Let’s talk formula

Because someone needs to.  So here it is from me- someone who wanted to breastfeed and supports breastfeeding where reasonable, yet used and uses formula for medical reasons. Maybe that makes me a mostly neutral party. Maybe not.

First off- everything I learned about formula is self-taught or I learned from a Lactation Consultant. A good LC, on seeing that you want or need to use formula should be able to give you some pointers. Theoretically all formulas should be pretty much the same, brand name or budget. The WHO is supposed to regulate the ingredients and basic proportions. However-sometimes things are not so straightforward.

What you want out of a formula is to have it be whey based. Not casein based. You want the from birth formula. The follow-ons  marketed from age 6 months + are not as well regulated and unnecessary (though they are often cheaper…). If your child requires supplementation beyond 1 year, full fat cow milk can be given (or mixed with formula if you are concerned about diet or intake).

Cow milk is recommended because growing brains need fat. If your child does not like cow milk to drink (mine didn’t), just be sure to supplement with other high fat foods alone or in cooking. Food such as- avocado, cheese, coconut oil or cream, peanut or seed butters, butter, cream, lamb, olive oils, and so on. For extra calcium try various vegetables like kale, alfalfa, etc and fish like sardines, salmon etc.

Back to formulas. Whey or milk solids should be the first ingredient. Maltodextrin is a common additive and should be around the 3rd-5th ingredient. It is sometimes seen as the first ingredient- this is not necessary and may make your baby eat more- its a carbohydrate that is digested quickly.

If you are combination feeding you do not need any special formula. Any birth to 12 month one that suits you is fine.

This sort of thing

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Image credit

Is straight up predatory marketing. I was always ambivalent about formula companies being big and bad and preying on the breastfeeding mother, but yeah. Not after seeing that. I’m pretty sure people are eating it up too. I’d hate to be more cynical but I’d imagine that if the one on the left cost more people would be paying for that too.

Let me reiterate: You do not need anything special to combination feed. No formula is better than any other. In fact less is often more.

Some reading on safe formula use can be found here http://info.babymilkaction.org/infant_feeding/formulafeeding

How to interview a lactation professional.

I’ve thought about this some, but then it came up in the comments for another post. A few of my posts reflect ideas I’ve had on this topic, so I’m going to expand on those as well as adding some new thoughts.

This should probably be broken into two groups: Prospective mothers (expecting), and/or those requiring generalist help and current mothers who have experienced a problem.

Let’s cover expectant mothers first.

If you are expecting your first baby, or your first baby you wish to breastfeed, you want to make sure you have an adequate amount of support. You should be focusing first on what resources are available to you.  This means checking with your hospital, your birth care provider, your pediatrician (if you are in the US for example), your local LLL chapter as well as seeing what private lactation professionals there are in your area. You should focus on how to access the services and what the cost will be to you. Having knowledge of where to find these resources is just as important as a birth plan, and for much the same reasons. The goal is to educate yourself to make informed choices. In addition, trying to find a lactation professional when you are desperate for help does not allow you to make informed choices. Try not to wait until you are desperate.

General questions to ask:

  • What are your qualifications? Here is a lovely guide I found on what all the titles mean.
  • How long in practice?
  • Is there any particular area you have additional expertise or interest in? (If you’ve got low supply and you are talking to a IBCLC specializing in oversupply she might not have the resources to give you the best help. If you are surveying what is available in your area then this is information worthy of noting down.)
  • What are your working hours? Do you work out of any hospitals or clinics?
  • What are your fees? What are your followup policies?
  • What breastfeeding challenges have you seen, treated, or overcome yourself?
  • Do many of your clients meet their breastfeeding goals?
  • If I experience a problem outside your area of expertise do you feel you have relevant resources to refer me elsewhere? What would you consider outside your area of expertise?
  • If I experience problems it will likely be a very emotionally turbulent time for me. Have you had experience supporting decision making and coming to a consensus about ways to resolve the problem (your provider should be willing to have a back and forth with you and if you decide that enough is enough support you in that as I refer to in this post).
  • What kinds of issues have been most difficult for you to help mothers and babies with and why? (as in, do they find the mother’s determination lacking, are surgical referrals difficult to get, etc. This is should act as a sounding board for their typical experience, if they have professional peeves as well as how understanding they may be to your situation)
  • How do you generally balance a mother’s well being with her initial desire to breastfeed? How do you manage situations that do not meet expectations and goals?

I also think that pursuant to this list, some of the general things you should ask a lactation professional if they have experience in are:

  • Do you have experience identifying lip and tongue ties, including posterior ties as well as other oral abnormalities like bubble palate? Are you confident identifying these types of abnormalities?
  • Do you have experience identifying a breast with  insufficient glandular tissue?
  • If you are a first time mother at risk for breastfeeding difficulties (PCOS, diabetes gestational or otherwise, history of thyroid disorders, lack of breast changes) you should certainly mention that. An appropriate response to my view would be a physical examination of the breasts as well as a wait and see with potential aggressive treatment if desired. Go the other way if you are told that any of those things will not matter.

Now for mothers who have previously experienced issues or are currently experiencing issues.

You’ll want any of the above that seem relevant as well as the following.

Specific questions:

Most of these are fairly situational so choose or adapt any that seem appropriate to you.

  • My issue last time was X. Will you help me explore solutions for that? How will you do that?

I’ve found some sounding board questions quite helpful to see how much recent research has been kept up with. You might ask if they know about the link between PCOS and breastfeeding issues, thyroid problems and breastfeeding difficulties, or even a more general tricksy question-what medical factors are you aware of that influence milk production in the mother and milk extraction or digestion in the baby?

  • What are your guidelines for supplementation in the infant.?

This is a personal preference one. The answers may range from over 7-10% weight loss, to watch the baby. I’d be wary if they say that supplementation is almost never necessary. If they say that I’d follow up with askance for some clarification i.e. in general or among your clients? What techniques do you use then for managing babies with milk extraction issues or mothers with milk production or ejection issues?

  • If supplementation becomes necessary which methods will you support me with? Are there any you will not support?

If you used donor milk last time and plan to should it become necessary again you’ll want a professional that supports you in that. If you used formula and prefer that, again, support. If you want to use bottles, you’ll want support in managing that, if you don’t you’ll want tips on other feeding methods.

  • As my issue was X last time can you give me some realistic expectations on what management of this issue will look like on a daily basis and what difficulties I am likely to face?

If they tell you you’ll need to pump 15 times a day as well as do some other things and this does not seem sustainable to you because of other children then bring that up. Discussion about an action plan is key.

  • Make sure to mention things you did or tried previously and whether or not you feel they worked as well as whether you’d be willing to do them again.

For instance, I tried domperidone and it inhibited my letdown reflex, and I am open to supplementing via SNS if it can be demonstrated to me that an oral abnormality is not the issue etc. You don’t need the frustration of reinventing the wheel and to avoid that the LC will need as much information as you can give her.

Warning signs:
  • Being told to wait and see or being told that every baby is different when you’ve experienced issues previously. Wait and see is a reasonable approach for some things but not if you want to be proactive. With some things it’s important to act quickly.
  • Your LC should never touch your breasts without permission.
provide support and encouragement to enable mothers
to successfully meet their breastfeeding goals

So if your goal is to breastfeed for 2 months then move to combination feeding for the next year she should be able to give you strategies on how to do that. She should also be supportive of your goals and willing to have an open and non-judgmental conversation with you. If your goal is to exclusively breastfeed with contraindicating issues she may (unpopularly) explain that that may not be possible, but give you long term management tips.

Note: there are a range of breastfeeding topics I do not have much experience with. Issues like oversupply, feeding multiples, flat or inverted nipples, breast size issues, prematurity in the infant, allergies in the infant, and reflux as well as others so I can’t give examples of more specific questions relating to those issues. However I can say that if any of your concerns are brushed off without explanation that is cause for alarm.
Overall you want to be having a conversation. Figuring out if this is the right person to help you if and when you need help.

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.