Supplementation Policy

(sample)

Policy Statement

Infants who are at risk for inadequate intake at breast due to conditions listed below will be identified and treated as necessary. The physician will be notified of the feeding plan and follow-up care will be arranged. The parents will verbalize the rationale for the supplementation and will be assisted with feeding methods so that they are providing the supplement to the infant.

Protocol/Procedure

Situations that do not warrant supplementation:

Healthy term infants.

• A sleepy baby who has had few feedings during the first 48 hours.
• Bilirubin levels between 12 and 20 mg/dl after 72 hours. (NOTE: the infant should be feeding well, having more than 4 yellow stools per day and have no hemolysis or other signs of pathology).
• Night time fussiness or constant feeding for several hours where baby is content and satisfied while on the breast, fussy if off.
• Growth spurts.

Possible medical indications for supplementation:

• Birth weight less than1500 grams or gestational age below 32 weeks.
• SGA with potentially severe hypoglycemia.
• Severely ill mother (e.g. PIH, shock, psychosis).
• nborn errors of metabolism such as Galactosemia, PKU or Maple Syrup Urine Disease.
• Acute water loss.
• Mother taking contraindicated medication (rare).

Possible infant indications for supplementation:

• Hypoglycemia.
• Significant dehydration.
• Weight loss greater than 10% at 24 hours of age.
• Weight loss of 8-10% accompanied by delayed lactogenesis at day 5 or later.
• Delayed bowel movements or dark stools at day 5.
• Insufficient intake despite an adequate milk supply.
• Hyperbilirubinemia related to poor intake. Breastfeeding evaluation and management have occurred and infant is unable to sustain adequate caloric and fluid intake).
• Prematurity, low birth weight necessitates fluids/calories and mother is not available or is unable to express sufficient quantities for the baby's immediate needs.

Possible maternal indications for supplementation:

• Delayed lactogenesis (day 5 or later) and signs of infant problems.
• Delayed lactogenesis and inconsolably hungry baby.
• Intolerable pain during feedings.
• Unavailability of mother due to severe illness or geographic separation.
• Primary glandular insufficiency (primary lactation failure), as evidenced by poor. breast growth during pregnancy and minimal indications of lactogenesis.
• Retained placenta causing delayed lactogenesis.
• Sheehan Syndrome (Post Partum hemorrhage followed by absence of lactogenesis.)
  

Supplementation methods
Choosing a method of supplementation depends on the individual situation and the functional capability of the infant at that time.

• If baby can latch properly and can sustain suck at breast and requires supplementation: use feeding tube at breast.
• If latch is problematic, but baby has normal gag and swallow, can use a dropper, curved syringe or cup.
• If supplementation is temporary but more than a few feedings: can finger feed provided baby is able to pace the feeding. Parents should do the finger feeding.
• For situations where baby cannot latch and above methods have proved ineffective means to get adequate calories and fluids into baby, use a bottle.
• For babies with poor suck, swallow and gag reflex: gavage.
• In most cases the mother should be taught to express milk and maintain milk supply until baby is fully breastfeeding.
  

Documentation procedure for supplementation
Supplemental feedings must be documented in the progress notes and should include:

• Indication requiring need for supplemental fluid.
• Method by which supplement was given.
• Infant's tolerance of procedure.
• Instructions given to parents.
• Notification of physician.
• Arrangements for follow-up care as needed.

References

American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the Use of Human Milk. Pediatrics. 1997; 100 (6): 1035-1039.

Powers N., Slusser W. Breastfeeding Update 2: Clinical Lactation Management. Pediatrics in Review. 1997; 18 (5): 147-161.

Lazarov M., Feldman A. WHO/UNICEF Ten Steps to Successful Breastfeeding, United States Committee for UNICEF Annotated Bibliography for each step, 1995.

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