The question of how long can one wait before supplementing is not easy
to answer. If one looks at practices in the not too distant past, one
could find that there were institutions where the first feed was with
held for more than 6hrs and literature which suggested that  healthy
term neonates could sustain themselves without harm for prolonged
periods, as long as 9 days without feeds and IV fluids. With the advent
of BFHI norms this time period has been cut short to within 30 minutes,
but one should realise that the purpose behind this is more to establish

breast feeding than to fully nourish a baby. If one goes about testing
for blood sugar in healthy term neonates on breast feed, as many as 30 %

of them would have borderline hypoglycemia (2- 2.6 mmol/L). The latest
WHO document on hypoglycemia states that this is inconsequencial in
healthy term neonates and need not be treated unless they have risk
factors like IUGR, maternal diabetes, h/o birth asphyxia, sepsis etc. So

in a situation where a healthy neonate refuses to breastfeed
satisfactorily, yet remains normoglycemic I don't see a reason to
supplement.

There are several other areas where supplemental feeding is often
resorted to. I have made an attempt to clarify this in an article titled

" Supplemental feeding in the context of BFHI setting" which was
recently published in the winter issue of the journal Middle East
Pediatrics. If there is any one interested in it I will be more than
happy to forward it.

Arun K Nair
Senior Specialist
Special Care Baby Unit
Royal Hospital
Muscat