The Right Time to Supplement
Q. I read your article on breastfeeding in the August issue, and as a breastfeeding counselor, I disagree with your advice to a nursing mom whose baby wasn't gaining weight well. You recommended nursing every three hours for five to ten minutes at each breast, removing breast milk via a pump, and then supplementing the baby. If the infant nurses for such a short length of time, however, she will be getting only the low-fat foremilk and none of the rich, fatty hindmilk, which is what helps babies gain weight. Better advice would be to nurse at least ten times during a 24-hour period, keeping the baby at the first breast for a good 10 to 15 minutes before switching her to the second side. Do you agree?
A.I appreciate your support of breastfeeding and am genuinely pleased that you have raised the question about the difference between breastfeeding advice for mothers of a healthy newborn and for those with a high-risk infant. Although your recommendations certainly represent sound counsel for a new mother who begins breastfeeding a full-term healthy baby, numerous risk factors existed with the underweight infant in the original question.
The baby was born several weeks early and had "a lot of trouble latching on to nurse during the first week." Receiving extra help and close monitoring during that time might have prevented the infant's subsequent weight-gain problems. However, by the time the question was asked, this baby was still below her birth weight at 3 weeks of age, and the baby's physician was rightfully worried about her welfare, since most breastfed infants are well above their birth weight by this time. Thus, this particular case represents an instance outside the norm, when standard advice could prove dangerous.
The breastfeeding law of supply and demand causes milk production to increase when the breasts are drained well and often. On the other hand, a mother's milk supply steadily declines if milk is removed ineffectively or infrequently, which is what undoubtedly happened here. Given an increasingly malnourished baby and a progressively diminishing milk supply, marathon nursing is likely to fatigue the infant while delivering little milk. To break this vicious cycle, I believe the baby requires appropriate quantities of supplemental milk in order to gain weight. Despite those who condemn supplementing a breastfed baby, I believe it is completely unacceptable to withhold essential, medically indicated, supplemental milk from a significantly underweight infant.
Temporarily limiting the duration of breastfeeding to ten minutes per side is usually necessary to assure that an underweight baby will drink enough supplemental milk after nursing. To increase the mother's milk production, I recommended that she pump after she breastfeeds. The residual, high-fat hindmilk she extracts with the pump can be used to supplement the baby, thus reducing the amount of formula required. As the mother's milk supply increases and the baby reaches a normal weight, the infant will probably obtain more milk through breastfeeding alone. Of course, breastfeeding frequency and duration should be increased as you suggest once the medical crisis is over.