Why bottle feeding and supplementing with formula may help you breastfeed

“As I gave that first bottle of formula, I sobbed and felt like I was failing.” (mom of a 3 week old baby struggling with breastfeeding).

While just about every one of us (mama or not) can immediately recognize that, OF COURSE THAT MAMA IS NOT FAILING! it can be really hard to believe that when you are knee deep in breastfeeding struggles and exhaustion, your hormones are all out of wack, you’re just not sure what’s happening and you love your baby so much that you want the absolute BEST for her or him and you are flooded with anxiety that just maybe something is really wrong but you are pretty sure you’re doing everything right…In those moments, no amount of reasoning and reassurance can fully help.

It’s ok to feel sad if your breastfeeding journey isn’t going as you had hoped (and it’s also ok if you’re one of those mamas who grabbed the formula and did not look back!) Either way, you are absolutely not a failure.

This post is for those mamas who are hoping to exclusively breastfeed but are having some difficulty in those first few days postpartum. Perhaps your pediatrician or lactation consultant recommended that you give your baby some formula and you’re wondering, “can I still breastfeed if I give my baby a few bottles of formula?” or “how will it impact my baby and breastfeeding if I give my newborn some formula?” or maybe you’ve already given your baby several bottles of formula and you’re wondering, “will I ever be able to exclusively breastfeed if I give my baby a bottle and what should I do to get my baby off the bottle???” We’re going to use Kim and baby Maeve as a case study to look at how formula (or donated breastmilk), bottles, finger feeding, and syringe feeding might be a sound way to support breast feeding when used strategically as an intervention.

We must acknowledge that, of course many women will breastfeed without any trouble and won’t need formula or bottles. And in fact offering bottles and/or formula early on (before your baby is 1-2 months old) may negatively impact breastfeeding if not done thoughtfully with support from a breastfeeding specialist who can see the big picture to get you back to breastfeeding. But there are actually reasons why bottle feeding, finger feeding, and supplementing with formula (or pumped milk or donated breast milk) can all support your breastfeeding relationship and even strengthen it!

That’s not just our opinion. There is actually some research on this and while it’s a small study, it is a randomized control trial. The study by Flaherman et al from 2013 looked at women whose baby lost more than 5% of their birth weight by 1-2 days old. They randomized half the moms to a plan where they were told to supplement with a small amount of formula (by syringe) and half to a plan where they were encouraged to just keep breast feeding (and they were given support with calming their baby). The mamas who supplemented ended up more likely to be exclusively breastfeeding when baby was one week old and at 3 months old than the group of moms who did not supplement.

Yes, this is a small study, but we have clinically seen this to be true in our experience with the acknowledgement that certain additional interventions should be used at the same time. Let’s discuss these next.

Why to use formula (or donated breastmilk), bottles, finger feeding and/or syringe feeding to get back to exclusive breast feeding

There are a few different reasons why formula (or donated breast milk if your hospital offers it!) should be used when your goal is to breastfeed:

• Mama isn’t available in the first day or so after birth (due to medical complications or other reasons)

• Baby isn’t latching well or at all over several feedings

• Your baby’s blood sugar is low and you can't get baby latched at the breast or baby isn't feeding well enough to get your colostrum

• Your baby has high bilirubin and is sleepy but isn't latching well totake enough colostrum.

Baby Maeve was born at 36 weeks and from the very beginning, Kim knew she was not latching well (hard to be a NICU/feeding therapist/IBCLC and new momma). As a late pre-termer, she was also challenging to calm when she was awake and challenging to wake once she was asleep. Kim kept at it and the hospital periodically checked Maeve’s blood sugar (routine for babies born before 37 weeks). By 6 hours of life, Maeve’s blood sugar had dropped significantly and the medical team suggested that Maeve be given a little glucose. This helped but when it happened again shortly after the next feed, it was clear that Maeve wasn't actually getting Kim's colostrum when she latched, so the team recommended that Kim consider using some extra milk to supplement the breastfeedings. The hospital where Maeve was born provides pasteurized donated breastmilk (amazing- we wish this was the case at all birth hospitals) and Kim and her lactation consultant decided to supplement with 5ml of donor milk using a syringe after each attempted breast feeding.

Ways to supplement breastfeeding

There are a few different ways to offer formula or pumped/donated breast milk if your baby isn't latching on your breast. Bottles, syringe feeding, finger feeding, and cup drinking are all options if your baby is not breast feeding well. Bottle feeding is arguably the most efficient yet there is a long standing belief in the lactation community that bottles will have the most disruptive impact on breastfeeding (though the research on this is conflicting). We believe the most important things to keep in mind are:

• The flow of the milk

• Protecting Mama's milk supply

• Helping baby practice a wide latch

Flow: If baby is having some difficulty latching or staying latched at the breast we recommend that all other feeding that happens not on Mom's breast, be offered with a very slow flow and with lots of pacing (aka- lots of breaks for the baby to stop swallowing and just breath). This helps reduce the risk that baby will develop a preference for the feeding method that is easiest (IE- if your baby can get a bunch of milk without working too hard from the bottle but when she latches at the breast she's has to work super hard but barely gets anything, your baby might learn to prefer there bottle, which can make it MUCH more challenging to get your baby to practice breastfeeding to help her become more efficient.)

Protecting mom's milk supply: any time baby isn't latching well and needs to take a feeding from a supplemental device (bottle, finger feeder, syringe, or cup) mom isn't getting as much stimulating input to her nipples as she needs to build a full milk supply. Even if baby is only one day old, if you're using a bottle, syringe, or cup for even one feeding we recommend pumping! Mom can just use hand expression like this or a manual pump like the haaka but if it's available, an electric pump works great. Even if you only get 1ml of colostrum out- that's like gold for your baby!

Helping baby practice a wide latch: we recommend if you decide to use bottles that you use a wide base nipple to keep baby practicing a wide open jaw and latch, which will be necessary for improving breastfeeding.

Around this time, Maeve was highly disorganized and would not latch at the breast. After a few feeds where Maeve was exclusively syringe fed and Kim pumped (getting 1-2mL of colostrum), Kim was able to get Maeve latched again at the breast using a Supplemental Nursing System which is a tool with a small tube that you can place on your breast with either a bottle or syringe attached to the other end that can help you deliver additional milk to the baby while he or she is breastfeeding. You can read our last post all about it here.

Baby Maeve also had her bilirubin checked (again, standard procedure) which came back as high intermediate risk. Kim knew the best thing for Maeve was for her to eat as much as possible so she could poop and pass more meconium. In addition to using the SNS for several feedings, when Kim was unable to get Maeve latched, she decided to offer paced bottle feedings for the now 10-15mL of donated breastmilk to help manage her high bilirubin.

Using paced bottle feedings

While her hospital team did not push bottle feeding, Kim knew it was an option. Although there are potential drawbacks, Kim felt she could minimize the risks by pacing Maeve. Kim also knew that there could be benefits to the bottle: Maeve's feeding could be more efficient, getting more “bang for her buck” for the work little Maeve was doing to eat. Kim knew that once Maeve was taking slightly more volume of (donated) breastmilk by bottle, she would be able to sleep a little more soundly and wake a bit more calm. A calm baby is much easier to help latch so this allowed Kim & Maeve to calmly practice latching and breastfeeding with less stress. Kim used another tool to help baby Maeve calm down during this stretch: she and her husband held Maeve non-stop skin-to-skin. This also contributed to Maeve's improved sleep and waking more calm and alert.

In Kim and Maeve’s case, these small bottles of donor breastmilk allowed for more consistent breastfeeding practice. By the time they left the hospital on day of life three, Maeve was latching better, transferring some colostrum, and also taking 15ml of donor milk from a bottle after each feeding. Kim’s milk came in on day of life four and with lots of practice, a few modifications and creative OT problem solving (lots of hand expression, breast massage, a nipple shield, and position changes!) Maeve was able to transition to breastfeeding on demand with one bottle of pumped milk during the wee hours of the morning so dad could participate and mom could sleep.

Now, of course that first bottle and each supplemental feeding was risky to breastfeeding but they also made it possible for Maeve to grow while working on her latch and waiting for Kim's mature milk to come in. Everyone's experience will be a bit different but we encourage you to work with someone who problem solves with you and takes your specific situation into account. You need someone who will make recommendations to both get your baby fed and protect your breastfeeding relationship if your goal is exclusive breast feeding.

And if it turns out that you do not go back to breastfeeding, that first bottle was a step in the right direction for you and your baby towards a new way of feeding that hopefully brings more calm, more bonding and more success. Some breastfeeding relationships just do not work out and it causes baby and mom significantly more stress and struggle to try to salvage and force than to accept this and then capture the benefits of breastfeeding (bonding, skin-to-skin, cuddles, flavor variations in the milk, and gut bacteria health) in other ways.

Looking back on the decision to supplement with donor milk AND transition to some bottle feeding on Maeve's second day of life, Kim wouldn’t change a thing. Providing that additional donor milk kept Maeve rooming in (and not in the special care nursery), practicing breastfeeding, and overall more calm and organized so she could be successful in learning to nurse. More on the special adaptations Kary and Kim used to improve Maeve‘s latch and breastfeeding efficiency in our next post :)