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How Formula Could Increase Breast-Feeding Rates

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One of the surprising ways to boost breast-feeding rates among new moms may involve formula, according to the latest research.

With a growing body of evidence supporting the benefits of breast-feeding for both mom and baby, public-health experts celebrate each time a hospital receives “baby-friendly” status, which indicates the facility endorses steps that encourage breast-feeding such as not separating moms and babies after delivery and offering formula only if it’s deemed medically necessary.

But a small study published in the journal Pediatrics suggests that giving newborns a little bit of formula actually helps boost breast-feeding rates. The formula primer may give moms the assurance they need to keep pursuing breast-feeding, say the study’s authors.

Not surprisingly, many breast-feeding experts are taking issue with the findings, worried the results may undermine public-health messages that breast milk alone is best for babies.

The study, from University of California, San Francisco (UCSF), followed 40 newborn babies who had lost at least 5% of their birth weight by the time they were 36 hours old. The American Academy of Pediatrics (AAP) notes that weight loss in an infant’s first days is typical as they become accustomed to feeding; average weight loss is about 7%. But lead author Dr. Valerie Flaherman, an assistant professor of pediatrics and epidemiology and biostatistics at UCSF, focused on this group since other data suggests that infants who lose this much are more likely to lose more weight; when babies drop 10% of their birth weight, pediatricians become concerned that the infants may be at risk of other health problems.

For the trial, Flaherman and her colleagues assigned half the babies a couple days of birth to receive two teaspoons of formula after each breast-feeding, via a syringe so as not to encourage “nipple confusion,” a condition in which a baby has trouble transitioning between breast and bottle. Mothers were instructed to discontinue the formula supplementation once their milk supply appeared, which generally takes two to five days. The other half were exclusively breast-fed unless the doctor ordered formula.

(MORE: Breast-Milk Donors Come to the Rescue of a New Mom With Breast Cancer)

When their babies were 1 week of age, 10% of moms in the formula group were still using formula in some way as part of their feeding strategy compared with 47% of those in the group originally assigned to breast-feed but who added formula. And when their babies were 3 months old, 79% of the formula-group moms were exclusively breast-feeding, significantly more than the 42% of those in the group originally instructed to breast-feed. Though it might seem counterintuitive, Flaherman suspects that introducing a small amount of formula early on, then withdrawing it, helped moms feel secure that their babies weren’t hungry and losing weight in their first days of life. That likely gave them confidence to go on breast-feeding exclusively. “Using that little bit of formula earlier really seems to have had a big effect on whether babies are getting formula at one week,” she says. “We wanted to try to find an early intervention we could do with these babies and moms to help them continue breast-feeding. I was surprised the effect was this big.”

In the U.S., most moms start off breast-feeding, but only 40% are still doing so at six months and just 20% make it to one year, which is the milestone that the AAP recommends at a minimum.

Not everyone is convinced that using formula in this way, however briefly, is going to increase that percentage. “This study goes against everything that’s been published for several years now from very reliable clinicians and researchers about the potential hazards of supplementing exclusively breast-feeding babies with formula,” says Dr. Kathleen Marinelli, an associate professor of pediatrics at the University of Connecticut School of Medicine and the chair-elect of the U.S. Breastfeeding Committee. “They’re flying in the face of years of research here and doing so rather glibly, stating that this is the new way to look at things.”

Tanya Lieberman, a lactation consultant who writes about scientific research for breast-feeding advocacy organization Best for Babes, says she’s “a little confused” by the results. “We know what works to increase breast-feeding exclusivity and duration and we’ve known it for 20 years. That includes no supplementation unless medically necessary.”

Lieberman says that the findings may have been affected by the attitude of the women themselves, who said they wanted to exclusively breast-feed but were also open to using formula. Mothers may also be under some misperceptions about how much milk newborns need. “Babies don’t need large volumes of milk in the first few days,” she says. “They are fine until their mother’s milk comes in.”

Flaherman says the study’s results are not necessarily applicable to all babies. “This isn’t something we think all people should do,” she says. “It is just a potential tool for moms to consider using if they think it might be helpful.”

She also says that the ultimate goal of the study was to find a way to help more mothers breast-feed, and to do so for as long as possible to help their babies. “It’s kind of crazy that only 20% of people reach the recommended duration of breast-feeding,” says Flaherman. “Different approaches to supporting breast-feeding may work better for different people.” And for some mothers, that may even include a little bit of formula.

MORE: 20 Ways to Make Breast-Feeding Easier

25 comments
AStanfordPR
AStanfordPR

Bonnie – excellent article, thanks for sharing this study with your readers! The statistic that only 20% of mothers are able to breastfeed for 1 year is spot-on, but truly devastating if you look at the health ramifications for mothers - a perspective that is often overlooked in contrast to the more common associations between breastfeeding and pediatric health. A Harvard/Pitt study that came out today looks at both health AND cost outcomes for U.S. mothers if they were to breastfeed for 1 year.

The study found that if 90% of mothers breastfed, U.S. women would significantly lower their risk of heart attack, breast cancer, and hypertension. On a macro level, further investment in lactation support for moms could prevent $17.4 billion in maternal health costs.

Feel free to reach out. Would love to connect you with one of the study co-authors to discuss the impact that this research could have on maternal health.

http://www.upmc.com/media/NewsReleases/2013/Pages/study-shows-breastfeeding-reduces-maternal-health-disease.aspx

- Andréa 

joylfelix
joylfelix

That fits with my own experience. Baby was born large after a c-section that left me incapacitated. I couldn't stand to hear the cries of hunger and had the nurses feed him formula, but gradually was able to switchover. I still give him occasional "relief bottles." Those are a huge relief - and help with the paranoia that he's not getting enough to eat. Everyone is different. Some people simply can't bear the idea of starving their children for the sake of what? A gold star for not giving a kid formula? Bragging rights? It seems so cruel!

ChristinaVentura-DiPersia
ChristinaVentura-DiPersia

This study should not be taken seriously because it is incredibly poorly done. 

First, the sample size is deplorable and I can't imagine that they had adequate power to make the conclusions that they are making due to this. 

Second, the definition of the control and treatment groups are perplexing to say to the least (the control group exclusively breastfed unless formula was ordered.... so what happened when formula was ordered? Was that baby/mother combo dropped from the study? Did they stick with intention-to-treat analysis or per-protocol analysis?) 

Third, utilizing percentages to make your statistics look presentable doesn't give you the right to use the word "significant". There were only 20 women in each experimental group - so throwing around 79% here and 42% there doesn't change the fact that you're talking about 15 women in the intervention group and 8 women in the control group. That's an incredibly small # of people and just because you randomized to their respective treatment assignments does not mean that the overall study was done properly.

I am highly disappointed that the journal of Pediatrics published this study and I plan on writing a letter to both the authors of this study as well as this journal to express my distaste and distrust in this article, which is seemingly just a ploy (just an epidemiologist, no doubt! An embarrassment to the field! (and I'm an epidemiologist myself so I do have some reason to be annoyed about this)) to get their names in the media and little more.

TenaTurner
TenaTurner

There seems to me to be so much misinformation given out about breastfeeding that it is no wonder mothers give up. Supplementing does not hurt, for the most part, as long as breast milk is offered first at every feeding. For my two sons, who were large at birth, my husband and I supplemented once a day, which was at the end of the day last feeding. Up to then, all feedings were strictly breast nursing, but at the end of the day when I was running dry and baby still hungry after nursing, my husband would  give a small bottle of formula. Baby slept better, parents slept better, and when it was time for the next feeding I was full of milk again. With this system we never worried that our babies weren't getting enough to eat, and yet I managed to successfully nurse for a full year with each infant. 

skschool
skschool

I agree with the research.  The important part about breast feeding is that babies get a fair percentage of breast milk for the antibodies long-term, not that they get exclusive breast milk.    We know this from twins and multiples, but then claim it's all or nothing with a single baby.  This leads women to give up on breast feeding, rather continuing with supplements if needed to ensure growth milestones.   Working full-time, I had to supplement after 6 months with my 3 children but still managed to provide over 1/2 from breast milk up to a year.  Perhaps a more middle ground approach is needed for both the mother and the baby- militant breast-feeding advocates often do more harm than good.

xrh
xrh

To the commentators who have said that they disagree with this study and that women just need to trust their own bodies and focus on the babies, not themselves, please be careful about being overly critical.  I have a healthy, happy three month old baby boy who is exclusively breastfed, but I did have to supplement the first two weeks.  Before I had my baby, I read the research on breastfeeding, attended the breastfeeding classes and swore I would follow all of the recommendations to the letter.  What I've learned since then is that the studies are great, but ultimately the only thing that really matters is what works for you and your baby.  When my son was born, he would latch on but would then sit there expectantly looking at me waiting (he wouldn't suck).  After a few times of this, where he was hungry and not getting anything and the hospital staff kept hounding at him, he started to become hysterical every time it came to feeding him until ultimately he became so weak he wouldn't even try to eat.  When the doctors started to panic because he'd lost 10% of his weight, the lactation consultant finally threw up her hands and told me to express milk onto a teaspoon and force his mouth open.  Unfortunately, this didn't work because I could only express a drop or two of colostrum (not enough to meet his needs) and forcing his mouth open to get the teaspoon in just made him upset (poor little guy wanted to breastfeed but didn't want a nurse shoving his head on my breast and holding it there while she tried to get his jaw to move).  It took 9 days before my milk finally came in and if a hospital aid hadn't finally recommended supplementing, my baby would not be breastfeeding now.  For those 9 days I was made to feel like a horrible mother because my baby was dropping so much weight and needed more nutrition, and then when I got him the nutrition through using the S&S system (supplementing) I was made to feel like a horrible mother because I gave him formula.  It wasn't until we got his weight back up and met with a different lactation consultant that I realized I was only a horrible mother if I cared more about what the research said and other people said rather than the cues my baby was giving.  Supplementing gave me the opportunity to meet his needs (so it was about my baby, not me) while still trying to get the breastfeeding to work. 

kmm900
kmm900

You know what discourages Breast feeding --- working full time. How about we take a page out of the parenting book from our European friends and allow mothers to be home for the 1st year of life to encourage breastfeeding and bonding?! 

jfernandezhiggins
jfernandezhiggins

Wow.   A lot of controversy about this.  With my 1st daughter, she was dehydrated after 3 days and had to be hospitalized to bring her fluids back up.  As a first mother, I was hysterical with worry for her- that I had been nursing her and she was starving and I didn't realize, etc.  I was a wreck.  I supplemented and started pumping.  After my milk came in, AND she learned how to nurse better, we were able to stop the supplementing.  But, that didn't happen in the first couple of days.  It took her a couple of weeks to be able to feed correctly and get enough.  When my son was born, after nursing for hours and hours and he wasn't receiving but a drop or two, I asked for a little bit of formula and received a lecture from the nurse instead- where I ended up in tears- I was just trying to help my baby and I fully intended to breastfeed.  It was just killing me that he was screaming and screaming because he was so hungry.  When I got home, I did the same as I did with my daughter, nursed, supplemented  and pumped and then just switched to breast completely when my milk was in.  I think this study is great- so many mom's want to breastfeed, but get discouraged because they're baby is sooo hungry and sooo upset, and they just feel so awful and guilty like I did.  I nursed my daughter until she was 17 months (stopped because I was 5 1/2 months pregnant with my son) and am still nursing my son now at 14 months.  I think this study is right on track with the results.  I think many moms would be lest stressed and positively encouraged to pursue breastfeeding with a little help.  I personally know many moms who didn't breastfeed because they were discouraged that their milk didn't come in right away and just used formula because they felt like they were failing, so why keep trying with the breast?  As I have another child, I will probably do the same if the milk didn't come in right away- and I would feel good about it because my baby wouldn't be starving and it would relieve my stress- (which lowers breast milk production).  

liquiddiamondzzzz
liquiddiamondzzzz

Hmm.  It isn't the formula that is reassuring the moms, it's the visual of baby getting any type of nourishment.. it's the supplementing "til the milk comes in" that is helping the woman to feel more confident..  Babies DO sometimes act rather unhappy at times when the milk isn't in yet.  My daughter was rather displeased and very fussy in the evening til my milk came in.   The supplement probably calms the baby down which is what the mom wants.  I don't understand why they are weighing the babies so frequently unless there was some indication of a problem with breastfeeding like a lack of wet diapers..  After the initial at-birth weight.. my daughter was not weighed til she was 5 days old, my milk had been in for 2 days and she had already gained nearly a pound.  I don't know why you'd weigh the baby so frequently unless you are trying to create a problem where none had to be.  And, frankly, very very small amounts of supplementing say.. expressed or donor breastmilk with a dropper.. and then ceasing doing so when the milk comes in.. would be a less harmful way to use supplementation.  Unfortunately, supplementation doesn't usually look like that!  Usually, supplementation is not donor milk or hypoallergenic formula, it is usually in bottles, it is usually way way too much, and usually it has no pre-determined end point to it where the woman is encouraged to stop supplementing and start just breastfeeding..    Frankly, the idea that supplementing could as a general rule help someone breastfeed is asinine and in practice with how things are generally done is probably going to be picked up by the wrong people (people who already are trying to justify feeding the baby) and going to cause more failure than success.

rebekers
rebekers

This is ridiculous.  This would only discourage a mother and undermine her confidence, not boost her desire to breastfeed!  If she wants to be "reassured" that she is making enough milk, explain to her how little a baby actually needs to drink the first three days (think a drop of breastmilk/colostrum the size of a small marble) and then buy her a scale so she can weigh her baby before and after she feeds.  This will show her how much the baby is getting. Not to mention the way this would affect breastfeeding mothers with AIDS or HIV. They can breastfeed as long as baby receives *nothing* else. If baby eats anything other than breastmilk, mother cannot breastfeed anymore because the baby has lost protection from the virus. (Info from Mercy in Action seminar, from a large study Vicki Penwell cited) Also, it should be common sense: don't feed the baby something else if you want him/her to still be hungry and breastfeed!

Lizziern
Lizziern

There is nothing that takes the place of or enhances breastfeeding.  There should be a huge push to breastfeed exclusively.  Billions could be saved as a result.  Does the public realize how many women are on public assistance and pumping their babies with formula on the tax payer's dime?  This supposed study strikes me as yet another way formula making companies are trying to get us to pump our babies with food made within a lab.  Rubbish!  

CatheyThomas
CatheyThomas

"The formula primer may give moms the assurance they need to keep pursuing breast-feeding, say the study’s authors."

Aha! So this is really NOT about the babies, it's about psyching out the moms. This advice is horribly misguided and I'd STRONGLY advise any woman who is serious about breastfeeding to flatly disregard it. Your body can take care of the baby! Just stay away from the doctors doing wacky research projects based on the presumed weakness and stupidity of mothers and you'll both do much better in general.

Did these docs fall into Mad Men thinking somehow? Women usually know better than this. Of course, I don't know about the group they experimented on in this study, but I'm not buying it for a minute! The whole idea is perfectly ridiculous. When did they go back to constantly reweighing normal newborns? They're MEANT to lose some weight initially; it's perfectly natural, NOT a negative thing. The VAST majority will gain it back on only what the mother produces. 

As I midwife, I weighed babies upon delivery and that was IT. Causing a new mom to unnecessarily worry  about her milk supply and obsess about whether or not baby is getting fat enough quickly enough sounds like backward, mid-century thinking and should be rejected.


phoenix1920
phoenix1920

What saved me and helped to last to the one-year mark for breast-feeding was discovering on my own that you can formula-feed AND nurse.  When it was time for me to go back to work and I had problems with pumping, I thought the only recourse was to discontinue with nursing because everybody kept telling me that if you ever gave formula, the baby wouldn't nurse.  Both of my babies were fine having formula when I worked and then nursing when I was home.  We need to stop giving advice to others based on fears!  60% of moms are stopping nursing by six-months. The top 4 reasons are: a rough start to nursing; worry that the baby isn't getting enough; discomfort with nursing in public; the moms need to go back to work.  Simply telling the moms who have these issues that they need to get over their fears and uncomfortableness will not work to change the numbers.  Giving them different options, including education them that a mom can do both, may really help.

mom_of_3
mom_of_3

Thank you for this study!!

 It takes 2-5 days for a milk supply to come in.  After you've gone through pregnancy, labor, delivery, and you're trying to recover, it is exceedingly hard to deal with a very hungry infant for five straight days and nights.  Breastfeeding is great...my three kids made it to 6 months exclusively breastfeeding and didn't fully stop nursing until 16+ months.  But I can't make it those first few days without formula.  Too much crying and not enough sleep for both Mama and baby...

If we want to increase breastfeeding rates, I think we need to stop telling new mothers how perfect they need to be.

2nagels
2nagels

Looks to me like more unnecessary intervention (repeat weighing of baby) by hospital staff (after many unnecessary intrusions during birth) creates mothers' anxiety about infant weight loss.  Then another unnecessary intervention is introduced to solve the fabricated problem. 

The hospital where I had a (probably unnecessary) C-section 35 years ago had no rooming in so we got a private room.  Maternity staff were so put out with us that they left us mercifully alone and breastfeeding proceeded with no problem, aided by one phone call to a LLL leader.

Seems to me that excessive treatment in maternity as well other hospital departments leads to many iatrogenic problems as well as the out of control costs we can't seem to get a handle on.


nancyholtzman
nancyholtzman

Agree with previous comment that this article/study is misleading and misrepresentation of why and how formula is used on many postpartum units. 20 babies in each study group cannot change 20 years of extensively peer-reviewed and validated research. (See Cochrane Review recommendations for exclusive breastfeeding).

In this (tiny) study, newborns were given small amounts of hypoallergenic (hydrolyzed) formula via syringe. In many postpartum units, mothers are handed bags full of 2 oz vials of ready to feed, cows milk based formulas, which can potentially sensitize the immature immune system to the foreign protein, with higher rates of allergy, eczema, asthma, and even diabetes, as a result to that early exposure. This is not opinion, this is fact. So a study (and headlines like that, above) which seem to say "go ahead, breastfeed but top off with formula, it will help - we tried it with 20 babies!" flies in the face of several decades of evidence quite to the contrary.  - Sad and concerning.
Nancy Holtzman, RN BSN IBCLC RLC CPN

Cairycat
Cairycat

That the study was co-authored by someone with ties to the formula industry tells us most all of what we need to know about this lousy study.  The only other thing that the public, but especially new mothers, is that even one bottle of formula can permanently alter the baby's gut flora.  Formula is not a harmless helper.  Sometimes - very, very rarely - it's a needed intervention, but its use should be considered as carefully as any medication.

kiyaelizabeth
kiyaelizabeth

Seriously, this is horrible advice. Getting through the tough times and realizing your body IS capable of fully feeding your child is the most important key to breastfeeding success. I have been nursing my son for almost a year and making it through those first couple months and realizing that I could trust my body is why I have succeeded.

"One study co-author has financial ties to the formula industry." Now that says it all right there, doesn't it? Breastfeeding rates are skyrocketing (thank goodness!) and the formula makers are freaking. This study and joke of an article (among the others who decided to publish stories about this study) is disgusting and will only serve to convince a mother who is on the fence about breastfeeding that formula "isn't so bad afterall".

Shame on you, TIME, for legitimizing this crap study.

liquiddiamondzzzz
liquiddiamondzzzz

@TenaTurner It depends on how much formula is given and how frequently they are adding this to feeds whether or not it'll affect milk supply.  Also, you basically trained your breasts to be empty for that feed.  Milk making is supply/demand.. If you'd nursed at that feed all along, you wouldn't have been empty at that feed.. ;)   There is nothing wrong with what you did, but if breastfeeding isn't established or going well (and it could be prudent to point out that losing weight can mean things are normal OR that they are slightly off!) feeding too much/too soon/too frequently supplemental feeds can have a HUGE impact in breast feeding success.. particularly when that supplement is given via bottle.   The truth is, this study doesn't prove that supplementing helps breastfeeding: it proves that tightly controlling the context/amount/frequently of supplementing and STOPPING at a set point encourages breastfeeding.. in other words, it proves the opposite.   The control group supplemented a lot too, but they used more formula (up to 4x as much), many used bottles, and they weren't strongly encouraged to stop so their milk could take over so unfortunately they had more lactation failure/perceived lactation failure and a lot of it could be directly attributed to excessive supplementing. 

liquiddiamondzzzz
liquiddiamondzzzz

@xrh Judicious and rare use of supplementing in cases like yours are not what is wrong with health care in regards to lactation today.  I don't know why folks would make you feel like a bad mom because your milk was delayed in coming in.. and I don't know why they'd make you feel that way for supplementing when you clearly needed to be doing so.    You were and obviously are a very good mother, because you were trying to do what you felt was best and were looking out for baby.

Cases like yours are not what I take issue with.  I take issue with things like the nurses giving baby a bottle before the baby has even been at mother's breast because "it was a couple of hours".. Things like babies bassinet having a bottle and mom being told her baby nursing every hour is abnormal and why don't you just give baby a bottle if he's hungry so fast again.  Things like baby not even losing weight and having 1 diaper the first day and the staff still freaking out because baby didn't poop on day 1 even though the baby pooped on the way out of the womb.  Things like nurses taking baby so mom can rest and giving baby bottles because the mom was "really emotional" and they thought she needed the sleep.   Women being told that one bottle won't affect anything, only to have it cause nipple confusion and baby won't latch without a nipple shield (which can affect supply).  Etc. etc.   Scenarios where supplementing is clearly unnecessary, is not handled in best practice manner, and is only done due to ignorance or arrogance.  Articles like this one don't go into the very strict best practice and limited nature of the supplementing that was used.. it has the potential to make the unhelpful professional or layperson feel smug in their ignorant and saboteur ways because all that they read is articles like this rather than the actual study!

ChristinaVentura-DiPersia
ChristinaVentura-DiPersia

@nancyholtzman Thank you - I couldn't agree more. As an epidemiologist that focuses on maternal and child health (especially birth outcomes) I am incredibly frustrated at how the media has picked up this study and touted it as the gospel. Why does this specifically capture the headlines? I can imagine it has something to do with the authors or the journal itself being funded by a parent company of a formula company.

MichelleScottOrthodoxou
MichelleScottOrthodoxou

@Cairycat I had also read that one of the co-authors was affiliated with a formula company.  Do you happen to know which one?  

ChristinaVentura-DiPersia
ChristinaVentura-DiPersia

@liquiddiamondzzzz @TenaTurner Correction - this study proves nothing because it was incredibly poorly done. It is methodologically volatile and should not be taken seriously. As an epidemiologist, it is maddening that someone can publish something  so insanely inaccurate and methodologically unsound and people take it seriously. It doesn't necessarily change the fact that supplementation may help with breastfeeding, but don't use this study as evidence for the cause.