Fortifying breastmilk with formula

[MoMuM7]

DD was very low birth weight due to undiagnosed IUGR though born full term. His weight gain has been slow and I'm worried to bits. I've been advised by HV to fortify my breast milk with powdered formula to increase caloric intake. Have you done this and what was your experience? How many bottles a day did your offer and how did your LO react? Any allergies, what brand of formula did you use? I was hoping to EBF but I'm desperate for DD to get all the calories she needs.

When you say fortify, do you mean adding in formula top ups?

Has the HV advised top-ups after doing things like speaking to a BFC or a Lactation Consultant about the slow weight gain? Have you tried one of the BFing Helplines? They can advise you on the slow weight gain and also formula top ups.

The only reason that I'm asking is because formula top-ups shouldn't be the first thing to try, it should be the last

Have a read of this from Kellymom and do think about calling one of the BFing Helplines this morning. The earlier you call, the more likely you are to speak to someone.

There is specific powder sold as breastmilk fortifier, I don't think it's meant to be done with ordinary formula.

Could you double check with a doctor? Are you under care of a consultant or paediatrician? I am not sure I would do this solely on the advice of a health visitor, as it essentially amounts to (extremely) underdiluted formula and that is risky to newborns because it considerably increases their intake of sodium and other nutrients which should be carefully balanced. I would (unfortunately) also worry that the HV might be misinformed about breastmilk, so I'd want to double check.

It might be appropriate to use a fortifier though because of the baby being IUGR, and honestly, I don't know if normal formula is ever used as a fortifier, so I would be really wary in general of advice on internet forums. The previous post, while well meaning, is more tailored for a term baby of normal weight.

Basically get medical advice. Experienced BF support or specialist qualified doctors.

I've been BFing then topping up with expressed breast milk. It's those Top ups that HV wants me to add powdered formula to add extra calories. DD seems to BF well, her latch has been checked but v slow weight gain hence my confusion 😕 I'll try adding an extra feed as Kellymom suggests

My concern has is the nutrient concentration too. My paediatrician seems very relaxed about the whole thing as DD is feeding well and has got lots of wet nappies. He insists I'm doing everything that will help DD gain weight but when?? It's been weeks of tests and appointments but no concrete reasons why there hasn't been an improvement.

Are you under a specialist due to the IUGR? Is DD on a normal centile now or is she still below the bottom?

Adding more breastfeeds can't hurt so I don't think that's a bad idea to try.

OK, I'd listen to the paediatrician over the health visitor. If he is relaxed then probably she will catch up. When you say weight gain is slow, what are you basing that on?

She's still at the 2nd percentile but GP and paediatrician don't think she needs anymore help as shes following her line. They seem to think I'm impatient. Am I?? I thought anything below 5th percentile was FTT.

Are you tall or short? The baby's father?
What ethnicity are you? And which country are you in?

These all affect how big your baby is, and how fast they gain weight. If you are ethically from India in the USA all their standard growth charts will be way too big & fast.

Is baby doing a poo each day? Are you feeding on demand? None of this 'every X hours' just feed feed feed. The more you breastfeed the more milk you will produce. Drink more water and feed baby more.

Adding formula runs the risk of decreasing your supply.

Offer breast more often. If she’s following her line and getting wet and dirty nappies, I wouldn’t interfere.

Make sure your diet is full of delicious things and vitamins.

Listen to your GP and paediatrician. They have more knowledge than your HV.

2nd centile is a normal line for a baby. All the lines on the growth chart are expected development for a healthy normal baby. Just keep feeding; nothing appears to be wrong, and doing the fortification thing would be an added risk from where I sit.

Please listen to your doctor and paed. If gaining, however small, and lively and wet nappies then all is going well. Someone has to be at the 2%, that is the whole point. One of mine was 99% and I was made to feel bad but that was where he was destined to be. He is now 6ft 8 despite both his parents being a normal height. He grew alongside the 99% , if your dc is growing on the 2% it is where she should be.

Obviously if she starts losing weight or refusing feeds, not having wet nappies then look to change but you are doing the best for her.

My DD was suspected IUGR (officially SGA) and we did formula top ups. I would ALWAYS offer the breast first, let her have up to 40mins feeding, then top up after each feed with 45ish ml formula. No special formula - just cow and gate.

It was clear that my DD wasn't doing well on bf alone as she was dropping down the centiles (to below 0.4 at one point) and our neonatal team were supportive of top ups. I also found topping up very reassuring to know that DD wasn't starving. But if i knew she was staying on her curve on bf alone, then i def wouldn't have bothered as it was a faff.

How are your HV, GP and paeds team working together? Does HV know what paeds is saying? My HV was amazing and I would update her after seeing GP or neonatal team so that she knew what was going on. But just a quick read of MN threads tells me I've been very lucky. I echo pp above that if the paediatrician is happy, then keep doing what you are doing.

You will get through this. After weaning, my DD went from 2nd centile to between 25th and 50th (more in line with her height which is 75th) so it doesn't mean your baby will follow the 2nd curve forever either.

Your baby isn't starting from same point others are, so if she's following the 2nd centile, that's good. A lot of low birth weight babies will trail under the bottom of the chart which is a concern.

2nd centile just means she's bigger than 2% of babies her age. That's no small feat! Following the line is exactly what you would expect and want her to do. It's not that you're meant to aim for 50th.

Please don't t take feeding advice from a health visitor, they are not qualified to give it. Certainly not in contradiction to a paediatrician.
You can't safely add formula powder to breast milk anyway. Formula needs to be made as per the instructions with water, at a high temperature to kill bacteria.
Breast milk is more nutritious and similar in calories to formula so the advice makes no sense anyway.
Feed on demand, use expressed top ups if it's working for you and listen to the paediatrician.

I'd follow paediatric and gp advice not the health visitors

No no no. Do not add powdered formula to ebm. I work on nicu and we would NEVER do this.
Breast milk fortifier is a separate powder that is available from a dietician.
Adding in powdered normal formula risks knocking off your babies vitamins, mineral and electrolytes.

Take the paediatrians advice. Health visitors are very poorly trained in infant feeding.

Thank you all for your words. The anxiety I've felt towards DD weight gain has been awful. My DS was born at 80th percentile for weight and 85th for height and is still at that line age 2 hence HV's concern for DD. I'm 5'7 and DH is 6'0 but we're slight people so maybe that where my little girl gets it from.

Will definitely stay away from the formula and stop seeing HV. She was brilliant with DS but v overbearing with DD.

To any medical professionals out there, why is there conflicting info about using regular formula as a fortifier? There are so many medical journals from reputable universities about the benefits of the practice online. I only posted here because I found ONE article warning against potential chemical imbalance and deep down I didn't want to introduce DD to formula. Horrified that i was so close to doing something that could have harmed her.

A BFC on the Helplines should be able to talk to you about the safety but I think there was a HPC further up who explained why it wasn't safe?

I wouldn't mix formula and breast milk.

Formula needs to be made up in a specific way to make sure the calorie content is right and the hot water removes any bacteria.

I would breast feed as much as possible but give a bottle of formula separately here and there if it's necessary.

Formula needs to be made up as on the box. Adding a scoop to a random amount of breast milk feed isn't going to ensure the calories, salts etc are properly distributed if you see what I mean. The concentration of the milk/formula mixture won't be right. It's the same principle as adding water to powder instead of powder to water, the concentration is wrong and can affect the baby's electrolytes and hydration.

Human milk fortifier is usually mixed 1 sachet to 25mls of milk and it's made for this purpose so it had the correct amount of iron, salts etc. Whether fortifier is needed generally depends on birth weight and weight gain. We give it to babies born under 1.8kg who are exclusively on breast milk. We usually stop giving it before a baby is discharged, very few need it at home unless they are not gaining weight.

Fortifier also comes in individually sealed packets and doesn't need to be added to hot water whereas formula needs hot water to kill off any bacteria.

Basically they are totally different substances. If it was as simple as adding a scoop of formula then nicu's would do it as it would save a lot of money but it's not the same stuff at all.

I would not just add formula to EBM. If a baby really is failing to thrive especially with extra feeds then push to be referred and seen by a peadiatrician.

If a baby is plunging down through the centiles or who loses 10% of their birthweight then that is a baby who needs to be seen by a specialist peaditrican for a check up. In most cases its just a scary blip but sometimes it can point to a baby who needs more help. If its a much smaller dip that begins to pick up that may be down to the demand of the baby being greater than the available breast milk BUT in most cases your body quickly supplies to meet the extra demand for more milk. My DD was born well under the 0.4th and then dropped off the scale losing 40% of her birthweight. It was a very scary time.

She was under specialist dieticians and peads at BCH. She HAD to have fortified breastmilk as extra feeds did not help and she would NOT accept formulas. She just threw it straight back up - however she was prescribed a mix of maxijul500 [soluable form of dense energy rich] which she loved and a liquid protein fortifier [peanut oil based cannot remember which one as the dietician stepped in and took it away due to her brothers peanut allergy] that was quickly swapped for pepti-junior which she absolutely hated. In the end it was extra maxijul followed by a dietician supervised calory dense weening diet that helped her hit over 10lb for her first birthday

She had to be fed every two hours just to survive. It took weeks before she started to gain a whopping 10g. It was a pain to express, fortify then syringe feed it back. If she could have had a top up botle of made up formula my life would have been easier but she continued to lose weight even when that was tried. DD found it easier to suck the end of a syringe to begin with. I found the support from le leche league the most helpful as they had a specialist who could advise on IUGR followed by severe failure to thrive and in keeping breastfeeding going with such a teeny baby.

Hope you baby begins to thrive soon. Wishing you both the very best.

@triballeader thank you for sharing your story. It gave me much needed perspective for thr long term. I was feeling disheartened today as DD was weighed and it was another dip on the charts. I'm definitely going to check out La Leche. I'm breastfeeding as much as possible and supplementing with expressed BF but the more weight DD loses the more tempting it is to just give her the bottle as then I can atleast measure how much she's taking in...

@fairgame84
Really appreciate your insight. HV sent me a YouTube video of a US based person (not sure what their qualification is) mixing formula with breastmilk to justify her recommendation 🤔.

I'm going to ask for a referral to a dietician to discuss what my options are as DD has lost weight again and ask if the human milk fortifier is worth trying.

I really think you need to consider putting in a complaint against your health visitor. That advice is scary and could cost a child their life.