Non-medical supplementing

Should I give my baby a bottle after breastfeeding?

Babies who breastfeed often accept a bottle of expressed breast milk or infant formula even if they don’t need it. This “non-medical supplementing” increases the risk of obesity and may cause other problems for mothers and babies whether the mother uses infant formula for the supplement or expresses milk. Sometimes it starts soon after birth while the mother and baby are still in hospital. This may depend on the health-care provider or on hospital policies. At home, a mother may decide to supplement because she mistakenly thinks the baby is hungry, wants the baby to sleep, or wants to make sure the baby gets enough milk. A baby does not need a supplement if the baby is growing well and does not show hunger signs after breastfeeding.

A) Describing non-medical supplementing

Supplementing for non-medical reasons is giving extra expressed breast milk or other milk to babies who don’t need it because they are getting enough milk through breastfeeding. This can lead to breastfeeding problems (Vehling 2018).

Normal babies often accept expressed breast milk or infant formula from a bottle even if they are not hungry. This does not mean they need the extra milk.

B) Supplementing in hospital

Milk supplements are sometimes started soon after birth while the mother and baby are still in hospital and are often given without a medical reason.

One study done in Washington, D.C., showed that 13% of babies required supplementation for medical reasons, but a survey of all U.S. hospitals that provide maternity care showed that in 2013 about 34% of babies received supplements ordered by a health-care provider (Nelson 2016; Tender 2009). Similarly, in the U.K., one study reported that 28% of babies received a supplement in hospital but only 10% were medically indicated (Biggs 2018). 

The hospital factors that increased the rates of non-medical supplementation included:

Supplementing while still in hospital is more common in the following situations (Garrison 2019):

  • At night (Gagnon 2005)
  • If the mother is anxious (Gagnon 2005)
  • If the mother lacks confidence (Tuthill 2016)
  • If the mother had no prenatal education (Biggs 2018)
  • After a Caesarian delivery
  • If this is the mother’s first baby
  • If the baby is large

All of this indicates that supplements are not always given for medical reasons.

There is no benefit to routinely giving newborn babies supplements and it can interfere with breastfeeding (Balcı 2021; Smith 2016).

D) Signs that supplements are not required

This mother was worried that her baby was not getting enough milk by breastfeeding. The mother continued to breastfeed at all feeds and started supplementing with infant formula in the first week after birth. The amounts of infant formula increased over time and resulted in very rapid weight gain.

A baby may not need a supplement if:

  • The supplements are not medically needed.
  • The supplements are given even without true hunger signs.
  • The baby only gets supplements on some days and not others.
  • The amount of supplement varies greatly each day.
  • The baby is equally happy with and without supplements.
  • The amounts of supplement are small (less than 150 millilitres [5 U.S. fluid ounces] for example).
  • The baby only receives supplements for the evening fussies.
  • The mother has a full milk supply and the baby breastfeeds normally.
  • Most or all of the baby’s supplement is with the mother’s own expressed milk.
  • The baby is gaining too quickly on the growth chart.

E) Risks of non-medical supplementing

Supplementing for non-medical reasons, even in small amounts, increases the risk of obesity in a baby (Young 2018). This effect happens when babies are given either infant formula or expressed breast milk but the effect is stronger with the former (Azad 2018).

Supplementing decreases the chances that mothers will reach their breastfeeding goals with their current child (Flaherman 2018; Santacruz-Salas 2020; Whipps 2021). Mothers are also less likely to start breastfeeding future babies and more likely to wean earlier than the current baby (Whipps 2021). 

1) Non-medical supplementing with expressed breast milk

Expressing for a baby’s supplement is a lot of work and can be eliminated if the supplements are not required. Furthermore, there are risks to expressing and giving milk when compared to breastfeeding.

If a mother is expressing for the baby’s supplement and expresses more milk than the baby can take, she risks creating an excessively large milk supply.

2) Non-medical supplementing with infant formula

If mothers use infant formula for the supplement and are not expressing, inappropriate supplementing can result in infrequent breastfeeding. This increases the risk of the following:

F) How to stop non-medical supplementing

If a mother had a full milk supply after birth and her supply is reduced, she may be able to return to exclusive breastfeeding by gradually reducing the supplements and increasing her milk supply. The baby should be closely monitored during the process.

References

Azad MB, Vehling L, Chan D, et al. Infant Feeding and Weight Gain: Separating Breast Milk From Breastfeeding and Formula From Food. Pediatrics. 2018 Sep 24. pii: e20181092

Balcı Yangın H, Akpınar A, Çakmak H, et al. Exclusive Breastfeeding for 6 Months Postpartum and Factors Associated With Success in a Tertiary Care Baby-Friendly Hospital: A Retrospective Cohort Study. J Perinat Neonatal Nurs. 2021 Jul-Sep 01;35(3):266-274

Biggs KV, Hurrell K, Matthews E, et al. Formula Milk Supplementation on the Postnatal Ward: A Cross-Sectional Analytical Study. Nutrients. 2018 May 14;10(5). pii: E608

Flaherman VJ, Narayan  NR, Hartigan-O’Connor  D, et al. The effect of early limited formula on breastfeeding, readmission, and intestinal microbiota: a randomized clinical trial. J Pediatr. 2018;196:84–90.e1

Gagnon AJ, Leduc G, Waghorn K, et al. In-hospital formula supplementation of healthy breastfeeding newborns. J Hum Lact. 2005 Nov;21(4):397-405
 
Garrison MP, Maisano P. Systematic Review of Factors Influencing Non-Medically Indicated Formula Supplementation of Newborns in the Hospital Setting. Nurs Womens Health. 2019 Aug;23(4):340-350

Hall  RT, Mercer  AM, Teasley  SL, et al. A breast-feeding assessment score to evaluate the risk for cessation of breast-feeding by 7 to 10 days of age. J Pediatr. 2002;141(5):659–664

Nelson JM, Perrine CG, Scanlon KS, et al. Provision of Non-breast Milk Supplements to Healthy Breastfed Newborns in U.S. Hospitals, 2009 to 2013. Matern Child Health J. 2016 Nov;20(11):2228-2232

Santacruz-Salas E, Segura-Fragoso A, Cobo-Cuenca AI, et al. Factors Associated with the Abandonment of Exclusive Breastfeeding before Three Months. Children (Basel). 2020 Dec 16;7(12):298

Smith HA, Becker GE. Early additional food and fluids for healthy breastfed full-term infants. Cochrane Database Syst Rev. 2016;(8):CD006462

Tarrant M, Lok KY, Fong DY, et al. Effect of a hospital policy of not accepting free infant formula on in-hospital formula supplementation rates and breast-feeding duration. Public Health Nutr. 2015 Oct;18(14):2689-99
 
Tender JA, Janakiram J, Arce E, et al. Reasons for in-hospital formula supplementation of breastfed infants from low-income families. J Hum Lact. 2009 Feb;25(1):11-7
 
Tuthill EL, McGrath JM, Graber M, et al. Breastfeeding Self-efficacy: A Critical Review of Available Instruments. J Hum Lact. 2016 Feb;32(1):35-45
 
Vehling L, Chan D, McGavock J, et al. Exclusive breastfeeding in hospital predicts longer breastfeeding duration in Canada: Implications for health equity. Birth. 2018 Mar 2

Whipps MDM, Yoshikawa H, Demirci JR, et al. Estimating the Impact of In-Hospital Infant Formula Supplementation on Breastfeeding Success. Breastfeed Med. 2021 Jun 10

Young BE, Levek C, Reynolds RM, et al. Bioactive components in human milk are differentially associated with rates of lean and fat mass deposition in infants of mothers with normal vs. elevated BMI. Pediatr Obes. 2018 Aug 9