When it Has to be Formula: Optimizing the Health Of Your Formula-fed Baby

baby holding bottleThere are occasions when a mother is unable to provide any human milk for her baby, or where serious supply challenges require artificial supplementation. 

What can you do to optimize the health of your formula-fed infant?

By Dr. Linda Folden Palmer

Modified August, 2013


First off, know that infant formulas are constantly improving. Research on breastmilk substitutes is growing every day, with a few bumps in the road. There are fewer drawbacks to these formulas than those seen historically. Additionally, some very recent fortification attempts hold the promise of partly buffering the greater risks of diabetes, heart disease, obesity and cancer found among children and adults who were formula-fed as infants.

Formula feeding poses immune and neurological drawbacks but there are strategies you can take now to improve your formula-fed baby’s health. Thesefactors can have a life-long impact on your child’s overall health.

Consider hydrolyzed milk formula 
The best choice for a first formula may be a hydrolyzed milk formula, especially if any kind of allergies exist in the family. Cow’s milk proteins are large and difficult for young babies to digest, and are highly allergenic. In hydrolyzed formulas, the proteins are broken down into smaller, more tolerable pieces.

baby holding bottleMany of the potential problems with milk intolerance can be avoided by using one of these hypoallergenic formulas from the beginning. Often, small but regular intestinal bleeding occurs in formula-fed infants (or breastfed infants not tolerating cow’s milk proteins in mother’s diet), even when dairy intolerance is not suspected. This common occurrence is usually undetected but can lead to anemia. It may be preventable by simply beginning with hydrolyzed formula for the first months of life, when formula is necessary.

Hydrolyzed formulas do not taste as good to infants who have tasted other formulas. Therefore, it’s sometimes difficult to switch to a hydrolyzed formula once you’ve begun with regular formula.

Some babies still react to the traces of intact proteins in these. There are alternative formulas made with only amino acids (the protein building blocks), but they’re very expensive. These formulas (Neocate AA, Nutramigen AA) are even more hypoallergenic and are good choices for the very allergic, formula-fed baby (although they still contain trace corn proteins).

Some mothers are erroneously told they should feed hydrolyzed or amino acid formula to their infant who is breastfeeding and is intolerant of dietary proteins in mother’s milk. This advice is sad and absolutely wrong. A food-intolerant baby will fare far better on mother’s milk while mother avoids dairy and any other problematic foods in her own diet.

Don’t avoid lactose
Many are mistaken about lactose tolerance when it comes to babies. Lactose is baby sugar. It’s available only in the milks of mammals to provide for their offspring and it provides valuable immune-protective properties. Many older children and adults develop lactose intolerance, as adults are not intended to be nursing; drinking milk.

A baby born with the extremely rare defect causing total inability to digest lactose quickly suffers brain damage and would not survive prior the rather recent development of lactose-free infant feeds. It is, however, common for an infant reacting to cow’s milk proteins or recovering from some other intestinal irritation to suffer a temporary reduction in lactase enzyme, needed for lactose digestion. This may cause some babies to test positively for lactose intolerance via laboratory tests. While these babies may appear to fare slightly better with lactose-free formula, this condition will reverse as soon as a child recovers from illness or is given a feed without cow’s milk proteins or other problematic proteins in it.

Use acidophilus 
Formula-fed infants develop adult-type flora in their intestines. These flora are part of the cause of formula-fed babies’ increased incidence of intestinal illnesses. Providing a daily dose of friendly bacteria (the kind found in yogurt) may help to maintain a gentler flora for baby.

Don’t give your young infant yogurt though. Instead, provide a twice-daily dose of a good quality powdered or liquid combination of Lactobacillus acidophilus, Bifidobacterium, and some other good bacteria. You can add the powder directly to the formula when preparing it (after warming), or place drops of the liquid directly in baby’s mouth. Store these friendly bacteria, known as probiotics, in the refrigerator.

Formula companies are currently studying the addition of probiotics to store formulas. They have been found to be safe for infants and to possibly reduce colic and diarrhea, although occasional constipation has been reported with probiotic-fortified formulas. Daily use of probiotics may reduce your baby’s potential for developing allergies, as formula-fed babies have a greater risk.

Consider DHA and ARA
There has been much research lately in regards to certain fatty acids known as DHA (docosahexaenoic acid) and ARA (arachidonic acid), important nutrients for brain and vision development. These long-chain polyunsaturated fatty acids found in breast milk have traditionally been very low in infant formulas. It is known that babies are able to make their own DHA and ARA, but it has been found that they are unable to create optimal amounts.

This discrepancy explains in part the slight neurological and visual deficits linked with formula feeding. Studies show some possible visual and cognitive benefits when these fatty acids are supplemented in formula-fed infants. Several recently released studies and ongoing studies are working to find the optimal levels and forms of these to add to infant formulas. 

Study results so far are mixed but mostly positive. Oxidation of these fatty acids during storage may be a problem and may account for some of the mixed results. Some infants experience diarrhea from these formulas. The chemicals used in the distraction process are under scrutiny today. Fresh forms of these fatty acids might be more beneficial to infants. Some consultants are recommending adding these directly to infants’ diets.

Cod liver oil is an excellent source of DHA and ARA, as well as EPA, another important fatty acid. An eighth to a quarter teaspoon per day may be appropriate for a small infant. Vegan DHA supplements are available as well.

ARA, DHA and EPA are found only in animal sources. Egg yolk is an excellent source for babies, but it’s not something to give newborns. Some nutrition consultants suggest providing one rinsed yolk plus a teaspoon of cod liver oil daily after 4 months. Since egg white is the part of eggs that can cause allergy, you should avoid using them with infants. Cod liver oil may loosen the stools.

“Nurse” your bottle-fed baby
The term “to nurse” means to provide gentle nurturing care. Nursing your baby during feeding provides face-to-face contact and rich non-verbal and verbal conversation — all extremely valuable for your baby’s social and neurological development. Skin-to-skin contact is shown in studies to provide an additional advantage and can be included in a cozy bottle feeding.

Reduce cortisol releases
When babies are allowed to cry without receiving a nurturing response, they release a large amount of the stress hormone cortisol into their systems. When this is allowed to happen regularly, their brains develop permanent, life-long patterns of increased cortisol release in response to stress. These excess stress responses are coupled with abnormally low base levels of cortisol. This abnormal cortisol-release pattern is strongly associated with depression, heart disease, and autoimmune diseases in later life.

In addition to the permanent modeling of brain receptor responses, chronic cortisol elevation makes babies more susceptible to illness. Incidentally, mothers release cortisol when their babies cry, too, increasing their own susceptibility to frequent illness, heart disease and depression.

In contrast, affectionate, responsive care induces the release of positive bonding and health-promoting hormones such as oxytocin in both mother and child.

Sleep with your baby in your bedroom
Sudden Infant Death Syndrome (SIDS) happens more often in formula-fed babies but studies show that the incidence of SIDS is greatly reduced when your baby sleeps in the same room as you do, compared to sleeping in a crib in another part of the house. When neither parent smokes and proper safety measures are taken, cosleeping in the parental bed provides the same safety as crib sleeping in the same room, especially after the first few weeks of life.

Take great caution with homemade formulas 
Concerns over formula difficulties and trends toward organic and raw products have created increasing interest in making infant formulas at home. While “organic” and “natural” are wonderful concepts, unmodified raw, organic, or standard cow’s and goat’s milk are dangerous infant feeds. The levels of many components are far too high in these milks, and the levels of other components are far too low. The number of problems that could arise is too high to mention.

Recipes are available using goat or other milk and simply adding sugar and water. The dilution of animal milks for babies is very important for the kidneys, and the sugar is extremely important for the brain, but other nutrients are far out of balance in this concoction. Companies developing breast milk substitutes have devoted over a century of research to create optimal formulas, and professionally made organic formulas have now hit the American shelves.

The only recipes I have seen that appear nutritionally adequate are those presented by the Weston-Price Foundation (though manganese seems low in the milk formula to me). Every ingredient in their recipes is there for a reason. I’ve heard of parents trying to use this formula leaving out the lactose (or replacing it with stevia) because they think less sugar is better or they are mistaken about lactose tolerance. The right amount of sugar (almost 50% of calories) is essential to proper brain development and lactose is the healthiest sugar for all babies. Others parents try to reduce the amount of fats. Again, adequate fats (almost 45% of calories) and a full spectrum of fatty acids are very important to developing babies.

Consider starting solids sooner
Studies show that delaying the introduction of solid foods is highly beneficial when a baby is exclusively breastfed — but the same does not always ring true for formula-fed or formula-supplemented infants. It is difficult for some formula-fed infants to gain enough iron from their formula, no matter how much is in it, and babies’ own iron stores may begin running out after several months. Dark-colored vegetables also have valuable antioxidants and fiber that have been missing in the formula diet.

Earlier solids are not for every formula-fed baby, but babies who have been experiencing a slight intolerance to their formula may robustly respond to the introduction of non-dairy, healthy solid foods. Some formula-fed babies fare better with introductions of strained vegetables, meats or a little fortified brown rice cereal as early as 4 months. Sugary foods, juice, or plain white-flour snacks have much less nutritional value than formula and are not appropriate for babies. Delay the introduction of fruit, which teaches babies to acquire a taste for sweet foods, unless you are trying prunes for constipation.

Keep formula in the diet for 18 months 
Studies show that children fare even better when infant formula is continued in the diet for 18 months or more, rather than switching to straight cow’s or goat’s milk, or other drinks at one year. “Follow-on” formulas are just cheaper versions of infant formulas. They have more calcium only because they have not replaced as many cow’s milk ingredients with the more-balanced nutrients put into infant formulas.

Consider avoiding the vitamin K injection
Babies are purposely born with low levels of vitamin K, which is meant to increase gradually through feedings of breast milk, which is deliberately “low” in vitamin K. This tightly managed vitamin K level controls the rate of cellular reproduction. When infants are injected with the huge amount of vitamin K routinely given at birth, cellular reproduction may be allowed to get out of hand. Some very slight increase in leukemia cases is associated with these injections, and there are other very rare complications as well.

On the other hand, serious damage from a rare bleeding problem may be prevented by vitamin K injections at birth. A baby born with an undetected liver disorder can suffer damaging or fatal bleeding into the brain, and the clotting action of added vitamin K can reduce this bleeding.

Studies have shown that breastfed babies can be supplemented in smaller oral doses spread out over the first weeks of life and still safely avoid this rare but dangerous bleeding complication. Formulas are already supplemented with much higher levels of vitamin K than are natural. Studies suggest that this gradually supplemented amount of vitamin K is adequate to prevent bleeding problems, negating the need for routine injection at birth in formula-fed babies. All babies need to be watched for signs of liver disorders, including advanced jaundice, or pale colored stools.

Take immune-protective measures
Because formula-fed infants miss out on the daily provisions of immunities and chemical defenses from mother’s milk, you should do all you can to assure your baby gets the best possible dose of antibodies from your body before birth. The greatest portion of these immunoglobulins are pumped into the newborn’s body during labor. A child born via scheduled cesarean section misses out on labor and its last-minute provisions. Even when a C-section is recommended, natural labor can often be allowed to happen first, giving your baby a big, important immunity boost.

A maternal diet high in antioxidants from fruits, vegetables, and nuts, can provide baby with good stores of antioxidants before birth. These stores can help for a while with some of the oxidizing effects of infant formula. A little liquid vitamin C may be added to formula to provide some extra antioxidant protection to formula-fed babies.

Newborns are more susceptible to illness when not receiving an exclusively breastmilk diet. The first weeks of life are the most dangerous. Simply keeping your baby close to home and screening visitors for any illnesses can help a great deal. Visitors should wear a snug mask if they’ve recovered from a virus less than 3 days prior to their visit.

Try just a little bit
When physical limitations or lifestyle circumstances may not allow for continued breastfeeding, supplying breast milk in the first few weeks of life can provide your baby with a large edge on health and survival, especially if he was born early or tiny. The first milk, called colostrum, is especially full of immune-providing, protective factors.

If you plan to formula feed by a certain date, your baby can benefit greatly if you avoid using formula supplements at all until it is nearly time for the switch. Any amount of formula supplementation weakens the advantages of the breast milk. American infants who are fed formula from birth enjoy more than a 99.3% survival rate; that rate is even higher when some early breast milk is received, growing proportionally with the amount of breast milk received to over 99.5% for fully breastfed infants.

If you cannot produce milk, you may be able to obtain donor milk from milk banks and occasionally directly from donating mothers. Long-term use of donor milk can be expensive and complicated, but short-term use could be a powerful investment in the future of your child. Donor human milk should be considered the first option when mother’s milk is unavailable.

You can go back
There are occasions when a parent feels that formula is just not working well for a particular child. Intolerance to all forms of formula is usually the dilemma involved. Re-lactation is a viable yet seldom-mentioned consideration in these situations. I saw one occasion in which a child developed an illness that could respond much better to breast milk feedings, so the mother decided to give re-lactation a try. With the assistance of a lactation consultant, re-lactation works fairly well or very well for most mothers who are determined to succeed.

Find resources for Relactation and Adoptive Nursing at KellyMom.com.



  • Carol A. Isaac January 11, 2015 at 7:52 pm

    This sounds like you are well acquainted and judicious in your interpretation of other studies. There is a controversy around sugars in marketed formulae. Have you researched that? What about the sugars in available marketed formula in the US and in Europe?

    • Linda F. Palmer February 8, 2015 at 10:08 am

      Breastmilk is nearly 50% sugar. Formulas MUST have sugars in them to support brain activity and growth. Lactose is the natural baby sugar and it’s designed to prevent many unwanted bacteria from taking hold in the gut — it’s an important part of baby’s immune system. Lactose can also be added to formulas (cow milk does not have enough for human babies) and some do this. That would be best. There’s a lot of disinformation about lactose intolerance in babies. If baby’s intestines are briefly, or constantly, irritated by allergy reactions to cow milk proteins or something else in his diet, then he will have a TEMPORARY reduction in lactase enzyme, and, if formula-fed, a lactose-free formula can help for that period of time, but it won’t help fully until the irritating factors are removed. Then the baby’s ability to digest lactose efficiently will return.

      Various other sugars are used in formulas instead of lactose. Glucose and rice syrup are benign — neither “beneficial” like lactose, nor “bad” like some may feel about corn syrup. Corn is another common allergen for babies and corn syrup clearly contains traces of corn proteins, or some other factor that lots of babies clearly react to — cut certainly not all of them. Some mothers are also concerned about GMO issues.

  • magda April 8, 2016 at 11:04 am

    The formula sold in the US is very bad. Even organic brands have in it corn syrup or fructose syrup instead of lactose. Can you imagine giving it to babies?
    When my baby was born I made a research and decided that I will buy formula from my country in Europe. The law in my country is very strict about baby food, I believe it is the same all around Europe. No corn syrup, no fructose syrup in babies food!
    So I decided to buy formula in my country and ask mu family there to send it to me. I had chose Hipp brand. No corn syrup, no fructose syrup. Only lactose and it is bio which mean it is organic too.
    I encourage people to look over internet and find one of European brands like Holle or Hipp.
    Plus the price even with shipment is so much cheaper than buying formula in the us. 600g good quality formula like hole or Hipp cost around $11 per package so even with the shipment cost is still cheaper. But most important it is healthier for your baby!!!!

    • Mika February 7, 2018 at 5:52 pm

      Where do you find it for $11?????? I can only find it for $25!

  • Olivia April 20, 2016 at 9:31 pm

    I agree with Magda..I’m German living in the US and I’m ordering the Holle Goat Infant Milk online. The ingredients are so much better, it’s totally worth it!

  • Steph March 21, 2017 at 1:28 pm

    Most of this is just plain wrong and I am disappointed that kellymom.com recommended this.

    There is no evidence hydrolysed formulas are any easier to digest and on top of this they are not regulated for safety the same as first infant milks are.

    You should never give your baby probiotics (or indeed anything but breastmilk and/or First Milk formula) unless under medical advice.

    (The cortisol and cosleeping thing does not only apply to formula fed infants so unsure why it is even in this article).

    Do not start solids sooner as your baby’s digestive system, immune system and kidneys are not developed enough to handle it, whether breast or bottle fed. Early weaning should also only be on advice from your doctor.

    Follow on formulas contain more harmful sugars than animal milk and increase the risk of childhood obesity and diabetes. They also contain less nutrients than animal milk as they are destroyed during production. It is true that some nutrients are added (though not the same ones that are destroyed) but there is no evidence they are of any benefit as your child should be getting them through his/her food anyway and as a result your child could ingest high concentrations of these vitamins which could potentially be harmful.

    Do not add vitamin C to your baby’s formula. It already contains all the nutrients necessary and adding more will only overload their systems.

    From reading a previous comment it looks like formulas in the US are very different from here in the UK/EU so that may account for this information seeming so misleading to me, but what I have said is definitely true for formulas regulated by the EU.

    • Linda Palmer July 1, 2017 at 9:46 am

      Hello Steph, thank you for writing. I receive many letters from moms who are heart-broken over not being able to breastfeed their infants, for whatever reasons. They are asking, wishing, hoping that there are ways to possibly optimize the formula choice. There are many homemade formula recipes out there and I find nearly all of them to be far less nutritionally balanced than industry formulas. I’ve learned that recommending exclusive donor milk is not always a welcome answer and is not at all an easy solution. I do not wish these loving and wise maternal voices to be ignored.

      In the U.S., there are many hydrolyzed formulas sold as “first infant milks.” I do not know anything about them being less regulated. I’m certainly not in love with them. I discuss some of their pro’s and con’s and only suggest that they be considered, as there are reasons to consider them.

      It’s an interesting comment that hydrolyzed formulas are not easier to digest. I’m not finding science journal papers on this in either direction, upon a quick, topical search. I understand that this could be a marketing ploy. It IS at least lore all over the web that pre-digested proteins (i.e. hydrolyzed) are easier to digest. They must be, by definition, but maybe this difference is insignificant?

      Without digging in to whom has performed the studies, the published studies suggest that the traces of bleeding seen in many formula-fed intestines are often reduced by feeding of hydrolyzed formula and are more successfully reduced (along with reduced eosinophilia) by amino acid formula use. I suppose this is not so much an issue of simple digestion but rather an issue of allergic and other intolerance reactions.

      The cortisol release comments are in reference to the title just above them… a recommendation to “ ‘Nurse’ your bottle-fed baby.” I see that the selection of a new title heading muddies this connection.

      In the U.S., many follow-on formulas contain lactose as their sugar, like cow’s milk. Breastmilk is nearly 50% lactose and this healthy (for babies) sugar is important for brain development and healthy immune-protective gut bacteria. As a child gets older, this simpler sugar should be replaced over time with more complex carbohydrates, so the lower sugar level in cow’s milk becomes more appropriate. Because of common negative reactions to cow milk proteins in infant formulas, and the temporary lactase enzyme reduction and uncomfortable gas that result, lactose has gained a bad name, and many infant formulas use corn sugars or other unhealthy sugars in its place, as do many follow-on formulas.

      Personally, I find non-soy infant formulas to be terribly lacking in antioxidant and anti-inflammatory acting agents, compared to human milk. A tad extra vitamin C could be a simple and safe means for partly compensating for this. I find that government nutrition standards are based on survival minimals, as opposed to optimals. It’s a popular personal opinion. Addition of vitamin C is something I would do for my own child but it is not something that has been studied and published, so a parent needs to make their own decision about it, just as with every other decision discussed in my article, and with the original decision to use infant formula.

      • Sue Jarman August 23, 2018 at 12:50 am

        Read First Steps Nutrition by Helen Crawley. She has analysed all available infant mills in the U.K. Many attempts to lure customers by saying products contain AHA, DHA, prebiotic and so forth are found to have no effect and may be harmful. Hungry baby and comfort milks are a marketing ploy – what baby isn’t hungry.

      • Tarah October 16, 2019 at 9:35 pm

        I feel like you should be citing these studies that you are mentioning. Without proper referencing so people can see where you’re getting your information it’s difficult to take these recommendations seriously.

        • Linda Palmer October 18, 2019 at 4:35 pm

          Hi Tarah, thank you for writing. I wrote this article as a light condensation of information from several chapters of my book, Baby Matters, the Revised 3rd Ed. The book itself has 1200 science journal references cited specifically throughout the 400 pages of text (plus 35 pages of references). Sorry, but to find my support for the statements in this article, you’ll have to read my book 🙂

    • ale August 29, 2018 at 5:30 am

      just on starting solids: northern european countries start solids at 4 months. There is debate about this, and my doctor also recommended me to do so – every baby might be different and it might be worth trying and observing with formula babies. The advice sounded logical to me.

  • Steph March 21, 2017 at 1:33 pm

    Also iron deficiency is twice as common in breastfed infants.

    • Sue Jarman August 23, 2018 at 12:52 am

      Please find out about lactoferrin.

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