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Supplementation

Supplementation is defined as the use of additional milk or fluid products to feed an infant, in addition to breastmilk, during the first 6 months of life. The Academy of Breastfeeding Medicine recommends only supplementing when medically indicated, as opposed to mixing use of formula and breastmilk for reasons that are not necessarily medical indications. Some medical indications for supplementation include low blood sugar, dehydration, excessive weight loss or poor gain, and jaundice in the infant; true low milk supply; severe nipple pain unrelieved by interventions; and medical contraindications to breastfeeding, as described below. Supplements can be delivered at the breast through a supplemental nursing system in order to stimulate the production of the mother's own milk and to preserve the breastfeeding relationship. Some parents may desire to supplement proactively if early signs of insufficient intake, such as decreased urination, dry mucous membranes, or persistent signs of hunger, are noticed. If these signs are noticed, it is important to have the mother-infant dyad evaluated by a breastfeeding specialist or pediatrician to determine the true cause of the symptoms and determine the need for supplementation. Often, these symptoms are caused by poor milk transfer at the breast, and can be solved with adjustments to the latch, but occasionally they may be caused by other processes, unrelated to breastfeeding, so evaluation is necessary. Supplementation with formula is associated with decreased rates of exclusive breastfeeding at 6 months, and overall decreased length of breastfeeding.

In terms of what to supplement with, the first choice is always the mother's own breastmilk, save any medical contraindications to its use. The second best option for supplementation is pasteurized human donor milk. Finally, specific formulas may be used for supplementation if maternal or donor breastmilk are not options. One situation where this may be the case is in cases of infant metabolic diseases, such as galactosemia. The Academy of Breastfeeding Medicine recommends that supplementation only be used when medically indicated and when overseen by a medical professional, such as a pediatrician or family physician, and after consultation with an IBCLC. Without sufficient breast stimulation, supplementation can reduce the mother's milk production, so pumping would be indicated in these cases if continued breastfeeding is desired.

Indications for use of donor breastmilk are very closely outlined by the American Academy of Pediatrics (AAP). Due to low availability and high cost of donor breastmilk, the AAP recommends prioritizing the use of the milk for infants born with a weight of less than 1500g (approximately 3lb 5oz), as it is helpful in decreasing rates of the severe intestinal infection, necrotizing enterocolitis, in this population.