Intended for healthcare professionals


Six months of exclusive breast feeding: how good is the evidence?

BMJ 2011; 342 doi: (Published 13 January 2011) Cite this as: BMJ 2011;342:c5955

Are 'top-up feeds' really so bad for babies?

We have recently admitted 3 neonates
with dehydration, jaundice and weight loss of up to 20%. The babies were
admitted with dangerous levels of sodium between 157 and 163. All three
babies were exclusively breast fed.

UNICEF's 'Baby friendly Initiative' has published 10 steps to
successful breastfeeding including to "give newborn infants no food or
drink other than breast milk, unless medically indicated" and to "give no
artificial teats or dummies to breastfeeding infants"(1). However,
neither WHO nor UNICEF offer much advice on what mothers can do if
breastfeeding is not going as planned. Cup feeds are only briefly
mentioned in the extensive strategy documentation(2). The list of
acceptable medical reasons for use of breast milk substitutes does not
include dehydration or weight loss(3).

WHO strategy states that "the vast majority of mothers can and should
breastfeed"(2). However, studies have shown that few women achieve the
international recommendations for breastfeeding(4). It is possible that
unrealistic expectations are placed on mothers, so much so that mothers
may continue to pursue breastfeeding to the detriment of their baby's
health. This problem was highlighted in the Archives of Disease in
Childhood a few years ago(5,6) but the issue has become even more
pertinent given the current climate.

No doubt 'breast is best' but in our view, a blinkered rigid approach
to feeding newborns can lead to disastrous consequences for some children.
A balance needs to be struck between the pursuit of UNICEF targets for
exclusive breastfeeding by all mothers, and the individual needs of every
baby. We appreciate all of the advantages of breastfeeding and this letter
certainly does not set out to challenge or undermine that. But if babies
are not getting adequate hydration with exclusive breastfeeding, is it so
wrong to supplement with top-up feeds while continuing to establish

Dr. Stephen Nirmal, Consultant Paediatrician

Dr. Rachel Hutchinson, FY1 in Paediatrics

1. UNICEF UK. Ten Steps to Successful Breastfeeding.
Friendly/Maternity/Ten-Steps-to-Successful-Breastfeeding/ (Accessed 9th
Oct 2011)

2. WHO/UNICEF. Global Strategy for Infant and Young Child Feeding.
World Health Organisation, Geneva, 2003

3. WHO. Infant and young child feeding. World Health Organisation,
Geneva, 2009. Available at;

4. Scott J, Binns C, Oddy W, Graham K. Predictors of breastfeeding
duration: Evidence from a cohort study. Pediatrics 2006;117:646-655 (doi:

5. Fawke J, Whitehouse W, Kudumula V. Monitoring of newborn weight,
breastfeeding and severe neurological sequelae secondary to dehydration.
Arch Dis Child 2008;93:264-265 (doi:10.1136/adc.2007.131136)

6. Leven L, Macdonald P. Reducing the incidence of neonatal
hypernatraemic dehydration. Arch Dis Child 2008;93:811

Competing interests: No competing interests

20 October 2011
Stephen Nirmal
Consultant Paediatrician
Rachel Hutchinson, FY1 in Paediatrics
James Paget University Hospital