A Guide to the Universe of Milks - The New York Times

When it comes to feeding your newborn or infant, milk options are generally simple: breast milk or formula (or a combination of the two). But the choices become more overwhelming once your child hits toddlerhood — and myths, misinformation and differing opinions (even among medical professionals) abound.
Whole milk or 1 percent? Does your kid even need cow’s milk at all? What about plant-based milks?
The multitude of options can be paralyzing, yet somehow you need to make a decision. I sifted through the science and consulted three pediatricians and one pediatric dietitian to compile all of the information you need to make the right milk choice for your toddler.
Start introducing milk at around 1 year.
While the American Academy of Pediatrics recommends introducing solid foods by around 6 months of age (with the eventual addition of dairy products like yogurt and cheese), they advise holding off on cow’s milk until your baby’s first birthday. This ensures her digestive system is mature enough to handle large amounts of milk protein.
“Milk is a great source of calcium, vitamin D, potassium and protein, all of which are important in a growing child,” said Kristi King, M.P.H., R.D.N., a dietitian at Texas Children’s Hospital.
An 8-ounce serving of whole milk, for example, provides more than half of the daily recommended amount of protein for toddlers age 1 to 3. It also supplies 40 percent of the daily recommended amount of calcium, 20 percent of the daily recommended vitamin D, 11 percent of the daily recommended potassium and 8 grams of fat.
If you’re still breastfeeding at one year, the A.A.P. suggests continuing as long as it’s working for you and your child. However, keep in mind that breast milk is neither a great source of calcium nor of vitamin D (compared with cow’s milk), so be sure to include other sources of these nutrients in your toddler’s diet. Same goes if your child doesn’t drink milk because she is allergic, lactose intolerant or simply doesn’t like the taste (more on that below).
Between ages 1 and 2, aim for 2 or 3 cups of milk per day.
One-year-olds should drink between 16 and 24 ounces of whole milk each day, according to 2019 guidelines developed by experts from the A.A.P. and other trusted organizations, and published by the Healthy Eating Research group, a nutrition advocacy group. Drinking 2 to 3 cups of milk per day ensures toddlers reap the benefits of dairy while still leaving room for plenty of other nutrients from foods. Milk is low in iron, for example, so drinking too much of it can block the absorption of iron from other foods, which could lead to a deficiency.
To help keep your 1-year-old within the 2- to 3-cup-per-day recommendation, offer milk to your toddler in a sippy cup or in an open cup, and only with meals, recommended Dr. Natasha Burgert, M.D., a pediatrician in Kansas City, Mo. “I don’t want it in a bottle at all, because then for sure they’re going to over-consume.”
If your toddler isn’t quite wanting to drink 2 cups in a day, don’t push him to drink more, Dr. Burgert stressed. “It’s impossible to micromanage a toddler, but especially if you’re trying to get them to drink something they don’t want, they’re only going to refuse it,” she said. If they’re growing well and eating a variety of foods, don’t worry about counting ounces.
For children between 2 and 3, the 2019 guidelines recommend 2 cups of dairy (including milk, yogurt and cheese) each day and 2.5 cups for children between 4 and 5. When serving milk and yogurt, stick with plain, unflavored versions, or low-sugar yogurts with no more than 23 grams of total sugars per serving.
Reduced-fat vs. whole? The jury is still out.
Pediatricians and nutrition experts generally recommend that 1-year-olds drink whole milk, “to provide energy and fat that little people need for growing bodies and growing brains,” said Dr. Jonathon Maguire, M.D., a pediatrician and researcher at St. Michael’s Hospital in Toronto. And that those ages 2 and up switch to 1-percent or nonfat (skim) to decrease their saturated fat intake.
But the National Heart, Lung, and Blood Institute guidelines say that if your toddler is growing well and is consuming enough healthy fats, he can move straight to a reduced-fat milk at age 1; and that all kids aged 2 and up should drink skim milk. The Healthy Eating Research guidelines agree that this approach can be appropriate for kids with a family history of — or other risk factors for — obesity or heart disease, as long as your pediatrician agrees.
However, there’s much debate in the scientific community over whether lower-fat milks are really the best options for young children, said Dr. Maguire. Several observational studies published in the past decade, for example, have found that 2- to 4-year-olds who drank whole milk tended to be leaner – not heavier – than those who drank lower-fat milk. And in 2016, Dr. Maguire’s research group published a study which found that 1- to 6-year-olds who drank whole milk not only had lower body mass indexes than those who drank lower-fat milk, but also had higher vitamin D levels — perhaps because vitamin D is better-absorbed when it’s consumed with fat.
As with many nutrition studies, it’s not clear why this is or whether the whole milk itself directly led to these benefits. But until we have more conclusive data, this is a choice without a clear answer, said Dr. Maguire, so it’s worth discussing with your pediatrician and considering the big picture of your child’s growth and diet.
You don’t have to spring for organic.
Your next dairy dilemma: Should you pay extra for organic milk? According to the most recent 2019 guidelines, there are no “clinically relevant” differences between organic and conventional milks. Both are safe to drink and, as with all milk, neither contains antibiotics. Any nutritional differences are minor and not likely to affect health.
Don’t buy raw milk.
If you’ve been tempted by raw or unpasteurized milk at the farmer’s market, know that public health and pediatrics experts unanimously think this is a bad idea, especially for young kids. “Raw milk can be a cesspool for bacteria that cause food-borne illnesses, some of which can be life-threatening,” said King, the dietitian at Texas Children’s Hospital. At the least, a bacterial infection from raw milk could cause days of vomiting and diarrhea for your child. At the worst, it could lead to hospitalization or even kidney failure, which in rare cases could cause death. Experts say that raw milk doesn’t provide any more health benefits than pasteurized milk, so it’s best to avoid it.
According to a study published in the American Journal of Clinical Nutrition in 2016, most toddlers in the United States eat enough protein but one in four don’t get enough fat, which is important for growth and brain development.
If your kid has a dairy allergy, is lactose intolerant or simply doesn’t like cow’s milk, it’s fine for him to skip it. But it’s important that he still get the nutrients it contains from other foods.
There aren’t official recommendations for how much saturated and unsaturated fats toddlers should eat, but whole foods like yogurt, cheese, eggs, avocados, fish, meat, oils and nut butters offer a healthy mix of both. Kids can get calcium from yogurt, cheese, tofu and dark green veggies. And most kids can get enough vitamin D through a combination of the sun’s ultraviolet rays (the vitamin can be synthesized in the skin) and regular or fortified food sources like salmon, tuna, eggs, cheese, orange juice, plant-based milks (more on those below) and some yogurts.
If you live in an area without much sunlight or if you’re a vigilant sunscreen slatherer and your child isn’t getting enough vitamin D, she may need a supplement. Talk with your pediatrician about whether that’s necessary. (And never skip sunscreen to get more vitamin D; it’s one of the most important ways to prevent skin cancer.)
What about goat’s milk and plant-based alternatives?
Goat’s milk is a bit higher in protein, fat, calcium and other minerals than cow’s milk, but at my grocery store, it’s also double or triple the cost. While goat’s milk is often touted as less allergenic than cow’s milk, most kids with a cow’s milk allergy are also allergic to goat’s milk, so it’s probably not worth the added cost.
None of the experts I interviewed for this guide were enthusiastic about plant-based milks for kids, and the new 2019 guidelines discourage their use in place of dairy milk unless there’s a medical or special dietary reason, such as if your family is vegan.
Most plant-based milks — aside from soy and pea milks — are lower in protein than cow’s milk, and while they’re often fortified with similar levels of nutrients as are present in cow’s milk, such as calcium, it’s not clear that these nutrients are well-absorbed. And although unsweetened versions exist, many kid-friendly versions are also “chock-full of sugar,” Dr. Burgert said. These added sugars are typically present to improve flavor, said King, and can come in the form of rice syrup, cane sugar or dried cane syrup.
For kids who don’t drink cow’s milk but who eat other dairy products such as yogurt and cheese, Dr. Burgert recommended that they drink water instead of plant-based milks.
If they don’t eat dairy or have a dairy allergy or intolerance, a carefully chosen plant-based milk can help meet nutrient needs. It’s important to check labels to avoid as much added sugar as possible, and to choose one fortified with about the same amounts of calcium (300 milligrams) and vitamin D (about 100 international units) as found per serving of cow’s milk, said Dr. Maguire. Shake the carton before every pour to disperse the added nutrients, which can otherwise settle to the bottom.
Here’s a quick breakdown of other nutritional considerations:
Soy milk: Soy milk has been around for years and is generally the preferred cow’s milk substitute because it’s a close match in terms of calories, protein, and fat. Some researchers and parents have been concerned about how estrogen-mimicking compounds in soy, called isoflavones, might affect young children. However, after reviewing the available data, the A.A.P. has said that soy protein formulas are safe for infants. Dr. Frank Greer, M.D., a professor emeritus of pediatrics at the University of Wisconsin-Madison School of Medicine and past member and chairman of the A.A.P.’s Committee on Nutrition, said that the A.A.P. doesn’t have an official policy on soy milk for toddlers. But given soy’s long history of safe use around the world, he thinks the concern about isoflavones has been overblown, and soy is his preferred alternative milk for kids who don’t consume dairy.
Hemp milk: Made from the seeds of industrial hemp plants, hemp milk is low-to-moderate in protein (2 to 3 grams per cup). It has a similar total fat content as whole or 2 percent cow’s milk but boasts higher levels of omega-3 and omega-6 fats and less saturated fat.
Nut milks: Nut-based milks such as those made from almonds or cashews contain few nuts and lots of water, so are very low in protein (about 1 gram per cup) and fat. You’ll get more nutrition from a nut butter sandwich and glass of water.
Grain milks: Rice and oat milks are low in fat and protein and high in carbohydrates. Oat milk has the better nutrient profile of the two, offering a bit more protein and a little fiber.
Coconut milk: A watered-down version of the thick coconut milk sold in cans, these drinks are high in saturated fat and have virtually no protein.
When to Worry
Dr. Burgert said that parents sometimes worry that their kids aren’t drinking enough milk, but “a bigger problem with my patients is that they’re milk junkies,” she said. Stick with the current recommendation of two to three servings of dairy (or about 16 — but no more than 24 ounces — of milk) per day. Above this amount, milk can crowd out other nutritious foods from the diet, Dr. Burgert said.
Editorial Note, Nov. 8, 2019: This guide has been updated to reflect new guidelines from Healthy Eating Research, which were published in September 2019.