ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017

Newborn physiology

Small quantities of colostrum are appropriate for the size of a newborn’s stomach, prevent hypoglycemia in a healthy, term, appropriate for gestational age infant, and are easy for an infant to manage as he/she learns to coordinate sucking, swallowing, and breathing. Healthy term infants also have sufficient body water to meet their metabolic needs, even in hot climates. Fluid necessary to replace insensible fluid loss is adequately provided by breast milk alone. Newborns lose weight because of physiologic diuresis of extracellular fluid following transition from intrauterine to extrauterine life and the passage of meconium. In a prospective cohort of mothers in a U.S. Baby-Friendly designated hospital with optimal support of infant feeding, the mean weight loss of exclusively breastfed infants was 5.5%; notably, greater than 20% of healthy breastfed infants lost more than 7% of their birthweight. A study of over 160,000 healthy breastfed infants resulted in the creation of hour-specific nomograms for infant weight loss for exclusively breastfed newborns that showed differentially increased weight loss in those born by cesarean section than by vaginal birth. In this study, almost 5% of vaginally born infants and >10% of those born by cesarean section had lost ≥10% of their birth weight by 48 hours after birth. By 72 hours, >25% of infants born by cesarean section had lost ≥10% of their birth weight. Breastfed infants regain birth weight at an average of 8.3 days (95% confidence interval: 7.7–8.9 days) with 97.5% having regained their birth weight by 21 days. Infants should be followed closely to identify those who lie outside the predicted pattern, but the majority of those breastfed infants will not require supplementation. It should also be noted that excess newborn weight loss is correlated with positive maternal intrapartum fluid balance (received through intravenous fluids) and may not be directly indicative of breastfeeding success or failure.

Early management of the new breastfeeding mother

Some breastfeeding mothers question the adequacy of colostrum feedings and perceive that they have an insufficient milk supply. These women may receive conflicting advice about the need for supplementation and would benefit from reassurance, assistance with breastfeeding technique, and education about the normal physiology of breastfeeding and infant behavior. Inappropriate supplementation may undermine a mother’s confidence in her ability to meet her infant’s nutritional needs and give inappropriate messages that may result in supplementation of breastfed infants at home. Introduction of infant formula or other supplements may decrease the feeding frequency of the infant, thereby decreasing the amount of breast stimulation a mother receives, which results in a reduction of milk supply.

Postpartum mothers with low confidence levels are very vulnerable to external influences, such as advice to offer breastfeeding infants supplementation of glucose water or infant formula. Well-meaning healthcare professionals may recommend supplementation as a means of protecting mothers from fatigue or distress, although this can conflict with their role in promoting breastfeeding. Several sociodemographic factors are associated with formula supplementation in the hospital, and vary geographically. It is important to recognize and address these factors in a culturally sensitive manner. Inappropriate reasons for supplementation and associated risks are multiple ( Appendix 1 Table A1 ).

There are common clinical situations where evaluation and breastfeeding management may be necessary, but SUPPLEMENTATION IS NOT INDICATED, including:

• 1.

  The healthy, term, appropriate for gestational age infant when the infant is feeding well, urinating and stooling adequately, weight loss is in the expected range, and bilirubin levels are not of concern (depending on gestational age, time since birth, and any risk factors).

  • Newborns are normally sleepy after an initial alert period after birth (~2 hours). They then have variable sleep–wake cycles, with an additional one or two wakeful periods in the next 10 hours whether fed or not.

  • Careful attention to an infant’s early feeding cues, keeping the infant safely skin-to-skin with mother when she is awake, gently rousing the infant to attempt frequent breastfeeds, and teaching the mother hand expression of drops of colostrum, may be more appropriate than automatic supplementation after 6, 8, 12, or even 24 hours.

  • Increased skin-on-skin time can encourage more frequent feeding.

• 2.

  Ten percent weight loss is not an automatic marker for the need for supplementation, but is an indicator for infant evaluation.

  • The infant who is fussy at night or constantly feeding for several hours

  • Cluster feeding (several short feeds close together) is normal newborn behavior, but should warrant a feeding evaluation to observe the infant’s behavior at the breast and the comfort of the mother to ensure that the infant is latched deeply and effectively.

  • Some fussy infants are in pain that should be addressed.

• 3.

  The tired or sleeping mother

  • Some fatigue is normal for new mothers. However, rooming out for maternal fatigue does not improve mothers’ sleep time and has been shown to reduce breastfeeding exclusivity. Extreme fatigue should be evaluated for the safety of mother and baby to avoid falls and suffocation.

  • Breastfeeding management that optimizes the infant feeding at the breast may make for a more satisfied infant AND allow the mother to get more rest.

The following guidelines address strategies to prevent the need for supplementation (also see Appendix 2) as well as indications for and methods of supplementation for the healthy, term (37- to 42-week), breastfed infant. Indications for supplementation in term, healthy infants are few. Table 1 lists possible indications for the administration of supplemental feeds. In each case, the medical provider must decide if the clinical benefits outweigh the potential negative consequences of such feedings.