ABM Protocol
ABM Clinical Protocol #3:
Supplementary Feedings in the Healthy
Term Breastfed Neonate, Revised 2017
Ann Kellams,
1
Cadey Harrel,
2
Stephanie Omage,
3
Carrie Gregory,
4,5
Casey Rosen-Carole ,
4,5
and the Academy of Breastfeeding Medicine
A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing
common me dical problems that may impact breastfeeding success. These protocols serve only as guidelines for the
care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards
of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
Definitions Used in This Protocol
Exclusive breastfeeding: Feeding only breast milk (at the
breast or own mothers’ expressed breast milk), no food or
water except vitamins, minerals, and medications.
Supplementary feedings: Additional fluids provided to
a breastfed infant before 6 months (recommended du-
ration of exclusive breastfeeding). These fluids may
include donor human milk, infant formula, or other
breast milk substitutes (e.g., glucose water).
Complementary feedings: Solid or semisolid foods
provided to an infant in addition to breastfeeding when
breast milk alone is no longer sufficient to meet nutri-
tional needs.
Term infant: In this protocol ‘‘term infant’’ also includes
early-term infants (gestational age 37–38 6/7 weeks).
Background
Given early opportunities to breastfeed, breastfeeding as-
sistance, and instruction the vast majority of mothers and
infants will successfully establish breastfeeding. Although
some infants may not successfully latch and feed well during
the first day (24 hours), most will successfully breastfeed
with time, appropriate evaluation and support, with minimal
intervention. Exclusive breastfeeding for the first 6 months is
associated with the greatest protection against major health
problems for both mothers and infants.
1–3
Unfortunately,
infant formula supplementation of healthy neonates in hos-
pital is commonplace,
4,5
despite widespread recommenda-
tions to the contrary.
6–8
Early supplementation with infant
formula is associated with decreased exclusive breastfeeding
rates in the first 6 months and an overall shorter duration of
breastfeeding.
9,10
Therefore, hospitals, healthcare facilities,
and community organizations that promote breastfeeding are
integral in improving the exclusivity and duration of breast-
feeding.
10
One way of achieving this is by following The Ten
Steps to Successful Breastfeeding (the basis for the Baby-
Friendly Hospital Initiative), both in the hospital and
community.
Newborn physiology
Small quantities of colostrum are appropriate for the size
of a newborn’s stomach,
11–13
prevent hypoglycemia in a
healthy, term, appropriate for gestational age infant,
14,15
and
are easy for an infant to manage as he/she learns to coordinate
sucking, swallowing, and breathing. Healthy term infants
also have sufficient body water to meet their metabolic needs,
even in hot climates.
16–18
Fluid necessary to replace insen-
sible fluid loss is adequately provided by breast milk
alone.
7,18
Newborns lose weight because of physiologic di-
uresis of extracellular fluid following transition from intra-
uterine to extrauterine life and the passage of meconium. In a
prospective cohort of mothers in a U.S. Baby-Friendly des-
ignated hospital with optimal support of infant feeding, the
mean weight loss of exclusively breastfed infants was 5.5%;
notably, greater than 20% of healthy breastfed infants lost
more than 7% of their birthweight.
19
A study of over 160,000
healthy breastfed infants resulted in the creation of hour-
specific nomograms for infant weight loss for exclusively
breastfed newborns that showed differentially increased
weight loss in those born by cesarean section than by vaginal
birth. In this study, almost 5% of vaginally born infants and
1
Department of Pediatrics, University of Virginia, Charlottesville, Virginia.
2
Department of Family & Community Medicine, University of Arizona College of Medicine and Family Medicine Residency, Tucson,
Arizona.
3
Discipline of General Practice, The University of Queensland, Brisbane, Australia.
Departments of
4
Pediatrics and
5
OBGYN, University of Rochester, Rochester, New York.
BREASTFEEDING MEDICINE
Volume 12, Number 3, 2017
ª Mary Ann Liebert, Inc.
DOI: 10.1089/bfm.2017.29038.ajk
1
>10% of those born by cesarean section had lost ‡10% of
their birth weight by 48 hours after birth. By 72 hours, >25%
of infants born by cesarean section had lost ‡10% of their
birth weight.
20
Breastfed infants regain birth weight at an
average of 8.3 days (95% confidence interval: 7.7–8.9 days)
with 97.5% having regained their birth weight by 21 days.
21
Infants should be followed closely to identify those who lie
outside the predicted pattern, but the majority of those
breastfed infants will not require supplementation. It should
also be noted that excess newborn weight loss is correlated
with positive maternal intrapartum fluid balance (received
through intravenous fluids) and may not be directly indicative
of breastfeeding success or failure.
22,23
Early management of the new breastfeeding mother
Some breastfeeding mothers question the adequacy of
colostrum feedings and perceive that they have an insuffi-
cient milk supply.
24,25
These women may receive conflicting
advice about the need for supplementation and would benefit
from reassurance, assistance with breastfeeding technique,
and education about the normal physiology of breastfeeding
and infant behavior. Inappropriate supplementation may
undermine a mother’s confidence in her ability to meet her
infant’s nutritional needs
26
and give inappropriate messages
that may result in supplementation of breastfed infants at
home.
27
Introduction of infant formula or other supplements
may decrease the feeding frequency of the infant, thereby
decreasing the amount of breast stimulation a mother re-
ceives, which results in a reduction of milk supply.
28
Postpartum mothers with low confidence levels are very
vulnerable to external influences, such as advice to offer
breastfeeding infants supplementation of glucose water or
infant formula. Well-meaning healthcare professionals may
recommend supplementation as a means of protecting
mothers from fatigue or distress, although this can conflict
with their role in promoting breastfeeding.
29–31
Several so-
ciodemographic factors are associated with formula supple-
mentation in the hospital, and vary geographically. It is
important to recognize and address these factors in a cultur-
ally sensitive manner. Inappropriate reasons for supplemen-
tation and associated risks are multiple (Appendix Table A1).
There are common clinical situations where evaluation and
breastfeeding management may be necessary, but SUPPLE-
MENTATION IS NOT INDICATED, including:
1. The healthy, term, appropriate for gestational age infant
when the infant is feeding well, urinating and stooling
adequately, weight loss is in the expected range, and
bilirubin levels are not of concern (depending on ges-
tational age, time since birth, and any risk factors).
32
Newborns are normally sleepy after an initial alert
period after birth (*2 hours). They then have vari-
able sleep–wake cycles, with an additional one or
two wakeful periods in the next 10 hours whether fed
or not.
33
Careful attention to an infant’s early feeding cues,
keeping the infant safely skin-to-skin with mother
when she is awake, gently rousing the infant to
attempt frequent breastfeeds, and teaching the
mother hand expression of drops of colostrum,
34
may be more appropriate than automatic supple-
mentation after 6, 8, 12, or even 24 hours.
Increased skin-on-skin time can encourage more
frequent feeding.
Ten percent weight loss is not an automatic mar-
ker for the need for supplementation, but is an
indicator for infant evaluation.
2. The infant who is fussy at night or constantly feeding
for several hours
Cluster feeding (several short feeds close together)
is normal newborn behavior, but should warrant a
feeding evaluation to observe the infant’s behavior
at the breast
35
and the comfort of the mother to en-
sure that the infant is latched deeply and effectively.
Some fussy infants are in pain that should be ad-
dressed.
3. The tired or sleeping mother
Some fatigue is normal for new mothers. However,
rooming out for maternal fatigue does not improve
mothers’ sleep time
36
and has been shown to reduce
breastfeeding exclusivity.
37
Extreme fatigue should
be evaluated for the safety of mother and baby to
avoid falls and suffocation.
38
Breastfeeding management that optimizes the infant
feeding at the breast may make for a more satisfied
infant AND allow the mother to get more rest.
The following guidelines address strategies to prevent the
need for supplementation (also see Appendix 2) as well as indi-
cations for and methods of supplementation for the healthy, term
(37- to 42-week), breastfed infant. Indications for supplementa-
tion in term, healthy infants are few.
7,39
Table 1 lists possible
indications for the administration of supplemental feeds. In each
case, the medical provider must decide if the clinical benefits
outweigh the potential negative consequences of such feedings.
Recommendations
Step 1. Prevent the need for supplementation
1. There is mixed, but mainly positive, evidence about the
role of antenatal education and in-hospital support on the
rates of exclusive breastfeeding.
40–42
(I)(Qualityofevi-
dence [levels of evidence I, II-1, II-2, II-3, and III] is based
on the U.S. Preventive Services
43
Task Force Appendix A
Task Force Ratings and is noted in parentheses.)
2. All staff who care for postpartum women should be able
to assist and assess breastfeeding infants, especially
when other staff with expertise are not available.
3. Both mothers and healthcare professionals should be
aware of the risks of unnecessary supplementation.
4. Healthy infants should be placed skin-to-skin with the
mother, if she is awake and alert, immediately after
birth to facilitate breastfeeding.
7,44
(I) The delay in
time between birth and initiation of the first breastfeed
is a strong predictor of infant formula use and may
affect future milk supply.
10,45,46
(II-3, II-2, II-3)
5. It is ideal to have the mother and infant room-in
24 hours per day to respond to infant feeding cues,
enhance opportunities for breastfeeding, and hence
secretory activation (lactogenesis II).
7,39,47,48
(III)
6. If mother–infant separation is unavoidable, milk supply
is not well established, or milk transfer is inadequate,
the mother needs instruction and encouragement to
express her milk by hand or pump to stimulate milk
2 ABM PROTOCOL
production and provide expressed milk for the in-
fant.
7,39,48,49
(I, III) This process should begin within
1hourofbirth.
45
(II-2)
Step 2. Address early indicators of the possible need
for supplementation
1. The infant’s medical providers should be notified if the
infant or mother meets any criteria for supplementa-
tion, as listed in Table 1.
2. All infants must be formally evaluated for position,
latch, and milk transfer before the provision of sup-
plemental feedings. This evaluation should be under-
taken by a healthcare provider with expertise in
breastfeeding management, when available.
7,48
Step 3. Determine whether supplementation
is required and supplement with care
1. The status of the infant requiring supplementation
should be determined and any decisions made on a
case-by-case basis (guidelines in Table 1).
2. Hospitals should strongly consider formulating and
instituting policies to require a medical provider’s
order when supplements are medically indicated and
informed consent of the mother when supplements are
not medically indicated. It is the responsibility of the
healthcare provider to fully inform parents of the
benefits and risks of supplementation, document pa-
rental decisions, and support the parents after they
have made a decision.
50,51
(III)
3. All supplemental feedings should be documented, in-
cluding the content, volume, method, and medical
indication or reason.
4. When supplementary feeding is medically necessary,
the primary goals are to feed the infant and to optimize
the maternal milk supply while determining the cause
of low milk supply, poor feeding, or inadequate milk
transfer. Supplementation should be performed in
ways that help preserve breastfeeding such as limiting
the volume to what is necessary for the normal new-
born physiology, avoiding teats/artificial nipples,
52
(I)
stimulating the mother’s breasts with hand expression
or pumping, and for the infant to continue to practice
at the breast.
5. Optimally, mothers need to express milk frequently,
usually once for each time the infant receives a
Table 1. Possible Indications for Supplementation in Healthy,
Term Infants (37–41 6/ 7 Weeks Gestational Age)
1. Infant indications
a. Asymptomatic hypoglycemia, documented by laboratory blood glucose measurement (not bedside screening methods)
that is unresponsive to appropriate frequent breastfeeding. Note that 40% dextrose gel applied to the side of the infant’s
cheek is effective in increasing blood glucose levels in this scenario and improves the rate of exclusive breastfeeding
after discharge with no evidence of adverse effects.
78
Symptomatic infants or infants with glucose <1.4 mmol/L
(<25 mg/dL) in the first 4 hours or <2.0 mmol/L (<35 mg/dL) after 4 hours should be treated with intravenous
glucose.
15
Breastfeeding should continue during intravenous glucose therapy.
b. Signs or symptoms that may indicate inadequate milk intake:
i. Clinical or laboratory evidence of significant dehydration (e.g., high sodium, poor feeding, lethargy, etc.) that is not
improved after skilled assessment and proper management of breastfeeding.
79
ii. Weight loss of ‡8–10% (day 5 [120 hours] or later), or weight loss greater than 75th percentile for age.
1. Although weight loss in the range of 8–10% may be within normal limits if all else is going well and the physical
examination is normal, it is an indication for careful assessment and possible breastfeeding assistance. Weight loss
in excess of this may be an indication of inadequate milk transfer or low milk production, but a thorough
evaluation is required before automatically ordering supplementation.
19,20,80
2. Weight loss nomograms for healthy newborns by hour of age can be found at: www.newbornweight.org
20,80
iii. Delayed bowel movements, fewer than four stools on day 4 of life, or continued meconium stools on day 5
(120 hours).
48,80
1. Elimination patterns for newborns for urine and stool should be tracked at least through to the onset of secretory
activation. Even though there is a wide variation between infants, the patterns may be useful in determining
adequacy of breastfeeding.
81,82
II-2. Newborns with more bowel movements during the first 5 days following
birth have less initial weight loss, earlier the transition to yellow stools, and earlier return to birth weight.
83
c. Hyperbilirubinemia (see ABM Clinical Protocol #22: Guidelines for Management of Jaundice)
i. Suboptimal intake jaundice of the newborn associated with poor breast milk intake despite appropriate intervention.
This characteristically begins at 2–5 days and is marked by ongoing weight loss, limited stooling and voiding with
uric acid crystals.
ii. Breast milk jaundice when levels reach 340–425 lmol/L (20–25 mg/dL) in an otherwise thriving infant and where a
diagnostic and/or therapeutic interruption of breastfeeding may be under consideration. First line diagnostic
management should include laboratory evaluation, instead of interruption of breastfeeding.
d. Macronutrient supplementation is indicated, such as for the rare infant with inborn errors of metabolism.
2. Maternal indications
a. Delayed secretory activation (day 3–5 or later [72–120 hours] and inadequate intake by the infant).
80
b. Primary glandular insufficiency (less than 5% of women—primary lactation failure), as evidenced by abnormal breast
shape, poor breast growth during pregnancy, or minimal indications of secretory activation.
84,85
c. Breast pathology or prior breast surgery resulting in poor milk production.
84
d. Temporary cessation of breastfeeding due to certain medications (e.g., chemotherapy) or temporary separation of
mother and baby without expressed breast milk available.
e. Intolerable pain during feedings unrelieved by interventions.
ABM PROTOCOL 3
supplement, or at least 8 times in 24 hours if the infant
is not feeding at the breast. Breasts should be fully
drained each time.
53
(II-2) Maternal breast engorgement
should be avoided as it will further compromise the
milk supply and may lead to other complications.
54
(III)
6. Criteria for stopping supplementation should be con-
sidered from the time of the decision to supplement
and should be discussed with the parents. Stopping
supplementation can be a source of anxiety for parents
and providers. Underlying factors should be addressed
and mothers should be assisted with their milk supply,
latch, and comfort with assessing the signs that their
infant is adequately fed. It is important to closely
follow up mother and infant.
7. When the decision to supplement is not medically
indicated (Table 1), discussions with the mother
should be documented by the nursing and/or medical
staff followed by full support of her informed decision.
Choice of Supplement
1. Expressed breast milk from the infant’s mother is the
first choice for extra feeding for the breastfed in-
fant.
7,55
(III) Hand expression may elicit larger vol-
umes than a breast pump in the first few days
following birth and may increase overall milk sup-
ply.
56
Breast massage and/or compression along with
expressing with a mechanical pump may also increase
available milk.
57
(II-3)
2. If the volume of the mother’s own colostrum/milk
does not meet her infant’s feeding requirements and
supplementation is required, donor human milk is
preferable to other supplements.
55
3. When donor human milk is not available or appropriate,
protein hydrolysate formulas may be preferable to
standard infant formula as they avoid exposure to intact
cow’s milk proteins and reduce bilirubin levels more
rapidly,
58
(II-2) although recent data are less supportive
of its role in preventing allergic disease.
59
(I) The use of
this type of formula may also convey the psychological
message that the supplement is a temporary therapy, not
a permanent inclusion of artificial feedings.
4. Supplementation with glucose water is not appropriate
because it does not provide sufficient nutrition, does not
reduce serum bilirubin,
60,61
and might cause hypona-
tremia.
5. The potential risks and benefits of other supplemental
fluids, such as cow’s milk formulas, soy formulas, or
protein hydrolysate formulas, must be considered
along with the available resources of the family, the
infant’s age, the amounts needed, and the potential
impact on the establishment of breastfeeding.
Volume of Supplemental Feeding
1. Several studies give us an idea of intakes at the breast
over time. In most studies, the range of intake is wide,
while formula-fed infants usually take in larger vol-
umes than breastfed infants.
62–66
(II-3)
2. Infants fed infant formula ad libitum commonly have
much higher intakes than breastfed infants.
65,66
(II-3)
Acknowledging that ad libitum breastfeeding emulates
evolutionary feeding and considering recent data on
obesity in formula-fed infants, it appears that formula-
fed infants may be overfed.
3. As there is no definitive research available, the amount
of supplement given should reflect the normal amounts
of colostrum available, the size of the infant’s stomach
(which changes over time), and the age and size of the
infant. Intake on day 2 postbirth is generally higher
than day 1 in relation to infant’s demand.
65
4. Based on the limited research available, suggested
intakes for healthy, term infants are given in Table 2,
although feedings should be based on infant cues.
Methods of Providing Supplementary Feedings
1. When supplementary feedings are needed, there are a
number of delivery methods from which to choose: a
supplemental nursing device at the breast, cup feeding,
spoon or dropper feeding, finger-feeding, syringe feed-
ing, or bottle feeding.
67
(III)
2. An optimal supplemental feeding device has not yet
been identified, and may vary from one infant to an-
other. No method is without potential risk or benefit.
68
3. When selecting an alternative feeding method, clini-
cians should consider several criteria:
a. cost and availability
b. ease of use and cleaning
c. stress to the infant
d. whether adequate milk volume can be fed in 20–
30 minutes
e. whether anticipated use is short- or long-term
f. maternal preference
g. expertise of healthcare staff
h. whether the method enhances development of
breastfeeding skills.
4. There is no evidence that any of these methods are
unsafe or that one is necessarily better than the other.
There is some evidence that avoiding teats/artificial
nipples for supplementation may help the infant return
to exclusive breastfeeding
20,52,69
(I); however, when
hygiene is suboptimal, cup feeding is the recommended
choice.
55
Cup feeding also allows infants to control
feeding pace
68
(II-2). Cup feeding has been shown safe
for both term and preterm infants and may help preserve
breastfeeding duration among those who require mul-
tiple supplemental feedings.
52,70–72
(II-2, I, I, I, II-2)
5. If bottles are being used, pacing the feed may be
beneficial, especially for preterm infants.
73
(III)
6. Supplemental nursing systems have the advantages of
supplying a supplement while simultaneously stimu-
Table 2. Average Reported Intakes of Colostrum
by Healthy, Term Breastfed Infants
Time (hours) Intake (mL/feed)
First 24 2–10
24–48 5–15
48–72 15–30
72–96 30–60
4 ABM PROTOCOL
lating the breast to produce more milk, reinforcing the
infant’s feeding at the breast, enabling the mother to
have a breastfeeding experience, and encouraging
skin-to-skin. However, mothers may find the systems
awkward to use, difficult to clean, relatively expen-
sive, requiring moderately complex learning, and the
infant must be able to latch effectively.
67
A simpler
version, supplementing with a dropper, syringe, or
feeding tube attached to the breast while the infant is
feeding at breast, may be effective.
7. Bottle feeding is the most commonly used method of
supplementation in more affluent regions of the world,
but concerns have been raised because of distinct
differences in tongue and jaw movements, and faster
flow may result in higher (and unnecessary) volumes
of feeds.
67
Some experts have recommended a teat/
nipple with a wide base and slow flow to try to mimic
breastfeeding and to avoid nipple confusion or pref-
erence,
68,74
(II-2), but little research has been done
evaluating outcomes with different teats/nipples.
Research Needs
Research is necessary to establish evidence-based guide-
lines on appropriate supplementation volumes for specific
conditions and whether this varies for colostrum versus infant
formula.
Specific questions include the following:
1. Should the volume be independent of infant weight or
a per kilogram volume? Should supplementation make
up for cumulative losses?
2. Should feeding intervals or quantities be different for
different types of delivery of supplementation (e.g.,
bottles, cup feeding)?
3. Are some methods (type and delivery mechanism) best
for infants with certain conditions, ages, and available
resources? Which methods interfere least with estab-
lishing direct breastfeeding?
Notes
This protocol addresses the healthy, term newborn. For
information regarding appropriate feeding and supplemen-
tation for the late preterm infant (35–37 weeks), see ‘‘ABM
Protocol #10: Breastfeeding the Late Preterm Infant’’
75
and
‘‘Care and Management of the Late Preterm Infant Toolk-
it.’’
76
The World Health Organization broadened the annex
of the ‘‘Global Criteria for the Baby Friendly Hospital In-
itiative: Acceptable Medical Reasons for Supplementa-
tion.’’
77
to include acceptable reasons for use of breast milk
substitutes in all infants. The handout (#4.5) is available at:
www.who.int/nutrition/topics/BFHI_Revised_Section_4.pdf
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ABM PROTOCOL 7
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ABM protocols expire 5 years from the date of publication.
Content of this protocol is up-to-date at the time of pub-
lication. Evidence based revisions are made within 5 years or
sooner if there are significant changes in the evidence.
The 2009 edition of this protocol was authored by Nancy
E. Wight and Robert Cordes.
The Academy of Breastfeeding Medicine Protocol Committee:
Wendy Brodribb, MBBS, PhD, FABM, Chairperson
Larry Noble, MD, FABM, Translations Chairperson
Nancy Brent, MD
Maya Bunik, MD, MSPH, FABM
Cadey Harrel, MD
Ruth A. Lawrence, MD, FABM
Kathleen A. Marinelli, MD, FABM
Sarah Reece-Stremtan, MD
Casey Rosen-Carole, MD, MPH, MSEd
Tomoko Seo, MD, FABM
Rose St. Fleur, MD
Michal Young, MD
Table A1. Inappropriate Reasons for Supplementation in the Context
of a Healthy Newborn and Mother, Responses, and Risks
Concerns/inappropriate
reasons Responses Risks of supplementation
There is ‘‘no milk,’’
5
belief that
colostrum is insufficient until
the milk ‘‘comes in’’
Mother and family should be educated about
the benefits of colostrum including
dispelling myths about the yellow color.
Small amounts of colostrum are normal,
physiologic, and appropriate for the term,
healthy newborn.
Can alter infant bowel flora and
microbiome.
86,87
Potentially sensitizes the infant to foreign
proteins.
88,89
Increases the risk of diarrhea and other
infections, especially where hygiene is
poor.
3
Potentially disrupts the ‘‘supply-demand’’
cycle, leading to inadequate milk sup-
ply and long-term supplementation.
Supplementation is needed to
prevent weight loss and
dehydration in the postnatal
period
5
A certain amount of weight loss is normal in
the first week of life and is due to diuresis
of extracellular fluid and passage of
meconium.
Supplementation in the first few days may
interfere with the normal frequency of
breastfeeding.
Supplementation with water or glucose
water, increases the risk of jaundice,
90
excessive weight loss,
91
and longer
hospital stays.
92
Infant could become
hypoglycemic
Healthy, full-term infants do not develop
symptomatic hypoglycemia as a result of
suboptimal breastfeeding.
15
Same risks as for weight loss/dehydration.
Breastfeeding is related to
jaundice in the postnatal
period
The more frequent the breastfeeding, the
lower the bilirubin level.
93,94
Same risks as for weight loss/dehydration.
Bilirubin is a potent antioxidant
95
and
jaundice is normal in the newborn.
Colostrum acts as a natural laxative helping
to eliminate meconium that contains
bilirubin.
94
(continued)
Appendix
8 ABM PROTOCOL
Table A1. (Continued)
Concerns/inappropriate
reasons Responses Risks of supplementation
Lack of time for counseling
mother about exclusive
breastfeeding when mothers
request a supplement
Train all staff in how to assist mothers with
breastfeeding.
Mothers may benefit from education about
artificial feeds and/or how supplements
may adversely affect subsequent
breastfeeding.
29
Time spent by healthcare professionals lis-
tening to and talking with mothers is at
least as important as other more active
interventions (which may be viewed more
as ‘‘real work’’ to them).
29
If the supplement is infant formula, which
is slow to empty from the stomach
96
and often fed in larger amounts,
66
the
infant will breastfeed less frequently.
Depending on the method of
supplementation,
52,74
or the number of
supplements
97
an infant may have
difficulty returning to the breast.
Feeds given before secretory activation
and copious breast milk production (as
opposed to supplementation) may be
associated with delayed initiation of
breastfeeding and negatively associated
with exclusivity and duration of
breastfeeding.
98
Medications may be contraindi-
cated with breastfeeding
Accurate references are available to provid-
ers (e.g., Medications and Mothers’ Milk
2017,
99
LactMed on Toxnet website
15
)
Risk of decreasing breastfeeding duration
or exclusivity.
9,10
For most medical conditions, medication safe
for breastfeeding mothers and babies is
available
Mother is too malnourished or
sick to breastfeed or eats an
inappropriate diet.
Even malnourished mothers can breastfeed.
Breast milk quality and quantity is only
affected in extreme circumstances.
Supplements are better given to the mother
(with continued breastfeeding) than the
infant.
Risk of decreasing breastfeeding duration
or exclusivity.
Supplementation will quiet a
fussy or unsettled infant
5
Infants can be unsettled for many reasons.
They may wish to cluster feed or simply
need additional skin-to-skin time or
holding.
67
Filling (and often overfilling) the stomach
with a supplement may make the infant
sleep longer,
96
missing important oppor-
tunities to breastfeed, and demonstrating
to the mother a short-term solution which
may generate long-term health risks.
Teaching other soothing techniques to new
mothers such as breastfeeding, swaddling
(but not if prone or side lying),
100
swaying, singing, encouraging
father or other relatives to assist. Caution
should be taken to not ignore early feed-
ing cues.
101
Ensure comfortable, effective latch to max-
imize signal to mother’s body and intake
for the infant
Risk of decreasing breastfeeding duration
or exclusivity.
Maternal engorgement due to decreased
frequency of breastfeeding in the
immediate postpartum period.
54
Concern about the cause of
frequent feeding and cluster
feeding and other changes in
infant behavior
Periods when infants demand to breastfeed
more are sometimes interpreted by moth-
ers as insufficient milk. This may happen
in later weeks but also in the second or
third night (48–72 hours) postbirth.
Changes in stooling patterns that often occur
after 6–8 weeks of age can also be
misinterpreted as insufficient milk.
Anticipatory guidance for normal infant
development and behavior is helpful.
Risk of decreasing breastfeeding duration
or exclusivity.
Mothers need to rest or sleep Postpartum mothers are restless when
separated from their infants and actually
get less rest.
29
Risk of decreasing breastfeeding duration
or exclusivity.
(continued)
ABM PROTOCOL 9
Table A1. (Continued)
Concerns/inappropriate
reasons Responses Risks of supplementation
Mothers lose the opportunity to learn their
infants’ normal behavior and early feeding
cues.
48
Infants are at highest risk for receiving a
supplement between 7 p.m. and 9 a.m.
102
Sore nipples will improve if
mother takes a break from
breastfeeding
5
Sore nipples are not a function of length of
time breastfeeding. Position, latch, and
sometimes individual anatomic variation
(e.g., ankyloglossia) are more
important.
103
There is no evidence that limiting time at the
breast will prevent sore nipples.
The nipple should not be rubbed or com-
pressed during breastfeeding even if the
feedings are frequent or
‘‘clustered.’’
104
Problem with latch not addressed.
Risk of decreasing breastfeeding
duration or cessation of breastfeeding.
Risk of breast engorgement.
10 ABM PROTOCOL
Appendix A2: Sample Maternity Care Infant Nutrition Algorithm
