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).

Protein
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.

Sodium
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.

Iron
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 gelatinous...is 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
http://www.bestforbabes.org/from-karo-syrup-to-goat-milk-the-formulas-may-change-but-the-booby-traps-remain-the-same

*More discussion at Unlatched
http://unlatched.wordpress.com/2013/04/02/the-weston-a-price-foundations-dangerous-breastfeeding-advice-should-not-be-ignored/

*Vitamin A toxicity
http://www.medceu.com/index/index.php?page=get_course&courseID=3903&nocheck

*Commercial formula composition
http://www.espghan.med.up.pt/position_papers/con_23.pdf

*Real Raw Milk Facts website
http://www.realrawmilkfacts.com/raw-milk-hot-topics

*Cow's milk induced intestinal bleeding in infancy
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1029246/pdf/archdisch00547-0084.pdf

18 comments:

  1. I'm still not comfortable with the proteins in the WAPF formulas - cooking/heat treating the protein as is done in commercial formulas makes it easier to digest and makes it less likely to cause occult intestinal bleeding. I'd be concerned about the untreated proteins in the milk formulas.

    Also, I'm not sure how much I trust their reported nutrient values, as they aren't a reliable source for any kind of nutrition information, and so much of what they advocate goes directly against established science. I think their formulas are very iffy for that reason.

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  2. Becky, do you have any information on the heat treatment of the proteins? I had heard something about that, but when I investigated I couldn't find anything specific, so I confined myself to talking about the casein-whey balance. If you have anything, I'd be interested in reading that.

    Regarding the reported nutrient values: I hear you. I checked out one or two values that were easy to check, like the Vitamin A, but the rest I just had to take on face value, because I couldn't see any easy way to check them.

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  3. Thank you! This has been vey helpful! I wanted so badly to breast feed but my milk still hadn't come in by day 5, unbeknownst to me, and my baby nearly died. He was hospitalized for 4 days and several pediatricians on his case said I should immediately begin formula and not try to continue breast feeding as he was expending so much energy trying to get nothing out of me. Given his condition and the fact that he immediately began to lose weight when I tried to breast feed him for 24 hours upon release from the hospital that clenched our decision. Anyway . . . people can make you feel like a real jerk for not breast feeding and for giving formula claiming that homemade formula is better as it's less processed. I've been skeptical. You make some excellent points and seem like you've done your research.

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  4. Thank you! This has been vey helpful! I wanted so badly to breast feed but my milk still hadn't come in by day 5, unbeknownst to me, and my baby nearly died. He was hospitalized for 4 days and several pediatricians on his case said I should immediately begin formula and not try to continue breast feeding as he was expending so much energy trying to get nothing out of me. Given his condition and the fact that he immediately began to lose weight when I tried to breast feed him for 24 hours upon release from the hospital that clenched our decision. Anyway . . . people can make you feel like a real jerk for not breast feeding and for giving formula claiming that homemade formula is better as it's less processed. I've been skeptical. You make some excellent points and seem like you've done your research.

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  5. Hi April, glad to hear you found the post useful. It sounds like you made the right decision for your baby. It's scary how often I hear recommendations for homemade formula online--I think the fact that we are used to thinking of home cooking and unprocessed as being good things can often dupe mothers into thinking that the same kind of rules apply to infant formula.

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  6. Wow. Do you truly believe that opening the can of formula is better than WAPF formula? Have you researched commercial formula? I have. It is not up to par in many ways whether it be organic or not. Please research the effects of soy in our systems, especially tiny baby systems. Soy is in commercial formulas here in the US, and can harm the endocrine system whether it is GMO/inorganic or organic. You can order non-soy formula from Europe. Ugh. I just don't like that your info listed here is one of the first links to pop up. You are advocating moms to poison their infants with disgusting ingredients. At least with homemade formula, you know what is in the mix, and it has been proven to be extremely beneficial for babies. But, as ALWAYS, breast is best.

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    1. Agree. I especially dont like the warning on raw milk when it has more nutrition in it then over pasturizing milk product. In comparison the homemade is still more nutritious by far then organic formulas. And your right. Breast is best :)

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    2. Agree. I especially dont like the warning on raw milk when it has more nutrition in it then over pasturizing milk product. In comparison the homemade is still more nutritious by far then organic formulas. And your right. Breast is best :)

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    3. WAPF's formula has NOT been "proven to be extremely beneficial to babies". There has been no research done on it at all. There HAS been lots of research done on commercial formulas, and they are a refinement of more than 100 years in the making. Are they perfect? no. They are not breastmilk. But WAPF's formula is an untested recipe based on a lot of philosophy and no proof. Plus it's nutritional profile is less like breastmilk than commercial formulas. The nutrient levels of all the recipes are scary high, and baby's immature kidneys have to process all of that. BTW, there are a lot of non-soy formulas available in the US. Both Similac and Enfamil formulas I've used are soy and corn sugar free.

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    4. WAPF's formula has NOT been "proven to be extremely beneficial to babies". There has been no research done on it at all. There HAS been lots of research done on commercial formulas, and they are a refinement of more than 100 years in the making. Are they perfect? no. They are not breastmilk. But WAPF's formula is an untested recipe based on a lot of philosophy and no proof. Plus it's nutritional profile is less like breastmilk than commercial formulas. The nutrient levels of all the recipes are scary high, and baby's immature kidneys have to process all of that. BTW, there are a lot of non-soy formulas available in the US. Both Similac and Enfamil formulas I've used are soy and corn sugar free.

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  7. Interesting post. I came across it while looking up the WAPF homemade formula recipe as I am trying to figure out the best formula to supplement my son with. ( I'm at about 40-50% breast/ formula. C section really threw things off).
    I think you bring up some really valid points and concerns about homemade. But I also know it's possible for a baby to thrive on homemade, as mi niece did. She consumed pastured raw goat milk mixed with grade B maple syrup and bad oil blend of flax, sunflower and coconut. She is 4 years old now and in the 90th percentile for height , 50th for weight and is rarely sick. She has a very advanced vocabulary and hand eye coordination. So her homemade formula was a success.

    This made me want to try the same for supplementing my son however he did not tolerate this mixture (I also pasturized the milk because I'm too paranoid to give a baby raw milk ) it gave him stinky gas that hurt him. So back to similar it was. However I'm just not comfortable giving him non-organic dairy based formula that also contains so much soy as well as high fructose corn syrup. Even if they have the caloric and nutrient ratios perfect I still don't think those are safe for consumption daily by anyone, esp a newborn. So I'm on the hunt to make a better formula though am leaning towards Baby's only and just adding a couple things to it.

    I wanted to address a couple of things in your post. There is a reason why people want to avoid a lot of iron in infant formula- there are links between leukemia and iron intake in ultero and in childhoo

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  8. Whoops my last comment got cut off...
    I'll find so e links for you to read about the iron/leukemia connection.

    Also, regarding vitamin A toxicity. All of the studies done which demonstrated toxicity of vitamin A were done with plant sources not animal. The risk of vitamin A toxicity is very very low with animal sources such as liver or cod liver oil. In fact, many women are very deficient in his vitamin and it's a huge reason for miscarriage as it's vital for the formation of the heart chambers. I've had some patients with recurring miscarriages finally conceive after taking cod liver oil for 3 months.

    I did not know about the intestinal bleeding from cows milk!! This is a bit frightening. I'm surprised WAPF recommends cows milk primarily and goats milk as a back up. I will have to look into this further. Does their addition of whey off set some of this?

    Anyway, thanks for your post. It gave me some things to think about and I can at least feel ok giving my son regular formula for another week or so in addition to

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  9. There's some major typos in my first comment . Not sure why it says "bad oil blend" I just meant to say "oil blend".

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  10. This comment has been removed by the author.

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  11. My son thrived on the homemade cows milk formula for more than a year and he is way above average. He is 2 yrs. old now and people who meet him for the first time guess he is 4 yrs. old! I could not breastfeed him very long because I got pregnant again when we was 3 months old and my milk supply dried up. I was a meticulous mommy who took every precaution in finding only the best ingredients and making the formula exactly as his body needed. I bought a couple ingredients from the Radiant Life website but searched hard to find local sources for everything else. I would encourage moms needing to supplement to read all the other success stories of the homemade milk-based formula (I never needed to try the broth-based). I am happy to add my son to the list of above-average kiddos! It's not too hard to make the formula and the results are so worth it!!

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  13. Homemade Toddler Formula is hard to prepare. Especially for me as a first time mum, I prefer buying the ones in the market which is recommended by my baby's physician.

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