Supplementing milk, whether with breast milk and/or commercial formula milk, is recommended in certain circumstances when milk transfer is poor or when the mother decides to do so. However, we often still find that healthcare professionals recommend supplementing without an appropriate reason, making it difficult for the mother to establish and maintain breastfeeding.

What is supplementing milk?

It is understood as administering a variable quantity of milk that is offered to the baby once or several times a day after the usual feed at the breast. Its purpose is to promote or recover weight gain.

When supplementing with milk is necessary

There are infant-related and maternal circumstances where the need for supplementation is indicated.

• Infant related indications:
  • Newborn with hypotonia, unable to obtain milk by own means due to prematurity (<32 weeks of gestation) or low birth weight (<1500g).
  • More than 10% of weight loss in the first days of life compared to weight at birth.
  • Delayed lactogenesis II along with an 8-10% decrease in weight compared to weight at birth.
  • Asymptomatic hypoglycemia despite frequent feeds at the breast: this must be confirmed by a laboratory blood glucose test. In case of symptomatic hypoglycemia, intravenous glucose administration is necessary. This point is controversial, and there are differences in the approach according to the scientific societies of reference.
  • Hyperbilirubinemia that needs treatment
• Indications related to the mother:
  • Primary glandular insufficiency
  • Secondary glandular insufficiency, for example, due to a thyroid pathology
  • Breast disorders or previous breast surgery leading to an objectifiable deficient milk supply
  • Temporary interruption of lactation due to certain medications (please see www.e-lactancia.org)
  • Unbearable pain during feeds
  • The mother’s decision

Supplementing milk during lactation may affect the natural lactation cycle of the mother-newborn dyad. Therefore, if you suspect the need to recommend supplementing, first, a good examination of the newborn, observation of an entire feed at the breast, assessing posture, positioning, and latch are necessary. Then, appropriate proposals for modifications should be made, followed up by monitoring to see if the situation improves.

There are times during lactation when some women question and doubt their own milk supply. In these cases, an approach of active listening and information is key to reassure the woman and improve her breastfeeding experience.

Supplementing milk is a bridging strategy until milk transfer is restored, and the baby can be breastfed exclusively by the mother if this is her wish and if the cause is not irreversible.

Choice of milk supplement

Freshly expressed breast milk is the first choice for infant supplementation. In this case, it is important to explain the techniques for expressing and storing milk to ensure that she has understood the information and that she is able to perform it in an optimal way. If the volume of expressed milk is not enough for the infant’s needs, donor breast milk could be offered. According to the WHO, commercial formula milk is the last option to be offered when supplementation is needed.

Methods for milk supplementing

There are several supplementing methods to offer milk to an infant. It is advisable to explore all of them with the family to choose the best option according to their individual needs, situation and preferences:

• The finger-syringe technique
• finger-tube feeding
• Cup or toddler sippy cup
• Spoon
• Bottle feeding
• Supplemental nursing system

Regardless of the chosen method, all supplementing techniques require a slow flow appropriate to the infant’s sucking-swallowing rhythm, and the infant’s hunger and satiety cues must be observed to recognize the optimal time to offer the baby milk. It is important to note that no method is risk-free or beneficial to breastfeeding.

Monitoring of milk supplementing

It is important to accompany families offering supplementing to their infants and closely monitor them to adjust the amount of milk needed according to the situation and weight of each infant. Likewise, support continues to be necessary for the event that a woman decides to return to exclusive breastfeeding, guiding her through the relactation process to increase breast milk supply and reduce supplementing amounts.

 

References

1. ABM Clinical Protocol num.3: Supplementary Feedings in the Healthy Term Breastfed Neonate (2017). https://www.bfmed.org/assets/DOCUMENTS/PROTOCOLS/3-supplementation-protocol-english.pdf

2. Whipps MDM, Yoshikawa H, Demirci JR, Hill J. Estimating the Impact of In-Hospital Infant Formula Supplementation on Breastfeeding Success. Breastfeed Med. 2021 Jul;16(7):530-538. doi: 10.1089/bfm.2020.0194. Epub 2021 Jun 10. PMID: 34115545.

3. Parry JE, Ip DK, Chau PY, Wu KM, Tarrant M. Predictors and consequences of in-hospital formula supplementation for healthy breastfeeding newborns. J Hum Lact. 2013 Nov;29(4):527-36. doi: 10.1177/0890334412474719. Epub 2013 Feb 25. PMID: 23439865.