Updated: Aug 2, 2021
Combination feeding is when you regularly feed your baby in more than one way. There are different reasons why and ways to combo-feed. The Internet has a wealth of information on breastfeeding and we also have lactation consultants to help with that now too. You can easily find a lot of information on formula feeding also. However, there is not much information on combination feeding, and it leaves this minority group of moms in the lurch. Now having combo-fed three children, I've learned a ton of information and want to share it for any confused new combo moms out there!
First of all, there are many reasons why moms may combo-feed their babies. It could be by choice, whether mom is working and can't pump very often so she decides to supplement a bit. It could be to give someone else a chance to feed the baby, like Dad or Grandma. For others like me, combination feeding is not a choice, but a necessity. I am a BFAR mom. BFAR stands for Breast Feeding After a Reduction. When I was in college, I had a breast reduction for medical reasons. I knew there was a possibility I wouldn't be able to breastfeed. At that time, there was no way of knowing until I tried. Fast forward almost fifteen years and I was pregnant with my first child, Gideon.
Long story short, I was able to breastfeed him, but had a low supply and therefore needed to supplement. I'll never know whether my low supply was due to the reduction or if I would've had issues anyway. Regardless, Gideon wasn't gaining weight properly, so I went to a breastfeeding support group and did a weighted feed. The group was run by a lactation consultant.
Side note: The breastfeeding support group was literally a lifesaver for us. It was a free group at the hospital where I delivered. I made relationships with the lactation consultants and other mamas that I still have today, three years later. I highly highly recommend finding one in your area and going whether you are having feeding issues or not. We all need support in those postpartum days, and this group was exactly that!
If you're in the Pittsburgh area, the group I went to is the Nursing Cafe at West Penn Hospital. It meets weekly and you don't have to have delivered there to go to the support group! It's free to any breast- or combo-feeding mama out there! Here's an article by Pittsburgh Parent about the Nursing Cafe. Contact them for more information: 412-578-7030. Also, for BFAR moms, there is a BFAR Facebook group you can join with 1.5k members.
More about Our Journey
Doing the weighted feeds helped me realize that Gideon was not getting enough from the breast. A weighted feed is when you weigh your baby before and after feeding. You don't change the diaper or clothes or anything in between. This allows you to find out exactly how much breastmilk your baby transferred during the feeding. At the hospital, they use scales that go down to a very small measurement. A baby his age (he was about 6 weeks when I first went) should've been taking in about double what he was receiving from me. Therefore, enter combo-feeding. There are many different ways to combo-feed: bottles, SNS, formula, pumped milk, donor milk, etc.
Both of these "Tree of Life" photos are equally beautiful!
In the beginning of combo-feeding, I chose to supplement with either my own pumped milk or donor milk. What this looked like was at least an hour-long process to feed him, known as triple feeding. I'd nurse him first, then "top him off" with a bottle of either donor milk or previously pumped milk, and then I would pump, both to try and up my supply and to get more milk to give him. I'd have to clean all the pump parts and then have a short little break before it was time to do it all over again. IT. WAS. EXHAUSTING.
I did briefly also try using an SNS (supplemental nursing system). Basically, it's a little container that you put the milk in and hang it above you (I used the ponytail on top of my head). There's a very tiny tube coming out of it that you tape to your breast. Then, when your baby nurses, he gets both what comes out of your breast and what comes out of the tube. It gives him more milk, stimulates your breast, and hopefully negates the need to bottle-feed. I had a major love-hate relationship with it that was like 15% love and 85% hate. So, the SNS didn't last long for me. It was way more stressful for me than it was helpful, and just was not something I could maintain with sanity intact.
I continued triple-feeding Gideon with nursing, the bottle, and pumping for about the first three months. At that point, I just could not maintain it anymore. Pumping can also be a love-hate relationship, and it was just too much for a new, working Mama. Plus, all of that pumping had never increased my supply. He still only took 1.5-2oz from me each time. So, I continued combo-feeding but took out the pumping. I would still nurse him first and then top him off with formula. This continued until he was about six months. He then began to prefer the bottle, and my supply began to drop further, so we went to full formula.
Long story short, when Phoebe came along, I promised myself I would give it my best shot again, but without pushing myself to the brink of insanity. I felt like I had missed out on so much joy in Gideon's newborn stage due to our feeding issues and the stress from triple feeding. I did not want to do that again. Phoebe and I went to the Nursing Cafe again; she was 4 days old her first time. We started doing weighted feeds and triple feeding again. Once I realized I was definitely going to have to supplement with her too, I skipped the fuss of triple feeding and just did nursing and formula. Then, when Ezra came along, I did the same. My experiences with Phoebe and Ezra were much more enjoyable because I wasn't stressing out as much. I still gave them as much breastmilk as I could, but I was at peace with also giving them formula.
There's a wealth of information out there about breastfeeding and about formula feeding, but there is not much to be found about combo-feeding. Thankfully, I had the West Penn lactation consultant's help with all of this, and I wanted to share what I learned to put it out there for anyone else who was in my spot. I highly encourage you to seek out a LC if you're having any feeding issues.
Breastfed babies generally take in about 3-4oz at a time, for a total of about 24oz/day, and don't really ever need more than that. However, formula-fed babies gradually need to increase how much they eat, some end up on 6-8oz at a time, and about 32oz/day. This is because breastmilk changes as your baby grows so that 3-4oz is always giving him the calories and nutrients he needs. Formula obviously doesn't change, so babies need more as they grow and need more calories. So, where does that leave a combo-fed baby? How much should he be taking if he's getting a little bit of both at each feed? The best answer I can give is to follow your baby's lead. They say you can't overfeed a breastfed baby, but you can overfeed a bottle-fed baby. Using small increments and stopping periodically to assess are the best ways to tell what he needs.
Assume he needs at least 3-4oz at a time. So, I knew from the weighted feeds that Gideon was only getting about 1.5-2oz from nursing. Therefore, I would offer another 2oz of formula after. Then, if he fussed and chewed on his hands and clearly showed me he was still hungry, I'd offer more, 1oz at a time. If he was content, I stopped. Since formula does not change to meet his growing needs like breastmilk does, he will still increase how much he takes in, even with that little bit of breastmilk. By 3 months old, he would nurse and then take an extra 3-4oz of formula. It wasn't because my supply was dropping, it was just because he needed more formula to support his growth. Continuing weighted feeds was what helped me when I started questioning my supply during these increases. Start small, listen to your baby, and go from there.
When you have a low supply, you can sometimes increase it by pumping. However, sometimes you also just have a "cap." For instance, it seemed like no matter what I did, I was just never able to make more than 2oz at a time. I pumped for a while, but since it wasn't much (to use) and wasn't increasing my supply, I eventually stopped altogether, unless I missed a feed. With Gideon, I pushed myself to the brink of insanity with pumping after every feed and trying to up my supply. With Phoebe, I pumped in the very beginning, but stopped once I realized I apparently still had the same 2oz cap. I promised myself I wouldn't go insane with it the second time, and I kept to that. Same thing with Ezra. Take it from me, don't let pumping ruin your joy of motherhood.
If you are triple feeding and pumping in order to see an increase, that will likely happen by 6 weeks. If you've killed yourself pumping for 6 weeks and it did nothing but cause stress, then you can stop. Be grateful for what breastmilk you can give your baby, but know that formula is not the devil. It's come a long way, there are organic versions, goat milk versions, whatever floats your boat for your child. Don't feel guilty giving your child formula to meet his needs.
Formula is not the devil. Don't feel guilty giving your child formula to meet his needs!
Breast to Bottle
There's disagreement out there about whether or not nipple confusion is really a worry. Regardless, it is generally "easier" for them to get milk from the bottle than from the breast. So, here are a few tips to be able to successfully go back-and-forth between breast and bottle.
Stay on a size 0/newborn nipple. You don't want the bottle to be super quick and easy while he has to work to get it out of the breast. A baby usually has to suck on the breast for a bit before your letdown happens and the milk starts flowing. Yet, it starts coming out of the bottle immediately. So, to encourage him to continue nursing, you want to keep him having to work a bit for the bottle too. Staying on the smallest size bottle nipple will help do that.
Let him latch onto the bottle. Again, you want to keep things as similar to the breast as possible. He has to work to open up and get a good latch on the breast. So, don't just push the bottle nipple right into his mouth. Offer it at his lips and make him latch onto it just the same.
Use pace feeding. Here is a PDF from kellymom.com that explains pace feeding. (By the way, kellymom is a great resource for breastfeeding moms, and there is some information about bottle feeding as well.)
Always nurse first. Giving him the bottle first and then trying to nurse after is like eating your dessert before dinner. You want him to get as much breastmilk as possible, so offer that first. Otherwise, he'll fill up from the bottle and not want to nurse. This will cause your supply to drop and him to likely prefer the bottle.
Another thing the lactation consultants helped me with was identifying that both Gideon and Phoebe had lip and tongue ties. When a baby has a tongue and/or lip tie, it can really affect their latch. This can result in painful nursing and the baby not being able to transfer enough milk. Revising these ties early can help with supply and painful nursing. Similar to pumping, this didn't help my supply as I seemed to have that 2oz cap, but it's been proven to help other moms.
Lactation consultants can't necessarily diagnose a tie, but many of them are knowledgable enough to tell you whether or not you should get it looked at. However I will say that my pediatrician missed i