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When Supplementation of a Breastfed Newborn Is Medically Necessary

Reasons for supplementation; nipple confusion

When Supplementation of a Breastfed Newborn Is Medically Necessary Sometimes, parents who are highly motivated to breastfeed will become alarmed when their baby's doctor prescribes formula supplement. They wrongly fear that their chances of breastfeeding will be ruined if their baby gets any formula. I have witnessed distressing power struggles between well-meaning parents and physicians over the matter. This always make me sad because parents and health professionals should be joint advocates for their child, never adversaries. Please understand that judgments about supplementing a baby are difficult to make. Giving some formula sometimes becomes necessary when a baby is premature, has low blood sugar, loses excessive weight after birth, or has severe jaundice. Ask your baby's doctor to explain the reasons why she recommends supplement for your baby and how long she expects it to be needed. Make it clear that breastfeeding is important to you, and request expert help for working out any breastfeeding problems that either contribute to the need for supplement or result from its use. With such assistance, chances are excellent that, even if your baby does require supplemental milk temporarily, you eventually will be able to breastfeed exclusively.

Nipple Confusion
Much has been written about the popular belief that early bottle-feeding of breastfed infants will result in "nipple confusion." Stories abound of babies who were exposed to bottle-feeding before breastfeeding was well established and who then displayed a preference for bottle-feeding over breastfeeding. A typical scenario goes something like this: An infant nurses well right after delivery, then stays in the nursery at night where she is fed by bottle one or more times. The next morning the baby fusses and frets at the breast, acts like she doesn't know what to do, and will not latch on to nurse. However, when offered a bottle, the baby takes it eagerly.

Having heard these stories, some parents become convinced that even a single bottle feeding during the early weeks of life will seriously jeopardize their breastfeeding attempts. Such parents may be hesitant to provide supplemental milk to their babies even when a valid medical reason exists because they fear that nipple confusion inevitably will result. However, the notion that a single bottle is likely to cause subsequent difficulty with breastfeeding never has been proved. Many breastfed infants receive one or more supplemental feedings by bottle during the first week of life, and yet go on to breastfeed exclusively. Other infants, including some whose mothers work outside the home, accept a bottle readily when the mother is absent and resume breastfeeding without apparent difficulty when the mother returns.

My own conclusion is that nipple confusion does occur in some, but certainly not all, babies. I think newborns are more susceptible than older babies to the negative effects of bottle-feeding because they are just learning to breastfeed and the volume of colostrum they obtain is relatively low. If a new baby who doesn't yet breastfeed well is allowed to take a bottle, he may perceive the longer and more rigid artificial nipple that yields a higher volume of fast-flowing milk to be easier and more rewarding than attempts at the breast. I also believe, however, that it is possible to predict which babies are more susceptible to nipple confusion. Anything that interferes with correct attachment to the breast or the free flow of milk from the breast is likely to make a baby prefer bottle-feeding to breastfeeding. Thus, the baby who is having difficulty attaching due to his mother's flat nipples and who obtains little milk due to her low supply will be more vulnerable to nipple confusion if allowed to bottle-feed than another infant who has nursed well numerous times and whose mother has protuberant nipples, with a generous, free-flowing milk supply. The important thing to remember is that even when bottle-feeds have caused a baby to nurse less well, all is not lost. By adhering to the basics of proper breastfeeding technique, using a pump to assure your own supply of milk remains abundant (see pages 124-125), and obtaining help from a breastfeeding specialist, you still can expect your baby to learn to nurse correctly and to breastfeed exclusively.

Options for Providing Necessary Supplemental Milk to Breastfed Babies
By far, the most common method for giving a breastfed baby supplemental milk is to use a bottle and nipple. Most parents and many health professionals are unaware that other options exist for feeding milk to a baby. If supplemental milk is necessary and you want to avoid bottle-feeding, ask your baby's nurse if one of these alternative methods is available in your hospital.

SNS device; supplement typesSupplemental Nursing System (SNS)
If your baby can latch on and breastfeed but requires supplemental milk for a legitimate medical reason, it is possible to feed the supplement while your baby nurses at the breast by using the SNS device. This method causes no disruption of nursing and actually enhances breastfeeding by giving the baby an immediate reward for her efforts. Convenient starter SNS kits are available for short-term use. Ask whether the lactation specialist at your hospital or one of the newborn nurses has experience using the SNS and could assist you. The SNS works best when a baby has learned to latch on correctly to the breast, but still requires additional milk. Babies with significant latch-on problems may not be able to correctly grasp the SNS tubing while taking the breast.

Cup, spoon, dropper, syringe. In other parts of the world, newborns who require supplemental milk frequently are fed by cup or other method that avoids the use of bottles. Some experts claim that alternative feeding methods are preferable to bottle-feeding, especially when a baby who does not yet know how to breastfeed effectively requires supplemental milk. Cup feeding is not difficult and several options exist, ranging from one-ounce plastic medicine cups available in every hospital to specially made cup-feeding devices designed for supplementing breastfed newborns. Inquire whether one of these methods might be used to give your baby the prescribed supplement and ask that the technique be taught to you.

To cup feed, the baby is held upright and the brim of the cup rests gently on the lower lip. The cup is tipped slightly so the milk just touches the baby's lips. The milk is not poured! Rather, the infant is allowed to lap and then sip the milk at his own pace.

Because babies need to suck, both for comfort and for proper development of the oral structures and speech, I don't advocate cup feeding for the long term. Rather, I see it as a temporary method of giving necessary supplement that is unlikely to interfere with learning to breastfeed. Once a mother's milk increases in abundance, supplement may no longer be necessary if a baby has learned to nurse effectively.

A baby also can be fed with a plastic spoon used in a similar manner to a cup. Some health care providers use an eyedropper to feed milk the same way oral medications are given to a baby. Others have experience feeding newborns with a regular syringe (without the needle, of course) or a periodontal syringe that has a curved plastic tip. If your baby needs supplement, and you prefer a bottle not be used, one of these options might be suitable when an SNS is not available. Don't try using any of these alternative methods yourself without receiving firsthand supervision from a health professional experienced in their use.

Deciding What Type of Supplemental Milk to Use
A mother's own expressed breast milk makes the ideal supplement. You may be able to obtain sufficient colostrum or milk using a hospital-grade electric breast pump. If a larger volume of milk is needed than can be expressed, formula will be necessary (unless you are fortunate enough to have access to screened, processed donor breast milk from a milk bank. If formula becomes necessary for your baby while in the hospital, deciding which one to use can leave your head spinning. Ideally the decision would be made jointly with your baby's doctor and based on your family history of allergies and other medical factors. Hopefully, only a minimal amount of supplement will be necessary until your own milk increases in volume. In addition to the multiple brands of cow's milk-based infant formula available in the United States, several soy-based options also exist. However, soy formula has no advantage over cow's milk-based formula for supplementing breastfed infants and has no proven value in preventing allergies. When a strong family history exists for allergic disease, such as food allergies, asthma, or eczema, I prefer to use a hypoallergenic formula, despite its extra expense. When one or more family members has allergic disease, it becomes especially desirable for mothers to breastfeed as long as possible. A lactose-free, cow's milk-based formula also is available. However, I see no advantage to avoiding lactose in a breastfed baby, since breast milk itself contains the milk sugar, lactose.