- When babies are ready to transition to whole cow’s milk, they should drink between 16-24 ounces per day; their remaining calories should come from solid foods.
- Cow’s milk can be introduced gradually to help babies with the transition.
- If your baby is allergic to or cannot tolerate cow’s milk, alternatives are available.
- Avoid follow-up formulas (also known as toddler formula).
- Don’t hesitate to discuss any nutritional concerns with your pediatrician.
A baby’s first couple of years are an exciting time – and filled with a lot of transitions! Among those big changes is the move from breastmilk or infant formula to cow’s milk.
The American Academy of Pediatrics recommends waiting until at least the 12-month milestone before introducing any type of milk other than breastmilk or infant formula. The nutritional composition of cow’s milk is not considered appropriate for babies less than 12 months old, as it contains high concentrations of minerals and certain types of proteins that are difficult for infants to digest.
If a baby was born prematurely, cow’s milk introduction should be delayed until the child reaches the corrected age of 12 months.
Parents who wish to continue to provide breastmilk beyond 12 months of age, in conjunction with regular meals and snacks of solid foods, should be supported in doing so. However, some babies are ready to transition around the one-year-mark, so for the purposes of this blog post, I’d like to focus on providing tips for families who are seeking information around that time frame.
THINK OF MILK AS A BEVERAGE
Unlike breastmilk and/or infant formula during the first year of life, cow’s milk should be treated as a beverage, not a meal. The majority of a child’s nutrition should be provided from solid foods during the toddler years. When babies are ready to transition to whole cow’s milk, the recommendation is 16-24 ounces per day. This volume helps to:
- Ensure adequate consumption of nutrients such as protein, calcium, and vitamin D, all of which are crucial for growth and development
- Minimize the risk of nutrient displacement
- Maintain an appetite for solid foods
- Prevent other nutrient-related concerns, such as iron-deficiency anemia
MAKE IT WHOLE
Between 12-24 months of age, it is vital to use whole milk, rather than 2%, 1%, or skim milk. Whole milk contains higher amounts of dietary fat, which is essential for brain development, particularly during the first two years of life. Milk with a lower fat content may be considered prior to 24 months if a child is gaining weight too quickly, has high blood lipid levels (elevated cholesterol and/or triglycerides), or if there is a strong family history of cardiovascular disease. These concerns should be discussed with your child’s pediatrician and/or a registered dietitian.
Once kids turn 2 years old, it is advisable to switch to a lower fat milk (or whatever the rest of the family drinks). In some cases, such as if a child is struggling to gain weight, whole milk may still be recommended after age 2.
INTRODUCE IT SLOWLY
A baby’s temperament, sensitivity to change, and gastrointestinal function can all influence the pace of whole milk introduction. Some babies accept whole milk well and may be able to tolerate a rapid transition without much difficulty. Other babies need to make the change more gradually.
Whole milk can be slowly introduced by mixing small volumes of cow’s milk with expressed breastmilk or formula, and steadily increasing the ratio of cow’s milk to breastmilk/formula over a period of days or weeks. For example, a parent can start by mixing 1 oz cow’s milk with 5 oz breastmilk/formula at each feed, then increase to 2 oz cow’s milk with 4 oz breastmilk/formula after 1-2 days, and so on, until the child is exclusively receiving cow’s milk. Children who are weaning from breastfeeding (via direct nursing) to cow’s milk should do so over the course of several weeks in order to progressively decrease the breastfeeding parent’s milk supply and reduce the risk of complications such as clogged ducts and mastitis.
OFFERING OTHER COW’S MILK-BASED PRODUCTS
Other dairy products, such as yogurt, cottage cheese, and shredded cheese, can be introduced prior to a baby’s first birthday. Offering infants these foods doesn’t necessarily facilitate the transition to drinking whole cow’s milk, but can provide valuable calcium, vitamin D, and protein. Exposing infants to these foods can also help parents evaluate how well they tolerate and digest lactose, which is the primary carbohydrate found in milk products.
KNOW THE ALTERNATIVES
Lactose intolerance is a common condition, and refers to a deficiency in lactase (the enzyme that is necessary to break down lactose in the intestines). Symptoms of lactose intolerance include gas, diarrhea, abdominal pain, and bloating. If you suspect your baby may be lactose intolerant, lactose-free whole milk can be substituted for standard whole milk.
If a child has a cow’s milk allergy (which is different than lactose intolerance), parents are advised to try fortified soymilk or pea protein-based milk (most common brand is Ripple). These specific non-dairy milks are rich in protein and have a similar nutritional profile to cow’s milk. In comparison, alternative milk choices such as coconut, flax, cashew, or almond milk should not be used for young children, as they do not contain sufficient amounts of protein and other essential nutrients. Rice milk is specifically not recommended for children under 5 years of age due to concerns for high levels of arsenic.
Other mammalian milks, such as goat or sheep, should not be substituted for cow’s milk if a child has a cow’s milk allergy. This is because the proteins found in all mammalian milks are considered to be cross-reactive with cow’s milk protein. In addition, these products contain lactose, so are often not tolerated by people with lactose intolerance.
In the absence of a cow’s milk allergy or lactose intolerance, goat’s and sheep’s milk are considered to be acceptable replacements for cow’s milk as long as they are pasteurized and fortified with vitamin D. Foods high in folate (e.g., legumes, avocado, fortified cereals) should also be prioritized, as goat’s milk and sheep’s milk are particularly low in folate. Raw milk of any type should never be offered to young children.
AVOID FOLLOW-UP FORMULAS
Follow-up formulas, also known as “toddler formulas”, “transition formulas”, or “growing up milks”, are marketed for older infants and toddlers from 6-36 months of age. Parents should be aware that follow-up formulas are not nutritionally complete nor regulated by the FDA. These formulas are not intended to be used as a primary source of nutrition, and are not considered adequate substitutes for children with growth faltering, nutritional deficiencies, swallowing dysfunction, feeding aversions, and/or disease-specific nutritional requirements.
Follow-up formulas are generally considered to be unnecessary for most children, without any specific role in the routine nutritional care of a healthy child. If a family chooses, they may be offered to children over 12 months in combination with a diet inclusive of all major food groups. Yet this does not provide any nutritional advantages when compared to a well-balanced diet that includes cow’s milk and/or breastmilk. Of note, follow-up formulas are more expensive than cow’s milk and cannot be bought with supplemental nutrition assistance programs, such as WIC.
WHEN TO SEEK HELP
A certain amount of worry is natural as parents help their babies move through a new milestone. Parents are encouraged to discuss any concerns regarding a baby’s nutritional intake with their pediatrician. Examples of issues that may warrant a referral to a pediatric dietitian include an acute change to a child’s diet, poor tolerance of an entire food group, or diagnosed deficiencies of specific vitamins and/or minerals.
To learn more about Nutrition Therapy at Cincinnati Children’s, please call 513-636-4211 or visit our website.
