Tales of my gourmet barracuda, and post up on the other blog

The American Association of Pediatrics apparently has cutesy nicknames for different types of  nursing/feeding behaviors: After extrapolating this to bottle feeding, my darling appears to be a "barracuda." She is currently wolfing around 38-40 oz a day! The "gourmet" title is earned because she still turns up her nose at the milk if it gets too cold. But yeah, mostly "barracuda." I'm so proud. And also afraid, because if we delay bringing that bottle to her by even 3 minutes, she opens her mouth to unleash the hounds of hell on us, and sobs so robustly that her breath catches. Then, when we frantically shove that nipple in her mouth...immediate, blessed silence. It is like flipping a magical mute switch.

Overall, two months in, she is doing wonderfully. No spit up, no colic, great growth, focusing and interacting beautifully, utterly sweet smiles of which I am increasingly a recipient, pooping like a breast-fed baby, and sleeping 7-8 hours a night! I kid you not on the last one. For a  painful 4-5 days, she had decided that between 1 am and 6 am was the time to stay up, demand cuddling, poop a couple of times, and drink about 12 ounces of milk spread out over 3 bottles. Sleep deprivation was me...there were nights I was afraid I would literally fall asleep on her. I figured she had day-night confusion, and decided to try to expose her to really bright sunlight during the day and do whatever we could in our very limited capacity to keep her from sleeping too much....it may have worked, or she may have simply "drifted" into a new pattern, because her "cluster feeding" shifted to the period between 9 pm-12 am, and when she goes to sleep after tanking up on about 12-13 ounces of my goat milk formula, she sleeps around 7-8 hours. This pattern has been in play for about ten days now, and I would totally commit murder to keep it from going away. It is really interesting that after consuming 10 oz of formula, she actually gets super excited and frantic while consuming that last bottle: the "tanking up" instinct definitely seems neurological. This cluster feeding occurs only once during the day; the rest of the time, she takes 5 ounces every 3-4 hours.

She also had the first of the "scary" vaccinations, getting the rotavirus drops and the DTP shot on the same day. Unfortunately, when we went in the acellular verison of the DTP vaccine (which is less efficacious but has fewer side effects) was out of stock and we had to get the whole cell version, which causes a more severe reaction, generally. Her response to that was a very mild fever and induration/redness at the site of injection and general crankiness, but thankfully, her appetite never suffered and she was as alert as ever after, so I heaved a giant sigh of relief, and she was entirely back to normal within 36 hours.  In about 30-45 days, we will go in for the Hib and the pneumococcus shots, or I may split those up. As I had first stated, I wanted to delay these shots till she was a little older (till about 3-4 months), but the guilt/pressure (external as well as internal), even when you want to delay vaccinations just a little is immense. Each vaccine decision is a war: I refused to get her the BCG shot at birth, and gave it only after she crossed the one month mark. Ditto the polio drops. In India, the oral polio vaccine is given at birth, and in very, very rare instances, can cause polio in itself. I hence refused the drops and got her the shot instead at 6 weeks. I had to have arguments with so many people, and also myself just to get these small but significant delays; blargh.

Finally, I have the a blogpost up on the the other blog. I had mentioned that there are some easy ways to ensure that your infant/child's immune system is at its fighting best, and I've addressed that in this first blogpost.

Updates

• I have finally started that other blog with my real name....bookmark it/follow it if you like the subject matter. I would also request you to share it (on Facebook and stuff) if you feel so inclined.  It is at http://decodingscience.wordpress.com The introductory post gives a pretty good overview of what the blog will be about. I eventually will move a lot of the science stuff from this blog there, once it gets a bit more search engine optimized. Next up will be a blogpost on  the benefits of a specific probiotic supplement in infants: I got really excited about it when I first found out about it, and I've been meaning to write this post forever, but I do not call myself the queen of all procrastinators for nothing. I will write it within the next week, I promise.

• I have also started detailing the first few weeks/months for Gauri to come find as she gets older, and have made it a sticky page. I'm still trying to decide the privacy level of this one.

• I have also updated the goat milk formula recipe post with a how-to on making the formula and some other tweaks/notes. Something interesting to share: I started adding 1/8th tsp homemade clarified butter (ghee) to 8 oz of formula to supply additional fats, and to my very pleasant surprise, it increased the frequency of her bowel movements from 1 per day to 2 per day (further investigation revealed that ghee IS used to treat constipation in adults). I know formula-fed babies have some serious issues with constipation, and I saw some of that when I was on Nestle Nan, but they have all gone away using this formula, and her pooping patterns now resemble that of a breast milk-fed baby. I feel pretty good about that.   

Will be updating this post and the sticky page with pictures soon. 

One month old!

It is going to be a little difficult composing blogposts now, because instead of one or two centralized topics to talk about, I have many little things to say, and I'm still struggling to find a format to fit that.

First up, I'm going to continue to talk about science, but in a new blog, using my real name. YAY! it is time to step out of the closet, so to speak. So exciting! The past 4 years, this blog was anonymous only because this journey was secret. Now that it is out in the open, I'm fighting the temptation to share this blog with people I know IRL. The only reason I'm holding back is because many of the posts on this blog are about personal struggles I would not want everybody reading.

But a blog only about science...that I would be happy sharing. First up on the new blog will be a post on probiotics and the ones out there that are a bit more useful. Next, I'm planning a writeup summarizing all the newest research on autism (there are some new rather exciting discoveries). Both these posts will require extensive research, and I need to get off my procrastinating ass to do that.

But.....coming to the nitty gritty of parenting:

• Gauri is an utter JOY to feed. In the breaks between sucking sessions, she looks so utterly pleased with life and makes lip-smacking noises and turns her head frantically to find that nipple. It makes you feel 10 feet tall.  I wish I had given my mom this very simple pleasure...I was a horrible, disinterested eater, to the point of it almost seeming like a neurological issue (in my defense, I was supposed to have been an excellent baby in all other ways though). But still, people still shudder when they describe their experiences in trying to feed me.
• She, on the other hand, is running through like 26 ounces in like 15 hours, which makes me wonder if there is an upper safe limit, and whether she is the one that gets to decide it. Anyway, she produces a lot of wet diapers a day and is gaining a little over an ounce a day, so I'm thinking I should leave this alone...right?
• Thumbs up for the goat milk formula: other than the fact that she loves the taste even when it has fish oil in it (our little highness does a taste test before graciously accepting it), the other great thing is convenience. I use an electric kettle to boil the water (best invention ever...why do formula websites still talk about boiling water on the stovetop?) and make up 28 oz at one go using a 16-oz pyrex measuring jar, which I split into multiple bottles (LOVE my Pura Kiki bottles; planning to write reviews about baby paraphernalia soon). I also love that I know exactly what is going in my baby's food, and can control it. Her constipation is less once we started the goat's milk; she also had really bad diaper rash in the first few days of life, and it is entirely gone now. I don't know what has fixed it (the diaper rash cream I use, the different brand of diapers, or the change in food). It is possible that the cow's milk contributed to the rash, and it was fixed by a change to goat's milk, but it is hard to say.She is a bit gassy once we started the goat'ls milk, and this could be because of the milk protein OR the lactose. Need to figure out what to do here. I can try changing the carbohydrate source.
• I've been trying to cloth diaper, but this kid really hates the feel of wet cloth (even the thick microfiber inserts) against her, and wakes up from sleep. The problem is she seems to pee every 30 minutes, and changing her while she is sleeping wakes her up. Are there CD inserts where the top stays dry like a disposable diaper? Right now, I'm using the Naty brand of disposable diapers, and they ROCK. It would take a really good CD to be as comfortable (for her) and user-friendly for me as this one.  
• Thank you Shannon, for your recommendation of The Piano Guys. She loves their songs (as do I!).
• This kid will be giving me grey hair very soon: As soon as she came home from the hospital,she was already using her feet to push off against people's torso's and thighs, depending on how we were positioning her. All these acrobatics are a little scary considering the fact that she can't support her neck. She is already trying hard to turn over too. at this rate, she is likely to be mobile a little ahead of schedule. I live in a house with really hard marble stairs, and it will be a year before the bones in her skull fuse....YIKES. If anybody has babyproofing ideas for the stairs (other than the gates), please let me know. Just FYI, Carpet in India would  be a really awful idea in the monsoons, where it rains so hard that the waterproofed concrete house starts to leak.
• Going to leave you all with a picture of the munchkin that has many many people wrapped around her little finger.
  

Parenting: the first days

I was tempted to title this post "Snot Factory," because that about sums up my general state for the past two weeks. I can't remember the last time I had the common cold, but I've had a relentless two weeks of symptoms now, and I'm beyond sick of it. At the height of things, where I was coughing every 10 mins, I stayed away from Gauri entirely. Since then, my symptoms have improved, but have not gone away fully.

Then my mom got sick, and we have two people (three including my father) coughing all over the place. A few days ago, it looked like Gauri had finally gotten this nasty infection, but thankfully, today, she seems to be mostly symptom-free, and her feeding (frantically knock on wood) has remained okay throughout.

I have a TON of help (an amazing (albeit slightly bossy) live-in nanny, a cousin who came and stayed a couple of days when everybody was sick, my parents, and my brother). The entire family is hands-on about taking care of her, which has literally saved my life. This is the amazing part of being here, and it is so lovely to see how much my family dotes on her. With my infection, I have not been able to fully bond the way I've wanted to with her, and sometimes, I literally elbowed out of the way by grandma and the grandpa and the uncle and even the nanny. Sigh....everybody wants their time with this little girl.

I went public on Facebook few days after the birth, and the response has been gratifyingly and very surprisingly overwhelmingly positive. It is quite amazing, but many really conservative family members have given me and my parents no grief and only offer congratulations and some even talk about how brave and intrepid I am, which just makes me blink in astonishment: I really did not see this coming, but I am so grateful (for my parents sake) that this response has been so positive.

As a technical note, I started the goat milk formula after ten days of being on Nestle Nan Pro 1 (which has soybean oil, yuck, I detest unfermented soy-based products). She tolerated the change very well, and her poop has become softer and the mild constipation she had on Nestle Nan has gone away.
From the formula I listed here, I increased the goat milk powder (to 1 tbsp per 8 oz), slightly decreased the lactose, halved the coconut oil, and threw out the blackstrap molasses as it appeared to be giving her too much iron (green poop the second day).  The only downside we could see with this formula is that she seems to get hungry a little more often, but her weight gain has been good (8.5 ounces/week). 

Understanding my infertility: four years in retrospect

When I had my first miscarriage and then my second in rapid succession, I had no idea what was going on, and I made truly valiant efforts to understand. I went off on a lot of tangents, and some of them (the Vitamin D deficiency, understanding the connection between Vitamin D and AMH, the thyroid autoantibody issue) yielded a lot of valuable information. There were some indicators that all of these (the vitamin D deficiency combined with the TPO antibodies, often seen in women with PCOS) may be indicative of a very low level of autoimmunity that may have interfered maybe oh-so-slightly with the progress of a pregnancy, but at the end of the day, I think these things were not my central problem.

There are two aspects to egg quality, both of which decline with maternal age. One is the state of the egg cytoplasm, which has all the mitochondria and the nutrients required to survive, divide, and thrive for the first 8 days of life by itself. The second is the chromosomes itself, and this is governed by the meiotic division process where your 46 chromosomes are divided into two sets of 23 chromosomes each. I talk about how one or both of these may be affected in the "Science of Infertility" section.

What was my problem? My cytoplasm quality was, by all accounts, really gosh darned good. It may be that I have an issue with the meiotic chromosomal division process, as a result of which a high number of my eggs are aneuploid, and I may have come into this problem (which is usually seen in women in their 40s) ten years or so too early. Compounding the problem may have been my "superfertility," which may have caused my rather stupid uterus to implant embryos that a "normal" person's uterus may have rejected. I have come to these conclusions based on the following statistics:

• My pregnancy rate was 75% (3 out of 4 unmedicated cycles), which is FAR higher than the figure (20%) reported in "normal" women. Two of my three embryos were shown to be aneuploid, and one of these aneuplodies was a Trisomy 4, which is extremely rare because embryos with a trisomy of this ginormous chromosome almost always fail to make it to the blastocyst stage, or after, fail to implant or grow. 
• Normally, the implantation rate for high-grade blastocysts is around 40-50% (i.e., 1 out of 2 blasts is likely to implant). The implantation rate for my high-grade blasts in women with "normal" fertility (the two surrogates) was far lower (1 out of 5 blasts, from 3 transfers).  

This suggests that most of my embryos were abnormal, and I kept implanting them anyway. This pregnancy may have come about because J's uterus could perform the selection that mine could not.

Had I not the "superfertility" issue, I may have just taken much longer to get pregnant, but may have stayed pregnant when I finally got knocked up. That would have been so much better, but as I gaze at my baby girl, I'm still fine with this version of events.

Now WHY I had the meiotic division problem is really the gzillion dollar question, that remains completely unknown. There appear to be no biomarkers or tests to indicate this. One has to wonder if the common problems seen in infertile women (The MTHFR mutation, the PAI variant, various autoantibodies) are biomarkers (indicators) for this issue, or are linked to it in some way, but nobody has ever looked at these particular questions, I think.

The other thing I wonder if there is a "cross talk" between my embryos and uterus that was messed up, and a developmental "brake" that malfunctioned in my embryos. Each time I ever got pregnant, it was an ovulation from my left ovary. The one time I failed to get pregnant was a right ovary ovulation, and honestly, I fail to see how that embryo could have been more messed up than the left ovary-derived Trisomy 4 embryo that implanted in my next attempt.

During IVF, I asked the embryologist to culture the eggs from my right and left ovaries separately, and the results were interesting. Normally, around 40% of fertilized eggs become blasts, and I saw this in my right ovary eggs. In contrast, over 70% of the fertilized eggs from my left ovary became blasts, which is far higher than normal. My daughter (feels SO amazing to say that), came from a right ovary egg. All this makes me wonder if the fault (for the messed up crosstalk between the uterus and the embryos) is a problem that is a problem specifically in the eggs of my left ovary. Of course, this last bit is wild speculation (even more so than the first bits, which are a lot more likely). 

There...the last 3 paragraphs will probably give everybody a headache, but I had to put down my thoughts for posterity. There is a part of me that wants to go back and do research on this issue, because I feel so passionately about it. I've actually been thinking about whether there are openings at RMA-NJ (because they are such a research-oriented fertility group).

Anyway...all is well that ends well, and I hope this recounting will be of use to somebody someday.

Gauri

She escaped the NICU on Monday (after spending 4 days in there), came to my hospital room on Monday, and we were discharged on Wednesday! We're home and are slowly settling in. The discharge day was especially rough...Hiranandani may be a nice hospital and the nursing staff is amazing and the doctors are pretty good, but they really don't pay any attention to infection control by keeping sick babies away from healthy babies: I was ordered to take her down from my nice clean hospital room to the OPD where we were surrounded by wailing children. I finally got to see the doctor, and when I was in the room with him, in came a baby with the viral flu! And all the doctor did down there was weigh her and pronounce her perfectly healthy.

The good news is that she is perfectly fine. The sucky bit is that I'm mildly ill, as is my father, but with different infections. I usually *never* fall ill, but given the stress of the first few days and the sleep deprivation (I also had horrible insomnia while being bone tired), I developed up a throat infection that has been slowly progressing. I was talking care of her while wearing a mask and suppressing my dry cough, but now that I'm bringing up phlegm every 15 mins, I've been barred from taking care of her.

She looks serene in the above shot (deleted), but this munchkin has a really mobile face...when she is awake she goes through a range of expressions that are amazingly comical. She smiles a lot in her sleep and while awake too...my favorite is the smile she gives just before she opens her mouth (like a shark) to attack that nipple.

I can't wait to get better, so I can be the one spending all day and night with her again, sans masks or worry.

Update

Sorry, this post is from my phone as well, so no pix. It kept telling me to download google plus, and I did, and it is still not working. Blaargh.

About my little miracle:At first, everbody thought that the respiratory issues stemmed from the c-section. However, soon after birth, it became increasingly apparent that Gauri had a infection, which, from the timeline, looks more like it was acquired in utero (the pediatrician says he sees this sometimes in babies born of surrogates--that is why he started antibiotics so very soon, which turned out to be the right call to make). It responded to antibiotics, and her respiration stabilized within 36 hours, letting them start feeding her.

She is now up to full feeds (she seems to be a good eater, knock on wood) and will be discharged to my hospital room tomorrow, where her antibiotics will have to be continued. Poor baby has been stuck with an iv in three different spots already, and I'm so sorry for that, and for the fact that she had this infection to start with.

Can't wait to get out of the hospital and go home! They are taking good care of us though, and NICU staff are awesome...I'm pretty impressed.

It is a girl!

Gauri was born yesterday evening: 5.5 pounds and a miracle all in all. Great apgars. J came through the c-section fine.

Will post about how things went down soon: she is doing well, but there are mild respiratory issues (mild to moderate transient tachapnea and maybe the beginnings of a lung infection) that are keeping her in the NICU.

The poor little thing has only saline so far: they will start feeds only when the respiratory rate stabilizes, and I'm praying that happens by tomorrow: she was started on antibiotics by the neonatologist within 12 hours of birth. The mildly high respiratory rate has not worsened, but it has not improved significantly either.

But she is beautiful, fiesty, alert, and fairly stoic about all the indignities we are subjecting her to.

Pics, more details, updates coming soon: this is posted from my phone.

To all my readers who have helped me cope and survive though this winding road to this beautiful destination, from the bottom of my heart, thank you.

No date set

I know some of you are checking back in for updates regularly, and I just wanted to keep you all in the loop: there is no date set for delivery. There was one (it was supposed to be the 9th), but it got scrapped. Long story, but I had little to do with this decision. J will come in for a checkup on the 9th, which is 37 weeks exactly, and the OB will decide what to do then.

I am trying be zen about things, but I will be slightly on tenterhooks till she gets checked.

It is really too bad I stopped working on the 1st of April, but the problem about that job was that it was all consuming, and I did need time off to prepare for various things.

With all this time on my hands, I really need distractions. I am reworking my way though the seasons of The Office (maybe my all-time favorite show, though I do have a lot of those). Fun ART-related piece of trivia: California Cryobank gives you the celebrity lookalike for a particular donor, and the celebrity with the most look-alikes in the CCB donor pool is apparently is John Krasinski. Sigh. That man would probably make very cute babies.

Wish me luck with the staying distracted!

The homemade goat milk formula revisited

This is a super technical post, and will be useful only for those who want to come up with a homemade goat milk formula.

First, here is an important point to take note of: Babies allergic to cow milk can ALSO be allergic to goat milk. The incidence of goat milk allergy and its severity relative to cow milk allergy appears to be a subject of some controversy. As previously noted, goat's milk has really low levels of the main culprit implicated in cow milk allergy, A1 casein, although it does have an another allerginic substance, beta-casein. I kind of got cross eyed when I tried to figure out what percentage of children with cow's milk allergy are also allergic to goats milk. One study puts this at 26%. There are also studies that show that infants that are not allergic to cow's milk may be allergic to goat's milk.

However, overall, studies as well as anecdotal evidence suggest that goat milk allergy/intolerance is far less of a problem than cow milk allergy/intolerance. It comes down to how your child responds to it: many children who are miserable with cow's milk fare very well when they go to goat's milk. Also, food allergies are insanely complex: I was struck by one story I read a long time ago on Amazon. This child was having issues when on a cow milk formula, and they switched him/her to goat's milk and  found a huge improvement.  At the same time, they were having him tested for allergies, and testing revealed that he WAS allergic to goat's milk (based on IgE, I think). They then took him off it, but what was surprising to me was that they noted a real improvement in symptoms when he was switched to goat's milk.

I tried to find where I had read this, but was unable to. The point of this is it may be better to see what your child tolerates best, rather than just looking at what the clinical testing reveals. Sometimes, only one clinical parameter (like IgE levels) may not provide the full picture. This point is made by Dr. Sears, who states that clinical studies about goat milk allergenicity really do not appear to correlate with parental observations as to how well it is tolerated.

However, keep your pediatrician in the loop and always proceed with caution when introducing something new: anphylactic shock has been observed in very rare instances in response to a milk allergy, and there has been one documented case of it occurring in response to goat milk. However, I would emphasize that such a situation may be exceedingly rare.

Also, while we spend so much time talking about allergy, keep in mind that true cow milk allergy is low in frequency: maybe only 2% of the population. Even if you suppose this quoted study under-represents this issue and you double this figure, this is still not a very widespread problem.

The majority of the population should do okay with either goat or cow's milk. However, goat milk has some advantages, and moreover, most formula makers have made some really poor choices when coming up with baby formulas (even the organic ones), and hence I would want to go with a homemade formula.

Most of this goat milk formula recipe comes from the one recommended by Joe Stout from Mount Capra. The first thing I did when I was analyzing his formula was to make sure the protein level was okay, because goat milk has about 3 times the amount of protein as human milk, which can mess with a newborn's kidneys.

The biggest issue in coming up with a formula to replicate human milk is that the levels of the various components of human milk can vary, apparently (I have not verified this statement myself). I found one study which stated that human milk contained about 1.1 g protein/100 mL.  Based on my calculations, the amount of protein suggested for use on the Mt. Capra site (1 scoop Myenberg's powder/8 oz) would deliver a little more protein (1.7 g/100 mL).

I communicated this to Joe Stout, who very kindly explained that trying to come up with the "correct" amount to mimic that in human milk is a crapshoot, because the composition of human milk can vary.

Moreover, formula manufacturers have to follow an extremely unclear system (or so I think):
Based off of the regulations in the 1980 Infant Formula Act, the infant formula must contain at least 1.8 grams of protein and no more than 4.5 grams of protein per 100 kcal formula.

The fact that they did not specify this per volume, and did it per 100 kcal of formula,  is rather insane, I think. This system is immensely difficult to follow and allows wide variation, and I decided to go with a slightly different approach.

I tailored everything to mimic what little we know about human milk composition, on a per volume basis, and I used most of the calculations specified in the Mt. Capra formula. The end result may not resemble everybody's milk, but atleast it resembles somebody's milk. The thing to remember is, no matter what minor variations there may be in the protein composition between formulas and even in different human milk sources, babies do just fine generally on all of them, unless you really overshoot or undershoot.

It would be a smart idea to take a formula recipe (this one or the Mt. Capra one), as a starting source and modify it slightly if required, based on your baby's response, growth, and general well being. 

Here is a formula, if one is making it with Myenberg's goat's milk powder. Note that ingredients can be purchased from iHerb or Amazon.com

Notes:

• For people confused about ounces and mL, 1 oz = 28 mL. 
• The amount of goat milk powder added is not set in stone:  I was planning to start with 0.7 scoops per 8 oz, but I quickly had to work up to 1 scoop per 8 oz (this delivers 1.7 g protein per 100 mL, which is a bit more than human milk (1.1 g/100 mL) or the Nestle Nan formula (1.53 g protein/100 mL) she was originally on.
• Note that if you add 1 scoop of Myenberg's, you would have to decrease the amount of lactose to 2.26 tsp per 8 oz. You can slightly adjust the lactose as needed based on your baby's response (for example, if he/she has green frothy poops, they may be getting more lactose than they can handle comfortably: this was the case with Gauri, and I reduced it to 1.75 tsp lactose per 8 oz, and the greenish poop issue went away, and the gassiness also reduced slightly.
• Alternatives to lactose include turbinado sugar, maple syrup, or organic brown rice syrup. I prefer lactose as it is what is present in human milk, and it helps in the establishment of a healthy normal flora (this is incredibly important). The reason that formula companies use other things (corn solids, maltodextrin etc) is because they are cheaper. When making your own formula, unless your baby shows signs of intolerance, lactose is a good choice.
• Blackstrap molasses (NOT INCLUDED IN THE FORMULA CARD ABOVE) supplies minerals and B complex vitamins. It made my newborn daughter's poop green, suggesting that she was getting too much iron, so I dropped it like a hot potato. The Mt. Capra formula uses it. It may be more suitable for babies over 3 months of age, I think.
• I don't like this multivitamin supplement(Country Life baby maxi), honestly. They use cyanocobalamin instead of methyl cobalamin, and have sodium benzoate in combination with vitamin C, which drives me batty as the two can apparently combine to give benzene, a carcinogenic substance. I'm listing it here because I've found no better alternative.
• The Vitamin D dosage can be tailored to meet your baby's needs (you just need to ensure that the levels are above 30 ng/mL for optimal health)
• I'll be writing a blogpost on the probiotic (Biogaia Protectis) soon.See here.
• I added homemade organic ghee as an experiment, and to provide high quality fats. Interestingly, it seemed to increase the frequency of poops per day, from 1 to 2, which was nice, and unexpected side effect. Turns out ghee is used in ayurvedic medicine to treat constipation.
• Quick tips to make this formula: Use a Pyrex 16-oz measuring cup (this fits in the Phillips Avent sterilizer). Sterilize all bottles, cutlery, whisks, and measuring spoons (I use steel ones). Boil filtered water using an electric kettle (do this many hours before preparation, so it cools enough). Add the ingredients (goat milk powder, lactose or another source of sugar, oils). Add a little warm to hot water, and make a super concentrated solution (you would have to use a spoon or a whisk to dissolve the lumps). Then make it up to 16 oz, and distribute into bottles (I highly recommend the PURA KIKI steel bottles), and store in the fridge till use. I only make little more than one day's worth at a time: I make 40 oz using my 16-oz measuring cup thrice.