This is part two of dealing with the dealing with a low milk supply series. Please see part one: Do you really have a low milk supply? for additional information.
*This article does not replace medical advice. Please consult a medical professional if you suspect your child is not getting enough to eat.
Most articles ignore combo feeding and supplementation because of the desire to encourage the mother to exclusively breastfeed. That is valid- there is the concern that the more one supplements, the less one will nurse, thus leading to a cycle that eventually ends the breastfeeding relationship (or the baby may develop a nipple preference). However, there are mothers (including yours truly) who combo feed successfully for months with a baby who still preferred nursing over the bottle and who eventually managed, especially with the introduction of solids, to move back onto breastmilk and no formula. In addition, instead of bottles, there are other ways of supplementing, especially with a younger baby, that doesn’t lead to as much danger of harming the nursing relationship.
The number one rule is “Feed the Baby.” If your baby has not lost a dangerous amount of weight, it is perfectly acceptable to continue to exclusively breastfeed while trying to increase your milk supply and to go in for regular weight checks to monitor progress. However, it is also acceptable to choose to supplement and/or combo feed. (It goes without saying that any feeding program is acceptable, whether combo feeding, formula feeding, or breastfeeding, regardless of reason. Just so we’re clear).
How to combo feed or supplement
The difficult thing about combo feeding and supplementing is that there is no rule really on how to do it – really, finding a rhythm that works for you and your baby is really the ideal.
When it comes to terms, “combo feeding” and “supplementing” are generally interchangeable. If you want to make a distinction, usually supplementation refers to offering formula or pumped milk after some or all breastfeeding sessions whereas combo feeding refers to a program of doing formula for some feedings and breastfeeding for others. Combo feeding, then, would apply to working mothers who give their children formula for when they are in childcare as opposed to their pumped milk.
Therefore, in general, when we are talking about actions when facing a low milk supply, we are talking about supplementation – offering formula and/or pumped milk after a nursing session. However, in some cases, a mother with low milk supply will choose to replace a whole feeding with formula or saved milk. (I did the whole gamut of options, but for a while, my lowest milk supply was around 6pm. Some mothers would choose then to just give up that feeding and offer a bottle instead. I usually still attempted to nurse first in the interest of stimulating milk production, but the baby would down about 6-8oz of formula, so in effect he didn’t really get any breastmilk around that time.)
For the interests of simplicity, I’m going to assume the combo feeding/supplementing is done with formula, not breastmilk. If you are pumping your own breastmilk to give to your baby while you are away for example, that’s not really combo feeding in this sense. (Now, in my case, I had some pumped milk saved from when I had a good supply, so when I started supplementing, I burned through my pumped milk stash first). There’s also the donor milk option, but it is less common. So, let’s go with the assumption formula is in those bottles.
The slippery slope
Why do we say that there could be a slippery slope when it comes to combo feeding?
First, we have the supply issue. Every time you replace a nursing session with a bottle (and don’t pump to make up for it), your breasts are getting the signal that milk production isn’t needed at that time.
Second, formula often makes babies full for longer. Therefore, your baby may go longer in between feeds, which means you are nursing less often, even if you nurse first then formula feed.
Third, many babies may develop a preference for the bottle, as it will have a faster flow than the breast (and if the mother truly has a low supply or slow let-down, the baby will associate being full with the bottle as opposed to the breast.).
Fourth, breastfed babies often suck down a bottle even if they are not hungry. They are obligated to suck when a nipple goes into their mouth and their mouth fills up with milk.
Fifth, growth spurts complicate matters. If you are exclusively breastfeeding with a great supply, your baby will still act super-hungry during a growth spurt. The answer is to nurse, nurse, and nurse some more and your supply will catch up. For low-supply moms who are supplementing, it is much harder. A fussy baby means supplement more. Which means your supply isn’t going to get ‘trained’ to catch up to the baby.
How to avoid these things as much as possible?
1.) Wait until the nursing relationship is established before combo feeding or supplementing.
Obviously, in some cases, one has to start supplementing for the baby’s health long before nursing is established. But if you can hold on about 4-6 weeks, your ability to combo feed long-term will be much better.
2.) Nurse first before every feed. Pump after every feed. Pump if you miss a feed. Pump when you are feeling full and your baby doesn’t want to nurse.
Nursing first helps avoid the slippery slope as you are still stimulating milk production (even if the baby isn’t getting a lot at the breast). Emptying your breasts about every 3 hours or so will help maintain and possibly increase your supply.
If your milk supply is generally established, you can get away with leaving formula with the baby if you are away. But if you can, try to pump to make up for that session (even if you aren’t getting much). Or, for pumping-haters like myself, nurse as soon as you get home, even if the baby isn’t hungry (I always called this ‘getting reacquainted with my baby’ as soon as I got home).
I didn’t pump at all and managed to maintain my nursing relationship, but to ensure you are successful, I would suggest pumping. (To be fair, in my case, I *did* hand express whenever possible. My body doesn’t react well to a pump but did fairly well with hand expression).
3.) Offer the smallest amount of supplement possible
Okay, this was the most stressful part of supplementing for me. Assuming you are dealing with a baby who is losing weight or not gaining enough, you are trying to make him or her healthy again. BUT, you are also trying to maintain supply. In my daughter’s case, I was told to give her as much as she would take. But she was in a much dire situation. We ended up giving up combo feeding in about two days and going exclusively to formula.
In my son’s case, it was up to me. So I would only give my son about two ounces at a time. It was frustrating though because sometimes he would be fussy 30 minutes later. Was he hungry? Was I starving him? Who knew? Eventually I decided it wasn’t worth the stress of wondering if he was still hungry, so I went to the ‘give him as much as he would take’ model. That meant that at times, he would get supplemented with 6 ounces of formula. I was convinced our nursing relationship was doomed. For many different reasons, it wasn’t, and we continued nursing for months thereafter. As I mentioned before, the reason we went to formula had nothing to do with supply issues, and instead because I needed to go on non-breastfeeding safe medication.
So,try not to offer too much supplement, but if it stresses you out, do what works for you.
4.) Pay attention to growth spurts
Try to nurse more often during common growth spurt times. (ex: 7-10 days, 2-3 weeks, 4-6 weeks, 3 months, 4 months, 6 months and 9 months)
5.) Alternative delivery mechanisms
Instead of bottles, consider using a supplemental nursing system, a syringe, or a cup to supplement your baby. (This is especially applicable for the younger baby, before the nursing relationship is established.)
A supplemental nursing system allows you to supplement at the breast, thereby letting the baby suck and stimulate your milk production while he or she is getting formula/extra pumped milk.
There are two main brands of supplemental nursing systems. One is the Medela SNS. (and here is the starter kit, useful if you have a newborn in a hospital who needs supplementation just in the short term) The other is Lact-Aid.
You can also make your own SNS. Here is one set of instructions. Google around to figure out what works for you.
6. Use the slowest nipple flow possible and Bottle feed the breastfed baby differently
The biggest thing here is to hold the bottle upright so the baby has to work more.
7. Encourage reverse cycling
Encourage the baby to nurse more when you have a higher milk supply and take less supplement when you have a lower milk supply. In my case, that meant nursing at night instead of encouraging night weaning. (This was easy. My son preferred nursing over bottles, so he naturally reverse cycled. The day I stopped nursing him at night and started offering him a bottle was the day he night weaned. It wasn’t worth it for him to wake up for a bottle).
In terms of increasing milk supply, nursing or pumping between the hours of 12-3am generally helps increase one’s supply anyway.
8. Breast compressions while nursing/pump right before nursing/work on latch and positioning while nursing
Kellymom has information on what to do if your baby develops a bottle preference while supplementing,and I used those techniques to avoid bottle preference as much as possible while I was combo feeding. For my baby,nursing upright made him happy (I would have to walk around the house while nursing him). Breast compressions also helped as it helped the milk let down faster. Most of the time, the reclined breastfeeding position helped him latch as it was a relaxed position (but as I had a slow let-down, sometimes it made it worse.).
Above all, do not force your baby to nurse. Seduce him to the breast.
Other experiences:This is a good blog post on another mother’s experience with combo feeding. Sounds similar to my experience in trying to balance the “feed the baby” rule with the “maintain your supply” rule. Go to BabyCenter for some support from other moms.