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Before I get into the question I'll mention that I fully understand the benefits of breastfeeding, and my wife and I do intend to attempt to breastfeed, hopefully as much as we can.

However, with the current global pandemic and increased difficulty making it to a grocery store or other purveyor of baby products without risking infection, I want to make sure that my wife and I cover our bases. Less access to our midwife may also be a problem.

What this means for us in terms of feeding is having formula as a solid backup after our boy's born. Currently we have about a month's worth of powdered formula, and plan to stock enough ready to feed formula for the first month - just in case he doesn't take to breastfeeding.

That aside we're also aware that formula supplementation is something we can do to make mom's life easier as she becomes increasingly exhausted from breastfeeding. I've heard comments like she should try to breastfeed exclusively for the first two months before we do any supplementation with formula, but it's surprisingly difficult to parse fact from fiction coming from Google.

My primary question is - what are the evidence-based best practices surrounding supplementing breastfeeding with formula? For example, is there a time period after birth where we should definitely avoid supplementing if we can, or is this rule looser than it seems? If we do supplement in the few months after birth, are there practical limits on how much or often we should supplement? Or are many of the sites found on Google somewhat alarmist, and we shouldn't be worrying this much?

  • You have to specify what outcomes you are aiming for. Do you want to avoid kernicterus? Supplement early and often. Are you trying to please professional lactation consultants? Then avoid formula no matter what. You want fewer ear infections, less RSV infection, us less antibiotics? Good news, you already have that by being the kind of family who intends to breastfeed. researchgate.net/publication/… – swbarnes2 Apr 14 at 21:51
  • While shopping is restricted, it is certainly possible to get essentials and baby food (all kinds) are seen as essential and available. So no need to stock up more than you already have till you see it is starting to be used. – Willeke May 17 at 12:37
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ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017 lays out the conditions when it's recommended to consider supplemental feeding, page 3. It's pretty jargon heavy, but the layperson-relevant parts are:

  • Weight loss of ‡8–10% (day 5 [120 hours] or later), or weight loss greater than 75th percentile for age.
  • Delayed bowel movements, fewer than four stools on day 4 of life, or continued meconium stools on day 5 (120 hours).
  • Newborns with more bowel movements during the first 5 days following birth have less initial weight loss, earlier the transition to yellow stools, and earlier return to birth weight.

Maternal indications:

  • Delayed secretory activation (day 3–5 or later [72–120 hours] and inadequate intake by the infant).80
  • Primary glandular insufficiency (less than 5% of women—primary lactation failure), as evidenced by abnormal breast shape, poor breast growth during pregnancy, or minimal indications of secretory activation.84,85
  • Breast pathology or prior breast surgery resulting in poor milk production.84
  • Temporary cessation of breastfeeding due to certain medications (e.g., chemotherapy) or temporary separation of mother and baby without expressed breast milk available.
  • Intolerable pain during feedings unrelieved by interventions.

So if you track the stool/urine output and weight of the newborn over the first couple of weeks, you should be able to tell that they are getting enough milk. Additionally, be aware that percieved milk output is not the same as actual milk output, and often women will under-estimate how much they are producing, see:

Maternal Perceptions of Insufficient Milk Supply in Breastfeeding

I also recommend the https://kellymom.com/ website for great information on this, like:

When will my milk come in?
Increasing Low Milk Supply
and
Is Baby Getting Enough Milk?

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We spoke to our midwife yesterday and asked the same question, I don't know if it was a complete answer but some of the points she gave us were as follows -

  • Typically formula feeding would be reserved for a baby with medical issues
  • If you wanted to supplement without medical issues you'd at least want to wait until breastfeeding is well established - mom and baby are both naturals
  • She also recommended using formula concentrate, or ready-to-feed formula, to begin with. Primarily because of sanitation issues
  • If you were supplementing she didn't really say how often was appropriate, but I got the sense it was kind of - as desired, but breastfeeding is preferred
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    So if your wife is one of the 44% of first time mothers who makes no milk in the first three days, your baby will have nothing but drops to eat for days? ncbi.nlm.nih.gov/pubmed/20573792 You wanted scientific research? Scientific research shows that early supplementation causes no harm, and in facts prevents harm. ncbi.nlm.nih.gov/pmc/articles/PMC3666109 – swbarnes2 Apr 21 at 1:16
  • @swbarnes2 while I agree that what you've said is true, it's slightly a bit too exaggerated ("nothing but drops to eat for days") and is more nuanced and less clear-cut than you present. Especially since milk production is very difficult to measure, and there are significant percentage of women who think they don't have good supply when they do: ncbi.nlm.nih.gov/pmc/articles/PMC4508856 – stan May 18 at 19:13
  • It is very easy to measure how much milk a baby gets. You weigh them before and after feeding. Scales are sufficiently accurate to do this, even in low resource settings. – swbarnes2 May 18 at 20:37
  • @swbarnes2 The average layperson isn't going to think to do that unless they are particularly academically inclined or advised to do so by a medical professional. I meant that it's difficult for laypeople to accurately estimate their production (or their wives) based off of breast engorgement, etc. – stan May 19 at 9:02
  • This paper shows that women who thought they had supply problems had biochemical markers of...supply problems. ncbi.nlm.nih.gov/pmc/articles/PMC5274566 It turns out that lots of women are not abysmally stupid, and can tell when something is wrong. They do not need to be tut-tutted out of "perceiving" a problem. – swbarnes2 May 19 at 17:21

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