Best practices for supplementing with formula for a tired mom

Question

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?

Answer 1

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?

Answer 2

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