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I find my tongue tie resources out of date, though you can see my experience here.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.

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.