SAMPLE FAQ: Supplementing the underfed newborn
What do I do if my breastfeeding newborn is underfed?
If a baby’s breastfeeding challenges cannot be quickly fixed, supplementing an underfed newborn may keep the baby from starving or prevent a return to hospital. Some babies will show clear hunger signs and only need to be supplemented following these signs after breastfeeding. Sleepy babies may not show hunger signs. They need a structured supplementing plan. They should be wakened three hours after the start of the last feed, fed from both breasts, and then supplemented. Ideally, mothers express after each of the baby’s feeds to maximize their milk supply and this milk is used for the baby’s supplements. Underfed newborns usually respond well to supplements, regain weight quickly, and then should continue to grow well. Those that do not may be sick. Mothers should work with their health-care providers in this situation.
A) Reviewing and supplementing underfed breastfeeding newborns
Most newborn babies have no trouble feeding. However, they are particularly vulnerable to being underfed, which may lead to major short- and long-term health consequences. They should be closely monitored to ensure they are taking in enough milk.
- Assess the baby’s current health.
- Rule out any other illness.
- Address all feeding barriers.
- Decide on the need to start milk supplements.
- Monitor the baby’s response to supplements.
- Guide the decreasing or stopping of supplements, when they are no longer necessary.
Increasing the amount of milk an underfed breastfeeding baby takes in may only require that any breastfeeding problems are solved. Other babies may need urgent milk supplements.
Short-term supplementing when newborns show signs of not getting enough milk can be critical as it (Kellams 2017):
- Will give a weak, sleepy baby the strength to start breastfeeding effectively.
- Prevents and treats jaundice, low sugar levels, starvation and dehydration.
- May prevent the baby from being readmitted to hospital (Flaherman 2013).
- May improve long-term breastfeeding rates (Flaherman 2013; Kair 2019; Straňák 2016).
Supplements will be needed until the baby is breastfeeding effectively. However, supplements should not be given if they are unnecessary.
B) How to breastfeed and supplement an underfed breastfeeding newborn
To feed an underfed newborn:
1) Choose an appropriate milk
Appropriate milks for the baby’s supplement in are, order of preference (Kair 2019):
- Expressed mother’s own colostrum or breast milk
- Pasteurized donor human milk
- Appropriate infant formula
Another mother's milk (shared milk) is another possibility if the donor is healthy.
2) Choose a supplementing tool
There are a number of ways to give extra milk to a baby. Choose an effective feeding tool. Commonly-used ones include:
Sick babies may be given a feeding tube.
3) Breastfeed the baby
- Feed the baby at least seven times in 24 hours.
- Breastfeed the baby as follows:
4) Supplement the baby
a) Vigorous babies
Healthy, full-term or near term babies usually act hungry after breastfeeding and can be supplemented according to their hunger signs. They are given as much milk as they want and until they no longer show hunger signs.
As soon as supplements are started, these babies should show all the signs of getting enough milk.
b) Sleepy, underfed babies
Sleepy babies may only suck well at the breast for five minutes. They should be taken off of the breast as soon as they are no longer sucking effectively. Leaving them on when they are not actively sucking will not give them more milk and will waste valuable time.
These babies must be given a supplement after every breastfeed with the minimum appropriate amount of milk and more if they are interested. For a newborn, this should be at least 15 millilitres (1/2 U.S. fluid ounce) at each feed during the first 24 hours and more if the baby will accept it. This quickly increases to about 30 to 60 ml (1 to 2 oz) at each feed by Day 4. Your health-care providers will guide you in this.
The exact amount of supplement is determined by:
- The baby’s degree of prematurity.
- The baby’s size.
- The baby’s hunger signs.
- How much milk the baby is getting from the breast.
- How underfed the baby is.
- How sleepy the baby is.
The process of breastfeeding, supplementing, and expressing can be called triple feeding. It can be time consuming but is generally needed only until the baby learns to breastfeed effectively. Triple feeding should not take more than one hour and preferably takes less.
Mothers should express after each feeding. This:
- Provides milk for the baby’s supplement.
- Helps establish and maintain the milk supply.
- May help to identify a low milk supply.
Expression is stopped:
Some babies in this situation may even require hospitalization, especially if the baby:
E) Monitoring the baby’s response to supplementing
Underfed babies respond quickly and dramatically when they are given extra milk. If not, the baby may be sick and should again be checked by a health-care provider.
1) Immediate changes
During the first day after supplements have been started, underfed babies show various feeding patterns such as:
- Starting with small amounts for the first one or two feeds as they get used to eating more.
- Asking for a lot of milk at the first supplement and then sleeping for one longer amount of time (for example, four hours).
- Feeding frequently (for example, every two hours) for several feeds.
As soon as the supplements are started, the baby should immediately:
- Be more content.
- Be happy when fed and held.
- Stop scowling.
Within 12 hours, the baby will:
- Start waking on her or his own every 2 to 3 hours.
- Have more quiet, awake time.
- Sleep better.
- Show regular hunger signs before feeds and not be frantic.
- Be contented after feeds.
- Possibly spit more.
- Have more tummy noises and cramping.
- Have normal pees and stools (poops).
Within a day, the baby will start taking in fairly similar amounts of supplement after each breastfeed until the breastfeeding problems are solved. They will also show predictable hunger signs. The hunger signs should then guide the amount of supplement. This process may take longer if the baby is premature.
Newborns should be regularly and carefully monitored and weighed every 24 to 48 hours until they have gained weight steadily and no longer show signs of low milk intake.
2) Later changes
Once underfed babies are supplemented, they show continuous good weight gain. Some who have lost a large amount of weight will gain very quickly, as much as 120 grams (4 oz) a day during the first few days.
3) Long-term options
Over time, it is often possible to reduce or end the supplements if the baby’s breastfeeding problems have ended and the mother has a full milk supply.
Newborn babies with latching problems may be able to breastfeed effectively with the help of a nipple shield. They may need to continue using one until they learn to latch. Other babies may never learn to latch and suck and will need on-going replacement feeds.
Some mothers have a low milk supply and their babies will need long term supplementing after breastfeeding.
F) Parents concerns about supplementing
Some mothers hesitate to give medically-necessary supplements for a variety of reasons.
It is very likely that unnecessary supplementation will decrease breastfeeding duration (McCoy 2020). Structured, limited early supplementation of underfed babies before the mother’s milk has come in have less of an impact (Flaherman 2019a; Flaherman 2019b).
1) Concerns about the use of infant formula
Some mothers worry about the negative effects of supplementing with infant formula.
When a newborn is underfed and if infant formula is the only milk option, it is still a much better one than not giving the baby anything. In this situation, infant formula is medicine and the benefits of feeding the baby outweigh the risks.
2) Concerns about the baby becoming used to bottles
Most babies are able to switch between the breast and the bottle without developing nipple confusion. Furthermore, most babies will give signs that they are about to reject the breast that if addressed, will prevent breast rejection.
3) Concerns about decreasing the milk supply
It is unlikely that the mother’s milk supply will decrease if the baby can latch and breastfeed normally when hungry. If the baby cannot breastfeed well, mothers can maintain their milk supply by expressing after each of the baby’s feeds. Appropriate supplementing will not decrease the milk supply but unnecessary supplementing can.
Flaherman VJ, Aby J, Burgos AE, et al. Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: an RCT. Pediatrics. 2013 Jun;131(6):1059-65
Flaherman VJ, Cabana MD, McCulloch CE, et al. (Flaherman 2019a) Effect of Early Limited Formula on Breastfeeding Duration in the First Year of Life: A Randomized Clinical Trial. JAMA Pediatr. 2019 Jun 3
Flaherman VJ, McKean M, Braunreuther E, et al. (Flaherman 2019b) Minimizing the Relationship Between Early Formula Use and Breastfeeding Cessation by Limiting Formula Volume. Breastfeed Med. 2019 Jul 16
Kair LR, Flaherman VJ, Colaizy TT. Effect of Donor Milk Supplementation on Breastfeeding Outcomes in Term Newborns: A Randomized Controlled Trial. Clin Pediatr (Phila). 2019 May;58(5):534-540
Kellams A, Harrel C, Omage S, et al. ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017. Breastfeed Med. 2017 May;12:188-198
McCoy MB, Heggie P. In-Hospital Formula Feeding and Breastfeeding Duration. Pediatrics. 2020 Jun 9:e20192946
Straňák Z, Feyereislova S, Černá M, et al. Limited Amount of Formula May Facilitate Breastfeeding: Randomized, Controlled Trial to Compare Standard Clinical Practice versus Limited Supplemental Feeding. Denning PW, ed. PLoS ONE. 2016;11(2):e0150053
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