Everything You Need To Know About *Not* Breastfeeding

by Emily Oster

If you’re a new parent, especially a new mom, you may have heard “breast is best.” Breastfeeding is the way to give your kid the best start, the best nutrition, the best SAT, LSAT, and FICO scores, somehow. If your plan is to breastfeed exclusively, there is advice everywhere — let’s put aside for the moment that it’s not always the support you need. There are lactation consultants, La Leche League, KellyMom, your mom, your doctor.

But if you’re not breastfeeding, or not breastfeeding exclusively, the advice dries up quickly. It’s easy to feel like the expert consensus is that if you’re giving your kid anything other than breast milk, you might as well put some Diet Coke in their bottle and call it a day. (Do not do this.) The silence around formula feeding is a shame because, in reality, there are tons of reasons you might not breastfeed. Your job doesn’t accommodate it; you’re a non-biological parent; you’re on medication; it doesn’t work for you, period. As I and others have written elsewhere, many of the claimed benefits to breastfeeding are not well supported by the best scientific data.

But not breastfeeding comes with its own questions. Do I need the fancy German formula that my parent group is on about? What about sharing breast milk with my friend? Is that weird? How can I wean my 2-year-old? Seriously, I have to wean him. Below, I looked at some of the questions I most commonly hear from new moms. Whether or not you breastfeed, we must provide better support to parents who don't.

Can I Just Use A Little Formula Sometimes?

There are two common reasons that parents choose to supplement breast milk with formula. The first is to address excessive weight loss in newborns, especially if breast milk is slow to “come in.” Typically breast milk begins to flow two to three days after birth, but this can be delayed in some women, especially first time moms. When infants lose a lot of weight, and especially if they are dehydrated, it is sometimes suggested that formula be used as a short-term supplement.

Some breastfeeding advocates are reluctant to supplement, however, based on the theory that any formula should be avoided at all costs. This is incorrect. For one thing, it may be medically necessary to supplement; some weight loss is normal for babies, but dehydration can be really dangerous. For another, randomized trials have shown that short-term supplementation generally either doesn’t affect breastfeeding (as in this study and this study) or actually may increase the chance of breastfeeding in the long-term (see here and here).

The benefits of exclusive breastfeeding compared to supplemented breastfeeding are statistically low stakes.

Parents also supplement over the long-term if supply is low, the breastfeeding parent is back at work and doesn’t want to pump, or for other reasons, including need for medication. It’s natural to wonder: Is some breast milk is better than none, or do you only reap benefits if you avoid formula entirely?

As I linked above, the data suggests the benefits of breastfeeding are often overstated, which makes the benefits of exclusive breastfeeding compared to supplemented breastfeeding statistically low stakes. As for the benefits we do see from breastfeeding — digestive benefits early in life, some effects on allergic rashes — we don’t have much evidence that would help us distinguish partial from exclusive breastfeeding.

What's With All The European Formula Hype?

There are some things we know Europe is better at. Cheese, for example. Or universal health care. Of late, some parents have added baby formula to the list. European formula — so it is said — contains fewer ingredients than U.S. formula, is more nutritious, and tastes better. It contains less sugar — or, more accurately, a different type of sugar — and even reduces obesity in the long term. So some claim.

Despite their popularity in U.S. parenting circles, European-branded formulas — Holle or HiPP, for example — are not actually approved for sale here. There is at least one start-up attempting to bring European formula to the U.S. officially, but it hasn’t happened yet.

For the time being, parents are paying a premium for European formula online, effectively on the black market. It’s unregulated by the FDA, which makes people nervous (including the FDA itself). Of course, European formula is regulated by European countries, so it’s not the Wild West. Still, getting your hands on some is a bit of a hassle and carries some risk. Is it worth it?

Parents pay a premium for European formula online, effectively on the black market.

An academic paper from October 2019 assessed a large number of European infant formulas, asking how they differed from those in the U.S. One major difference — and probably a big part of the reason they make the FDA nervous — is labeling. The FDA has many rules about what information must appear on the label (e.g. how long formula can sit out after being mixed), which the European brands do not list. In terms of nutritional content, the authors found that all the formulas they looked at had most of the same vitamins, minerals, and nutrient mixes as the U.S. versions.

One significant difference is that U.S. formulas contain much more iron. European formulas contain less than infants may need, and FDA regulations would require them to indicate this. Another difference is that most European formulas are made with lactose, rather than sucrose or corn syrup, which some people perceive as better. There isn’t really any data to support that, though, and it’s worth noting that many U.S. formula brands also make lactose-based formulas.

Overall, there isn’t any evidence to suggest these formulas are superior. The most important consideration is whether a formula provides an appropriate mix of fat, carbohydrate, and protein, as well as required nutrients. American and European formulas do that. In the end, their ingredient makeup is extremely similar.

Does Anybody Still "Wet Nurse"?

Maybe you’re not able to breastfeed but you’re really, really committed to providing your child with breast milk. Again, I’d go back, review the evidence on breastfeeding, and ask yourself if it’s worth it. But parenting is about making choices that work for you. Should you try to get breast milk elsewhere if you cannot produce it yourself?

If your baby is premature and in the neonatal intensive care unit (NICU), the answer is likely yes. Using breast milk rather than formula seems to lower complication risks in preterm babies, especially very small ones. If the mother cannot breastfeed, many NICUs will use milk banks. Milk bank breast milk is heavily regulated and processed, and donors are carefully screened. It is also very expensive and not available on the open market.

When researchers bought breast milk online they found a reasonable share of it contained some cow milk.

Outside of milk banks, the world of milk sharing is much harder to get a handle on. Small surveys of women suggest the phenomenon is mostly limited to women sharing with people they know, or donating to people they connect with through friends or online resources. Is it risky? It’s hard to know; contamination can be difficult to evaluate, and the risk may depend on how well you know the donor. Milk sharing is effectively a modern version of wet nursing, which has been around for millennia. But the fact is that receiving bodily fluids from someone you do not know well simply entails some risks.

What’s not worth the risk is buying breast milk. How do we know? From academic papers in which researchers tried it. When researchers bought milk online, they found a reasonable share of it was contaminated by bacteria. A good share also contained some cow milk. Do not buy breast milk online.

Can I Stop Breastfeeding Now?

Let’s say you choose to breastfeed initially, and now you’re ready to stop. Resources can, again, be hard to come by. A lot of what you hear is along the lines of: Are you really ready to stop? Is your baby ready? Lots of moms enjoy extending breastfeeding past a year! The WHO suggests up to two years. What you don’t get is a play-by-play of how to actually stop, if that’s what you want to do.

Make a plan, communicate the plan, stick to the plan.

Unfortunately, the lack of guidance is probably in part due to very limited data. We have case studies about how parents wean, but nothing very systematic. For a younger baby, weaning may be easier — many babies take to bottles fine, and if you’ve been giving some bottles anyway, substituting more is not generally very difficult. The hardest part is probably managing your own discomfort, physical and emotional. Drop one feeding at a time, waiting a few days between and your body will adapt.

Weaning a toddler can be more difficult for all the reasons toddlers are difficult. They want what they want when they want it, and they have a tough time with no. The best guidance is probably to treat this like any other restriction you put on your kid: Make a plan, communicate the plan, stick to the plan. With a younger toddler, distraction may work well. With an older child, they may be able to understand more reasoning. Or the old parenting standby: bribes.