Supplemental Feeds for Breastfed Babies During the First Month
After Birth:Who Needs It, How Much and For How Long
September 2005
As pediatricians, we are partners with the families for which we care. Our shared goal is to raise as healthy a child as possible. One of our first responsibilities is to encourage and support a mother’s choice to breastfeed while maintaining her baby’s overall health.
Breastfed babies are at risk for hypernatremic dehydration. Until the last ten years, pediatricians rarely saw this condition in neonates as almost all babies were bottle-fed formula or supplemented. Several literature articles delineate this rise in the incidence of dehydration.(1,2,3,4) Oddie et al estimate an incidence of about 7.1 per 10,000 breastfed newborns or 22.3 per 10,000 breastfed newborns of first-time mothers.
The American Academy of Pediatrics (AAP) recommends that no supplemental feedings of any kind be given unless medically indicated.(5) The use of supplements has been shown to increase breastfeeding problems and decrease breastfeeding duration.(6,7,8,9,10) In the 521 newborns studied by Blomquist et al, infants who had received supplements in the hospital were 3.9 times less likely than infants who had not received supplements to still be breastfeeding at three months of age. Many of the benefits of breastfeeding are increased with longer duration. While we should discourage the use of “convenience bottles,” we should not hesitate to give supplemental feedings when indicated.
Maintaining adequate nutrition and fluid intake will prevent dehydration. Intake is monitored with several parameters. These measurements are taken into consideration along with the baby’s overall health status to determine whether or not supplemental feeds are indicated. The recommendations below assume that the only issue is nutrition and fluid intake, and that the baby is normal in all other respects:
When supplementation should be considered:
- If there is > 8% weight loss in the first 48 hours after birth
- If there is > 10% weight loss in the first week after birth
- If birth weight has not been regained by 14 days after birth
- If there is < 20 grams of weight gain (on average) per day once birth weight has been regained
- If stool and urine output do not meet the following criteria:
Time After Birth Stool (minimum) Urine (minimum number) By 24 hours 1 dark 1 24-48 hours 1 dark 2 48-72 hours 2 dark - transitional 2 4 days 2 transitional - yellow 4 5 days 2 yellow 5 6 days+ 2 yellow 6
Things to check before introducing supplemental feeds:
- Is the baby nursing frequently enough (minimum 8x/24 hours)?
- Is the baby latching on properly and able to remove milk from the breast?
- Does the mother or baby have anatomic or medical conditions (i.e. breast surgery, retained placenta, OCPs, neurological deficits) that may affect milk production or successful nursing?
- Is the mother’s milk production on schedule? Has she worked with a lactation consultant?
How much supplementation should be given?
- Supplements are given in addition to what the baby takes from the breast. Normal nursing should be encouraged if at all possible.
- The newborn’s stomach is small and his/her nutritional requirements are low. Even non-breastfeeding babies need only 10-15 mls every 3 hours in the first 24 hours after birth to meet daily requirements. Do not feed the baby too much in order to avoid stretching the stomach.
- Small supplementation amounts may get a baby “over the hump” to attain weight/output goals.
- Consider starting supplementation with 10-30ml/kg/day divided over several feedings. Increase the amount given if goals are not being attained.
- “Test weights” (weighing the baby before and after feeds using a scale accurate to 2 grams) can be used to measure milk intake from the breast. This amount can then be used to estimate the baby’s total daily intake and help determine how much supplemental volume is needed.
- Supplement with pumped breast milk rather than formula if at all possible.
- Follow the baby’s progress very closely (every 24-48 hours) until weight goals are being met. Adjust supplemental plan accordingly.
How long should supplements be given?
- Have a specific goal to achieve. Once the goal has been met, reduce supplemental volumes over a few days prior to stopping to be sure goals are maintained.
- Continue to follow the baby’s progress closely over the next few weeks to be sure supplementation does not need to be reinstituted.
Other things to remember:
- Supplementation can negatively affect breastfeeding success. Be sure there is a clear medical need for supplementation. Discourage "convenience bottles."
- Explain to the family your concerns and goals. The need for supplements is usually temporary and does not mean the mom is a breastfeeding failure, nor is it her “fault.”
- Prescribe supplements as you would a medication — specify a dose, frequency and duration to treat a specific condition. Once the condition is cured, stop the treatment. If the baby does not respond to treatment within a short period of time, the treatment must be adjusted.
- Consider involving a lactation consultant to address underlying problems.
- Protect the mother’s milk supply while supplementing through the use of a breast pump.
- If a baby is severely dehydrated or undernourished, a more aggressive approach is indicated. Lab tests, unlimited supplemental feeds or hospitalization should be used as warranted.
References
1. Oddie S et al, Archives of Disease in Childhood 85(4): 318, 2001
2. Laing IA and CM Wong, Archives of Diseases in Childhood, Fetal Neonatal Ed 87:F158, 2002
3. Escobar JE et al, Arch Pediatr Adol Med 156:155, 2002
4. Manganaro R et al, J Pediatrics 139:673, 2001
5. AAP Policy Statement, Pediatrics 115(2):496, 2005
6. Feinstein JK et al, Pediatrics 78:210, 1986
7. Hill PD et al, Clin Pediatrics 36:345, 1997
8. Kurinij N et al, Pediatrics 88:745, 1991
9. Loughlin W et al, Pediatrics 75:508, 1985
10. Blomquist HK et al, Acta Paediatrica 83(11):1122, 1994
This information provided by David A. Lee, M.D. and the Division of Neonatology
Tel. (415) 600-6211
- Is the baby nursing frequently enough (minimum 8x/24 hours)?