Does my infant really need a top-up?
Way too often when I ask the question “Has your baby received any supplementation?” Do I get a “yes”
My follow-up questions are then “with what? how was it provided? what is the volume of each supplemented feed? And at what age was supplementation started?”
The responses to these questions are typical in that supplemented feeds are of infant formula being provided via a bottle seeing a volume varying between 50-80mls and starting very early on in the infant's life.
I am seeing supplemented feeds started when a health professional is questioning a mother's milk supply and is under the belief that it is low causing issues with the infant such as perceived low weight gain or normal cluster feeding behaviours.
The mother is then told to begin supplemented feeds also referred to as top-ups.
The issue with this is that there is typically very minimal evidence to support this health professional's beliefs and that they are causing more harm than good.
Here in Australia, more than 40% of mothers say they had to stop breastfeeding because they had a “low milk supply”, that is a huge amount of mothers stopping breastfeeding before they were ready to do so.
Why is it that these mothers are led to believe that they have a low supply?
Many of these mothers have this belief due to being given a ridiculous random figure for the volume that is required of the top-up such as 50mls, 60mls or even of late I have had a mother told to give a top-up of 80mls. Now let me just clarify that these amounts are certainly not what I or many other professionals working in the lactation field would consider a “top-up” These amounts are full feed quotas. I consider a top-up to be 15 to 30mls and certainly no more than 40mls after a breastfeed.
These poor mothers are breastfeeding around the clock every 3 hours and then trying to express these impossible amounts on top to keep up with the “top-up” figure they have been told they need to give their infant. Once they realise they just can’t meet this quota they then believe they must start using infant formula so they can provide the required top-ups.
This is where we see “The top-up spiral”.
The “Top-up spiral” is when a mother worries she doesn’t have enough milk so gives her infant a top-up of formula, the infant is then overfull and skips the next breastfeed or drinks less than they normally would from the breast. The mother now makes less milk and the spiral continues. Usually this spiral starts off by the mother expressing after a feed and not getting the large amounts they were expecting causing them to believe they just don’t have enough milk.
This mother now tops-up with formula seeing her infant sleep 4 or 5 hours which has caused 2 missed breastfeeds. After 3 or 4 days of daily top-up formula feeds the breasts are no longer being emptied as frequently as before. The breasts now think they are weaning and start to produce less milk.
The infant is now becoming hungrier again so another top-up is given the infant now sleeps through 3 to 4 breastfeeds per day.
Eventually the breasts think they need to wean further causing reduction of overall milk supply for each day and as you can see this cycle goes on and on till the mother now has an actual low supply with an infant who is mostly formula feeding.
This poor mother blames herself and her milk supply as the reason she couldn’t feed her infant.
Pregnancy prepares your breasts for making milk. In the early days after birth, high hormone levels drive the amount of breast milk you make. When your baby drinks the milk stored in your breasts, they make more milk to replace it. After those early hormones settle down, the amount of milk you make becomes controlled by the amount of milk that is removed from your breasts.
Your body makes milk all the time, so your breasts are never “empty”. If the milk is not removed, this process slows down and after a while, your breasts make less milk.
If you do have a low supply, it is often because your baby isn’t taking enough milk, rather than you not being able to make enough milk. Usually, feeding more often and improving your baby’s attachment will increase your supply.
Only a few rare medical conditions will see a mother with a true low supply such as having insufficient glandular tissue. Other reasons may include having a history of breast surgery such as augmentation.
Mothers who give birth before 37 weeks gestation, women with PCOS, diabetes or a very high BMI in pregnancy may have a delay in their milk “coming in” initially though with the right support in the early days can go on to have a good supply and successful feeding journeys.
When feeding your infant via a bottle you may notice that they seem to take a large amount quite quickly. Many a time mothers think this is because they are hungry reinforcing the belief they aren’t making enough milk and top-ups are required. The reason your infant appears to be taking a large amount from the bottle is the flow of the milk and not being able to control it, the milk from a bottle flows much quicker than from the breast. Another reason is that they don’t have to do any work for the milk it just flows for them.
An infant sucking from a bottle will continue to suck even when they have had enough due to how strong their sucking instinct is.
Before topping up I suggest doing the following ~
See a lactation consultant for advice, support and guidance.
Check your milk supply first by running through your infant's feeding frequency, and behaviours. Taking a look at your breasts and reasons you may be only expressing a small amount.
Check if your infant is getting enough by their output- are they having 5+ heavily wet nappies in 24 hours for disposable and 6 pale very wet nappies for cloth. Poos are soft. Your infant has a good skin tone and bright eyes. They are generally content between feeds. Weight is increasing when looked at over some time with an increase in length and head circumference also seen.
If your infant has good output, looks healthy and has weight gains then your supply is likely to be adequate
What to do if you find yourself in this trap or cycle
Increase the number of feeds in 24 hours
Increase the number of sides at each feed, you can offer each side twice.
Improve your infants attachment
Use breast compressions during feeding to help with milk flow
What if my infant needs to be topped up
Express between feeds so you can top-up with your own milk
Start replacing formula top-ups with small amounts of breastmilk eg 30mls a day
Provide top-up feeds via a supply line, syringe or cup. If you must use a bottle make sure to use the paced bottle-feeding technique
Offer small top-ups, just enough to keep your infant satisfied for a short time so they are hungry for the next breastfeed if able.
If you don’t feel well drained then you can express after a feed
I want you to remember ~
You can’t judge your milk supply by how much your infant takes from a top-up feed.
Your infant will always be able to remove more milk than any expressing device.
If you give extra formula feeds regularly your milk supply will be reduced.
Most mothers can successfully increase their supply if they have the right support, information and help.
If you have any concerns with your milk supply be sure to reach out so we can take a look at what is going on, develop a plan, and make sure you have the right support in place that is needed to have a successful breastfeeding journey.