There have been several messages recently about hospitals who are reluctant
to end free and low-cost supplies of formula because of budgetary
constraints.  I have just copied this out, in an individual reply, from the
yellow UNICEF WHO manual "Breastfeeding Management and Promotion in a
Baby-Friendly Hospital, an 18 hour course for maternity staff".  Maybe
others on Lactnet may find it useful too.  There are, as you can see, *very*
few reasons why babies would require formula supplementation.

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Acceptable medical reasons for supplementation


A few medical indications in a maternity facility may require that
individual infants be given fluids or foods in addition to, or in place of,
breasmilk.

It is assumed that severely ill babies, babies in need of surgery, and very
low birth weight infants (< 1OOOg) will be in a special care unit.  Their
feeding will be individually decided, given their particular nutritional
requirements and functional capabilities, though breastmilk is recommended
whenever possible. These infants in special care are likely to include

* infants with very low birth weight, or who are born preterm, at less than
1000g or 32 weeks gestational age

* infants with severe dysmaturity with potentially severe hypoglycaemia or
therapy for hypoglycaemia, and who do not improve through increased
breastfeeding or by being given breastmilk.

For babies who are well enough to be with their mothers on the maternity
ward, there are very few indications for supplements.  In order to assess
whether a facility is appropriately using fluids or breastmilk substitutes,
any infants receiving additional supplements must have been diagnosed as:

* infants whose mothers have severe maternal illness (EG psychosis,
eclampsia, or shock)

* infants with inborn errors of metabolism (e g galactosaemia,
phenylketonuria, maple syrup urine disease)

* infants with acute water loss, for example during phototherapy for
jaundice, whenever increased breastfeeding cannot provide adequate hydration.

* infants whose mothers are taking medication which is contraindicated when
breastfeeding (e g cytotoxic drugs, radioactive drugs, and anti-thyroid
drugs other than propylthiouracil.)

When breastfeeding has to be temporarily delayed or interrupted, mothers
should be helped to establish or maintain lactation, for example through
manual or hand-pump expression of milk, in preparation for the moment when
breastfeeding may be begun or resumed.

For a full discussion of this and related issues see: Chapter 3, Health
factors which may interfere with breastfeeding.  In Infant Feeding: The
Physiological Basis.  Bulletin of the World Health Organization, 67,
supplement (1989)

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Pamela, Zimbabwe