Seconding Sarah's response to this post - though adding a scoop of
formula to expressed breastmilk is a widespread practice where I Iive,
recommended by consultant pediatricians for older babies who come onto
the health services' radar for not being heavy enough (before any
attempts are made to find out WHY the baby's weight deviates from
expectations, I must add, with a groan), this means the feeds will be
too concentrated in all ways - there will be too much protein and too
many solutes.  The two most recent babies I have worked with turned
out to have serious tracheomalacia which meant increased respiratory
effort with consequent higher nutritional needs.  The mothers had
plenty of milk but the babies were so compromised by their breathing
difficulties that they struggled to ingest the milk that was
available, and they burned more than they took in.  Adding powdered
formula caused vomiting in both of them and made them even more
aversive to feeding - big huge help, thankyouverymuch.  The babies
didn't end up back at square one, they were made worse by the
'treatment'.  I was not part of the treatment team; I was contacted in
my role as a volunteer mother-to-mother counselor.  A bit awkward
since it was the same hospital trust that employs me, but the
pediatrics department, serving an area with about 150, 000 people, has
no clinical staff with specific expertise on complex breastfeeding
problems.

Whoever is recommending this practice for a premature baby has the
burden of proof. They must be able to convince the mother that it will
not harm her baby and they will be hard put to find support for this
in any reputable literature - but I have no illusions that simply
informing the mother or the HCP of this will solve the problem, though
referring to the instructions on the package of formula might do the
trick.  Sarah mentioned life-threatening dehydration and electrolyte
imbalance as possible outcomes. Short of death, the baby can lose
limbs from gangrene too, secondary to impaired circulation from
dehydration/hemoconcentration.  It is bad practice for any baby and
MADNESS for a premature one.

It should help to find out what the rationale for the recommendation
was.  Is the baby too immature to feed effectively?  Are growth
expectations unrealistic?  Does the baby have some underlying medical
problem other than immaturity, making it difficult to take in enough
milk?  Is mother's supply too low to meet baby's estimated needs?  The
purported indication will tell you what kind of strategy is needed to
preserve and promote the breastfeeding - and all of these
possibilities are quite different from one another.  Simply increasing
the concentration of the feeds is rarely the first choice, especially
in an otherwise healthy baby.

Good luck, you'll need it!
Rachel Myr
Kristiansand, Norway

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