It is perhaps the most important and complex question for hospital staff and medical professionals caring for newborn babies with mothers wishing to breastfeed: what are the proper procedures to ensure the safety of the baby when the mother’s milk is not yet (or never becomes) sufficient to satisfy the baby’s nutritional and hydration needs?

We posed this question to two veteran breastfeeding practitioners – Casey Rosen-Carole, MD, MPH, MEd and Bobbi Philipp, MD – who have extensive experience with this issue.

Casey Rosen-Carole is the Medical Director of Lactation Services and Programs at the University of Rochester Medical Center. A pediatrician by training, she now calls herself a “full time breastfeeding medicine provider.” Most important to the issue at hand is that Dr. Rosen-Carole is the senior author of the Academy of Breastfeeding Medicine (ABM)’s Clinical Protocol on the Use of Supplementary Feedings in the Healthy Term Breastfed Neonate, which means she is one of the country’s foremost authorities on this subject.

“Delayed lactogenesis is actually increasingly common because the risk factors for it are potentially increasing,” Dr. Rosen-Carole says. “When a baby is born into that situation, the goal is to closely monitor what the baby is doing, instead of giving a bottle right away. Does the baby appear satisfied at the breast? Is the baby distressed? Are they peeing and pooping? And are they having regular weight loss or excess weight loss?”

“Every Breastfeeding Expert Is Going to Agree”

“If the baby is hungry and they’re not getting enough milk out of the mother’s breast, then they need to be supplemented,” she says. “If lactogenesis hasn’t happened and you’re at day 2 or 3 and the baby is not acting full at the breast, they have excess weight loss, or they are not peeing or pooping appropriately, then I think every breastfeeding expert is going to agree that it’s time to develop an infant feeding plan that includes supplementation.”

Bobbi Philipp agrees. Dr. Philipp is a pediatrician and former Director of the Mother-Baby Unit at Boston Medical Center (BMC), an inner-city, safety net hospital in Boston’s South End. Philipp was the primary driver who led BMC to become the first Baby-Friendly designated facility in Massachusetts in 1999. She is a one of the pioneers and foremost champions of Baby-Friendly practices in our country.

“If you see signs that the mother’s milk is insufficient, you need to feed the baby,” she says. “And if the mother is really committed to breastfeeding, you’ve got to bridge the gap in a way that you support her, feed the baby, and don’t undermine the breastfeeding. It’s that simple.”

“That’s why educating all staff is so important,” continues Philipp, “so everyone on the unit has the knowledge needed to see the early warning signs and they can work together to ensure infants and mothers are adequately monitored and assisted with breastfeeding.”

“Supplementing as Part of a Medical Plan”

“The next question is what does the baby eat?” says Rosen-Carole. “Is it that the baby can’t get the milk out of the mother’s breast? If so, can mom pump and give expressed milk? And if not, then the baby can get pasteurized human donor milk or formula, depending on where they live in the world.”

Donor milk “takes a lot of the fight out of everything,” says Philipp. “If breastfeeding is not going well and the baby is getting too yellow or is losing too much weight, but the mother is still adamant that she doesn’t want to use formula, donor milk buys you some time while you keep working to get breastfeeding established. Then, if donor milk isn’t an option after discharge, you need a feeding and follow-up plan.”

“There’s supplementing blindly or for the wrong reasons and then there’s supplementing as part of a medical plan that supports long-term breastfeeding success,” continues Rosen-Carole. In a popular seminar she teaches for providers, she tells participants that there are five basic steps to the supplementation decision:

  1. Think about why this baby is being supplemented – “This has to be the first step,” says Rosen-Carole, “because if you’re not doing it for a medical indication or another clear reason, you could undermine breastfeeding.”
  2. Consider how much to supplement – “If there is some milk supply but not enough, you have to figure out how much the baby needs to grow,” she says. “Generally, in the first few days, we recommend 10cc after each nursing session as a starting point. We have to trust babies. If they are satisfied with less and weight loss trajectory improves, then we are on the right track. If they continue to act hungry, they should be fed. We tell parents to feed when hungry and stop when full at all ages.”
  3. Figure out what you’re going to supplement with – Expressed breastmilk, donor milk or formula?
  4. Determine the mechanism – “We need to consider the age of the baby and what’s most appropriate for the parents,” says Rosen-Carole. “Would it be best to use cups, syringes or bottles? We also recommend slowing down bottle feeding and burping the baby frequently to allow the baby’s stomach and brain to catch up with the sensation of being full.”
  5. Chart a path back to breastfeeding – “In most cases, this is a short-term medical solution,” she says. “We need to support the maternal milk supply. This may mean the parent needs to start pumping to bridge the gap between what the baby gets at the breast and supplemented volumes. In rare cases, when mothers can’t make the milk their baby needs, they should be supported in making new goals. The family’s wellbeing and goals need to be considered at all stages.”

“The Most Important Thing”

Rosen-Carole and Philipp both agree that the most important thing is for the medical professionals in charge to carefully monitor the situation, engage in collaborative conversations with the family, and intervene when necessary to ensure the safety of the infant while also respecting the values and wishes of the family.

Rosen-Carole suspects this is what was lacking in some high-profile cases of infant harm reported in the media. “There are many red flags that should have been raised or where the ABM protocol would point toward supplementation,” she says. “Trusting breastfeeding and wanting to support exclusivity doesn’t mean that you ignore the fact that some babies are going to need to be supplemented from time to time. It’s a balance.”

“Individualized Care”

It is important to note that this approach is consistent with Baby-Friendly protocols and the philosophy of “individualized care.”

“Most infants exclusively breastfeed successfully with no major health concerns,” says BFUSA CEO Trish MacEnroe. “But some circumstances require further assessment and close follow-up with the mother, infant or both.”

In fact, BFUSA’s Guidelines and Evaluation Criteria clearly state that “additional individualized assistance should be provided to high risk and special needs mothers and infants and to mothers who have breastfeeding problems.” (page 17)

“It is critical that mothers and infants who are identified prenatally or soon after delivery as being at risk for breastfeeding challenges receive an individualized feeding plan, close observation for adequate hydration and nutrition, assistance to monitor and optimize a milk supply, and close follow-up after discharge,” says MacEnroe.

“The decision to supplement is a delicate one,” she continues. “Infant formula changes the infant’s gut. It can also negatively impact the establishment of the mother’s milk supply, thus affecting long term breastfeeding success. Practitioners and parents should carefully weigh the risks and benefits of these decisions.”

“We Almost Lost It”

MacEnroe, Rosen-Carole and Philipp all recognize these decisions are complicated by social pressures.

Rosen-Carole says she spends a lot of her time helping patients understand that how much milk they have is not what defines them as a parent. “We need to start divorcing this from the idea that this is what’s going to make you a great mom,” she says. “This is a part of your parenting, but it’s not your whole parenting.”

For her part, Philipp believes these pressures are part of a social evolution in which breastfeeding advocates had to push hard to restore breastfeeding as the cultural norm. “We almost lost breastfeeding in our country,” she says. “When I was born in the 1950s all the way to the 1970s, very few mothers were breastfeeding – and we almost lost it. To bring it back, I think we might have needed to swing hard to correct things.”

Rosen-Carole agrees. “When the medical field was less bought-in to breastfeeding, advocates had to be a lot louder and it’s possible that maybe some of those reverberations are still being felt,” she says.

With breastfeeding initiation rates now well above 80% in the US, it is clear this public health effort has been successful. Both Dr. Rosen-Carole and Dr. Philipp feel the emphasis shifting to a more collaborative approach.

“We don’t have to convince people to breastfeed anymore,” says Philipp. “Everybody knows it’s the best thing for the baby.”

“Our main focus now is on helping people reach their goals,” adds Rosen-Carole. “This means providing excellent medical care for lactating families and creating the conditions where they have the greatest possibility of success.”