For pediatricians and neonatologists caring for healthy newborns, the issue of how and when to supplement breastfed infants with formula remains a challenge. While we have all been engrained with the “breast is best” mantra for a few decades, many pediatricians have to deal with the potential adverse consequences of inadequate nutrition after discharge – including hyperbilirubinemia, significant weight loss, and maternal anxiety/depression. The corollary to “breast is best” has been the “fed is best” movement – an approach that tries to relieve the stress and anxiety new mothers feel around breastfeeding and avoid the potential complications of inadequate nutrition. What isn’t known, is what is the right approach that balances the benefits of exclusive breastfeeding with minimizing the risks of inadequate nutrition.
Fortunately, in this month’s Pediatrics, a very helpful and well-done study by McCoy and Heggie (10.1542/peds.2019-2946) and an accompanying editorial by Feldman-Winters and Kellams (10.1542/peds.2020-1221) provide some initial guidance to the “hazard” of in-hospital formula feeding (IHFF). Using propensity scoring methodology to control for many potentially confounding variables, McCoy and Heggie found that IHFF resulted in a 2.5 greater hazard risk of not completing a year of breastfeeding. The conclusion of their study is that any IHFF risks a shorter duration in breastfeeding. While many of the recommendations from the World Health Organization’s Ten Steps to Successful Breastfeeding can help minimize the use of IHFF, some research questions remain. When is IHFF needed for medical reasons? How much weight loss is too much? Do we have good measures of parental anxiety around feeding that can guide effectiveness of breastfeeding? Will glucose gel supplant the need for supplemental formula?
While we don’t have all the answers, all pediatricians and providers caring for newborns should think twice before telling a mother to supplement. What happens in those first few days of life can and does have long-term implications for breastfeeding duration and sends the message to mothers that we expect her breastfeeding to fail. We need to advocate for supports for breastfeeding mothers. If we send a new parent home without the needed resources– like breast pumps, lactation consultants, and early follow up with a provider comfortable supporting a breastfeeding mother – we set them up to fail.