Updated: Aug 2
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 it, even after I asked her about it. I love her as a general pediatrician, but if you have heart problems, you see a cardiologist, not your PCP. If you suspect ties, see a lactation consultant or pediatric dentist.
If you're in the Pittsburgh area, I highly recommend the Laser Center for Pediatric Frenectomies. If you're not in this area, I still recommend finding somewhere that does the quick, pain-free laser frenectomy rather than cutting the ties. With cutting, you have to do exercises to keep the tie from growing back, and there's more pain involved. With a laser procedure, there are no exercises needed and he was fine moments later. I was actually able to nurse each of them in the office right after the procedure.
There are a lot of herbs out there marketed to help increase milk supply. However, some of them can actually cause a decrease in supply for some. One of these is fenugreek. Some women swear by it, while others claim it tanked their milk supply. Some other popular ones are blessed thistle, moringa, and goat's rue. Sifting through all of these can be stressful- you have no idea which ones will work.
I did try a few with Gideon and honestly, I could never tell a difference either way. I didn't take anything special when Phoebe came around (other than drinking tea) and my supply was still the same for her. When you're already struggling with a low supply, I don't think it's worth risking a further dip in that supply in order to maybe get a boost. Some low-supply women have a really low supply, only making a couple ounces a day or even less. In this case, go ahead and try all the herbs- you've got lots to gain and little to lose at that point. However, if you have a decent enough supply that you can continue combo-feeding, then I wouldn't rock the boat to possibly get a few more ounces. You could also lose more.
The one herb I would recommend for BFAR moms is goat's rue. You're not supposed to take it while pregnant though, and I'm not sure if it really helps while nursing. I did take it while nursing Ezra and didn't experience an increase. However, this is one I would take before you get pregnant because it supposedly helps to repair mammary tissue that could've been damaged during surgery. Since you're taking it beforehand, there's no risk of hurting your milk supply. Even if it doesn't help, it won't hurt either. I didn't learn about this herb until after I had Phoebe. So, I did take a bit before getting pregnant with Ezra and then again while nursing him. Again, I didn't see increase. If I could go back to the beginning though, I would've been taking this long before getting pregnant at all to see if that would've helped.
You have to be well hydrated in order for your body to make milk. I tried all the gimmik hydrators: Body Armour, Gatorade, Liquid IV, coconut water, coconut milk, oat milk, are you catching my drift? I tried it all and similar to the herbs, I never noticed a difference. I don't know if it's just because my supply was what it was or if its because these things are just gimmiks.
At the end of the day, plain water is perfectly fine to stay hydrated. You don't need all the special stuff. However, if the special stuff makes you drink more than just plain water, that's when it's worth it. Some people don't like drinking plain water, so for them, these types of hydrators may cause an increase in supply. That increase is likely due to the increase in them drinking, though, not the specific thing they drank. Regardless of what it is you're drinking, just stay well hydrated.
My Note to BFAR and Combo-Feeding Moms
I see you, Mama. The tears, the stress, being awake pumping when you should be sleeping, the constant wondering if you're doing the right thing for your baby, feeling like a failure because you're not able to exclusively breastfeed. Take a deep breath.
You are a good mom. You are not a failure.
Please read those two sentences as many times as you need to until you believe it. By all means, try. Give it your all. But when you can't do it anymore, when you realize it's not doing anything more than causing undue stress...It. Is. Okay. To. Stop. Notice I didn't say quit, I said stop. There is a difference. You may have been a quitter if you quit after the first day. But after all you've been through, you are not a quitter. If you are too stressed out to enjoy your baby...it may be healthier for you both to stop.
I remember when I was in the middle of triple feeding Gideon, I wanted to stop so badly. I knew it wasn't a healthy feeding relationship; it was causing more stress and anxiety than anything. But I just couldn't allow myself to stop because I felt like I HAD to keep going in order to be a good mom. I talked to many people about it, my husband, mom, close friends, and lactation consultant, fishing for them to give me the "approval" to stop. Out of kindness, they would encourage me to keep going, thinking that's what I wanted. So, I kept going because I felt like it was expected of me.
Eventually, I told my lacation consultant that I didn't know if I could keep going like this. Finally, she unknowingly gave me the approval I needed to stop. You know what happened? Gideon was perfectly fine. He continued growing and developing normally. I was much happier and was able to enjoy our relationship much more.
So, Mama, if you're in that place of desperately searching for someone to give you the approval to stop, please let me be that person. If you feel smothered by your pump, it's okay to stop pumping. If you wince and cry every time you latch your baby, only to give him an ounce, it's okay to stop nursing. You are still a good mama. Your baby will still grow and develop normally if he gets more formula or even all formula. Our society is so bent towards "breast is best" that we feel less of a mother if we can't do it. Don't let that steal your joy. Fed is best, so if you want to stop, go ahead and stop
~Ashley Bell, your pediatric sleep consultant