Breastfeeding Medicine

Physicians blogging about breastfeeding

Early, limited data for early, limited formula use

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A small study published in Pediatrics suggests that supplementing newborns with small quantities of formula may improve long-term breastfeeding rates. The results challenge both dogma and data linking supplementation with early weaning, call into question the Joint Commission’s exclusive breastfeeding quality metric, and will no doubt inspire intimations of a formula-industry conspiracy. Before we use this study to transform clinical practice, I think it’s worth taking a careful look at what the authors actually found.

First, I think it’s very important to be clear about what the authors meant by “early limited formula.” The authors used 2 teaspoons of hypo-allergenic formula, given via a syringe, as a bridge for mothers whose infants had lost > 5% of their birthweight and mom’s milk had not yet come in. At UNC, we use donor milk in a similar way, offering supplemental breast milk via a syringe as a bridge until mom’s milk production increases.

This is very different from the way that formula supplementation is handled in many US hospitals. We know that in the US overall, 1/4 of breastfed infants are given formula by day 2 of life, and that number reaches as high as 40% in some areas. Typically, when a family member expresses interest in giving the baby some formula, a hospital staff member plunks a 6-pack of 2-oz bottles of ready-to-feed formula in the baby’s bassinet with no instruction about how much to feed. A neonate whose stomach holds one to two teaspoons gets 2 ounces (12 teaspoons) of milk poured into him. The baby then sleeps for the next four to six hours, like someone who’s just over-indulged at a Thanksgiving buffet. In this scenario. Mom doesn’t get any breast stimulation, and family members all express relief that “finally the baby is happy.” When baby finally wants to eat again, there are five more convenient, ready-to-feed, six-hour-nap-inducing bottles sitting in the bassinet. This does not tend to help mothers breastfeed successfully. I worry that the headlines from this study — such as “How Formula Could Increase Breastfeeding Rates (TIME)”  and  “How Formula Can Complement Breastfeeding (NYT)” —  will translate into “a six pack of formula back in every bassinet!”

It’s also notable that there were more multiparous women in the ELF group than in the control group (70 vs 50%)— and multiparty was a powerful predictor of exclusive breastfeeding. At three months, 78% of multiparous moms were exclusively breastfeeding, vs. 33% of primiparous moms. Based on these numbers, if you treated both groups exactly the same way, you’d expect 65% of the ELF moms to be exclusively breast-feeding at 3 months (.70 * .78 + .30 * .33 = .65), compared with 55% of the control group moms (.50 * .78 + .50 * .33). In a larger study, one would adjust for this difference statistically, but this sample was too small to allow for such adjustment.

In a future study, researchers could avoid this issue by randomizing first-time moms and experienced moms separately, ensuring equal numbers in each intervention group. Bigger numbers would also increase the precision of the estimated difference between the two groups. The authors report that 15/19 moms in the ELF group were exclusively breastfeeding at 3 months, vs. 8/19 in the control group. Those are very small numbers. Intuitively, 150/190 is more precise than 15/19 — and if the authors reported an exact confidence interval, they would have reported that 15/19 is 79%, but the precision on that estimate (the 95% CI) ranges from 54-94 percent. For the control group, 8/19 = 42%, with a 95% CI of 20-67 percent. So it’s possible that the real difference between the groups is much smaller — or much bigger — than the one described in the paper.  A larger study would improve that precision.

I wonder as well about 5% weight loss as the threshold for intervention. For a pilot study, the goal is to find out whether it’s feasible to enroll patients, so researchers tend to use fairly loose inclusion criteria. In fact, it may be that waiting a bit longer, or for a higher threshold for weight loss, better identifies the dyads who need a bridge. I’d be hesitant to use this study to change practice to “syringe feed every baby down 5%”

A larger study would also test whether the intervention would work the same way “in real life.” A study doctor or nurse administered the intervention, staying at the patient’s bedside to teach her how to use the feeding syringe or use the soothing techniques. Study personnel are, by definition, deeply invested in doing the intervention in a way that ensures continued breastfeeding, and probably chose their words very carefully so as to maintain mom’s confidence in her ability to breastfeed. For this approach to successfully scale to a non-study setting, the authors will need to define the language, context, and training that they used and teach it to other care providers so that it achieve the desired outcome.

I also wonder a bit about the potential for bias during the control intervention, in which study physicians or nurses taught mothers about infant soothing techniques. The people doing this piece of the intervention did this study because they thought that ELF might be beneficial. In the course of a 15-minute conversation with the control mother about soothing a hungry baby without supplementing, they may have telegraphed that belief to the mother, possibly making her more likely to give up breastfeeding than she might have had she never been in the study at all. This is a challenge in any randomized trial — you have to give the control group “something,” and it’s always possible that that “something” affects the outcome.

Future studies should also explore the effect of offering expensive, hypo-allergenic formula to infants, compared with using donor milk. The rationale for using the hydrolyzed formula is that this would reduce the risk of formula exposure for the infant, and this is supported by the TRIGR study, which found that infants at high risk of Type I diabetes who received regular formula were more likely to develop islet cell antibodies than infants who received hydrolyzed formula. However, having a health care provider recommend hydrolyzed formula could lead parents to continue buying this product long-term. I wonder about whether this approach could be co-opted as a marketing strategy for high-priced formula. I could imagine formula manufacturers selling “syringe-ready” feedings for newborn nurseries branded with their logo and product line. Using donor milk would obviate this issue entirely.

Finally, one of the underlying questions in this type of research is why it’s so common for babies to lose more weight than expected in the first few days of life. Some of this may reflect obstetrical practices — there are a few studies that suggest when moms large volumes of IV fluid during labor, some of the extra water goes to their babies. That extra water registers as an exaggerated birthweight, and as they pee off the extra fluid, they appear to lose too much weight, when they actually are doing just fine.

Laurie Nommsen-Rivers has done some ground-breaking work looking at the prevalence of delayed lactogenesis — i.e. Milk coming in more than 72 hours postpartum — and found that this is incredibly common in the U.S., but not in other parts of the world. She posted the following comment on a blog I wrote last fall:

In our prospective study of 431 first-time mothers residing in Sacramento, CA, 44% experienced onset of stage II lactogenesis after 72 hours, but only 1.7% still had not experienced stage II lactogenesis at the end of the first week postpartum (Nommsen-Rivers, et al, Am J Clin Nutr, 2010). In contrast, a companion study lead by Susana Matias in peri-urban Peru found that only 17% of first-time mothers experienced onset of stage II lactogenesis after 72 hours and NONE were still waiting for their milk to come in after 1 week (Matias, et al, Mat Child Nutr, 2009). Another interesting contrast comes from rural Ghana: in a study published by Otoo, et al (JHL), in which <5% of a cohort delivering at a baby-friendly hospital in rural Ghana experienced onset of stage II lactogenesis beyond 72 hours. All of these studies used similar, validated measures of stage II lactogenesis.

One of the key risk factors for US mothers in her study was maternal body mass index, with 54% of women with a BMI > 30 experiencing delayed onset of lactogenesis, compared with 31% of normal BMI women. Older maternal age and higher education were other risk factors. A central question for future research is why so many American mothers start making milk so much later than women in other parts of the world.

The bottom line is that this is a complex issue.  We know that the onset of mature milk production comes later in American mothers than in women in other parts of the world, and we need to develop and test strategies that can support long-term breastfeeding success. This small pilot study suggests that bridging mothers with a syringe of a breast milk substitute may ultimately help them establish breastfeeding.  The next step is to replicate these findings, ideally using donor human milk, to test whether these results hold up in a larger sample.
Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician, breastfeeding researcher, and assistant professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine. She is a member of the board of the Academy of Breastfeeding Medicine.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.

Written by astuebe

May 13, 2013 at 6:27 am

38 Responses

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  1. The article on which this is a comment is beyond silly and I cannot believe that Pediatrics would publish such an article. This is “breastfeeding support” based on weights, in a situation where almost all babies are born “overhydrated” because of maternal IV infusions during labour and birth. Assuming there is actually a problem (not proved by the article), then the mother should receive help with the breastfeeding which includes: 1. observation of a feeding to see if the baby is actually drinking from the breast and this information should be transmitted to the mother. 2. If the baby is not drinking, then the mother should be helped with the latching on of the baby, taught breast compression to help the baby get more milk, and not limiting feedings on the breast.

    There are two things about any supplementation, be it donor milk or formula:
    a) the message that is sent to mothers that tells them “yes, you were right all along, your baby was indeed starving and you didn´t have enough milk”
    b) it provides a “solution” that prevents mothers from getting real good hands on help and it prevents them from learning what they really need to learn to have confidence in breastfeeding

    There is nothing worse than “proponents of breastfeeding” who believe in solving problems with breastfeeding by giving formula. Those are the ones that confuse the mothers the most.

    The quotes in the article are so typical – the mothers are worried about the baby starving for the first three days, they say. So what do they do? They help them by “weighing the baby and the mothers get to see the weight droping and droping”. That is fantastic practical and psychological help.

    And which babies got the formula? Those that lost 5% but no more than 10% of birth weight.

    And one of the last sentences is fascinating too: “their study at least suggests that formula may be a viable option – even for women who are inclined to dismiss it”. I also love it how they say their results may not be applicable elsewhere because they live in a community where women are eager to breastfeed and 98% initiate breastfeeding. So surely they must find ways to give these babies formula.

    Jack Newman

    May 13, 2013 at 7:59 am

    • Thank you for being the voice of intellect and reason! Mary Baracco, CNM, IBCLC

      Mary Baracco

      May 14, 2013 at 11:02 am

    • Thanks so much for counter disagreeing with this article that is not based on the truth. This article is full of falsehoods and the last thing that women need is to think that what they produce for their infant is not enough just to further add to their insecurities as a new mother.

      Michele L Lobo

      June 20, 2013 at 9:24 am

      • scatch the double negative. I meant to just say disagreeing 🙂

        Michele L Lobo

        June 20, 2013 at 9:26 am

  2. Brilliant post, Alison! Thank you for spelling it all out for us.

    All this talk about syringes and supplements makes me think of an intervention many of us recommend for our mothers at risk of low milk production (high BMI, diabetic, previous “lactastrophe,” physical markers of IGT, for example)–prenatal expression of colostrum. The mothers don’t hesitate to supplement with their own colostrum, the babies stay strong and able to keep up their end of the bargain in establishing breastfeeding, and I’ve seen self-efficacy improve (“look at what I produced!”) in mothers who’ve collected their own colostrum before their babies were born.

    Of course, this is only recommended to mothers in low-risk pregnancies. The link below is to the abstract of Suzanne Cox’s paper in “Breastfeeding Review.”

    Thanks again for your fabulous post!

    • Diana,
      I used to agree with this idea of supplementing to hold the baby over ‘until the milk is in’. However, after viewing the videos by Dr. Jane Morton, I completely disagree with using this method as a regular practice. If you are interested, google burgess + breastfeeding and go to Dr Jane Morton videos (3) and see if you change you mind! Perfecting hand expression technique can make all the difference. Hope that these videos open your eyes as they have mine.

      Michele Lobo IBCLC

      Michele L Lobo

      June 20, 2013 at 9:37 am

  3. Thanks so much for this analysis!


    May 13, 2013 at 11:08 am

  4. Following on from the first comment, early postpartum feeds followed by manual expression of colostrum, whatever drops are available, subsequently fed to the baby by cup or spoon. This gives the baby a few easy calories after a feed and provides stimulation and more thorough breast emptying, follows NICU protocols which might be appropriate in these cases. I know as a private practice LC I have a purely clinical perspective but it might provide another practice worth studying to see if it assists in bringing on lactogenisis II.

  5. […] First of all, there is another blog out there that has already done a great job of pointing out many of the flaws, here. […]

  6. Thank you Alison for the wonderful breakdown. Having done both inpatient PP and outpatient lactation, I have to say I feel the PP IBCLC has the most difficult part of the bargain. It can be so challenging convincing mom’s who are in pain and exhausted to keep the baby on the chest and demand feed. With the exception of my Mexican mothers who look at you cross eyed when you suggest they take a break and put the baby in the crib. If you can convince them and they feel better after an hours time because of the hormonal benefit to mom and baby, usually a filter member or staff member comes in and recommends a pacifier or q 3 hour feeds and derails the whole thing. I firmly believe lack of frequent demand feeding in the first 3 days is the reason for delayed lactogenesis in American women.

    Lisa Mooney

    May 13, 2013 at 12:53 pm

  7. […] in soothing techniques, to even out the amount of contact each group got from providers.  As Dr. Alison Steube notes, this may have “telegraphed” a lack of faith that exclusive breastfeeding would work […]

  8. Reblogged this on melissarnibclc's Blog.


    May 13, 2013 at 2:05 pm

  9. The original article to which this blog refers seems to completely miss the point. The point being that it is actually possible to help mothers and babies breastfeed in the first few days without supplementation (be it formula or donor milk) and if the article suggests that formula (or even donor breastmilk) is the answer for babies who lose 5 – 10% of birth weight, i. e. for normal healthy babies who in fact have no reason for being supplemented, then we need to re-think what actually happens in hospitals: Women are constantly given the message that their bodies are failing them – they fail to give birth and need medical help, they fail right after birth because they are told their babies can´t be in their arms and must be taken away and they fail in the first few days because they they are told they must supplement. Something is always better than the mother – medical equipment, incubators, nursery, syringes with “just a little bit” of formula, scales.

    Giving formula seems to “solve the problem” of mothers asking for help, but in fact prevents mothers from getting help and gives everyone a false feeling of “all is well”. But was the mother shown how to tell that the baby is drinking milk from the breast? What the mother shown how to latch the baby? What she shown how to use compression to get the baby to drink better? What she told it is okay to not to limit feedings on the breast to 10 to 15 minutes?

    Providing help and support for mothers is a laborious process, providing formula/donor milk is the easy shortcut. The same is true for asking mothers to express their milk after breastfeeding the baby. Whether all this happens is a litmus test of our ability to truly help mothers and babies: Why not teach mothers something that will make them feel competent and proud of their ability to breastfeed? What can be more devasting for mothers than hearing that “don´t have enough milk” and should supplement? Once you say that and you close the door on their room, you don´t see the tears that well up in their eyes, you don´t hear their cry that says: “I thought you were going to help me breastfeed!” And if we are able to get mothers to express their milk, as some other comments suggest, then a well-latched baby should be able to drink that milk from the breast directly and drink much more than the mother is able to express. So why give her one more task? And more importantly, why give her the message that there is something not quite right with breastfeeding simply because we are unable to help?

    Mothers want and need help in the first few days. They initiate breastfeeding because they want to breastfeed. So many are disappointed in their expectation to be supported and say: “I wanted help with breastfeeding and was given formula instead.” Formula/Donor milk feeding does not teach breastfeeding. It´s really simple: Mothers and babies learn to breastfeed by breastfeeding.

    Start listening to mothers: No pregnant woman comes to hospital believing that help with breastfeeding will include supplementation.

    Andrea Polokova

    May 13, 2013 at 4:19 pm

    • Your response is so refreshing Andrea. I may have agreed with it before I saw videos of hand expression by Dr. Jane Morton. I thought maybe you could use these videos as a teaching tool as I do. Google
      Burgess + breastfeeding, click on Dr Jane Morton videos (3 videos that are 10min each) I have found that mothers who see these videos know exactly how to breastfeed and hand express and gain so much confidence after viewing them. I hope that you can benefit too.

      Michele L Lobo

      June 20, 2013 at 9:45 am

  10. Thanks, Dr. Jack Newman for pointing out the problems with this rebuttal.

    In other parts of the world, new moms don’t feel the need to cover up or delay feeding baby when guests or hcp enter the room. They have baby at the breast almost continuously; therefore, their milk comes in quickly. In American hospitals mothers could get their milk in just as quickly if they kept baby in arms and at the breast in this way. It’s mechanics, not mystery. American breasts don’t work differently than Peruvian ones.


    May 13, 2013 at 5:52 pm

  11. Could I ask that this reply be sent to the journal of Pediatrics as a reply to this article to be published in a future issue? I am sure you won’t be the only one but in the event that you are, it’s important to herald objective methodology

  12. […] The formula industry today increased its grip on infant feeding with a study published today in the medical journal Pediatrics. News about this study has spread like wildfire across the Internet; I saw one headline “Tiny bit of formula preserves breastfeeding.”  Already many, including myself, have written responses to this small, risky, and foolish study, pointing out all its shortcomings; the best one comes from Dr. Alison Steube for the Academy of Breastffeeding Medicine. […]

  13. I seem to recall that when I was working as an LC at a small community hospital, a 5% loss was not a concern in a healthy newborn, so whey would such a study even be done? Why alarm the mothers of these babies by suggesting they needed formula? We’d encourage skin to skin, and if a baby was slow on the uptake, have the mother express some drops of milk onto the baby’s lips, or onto her own finger and let the baby suck on it. This often got a sleepy baby more interactive with the breast.

    Also, staying with the mother to help her learn the signs of the baby stirring and getting the baby to the chest before the baby is wide awake and showing stronger signs and getting frantic, often helped to get the baby attached and sucking. So much information is out there about massage and hand expression in the early days, or if a pump is used, hand expressing into the pump flange at the end of the feeding as ways to collect more milk for the baby. I often observed that if a mother pumped and got a tiny bit of milk, waited a short while and pumped again, she got much more milk. Two to 5 cc. instead of a few drops. We made a big deal about the mother getting a few drops and made sure they got to the baby.

    Does the study say anything about what methods might have been used first to obtain more milk from the mother, or check whether there was too much separation, or not enough time spent supporting the mothers? Once I was sent into a room because a “baby hadn’t really latched yet,” and saw the grandmother with the baby swaddled, both asleep.The mother was awake, alone in her bed. The baby was past 24 hours old. How long had that been going on? When I brought the baby over to the mother placing baby on her chest, the mother started to stroke her baby and to bond. And when the baby stirred, she made great attempts to latch. Was the culture at the study hospital(s) studied to see if it interfered with mother-baby interactions, or didn’t allow nurses enough time with the mother to help her recognize the baby’s state and readiness to fed?

    Mardrey Swenson IBCLC

    May 14, 2013 at 12:05 am

  14. I respect Valerie and I think her intention was an interesting one. However, as with any research study, it is vital to read and critique a study to interpret it correctly. I too am surprised at Peds but, in my opinion, they have been publishing a lot of things lately that simply have not been adequately reviewed.
    With respect and support for my colleague, Dr Flaherman, there were a few serious issues with this study:
    1. To be in the study, the mother had to agree that she did not mind getting formula, selecting for a population willing and ready to use formula in both control and intervention groups.
    2. Once they were assigned to a group, the intervention group were visited at each feeding with a bit of formula, but also with encouragement to breastfeed and not use formula later. The control group had no breastfeeding encouragement nor formula dissuasion visits.
    3. The control group only were taught the 5 S’ to shush a baby. These behaviors that can actually decrease feeding frequency, reducing milk supply,and, consequently, increase the need for supplementation unless it taught along with breastfeeding support, which is was not.
    4. The study does not follow the infants long enough to fully measure the potential negative impact on their guts over time.

    So, all in all, we really cannot say that early formula increases duration of breastfeeding among those who intend exclusive breastfeeding, nor can we say that this can be compared to a group without breastfeeding encouragement. In sum, let’s all read the article, rather than just the headlines and conclusions!!

    Miriam Labbok, MD

    May 14, 2013 at 8:33 am

    • Thank you very much…to know what was not said in the article is invaluable. Mary Baracco, CNM,IBCLC

      Mary Baracco

      May 14, 2013 at 11:10 am

    • That is truly invaluable information! Thank you!

      Jen Chendea

      May 16, 2013 at 10:38 am

    • Dr Labbok, with regard to your points:

      1. Most mothers in the Western world today don’t mind giving at least some formula. That means that the subgroup of mothers willing to give formula is a very large and important one to be studying in terms of what might help or hinder breastfeeding.

      2 and 3 have been addressed below by Dr Aby, one of the study authors, who helpfully clarified that all mothers in the study *did* get intensive breastfeeding support.

      4. Astonishingly little research *does* look at long-term health outcomes with formula supplementation in a breastfed baby. In fact, I found one of the most interesting features of this study to be that it actually did look at health outcomes for the babies in the different groups rather than treating breastfeeding itself as the only outcome of note. The authors clearly plan to follow this line with further research as well, which could be a great way of investigating the truth of the oft-quoted dogma about all formula supplementation being harmful. I for one look forward to hearing more from them on this.

      Dr Sarah

      May 19, 2013 at 1:55 am

  15. Thank you Miriam for pointing out the bias in the study, that the not only was the experimental group self-selected, but also that the control group was given instructions that were not supportive of breastfeeding. Associating the “5 S’s” with duration of breastfeeding/formula supplementation would be a study all by itself.
    It is unfortunate that this “research” centered on fixing something that may or may not have been broken, when normalizing birthing and postpartum protocol would be much more effective in improving milk intake in the first 36 hours. Continuous contact between the mother and baby from birth seems to be the missing factor here.
    Continuous contact is not a complicated concept; however it is quite foreign to North American culture. When I learned that a local hospital was focusing on skin-to-skin care immediately after birth, I was extremely pleased. Then I heard that once the baby has done his skin-to-skin time, he goes into a bassinet. There is universal rooming-in, and baby is IN the room, but mom has to get out of bed to go get him. When it is time to feed the baby, mother is to strip the baby down, change his diaper, and then do skin-to-skin before offering the breast, as AN EXTRA STEP in the feeding routine. As you can imagine, most babies are screaming and thrashing and skin-to-skin is not relaxing them. No one is saying, “Keep the baby on you, and feed him any time he begins to stir.”


    May 14, 2013 at 12:25 pm

  16. If I was doing a study on why women in America start to produce milk later I’d take a look at how induction of labor impacts when a new mom’s milk comes in. Given how often first time moms are induced for being “late” and how often heavier women are induced early because of the baby’s suspected size it stands to reason the two may be related.


    May 14, 2013 at 1:29 pm

  17. As one of the co-authors of this study, I’d like to address a couple of questions and inaccuracies reflected above.

    1. Both groups were given intensive lactation help, taught correct latch, on demand feedings (no time limits), and the need for >8 feedings per day. It is true that the control group was not told to stop formula use (because they weren’t using it!), but they were instructed to continue exclusive breastfeeding (without ever starting formula).

    2. Inclusion criteria stated that the infant must have lost >5% of birthweight in LESS than 36 hours. Given that we know those with fairly rapid early weight loss are more likely to go on to lose >10% of birthweight, this group was considered to be at higher risk than your average baby of eventually getting “rescued” with formula. We all agree than 5% weight loss at some point in the first few days is normal. No one is suggesting this approach for them.

    3. While you may vehemently diagree with our approach, it is a fact that many of our “exclusively breastfed” babies quit breastfeeding well before they should. In our nursery, we spend countless hours trying to talk moms OUT of giving formula. We are not proponents of it’s use when breastfeeding is going well. You may rightly argue that our breastfeeding support should be improved. Indeed it should. But in the meantime, I’d rather try to support breastfeeding with methods that might actually support it. I see LESS risk in giving limited amounts of formula for a few days than in exclusively breastfeeding for a few days and then drinking formula for the next two YEARS. I know there are many moms out there who never gave a drop of formula. I think that’s fantastic! I hope we have more and more of them. But, I also know of many others who became so frustrated with breastfeeding that they finally just quit. I want to see fewer and fewer of them. And if a little formula, or donor milk, will help them hang in there, then unless someone can show that the risk is greater than the benefit, I’m all for it.

    Janelle Aby, MD

    May 14, 2013 at 1:39 pm

    • @Dr Aby – delighted to see one of the study authors show up here with more information, as I find this study very interesting! I was wondering about the breastfeeding help provided, so find it very useful to have that question answered.

      If you’re still reading, I wonder whether you could clarify something else that has been a point of contention on a list where I’ve been discussing this study – the teaching of soothing techniques as the study control. Concerns have been raised that this could have made the control group *more* likely to develop breastfeeding problems, as they might have tried to use the soothing techniques in place of putting the baby to the breast frequently enough, thus causing eventual problems with their milk supply which could have skewed the study. Is this in fact a possibility? Was it clarified to the control group mothers that the soothing techniques were to be used only after first trying the breast to see whether hunger was accounting for the fussiness?

      Dr Sarah

      May 19, 2013 at 1:40 am

  18. […] via Early, limited data for early, limited formula use | Breastfeeding Medicine. […]

  19. Thanks for authoring this post and starting the discussion. I feel this study was a sensible approach to understanding how we can support babies with early weight loss and a helpful study for some of us who wonder about those early moments of small volume formula feeds. I don’t recommend formula to moms whose babies are 5% down. This small study doesn’t convince me to change my tune yet I still like knowing the results.

    That being said, I do see the implication that the commercial world will blow this out of proportion. I get why some are frustrated. But the anger I hear online seems to only scare moms who already feel enormous pressure and a sense of failure. This fight never seems to align advocates with those seeking advice.

    As a pediatrician and mom who failed to meet my own goals for breastfeeding (with my first son), I think the ELF approach is sensible. But like so many other health initiatives, it’s a slippery slope. May be very difficult for moms/RNs/hosp staff to stay with 10mL bolus, supporting this type of feeding regimen for newborns may lead to larger formula feeds and deter the original intent.

    Formula, of course, isn’t the only option for moms with babies losing weight: education, support, empathy, information and hands-on care to support 8 feedings daily at DOL 1 or 2 may help, too as Dr Aby notes above.

    But I’m biased ~~ I had a terrible challenge breastfeeding my first son and it was a huge education for me (problematic latch, used finger feeds after nursing attempts, saw over 8 lactation consultants in Seattle, ELF bolus via tube for first 2 weeks along with EBM and then subsequent severe mastitis at week #4 that led to a 4-day hospitalization for IV abx which left me exclusively pumping for 4 months). It was an awful experience.

    I’ve always felt a sense of failure as a breastfeeder for my son and this study helped me feel better that those lactation consultants and nurses who helped me create a plan to get food into my dehydrated boy while also supporting my desire to exclusively breast feed didn’t lead me astray — trying to improve my breast-feeding by providing EMB and ELF bolus via syringe and tube starting on DOL 1-2 because of his weight loss may not have been the nidus of the problem after all.

    Wendy Sue Swanson, MD

    May 15, 2013 at 6:54 pm

  20. There was a post recently on Lakeshore Medical Breastfeeding Medicine Clinic’s facebook page talking about Toll Like Receptors. This is not my area of expertise but it certainly addresses Dr. Aby statement that “….unless someone can show that the risk is greater than the benefit, I’m all for it.” I’m putting a quote of part of the post here from Dr. Jenny Thomas, MD, MPH, IBCLC.

    “The effect of these Toll like Receptors is present only in the *first 5 days* of the baby’s life. We supplement somewhere around 20% of our babies nationwide in the first 48 hours. We need to know that there are consequences to that. Any alteration in human milk or addition of formula messes up the regulation of Toll like Receptors, leading to inflammation and altering the development of the immune system.”

    We have to keep in mind also that National Surveys that collect breastfeeding in the US – National Immunization Survey, does not consider any infant to be exclusively breastfeed once they receive *anything other than breastmilk, even water* so early, limited supplementation is certainly not helping to increase exclusive breastfeeding rates and presents another reason why the results of this study are inherently flawed.

    Sally Greene, MS, IBCLC, RLC

    May 16, 2013 at 1:23 pm

  21. I have another point of view on this study that is unrelated to the many valid points raised here. I currently provide corporate lactation support to mothers by phone during and after maternity leave. As mentioned, many mothers begin supplementing with formula early on. What was noteworthy to me about the study was that the intervention group was taught to supplement these newborns with biologically appropriate feeding volumes, such as those recommended in the Academy of Breastfeeding Medicine’s Protocol #3.

    Many parents who supplement—including I’m sure those in this study’s control group–overfeed their babies exponentially, 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. To accomplish this, she was pumping, adding formula to her milk, and force-feeding this massive amount to her newborn.

    In my opinion, this study’s results should NOT be interpreted to mean that early formula can help keep mothers breastfeeding. My take-away message is that teaching mothers to feed their babies physiologically appropriate volumes (whether expressed milk, donor milk, or formula) prevents the kind of rampant oversupplementation that undermines breastfeeding and increases later risk of obesity. This is also a message that health professionals who work with new parents should hear.

    I would love for members of the Academy of Breastfeeding Medicine emphasize this aspect of the story.

  22. […] of the study include this one by lactation consultant Katrina Pinkerton-Lloyd, ICCE CLEC and this one by Dr. Alison Steube. As usual, the mainstream media is all over this study  with both and Time Health & […]

  23. […] responses to the study can be found at The Academy of Breastfeeding Medicine and Best for […]

  24. Reblogged this on St. John Mother Nurture Project and commented:
    The Academy of Breastfeeding Medicine Blog this week, by Allison Stuebe, MD, MSc, is a great read for all who, like me, were concerned about the ramifications of the newly published article–Effect of Early Limited Formula on Duration and Exclusivity of Breastfeeding in At-Risk Infants: an RCT.

    Dr. Stuebe did a thorough job of highlighting the shortcomings of the small study. In addition, I would also comment that the authors have financial ties to the formula industry. Please read as it will help us, in the field, answer the inevitable questions that will come our way.

  25. […] 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 […]

  26. […] A whole lot of research done in lactation is underwritten by the boob’s main competitor: the pharmaceutical companies that manufacture formula. It just makes sense that they want to unlock the mysteries of the breast so that they can create a product as close to it as possible (one has to wonder why, if breastmilk isn’t that great after all, creating infant formula as close to human breastmilk as possible is such a holy grail). It also makes sense that they’d like to demonstrate that it doesn’t really matter if you breastfeed or not, as they make a whole lot of money when people don’t breastfeed, or if they can be convinced that supplementation will help them breastfeed. […]

    The Boob Geek

    October 16, 2014 at 12:00 am

  27. […] A whole lot of research done in lactation is underwritten by the boob’s main competitor: the pharmaceutical companies that manufacture formula. It just makes sense that they want to unlock the mysteries of the breast so that they can create a product as close to it as possible (one has to wonder why, if breastmilk isn’t that great after all, creating infant formula as close to human breastmilk as possible is such a holy grail). It also makes sense that they’d like to demonstrate that it doesn’t really matter if you breastfeed or not, as they make a whole lot of money when people don’t breastfeed, or if they can be convinced that supplementation will help them breastfeed. […]

  28. This is a great commentary on the study, and I think many of the other people who commented should go to the original publication and read through it properly before offering their pearls of wisdom. I am not sure how a study that shows that giving newborns a very small amount of formula for a couple of days and caused greater breastfeeding rates (i.e. less formula use overall) can promote infant formula use – it seems to me that Big Formula would not be so happy with the results of the study.


    December 8, 2015 at 8:34 am

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