Given new scientific data that exclusively breastfed newborns are in fact at significant risk for brain-threatening hypoglycemia, jaundice and dehydration, mothers are asking how they can supplement in the first days of life without compromising their long-term breastfeeding success. What they don’t realize is that supplemented breastfeeding in the first days of life transitioning into full breastfeeding or combination feeding was in fact the norm before the WHO/UNICEF Baby-Friendly exclusive breastfeeding guidelines. In fact, the historical evidence shows that all native breastfeeding countries, before the Baby-Friendly guidelines, supplemented their newborns with the milk of wet nurses, sugar water and other forms of liquid nutrition, also called “pre-lacteal feeds,” almost universally until a mother’s milk came in. The reasons for supplementation were to prevent newborn hunger, starvation, jaundice, dehydration and hypoglycemia. Despite widespread mother-led supplementation of newborns in places like Bangladesh, mothers successfully breastfed the vast majority of their babies up to one (98%) to two years (89%) of age. We used common sense to feed our babies and that is how we protected them in the first days of life and beyond. Sadly, since the publication of the exclusive breastfeeding guidelines, hospitalizations for jaundice and dehydration have steadily increased and are now the leading causes of newborn hospitalization worldwide.
Here is Dr. Brian Symon talking about supplemented breastfeeding in the early days and how to transition over to full or combination breastfeeding.
By Dr. Brian Symon, General (family) Practitioner, Adelaide, South Australia
My heart goes out to the mothers writing about their struggle to breast feed and in some cases, babies ‘failing to thrive‘. Landon Johnson’s story is a tragedy.
As a Family Physician my work is largely focused on the care of pregnant women and newborn babies.
My stance is very simple.
1. The ONLY logical reason for having a child is ‘the joy of parenting’.
We don’t do it because it’s easy.
We don’t do it for the “life style”.
We don’t do it for the “money”.
We do it for the deep joy of raising a child and seeing that baby thrive and develop.
If it’s not being joyful for the mothers whom I care for I want to change things so that the pleasure and joy returns.
2. Like all biological organisms. Like every plant and animal on the planet we need to grow. Growth can occur well, poorly, fail or be at a ‘biologically optimum’ rate.
My role includes watching babies closely and helping them achieve their optimums in every possible way.
3. Breast milk is a biological product.
Like every single biological variable like height, weight, hair colour, skin colour, IQ there are variables. That’s nature.
Breast milk production varies from woman to woman. That’s nature.
Some women produce large volumes of high energy density milk and some women, with the best will in the world, produce low volumes of low energy density milk. That’s nature.
As a result. For our society to tell every woman that she can ‘exclusively breastfeed’ makes as much sense as to tell every woman to aspire to being 6 foot tall. It is simply a biologically false statement which puts babies at risk.
As a doctor I watch my babies growth closely and modify the feeding regime in such a way that the baby, whose needs are paramount here, achieves their best possible growth.
My plan of care is quite simple. It can be used by any mother and can be freely modified to fit with your own feeding plans. The main aim is to give you permission to give supplemental feeds if in your opinion your baby is hungry after a breastfeed.
Supplemented Breastfeeding Until Full Milk Production
Day one of birth
AFTER a short breastfeed i.e. 5-15 minutes per breast, you may choose to supplement with safe, test donor milk or formula. My experience is that a shorter feed on day one works better. Certainly stop the feed if your baby is tiring. Overtiredness is the second most common cause of irritability after hunger at this stage.
Offer half to 2 ounces oz of milk and see how much the baby takes. Give it half an ounce at a time and burp after to prevent gas and regurgitation. Stop when baby declines. It is often quite a small volume but is usually very settling and allows the baby to begin to sleep.
Offer the supplementation after every feed. A rare mother may have their full milk supply on day one and may not need to offer any supplemental feedings.
The reasons for shorter feeding sessions are that it takes about three days for most mothers to achieve a milk flow that requires longer feeding sessions and these longer feeding sessions can cause a newborn to expend more calories than they receive. Secondly, I suggest shorter breast feeds initially to protect the nipples from pain and trauma. Thirdly, supplemental feeding helps prevent early low blood sugar, which newborns are susceptible to, particularly in the first days of life. Feel free to be flexible, but my experience has shown good outcomes for mother and baby with shortish early feeds.
Extend the breast feeds used on day one by 2-5 minutes extra time per side. Thus if you chose short feeds on day one i.e. say five minutes per side then increase this to something like 5-10 minutes per breast and offer the supplement as a “dessert” at the end of each feed. If you began with longer feeds say 15-30 minutes then the feeds stay at about the same length followed by the supplement.
Again the logic here is that the baby is wanting to grow or at the very least remain well hydrated and for the majority of women their milk flow has not been established by day two. Some women have ample milk and the baby may be well satisfied after a breast feed which is great but this is a little uncommon. Adjust the times as you see fit. The above is a gentle guide rather than hard and fast rules.
Remember that a major principle here is that we want to avoid low blood sugar and dehydration while waiting for your full milk flow to be established.
Breastfeed for a few more minutes per breast and offer supplementation as “dessert” at the end of each feed. If you chose longer feeds i.e. 15-30 minutes stay in that time frame but still offer the top up.
Often the mother’s milk has “come in” and there is a good supply.
Breast feed for 10-30 minutes per side and offer “dessert”. You may find that your milk supply has now established and the baby politely declines the formula.
Later days and weeks
Feed as you feel is appropriate at the breast. Try to limit feeds to 10-15 minutes per breast. If your nipples become sore or even begin to become sore, then shorten the breast feeds to no more than 10 minutes per side and offer supplementation. Prolonged suckling is the most common cause of sore nipples in my experience.
Offer formula or expressed breast milk as a “dessert” when you feel that it is needed.
Remember that your milk supply has a rhythm and is often lower in the evening and the baby may either cluster feed or need supplementation in the early evening. This is particular true for boys and even more true for boys who are going to be tall.
Interestingly my experience and other research shows that this technique of early supplementation increases breast feeding success rates at three months by about 50%. (1,2) I think the reason is that the trauma and difficulty of the first few days and weeks is removed and a mother’s confidence in her skills at breast feeding increases.
In 17 years of delivering babies in a country hospital, I never once readmitted a baby for dehydration, low blood sugars or poor weight gain.
I hope to help you feel confident and relaxed about your baby, your skills and your ability to breastfeed.
You have nourished your baby for every minute of every day for the last nine months. Do not stop now. If you suspect that your baby is hungry, you are the one who will protect them the most. Hunger and consequent hypoglycaemia and dehydration can be dangerous. Supplementing with correctly-prepared formula is NEVER dangerous. Trust your instincts and if you are worried about hunger, you may offer intermittent supplementation while you are breast feeding. Make sure you are always offering the breast first and use good technique to ensure that the breasts are empty. Pump the breasts for any missed feedings. You may also consider a pumping regime if you are seeking to increase your milk supply.
In terms of your baby’s long term physical and emotional well being, having a happy, confident and loving mother is vastly more important that the exact content of the feeding regime.
For more information please visit my website at http://www.thebabysleepdoctor.com.au/
Dr. Brian Symon
- Breast feeding retention rates and supplementary feeds.
Symon B, Marley J.
J R Soc Med. 1994 Nov;87(11):721. No abstract available.
- Effect of Early Limited Formula on Duration and Exclusivity of Breastfeeding in At-Risk Infants: An RCT. Valerie J. Flaherman, MD, MPH, Janelle Aby, MD, Anthony E. Burgos, MD, MPH, Kathryn A. Lee, RN, PhD, Michael D. Cabana, MD, MPH, and Thomas B. Newman, MD, MPH. Pediatrics. 2013 Jun; 131(6): 1059–1065. PMCID: PMC3666109
For more information on how to protect your baby from feeding complications due to early exclusive breastfeeding, please read and download the Fed is Best Feeding Plan, a way to communicate your feeding choices to your health care providers.
In addition, please read and download the Fed is Best Weighing Protocol to prevent newborn dehydration and failure to thrive.
Lastly, for more detailed information, please watch our educational videos on Preventing Feeding Complications.
Our full list of parent resources can be found on our Resource Page.
Disclaimer: This document does not replace in-person physician evaluation and treatment. This document is meant to inform parents of the most recent data regarding infant feeding and to increase their knowledge on how to protect their newborns from hyperbilirubinemia, dehydration, hypernatremia, hypoglycemia and extended or repeat hospitalizations due to complications from underfeeding. Earlier supplementation may be needed for babies who are premature or have medical conditions. It is recommended that a parent seeks evaluation by a pediatrician for any concerns regarding the health and safety of her baby if they arise.