Executive Summary

I had a thought today that I would like to know the answer to. With so much publicized research being done on the properties of breast milk (antimicrobial, stem cell properties, brain development and so on), where is the research into real lactation problems? Where is the safe approved drug to increase milk supply (Metclopramide isn’t really ‘safe’ and Domperidone isn’t really ‘approved’), where are the actual diagnoses for supply problems? Maybe companies would rather head toward synthesizing the properties of breast milk rather than helping to fix bodies to produce it. After all it’s only several hundred thousand women a year, and formula does exist (my tongue is so far into my cheek it might poke through…)

I don’t know. I suspect there is not a satisfactory answer.

So I leave you with this. A short guide to various posts that are intended to be helpful.

I need help:

How to interview a Lactation Consultant

11 things a Lactation Consultant should know how to do (IMO).

Do I need help?

I find my tongue tie resources out of date, though you can see my experience here. For better information I would urge joining this Facebook group. They maintain lists of providers and are fairly knowledgeable about what is to be expected. If a provider is not on their list people can often recommend local alternatives (for instance I know of at least 4 laser tongue tie release places in New Zealand now, but none has made the general list. Do see the New Zealand Tongue Tie resources page instead.)

I need to combination feed-how do I do this?

The big fat Combo feeding FAQ

Walking the line

Benefits of

With low supply

SNS tutorial

Nipple confusion

Managing long term

Formula

Solids

Weaning

Body Image

What is causing this?

Able

Potential causes

Birth complications

Rare vs Undiagnosed

My most popular post

Making Milk beads

And the rest of my life.

I think I no longer feel bad, because it isn’t something I did wrong. It’s purely a medical issue.  A medical issue that some people would have me believe is my fault. A medical issue I cannot get satisfactory treatment for and that is largely undiagnosed. That makes me mad.

I lie. I still feel bad and somewhat inadequate, but I no longer feel guilt. I do wonder how much of my feeling bad is a normal level for someone suddenly faced with a non-life threatening failure of a body part. Somehow I can’t imagine people feel a mix of loss of gender identity and self loathing after losing a kidney or having a splenectomy. Or losing a finger or a limb. I’m sure there are other mixed feelings but I wonder how often self hatred/loathing/failure is a part of that.

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Cooking with Milks

Another consequence of my second child being such a fuss butt was that when I went back to work she refused a bottle. I feel like a meme belongs here.


Anyhow, in two children I’ve learned to use up my milk. It was hard to come by, be damned if I’m going to tip it down the drain.

Milk jello.
This sounds so grody, but it’s a reasonable option. I tried it first with formula, but it will work well with expressed milk too. A half and half mix with powdered or concentrated formula will likely work best for technical reasons.
Add gelatin to boiling water and dissolve. This is the technical reason I mentioned. Gelatin dissolves a lot slower in milk than water. So you could boil your breast milk and dissolve gelatin into it. But it will take longer. Add appropriate amount of formula for the amount of water the gelatin is dissolved in. Add your milk. Pour into containers and allow to set. I found 14g (1/2oz) ad 200ml far too firm. My baby could pick it up but couldn’t really suck bits off. I doubled it (you can melt it back down in a double boiler set up. If you don’t have a double boiler a frying pan with water and a pot in that will work just fine) and it was still a bit too firm. Follow the directions on the package. Use within 3 days.

Milk custard.
One version requires your child able to have eggs so after solids are more established perhaps. You can omit the egg and make the custard more of a roux instead though if you do that I would definitely make it in a pan stove-top.
The smallest amount is about 100ml of milk, 1 egg yolk and 2 tsp of corn flour or corn starch(I wonder if you could use tapioca/arrowroot or other flour for this instead). You can even do this in the microwave. Mix ingredients and whisk. Heat for 1 minute in your microwave and whisk again. heat for 30 seconds and whisk again. Repeat until it starts looking thicker around the edges. It should be setting up by this point. If doing in a pan just heat and whisk until setting up. Cool and serve or put into containers to set. To double it use 200ml milk 1 egg yolk and 2-3tsp flour. After that you will need another egg. Also more flour. Feel free to add extras-fruit, sugar etc. This was intended to get fluids into my non-drinking kid so I started out with basics. Keeps for 2 days.

Muffins
This is what I did with all my lipasey milk from my first child. She wouldn’t drink it so I baked with it.  I also made some jewelry…

Anyhow.
1/2 cup flour, 1 small egg, 1/2 cup milk, 1tsp baking powder, 1 tbl oil and whatever fruit, spices and extras you want to put in there. This recipe doubles as a pancake recipe. Our favourites were apples and cinnamon, pumpkin, lemon zest, berries etc. Keeps for up to a week and can also be frozen.

Human milk proteins, carbohydrates and fats are still good, so if you need to use up some old or slightly off milk cook with it. I use these techniques on milk that for example is lipasey, has not been drunk all day at daycare etc.

We also found soaking some bread in the milk worked well. Pretty much the cereal principle, but for the Baby Led Weaning self-fed child.

After 3 weeks of fussing, losing weight and playing around we found a sippy cup (just a cheapo plain one) that she would take that made daycare happy. But I’m still pumping milk and occasionally need to use some of it for non-drinking activities.

Take 2: When you think you know what to do and are so very wrong.

Now that we have put the SNS away at home, a little earlier than with the first kid, I should get what I learned from my difficult second child down somewhere.
Well I say difficult, but she was difficult only because of my milk supply issues.
She developed very minor jaundice early on. Not enough to worry anyone but enough to get really really sleepy.

By 6+ days old we had to institute a waking and feeding schedule and we had to continue waking her for feeds until well over 2 months of age. Yay baby sleep you might think. Yes, on one hand this was nice because my first did not sleep and instead ate all the time. Sleep also makes it possible to do hard things. Like lots of pumping. But with low supply you do want an eager baby stimulating your supply. So every 3 hours I had to wake her up and then came the 1-2 hour long ordeal of keeping her awake through feeds just in time for the next feed to start. Every 3 hours 24 hours a day. Blargh. Wet cloths, undressing, blowing in her face, and even icepacks on her feet. And because she was so sleepy and not able to get enough from me part of this routine came to involve force-feeding with a bottle. She came to hate the bottle. In fact she hated anything not a breast in her mouth. Maybe having her tongue tie and upper lip tie lasered at 3.5 weeks oversensitized her but she developed into an orally particular baby.

As I knew how to use the supplemental nursing system I was eager to do that rather than bottles, but she became quite particular about the tube in her mouth. The medium tube which had a faster flow was not acceptable and occasioned screaming if it even touched her. The small tube was never fast enough initially (not that she seemed to care…) and often feeds would take over an hour to complete (even into her 4th+ month). Instead of latching her with the tube near her upper lip I started sliding it into the corner of her mouth around 7-8 weeks and that was the only thing that would work. If she detected it she would fight to get it out, preferring plain breast but of course that wasn’t an option. She developed aversions to one breast and for a while even one position because of association with the tube and I had to exclusively use it on the other one.
She made feeding my first look easy. Sure with number one I had low supply and I was learning as I went but after working out the initial technical problems and difficulty it became routine and predictable. Not so this time. Things were always irregular and a struggle if not an outright fight. I was tracking her intake, output and weight gain until nearly 7 months, where I pretty much stopped the tracking with my first by 3-4 months as things were so routine. The part that bothered me most was that she could not be trusted to self regulate with milk. she would stop and if we let her do that she would not gain appropriately so there were minimum intake volumes she had to meet. This often required waking her up and trying to get more milk into her. So it was a chore.

Things that helped with this difficult baby?

  • Primarily putting the tube in the corner of her mouth. Here is a short and not very good video.

She so very much hated the texture of the tube that putting the tube against her upper lip lost us some breastfeeding positions for a while as she came to associate them with tubes in her mouth. The latch wasn’t great but it was hard to fight about drinking and fight about latch. Especially when she preferred to slip down.

  • Using the NG (naso gastric) feeding tube in a bottle. I was at the point where she would not feed in several positions, would not take the Medela SNS tubing the ‘right’ way and would not take a bottle and I thought I would have to finger feed her or start syringing milk into her mouth. Its a very frustrating position when you want and need help but you know that you know more about alternative feeding methods than any professional you might ask for help. I got one of these NG tubes-which by the way is fairly stiff and inflexible- and stuck it in the corner of her mouth…and away she went. It wasn’t bothering her.

So I then learned how to sneak the SNS tubes into the corner of her mouth. The SNS medium tube is far more flexible than the NG tubing but not nearly as thin and flexible as the small SNS tubing (case in point I have been through multiple small tubes as they develop pinholes just from regular use. At least 2 per child. I have not had to replace the medium SNS tubing through 2 children, but then I don’t use it every day either). But I learned to stick both of them in the corner of her mouth. And things worked. Mostly. Sure feeds took 20 minutes for ~60ml supplement on a good day (and 40-60 minutes on a not good feed- keep in mind this is after 10-20 minutes of regular breastfeeding). And the tube would wiggle and it would need a lot of adjusting (this is why I was happy I had the Medela SNS because when liquid is being consumed you can see air bubbles. Not possible with NG tube in a bottle method), but it worked. But maaaan was I glad to put it away.  No excitement that I was finally meeting her needs (+solids), just relief to be done with such a tedious fussy feeding regime. She’s been fine with plain breast. Which was part of the problem, as that is what she preferred and was not an option because of my supply.

Lesson learned. Never think you know what you are doing.

Why a correct diagnosis is important.

Or how wait and see doesn’t cut it.

For the first 8 months of my first child’s life I thought I had low supply, probably from insufficient glandular tissue. I wanted a definitive diagnosis though and couldn’t find anyone to give me one. Then around 8 months, after we’d transitioned to just solids and breastfeeding and put the SNS away in the closet I noticed something that led me to believe that a posterior tongue tie might be the real problem. I couldn’t get a diagnosis for that either, but the more I read and researched a tongue tie did seem to be present. That discovery filled me with hope. Hope that next time would be different, that there was something I could do to make things better. So I planned my next breastfeeding experience around that. I lined up tongue tie release, made my midwife aware of my history and suspicions and mostly did as I was told- to wait and see because this time things might be different. I was told different child, different mouth shape, maybe no problems this time. I was dubious, and didn’t use as my midwife anyone who refused to take my concerns seriously, but I did get some variation of wait and see from everyone I talked to.

Just to hedge my bets I drank various teas throughout my pregnancy and made all my postpartum meals full of lactogenic ingredients.

And then I had my second baby, not how I planned, in fact things went in a way I hadn’t thought to plan for, but I had her and it was ok. Not great, not bad, but ok. And there was an obvious tongue tie, not a posterior one, and there was some waffling about whether it would cause problems from the hospital lactation consultants, and my midwife went to bat for me and we got it snipped anyhow. It made the latch a bit better and things were going normally. We were proceeding with caution, and I was getting some varying opinions on whether intake was good. Some people said looks good, some people were concerned about swallow frequency. I was a little stressed out, but I was assured that if I hadn’t had any history that no one would be worried. I was cautiously optimistic. Things were already different and better by leaps and bounds in terms of latching and output and weight loss.

After 5 days we went home. My milk came in, though there wasn’t engorgement as such, just a feeling of fullness and heaviness. I wasn’t too worried. After all some women don’t have much engorgement, right? Yes, but. Be concerned when you keep running into signs and symptoms that by themselves don’t mean much but when accumulated paint a more dire picture.

We’d had 8% weight loss by day 6. Well within normal ranges. Considering last time we’d had 11%+ by day 5 and more after that, 8% was fantastic. Output was good, my optimism was increasing. There was still concern about swallow frequency, but things seemed to be going well.

By day 11 only 60g (2oz) had been gained. Normal newborn weight gain should be at least 30g/day. I’d been expressing milk on top of feeding to boost my supply and to give as top ups to combat the cluster feeding. My midwife wanted me to get more than 2 hours sleep per day to help my milk, and also because having a toddler and a newborn isn’t sustainable on 2 hours of sleep out of 24.

The baby was sleeping more and more. We were feeding on demand, but where #1 had screamed and cried and never slept unless held, this one would sleep for 4+ hours, fall asleep at the breast and was generally very lethargic. I was pumping 4-6 times per day on top of feeds, and giving that milk via the SNS. Output was still good.

And day 15 came and the weight was the same as at day 11, 210g below birth weight. And the baby was so lethargic at that point that getting her to take a bottle was over a 1 hour affair of cold cloths, stripping, changes and so on for 60ml consumed.

So now we went into disaster management mode. I was to give 60-100ml via bottle every 3 hours day and night and pump afterward. We practically have to force feed the baby at this point.

It’s been a few days of that and hopefully birth weight will be regained in another day or two and we can revisit other feeding options, or even go back to feeding on demand.

And that’s where we are now. I wish we’d known before that IGT was the issue. I wish I’d been able to get that diagnosis. I could have been using the SNS from around day 10 or before and doing test weights to measure intake rather than disaster management of a lethargic and dehydrated baby.

Now I’ll likely have to contend with nipple confusion, breast refusal and possibly losing any kind of breastfeeding relationship. I might still be able to pull this situation out of the fire, but a diagnosis last time would have made this easier.

 

Oral confusion-how nipple confusion works

Let’s talk about nipple confusion. Wherever anecdotes are valued as useful you’ll find plenty of stories that illustrate either view on nipple confusion. Babies who were given bottles early on and the mothers who had huge struggles getting them back, if ever, to the breast, as well as those who routinely gave their babies bottles and never had any issues at all.  So what’s the deal with nipple confusion? Nipple confusion is a collective name for something that is a combination of factors. Side note: I found this article, which looks like it would be a fantastic resource. Unfortunately, like many of Dr. Neifert’s articles, I can’t get electronic access to it (even at work where I have access to all kinds of journals). I’m sure that would pretty much replace my little post here, but since I can’t read it, I’ll just write this instead.

Teat Confusion:

First off there is teat confusion. How something is sucked. Babies are crafty, tricky little beasts. It’s part of their biological programming to experiment and problem solve in order to figure out how to best get milk out of breasts.  So teat confusion can arise from bottle teats and pacifier teats. Bottle teats as the method of getting fluid out of a bottle teat is different than out of a breast (see Myth 15 and associated citations). With a breast the mouth needs to gape wider and the tongue move to extract the milk via a peristaltic action. So undulation of the tongue.

With a bottle, the mouth does not need to open as wide and the tongue does not need to move out to extract the milk, but instead stops the milk from running down the throat too fast.

With a pacifier the method of suck also can effect musculature changes and the pacifier is inherently a non-nutritive sucking action. So the baby will do it because they enjoy the action of sucking. Something they are also biologically conditioned to like. With pacifiers there is no reward for improved technique (as with breast and in some cases bottle feeding) and the sucking action does not train the tongue appropriately. In addition the baby may associate sucking with no reward and be less enthusiastic about trying their luck with sucking from the breast.  With normal breast feeding let down can take a short while to start, so a baby who is conditioned early to suck an artificial nutritive teat may lose patience with waiting for letdown to produce milk

Flow Preference:

Another factor in nipple confusion is flow preference. Bottles have different flows, slow to fast. Not all slow flows are created equal as well. Probably each bottle/teat type is slightly different. So if a bottle, which has a different sucking method required, produces a faster, more generous flow of milk, or conversely a slower and more manageable flow, then the infant may find that preferable.  There is evidence that bottle fed infants suck less frequently and in different patterns than breast fed infants. Flow from the breast changes over the duration of the feed and a bottle is constant.

Latch:

The main factor in nipple confusion, however, is how good the latch is. The better the latch, the less likely the infant will experience nipple confusion. So babies with tongue ties or other oral abnormalities, or who have mothers with difficult nipples, will exhibit higher rates of nipple confusion signs. In addition to these conditions often producing issues with appropriate latch and milk extraction, often resulting in early bottle use, extracting food from the bottle is often easier for those without a normal range of oral movement.

Time sensitive:

Another factor to consider is that nipple confusion may not be immediate. I found when I needed to start combination feeding that while things were fine at first with supplementing by bottle, starting at 5 days with expressed milk and moving to formula by 2 weeks, by 4-6 weeks we had had some strong instances of breast refusal. This goes back to babies being tricky beasts. They start learning that if they fuss or refuse the breast that they can get some other potentially easier food. The most common ages for breast refusal due to nipple confusion or flow preference are  under 1 week, 2-3 weeks, 6 weeks, and 4-5 months. These coincide fairly consistently with growth spurts.

This is why it is recommended to not introduce bottles or artificial soothers before 4-6 weeks. By that age it’s assumed that the infant will have figured out milk extraction from the breast and will be less inclined to prefer the bottle over the breast. In addition, the mother’s milk supply will have begun to stabilize and a missed feed here or there under normal circumstances will not unduly affect supply. This guideline obviously errs well on the side of caution.

Prevention:

When you need or want to supplement with breast milk or formula and you want to minimize nipple confusion there are a few ways you can do this

  • The bottle latch: You’ll need a wide base bottle that encourages a wide opening of the mouth. Choose the slowest flow teat you can find to start with. Here is a  guide on choosing a teat. Purely by chance we used the Avent newborn flow. We used these until 12 months of age.
  • Finger, syringe, cup, and spoon feeding. Of these finger feeding may be the least pain in the ass. I’ve done both syringe and cup, as well as suck training with my finger and finger was by far the easiest. I’d imagine spoon feeding is similar to cup feeding in mechanism. This article sums up alternative feeding methods well. It says that cup is often not worth the hassle unless repeated supplementation is required more than 3 times. You can also use an at breast supplementer taped to your finger.
  • At breast supplementation: If you have a latching baby under 6 weeks this is the way to go. After 6 weeks if you have not yet experienced any latching issues or breast refusal you can try bottles. If you have been using bottles up until now and your child is not  yet at that grabby phase you can give this a go. Some babies are ok with it, some hate it. It’s just something to try.

The Big Fat Combofeeding FAQ

I see a lot of people combination feeding (combining both formula and breast milk in various ways) either out of necessity or desire. Many professionals either disregard the impact this practice can have on one’s supply of breast milk, or believe that combination feeding is unworkable. Many people who start combination feeding without proper knowledge may find themselves stopping breastfeeding prematurely. I had a lot of questions when I started so here are the questions I see asked most often and some answers.

Why combination feed?

  • Work

Perhaps you have a job where pumping is not an option, either due to social considerations, the nature of the work, or simply that you are unable to pump  enough to feed your baby while you are apart.

  • Supply

If you suffer from a low supply or milk transfer issues you may wish to breastfeed but be unable to do so exclusively.

  • Preference

You may prefer to have a family member do one or more feeds per day via a bottle.

Is combination feeding hard?

Yes it can be. Depending on when and how you start, as well as your personal biology and situation, it can also be a good alternative to stopping breastfeeding completely.

How do I do it?

  • Frequency

How often does my baby need formula? This is something that will depend on your circumstances and why you are combination feeding. If you are doing it for work or other separation from baby then you should feed your baby as normal when you are together and have a caretaker feed them as much as they would like during the day. If you are combination feeding due to low supply then you need to figure out how much milk your baby can get from you and offer the balance. There are calculations for this, but I did it by breastfeeding first and allowing my daughter to take as much as she wanted via at breast supplementer.

  • Amount
Breastfed babies often take smaller volumes than fully formula fed babies. The average breastfed stomach volume is 2.5oz to 6oz. Don’t worry if your combination fed baby is not taking a full 5-9oz. This is normal. The entire time my daughter was combination fed her usual volume intake per session was 3.5oz, or around 100ml.
  • Supply

How do I keep my supply? The best way I’ve found to do this is to have rules about combination feeding. You need rules because you are beating back biology. Producing breast milk is a resource heavy process. This is why it burns 20+ calories per ounce/30ml. So your body would naturally prefer to not burn those calories and store them for later. You need to challenge your supply to some extent. A one off break in routine (you are ill and need sleep so you do not breastfeed the baby at the normal time) will not ruin your method, but a consistent pattern of breaking your rules will erode your supply (I’m too busy/tired etc to maintain my rules). This is especially important early on (before 3-6 weeks) before your supply stabilizes. My maxim for this is formula feed on a schedule and breastfeed on demand.

  • Method

How you combination feed will depend on a few factors. Why you are combination feeding, the age of the child when you start, and your schedule.

If you are combination feeding for low supply or milk transfer issues and your child is not very old I highly recommend trying an at breast supplementer.

If your child is older (6 weeks +) and you have supply issues and the latch is fine then you may have better success with a bottle. Of the people I know who have combination fed long term using bottles they started after 6 weeks. If using a bottle I recommend using teat that most replicates your personal let down. Many people find a slow flow teat to do the trick, but if you have a fast let down (not usual in low supply), you may find a slightly faster teat works better for you. I don’t know if any of the specialty teats marketed as breastflow or otherwise will help with nipple confusion. We used a newborn flow (single hole) Avent teat for home and daycare until 12 months.

If you are combination feeding due to work or other separation from baby or preference you may find bottles or cups more appropriate for your situation.

  • What’s the best formula for combination feeding?

Short answer-there isn’t one.

Long answer-The WHO (World Health Organization) mandates that all commercially available baby formulas have similar ingredient lists. Not to say they are all the same. There are variations. The best way to see which is right for you is to give your child 2 weeks on it. If after 2 weeks (or you are experiencing some other major issue) it is not working, feel free to try another brand. I know that’s not very helpful. Sorry. Some formulas have more protein, some have more iron. What you do want, especially if your baby is under 6 months old,  is a whey based formula. The casein based formulas are not suitable for younger babies. Things like hungry baby milk have a higher proportion of casein than whey as it’s more difficult to digest. Here are some articles on that: Gut floraChoosing a formula #1, Choosing a formula #2

  • Is there some kind of magical breast milk formula balance?
No there isn’t. Any amount you can give will be beneficial. Formula doesn’t do any ‘cancelling out’ of the benefits of continuing to receive breastmilk. You may be interested in reading about the benefits of combination feeding.

Personal considerations Your biology

A sensitivity of a woman’s supply is highly variable. Some women can miss a pumping session or feed and find their supply tanking almost immediately. Others stop breastfeeding completely and still leak milk weeks down the line. You’ll need to determine through observation where on that continuum you lie. Generally though, you will not see significant changes in under 3 days. That means, that after your supply is established it will take 3 days of dropping a feed for your body to get the hint and slow down production. This also means that it can take 3 days to see an increase. This is not necessarily applicable during the early stages. Before 3-6 weeks milk supplies are much more variable. Small things like pumping in addition to feeding can cause your supply to increase, and skipping feeds early on can cause your supply to dry up very quickly. Engorgement will also slow down your milk production. The fuller your breasts are the slower you produce milk. A consistent pattern of engorgement will decrease your supply during that time frame. You will need to tailor your combination feeding plan to work with your body.

Poop- what is normal?

Considering one of the main ways we communicate with our babies is observing poop this is a pretty important consideration.

There seem to be fair number of resources on what normal breastfed poop is like and what normal formula fed poop is like, but what about a baby receiving both?

  • Appearance:

This is very dependent on what your formula looks like (as poop) and how much your baby has.

For example, my baby was on three different formulas. Formula #1, which my baby was on from 2 weeks to 2-3 months was a probiotic formula. This formula started off coming out as yellow, but eventually progressed to coming out green. The consistency started off as loose and semi-solid and progressed to being more like modeling clay. The second formula was used in various emergency situations and not regularly. The color was yellow, the consistency semi firm, similar to paste. The Third formula was used from 2-3 months until no longer needed. The color was yellow and the consistency was like mashed potatoes.

  • Frequency:

A breastfed baby, after several weeks of age, may poop as infrequently as once every 10+ days. A formula fed baby may need treatment for constipation if poop is less frequent than every three days. A combination fed baby may fall somewhere in the middle. I found mine would go daily, or more, at first but by several months of age had progressed to every 3-5 days. No one could answer my questions about how frequently my baby should be pooping so we were treating her for constipation with diluted fruit juices and sugar water. After pushing a bit more some of my health care professionals decided that since she was not in pain during the bowel movements, the consistency was not hard or pellet like that the 3-5+ days was fine.

So I’ll pass that on. As long as the consistency is not hard or pelletlike, the child is not in pain from pooping and is not unduly uncomfortable from not pooping then it is not a major concern. This is also dependent, in my opinion, on how much formula your child is receiving on a daily basis. The less formula, the longer you may wait between bowel movements, more then less. My child was receiving 300-400ml (12-14oz) of formula daily, so about 1/2 her expected intake.

Update: In response to a some search engine hits I get I’ll expand on this to cover the other end of the spectrum. Breastfed babies, instead of not pooing, can also poo upwards of 10 times a day. And this is normal as well. If your combination fed baby is pooing frequently there is unlikely to be any cause for concern. Normal breastfed baby poo is fairly liquidy, seedy and yellowish.  What is not normal even for the combination fed infant is dark poo (after the meconium has all passed), ongoing greenish poo that may be frothy, excessive mucus (again, this may be expected around teething), and of course blood. Green poo is  ok for a few days as it can be a sign of illness, and is also normal after vaccinations and if you are giving a probiotic formula. The other ones may merit a doctor visit.

Important things to consider

  • The importance of establishing your supply.

The first 2-3 weeks are important for your development of prolactin receptors. It’s very important to feed on demand during these times so that you will have an adequate supply later on. After 2-4 months your supply stabilizes, your breasts soften and milk production becomes less hormonally controlled and instead based on what is removed. The amount of prolactin receptors you created early on can help you maintain your supply long term.

  • Breast milk is use it or lose it

As mentioned earlier breast milk is a system with high production costs. If your baby isn’t using it (emptying the breast) your body will make less. Your body is lazy and wants to do as little work as possible.

  • Your baby is a person too and may not cooperate with best laid plans!

Your baby may decide they don’t care for the at breast supplementer, or like the bottle, or don’t like the bottle or any number of other things. Or you know, maybe they just aren’t that into breastfeeding as they get older. Early on when we were using bottles and breast my child went through some breast refusal which is what prompted me to swap to an at breast supplementer. Then when she went to daycare at 4 month she had to be retrained to take bottles. Now at 14+ months she will not take a bottle from me.

  • How your baby can help

Consider this if you find yourself losing your supply: if your baby increased your supply once they can do it again. Sure it means clusterfeeding, but it can come back up.

Managing being away from baby

  • Pump or no pump?

To pump or not to pump will depend on several factors. How touchy your supply is should be one of them. However, you may be combination feeding because you cannot or do not want to pump during the time you are away. While dealing with low supply I pumped at least n or n-1, where n is the number of feeds my baby would have had, times during the day when I was apart from my baby. I managed between 30-50ml per session from both breasts combined. I was away from my baby from 8am until 5pm+. From 4-6 months I pumped 3x per day (10am, 12pm, 2pm), from 6-8 months I pumped 2x per day(10am, 2pm) and from 9-11 months I pumped 1x per day (12pm). At 11 months I stopped pumping during the day and fed from the breast when at home. During this period my first day home was full of frequent feedings as my daughter increased my supply again.

If you are unable to pump you may find some benefit in hand expressing during bathroom breaks. This will continue to stimulate your milk production and help prevent blocked ducts and mastitis.

  • The 5 day work week

I had a part time job so I only had a 3 day work week. For those with a 5 day work week (or longer) you will find that by midweek your supplies are decreasing. If you are pumping add an extra session later in the week. You will also want to encourage you baby to eat from the breast as much as possible at the weekend, or on other not work days to maintain your supply. It may go without saying, but I’ll say it anyhow, but the longer you can give your baby time to establish breastfeeding the easier it will be to maintain when back at work, whether pumping or not.

Nipple confusion and flow preference

Nipple confusion is thought to be most prevalent the younger the baby is.  From reading I’ve done it has a few other factors as well including how good the latch is (if bottle milk is vastly easier than breast milk for the infant to obtain then bottle milk will be preferred) as well as the milk flow from the teat. I’ve mentioned it previously, but many people find a slower flow teat helps preserve the breastfeeding relationship. I find that whatever is closest to your let down (slow or fast) will keep the confusion to a minimum. The times when you are most likely to see issues with swapping between breast and bottle are any of the growth spurts (10 days, 3 weeks, 6 weeks, 12 weeks, 4 months, etc), although the 6 week one is the worst. The other one where people doing breast and bottle are likely to hit issues is around 4-5 months. This is an incredibly fussy time with teething, sleep regression and similar and if breastfeeding is not well established as both a comfort and food activity then babies may not be willing to expend the effort to continue. This outlines some details on nipple confusion and how to prevent it.

  • Momma vs not-the-momma

Babies will form different rules for different people. They may expect only breastfeeding from their mothers, and refuse a bottle, but happily take a bottle from another family member or caretaker. I found that preserving our breastfeeding relationship depended early on on how my baby knew to get food from me. Because I had to start so early I had to be very strict with what rules we followed so that we could continue breastfeeding. After we started using the at breast supplementer I did not give my baby bottles. She had bottles from dad and bottles at daycare but mom=boob. If you do want them to take bottles from the breastfeeder I recommend waiting until after 6-8 weeks to introduce them, and certainly by 8-9 months.

What’s the deal with growth spurts? 

This is a new subsection in response again to search engine hits. So what do you do with a combination fed baby having a growth spurt? Be aware that typical growth spurt ages are 7-10 days, 3 weeks, 6 weeks, 3 months, 4 months, 6 months, 9 months and 12 months. This is on average. You may miss or not notice one, or have an extra one (we had an additional one at 9-10 weeks).  During this time babies are unsettled and may want to eat frequently either for comfort or out of hunger. I found during these times that it wasn’t strictly necessary to increase the amount of formula, but it was necessary to give smaller more frequent feedings. As our typical supplementation pattern was 7am, 12pm, 4pm, 7pm, (with breastfeeding sessions at those times and also at 10am, 2pm and several times overnight), during growth spurts breastfeeding became more constant between 9am and 11 am, and also between 1pm and 3pm. At times I split the 12 pm supplementation into two sessions, with smaller amounts at 11am and 1pm.  Do be aware that this is temporary and your baby will be fussy.  Try to stick to your schedule and plan and get through it. Growth spurts and teething are times when your combination fed baby will be more likely to refuse the breast.

Other tips:

If you can, avoid mixing expressed breast and formula milks. Why? Because if your baby doesn’t drink all the breast milk you can re-refrigerate it and reuse it at the next feed and you can’t do the same with mixed or straight formula milk.

The benefits of combination feeding

I don’t know why I didn’t do this earlier. I think I thought I had it covered with the pros and cons of breastfeeding with insufficient supply, and my how-to post Walking the line with combination feeding , but I remember feeling so down about combination feeding because everything I read, written by somewhat inflexible lactivists, was about how artifical breast milk, formula, was going to undo any good that breastmilk was doing. That simply is not true. There is no evidence to support this in the majority of situations, and I’ve found most claims otherwise to be wholly conjecture. Exclusive breastfeeding is best (because it’s what is normal), but if you can’t for mental or physical reasons and can provide some breast milk without undue trauma, then that is what is best. There are a few select areas where I’ve read the research and I agree it does indicate that early introduction of formula removes some protective effect that exclusive breastfeeding provides (and I’m not going to link it here because if you are reading this you probably don’t need something else depressing you!), but by and large if you must combination feed the formula isn’t somehow counteracting the benefits of human milk.
The biggest reason:
It’s what babies expect. Babies expect the breast externally and internally expect breast milk.
Let’s talk about internally first. To use a food based analogy that I think won’t be offensive (unlike the ones comparing formula to Slimfast, Ensure or McDonalds) People are meant to be omnivores. Lots of research supports us, as cave people, eating eggs, fish, fruit, greens and some grains. But some people are vegans. What you get from animal products are bioavailable molecules like cholesterols, fats, proteins and carbohydrates that are most similar to our own. You can live, and some live quite well, as a vegan. Eating a balanced vegan diet with no animal products your body will manufacture cholesterols from plant oils, will take the vegetable based fats, amino acids, proteins and carbohydrates and create whatever chemicals the body needs. It’s simply easier for our body to do this with animal products. And so with breast milk and formula. With some human milk in the diet a baby will have easy access to easily converted human fats, proteins and carbohydrates. With formula the child’s body can make what it needs from the building blocks available. That said, the more available the better, but the big benefit of combination feeding here is that a combination fed baby will use the most easily digestible, the most bioavailable fats, proteins and carbohydrates first, before using the building blocks from artificial milk. So what benefits are we looking at here? Myelination of nerve sheathes, presence of bioavailable cholesterol, promotion of appropriate gut flora though the presence of human milk fatty acids such as lauric acid (also found in coconuts), mother’s immunities (some research suggests as little as 2 ounces per day aids with this), reduced constipation and the majority of the other benefits of breastfeeding can be obtained by having some human milk daily. Of all I’ve read there are only two, possibly three, benefits of breastfeeding that are known to be reduced or changed in any way by the early (pre six-month) introduction of artificial milk. So next time someone touts the benefits of breastfeeding know that if your baby is getting any human milk per day that you have a stake in those benefits as well.
Now externally, babies expect closeness, expect skin to skin, expect the oral development from sucking on the breast. Babies expect the problem solving skills they learn at the breast, how is best to get milk out of this thing? Much of this can be replicated with bottle feeding and thoughtful parenting because what babies expect most is care and love.
Now to shift back to modern life people may find benefit in combination feeding while separated from baby, especially if expressing is impossible or impractical. People may find benefit, because we now lack the extended family structure that used to be available to aid with child upbringing-something that causes a fair amount of pressure I believe, of having some time away from a baby. These are all personal choices and unique to your family and situation. I’m inclined to believe that if it keeps breastmilk coming for longer then it is better than having pressure build up to an untimely end of breastfeeding. But for those who find combination feeding an unwanted necessity there are positives to focus on.
But how much is enough? There’s no real research on that. Some studies indicate that two ounces (50ml) per day contains all the immunological necessities, but that study was done on toddlers in combination with solids, not breast milk and formula in younger infants. As it’s the only real volume based piece of research available that is the number I’ve clung to in the past. I’ve told it to other people as well and having something concrete to fixate on has enabled many of them to keep going and meet their alternate goals. Two ounces per day is a more relaxing goal than some unknown amount. If your output varies from day to day you aren’t feeling as much despair as it goes from 12 to 10 to five, you are feeling happy about keeping it above two. And more is obviously better, but when more isn’t an option, having an achieveable limit to aim for can be a mental lifesaver.

All of these things are like the others

What do milk expression, donated milk and formula have in common? They are some of the most commonly misused tools for feeding babies.

A mother should never be set to pumping to fix a problem. Sadly it’s something I see all the time. Women who have problems start pumping and can’t break the habit. Pumping as a longer term solution should be reserved for mothers separated from babies, ill infants or babies otherwise unable to nurse. Pumping is an amazing tool for premature infants, working mothers and as a temporary measure for other issues. Pumping can even work for some women who do not want to breastfeed, but still want to be the sole provider food for their child. It is rarely emphasized, however, that this is an unrealistic ideal for many women. Pumping shouldn’t be seen as an alternative to breastfeeding for mothers experiencing pain or a non-latching baby. Those are real problems that can be addressed through actual support, but too often women are fobbed off, either by their care team, or as a misguided self preservation method, to using a pump.

Donated milk is an amazing tool for ill mothers, orphaned or adopted babies, those required to take medications unsuitable for breastfeeding, those with chronic lactation issues and as a temporary measure for those with potentially solvable lactation issues. I’ve talked to a few women who had breastfeeding difficulties and instead of getting (and sometimes even seeking) professional support turned to donated milk and eventually formula.

Similarly with formula- an amazing tool for those who do not wish to breastfeed for whatever reason, a shelf stable resource for feeding babies, or for those not wishing or able to use donor milk.

Formula, by far, seems to carry the most emotional baggage. Far too often women are urged to use formula by a health care team to smooth over something anomalous and end up in a downward spiral ending in lactation failure. In these circumstances the infant formula is demonized, ignoring the reality that it is just a tool. A tool that is being misused the same way as milk expression or donor milk can be. When I was supplementing (with a tube taped to my breast) someone had the temerity to ask me why I wasn’t using donated milk. Because, what I was doing (through luck I may add, no credit for any equivocal mothering skill here) wasn’t apparently good enough. So much pressure for those that have problems.

In the absence of any real help all these tools achieve the same result-women unhappy with their experiences, potentially prematurely ending a much desired breastfeeding experience. I can say that had I had a good supply of diet controlled donor milk, or expressed milk of my own, I would have still felt bad. Other people may have looked more kindly on me, but I would still have been unhappy. Justified sadness, in my view. I was not doing something the way I had envisioned it. And I was getting no help. Don’t forget that. Too often our health care teams have fallen prey to wanting to meet goals, check boxes and move on in the name of efficiency and overwork. I’m trying to be generous to the health care teams, but the failure to treat every mother-baby pair as an individual case potentially needing individual solutions and support has a huge fallout. Emotional trauma appearing as regret, fear, anger and grief is unfortunate and common.

I’m not saying that breast feeding is complex, but the practices surrounding labour and childbirth may be, and  can and do complicate matters. And without knowledge even simple problems are very problematic. Breastfeeding shouldn’t be this complicated.  And I don’t think it really is, but for the fact that we’re re-learning how to do it.

Romanticizing the potato

Potatoes are great. I mean, packed full of vitamins and minerals, able to be prepared in a variety of ways. Easy to grow, easy to eat. And healthy! You can get all your essential amino acids from a diet of milk and potatoes. I mean, I could go on and talk about the health benefits of the potato, but at the end of the day it’s still a potato and potatoes are kind of boring. Because they are just food. They aren’t hyped up, they aren’t romanticized. If you get sick when you eat potatoes, they aren’t grown in your part of the world, or you plain don’t like them there are plenty of other things you can eat to fulfill your same nutritional needs.

But you know what they aren’t? Magic. And neither is breast milk. It’s food. It’s what babies are supposed to eat. Like adults are supposed to eat potatoes.

I think that breast feeding, in a way, is too over romanticized. There is no rosy mother and baby rocking by the window breastfeeding with a glow surrounding them. At least not at first or without a special lighting crew. There is a mother up at 0’dark thirty trying to latch her gassy, screaming infant and everyone is crying. But that image doesn’t sell boobies, and since there has been a disconnect in how feeding babies is done then maybe, yes, they do need to be sold. It’s certainly a result of the push to get people back to doing it after the lost breastfeeding generation of the 1940’s to 1970’s. Which is all well and good. I’m all for being mammals. Breast feeding and breast milk is how and what babies are supposed to eat, but this push has an unfortunate side effect of people proscribing magic qualities to breast milk and getting all fussy and adamant about it when the support structures are, unfortunately, still catching up to people’s inclinations. Pro-propaganda if you will.

It’s not good for all that ails you, no more than a potato is.  It’s not going to solve all your problems, do your taxes and help you find inner peace. It’s just food. It has some perks for vulnerable and developing baby insides, but it’s just human milk. It’s going to start them out how our DNA sets us out to be started, but beyond that is it just food. Like potatoes and carrots and berries. Things we were designed to eat that now have a ‘health-food’ tag affixed to them. These things are only so called ‘healthy’ because it’s what humans are supposed to eat. Like breast milk, there’s no ‘real’ alternative to potatoes either.

What is not just food is a mother’s biological imperative to feed her baby. So when it’s not possible, for whatever reason, to give your baby your milk it’s pretty great that there is something else available. The only thing that ticks me off is using it as a replacement for adequate support. But that’s another post. I hesitate to say that it’s not as good, because I feel that in some cases the need to be fed outweighs the method of feeding. I’ll stick with they aren’t equal, because they aren’t. But you may find one or the other suits your life, your circumstances, your needs, better than the other.

Either way, let’s ditch the romantic rosy image and treat breast milk like potatoes. A normal, slightly boring, part of life.

I did it, why can’t you?

I’ve been really wondering about this mentality lately. What is it about some breastfeeding mothers that had a hard time that makes them think that if they overcame that it’s doable for all mothers? I guess I ought to count myself in that category now, one of the ‘overcomers’, though for seven or eight months I really felt like a failure. I mean, I’ve stared failure in the face and it knocked me back (in my eyes because I didn’t meet my goal. I still limped along until I could meet an alternate goal) and all it has done is made me more compassionate, more eager to give information and more willing to support. So what happened with the women that had a hard time and got through it and then become critics of those who didn’t?

I guess for many of those women they feel that they were wholly responsible for making breastfeeding work and thus everyone is. I wonder if they believe that everyone’s circumstances are generally the same and that all that is needed is to for the mother to soldier on. Which completely disregards any time that it’s unhelpful professionals, bad advice, scary situations or the baby who isn’t bringing the necessary help to the booby party. It’s not all about bloody nipples, cluster feeding and sleepless nights for some of us.

I guess I just feel like people who come out on the side lacking compassion must feel resentful of their own breastfeeding experience and thus direct their anger at those who do stop, for whatever reason. I’ve got to say, direct your anger where it’s due. And it’s not due at other mothers. Have empathy and realize that everyone’s struggles are different. Be proud of your strength, but don’t condemn what you might see as weakness in others. Pride does not need censure to raise itself up. Depreciation of others makes your pride look cheap. Say: I’ve been there, I know how hard it was. It could have been me. And leave it at that.

If a professional set you on the path of unnecessary interventions and damaged your milk supply, then direct your anger there-NOT at the mother who faced something similar and took her professional’s advice and thus ended her breastfeeding relationship prematurely. If you have unhelpful family members picking at your normal breastfeeding relationship until in a moment of exasperation you give in to their nagging and things go south from there…direct your anger at the unhelpful attitudes you encountered-NOT at another mother that fell into that trap and didn’t make her way back out.

Most of all, if you suffered through painful, exhausting, stressful days let other mothers know what helped you. Don’t be angry that no one helped you when you wanted it.  Help them. Break the cycle.