How to Supplement with Formula (ELF), and Breastfeed Long Term

Breastfeeding is recommended by the American Academy of Pediatrics (AAP) as the exclusive source of nutrients in the first 6 months of a baby’s life. However, after childbirth, your milk can take anywhere from 2 to 5 days to come in. For those that are committed to breastfeeding, the idea of supplementing with formula in these early days can be a scary proposition.

However, supplementing with formula in the days following delivery is crucial to ensure that your baby receives sufficient nutrition before your milk “comes in.” and can be part of medical management of jaundice or hyperbilirubinemia. This strategy of early supplementation is often referred to as Early Limited Formula (ELF), and studies have shown that ELF, rather than derailing breastfeeding efforts, can actually lead to long-term breastfeeding success.

By better understanding the timing of breast milk production, and how to supplement with early limited formula, you can feel more comfortable with any breast milk production delays you experience and stay on track with your breastfeeding goals.  

A Pediatrician’s Plan for Breastfeeding and Early Limited Formula Supplementing

“Those early days are hard,” Dr. Meg Alden, mōmi’s Chief Medical Officer, said. “Exhaustion coupled with the stress of establishing breastfeeding can quickly become overwhelming. I see moms whose milk hasn’t come in, and their babies are just hungry! Often these parents are aware that something isn’t going right but can be reluctant to offer anything other than breast milk and everyone is so stressed out.”

Stress exacerbates most medical situations, including breast milk production delays. Besides the stress that comes with producing little milk, many moms are already dealing with many other stress factors, such as significant changes in hormone levels, blood loss from labor, potential trauma from preterm or complicated delivery, and sleep deprivation. With even typical, uncomplicated deliveries, the post-partum fluid shifts can be a factor in breast milk supply becoming established. The temptation to give up on breastfeeding altogether when it is off to a rough start is all too real. However, early supplementation doesn’t mean breastfeeding is off the table forever.

“In these moments, I work with moms to take a step back and decompress,” Dr. Meg said. “A good plan is to put the baby to breast every 2-3 hours for a maximum of 15 minutes per side, and then supplement with either pumped milk or formula (around 1 ounce) after nursing. So nurse first, supplement on the backside, and try to decompress the stress.”

Dr. Meg continues, “studies have even shown that supplementing using the ELF strategy in the first two weeks can lead to more long-term success with breastfeeding. So don’t feel like all is lost on day five if you have to supplement!”

What is Early Limited Formula (ELF)?

Early limited formula is a formula supplementation strategy where the primary goal is to resume breastfeeding once breast milk production begins.

ELF involves feeding a newborn infant (typically one- to six-days-old) with formula from a syringe or a bottle to ensure that the baby gets proper nutrition and energy when the mother’s breast milk production is delayed. 

Studies Show That Early Supplementation Can Lead to Long Term Breastfeeding Success

The ELF supplementation strategies aim to help moms resume breastfeeding once they start producing breast milk. In fact, early limited formula supplementation practices have been shown by various scientific studies to increase the likelihood of short-term and long-term breastfeeding success.

A study published in the Journal of the American Medical Association (JAMA) Pediatrics in 2013 found that early limited formula supplementation may “reduce longer-term formula use at 1 week and increase breastfeeding at 3 months.” 

This study looked at 40 exclusively breastfed infants, 24 to 48 hours old, who had lost more than 5% of their birth weight. A control group of 20 infants kept breastfeeding exclusively, and the other 20 infants were assigned to the ELF intervention group and given 10mL of formula after each breastfeeding session. Strikingly, the study found that only 10% of the ELF group (vs. 47% of the control group) used formula at 1 week of age. Moreover, at 3 months of age, 79% of the infants in the ELF group were exclusively breastfed, whereas only 42% of the control group were still exclusively breastfed.

Overall, this study showed how early limited formula may actually promote longer-term breastfeeding. As a result, parents can be assured that, instead of increasing a baby’s dependence on formula,  ELF supplementing in the first week can help reduce long-term formula use.

A similar randomized clinical trial in 2017 looked at 164 exclusively-breastfeeding infants whose weight loss was greater than the 75th percentile for their age, and whose mothers’ ample milk production had not yet commenced. This study found that supplementing with formula at one week neither interfered with breastfeeding at one month nor diminished the quantity of healthy bacteria (Lactobacillus or Bifidobacterium) found in a healthy infant's digestive system.

Given these benefits of ELF, you might ask: when is the right time to supplement with early limited formula before your milk comes in? To answer this question, let’s go over the three different stages of breast milk composition.

Timing of the 3 Stages of Breast Milk and Their Composition

Colostrum: 1-3 days after delivery, orange or deep yellow in color

Colostrum is a highly concentrated thicker liquid produced in the early days of breastfeeding. Colostrum is yellow in color and nicknamed “liquid gold” for its concentrated strength of minerals and nutrients. It is also rich in antibodies to help babies fight diseases. You might only produce a little over 2 tablespoons on the first day following delivery, and around 4 tablespoons of Colostrum on the second and third day.

Transitional Breast Milk: 3-5 days up to 14 days after delivery, light yellow in color

Milk production “coming in” refers to the transitional milk stage. In the days following delivery, your mammary glands go into overdrive, working to produce breast milk. Your breasts tend to swell and become hard and heavy. Transitional milk is high in fat, calories and lactose, and contains active enzymes and hormones to meet the baby’s needs. It is tinted yellow because it contains some remnants  of Colostrum.

Mature Breast Milk: 14+ days after delivery, white or cream in color

After the initial surge of breast milk, your body begins to better regulate supply and produces milk on demand – when a baby suckles and latches on to the breast. It is completely normal for moms to stop feeling engorgement in their breasts at this stage, and not a sign of low milk supply.

Mature milk has a white or cream color and is made up of fat (3%-5%), protein (.8%-0.9%), sugar (6.9%-7.2%), and 0.2% mineral constituents.

Do’s and Don’ts for Early Limited Formula Supplementing with Exclusive Breastfeeding as the Goal

1. Don’t feel like you can’t get back on track with your feeding goals.

Remember that not everything will go according to plan. That is okay. “Remember to give yourself grace. The most important things are for mom to get some sleep, and for baby to eat — even if the method of feeding is different from what mom first envisioned,” Dr. Meg Alden said. A feeding plan might involve a combination of nursing at the breast, offering breast milk from a bottle, and / or offering formula from a bottle.

2. Don’t rely on supplementing after your mature milk has come in. 

This is because once your body switches to a supply and demand basis for milk, every lost breastfeeding session will potentially lower your milk supply. If you are still supplementing with formula after the first two weeks, make sure to pump after each nursing session to show your body that demand is still high.

3. Do nurse every time before offering formula to an infant.

The goal is to get back into a healthy breastfeeding routine, so you want your infant to feel confident about the breast first.

4. Do pick a bottle that is designed to reduce nipple confusion.

“If you are worried about nipple confusion, know that we designed mōmi bottles with this scenario in mind,” Dr. Meg Alden said. “We’re hopeful that the mōmi bottle will allow parents to supplement without fear of nipple confusion and to get started on the right track with feedings.” The mōmi bottle works similarly to a mother’s breast in mimicking the natural ‘suck, swallow, breathe’ cycle an infant uses at the breast. Unlike traditional bottle nipples, the momi bottle has a slow-flow nipple that won’t overwhelm a newborn right at the start.

Recommendations for Breastfeeding Long Term

The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for six months, followed by tandem breastfeeding and solid food introduction, with a continuation of breastfeeding for one year or longer.

Breastfeeding is strongly promoted, supported, and encouraged by many health organizations including the AAP, the American College of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians (AAFP), and the World Health Organization (WHO).

Breastfeeding decreases an infant's risk of many health problems including:

• Respiratory infections such as pneumonia, whooping cough, and bronchitis.
• Gastroenteritis, an intestinal infection marked by diarrhea, cramps, and vomiting.
• Otitis media, a middle ear infection caused by bacteria or viruses.
• Necrotizing enterocolitis, a disease found in preterm infants that causes infection and inflammation of the intestine.

Breastfeeding may include feeding from the breast or offering breast milk in a bottle. If you need to supplement with early limited formula, you can feel confident that your goals of exclusive breastfeeding are still possible.