Friday, April 5, 2013

Homemade formula and the Weston A. Price bust-up

It's always kind of interesting when crunchy people fall out with each other (you know, like elimination communication fans vs. let-your-child-sit-in-diapers-till-they're five-if-they-want-to people... that kind of thing). The latest bust-up--if you'll pardon the pun--concerns the Weston A. Price Foundation (WAPF) vs. breastfeeding advocates.

WAPF is a kind of nutritionist movement that's been around for decades, and which advocates for "traditional foods"--organic everything, lots of animal products and lots of fermented/home-processed foods, from konbucha to bone broth to a yohurt-like product called kefir. It also advocates making homemade formula. Some breastfeeding advocates have become suspicious of WAPF in recent times, claiming that WAPF proponents are too quick to push homemade formula recipes on struggling mothers, rather than getting to grips with their latch issues, tongue ties, lack of support and so on. In the most extreme form, some WAPF advocates have stated that WAPF homemade formula can be better than breastmilk... if the mother eats an imperfect diet, and especially if she's vegan. WAPF doesn't actually sell its formula, obviously (this formula has to be made freshly), but it does encourage followers to purchase ingredients from a sponsor company called Radiant Life, which sells $170-$400 kits containing one to six months' worth of the supplements and powders needed to make the formula at home.

I don't always agree with Best For Babes but I think their piece on the WAPF thing got it more or less right. Full-on malnutrition can affect breastmilk quantity and quality, but this is rare in developed countries. In spite of its hippy image, woo/crunchy stuff/pseudoscience is often big business, and WAPF may well be subtly encouraging homemade formula use because it's in its business interests to do so, no different to Similac or Cow & Gate. Women who want to breastfeed would therefore be advised to be wary. Incidentally, this is not really about whether we think formula is wonderful, evil or something in between; it's because it behoves us to maintain a proper degree of skepticism concerning the advice given by anyone who is trying to sell us stuff. I mean, I use disposable diapers and wouldn't want to live in a world where they didn't exist; however, I have no intention of getting my toilet-training advice from a Pampers helpline. After all, businesses are businesses, not charities; it ought to be possible for us all to take advantage of their products appropriately and take what they say with a good pinch of salt.

However, amid all this talk, there's actually been very little discussion of the homemade formulas themselves. So I thought I 'd talk about that.

How to make formula (quick explanation)
Bit of background: You can't give straight cow's milk to young babies as a main drink because it's pretty different from human milk. Too much protein, for a start. Also, there are two types of protein in all animal milks: casein and whey protein. Human milk is about 30:70 casein-to-whey, while cow's milk is more like 80:20. All that casein's hard for a baby's belly to digest. The resultant stress on the intestines causes microscopic bleeding, which can add up to quite a lot of blood loss. Now, there's hardly any iron in cow's milk, which tends to cause anemia, and that gradually accumulating blood loss makes things even worse. Cow's milk also has too much sodium, and not enough carbohydrates. (It's a similar story for goat's milk, by the way, despite the urban legends about how it's supposedly similar to mother's milk)

Formula companies therefore process cow's milk and add things and take things away to make it more similar to breastmilk. Not the same, mind you; many nutrients are better absorbed and more useable ("bioavailable") in breastmilk than they are in formula, and the storage and preparation of formula may cause loss of some nutrients. So in order for the formula-fed baby to get the same amount of, say, calcium as the breastfed baby, you may actually have to create a formula with more calcium in it than breastmilk.

Now, the WAPF formulas purport to do the same thing--just on a homegrown scale. The website lists three types of formula--cow's milk-based, goat's milk-based, and liver-based--and explains the ingredients and preparation method for each. There is also a nutritional chart comparing what's in them (maddeningly, however, it uses ounces which makes it difficult to compare with scientific data on formula composition).

Now, the WAPF cow's milk and goat's milk formulas are certainly better than the crude recipes your grandma might have used--the sort where you just watered down evaporated milk and then bunged in a bit of sugar. Like commercial formula, the WAPF recipes get you to "rebalance" the casein-whey ratio, by making a separate batch of curds-and-whey (remember Little Miss Muffet?) and then adding some of that whey into your formula mixture. The actual amounts of protein also turned out to be comparable with commercial formulas, when I checked. So far, so good.
UPDATE: I've had a chance to read through some of the materials linked to me by Becky (the commenter below) on cow's milk in the first year. Cow's milk protein in the first year irritates the intestines and causes occult enteric blood loss in babies, meaning that their stools contain unusually large amounts of blood when examined. This over time can add up to substantial blood loss, greatly increasing the risk of iron deficiency anemia, which is strongly linked with mild cognitive problems later on in life. In commercial formulas, these milk proteins are heat-treated, making them easier to digest and minimizing blood loss. As I discuss below, the WAPF milk-based formulas are already low in iron; the fact that they contain elements which could cause the baby to loose what little iron they have must be considered a further strike against using such concoctions. And I think this also ties in with what I talk about in the final section--that when it comes to infant formula, processing is generally a good thing.

Raw milk
It is concerning, however, to see that WAPF is advocating raw (unpasteurized) milk for babies. When a person consumes raw milk, there is a small but real risk of infection which can have very serious consequences including organ failure, as the Real Raw Milk Facts website explains--no matter how clean the milking barn is. And most adults who drink raw milk are only having the odd glass. A baby is getting many bottles of milk a day--the chances of coming across a bad batch sooner or later are going to add up fast.

One reason you shouldn't feed straight cow's/goat's milk in lieu of formula/breastmilk is their high sodium levels--about 430mg per 36oz (compared to breastmilk's 180mg). Commercial formulas, when I did the calculations, ranged from 180-360mg per 36oz. So the sodium levels in WAPF's milk-based formulas--308-320mg--seem to be fine.

Breastmilk iron is unusually bioavailable--there doesn't need to be a lot of it. Formulas need more iron in order for baby to get enough. Commercial ones usually have around 3.5mg per 36oz in the case of low-iron formulas, and up to 14.5 mg in the high-iron types. WAPF's cow's milk and goat's milk formulas, however, contain only 1.4mg and 2.2mg per 36oz, respectively, which looks rather low to me. The WAPF does emphasize that parents should start egg yolk feeding at 4mo, which will certainly help, but I wonder how the baby is supposed to manage till then--or what happens if your baby just can't take a spoon at 4mo.

Vitamin A
Perhaps mindful of the low iron levels in its other formulas, WAPF have come up with a third formula--"Liver based." You make this one by grating raw liver into meat broth, plus vegetable oils and other things. This formula has more iron in it (and it's haem iron, which is well absorbed).

Unfortunately, the liver means it has potentially toxic levels of Vitamin A as well. 20,000iu of Vitamin A per 682 calories means 2,933iu per 100kcal; meanwhile, "Toxic manifestations have been reported in infants when the daily intake was 2,100 iu/100 kcal or higher." I can't really imagine that very many people are actually going to bring themselves to feed their baby a pureed liver concoction all day long, but I do think it's a bit scary to think that if you followed WAPF s instructions to the letter, you could risk poisoning your child. Of course, a few decades ago, mega vitamin doses were very much the thing; I remember my mum's Adelle Davis books recommending that readers take some truly scary amounts of Vitamin This and That. Since then, the pendulum has swung very much towards recommending low doses of vitamins only; high doses of Vitamin A in particular have come out very badly in recent times, including concerns about teratogenicity (birth defects) in pregnant women; that's why pregnant women are supposed to take prenatals (with special low Vitamin A) rather than normal vitamins.

Other nutrients
Most of the micronutrients in the formula seemed to be higher than comparable amounts in commercial formula, when I did a comparison. One or two--like Vitamin E--were lower. Other than the scary liver-Vitamin A thing, I can't see anything here that would cause acute toxicity.  Still, from a long-term perspective, I think I'd rather feed my baby something where the levels of all these nutrients have been balanced reliably and consistently to just the right levels, based on research by dietitians.

The advantage of manufacturing formula using artificial vitamin and mineral drops and powders is that if you want to add exactly such-and-such amount of, say, manganese, you can go ahead and do just that. When you use natural materials, anything you add tends to come packaged with other nutrients, which then throws the mixture's balance off. Like... okay, one can boost the iron content of a formula by adding liver. But that iron comes bundled up with way too much Vitamin A. Or, perhaps we could bump up the rather low vitamin E level by adding more vegetable oil? But then the mixture might face composition/texture problems such as excessive oil separation. We could add something else to deal with the separation issue... but then you're inadvertently adding other nutrients. And so on. And the more steps and ingredients you have, the more opportunities for errors. I just think it's going to be really, really difficult to produce a well-balanced and foolproof formula on a home-kitchen scale.

Margin for error
Honestly, though, in a way the recipes themselves are less scary than the comments below. People saying stuff like "We have been using the cows milk formula and have replaced the yeast with vitamin b and maple syrup..." "My bottle of yeast flakes was crushed entirely in my check-in luggage; is yeast flakes absolutely required for this recipe or can I do without it for 3 weeks?" "I have been feeding our adopted newborn the goat milk formula since he was 3 weeks old. I did not realize that I was supposed to wait on giving him the cod liver oil until he was 3 months old. Have I done something dangerous to his health?" "I increased the cream by a tablespoon because he is a big boy..." "How about coconut nectar from the company called coconut secret? Just ideas....." "I noticed that it had curdled almost, more like became this suppose[d] to happen?" Seriously, people, why are you even asking these questions? This is your baby's lifeblood we are talking about, not a fun baking experiment. The newborn period is a time when most of us feel like we deserve a round of applause just for getting a simple meal cooked. Creating formula using all these elaborate rules when you are sleep deprived seems like an invitation to disaster (especially when one considers how many parents make errors even with commercial infant formula preparation).

The food that breaks the rules
Formula breaks all the rules of normal food. We all know these rules: "Cook food at home," "Use real produce," "Eat fresh food," "Try to eat foods with as short an ingredients list as possible" and so on. But formula is a food with a unique job to do: it's got to mimic a natural food (breastmilk) as closely as possible. So the processing that commercial formula undergoes and the long list of ingredients on the package are good things; they make the formula more like breastmilk and less like cow's milk. A simple homemade formula using fresh materials is likely to behave less like breastmilk, and is therefore less suitable for a baby.

To be fair, the WAPF's milk-based formulas (as opposed to the scary liver puree thing) don't look to me like they could induce toxicity in an infant, which fits in with the fact that many people do use these formulas and their babies seem perfectly alright...although to be honest, the impression I get from the comments on the WAPF page is that the greater part of parents using homemade formula are doing so as a supplement for a predominantly breastfed infant rather than as a full-time thing, which would greatly reduce the risks. In a situation where commercial formula and donor milk weren't available (and yes, this can happen: after the earthquake in Japan around the time I gave birth, formula started disappearing from the shops due to distribution problems and panic-buying) I have no doubt that something like the WAPF cow's milk formula, with pasteurized milk, would keep baby ticking over OK until supplies resumed. However, I'd really question the utility of using homemade formula by choice in peacetime conditions.

The optimal milk drink for a baby is breastmilk, but if a mother can't nurse or prefers not to, I think the next best thing is a commercial infant formula correctly made up. Buy a tin and follow the instructions on the label. Done. This is one of those pleasantly hedonistic moments in childrearing where the easiest approach is actually the best and safest too. Making your own formula falls into that interesting category known as "Putting a lot of effort into actually making your parenting worse." It's complicated, there's no evidence it's any better, and there's at least some indications that it may be less well balanced and riskier.

Further reading

*Best For Babes's take on the WAPF bust-up

*More discussion at Unlatched

*Vitamin A toxicity

*Commercial formula composition

*Real Raw Milk Facts website

*Cow's milk induced intestinal bleeding in infancy