What SHOULD Happen When a Mother Who Planned to Breastfeed Asks for Formula

“The best laid plans…”

Things don’t always go as planned for moms who enter the hospital with a goal of breastfeeding their infant. Sometimes the mom and baby initially struggle with breastfeeding.

Some popular social media videos have recently put forth some inaccurate information on this subject and BFUSA would like to set the record straight. We discussed the issue with Paula Schreck, MD, IBCLC, FABM. Dr Schreck is the Medical Director for Breastfeeding Support Services at Ascension St. John Hospital in Detroit, Michigan. She is a veteran breastfeeding practitioner with extensive experience implementing Baby-Friendly.

“More than 80 percent of families intend to breastfeed, but a much smaller percentage, around 30-40 percent, actually reach their breastfeeding goals. That’s a huge gap.” says Dr. Schreck. “We know that sometimes to reach your goals, you need encouragement and support and validation from an external source. Encouragement goes a long way, especially in times of vulnerability.”

So, what SHOULD happen when breastfeeding doesn’t initially go as planned and the mother asks for formula?

“The first step is a conversation,” says Dr. Schreck. “I teach providers and staff that at moments like this, they should go into ‘deep listening mode.’ That’s when we truly listen to the patient with empathy, using terms like ‘Go on,’ ‘Tell me more’ and ‘Please continue’ to really get to heart of the issue. We reflect back and check in and make sure that we understand what the patient is telling us. And we repeat the cycle until we’re both in agreement as to why the parent is requesting formula.”

Dr. Schreck says it’s important to remain open-minded and curious during this process.

“A lot of requests for formula have to do with cultural practices,” she says. “So again, we’re back to listening to gain a deep understanding of what’s behind the request.”

“Staff also need to pause and make sure that they are not acting under the influence of bias — racial, social or the ‘bias of low expectation,’” she says, noting that Black and brown families are offered formula more frequently than their White counterparts.

This is also an opportunity for the practitioner to address any misperceptions that the parents may have.

“For example, many working parents believe the infant should trial formula as early as possible, just in case formula is needed during separations, but that is not the case,” says Dr. Schreck. “There are no benefits to early formula introduction as far as tolerance, and there are many benefits to exclusive breastmilk in the first days of life.”

Once the practitioner and patient have a shared understanding of the situation, it’s time for a full assessment of the infant.

“Parents are concerned about their children – and they should be,” says Dr. Schreck. “We can help reassure the parent with our expert assessment. We either validate their concerns or illustrate why their concerns may not be as urgent or potentially dangerous as they fear. For example, with perceptions of low milk supply, it may be helpful to point out that the infant’s physical assessment is normal, that the infant has not lost excessive weight, has stable vital signs, and has adequate output.”

Of course, appropriate interventions are triggered if the assessment leads to specific medical indications. If there are no medical concerns discovered in the infant, the practitioner should work with the parent to address any physical/medical difficulties they themselves are experiencing. For example, if the mom is complaining about pain, the staff can work to reduce this discomfort.

What do we do if all the above steps have been taken and we have appropriately counseled parents who still want to give formula?

“At that point, it’s important to ask if the parent is specifically requesting formula or if they are more generally requesting supplementation,” says Dr. Schreck. “Those are two different things.”

The mother should be made aware that there are options for supplementing with human milk. Dr. Schreck points to a Policy Statement recently issued by the American Academy of Pediatrics, which supports the use of pasteurized donor milk for term infants, as evidence that this option has become more widely accepted and practiced.

“The staff can help facilitate pumping or hand expression of the mother’s own milk, or a lot of facilities now offer pasteurized donor milk,” she says.

If the mother decides on formula, what do we do then?

“Once the staff is satisfied that the mother understands all of the options and has weighed the potential risks associated with formula feeding, we honor the request,” Dr. Schreck says. “And we document that we had a conversation and that this was the mother’s decision.”

“But we also make it clear that this doesn’t have to be a lifetime decision,” she says. “Let’s use formula for this feeding and see how it goes next time. We’ll continue to support the mother and maybe in the light of day, things will look and feel different.”

What about the belief, which has been propagated on social media, that parents who decide to feed their infant with formula are required to complete a consent form?

“That’s not in the Baby-Friendly guidelines,” says Eileen FitzPatrick, BFUSA’s Chief Executive Officer. “Step 6 in our Guidelines and Evaluation Criteria requires only that a staff member have a conversation with the mother about the potential consequences to the health of her infant, and then document that conversation and the mother’s infant feeding decision in the patient’s medical record. It’s possible that some facilities use consent forms as a way to ensure consistency in documentation, but signed consent is not a requirement of the Baby-Friendly Hospital Initiative.”

In fact, Dr. Schreck says that, at this point, she believes consent forms are “very rare.”

“Baby-Friendly doesn’t require anything be signed by the patient,” she says, “but the efforts to educate need to be documented.”

What about the notion that this process puts undo pressure on the parents?

“This is not about pressure; this is about encouragement,” says Dr. Schreck. “We need to set realistic expectations of the maternal experience. Infants cry a lot. New mothers experience pain and frustration and fatigue. They need support and encouragement to reach their goals.”

“Education and encouragement should not create pressure or guilt. They should provide knowledge and prevent regret,” she says.