Navigating Conversations about Infant Formula

With the recent announcement regarding infant formula regulations, I’ve seen a disturbing uptick in harmful rhetoric surrounding the use of infant formula. As a former NICU RD, I am qualified to speak on this subject and feel it would be irresponsible to not use my (albeit small) platform to educate and inform in whatever way I can.

To be clear, my goal is to promote health and a healthy relationship with food. I firmly believe that is the goal of most individuals that raise concerns about nutrition, our food supply, and the general health of the population. However, when non-experts speak on such topics from a place of authority, the resulting misinformation can be downright dangerous. Becoming a credentialed expert in nutrition requires many years of education and training; to specialize in pediatrics and/or neonatal nutrition requires even more.

I’ve had the privilege of working with many, many children throughout my career that required the consumption of infant formula in order to survive. As a result, I’ve also had the opportunity to work alongside and learn from countless other pediatric and neonatal nutrition dietitians, PhDs, MDs, and even scientific liaisons from various formula companies. Every single one of these individuals has cared immensely about improving the health and overall wellbeing of the babies they serve.

The medical and scientific community is constantly striving to learn more and do the best it can to promote health. Part of loving science, including nutrition, is the constant quest to learn more and make adjustments to your practice and recommendations. The resistance to Operation Stork Speed by qualified professionals is rooted in fear that these changes are being made by individuals with no true training or experience in the field. I will not speak on whether or not the motives behind these changes are nefarious because I believe most people’s intentions are good and, frankly, the perception of good versus bad rationale doesn’t really matter. The primary concern should be the effect these announcements will have on babies.

I intend to outline some of my thoughts below. To be clear, this is by no means a comprehensive list of my thoughts or concerns. My intention is to educate, but I acknowledge that I will miss things in this discussion that you may feel are very important. However, I think that not posting anything would be far more harmful than letting the uneducated voices be the loudest in the room. If you have any interest in discussing formula, infant nutrition, or anything nutrition-related in more depth, please feel free to reach out via comment, DM, or email. I am more than happy to answer any questions you may have and provide you with additional resources.

1. Formula saves lives.

I have worked with thousands of families whose babies have needed formula as a life-sustaining measure. There are a multitude of reasons why formula may be recommended, including (but certainly not limited to) breast milk intolerances, poor growth, and lack of maternal breast milk. Put bluntly, many babies would die without the use of formula. My primary concern regarding the discussions happening in-person and online is that more families will be resistant to the use of formula in order to save their child’s life. I have encountered such resistance in the past when making professional recommendations and I can only imagine how much more difficult these conversations will be in the coming weeks.

By no means do I blame parents/caregivers for their fear and misunderstanding of formula. The fault lies solely in our collective cultural need for a binary. Unfortunately, nutrition can’t be distilled down into good versus bad, healthy versus unhealthy, etc. It can’t be overstated how difficult it is for families to overcome the societal pressure to conform to what is considered “healthy” and to risk the judgement associated with formula use. The messaging around nutrition is so cluttered and confusing that the binary has become the default for interpersonal discussions and media headlines; this is incredibly dangerous. At best, continuing on this track is reckless and we will continue to have a poor societal understanding of nutrition. At worst, more babies will die as a result of families living in fear of formula.

2. Breast milk is sometimes great, but not always.

Remember what I said about breaking out of that binary way of thinking? Here’s another example of that. I’ve already listed a few of the reasons (see above) why some babies would be better suited for formula. One of the common retorts I hear when engaging in this conversation about being “not anti-formula” is that when a parent’s breast milk is unavailable, the next best substitute is donor milk. The donor milk process from start to finish can be somewhat complex, but I will do my best to summarize my collective thoughts. Donor milk is an excellent bridge for some preterm infants whose mothers’ own breast milk has not yet come in to meet the needs of their neonate. However, it is my professional opinion that the more widespread use of donor milk over the past few years is problematic. Firstly, donor milk is most commonly collected from mothers of older, term infants (the most recent data I saw was that the average age of the child of a donor mother was between 8 and 12 months old). Babies’ nutrition needs change as they age and breast milk, in turn, changes over time to meet the unique needs of the infant in their current stage of life. While this is an awesome example of the amazing things the human body can do, it is important to consider the problematic implications of this as it relates to the infants (often preterm and medically fragile) that would be receiving the milk produced to accommodate the needs of a 1-year-old. Donor milk is often significantly lower in calories, protein, and various vitamins and minerals that are absolutely essential to the growth and wellbeing of an infant in the NICU. Prolonged use of donor milk in many of these infants results in longer hospital stays, inadequate weight gain, and overall poorer outcomes. There are other problematic aspects of the donor milk process that I will briefly outline, but I acknowledge I can’t go into adequate detail about all of them this particular post.

• The adaptive properties of breastmilk/breastfeeding begin immediately. When donor milk is offered to all babies in the hospital setting, it can inhibit this process by providing mixed signals to the mother’s body on how much milk the infant is ingesting and what their overall needs are.

• The widespread offering and use of donor milk to all infants perpetuates the idea that formula is inadequate in the eyes of the qualified medical community.

• Not all “donor milk” is “donated.” There are various organizations that promise monetary compensation for breast milk deposits. Unfortunately, these companies often target economically vulnerable communities and have a history of significantly delayed payment. At the end of the day, children are harmed in this process. There are much deeper implications here that I can’t do justice in this post. Again, please feel free to reach out to me if you would like to engage in further discussion.

3. The nutrition experts working for formula companies are constantly working to make products to best promote healthy infants.

There is an immense amount of work, research, and discussion that goes into infant formula production. Nutrition science is ever-evolving and the world of pediatrics is no different. Dietitians and nutrition PhDs work for nearly all of the major formula brands in order to produce and adjust products to be in line with that science every single day. There is an immense amount of work that goes into producing standard formulas that attempt to replicate all of the compounds and ratios involved in human milk. An equal amount of emphasis is placed on producing specialized formulas to meet the needs of the more medically complex infants. I have yet to encounter an RD working for one of these companies that does not take that aspect of their job extremely seriously. Furthermore, there are many incredible RDs in the patient care realm that do their due diligence in questioning the science behind each brand’s formula and whether or not it will help their patients.

I would be remiss to not acknowledge the questionable players in the world of a for-profit product, as well as the painful historical ties some of these companies have with marginalized communities. I understand how these factors breed a deep mistrust of the healthcare system as a whole, but more specifically of formula and its use with vulnerable individuals. However, I can only speak to the many nutrition professionals I have encountered in my career who have dedicated their lives to the betterment of these same populations.

4. European formulas are not inherently better.

People commonly cite European standards as being “healthier” than those in America. This indicates a general misunderstanding of food regulation. Formula components in Europe (whether banned or allowed) are subject to many of the same external forces as those in the United States, including political and economic. Public policy on what terminology to use in an ingredients list is not indicative of how healthy or beneficial a product is. Even in cases where one entity allows a product that is banned in another, this is also provides minimal insight into which perspective is actually superior. While the FDA undoubtedly has flaws, it is a system set up to keep people safe ideally through the use of science-based safeguards on products produced in the US. Formulas brought in from other countries are not subject to these same safeguards, and therefore, can’t be guaranteed to be safe by American standards. I understand that there are many people who distrust the FDA and the standards that have been set, but there is not logic behind the reasoning that European (or any other continent or country’s) formulas are inherently safer. On the contrary, when you purchase a formula from overseas (this does not include those sold in the US by grocery stores or other US-based physical establishments), you are stripped of all protections from harm that could come about from using that product. Because it was not subject to FDA approval, communications regarding recalls or other warnings will also be difficult to obtain unless you are actively searching for them.

5. Corn syrup solids are not evil.

Although I am hesitant to get even more in the weeds on this topic, I can’t avoid discussing corn syrup solids. In my years of working in the NICU, the inclusion of corn syrup solids was the single most common hesitation families had about giving their children infant formula. The amount of time I have dedicated to this one ingredient would truly horrify you; although if you have read this far, you must have a passion for this subject and, perhaps, would be somewhat impressed with my corn-derivative knowledge. To put it simply, corn syrup solids are a form of carbohydrate (glucose) that is more easily digested in the gut of a neonate versus lactose. Formulas that tout themselves as “more natural” are often lactose-based and much more difficult to digest. Many infants, especially this born prematurely, have much more sensitive GI tracts and need formulas that can be digested easily while also providing an adequate amount of carbohydrates.

On a related note, there is a false narrative attached to this topic that there are studies that prove that babies fed formula with corn syrup solids have a propensity for sugar-rich foods or are more likely to develop diabetes or obesity later in life — I can definitively say that, as of the time of writing this, there are no reputable studies that prove this. If you find good data to the contrary, please email it to me so I can read it for myself. I remain open, as with all things nutrition-related, to change my practice recommendations based on updated science.

6. All nutrition is individualized.

The bottom line is that good nutrition advice is both individualized and based in science. While breastmilk may be a wonderful option for some babies, there are many that will benefit even more from the use of formula. There is never a one-size-fits-all option in the world of dietetics and there is no substitute for professional expertise when it comes to seeking help.

With all of the aforementioned in mind, the most concerning potential outcome of all of the Operation Stork Speed dialogue is in regards to the ill-effects it will have on babies, the very population that both sides of the discussion are trying to protect. It is more important than ever to elevate the voices of the qualified in order to best arm the public with science-based facts. If the discussions being had and decisions being made promote fear-mongering, misinformation, and judgement, then infants will be worse off. If babies are not getting adequate nutrition because parents are fearful of formula, then babies are worse off. If we dismantle systems put in place to hold companies to a standard that keeps us safe, then babies are worse off. If we are not having science-backed discussions about how to better serve the community and meet their nutrition needs, then babies are worse off.

My hope is that all of this information empowers you to have more informed, meaningful conversations about this topic in a way that is sensitive to the needs of others and promotes the assumption of positive intent from all perspectives in order to hopefully bring about changes that collectively benefit us as a society.

If you have made it this far, please continue seeking out credible resources. I remain available to steer you in the right direction if you need additional information or just want to have a deeper discussion about anything nutrition-related.