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7.0 Supplementation

Step 6 of the Ten Steps to Successful Breastfeeding (revised 2018):

Step 6: Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.

(Canada) Step 6: Support mothers/parents to exclusively breastfeed for the first six months unless supplements are medically indicated.

(New Zealand) Step 6: Avoid giving breastfed newborns any food or fluids other than breastmilk, unless clinically indicated.

Point 4 of the Seven-point Plan for Sustaining Breastfeeding in the Community:

Point 4. Support mothers to establish and maintain exclusive breastfeeding to six months

Human milk substitutes

Human milk substitutes (including infant formula, water, or glucose water) interfere with the infant's ability to learn to breastfeed and the establishment of lactation. There is a significantly higher rate of premature weaning amongst infants who are given human milk substitutes in the early postnatal days1, 2, 3.

Colostrum is essential for gut protection, growth, and repair as well as the establishment of the bifidobacterium environment. Colostrum aids the expulsion of meconium which reduces enterohepatic circulation of bilirubin. Human milk substitutes do none of these things.

Preparing powdered human milk substitutes as safely as possible

Click on the title above. This links to a leaflet for mothers/parents that describes, with very good graphics, how to safely prepare human milk substitutes. Read the leaflet, print it out, and file it.

Go through the leaflet or a similar one that your hospital or clinic may use, as you demonstrate to a mother/parent how to prepare the formula. Then, most importantly, ask for a return demonstration on making up another bottle of formula, confirming that the instructions are understood at each step of the process.

Note the minimum temperature of the water at the time the powdered formula is added - this minimum temperature is necessary to kill bacterial contaminants (70 degrees Celsius or 158 degrees Fahrenheit). The prepared formula must be cooled before giving to the infant.

Self-test quiz

The decision to introduce any supplement other than human milk is a serious one that must weigh the risks of infant formula feeding and the benefits of breastfeeding should be weighed against the risks posed by the presence of the specific condition listed. These are based on the PDFWHO's recommendations. This document called PDFMedical Indications for Supplementation by the Breastfeeding Committee of Canada may also be helpful in guiding decision-making about supplementation.

Infant Indications

Infants with specific inborn errors of metabolism (eg: classic galactosemia, maple syrup urine disease, phenylketonuria) will require lifelong special diets, including specialized infant formula. In the case of phenylketonuria, partial breastfeeding is possible and should be encouraged. Lactating parents should be encouraged to maintain their milk supply through the planning so that they have all options open to them as their infant's feeding plan is finalized.

Infants with very low birth weight (<1500g) or who are before 32 weeks gestational age may require donor human milk until their parent can produce their full intake and may also require some specific nutrient fortification.

Infants at risk of hypoglycemia and who fail to respond to human milk feeding may require short-term supplementation with human milk substitutes. Donor human milk should be offered wherever possible in these cases.

Maternal Indications

There are few medications routinely administered to healthy adults of child-bearing age that pose a risk to the breastfeeding infant. Where there are concerns, safe alternatives often exist or dosing and treatment length can be adapted to minimize the risk while maintaining some or complete breastfeeding.

If treatment can be delayed, an older infant will generally be more able to metabolize any medications that pass through the milk and also be less severely impacted by reduction or elimination of breastfeeding.

A few drugs and treatments, such as cytotoxic chemotherapy and radioactive iodine are firm contra-indications regardless of the age or amount of breastfeeding. Some recreational drugs, but not all, are also an absolute contraindication, such as cocaine and heroin. If you are interested to learn more you can listen to this conversation with Dr. Lisa Graves "ExternalPregnancy and postpartum substance use"

Pregnancy and substance use.
© Health e-Learning-IIHL

Supplementing the breastfed infant

When breastfeeding alone is insufficient or temporarily not possible, the choice of supplement should be, in order of preference:

  1. The mother's/parent's own expressed milk, if it is available and suitable.
  2. Donor human milk - from another healthy mother/parent or human milk bank
  3. Commercial infant formula

PDFInformal (Peer-to-Peer) Milk Sharing: The Use of Unpasteurized Donor Human Milk

How much supplement should be given?

Your goal is to give the infant as much as he would normally have taken at the breast. ie 2 - 10ml per feed in the first 24 hours; 5 - 15ml per feed in the second 24 hours; 15 - 30ml per feed between 48 and 72 hours of age and 30 - 60ml per feed from 72 - 96 hours of age.

How should this supplement be given?

Tube-device at the breast, cup feeding, finger-feeding, syringe feeding, spoon feeding, dropper feeding, and bottle feeding are all alternatives available, with bottle feeding being the least desirable for promoting normal infant feeding behaviours.

The following methods are detailed in the following topic pages.

  • Feeding-tube device at the breast
  • Cup feeding
  • Finger feeding
  • Bottle feeding

Drip drop feeding

What effect do supplements have?

The WHO strategy states that infants who are not breastfed should receive special attention from health systems as they constitute a group at risk for growth and health problems.

Short-term effect on the mother/lactating parent

A loss of maternal self-confidence occurs when supplements are given without a valid medical indication.4, 5

The reduced breast stimulation and reduced milk removal that occurs as a result of the infant being given supplements results in

  • An increased incidence of breast engorgement, and
  • More severe engorgement can cause breast involution and the failure of adequate lactation. Early, frequent milk removal is pivotal to the success of breastfeeding in the coming weeks.
  • Shorter duration of lactational amenorrhoea6, 7

Short-term effect on infant health

Infant ability to suck at the breast can be disturbed as they learn a different sucking technique8.

Supplements change the normal flora of the intestine,9, 10, 11 increases gut permeability and decreases gut motility.

Commercial infant milk can be contaminated during manufacture and preparation, and the feeding implements can introduce another source of infection12.

Protective properties in human milk, such as lactoferrin, are inactivated by commercial infant milk13.

Effect on digestion and absorption

Commercial infant formula is poorly digested and absorbed14 compared to human milk as

  • There is a normal immaturity of digestion and absorption at birth
  • Human milk contains enzymes to aid digestion (eg lipase) that are not in infant formula
  • Human milk macronutrients are in easily digested form,15unlike the macronutrients in infant formula
  • Absorption of minerals is enhanced by human milk 'transporters'

Effect on serum glucose levels

Serum glucose levels normally drop to their lowest levels at about 2 hours of age, stimulating the infant's physiology to mobilize other sources of energy ensuring euglycemia is achieved and maintained for up to 24 hours, irrespective of oral intake16.

Giving babies glucose water or commercial infant formula interferes with this normal physiological process and may result in further interventions being required.

Effect on jaundice

Likewise the normal physiology of bilirubin metabolism is interrupted when artificial supplements are given. Reduced breastfeeding frequency and supplementation with water or glucose water have been associated with increased serum bilirubin concentrations in the first 5 days of life17 Lack of early feeding delays passage of meconium and increases enterohepatic reabsorption of bilirubin.

Increased breastfeeding is the best way to treat the additional insensible water loss that is caused when phototherapy is required18, 19.

Effect on atopic disease

Even just one or two commercial infant milk feeds at this time may result in the development of cow's milk intolerance or cow's milk allergy, which will become symptomatic later in infancy20, 21.

Effect on breastfeeding

The use of supplements during the hospital stay (and afterwards) is closely associated with earlier cessation of exclusive breastfeeding and earlier weaning3, 22, 23.

Breastfeeding is negatively affected when formula is used, even in hospitals where educational materials, counseling, support and policies are generally favorable to breastfeeding. Research was conducted in a unit where nursing staff attitudes regarding breastfeeding were very positive with more than 80% reporting discussing the advantages of breastfeeding routinely with mothers24. However, 77% of mothers had started bottle-feeding 2 to 3 weeks after birth, the majority (93%) remembered which brand of formula was used to supplement their baby in hospital and most were using that brand.

Parents may interpret the use of formula as an endorsement by hospital staff, despite clear verbal messages promoting breastfeeding.

But the mother/parent requested a supplement ...

Lack of understanding of normal newborn behavior, volume of human milk required in the early days and maternal fatigue are the major reasons mothers give for requesting a supplement.

Education about newborn behavior and the importance of giving their infant only human milk change parental expectations and decrease requests for supplements.

But what about maternal fatigue ...

Time for some brainstorming!

Brainstorm with your colleagues ways of supporting a tired mother/parent in hospital who has requested a supplement, or who, in the community setting, is wanting to give supplements to change the baby's behavior.

Unit Activity

Review your Unit's policy on supplementation AND common practices of the staff. Ensure that there are very clear policy guidelines for when a supplement is medically indicated. Discuss with your colleagues the implications for the dyad should they not follow this policy. You can review thePDF ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017.

Do you have an "Informed Consent" form to ensure mothers/parents are aware of the risks of infant formula for non medical reasons?

What should I remember?

  • the medically valid reasons for the use of human milk substitutes
  • the best choice of supplement when indicated, in order of preference
  • how best to give a supplement when it is required
  • how much supplement to give according to the age of the infant
  • the effects of supplements on the infant's health, the mother/lactating parent, and their ongoing breastfeeding relationship

Self-test quiz

Skills Competency

If you are working with families needing to supplement their infants, please take the time to download and review the information in the skills competency. You can then ask a colleague or supervisor to confirm your competencies in this area related to knowledge, skills, and attitude.

Domain 6 Teaching formula preparation, supplementation and feeding

When you have successfully completed this topic and practiced what you have learned you will be ready to do your Skills Competency. Click on the title of this box to download Domain 6 Teaching formula preparation, supplementation, and feedingPDF competency form for you to complete with your supervisor.

Notes

  1. # Pinheiro JMF, Flor TBM, Araújo MGG, Xavier AMSF, Mata AMBD, Pires VCDC, Oliveira LIC, Andrade FB. (2021) Feeding practices and early weaning in the neonatal period: a cohort study. Rev Saude Publica. 2021 Oct 25;55:63. doi:
  2. # Lakati AS et al. (2010) The effect of pre-lacteal feeding on full breastfeeding in Nairobi, Kenya.
  3. # Parry JE et al. (2013) Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns.
  4. # Jakaitė, V., Peštenytė, A., Zakarevičienė, J., Sniečkuvienė, V., Žitkutė, V., Ramašauskaitė, D., & Domža, G. (2021) Predictors of exclusive breastfeeding in the first six months: Four consecutive surveys in a tertiary hospital in Lithuania
  5. # Gagnon AJ et al. (2005) In-hospital formula supplementation of healthy breastfeeding newborns
  6. # Figaroa, M. N., Bellizzi, S., Delvaux, T., & Benova, L. (2020) Lactational amenorrhoea among adolescent girls in low-income and middle-income countries: A systematic scoping review.
  7. # McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women
  8. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
  9. # Chin, N., Méndez-Lagares, G., Taft, D. H., Laleau, V., Kieu, H., Narayan, N. R., Roberts, S. B., Mills, D. A., Hartigan-O’Connor, D. J., & Flaherman, V. J. (2021) Transient effect of infant formula supplementation on the intestinal microbiota
  10. # Edwards CA et al. (2002) Intestinal flora during the first months of life: new perspectives.
  11. # Guaraldi F et al. (2012) Effect of breast and formula feeding on gut microbiota shaping in newborns.
  12. # Holy O et al. (2014) Cronobacter spp. as emerging causes of healthcare-associated infection.
  13. # Wharton BA et al. (1994) Faecal flora in the newborn. Effect of lactoferrin and related nutrients
  14. # Gan J, Bornhorst GM, Henrick BM, German JB. (2018) Protein Digestion of Baby Foods: Study Approaches and Implications for Infant Health
  15. # Kim, S. Y., & Yi, D. Y. (2020) Components of human breast milk: From macronutrient to microbiome and microRNA
  16. # Eidelman AI (2001) Hypoglycemia and the breastfed neonate
  17. # Gartner LM (2001) Breastfeeding and jaundice
  18. # de Carvalho M et al. (1981) Effects of water supplementation on physiological jaundice in breast-fed babies
  19. # Flaherman VJ et al. (2017) ABM clinical protocol #22: Guidelines for the management of jaundice in the breastfeeding infant 35 weeks or more of gestation - revised 2017
  20. # Wegienka G et al. (2006) Breastfeeding history and childhood allergic status in a prospective birth cohort
  21. # MacIntyre EA et al. (2010) Early-life otitis media and incident atopic disease at school age in a birth cohort.
  22. # Chantry CJ et al. (2014) In-Hospital Formula Use Increases Early Breastfeeding Cessation Among First-Time Mothers Intending to Exclusively Breastfeed.
  23. # Biro MA et al. (2011) In-hospital formula supplementation of breastfed babies: a population-based survey.
  24. # Reiff MI et al. (1985) Hospital influences on early infant-feeding practices.