Re: “ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate,Revised 2017” by Kellams et al. ( Breastfeed Med 2017;12:188–198)

To the Editor:

We read with interest the revised “Academy of Breastfeeding Medicine Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017.” ¹ The authors should be commended for their efforts in updating the evidence and highlighting that appropriate breastfeeding support and management during the birth hospitalization can potentially prevent the need for supplementation. Additionally, they suggest a thoughtful approach when supplemental feedings are necessary, urging clinicians to act as stewards and to prescribe the smallest volume necessary to protect the mother's milk supply. These updates serve as a welcome guide for clinicians and are especially important in our setting here in the United States, where more mothers than ever intend to breastfeed, yet most do not reach their intended goal. ² However, we would respectfully like to share some concerns we have with this revision.

The introductory paragraph on newborn physiology only cites Western studies from the United States and Scotland in describing patterns of newborn weight loss and return to birth weight. The Academy of Breastfeeding Medicine is an international organization and thus we believe that guidelines need to take into consideration the widely varying contexts of newborn care and maternal physiology across the globe. With regard to globally generalizable norms for return to birth weight, please consider reference to the World Health Organization (WHO) growth velocity standards released in 2009. ³ Based on 1,743 exclusively breastfed infants from six different sites around the world (Brazil, Ghana, India, Norway, Oman, and the United States), weight gain percentiles are presented in 1- and 2-week increments from birth to 60 days of age.

Regarding the reference to …97.5% having regained their birth weight by 21 days…, we are concerned that the implication is (intended or not) that a watch and wait approach is appropriate up until this time point. Indeed, this is in contrast to data from the WHO growth velocity tables, where 75% of exclusively breastfed newborns were back to birth weight by 7 days of life. While this guideline appears to focus on conditions that arise during the newborn hospitalization period, and since the timeline covered by the guideline is not well defined, we suggest including insufficient weight gain as a relevant indication for possible supplementation after hospital discharge.

We are pleased to see the protocol's emphasis on facilitating a postdischarge follow-up plan when supplementation is initiated, but we believe this follow-up is just as important, if not more so, where indications may not presently warrant supplementation, but when the newborn's weight loss has not yet plateaued. In the context of settings with high rates of maternal obesity, gestational diabetes, or other risk factors for insufficient milk production, we believe it is prudent that close follow-up is indicated for weight checks and reevaluation of supplementation indications until the infant is gaining within WHO growth velocity norms and a stable feeding plan is in place.

The hospital experience can be critical to achieve successful breastfeeding outcomes, and consistent adherence to evidence-based guidelines can help standardize the approach to supplementation, decrease variation, and reduce unnecessary formula supplementation. However, it is important to acknowledge emerging evidence that the proportion of mothers who are unable to achieve exclusive breastfeeding, despite their best efforts, may indeed be greater than the often-cited 3–5%, particularly in the context of settings with high rates of maternal risk factors for insufficient milk production. ⁴ Unfortunately, we do not yet know what this proportion is, but accumulating research is challenging the old paradigm. We recognize that it is extraordinarily difficult to find the right balance in this type of guideline. However, we feel there should be equal emphasis on removing barriers to exclusive breastfeeding and realistic expectations for mothers who are at risk for insufficient milk production.