More on Baby Formula
Comparing EU and US Formulas
Perhaps the latest victim of green-washing is baby formula. Choosing how to feed a new baby can be a stressful experience. New parents are inundated with advertisements, opinions, and collaborations on influencer platforms touting the supposed superiority of their formula. To complicate matters, there exist several groups on social media platforms such as Facebook filled with underground European baby formula importers. The term underground is perhaps misleading here, as they are highly accessible and pervasive across social media platforms. These groups are filled with posts and spreadsheets of ingredients to supposedly exemplify that European baby formula is superior to FDA-approved American formula. But do these claims hold up? Not really. The subtle differences in nutrient profiles are not beneficial enough (or at all) to outweigh the risks associated with importing formula from a third-party. Note that amidst the current US formula shortage, the US has begun importing international formulas that meet US health and safety standards, which includes labeling in English. Any international formula available on US shelves is safe to feed. The best formula for an infant may simply be the formula that is available to you, and a fed baby is always the best option.
The top players in the illegally imported formula game are Holle, HiPP, Kendamil, Lebenswert, and Loulouka. The most notable difference between these formulas and the most popular formulas in the U.S. is easily the price: a six-ounce bottle of Holle costs about $1.60 to make, that’s almost four times the price of the same six-ounce bottle of American formula, which costs around $0.45. When it comes to nutrition, these formulas all contain very similar profiles. When Yale examined 16 European formulas using FDA labeling and nutrition requirements, 15 out of 16 met the nutrient requirements, but zero of them met FDA labeling requirements.
While 15 out of the 16 formulas met the FDA requirements for nutrients, due to being an unregulated product, the standards of transport cannot be verified. This leaves the formula open to the possibility of improper storage, which can lead to nutrient breakdown and chemical instability. Newborns have very immature digestive systems and can be particularly sensitive to toxic effects of autoxidation products. A study examined the stability of formulas containing polyunsaturated fatty acids. While the study showed that when infant formulas remain sealed, they are quite stable at temperatures up to 104ºF (40ºC), a steady rise in malondialdehyde was observed if stored at that temperature. Additionally, there was a rapid rise in malondialdehyde at temperatures of 131ºF (55ºC). Levels of malondialdehyde increased by 30% over 14 days stored at these temperatures. While this temperature may seem drastically high, on a sunny day where the air temperature is 95ºF, the inside of a vehicle reaches 140ºF after one hour.
Even if the formula is transported safely and the nutrients avoid oxidation, another major concern with European formula is labeling. Namely, the labels are not in English. Unless the consumer is fluent in the language on the canister, this can lead to misuse of the product and improper storage. The biggest concern regarding the language barrier is that most European formulas require a 1:1 ratio of ounces of water per formula scoop, whereas American brands require 2:1 ounces of water per formula scoop. This can lead to accidentally diluting the formula for infants by half, which would mean the bottles prepared no longer meet their nutrient requirements. For infants, ingesting too much water, such as in the form of dilute formula, can lead to electrolyte imbalances, seizures, and water intoxication as their kidneys are too immature to handle water for several months after birth.
Importing European formula comes with a massive price tag, risk of unstable transport conditions, and increased likelihood of improper preparation. This really begs the question: is it worth it? Is European formula better for babies? Certainly, along with affordability, one of the highest priority items when considering what to feed an infant is nutrition. European formula supporters claim that their ingredients are superior, and the nutrition profiles are better suited to newborn needs. Between regulatory bodies of the European and US, the vitamin and mineral requirements are almost identical. While there are some differences between the two, there is no evidence to support that one is superior to the other. For instance, European formulas contain less iron than US formulas, an important ingredient in preventing iron-deficiency, a condition that can severely impact neurocognitive development. On the flip side, the FDA doesn’t require DHA in formula, and although many formulas do contain it, it is a requirement in European formula. When considering nutrient profiles of formula, it is relevant to consider that formulas are formulated with the intention of replicating breast milk composition as closely as possible. In the case of DHA in breast milk, the amounts detected can vary widely from person to person as levels are directly correlated with consumption of DHA-rich foods (such as fatty fish). That being said, research indicates that the optimal level of DHA in breast milk is around 1%, which is notably higher than can be found in people consuming typical western' diets, but is a helpful target when choosing an infant formula.
If we zoom out from nutrient levels to ingredients, commonly touted advantages of European formula are that they are free of: GMOs, “corn syrup”, and “hormones”. These buzzwords can elicit a reaction in parents looking for the safest, healthiest options for feeding their child. However, they are just that: buzzwords. Using them as a stance for superiority is nothing but fear-mongering. Let’s dive in with GMOs. In US formulas, the ingredients which may contain genetically modified organisms are corn syrup solids and soy oil. An in-depth study by the National Academies of Sciences, Engineering, and Medicine revealed absolutely no risk to human health from genetically modified food. Where corn syrup is concerned, the ingredient commonly used in baby formula is corn syrup solids: a form of corn syrup that has been dehydrated to concentrate the sugars (a type of carbohydrate). The FDA requires formulas to contain at least 40% of their calories from carbohydrates. The main sugar in breast milk is lactose, and this is true for many formulas as well. However, hypoallergenic formulas often contain corn syrup solids so that infants can get the energy-dense carbohydrates they need to grow if they cannot safely consume lactose. Finally, to say that European formulas are free of hormones suggests that US formulas do contain hormones. Firstly, any milk-derived product contains hormones: they are naturally occurring compounds that are present even in human milk. Hormones are not added to infant formula in the US. This study found that infant formulas from all over the world contain some steroid hormones, but that the levels of hormones in infant formulas are generally lower than those in human milk. Overall, choosing ingredients to feed infants is a deeply personal choice, but parents should rest assured that all the ingredients in formula are FDA-approved, making US formula an equally safe choice.
Factors influencing purchase of European formulas, where to go from here
As we’ve examined, there is a lack of evidence to support the purchase and import of European formula over FDA-approved infant formula. However, new parenting comes with a plethora of stresses, pressure, and uncertainty, and making a choice about what to feed an infant can be overwhelming. With increased pressure to breastfeed, but little to no increase in accessibility or education on breastfeeding, parents may have feelings of guilt or feel pressure to purchase the “best” infant formula. As such, they are more likely to make purchasing decisions based on price-quality heuristic: the consumer perception that higher priced items are therefore of better quality. While the choice of which brand and formulation to buy is ultimately up to the consumer, increasing parental education on suitable formula options, as well as the potential dangers of importing non-FDA approved products via third party may allow parents to make more holistic purchasing decisions when it comes to feeding their infant.
Sources:
https://www.nytimes.com/wirecutter/blog/us-parents-european-baby-formula/
https://naspghan.org/wp-content/uploads/2019/10/October-2019-Article-B.pdf
https://www.healthline.com/health/baby/why-cant-babies-have-water#cautions
https://www.milkgenomics.org/?splash=much-dha-human-milk#:~:text=DHA%20concentration%20in%20breast%20milk,fish%20products%20daily%20(5)
https://www.straitstimes.com/opinion/the-behavioural-science-behind-baby-milk-formula
Great piece! FYI for additional resources there is an RD who runs a great formula website with info on ingredients for families to learn more about: https://formulasense.com/
Thanks for your work on this and dispelling myths and calming unnecessary fear about our US formulas!