Cup Feeding: An Alternative to Bottles

Cup feeding is an alternative method to bottle feeding that involves using a small cup to feed a baby, typically with expressed breast milk or formula. This method can be particularly useful in certain situations and offers several benefits. Here’s a comprehensive look at cup feeding and its importance.

What is Cup Feeding?

Cup feeding involves using a small, open cup to feed a baby. The baby sips or laps the milk from the cup, much like how an adult would drink. This method is often recommended for newborns, especially preterm infants, or when direct breastfeeding is not possible.

When is Cup Feeding Used?

Cup feeding can be an appropriate option in several scenarios:

- **Premature Babies**: For babies born prematurely who may have difficulty latching onto the breast.

- **Transitioning from Tube Feeding**: To help babies transition from nasogastric tube feeding to oral feeding.

- **Temporary Separation**: When the mother is temporarily unable to breastfeed due to medical reasons or separation.

- **Avoiding Nipple Confusion**: To prevent nipple confusion in breastfed babies who need supplementation.

Benefits of Cup Feeding

Preserves Breastfeeding Skills: Unlike bottle feeding, which can cause nipple confusion, cup feeding allows babies to maintain their breastfeeding suckling patterns. This makes it easier for them to transition back to the breast

Encourages Natural Feeding Behaviors: Babies can control the pace of their feeding, similar to breastfeeding. This can reduce the risk of overfeeding and helps babies develop their feeding cues

Avoids Nipple Confusion: Since cup feeding doesn’t involve artificial nipples, it helps avoid nipple confusion, making it easier for the baby to switch between breast and cup

Promotes Oral Development: The use of cup feeding supports the development of the baby's oral muscles, which are important for speech and eating solid foods later on

Simple and Accessible: Cup feeding requires minimal equipment – just a small cup. It’s easy to clean and sterilize, making it a hygienic option

How to Cup Feed a Baby

Cup feeding requires patience and proper technique to ensure the baby feeds safely and effectively. Here’s how to do it:

Prepare the Cup: Use a small, clean cup. A medicine cup or a small shot glass works well. Fill the cup with a small amount of breast milk or formula

Hold the Baby Upright: Position the baby in an upright, seated position. Support their head and neck with one hand

Offer the Cup: Hold the cup at the baby’s lips, tilting it just enough so that the milk touches their lips. Allow the baby to lap or sip the milk at their own pace. Do not pour the milk into the baby’s mouth, as this can cause choking

Take Breaks: Give the baby time to swallow and breathe. Watch for their cues to know when they need a break or are full

Burp the Baby: After feeding, gently burp the baby to release any swallowed air

Safety Considerations

- **Supervision**: Always supervise your baby closely during cup feeding to prevent choking.

- **Hygiene**: Ensure the cup is thoroughly cleaned and sterilized before each use.

- **Small Amounts**: Start with small amounts of milk to avoid spillage and waste.

Cup feeding can be an excellent alternative to bottle feeding, offering numerous benefits for both the baby and the mother. It supports breastfeeding efforts, promotes natural feeding behaviors, and aids in the baby's oral development. With proper technique and patience, cup feeding can be a successful and rewarding feeding method. If you’re considering cup feeding, consulting with a lactation consultant or pediatrician can provide additional guidance and support.

Pace bottle feeding

**What is Paced Bottle Feeding?**

Pace(d) bottle feeding is a responsive feeding technique designed to mirror the slower, more controlled flow of breastfeeding. The idea is to allow babies to feed at their own pace, promoting better digestion, reduced gas, and helping to prevent overfeeding. There are a few things about how it’s being taught to families with older babies, though, that have always bothered me as NICU trained SLP.

Pace bottle feeding was originally used and taught in the NICU setting with preemie babies for before their suck, swallow, breathe coordination was fully developed. We needed to be in charge of the bottle, because babies born before their due date lack maturity for self pacing and are at a higher risk of fatigue and other medical issues like aspiration and bradycardia/tachycardia from feeding.

Pace bottle feeding is often shown as baby sitting upright with the bottle nipple only half full of milk. Caregivers are encouraged to tip the bottle down frequently every few swallows to slow baby down. The bottle is also removed at regular intervals for burping. This can work fine for the first week or two while baby is learning to feed, but there are a few flaws to this.

📌I’m not a fan of half full nipples. Air mixed with milk is what increases swallowing air which can cause reflux and digestive discomfort. I recommend keeping the nipple full

📌Externally pacing the baby is fine in the initial weeks after birth, but we really want baby pacing themselves. If they are constantly chugging from the bottle, that’s a bottle issue. Decrease the level or nipple or change bottles to find a flow that allows baby to take breaks when they want to

📌An upright position is fine for babies 3+ months, but I see so many newborns hunched or scrunched in this position, which leads to pressure on the belly. Having baby in an upright side lying position mimics being at the breast and allows a long, straight torso for easier digestion

📌Yes!!!! We want baby to pace their feedings. That means it would take a similar amount of time as the breast: 15-30 minutes for the first 6-8 weeks and then to match the time at the breast after that it can range from 5-30 depending on how fast mom’s let down is.

How Paced Bottle Feeding has been taught:

👶🏻Hold Baby Upright: Sit baby in a semi-upright position to reduce air intake and reflux

🍼Controlled Bottle Angle: Hold the bottle horizontally, allowing milk to fill the nipple (some are taught to only fill it half way) but not flow freely.

🧭Pause and Check-In: Offer short breaks during feeding to gauge baby's cues for hunger or fullness.

💡Encourage Sucking Reflex: Let baby control the pace of feeding by actively sucking to draw milk, rather than having milk continuously drip.

🔮Observe Cues: Watch for signs of satiety (e.g., slowing down, turning away) to know when baby is full.

Benefits of Paced Feeding:

- **Supports Digestion:** Reduces the risk of overfeeding and minimizes gas and spit-up.

- **Mimics Breastfeeding:** Helps babies develop a natural feeding rhythm similar to breastfeeding.

- **Promotes Self-Regulation:** Encourages babies to eat until they are satisfied, rather than finishing a bottle due to continuous milk flow.

**When to Use Paced Bottle Feeding:**

- **Breastfeeding Transition:** Ideal for young babies who are both breastfed and bottle-fed to maintain consistency in feeding patterns.

- **Preventing Overfeeding:** Helps prevent babies from overeating by allowing them to control the pace.

- **Bonding and Interaction:** Fosters a closer feeding experience between caregiver and baby.

**Final Thoughts:**

Paced bottle feeding is not just about feeding; it's about creating a nurturing and responsive feeding environment for your baby. By tuning into your baby's cues and allowing them to guide the feeding process, you can support healthy growth and development while fostering a positive feeding relationship.

Have you tried paced bottle feeding with your baby? Share your experiences and tips below! 💬🍼 #PacedFeeding #ParentingTips #BabyCare

Alternatives to bottle feeding a baby: Cup feeding

Cup feeding involves using a small, open cup to feed a baby. The baby sips or laps the milk from the cup, much like how an adult would drink. This method is often recommended for newborns, especially preterm infants, or when direct breastfeeding is not possible.

When is Cup Feeding Used?

Cup feeding can be an appropriate option in several scenarios:

- **Premature Babies**: For babies born prematurely who may have difficulty latching onto the breast.

- **Transitioning from Tube Feeding**: To help babies transition from nasogastric tube feeding to oral feeding.

- **Temporary Separation**: When the mother is temporarily unable to breastfeed due to medical reasons or separation.

- **Avoiding Nipple Confusion**: To prevent nipple confusion in breastfed babies who need supplementation.

Benefits of Cup Feeding

  1. Preserves Breastfeeding Skills: Unlike bottle feeding, which can cause nipple confusion, cup feeding allows babies to maintain their breastfeeding suckling patterns. This makes it easier for them to transition back to the breast.

2. **Encourages Natural Feeding Behaviors**: Babies can control the pace of their feeding, similar to breastfeeding. This can reduce the risk of overfeeding and helps babies develop their feeding cues.

3. **Avoids Nipple Confusion**: Since cup feeding doesn’t involve artificial nipples, it helps avoid nipple confusion, making it easier for the baby to switch between breast and cup.

4. **Promotes Oral Development**: The use of cup feeding supports the development of the baby's oral muscles, which are important for speech and eating solid foods later on.

5. **Simple and Accessible**: Cup feeding requires minimal equipment – just a small cup. It’s easy to clean and sterilize, making it a hygienic option.

How to Cup Feed a Baby

Cup feeding requires patience and proper technique to ensure the baby feeds safely and effectively. Here’s how to do it:

1. **Prepare the Cup**: Use a small, clean cup. A medicine cup or a small shot glass works well. Fill the cup with a small amount of breast milk or formula.

2. **Hold the Baby Upright**: Position the baby in an upright, seated position. Support their head and neck with one hand.

3. **Offer the Cup**: Hold the cup at the baby’s lips, tilting it just enough so that the milk touches their lips. Allow the baby to lap or sip the milk at their own pace. Do not pour the milk into the baby’s mouth, as this can cause choking.

4. **Take Breaks**: Give the baby time to swallow and breathe. Watch for their cues to know when they need a break or are full.

5. **Burp the Baby**: After feeding, gently burp the baby to release any swallowed air.

#### Safety Considerations

- **Supervision**: Always supervise your baby closely during cup feeding to prevent choking.

- **Hygiene**: Ensure the cup is thoroughly cleaned and sterilized before each use.

- **Small Amounts**: Start with small amounts of milk to avoid spillage and waste.

Cup feeding can be an excellent alternative to bottle feeding, offering numerous benefits for both the baby and the mother. It supports breastfeeding efforts, promotes natural feeding behaviors, and aids in the baby's oral development. With proper technique and patience, cup feeding can be a successful and rewarding feeding method. If you’re considering cup feeding, consulting with a lactation consultant or pediatrician can provide additional guidance and support.

Do I need to fortify my preemie’s milk

In the delicate world of premature babies, every ounce of care and nutrition matters profoundly. For mothers of preemies who choose to breastfeed, human milk fortification emerges as a vital intervention that can significantly impact the health and development of their fragile infants.

Breast milk is undoubtedly the gold standard for infant nutrition, offering a unique blend of nutrients, antibodies, and growth factors that promote optimal growth and immunity. However, many families with preterm infants typically 31-33 weekers) may be told their breast milk isn’t nutritionally adequate and they either need to supplement baby with formula or a human milk fortifier. It’s not that your milk is inadequate, it’s that babies born early miss out on a surge of nutrient absorption that normally would have occurred during the third trimester. Preemies have higher nutrient requirements, especially for protein, minerals like calcium and phosphorus, and certain vitamins like vitamin D. They should have been getting these nutrients from your placenta which takes these nutrients from your blood and bones. A preemie’s gastrointestinal tract is also very immature, less efficient at processing nutrients and more prone to distress. Preemies who experience medical complications including infection, respiratory disorders, surgeries, and stress, experience an increase in metabolism and increased caloric demand. So babies born prematurely have multiple reasons for needing more nutrients than an otherwise healthy full-term baby. Human milk fortifiers are designed to supplement breast milk with these essential nutrients to match the specific needs of premature infants, supporting their growth and development, that they missed.

Currently there are two main types of human milk fortifier available. The first is made using cow-based protein. It comes as either a powder or liquid which get added to pumped breast milk. The second fortifier is actually made of donated human milk from other pumping mothers. The only manufacturer of human based fortifier in the US currently is Prolacta Bioscience, and is only available to hospitals. Donated milk is modified into a frozen liquid concentrate which is added to pumped milk in the NICU.

Premature infants often struggle with catching up to the growth milestones of full-term babies. Fortifying breast milk helps enhance calorie intake and nutrient absorption, aiding in weight gain and promoting more rapid growth without increasing the volume of milk intake.

Preterm infants are at increased risk of various health complications, including necrotizing enterocolitis (NEC) and developmental delays. Fortified breast milk has been shown to lower the incidence of NEC and other serious conditions by providing a more robust nutritional profile.

Adequate nutrition during the neonatal period is critical for preventing long-term health problems such as neurodevelopmental impairments and metabolic disorders. Fortifying breast milk ensures that preemies receive the essential nutrients necessary for optimal brain and organ development.

Human milk fortification enables mothers to continue breastfeeding while meeting their preemie's unique nutritional needs. This approach supports the emotional and physiological benefits of breastfeeding while addressing the challenges posed by premature birth.

How long after birth they need to be supplemented depends upon many factors, including baby’s gestational age at birth, medical condition, nutritional status, and the individual practices of the NICU team your baby worked with. It’s very common for NICU graduates to require special nutrients for weeks to months after going home. This might be as simple as adding small amounts of over-the-counter preemie formula to pumped milk, adding in a few bottles of preemie formula each day, or as complex as using specialized prescription formulas. 

Ultimately, human milk fortification represents a critical component of neonatal care for premature infants. It empowers mothers to provide the best nutrition possible for their preemies, supporting their babies' health and development during this vulnerable stage of life. Healthcare providers play a pivotal role in guiding mothers through the process of human milk fortification, offering education and support to optimize outcomes for these tiny fighters.

By recognizing the importance of fortifying breast milk for preemie babies, we can enhance the quality of care and improve the long-term health prospects of these resilient little ones. Every drop of fortified breast milk signifies a step forward in nurturing and protecting the smallest members of our communities.

The composition of breast milk undergoes significant changes to meet the evolving nutritional needs of infants as they grow. The differences between preterm (colostrum and transitional milk) and mature breast milk are particularly important for understanding how mothers can support the unique requirements of preterm babies. Here's a breakdown of these differences:

**1. Protein Content:**

   - Preterm Breast Milk: Higher in protein, specifically whey protein, which is easier for preterm infants to digest.

   - Mature Breast Milk: Lower in total protein compared to preterm milk, with a higher proportion of casein protein.

**2. Fat Composition:**

   - Preterm Breast Milk: Contains more medium-chain fatty acids and higher levels of essential fatty acids like DHA (docosahexaenoic acid) and ARA (arachidonic acid), which are crucial for brain and visual development.

   - Mature Breast Milk: Higher in long-chain fatty acids, reflecting the changing needs of the growing infant.

**3. Carbohydrates:**

   - Preterm Breast Milk: Contains higher levels of lactose and oligosaccharides, providing readily available energy for the developing preterm baby.

   - Mature Breast Milk: Still rich in lactose but with a slightly lower concentration compared to preterm milk.

**4. Minerals and Vitamins:**

   - Preterm Breast Milk: Generally higher concentrations of certain minerals like calcium, phosphorus, and zinc to support bone and overall growth.

   - Mature Breast Milk: Adequate levels of minerals and vitamins tailored to the needs of a growing infant.

**5. Immunological Factors:**

   - Preterm Breast Milk: Richer in immunoglobulins (especially secretory IgA) and other immune factors to bolster the preterm baby's immature immune system and protect against infections.

   - Mature Breast Milk: Continues to provide valuable immunological support but at levels adjusted for the older infant's immune needs.

**6. Growth Factors:**

   - Preterm Breast Milk: Higher levels of growth factors like insulin-like growth factor (IGF) to support rapid growth and development.

   - Mature Breast Milk: Contains growth factors in appropriate proportions to sustain healthy growth without promoting excessive weight gain.

**7. Micronutrients:**

   - Preterm Breast Milk: Often supplemented with higher levels of vitamins and minerals to meet the increased requirements of preterm infants.

   - Mature Breast Milk: Provides sufficient micronutrients for the needs of older infants, although additional supplementation may be necessary depending on the infant's diet.

Understanding these differences underscores the importance of tailored nutrition for preterm infants. While human milk is always beneficial, preterm breast milk offers a specialized blend of nutrients and bioactive components uniquely suited to support the growth and development of premature babies during the critical early stages of life. As preterm infants transition to mature breast milk, the composition adjusts to meet their changing nutritional demands, ensuring optimal health and development as they continue to thrive on mother's milk.

 

Breast vs Bottle Feeding

Did you know that babies use completely different muscles to feed from the breast than from a bottle? They use more of their tongue and jaw at the breast and more lips and cheeks on a bottle. Breastfeeding is also a more complex feeding process where a vacuum is made in baby’s mouth from the tongue forming a seal against the roof of their mouth. Babies don’t need to create as strong a vacuum in the mouth to still bottle feee, as they can compress the nipple and milk still flows.

Bottle feeding is not a developmental skill. There is no age when a baby needs to take a bottle if breastfeeding is going well. Historically, babies went from breast to cup. Bottles are a relatively new invention with the formation of rubber nipples. It is developmentally appropriate to start open cup drinking by 6 months. That means if you’ve been exclusively breastfeeding and need to go back to work or your baby is starting table foods, you can skip the bottle and go straight for a cup. Starting with a small cup, like a medicine cup, shot glass, or @ezpzfun Tiny Cup are great ways to start. Your baby has been watching you drink from a cup for months and understands how it works. Straw cups are also great at this age and many babies will get the hang of it in a few tries. Using a straw cup like the Honey Bear has the advantage of you being able to squeeze the milk up to baby to teach baby how to get the milk by sucking.

When did you start cup feeding? Want to learn more? I have many videos of cup and straw feeding on my YouTube channel. Link in bio!

Want to learn more? Consider taking my parent class, LATCHED

 

#cupfeeding #cupfeedingbaby #honeybear #honeybearstrawcup #6monthsold #6monthsbaby #6monthsoldbaby #breastfeeding

Which formula is best for the breastfed baby?

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FORMULA

Being pro breastfeeding does not mean being anti formula. As an IBCLC lactation consultant, my job actually includes education on safely preparing, handling and feeding infant formula. This includes helping families choose an infant formula that is right for them based on solid evidence based research. If there was more education and less demonizing of formula, families would feel less guilt and stigma around just trying to feed their babies. 

So let’s break down how to choose an infant formula. Here’s the disclaimer: what works for one baby won’t work for all babies. So always speak with your pediatrician or personal health care provider if your baby is struggling to tolerate any infant formula you are using. 

There are three main ingredients that are essential and needed in all infant formulas. The carbohydrate, or sugar source, the protein and the fat. In this video we will just be concentrating on the carbohydrate. Carbohydrates are an important source of energy for growing babies, as they account for 35 to 42% of their daily energy or caloric intake. The number one sugar or carb in breastmilk is lactose. Lactose is not only a good source of energy, it also aids in the absorption of the minerals magnesium, calcium, zinc and iron. It’s also lowest on the glycemic index scale – meaning that it won’t increase blood sugar levels nearly as fast as glucose or sugar will. Lactose is healthier for babies to metabolize, and can help maintain stable blood sugar (and therefore insulin) levels. All human babies have an enzyme called lactase which breaks down the lactose and make sit easily digestible. After about 5 years of age, most people (about 75% of the world's population) stop producing the lactase enzyme. Without lactase, they can no longer digest milk, and they become lactose intolerant. This is actually the age of biological weaning, as in if children were left to self wean, they would do so some time between 2.5-7 years old, meaning the weaning age coincides with no longer being able to break down the sugar. Because of this it is EXTREMELY RARE for a human baby to be lactose intolerant. That disorder is called galactosemia and is an inherited genetic condition This hereditary condition is passed from parent to child as an autosomal recessive disease. This means that a child needs to inherit two copies of the defective gene (one from each parent) in order to have the disease and occurs in only 1 of every 30-40K babies born. 

To replicate the sugar in breast milk, most cow's milk-based formulas will also have lactose as the main source of carbohydrates. When possible, I typically recommend a lactose based formula for most babies because most of the time if an infant is having a reaction to a formula, they are reacting to the protein and not the sugar source. More on protein in a different blog/video. But more on carbs. 

So again, I typically recommend looking for a lactose based formula first. Human babies are designed to break down lactose and it is the most easily digested by the human gut. If you are using a lactose based formula and baby doesn’t seem to be tolerating it, consider a lactose based formula with an alternative protein source first before going to a lactose free formula. 

Because formulas without lactose will use other sources of carbohydrates. Both the FDA and the European Commission require that infant formulas provide 40% of their calories from carbohydrates. However, the source of those carbs is up to the manufacturer of the formula. In the US, carbs can come from five main sources: Lactose, Maltodextrin, Glucose, Sugar, or Corn syrup. Not all of these sugars are created equal! 

Glucose and corn syrup are the sugar source in over half of the formulas produced in the USA. WHY? Because they’re widely available and very cheap to produce. The problem with corn syrup (and all glucose/sugar in general) is that it’s a fast-acting carbohydrate. This means that it’s high on the glycemic index, and quickly increases blood sugar. The EU has some limits and guidance on how much corn syrup can be used, and bans the use of corn syrup solids in organic baby formula, but the US does not. Which means that infant formula in the US can contain 100% of its carb source from corn syrup! Now before you get all fired up, corn syrup is NOT the same as high fructose corn syrup, which is what we are told as adults we need to stay away from. High-fructose corn syrup is corn syrup that has been further treated with enzymes to break down some of the glucose into another common sugar, fructose to make foods taste sweeter. Infant formulas are nutritionally complete and need a source of carbohydrate to provide energy. 

Maltodextrin is a type of sugar that is made up of glucose. Maltodextrin will become syrup if it is broken down further, so it’s essentially the same thing as added sugar.

Glucose syrup is the same thing as corn syrup! It just means that the syrup was extracted from a different plant – but it’s still the same as sugar.Sucrose is table sugar, and has a lower glycemic index than glucose, but higher than lactose.

Corn syrup, sucrose, maltodextrin are most used in “sensitive” formulas. That’s due to the fact that these formulas are designed for babies who are lactose intolerant, and so formula manufacturers are trying to replace lactose with an alternative carbohydrate.

Sometimes some corn syrup or glucose syrup is necessary in hypoallergenic formulas, because those formulas use hydrolyzed milk proteins, which are essentially partially digested milk proteins – and they taste/smell bad! So the corn syrup is used to try to mask the taste of the hydrolyzed milk protein.

But there are hypoallergenic formulas that do not overuse glucose and use healthier forms of carbs. 

There are a few reasons why formula manufacturers choose corn syrup over lactose in baby formula:

  • It’s a carbohydrate that babies can digest
  • It’s cheap to produce
  • Some sugars like maltodextrin also provide the function of thickening and emulsifying the formula for a better “mouth feel”
  • Corn syrup is sweet! And babies like sweet things – which might make formula more palatable to babies.
  • In hypoallergenic formulas, corn syrup might be used to make the formula taste better and mask the hydrolyzed milk protein taste.

So to recap, when choosing a baby formula, lactose is the preferred sugar or carb source for human babies. Prior to switching to a lactose free version, which will have the sugar source coming from another carb product, we should be switching to a formula with lactose with a different protein source which we will be discussing next. 

Formulas: Protein source 

Infant formulas come in powder, liquid concentrate, and ready-to-feed forms. They are designed to be prepared by the parent or caregiver in small batches and fed to baby, usually with either a cup or a bottle. 

There are an overwhelming number of infant formulas on the market and it can be difficult to determine which one is best to give to your baby. As an IBCLC lactation consultant, my job actually includes education on safely preparing, handling and feeding infant formula. Which includes helping families choose an infant formula that is right for them based on solid evidence based research. If there was more education and less demonizing of formula, families would feel less guilt and stigma around just trying to feed their babies while also feeling supported in the medical and nutritional care of their babies. 

So let’s break down how to choose an infant formula. Here’s the disclaimer: what works for one baby won’t work for all babies. So always speak with your pediatrician or personal health care provider if your baby is struggling to tolerate any infant formula you are using. 

There are three main ingredients that are essential and needed in all infant formulas. The carbohydrate, or sugar source, the protein and the fat. In this video we will be talking about the protein source. In my experience, if an infant is going to have difficulty tolerating an infant formula, it’s usually the protein piece that they are struggling to digest and changes to the formula can make a drastic difference in baby’s gut. 

So what is protein? Protein is the building block of all things. Excluding water and fat, the human body is made up almost entirely of protein. Protein is the main component of muscles, bones, organs, skin, and nails. For example, your muscles are composed of about 80% protein. There are at least 10,000 different proteins that make up and maintain different functions throughout your body. Protein is made from over 20 different basic building blocks called amino acids. Because we don’t store amino acids, our bodies make them in two different ways: either from scratch within our own cells, or by modifying others from the foods that we consume. There are 9 amino acids—histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine—known as the essential amino acids, which we can only get for our bodies from the food that we eat. The body breaks down consumed protein into these amino acids, and absorbs it for use. It is used to build muscles and organs, to make hormones and antibodies, to be stored as fat, and to be burned as energy. 

Human milk is made up of protein from the foods we consume and is designed for feeding human babies. When you eat your food, proteins and nutrients go from your mouth to your stomach where they are broken down and passed to your intestine. These nutrients are absorbed in your intestines to your blood stream where it goes to the back of your breast to little sack like cells called alveoli. The alveoli pull nutrients, including protein, from your blood as well as water and milk is made. This milk then goes to your baby’s mouth, their stomach to be broken down and then absorbed in their intestines for their body to use.  Baby’s intensities have human protein receptors to accept and use the protein from human milk, which makes it easily digestible for baby. Protein levels in human breast milk are constantly changing based on the stage of lactation, frequency of nursing, and other biological factors of the mother. Human milk protein concentration, how much protein is in each ounce, is not affected by maternal diet, but increases with maternal body weight for height, and decreases in those producing higher amounts of milk. 

There are actually many types of proteins in human milk, but can be generally divided into two kinds of protein classes: whey and casein. These two kinds can also be further subdivided by a remarkable array of multiple other specific proteins and peptides. So protein is like saying letters, numbers or colors. It’s a general category that can be further broken down into many types of proteins. 

Whey and casein are two different classes of protein found in both breast milk and cow’s milk, as well as the milk of any other mammals. What are whey and casein? Have you heard the nursery rhyme about little miss muffet who sat on her tuffet eating her curds and whey? The curds are the casein and the whey is the liquid. The ratio of curds to whey, as well as then adding additional ingredients, is how we make dairy products like cheese and butter.  This is why they’re the protein sources in routine infant formulas. As we explore these two protein types, there’s one key concept to keep in mind: although both human and cow’s milk contain whey and casein protein, the actual whey and casein proteins in each type of milk are significantly different. In human milk, the ratio between whey and casein is dynamic, and it shifts throughout the course of lactation. In the very early days of milk production, breast milk will have more whey than casein, with a whey:casein ratio of 80:20. After the first few weeks of life, the concentration of whey declines and casein increases until the proteins reach the concentration seen in “mature” breast milk with roughly equal amounts of each protein type, about 60% whey and 40% casein. On the other hand, casein is the dominant protein in cow’s milk, contributing roughly 80% of the protein, while whey makes up about 20%. These differences in proportions relate to different developmental needs of human and cow newborns. Whey proteins are easier to digest, and as a result, provide a more rapid source of amino acids. In contrast, the unique structure of casein proteins—called the casein micelle—makes them harder to break apart and requires a longer digestion time. Such gut muscle activity is referred to as gut motility and its rate is measured as gastrointestinal transit time. Baby cows digest differently than baby humans as a species. Cows’ milk and its proteins are known to delay gastrointestinal transit time. In some people, this may manifest as constipation. In others, delayed transit time in the gut may allow more time for fermentation of fermentable carbohydrates and which leads to intestinal fluid resorption, resulting in softer stools. This is what makes the gassiness and constipation symptoms in babies when consuming milks other than human breast milk. There is much discussion on the digestibility of whey vs. casein. Overall, whey remains a liquid during the course of digestion, while casein forms curds or clots. The pH (or acid level) of the stomach influences how these different proteins behave in the GI tract. The high proportion of casein in unmodified cow’s milk is one of the reasons why regular milk is not an appropriate to feed to young babies. Even after birth, the GI tract still has a lot of maturing to do, and a feeding that provides primarily casein can cause issues for many babies. While it makes some sense for infant formulas to mimic the whey and casein ratio of breast milk, protein is more complex than just ratios! The finer details of the composition of different types of whey and casein, as well as how they function in the body, are also considered when infant formulas are designed. Both whey and casein are considered high-quality proteins and provide all nine essential amino acids we know are required to support growth and development.

Now let’s jump in to the nitty gritty of the different kinds of proteins found in infant formulas so you understand what to look for when you’re staring at the ingredient list on the side of the can. There are many sources of protein used in baby formulas. Animal-based (dairy-based) sources of protein used in baby formulas include cow’s milk, goat’s milk, whey protein, organic milk protein concentrate, milk protein isolate, and casein hydrolysate. Plant-based sources of protein used in baby formulas include soy protein, pea protein, and some times almond butter protein

  • Cow's milk formula is the most commonly used type. An alternative to cow protein would be goat milk protein. 
  • Soy protein based formulas are frequently used for infants allergic to cow's milk or lactose and for those who are avoiding animal products like vegetarians or vegans. 
  • Protein hydrolysate formulas contain protein that's been broken down into smaller sizes than are those in cow's milk and soy-based formulas. Protein hydrolysate formulas are meant for babies who do not tolerate cow's milk or soy-based formulas.
  • Specialized formulas are also available for premature infants and those with specific medical conditions where the protein has been broken down even further. 

Those are the options for protein sources, but let’s break it further down to understand those food labels better. Also, research has shown that baby formulas with high casein may be more difficult to digest. For this reason, baby formula manufacturers often add whey protein, resulting in an adapted whey to casein ratio. Adding whey protein to baby formula may help to reduce tummy troubles in little ones. Remember the whey remains a liquid while digesting but the casein protein stays a solid and is harder to digest. A formula with at least 50, ideally 60% whey is ideal. Each manufacturer determines for their own brand this ratio but the trick thing is they don’t have to list the ratio. Some manufacturers will only list the ratio it there is 100% whey with no casein, (like Gerber Gentle Soothe Pro or Burt’s Bees Ultra Gentle). Most of the time you’ll have to call the manufacturer how much their particular ratio is or you can sometimes deduce how much is in there based on the position of “whey protein” in the ingredients list. For more whey in the ratio, you want it in the top 3-4 ingredients of the list on the label. Now if your baby is already drinking formula and they are tolerating it well, I will always say there is no one size fits all approach to feeding. If your baby seems to be drinking their formula fine with no digestion upsets, meaning constipation or fermented gas, if it ain’t broke, don’t fix it. But if you feel like your baby is struggling in their current formula, this is the ingredient to change first. So when we’re talking about picking formula by protein, first we want to look at the percentage of whey to casein. We usually want 50-60% of whey or possibly more depending on your baby. 

Now let’s break down the casein portion. There are subtypes of casein called “beta-casein” proteins there are a couple of different types, but we will focus on this. It comes in a 1 beta-casein or a  2 beat-casein formula. This is A1 versus A2 beta-casein formulas. The majority of mammal milks, including human milk, produce predominantly or exclusively A2 beta casein. That’s what we as humans are designed to digest. But the majority of our cows in the US produce both A1 and A2 beta proteins. Because we as humans weren’t really designed to digest A1 beta casein, some times we see digestive issues with both adults and babies. Sometimes we see symptoms that are less severe than a true milk allergy but are indicative of a milk protein sensitivity. These babies may benefit from an A2 formula that doesn’t have these beta-casein proteins. These symptoms can include eczema, raspiness, congested-sounding breathing, occasional mucous in the stools, and digestive discomfort. But without the extreme symptoms that we see with CMPA, like widespread rash, projectile vomiting, blood in the stool, poor growth or weight gain and feeding aversion or refusal. So if your baby has trouble with milk protein but testing negative in their stool test for milk allergy, switching to an A2 formula can be a good place to start before jumping to a hypoallergenic milk if there’s no diagnosed CMPA. 

Another option for a gentle formula is to pay attention to whether or not your formula is hydrolyzed. This means they have taken the intact milk proteins and broken them down into smaller pieces which can be easier to digest and have a lesser risk of an allergenic response. A partially hydrolyzed formula means they have some of their proteins broken down. A hypoallergenic formula means it has been extensively hydrolyzed where above 90% of the proteins are significantly broken down. 

Some babies may need an elemental or amino acid formula where there’s no detectable protein at all but instead the amino acid components of protein so there is no protein to react to. Unfortunately many pediatricians will jump to this type of formula when baby is reacting to other formulas instead of systematically working through other formula options first. If you read my other blog on the carbohydrate, one of the biggest concerns with the hydrolyzed and elemental formulas is the sugar source. They are most often using sugars other than lactose, which is the number one sugar in breast milk, to mask the flavor of these formulas. For more information on that see my other video. 

So here’s the summary:

IF your baby is having trouble with their formula, I suggest the following order to try to find a more digestible formula, unless there is obvious evidence there is an allergy:

  1. A formula with more whey protein in the ratio
  2. A formula with A2 protein (even better if it’s an A2 with added whey
  3. A formula that’s partially hydrolyzed (but remember you’re often sacrificing the lactose)
  4. An extensively hydrolyzed formula
  5. An elemental formula 

The other protein options for infant formulas are those the are plant based. Eating plants in the form of fruits and vegetables is good for babies (when they are developmentally read for them of course!). However, there is no nutritional advantage to plant-based infant formulas. For many health care providers, the use of soy-based formulas is often recommended for only those infants who cannot not have dairy-based products because of health, cultural or religious reasons, such as a vegan lifestyle or due to galactosemia. Soy formula is made from soy protein isolate, a product that comes from whole soybeans that have had fat removed (defatted). However, plant based protein is nutritionally deficient compared to animal based protein formula sources as soy is an incomplete protein, which has been a concern with soy formulas. Since infant formula is the only source of nutrition for many babies, it must contain all the nutrients that infants need to grow and thrive. So current soy formulas have added 3 amino acids which are naturally deficient in soy protein including methionine, taurine, and carnitine. 

The other concern with soy protein based infant formulas used to be higher amounts of aluminum found in soy, up to 50% more aluminum in soy than human breast milk. However, 95% of the ingested aluminum is not absorbed in the gut, and the kidney excretes the absorbed 5%, so there are no differences in plasma aluminum levels in children fed with different formulas  

Two potential issues remain for the use of soy formulas: One is the concern about possible hormonal effects on the reproductive system caused by phytoestrogens found in soy protein. Although at present there is no definitive evidence that phytoestrogens have toxic effects in human babies who are fed soy formula, concern has been raised from research carried out in vitro and in animal studies. Phytoestrogens are plant-derived substances with estrogenic activity. There is concern that these isoflavones may mimic the actions of estradiol or alter estradiol metabolism, and consequently modify the processes influenced by estradiol in the body. Estradiol is the primary form of estrogen found in the body during reproductive years that plays a significant role in initiating and maintaining postpubescent female secondary sex characteristics including breast development, changes in body shape, and affecting bones and fat deposition. Despite this theoretical possibility, practical experience has shown that the millions of babies who have consumed these products since the 1960s appear to have grown and matured as expected. Although no overt toxicity is associated with the consumption of soy-based formula in healthy babies, clinical research has shown that babies with congenital hypothyroidism should be cautious when consuming soy based formulas and have their thyroxine levels routinely monitored. 

A recent retrospective human study showed that adults who consumed soy-based formulas as babies showed no difference in rates of reproductive maturity, cancer development and general health as adults who had been fed cow’s milk-based formulas. Additionally, soy formulas appear to be safe from a neurodevelopmental perspective, as shown in a nationwide study of infants born in Korea. Soy formula intake did not increase the risk for developing epilepsy, attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), or decreased developmental status. Currently available soy-based formulas support normal growth and nutritional status for the first year of life, with no overt toxicities observed in healthy babies. However, soy-based infant formulas may not adequately promote growth in babies who were born premature, and it is not recommended for these babies. 

The other problem to take into consideration is the use of transgenic soy in formulas. The US Department of Agriculture records that up to 93% of soybean crops are transgenic. Due to these nutritional disadvantages, higher allergenicity and less tolerance, the European Academy of Allergy and Clinical Immunology (EAACI) and the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) recommend not giving soy to babies with CMPA during the first 6 months of life or to children who have experienced gastrointestinal symptoms like constipation or foul smelling gas. Rarely, a soy-based formula is necessary to treat a metabolic disease. In this case, formula is used as a clinical intervention, much like medicine is used. These are exceptional cases and parents are encouraged to follow recommendations of their medical team.

Some families turn to soy-based formulas because of suspected cow’s milk protein allergy. Soy proteins can cross react with cow’s milk proteins; therefore, soy is not an appropriate formula for infants with a cow’s milk allergy. In fact, up to one half of infants with a cow’s milk allergy who are fed a soy formula are also sensitive or allergic to soy proteins (this is called cross reactivity). Both the American Academy of Pediatrics and the European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Committee on Nutrition recently produced papers on soy protein infant formulas (38,49). They recommend extensively hydrolyzed protein (or amino acid-based formulas if hydrolyzed formulas not tolerated) for the treatment of infants with CMPA. A 2020 review article from Europe recommends avoiding soy formula for infants with cow’s milk allergy who are under 6 months of age. (Concerns for the use of soy-based formulas in infant nutrition. Paediatr Child Health. 2009 Feb;14(2):109-18. PMID: 19436562; PMCID: PMC2661347.)

Rice is one of the less allergenic foods, reacting in less than 1% of allergic children. It has no lactose and no phytoestrogens. For this reason, hypo-allergenic formulae that uses hydrolyzed rice proteins have been developed as another plant based protein alternative for infant formulas. These formulae have now been in use for more than a decade in several westernized countries. Rice protein composition is naturally different from cow proteins: although they are rich in essential amino acids, three of these do not reach the respective value contained in breastmilk.

For this reason, to guarantee nutritional safety to infants allergic to cows milk or soy, partially hydrolyzed rice proteins formulas (HRF) are supplemented with multiple amino acids as several key nutrients like, iron and zinc. Although several studies have shown the hydrolyzed rice protein formulas to be nutritional and allergy safe, they are still recommended as a second choice to elemental or amino acid formulas. 

The BEST formula for you is the one that works best for your baby. This is NOT one size fits all and what works for your baby may not work for other babies. As always, please consult with your child’s health care provider or pediatrician for questions and concerns about your baby’s nutrition growth, and digestive system. This is not medical advice, this is the most current education on the choices available to you and how to interpret the labels on the containers of infant formula.  Manufacturers do not have to disclose their whey to casein ratio on the side of the can, but remember: human milk has a higher whey to casein ratio. If your baby is struggling with a whey based formula, switching to one with a higher amount of whey may help baby digest the formula quicker resulting in less constipation or fermenting gas. 

  • Breast milk has 400+ different proteins.
  • These proteins fit in two categories: i) casein and ii) whey.
  • Protein itself is a nutrient, but also helps absorb other nutrients.
  • Proteins also have antimicrobial and immune-supporting functions.
  • Amino acids are the building blocks of proteins, and each has a unique combination.
  • Therefore, the amino acid profile of whey and casein proteins are distinct.
  • From colostrum to mature milk, the ratio and amounts of whey/casein protein changes.
  • Between the two, whey protein is predominant. It makes up 50-80% of protein content in breast milk.
  • Suffice to say that the protein composition of breast milk is dynamic!
  • Nucleotides are also found in breast milk. They are the building blocks of our DNA.
  • Nucleotides are conditionally essential nutrients during the early stages of life.
  • In infants, they help the immune system and the gastrointestinal tract.

Freeze Dried Breast Milk

Freeze drying milk is not a new concept. Powdered milk, also called milk powder, dried milk, or dry milk, is a manufactured dairy product made by evaporating milk to dryness which can then later be reconstituted to the liquid form by adding water later. The first modern attempts at drying milk started as early as 1802 with specific processes for drying milk being created by 1837. Powdered milk is frequently used in the manufacturing of infant formula, confectionery such as chocolate and caramel candy, and in recipes for baked goods where adding liquid milk would make the final product too thin. During the 1960s, commercial infant formulas became popular, and by the mid-1970s they had all but replaced evaporated milk formulas as the "standard" for infant nutrition.

Typically when we think of breast milk storage, freezing in either a standard freezer or a deeper freezer have been the go-to for years. Milk that has been frozen correctly and stored in a deep freezer is optimal for about 6-9 months before the flavor begins to change. Newer guidelines are saying that frozen milk may still be good about a year in the freezer. But freeze-dried milk which can last from 3 to 20 years on the shelf! So the while the idea and concept of freeze dried breast milk isn’t new, it’s taking the market by storm with many new companies popping up in recent months. So let’s do a deep dive into the world of freeze dried breast milk, the pros and cons, and the expense. 

HOW IT WORKS

Sublimation is the fancy term for the freeze-drying process which basically means all the water has been removed from the breast milk and turns it into powder. Low temperatures are used for a long time in the drying process to ensure the nutrients in the milk are protected. Freeze drying is different than dehydrating, which uses very high heat and is relatively faster. With freeze drying, 'low and slow' is the name of the game to protect precious nutrients.

Here is the basics of a freeze-drying process:

  • Deep freezing: Milk is deep frozen in a chamber at temps below -40 degrees Fahrenheit.
  • Pressure dropping: Air inside the chamber is removed via a pump, which drops the pressure to create a vacuum. The low pressure turns the solid to gas. The vacuum pumps out the water particles.
  • Drying: Ice crystals inside the frozen breastmilk is vaporized by drying the milk with alternating warm and cold air (without thawing the breast milk) leaving behind a breastmilk powder
  • Packaging: The powder is sealed in special airtight bags or packages that protect against air, light, oxygen, and moisture. 
  • Since everyone’s breast milk is unique, the company will send you specific directions for reconstituting your milk for baby to drink. This is NOT like standard formula where 1 scoop gets 2oz of water. Each bag of powdered breast milk will need specific amounts of water unique to your milk. 
  • You should expect that however much milk you send will equal however much you receive back. If you send in 200oz of your breast milk, your powdered milk will make 200oz of breast milk when you’re ready to use it. 

Breast milk powder should be stored and prepared properly in order to prevent contamination with Cronobacter and other bacteria that can cause serious illness if safe handling guidelines are not followed.

THE PROS TO TRY IT:

  • To preserve milk for longer than it would last in the freezer, especially if it is going to expire soon
  • For the convenience factor
    • It’s easy to travel with or to ship to someone else
  • Can help with high lipase
    • While freeze-drying doesn’t reduce the amount of lipase in the milk, by removing the water it reduces the enzyme activity that breaks down breast milk which can make the taste and smell much milder. For some whose baby rejected pumped milk in bottles because of high lipase may have a higher chance of taking it freeze dried
  • For those who are doing elimination diets, this may preserve the milk longer for when your baby outgrows the allergy or intolerance so you can offer your milk later in your feeding journey
  • In cases where breast cancer has been identified and a mastectomy would be life saving, freeze drying milk can ensure future children conceived after mastectomy could still receive mother’s own milk
  • Can add some nutritional value to your older child’s meals by sprinkling it in purees or on solid foods, or even baking with it for the whole family
  • Could be an option for surrogates or donor milk
  • Saves space 

THE CONS AND THE COST

The big concern medical professionals have is that freeze-dried milk has not been widely studied. Yet. Most current health care providers will stick with AAP guidelines, CDC guidelines, FDA guidelines, and they have not released a formal statement on the safety and the efficacy of freeze-dried breast milk. But I would anticipate as it gains popularity and traction that eventually studies will be down on it. Without sufficient studies, it’s unclear if freeze-dried milk has the right protein, fat, carb ratio that infants need. We don’t know exactly how freeze-drying impacts the nutritional composition of breast milk. Some research suggests that breast milk's natural carbohydrate and protein content remains intact for up to six months after freeze-drying. But other studies report that freeze-drying may lower the amount of key antioxidants, like vitamin C, that are naturally present in breast milk. There really is a lack of evidence in terms of the nutritional safety of freeze-dried human milk at this current moment in time. Another concern is that freeze-dried milk does not undergo a pasteurization process which kills harmful bacteria. Pasteurization is avoided on purpose, in order to preserve the vital probiotics that are present in breast milk, and which would be destroyed with pasteurization. Just as bacteria can grow in freshly expressed milk if it is left at the right temperature for extended lengths of time, the same can happen with rehydrated breast milk powder. And there is room for error when making up bottles of freeze-dried milk. Each bag may require different amounts of water for rehydration, which means parents need to pay close attention to how they are preparing each bottle. Too much or too little water too often can lead to adverse effects in baby, like low sodium levels or not enough calories per feeding. 

Freeze drying breast milk is still a relatively new science when we are talking about using it for breast milk. Even though there are multiple new companies specializing in this, no matter what company you choose, it is going to be an investment. The cost to freeze dry your milk will vary based on the company you choose as well as the quantity of milk that you have.

Several companies will wait until they have your milk in hand before charging you. This way they know exactly how many ounces of milk there are! This is because we often aren’t accurate in our measurements of what we collect. The bag or the bottle lines can be inaccurate or we can tilt the bottle to see a different number than what’s actually there. Companies are very particular in measuring so that they can ensure proper ratios at the end too. They want to make sure they aren’t over or under charging you. Other companies may charge a flat rate or give you an estimate. Do your research but expect to pay several hundred dollars for your batch of milk!!

Freeze-drying human milk may still be an appealing option depending on your circumstances. If you are adamant about freeze-drying your milk, make sure to use a legitimate company with lots of reviews. And DON’T try it at home yourself as you're risking contamination.

 

References:

  • Basics of Breastfeeding Support for the NICU or PICU Dyad. IABLE- Institute for the Advancement of Breastfeeding and Lactation Education
  • Blackshaw, K., Wu, J., Valtchev, P., Lau, E., Banati, R. B., Dehghani, F., & Schindeler, A. (2021). The Effects of Thermal Pasteurisation, Freeze-Drying, and Gamma-Irradiation on the Antibacterial Properties of Donor Human Milk. Foods (Basel, Switzerland), 10(9), 2077. https://doi.org/10.3390/foods10092077
  • de Halleux, V., Pieltain, C., Senterre, T., Studzinski, F., Kessen, C., Rigo, V., & Rigo, J. (2019). Growth Benefits of Own Mother’s Milk in Preterm Infants Fed Daily Individualized Fortified Human Milk. Nutrients, 11(4), 772. https://doi.org/10.3390/nu11040772
  • Ginglen JG, Butki N. Necrotizing Enterocolitis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513357/
  • Jarzynka, S., Strom, K., Barbarska, O., Pawlikowska, E., Minkiewicz-Zochniak, A., Rosiak, E., Oledzka, G., & Wesolowska, A. (2021). Combination of High-Pressure Processing and Freeze-Drying as the Most Effective Techniques in Maintaining Biological Values and Microbiological Safety of Donor Milk. International journal of environmental research and public health, 18(4), 2147. https://doi.org/10.3390/ijerph18042147
  • Lima, H. K., Wagner-Gillespie, M., Perrin, M. T., & Fogleman, A. D. (2017, August 2). Bacteria and bioactivity in holder pasteurized and shelf-stable human milk products. OUP Academic. https://academic.oup.com/cdn/article/1/8/e001438/4735239
  • Meredith-Dennis, L., Xu, G., Goonatilleke, E., Lebrilla, C. B., Underwood, M. A., & Smilowitz, J. T. (2018). Composition and Variation of Macronutrients, Immune Proteins, and Human Milk Oligosaccharides in Human Milk From Nonprofit and Commercial Milk Banks. Journal of human lactation : official journal of International Lactation Consultant Association, 34(1), 120–129. https://doi.org/10.1177/0890334417710635
  • Putting Evidence Into Practice: Freeze Dried Human Milk
  • Salcedo, J., Gormaz, M., López-Mendoza, M. C., Nogarotto, E., & Silvestre, D. (2015). Human milk bactericidal properties: effect of lyophilization and relation to maternal factors and milk components. Journal of pediatric gastroenterology and nutrition, 60(4), 527–532. https://doi.org/10.1097/MPG.0000000000000641

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