Katie has described a situation of a slow gaining baby and the  
recommendation to mix 1oz of powdered formula into 1oz of pumped breast milk.  Leaving 
aside all of the other parameters to check in order to  evaluate what the 
underlying problem might be, use of powdered formula in this  manner is an off label 
use of the product. Here are a few of the hazards of this  recommendation that 
come to mind:
 
- it over-concentrates the product. 1 oz of powdered formula is 30 grams.  
The scoop in the can is 8.5 g. According to instructions on the back of the  
formula can, 34 grams/4 scoops is to be used to make an 8 oz bottle of formula!  
1 scoop of 8.5 g is supposed to be used for 2 oz of water to prepare standard  
formula. In looking at the American Dietetic Assoc's calculations for 
increasing  the caloric value of standard formulas, their chart doesn't even go up to 
the  point of using 30 g of powdered formula for anything (even to raise the 
caloric  value to 30 calories per oz)!
 
- powdered formula is not sterile and can harbor bacteria such as  
Enterobacter sakazakii throughout its entire shelf life. Mixing powdered formula  into 
breast milk neutralizes some of the anti-infective properties of breast  milk. 
Mixing a potentially contaminated product into human milk that is  neutralized 
by such a product increases the risk for disease in the  infant.
 
- what will this type of concentrated supplement do to immature  kidneys?
 
Why can't the mother use the cream portion of pumped milk that can be  ext
remely calorie-dense? The mixing of formula into  breastmilk recommendation 
sounds very dangerous to me and this mother may  benefit from a more thorough 
work-up of her situation and a second medical  opinion.
 
Marsha Walker, RN, IBCLC
Weston, MA

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