Table 4.

Description and Examples of Main Categories of Maternally Reported Reasons for In-hospital Formula Supplementation^a

Main category	Description of main category	Examples of maternally reported reasons, grouped under each main categoryb
Low maternal supply	Not enough breast milk being produced to meet the infant’s perceived need	Perceived physical evidence of insufficient milk supply Milk not in yet (“milk not in-worried baby not getting enough”) Breasts seem/feel empty (“felt I didn’t have enough milk- breasts felt empty”) Pumping extracts little breast milk (“Baby is not getting breast milk-I don’t have any. I pump but nothing comes out”) Baby’s response to breastfeeding Baby fussy after breastfeeding but satisfied after formula (“she’s hungry and crying, not satisfied after breastfeeding”) Baby frequently seems hungry (“my baby is never satisfied-he’s acting like he’s starving to death”)
Signs of inadequate infant intake	A clinical sign that the mother or a health care provider perceived as indicative of a need to supplement	Hypoglycemia (“to stabilize blood sugar”) Excess weight loss in infant (“baby losing too much weight”) Jaundice Not enough bowel movements or voids (“no wet diapers in the first 24 hours”)
Poor infant breastfeeding behavior	Reasons related to the infant’s ability to feed effectively at the breast	Difficulty latching (“baby getting frustrated, can’t latch”) Baby too sleepy to breastfeed well (“baby falls asleep at breast”) Baby refusing to latch/prefers bottle (“baby now is used to the bottle”)
Separation of dyad	Any instance where the mother included in her response that supplementation occurred when she and the baby were separated	Baby in NICU/re-hospitalized (“Baby in NICU, initially the nurse fed her”) Mother in special care unit (“recovering from emergency C-section and seizures”) Nurse gave formula while caring for baby (“nurses gave the baby formula to calm him down, without our consent”)
Psychosocial reasons	Includes any response where the mother reported supplementing with formula for psychosocial reasons, particularly related to attitudes toward, knowledge about, or confidence in breast- feeding	Socio-emotional discomfort with breastfeeding The idea or connotations of breastfeeding (“at first, I didn’t want to breastfeed: I thought it was disgusting”) Embarrassment to breastfeed/preference for privacy (“my parents were around-I didn’t feel comfortable breastfeeding around them”) Unsure how to breastfeed properly More confident in ability to formula feed (“decided to give more formula because I’m more comfortable with it”) Unsure how to determine how much milk the infant is getting (“so I know how much formula my baby is getting”) Breastfeeding more inconvenient, difficult, or time-consuming than formula feeding Too tired to breastfeed at times (“I was tired and needed a break from my baby crying”) Breastfeeding is more difficult than formula feeding: at night, because of a C-section, etc. (“was in a lot of pain and couldn’t hold my baby; wanted someone else to feed him”) The baby isn’t satisfied for long-enough stretches (“baby wants to breastfeed all the time”)
Breastfeeding pain	Report that sore breasts or painful nipple led to formula supplementation	Sore, damaged, bleeding, painful nipples (“to rest nipples, which have blisters and cracks”) Breast pain (“engorgement”)
Maternal incapacitation	Report of being too incapacitated to breastfeed	Mother was told by health care professional that she was too incoherent/heavily medicated to breastfeed (“was too out of it to breastfeed-I had lost a lot of blood’)
Maternal medication	The effect a medication has on breastfeeding ability or safety, regardless of true medical indication.	Mother believes that a medication has affected her milk supply or the breastfeeding process (“concerned my baby is not getting enough because he’s sleepy from magnesium”) Health care provider said that lactation is contraindicated (“had to ingest dye for radiology-the radiologist said not to breastfeed for 24 hours”)

^aMothers were asked at the Day 3 interview to provide reasons for formula supplementation (if any) for each 24-hour interval since birth.

^bMothers could give multiple reasons in their open-ended response, and some reasons were coded under more than one main category. Examples of maternally reported reasons under main categories are enclosed in parentheses.