Hierarchy of Infant Feeding Choices

Two days ago, I received a text message from R, a nursing mom I previously counselled. She was very worried with the amount of milk she stored for her baby. Apparently, her baby was drinking more milk that she could express at work. She was already down to about 12oz. which was less than what her baby drinks while she was at the office.

R's baby just recently turned 6 months but did not start solids yet. Her baby's pediatrician had already given the go-signal for them to start solids but she was still hesitant unsure what to feed her baby. I suggested that at 6 months, her baby could already start solids and referred her to my previous post. However, this does not mean that her baby's milk feedings will decrease. Until 1 year old, babies still need to get their primary nutrition from milk while solids are only for complementary feedings.

R did not want to give her baby formula so she asked if she could give water or dilute her breastmilk with water instead. I was reminded of the hierarchy of infant feeding choices which the World Health Organization established, in paragraphs 18-19 of the WHO's Global Strategy for Infant and Young Feeding:

The vast majority of mothers can and should breastfeed, just as the vast majority of infants can and should be breastfed. Only under exceptional circumstances can a mother’s milk be considered unsuitable for her infant. For those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or a human-milk bank, or a breast-milk substitute fed with a cup, which is a safer method than a feeding bottle and teat – depends on individual circumstances.

For infants who do not receive breast milk, feeding with a suitable breast-milk substitute – for example an infant formula prepared in accordance with applicable Codex Alimentarius standards, or a home-prepared formula with micronutrient supplements – should be demonstrated only by health workers, or other community workers if necessary, and only to the mothers and other family members who need to use it; and the information given should include adequate instructions for appropriate preparation and the health hazards of inappropriate preparation and use. Infants who are not breastfed, for whatever reason, should receive special attention from the health and social welfare system since they constitute a risk group.

As summarized by IBCLC Diane Wiessinger, the hierarchy is (1) breastfeeding; (2) mother's own milk expressed and given to her child in some other way; (3) milk of another human mother; and (4) artificial milk feed.

For premature babies, a publication entitled "Global health policies that support use of banked donor human milk: a human rights issue" authored by Lois DW Arnold presents a further classification within the hierarchy - between premature mother's milk vs. mother's milk and premature artificial milk feed vs. regular artificial milk feed, as can be seen from the author's diagram reproduced below:

Clearly, for both full-term and premature babies, water is not a safe option for feeding your baby. Water is included as an option only for infant feeding during emergencies.

The choice of donated breast milk is also a difficult subject. The American Academy of Pediatricians frowns upon using unpasteurized donated milk and recommends only using pasteurized milk from human milk banks.

In the Philippines, we are not too particular and although I know some pediatricians who would prefer to use pasteurized human milk, for some moms this is just not an option. I only know of 3 pasteurizers in our country and these pastuerizers do not run until the milk banks receive enough donated milk to operate the pasteurizers at full capacity. I myself have donated to moms and babies who come by my place to pick up my frozen unpasteurized milk.

When donated milk is not available, I believe that formula would be the remaining option. Some lactivists might disagree with me but I believe that formula is not at all evil. Diluting your breastmilk or giving your baby water is WORSE than giving your baby formula milk. If you are faced with this choice, call your pediatrician and ask what formula to give your baby. Then don't beat yourself up about it - stressing about the one bottle won't help you. Work extra hard to bring your supply back up so you can get rid of the artificial milk feeds.