Formula Use & Breastfeeding: The Moral of the Story

Earlier this week a study appeared in Pediatrics that has the media buzzing about whether giving formula in the first few days can actually improve breastfeeding rates. Both Time magazine and the New York Times featured stories on this. Not surprisingly, the media stories (and in my opinion, the researchers themselves) missed the central point.

This study compared breastfeeding outcomes in two groups of mothers whose babies had lost enough weight shortly after birth to be considered at risk. Both groups were given lactation help. In the control group, the mothers were encouraged to exclusively breastfeed. In the intervention group, after each breastfeeding the mothers were instructed to feed their babies by syringe a tiny amount of formula supplement: 10 mL, or about one-third of an ounce. This is about how much colostrum babies consume at each breastfeeding during the first 2 days of life.

The study found that more of the mothers who gave this small amount of formula after feedings breastfed longer and more exclusively than the mothers who didn’t.

Unlike the authors and the media, I don’t interpret these results to mean that early formula can help breastfeeding. In addition to all of the valid points made by other breastfeeding supporters, what was noteworthy to me was that the mothers in the intervention group were taught to supplement their newborns with biologically appropriate feeding volumes consistent with the recommendations of the Academy of Breastfeeding Medicine.

Many parents who supplement—including I’m sure those in this study’s control group—overfeed their babies incredibly, either without realizing it or because they are unwittingly instructed to do so by health professionals. Yesterday I spoke to a mother who was told by a pediatrician to make sure her jaundiced 4-day-old took 2 oz. (60 mL) at every feeding, which is twice the size of a 4-day-old’s stomach. To accomplish this, she was pumping, adding formula to her milk, and force-feeding this massive amount to her newborn.

My take-away message from this study is that any mother who supplements her newborn (whether with expressed milk, donor milk, or formula) should learn the appropriate amount to feed so she can prevent the kind of rampant oversupplementation that undermines breastfeeding and increases later risk of obesity. Babies overfed at this magnitude breastfeed much less often and milk production suffers.

What are the long-term effects of early overfeeding? One study followed to adulthood 653 people who were formula-fed from birth. Amazingly, greater weight gain during the first 8 days of life was associated with increased incidence of overweight 20 to 30 years later.  These researchers concluded that the first 8 days may be a “critical period” during which human physiology is programmed.  This may mean that breastfed babies’ greater weight loss after birth and slower return to birth weight may help promote a healthier metabolic program, which reduces the risk of overweight and obesity during childhood and beyond. At the very least, it most certainly means that parents and health professionals should be extremely wary of overfeeding newborns. To me, that’s the real moral of the story.

References

Academy of Breastfeeding Medicine.  ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate.Breastfeed Med 2009; 4(3): 175-82

Bakalar, N. How formula can complement breastfeeding.New York Times, May 13, 2013.

Flaherman, V.J., Aby, J., Burgos, A.E., Lee, K.A., Cabana, M.D., & Newman, T. Effect of early limited formula on duration and exclusivity of breastfeeding in at-risk infants: An RCT.Pediatrics 2013; 131(6):1059-65.

Naveed, M. et al.    An autopsy study of relationship between perinatal stomach capacity and birth weight. Indian J Gastroentero 1992;11(4):156-58.

Rochman, B. How formula could increase breastfeeding rates.Time, May 13, 2012.

Stettler, N. et al.  Weight gain in the first week of life and overweight in adulthood.Circulation 2005; 111:1897-1903.

Stuebe, A. Early, limited data for early, limited formula use. Academy of Breastfeeding blog. May 13, 2012

Why Do So Many Breastfeeding Mothers Supplement with Formula?

According to the U.S. Centers for Disease Control and Prevention, fully one-quarter of the babies born in America in 2009 were supplemented with infant formula by two days of age, and by three months, this had increased to nearly two-thirds. A very small number of breastfed babies really do need supplements, but most do not. Why then do so many mothers planning to exclusively breastfeed supplement their babies with formula? A recent study provided some revealing answers. 

In this study, 97 English- and Spanish-speaking low-income mothers participating in a U.S. government Women, Infants & Children (WIC) food subsidy program took part in 12 focus groups. The conversations in these focus groups were recorded to allow the researchers to analyze the mothers’ responses and better understand their motivations.  

After analysis, the researchers concluded that these mothers supplemented with formula during their hospital stay primarily because they were unfamiliar with infant and breastfeeding norms and they misinterpreted their babies’ behaviors. In other words, they considered formula the solution to imaginary problems. For example, many mothers did not realize that newborns woke to feed so often and thought that giving formula would give them more rest. 

“I think I just really wanted to sleep because every time I would fall asleep he would wake up hungry and I started to become frustrated. I felt that maybe I did not fill him, because it was every 2 hours…but now sometimes it’s still like that every 2 hours.”

The mothers also believed that their colostrum, the early milk, was not enough for their babies.  Many assumed their milk would increase at birth, and when they learned this did not happen for about 2 to 3 days, they assumed wrongly that their babies needed supplements. Others perceived comments from the hospital nurses to mean they didn't have enough milk.

The mothers assumed that latching should be easy and automatic, and when their babies had any difficulty at all taking the breast, they perceived this as “breast refusal,” thought their babies didn’t “like” breastfeeding, or saw it as a sign their baby preferred formula. When they experienced breastfeeding problems, such as sore nipples, some chose to give formula rather than requesting breastfeeding help.

On the second day of life when babies are normally wakeful and fussy, many of the mothers interpreted this typical behavior as a sign their baby needed formula. As one mother said:

“I really wanted to breastfeed him, but like I said, he was hungry all the time; he wasn’t sleeping as much because of it, so I had to switch over.”

This was true even among Latina mothers, who many believe supplement routinely because of their cultural beliefs. The researcher found that cultural beliefs were not the root cause of supplementation; the Latina mothers gave supplements for the same reasons as the non-Latina mothers.

What can be done to correct these kinds of misunderstandings? Thankfully, there’s an answer.  A research team led by Jane Heinig at University of California Davis has developed a program called Secrets of Baby Behavior that was designed to give new parents the information they need about infant and breastfeeding norms to reduce unnecessary formula supplementation and to help prevent childhood obesity caused by overfeeding. These materials, which are available to everyone, describe:

• How to interpret baby’s cues
• How to deal with baby’s crying 
• Infant sleep norms

When new parents understand what’s normal, they’re less likely to interpret typical baby behaviors as indicating a need for infant formula.

The Secrets of Baby Behavior blog provides parents with ongoing evidence-based guidance and support. See its explanation of why newborns usually become fussy on the second day of life  (this is true no matter how they’re fed) and its four-part series on infant sleep. 

For the full California Baby Behavior program implemented by California WIC, including training materials, click here.

Thank you Dr. Heinig and the team at UC Davis for these outstanding resources for breastfeeding families!

Reference

DaMota, K., Banuelos, J., Goldbronn, J., Vera-Beccera, L.E., & Heinig, MJ. (2012). Maternal request for in-hospital supplementation of healthy breastfed infants among low-income women. Journal of Human Lactation, 29(4):476-482. doi: 10.1177/0890334412445299. Epub 2012 May 24.

Formula Supplements Put Mothers at Risk

We know that anything less than exclusive breastfeeding increases health risks for babies.  But what about mothers?  I often talk to breastfeeding mothers who decide to supplement their babies with formula because they assume they will get more sleep and that sharing feedings will reduce the stress of the early postpartum.  Most don’t realize this strategy actually has the opposite effect. 

In an earlier post, I reported on research that found exclusively breastfeeding mothers get more sleep at night than mothers who also feed formula, even when others handled some night feedings.  Now a new study1 takes this insight one step further by examining how formula supplementation affects the amount of sleep new mothers get, their risk of depression, their overall health, and their feeling of well-being.  During the early postpartum all of these measures profoundly affect a new mother’s enjoyment of her baby and her ability to cope. 

This study, which will appear in the June issue of the journal Clinical Lactation,surveyed 6410 mothers during the first year after birth.  Although all new mothers experience fatigue, it found thatexclusively breastfeeding mothers not only slept significantly more hours during the night than other mothers but also reported significantly more energy during the day, a better mood, better overall health, and a greater sense of well-being.  Another surprising finding was that there was no statistically significant difference in any of these areas between the mixed-feed and the exclusively formula-feeding groups. 

This means that rather than making a new mother’s life easier—which is often her goal—feeding her baby formula supplements can significantly decrease her quality of life.  The authors note that some popular books on postpartum depression recommend that after birth at-risk mothers sleep apart from their babies and let others handle night feedings.2  Some hospitals have even begun implementing this strategy among at-risk mothers before discharge.  Even more extreme, others recommend at-risk mothers avoid breastfeeding altogether as a way to prevent postpartum depression, despite the substantial evidence that breastfeeding mothers have a lower risk of postpartum depression.3

This new study indicates that although trying to help at-risk mothers get more rest after birth may seem to make logical sense, strategies that separate and supplement newborns are misguided.  They actually put mothers at greater risk of sleep disruption, depression, and poorer health.

References

1Kendall-Tackett, K., Cong, Z., & Hale, T.W.  The effect of feeding method on sleep duration, maternal well-being, and postpartum depression.  Clinical Lactation 2011; 2(2): 22-26.

2Bennett, S.  Postpartum depression for dummies. Hoboken NJ: Wiley Publishing, 2007.

3Dennis, C.-L., & McQueen, K.  The relationship between infant-feeding outcomes and postpartum depression: A qualitative systematic review. Pediatrics 2009; 123(3):e736-e751.