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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!


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.


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Reader Comments (9)

I totally agree that all new moms should have not only adequate information, but also an adequate support system of professionals, family and friends to help with breast feeding success. I think many times, however, the "militant" attitude many have towards supplementing with formula (or even exclusive formula feeding for that matter) is just as bad, if not worse, than the attitude many people used to have towards breastfeeding.

This isn't to necessarily say that your article reads in this tone, I just feel compelled to leave this comment because of my own recent experience.

My baby is 2 months old, and though I was planning on exclusively breast feeding, it simply did not work out that way. At 4 days old she'd already lost 12% of her body weight and we were told by our pediatrician (who is an avid breast feeding supporter) that it would probably be a good idea to start supplementing with a little bit of formula. As a new mom I was having trouble getting her to latch, and my baby happens to be a rather finicky eater, liking to snack instead of filling herself up at any one (or even several) feeding. That combined with my own incredibly sensitive skin and incredibly painful nipples made the beginnings of breastfeeding really awful!

I dreaded her waking up because I knew she'd want to eat, and because of those militant breast feeding supporters I felt extreme guilt any time I got out the formula (even though it was doctor prescribed and I was still hoping to exclusively breast feed eventually). That guilt is something no woman should have to face, especially not one who is hormonally postpartum. For the first several weeks of my baby girl's life I didn't enjoy having her hardly at all, which made me feel about a million times guiltier. I felt like a bad, inadequate mom.

Eventually the hormones subsided, as did my own guilt and the need I felt to constantly justify using the formula. Now she might get more formula than she does breast milk and while that's not ideal, in our situation it was the right thing to do. I can finally enjoy her being awake since the longer periods of time between breast feeding sessions give my nipples a chance to recover, and I know that although formula isn't as good as breast milk she's getting the nutrition she needs even when I'm not the one giving it to her.

All of this wasn't because of a lack of support or information. During the last two months I've seen TWO board certified lactation consultants, sought help from TWO of her pediatricians as well as the midwife at my own doctors office whom my OB/GYN called their "breast feeding specialist".

I just want all the moms reading this to know you're NOT a bad mom if you decide to give your baby formula - whatever your reasons are. Each baby and mommy pair is unique and different, and anyone who tries to make you feel guilty for making your own breast feeding choices doesn't deserve the privilege of being part of your life.

October 17, 2012 | Unregistered CommenterStacy

Stacy, you made a choice. I was in a very similar situation, my baby lost too much weight according to my pediatrician, who also is a very strong supporter of breastfeeding. It was day 3 and she asked me if my milk fully came in and it didnt yet and of course she suggested formula, but I told her that I will wait. I know what nipple pain is like it brings tears and it feels like your wounds are open over and over again, but with the support of website I knew what to expect in those first days, when it is so easy to move towards formula, because you want best for your baby, and you don't trust your body. I'm glad that I didn't supplement because at the 1 week visit my daughter not only regained her 1lbs that she lost, but also packed on 1 extra pound and only on breastmilk. It is not wheter someone is a bad mom if they give their baby formula, but it is about trusting your own body's ability. We can do this we just need support of people around us and a lot of education

October 18, 2012 | Unregistered CommenterAnia

Stacy, as this post acknowledges, some babies really *do* need to be supplemented. Someday, ideally, donor human milk will be available for babies with a medical need for supplementation. It is clear from your comment that your baby's need for supplementation was really difficult for you to accept. You describe what you were feeling as "guilt." I hope you know that you have nothing to feel guilty about, because you did nothing wrong. I couldn't help but wonder if your feelings might be more accurately described as grief over the loss of the exclusive breastfeeding relationship you had planned. If so, that's completely understandable. If that happened to me, I would also need to grieve this loss. In the meantime, I hope you know that any amount of breastfeeding is a wonderful gift for your baby. You have my full support! --Nancy

Ania, yes I did make a choice, and for me and my baby it was the right one. There are many moms that would tell me the choice I made was wrong, and that's the problem. No, formula isn't as good as breast milk, but it's not bad either. It isn't really a question of good or bad, it's really a matter of good (formula) and better (breast milk). It's a healthy alternative with lots of research behind it for babies and mommies who either need, or simply want, to supplement. I'm glad you were able to stick with breast feeding exclusively, I just hope you're not one of the moms who make other moms feel bad about their choices :) Being a mom is hard enough without other people making it harder.

Nancy, donor human milk would be wonderful! Yes, I think you're right about there being grief involved. Exclusive breast feeding was something I, and my husband, felt really strongly about, and it was incredibly hard to give that up. I've been a mom for a short two months and I've already had to change my plans more times than I can count (not to mention eat my words over and over again, but that's another story haha). My aunt says babies are the best teachers (she had six, according to her she must have had a lot of learning to do), and I can already say my daughter has definitely been teaching me, especially on the subjects of flexibility and tolerance. Unfortunately there was some guilt too, and I'm sure it was because I felt like other people would think I had done something wrong. Just like any subject I believe some of the most vocal breast feeding advocates can be the most harmful. Thank you for your support! I also have the support of our local lactation consultant. She's a wonderful, understanding, educated woman. Without her support I might have stopped breast feeding altogether because of the grief, guilt and frustration. I cherish the times I am able to breast feed and am thankful to those who do support me every day for that. :) This was a good educational post, thank you for your hard work.

October 18, 2012 | Unregistered CommenterStacy

Stacy, please keep in mind that no one can "make" anyone else feel guilty. Honestly, if someone has a problem with something you do, that is *their* problem, not yours. I'm glad to hear that you had the support you needed from your lactation consultant to keep breastfeeding. Those of us working with breastfeeding women are first and foremost about supporting women and families. I've honestly never met anyone in my field who wants to make the challenging job of mothering more difficult. Keep up the great work! --Nancy

I am a La Leche League Leader. Over the past 25 years I have met mothers who supplemented with formula because having the flexibility to allow others to feed their baby was important to them. Many mothers who supplement with formula did not want to express their own milk. Not every mother chooses to exclusively breastfeed. They are nonetheless breastfeeding mothers. I did not want to supplement with bottles, I did not want anyone other than me to be responsible for my babies. Mothering like my ancient ancestors appealed to me. I understand that most women who want to be active in the world and interact with the wider culture do not find the practice of exclusive breastfeeding appealing.

October 18, 2012 | Unregistered CommenterElly Egenberg

Thanks for your comment, Elly. This post was not actually about women who don't want to exclusively breastfeed. Its focus was on why women who *do* want to exclusively breastfeed decide to supplement with formula. Considering there's a large percentage of women who fall into this category, I think the information from this study is extremely valuable. --Nancy

I have also offered support to non-white WIC mothers. Perhaps the cultural gap is responsible for the disparity between self reported desire to exclusively breastfeed and the actual outcome.

October 19, 2012 | Unregistered CommenterElly Egenberg

In answer to your idea, Elly, this particular study found that cultural beliefs were not at the root of the formula supplementation. The Latina mothers--which many believe give breast and bottle for cultural reasons--supplemented their babies for the same reasons as the non-Latina mothers. Interesting! --Nancy

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