A Little Formula in First Days of Life May Not Impact Breastfeeding at 6 Months

A study has lodged a new kink in the breastfeeding dilemma that adds to the angst of exhausted new parents: While most newborns lose weight in the first days of life, do you or don’t you offer a little formula after breastfeeding if the weight loss is more than usual?
 
For years, the answer has been “no,” as infant formula was seen as a deterrent to breastfeeding. The American Academy of Pediatrics recommends exclusive breastfeeding until 6 months of age, and continuing breastfeeding until 12 months while transitioning to solids. But according to the Centers of Disease Control and Prevention, just over one-third of infants in the United States are breastfeeding at 12 months.

The answer is no longer clear-cut, say researchers of the UCSF Benioff Children’s Hospitals-led study, published in JAMA Pediatrics on June 3, 2019. It depends on breastfeeding duration goals and attitudes, and needs to be balanced against the risks that newborns face in the first days of life when their weight is dropping.

In the study, the researchers tracked the long-term feeding habits of 164 babies born at UCSF Benioff Children’s Hospitals and Penn State Children’s Hospital. The infants had been breastfed between 1-to-3 days old, and their weight loss had been in the 75th percentile or above for age. Half of the mothers added syringe-fed formula after each breastfeeding, which stopped when the mother’s milk came in at two-to-five days after delivery. The other half had continued to breastfeed exclusively.

Marital Status, Breastfeeding Goals Factors in Weaning

The researchers found that at 6 months of age, the infants in the supplemented group were as likely to breastfeed as those who had exclusively breastfed. But by 12 months of age, that had changed. In the supplemented group, 21 of the 12-month-olds (30 percent) were still breastfeeding, versus 37 of the infants (48 percent) in the non-supplemented group. The disparity between the two groups was less marked when the researchers accounted for married status and longer breastfeeding duration goals, both of which are associated with longer-term breastfeeding.

“The results suggest that using early, limited formula may not have a negative impact on infants, but it may alter maternal attitudes toward breastfeeding,” said first author Valerie Flaherman, MD, a pediatrician at UCSF Benioff Children’s Hospitals and associate professor in the UCSF departments of pediatrics, and epidemiology and biostatistics.

While limited formula in the first days of life did not seem to change feeding habits among newborns that were exclusively breastfed, “it’s possible that supplementation reduced commitment, by the mother or other family members, to avoid it later in infancy,” she said.

Formula Benefits and Risks

An earlier study of the same 164 infants, also led by Flaherman, found that the supplemented newborns may have been at lower risk for hyperbilirubinemia, a condition that leads to jaundice and may be caused by inadequate nutrition. Of the five infants readmitted to the hospital by 1 month of age, four were in the non-supplemented group.

“Our study’s results show that early, limited formula may have significant benefits as well as risks for subsequent breastfeeding duration,” said Flaherman.

“Counseling that implies all formula is harmful would be inaccurate and may be detrimental to long-term breastfeeding success,” she said. However, if formula is used in the first few days after birth to prevent hyperbilirubinemia or dehydration, “it should be discontinued as soon as possible, since ongoing use at 1 week of age indicates a mother is at high risk of early breastfeeding cessation.”

Senior author Ian M. Paul, MD, of Penn State College of Medicine, emphasized that a “rigid, one-size-fits-all approach” was inappropriate. “Guidelines for care and standards set by hospital accreditation agencies should consider these data and how best to support babies and their mothers,” he said.

Co-Authors: Michael Cabana, MD, of UCSF Benioff Children’s Hospitals and Charles McCulloch, PhD, of UCSF.

Funding: Healthcare Resources and Services Administration/Maternal Child Health Bureau.

Disclosures: Cabana has served as a paid consultant for Nestle; Paul has served as a paid consultant for Johnson & Johnson and the Consumer Healthcare Products Association.

UC San Francisco (UCSF) is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing and pharmacy; a graduate division with nationally renowned programs in basic, biomedical, translational and population sciences; and a preeminent biomedical research enterprise. It also includes UCSF Health, which comprises three top-ranked hospitals – UCSF Medical Center and UCSF Benioff Children’s Hospitals in San Francisco and Oakland – as well as Langley Porter Psychiatric Hospital and Clinics, UCSF Benioff Children’s Physicians and the UCSF Faculty Practice. UCSF Health has affiliations with hospitals and health organizations throughout the Bay Area. UCSF faculty also provide all physician care at the public Zuckerberg San Francisco General Hospital and Trauma Center, and the SF VA Medical Center. The UCSF Fresno Medical Education Program is a major branch of the University of California, San Francisco’s School of Medicine.