Factors Influencing Non-Medically Indicated Formula Supplementation of Newborns
by Anne Eglash MD, IBCLC, FABM
The Baby Friendly Hospital Initiative’s Step 6 states ‘Give infants no food or drink other than breastmilk unless medically indicated’ because there is strong evidence that giving newborns formula supplementation when not medically indicated is associated with lower breastfeeding rates. The Healthy People 2020 breastfeeding objectives include the goal of lowering formula supplementation to 13.2% nationwide, while it is currently 6.3-26.9%.
In order to lower non-medically indicated formula supplementation early postpartum, it is important for us to understand risk factors, so that these can be addressed either prenatally or intrapartum.
The authors of a recent systematic review summarized 5 rather large studies that researched risk factors of non-medically indicated formula supplementation. The data on supplementation in these studies mainly came from interviews of nurses and parents, observation of nursing staff, as well as chart review.
Several of the findings are not surprising, given that they are consistent with the demographics of breastfeeding rates in the USA. Women with less education and who are younger, lower income, African American, and unmarried are more likely to supplement when it is not medically indicated.
Not surprisingly, women with a negative attitude of breastfeeding, and mothers having breastfeeding problems postpartum were more likely to supplement when not medically indicated.
For information on the medical indications for supplementing breastfeeding newborns, please visit the Academy of Breastfeeding Medicine’s Protocol on Supplementation.
- Maternal anxiety
- Male infant
- Cesarean birth
- Neonates born between 9 pm and 6 am
- Being born in a level 3 hospital (more complex care) vs level 1
- Receiving physician advice on breastfeeding
See the Answer
To examine maternal and newborn factors that influence non–medically indicated (NMI) formula supplementation of newborns in the hospital setting.
Electronic databases CINAHL and Ovid MEDLINE were searched for peer-reviewed articles published in English between January 1, 2000, and September 30, 2017.
A total of 616 studies were returned from the search. After removal of duplicates, 558 studies remained, 531 of which were excluded based on factors of not being related to term newborns, not being published in a peer-reviewed journal, or study not completed in a hospital setting. Five studies were included that met the inclusion and exclusion criteria.
Data from the five studies were extracted and compiled into a summary table.
Synthesis indicated that maternal ethnicity, educational level, and income influence the decision to provide NMI formula supplementation to newborns. First-time mothers and those with cesarean birth, no previous breastfeeding experience, female newborns, and large-for-gestational-age newborns were at greater risk for NMI formula supplementation. Neonates born at night are more likely to receive NMI formula supplementation, and NMI formula supplementation increases during the night hours and during the first 24 hours after birth.
Identification of newborn/maternal risk factors, continuous breastfeeding support, and provision of consistent breastfeeding education to women are factors that influence NMI formula supplementation of newborns. With collaboration among hospital physicians, midwives, nurse practitioners, nurses, and lactation consultants to identify at-risk newborns, the goal of decreasing NMI formula supplementation of newborns in the hospital can be achieved.
One of the studies in this review found that female infants were more likely to receive formula supplementation vs males.
Interestingly, receiving physician breastfeeding advice was associated with 2x the risk of non-medically indicated formula supplementation. This speaks to the lack of breastfeeding education among health professionals.
One of the studies in this systematic review evaluated factors associated with formula supplementation in 126 hospitals in New York. It found that 18.2% of infants received formula supplementation in level 1 hospitals, 51% in level 2, 51.3% in level 3, and 57% in regional perinatal centers. There may be several reasons for this, including the likelihood of higher risk mothers delivering in level 3 as opposed to level 1 hospitals.
The authors of this review summarize their findings by providing a set of recommendations for clinical practice, including early and accurate assessment of maternal and newborn risk factors associated with formula supplementation, educating low income primiparous women about breastfeeding, optimizing support for all breastfeeding dyads 24 hours a day, and providing consistent education and support early postpartum for all breastfeeding mothers to alleviate their anxieties and apprehension about breastfeeding.