Should Your Child See a Doctor?
Bottle-Feeding and Formula Questions
- This guideline covers common questions asked about formula and bottlefeeding
If your infant is healthy, go directly to the number of the topic that relates to your child for specific care advice:
- Types of formulas
- Switching formulas and milk allergies
- Powdered versus liquid formulas
- Whole cow's milk, 2%, 1% and skim milk
- Vitamins and iron
- Water to mix with the formula
- Extra water
- Amounts: How much per feeding?
- Schedules or frequency of feedings
- Length of feedings
- Night feedings: How to eliminate?
- Formula temperature
- Formula storage
- Cereals and other solids
- Baby bottle tooth decay
- Nipples and bottles
- Normal stools
- Breast discomfort
When to Call Your Doctor for Bottle-Feeding (Formula) Questions
Call Your Doctor Now (night or day) If
- Your child looks or acts very sick
- Age under 1 month old and looks or acts abnormal in any way
- Signs of dehydration (no urine over 8 hours, sunken soft spot and very dry mouth)
- Too weak to suck
- Age under 1 month old and refuses to bottlefeed for over 6 hours
- Refuses to drink anything for over 8 hours
- Age under 12 weeks with fever above 100.4° F (38.0° C) rectally (Caution: Do NOT give your baby any fever medicine before being seen.)
Call Your Doctor Within 24 Hours (between 9 am and 4 pm) If
- You think your child needs to be seen
- Doesn't seem to be gaining enough weight
Call Your Doctor During Weekday Office Hours If
- You have other questions or concerns
Parent Care at Home If
- Bottlefeeding question about healthy child and you don't think your child needs to be seen
Home Care Advice for Bottle (Formula) Feeding, Topics 1-20
- Types of Formulas:
- Milk-protein formulas, soy-protein formulas, and hydrolysate formulas
- Soy formulas don't contain lactose or cow's milk protein. Currently, 20% of infants in the U.S. are fed soy formula (often without valid reason).
- Hydrolysate formulas (protein is broken down) are indicated for children who are sensitive to both milk protein and soy protein.
- Switching Formulas and Milk Allergies:
- Switching from one milk-based formula to another milk-based formula is not helpful for any symptom. It is also not harmful.
- Switching from milk formula to soy formula is helpful for severe diarrhea (from acquired lactase deficiency) and for vegetarianism.
- Switching from milk formula to soy formula is sometimes helpful for cow's milk allergy (occurs in 1-2% of infants). However, protein hydrolysate formulas (such as Alimentum or Pregestimil) are usually recommended because 15% of these infants are also allergic to soy protein.
- Switching formulas for excessive crying, spitting up or gas is rarely helpful.
- Don't switch formulas without discussing it with your child's doctor
- Powdered vs. Liquid Formulas:
- Formulas come in 3 forms: powder, concentrated liquid and ready-to-feed liquid.
- Concentrated formulas are mixed 1:1 with water.
- Ready-to-feed formulas do not need any additional water.
- Powdered formulas are mixed 2 oz. (60 ml) of water per each level scoop of powder. Never add extra water because dilute formula can cause a seizure.
- Powdered formula is the least expensive and ready-to-feed formula is the most expensive.
- Powdered formula is the most convenient to supplement breastfeeding.
- Ready-to-feed formula is the most convenient for traveling.
- Whole Cow's Milk, 1%, 2% and Skim Milk:
- Whole cow's milk should not be given to babies before 12 months of age (Reason: increased risk of iron deficiency anemia and allergies.)
- Skim milk (fat free milk), 1% low fat milk or 2% milk should not be given to children before 2 years of age (Reason: The fat content of whole milk (3.5%) is needed for rapid brain growth.)
- Vitamins and Iron:
- Use a formula that is iron fortified in all infants to prevent iron deficiency anemia.
- The amount of iron in iron-fortified formulas is too small to cause any symptoms including constipation and diarrhea.
- Iron-fortified formulas contain all vitamin and mineral requirements except for fluoride.
- Vitamin supplements are therefore not needed for infants taking formula.
- From 6 months to 16 years of age, some children need fluoride supplements (prescription item) to prevent dental caries. (EXCEPTION: present in child's water supply in most cities.) If prescription needed, discuss with your child's doctor during office hours.
- Water to Mix With the Formula:
- Most city water supplies are safe for making 1 bottle at a time. Run the cold tap water for 1 minute. Don't use warm tap water. (Reason: to avoid potential lead exposure). Heat cold water to desired temperature. Add this to powder or formula concentrate.
- EXCEPTIONS: Untested well water, city water with recent contamination, or your child has decreased immunity.
- For these situations, use distilled water, bottled water, or filtered tap water.
- Another option is to use city water or well water that has been boiled for 10 minutes (plus 1 minute per each 1,000 feet or 305 meters of elevation).
- Bottled water is more expensive than distilled water.
- For preparing a batch of formula, distilled, bottled or boiled water is required.
- Extra Water:
- Babies do not routinely need extra water. (Reason: plenty in formula)
- Excessive water can cause seizures from water intoxication.
- Can offer some water if weather is very hot.
- Don't give more than 4 ounces (120 ml) of extra water/day during the first 6 months of life. (EXCEPTION: don't give any during the first month)
- After starting solid foods, infants need more water.
- Amounts - How Much Per Feeding:
- The average amount of formula (in ounces) that babies take per feeding usually equals the baby's weight (in pounds) divided in half (or equal to the weight in kg).
- The average ounces of formula the baby takes in 24 hours is the baby's weight in pounds multiplied by 2 (or kg multiplied by 4).
- A baby's appetite varies throughout the day. If the infant stops feeding or loses interest, the feeding should be stopped.
- If your baby is healthy and not hungry at several feedings, increase the feeding interval.
- The maximal amount of formula recommended per day is 32 ounces (1 liter).
- Overfeeding can cause vomiting, diarrhea or excessive weight gain.
- If your baby needs more than 32 ounces (1 liter) and is not overweight, start solids.
- Discard any formula left in bottle at end of each feeding. (Reason: It's contaminated)
- Frequency Of Feedings (Schedules): Babies mainly need to be fed when they are hungry. If they are fussy and more than 2 hours have passed since the last feeding, they usually need to be fed. The following are some guidelines:
- From birth to 3 months of age, feed every 2 to 3 hours
- From 3 to 9 months of age, feed every 3 to 4 hours
- Infants usually set their own schedule by 1 to 2 months of age
- Length Of Feedings:
- Feedings shouldn't take more than 20 minutes.
- If the feeding is prolonged, check the nipple to be sure it isn't clogged.
- A clean nipple should drip about 1 drop per second when bottle of formula is turned upside down.
- Night Feedings - How to Eliminate: Most newborns need to be fed at least twice each night. By 3 to 4 months of age, most formula-fed babies give up middle-of-the-night feedings. The following tips can help your baby sleep for longer intervals during the night:
- Keep daytime feeding intervals to at least 2 hours. Gradually stretch them to 3 hours.
- If your baby naps for over 3 consecutive hours during the day, awaken him for a feeding.
- Place your baby in the crib drowsy but awake. Don't bottle feed or rock until asleep.
- Make middle-of-the-night feedings brief and boring compared to daytime feedings. Don't turn on the lights, don't talk to your child, and feed him rather quickly.
- Formula Temperature:
- Most infants prefer formula at body temperature.
- In the summertime, some infants prefer formula that's cooler.
- In the wintertime, some prefer warm formula.
- The best temperature is the one your infant prefers.
- There's no health risk involved except to make sure the formula is not so warm that it might burn your baby's mouth.
- Formula Storage: If possible, prepare your child's formula fresh for each feed. However, if formula needs to be made in advance:
- Prepared formula should be stored in refrigerator and must be used within 24 hours
- Open cans of formula should be kept in refrigerator, covered and used within 24 hours
- Prepared formula left at room temperature for more than 1 hour should be discarded
- Leftover used formula should always be discarded (Reason: It's contaminated)
- Cereals and Other Solids:
- Bottle-fed infants should be started on baby foods (cereal or fruit) between 4 and 6 months.
- Starting before 4 months is unnecessary and has the disadvantage of making feedings messier and longer. Early solids can also cause gagging.
- Solids don't increase sleeping through the night for bottle-fed infants.
- Delaying solids past 9 months of age runs the risk that your infant will refuse solids.
- It is not harmful if a baby doesn't burp.
- Burping is unnecessary.
- It doesn't decrease crying.
- It does decrease spitting up.
- Burping can be done twice per feeding, once midway and once at the end.
- If your baby does not burp after 1 minute of patting, it can be discontinued.
- Baby Bottle Tooth Decay:
- Some older infants and toddlers have learned to expect their bottle at naptime and bedtime.
- Severe tooth decay can be caused by falling asleep with a bottle of milk or juice.
- Prevent this bad habit by not using the bottle as a pacifier or security object.
- If you cannot discontinue the bottle, fill it with water instead of formula or milk.
- Use prepackaged bottles of ready-to-feed formula (most expensive).
- Or mix formula ahead of travel and carry in a cold insulated container.
- Or use powered formula. Put the required number of scoops in a bottle. Carry clean water in a separate bottle. Mix prior to each feeding.
- Nipples and Bottles:
- Any commercial nipple/bottle is fine.
- It is not necessary to sterilize bottles or nipples if they are washed with soap and water and thoroughly rinsed.
- It is OK to wash bottles and nipples in the dishwasher.
- Formula-fed Stools, Normal:
- Meconium Stools are dark greenish-black, thick and sticky.They normally are passed during the first 3 days of life.
- Transitional Stools (a mix of meconium and milk stools) are greenish-brown and more loose.They are passed day 4 to 5 of life.
- Milk Stools without any meconium present are seen from day 6 onward.
- Formula-fed babies pass 1 to 8 stools per day during the first week, then 1 to 4 per day until 2 months of age.The stools are yellow in color and peanut butter in consistency.
- After 2 months of age, most infants pass 1 or 2 stools per day (or every other day) and they have a soft solid consistency.
- Breast Discomfort In Bottle-feeding Mothers: Your breasts will make milk for several days even though you chose not to breastfeed. Breastmilk comes in on day 2 or 3 and swollen breasts can be painful for a few days. Here is what to do:
- Ibuprofen. Take 400 mg of ibuprofen 3 times per day to reduce pain and swelling.There's no special prescription medicine for this.
- Ice. Apply a cold pack or ice bag wrapped in a wet cloth to your breasts for 20 minutes as often as needed. This will reduce milk production. Do not apply heat because it will increase milk production.
- Pumping. For moderate pain, hand express or pump off a little breastmilk to reduce your pain. While pumping breastmilk can increase milk production, doing this to take the edge off your discomfort is not detrimental.
- Bra. Wear a supportive bra (e.g., sports bra) 24 hours a day.
- Binding. Binding the breasts by wearing a tight bra or elastic wrap is no longer recommended. It can increase the risk of breast infections (mastitis).
And remember, contact your doctor if your child develops any of the "When to Call Your Doctor" symptoms.
- American Academy of Pediatrics Committee on Nutrition. Iron fortification of infant formulas. Pediatrics. 1999;104:119-123.
- American Academy of Pediatrics Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics. 2000;106:346-349.
- American Academy of Pediatrics Committee on Nutrition. Soy protein-based formulas: Recommendations for use in infant feeding. Pediatrics. 1998;101:148-153.
- Bhatia J, Greer F, AAP Committee on Nutrition. Use of soy protein-based formulas in infant feeding. Pediatrics. 2008;121 (5):1062-1066.
- Bock A and Sampson H. Food allergy in infancy. Pediatr Clin North Am. 1994; 41:1047-1067.
- Hall RT and Carroll RE. Infant feeding. Pediatr Rev. 2000;21:191-199.
- Hyams JS, Treem WR, Etienne NL, et al. Effect of infant formula on stool characteristics of young infants. Pediatrics. 1995;95:50-54.
- Scariati PD. Water supplementation of infants in the first month of life. Arch Pediatr Adolesc Med. 1997;151:830-832.
This information is not intended to be a substitute for professional medical advice. It is provided for educational purposes only. You assume full responsibility for how you choose to use this information.
Author and Senior Reviewer: Barton D. Schmitt, M.D.
Copyright 1994-2015 Barton D. Schmitt, MD. All rights reserved.