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The truth about top-ups in breastfed babies

Supplementary feeds or “top-ups” have derailed many a woman’s breastfeeding journey. Unfortunately, many healthcare providers still recommend – even insist on – unnecessary top-ups. And while there are some situations where a top-up is needed, the vast majority of top-ups that are given to babies are totally unnecessary, and do far more harm than good. As a mom, you need to be aware of the dangers of inappropriate top-ups so that you don’t get caught in this trap. We’ll look at the situations in which you really don’t need to give a top-up, the risks and dangers of giving top-ups, and finally we’ll also look at those rare situations where a top-up may be needed and how you should handle it.

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Some dodgy reasons for giving top-ups

Not too long ago, I wrote a post on the false alarms that make women think they have low milk supply. These same things are often used as reasons for giving top-ups. They include:milk supply false alarms infograohic

  • Baby wants to breastfeed “too often”
  • Baby cries a lot
  • Baby does not sleep for long periods and wakes up a lot at night
  • Baby is not settled at the breast and is difficult to feeds.
  • Baby sucks on his hands
  • Mom can’t express any milk (or only a little bit)
  • Mom’s breasts are soft and floppy
  • Mom doesn’t feel a let-down in her breast; or she used to feel it but doesn’t anymore
  • Mom doesn’t leak milk
  • They gave the baby a bottle and he gulped it down

 

If any of these are your worries, please go back and read the original post to get reassurance that you probably don’t need a top-up! And while you’re at it, have a look at this post which explains exactly how you can know that your baby is getting enough milk.

One time where top-ups are especially common is in the first few days, before the milk starts to increase. Many moms, even many healthcare professionals, struggle to believe that the small volumes of colostrum can be enough to meet a baby’s needs. The mistake they make is in not realising the uniqueness of colostrum: it is an extremely concentrated source of nutrients, and is perfectly designed to meet all baby’s needs in minimal volumes. If you want more information about colostrum, check out this post.

So why are top-ups so common? I have a few theories. I think we’ve become so used to formula-fed babies that we no longer understand how breastfed babies normally behave (e.g. frequent feeds). So when our breastfed babies act like, well, breastfed babies, we panic and try to make them fit the formula-feeding pattern – and that’s impossible to do without top-ups (because it’s not normal for breastfed babies to go so long between feeds! See what I’m getting at here?) I also think in some cases it’s because we’re such a scientific society. We are distrustful of things that we can’t measure, and the “trust your body and follow your baby” philosophy of breastfeeding just seems to be too airy-fairy and outside our control (It seems that men and medical specialists are especially prone to this). In the end, it all boils down to living in a society where the scientific has become normalised, and we have lost our intuitive sense of how our biology works.

Risks of giving top-ups

Even having said all that, many parents and healthcare providers still wonder whether it’s really that bad to give a top-up – you know, just in case baby is still hungry. Surely it can’t hurt?

Actually, the truth is, giving an unnecessary top-up can do a great deal of damage, as I’ll explain in several points below.

Milk supply

Perhaps the biggest risk of top-ups is that they can lead to a decrease in your milk supply. Milk production is regulated in such a way that the amount of suckling your baby does at the breast determines how much milk you produce (see this post for the details). Any time you are giving a top-up, it means that baby is not suckling at the breast, and your milk supply will not be stimulated. If this happens a few times, your milk supply will no longer be keeping up with your baby’s needs – and in this way a top-up can actually cause you to develop a low milk supply even when your supply was initially fine. This is called the “top-up trap.”

Now, at times it can feel like a top-up is really, really necessary, when your baby wants to breastfeed non-stop for hours on end. This commonly happens during the first few days, during growth spurts, and for a while every day (this is called cluster feeding). It is extremely important that you just continue to breastfeed as much as baby wants during these times! Your baby is suckling more often to increase your milk supply, because his needs are increasing. If you give a top-up at this time, your breasts will not know that they need to increase their production, and before you know it you’re no longer making enough milk.

top-ups - the trap

Nipple confusion

Another big problem with top-ups is that they’re usually given with a bottle. Whenever a breastfed baby is given a bottle, you run the risk that baby will learn to prefer the bottle over the breast and eventually reject the breast altogether. This happens simply because drinking from a bottle requires virtually no effort, while at the breast baby doesn’t get milk unless he sucks. If you don’t want to stop breastfeeding, be very wary of bottles.

Illness

One of the biggest benefits of breast milk is that it contains immune factors that destroy any illness-causing germs that your baby may ingest. Breast milk is absolutely unique in this regard – there is not a single other foodstuff that offers this advantage. So whenever you give a baby anything other than breast milk to drink, you are diluting this illness-fighting power, and the risk that baby will get sick increases.

Effects on baby’s gut

Top-ups of anything other than breast milk also have a significant effect on baby’s gut. Now, the gut may not seem like such a big thing, but science is learning that the health of your gut affects the health of all the rest of your body. Take the fact that your gut contains more nerve cells than your brain – what on earth are they all doing over there? It’s also interesting to note that a huge portion of your immune system is actually situated in the gut walls. Clearly, your gut is your first line of defence against illness. Dietitians working in ICUs have long known that if you keep the patient’s gut healthy, he has a much better chance of survival. We don’t know exactly how the gut influences our health, but it is clear that its influence is dramatic.

Your gut is also home to billions of bacteria (fun fact: you have roughly 10 times more bacteria living in you that you have cells in your body – so your bugs outnumber you!). More and more new research is showing that the type of bacteria that live in your gut influence your health in a myriad of ways – not just for intestinal diseases like colic and IBS, but for things like diabetes and heart disease and mental health. And one thing has been shown consistently: exclusively breast-fed babies have a very different population of bacteria in their gut than non-breastfed babies. And the scary thing is, even small amounts of formula can change the gut bacteria to less healthful types. All in all, it’s not worth the risk to tamper with his delicate system. (If you’re interested in reading more about this topic, click here for an excellent article by The Alpha Parent).

Allergen exposure

If you give your baby formula, you’re exposing him to potentially allergy-causing proteins. A baby who’s at risk of allergies will be more likely to develop an allergy if they are exposed to foreign proteins (such as those found in infant formula) early in life rather than later. Ironically, infant formulas are generally made from two of the most allergenic proteins out there: cow’s milk and soy. I’m not saying that exclusive breastfeeding will prevent your baby from ever developing an allergy, but earlier introduction of proteins other than breast milk certainly seems to increase the risk of allergies, and of developing allergies earlier.

Poor growth

Finally, babies who are given top-ups may not grow well. This is not so often a concern with formula, but babies who are given anything else (water, tea, juice, cereal…) before six months are at significant risk of malnutrition. And even formula top-ups are not exempt from this effect: I cannot tell you how many growth charts I’ve seen where the baby was growing beautifully on breast milk, and the moment mom introduced formula, the growth slowed down. The fact is simply that nothing, not even formula, is as perfectly suited to growing baby humans as breast milk is.

When a top-up is truly needed

Having said all that, though, we must face a simple truth: there are times when a top-up really, truly is necessary. In cases where a child really is not getting enough breast milk to meet his nutritional needs, we have to give top-ups. The first rule is always to FEED THE BABY – no potential health risk is so important that a baby should be allowed to starve!

It may surprise you to know, however, that “give a top-up” doesn’t mean “give formula”. In fact, the best choice of infant feeds (as explained by WHO) is as follows:

  1. Breastfeeding
  2. Mom’s own expressed breast milk
  3. Donor breast milk
  4. Formula

So formula is only a fourth choice! Granted, donor breast milk is not generally available outside of an ICU setting, but even so your own expressed breast milk should be your first choice for top-ups. Formula should never be suggested without first exploring the possibility of expressing your own breast milk.

Which babies may need a top-up?

  • Babies who are unable to suckle from the breast effectively. This can include premature babies, babies with oral abnormalities that interferes with effective suckling and babies who are so drugged from pain medications used in labour that they have no sucking reflex. In all of these cases, expressing breast milk is ideal, both to get milk for the baby and to stimulate milk production in mom.
  • Any case where it has been confirmed that the baby is not getting enough milk to sustain normal growth. In this case it is so important to work with a Lactation Consultant or similarly qualified professional, to determine whether you need a top-up or just improved breastfeeding technique, and to help you decide whether it is necessary for formula to enter the picture. Also read this post on ways to increase weight gain in breastfed babies.

A few more things to keep in mind

A top-up should ideally always be a temporary measure while you work on sorting out the underlying problem. To ensure that baby will be able to get back to exclusive breastfeeding as easily as possible, you can do the following things:

Choose your feeding method carefully: As I mentioned earlier, using bottles can lead to complete breast refusal. If your baby is under 6 weeks old, or if there is any kind of suckling problem, I strongly suggest that you avoid using a bottle and rather feed with a cup: you can read how to do that here. If you do use a bottle, it is very important that you use paced bottle feeding to minimize the risk of breast refusal.

Protect your milk supply: Because top-ups pose such a significant risk to your milk production, you need to take steps to ensure that you do not lose your milk. The simplest way to so this is to pump every single time when you give a top-up. Bonus: you can use the milk that you express to feed your baby!

Get professional support: Get help from a Lactation Consultant or other appropriately trained medical professional who can help you to monitor your baby’s intake and feeding skills, as well as your milk supply. Just be aware that nurses, doctors and even paediatricians are not trained in how to do this – you need to find someone who is trained and experienced in breastfeeding.

If you get the right help and take the appropriate precautions, a period of giving top-ups need not mean the end of your breastfeeding journey.

Recap

So, let’s see if we can condense all of that in nutshell:

  • In mind that in the majority of cases, top-ups are unnecessary. There are many false alarms that can cause you to give an unnecessary top-up even though you have enough milk. Do your homework first!
  • Top-ups can have significant negative effects:
    • It can decrease your milk supply
    • It can cause baby to refuse the breast
    • It can increase baby’s risk of illness, allergies and malnutrition
  • Sometimes, when baby truly can’t take in enough milk at the breast, top-ups may really be necessary. In these cases, it is wise to
    • Always use expressed breast milk as the first choice of supplementary feed
    • Feed baby with a cup, or at least practice paced bottle feeding, to prevent breast refusal
    • Enlist the help of a properly qualified Lactation Consultant or other professional, to help you transition back to exclusive breastfeeding as easily as possible.

Have you ever needed to give top-ups? Were you bullied into giving unnecessary top-ups? Please share your experiences by leaving a comment below!

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