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.

top-ups title

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.


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.


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!


  1. Tlhalefang

    Does everything that I eat go to my bby through breast milk even if its not tht healthy like fried chips,tea &bread and others?

    1. Sanja (Post author)

      Not exactly – your breast milk is healthy even when your diet isn’t. But eating heathy is very important for YOUR health! Have a look at this post for more info: http://loveandbreastmilk.com/wp/eat-while-breastfeeding/

  2. Mel

    I had to top up with formula from 3 weeks old because my baby stopped gaining weight. I had low supply and she had IUGR so was very small and never managed to get a nice wide latch. She is now 10 weeks old and all the things that you have warned about in this post have happened! I have nearly no milk it seems and she nurses for only a few minutes before refusing so I am giving more and more formula. Is there any way to reverse this??

    1. Sanja (Post author)

      Sorry to hear you had such a rough start . I think the first thing you need to focus on is building your supply again – look at some of the tips in this post: http://loveandbreastmilk.com/wp/increase-milk-supply/. Power pumping should help a lot. Whatever you pump, give with the bottle instead of formula. Be sure to always use paced bottle feeding, even for formula (see http://loveandbreastmilk.com/wp/paced-bottle-feeding/). Also consider using a nursing supplementer to coax baby back to the breast.
      But at the end of the day, please don’t beat yourself up – you did the best thing for your baby that you knew how to do at the time, and that deserves praise!

  3. jovana

    Is top our of breast milk the same issue? I am currently topping up expressed breast milk after every feed, and the amount the baby takes varies. This seems to settle him quickly.

    He is 13 days old and born 2.4kg at 38 weeks. The latch looks good and he feeds on the breast for 20-1 hour depending on how tired he is.

    I tried stopping the top up for a few days and then he started to become very unsettled and nursing took a long time. He is doing wet nappies after every feed though..

    1. Sanja (Post author)

      Because you’re still giving breast milk, your supply shouldn’t suffer, because you’re pumping for the top ups. The biggest risk is that baby will start to refuse the breast because the bottle is less effort. Be sure to do paced bottle feeding to prevent baby refusing the breast.
      It sounds as if your baby might not be suckling optimally – a lactation consultant could check that out for you and give you some help to get him suckling well enough that he can feed only from the breast. Depending on the problem, it may either improve or get worse with time.

      1. Jovana

        Thanks so much Sanja, I am hoping this isnt the case.. he seems to be just content with a top up. Will definately book a lacation consultant appointment and see what the issue is!


  4. Rebecca

    I felt slightly pressured into giving a top up of formula by my mum and sister. They were making me paranoid that my baby was hungry. Even though he was growing well. At 3 months I slowly introduced one formula feed in the evening but it has made no difference to his sleep or behaviour. I’ve only been doing it for a week and regret it now. I think he actually sleeps worse! I fear I have ruined his gut bacteria. It took my breasts a couple of days to adjust to missing one feed.
    Is it possible to go back to just breast? Will my supply readjust quickly. Also will his tummy bacteria recover?
    I tried expressing but only literally got a few drops out.
    Many thanks

    1. Sanja (Post author)

      Hi Rebecca. I would suggest just putting him straight back on the breast; your supply should catch up again in a day or two.

  5. Jess

    I got told by a baby doctor to give top ups to my 4 day old because she had lost 11% of her birthweight.. i was using the bottle to top up her breast feed on about 2 of her feeds in the evening for 2 or 3 days.. her weight is now up and i decided today to put the bottles away and just exclusively breatfeed (now 8 days old) she seems very fussy at the breast and a bit unsettled after feeds as if not quite satisfied.. is it just persiverence at this point? Do you think my milk has already taken a hit and is it reversable..?? She hasnt had a bottle top up since yesterday evening and it was always after 30 min feed on each breast. Any tips for fussy latchers?
    Thanks in advance.

    1. Sanja (Post author)

      Hi Jess. If your baby had to get top-ups due to poor weight gain, I would recommend you monitor her weight very frequently (like, every 2-3 days) when you discontinue the top-up to make sure she is getting enough milk. If she doesn’t manage to gain weight well without the top-up, it’s possible that there is some sucking issue that prevents her from transferring milk effectively – the best person to check this out would be an IBCLC/SACLC or a speech therapist who’s experienced in infant feeding. If you do need to continue a top-up, I would recommend you use pumped breast milk instead; it will protect your milk supply and also be better for baby nutritionally. Also, if you do need to give a top-up be sure to use paced bottle feeding:

  6. Mantsho Rantsho

    I have just recently gone back to work after being home for 4 month and exclusively breastfeeding. I am a bot worried as the milk supply i had managed to express is disappearing faster than i can express now that i am at work and my baby will not have any milk when i am at work. i am also expressing less than what i used to, +-100ml from both breasts, im not sure what is causing this. i breastfeed baby as soon as i get home as well as evening and morning. i do not want to stop breastfeeding and i will continue expressing but i also do not want baby to starve as she is not picking up much weight. Can i let her have the little expressed milk and then top that up with formula during the day and then breastfeed like i have been doing until my milk increases?

    1. Sanja (Post author)

      What you’re describing is not uncommon. Of course you can top up with formula if needed; please don’t let baby go hungry! Also look at my post on how to pump more milk for ways to increase your milk production: http://loveandbreastmilk.com/wp/pump-more/

  7. Sneha

    Hello…my baby’s birth weight was 2.6 kg….now he’s 43 days but weighs only 3 kg…. is it a serious condition? He’s otherwise quite active…but sometimes unable to find out a reason as to why he cries ….producing around 8-10 wet nappies per day…passes stool once or twice every 5-6 days…blood , physical examination and echo tests are normal…im exclusively breastfeeding him every 2 hours except in the afternoon and night when he sleeps…kindly give your valuable suggestions…im very tensed

    1. Sanja (Post author)

      A weight gain of only 400g in 6 weeks is concerning; at this age you would expect a baby to gain around 900-1800g in that time frame. I would suggest you see a lactation consultant or dietitian to do a weigh-feed-weigh, so that you can find out how much baby is actually getting out of the breast during a feed. It could be that his suck is not well co-ordinated or strong enough, so that he’s not getting enough milk out in each feed. A lactation consultant will be able to assess that. It could also be that there’s a milk production problem on your side for whatever reason. I really suggest you see a lactation consultant for an in-person assessment. If there’s no feeding problem, and you’ve determined that baby is definitely getting enough milk, then there could be another medical problem causing the poor weight gain. Either way, you should get it checked out.

  8. brenna

    my health visitor advised me to start giving top ups at 3 weeks old as my baby was not gaining weight properly, was not producing the expected amount or type of stools, and was coming off the breast screaming in hunger despite my best efforts to feed him on demand (every 45 mins at that point)
    he’s 4 weeks now and i always feed him from the breast first before offering any formula (around every 1.5-2hrs), i never use it to replace feeds. he also only nurses from me throughout the night, never a bottle. my supply is not increasing, and when i pump, i only get around 10ml total (regardless of when i pump – straight after feeding, an hour after, morning, afternoon etc).
    breastfeeding support have watched me feed him and, although he had latch issues to begin with, he is now suckling correctly, and yet my supply is still not increasing with the demand and my baby now wants more formula as a result.
    is there anything i can do??

    1. Sanja (Post author)

      It sounds like their may be a problem with producing milk on your side. This can have various causes, many of which are treatable – for example, problems with thyroid hormones can cause low milk supply. I would suggest you see a lactation consultant or a doctor who is very familiar with the causes of low milk supply to figure out what’s wrong and make sure you manage it correctly.

  9. Shilpa


    I just gave birth to a newborn baby and on day one my midwife suggested top up feed as she felt I have low milk supply and my baby is crying all the time. Now she is 7 days old and my milk supply is low I think. Because after each feed she is unsettled and wants formula feed. What can I do to get my milk supply back or is it too late.


    1. Sanja (Post author)

      Congratulations with your new baby! The good news is, it’s never too late to work on increasing your milk production. Here’s a few tips that may help: http://loveandbreastmilk.com/wp/increase-milk-supply/. I’d recommend you try see a lactation consultant who can work through the process with you and also monitor your baby to make sure she is getting enough milk. All the best of luck to you!

  10. Milkias

    Hi Sanja
    Thank you so much for your depth explanation. It is so helpful specially for the fresh parents, our child is 7 weeks old boy and by the strong suggession of the docters he was getting his top-up by the second day with with 30 ml and we continued that fir for weeks and we stoped by the end of the 4th weeks and we brest feed him for one week and we started the top-up again by the 5th week two times a day with 120 ml and his tomy upsets a lot!!! And less sleepy what can we do please?

    1. Sanja (Post author)

      Hi dear. It’s difficult to answer your question without seeing your baby, but here are some thoughts.
      First off, does your baby really need the top-up? If he gains weight okay without it, I would leave it. The formula may be causing the tummy upset, especially since it’s a pretty big volume to be giving on top of breastfeeding. If baby really does need the top up (i.e. does not gain weight without it), I would suggest (a) trying to top up with expressed breast milk rather than formula, and (b) splitting it up into several smaller top-ups, say 30-40 ml, and after a breastfeed.
      As for the sleeping issue – that is very common at this age. It is related to baby’s neurodevelopment, not to his feeds. Babies sleep less as they get older, and at certain times when there’s a lot of brain development going on, they sleep more poorly at night. The best thing to do is just to roll with it.
      Hope that helps at lease a bit.

  11. Evan Smith

    Our baby lost 9.5% of its body weight in the first 24 hrs . She latched immediately out of the whom and fed well. Pooped 4 times in the first 24hrs. When the blood sugar read 2.2 they put us on top up formula. We were pumping after the feeds and getting anywhere from 8-20 ml of colostrum. The baby started to gain weight on day 3 and blood sugar was at 4.7 when we were discharged. They want us to continue topping up with formula. Which now reading this article has me concerned.

    1. Sanja (Post author)

      Considering the volumes of colostrum you were expressing (which is a LOT, by the way), i really doubt if there is a milk production issue. I would leave the top-ups and monitor baby’s weight gain. If baby continues to gain weight, great stuff, problem solved. If not, try topping up with expressed breast milk instead, and see a lactation consultant or La Leche League leader to try and figure out why baby is not effectively transferring milk from the breast.
      Best of luck on your parenting journey!

  12. Lauren

    My baby is 5 and a half weeks and we had to use formula as her weight dropped by over 12% in the first few days. Her latch has now improved and we are now exclusively breastfeeding and expressing. I have a routine going of pumping in the morning and using this (normally about 100ml) to top up feeds during the night as sometimes she doesn’t go to sleep after a feed and is rooting and anxious and a 50ml too up settles her. Is this a bad thing to do? Is it forming a bad habit? She normally sleeps between 1.5-2.5 hrs at night between feeds if I have a backup of expresses milk.

    1. Sanja (Post author)

      If it’s working for you, I don’t see a problem, as long as you keep two things in mind: firstly, use paced bottle feeding so that baby doesn’t develop a preference for the bottle over the breast; and secondly, you should let baby breastfeed before the top-up to protect your milk production. As long as you do those two things it should be fine.

  13. Sara

    Thank you for the very helpful article. I wonder if you have any thoughts on my situation. My baby is 4 and a half months old. He was quite a terrible latcher and difficult to breastfeed but we persevered and he finally got the hang of it. He was exclusively breastfed and was growing fine and nearing 6kg at the beginning of September (he was born 2.5kg). However, for the last month I’ve been noticing that during some feeds he would get very fussy at the breast, unlatching and then relatching many times, especially in the evening or when the gaps between feeds were shorter. I wonder if it could be my milk supply (he doesn’t seem to have the issue in the morning or when my breasts are fuller). I also started to top him up with some let down milk, but I can only get about 50-60ml tops a day and that doesn’t seem to satisfy him. Even so, he’s gained only 200g in the last 3 weeks… Have also tried to give him some formula on top of that, but don’t really want to go that route…

    1. Sanja (Post author)

      Four months is a common age for “fussies” that are not related to feeding – have a look at this: http://loveandbreastmilk.com/wp/four-month-fussies/
      Also keep in mind that weight gain slows down as babies get older, and 200g over 3 weeks is well within the normal range for a 4-5 month old baby, according to the WHO Weight Velocity standards (it plots between the 25th and 50th percentile). I would suggest you consult a knowledgeable dietitian/LC in person before making any drastic changes.


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