Routine formula supplementation of breastfed newborn babies may negatively impact on the successful initiation of breastfeeding and on the duration of exclusive breastfeeding. Supplementation may reduce the frequency of breastfeeding, contributing to engorgement in the first few days, decreased milk production and decreased maternal confidence. Supplementation with infant formula may also significantly alter the intestinal microbiome of the newborn.

There are some circumstances when supplementation of breastfeeds with expressed breastmilk and/or formula may be medically required or requested by parents. This guideline outlines the use of supplementary feeds for newborn breastfed babies for medical indications or parental request.

The objectives of this guideline are to:

• Guide the provision of nutritional support to both well and unwell newborn babies while lactation is being established.

• Prevent hypoglycaemia, excessive weight loss, hypernatraemic dehydration and any other complications related to delayed or suboptimal onset of lactation.

• Minimise the non-medically indicated use of formula supplementation for newborn babies.

• Assist staff to implement evidence based strategies that will support the successful establishment of lactation.

• Promote maternal confidence in breastfeeding.

Supplementary feed: one or more feeds of expressed breastmilk or infant formula given to a breastfed baby in addition to breastfeeding.

EBM: expressed breast milk

This guideline is not relevant when an infant is being exclusively formula fed.

Initiation of supplementary feeds
Supplementary feeding is most commonly initiated in the early postnatal period for medical reasons. When this occurs, the mother should be provided with appropriate support to establish and continue breastfeeding. A full assessment of breastfeeding should be undertaken.

Sometimes supplementary feeding may be initiated for non-medical reasons at the parents' request. Exploration of the reasons for this request and information about how supplementary feeds may affect breastfeeding should be provided. Consideration of other options such as use of expressed breastmilk and a full assessment of breastfeeding should all be undertaken.

Babies admitted to Paediatric and Adolescent Unit

This guideline primarily relates to babies admitted to the Postnatal Ward or Special Care Nursery, however it may also be applied to babies admitted to Paediatric and Adolescent Unit during the newborn period (first 28 days of life).

Written consent for supplementation with infant formula should be obtained if a baby admitted to Paediatric and Adolescent Unit is less than 4 weeks old and has been exclusively breastfed from birth. See section 4 Use of infant formula and written parent consent

Preventing the need for early supplementation

Practices that may prevent or minimise the need for early supplementation include:

• Antenatal education of parents about normal breastfeeding and newborn behaviours.

• Offering additional antenatal breastfeeding counselling and information to parents who may be more likely to request non-medically indicated formula supplementation.

• Antenatal expression of colostrum from 36 weeks where appropriate, particularly for women with higher risk pregnancies.

• Early initiation of breastfeeding or breastmilk expression.

• Early and prolonged skin-to-skin contact to minimise hypoglycaemia and hypothermia and to facilitate breastfeeding.

• Postnatal counselling and support of mothers in relation to normal newborn feeding behaviours.

• Early skilled evaluation and support with positioning and attachment.

• Rooming-in and avoiding mother/baby separation.

• Responsive or baby-led feeding and awareness of early feeding cues.

• Gently rousing a sleepy newborn for frequent breastfeeds.

• Teaching the mother how to express her breastmilk.

Indications for supplementation

There is no evidence to support routine supplementary feeding for healthy, term newborns.

Many well babies are sleepy and disinterested in breastfeeding in the first few days after birth, and may only need supplementation with small volumes of expressed breastmilk (EBM) if necessary.

During the newborn period, medical indications for supplemental feeds of EBM and/or the temporary use of infant formula if there is insufficient EBM may include:

Infant indications

• Hypoglycaemia that does not respond to frequent breastfeeding and glucose gel administration (refer to BHS CPG0110 Neonatal Hypoglycaemia Prevention and Management)

• Clinical signs of dehydration such as lethargy and poor feeding

• Weight loss > 10% after assessment of breastfeeding indicates inadequate intake (see assessment of breastfeeding below)

• Jaundice requiring phototherapy and associated with poor feeding, weight loss and inadequate output

• Baby is not breastfeeding effectively enough to maintain adequate nutrition and hydration

• Delayed stooling e.g. meconium stools after day 4-5.

• Low birth weight < 2.5 kg birth weight

• Preterm baby < 37 completed weeks gestation

• Inborn errors of metabolism

Maternal indications:

• Mother is unwell and/or unable to provide adequate breastmilk

• No signs of milk coming in (secretory activation) by 72 -120 hours and there are signs of inadequate milk intake

• Primary glandular insufficiency (hypoplastic breast tissue)

• Intolerable pain during feeds despite appropriate support and management

• Breast surgery resulting in suboptimal milk production

• Where mothers should avoid breastfeeding (either temporarily or permanently) such as:

  • HIV infection,

  • Herpes Simplex lesions on the breasts,

  • Maternal medications incompatible with breastfeeding (rare)

  • Other severe maternal illness.

The following are NOT medical indications for supplementation

• The sleepy infant with fewer than 8 to 12 feeds in the first 24-48 hours who is otherwise feeding effectively at the breast when they do feed, with no signs of illness

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

• The tired or sleeping mother

For strategies to assist with these situations, please refer to the BHS CPP0443 Breastfeeding the Healthy Term Baby

Procedure

1. Assess mother and baby and optimise breastfeeding

• Refer to BHS CPP0443 Breastfeeding the Healthy Term Baby

• Refer Appendix 1 - Assessment of Breastfeeding

2. Implement breastmilk expression to obtain supplemental EBM

• The mother's own expressed breastmilk is the first choice when supplementation is required. Refer to CPG0186, Breastmilk - Expressing, Storing and Feeding

• Donor expressed breastmilk may be used on maternal request - the following guideline MUST be used in this situation - BHS CPP0395 Breastfeeding - Donor Breastmilk

3. Implement strategies to establish or increase breastmilk supply

• Always offer a breastfeed prior to supplementation

• Use infant formula only if insufficient EBM is available and there is a medical indication for supplementation

• Refer to BHS CPP0443 Breastfeeding the Healthy Term Baby

• Refer to BHS CPG0186 Breastmilk - Expressing, Storing and Feeding

• Refer to BHS CPP0010 Breastfeeding Challenges Low Supply

4. Gain informed, written parental consent for the use of infant formula

• Provide the parents with the Supplementary Feeding for Breastfed Babies consumer information

• Discuss the information outlined on the pamphlet and the specific indications for introducing formula

• Complete Consent - Supplementary Feeding  (MR055.0). If the mother is unwell and unable to sign her partner / baby's other parent may sign

• Standard newborn infant formula in stock is used for supplementation if required. Parents may provide a different newborn infant formula if preferred

• Parents of babies on the postnatal ward using non-medically indicated supplemental formula should provide their own tin of formula. Ready to feed formula is used in Special Care Nursery

5. Volumes for supplementary feeds

5.1 Volumes for medically indicated supplementation

Supplementation volumes should be enough to ensure adequate nutrition and hydration without negatively impacting on the establishment of breastfeeding and breastmilk supply. Consideration should be given to the usual volume a baby would receive when effectively breastfeeding. (Refer to Appendix 2 Supplementary Feeding Volumes).

Volumes offered depend on a number of factors including:

• gestation, age, weight, hydration

• medical condition and reason for supplementation

• feed tolerance

• how effectively the baby is breastfeeding

• maternal milk supply and availability of expressed breast milk

• newborn feeding cues

Healthy term baby requiring medically indicated supplementation

Volumes offered should reflect the reported average breastmilk intake of healthy term babies which are as follows:

0-24 hours: 2-7 ml per feed

24-48 hours: 5-15ml per feed

48-72 hours: 15-30ml per feed

72-96 hours: 30-60ml per feed

Preterm, low birth weight or unwell baby requiring medically indicated supplementation.

As a general guide, the following top-up volumes should be offered unless otherwise medically prescribed:

• 0 - 24 hours of age 5-10 ml after a breastfeed

• 24 - 48 hours of age - 10-20 ml after a breastfeed

• 48 hours onwards - depending on assessment of feeding, milk supply, medical indications for supplementation, volumes will usually follow those recommended for exclusively formula fed babies. (Refer to Appendix 2 Newborn Fluid Requirements). The following table is a guide to volumes to be offered until the indication for supplementation has resolved. At all times, individual assessment should be used in conjunction with this guide.

If supplementation is required for a baby who has lost more than 10% birth weight at 48 hours, please refer to Appendix 2c in CPP0443 Breastfeeding the Healthy Term Newborn. Link is provided in related documents below.

5.2 Volumes for non-medically indicated formula supplementation

Volumes for non-medically indicated supplementary feeds (e.g.. Maternal request) should be enough to satisfy the baby while avoiding large volumes which may affect a baby's desire to breastfeed, and may negatively impact on the successful establishment of breastfeeding. Small volumes (5-10ml) should be offered but may be varied based on infant feeding cues.

6. Method and documentation of feeding

• Finger or cup feed if possible: avoid teats and bottles if possible until effective breastfeeding is established. Consideration should be given to the most appropriate method of supplementation for individual babies. Refer to CPG0186, Breastmilk - Expressing, Storing and Feeding

• Document the reason, type, amount and method of supplementary feeds on the Infant Care Chart MR450

7. Discharge home

• Consider delaying routine discharge home if baby is requiring frequent top up feeds and there are medical concerns

• Provide a written feeding plan for the parents including timelines and criteria for ceasing supplementation depending on further assessment by Domcare and MCHN. Feeding plans are written using BOSSnet MR315.03 Infant Feeding Plan.

• A Domcare visit should be planned for the day after discharge for babies requiring supplementation

• Consider an appointment at Breastfeeding Clinic within 1 week of discharge for ongoing breastfeeding support

• Ensure parents are capable and competent with alternative feeding methods for supplemental feeds (e.g. cup, finger feed, bottle).

• One to one supervised education on the preparation of infant formula should be given to parents of any baby going home who is receiving infant formula. If other family members will be preparing formula, they should also receive this education. Refer to CPP0402 Formula Feeding of the Healthy Term Newborn.

• Provide a copy of the Consumer Information Pamphlets where appropriate (available in PNW and SCN or print from related documents below)

  • Supplemental feeds for breastfed babies

  • Expressing and bottle feeding

  • A Guide to infant formula and bottle feeding