Let me be clear—there is no real substitute for breast milk. It is simply the best food for your baby. It provides all the nourishment they require and builds immunities protecting your baby against developing certain infections to which they will be exposed. Now that I’ve said that, I know some of my patients decide to bottle-feed. If you do please discuss this with your health care professional, and investigate all of the formula alternatives.

How Formulas Are Made
Comparison of Formula and Breastmilk
Choosing Formulas
Soy Formula?
Follow-Up Formulas
Comparing Formulas
Lactose-Free Formula
Hypoallergenic Formula
How Much and How Often to Feed
Safe Formula-Feeding Tips
Bottlefeeding Tips
Sterilizing
Choosing Nipples
Switching from Formula to Cow's Milk
Bottlefeeding Questions of the day

Using human milk as the nutritional standard, formula manufacturers follow a basic recipe that includes proteins, fats, carbohydrates, vitamins, minerals, and water. They combine various ingredients so that the nutrients in artificial baby milks follow the same rough proportions as human milk. The big difference between formulas is the different sources of these elements – cow's milk, soybeans, or something else. Most formulas are cow's-milk based, meaning that the basic nutritional building blocks of proteins, fats, and carbohydrates are taken from this nutritional base. Cow's milk contains most of the nutrients necessary for adequate infant nutrition, although not in quite the proper proportions. Soybeans are also a ready source of certain nutrients necessary for human nutrition. Formula manufacturers start with the basic nutritional elements in cow's or soy milk and add ingredients until the mixture approximates human milk as closely as possible. They adjust levels of carbohydrates, proteins, and fat and add vitamins and minerals.

To be fair, formula companies have produced milk for babies which, at least on paper, seems to resemble the real thing. Formula is definitely better than it used to be. But on close inspection, what the factories make doesn't quite measure up to what mom makes. It is nearly impossible for artificial baby milk manufacturers to make a milk with nutrients even close to what mothers' bodies can make. And these companies' primary goal is to make a profit, so marketing and manufacturing issues influence what finally gets into the can.

One of our concerns is that even though formula-fed infants appear to grow normally, are they really thriving? Thriving means more than just getting bigger. It means developing to the child's fullest physical, emotional, and intellectual potential. We just don't know about all the long-term effects of tampering with Mother Nature – though we do know that there are significant health differences between formula-fed and breastfed infants. Human milk is a live substance containing live white blood cells and immune-fighting substances, and is a dynamic, changing nutritional source, which daily (sometimes hourly) adjusts to meet the individual needs of a growing baby. Formulas are nothing more than a collection of dead nutrients. They do not contain living white cells, digestive enzymes, or immune factors. In terms of human history, they are a new experiment.

Even though the Infant Formula Act passed by Congress in 1985 mandates the Food and Drug Administration to see that formulas contain all the nutrients that babies need, we don't really know everything there is to know about what babies need. The good news is that formula companies are constantly updating their recipe in order to keep up with new research into infant nutrition. The bad news is that each change in formula is really just a new experiment.

Be sure to choose a DHA-enriched formula. Most, if not all of the US formula companies will offer AA/DHA-enriched formulas. For information about the brain-building benefits of DHA, try Dr. Sears’ Go Fish DHA soft gels.

When it comes to infant formula, parents need to know a few simple facts:

There are some subtle differences among the major brands of infant formulas which may affect how your baby tolerates one formula over another. Reading the labels may leave you feeling like you need a Ph.D in biochemistry to make an intelligent decision. We want to help you with an analysis of the big three nutrients: proteins, fats, and carbohydrates. The vitamins and minerals in all formulas are similar, since these are governed by strict regulations, however, the nutritional fine points of the fats, carbohydrates, and proteins differ from one brand to another, as the marketing departments of each company are very willing to point out, especially to pediatricians.

Standard formulas are those that are tolerated by most infants. Infants with special digestive needs require special formulas. Here are some guidelines on how standard formulas differ and how to match the formula to your baby's needs.

Comparing proteins. In looking at the protein content of the big three brands (Similac , Enfamil, and Carnation), you will notice the main difference is in the whey/casein ratio. In recent years there seems to be a whey war going on among formula makers, and each company has its own semi-scientific rationale as to why their product is best. Carnation contains 100 percent whey, claiming that the cow's milk casein used in other brands, unlike the casein in human milk, forms difficult-to-digest curds that contribute to constipation. As an added perk, Carnation predigests the whey, breaking the protein up into smaller particles which are supposed to be easier for a baby to digest.

Enfamil promotes a 60/40 whey-to-casein ratio similar to human milk. Actually, a 70/30 whey/casein ratio is more typical of human milk, and the whey content of some human milk can be as high as 80 percent. Similac has always claimed that casein was the best protein, and for many years Similac formulas were 82 percent casein and 18 percent whey. In recent years, Similac has "improved" on this, and now boasts 48 percent whey and 52 percent casein. How much of this is science, how much is market pressure, and how many other factors are involved is hard to say. A consumer might conclude that Similac isn't sure about the optimal protein composition and seems to be going along with the whey crowd, but not as far as Carnation. Similac backs up their protein choice with studies showing the amino acid profile in the blood of Similac-fed infants is similar to the amino acid profile in the blood of breastfed infants. Unlike the manufacturers of Carnation and Enfamil who claim their formulas are most like human milk "on paper," Ross, the maker of Similac, has departed from this way of thinking and formulates their protein based on what actually gets into baby's blood, not what is listed on the can. This approach seems to have more scientific merit. Until this whey war is settled, let your baby's own digestion system be the guide.

Comparing fats. The label tells you that the fat in all artificial baby milks comes from vegetable oils. There is no acceptable alternative source, though long ago some infant formulas were made with lard. The five types of vegetable oils that are used are palm olein (not to be confused with saturated palm or palm kernel oil), soy, coconut, safflower, and sunflower. The different blends of these oils all have percentages of saturated, monounsaturated, and polyunsaturated fatty acids similar to breastmilk, though some rely more on one oil than another. Sunflower oil, for example, is extremely high in monounsaturates, whereas safflower is high in polyunsaturates. Formula companies claim that regardless of the source of the fat, as long as the final blend yields a fatty acid profile similar to human milk it's okay for babies. Enfamil has even published a study showing that their product has a fatty acid profile similar to that of breastmilk. Actually, comparing the fat profile of human milk with the fat blends of formulas is more difficult than it seems because the fat content of human milk changes with the age of the baby and from feeding to feeding. The fat blend of formulas tries to match an "average" fat profile for human milk (whatever that means).

Of all the nutrients in formulas, the fatty acid profile is the most concerning. While formula fat does contain the two essential omega acids, linoleic and linolenic, it does not have any DHA , the fatty acid vital for brain development. Up until recently, researchers believed that infants could make DHA from these essential fatty acids as adults do, but recent studies have shown that formula-fed infants don't have the same high DHA levels that breastfed infants do. Babies may need a supply of DHA ready-made. This biochemical infant quirk has caused a lot of controversy among formula manufacturers as to whether or not to add DHA. As it stands now, the DHA precursors, linoleic and linolenic acids, are there, but they are not as biochemically active as they are in breastmilk. In Europe, additional DHA fatty acids are added to artificial baby milks, and some nutritionists believe that without added DHA, American babies are currently fed formulas that have a fatty acid deficiency. Many researchers attribute the intellectual advantages of breastfeeding that are showing up in new studies to DHA. For the most updated information on DHA in infant formulas, see www.Store.Martek.com.

Another problem with the current fat blends is they don't contain any cholesterol . On the surface this may sound like a nutriperk, yet we are once again tampering with Mother Nature. Human milk is sort of a medium-cholesterol diet, like all animal milks. The absence of cholesterol is another reason for concern in artificial baby milks.

Carbohydrate comparisons. Similac and Enfamil are practically the same in carbohydrate content, both containing only lactose. Carnation, on the other hand, contains 70 percent lactose and 30 percent malto-dextrin, a table-sugar- like carbohydrate that is, according to the manufacturers, necessary to balance the biochemical properties of the whey.

Let baby be the judge. With current knowledge, it's impossible to rate one formula higher than another, and they're all likely to change with time. While the three main brands seem to be nutritionally similar, it all comes down to which formula works better in your baby's intestines.

Iron-fortified formulas. You will notice at the store that both Enfamil and Similac produce iron-fortified formulas and formulas that are lower in iron. In our opinion, and that of the Committee on Nutrition of the American Academy of Pediatrics, low-iron formulas have no place in infant nutrition. Carnation does not make a low iron formula, but only one formulation that contains the recommended amount of iron similar to that in the other two formulas.

A new trend in artificial baby milk, popular in Europe and now on the shelves in U.S. supermarkets, is formula designed for the infant older than six months and are meant to be a bridge between regular formula and cow's milk, which should not be introduced until some time after age one. Two questions arise about follow-up formulas: are they nutritious and are they necessary? The rationale for follow-up formulas is that the nutritional needs of infants greatly increase after the age of six months (especially for calcium, iron, and protein), and some infants may have difficulty meeting these increased requirements with greater volumes of standard formula, plus solid foods. The following discussion concerns Carnation Follow-up Formula. Here are the advantages and disadvantages of follow-up formula.

Advantages:

• Contains more calcium. From six months to a year the RDA for calcium in infants increases by fifty percent, from 400 milligrams to 600 milligrams. Carnation Follow-up formula contains 600 milligrams of calcium in 24 ounces. It would take 39 ounces a day of standard formula to meet these calcium requirements.
• Contains more iron. From six to twelve months a baby's daily iron requirements increase from six milligrams to ten milligrams a day. This extra iron could be supplied in 26 ounces of follow-up formula or 27 to 33 ounces of standard formula, so there isn't a great advantage to the follow-up formula here.
• Contains more protein. From six to twelve months an infant requires an extra three to four milligrams of protein a day. Follow-up formulas contain from 10 to 25 percent more protein. A baby would need an extra three to eight ounces of standard formula per day to get this extra protein.
• Costs less. The cost is around 20 percent less than the price of regular formula.
• May taste better. Because it is basically milk, it tastes more like milk.

Disadvantages:

• Casein/whey ratio different from human milk. Basically, Carnation Good Start Follow-up is like the older version of Similac: 82 percent casein and 18 percent whey, plus calcium and a newer fat blend.
• Sweetened with corn syrup. The rationale for replacing lactose in the milk with corn syrup is to get it to taste sweeter. In our opinion, using corn syrup as the prime milk-carbohydrate source in an infant under a year is nutritionally unwise. Besides insuring proper nutrition, one of the main goals in feeding an infant over six months is to shape young tastes toward the normal taste of fresh foods. Corn syrup is a sweetener and certainly shouldn't be part of a food babies eat several times each day. Our conclusion: we do not recommend follow-up formulas that contain corn syrup. They are nutritionally unwise and unnecessary. Better to give your baby a higher volume of standard formula (growing babies need more fluid anyway), plus calcium and iron-containing solid foods.

Even though around 25 percent of formula-fed American babies take some form of soy formula, we recommend that parents begin their baby on a standard cow's milk-based formula unless advised otherwise by their doctor. Soy formulas became popular as an alternative formula in infants who are allergic to cow's milk. Some babies are less allergic to the soy protein than to cow's milk protein. Yet, we have the following reservations about soy formulas:

• Even though soy-based artificial baby milks may be less allergenic for some babies, between 30 and 50 percent of infants who are allergic to cow's milk are also allergic to soy.
• There is no precedent in nature for feeding young mammals a plant-based protein. In the early 1970s it was discovered that soy proteins are deficient in some amino acids that babies need. For this reason, methionine, carnitine, and taurine have to be added from other sources. Not only is soy protein deficient in some amino acids because plant protein in general does not provide the same growth equivalent as animal protein, but more needs to be added so that soy formulas have a higher level of this protein to make up for its lesser quality. According to the amino acid profile, at least in All-Soy, there is no carnitine or taurine. Even though current biochemical knowledge has fixed some of the previous problems with soy protein for babies, we are still tampering with Mother Nature's recipe, leading us to conclude that feeding soy protein to growing babies is still experimental. Plant protein is a good protein for older infants and adults, but the protein made by big mammals for little mammals is ideal for babies.
• Another problem with soy is that the protein itself contains phytates, substances that bind calcium and phosphorus. To prevent calcium deficiencies and consequent deficiencies in bone mineralization, the calcium content of soy formulas is generally 20 to 30 percent higher than the calcium content of milk- based formulas.
• These phytates also bind iron and zinc. As a result of this finding, artificial soy baby milks, such as Carnation, Allsoy, and Mead Johnson's Prosobee, have added extra iron and zinc. Isomil's Soy formula (made by Ross Laboratories) does not have more zinc or iron than the company's cow's-based formulas. Studies done by Ross Laboratories show that the blood-mineral profile of babies on cow's milk and soy formulas are no different.
• In 1996 the Committee on Nutrition of the American Academy of Pediatrics voiced some concern about the relatively high content of aluminum in soy-based formulas and the possible toxicity to infants. Although the American Academy of Pediatrics concluded that the elevated aluminum levels in some soy formulas do not seem to be harmful for term infants, the fact is no one really knows. Because of this worry and studies showing less bone mineralization in preterm infants on soy formula, the Committee of Nutrition of the American Academy of Pediatrics recommended that soy formula be reserved for term infants and not be used for preterm or small-for-date infants.
• Soy formula was once routinely recommended for infants with a family history of milk allergy in hopes of preventing allergies from developing. Research has failed to support the idea that starting a newborn on soy formula will decrease the later incidence of allergy. Also, recent research has disproven the belief that babies are less colicky with soy formulas. Studies comparing cow's milk- based and soy formula showed that soy formula does not lower the risk of infant colic. For this reason, the Committee on Nutrition of the American Academy of Pediatrics recommends against the use of soy formulas in the routine management of colic or in infants who are potentially allergic to cow's milk. Instead of soy, hypoallergenic formulas are recommended.
• Giving an infant soy in the early months before intestinal closure may predispose the infant to soy allergies later on. Since soy is used as a filler in so many foods in the American diet, this is a serious concern.
• Soy formulas contain around 33 percent more sodium than standard cow's milk- based formulas, and formulas in general are saltier than human milk. It is nutritionally unwise to shape young palates to get accustomed to salty tastes. It's unwise to give a baby a salty formula unless absolutely necessary.
• Carbohydrate sources in soy formulas are even more of a concern. Just as there is a whey war going on between formula companies, there now seems to be a sugar war, too. Enfamil now advertises "no table sugar" in their soy formula, Prosobee, so they use corn syrup instead of sucrose. Does this make a big difference? Some nutritionists might prefer plain old table sugar to corn syrup. Corn itself is an allergen, and corn syrup is very sweet.
• Because soy formulas are made with bean "milk" and not cow's milk, they are naturally lactose-free. The problem is that lactose is the sugar in human milk and in the milk of all other mammals. There is no basis in nature for feeding mammals lactose-free milk. Lactose is an intestinal-friendly sugar, enhancing calcium absorption and helping to colonize those little intestines with favorable bacteria. While the "lactose-free" nature of soy formulas benefit infants who are congenitally lactose intolerant (which is really quite rare in the first year of life), this is really tampering with Mother Nature. Because soy does not contain lactose, soy formulas are often recommended for infants who develop a temporary lactase deficiency following an intestinal infection. Studies as to whether or not this helps show mixed results. The American Academy of Pediatrics does not recommend the routine use of soy formulas in infants recovering from diarrhea, but suggests they be used only in babies shown to be temporarily intolerant of cow's milk-based formulas.

Our conclusion: Unless recommended otherwise by your baby's doctor, soy formulas:

• Should not be routinely used in infants with a family history of milk allergy in hopes of preventing later allergy.
• Should not be as a substitute for cow's milk-based formulas unless baby has been proven to be allergic to cow's milk-based formulas.
• Should not be used to prevent or treat "colic" unless advised by your doctor.
• Should not be used in preterm or small-for-date babies.

Even though we discourage the use of soy formula as a first-choice artificial baby milk, in some babies it is a necessary alternative to cow's milk-based formulas. Many of the objections to soy formula are perhaps more theoretical than practical (since studies have shown that healthy term babies grow just as well on soy as they do on cow's-milk-based formulas). It's what we do not know about soy that concerns us. The soy bean protein brings along with it a lot of other phytochemicals (plant nutrients), some of which may be healthful, and others we just don't know about. Cow's-milk-based formulas have been around for nearly a century. We don't have that much experience with soy, so be cautious.

Special formulas are those in which one of the basic nutrients (usually the protein and/or carbohydrate) has been changed to an alternative nutrient that an individual baby may better tolerate. When formula shopping, be sure not to make a change to these specialty formulas without your doctor's advice. Specialty formulas:

• are usually much more expensive
• usually taste bitter to downright bad because the technology required to predigest (hydrolyze) the protein into more easily-digestible units results in a more bitter-tasting protein
• The nutritional quality of the changed or absent nutrient may be less than in standard formulas.
• Less is known about the long-term effects of feeding babies these special formulas. In other words, all formulas are experimental, but some are more experimental than others.

The following are the most popular specialty formulas at this writing: Lactose-free formulas (e.g., Lacto-free, Mead Johnson) are an example of new formula products that are driven more by market demand than scientific sense. Many formula-fed babies (and breastfed babies, too) get fussy, resulting in what we call the formula parade: switching from one formula to another until either something works or the baby's intestines mature and he outgrows the problem. Whatever formula you're using at the time gets the credit. The fact is that oftentimes baby's fussiness is not due to the formula, but to other unrelated causes. Nevertheless, formula gets the blame, so factories step up with new varieties to keep up with the demand. Hence lactose- free formulas.

Lactose-intolerance is over-diagnosed in babies (as it is in adults). It's easy to blame formula, and therefore lactose, for baby's fussiness. Think for a moment. If so many babies are lactose-intolerant, why would lactose be the sugar in human milk? True, human milk also contains the enzyme lactase that helps babies absorb the lactose, whereas formula does not, but milk lactase doesn't do the whole job. It does seem that nature would provide the intestines of nearly all babies with enough lactose to get through at least a year or so of milk-feeding (lactose is only present in dairy products and not other foods).

The main difference in lactose-free formula is that the lactose sugar has been replaced by other sugars, usually corn syrup and sucrose (table sugar). The protein and fat blend is the same as in cow's milk-based formulas. The biochemist who dreams up the formula believes that sugar is sugar, and substituting corn syrup and sucrose for lactose is no big deal. Lactose is eventually broken down into glucose, as are corn syrup and sucrose, so it shouldn't matter. Actually, the intestines break the lactose down into two sugars – galactose and glucose. Both of these sugars are absorbed into the bloodstream. No one really knows what galactose does or why it's beneficial, just as no one knows the whole story about how the body reacts to sugars from corn syrup and sucrose. So, we're back to the non-science of common sense. If the human baby (like all mammals) didn't do better with galactose, it wouldn't be there in the first place. The milk sugar would have been pure glucose. Like so many other nutrients in formula, there is one big WE DON'T KNOW about lactose-free formulas.

We also know that lactose does more than just supply energy. The lactose that doesn't get digested in the upper intestine contributes to what is called the friendly ecology of the gut. Lactose helps healthful bacteria thrive. Lactose- free formulas not only deprive baby of lactose, they also deprive those trillions of friendly bugs that live in the intestines and do good things for the body. Lactose also facilitates calcium absorption in the gut, so that babies on lactose-free formulas may run the risk of not getting enough calcium.

Lactose-free formulas (including soy formulas) are often tried when a baby has symptoms of lactose intolerance, such as excessive bloating, gas, diarrhea, a red burn-like rash around the anus, and abdominal cramping. They are useful in babies who have rare metabolic diseases in which they are missing the enzyme that metabolize lactose. (This only occurs in around one of 65,000 babies.) Lactose-free formulas can also be tried in babies recovering from a diarrhea- producing illness and who suffer from a temporary lactase-deficiency while the intestinal lining is healing.

(Alimentum, Nutramigen, Pregestamil)If you see the term "hypoallergenic" on the label, this means that the formula has been proven to cause fewer allergies in babies than standard formulas. Since, by definition, the term "allergy" implies a sensitivity to a protein, the term "hypoallergenic" means that the protein in the formula has been "hydrolyzed" or "predigested," broken down into tinier proteins that are less likely to cause allergic reactions. Consider these potential problems with hydrolyzed protein formulas.

• The protein problem: In contrast to formulas that advertise "partially hydrolyzed protein," in these formulas the proteins need to be completely hydrolyzed or broken down into smaller parts in order for the label to carry the term "hypoallergenic." This requires intense processing that results in a bitter, almost unpalatable flavor, despite the high content of sweeteners. Tasting one of these formulas is enough to make any mother want to re-lactate.
• The carbohydrate problem. When the protein is hydrolyzed, the lactose is also taken out of the milk, so the manufacturer has to add carbohydrates -- usually corn syrup, sucrose, corn starch, or even tapioca. As we described above, substituting other sugars for lactose may not be a good idea. Nor is it necessarily true that a baby with protein allergies will also be lactose intolerant.
• The salt problem. Hypoallergenic formulas are 30 to 90 percent higher in salt.
• The fat problem. The fat blend of Alimentum or Nutramigen is the same as found in each manufacturer's cow's-milk-based formulas, Similac and Enfamil, respectively. The primary fats in Pregestamil are medium-chain triglycerides, an intestinal-friendly fat that is used in children with fat malabsorption disorders. MCT's are a factory-made fat. They do not occur in nature, and they provide no essential fatty acids essential for a baby's growing brain and body. MCT's can be used as an energy supplement to boost weight gain in infants growing slowly. Yet, they should not be a baby's main fat source unless advised by your doctor. Pregestamil should not be given to healthy babies with no proven fat malabsorption disorders, or to infants with impaired liver function.
• The price problem. The infant pays a high nutritional price for these formulas, and parents discover that hypoallergenic formulas are four to five times more expensive than standard formulas.

Our conclusion: Hypoallergenic formulas should not be used without a doctor's recommendation, and then only if there is a definite medical reason. Don't switch to one of these formulas just because baby is "fussy" without trying different standard formulas first.

As you develop a bottle-feeding routine for you and your baby, the two of you will work out which formula is best, how much, and how often. This routine may change as your baby grows. As a general guide:

Between birth and six months of age your baby will need an average of 2 to 2.5 ounces of formula per pound per day. So, if your baby weighs ten pounds, she will need 20 to 25 ounces per day.

• Newborns may take only an ounce or two at each feeding
• One to two months: 3 to 4 ounces per feeding
• Two to six months: 4 to 6 ounces per feeding
• Six months to a year: as much as 8 ounces at a feeding

Small, more frequent feedings will work better than larger ones spaced farther apart. Your baby's tummy is about the size of his fist. Take a full bottle and place it next to your baby's fist and you'll see why tiny tummies often spit the milk back up when they're given too much at one time.

IS BABY GETTING TOO LITTLE OR TOO MUCH FORMULA?
Signs that your baby may be getting too little formula are:

• slower-than-normal weight gain
• diminished urine output
• a loose, wrinkly appearance to baby's skin
• persistent crying

Signs that your baby is being fed too much at each feeding are:

• a lot of spitting up or profuse vomiting immediately after the feeding
• colicky abdominal pain (baby draws his legs up onto a tense abdomen) immediately after feeding
• excessive weight gain

If these signs of overfeeding occur, offer smaller-volume feedings more frequently, burp baby once or twice during the feeding, and occasionally offer a bottle of water instead of formula.

• Use before the expiration date on the label
• Use refrigerated, opened, ready-to-feed and prepared formula within 48 hours.
• Don't leave bottles of formula out of the refrigerator for more than two hours.
• Throw away the formula left in the bottle after a feeding, since germs from baby's saliva will multiply in the warm formula.
• Refrigerate any formula saved from one day to the next.
• Be very careful if you are using a microwave oven to warm formula. It's better not to microwave. Because of uneven heating, hot spots develop. If you do use the microwave, shake the bottle well before testing the temperature on your wrist.
• Avoid bottle propping, and don't let a baby fall asleep holding his own bottle. He could choke or aspirate the formula into his lungs. Falling asleep with a bottle allows the sugary formula to pool in the mouth, in contact with teeth, causing dental caries. When bottle-feeding in the lying-down position, formula may travel from the back of the baby's throat up through the eustachian tube into the middle ear, causing ear infections. Remember, bottle-feeding, like breastfeeding, is a social interaction, in addition to a method of delivering nutrition. There should always be a person at both ends of the bottle, and babies should go to sleep attached to a person, not a bottle.

To make feeding time pleasant for you and baby, here's how to get the most milk in and the most air up, and to do it safely.

Giving the bottle:

• Most babies enjoy their formula slightly warmed; run warm tap water over the bottle for several minutes. Shake a few drops on your inner wrist to check the temperature.
• To minimize air swallowing, tilt the bottle, allowing the milk to fill the nipple and the air to rise to the bottom of the bottle.
• Keep baby's head straight in relation to the rest of the body. Drinking while the head is turned sideways or tilted back makes it more difficult for baby to swallow.
• To lessen arm fatigue and present different views to baby, switch arms at each feeding.
• Watch for signs that the nipple hole is too large or too small. If baby gets a sudden mouthful of milk and sputters and almost chokes during a feeding, milk flow may be too fast. Turn the full bottle upside down without shaking. If milk flows instead of drips, the nipple hole is too large; discard the nipple. If baby seems to be working hard, tires easily during sucking, and his cheeks cave in because of a strong suction vacuum, the nipple hole may be too small (formula should drip at least one drop per second).
• Know when to quit. Babies know when they've had enough. Avoid the temptation to always finish the bottle. If baby falls into a deep sleep near the end of the feeding, but has not finished the bottle, stop. Often babies fall into a light sleep toward the end of the bottle, but continue a flutter- type of sucking. They have had enough to eat, but enjoy a little "dessert" of comfort sucking. Remove the bottle and allow baby to suck a few minutes on your fingertip.

A dishwasher with a water temperature of at least 180?F (82?C) will adequately sterilize bottles and accessories. If not using a dishwasher, try the following sterilization process. (Sterilize six bottles, or a daily supply, at one time.)

• After a feeding, thoroughly rinse the bottle and nipple under warm water and leave them on a clean towel by the sink, ready for your next sterilizing session.
• Wash all the equipment in hot soapy water, rinse thoroughly in hot water, and remove the milk scum with a bottle brush.
• Pad the bottom of a large pan with a towel or dishcloth. Immerse open bottles, nipples, and other equipment in the pan (place bottles on their side to be sure that they are filled with the sterilizing water) and boil for ten minutes with the pan covered. Allow to cool to room temperature while still covered. Remove the bottles and nipples with tongs or a spoon and place the bottles upside down on a clean towel with the nipples and caps alongside. Let the equipment dry.

These rubber and silicone subs come in a variety of contours all claiming to imitate the natural action and shape of mother's breast. None do! Orthodontic- type nipples insert farther back into baby's mouth, allowing a more natural milking action of the tongue, but inconveniently require a "which way to turn the nipple" decision. Be sure baby sucks on the widened base of this nipple, not just the tip. The expandable nubbin-type nipples are designed to elongate during sucking but only if baby opens his mouth wide enough and sucks hard enough to draw the nipple farther in. Most, however, only suck on the protruded part. This nipple should be avoided for the breastfeeding baby, who may learn lazy latch-on habits from it. The easiest is the standard bulb-type with a wide base that best allows baby to form a tighter seal.

For the full-time bottlefeeding baby, simply experiment with various types of nipples to see which one works best for your baby. If baby is both breastfeeding and bottlefeeding, use a nipple with a wide base.

To lessen the rubbery taste of an artificial nipple and to sterilize them, boil for five minutes before first use. To avoid baby's choking on a nipple, carefully follow the manufacturer's caution advice on the package. If the nipple becomes cracked or torn, discard it. Some nipples come with a variety of hole sizes to fit the type of liquid and the age of the baby. The nipple hole should be large enough for the formula to drip at one drop per second when you hold a full, unshaken bottle upside down. Larger nipples and nipple holes are available for older babies.

I've been feeding my baby iron-fortified formula. When is it okay to switch to whole cow's milk? Research comparing cow's milk and formula-fed infants during the first year of life has shown that cow's milk is irritating to the intestines of a tiny infant, causing infants to lose a tiny bit of blood in their stools, contributing to iron deficiency anemia. There is very little iron in cow's milk anyway, and the iron that is there is poorly absorbed. Concern about iron-deficiency anemia has led the American Academy of Pediatrics, backed by solid research, to discourage the use of cow's milk in children under one year of age. One of America's top pediatric hematologists (blood specialist), the late Dr. Frank Oski , Professor and Chairman of the Department of Pediatrics at Johns Hopkin University (and co-author of a book entitled: Don't Drink Your Milk) advised parents to be cautious and not rush into the use of cow's milk, even during the second year of life. At present it would seem prudent to continue giving your baby iron-fortified formula during the second year of life and very gradually wean him to dairy products, beginning with yogurt. If your toddler generally has a balanced diet and routine hemoglobin tests show that he is not even close to being anemic, then switch from formula to whole milk sometime during the second year, but don't be in a hurry.

Dairy Dates