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7.3 Supplementation

Baby Friendly Point 5 and Step 6

Step 6 of the Ten Steps to Successful Breastfeeding, and Point 5 of the Seven-point Plan for Sustaining Breastfeeding in the Community state:
Step 6: Give newborn infants no food or drink other than breastmilk, unless medically indicated.
Point 5: Encourage exclusive and continued breastfeeding (beyond six months) (to two years or more), with appropriately-timed introduction of (adequate and safe) complementary foods.

In-hospital breastmilk substitutes

Breastmilk substitutes (including infant formula, water or glucose water) interfere with the infant's ability to learn to breastfeed and the establishment of lactation. There is a significantly higher rate of premature weaning amongst mothers whose infant's were given breastmilk substitutes in the early postnatal days. 1 2

Colostrum is essential for gut protection, growth and repair as well as the establishment of the bifidobacterium environment. Colostrum aids the expulsion of meconium which reduces enterohepatic circulation of bilirubin.

Breastmilk substitutes impair these processes. They also fill the infant's stomach lessening the urge to breastfeed. As a result, breastmilk intake is minimal ...

  • increasing breastfeeding problems, 3
  • decreasing the likelihood of a return to exclusive breastfeeding
  • decreasing the duration of breastfeeding, 3 4 5 1 and
  • the cycle of delayed initiation of lactation has the propensity to cause further use of breastmilk substitutes. 6

Reasons proferred for the giving of post-breastfeed supplements, or additional bottles of water, glucose water or artificial infant milk have included:

  • the infant is sleepy and has not had 8 feeds in the first 24 - 48 hours (see 7.2 Breast refusal for how to manage this)
  • to give the mother a rest
  • because the mother doesn't have her milk 'in' yet
  • to calm a crying infant
  • to prevent hypoglycemia
  • to reduce jaundice, or to prevent dehydration in a baby under phototherapy lights

None of these reasons are indications for giving supplements, with some having the opposite effect to the result desired.

Medical indications for supplementation

The World Health Organization states that there are few medical indications that may require individual infants to be given fluids or food in addition to, or in place of, breastmilk. Whenever stopping breastfeeding is considered, the risks of infant formula feeding and the benefits of breastfeeding should be weighed against the risks posed by the presence of the specific condition listed. The following circumstances may be considered:

Infant conditions:

  • These infants should receive only specialized infant formula:
    • infants with specific inborn errors of metabolism; eg classic galactosemia, maple syrup urine disease, phenyloketonuria (some breastfeeding possible with careful monitoring)
  • These infants should continue to receive breastmilk, but may require other food in addition for a limited time:
    • infants with very low birth weight (<1500g) or who are born preterm (before 32 weeks gestational age)
    • infants at risk of hypoglycemia due to impaired metabolic adaptation or increased glucose demand and who fail to respond to optimal breastfeeding or breastmilk feeding (eg. prematurity, small for gestational age, have experienced significant intrapartum hypoxic stress, or are ill or mother is diabetic)

Maternal conditions:

  • HIV infection. Individualized assessment required that includes the availability of counseling and support, and that infant formula feeding will be acceptable, feasible, affordable, sustainable and safe (AFASS). (See topic 8.5 Medical and Surgical Issues for managment of maternal HIV)
  • Temporary infant formula feeding may be necessary when
    • the mother is taking medication which is contraindicated when breastfeeding, and for which there is no safe alternative. Rarely are there no safe alternatives, however cytotoxic chemotherapy is one example.
    • the mother abuses drugs such as heroin, cocaine, amphetamines, cannabis, alcohol etc. Seek individual counseling for mothers in these instances to assess their dependency and the needs of their infant.

Adapted from ExternalWHO/UNICEF: Acceptable medical reasons for use of breast-milk substitutes. 2009

Protect breastfeeding

When breastfeeding is temporarily delayed or interrupted for any reason

Supplementing the breastfed infant

When breastfeeding alone is insufficient or temporarily inappropriate, the choice of supplement should be, in order of preference:
  1. The mother's own expressed breastmilk, if it is available and suitable.
  2. Donor breastmilk - from another healthy mother or human milk bank
  3. Protein hydrolysate formula. This type of formula is preferable to standard formula for the breastfed infant as it is hypoallergenic, reduces bilirubin levels more rapidly 7 and is more likely to be seen by the parents for what it is - a temporary medicine until such time as the infant can resume exclusive breastfeeding.

How much supplement should be given?

Your goal is to give the infant as much as he would normally have taken at the breast. ie 2 - 10ml per feed in the first 24 hours; 5 - 15ml per feed in the second 24 hours; 15 - 30ml between 48 and 72 hours of age and 30 - 60ml from 72 - 96 hours of age. (refer to the table found in 6.2 Breastfeeding Messages )

How should this supplement be given?

Tube-device at the breast, cup feeding, finger-feeding, syringe feeding, spoon feeding, dropper feeding and bottle feeding are all alternatives available, with bottle feeding being the least desirable and is unacceptable in Baby Friendly organisations.

The following methods are detailed in the following pages.

Feeding-tube device at the breast

Cup feeding

Finger feeding

Bottle feeding (this topic includes a Competency form)

What effect do supplements have?

The WHO strategy states that infants who are not breastfed should receive special attention from health systems as they constitute a group at risk for growth and health problems.

Review 1.0 Why Breastfeeding is Important to refresh your memory regarding the short- and long-term effects of infant formula feeding.

Short-term effect on the mother

A loss of maternal self-confidence occurs when supplements are given without a valid medical indication. 8

The reduced breast stimulation and reduced milk removal that occurs as a result of the infant being given supplements results in

  • an increased incidence of breast engorgement, and
  • more severe engorgement, which can cause breast involution and the failure of adequate lactation. Early, frequent milk removal is pivotal to the success of breastfeeding in the coming weeks.
  • shorter duration of lactational amenorrhoea 9

Short-term effect on infant health

Infant ability to suck at the breast can be disturbed as s/he learns a different sucking technique.10

Supplements change the normal flora of the intestine, 11 12 increase gut permeability and decrease gut mobility.

Artificial infant milk can be contaminated during manufacture and preparation, and the feeding implements can introduce another source of infection. 13

Protective properties in breastmilk, such as lactoferrin, are inactivated by artificial infant milk. 14

Effect on digestion and absorption

Artificial infant formula is poorly digested and absorbed compared to breastmilk as

  • there is a normal immaturity of digestion and absorption at birth
  • breastmilk contains enzymes to aid digestion (eg lipase) that are not in infant formula
  • breastmilk macronutrients are in easily digested form, unlike the macronutrients in infant formula
  • absorption of minerals is enhanced by breastmilk 'transporters'
Effect on serum glucose levels

Serum glucose levels normally drop to their lowest levels at about 2 hours of age, stimulating the infant's physiology to mobilize other sources of energy ensuring a euglycemia is achieved and maintained for up to 24 hours, irrespective of oral intake.15
Giving babies glucose water or artificial infant formula interferes with this normal physiological process and may result in further interventions being required.

Effect on jaundice

Likewise the normal physiology of bilirubin metabolism is interrupted when artificial supplements are given. Reduced breastfeeding frequency and supplementation with water or glucose water have been associated with increased serum bilirubin concentrations in the first 5 days of life.16 Lack of early feeding delays passage of meconium and increases enterohepatic re-absorption of bilirubin.

Increased breastfeeding is the best way to treat the additional insensible water loss that is caused when phototherapy is required.17

Effect on atopic disease

Even just one or two artificial baby milk feeds at this time may result in the development of cow's milk intolerance or cow's milk allergy, which will become symptomatic later in infancy.18,19

Effect on breastfeeding

The use of supplements during the hospital stay (and afterwards) is closely associated with

earlier cessation of exclusive breastfeeding and earlier weaning.2 20 21

Breastfeeding is negatively affected when formula is used, even in hospitals where educational materials, counseling, support and policies are generally favorable to breastfeeding. Research was conducted in a unit where nursing staff attitudes regarding breastfeeding were very positive with more than 80% reporting discussing the advantages of breastfeeding routinely with mothers.22 However, 77% of mothers had started bottle-feeding 2 to 3 weeks after birth, the majority (93%) remembered which brand of formula was used to supplement their baby in hospital and most were using that brand.

Parents may interpret the use of formula as an endorsement by hospital staff, despite clear verbal messages promoting breastfeeding.

But the mother requested a supplement ...

Lack of understanding of normal newborn behavior, volume of breastmilk required in the early days and maternal fatigue are the major reasons mothers give for requesting a supplement.
Education about newborn behavior and the importance of giving their infant only breastmilk change parental expectations and decrease requests for supplements.

But what about maternal fatigue ...

Time for some brainstorming!

Brainstorm with your colleagues ways of supporting a tired mother in hospital who has requested a supplement, or who, in the community setting, is wanting to give supplements to change her baby's behavior.

Human Immunodeficiency Virus (HIV)

  • Exclusive breastfeeding to 6 months of age, combined with antiretroviral therapy has a low risk of mother-to-child transfer of HIV. 23 24 25 26

Exposure to cow's milk protein and other foods damages the permeable infant gut allowing transfer of the HIV virus. 27 Unless it is known, without doubt, that a mother is HIV negative then there is a likelihood the baby may suffer serious morbidity and eventual mortality from giving a breastfed infant just one supplementary bottle.

Workbook Activity 7.6

Complete Activity 7.6 in your workbook.

Unit Activity

Review your Unit's policy on supplementation AND common practices of the staff. Ensure that there are very clear policy guidelines for when a supplement is medically indicated. Discuss with your colleagues the implications for them, the mother and the baby should they not follow this policy.

Do you have an "Informed Consent" form to ensure mothers are aware of the dangers of infant formula?

Extend your knowledge

Click on the icon or wording above to open and read the Protocol for the Hospital Guidelines for the use of Supplementary Feedings.
Print it out and file it in your Workbook.

What should I remember?

  • the medically valid reasons for the use of breastmilk substitutes
  • the best choice of supplement when indicated, in order of preference
  • how best to give a supplement when it is required
  • how much supplement to give according to the age of the infant
  • the effects of supplements on the infant's health, the mother and their ongoing breastfeeding relationship
  • be aware of the legal implications of giving infant formula with no valid medical indication
  • safe preparation of infant formula

Self-test quiz

Notes

  1. # Lakati AS et al. (2010) The effect of pre-lacteal feeding on full breastfeeding in Nairobi, Kenya.
  2. # Parry JE et al. (2013) Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns.
  3. # Isenalumhe AE et al. (1987) Prelacteal feeds and breast-feeding problems.
  4. # Hossain MM et al. (1992) Prelacteal infant feeding practices in rural Egypt.
  5. # Pérez-Escamilla R et al. (1996) Prelacteal feeds are negatively associated with breast-feeding outcomes in Honduras.
  6. # Ahmed FU et al. (1996) Prelacteal feeding: influencing factors and relation to establishment of lactation.
  7. # Gourley GR et al. (1992) The effect of diet on feces and jaundice during the first 3 weeks of life.
  8. # Gagnon AJ et al. (2005) In-hospital formula supplementation of healthy breastfeeding newborns
  9. # McNeilly AS (2001) Neuroendocrine changes and fertility in breast-feeding women
  10. # Howard CR et al. (2003) Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding
  11. # Edwards CA et al. (2002) Intestinal flora during the first months of life: new perspectives.
  12. # Guaraldi F et al. (2012) Effect of breast and formula feeding on gut microbiota shaping in newborns.
  13. # Holy O et al. (2014) Cronobacter spp. as emerging causes of healthcare-associated infection.
  14. # Wharton BA et al. (1994) Faecal flora in the newborn. Effect of lactoferrin and related nutrients
  15. # Eidelman AI (2001) Hypoglycemia and the breastfed neonate
  16. # Gartner LM (2001) Breastfeeding and jaundice
  17. # de Carvalho M et al. (1981) Effects of water supplementation on physiological jaundice in breast-fed babies
  18. # Wegienka G et al. (2006) Breastfeeding history and childhood allergic status in a prospective birth cohort
  19. # MacIntyre EA et al. (2010) Early-life otitis media and incident atopic disease at school age in a birth cohort.
  20. # Chantry CJ et al. (2014) In-Hospital Formula Use Increases Early Breastfeeding Cessation Among First-Time Mothers Intending to Exclusively Breastfeed.
  21. # Biro MA et al. (2011) In-hospital formula supplementation of breastfed babies: a population-based survey.
  22. # Reiff MI et al. (1985) Hospital influences on early infant-feeding practices.
  23. # Thakwalakwa C et al. (2014) Growth and HIV-free survival of HIV-exposed infants in Malawi: A randomized trial of two complementary feeding interventions in the context of maternal antiretroviral therapy.
  24. # Horvath T et al. (2009) Interventions for preventing late postnatal mother-to-child transmission of HIV.
  25. # Iliff PJ et al. (2005) Early exclusive breastfeeding reduces the risk of postnatal HIV-1 transmission and increases HIV-free survival.
  26. # Coovadia HM et al. (2007) Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.
  27. # Smith MM et al. (2000) Exclusive breast-feeding: does it have the potential to reduce breast-feeding transmission of HIV-1?