Do you still need to top up?
Many babies leave hospital receiving complementary feeds - comps - of infant formula, used to “ top up” after breastfeeding. Usually this is because the baby has lost more weight than desirable and has yet to begin gaining weight. Up to 10% of birth weight is acceptable but beyond this doctors and nurses will routinely recommend topping up with expressed breastmilk and/or infant formula. This begins around the same stage as discharge from hospital and the mother will go home with instructions to pump after every breastfeed, give the expressed milk to the baby plus formula so the combined total meets the recommended amount. This is often called “triple feeding”.
What happens next?
The handover process between hospital and community care depends on where you live and what is provided in your area. Ideally you will have some visits in the home from midwives associated with your birthing hospital before your first appointment with a maternal and child health nurse. Alternatively, you might see a paediatrician or some other professional. In NZ it might be a Plunket nurse while in the UK you will see a Health Visitor. Amid this changeover period, mothers can be given different advice as they see multiple providers within a short period of time.
A breastfeeding plan should be part of this process but often isn't. The focus is generally on the baby's weight gain. Mothers might be advised to continue topping-up after feeds without a projected end-date. It is also common that nobody is investigating if the mother does actually have a low milk supply or why the baby is not effectively removing milk from the breast.
Babies receiving infant formula behave differently to those fed directly at the breast. They fall into a deeper sleep state more quickly and sleep longer. In our culture, these have become indicators of a “good baby” who is getting enough milk. Unfortunately, this isn't actually natural sleep behaviour and breastfed babies don't fall into such deep sleep. They wake sooner and want to feed more frequently. Breastmilk is easily digested but infant formula takes longer to process. So they don't signal needing another feed as soon.
Parents who are in a pattern of “topping up” with formula after feeds see this “settled” and deep sleep as normal and when they try to wean off the formula, the typical breastfed baby behaviour feels different and they worry the baby is not getting enough milk.
This is sometimes called “The Top-up Trap”: the infant formula produces the desired outcomes of sleep, weight gain and infrequent feeds.
Breastfeeding directly worries parents who have become reliant on the volume of milk in a bottle as an indicator of intake. They find it hard to trust the breast because they have no data. They have been relying on what they see disappearing into their baby. But there is a better way to track babies intake.
All babies, regardless of what they are fed, have the same urine output. At least five heavily-wet disposable nappies in 24 hours.
What goes in, must come out!!
As you increase the breastmilk and decrease the formula, your baby should maintain or increase their urine output. A drop in total wet nappies or noticeably dryer nappies is a sign you need to increase input.
Your baby’s bowel motions also show you what they are getting. Breastmilk poo is mustard yellow and liquid. Formula poo is brown and solid. Mixed-fed poo is somewhere in between, changing as more or less breastmilk is taken. As you increase breastfeeding, you will see the appearance of the poo becomes more yellow, more liquid and more frequent.
An effective way to increase your baby’s breastmilk intake is a “babymoon” in bed with them. 24 - 48 hours of skin to skin contact, co-sleeping and frequent access to the breast maximises feeding opportunities and boosts hormone levels, allowing baby and breast to regulate the supply between them. Nurturing the mother during this restoration period allows them to focus on feeding the baby and resting.
Only rarely is a mother unable to fully breastfeed her baby. But often, they become reliant on mixed feeding and are never supported to return to exclusively breastfeeding, even though they could.
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