After supplementation has been introduced to the breastfeeding baby, we can’t assume that we need to continue in frequency, amount, or pattern. If a baby needs to be supplemented, sooner or later we need to figure out how to make supplementation adjustments.
Generally, that means making good observations, and good judgments.
Observations
Here are three observations that affect your decision to increase or decrease the amount of supplementation (or continue as is.)
Semi-subjective: Baby’s signs of hunger and satiety
Admittedly, this is a little subjective. But if you can see these signs, you should feel mostly reassured:
- milk is dripping from the contralateral breast
- swallowing can be heard
- baby is regaining birth weight by about 7-10 days after birth
- at least 6-8 wet diapers per day with at least one really soaked
- at least 3 soft stools per day in the first month
- parents respond quickly to early hunger cues
- vigorous suckling with good latch
- infant ends the feeding and appears satisfied.
These signs are worrisome:
- two or more reassuring signs are not present
- audible swallowing is lacking
- losing weight, rather than gaining
- a known medical condition that affects feeding
- mother has past or present medical or surgical condition that affects lactation
- baby is fussy after feedings
- baby does not exhibit hunger cues before feeding
- mother is unable to list at least 3 sources of support for breastfeeding
- baby has signs of dehydration
(Adapted from Breastfeeding the Newborn: Clinical Strategies for Nurses, page 174.)
Just remember, however, that reassuring signs don’t mean that all is well in 100% of the situations. Conversely, the worrisome signs don’t mean the baby is at death’s door. But in general, the reassuring signs usually suggest continuing supplementation as is, whereas the worrisome signs deserve careful follow up and probably supplementation adjustments.
Near-term semi-objective: Intake and output
Intake is critical.
You’ve heard me say this before, but I’ll say it again. Lack of audible swallowing is always worrisome. (This presumes that the person who is listening knows what it sounds like.)
The reverse, however, is not necessarily the case. Sometimes, you can hear swallowing, but that can be falsely reassuring, depending on the baby’s needs.
When observing the intake, I want to see the baby alert, eager, and — assuming all else is well — I’d want to see suckling sustained for about 10 minutes. Meaning, if the baby easily or quickly putters out, or can’t consistently latch and transfer milk, I’m not convinced of adequate milk intake.
Longer-term objective: Weight gain
We don’t expect babies to simply exist. We expect and nurture babies to grow and thrive.
In general, babies gain an average of about 15 ounces (450 grams) by the end the first month of life.
Judgements
After making the observations, here are some steps to making judgments about the next steps for supplementation.
Make sure you know the facts
Collect all the data about intake, output, weight gain/loss, growth chart. All too often, I’ve too often seen judgments and actions made on one data point.
And make sure the weights were done correctly. There are at least three elements that affect accuracy when weighing the baby.
Make sure you understand the age-related concepts
So much of the data you just collected is related to the age of the baby. What’s appropriate for a 2-day old is not necessarily normal for a 2-week old, or a 2-month old.
Generate the right questions
Always ask: When should the amount of prescribed supplement be reduced, and who will be involved in the decision to do so?
Don’t be afraid to generate more questions about supplementation adjustments if you are uneasy.
Use some basic principles, or “rules” to help:
- When: Supplementation may need to continue, but not necessarily after each breastfeeding.
- How much: The amount of supplement needed at each feeding may vary from one feeding to the next and the caregiver will need to offer
- less if baby seems satiated, without coaxing him to take more.
- more if the baby appears ravenous, offer more; be prepared to offer “second helpings.”
Freeze human milk in ice cube trays. Each cube contains about 1 ounce (about 30 ml) of milk. I call these “second helpings.” If you need to conserve the milk, you could even freeze the milk in smaller portions by filling the cubes halfway.
Rather than opening a completely new bag or bottle when the baby is a little hungrier than usual, this is an easy way to give provide more milk without creating more waste.
Summarizing observations to make judgements
Let’s review those observations and judgments.
Observing signs of hunger and satiety is helpful because it can be done on-the-spot; no waiting until tomorrow. But those signs are semi-subjective.
Observing intake and output can be done in the near term, but often, those signs are a semi-objective. (What constitutes a “big” stool?)
Observing weight gain or loss could be done immediately, as in test weighing, or daily, or weekly. But presuming that the baby was weighed correctly, weight loss is the most objective sign of the need for continued or increased supplementation.
| Observations | Judgment |
|---|---|
| – signs of satiety + output + weight gain | May need more milk |
| + signs of satiety + output – weight gain | May need more milk |
| – weight gain – output | Needs more milk |
Sometimes, the signs of satiety are questionable. But if the baby has a good output and good weight gain, that is somewhat (but not completely) reassuring. This situation often occurs when the baby is having a growth spurt.
If the baby shows signs of satiety and good output, but weight loss is concerning, look at each of those factors more carefully. Are the positive signs strongly positive, or just marginal? If so, that baby probably needs more milk. This situation could occur in cases where the baby has an undiagnosed medical condition.
If the weight gain is unacceptable, and the output is poor, the baby needs more milk. Remember, signs of satiety are semi-subjective. In this case, you may be seeing a “good baby.”
After summarizing observations, you can make judgements about next steps in order to make adjustments to supplementation amounts.
What cues do you look for when observing? How do you make adjustments?