The first step is to try to determine whether or not supplementation is truly needed.  Take time to review the situation and any special circumstances; don't supplement automatically.  Consult a professional lactation consultant (IBCLC).  These are the professionals truly trained to know when supplementation is necessary.  They will work with your baby's doctors to work out the best plan for meeting your baby's needs while still trying to preserve breastfeeding as well.  

The following are some general considerations on when supplementation may not be necessary and when it may indeed be needed. However, these are only considerations; they are not strict guidelines and not medical advice. It is important to emphasize that supplementation decisions should only be made in consultation with lactation consultants and your baby's doctors; the issues involved can be complex. 

When Supplementation May Not Be Necessary

As noted previously, supplementation should never be routine for any condition; it should be based on a documented medical need.  Ask for lab tests to show the need for supplementation whenever possible (barring an emergency).  Then seek an expert opinion of a professional lactation consultant to confirm this need.  Oftentimes, the standards that are used to diagnose and treat conditions like hypoglycemia and jaundice are open to interpretation, and it may help to review the standards and variations of interpretation with an impartial observer.  See the sections on hypoglycemia and jaundice above for further information.

Many women assume that if a baby cries even after nursing, he is still hungry and needs supplementation.  Actually, babies cry for many reasons; perhaps the baby is crying to tell you that something else is wrong.  Don't assume crying is only about hunger. Sometimes the baby cries simply because he is uncomfortable or because he wants to be nearer to you.  Check thoroughly for other reasons and resist the temptation to supplement unless the baby is showing signs of truly needing it. 

Don't assume that if your milk 'comes in late' (later than day 2 or 3) that the baby must be supplemented.  Because mature milk can sometimes take extra time to 'come in' after a cesarean, women may be told that they must supplement in the meantime.  Many doctors and nurses are not aware that is common for the milk to take longer to come in after a cesarean, and so they may start jumping to conclusions about "low milk supply" and recommend supplementation.  

Colostrum (the first 'milk', a golden or clear substance produced in the first days after birth)  is so highly concentrated that not much is needed to sustain the baby. You will not produce great quantities of colostrum, but what is there packs tremendous nutritional and immunological punch.  It is the ideal first food for baby.  It has plenty of protein and energy concentrated into a few small drops, is baby's first immunization, is full of antibody protections, helps protect baby's intestines against harmful bacteria, helps baby produce his first meconium stool, and is easily digestible. These benefits are vitally important for baby's protection; any supplements reduce the amount of these protections.  Therefore, supplements should be added only if absolutely necessary.

Many women see how little colostrum they produce and panic that this is not enough for baby to survive on, or worry that they will not make enough milk to satisfy the baby.  Rest assured that colostrum production is small because it is so highly concentrated, and that this does not indicate what your production will be once your mature milk comes in. You will produce plenty of milk eventually.  

In the meantime, the small amount of colostrum is part of nature's design to promote breastfeeding.  These small amounts of colostrum ensure that baby wants to nurse quite often in the first few days.  This frequent stimulation helps ensure a greater milk supply later on for the mother, reduces engorgement for the mother when the milk does come in, and ensures the baby gets more frequent doses of the important immunological protections in colostrum.  Supplements fill the baby up and make him want to nurse less often, thus decreasing the mother's supply and giving the baby less protection immunologically.

Because colostrum is produced in smaller amounts, nursing the baby very frequently during the first few days is extra important. Nursing 8-12x per day is usually enough to sustain the baby until the mature milk comes in, as long as the mother has unrestricted access to her baby and does not limit time on the breast. 

Dehydration is a potential concern if the mature milk does not come in within a few days, but a great deal depends on how often the baby is nursing, how the baby's weight is doing, and whether the baby has symptoms of problems.  Each situation must be judged on its own individual circumstances; a professional lactation consultant can help you decide if supplementation is needed.

Remember that nature designed baby to get frequent, small, powerful doses of colostrum for a few days after birth; this is the system that evolved over millions of years to become the one that is safest and most efficient for baby.  Unneeded supplements tamper with this system and interfere with the intended chain of events. Unless circumstances clearly show the baby is in need of supplements, this is not something to tamper with lightly. 

When Supplementation May Be Necessary

However, there are times when supplementation can become necessary.  In some situations, supplementation can be life-saving.  The ultimate goal is the health and well-being of the baby, so of course if the baby truly needs a supplement we must not hesitate to give it. 

It is important to watch for signs of dehydration in the baby when the mature milk takes a long time coming in, if the mother and baby are unable to nurse frequently, or if there is reason to believe that the mother's supply may be affected.  Usually, nursing every 2-3 hours in the day (and every 3-4 hours at night) is enough to keep a baby well-hydrated and in good shape, but if it is not possible to nurse that often or if low supply is an issue, dehydration can occur. 

If the baby becomes truly dehydrated, he is at risk for many problems and must be treated.  Symptoms of dehydration include:

• Not enough wet diapers
• Sunken fontanel
• Excessive weight loss after birth
• Dark/scant urine
• Little stool output
• Dry mouth and eyes
• Listless baby
• Skin losing its resiliency
• Weak cry
• Fever

These are signs of serious problems that need to be treated immediately.  Sometimes nursing more often can rectify the situation; at other times, supplements become necessary.  If in doubt, consult an IBCLC lactation consultant to know if dehydration is a problem and what to do about it.   

If the baby is losing too much weight, this can be another sign that he needs supplementation.  However, this can be complicated by the fact that babies' birth weights are often inflated by the excessive amounts of I.V. fluids that are given to the mother during labor and birth.  When this  transient fluid is lost, it looks like the baby has lost an excessive amount of weight and 'needs' supplementation.  

As quoted previously, Henci Goer  (The Thinking Woman's Guide to a Better Birth) documents that this overload of fluids  "also result[s] in a transfer of water into the baby's tissues.  This extra fluid inflates the baby's birth weight and the subsequent weight loss after birth.  Doctors and others often gauge breastfeeding adequacy by how fast the baby regains her birth weight, so this misleading weight loss may lead a doctor or mother to mistakenly conclude that breastfeeding is inadequate" or that supplementary feedings are needed. 

It is not always easy to tell when a baby is truly losing too much weight after birth; this is another situation where the evaluation of a neutral breastfeeding expert can help clarify the baby's true condition and needs.  Sometimes a small amount of supplementation is enough to 'tide over' a baby until the mother's milk supply increases or the baby learns to nurse more efficiently.

Sometimes a baby has a problem learning to suck well and may need a supplement while he learns to nurse.  If the baby is "tongue-tied" (a problem with the frenulum on the bottom of the tongue), has an extremely high and arched palate, or is unable to coordinate sucking and tongue motions very well, he will tend to not nurse very well and not regain his weight after birth.  This situation needs evaluation by a professional lactation consultant (IBCLC) to determine what the exact problem is.  Often there are things that can be done to help the baby learn to suckle more efficiently. It is vital that an IBCLC lactation consultant be seen as SOON AS POSSIBLE in this situation so that supplementation is minimal and the baby learns new habits quickly.   

Another situation that may justify supplementation is if the baby's condition is unclear (there are possibly troubling symptoms) and you cannot see an expert right away to know for sure how serious the problems may be. Although the best choice is to get advice from an lactation consultant, not all hospitals have these readily available.  Until an LC can be called in to help evaluate the situation, if the baby has symptoms that may indicate a real problem, it may be better to err on the side of caution and give a supplement. However, this does not have to mean giving a bottle!

Bottles should be avoided if at all possible, because the sucking mechanism for bottles is completely different than the sucking mechanism for nursing.  In bottlefeeding, a baby's role is basically sucking.  In breastfeeding, a baby's role is basically "pumping" the mother's areola to produce the milk.  In other words, the baby's tongue motions plus the pressure from its tongue and gums "pumps" the areola, producing milk.  In bottlefeeding, none of these tongue motions are needed, and the baby's tongue basically pushes forward to stop the flow of the milk from the single hole in the end of the artificial nipple when baby needs a rest.   

Because the tongue movements are totally opposite, many babies have difficulty switching between breastfeeding and bottlefeeding.  Also, a baby must open his mouth very wide for nursing at the breast properly, whereas he needs to only open his mouth a little to suck on a bottle nipple.  This often means that babies given bottles try to 'nipple-feed' when breastfeeding---instead of opening the mouth wide to encompass the mother's areola, the baby sucks on the nipple only.  This creates tremendous soreness for the mother and leads to baby not getting very much milk because the mother's areola is not stimulated.

Although many  will tell you that 'nipple confusion' doesn't exist and bottles won't interfere with breastfeeding, research clearly shows that it does (Samuels 1985, Hill 1997, Blomquist 1994, Cronenwett 1992). Many professionals (not breastfeeding professionals) will also tell you that the only way to supplement is with a bottle, but there are actually many alternatives.  Many nurses / midwives/ GPS..have not been trained to be familiar with non-bottle supplementation techniques, but outside the U.S., these alternate methods are more common.  

Alternative Methods of Supplementation

There are many ways to supplement a baby without using a bottle.  These include a syringe, eye dropper, spoon feeding, supplemental nursing systems, cup feeding, finger feeding, or supplemental nursing systems.  There are also special bottles for certain situations that may be less confusing to a newborn.  

The following section briefly summarizes some of the alternative supplementation options to bottles.  Much of this information was covered above in the section on nursing a premature baby and is repeated here for readers who may not read this FAQ in a continuous fashion.  Readers may wish to skip ahead if they are already familiar with the material.

• Spoon Feeding, Eye Droppers, and Syringes

Mathur (1993) found that spoon-feeding instead of bottlefeeding improved the long-term breastfeeding rate.  In the study, 86.8% of those who received their first feeds by spoon were still practicing total breastfeeding, while only 33.3% who received first feedings by bottle were still nursing.  

Spoon Feeding is very similar to cup feeding, except that the baby is fed from a spoon instead of a cup.  No special equipment is needed; any clean and sterile spoon is suitable.  Follow the same directions as setting up for cup feeding, then bring the spoon to the baby's lips.  Gently tilt it so that it rests lightly on his lower lip when he opens up, with the milk just touching his lips. Tip the spoon slightly so that the milk flows into the baby's mouth.  Repeat as needed.  

Eye droppers are another way to get baby extra nourishment, and a syringe can also be used, although there is less research available on these methods. With eyedroppers, a soft plastic type is best because it is unbreakable.  With feeding syringes, peridontal or orthodontic syringes can be used in the same way; their advantage is that they hold more fluids.  Both eye droppers and feeding syringes are available in most drug stores; this is advantageous because the mother doesn't have to wait for special equipment to arrive.  

Again, prepare the baby the same way you would for cup feeding, holding him upright and swaddled.  Protect all clothing as sometimes spills happen in this process. Bring the eye dropper or syringe to the baby's mouth, and slowly drip in the milk.  It is important not to go too fast, so that the baby has a chance to swallow before more is given.  When the baby needs to pause, it is important that the person feeding the baby take a break too.  To avoid choking, keep the baby upright and give only small amounts at a time.  

• Cup Feeding

Cup feeding is a bit more familiar to most NICU nurses than spoon feeding, eye dropper or syringe feedings.  In studies of several African and English hospitals, researchers found that cup feeding preemies resulted in less nipple confusion and higher breastfeeding rates than bottlefeeding.  Lang (1994) found that 81% of babies who had received supplements via cup feeding were fully breastfeeding at hospital discharge, vs. 63% who had received supplements by bottle.  

To cup feed, you need to have a small flexible cup, like a medicine cup or even a Dixie cup.  Medela, Ameda/Egnell and La Leche League make a series of cups specially made for this purpose.  Hold the baby as upright as possible (swaddled so his hands won't bump the cup), and use a bib or blanket to protect clothing.  Put a small amount into the cup (measure it so you will know how much baby is drinking), and if necessary, fill several cups ahead of time so that the feeding process can be continued smoothly and without interruption.  

Gently tilt the cup to the baby's lips.  Place the edge of the cup at the outer corners of the baby's upper lip and resting gently on the lower lip with the baby's tongue inside the cup. (Some babies reportedly prefer their tongue under the lip of the cup.)  Tilt the cup so the milk touches the baby's tongue. Don't move the cup during the feeding----the baby will lap the milk or sip it on his own rather than you pouring the milk into baby's mouth.  Let the baby swallow before offering more, and let the baby set the pace for feedings.  If he tires, don't force the issue.  

Some US hospitals have pioneered the use of cup feeding in the United States (Stine 1990).  Unfortunately, at this time, most NICUs in the U.S.A. view cup feeding as too difficult to do, impossible, or even 'risky' to try. However, there are some hospitals that are willing to try cup feeding, and with the help of a lactation consultant as advocate, others are learning to try it.  You can find out more about cup feeding from www.mother-2-mother.com/cup_feeding.htm, www.askdrsears.com/html/2/T026000.asp, or the article by Dr. Jack Newman at www.breastfeeding.com.  There is a video of cup feeding available at www.breastfeeding.com/aaavideo/cup1.mov. 

• Finger Feeding

Another alternative to bottles is finger feeding. This works especially well as a transition to breastfeeding.  

A small tube (often a #5 French tube) is attached to a bottle of expressed breastmilk or formula.  The tubing is then taped to the caregiver's largest finger, either to the pad or to the side.  If the baby cannot open his mouth very wide, then the caregiver can use the smaller fingers, but the idea is to use the largest finger possible so that baby learns to open its mouth very wide.  The caregiver's finger is then inserted into the baby's mouth, pad side up, and the baby sucks the milk/formula out of the tubing. This is more like breastfeeding sucking than bottle feeding sucking, and many babies do very well on this regimen (Kurokawa, 1994). 

Photos and information about finger feeding can be found online at several different websites, including www.promom.org/bf_info/Fingerfeed.htm,  www.asac.ab.ca/BI_fall01/wbdw.html, www.deleons.com/breastfeed.html, and www.preemie-l.org/bfaq.html.  There is a video of finger feeding available at www.breastfeeding.com/aaavideo/finger1.mov. The Hazel Baker Finger Feeder can be bought at many sites, including www.medela.com/NewFiles/specialtyfdg.html. 

Finger feeding has numerous advantages over bottles.  It teaches the baby that sucking is rewarded with milk, it teaches the baby to open its mouth very wide, it won't cause nipple confusion, and the baby is not taught poor sucking habits.  The sucking mechanism with finger feeding is more like breastfeeding sucking.  In addition, any caregiver can finger feed; the mom does not have to be present 100% of the time.  Bottles can also be given by any caregiver, but they interfere with proper sucking te chnique, whereas finger feeding does not.  Dr. Jack Newman writes at www.breastfeeding.com/all_about/all_about_f_feed.html: 

Finger feeding is much more similar to breastfeeding than bottle feeding is. In order to finger feed, the baby must keep his tongue down and forward over the gums, the mouth wide open (the larger the finger used, the better), and the jaw forward. Furthermore, the motion of the tongue and jaw is similar to what the baby does while feeding at the breast. Finger feeding is best used to prepare the baby to take the breast.

Finger feeding helps prepare the baby for breastfeeding by learning the correct type of suck.  Eventually, when the baby is ready, he can be put to the breast.  Some babies transition to full nursing quickly, but many babies take quite some time to learn to transition to the breast.  Don't get discouraged; this is not unusual.  Perseverance is important.  

Some women report that if they give the baby a minute or two of finger feeding first before switching to the breast, the baby latches on and suckles more efficiently.  This soothes the frantically hungry baby with immediate food, rewards the baby for suckling, and quickly switching from finger feeding-suckling to breastfeeding-suckling often eases the transition to suckling at the breast.  

• Supplemental Nursing Systems

In some cases, a supplementary nursing device such as a "Lact-Aid" or "Supplemental Nursing System" can provide baby with the nourishment he needs while still preserving breastfeeding and stimulating supply.  This can be ideal for many cases where long-term supplementation is needed.  It is the only method of supplementation that involves being fed at the mother's breast and stimulates her milk supply.  

This is a bag or bottle containing formula that hangs on a cord around the mother's neck, usually resting between her breasts.  A thin tube comes out from the container and is taped to the mother's breast.  The end of the tubing extends just beyond the end of the nipple. The baby is put to the breast and sucks on both the mother's breast (thus stimulating her supply) and the tube (thus getting supplementary formula).  

As The Breastfeeding Answer Book summarizes:

When a baby swallows, the natural response is to suck.  A nursing supplementer--a device that allows the baby to receive supplements through a tube taped to the mother's breast---is designed to stimulate this natural response to help improve a baby's suck while providing needed supplement...A nursing supplementer may help a baby learn to suck more effectively because the extra milk he gets from the supplementer stimulates him to swallow and consequently suck more often.  As the baby's suck becomes more vigorous, he will receive more milk from the breast and further stimulate the mother's milk supply.  As the baby begins to take more milk from the breast he automatically takes less from the supplementer.  The mother can gauge her baby's progress in part by how much of the supplement is left after nursings...The nursing supplementer allows the whole feeding time to be spent at the breast, while bottles and other alternative feeding methods are used after nursings.  

A nursing supplementer rewards even relatively weak suckling, provides stimulation for the mother's milk supply, and provides supplements to be sure baby is being well-nourished.  It is designed in a way that when the baby learns to suckle more effectively, less supplement is taken, hopefully leading to weaning from the supplementer. However, not all babies are able to learn to breastfeed fully, and many will continue using the supplementer for many months.  

A nursing supplementer is best used for long-term supplementation instead of short-term needs.  It is a good alternative to bottles because it keeps the mother's supply stimulated, doesn't cause nipple confusion, and makes it less likely that the baby will come to prefer the bottle.  It works well for long-term supplementation of the premature baby.  It can also be used for re-lactating if a mother weans prematurely and then wants to go back to breastfeeding.  Adoptive mothers also have used it to successfully induce lactation or combine breastfeeding with supplements.  

Nursing supplementers come with different sized tubing, which can help control how fast the formula flows to baby.  Large tubing gives the fastest flow.  Breastfeeding books recommend starting with medium size tubing and then experimenting to see what works best for each mother-baby pair. Where the nursing supplement container is placed also makes a difference; the higher up on the mother's body it is, the faster the flow.  If the bottom of the container is above the mother's nipple, the supplement flows non-stop, which can be too much for many babies.  The lower the container is, the harder it is for baby to suck the supplement. As the baby learns to suckle more effectively, the mother can switch to a smaller tubing and change the position of the container on her chest.

It is extremely important that the baby be well-positioned at the breast, even though baby is getting more of its nutrition at first from the supplementer.  The baby must open wide and take in as much of the mother's areola as possible in order to help stimulate the mother's milk supply better, and to assure that the baby receives the most breastmilk possible.  This is a very important point that is often overlooked when using supplementers.

There are several different brands of nursing supplementers, including the Supplemental Nursing System (SNS) from www.medela.com, and the Lact-Aid from www.lact-aid.com.  Women who have used both often report that they prefer the Lact-Aid for long-term supplementation.  They report that it is faster to use, easier to conceal, more comfortable, easier to clean, and more conducive to proper suckling.  However, both are excellent products and valuable options.  For further discussion of this issue, see www.adoptionbreastfeeding.com/supplementers.asp. 

If the baby has very poor sucking or refuses the breast completely, the nursing supplementer can also be used for finger feeding as well.  Thus, the nursing supplementer is a versatile and valuable option for long-term supplementation needs.  For more information about lactation aids, see the FAQ at http://users.erols.com/cindyrn/5print.htm.  For photos, see www.fourfriends.com/abrw/Photo%20Album/album.htm.  For further information about lactation aids, see www.fourfriends.com/abrw/Articles/uala.htm. 

• Haberman Feeder

Babies who have problems with weak sucks may be helped by a special device such as a Haberman Feeder. In this special type of bottle, the baby is rewarded for even very weak sucking efforts.  

This bottle was invented by Mandy Haberman, a British graphic designer whose baby was born with a congenital syndrome that include sucking problems and a cleft palate.  She designed a bottle that would be more like breastfeeding and would help babies with weak or ineffective sucks, such as babies with cleft lip/palate, Down Syndrome, congenital heart disease, neurological or genetic disorders, and premature babies. 

Haberman studied cineradiographs of suckling babies to better understand the mechanics of feeding.  She found that bottlefeeding involved primarily sucking, while breastfeeding primarily involved pumping actions on the areola with the baby's tongue and gums (suckling).  In breastfeeding, the baby must open very wide to take the mother's nipple and areola into his mouth.  The tongue then elongates the breast tissue and presses it up against his palate, while the tongue and jaw work rhythmically to stimulate milk production.  The baby swallows and takes a breath, then repeats the process.

In bottlefeeding the baby is trained to push its tongue forward to stop the flow of milk (so he doesn't get too much at once), just the opposite of what needs to happen during breastfeeding. He does not need to open his mouth wide to take in the mother's areola, so he tends to "nipple feed" with his lips tightly surrounding the firmer artificial nipple in the front of his mouth, and his jaws don't need to move to stimulate milk production.  

With the Haberman Feeder, the baby is encouraged to have mouth movements more like breastfeeding than like bottlefeeding.  Joan McCartney at www.widesmiles.org/outreach/ws322.html writes, "The unique design enables the feeder to be activated by tongue and gum pressure, imitating the mechanics involved in breastfeeding, rather than by sucking."   The result is thought to be closer to breastfeeding.

A one-way valve separates the nipple from the bottle, so there is a small reservoir for milk near the nipple, away from the rest of the bottle.  Because of this, milk will not flow backwards back into the bottle.  The end of the bottle's nipple is slit, making it easier for milk to come out with less suckling pressure, but a valve prevents the baby from being flooded with milk due to the easier flow.  You can see a picture of a Haberman Feeder at www.ciaccess.com/moebius/haberman.htm. 

The Haberman feeder is designed so that the baby does not get any milk unless the baby sucks, but even weak sucks are rewarded.  Thus it reinforces the baby's sucking efforts, and progressively trains the baby to suck more effectively.  Rotating the bottle's nipple in the baby's mouth helps control the rate of flow, which can help train the suck to be stronger. Air flow is also controlled so that babies swallow less air while feeding

An information FAQ about the Haberman Feeder at  www.breastfeedingbasics.com/html/haberman_hazelbaker.htm states, "The Haberman...allows many infants to develop an effective suck utilizing the tongue striping motion necessary for successful breastfeeding as well as neural development...the Haberman has been shown to improve muscle tone, awake cycles, and ability to retain sucks effectively in pre-term babies."

There is a "Mini-Haberman Feeder" available for use with premature babies. Its nipple is smaller and more suitable for the mouths of very low birthweight babies.  Information on this can be found at www.selfexpressions.com/habermanfeeder.html. Remember that the nipple and the valve need replacement about every 5-6 weeks of use in a Haberman feeder of any size, so it may be helpful to order extras of these.

A Haberman Feeder can be ordered through Medela and many other breastfeeding supply companies, including:

www.medela.com/NewFiles/specialtyfdg.html

www.motheringwithease.com/habermanfeeder.html

www.selfexpressions.com/habermanfeeder.html

www.pharmnet2000.com/medela/special_feeding.htm

If supplementation must be done, it is best to do it in such a way that preserves breastfeeding as much as possible.  Whenever possible, NURSE BEFORE ANY SUPPLEMENTATION. Your milk is dependent on the supply and demand principle.  If you are not receiving regular stimulation, your breasts will down-regulate production and supply will go down.  Furthermore, baby will suckle more strongly and effectively prior to supplementation, and will receive a higher amount of immunological protections than he would from half-hearted suckling after supplementation.  Therefore, it's to your great advantage to always nurse first and then give any supplementation.

Furthermore, some authorities suggest supplementing 2-5 times per day, rather than after every nursing.  In other words, nurse first, then offer a few ounces of supplement in some feedings, but in other feedings, nurse longer, skip the supplement altogether, and then give a larger amount at the next feeding.  By doing this, the baby will not learn to expect supplementary feedings after every nursing.  

It is important to keep up your own supply, even when supplementing.  Use a hospital-grade pump (i.e. Medela Lactina) to help stimulate milk production, not a cheap pump that is less effective.  Remember that double-pumping produces a greater milk yield and stimulates prolactin levels more effectively (Breastfeeding Answer Book).  If you can, double pump whenever possible. Alternatively, you can pump one side while nursing the baby on the other side and/or use breast compression ( www.fourfriends.com/abrw/bc.htm) to help pump more productively.

You may also want to investigate using herbs to increase your supply. Some women find herbs a significant help and some do not; because herbs are medicine too, it is important to consult an expert before using them.  See a professional board-certified lactation consultant about the proper use of herbs before trying any. There are also pharmacological medications that can increase milk supply, but some of these can have severe side effects in some women and must be carefully supervised.  See article on Increasing milk supply in A-Z of common concerns.

If the baby has become nipple confused due to bottle supplementation, this can often be remedied with time, great patience, and careful guidance from an expert lactation consultant.  There are women who have had babies who were unable to nurse and fed by bottle for many months, but were eventually able to learn (or re-learn) the ability to nurse. Many adoptive mothers have found that they were able to teach their older adopted infants to nurse, even after many months of bottles ( www.adoptivebreastfeeding.com and www.fourfriends.com/abrw/).  The process is not easy, but it is not hopeless.  It is certainly worth trying, given the superior health benefits associated with breastfeeding.  

If the baby is not succeeding in breastfeeding because of a weak suck, this can also sometimes be remedied.  However, careful guidance from an LC  in helping retrain a baby's suck is vital, and the baby must be carefully monitored to be sure he stays well-nourished and hydrated. 

If supplementation does become medically necessary, by all means do so, knowing that this is what your baby needs. You can also take comfort from the fact that many times, with help, a breastfeeding relationship CAN be preserved, even in spite of substantial supplementation.  Once the baby is doing better, the supplements can eventually be decreased until they can be discontinued altogether.  

Although breastfeeding does not always work out in these situations, supplementation does not have to be the end of breastfeeding.  Sometimes it is a necessary middle step to getting  baby back on track to breastfeeding.  Sometimes, when done judiciously, it is the factor that gives breastfeeding a second chance. Although it is hard for many mothers to see supplementation in a positive light, sometimes it really can be a helpful tool, both for baby's overall health and in re-establishing breastfeeding.  Use it judiciously.