Early and Higher Volumes of Formula Supplementation after Birth Impact Breastfeeding Rates at Discharge in Well-Baby Nursery: A Retrospective Cohort Study

Abstract

Objective Physiologic breast milk production in the first 24 hours is estimated to be between 2 and 10 mL per feed. Many mothers intending to breastfeed use formula supplementation (FS) early on, which can affect successful breastfeeding. Whether the volume and timing of FS introduced in the first 24 hours of life (24 HOL) impacts the rate of “breastfeeding at discharge” (BFAD) is not well-studied and was investigated herein.

Study Design Single-center, retrospective, chart review of breastfeeding infants born at ≥35 weeks who received supplementation in the first 24 HOL. Comprehensive demographic data pertaining to maternal and infant characteristics, along with infant feeding data, were collected. Four supplementation characteristics, (timing, rate, volume [mL/kg per feed], and type [expressed breast milk (EBM) or formula]) were correlated with BFAD.

Results Among 3,102 supplemented infants in whom mothers intended to breastfeed, 1,031 (33.2%) infants were BFAD. At baseline, African American, Medicaid-insured, and single mothers had lower odds of BFAD. The overall maximum volume of FS per feed was 11.0 mL/kg (interquartile range 8.0–14.4). With each hour of delay in first supplementation, the odds of BFAD increased by 2.8% (95% confidence interval [CI] 0.022, 0.035). With every 1 mL/kg increase in the first formula volume, subsequent supplementation frequency increased by 4.5%. A positive association was observed between BFAD and a lower rate of supplementation (cutoff value ≤35.1%). However, among infants with these lower rates of supplementation, each unit increase in maximum FS, from 2 to 15 mL/kg, decreased the probability of BFAD by 4.2% (3.6–4.7%). Additionally, we observed that infants who were given at least one EBM supplementation (n = 223; 7.2%) had substantially increased rates of BFAD (odds ratio [OR] = 9.8, 95% CI 7.2–13.3).

Conclusion Early and higher volumes of FS negatively impacted BFAD. Birthweight-based FS of feeding with physiological volumes may increase breastfeeding rates at discharge.

Key Points

• Higher volumes of first supplementation increases subsequent supplementation frequency.

• For each unit increase in maximum supplementation, BFAD probability decreases by 4.2%.

• Even one EBM supplementation increases rates of BFAD.

Keywords

breastfeeding at discharge - breastfeeding supplementation - volume of formula supplementation - birthweight-based supplementation

Authors' Contributions

N.K. conceptualized and designed the study, performed the analyses and interpretation of data, and critically reviewed the manuscript for important intellectual content. M.A. and N.H. designed the data collection instruments and collected data and drafted the initial manuscript. V.S. conceptualized the study and critically reviewed the manuscript for important intellectual content. All authors contributed substantially and approved the manuscript in its final version.

Publication History

Received: 05 September 2023

Accepted: 24 November 2023

Accepted Manuscript online:
27 November 2023

Article published online:
29 December 2023

• References

• 1 Stellwagen LM, Richard JS. Breastfeeding the newborn. In: Textbook of Pediatric Care. American Academy of Pediatrics; 2016
• 2 World Health Organization. Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. Geneva: World Health Organization; 2017
• 3 Ekubay M, Berhe A, Yisma E. Initiation of breastfeeding within one hour of birth among mothers with infants younger than or equal to 6 months of age attending public health institutions in Addis Ababa, Ethiopia. Int Breastfeed J 2018; Jan 23; 13: 4
• 4 CDC. Analysis: Breastfeeding Rates | Breastfeeding | CDC. 2022
• 5 DiMaggio DM, Cox A, Porto AF. Updates in infant nutrition. Pediatr Rev 2017; 38 (10) 449-462
• 6 Meek JY, Noble L. Section on Breastfeeding. Policy Statement: Breastfeeding and the use of human milk. Pediatrics 2022; 150 (01) e2022057988
• 7 Boban M, Zakarija-Grković I. In-hospital formula supplementation of healthy newborns: practices, reasons, and their medical justification. Breastfeed Med 2016; 11: 448-454
• 8 Nguyen T, Dennison BA, Fan W, Xu C, Birkhead GS. Variation in formula supplementation of breastfed newborn infants in New York Hospitals. Pediatrics 2017; 140 (01) e20170142
• 9 Walker M. Formula supplementation of breastfed infants: helpful or hazardous?. Infant Child Adolesc Nutr 2015; 7 (04) 198-207
• 10 Watchmaker B, Boyd B, Dugas LR. Newborn feeding recommendations and practices increase the risk of development of overweight and obesity. BMC Pediatr 2020; 20 (01) 104
• 11 Sase M, Asada H, Okuda M, Kato H. Fetal gastric size in normal and abnormal pregnancies. Ultrasound Obstet Gynecol 2002; 19 (05) 467-470
• 12 Ennen CS, McGlynn AF, Ju H, Crino J. 421: Fetal gastric size: linear and volume measurements and temporal changes. Am J Obstet Gynecol 2018; 218 (01) S256-S257
• 13 Bergman NJ. Neonatal stomach volume and physiology suggest feeding at 1-h intervals. Acta Paediatr 2013; 102 (08) 773-777
• 14 Lander A, Newman J. Paediatric anatomy. Surgery (oxford) 2010; 28 (01) 11-15
• 15 Adamkin DH. Neonatal hypoglycemia. Semin Fetal Neonatal Med 2017; 22 (01) 36-41
• 16 Flaherman VJ, Schaefer EW, Kuzniewicz MW, Li SX, Walsh EM, Paul IM. Early weight loss nomograms for exclusively breastfed newborns. Pediatrics 2015; Jan; 135 (01) e16-e23
• 17 Quintero SM, Strassle PD, Londoño Tobón A. et al. Race/ethnicity-specific associations between breastfeeding information source and breastfeeding rates among U.S. women. BMC Public Health 2023; 23 (01) 520
• 18 Snyder K, Hulse E, Dingman H, Cantrell A, Hanson C, Dinkel D. Examining supports and barriers to breastfeeding through a socio-ecological lens: a qualitative study. Int Breastfeed J 2021; 16 (01) 52
• 19 Mieso BR, Burrow H, Lam SK. Beyond statistics: uncovering the roots of racial disparities in breastfeeding. Pediatrics 2021; 147 (05) e2020037887
• 20 Kellams A, Harrel C, Omage S, Gregory C, Rosen-Carole C. ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017. Breastfeed Med 2017; 12: 188-198
• 21 World Health Organization. Implementation Guidance: Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services—the Revised Baby-Friendly Hospital Initiative. 2018 . Accessed October 21, 2023 at: https://www.who.int/publications/i/item/9789241513807
• 22 Bentley JP, Nassar N, Porter M, de Vroome M, Yip E, Ampt AJ. Formula supplementation in hospital and subsequent feeding at discharge among women who intended to exclusively breastfeed: an administrative data retrospective cohort study. Birth 2017; 44 (04) 352-362
• 23 Chantry CJ, Dewey KG, Peerson JM, Wagner EA, Nommsen-Rivers LA. In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. J Pediatr 2014; 164 (06) 1339-45.e5
• 24 McCoy MB, Heggie P. In-hospital formula feeding and breastfeeding duration. Pediatrics 2020; 146 (01) e20192946
• 25 Lau Y, Htun TP, Lim PI, Ho-Lim S, Klainin-Yobas P. Maternal, infant characteristics, breastfeeding techniques, and initiation: structural equation modeling approaches. PLoS ONE 2015; 10 (11) e0142861
• 26 Kemper AR, Newman TB, Slaughter JL. et al. Clinical Practice Guideline Revision: management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics 2022; 150 (03) e2022058859
• 27 Kumar N, Oredein I, Al-Nahar M, Harris N, Sampath V. Impact of feeding volumes in the first 24 hours of life on neonatal feeding. Front Pediatr 2023;11;
• 28 Chin N, Méndez-Lagares G, Taft DH. et al. Transient effect of infant formula supplementation on the intestinal microbiota. Nutrients 2021; 13 (03) 807
• 29 O'Sullivan A, Farver M, Smilowitz JT. The influence of early infant-feeding practices on the intestinal microbiome and body composition in infants. Nutr Metab Insights 2015; 8 (Suppl. 01) 1-9
• 30 Morais LH, Schreiber IV HL, Mazmanian SK. The gut microbiota-brain axis in behaviour and brain disorders. Nat Rev Microbiol 2021; 19 (04) 241-255
• 31 Milani C, Duranti S, Bottacini F. et al. The first microbial colonizers of the human gut: composition, activities, and health implications of the infant gut microbiota. Microbiol Mol Biol Rev 2017; 81 (04) e00036-17
• 32 Mathias JG, Zhang H, Soto-Ramirez N, Karmaus W. The association of infant feeding patterns with food allergy symptoms and food allergy in early childhood. Int Breastfeed J 2019; 14 (01) 43
• 33 Victora CG, Horta BL, Loret de Mola C. et al. Association between breastfeeding and intelligence, educational attainment, and income at 30 years of age: a prospective birth cohort study from Brazil. Lancet Glob Health 2015; 3 (04) e199-e205
• 34 Isaacs EB, Fischl BR, Quinn BT, Chong WK, Gadian DG, Lucas A. Impact of breast milk on intelligence quotient, brain size, and white matter development. Pediatr Res 2010; 67 (04) 357-362
• 35 Gale C, Logan KM, Santhakumaran S, Parkinson JR, Hyde MJ, Modi N. Effect of breastfeeding compared with formula feeding on infant body composition: a systematic review and meta-analysis. Am J Clin Nutr 2012; 95 (03) 656-669
• 36 Stuebe A. The risks of not breastfeeding for mothers and infants. Rev Obstet Gynecol 2009; 2 (04) 222-231
• 37 Centers for Disease Control and Prevention. mPINC 2022 National Results Report. 2022 . Accessed June 7, 2023 at: https://www.cdc.gov/breastfeeding/data/mpinc/national-report.html
• 38 Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 2012; 129 (03) e827-e841
• 39 Wight NE. Academy of Breastfeeding Medicine. ABM Clinical Protocol #1: Guidelines for Glucose Monitoring and Treatment of Hypoglycemia in Term and Late Preterm Neonates, Revised 2021. Breastfeed Med 2021; 16 (05) 353-365