By Molly Mustafa, BSN, RN, IBCLC

Supporting Growth and Well-being with Thoughtful Choices

Breastfeeding is a beautiful and essential way to nourish an infant, offering numerous health benefits for both mother and baby. However, there are instances when a breastfed infant may struggle to gain weight or breastfeed effectively. In such cases, supplementation can provide the additional nutrition the baby needs. This blog post will guide you through options for supplementation, including donor breast milk and formula, methods of formula preparation to ensure safety, and appropriate supplementation volumes for breastfeeding infants.

Understanding When Supplementation Is Necessary

Supplementation is typically recommended when an infant is not gaining weight adequately, showing signs of dehydration, or unable to latch and breastfeed efficiently. Consulting with a pediatrician or lactation consultant is essential to determine the underlying cause and the best course of action.

Choosing the Right Type of Supplement

There are three primary options for supplementing a breastfed infant: pasteurized donor breast milk, unpasteurized donor breast milk, and formula. Each option comes with its own benefits and risk considerations.

Pasteurized Donor Breast Milk

Pasteurized donor breast milk is sourced from milk banks and undergoes rigorous screening and pasteurization processes to ensure safety. It is often recommended for preterm infants or those with specific medical needs, as it closely mimics the nutritional composition of maternal breast milk. Pasteurized donor breast milk is a reliable and safe option, especially when breastfeeding challenges arise.

Unpasteurized Donor Breast Milk

Unpasteurized donor breast milk may be obtained informally, such as through family or friends. While it retains its natural properties, it carries risks of bacterial contamination and transmission of infections. If choosing unpasteurized milk, it is vital to ensure thorough screening of the donor and safe handling practices. Many healthcare professionals recommend pasteurized options over unpasteurized due to safety concerns.

Formula

Formula is a widely available and effective supplement option for breastfed infants. It comes in two main forms: sterile liquid formula and powdered formula.

• Sterile Liquid Formula: Sterile liquid formula is ready-to-feed and requires no mixing or preparation. It is the safest option for preterm, immunocompromised, or infants under 2 months, as it eliminates the risk of bacterial contamination during preparation.
• Powdered Formula: Powdered formula is more economical and commonly used. However, it carries a small risk of contamination with harmful bacteria such as Chronobacter. Special precautions must be taken to prepare powdered formula safely, particularly for vulnerable infants.

Considering Unpasteurized Donor Milk

When using unpasteurized donor breast milk, it is vital to evaluate its safety and suitability. Screening potential donors should include asking the following questions:

• Does the donor have any transmissible infections, such as HIV, hepatitis B, or hepatitis C?
• Has the donor undergone recent medical screenings or testing for infectious diseases? Does the donor have any chronic medical conditions?
• What medications, supplements, or substances does the donor take, and could any affect the milk’s safety?
• Does the donor smoke, use drugs, or consume alcohol, and if so, to what extent?
• Is the donor’s diet balanced and nutritious, supporting the quality of their milk? Do they follow any special dietary restrictions?
• Are there any storage and handling practices, such as how the milk is expressed, stored, frozen, or thawed, that might compromise its safety?

Engaging in open communication with the donor is essential, and consulting with healthcare professionals can provide additional guidance to ensure that unpasteurized donor milk meets your baby’s nutritional and safety requirements. Generally, informal milk sharing is done in an altruistic manner and no money is exchanged. Some parents will provide breast milk storage bags or small pump maintenance parts, such a valves or membranes, for the person who is donating milk to them. There are studies that show some breast milk purchased for money on the internet are contaminated with cow milk or other liquids to increase the volume of the milk to increase profit. At MedCity Lactation, we recommend avoiding informal milk sharing with someone who is trying to charge money. 

Preparing Formula Safely

For parents choosing powdered formula, proper preparation is crucial to minimize the risk of Chronobacter infections. This is especially important for preterm infants, immunocompromised babies, or those less than 2 months old.

Follow these steps to prepare formula safely:

• Boil water and allow it to cool for no more than 30 minutes to maintain a temperature of at least 70°C (158°F).
• Measure the correct amount of powdered formula according to the manufacturer’s instructions.
• Mix the formula thoroughly with the boiled water, ensuring all powder is dissolved.
• Cool the bottle to feeding temperature by placing it in a container of cold water or running it under cool tap water.
• Feed the infant immediately or store prepared formula in the refrigerator and use it within 24 hours.

These precautions significantly reduce the risk of bacterial contamination, offering peace of mind and safety for your baby.

Determining Appropriate Supplementation Volumes

Supplementation volumes vary depending on the infant’s age, weight, and individual needs. A lactation consultant or pediatrician can provide tailored recommendations. Below are general guidelines:

• The Academy of Breastfeeding Medicine Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate lists the following volumes as a guideline for newborn infant feeds:
  • First 24 hours: 2-10 mL/feed
  • 24-48 hours: 5-15 mL/feed
  • 48-72 hours: 15-30 mL/feed
  • 72-96 hours: 30-60 mL/feed
• Supplementation should aim to complement breastfeeding, not replace it entirely, unless medically necessary.

Monitoring the infant’s weight, urine output, and overall health will help determine whether supplementation volumes are meeting their needs. Working with a skilled lactation consultant is essential to support breastfeeding, especially when supplementation is needed. They can closely monitor your family and create a plan to help you meet your goals. 

Maintaining the Breastfeeding Relationship

While supplementing, it is crucial to preserve the breastfeeding bond. Strategies include:

• Offering the breast first before supplementing.
• Using alternate methods like supplemental nursing systems (SNS) to deliver supplements while the baby is at the breast. Finger feeding and cup feeding are also great alternatives to bottle feeding that can help preserve breastfeeding dynamics.
• If you are supplementing your baby with a bottle, using a slow flow nipple and paced bottle feeding in a side-lying position can be helpful to prevent babies from developing a preference for the quick and easy flow of a bottle nipple. See our article about bottle choice and feeding techniques for more information. 
• Continuing to work with a lactation consultant to address any underlying breastfeeding challenges.

Breastfeeding provides more than nutrition; it fosters emotional connection and comfort for both mother and baby.

Conclusion

Supplementing a breastfed infant requires careful consideration and informed choices. Whether opting for pasteurized donor milk, unpasteurized donor milk, or formula, safety and appropriateness for your baby’s unique needs must guide the decision. By preparing formula correctly, monitoring supplementation volumes, and maintaining the breastfeeding relationship, parents can support their infant’s growth and well-being while navigating feeding challenges.

For any concerns or questions, seek guidance from healthcare professionals to ensure the best outcomes for your little one. Every feeding journey is unique, and with the right support, parents can feel confident in their decisions to provide optimal care.