What is combi-feeding?
Combi-feeding
Combi-feeding, also known as combination feeding, or combo feeding, is where a baby is fed both breastmilk and formula. This can be done successfully, although there are a few pitfalls you need to avoid, if you want to combi-feed long-term. This article will look at:
- Why babies are combi-fed
- Pitfalls to avoid, aka the top up trap
- How to move away from combi-feeding, if you want to exclusively breastfeed
- How to establish a successful combination feeding schedule
- Some commonly asked questions
Exclusive breastfeeding
All reputable organisations involved in promoting the wellbeing of babies recommend exclusive breastfeeding, with no other food or water, for the first six months of a baby’s life. We know that this does promote the best health outcomes for most babies. It helps to protect against infections and allergies. Additionally, babies that are exclusively breastfed have a healthier gut microbiome.
Please note:
Babies that have formula (even small amounts) are at increased risk of developing cows milk protein allergy, and also have an altered gut microbiome. However, giving some formula doesn’t cancel out the immune-boosting benefits of breastfeeding. Breastfeeding doesn’t have to be all or nothing. As a lactation consultant, I take a pragmatic view that any breastmilk a baby gets is a bonus. If combi-feeding allows you to breastfeed for longer, instead of switching completely to formula, than it can be a really positive choice for some families.
Why are babies combi-fed?
There can be many different reasons why women want to combi-feed, or end up combi-feeding. So, before we look at how to combi-feed successfully, let’s look at why you may be combi-feeding:
Perceived milk insufficiency
Newborn behaviour can make doubt whether you have enough milk
One of the biggest fears that new mothers have is that they won’t have enough milk for their babies. At a basic, instinctive level, we all want to make sure that our babies are well fed. Often, newborn babies behave very differently from what we expect. Newborn babies feed very frequently! The hardest day for new parents is usually day 2 (24-48 hours after birth). Newborns are often very unsettled, wanting to feed constantly, and this comes as a big shock to new parents. Understandably, if you aren’t prepared for this behaviour you may start to question whether you are making enough milk for your baby. If you aren’t sure whether you are making enough milk for your baby, I cover this in a lot more detail in this article: https://rebeccascottpillai.co.uk/breastfeeding/making-enough-breastmilk/.
Breastfeeding is really intense at the start
The first six weeks of breastfeeding are often very intense. Babies feed very frequently and often only settle in your arms. They may cluster feed for several hours. Usually, this pattern of prolonged feeds doesn’t last forever. However, if you don’t feel very confident about breastfeeding, then you may start to doubt whether you have enough milk or not. Often, mums start to give a few bottles of formula because they are worried. Then they end up in this “top up” trap – they give more and more bottles of formula, and breastfeed less and less over time.
Babies feed very frequently
Babies feed very frequently for the first few weeks for lots of different reasons. One of the main ones is that lots of frequent feeding stimulates milk production and helps to establish a good supply. The more you feed, the more milk you make. A baby feeding frequently is not usually a sign that you don’t have enough milk. It’s just the way babies are programmed to feed. As long as they are gaining weight well, and have reassuring wet and dirty nappies, they are getting enough milk.
Actual milk insufficiency
Some women genuinely don’t make enough milk
In some cases, mums really are struggling to make enough milk. Your baby may be feeding very frequently, but perhaps they aren’t gaining weight as they should. Or perhaps they don’t have a reassuring number of wet and dirty nappies. While it’s hard to pin point the exact percentage of women who can’t make enough milk for their babies, it is probably somewhere around 5% of all women. Which means that statistically, you probably are in the 95% of women who CAN make enough milk for your baby.
However, actual milk insufficiency does constitute a real issue for some women, and it can be a tricky issue to resolve. Around half of my breastfeeding clients are struggling with low supply (and/or babies gaining weight slowly). Again, the article I linked before goes into more detail about this: https://rebeccascottpillai.co.uk/breastfeeding/making-enough-breastmilk/.
Combi-feeding can be a life line in this situation
When women do have a lower supply than expected, combi-feeding can provide a real life line for them. Their babies can continue to get breastmilk, with all the associated benefits, plus they get a bit of extra formula to increase the amount of milk they get in total. This then allows them to grow and thrive appropriately.
Breastfeeding is an intense experience, and combination feeding gives you a break
The first few weeks are a steep learning curve
I’m not going to lie. The first few weeks of breastfeeding are really, really intense. Most mums find it a real shock to the system to be stuck on the sofa for hours at a time, breastfeeding. It can feel overwhelming and exhausting. You may feel touched out, experience sensory overload, or just feel like you don’t want the whole responsibility of nourishing your child to rest solely on you.
This is especially true if it is your first baby. You are learning to be a mother, while also being completely responsible for keeping a baby alive! It is a very steep learning curve. I remember feeling trapped with my first baby, like my life was no longer my own. And of course, my life WAS no longer my own! I had to put my baby’s needs first most of the time. By the time my second child came, I was much more used to that feeling of being constantly needed by someone else. It’s certainly not easy, but you do get used to it.
It can be hard when you have other children
It may also be the case that if you have a very young toddler in the house, it is difficult to dedicate the time you need to, to breastfeeding. Being completely pragmatic, sometimes it’s just not possible to sit on a sofa for hours at a time, if you also have a 16-month old wrecking havoc! While some mums master feeding a baby in a sling or carrier, there is still a learning curve involved. Breastfeeding in a carrier is still not something you can do hands-free either.
Combi-feeding can give you a break
Some families want to share the responsibility of feeding with a partner. Now, on the one hand, I do think that other family members can bond with a baby without feeding them. In fact, in can be a really good experience for babies to learn that food and love don’t always go hand in hand. However, if you also can benefit from the time that someone else is looking after your baby, then it’s not just about your partner getting something out of feeding your baby. You get a break, or time for some self-care, or even time to spend with your other children, who may be struggling with the addition of a new baby.
Combi-feeding suits your family’s circumstances
There can be any number of reasons why you want to combi-feed. Perhaps you’re going back to work soon after the baby is born. Or perhaps you need to be away from your baby for long periods of time. Perhaps you just really need to know that your baby is ok taking formula and drinking from a bottle. This article is not saying that some choices are valid and some aren’t. At the end of the day, breastfeeding needs to work for you. And, if combi-feeding means that you can keep breastfeeding, instead of switching completely to formula feeding, then carry on!
Pitfalls to avoid (the top up trap)
You can combi-feed long term. However, it’s important that you avoid some common pitfalls. Otherwise what happens is that over time, you end up breastfeeding less and less, and end up giving more and more bottles. Before you know it, you’ve stopped breastfeeding altogether.
Not breastfeeding often enough
Supply and demand
It’s really important that you breastfeed at least 8 times in 24 hours, including at least once overnight. Most breastfed babies feed at least 10-12 times. Your milk supply is established through supply and demand. The more milk you remove from your breasts, the more milk they make. Additionally, they work harder at making milk when they are emptier. So, if you breastfeed frequently, your breasts work harder to make milk because your breasts are emptier more often.
Every time you give a bottle of formula in the early days, you are essentially reducing the demand on your body to make breastmilk. Instead of your baby breastfeeding, they get a bottle. This is partly why breastfeeding is just so intense for those first few weeks. Babies feed very frequently to increase your milk supply.
Prolactin levels
For the first few weeks (up to around 6 weeks) your prolactin levels help to drive milk production. So it’s not just about supply and demand. If you have high prolactin levels, you may produce a very good volume of milk, even if your baby isn’t feeding very frequently. So, you may initially get lulled into a false sense of security, thinking that 5-6 breastfeeds a day will be enough.
Unfortunately, at around six weeks, your body stops pumping out prolactin no matter what else is going on. Instead, your body only produces prolactin in response to feeding. This means that if you haven’t been breastfeeding frequently, your prolactin levels drop too much and your milk supply drops as well.
Night feeds
It’s also worth bearing in mind that prolactin levels are stimulated most with night feeds. Therefore, if you have been giving bottles of formula at night time instead of breastfeeding, your supply may also drop at around 6 weeks for the same reason: there just isn’t enough prolactin stimulation to sustain long term breastfeeding.
Not bottlefeeding in a way that supports breastfeeding
There are three issues that commonly occur with babies that are bottlefed, which can lead to problems with breastfeeding.
They aren’t encouraged to “latch on” to the bottle
Ever noticed how your breastfed baby opens their mouth wide to latch on to the breast? They need to do this to draw enough breast tissue into their mouth for a comfortable latch. You can, however, push a bottle into a baby’s closed mouth and they will start sucking. If you want to move between breastfeeding and bottlefeeding easily, you have to encourage your baby to “latch on” to the bottle too. Otherwise, they forget that they need to open wide to breastfeed.
Stimulate your baby’s rooting reflex by running the bottle teat down from their nose to their chin. This mimics your baby coming to to breast and feeling the breast on their face. Wait for them to open their mouth wide before putting the bottle in their mouth. Allow them to draw the bottle as far into their mouth as possible. Their lips should be around the base of the teat!
They are given volumes that are much bigger than they would get directly at the breast
It is fairly easy to overfeed a bottle fed baby
For the first 8 weeks or so, a baby has a very strong stuck reflex. This means that anything that touches a baby’s palate will trigger them to suck, whether they are hungry or not. This is why you could breastfeed for an hour, and your baby will till take a full bottle of milk after!
Babies get milk every time they suck on a bottle
When babies are at the breast, they don’t get a steady flow of milk. In fact, they will often spend a lot of time doing what we call “non-nutritive sucking”. This is where they chill out at the breast doing lots of little fast sucks without many swallows. When babies suck from a bottle, they always get milk. If you put a lot of milk into the bottle to begin with, they will suck until the bottle is empty, whether they needed that volume of milk or not.
How much milk should you give?
As a rough guide, a full feed in week one is usually around 15-30 mls, and from week 2 onwards 60-90 mls would be an appropriate amount to give as a full feed. This would be roughly similar to the volumes of milk that a baby gets directly at the breast. Bear in mind that these are full feeds. If you are giving a “top up” after a breastfeed, then you would need to give smaller volumes. I usually suggest 5-10 mls as a “top up” in week one, and 15-30 mls from week 2 onwards.
The feed isn’t paced
We usually recline babies when we feed them and then tip the bottle up (see the picture below). When you do this, gravity is going to give the milk flow a helping hand. Basically, the milk is more likely to pour into the baby. When a baby is breastfeeding, they only get milk if they suck. So, we want to make the flow of milk in a bottle a bit slower. This usually involves sitting a baby upright to feed, and holding the bottle horizontal. You can find out more about paced bottlefeeding here: https://rebeccascottpillai.co.uk/breastfeeding/paced-bottlefeeding/
How to move away from combi-feeding to exclusive breastfeeding
Many mums find themselves in a “top up trap”. Perhaps they gave a few bottles in the early days, and then they never seem to be able to breastfeed enough to meet their baby’s needs. Or perhaps they find themselves giving more and more bottles as time goes on, and they breastfeed less and less.
Increase your milk supply
If you want to move away from combi-feeding, the first and most important thing to do is to increase your milk supply. There are three ways you can do this:
1. Introduce more breastfeeds
If your baby isn’t breastfeeding very frequently, you can offer a breastfeed instead of a bottle. This will often work best in the first 4 weeks, when your milk supply is being established. If you are giving your baby a dummy/pacifier, consider offering the breast instead.
2. Switch feeding
Switch feeding is a very particular way of breastfeeding that works really well at increasing your supply, and getting more milk into a baby at the breast. Babies transfer the most amount of milk at the start of a feed – this is when you see big sucks and swallows at the breast. With switch feeding, you watch for those big sucks and swallows, and then when they stop, you switch to the second breast. Watch for big sucks and swallows on the second breast, then switch back to the first breast. Watch for big sucks and swallows, then switch back to the second breast again.
You can do switch feeding, in conjunction with adding more breastfeeds, to really increase the amount of milk your baby gets at the breast.
3. Pumping
If your baby is feeding well, I’d always start with introducing more breastfeeds and switch feeding. However, you may also need to pump if your baby struggles to latch on to the breast, or they aren’t transferring milk well. You can:
- Pump after every breastfeed for 5-10 minutes to increase the demand placed on your body to make milk.
- Ideally pump any time your baby gets a bottle of formula to increase the demand for milk. So, for example, if you are giving a full feed of formula at 4 pm, ideally you’d pump for around 20-30 minutes to tell your body to make enough milk to replace that bottle of formula.
Other issues that might affect your supply
If you feel that there may be other issues affecting your milk supply, then it may be helpful to get some support with this. Common issues that affect your milk supply include:
- With your baby – shallow latch, ineffective feeding, a tongue tie, birth injury.
- With you – underlying hormonal issues, large blood loss after birth, breast surgery, breast hypoplasia (insufficient glandular tissue).
How to establish a successful combinaton feeding schedule
What are your combi-feeding goals?
Let’s start off by looking at what your goals are. Your combi-feeding schedule will look different, depending on how often you want/need to give formula.
As much breastfeeding as possible, with the occasional bottle of formula
This may be the case if you don’t want to pump, you want to mostly breastfeed, and just give the occasional bottle of formula. I’d suggest that you:
- Work on exclusively breastfeeding for the first 3-4 weeks.
- Make sure that you have a full supply of milk before you introduce formula (usually by 4 weeks).
- Make sure that your baby is latching well and you feel confident with breastfeeding. Sometimes, giving a bottle early on in the process can make latching and breastfeeding harder.
- Introduce a bottle once you feel breastfeeding is well established. You may decide to give it at a certain time of the day, for example, bedtime is popular for a lot of families. Or perhaps you want to make sure that your baby can take a bottle if you need to leave your baby for a few hours, so you may want to offer it during the day instead.
- Make sure that you are offering a bottle in a way that is protective of breastfeeding (see above, under Pitfalls).
- Make sure that any one looking after your baby is confident with soothing your baby with other means rather than milk! This may sound like a strange one, but some carers will automatically put a bottle in a baby’s mouth at the slightest fuss. If your baby has had a decent amount of milk while you’ve been away from them, then you can be reassured they are not hungry. You need to leave 1-1.5 oz (30-45 mls) of milk for every hour that you are way from your baby. Perhaps let carers know that they can offer a dummy, put them in a sling or a carrier, or take them for a walk, to help to settle them, especially if they have already had a good volume of milk.
A regular number of bottles (1-3 per day)
If you are giving at least one bottle a day, but no more than 3 bottles, you want to:
- Make sure that you are breastfeeding at least 8 times a day. This is true for at least the first six weeks, to ensure that you establish a stable milk supply. If, after six weeks, your supply seems to be holding steady, you may be able to drop below 8 breastfeeds a day, especially if you need to give more bottles. However, bear in mind that the more often you breastfeed, the more likely you are to continue to be able to breastfeed, while also giving bottles. The more bottles you give, the less likely you will be able to sustain breastfeeding long term.
- Ideally, don’t introduce a bottle before 3 weeks of age. However, if you really do need to give a bottle before 3 weeks, aim to use a paced feeding technique: https://rebeccascottpillai.co.uk/breastfeeding/paced-bottlefeeding/. In particular, you want to make sure your baby opens their mouth wide to latch on to the bottle.
- Offer appropriate amounts. In week one, a bottle feed may be 15-30 mls (0.5-1 oz). From week 2 onwards, an appropriate feed is around 60-90 mls (2-3 oz).
- You can give the bottles at any times that work for you. However, make sure that you don’t go longer than 5-6 hours without breastfeeding, and that you still breastfeed at least once overnight. So for example, if you are giving 2 bottles, you may choose to give one around 4 pm, and another at 10 pm, and breastfeed in between those two bottles. If you are giving 3 bottles, you may wish to give them at 10 am, 4 pm and 10 pm. However, you decide the times that work for you!
- If your baby still has a strong need to suck after having a bottle, you can either offer the breast, or a dummy/pacifier.
Several bottles a day
Usually, mums who are giving several bottles a day are doing so because there are issues either with a baby’s weight gain, or they have low supply. It does get trickier to sustain breastfeeding long term if you are giving several bottles a day. Ideally, you want to:
- Make sure that you are still breastfeeding at least 8 times a day. This is especially important if you are giving more formula than breastmilk in 24 hours. So, if you are giving more than 100 mls formula per day in week 1, 250 mls per day in week 2, or 400 mls per day from week 3 onwards, you need to make sure that this big volume of formula isn’t impacting on the frequency with which your baby breastfeeds.
- Make sure baby is being bottlefed in a way that is protective of breastfeeding (see under Pitfalls, above).
- Work out which pattern of bottlefeeding works best for you:
- You could give a small amount of formula in addition to most breastfeeds during the day. So, for example, 15 -30 mls at 6-8 breastfeeds during the day. I suggest giving it before a breastfeed, rather than after! This just allows your baby to finish their feed at the breast, which often keeps breastfeeding as a satisfying and happy experience for them.
- You could divide the total amount of formula you give in a day into 90 ml (3 oz bottles). So for example, if you are giving 360 mls in total, that would work out at 4 bottles a day. (You’d also need to make sure you breastfeed at least 8 times in addition to these 4 bottles.)
Some commonly asked questions
Can you mix breastmilk and formula in a bottle?
The short answer is yes, you can combine the two if you need to. However, it may make more sense to feed them separately. If you’re pumping as well as breastfeeding and giving formula, your breastmilk is a precious commodity. It can be soul-destroying if you have to throw out any breastmilk, which would be the case if it’s been mixed with formula and your baby doesn’t finish the bottle. So, it would make more sense to give small amounts of breastmilk first and then “top up” with formula once the breastmilk runs out.
There is some evidence that mixing formula and breastmilk in the same bottle may neutralize some of the “live” components of breastmilk, and reduce the absorption of nutrients. However, it is probably best not to overthink this too much, because the milk will no doubt mix in your baby’s tummy anyway! Ultimately it is still more beneficial to give breastmilk if you have it, rather than to avoid giving it at the same time as formula.
What is the best formula to give a breastfed baby?
There are still some health care professionals that will suggest certain brands because they are “more like breastmilk”. This, unfortunately, just shows how clever the formula manufacturers are at marketing! All stage 1 formulas are made with the same basic ingredients. Pick one that suits your budget, and be aware that more expensive definitely does not mean better. This is a great impartial and simple guide to formula: https://www.firststepsnutrition.org/parents-carers
Does combi-feeding cancel the benefits of breastfeeding?
No, breastfeeding and giving any amounts of breastmilk (no matter how small) always benefits your baby. Combi-feeding is still breastfeeding! There are some risks to giving formula, as these babies are at higher risk of developing an allergy. They will also have an altered gut microbiome. However, the less formula you give and the more breastmilk you give, the better.
Can I combi-feed long term?
Yes, many parents give some formula regularly to their baby, and still manage to maintain breastfeeding long term. Providing you avoid the top up trap, it’s perfectly sustainable.
Can I move away from combi-feeding at any stage?
It will be easiest to move away from combination feeding in the first few weeks. This is when your supply is most sensitive to stimulation. However, it is still possible to increase your supply weeks down the line, and eliminate bottles. Sometimes, when babies get well established on solids they need less milk. If you are combi-feeding because of a low supply, sometimes this is when you find yourself exclusively breastfeeding, and you no longer have to give any formula.
Is it ok to give a pacifier/dummy?
Giving a pacifier or dummy after a bottle of formula can be a great way of ensuring that babies don’t overfeed. Babies do still have a strong need to suck and may finish a bottle quickly before they have a chance to satisfy this need to suck. However, dummy use can also have an impact on your milk supply. If you are trying to build your supply, you may want to offer the breast instead. This article on pacifier/dummy use will help you weigh up if it’s a good choice for you or not: https://rebeccascottpillai.co.uk/newborn-babies/giving-a-baby-a-pacifier-dummy/
Do I have to use a bottle if I’m combi-feeding?
What do I do if my baby refuses a bottle or formula?
Babies are funny little creatures! I’ve seen them refuse to take breastmilk from a bottle, but take formula. Or, they will take breastmilk but not formula! Introducing a bottle early on is also not a guarantee that they will always take a bottle either. Babies lose their suck reflex somewhere between 8-10 weeks, and so they may refuse to take a bottle at this stage. However, if you introduce a bottle before the 8 week mark, and bottlefeeding is a pleasant experience for them, they are more likely to continue accepting one.
If your baby does refuse to take a bottle, then you may have to work on increasing your milk supply to meet your baby’s needs. Alternatively, you could try a different method of feeding them – such as a supplemental nursing system, or cup feeding. If they turn their nose up at the formula, you may need to mix a bit of breastmilk so that they accept the smell/taste.
Need some help?
Do you want some help with breastfeeding, bottlefeeding or combi-feeding? You can see the different consultations that I offer here: https://rebeccascottpillai.co.uk/book-a-consultation/
