With good instruction and support, most moms can breastfeed their babies exclusively for the first six months. Unfortunately, many U.S. newborns are still fed something other than their own mother’s milk during their initial hospital stay. These supplemental, or supplementary, feedings are typically artificial infant formula, but they may be donor human milk or glucose water. Because unnecessary supplementation in the hospital has been associated with less exclusive breastfeeding, as well as a shorter duration of any breastfeeding, the Academy of Breastfeeding Medicine (ABM) has issued guidance on when otherwise healthy babies need supplementation or not.
When supplementation may not be necessary
The ABM encourages parents and health care providers to adopt a preventive approach to supplementation with:
- prenatal education
- in-hospital breastfeeding support
- breastfeeding immediately after birth
- skin-to-skin care after birth
- instruction on milk expression (if necessary, such as when the mother and her infant must be separated)
In some cases, concern about a baby’s weight loss is identified as a reason for supplemental feedings. All babies do lose weight after birth. While this can be scary to new parents, it doesn’t necessarily mean that their baby isn’t feeding well; many factors influence the baby’s birth weight and weight changes, including gestational age, the method of birth (vaginal or cesarean), and the amount of fluid the mother received during labor. As long as the infant is “feeding well, urinating and stooling adequately,” and has weight loss “in the expected range” while “bilirubin levels are not of concern,” the ABM recommends adopting a watch and wait approach.
During this time, parents can focus on:
- recognizing early feeding cues
- keeping the baby safely skin-to-skin with the awake mother
- gently awakening the baby for frequent feedings
- hand expression of drops of colostrum to be fed to the baby
Parents, with the support of health care providers, should also pay attention to the baby’s feeding behavior, including the latch, positioning, and signs of discomfort. They should also look for signs of maternal fatigue, which can interfere with breastfeeding.
When supplementation may be necessary
There are situations in which supplementation may be necessary, even for an infant who is born full-term and seems healthy. The ABM identifies the following reasons for supplemental feeding of the infant during the hospital stay after birth:
- hypoglycemia that has been documented by lab test and is unresponsive to frequent breastfeeding; dextrose gel or intravenous (IV) glucose can be given, and breastfeeding should continue.
- inadequate milk intake, as shown by significant dehydration, weight loss outside of normal range (with other factors), delayed or persistent meconium bowel movements (black, tarry stools).
- hyperbilirubinemia, sometimes with ongoing weight loss, few bowel movements, and uric acid crystals with urine; breastfeeding should continue during evaluation.
- metabolic conditions of the newborn, requiring special supplements.
- delayed maternal milk supply
- insufficient maternal mammary glands (estimated to affect less than 5 percent of women)
- past breast surgery affecting milk production
- medical cause, such as chemotherapy or other medication, or separation of mother and infant
- intolerable and unrelieved pain during breastfeeding
What supplement to give
Most parents find that even if they must, temporarily, give a supplement to their breastfed baby, breastfeeding can continue. The ABM ranks possible supplements in order of preference:
- Mother’s own milk, gathered by hand expression or pump; use breast massage and/or warm compresses to help with letdown and consider pumping one breast while the baby breastfeeds on the opposite breast to increase milk yield.
- Donor human milk, which is preferable to artificial supplements.
- Protein hydrolysate formula, to avoid exposure to cow’s milk protein while conveying that supplementation is temporary.
- Other artificial formula, such as cow’s milk-based or soy-based formula, as determined appropriate for the baby’s age, amount needed, and potential effect on breastfeeding.
Note that glucose water is not considered an appropriate supplement, since it doesn’t provide nutrition or reduce bilirubin, and it poses a risk of hyponatremia or “water intoxication,” due to an imbalance of water and sodium in the body.
How to give a supplement
No single device has been shown to be better for all babies, and some babies may respond better to one feeding method than another. Mothers who are breastfeeding in addition to supplementing may wish to avoid bottles until 4-6 weeks after birth, since artificial nipples require different sucking patterns and can interfere with a baby’s ability to breastfeed (nipple confusion).
In addition to bottles, there are many options parents can use to provide supplemental feedings to their breastfed infants including:
- supplemental feeding devices (Lact-Aid or Supplemental Nursing System)
When selecting how you will administer your baby’s supplemental feeding, the ABM encourages parents and health care providers to consider the following:
- cost and availability
- ease of use and cleaning (cup-feeding is preferable when hygiene is a concern)
- long-term or short-term use
- stress to the infant
- how much supplement can be fed in 20-30 minutes
- mother’s or caregiver’s preference
- expertise of health care provider
- effect on baby’s breastfeeding skills
- effect on mother’s milk supply (supplemental nursing devices provide breast stimulation, as well as skin-to-skin contact)
In most cases, supplementation is given temporarily to help you and your baby overcome a difficulty and to get back on track with breastfeeding. While your baby is receiving supplements, be sure to take steps to maintain and, if necessary, increase your milk supply.