Valid indications for supplementation. While many reasons for giving supplementation are inappropriate, there are some infants with very valid indications for supplementation.^20-22 (See Table 1)

What to Supplement. Ideally, the volume of supplementation should mimic the normal volume of colostrum and transitional milk after Lactogenesis II. Feeding 5-15 ml per feeding days 1-2, and 10-45 ml per feeding day 3 and beyond is appropriate for a full term or near term infant. Occasionally infants will need or want more, but a common reason for NICU evaluation is excessive feeding of 45-60 ml of supplement per feeding in the first 24 hrs with resultant emesis.

If available, expressed mother's own milk should be used to supplement her infant. Hand expression can often elicit more useable milk than using a breast pump before Lactogenesis II. Pasteurized donor human milk would be the next choice

so as to prevent exposure to whole cow's milk proteins, especially in allergy-prone families. If pasteurized donor milk is not available, my next choice would be elemental or hypo-allergenic formulas, also to reduce exposure to cow's milk proteins and to reduce bilirubin faster. ²³ They also offer the psychological advantage of being "different"; a special treatment to be discontinued once full breastfeeding is achieved. Last on the list are regular formulas. Soy formulas are no less allergenic than regular formulas and should not be used without a medical indication (e.g. galactosemia). Glucose water is inadequate nutrition; although "stretching" expressed human milk by combining it with glucose water (D10W) may be appropriate for 1-2 feeds.

How to Supplement. How to supplement a breastfed infant is more of a political, than a medical, controversy. The goal of any alternative (to the breast) feeding method is to establish or restore full direct breastfeeding eventually. The main advantage of supplementing without the ubiquitous bottle is to give the non-verbal message to the parents that whatever method used is temporary. Also, some infants learn to prefer the immediate, faster flow through a bottle nipple and have difficulty returning to the breast.⁹

In most of the world cup feeding is the method of choice for supplementation, but infants are amazingly adaptable to any chosen method. Multiple studies have demonstrated cup feeding is safe, ^6,24-29 but so far, only 2 have shown some benefit in extending breastfeeding duration. ^4,29 It appears that the more supplementation with a bottle (> 2-3 feeds), the less likely the infant will be to establish full breastfeeding.

Finger feeding, syringe feeding, spoon feeding, etc. all appear safe, but there is no evidence as to efficacy in improving breastfeeding duration. Using a supplemental nursing system or feeding tube at the breast seems to be an ideal way to provide supplementation, but it is sometimes awkward for the mother and lacks any research as to long term breastfeeding success.

Conclusions. There are many reasons infants are given supplements, most of them spurious. When supplementation is truly needed, it should be provided in a way to minimize the risk to future exclusive breastfeeding. The goals of supplementation are to provide needed nutrition and hydration, avoid feeding-related morbidities, and to establish and maintain a mother's milk supply. Anticipatory guidance regarding the normal course of lactation and education of health care providers can reduce the need for supplementation. When supplementation is requested without medical indication, health care providers have a responsibility to inform mothers of the possible consequences.

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