to threats, according to diplomats and government officials who took part in the discussions. Ecuador, which had planned to introduce the measure, was the first to find itself in the cross hairs. The Americans were blunt: If Ecuador refused to drop the resolution, Washington would unleash punishing trade measures and withdraw crucial military aid. The Ecuadorean government quickly acquiesced." That is the part that bothered me. I don't think we should go threatening countries to get policy changes. That is something that I think is wrong and seems to be behaving kind of like a bully. 

So that was kind of a crazy response to something like breast feeding. I honestly was quite surprised to read that article. Then there started to be more articles and other opinions written. and I wanted to make sure to share those with you too. I really liked this article by VOX because I thought it did a good job at outlining the main issue that was being debated by the United States and other countries. "The UN group responsible for setting the standards on how countries should regulate food products, the Codex Alimentarius, hasn’t yet decided whether follow-up formulas should be treated like infant formulas — as “breastmilk substitutes.” Calling them a substitute for mother’s milk would mean heavier scrutiny and regulation — something public health advocates want. The US wants to call it a food, not a breast milk substitute,” said Elizabeth Zehner, project director for Helen Keller International’s child feeding project, who was present at the Codex negotiations. “That will leave the door open for all countries to call these products as non-breast milk substitutes, so they will get advertised on TV — and they look just like the infant formula.” 

So that is the main part of the debate ... how to categorize this formula products. I know it seems like a simple issue, but it can have big ramifications. Food is a complicated thing and when it is regulated different can lead to a large variance in products. The supplement industry is that perfect example. That is the under the Food and Drug Administration and anything classified as a supplement doesn't meet the same scrutinized criteria as other actual food items. So companies can put whatever health claims on those products and they aren't held to the same regulations as the food industry. I would say most of the time that can be ok, but I understand the concern voiced in the VOX article about how toddler formulas are regulated, because if they are labeled as "breastmilk substitutes" that would change their nutrition make up and how they are marketed to families. 

There was another story published on NPR on this topic and I wanted to make sure you had access to that as well, CLICK HERE. I think that this debate is not other and the formula industry does have a lot more money to lobby with compared with advocates for breast feeding. They are pushing a product and want to make money. That being said I believe in a baby being fed and healthy and that can be accomplished through either breast milk or baby formula. The debate here isn't necessarily which is better nutritionally, the debate comes down to money and how these formulas are categorized. That will then have a big influence on the products that are manufactured and then marketed to families. I would say our country has come a long way in encouraging mothers to breast feed and educating families on why that is the best thing for your baby. I think like any basic mothering skill, there are so much emotion that gets ties into this topic and can lead to guilt and regret. That is another blog post, but I wanted to make sure that you got some information on this debate and maybe some more insight as to why the President cared if women were breast feeding or using formula. 


Working In A Formula Room

It has been awhile since I have spoken about my day job here on the blog. As you may recall, I work in a Neonatal Intensive Care Unit (NICU) and I am a pediatric dietitian. I work with newborn babies and I calculate their nutrition needs to help them grow appropriately since most of our patients are born early. Another part of the job, is helping to oversee our Formula Rooms. This is the part of the NICU where all of the feedings are put together/made for our patients in 24 hour batches. We help to schedule, oversee and hire the Formula Room Technicians that work in those mixing rooms. Sometimes the dietitians fill in those shifts as well if we don't have enough techs to fill the spots on a particular weekend. 

This last week I have had the opportunity to work in our Formula Rooms a couple of times. I am always impressed with our system and how we so accurately get all of our babies fed ~ 8 times a day. It is truly a well oiled machine and is so neat to be a part of that. 

I thought it might be neat to address some of the Frequently Asked Questions that I get about our Formula Room/NICU and how nutrition plays a role in that environment. Most people are surprised to learn that there are dietitians in the NICU and that we have a mixing room for feedings. 

Frequently Asked Questions

  1. What does a dietitian do in a NICU?
    • This is a great question. The role of a dietitian in a NICU varies, but the main role is to help provide nutrition care to this specialty population. The RD serves as the nutrition expert on the medical team and provides guidance/advice to the neonatologist about  the best feeding recipe for each patient. Each week the RD sees every patient in the NICU and writes up a nutrition note about their plan of care that week. The RD would suggestion what feeding option might be best for that patient, the avenue of administering the feeding, when start vitamins, how feedings might change based on lab values and monitor growth velocity and tweak the nutrition plan as needed. 
  2. Do you just mix formula in the Formula Room?
    • No. In our Formula Room we prepare ALL of the feedings for ALL of our patients and they are stored in a refrigerator in that room. The RN will come in and out of the Formula Room to get the feedings and take that aliquot to the bedside and feed the baby. Each patient has their own bin in the refrigerator and their feeding is in that bin for the RN to grab anywhere from 6-8 times per day.
  3. How do you feed your patients?
    • In the NICU, since our patients are normally premature, our most common form of administering nutrition is via a feeding tube or via TPN. We prefer to use the GI tract and will try to give feedings via the feeding tube and we work to wean TPN support as soon as possible due to line infection risk and liver damage. Infants do not have their swallow/feeding reflex developed until ~34 weeks gestation and so that would be the point that with cues, we might start some bottle feedings. 
  4. Do you feed your patients breast milk? 
    • Yes. Our goal is to use maternal breastmilk whenever possible. That is the gold standard for all of our babies, because it has so many protective properties. Some times there are medical diagnoses that prevent the use of breastmilk, but those cases are limited. Premature babies also need higher calories, more fat and more protein. They are born early and their nutrition needs are higher compared with a term infant. This means that unfortified breastmilk won't meet their nutrition needs so in the NICU we use different formula/fortifier to add to the breastmilk to increase the calories, protein, fat and other vitamins the infant is receiving. We have recipes that we use to mix these feedings and that is the primary role of our formula room technicians. They are the ones that will mix up these recipes for each baby in 24 hours batches and those feedings will be used throughout the day by the nursing staff.
  5. How much do you prepare each day in the Formula Room?
    • Our technicians make 24 hour batches for all the babies that we are mixing for that day. Our NICU holds 90 babies and our nursery unit holds an additional 10 babies. There is the potential that we could mix for all 100 babies, but that is normally not the case. It is inevitable that there is a baby or two who are NPO (nothing by mouth). Our average census is ~70-80 patients at a time. 
  6. Why do you have technicians mixing feedings compared with nursing staff? 
    • Nursing staff in some hospitals do mix feedings and they have at our hospital in the past. With this creation of a Formula Room space it is more conducive to having one person mixing up feedings compared with each RN mixing their feedings. It decreases the number of people in the room and would decrease risk of errors/infection risk. We work hard to make sure that our technicians are trained well and mix the feedings appropriately. This helps give the RNs more time at the bedside to do what they do best, provide that direct care for our babies. 

Hopefully this has given you a little better idea about what we do in the NICU and how we provide top-notch nutrition care to our patients. We have some of the sickest babies in the state at our hospital and I am so proud of our medical staff for the level of care that we provide each and every day! 

Not All Formula Is Created Equal

I decided to put together this blog post because I work in a NICU (Neonatal Intensive Care Unit) and we work with a lot of breastmilk and baby formula to feed our patients. This is my area of expertise and I had the pleasure of recently attending lunch with a formula rep and talking about formula. This luncheon, brought this topic to the fore front of my mind - Not all formula is created equal. I don't want this post favor one brand over another. I just want to bring some facts to light that you might find helpful. My perspective is that for all babies, breastmilk is best and is a very unique substance. We have worked for years and years to try to create a formula that mimics breastmilk. For some of our babies in the NICU, we have to add things to the breastmilk to increase nutrients because our patients are born early and breastmilk isn't designed to meet their unique nutrition needs. 

That being said ... I wanted to discuss all the different types of formula and how there are various brands. In the US, we have Similac, Enfamil, Gerber and Store brand options. All of these companies abide by rulings set out by Congress in the 1980s, referred to as The Formula Act. This piece of legislation has been around for awhile and unfortunately hasn't been totally updated since then. There have been guidances given for the formula industry and an example in includes the health claims made by formula companies (September 2016).  Baby formula always ends up being a controversial topic. Thankfully all of these companies continue to create and work on new research in the area of baby formula even though the standards they have (required by law to follow) are now ~35 years old.  There are lots of different types of formula options within each brand and some times the options can be overwhelming for parents. The main focus that I wanted to bring to your attention is that the brand name formulas may cost more, but there is more research being done in those products and they are up to date with the best nutrition compared with the generic products. Just so you are aware, the generic version of the formulas are the older recipes from the brand name companies. This means they may not contain some of the important nutrients that we have discovered and are now able to add to formula. This means that as the consumer you are getting a product that is based on older research and may not be as helpful for their baby's growth and development. This is the one time in your baby's life when they are eating 1 food item to get all the nutrients that they need to grow and develop. Whether it is breastmilk or formula this is a very unique time for your child (the 1st 12 months of their life). 

For example, we have learned that DHA (docosahexaenoic acid or omega-3 fatty acids) and ARA (arachidonic aicd or omega-6 fatty acid) are very important for brain development in infants. These fatty acids have been around awhile and most of the generic formulas that I looked at had at least DHA in them. Another important phytonutrient that is now being added to formula is Lutein. It helps with eye health and is a carotenoid that has an important role to play in brain function/development. We didn't necessarily have this information back when the Formula Act was put together so if you read the label for a generic baby formula and make sure that these formulas have these nutrients added. Most of the ones that I glanced at, did have these nutrients added, which was reassuring. These nutrients are naturally found in breastmilk and has we do more research they are being added to infant formulas as well. 

I wanted to also just touch on the different types of baby formula so that you know what you are looking at when you go to the baby aisle of the grocery store. There are lots of options and often the challenging is just determine, which product is appropriate for your baby.

Different Types of Baby Formula

  • Cow milk protein-based formulas. Most infant formula is made with cow's milk that's been altered to resemble breast milk. This gives the formula the right balance of nutrients — and makes the formula easier to digest. Most babies do well on cow's milk formula. Some babies, however — such as those allergic to the proteins in cow's milk — need other types of infant formula.
  • Soy-based formulas. Soy-based formulas can be useful if you want to exclude animal proteins from your child's diet. Soy-based infant formulas might also be an option for babies who are intolerant or allergic to cow's milk formula or to lactose, a carbohydrate naturally found in cow's milk. However, babies who are allergic to cow's milk might also be allergic to soy milk.
  • Protein hydrolysate formulas. These types of formulas contain protein that's been broken down (hydrolyzed) — partially or extensively — into smaller sizes than are those in cow's milk and soy-based formulas. Protein hydrolysate formulas are meant for babies who don't tolerate cow's milk or soy-based formulas. Extensively hydrolyzed formulas are an option for babies who have a protein allergy.

*In addition, specialized formulas are available for premature infants and babies who have specific medical conditions.

My intent with this blog post is not to make you hate formula or purchase only a certain type of formula. I just wanted to make sure that you knew how much research goes into infant formula and how it is always being updated and our knowledge base is growing. Breastmilk is an amazing substance that women's body can produce and we have spent lots of time and money trying to find ways to create a formula that mimics what nature can create. I am a huge proponent of additional research and I am always excited to hear what companies have learned and are able to add to their formula products. 

If you end up with questions about formula, please don't hesitate to get in touch with me and I would be happy to talk with you more about this fascinating topic of infant nutrition!