The first time you find yourself standing in the aisle of baby formulas, it can be overwhelming (to say the least!) There are so many brands, and so many choices - recent shortages notwithstanding- how do you know which one will be right for your baby? More specifically, is there a certain formula that will help with their reflux? Which one?!
We get it! It’s a LOT.
And oftentimes, the wording on labels can make it even more baffling. But one really important thing to remember is that there is no bad choice. Formula is a highly regulated food source, and all of the choices available at your local store have been formulated to make sure your baby will get all the nutrients they need to grow and gain as they should.
We wish that we could say ‘this is the perfect baby formula for relfuxers!’ But unfortunately it’s not that simple. What works well for one baby may not for another. That said- understanding the different options out there can go a long way in helping you make an informed decision for your little one. Of course working with a professional to help you make those choices is best but this page can help.
98% of baby formulas are made up of three things:
In terms of digestion, it’s protein and carbohydrates that tend to have the most impact- and so focusing on those ingredients can help.
Fun fact! Words like ‘gentle’ and ‘sensitive’ are not regulated and don’t actually mean anything in terms of what you may or may not be getting. Rather than focusing on the front of the can or bottle, have a look at the back of the label- the first couple of ingredients that are listed will give you the best information about the type of protein and carbs present.
Standard baby formulas have fully intact proteins and are suitable for most babies- that said, they do take more digestive work and so if your baby is already struggling with some GI issues, you may want to consider some other option.
Whether you are using a standard cow’s milk based formula or a soy based formula, the proteins are exactly the same size as they were when they came out of the cow (or bean)
In the ingredients section, you’ll see these listed as:
Partially hydrolyzed proteins are smaller, and more broken down. They are closer in size to the proteins in breast milk and may be easier to digest. Both cow’s milk and soy based formulas can be partially hydrolyzed.
If a baby formula is partially hydrolyzed, don’t just look for words like ‘sensitive’ or ‘soothe’- it should have ‘partially hydrolyzed’ before the protein. For instance: Partially hydrolyzed nonfat milk. Because partially hydrolyzed proteins are easier to digest and absorb, they are often good choices for babies with reflux or other similar digestive issues. However, they do not work for babies with diagnosed cow’s milk protein allergy.
Fully hydrolyzed proteins are very tiny and considered hypoallergenic. Although the protein is still present, it is so broken down that many babies with allergies are able to tolerate them well.
The very small proteins may also help with digestion- however- it should be noted that these formulas also tend to be very thin. So, if your baby has been diagnosed with GER/GERD but does not have a diagnosed cow’s milk protein intolerance or allergy, a hydrolyzed baby formula may not be appropriate and may even make symptoms worse. It is for this reason that it’s usually best to talk it through with your baby’s doctor before switching to a hydrolysed formula.
A note about extensively hydrolyzed formulas: One key difference is that the powdered and ready to feed versions of certain hydrolyzed options have different amounts of certain ingredients. The powdered versions of Similac Alimentum and Enfamil Nutramigen are both less hydrolyzed than the ready to feed versions. In addition, the ready to feed version of Alimentum is corn free, while the powder version is not.
This gets very in-depth and because it's an area of unknown and lots to trial and error, it is always a great idea to work with a knowledgeable and highly educated care provider in this area that can help you navigate what to do, when and how. Playing around with different formulas can take months to find the right one. Meanwhile your baby could be suffering during this time.
Mary Graham is a skilled nutritionist that specializes in infant GERD and formulas is just one of her specialties.
Some babies are not able to tolerate any amount of milk and/or soy protein, even if it is fully broken down as with extensively hydrolyzed formulas. For instance, they may still be presenting with symptoms such as blood in their stool and/or failure to thrive despite several weeks on an extensively hydrolyzed formula.
This is where amino acid formulas come in. These are formulas made from individual amino acids. They are the most hypo-allergic options and are usually the best choice for babies suffering from severe cow’s milk protein allergy. They are often available via prescription and the cost may be covered by your insurance. Some states even mandate prescription formula coverage for amino acid options, so it is always worth checking
It is important to note that for a baby with reflux but no allergy, an amino acid will rarely be the best choice. These formulas can be very expensive and tend to smell and taste much worse than other options. They are also extremely thin, which is usually not ideal for babies with reflux.
If your baby does need an amino acid formula, the most common options are
Out of these, Neocate is the only option that is also free from soy protein.
If your baby has reflux- whether they be a ‘happy spitter’ or suffer from GERD (painful, continuous reflux) something that may help is looking for a formula with a higher whey content.
Whey and casein are the two types of proteins in cow’s milk. Whey proteins are easier to digest and empty out of the stomach more quickly (which is helpful is you are looking to reduce spit up and vomiting). Enfamil Infant is a ‘standard’ formula that is 60% whey. Partially hydrolysed options that are 100% whey include:
Another option would be an ‘AR’ formula. The most common of these are
These options all have ‘full sized’ proteins (the majority of which are casein) and also contain thickeners- the idea being that gravity will help keep the contents down more effectively. Because AR formulas have fully intact proteins they are not suitable for reflux babies with in tolerances or allergies.
A note on formula options in general…
More and more, we find that parents are asking us about formulas with more natural or organic ingredients- which is great! But the most important thing, particularly if your baby has an allergy or gastrointestinal symptoms, is to think about the types of ingredients- especially the protein source and how broken down it is. For instance, if full sized casein protein causes your baby to have blood in their stool, then a standard organic formula isn’t the right choice.
It is also important to reiterate that while diet can play a very important role in managing reflux symptoms, it is very often just a piece of a much larger puzzle- and this is especially true for babies. We will always support our patients and their families with more information about diet and formula choices, especially if that’s something you’d like to try before other treatments. Equally, if a formula change isn’t helping symptoms we will also help to determine when new treatments are needed before going down a rabbit hole of formula changes that may never get your baby out of pain.
According to the CDC, ‘no brand of baby formula is best for all babies’ and we agree.
If your baby has obvious signs of an allergy or intolerance- particularly blood in their stool- then starting with an extensively hydrolyzed or amino acid formula is a typical step.
If your baby has been constipated, avoiding palm oil (an ingredient known to cause constipation in infants) is another option. Currently, Similac brand formulas are all palm oil free.
Things we recommend that you watch for when starting a new formula include:
One common mistake parents make is switching formulas too quickly. Sometimes, it’s hard not to switch, especially if your baby is miserable or your pediatrician is recommending it. In general though, we have seen that giving any new formula a minimum of two weeks is optimal.
Baby’s digestive systems are still developing, and even small changes can be a big transition for them. By giving it at least two weeks you are allowing time for things to settle and also avoiding making too many changes too frequently (which can make it hard to know if a formula is working or not anyway)
Ideally, it is best to switch to a new formula by going slowly. Over several days you can decrease the amount of old formula in each bottle while gradually increasing the new formula. This is especially important if you are transitioning to a formula with more intact proteins or more lactose- their body will need time to adjust to making more of the enzymes needed to digest these components.