In 2022, about 75% of parents use infant formula to nourish their baby in some capacity. However, misconceptions about combo-feeding infants causes the spread of misinformation, an increase in parental guilt, and unrealistic feeding expectations. Debunking these myths about using infant formula in addition to human milk will help educate, empower,  and support parents while keeping lactation in the picture longer. Below, evidence is provided against the most common misconceptions I encounter as a feeding consultant.

If you would like to learn more about supporting combo-feeding parents, join us for a webinar on Supporting Combination Feeding: Navigating the Spectrum of Infant Supplementation.

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1. Supplementing with formula will ruin a parent’s supply.

There are many reasons that a parent may need to or want to supplement with formula. Some of these reasons include:

• Low milk supply 
• Previous breast/chest surgeries 
• Preserving mental health
• Taking a medication that is contraindicated in lactation
• Going back to work
• Wanting a partner to be involved in feedings 
• Extending the amount of time lactating by adding balance to feeding

As a certified breastfeeding consultant, the myth that supplementing will ruin milk supply is the most widely spread misconception when it comes to infant feeding. It is true, however, that supplementing in certain ways will decrease your milk supply, but this depends on so many factors. Sometimes the goal of this partial “weaning” process is to decrease supply - but in general, will not ruin supply to the point of not being able to lactate.

Because milk supply and reaction to partial weaning is so individual, keeping consistency with feedings is the key to success. Emptying the breast/chest fully on a regulated schedule typically provides the body with enough feedback to continue to produce human milk. This is in part a result of the education gap that clinicians have on how to support sustained lactation while introducing formula. This is obviously individual to the parent and family, but in general, encouraging full removal consistently, will encourage long term lactation while supplementing.

A great, evidence based resource for low supply is Kaia Lacey, CLC. She is excellent at teaching the biological reasons for low milk supply and is formula inclusive.

2. You can’t mix formula and expressed human milk.

Formula and human milk CAN be mixed! This is often done in the form of fortification, but can also be done with 20 calorie formula and expressed milk.

Things to keep in mind when mixing formula and expressed milk:

Make the formula first as directed.

• It’s imperative to make the formula first as adding water to expressed milk and then adding powder can become confusing and lead to accidental errors. Infant formula is designed to be mixed with water, NOT with expressed milk (unless the baby requires fortified expressed milk).  Prepared formula can be added to expressed milk.‍

Be careful of the expiration date when mixing.‍

• Fresh expressed milk and formula will expire 24 hours from mixing date, or expiration of the expressed milk, whichever comes first.
• Thawed milk and formula mixture will expire in 24 hours or the expiration date of the thawed milk. ‍

Bottles should be used within 2 hours of baby sipping or discarded.

3. Offering a bottle to a baby too early will cause them to refuse the breast/chest and cause nipple confusion.

Offering a bottle or pacifier to a baby will NOT cause “nipple confusion”, also known as preference for the bottle over latching. The thought behind nipple confusion is that the baby has to work “harder” at the breast and “easier” at the bottle, which in this theory leads the baby to prefer “less” work at the bottle. 

Firstly, babies have a natural reflex called the sucking reflex. This reflex is present until about 8 weeks of age. This sucking reflex is crucial to baby’s survival - allowing them to have the instinct to latch, feed, and survive. During this reflextive time, baby will suck on anything that is offered to them - a human nipple, pacifier, bottle nipple, even a finger (theirs or a caregivers’) both for feeding and for comfort. 

What I have noticed as a CBC, NICU RN, and a breastfeeding mom, it is before and during this transitional period of 6-8 weeks when the sucking reflex is diminishing, is the most crucial time to offer a bottle consistently to prevent bottle refusal. We have worked with hundreds of families on bottle refusal, and this is the sweet spot! Offering the bottle before this time every at least 48 hours is the key to bottle acceptance while preventing breast or bottle refusal.

However, the positioning and way the bottle should be offered is paramount! While I have seen babies start to prefer the bottle, it is not due to nipple confusion, but what call “flow confusion” at bumblebaby. 

Babies are typically fed in the crook of the arm like so:

The problem with this position is the flow of the bottle is now gravity lead and not controlled by the baby. This will cause:

• Fast flow not controlled by baby
• Possible preference for faster flow
• Chugging, gasping, aspiration 
• Negative experience at the bottle (possible bottle refusal)
• Overflow of milk and inability to pause to breathe can lead to ear infections (read more in my blog post here).

Changing the position of the baby to be side lying while feeding:

• Mimics the position and flow of breastfeeding/chestfeeding
• Is not gravity lead, baby is able to pause to breath and pace themselves
• Creates a positive experience at the bottle, less bottle refusal and less bottle preference
• Allows baby to go back and forth from bottle to breast/chest

As for the pacifier and negative impact on lactation - it’s been debunked here! This study suggested that pacifiers should not be restricted as there is no evidence to support restriction.  A systematic review of the use of pacifiers and breastfeeding showed:

• Pacifier use in preterm and term infants had no impact on breastfeeding at 2, 3, 4 and 6 months of age
• Preterm infants who used pacifiers had a 7 day reduction in hospital stay
• Pacifier use decreased the time gavage feedings were used and oral feedings were successful by 3 days

Pacifiers are also encouraged due to their link to lower incidence of Sudden Infant Death Syndrome.

4. Formula supplementation and combo feeding disrupts the gut microbiome. 

This common misconception can be potentially dangerous to new parents and babies. In the recent years, there has been more focus on gut health both in infants and adults. In a recent study by Chin et. al, “ No immunologic differences were found to be associated with supplementation, including the development of T-cell subsets, B cells, or monocytes. These data suggest that early formula supplementation, given in addition to breast milk, has minimal lasting impact on the gut microbiome or immunity.” There was a change in the microbiome of infants who were supplemented but “Supplementation with formula during breastfeeding transiently changed the composition of the gut microbiome, but the impact dissipated by six months of age” (Chin et. al,)

5. Babies don’t bond with parents who bottle feed.

There are so many ways that parents can be encouraged to bond with their baby, bottle feeding or not. Some of these ways include:

Skin to skin

• Wear baby in a carrier skin to skin, place a robe or large button down over you 
• Take a bath (safely) with baby
• Feed baby skin to skin with the bottle by laying baby side lying on your chest

Make eye contact with your baby while feeding

Sing and play

In this study, “breastfeeding was not associated with the quality of mother-infant bonding, nor did it attenuate the association between mood and sleep difficulty symptoms with bonding”. Parents should be reassured that bottle feeding doesn’t affect how they bond with their baby or how their child bonds with them. Encouraging parents to find ways to bond with baby and educating them on how to do so is comforting to parents.

6. A parent’s end goal needs to be either formula feeding or breastfeeding.

There are SO many options and combinations of using human milk and formula to nourish infants. This can vary between families, and even between babies in the same family. 

The truth is, if a parent wants to keep lactation in the picture (through directly latching, pumping, storing some amount of expressed milk for use at a later date), they should be encouraged to find a way to EXTEND the amount of TIME baby gets human milk. This can be achieved by:

Offering formula from the beginning

• This feeding can be completely replaced by formula or mixed with any amount of expressed milk. Expressed milk for this feeding session can be directly stored for use later.
• Using a silicone pump during direct feedings is an easy way to collect milk without pumping. Read more in my blog post here.‍

Feeding every other feeding at the breast/chest, offering formula only at the opposite feeds. Option to collect milk with a silicone collector to store for later.

Offering the breast/chest first, then offering a supplemental bottle of formula or mixed milk/formula. NO PUMPING. This is my favorite option for low supply as typically primary low supply will not provide adequate milk production for exclusive feeding. 

• This takes the stress and pressure off of triple feeding, which exhausts parents, causes burnout, and often leads to a false sense of low supply.

Exclusive pumping and store 25-50% of output, replace with formula.

Pump one a day, store, replace completely with formula

• Milk is good for 12 months in a freezer and can be portioned to last weeks to months after weaning or partial weaning.

Often, when the stress and pressure is taken off exclusive breastfeeding/chestfeeding, parents feel empowered by a feeding plan that they can feel confident in, without being the sole source of nourishment to their baby. This in turn makes the feeding experience positive for both the parent and the baby, which often leads to longer periods of lactation and providing human milk to their baby. Less stress ironically often leads to better milk supply! This allows lactation to be achievable for parents in a realistic way in 2022.

Many clients that I work with had never even been approached with a feeding plan that involved combination feeding. And to their relief, this is SO achievable. Instead of weaning completely, we are able to come up with a tailored plan to suit their lactation goals while partially weaning, adding in formula, and extending the amount of time human milk is provided to baby by removing the stress of exclusivity. 

Conclusion

Parents often come to their health care providers for information on how to care for their baby, and much of this is feeding based. Educating health care providers on how to support parents who wish to continue providing human milk to their baby will empower parents to keep lactation in the picture, in whatever amount works for the feeding pair.

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Want to learn more about supporting combo-feeding parents? Join us for a webinar on Supporting Combination Feeding: Navigating the Spectrum of Infant Supplementation and become a Feeding Friendly provider.

Join our Feeding Friendly provider network