At-Breast Supplementer Nursing

Charlotte Yonge, LLL Paris English Leader and IBCLC, Paris, France

Originally published in September 2010, updated October 2018 and republished with the express permission of the author.

It is important to know that if a baby gets supplements with an artificial nipple, there is a high risk that he will end up being bottle-fed and will miss out on the benefits that a nursing child has, both emotional and physical.

At-breast supplemented nursing: breastfeeding for everyone

I am a mother of two children (aged seventeen and twelve) whom I breastfed above and beyond the recommended WHO minimum of two years. I was however unable to exclusively breastfeed the recommended first six months. Before the birth of my first child I had asked the midwife if the fact I had had breast reduction surgery would affect my breastfeeding. Her answer was very clear, “Not at all. One breast per feed, ten minutes, no more, every two to three hours, and let him really cry before you give him the breast, to make sure he’s really hungry.” I tried very hard to follow her instructions. I considered myself very generous in letting my baby suckle for up to half an hour, and every one and a half to two hours.

But by day four my baby was on bottles. Half the staff accused me of being weak, the other half of sabotaging my breastfeeding. For the first eight weeks of my baby’s life I was torn between knowing I shouldn’t be giving bottles and seeing my baby hungry, nervous, crying, and not sleeping. My ex-husband kept yelling at me “He doesn’t want your breast, he wants the bottle! Stop starving him!”.

Then I went to my first La Leche League meeting. I was suffering from postpartum depression, but at last I heard something that made sense. I could breastfeed, of course, but perhaps I wouldn’t be able to provide 100% of my baby’s needs in breast milk because I’d had breast surgeryBreastfeeding after breast reduction surgery is certainly possible. With advances in surgical techniques for breast reductions, surgeons are increasingly able to preserve milk-producing tissue so that women who have had breast reductions are able to produce significant amounts of milk. The techniques that have resulted in the most milk production are those in which the nipple is not completely severed, even though it may have been moved.

I might need to supplement, but my baby would get a lot more of my milk if I used an at-breast supplementer. An at-breast supplementer consists of a paediatric feeding tube threaded through the nipple of a baby bottle of supplement milk or through a valve at the top of a little bag of milk that can be hung around your neck. You latch the baby on to both the breast and the tube at the same time, so he is sucking on the breast but also gets milk from the bottle. It keeps the baby in control of how much he takes, and keeps the demand for milk supply stimulated in the breasts. See my demonstration videos in both English and in French, here:

Supplementing my milk was necessary to get my baby back on his weight curve. So for the first time since his birth, I supplemented with no holding back. My baby drank up to 700 ml of artificial milk per day until he reached his normal weight. I pumped, as advised, with a good pump, but only ever obtained 10 to 20 ml maximum, from both breasts, after 20 to 40 minutes of pumping. Facing such a harvest was very depressing. So I eventually sent the pump back.

As time went by, my baby needed less supplement (about 300 to 500 ml of supplement per day). I was resigned to supplementing—not exactly what I’d envisioned before birth, but at least I was breastfeeding. When my baby was six months old and had started solid foods, he suddenly refused the artificial milk supplements.

His consumption of artificial milk supplements had gone down with the introduction of solid foods to about 50 to 100 ml total per day. I was terrified that my baby would starve again. I weighed him once a week in a panic but after two months of refusing my occasional attempts to give him milk supplements, I had to admit, that my baby was still gaining weight properly, with solid foods and my milk!

The World Health Organization’s infant-feeding recommendation in the Global Strategy on Infant and Young Child Feeding states:

“As a global public health recommendation, infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues for up to two years of age or beyond.”

My at-breast supplemented baby was able to go on to breastfeed beyond the World Health Organization’s recommended minimum.

In 2003 I accredited as an LLL Leader and I became the reference for LLL France for mothers who wanted to know about breastfeeding after surgery. Despite investing hours talking to mothers and recommending books, the mothers I talked to were not pursuing breastfeeding after surgery. They were abandoning breastfeeding because they “couldn’t produce enough milk.” Not having enough milk is inherent to breastfeeding after breast reduction surgery. That was a given! I had prepped them about that. So why had I succeeded and they didn’t? I realised that those mothers were reliant on their immediate family, entourage or perhaps medical staff without the slightest idea of how to help the mothers in this very particular situation. Most of these mothers didn’t dare go to LLL meetings because they said that they felt that they “didn’t qualify as breastfeeders” if they were using an at-breast supplementer.

So I wrote a 50-page illustrated document, in French, based on my interpretation of the book Defining Your Own Success: Breastfeeding After Reduction Surgery by Diana West and she gave me permission to circulate it. By that time more and more women were not accepting, “No, you can’t breastfeed” as an answer and were using an at-breast supplementer by a well known company, but they were still not comfortable attending breastfeeding support group meetings, which were full of mothers who “had no problems.”

So I created an email mother-to-mother support list called “Allaitement Pour Tous” (Breastfeeding for all) for at-breast supplementer users, regardless of the mothers’ reasons for using these aids. (The original version was invented by the husband of a US LLL Leader who breastfed all her adopted children, it is, in my opinion, the best one.) In this safe virtual environment, protected behind an avatar, mothers who cannot breastfeed exclusively find information and support. Some of those mothers started out with poor breastfeeding management—Others mothers discovered their troubles were not management problems but dysfunction problems due to a high palate, often caused by tongue tie. We were all on a steep learning curve concerning mechanical problems like high palates and tongue and lip ties and the oh-so-important structural tension work. A lot of those APT discussion list mothers were able to build up their milk supplies by pumping and taking galactagogues and were able to use their own milk in their at-breast supplementers. The ones who really could not increase their milk supplies through pumping and galactagogues were the ones who had had breast surgery, thyroid problems, or they had adopted their babies and were inducing lactation. Those mothers did not starve their babies as I had in order to follow some obscure instructions supposed to encourage exclusive breastfeeding at all cost. Those babies received infant formula supplements, at least for the first six months. Regardless of the milk in the at-breast supplementers, all mothers on that APT discussion list were able to breastfeed 100% bottle free, for as long as they liked, and most of them did for well over 6 months, and many of us did for well over the two year recommended minimum.

Mothers who use an at-breast supplementer don’t always feel at ease in “gadget-free” breastfeeding meetings. They often shy away from LLL meetings or any form of social situation where they will be seen breastfeeding. Or if they go, they often don’t stay long, because they don’t want to give formula supplements with other mothers around. Those mothers feel isolated and need a safe environment where they will not be encouraged to reduce the amount of supplements—be it real mother’s milk or the artificial stuff—in the hope that their babies will magically become efficient feeders. Those women need a competent diagnosis of their babies’ sucking problem or of their own problem; alternatively, they simply need encouragement to continue breastfeeding, whatever percentage of artificial milk they are using. There is always a breastfeeding solution for a breastfeeding problem.

A baby may need supplements (given at the breast) for as long as eight months (not longer) but by around the middle of the first year a baby can be given high calorie, iron-rich solid foods in increasing quantities, until the calories provided by the milk supplements are replaced by the solid food calories. Dr. Jack Newman and Dr. Carlos González recommend very little fruit and vegetables, which are, according to Dr. González, just “green water.”

It is important to know that if a baby gets supplements with an artificial nipple, there is a high risk that he will end up being bottle-fed and will miss out on the benefits that a nursing child has, both emotional and physical.

The Allaitement Pour Tous discussion list got so big and so unmanageable with hundreds of emails every week that we moved it to a forum. The forum was too complicated for most of the members, so it slowly died out over the following years and I finally closed the association in 2017. Allaitement Pour Tous did not support mothers who human-milk feed (mothers who pump their milk and give it by bottle). As admirable as their efforts are, we only supported mothers who wanted to or who were able to maintain an at-breast relationship with their children. LLLI has excellent online support via its English and Spanish speaking Facebook groups Mothers who human-milk feed can also find support in LLL groups in over 70 countries around the world – look for local support here

Our support list was so popular the “old” mothers who no longer needed to use milk supplements stayed on to keep the party going as it were. So we had many mothers who were very experienced at using an at-breast supplementer, and everyone was sharing all kinds of related knowledge like table food quality, and lots of medical conditions that exist that can affect breastfeeding. LLL Leaders and IBCLCs joined the list and actively participated. Everyone was learning about the particular support that our 100% at-breast feeding mothers needed. Almost none of us were able to exclusively human-milk feed our babies, but we all were able to breastfeed 100% at the breast, which enabled everyone who wanted to, to breastfeed “normally” after the milk supplement period, for as long as we wanted.

Many mothers supported by Allaitement Pour Tous went on to be accredited as LLL Leaders. I would like to see “Breastfeeding for all” support lists all over the world, in every language. Breastfeeding while supplementing at the breast should be seen as heroic instead of “not worth it” as it so often is declared to be by health professionals and isolated mothers with no idea of what is at stake.  For whom is using an at-breast supplementer “not worth it” I would like to know. All that accumulated at-breast time that all those babies got from starting out life at the breast, who would otherwise have been on bottles exclusively after a few days or weeks at best without an at-breast supplementer. Who loses out I wonder?

In 2009, tired of having to email my PDF file on breastfeeding after breast reduction surgery to every single individual who contacted me about it, I created a website for Allaitement Pour Tous, where women could download the file, or read it online. Then I began to add other pages of information, studies, articles and mothers’ testimonies, photos and related information. Now it’s a vast website. I also have three Youtube channels, all dedicated to breastfeeding, the main one is called, (have you guessed?) Allaitement Pour Tous. I also have “Radio Allaitement Pour Tous” where I put my recorded interviews. Please feel free to start your own “breastfeeding for all” mother-to-mother email list and or association in your country, wherever you feel mothers may abandon breastfeeding because they can’t ensure the first six months of exclusive breastfeeding. Involve experienced mothers, LLL Leaders, and IBCLCs. Mothers who supplement at the breast need special, experienced support in a protected environment.

Breastfeeding our babies is important and the benefits of “extended” breastfeeding are just as precious to our babies as to those who have benefited from six months exclusively on mother’s milk, if not even more so.

West, D. Defining Your Own Success: Breastfeeding After Reduction Surgery LLLI, 2001.