How to supplement

How do I supplement my baby?

If mothers need to supplement their baby, they should work with their health-care providers. They will need to figure out what type of milk to give, how much to give, and how to give it. With healthy full-term babies, the amount is determined by the baby’s hunger signs. Generally, mothers breastfeed the baby with both breasts and then supplement if hunger signs persist. After that, they may express for the next feed, if it is helpful. Babies with latching and sucking problems should be offered the breast but will rely mostly or completely on supplements. Offer the breast at most feeds but do not struggle with the baby. Mothers will need to express after every ineffective feed. Babies who are premature, sleepy newborns, or sick may not be able to show hunger signs and need a structured supplementation plan. Their mother will also need to express regularly.

A) Supplementing guidelines

If your baby requires supplementing with milk, please work with your health-care providers until the baby is growing well and the supplements have stabilized or are no longer needed.

A supplement may be required because the mother does not have enough milk or because the baby cannot access it. The exact amount of supplement and how it is given will depend on:

Healthy babies are generally supplemented with amounts that are determined by their hunger signs. The amount of supplement they need can also provide an idea of the mother’s milk supply: the larger the amount of supplement, the less they take from the breast and the lower the mother’s milk supply.

Babies who have latching and sucking problems are offered the breast but rely mostly or completely on supplements for their nutrition.

Babies who are premature, sleepy newborns, or sick may not be able to show hunger signs and are supplemented in a more scheduled, structured way until they are healthy.

These guidelines ensure that mothers do not struggle with the baby, waste time, and frustrate and tire the baby. The whole process of breastfeeding or trying to breastfeed, supplementing, and if appropriate, expressing should take less than one hour. It can be faster if another person supplements the baby while the mother expresses.

B) Supplementing tools

When babies need extra milk, they can be given supplements in a variety of ways, including:

Each has its advantages and disadvantages. The feeding tool needs to be:

  • Effective in feeding the baby.
  • Acceptable to the baby.
  • Acceptable to the caregivers.
  • Time-efficient. 

Bottles are often favoured by parents because of their ease of use and familiarity (Penny 2019).

Healthy babies with latching problems are generally able to use a bottle or cup. A tube-at-the-breast system will not work for them as they cannot latch onto the breast. However, mothers with a very low milk supply may consider a tube-at-the-breast system to prevent or address breast rejection or to promote re-lactating

Mothers and their health-care providers can often obtain valuable information about the milk supply from knowing how much supplement a baby wants after breastfeeding. This information is not as readily available when using a tube-at-the-breast system.

Consider warming the supplement to close to body temperature.

Ill babies with a feeding tube are cared for in hospital and mothers will be guided by their health-care providers about the feeding times and the amount of milk the baby needs. These are inappropriate for an otherwise healthy baby.

C) Supplementing the baby who can latch and suck effectively

Healthy babies who can breastfeed well:

  • Wake on their own.
  • Latch and suck well.
  • Show hunger signs:
    • When they need to feed.
    • After breastfeeding, if they need a supplement.

They need to be supplemented if their mothers do not have enough milk.

These are the steps to supplement a healthy baby:

1) Start the feed

Start the feeding process once the baby shows hunger signs.

2) Offer the first breast.

Change the starting breast if the breasts have roughly similar amounts of milk. Offer the weaker breast first at each feeding if there is a big difference in the amount of milk between the breasts.

The baby should be taken off the breast once the baby is done feeding and shows any of the following:

  • Is no longer sucking well
  • Keeps popping off and onto the breast
  • Gets angry when returned to the breast
  • Has fed for 20 minutes

Mothers with a low milk supply can expect shorter feeds than those of mothers with a full milk supply. Feeds will shorten further as the baby grows. Occasionally they will feed for more than 20 minutes, trying to get more milk. 

If the baby is very hungry and upset after trying to breastfeed on the first breast, mothers can give the baby a little bit of milk supplement to calm the baby before offering the second side.

3) Offer the second breast

Offer the second side once the baby shows hunger signs.

The baby should be taken off the breast once the baby is done feeding and shows any of the following:

  • Is no longer sucking well
  • Keeps popping off and onto the breast
  • Gets angry when returned to the breast
  • Has fed for 20 minutes

4) Supplement if the baby is hungry 

If the baby shows hunger signs after the second breast, supplement the baby with appropriate milk.

The exact amount is determined by the baby’s hunger signs. These usually develop within 10 minutes after finishing on the second breast. The daily amounts should be reasonable and in keeping with the baby’s age and weight.

When the milk supply is low, most babies are hungry within 10 minutes of finishing on the second breast. If the baby only seems to need a supplement one hour or more after breastfeeding, the baby may be getting excess or unnecessary supplements or may be fussy for other reasons.

5) Use the third breast to settle the baby

If the baby is slightly unsettled but not hungry after supplementing, consider offering the ”third breast” for a few minutes. This can calm the baby or allow the baby to breastfeed to sleep.

6) Express if appropriate

If expressing to increase the milk supply, do so once the baby has settled. Store the milk to use as a supplement at the next feeding.

7) Repeat at each feeding

Repeat these steps at each feeding.

Exclusively breastfed babies tend to breastfeed 7 – 10 times each day. Supplemented babies may feed as little as 6 times each day however, such infrequent feeds may also mean the baby is getting too much supplement.

D) Supplementing when the baby has latching and sucking difficulties

Some healthy babies do not breastfeed well enough. These babies will receive most or all of their milk by supplementation. Mothers need to express after every missed or ineffective feed, in order to maintain the milk supply and provide breast milk for the baby. The expressed milk is stored to use for a supplement at the next feeding, and excess milk can be frozen.

This whole process, including offering the breast, supplementing, and expressing, should take less than an hour. It can be faster if another person supplements the baby while the mother expresses. Some mothers do not offer the breast at night and simply express and supplement to save a little time and allow for more sleep. 

1) Babies who can latch but do not suck well

Babies who can latch but do not breastfeed well enough should still be offered the breast at most feeds when they act hungry and before supplementing. This:

  • Allows the baby to practise breastfeeding.
  • Provides some breast stimulation.
  • Allows mothers to see if the baby’s breastfeeding is improving.

Babies who are slightly unsettled but not hungry after supplementing, can be offered the breast after supplementing (the third breast) to settle them.

2) Babies who cannot latch or stay latched

Babies who cannot latch or suck can be offered the breast a few times each day. This:  

  • Allows the baby to practise breastfeeding.
  • Allows mothers to see if the baby’s breastfeeding is improving.

If unsettled after being supplemented, they can be rocked, held, bounced, or walked. They can be given a pacifier for a few minutes; this is appropriate for babies who are unable to latch and stay latched.  

E) Supplementing premature, sleepy newborn, or sick babies

Very premature babies need a structured feeding plan and close supervision by health-care providers.

Sleepy, underfed, newborns sometimes do not wake to allow for six to eight feeds in 24 hours, nor do they show hunger signs. They often do not breastfeed effectively and need to be pushed to take in enough milk. The sleepiness clears quickly as the baby is supplemented. If they do not have an underlying breastfeeding problem, they can then be supplemented after breastfeeding, following their hunger signs.

Some babies are sick and do not want to take in enough milk to grow normally. Sometimes illness is hard to diagnose and everyone assumes that breastfeeding is the problem. If your baby is growing slowly, refusing supplements, or if supplements are started and the baby does not gain weight quickly, your baby may be sick. These babies need treatment and then may be able to breastfeed without supplements. 

In all of these situations, mothers need to express after the baby is fed in order to provide breast milk supplements for the baby and to maintain the milk supply.  

F) Decreasing or stopping supplements

As babies’ breastfeeding improves, supplements may be decreased or stoppedThe baby does not need to be supplemented if:

  • The baby is healthy, gaining well, and:
    • Had fed well at the breast.
    • Does not show hunger signs after breastfeeding.
    • Is often awake and content when held. 
    • Refuses a supplement.
  • The mother has a full milk supply.

G) Monitoring the baby

To monitor the baby:

  1. Ensure that the baby is getting enough milk and not showing signs of being underfed.
  2. Ensure that the baby is feeding at least six times in 24 hours if supplemented and at least seven if not.
  3. Have the baby weighed and examined by a health-care provider:
    1. Frequently until the baby is growing well or if there are major changes to the baby's feeds.
    2. Regularly once the baby is growing well.

H) Spitting, vomiting, and tummy pain

Underfed babies will start taking in more milk once the supplements are started. They may:

  • Start spitting.
  • Vomit once or twice a week especially if the amount of supplement is very large.
  • Have more tummy cramps and noise.
  • Stool (poop) and pee more.

Babies are usually unhappy for a few minutes after a vomit. They need a little recovery time and then may ask to feed again. Just follow the baby’s hunger signs. If the baby throws up more than once or twice a week, please see your health-care providers as soon as possible.

References

Penny F, Judge M, Brownell EA, et al. International Board Certified Lactation Consultants' Practices Regarding Supplemental Feeding Methods for Breastfed Infants. J Hum Lact. 2019 Apr 19:890334419835744