Although mixing formula powder into mother's own milk is a very commonplace practice, it is not a best practice. There are evidence-based and more effective alternatives that allow for exclusive breastfeeding with robust infant weight gain! Today's parents want options, because they are educated on the benefits of breastfeeding, and the risks of powdered infant formula (PIF). Below you will find tools and references to support exclusive breastfeeding along with catch-up infant weight gains.

Please note the following facts regarding the fortification of human milk:

• There is a difference between "Human Milk Fortifiers" - bovine (cow)/corn syrup based, and "fortifier made from human milk" - powdered human milk (like the unicorn, often talked about, but rarely seen).
• Neosure is a 22 calorie per ounce infant formula that is supposed to be used as directed (mixed with water).
• Mixing with mother's milk is off-label and experimental use of this product.
• There is no evidence proving that this product is safe to mix formula with breast milk.
• There are specific breast milk fortifiers designed for mixing with human milk, however the cost is prohibitive.
• When used as directed, Neosure provides only and additional 2 calories per ounce, when compared with mother's own milk.
• Adding this powder to mother's own milk rather than mixing with water as directed, changes the kidney solute load, taxes the infant's kidneys and changes infant electrolyte status. **
• Infants who receive this intervention are at risk for readmission to the hospital for hypercalcemia, dehydration and other sequelae.
• This product, like all commercial infant formulas, lists cow's milk and high fructose corn syrup as the two main ingredients.
• Adding just a little formula powder to mother's own milk does not result in significant augmentation of calories- but adding too much poisons the kidneys.

Research facts on fortifiers in general:

• Breast milk "fortifiers" have never been shown to change infant weight gain vs. mother's own milk, after the infant surpasses 1500 grams (very low birth weight- VLBW).
• Fortifying mother's own milk with powders may result in short term modest weight gain during hospital stay, but does not impact babies long term (see Cochrane Review).
• Studies "proving" safety of fortifier products being brought to market, compare the new product being tested to another formula. There is no control group of the breastfed babies for comparison.
• Short-term above baseline weight gain of preterm babies, although a commonly sought after goal, has never been shown to provide long-term benefits.
• Exclusive breastfeeding to 6 months of age universally decreases infant morbidity and mortality.
• Exclusive breastfeeding does not include formula additives, it is then considered partial infant breastfeeding.
• American culture emphasizes preterm weight gain as an important marker of health, or outcome, but other countries with better infant morbidity rates emphasize exclusive breast milk feeding.
• Preterm intestinal lining is much thinner and more susceptible to damage from foreign proteins and food poisoning particles contained in powdered infant formulas (PIF).
• Liquid formulas which have been pasteurized do protect the infant from food poisoning, but have less impact on weight gain than PIF.

Calorie counting:

• Although studies of human mother's milk show a generalized average value of 20 kcal/ounce, this is only an average.
• Mother's own milk (MOM) is dynamic and responsive to her infant.
• Infant saliva communicates with receptors in the mother's nipple to influence the constituents in her milk.
• The more often the mother bottle feeds in order to fortify her expressed milk, the greater reduction in biofeedback and chemical communication between mother and infant, and the less mother's milk constituents can match infant's current caloric needs.
• Then more mother bottle feeds in order to fortify her milk, the more her milk supply decreases, since no pump can move milk as effectively as the nursling.
• The constituents in mother's own milk differs significantly between premature infants, and full-term and from day-to-day and hour-to-hour.
• Mother's own milk has been proven to increase in cream and caloric value based on infant's needs.

Other proven ways to promote weight gains with best practices supported by evidence-based research:

Infant Massage

Fifteen minutes per day resulted in significant short-term weight gains for newborns (47% greater gains in 10 days) in several well-designed studies and systematic reviews (enhanced vagal activity leading to greater gastric motility, higher levels of insulin, IGF-1, and oxytocin and cortisol levels in the massage versus the control infants at the end of the study; and/or increase in heart rate oxygen consumption and temperature leading to greater weight gain). This best practice is GROSSLY underutilized. See YouTube for lovely instructional videos.

Skin To Skin

This kind of care daily increases milk supply and reduces newborn energy requirements.

Nursing at the Breast

Contrary to popular belief, nursing at the breast, even for preterm infants, DECREASES newborn energy requirements and expenditure. Whereas, bottle feeding INCREASES energy requirements. Newborns don't "tire" at the breast. Feeding time should be limited only for time management purposes, not to support baby!

Swaddling

Do not swaddle infant arms. This results in more frequent waking and feeding, since infants paddle their arms as they wake,

Minimize Pacifier Use

Pacifiers can artificially delay and reduce infant feeding when parents could be missing early hunger cues. Minimize pacifier use and feed the baby more often.

Visitors

Visitors are well meaning but often take away from valuable mom and baby time. Limit visitors to allow frequent nursing, or ask them to assist with errands and chores if they are offering to help.

Probiotics

Infant probiotics influence gastric motility, reduce intestinal inflammation and increase nutrient absorption, and treatment with probiotics is associated with stronger weight gains (standard practice for micropreemies at St. Joseph's hospital in Denver).

Nipple Shield

Introduce a well-fitting nipple shield temporarily if infant is preterm, small for gestational age (SGA) or late preterm (LPT) and if they are not vigorous at the breast to enhance milk transfer (sizes available: 15mm-28mm).

Breast Compressions

Do breast compressions when the baby is at the breast and when pumping to enhance milk output. Do not mess with the baby to make them eat faster, this backfires and prolongs feedings.

Baby Wearing

Wear the baby in a carrier for skin to skin contact and more opportunities to nurse (kangaroo care).

Hand Expression and Cluster Pumping

Occasional hand milk expression and interval/cluster pumping result in great milk output the following week because they cause a greater surge in prolactin which supports the milk factory.

Slow Gains When Mom has Plenty of Milk

Double cream routine (lactoengineering):

• Mother pumps twice in one day, allows cream to separate from one bottle of milk in the fridge overnight.
• Mother can spoon the cream off the top of one bottle, and add the cream to the second bottle
• Heat milk enough to melt the cream so that it does not stick to the sides of the bottle.
• When feeding by NG tube, the syringe should be pointed upwards like a rocket ship, so the creamy fraction of the milk enters the tubing first.
• This "double-cream routine" can be done once or twice a day for a week to accelerate gains in the infant.
• Save the "skim milk" for a hot summer day!


This is an evidence based method that I have had great results with. Case study results can be provided upon request. I encourage medical professionals to research lactoengineering and creamatocrit (info below) for ways to fortify mother's own milk without discontinuing exclusive breastfeeding.

Almost every cause of low milk supply is treatable. Milk Mechanics is available to do low milk supply consults over the phone nationwide, and internationally. 

If you don't know your options, you don't have any!

All of the statements are supported by a myriad of research. References listed in the document below. If you want to know exactly which information is found in each study related to the statements above, or if you want copies of any studies, please contact us.