Supplementing the Breastfeeding Baby
Knowing the questions to ask when a mother inquires
about supplementation can help her meet her baby's needs and preserve
the breastfeeding relationship.
Kathleen G. Auerbach, PhD, IBCLC
Anne Montgomery, MD, IBCLC
From: LEAVEN, Vol. 35 No. 4 August September 1999 p. 75-77
We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.
Should I supplement my baby? This is one of the most emotion-laden questions for breastfeeding parents. For purposes of this discussion, supplementation refers to replacing a breastfeeding with expressed human milk or some other fluid or food. Before deciding whether a baby should or should not be supplemented, certain questions should be asked.
The first question to ask is, "Why is a supplement recommended?" This question may be obvious but it is seldom asked first. The most appropriate answer is simple: to preserve the baby's health and growth. Rarely is a mother unable to fully provide for her nursing infant in his first several months of life. Most situations involving a baby who is not gaining weight appropriately can be corrected quickly, particularly if they are identified soon after the baby's birth (Newman 1996).
Serious illness in the mother or baby-Some mothers are too ill to breastfeed immediately after birth (Lawrence 1989; Zavaleta et al 1995). Some babies must be cared for in a special nursery as a result of premature birth or the presence of a life-threatening condition that precludes breastfeeding. In such circumstances, it may be necessary to supplement the baby for a period of time.
The mother's own expressed milk is the first choice, of course (Auerbach & Walker 1994; Kavanaugh et al 1995). Even if the mother's illness prevents her from immediately breastfeeding, she can express her milk in order to preserve her opportunity to breastfeed later.
Baby not gaining sufficient weight to maintain health- Physicians and other health care providers often use growth charts to monitor infant growth. These charts include height/length, weight and head circumference parameters. Many growth charts are based on a limited sample of mostly formula or mixed (breast milk and formula) fed white babies and may not reflect growth patterns for fully breastfed babies or babies of nonwhite ethnicities. New research studies indicate that breastfed babies may, in fact, gain weight faster in the first six months and slower in the second six months, although their rates of growth in length and head circumference are similar (Dewey et al 1993; 1995).
Health care providers are appropriately concerned when babies "cross two lines" on the growth chart. Breastfed babies should gain at least four to seven ounces a week during the first six months of life. Breastfed babies should not fall off even standard growth curves in the first six months.
However, in the second six months, a slowing of growth may represent normal growth in a breastfed baby, assuming other growth parameters are normal and the baby appears healthy. It is never normal for a baby to significantly drop off his own growth curve, particularly if this involves dropping below the fifth percentile or actually losing weight.
Growth charts can be useful tools for tracking information about a baby's growth, but this information needs to be considered in the context of the whole picture of the baby's health, growth and development. If the baby has failed to gain sufficient weight, it is essential to supplement the baby in order to provide adequate nutrition while the mother increases her milk supply.
Jaundice- It is important to remind the mother that jaundice is usually a normal consequence of birth and that, in most cases, it is unnecessary to supplement the baby's frequent feedings from the breast. If she has been told to supplement by her physician, encourage her to supplement her baby with additional breast milk she has expressed or a non-human commercial substitute. Neither plain water nor glucose water is an appropriate supplement when the goal is to increase the baby's stooling, which will in turn decrease his level of serum bilirubin (Martinez et al 1993; Gartner 1994; Catz et al 1995).
Cleft lip and/or palate, ankyloglossis (tongue-tie) or other oral or facial difficulty-When a baby is born with a complication that interferes with his ability to suckle effectively, he may require supplementation until the anomaly has been repaired.
Adoption-When a family adopts a baby, breastfeeding is possible but may not result in a complete milk supply. The need to supplement is usually obvious, regardless of the mother's reproductive or lactational history (Sutherland & Auerbach 1987).
Maternal breast surgery or other trauma-Whether to correct a congenital anomaly, repair an injury to the breast/chest area or for cosmetic augmentation/reduction, any scarring of the breast tissue may reduce the potential adequacy of breast function (Varsos & Yahalom 1991; Hurst 1996).
Primary breast insufficiency-Although an extremely rare condition, a mother may not have enough glandular tissue to make milk in quantities that meet her baby's growing needs (Neifert et al 1985).
Mothers are often told that supplementing will help their babies sleep through the night-Babies will sleep through the night when they are developmentally ready to do so. Research investigators have found no relationship between the introduction of nighttime foods and infant sleep (Grunwaldt et al 1960; Macknin et al 1989).
Mother and baby separated by employment situation- Some employed women ensure continued breastfeeding by restricting supplementation to the sitter's or day care provider's location. Many women also reserve exclusive breastfeeding for whenever they are with their babies, such as evenings and weekends.
When to Supplement
When supplementation is medically indicated, it should begin promptly to avoid serious consequences to the baby's health. When not medically indicated, supplementation should be used only if the baby must be separated from the mother. Supplementing too soon and too often can create difficulties that may require continued supplementation (Armstrong 1996).
How to Supplement
Most babies prefer the breast to all other containers! In the absence of the breast, a cup, spoon, feeding syringe, nursing supplementer or bottle can be used. Each has its proponents--for different reasons.
Cups and spoons can be used from the baby's birth and involve a lapping (by the very young baby) or sipping (by the older baby) action that is less intrusive to suck patterns than bottle-feeding (Lang et al 1994). Many older babies who refuse a bottle will happily imitate the parents by cup-feeding. When cup feeding is used exclusively for a lengthy period, the baby should be allowed to suck for comfort. A parent's finger, knuckle or a pacifier may be used.
Last on the list, but most often thought of first in discussions of supplementation, is bottle-feeding. The timing and frequency of these feedings are most often implicated in later problems with breastfeeding (Neifert, Lawrence & Seacat 1995). Therefore, bottle-feedings should be avoided or delayed until after the baby is well acquainted with breastfeeding and accomplishes it with ease.
When the baby breastfeeds well and then is introduced to a different container for supplemental feedings, he will often surprise his parents by quickly learning another way of eating. Babies are smart!
What to Supplement
Whenever a fluid other than breast milk is offered, the baby should receive at least as many calories as human milk provides. Using this rule of thumb, water, glucose water, juice, tea or diluted milk are all inappropriate choices. Tops on the list of supplementation fluids is fresh human milk, followed by refrigerated human milk, frozen and thawed human milk (all from the baby's mother, followed by milk from another mother whose baby is the same age as the recipient infant), banked human milk (from mothers whose babies may vary in age from that of the recipient infant) and artificial baby milk.
Whenever a non-human milk is used, alterations in the baby's gut flora occur and will cause changes in the frequency, odor and consistency of baby's stool as well as how the baby settles after a feed (Kleessen et al 1995). In order to reduce the likelihood of an adverse reaction, the baby whose family has a history of allergies should not be exposed to non-human milk if it can be avoided (Saarinen & Kajosaari 1995; Gustafsson et al 1992). In this case, the longer the delay before first exposure, the better.
Giving a Supplement
This frequently depends on the reason for the supplementation. At home, the person giving the supplement may be the father, another relative or an adult care giver other than the parents. If the baby is young and accustomed to breastfeeding, he may object to supplementary feedings by his mother. A baby associates a certain activity with the person doing it as well as the place where it occurs. Thus, if the mother sits where she usually breastfeeds, the baby may object to being fed another way.
Asking the father to give the baby a feeding in a setting not usually associated with breastfeeding is a better choice. Likewise when a sitter offers the supplement, the baby is less likely to object and may come to expect such feedings from her while continuing to happily breastfeed from his mother.
Making Supplementation Work
In order to keep supplementation from shortening or interfering with breastfeeding, it is best to begin after the baby is effectively breastfeeding and thriving on his mother's milk. However, when supplementation occurs very early, very often and replaces feedings before lactation is well established, it can result in a much shorter breastfeeding experience than the mother planned. This need not occur.
Encouraging the mother to practice full breastfeeding while getting to know her baby is the first step in the breastfeeding experience. Thereafter, she can make plans so that supplementation-if it occurs at all- does not mean the end of breastfeeding.
Knowing the questions to ask when a mother inquires about supplementation can make the discussion less fraught with "shoulds." The end result may be a question from the mother: Is supplemental feeding really necessary?
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Kathleen Auerbach was accredited as a Leader in 1971 and remained active until 1996. She has served as District Advisor and Area Professional Liaison as well as Assistant Editor and Editor of BREASTFEEDING ABSTRACTS and the first editor of the Lactation Consultant Series. She served on the first exam committee for IBLCE and was certified as an IBCLC in 1985. Currently, she is Adjunct Professor at the School of Nursing, University of British Columbia, Canada, and maintains a private lactation consulting practice in Ferndale, Washington, USA. She is co-author with Jan Riordan of Breastfeeding and Human Lactation and four other books including the recently published Clinical Lactation: A Visual Guide. Anne Montgomery has been a Leader since 1993. After several years on reserve, she has reactivated as AAPL for LLL Washington, USA. She is a board-certified family physician, IBCLC and serves on the faculties of both the University of Washington and Providence St. Peter Hospital. Kathleen and Anne are each the mother of sons.