Formula supplementation of the breastfed baby is a common practice in many hospitals.
Most of the time when formula supplementation is given, it’s not medically necessary.
There are, however, situations where formula supplementation may be medically necessary.
Some health professionals and parents may view giving a breastfed baby formula supplementation as something that is benign and without risk. This isn’t the case however.
For example, giving formula supplementation to a breastfed baby in hospital significantly increases the risk of early breastfeeding cessation. There can also be negative effects on a mother’s milk supply and on a baby’s gut microbiome.
Reasons Early Formula Supplementation May Be Medically Required
There may be situations (as per below) when formula supplementation may be used for medical reasons. The lists below are not exhaustive or definitive in every individual situation. In some situations, donor milk may be an option. In most cases, the supplementation can be ceased once the medical need is over. It’s important to be guided by the medical staff around you, who are hopefully those you trust.
There may be other individual circumstances that lead to formula supplementation.
Ultimately, you get to determine what is best for your baby.
Baby Indications For Early Formula Supplementation
Below are certain situations where early formula supplementation may be recommended due to issues with your baby:
- The baby has low blood sugar levels (as determined by laboratory blood sugar measurement), but the baby isn’t showing signs of it. The baby’s blood sugar levels are unresponsive to appropriate and frequent breastfeeds. In this case, some hospital protocols may recommend formula supplementation. The ABM hypoglycemia protocol recommends intravenous (IV) glucose for such babies. Testing a baby’s blood sugar levels is not routinely done. It’s only done for ‘at-risk’ babies (e.g. diabetic mother, prematurity, low birth weight) or for babies who have signs of low blood sugar levels (e.g. jitteriness, seizures, irregular breathing, temperature instability).
- The baby is showing signs of low blood sugar levels. While some hospitals may recommend formula supplementation for such a situation, the ABM hypoglycemia protocol recommends IV glucose for such babies.
- Clinical and laboratory evidence of significant dehydration (e.g. greater than 10% weight loss, high sodium, poor feeding, lethargy) which isn’t improved after skilled breastfeeding management.
- Weight loss in the baby of 8–10% along with a delay in a mother’s milk coming in (day five or later).
- Delayed poos or continued meconium poos on day five.
- Hyperbilirubinemia associated with insufficient breastmilk intake despite appropriate breastfeeding management or ‘breastmilk’ jaundice when levels reach greater than 20–25 mg/dL (342-427.5 µmol/L)
Mother Indications For Early Formula Supplementation
Below are certain situations where early formula supplementation may be recommended due to issues with the mother:
- A delay in a mother’s milk coming in (day 3–5 or later) combined with inadequate intake by the baby.
- Retained placenta.
- Sheehan’s syndrome. This is where part of a mother’s pituitary gland becomes necrotic (dies). This can impact breastfeeding as it’s the pituitary gland which makes the hormones prolactin and oxytocin that are imperative for breastfeeding. Sheehan’s syndrome can be caused by a significant postpartum haemorrhage and can result in a mother’s milk not coming in.
- Insufficient glandular tissue meaning a mother is unable to make a full supply for her baby’s needs.
- Breast pathology or prior breast surgery resulting in low milk supply.
- Intolerable pain with breastfeeds unrelieved by appropriate breastfeeding management.
Reasons When Early Formula Supplementation Is Not Medically Required
Most of the time, when formula supplementation is given it’s not medically necessary.
Here are some reasons when formula supplementation may be given, but isn’t medically necessary to do so:
- The baby is sleepy, has less than 8 breastfeeds in the first 24-48 hours, has a weight loss of less than 7% and shows no signs of sickness. It’s normal for newborns to be sleepy after an initial alert period of a couple of hours straight after the birth. Thereafter, they typically have variable sleep and awake cycles, with an additional one or two wakeful periods (which can involve cluster feeding) in the next 10 hours, regardless of whether they are fed or not. It’s important for a mother and her baby to be together (including skin-to-skin) whenever possible and for a baby’s feeding cues to be responded to rather than to automatically supplement after an arbitrary number of hours.
- The healthy, term baby with bilirubin levels less than 18 mg/dL (307.8 µmol/L) after 72 hours of age, when the baby is breastfeeding well, pooing adequately and weight loss is less than 7%.
- The baby who is fussy at night or constantly wanting to feed, even if for several hours.
- A tired or sleeping mother.
A Word About Premature Babies
A foetus normally accumulates stores of many nutrients in the last trimester of pregnancy. So a premature baby misses out on this. Hence, some very premature babies are given human milk fortifier to supply them with additional protein and minerals.
The name ‘human milk’ fortifier is a bit misleading, as it is most commonly based on cows’ milk (like formula) and not human milk at all. True human milk human milk fortifier is only made currently by a for-profit company in the US.
Some people think premature babies need formula, perhaps because they confuse formula with human milk fortifier. Human milk fortifier is different to formula, however, because it has been made with the special needs of premature babies in mind.
Risks Of Formula Supplementation
There are risks associated with formula supplementation. For example, early formula supplementation:
- Significantly increases the risk of not fully breastfeeding between days 30-60 after the birth, and stopping breastfeeding altogether by day 60.
- May interfere with a mother’s ability to make a full milk supply. The likelihood of this increases if suboptimal breastfeeding management has occurred, especially when the original reason for the supplementation has not been adequately addressed.
- May sensitise a susceptible breastfed baby to cows’ milk protein, and hence increase the risk of the baby being allergic to cows’ milk protein. A susceptible baby may be one for whom there is a family history of sensitivity to cows’ milk protein.
- May increase the risk of developing type 1 diabetes in susceptible babies (i.e. for whom there is a family history of this condition).
- Increases the risk of infection. Exclusive breastfeeding (meaning no other liquids or solids are given, not even water) during the first 6 months of a baby’s life are important to protect a baby against infection. Lack of exclusive breastfeeding can increase a baby’s risk of infection.
- Increases the risk of necrotising enterocolitis (NEC) in premature babies. Exclusive breastfeeding is important to help prevent NEC in premature babies. NEC is a disease of the bowel where part of it becomes necrotic (dies).
- Can alter the bacteria in a baby’s gut (the gut microbiome). Evidence is emerging about how a resilient gut microbiome is important for our health. A resilient gut microbiome is one that is more diverse and less likely to shift towards unhealthy bacteria. Exclusive breastfeeding leads to the normal healthy colonisation pattern of a baby’s gut. There are significant differences in the bacteria that are found in the gut of breastfed babies compared to formula fed babies. Even small amounts of formula can result in changes to a baby’s gut microbiome, and this may increase the risk of various health outcomes.
There are many steps you can follow to try to get breastfeeding off to the best start possible and help avoid formula supplementation. Read here for more information.
Sometimes formula supplementation is medically necessary and sometimes it isn’t. Much of the time formula supplementation is given in hospital, it’s not medically necessary. Making your own fully informed decisions and doing what is best for you given your individual circumstances is important.
The information in this article has mainly been sourced from the Academy Of Breastfeeding Medicine (ABM) Clinical Protocol #3: Hospital Guidelines for the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate.