In November, we launched our first live webinar on combo-feeding for healthcare professionals. There were so many good questions that we couldn’t get through them all. This article answers your questions on supporting combo-feeding parents in their feeding journey. You can find the session recording here. You can also join our Feeding Friendly medical community for updates, and future educational events. 

Your questions:

Why would you even suggest combo feeding if you are encouraging breastfeeding? Does the American Academy of Pediatrics not encourage breastfeeding?

The American Academy of Pediatrics recommends breastfeeding for two years or beyond if mutually desired. We know that breastfeeding has numerous benefits, and parents should be supported and encouraged to breastfeed when it fits their goals and preferences. That being said, many parents face circumstances where exclusive breastfeeding may not work for them. Sometimes parents simply just don’t want to exclusively breastfeed. 

We want to empower patients and clinicians to not see infant feeding as black or white. Educating parents in these situations that combo-feeding is an option allows them to sustain breastfeeding even if exclusivity isn’t the right fit.  

What is the evidence on postpartum depression (PPD)  and postpartum anxiety (PPA), and low milk supply?

PPD - Maternal mood and lactation may be impacted by the same neuroendocrine mechanisms. Following birth, mom experiences a substantial hormonal shift, specifically with estrogen, progesterone, prolactin, oxytocin, and cortisol. These same hormones are either necessary for milk production or impede the process¹

• Progesterone: Immediately after delivery, mom will experience a rapid decline in progesterone. This drop is necessary to begin the process of milk production. Progesterone contributes to one’s ability to handle stress, and this sharp decline can lead to PPD¹

• Estrogen: Estrogen levels also decline after birth and remain low through continued lactation. Similar to progesterone, estrogen is necessary for mood stability. The rapid decline can result in depression, anxiety, and challenges when working through feeding difficulties.¹ 

• Oxytocin: Oxytocin stimulates the let down of milk when breastfeeding and the onset of maternal instincts. Disruptions in oxytocin levels have been associated with maternal mood and breastfeeding success. Stressors, often correlated with PPD, may decrease the release of oxytocin.¹

• Prolactin: Prolactin levels increase throughout pregnancy and during the early postpartum period. Each time a baby suckles at the breast, prolactin levels temporarily increase to induce milk synthesis. Low prolactin levels have been found to increase anxiety in mothers, and stress may impede prolactin release.¹

• Cortisol: Certain levels of the stress hormone cortisol are necessary for milk production. However, if cortisol levels are too high, the body may not be able to efficiently produce milk. Cortisol is a by-product of stress and is often linked to increased levels of stress and anxiety.¹

PPA- As previously discussed, anxiety may impede the release of oxytocin and prolactin. This, in turn, will decrease the production and secretion of milk. Elevated levels of cortisol can decrease breast fullness and milk volume.²

It has also been found that women experiencing PPA are more likely to terminate breastfeeding early and supplement with formula. They may also have decreased feelings of self-efficacy and increased breastfeeding challenges as a result.²

For chronically low milk supply, what evidence is there for mom's nutritional support? I have read evidence related to hormonal support with organ meats, dairy milk, eggs, etc.

The ability of a mother to produce enough milk for her baby is generally thought to be independent of her dietary composition. However, milk production impacts maternal body composition and nutritional status leading to an increased need for macro and micronutrients.³

Making milk uses a lot of energy, and lactating women need roughly 300-400 kcal per day more than non-lactating women. Protein needs are also increased by about 25 grams per day. Both water and fat-soluble vitamins are released into the breast milk, and it is recommended for breastfeeding women to take a daily multivitamin.³

There is a reason you may have heard mothers need more eggs and dairy when breastfeeding. Both are rich in choline. Choline is required in the maternal diet during lactation to ensure the infant receives enough through breastmilk. Choline needs while breastfeeding increase from 425 mg/day to 550 mg/day.⁴

Triple feeding is helpful for creating demand and building supply, but does not make milk come in any “faster,” correct?

Triple feeding is a temporary feeding approach that can help increase milk supply and establish a healthy breastfeeding relationship. When triple feeding, first, a parent will nurse at the breast. Next, they offer a supplement from the bottle. This bottle can either be expressed breast milk or formula. Lastly, they pump or express milk to empty breasts and maintain milk supply.

Moms will start to produce milk around day three to five. Delayed milk production can be caused by a multitude of factors including stress/trauma, cesarean delivery, severe bleeding, or preexisting medical conditions. As we know, milk production is all about supply and demand, and milk should be expressed at least 8 to 12 times a day by either the baby or a pump. Theoretically, triple feeding can help milk come in faster by simply increasing stimulation.⁵

As an L&D nurse. What advice do I send my patients home with?

As a labor and delivery nurse, you are in a vital position to educate families on all their infant feeding choices. Studies have shown that nurses are influential in both the initiation and continuation of breastfeeding.⁶ We know exclusive breastfeeding for at least 6 months is recommended by the American Academy of Pediatrics. We should support parents to meet this guideline if that is their goal. 

However, we also know that not every mother has the desire or ability to breastfeed. It is just as important to inform the parents of all the feeding options available. Education on feeding should be provided in a way that does not make the parents feel guilty about their decision but rather empower them to make an informed choice.This may include how to prepare formula, how to safely offer a bottle, and supplementation options.⁶

So it seems that a formula-fed baby, over 1-6M, will gradually increase his total daily volume intake; but a BF baby will still maintain the same daily volume intake 1-6M, due to changing nutrient composition, though will take more volumes at once with longer breaks in between??? I.e., if he took 30oz/day at 1M of age, he'll still be taking 30oz at 5-6M even though his actual kcal requirements did increase over that time with his increasing weight?

Research has shown that breastfed infants have consistent milk intake, about 25 oz, from one to six months. This can be attributed to two main factors. First, younger infants (1-3 months old) grow at a much more rapid pace than older infants (4-6 months old). Secondly, the younger, smaller infants have a greater surface area to volume ratio. This creates a higher metabolic rate per kilogram of body weight. More of their nutrient intake is used for the maintenance of body temperature compared to older babies.⁷

For the moms who are going to drop pumping or not pump overnight, how do you protect their supply from taking a hit? 

About 64% of infants breastfeed one to three times per night. However, research has found no significant difference in the total 24-hour milk production for infants who did or did not breastfeed at night. The infants from each group were still breastfed an average of 11 times per day.⁷

However, parents can follow a few tips to ensure her supply is maintained. First, nurse or express milk more frequently during the day. This also helps to ensure that the baby is getting enough calories during the day and is less likely to wake hungry at night. 

Dream feeds can also be beneficial. This is the practice of offering a feed before going to bed (around ten or eleven) after the baby has already been asleep a couple of hours. The dream feed allows the parent to express milk once more and provides the baby with another substantial feed. Doing so may promote a longer stretch of sleep for both mom and baby.⁸

Is combo feeding a good tool for neurodivergent moms? i.e. Autistic Moms

The research regarding autistic mothers and breastfeeding/combo-feeding is limited. One study did find that 64% of autistic mothers reported difficulty breastfeeding their first child compared to 58% of non-autistic mothers. Reasons included latch pain, hypersensitivity to touch, unpleasant sensory experiences related to the baby’s touch, milk letdown, and engorgement.⁹

The review also found that formula was often promoted as the second choice when the baby’s weight gain was inadequate or breastfeeding had “failed.” For some, formula feeding was beneficial, but others found it to be a source of anxiety.⁹

Education and support regarding infant feeding practices were found to be unsatisfactory by both healthcare professionals and personal support networks. Similar to neurotypical mothers, infant feeding recommendations should be tailored to meet the needs and wants of neurodivergent mothers. ⁹

For moms who skip feeds and sub formula - how do you advise them to deal with engorgement? ie the pregnant mom who doesn't want to feed at night

If mom decides to skip feeds and provide formula instead, she should do so gradually. If she abruptly stops nursing, it can lead to engorgement, clogged ducts, and mastitis. It is best to drop one feed at a time. It is recommended to give her body about one week to adjust before dropping the next nursing session.¹⁰

If her breasts feel uncomfortably full, she can express small amounts of milk at a time. Breastfeeding is based on supply and demand. The more often and effectively a parent removes milk, the more your breasts will produce. Expressing just enough milk to relieve the pressure does not signal the body to produce more milk.¹⁰

What is the most up-to-date evidence on nipple confusion and combo feeding?

Nipple confusion is a confusing topic for everyone. Even the literature shows a divide between those who support nipple confusion and those who don’t. A 2015 systematic review found that four of the six studies reported evidence of nipple confusion when a bottle was offered whereas the other two studies did not. However, the same review did not find evidence to support nipple confusion related to pacifier use.¹¹

Once the bottle is offered, it may take some time and practice to find the correct bottle or feeding system for the baby.¹²

The hospitals are really pushing exclusive breastfeeding.  How do we as providers deal with that?

Many hospitals do promote exclusive breastfeeding for the first year of life as it is recommended by the American Academy of Pediatrics. Furthermore, many hospitals are part of the Baby-Friendly Hospital Initiative who follow the “Ten Steps to Successful Breastfeeding”. One of these steps instructs to avoid offering anything other than breast milk unless medically indicated.¹³

However, we know many families choose or need to supplement with formula. We also know that many parents rely on health professionals for advice on how to safely feed their baby. Studies have shown that the emphasis placed on breastfeeding has resulted in a lack of information being shared about formula feeding. This may lead mothers to feel unsure or unsafe when feeding their baby formula.¹⁴ The findings of this study suggested that parents who are formula feeding may be underserved by healthcare professionals, and it is imperative that we provide evidence-based advice to these families.¹⁴

Don't breastfeed babies gain slower than formula-fed babies? How do you factor this in with establishing a need for combo feeding?

Formula fed infants have been found to reach a higher weight and length for age by six months when compared to breastfed infants.¹⁶ The Academy of Breastfeeding Medicine (ABM) provides possible indications for formula supplementation in a term, healthy infant in regards to growth and weight. ¹⁷

The ABM suggests:

• Clinical and laboratory evidence of significant dehydration - >10% weight loss
• Weight loss of 8-10% accompanied by delayed lactogenesis 2 around day five

What are your thoughts on SNS?

Supplemental nursing systems (SNS) or supplemental feeding tube devices (SFTDs) are used for the supplemental nourishment of a baby whilst breastfeeding. A container of either breast milk or formula is connected to a thin tube that is placed alongside the mother’s nipple. The milk is released as the baby feeds at the breast. 

In certain situations an SNS might be recommended. Using a SFTD provides skin-to-skin contact and may positively impact bonding between the infant and the mother. One study found that 91.3% of mothers were satisfied using a SFTD because it allowed them to successfully breastfeed. However some participants in the study found the device made breastfeeding more difficult.¹⁸ Professionals should weigh the complexity of using an SNS or SFTD with the potential benefits and goals of the parent. 

How is low glandular tissue assessed? Is this something the MD assesses, or can a lactation consultant do it?

Mothers who suspect they have low or insufficient glandular tissue can actually screen themselves before seeking out a provider. The size of the breast is not indicative of insufficient glandular tissue but rather breast shape and asymmetry. Other signs of insufficient glandular tissue include²⁰:

• More than 4 centimeter flat space between breasts
• One breast much larger than the other
• Tubular shaped breasts - a narrow base and long shape
• Overly large and bulbous areola - they may appear puffy
• No breast changes during pregnancy or after birth

If mom notices any of these signs, she can see an internationally board certified lactation consultant (IBCLC) for assessment. However, she would need to see a medical doctor for an official diagnosis and treatment.²⁰

Any recommendations for families re: hand expression, electric pump etc?

Mothers may express their milk for a variety of reasons. This may include difficulty establishing breastfeeding, premature or low birth weight infants with suckling problems, supply management, or the need or desire for someone else to feed the baby. If/when mothers decide to express her milk, she has several options on how to do so. ²¹

Hand Expression

Arguably the most convenient way to express milk is by practicing hand expression. Hand expression has been found to be especially effective when expressing colostrum in the early postpartum period. Furthermore, a randomized trial found that early hand expression was correlated with improved breastfeeding rates at two months when compared to pump use. However, some mothers have reported increased levels of local pain compared to an electric pump.²¹

Breast Pumps

Breast pumps may be a good choice if mom does not know how or want to hand express. Some studies have shown that pumps do remove more milk than hand expression. There are many different kinds of breast pumps available. Electric pumps are the most popular choice for women who express their milk regularly. However, breast milk production was similar when using an electric and manual pump.²¹

The decision on how to express milk is up to the mother as there are pros and cons to both options.

How do you support a family where the dad wants the mom to exclusively breastfeed, but the mom is okay with combo feeding to get a break?

Ultimately, it is up to the family how they want to feed their baby. This is a decision they will need to make together. Not every mother has the desire or ability to breastfeed. It is equally as important to inform families about all the feeding options available to them. Education on feeding should be provided in a way that does not make parents feel guilty about their decision but rather empower them to make an informed choice. In this scenario, this might include listening to and supporting the non-feeding partner in their concerns or questions about different feeding methods.

Is there evidence that anxiety causes a low milk supply?

There is evidence to support that anxiety impacts both breast milk supply and composition through physiological stress responses. Anxiety can disrupt the release of prolactin and oxytocin, which are needed for the milk ejection reflex. Repeated inhibition of this reflex can result in reduced milk supply. Stress also causes elevated glucose and cortisol levels. Increased levels of these hormones may delay breast fullness and decrease milk volume.²

If someone gets sleep and their anxiety improves, is there evidence that it will improve their milk supply?

In theory, if a mother gets more sleep, she would see an increase in her milk supply. The stress that is associated with night wakings could inhibit the release of prolactin and impede both lactogenesis (milk secretion) and galactopoiesis (supply maintenance).²² Furthermore, her cortisol levels may be high. Cortisol is a by-product of stress and is often linked to increased levels of stress and anxiety. Elevated levels of cortisol can decrease breast fullness and milk volume.²

Simple relaxation techniques can positively affect both the mother and baby when breastfeeding. A trial using relaxation techniques found the intervention resulted in lowered stress levels for the mother and higher weight gain/BMI in the infants. The same study found that relaxation therapy resulted in increased breast milk yield in the mothers of preterm infants.²³

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Thank you for all the fantastic questions from those who joined our live combo-feeding webinar. If you were unable to attend live, you can watch the session here. You can also join our Feeding Friendly medical community for updates, and future educational events.

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References

¹ Stuebe, A. M., Grewen, K., Pedersen, C. A., Propper, C., & Meltzer-Brody, S. (2012). Failed lactation and perinatal depression: common problems with shared neuroendocrine mechanisms?. Journal of women's health (2002), 21(3), 264–272. https://doi.org/10.1089/jwh.2011.3083

² Fallon, V., Groves, R., Halford, J. C. G., Bennett, K. M., & Harrold, J. A. (2016). Postpartum anxiety and infant-feeding outcomes: a systematic review. Journal of Human Lactation, 32(4), 740-758.

³ Butte, N., Stuebe, A., & Motil, K. J. (2010). Maternal nutrition during lactation. Pediatric Upto-Date.

⁴ Lewis, E. D., Richard, C., Goruk, S., Wadge, E., Curtis, J. M., Jacobs, R. L., & Field, C. J. (2017). Feeding a mixture of choline forms during lactation improves offspring growth and maternal lymphocyte response to ex vivo immune challenges. Nutrients, 9(7), 713.

⁵ “Breastfeeding and Delayed Milk Production.” Breastfeeding and Delayed Milk Production | Johns Hopkins Medicine, John Hopkins Medicine, 2 July 2020, https://www.hopkinsmedicine.org/health/conditions-and-diseases/breastfeeding-and-delayed-milk-production

⁶ Radzyminski, S., & Callister, L. C. (2015). Health professionals’ attitudes and beliefs about breastfeeding. The Journal of perinatal education, 24(2), 102-109.

⁷ Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), e387-e395.

⁸ Bonyata, K. (2011, July 28). Night Weaning • KellyMom.com. KellyMom.com. https://kellymom.com/ages/weaning/wean-how/weaning-night/

⁹ Grant, A., Jones, S., Williams, K., Leigh, J., & Brown, A. (2022). Autistic women’s views and experiences of infant feeding: A systematic review of qualitative evidence. Autism, 13623613221089374

¹⁰ Find out about how you can increase or reduce your breast milk supply on Start for Life. (n.d.). Start4Life. Retrieved November 13, 2022, from https://www.nhs.uk/start4life/baby/feeding-your-baby/mixed-feeding/adjusting-milk-supply/

¹¹ Zimmerman, E., & Thompson, K. (2015). Clarifying nipple confusion. Journal of Perinatology, 35(11), 895-899.

¹² Maxwell, C., Fleming, K. M., Fleming, V., & Porcellato, L. (2020). UK mothers' experiences of bottle refusal by their breastfed baby. Maternal & Child Nutrition, 16(4), e13047

¹³ Burgio, M. A., Laganà, A. S., Sicilia, A., Prosperi Porta, R., Porpora, M. G., Ban Frangež, H., DI Venti, G., & Triolo, O. (2016). Breastfeeding Education: Where Are We Going? A Systematic Review Article. Iranian journal of public health, 45(8), 970–977

¹⁴ Appleton, J., Fowler, C., Laws, R., Russell, C. G., Campbell, K. J., & Denney-Wilson, E. (2020). Professional and non-professional sources of formula feeding advice for parents in the first six months. Maternal & child nutrition, 16(3), e12942. https://doi.org/10.1111/mcn.12942

¹⁵ Hörnell, A., Hofvander, Y., & Kylberg, E. (2001). Solids and formula: association with pattern and duration of breastfeeding. Pediatrics, 107(3), E38. https://doi.org/10.1542/peds.107.3.e38

¹⁶ Mihrshahi, S., Battistutta, D., Magarey, A. et al. Determinants of rapid weight gain during infancy: baseline results from the NOURISH randomised controlled trial. BMC Pediatr 11, 99 (2011). https://doi.org/10.1186/1471-2431-11-99

¹⁷ Academy of Breastfeeding Medicine Protocol Committee. (2009). ABM clinical protocol# 3: hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeeding Medicine, 4(3), 175-182.

¹⁸ Çalıkuşu İncekar, M., Çağlar, S., Kaya Narter, F., Tercan Tarakcı, E., Özpınar, E., & Demirci Ecevit, E. (2021). An alternative supplemental feeding method for preterm infants: the supplemental feeding tube device. Turkish journal of medical sciences, 51(4), 2087–2094. https://doi.org/10.3906/sag-2009-323

¹⁹ Lindholm, A., Bergman, S., Alm, B., Bremander, A., Dahlgren, J., Roswall, J., ... & Almquist-Tangen, G. (2020). Nutrition-and feeding practice-related risk factors for rapid weight gain during the first year of life: a population-based birth cohort study. BMC pediatrics, 20(1), 1-14.

²⁰ “Insufficient glandular tissue (breast hypoplasia).” Australian Breastfeeding Association, https://www.breastfeeding.asn.au/resources/insufficient-glandular-tissue-breast-hypoplasia

²¹ Johns, H. M., Forster, D. A., Amir, L. H., & McLachlan, H. L. (2013). Prevalence and outcomes of breast milk expressing in women with healthy term infants: a systematic review. BMC Pregnancy and Childbirth, 13(1), 1-20.

²² Doan, T., Gardiner, A., Gay, C. L., & Lee, K. A. (2007). Breast-feeding increases sleep duration of new parents. The Journal of perinatal & neonatal nursing, 21(3), 200-206.

²³ Mohd Shukri, N. H., Wells, J., Eaton, S., Mukhtar, F., Petelin, A., Jenko-Pražnikar, Z., & Fewtrell, M. (2019). Randomized controlled trial investigating the effects of a breastfeeding relaxation intervention on maternal psychological state, breast milk outcomes, and infant behavior and growth. The American Journal of Clinical Nutrition, 110(1), 121-130.

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