Preventing unnecessary supplementary feeding starts with good knowledge about and support for normal baby restlessness and weight loss.

And that applies to parents as well as healthcare professionals and the network around them.

It seems so easy, ‘just give some supplementary feeding’, but in the longer term many parents still turn out to remain uncertain for a long time. And there are plenty of reasons to be cautious about supplementary feeding, including supplementary feeding with pumped milk.

It understandable when as a healthcare professional you get a call at 4am from worried parents with a restless baby, or a baby with low temp.

Describing the need for supplementary feeding as ‘very common’ or ‘that is very often needed for a while’ is a vote of no confidence in women’s ability to feed their babies. It implies that it is very common for a mother to be unable to feed her baby safely on her own. Physiologically, it is not ‘normal’ that that would be necessary so often.

Parents need information about milkproduction:

• There is milk in the first days, it’s just not white! The expression ‘it takes 3 days for your milk to come in’ has apparently lost a word, the word “White’.
• Babys loose weight after birth, even those on formula.
• Restlessness  around the second night/third day is a given.

In practice, it appears that in hospitals and in the homecare in the Netherlands, pumping and supplementary feeding are strongly encouraged s early as at 7% weight loss. And in addition the advice to start supplementary feeding is quickly given when the baby is restless or has a low temperature, even without the indication of actual weightloss.

There are studies indicating that supplementary feeding with small bits of artificial milk has no adverse effect on breastfeeding duration. There are doubts about suckling confusion when early introduction of the bottle in addition to the breast. And not every mother makes ample milk for her baby as easily and quickly.

But there are proven issues with supplementary feeding in the first days of life.
Pumping alongside or in combination with breastfeeding is a strain on the family. Mother feeds the pump and gives the bottle to her baby. And pump rental and purchase cost money.
Supplementary feeding has disadvantages: there is a risk of overfeeding, pumping changes the microbiome of the breast and the pumped milk, artificial feeding affects the baby’s gut flora, and using plastic bottles burdens a baby with far more microplastics than breastfeeding does.
And with the new findings that early introduction of artificial milk-based formula increases the chances of developing cow’s milk protein allergy, preventing supplementary feeding is even more worthwhile.

In short: prevention of supplementary feeding should be higher on the agenda of healthcare professionals as far as I am concerned.

Restlessness on the 2nd night is a real experience for many parents, and when unprepared, the conclusion is often ‘there is insufficient milk so supplementary feeding is needed’. Predicting this normal restlessness during pregnancy and in the 1st 24-48 hours postpartum reduces the likelihood of unnecessary supplementary feeding when the issue arises.

Use of the special growth curve for weight loss in breastfed babies in the first 10 days can help parents and those around them to properly estimate normal weight loss.

After a labour with a lot of intravenous fluid in the last 2 hours before birth, the baby may have a biased high birth weight. After a c-section some babies lose 200 or more grams within 24 hours. If there are no other clinical red flags this is probably just extra  fluid and not a concern. Discuss this with parents. A father once remarked after this explanation ‘so my son was a cheap chicken filet?’ Ummm, yes I’m afraid so. His son, with beautiful pink plump body, was lying delightfully skin to skin on his mother and certainly did not look like a baby who had lost 9% weight or who was in jeapardy.

Good latching is essential in the first hours and days after birth. Possibly because colostrum does not yet have much volume, pressure on the areola seems almost more important than the letdown reflex to get the colostrum flowing. ‘Nipple feeding’ is then not only painful for mother but also provides the baby with no or too little nourishment AND the experience that drinking at the breast requires a lot of energy for little. Pain is not gain when breastfeeding is concerned. Small changes in posture or control can already have an effect on both mother’s and baby’s experience.

Hand-pumping and offering those drops to baby on a spoon is a more approachable intervention than using a pump. If parents are aware of this option before delivery, and if mothers give it a try in the last weeks of pregnancy (in the shower, when no one is looking?) then the threshold for using this postpartum is lower.

And if supplementary feeding is needed in the first week, consider not doing it consistently after drinking at the breast. Consider Pavlov: getting satiated with the bottle is not conducive to more confidence in breastfeeding/feeding.

If a baby keeps getting satiated by supplementary feeding (be it bottle or finger or cup), then the breast will remain ‘hard work’ for all concerned and the becomes the bottle’s reward. Alternate when supplementary feeding is offered: sometimes after 2 breasts, sometimes after the 1st breast and then the 2nd breast after the supplementary feeding, or after 2 breasts and then back to the first for a while.

If the baby stops taking the breast halfway through the feeding after supplementary feeding, too much supplementary feeding may have been given. Or try supplementary feeding during the feeding with a tube next to the nipple. This is laborious, but it doesn’t have to be 24 hours a day. The experience at the breast is more positive even if the baby gets supplementary feeding during daytime drinking from the breast, and at night with the bottle.

Or use the block method described in this case study even in the first week.

An additional risk of supplementary feeding alongside breastfeeding is the increased risk of obesity, both from overfeeding and from disturbances of the microbiome.

To reduce the risk of overfeeding, good information about body language in babies is essential. Discuss the ‘restaurant effect’: you resolve not to have dessert, do it anyway and an hour later you regret it because you are too full. Discuss that even adults don’t eat until all we can/will do is binge on the sofa. That’s fine sometimes, but if you always do that, you’ll get too fat and probably not happier.

Normal behaviour after a feeding:

• Relaxing or even ‘drunk’ release
• Waking up after a few minutes and looking around for 5-45/90 min* with fluid movements
• *depending on age and time
•  Then restless, jerky movement, searching = tired

This is often interpreted as hunger. Then check with baby what the response is to (supplementary) feeding:

• Does she lie down to drink delightfully again and is calm afterwards? Then she needed it.
• Does she lie down to drink delightfully again and is inconsolable afterwards? Then she ate too much.
• Does she lie down to suckle but let go as soon as the milk starts flowing (breast) or after the first sips (bottle)? Then she is full.
• Is she not latching on or can’t find the nipple/teat properly? Then she is either full or a burp is bothering her.

And discuss that a baby will always drink something from a bottle. Most babies do not stop drinking when they have had enough. Certainly not if they get the bottle after the breast.

People eat the most and tend to over-eat when:

• The meal consists of different textures: crunchy and creamy, for example.
• The meal contains different flavours: sweet-sour, salty-sweet for example. After a main course with rice, we eat less of a dessert with rice.
• Little effort is needed to eat: because the food is offered and/or goes easily into the mouth (ice cream for example)

Bottle after breast meets all these criteria to promote over-eating:

• The breast is soft and requires a different approach and sucking technique than the harder bottle teat.
• Pumped milk and/or formula tastes different, and has a different temperature. With most bottles, milk flows quite spontaneously into the mouth regardless of how full the bottle is. A more empty breast flows more slowly towards the end of feeding.

When combining breastfeeding and supplementary feeding, regular weighing is therefore necessary to prevent overfeeding and thus possible obesity.

At around 3 months of age baby’s sucking reflex starts to fade out. This is when babies may start to refuse the bottle. But they can also start to prefer the bottle: breast refusal.

My strong impression is that this is more likely if a baby has been given supplementary feeding in the first months because breastfeeding was not working well and there were concerns about enough milk for the baby. My explanation is that these babies have had the experience that the breast is hard work and that satiety lies with the bottle. And in addition parents also often unconsciously or consciously trust the bottle more than the breast.

Breastfeeding changes around 3 months. Breastfeeding is getting easier and more comfortable:

• Breasts become supple again, while making the same amount of milk or more
• Babies start drinking faster
• Many babies start drinking the first breast for shorter periods than the 2nd
• The feeding position has to adapt to a bigger and more curious baby

This is very similar to what parents experience when there is too little milk in the first days/weeks or latching on does not work well. So then it seems obvious to conclude that there is too little milk again, or that the baby has a setback/regression. And if the bottle is then given, that image is reinforced to and by both parents and baby.

Aim to avoid rewarding issues with one kind of feeding (breast or bottle) with the other (bottle or breast):

•  If the baby struggles with the bottle: verbalise that this is ‘a bit silly’, distract him for 10 minutes and give him the breast elsewhere. Or (if bottle refusal is really an issue) offer the bottle again.
• If the baby is struggling about the breast: verbalise that that is ‘bit silly’, distract for 10 minutes and give bottle in another place. Or if there really seems to be an infant strike, offer fine body contact and offer the breast again a little later.

But breast and bottle refusal are 2 separate and complex stories, which will be covered elsewhere.

Careful handling of supplementary feeding can hopefully prevent breast refusal, which is nicer than having to cure.