Laura asks for references for _not_ mixing powdered formula into
breastmilk to increase calories and weight gain for a slow gaining
healthy full term infant.
This is an excellent question because I hear this advice often. Of
course there is a precedent due to mixing so-called HMF in with
breastmilk for preterm infants when the neonatologist wants to
increase weight gain in a stable premie, but is apparently reluctant
to increase breastmilk volume/intake... a practice I cannot
understand and have written frequently about on Lactnet....:-(
But it would seem that the reasons that are given about the risks of
feeding under-diluted formula to infants would also apply to mixing
in a scoop or two or formula with breastmilk. Breastmilk is already
a complete food, with a physiologically suitable ratio of proteins,
fats, sugars and micronutrients to water. Adding in powdered infant
formula, yet omitting the water, would skew the ratio, and (I would
think), placing the infant at risk of dehydration/hypernatremia as a
result of high renal solute load, eg when the diet is calorie dense
but low in fluid. If the infant's feeding/thirst cues were responded
to with feeding additional breastmilk+formula powder, I'd imagine
that the risks could escalate quite quickly.....
There's a little on the risks of feeding under-diluted formula in
USDA and WIC documents at
<http://www.nal.usda.gov/wicworks/Topics/FG/Chapter4_InfantFormulaFeeding.pdf>http://www.nal.usda.gov/wicworks/Topics/FG/Chapter4_InfantFormulaFeeding.pdf
and
<http://healthandwelfare.idaho.gov/Portals/0/FoodCashAssistance/WomenInfantsandChildren/ID_FY2015_Appendix%20NRC%20411.docx>http://healthandwelfare.idaho.gov/Portals/0/FoodCashAssistance/WomenInfantsandChildren/ID_FY2015_Appendix%20NRC%20411.docx
Then there's this in an Alberta Health Services document on the safe
preparation and handling of infant formula
<http://www.albertahealthservices.ca/hp/if-hp-nghiyc-infant-formula-safe-preparation-handling.pdf>http://www.albertahealthservices.ca/hp/if-hp-nghiyc-infant-formula-safe-preparation-handling.pdf
Adding less water than recommended can create an over concentrated
formula which may result in an infant suffering from hypernatremic
dehydration.10,12 Infants with hypernatremic dehydration often
present with minimal or generic symptoms such as diarrhea early on.
The absence of clear symptoms can lead to delayed diagnosis.12
However, hypernatremic dehydration can result in severe complications
including "seizures, cerebral edema, venous sinus thrombosis, pontine
myelinolysis, permanent brain damage, disseminated intravascular
coagulation, acute renal failure, and even death."12
10 Egemen A, Kusin N, Aksit S, Emek M, Kurugol Z. A generally
neglected threat in infant nutrition: incorrect preparation of infant
formulae. Turkish J Pediatr. 2002;44:298-303.
12 Leung C, Chang WC, Yeh SJ. Hypernatremic dehydration due to
concentrated infant formula: report of two cases. Pediatr Neonatol.
2009;50(2):70-3.
Hope this helps, Laura
Pamela Morrison IBCLC,
Rustington, England
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