These days, it's very common to hear, “Not all mothers can breastfeed you know!”
Yes, while true, you may be curious about which mothers actually cannot breastfeed and why.
Of course, there can be individual circumstances that mean not breastfeeding is the best option.
But, what are the actual medical reasons that mean mothers cannot breastfeed or have to use supplementation?
Here are 26 reasons why your baby may need formula:
Baby Based Medical Conditions Requiring Formula
According to Australia’s National Health and Medical Research Council (this would be the same or very similar in other developed countries) infant conditions that preclude breastfeeding and where a specialised formula is needed include:
#1: Galactosaemia (Galactosemia in the US)
Galactosaemia is a rare metabolic disorder whereby a baby has trouble metabolising (or cannot metabolise) the sugar galactose.
Since lactose in breastmilk is broken down to glucose and galactose, a baby cannot have breastmilk but rather needs a galactose-free formula.
Babies with the Duarte variant of galactosaemia are able to metabolise some galactose and so can breastfeed to some extent.
#2: Maple Syrup Urine Disease
Maple syrup urine disease is another rare metabolic disorder.
Babies with this disorder have trouble metabolising (or cannot metabolise) the amino acids, leucine, isoleucine and valine (which are in breastmilk).
Hence, babies with this disorder need a formula that is free of those amino acids.
Phenylketonuria (PKU) is another rare metabolic disorder.
A baby with PKU needs a formula that is free of the amino acid phenylaline.
Some breastfeeding is possible for babies with PKU under careful medical monitoring.
Maternal Based Medical Conditions Requiring Formula
According to the National Health and Medical Research Council (NHMRC), the following maternal conditions preclude breastfeeding:
In Australia the national recommendation is for HIV positive women to not breastfeed. This recommendation is similar in other developed countries.
According to the NHMRC:
“At present, breastfeeding is contraindicated when a mother is known to be HIV positive (specialist advice is needed for each individual case).”
There is evidence from developing countries that there are very low rates of HIV transmission of babies who are exclusively breastfed and whose mothers receive antiretroviral drugs.
From a single transfusion with HIV positive blood, there is about a 90% transmission rate. Meanwhile, there is only a 0.6%-4% HIV transmission rate to exclusively breastfed babies from birth to 6 months from HIV positive mothers through their breastmilk.
It is more mixed feeding that increases HIV transmission rates.
For more information about HIV and infant feeding refer to the WHO guidelines on this topic.
#5: Herpes Simplex Virus Type 1 Lesions On Breast
If a mother has herpes simplex virus type 1 lesions on her breast, direct contact between the lesions and her baby’s mouth should be avoided until all lesions have resolved.
#6: Breast Cancer Treatment
If a mother has breast cancer detected during pregnancy and she is undergoing chemotherapy, breastfeeding is not permitted. If a mother is not undergoing chemotherapy, breastfeeding continuation should be evaluated on an individual basis.
#7: Active Tuberculosis
If a mother has active tuberculosis (TB), due to the risk of respiratory transmission, any close contact with her baby is not permitted until she has finished 2 weeks of treatment. The mother can express and provide her expressed breastmilk (EBM) to her baby.
However, if she has an active breast lesion or TB mastitis, she can provide her EBM to her baby only once the lesion has healed or the TB mastitis has resolved.
#8: Untreated Brucellosis
If a mother has untreated brucellosis, she should not breastfeed but once treatment has been completed, breastfeeding can resume.
#9: Syphilis Lesions On Breast Or Nipple
If a mother has recently acquired syphilis, close contact with her baby and breastfeeding can resume after 24 hours of treatment — provided there are no lesions around the breasts or nipples. If there are lesions, breastfeeding can resume once treatment is complete and the lesions have healed.
Medications That Don't Mix With Breastfeeding
According to the NHMRC: “Breastfeeding can be continued while the mother is on most of the medications commonly prescribed in Australia.”
However, there are certain medications that a breastfeeding mother is advised not to take, especially if their use is not absolutely necessary or if a better alternative is available. There are some medications that can lower a mother’s milk supply for example.
An individual risk/benefit analysis is often required when it comes to use of medications while breastfeeding. Speaking with a pharmacist (for example) with specialist knowledge about breastfeeding and medications is advisable.
According to the NHMRC, the following medications preclude breastfeeding:
#10: Sedating Psychotherapeutic Drugs, Anti-epileptic Drugs, Opioids And Their Combinations
These drugs may cause side effects such as drowsiness or respiratory depression and are “better avoided if a safer alternative is available”.
#13: Radioactive Iodine-131
The use of radioactive iodine-131 is associated with nuclear energy, medical diagnostic and treatment procedures for example. It “is better avoided given that safer alternatives are available”.
#14: Cytotoxic chemotherapy
Cytotoxic chemotherapy, which are drugs used to destroy cancer cells, “requires that a mother stops breastfeeding during therapy”.
#15: Excessive Use Of Topical Iodine Or Iodophors
Use of these “especially on open wounds or mucous membranes, may result in thyroid suppression or electrolyte abnormalities in the breastfed infant and medical advice is required”.
Supplementation For Baby
Supplementation may be required under some circumstances. What is used as the supplement (e.g. a mother’s own expressed breastmilk, donor milk or formula) depends on the reason why supplementation is used and sometimes a mother’s preference.
Sometimes hospital policies (or lack thereof) may impact a mother’s choice as to what form of supplementation is used. All hospitals should (but not all do) have a donor milk policy to allow mothers to make their own fully informed decisions (including being informed about the risks of formula and donor milk). Even better, more hospitals need to have milk banks where more babies can have access to screened and pasteurised donor milk.
How long supplementation is used depends on the reason why supplementation is needed. Here are short and long term reasons why supplementation may be needed:
Short Term Supplementation
There are some medical situations in which supplementation may be required in the short term. According to the Academy of Breastfeeding Medicine (ABM) supplementation protocol, possible indications for supplementation of healthy term babies include:
#16: Hypoglycaemia (Low Blood Sugar)
Babies who are not showing signs of hypoglycaemia but who have blood test results showing hypoglycaemia may need to be supplemented if they don’t respond to appropriate frequent breastfeeding.
The ABM indicates that babies who are showing signs of hypoglycaemia (eg lethargy, jitteriness, irregular breathing, temperature instability etc) should be treated with intravenous glucose.
For more information about hypoglycaemia, see the ABM hypoglycaemia protocol.
#17: Significant Dehydration
Supplementation may be needed if a baby is showing signs of significant dehydration (which may include > 10% weight loss, high sodium, poor feeding, lethargy, etc) that is not improved after skilled assessment and proper breastfeeding management.
#18: Newborn Weight Loss Of 8–10% Accompanied By A Delay In Milk Coming In
If a mother’s milk is delayed in coming in (i.e. day 5 or later) and her baby has a weight loss of 8-10%, supplementation may be needed.
#19: Delayed Poos Or Continued Meconium Poos On Day 5
If a baby is getting enough milk, they will poo enough. If a newborn isn’t pooing often enough or is still is passing meconium (the first black sticky poo) after the first few days, medical advice should be sought and supplementation may be needed.
#20: Insufficient Intake Despite Adequate Milk Supply
Just because a baby is at the breast, doesn’t mean he is getting milk. Skilled help from a lactation consultant can help you work out if your baby is effectively removing milk from your breasts.
At the start of the breastfeed, your baby’s sucks will be fast and shallow as he gets the milk flowing by triggering your let-down reflex. After this, he will do groups of deeper, slower, suck and swallows. A pause in his chin when it drops down to its lowest position means that he has a mouthful of milk. Rest periods between sucking bouts are a normal part of breastfeeding. As the breastfeed continues, the groups of sucks and swallows gradually become shorter and the rest periods longer. Most of the time, a baby will come off on his own accord when he has finished with that breast.
#21: Hyperbilirubinemia (High Bilirubin Levels)
All newborns have some elevation of their bilirubin levels relative to normal adult levels. This is because newborns begin to break down all the red blood cells they are born with as they are no longer needed as they can get oxygen by breathing once born. When red blood cells are broken down, bilirubin is made and this is what makes babies with jaundice look yellow. This is called normal physiological jaundice and it usually resolves within 7-10 days.
Nonetheless, there may be some situations where a baby’s jaundice may warrant supplementation. For more information, see the ABM’s jaundice protocol.
#22: Intolerable Pain With Breastfeeds
Despite appropriate management (e.g. skilled assistance with optimising correct positioning and attachment), a mother has intolerable pain during feeds, supplementation may be required.
#23: Retained Placenta
Since complete placenta removal is necessary for a mother’s milk to properly come in, this may not occur if some placental fragments remain. Once all the placenta is removed, then her milk will likely come in.
Long Term Supplementation
Most mothers are able to make plenty of milk for their baby or babies. Nonetheless, a few mothers have a primary low milk supply, whereby, despite appropriate breastfeeding management from the start, they cannot make a fully supply. In such cases, supplementation would be required long term. Some causes of primary low milk supply include:
#24: Insufficient Glandular Tissue
If a woman has insufficient glandular tissue (IGT) this means that she doesn’t have enough milk-making tissue in her breast to make a full milk supply.
If you are worried about (or have been diagnosed with) IGT and breastfeeding is important to you, see a lactation consultant who can help you maximise your ability to make milk and can talk about ways in which you can breastfeed.
#25: Previous Breast Surgery
If you are worried about how previous breast surgery may impact breastfeeding, see a lactation consultant who can help you maximise your ability to make milk and can talk about ways in which you can breastfeed.
#26: Sheehan’s Syndrome
Sheehan’s syndrome is a condition that can affect women who lose a life-threatening amount of blood during or after giving birth.
In Sheehan’s syndrome, damage occurs to the pituitary gland and can result in permanent underproduction of essential pituitary hormones such as oxytocin and prolactin (the most important hormones for breastfeeding).
Hence, Sheehan’s syndrome can result in a mother’s milk not coming in.
This article does not provide an absolute list of conditions when breastfeeding may not be possible or supplementation required. There may be other conditions, situations or medications that need to be considered on a case-by-case basis. If you are unsure, speak with your doctor. Or for help with breastfeeding, contact a lactation consultant.
There are other reasons why some mothers may experience primary low milk supply problems.
Note from BellyBelly: If you're having trouble breastfeeding, please seek the help of a highly trained breastfeeding professional before you self diagnose. It's best to choose an IBCLC (International Board Certified Lactation Consultant). No other health professional receives the extensive training or experience that an IBCLC does. If your baby needs a specialist, an IBCLC will refer you.