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Conference Report: Resisting the Tide of Early Supplementation and Other Selected Barriers to Breastfeeding

Elizabeth Campion
Harper Woods MI USA
From: LEAVEN, Vol. 41 No. 5, October-November 2006, pp. 104-105.

"Even one bottle of formula will hurt" was the conclusion of Marsha Walker, RN, IBCLC in the session "Resisting the Tide of Early Supplementation and Other Selected Barriers to Breastfeeding" at the 2005 LLLI Conference in Washington DC, USA. Marsha, founder of the National Alliance for Breastfeeding Advocacy, stated that babies given two or more bottles within the first 24 hours of life are at serious risk for complete weaning from the breast within seven to 10 days.

The presentation focused on reasons for, and outcomes of, supplementation of breastfeeding in the first few days after birth. Speaking from a historical perspective, Marsha noted that although breastfeeding rates in the United States have increased markedly in the last 30 years, rates of supplementation have also jumped. For example, in 1982, the overall breastfeeding rate was 61.9 percent, with 55 percent of babies exclusively breastfed and 6.9 percent breastfed along with supplements. By 2003, the overall breastfeeding rate was 66 percent, with 44 percent of babies exclusively breastfed and 22 percent breastfed along with supplements.

When surveyed, mothers have expressed clearly that they wish to breastfeed exclusively, but statistics show that hospital staff has given formula samples or coupons for formula to 80 percent of women who had stated this intention. Use of formula undermines the mother's own belief and desire, so the rate of supplementation rises in the first week.

The session examined many of the reasons why supplements are given, in addition to formula manufacturer marketing strategies. Some health care providers believe that supplements are needed to clear out the meconium from the infant's body or until the milk comes in and the breasts feel full. Other reasons include the health care providers' desire to know how much the baby is getting, or because the mother may believe her milk supply is too low. Marsha noted that most of these point to a "fundamental disbelief that human milk can adequately nourish an infant." She countered this belief with the fact that a newborn's stomach can only hold seven cubic centimeters (cc) -- about a teaspoon and a half -- of fluid. A baby will swallow out of a bottle as a reflex, not as a sign of hunger. However, many professionals and parents interpret this swallowing from the bottle as a sign that breastfeeding was not adequately fulfilling the baby's needs.

Marsha suggested that early supplementation is often a direct result of the culture in maternity units in US hospitals. Many babies are supplemented because it takes less time to offer a bottle than to teach the mother how to breastfeed properly. She also stated that many professionals fail to recognize that "humans are a continuously feeding species." The high carbohydrate and moderate protein composition of human milk tells us this. Babies should feed very frequently without schedules or supplements.

Although medical reasons for supplementation do exist, in most circumstances supplementation is used before other options have been adequately explored. For example, formula may be used to treat hypoglycemia in the newborn, but this could also be treated through skin-to-skin contact and hand expressing colostrum onto a spoon and spoon feeding the baby in all but the most severe cases. Marsha recommends evaluation and possible supplementation in babies who demonstrate symptoms such as impending dehydration, weight loss greater than eight to 10 percent after day five, meconium stools at day five, infants with oral anomalies, early high bilirubin levels, delayed milk coming in, maternal illness, and/or the inability to transfer milk from the breast. Supplementation can be accomplished with the mother's own milk or banked donor human milk when available.

After thoroughly examining the reasons for supplementation in the breastfed baby, Marsha then discussed the consequences of inappropriate supplementation. Most important is the fact that this supplementation reduces maternal confidence, which then usually leads the mother to rely on supplements and to wean early. Marsha noted that the higher the intensity or dose of human milk received by the baby in the first two weeks of life, the greater the likelihood of breastfeeding continuing at 20 weeks and at six months.

Some key consequences of supplementing with infant formula include: provoking allergies, triggering diabetes, and causing nipple confusion or nipple preference. Significantly, supplementation interferes with lactogenesis III -- the calibration and maintenance of sufficient milk supply. This repeating cycle of decreased supply and increased formula can continue until milk production shuts down, thereby ending the possibility of breastfeeding.

Marsha notes too that when supplementation is necessary, a hierarchy of foods should be used. The first supplement used should be the mother's own fresh milk, if at all possible. If not, the following choices could be used, listed in order of what is best for the baby:

  • Baby's own mother's refrigerated milk
  • Baby's own mother's frozen milk
  • Baby's own mother's fortified milk (for preterm babies)
  • Banked pasteurized human donor milk
  • Hypoallergenic or hydrolyzed formula (the proteins in these formulas have been subjected to a splitting process that reduces their allergy potential. Examples are Nutramigen, Pregestimil, and Alimentum)
  • Elemental formula (specialty formulas consisting of basic amino acids that are used in more extreme situations)
  • Cow's milk formula
  • Soy formula
  • Water or glucose water

Marsha Walker presented a great deal of fascinating information regarding supplementing the breastfed baby. Her energetic and interesting presentation was balanced between providing technical information in a way that the lay person could understand while still engaging health care providers.


Ryan, A.S. et al. Breastfeeding continues to increase into the new millennium. Pediatrics 2002; 110:1103-09.
Mothers Survey, Ross Products Division of Abbott, Breastfeeding Trends-2003.
Declerq et al. Listening to Mothers: Report of the First National USA Survey of Women's Childbearing Experiences. New York: Maternity Center Assoc, 2002.

Elizabeth Campion is a Leader with Eastside LLL outside of Detroit, Michigan, USA. She is also the Area Leaders' Letter Editor (ALLE) for Michigan, USA. She and her husband, Harry, have four children: Thomas (9), Ethan (7), Samuel (4), and Eleanor (1).

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