Every toddler at some stage becomes a picky eater. When I was that age, my twin brother preferred to stash his unwanted food behind the refrigerator, and my mother would threaten to call our monster neighbors to come over and eat us if we didn’t finish our food. He turned out just fine (in his opinion). Our own little Alex has already had a phase of pickiness with his formula, so we did what any first time parents would do: total panic, harassing our pediatric doctors and demanding a full workup. Of course he was fine and is now chubby again, happily oblivious to our hypochondriasis.

Here in my family medicine clinic I frequently have to reassure parents worried that their child isn’t eating enough. I’m happy to say that the vast majority of these toddlers are normal on their growth curves as well as developmental milestones. As the American Academy of Pediatrics states on their parenting website, “picky eating is often the norm for toddlers.” I’m much more concerned about the non-picky eaters than the picky ones! In other words, for every “picky child” I see who actually is dangerously falling off the growth curve, I have a thousand other kids who are the opposite — far above the 85% and 95% growth curves for overweight and obesity, respectively. It’s a classic example of old China’s poverty-stricken undernutrition versus new China’s modern malnutrition.

Which brings me to today’s topic: toddler formula, a recent invention of the infant formula companies as a way to milk more money from parents, who usually would stay loyal to the same brand. They usually market these as a “nutritious alternative to milk,” “specially designed for picky toddlers” and packed with ingredients to “support the immune system”. While breast milk will always be the preferred food for all infants, infant formula certainly has proven an invaluable alternative for tens of millions of parents worldwide . But these new follow-on and toddler formulas are a whole different beast. No major pediatric or family medicine group, including the WHO, endorses follow up or toddler formula as the first choice for any healthy child. The first choice is always breast milk or whole milk for a child over 12 months as an increasingly smaller part of a balanced diet.

The biggest complaint from pediatricians and nutritionists against toddler formulas is that they usually contain more sugars than milk, often with added flavoring such as vanilla. There actually was a chocolate version which was quickly pulled from the market in 2010 after massively negative pushback. If we compare 100 grams of toddler formula such as Enfagrow Ready with whole milk using the USDA Nutrient Database, the toddler formula has 7 grams of sugars versus 5 in whole milk. While that may not seem like a lot, those extra grams collectively add up. Our modern world’s greatest threats are from diabetes and obesity, and simple, processed sugars and carbs are a major contributor to this. So why risk a sweet tooth in your child, or get them to prefer this yummy formula over other healthier foods?

Toddler formula also claims to have many other special nutrients which indeed are healthy — but again they are usually far less ideal than from other sources, such as vegetables or meats. A fellow blogger, Seattle Mama Doctor Wendy Swanson, wrote,

“I would NEVER recommend this “formula” nor would the dozen or so pediatricians, pediatric gastroenterologists, nutritionists, and pediatric obesity experts I’ve spoken with. Read this and this. This will hurt children, not help them… No child needs formula after 12 months of age unless a prescription for special formula is suggested by their pediatrician in extremely rare cases.”

Back in California, I saw very few parents using these toddler formulas. But here in my Beijing practice, an enormous percentage of parents, especially Chinese, use these toddler formulas instead of milk. The online Chinese stores also sell a much larger variety than in the US. Why is this? Is China full of picky eaters who just don’t like milk?

My Beijing parents’ usual answers to this question shouldn’t be surprising to anyone living in China: most people simply don’t trust any locally made dairy products. It’s honestly quite difficult for me to blame them, as everyone still remembers the horror of the melamine scandal, which just five years ago killed six children and injured 300,000 others in China from the deliberately adulturated milk and formula. Who am I to say, even right now in this article, that any local brand of milk is now 100% guaranteed to be perfectly safe for your child? What proof do I have of this? Of course I can’t say anything of the sort. Can anyone? This scandal is already five years old, but even right now I can’t find one parent or doctor here, either Chinese or expat, who confidently recommends any specific local milk brand for children. I can’t say if this continued mistrust is justified or not, but I totally understand if a parent doesn’t choose to have their child be a guinea pig.

And thus we have this uniquely Chinese phenomenon; parents don’t trust local milk but need to feed their toddler. What other options are there?

First, let’s step back a minute: why do toddlers need any milk at all? We baby doctors recommend that toddlers drink milk mostly due to its high concentration of calcium and fats, which are crucial for development at this age. It’s difficult to get as much calcium from other foods — but certainly not impossible, as I will discuss.

One way for confused parents to cut through all the hype and misinformation is just to ask their child’s doctor, “what would you use for your own kids?” It’s a great question: what will I give to my own Alex when he turns one year old? We still have more than half a year to prepare, but my wife and I are already discussing this hot topic. Honestly, I still am not sure what we will do. My wife feels that toddler formula (imported, not domestic) isn’t such a horrible alternative. But I would prefer we think of healthier foods to get the needed calcium and fats, including local organic milk, imported UHT milk, yogurt and cheese, fortified soy or rice milk, leafy green vegetables, and canned salmon or sardines. As a last resort, a daily multivitamin may be reasonable for some, but certainly isn’t needed for any typically healthy child.

Why Cow Milk — Ever?

While I do understand the push for milk as a valuable part of a balanced diet, I do feel that we are quite brainwashed by the dairy industry into thinking that cow products are best for us humans. Right now in China, where a great percentage of people can’t even properly digest dairy due to lack of the lactase enzyme, the cow dairy industry continues to expand and push their products. I hope people realize that the massive amounts of landscape and feed that cows require, not to mention their methane production and other industry pollutants, really makes the entire cow (and sheep) industry a poor choice for our rapidly degenerating world environment. I’m not saying we should all go vegan, but more of us should follow the Meatless Mondays philosophy to raise awareness.

The Bottom Line

China until very recently did indeed have a lot of children with poor nutrition, including low calcium levels. But since its dramatic increase in living standards, such problems are much less common. Now the problem is no longer undernutrition but malnutrition: an excess of bad foods as much as a deficiency in good foods, leading to China’s increasing problem with childhood obesity and diabetes.

Maybe in a few years someone will finally do proper studies of these toddler formulas and directly compare them to milk, assessing health outcomes and development. If such studies showed benefits, and if the WHO, AAP, AAFP and others specifically recommended these formulas, then I would consider changing my mind about them. But until then, without any proper research or endorsement, there’s no way I’d recommend them as first line for toddlers — not even here in China. I would much prefer they still try milk or other products. The milk definitely doesn’t have to come from a cow. And yes, maybe imported UHT milk right now is the best option for most people here in China — organic versions even better.

As for my Alex, when he reaches twelve months I still prefer to use our local organic milk. But we still have time to look into this, and for now I will continue to practice what is always the healthiest option: following whatever my wife decides.