IN BRIEF

When Should Breastfed Babies Be Supplemented?

August 27, 2020
Written by

Vanessa L. Shanks, MD, neonatologist and medical director of the Lactation program at Nationwide Children’s Hospital answers this commonly asked question.

This question has received increasing attention in the last several years, especially when considering supplementation for late preterm and early term babies. As more hospitals focus on promoting and supporting breastfeeding, supplementation rates have decreased for infants in the newborn nursery. However, there has been increasing awareness from primary care providers who may see these babies dehydrated and distressed just a few days later.

Supplementing a healthy newborn unnecessarily can be dangerous for breastfeeding success, but it is difficult to define what constitutes a healthy newborn, and that is why we have such great variability. In 2016, an article investigating reasons for supplementation in Croatia showed 49 percent of infants received supplementation in the first 48 hours and 85 percent of those babies were supplemented for potentially non-medical reasons (specifically, maternal perception of insufficient milk or a crying baby). While rates of supplementation in the United States have decreased, a study published in 2017 looking at delivery hospitals in New York showed persistent variability with supplementation rates from 2.3 to 98.3%.

The risks associated with supplementation have also escalated with increasing interest and research looking at the differences in the gut microbiome for exclusively breastfed infants compared with infants who receive even one bottle of formula. This area of research is still new, and the clinical significance of these differences remains unknown. 

Physicians and practitioners may recognize a 36-37 week infant to be at greater risk, but wait for the infant to show signs of distress to avoid the unnecessary supplementation for fear of sabotaging the breastfeeding relationship and affecting long-term health. Conversely, mothers are afraid to supplement knowing the risks of doing so, but do not realize their term-appearing 36-37 week infant may not be mature enough to efficiently breastfeed.

We are seeing more research now that will help guide us, particularly with regards to this vulnerable population. My own mantra is “Feed the Baby, Protect the Supply.” It is important for hospitals and physicians to work together to support the breastfeeding dyad. I think there are many instances, particularly in the late preterm-early term population, when supplementation is appropriate.

It is crucial, however, to emphasize the importance of pumping to help establish Mom’s milk supply when supplementation is occurring. Similarly, I think close outpatient follow-up is crucial — both pediatrician follow-up and lactation follow-up with a lactation consultant if possible.

It is also important to speak with expectant mothers prior to birth to prepare them for the possible complications associated with early delivery and the importance of close follow-up with their physicians and lactation specialists. It is helpful to identify mothers’ support systems before the baby is born, if possible, when they aren’t exhausted and desperate.

Below are links to publications that may help with context and more specific guidance in supplementing newborns: