Rule number one, while you’re nursing out why your milk production is low and what you can do to improve it, is to make sure that your baby has enough to eat. Supplementation can seem like a step away from breastfeeding, but it really is a step forward, because it will ultimately help your baby be strong and able to breastfeed better. The next two Blogs focus on ways to optimize your production. If baby needs more than he’s been getting, this Blog will help you learn how to supplement without reducing supply or interfering with your developing breastfeeding relationship.

When to Begin Supplementation

The urgency to supplement depends on how much milk your baby is currently getting. The lower your baby’s diaper output, weight gain, or feeding test weights, the more critical it is to begin supplementation immediately. On the other hand, if your baby’s diaper output is borderline or just below minimum, weight gain is just below normal, or test weights are only slightly low, you may have more leeway in deter- mining if, when, and how to give supplements An otherwise healthy baby who is not getting quite enough because of something simple like infrequent nursing may be able to bring up your supply in a short amount of time without com promising his health.

How Much to Supplement: A Starting Point

Figuring out how much to supplement means finding the right balance between enough and not too much. Your baby needs sufficient food but not so much that he feeds less often and under-stimulates your production. The following information is a starting point in determining how much to give. From there, you can customize it to your baby’s needs.

Step One: Determine the Total Amount Needed

The first month is a time of rapid growth and building up of your milk production. By the end of that first month through at least the next five months, most babies are taking an average of about 25 ounces (750 milliliters) of milk per twenty-four hours. Babies under a month or who weigh less than 10 pounds (4,540 grams) often need less. An old rule of thumb is about 2.5 ounces (75 milliliters) of milk for every pound (454 grams) of body weight per twenty-four hours. Divide the total amount needed each day by the average number of feedings per day to determine the average amount baby needs at each feeding.

Step Two: Determine the Amount of Supplement Needed

If you’ve taken test weights and have an idea of the average amount baby is getting from you each feeding (BLOG 3), subtract it from the total amount you determined baby requires each feeding. The result is the average amount of supplement needed per feeding. For example, if you know that your six-week-old baby feeds about eight times a day and needs about 3 ounces per feeding but has been getting only 2 ounces at the breast, you can probably expect him to want an additional ounce per feeding.

If you don’t have a good idea of what baby has been getting, take baby’s weight gain deficit for the previous week and then multiply it by 2 for the ounces of total extra milk he may need per twenty-four hours. So if baby should be gaining 7 ounces a week but gained only 2 the previous week, then he may need 10 ounces of supplement (5 ounces x 2) per day to start.

Once you’ve found your starting point, offer this amount and watch carefully to see if baby wants less or more. Give him whatever he will take, but don’t ask him to take more than he really wants. Keep in mind that babies, like adults, vary in how much food they want fronm one feeding to the next. Estimating the amount of extra milk needed is as much an art as it is a science, and baby himself needs to play a role in this process. If he seems ravenous and he wasn’t feeding too quickly, don’t hesitate to give him a little more than you planned. The key to making adjustments lies in balancing three factors: (1) good diaper output, (2) appropriate weight gain, and (3) baby’s satisfaction. Adjust the amount you offer up or down a half ounce at a time unless it’s obvious that your estimate was really far off. If the change works, stay with it until it isn’t working, and then adjust again.

The Significantly Underfed Baby

While we usually trust babies to tell us how much food they need, some circumstances do require parents to take over for a while. A seriously underfed baby (who may have misled you with his passive behavior) may not show strong hunger cues or may quit nursing before he has had enough. His diaper output and weight gain are poor, and his feeding behavior may be lethargic. Giving him at least a half ounce by bottle or another method prior to breastfeeding can energize him to feed better. Or he may simply need to be fed in whatever way it takes to get enough milk into him untıl he’s stronger.

Once they start really eating, underweight babies frequently want more than the usual amount while they catch up on their weight. This usually slows down once baby reaches the weight he should be based on his birth weight and current age. At-breast supplementation, as described later in this blog, is not a good choice until baby grows stronger. Be sure to pump after breastfeeding to ensure thorough drainage.

Supplementation at Night

At first, you may need to offer supplements at every feeding, including nighttime. Later, when your baby has begun gaining well or he is older and able to go longer between feedings, it may be possible to forgo supplementing at night.

Choosing a Supplement

According to the World Health Organization, the best supplement is expressed milk from baby’s own mother, followed by pasteurized human donor milk, and then commercially synthesized infant milk (formula). Consult with your baby’s pediatrician to determine which most appropriate for your situation is. More information about supplementation options is available on our website.

If you’re making plenty of milk but baby is having difficulty getting it out, you should be able to provide everything he needs by pumping. But if baby needs formula, first offer whatever you can express -no amount is too small. It’s preferable to give your milk separately to ensure that baby gets every precious drop and none is thrown out because he didn’t finish a supplement combined with your milk.

Supplementation Devices

There are many devices that can be used to feed supplementary milk to your baby including at-breast supplementers, bottles, finger-feeders, cups, eyedroppers, medicine droppers, and syringes. Each has advantages and disadvantages, and you may decide to use different devices at different stages as circumstances change. Some work best when you have a skilled consultant to teach you the little tricks of the trade that you may need and how to avoid the pitfalls that could sabotage your success. No matter which supplementation device you choose incorporate as much feeding at the breast as possible to maximize milk removal, minimize flow preference, and maintain baby’s familiarity with the breast.

Pasteurizing Human Milk

The U.S. Centers for Disease Control and Prevention recommend against informally donated human milk because of the risk of transmitting harmful bacteria or viruses, but some mothers prefer to use milk from a trusted friend or relative when banked milk is not an option. Heat treating the milk first can minimize any risks.

Containers for storing your milk should be washed and clean, but they don’t need to be sterilized. First, place about 2 to 5 ounces (60 to 150 milliliters) of milk in a pint-sized (450 milliliter) covered glass jar and set aside. Then bring about 2 cups (450 milliliters) of water to a boil in a small pot. Turn off the heat and place the jar in the water for twenty minutes. When the milk is cool, it can be fed to baby. Treated milk should be stored in the same sealed container that it was pasteurized in to avoid bacterial contamination. It can be kept safely at room temperature for up to eight hours and refrigerated for up to twelve.

At-Breast Supplementers

At-breast supplementers use a receptacle to contain milk and a plastic tube to carry milk to the mother’s nipple, where baby can draw from it as he nurses. They are especially appropriate when low milk production is due to maternal causes. At-breast supplementers also can be used for some infant-related situations as long as the baby is able to draw enough milk out in a reasonable amount of time. There are commercial products such as the Medela SNS (Supplemertal Nursing System), Ameda Breastfeeding AidT*, and Lact-Ald. Or, a 3.5 or French gavage tube can also be used by attaching it to a syringe or threading it into a regular baby bottle with a slightly enlarged nipple hole and submerging the end of the tubing in the milk.

At-breast supplementers can be awkward to manage with newborns who have difficulty latching. An alternative is to use a Monoject 412 periodontal syringe commonly used by dentists, which has a nicely curved hard tip instead of a needle. Baby first latches to the breast, and thern the plastic tip of the syringe is gently sneaked into the corner of his mouth no more than an eighth to a quarter of an inch (two and a half to five millimeters). As he sucks, the plunger is depressed with short taps to deliver small amounts of milk whenever baby s jaw drops. Several syringes can be prepared for a feeding so that thev can easily be switched out to maintain a constant flow. Since they hold a small amount and last only about a week, syringes may not be practical for long-term use.

Not all mothers feel entirely comfortable with these devices. For some, it is a blatant reminder that they don’t have enough milk and need a “prosthesis” in order to breastfeed. More effort is required to prepare, set up, and clean them than regular bottles, and it can take a few days or even weeks to become proficient and feel comfortable using them. At-breast supplementers can leakif not properly assembled and aren’t as discreet for public nursing. However, many mothers over- come these challenges and say they feel more like a regular breastfeeding mother because the entire feeding is at breast and they prefer the intimacy it allows to other methods.

Supplementing at breast with a feeding tube and syringe combination

Bottles

The upside of bottles is that they are easy, con- venient, and socially acceptable. The downside is that there is a risk of nipple confusion and flovw preference that could ieopardize vour breast feeding relationship. However, there are ways that bottles can be used to support breastfeeding and reduce these risks .

Nipple confusion and flow preference are two very different problems. Debra Swank, IBCLC, explains that nipple confusion happens when a baby given an artificial nipple or pacifier forgets how to breast feed. He starts toroot for the breast but either can’t latch or doesn’t move his tongue correctly when he does latch commonly in newborns who have had only limited opportunities to nurse and received a bottle before imprinting up on the breast. When babies arch, cry, scream, or otherwise actively push away the breast, or simply turn away in quiet disinterest after exposure to bottles, it may be due to flow preference. Once a baby has become accustomed to the instant gratification of a bottle that flows immediately and never stops until its empty, it can be harder for the breast to compete when it doesn’t flow until mother has a milk ejection and then does so in spurts according to baby’s demand. This can be worsened when milk production is decreased.

Nipple preference can happen when there is a significant mismatch between the mother’s nipple shape and the shape of the artificial nipple For instance, when a mother has very small nipples that protrude only slightly and the artificial nipple is large and long and easier to grasp, baby may prefer the more prominent artificial nipple.

When choosing an artificial nipple When choosing an artificial nipple for bottle supplementation, look for one that approximates breastfeeding by encouraging baby to latch deeply, extend his tongue, and cup it around the nipple with relaxed lips. Ultrasound studies show that round nipples with a broad base encourage these motions.2 Although flattened-tip orthodontic nipples are often recommended, babies tend to retract their tongues while sucking on them, the opposite of what should happen on the breast. In addition to reducing milk transfer, this type of tongue movement can cause abraded, sore nipples when baby breastfeeds.

The most important factor in minimizing flow preference is slowing the flow rate of the bottle. Look for slow-flowing nipples; they are usually labeled”slow-flow” or “newborn.” Not all nipples are created equal. You can test and compare them by turning them upside down and seeing how fast milk drips out. Check those you select periodically as well, since they can wear out and flow more rapidly over time. Products that use an inner chamber to regulate flow seem to help ease the transition to the breast. Babies respond differently to various nipples, so it may take some trial and error to find the best one for your baby. Since the flow from your breast doesn’t tend to increase over time, slow-flow nipples will continue to be best even when baby gets older.

Bottle-Feeding Methods That Minimize Flow Preference. You can help baby maintain or learn breastfeeding behaviors while he feeds from the bottle by teaching him to take it in a way that is similar to how he latches to the breast. Instead of “poking” the nipple in his half-opened mouth offer it pointed up toward the ceiling and touch or stroke the side downward across his lips. This eventually triggers a wide gape, like a yawn Then move the base of the nipple to his lower lijp and roll it downward into his mouth so that he takes it in deeply. Holding baby upright with the bottle parallel with the floor can further reduce the flow. Despite marketing efforts to convince you otherwise, there is no need to keep the nip- ple full of milk, nor is swallowing air an issue because air tends to come right back up naturally as baby burps.

Babies feed better when bottle feedings are periodically paused, or paced, simulating the way that breastfeeding babies slow down in between milk ejections. After a few minutes of sucking, or if you see baby ‘s forehead and eyes show signs of stress, tip him forward gently until the milk runs out of the nipple, without removing the nipple from his mouth. This helps baby retain control of the feeding, reminds hinm to stop when he is full, and helps him to better coordinate sucking, swallowing, and breathing.

Latching a bottle deeply

When to Offer the Bottle. Traditional wisdom says that bottles should be given only after offer- ing the breast so that baby sucks actively to remove the most milk. However, a hungry baby may have less patience fora breast with low sup- plv and may stop trving without taking all the milk that’s there. It’s as if they know the bottle is coming and are iust “paving their dues” at breast. As a result, they take increasing amounts by bot- tle, and milk production slows down, requiring even more supplements. This downward spiral effect is the reason that supplementing by bottle has such a poor reputation.

Christina Smillie, M.D., IBCLC, suggests an alternative way that she calls the “Finish at the Breast” method of bottle supplementation. In her practice, she observed that babies who quenched their initial hunger and thirst with a bottle first tended to have more patience feeding at the breast. She began suggesting that mothers give a limited amount of supplement before breastfeeding and discovered that babies would breastfeed longer even if the flow was slow, removing more milk and increasing milk production.

Another great aspect of the “Finish at the Breast” method is that baby learns to associate the euphoria of fullness with the breast rather than the bottle, while you get the satisfaction of a contented, “milk drunk” baby falling asleep at your breast. When it happens the other way around, it can be disheartening and undermine your confidence to the point that you end up breastfeeding less and less.

The key to this technique is giving about one- fourth to one-half ounce (7 to 15 milliliters) ess by bottle than the amount your baby usu ally needs or takes. If too muchis given, babv will not be hungry enough to feed well or long enough at breast. If too little is given, he may not have the patience to nurse. When he looks relaxed or finishes the bottle, whichever comes first, switch to the breast. If he fusses and seems to want more supplement after breastfeeding, give it to him, but be sure to finish at the breast, even if for just a minute or two. It may take a few days of trial and error to determine the best amount.

Be flexible and watch baby’s body language sa you can respond to the normal fluctuations in your production. You may find, for example, that vou can give fewer supplements (or none!) dur- ing the night and before the morning feedings, but in the late afternoon or early evening, you need to give more. This is fine when it follows the normal fluctuations in vour milk supply. As vour supply increases, you’l1 be able to decrease the amount offered up front, little by little. The degree to which this method can increase millk production depends on the reason it is low. If the cause is secondary, it is likely to respond better to this technique than if the cause is primary But either way, this method can work well to encourage baby to breastfeed as much and as effectivelv as possible.

Breast Refusal. If baby begins to show signs of breast refusal, don’t think he is rejecting you as his mother or that it’s permanent. It just means that conditions need to change to make feeding at the breast more desirable. A baby who has experienced milk flowing more easily from the bottle may not trust the breast, even when milk production is improved. He has found something that works for him, so why change? Increasing milk production and flowis helpful, but regaining baby’s trust takes time and a gentle approach. Efforts to woo him back to the breast can be draining, and you may question whether it is right to force the issue.” But in this case, your baby doesn’t know what is best for him-you do A gentle approach will work better than trying to impose your will on your baby. You may have to work slowly and help him make the transition in stages. Giving the bottle with baby turned toward the breast or with a cheek on your bare breast can help build more positive associations You can also try placing the bottle under your armpit, preferably by a bare breast, so that baby must face you more fully when he feeds from the bottle as he would at the breast. Offering the breast when he is sleepy and placing him upright skin to skin to take advantage of his nursing instincts can also help baby overcome his resistance. Once he begins latching, hell gradually learn to trust the breast again over several feedings or days, and then feedings will become the enjoyable experience that they were meant to be. If nothing seems to work, a lactation consultant may have more ideas using methods that tap into his natural reflexes.

Finger-Feeding

If baby must be fed away from the breast and you don’t want to use a bottle, finger-feeding is another option. This avoids the use of an artificial nipple and may be especially useful for babies who have certain types of suck problems. A finger-feeder can be made at home using the same gavage tube system described previously. The Hazel-baker FingerFeederM is a commercial finger-feeding device. You can also use an at- breast supplementer clipped to clothing or hung around the neck as usual, with the tubing attached to a finger.

As with using a bottle, it is important to encourage your baby to open his mouth widely before the finger is offered so that he learns the same skills he needs for breastfeeding. Some lactation consultants also recommend using the finger or thumb that is closest to the approximate diameter of your nipple.

Monoject 412 periodontal syringes with a curved hard tip instead of a needle are another option for finger-feeding. They hold from one third to one-half ounce of liquid and are inexpensive (about US$1.00). Those with larger barrels usually give too much milk with even a small push, while smaller ones simply may not hold enough milk. Finger-feeding with a syringe is “parent-led” rather than “baby led,” allowing more parental control over milk flow. This can be an advantage for babies who have trouble drawing the milk out of feeding tubes. Eye and medicine droppers have also been used to finger- feed but do not offer as much control over how much milk is coming out.

Important Note: Finger-feeding is great in the right circumstances, but if done incorrectly or at the wrong time, it can cause problems as well. For best results, have a skilled lactation consultant teach and observe you; their input is a worthwhile investment.

Finger-feeding with a peridontal syringe(glove optimal)

Cups

Although you might think that drinking from a cup is an advanced skill beyond the capability of infants, babies as young as thirty weeks gesta- tion have been successfully cup-fed, sometimes before thev can effectivelv breastfeed or bottle-feed. Cup-feeding supports breast-feeding by avoiding nipple or flow preference. However, there can be significant spillage, which can be frustrating and expensive.

Almost any clean, small plastic or glass cup or bowl can be used to cup-feed, with the exception of disposal paper cups that may contain a plastic coating toxic to infants. There are also ups especially designed for feeding small babies c , such as the Medela Soft-Feeder* and Baby Cup Feeder”, the Ameda Baby Cup, and the Foley Cup Feeder. The Medela SoftFeeder and the Foley Cup Feeder work especially well because they feature a small self-filling reservoir that allows control over the flow of supplement.

Weaning from Supplements

If your milk production increases significantly and baby begins consistently refusing supple- ment while continuing to gain well, then it is time to stop supplementing. Test weights can confirm that he is getting the amount he needs, or you can just monitor his diaper output and weight gain.

If baby is not yet refusing supplements but your milk supply seems to be increasing or he begins to gain more quickly than necessary. try decreasing the supplement by one-fourth to one-half ounce (7 to 15 milliliters) per feed every few days. You may need to go more slowly, or you may not be able to go lower. Never stop supplementing abruptly if your milk production is not adequate to replace the supplementary feedings.

Solids as Supplements

The introduction of solids around the middle of baby’s first year is an important milestone. While the first amounts of solid foods babies eat are usually small, about a teaspoon (5 milliliters or 4.7 grams) per meal, starting solids marks the end of baby’s complete nutritional dependence on your milk or formula. It is often at this point that mothers are able to gradually replace supplemental feedings with solid foods. However, be sure that solid foods replace supplements, not your milk.

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