A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
Definitions
- •
Supplementary feedings: Feedings provided in place of breastfeeding. This may include expressed or banked breastmilk and/or breastmilk substitutes/formula. Any foods given prior to 6 months, the recommended duration of exclusive breastfeeding, are thus defined as supplementary.
- •
Complementary feedings: Feedings provided in addition to breastfeeding when breastmilk alone is no longer sufficient. This term is used to describe foods or liquids given in addition to breastfeeding after 6 months, a “complement” to breastfeeding needed for adequate nutrition.
Background
Given early opportunities to breastfeed, breastfeeding assistance, and instruction, the vast majority of mothers and babies will successfully establish breastfeeding. Although some infants may not successfully latch and feed during the first day (24 hours) of life, they will successfully establish breastfeeding with time, appropriate evaluation, and minimal intervention. Unfortunately, formula supplementation of healthy newborn infants in the hospital is commonplace, despite widespread recommendations to the contrary. , The most recent scientific evidence indicates that exclusive breastfeeding (only breastmilk, no food or water except vitamins and medications) for the first 6 months is associated with the greatest protection against major health problems for both mothers and infants. , ,
Newborn Physiology
Small colostrum feedings are appropriate for the size of the newborn’s stomach; , , are sufficient to prevent hypoglycemia in the healthy, term, appropriate for gestational age infant; and easy to manage as the infant learns to coordinate sucking, swallowing, and breathing. Healthy term infants also have sufficient body water to meet their metabolic needs, even in hot climates. , , , , , , Fluid necessary to replace insensible fluid loss is adequately provided by breastmilk alone. , , Newborns lose weight because of a physiologic diuresis of extracellular fluid following transition to extrauterine life. The normal maximal weight loss is 5.5% to 6.6% of birth weight in optimally exclusively breastfed infants , , , and occurs between days 2 and 3 of life (48-72 hours after birth). , , Optimally, breastfed infants regain birth weight at an average (95% confidence interval) of 8.3 days (7.7 to 8.9) with 97.5% having regained their birth weight by 21 days. Percentage weight loss should be followed closely for outliers in this regard, but the majority of breastfed infants will not require supplementation.
Early Management of the New Breastfeeding Mother
Because some breastfeeding mothers question the adequacy of colostrum feedings and may receive conflicting advice, they may benefit from reassurance, assistance with breastfeeding technique, and education about the normal physiology of breastfeeding. Inappropriate supplementation may undermine a mother’s confidence about her ability to meet her infant’s nutritional needs and give inappropriate messages that may result in continued supplementation of the breastfed infant at home.
Postpartum mothers with low confidence levels are very vulnerable to external influences, such as advice to offer breastfeeding infants supplemention such as glucose water or artificial baby milk. Well-meaning health care professionals often offer supplementation as a means of protecting mothers from tiredness or distress, although this at times conflicts with their role in promoting breastfeeding. , Inappropriate reasons for supplementation and associated risks are multiple (see Appendix for quick reference).
There are common clinical situations where evaluation and breastfeeding management may be necessary, but supplementation is not indicated, including:
- 1.
The sleepy infant with fewer than 8 to 12 feedings in the first 24 to 48 hours with less than 7% weight loss and no signs of illness
- •
Newborns are normally sleepy after an initial approximately 2-hour alert period after birth. , They then have variable sleep-wake cycles, with an additional one or two wakeful periods in the next 10 hours whether fed or not.
- •
Careful attention to an infant’s early feeding cues and gently rousing the infant to attempt breastfeeding every 2 to 3 hours is more appropriate than automatic supplementation after 6, 8, 12, or even 24 hours.
- •
The general rule in the first week is: “an awake baby is a hungry baby!”
- •
Increased skin-on-skin time can encourage more frequent feeding.
- •
- 2.
The healthy, term, appropriate for gestational age infant with bilirubin levels less than 18 mg/dL (mol/L) after 72 hours of age when the baby is feeding well and stooling adequately and weight loss is less than 7%
- 3.
The infant who is fussy at night or constantly feeding for several hours
- 4.
The tired or sleeping mother
For both points 3 and 4 above, breastfeeding management that optimizes infant feeding at the breast may make for a more satisfied infant and allow the mother to get more rest.
Before any supplementary feedings are begun, it is important that a formal evaluation of each mother-baby dyad, including a direct observation of breastfeeding, is completed. The following guidelines address indications for and methods of supplementation for the healthy, term (37- to 42-week), breastfed infant. Indications for supplementation in term, healthy infants are few , ( Table J-9 ).
| 1. Separation |
| • Maternal illness resulting in separation of infant and mother (e.g., shock or psychosis) |
| • Mother not at the same hospital |
| 2. Infant with inborn error of metabolism (e.g., galactosemia) |
| 3. Infant who is unable to feed at the breast (e.g., congenital malformation, illness) |
| 4. Maternal medications (those contraindicated in breastfeeding) |
Table J-10 lists possible indications for the administration of such feedings. The physician must decide if the clinical benefits outweigh the potential negative consequences of such feedings.
| 1. Infant indications |
| a. Asymptomatic hypoglycemia documented by laboratory blood glucose measurement (not bedside screening methods) that is unresponsive to appropriate frequent breastfeeding. Symptomatic infants should be treated with intravenous glucose. (Please see ABM Hypoglycemia Protocol for more details. , ) |
| b. Clinical and laboratory evidence of significant dehydration (e.g., > 10% weight loss, high sodium, poor feeding, lethargy, etc.) that is not improved after skilled assessment and proper management of breastfeeding , |
| c. Weight loss of 8-10% accompanied by delayed lactogenesis II (day 5 [120 hours] or later) |
| d. Delayed bowel movements or continued meconium stools on day 5 (120 hours) , |
| e. Insufficient intake despite an adequate milk supply (poor milk transfer) |
| f. Hyperbilirubinemia |
| i. “Neonatal” jaundice associated with starvation where breastmilk intake is poor despite appropriate intervention (please see ABM Jaundice in the Breastfed Infant Protocol) |
| ii. Breastmilk jaundice when levels reach > 20-25 mg/dL (mol/L) in an otherwise thriving infant and where a diagnostic and/or therapeutic interruption of breastfeeding may be helpful |
| g. When macronutrient supplementation is indicated |
| 2. Maternal indications |
| a. Delayed lactogenesis II (day 3-5 or later [72-120 hours]) and inadequate intake by the infant |
| i. Retained placenta (lactogenesis probably will occur after placental fragments are removed) |
| ii. Sheehan’s syndrome (postpartum hemorrhage followed by absence of lactogenesis) |
| iii. Primary glandular insufficiency, occurs in less than 5% of women (primary lactation failure), as evidenced by poor breast growth during pregnancy and minimal indications of lactogenesis |
| b. Breast pathology or prior breast surgery resulting in poor milk production |
| c. Intolerable pain during feedings unrelieved by interventions |
Recommendations
- 1.
Healthy infants should be put skin-to-skin with the mother immediately after birth to facilitate breastfeeding, , , because the delay in time between birth and initiation of the first breastfeed is a strong predictor of formula use. ,
- 2.
Antenatal education and in-hospital support can significantly improve rates of exclusive breastfeeding. Both mothers and health care providers should be aware of the risks of unnecessary supplementation.
- 3.
Healthy newborns do not need supplemental feedings for poor feeding for the first 24 to 48 hours, but babies who are too sick to breastfeed or whose mothers are too sick to allow breastfeeding are likely to require supplemental feedings.
- 4.
Hospitals should strongly consider instituting a policy regarding supplemental feedings to require a physician’s order when supplements are medically indicated and informed consent of the mother when supplements are not medically indicated. It is the responsibility of the health professional to provide information, document parental decisions, and support the mother after she has made the decision. When the decision is not medically indicated, efforts to educate the mother ought to be documented by the nursing and/or medical staff.
- 5.
All supplemental feedings should be documented, including the content, volume, method, and medical indication or reason.
- 6.
If mother-baby separation is unavoidable, established milk supply is poor or questionable, or milk transfer is inadequate, the mother needs instruction and encouragement to pump or manually express her milk to stimulate production and provide expressed breastmilk as necessary for the infant. , , ,
- 7.
When supplementary feeding is necessary, the primary goals are to feed the baby and also to optimize the maternal milk supply while determining the cause of poor feeding or inadequate milk transfer.
- 8.
Whenever possible, it is ideal to have the mother and infant room-in 24 hours per day to enhance opportunities for breastfeeding and hence lactogenesis. , , ,
- 9.
Optimally, mothers need to express milk each time the baby receives a supplemental feeding, or about every 2 to 3 hours. Mothers should be encouraged to start expressing on the first day (within the first 24 hours) or as soon as possible. Maternal breast engorgement should be avoided as it will further compromise the milk supply and may lead to other complications. ,
- 10.
All infants must be formally evaluated for position, latch, and milk transfer prior to the provision of supplemental feedings. , Most babies who remain with their mothers and breastfeed adequately lose less than 7% of their birth weight. Weight loss in excess of 7% may be an indication of inadequate milk transfer or low milk production. Although weight loss in the range of 8% to 10% may be within normal limits, if all else is going well and the physical exam is normal, it is an indication for careful assessment and possible breastfeeding assistance.
- 11.
The infant’s physician should be notified if:
- a.
The infant exhibits other signs of illness in addition to poor feeding.
- b.
The mother-infant dyad meets the clinical criteria in Table J-9 .
- c.
The infant’s weight loss is greater than 7%.
- a.
Choice of Supplemental Feeding
- 1.
Expressed human milk is the first choice for supplemental feeding, , but sufficient colostrum in the first few days (0 to 72 hours) may not be available. The mother may need reassurance and education if such difficulties occur. Hand expression may elicit larger volumes than a pump in the first few days and may increase overall milk supply. Breast massage along with expressing with a mechanical pump may also increase available milk.
- 2.
If the volume of the mother’s own colostrum does not meet her infant’s feeding requirements, pasteurized donor human milk is preferable to other supplements.
- 3.
Protein hydrolysate formulas are preferable to standard artificial milks as they avoid exposure to cow milk proteins, reduce bilirubin levels more rapidly, and may convey the psychological message that the supplement is a temporary therapy, not a permanent inclusion of artificial feedings. Supplementation with glucose water is not appropriate.
- 4.
The physician must weigh the potential risks and benefits of other supplemental fluids, such as standard formulas, soy formulas, or protein hydrolysate formula, with consideration given to available resources, the family’s history for risk factors such as atopy, the infant’s age, the amounts needed, and the potential impact on the establishment of breastfeeding.
Volume of Supplemental Feeding
Several studies give us an idea of intakes at the breast over time. In one study the mean yield of colostrum (using infant test-weighing) for over the first 24 hours after birth was 37.1 g (range, 7 to 122.5 g) with an average intake of 6 g per feed and six feedings in the first 24 hours. A similar study also using test-weighing revealed a mean intake of 13 g/kg/24 hours (range, 3 to 32 g/kg/24 hours) for the first 24 hours, increasing to a mean of 98 g/kg/24 hours (range, 50 to 163 g/kg/24 hours) on day 3 (by 72 hours). Yet another study noted breastmilk transfer of 6 mL/kg/24 hours for day 1 (24 hours), 25 mL/kg/24 hours for day 2 (48 hours), 66 mL/kg/24 hours for day 3 (72 hours), and 106 mL/kg/24 hours for day 4 (96 hours) in healthy, vaginally delivered infants allowed on-demand breastfeeding. Interestingly, the intake of infants delivered by cesarean section was significantly less during days 2 to 4 (within 48 to 96 hours). In a study where there was no rooming in and infants were fed every 4 hours, the average intake was 9.6 mL/kg/24 hours on day 1 and 13 mL/kg/24 hours on day 2 (48 hours). In most studies, the range of intake is wide, with formula-fed infants usually taking in larger volumes than breastfed infants.
- 1.
Infants fed artificial milks ad libitum commonly have higher intakes than breastfed infants. Acknowledging that ad libitum breastfeeding recapitulates evolutionary feeding and considering recent data on obesity in artificially fed infants, it can be concluded that such artificially fed infants may well be overfed.
- 2.
As there is no definitive research available, the amount of supplement given should reflect the normal amounts of colostrum available, the size of the infant’s stomach (which changes over time), and the age and size of the infant.
- 3.
Based on the limited research available, suggested intakes for term healthy infants are given in Table J-11 , although feeding should be by infant cue to satiation.
Table J-11
Average Reported Intakes of Colostrum by Healthy Breastfed Infants , , ,
Time
Intake (mL/feed)
1st 24 hours
2-10
24-48 hours
5-15
48-72 hours
15-30
72-96 hours
30-60
Methods of Providing Supplementary Feedings
- 1.
When supplementary feedings are needed there are many methods from which to choose: a supplemental nursing device at the breast, cup feeding, spoon or dropper feeding, finger feeding, syringe feeding, or bottle feeding.
- 2.
There is little evidence about the safety or efficacy of most alternative feeding methods and their effect on breastfeeding; however, when cleanliness is suboptimal, cup feeding is the recommended choice. Cup feeding has been shown safe for both term and preterm infants and may help preserve breastfeeding duration among those who require multiple supplemental feedings. , , , , ,
- 3.
Supplemental nursing systems have the advantage of supplying appropriate supplement while simultaneously stimulating the breast to produce more milk and reinforcing the infant’s feeding at the breast. Unfortunately, most systems are awkward to use, difficult to clean, expensive, and require moderately complex learning. A simpler version, supplementing with a dropper or syringe while the infant is at breast, may be effective.
- 4.
Bottle feeding is the most commonly used method of supplementation in more affluent regions of the world but is of concern because of distinct differences in tongue and jaw movements, differences in flow, and long-term developmental concerns. Some experts have recommended a nipple with a wide base and slow flow to try to mimic breastfeeding, but no research has been done evaluating outcomes with different nipples.
- 5.
An optimal supplemental feeding device has not yet been identified, and they may vary from one infant to another. No method is without potential risk or benefit. ,
- 6.
When selecting an alternative feeding method, clinicians should consider several criteria:
- a.
Cost and availability
- b.
Ease of use and cleaning
- c.
Stress to the infant
- d.
Whether adequate milk volume can be fed in 20 to 30 minutes
- e.
Whether anticipated use is short- or long-term
- f.
Maternal preference
- g.
Whether the method enhances development of breastfeeding skills.
- a.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
