These mothers each have their own breastfeeding goals, which vary from giving it a try - maybe, to aiming to exclusively breastfeed for six months and continuing to breastfeed for two years or more (The World Health Organisation recommendation.)
The majority will fall somewhere in between - intending to breastfeed for a period of weeks or months, with or without the addition of expressed breastmilk (EBM) or formula. When breastfeeding is combined with formula feeds, we describe it as mixed feeding.
Some mothers intend to mixed feed from the outset but here I am addressing the most common scenario where formula top-ups - complementary feeds or "comps" are introduced early-on due to concerns about the baby's intake from the breast or the mother's supply.
I have been told as many as 70% of babies born in Victoria are given formula in the first week - leaving very few "eligible" to meet our dietary guidelines of no foods other than breastmilk until around six months. The reasons this might be so are generally centred around babies weight loss in the first week: weight loss is normal and expected but 10% of birth weight is the accepted amount and more than this could indicate a baby is not taking enough milk at the breast. The most likely causes are inefficient or insufficient milk removal - either the baby is not feeding well enough or the baby is not feeding often enough - or both.
Ideally, the introduction of formula top-ups in this situation should be considered short-term, while the causes are addressed. Improving technique, increasing feed frequency, assessing the infant for issues like jaundice or tongue tie, improving pumping efficiency ... most problems can be resolved within days and mothers should be given a plan to bring them back to fully breastfeeding by weaning off comping.
What seems to happen, in many cases, is that last bit gets forgotten. Weeks or months after the birth, babies are still being routinely comped and when asked why, their mother explains concerns about weight gains in the past. Often she describes herself as not making enough milk or her baby being extra hungry, big, frustrated or demanding. If she is happy to continue comping, then she can continue mixed feeding as long as she wishes - provided her supply isn't compromised or her baby shows a bottle preference.
But if the mother's original goal was to fully breastfeed her baby, then there are many things she can do to achieve that.
- Finish at the Breast technique: Christina Smillie's excellent article Finish at the Breast Method of Supplementation describes a really obvious approach - to get the business of supplementing out of the way at the beginning of the feed, leaving the remainder of the feeding session to be calmer, the breast to become a happy place and the mother and baby can enjoy the "milk drunk" result of falling asleep at the breast with a full tummy. It allows a controlled approach to gradually reducing the volume of formula, allowing stimulation at the the breast to increase production.
- You don't have to use bottles and teats: Dr Jack newman advocates an alternate method of topping up, where the formula is delivered during the breastfeed, not before or after. Supplementary Nursing Systems (SNS) have been around for decades, yet are still overlooked by mothers and health professionals alike. Old Midwives Tales are spread, claiming they are fiddly to use, take too long or rejected by babies - based not on personal or professional experience, but passed on as lore by those who may never have even seen one used!!! Dr Jack Newman discusses their use here and you can see a video of them in use here and read more about them here.
- Improve milk removal from the breast: Both babies and mothers can remove milk from the breast and it is the effective and frequent removal which establishes and maintains supply from the first feed to weaning. Breast milk supply is flexible, like a rubber band: if it drops for any reason, you can reverse that and take it back to where it was before - or higher! If adoptive mothers can establish breastfeeding and weaned mothers can reverse that process, then modifying milk supply when you are breastfeeding is relatively simple!!!
- Fix the most likely cause - the baby!: Despite what mothers tend to believe, most breastfeeding problems are baby-related. A mother's supply relies on feedback from her baby and if that baby is not feeding correctly, that feedback loop sends the wrong data back to the breast. If your baby is only removing 50% of the milk, then the breast gets the message to halve production. Do what you need to find the skilled and knowledgeable help your baby needs - if the doctor, midwife or lactation consultant don't seem to be focused on how the baby feeds: find one who does. Steer clear of any who say things like "You just don't make enough milk - some women can't, you know" and run from any who say "I couldn't breastfeed my babies and they are okay!" Make sure your lactation consultant is in fact, a board-certified IBCLC. Ask when she sat the exam last and look for positive reviews or recommendations before making your appointment. Your family doctor may not have more than a basic knowledge of lactation, picked up in medical school back in the day. Before taking their advice onboard, ask what seminars, conferences, journals or lactation resources for professionals they have accessed in the past year. If they dismiss concerns over issues like tongue ties (particularly the less obvious posterior tongue tie and upper lip tie) or suggest restricted feeding times/frequency, don't ask to assess a breastfeed or fail to examine your breasts if you present with issues like damaged nipples, mastitis, thrush or white spot - these can indicate a poor knowledge of breastfeeding problems. Ideally, your GP will offer you details of an IBCLC or breastfeeding counsellor and/or support group - if they don't, ask for them and if they cannot provide them, again be wary of their knowledge base.
- Improve the back-up system: If your baby is not effectively removing milk from the breast, you will need to help. Expressing by hand or breast pump is the second-best way to get milk out of the breast - but you can make it very effective by using the right techniques and equipment. If you are expressing to establish or increase your milk supply, get the very best pump you can. Hospital-grade pumps like the Medela Symphony or Ameda Platinum, with a double milk collection kit, are vastly better in these circumstances than personal use pumps intended to maintain your existing production when you cannot be with your baby. Maximizing Milk Production with Hands On Pumping is my number one recommendation for anyone expressing milk by pump: breast pumps use negative pressure (vaccum) to remove milk. Hand expressing uses positive pressure (squeezing). Babies use both. By combining the two, you can double the volume of milk expressed, therefore giving the breast very different feedback on how much to make.
- It isn't what you put in, it's what you take out: Before you invest all your money in galactagogues, try investing all your time in milk removal. While some foods and herbs claimed to increase milk supply are probably quite good for you, while others do no harm, prescription medications are expensive and don't have evidence to support they work in all cases of low supply. What we do know is they only work if combined with increased removal of milk from the breasts. So - while you can happily munch away on lactation cookies made by your best friend or sip the breastfeeding tea your mother bought, they will work even better if you do so with a double pump tucked into your bra at the same time! If your health professional reaches first for their prescription pad without working out IF your supply is actually low, WHY is is low and working out a plan to increase it by more effective milk removal ... perhaps seek a second opinion.
- Finally, learn what is normal for a breastfed baby: Human milk is designed for human babies. Cow's milk is designed for cow babies. We don't feed our children cow milk because it is closest to human, we do so because cow's are docile creatures taken into farming early on in human history - and getting a breast pump on a gorilla or chimpanzee several times a day would not be easy!!! I have written previously about Just what is normal, anyway? and Why your baby won't let you put him down. When we understand that human babies should not be sedated in the same way calves are and that natural behaviour for human babies is relatively constant contact with the mother, frequent access to the breast for feeding and sleeping in contact with the mother's body; we can see that our society's "normal" of deep sleep after feeds every few hours, in a static sleep space in a room away from the mother are totally incompatible with breastfeeding! Yes, it is very convenient for these things to happen, when you have other demands of your time; yes, comping with cow's milk formula is likely to achieve deeper sleep (associated with SIDS risk) and less frequent feeds (because cow's milk curds are tougher and harder to digest than those in human milk) BUT we must not use the word NORMAL to describe these out-comes.If these behaviours are used as the benchmark for human infant feeding and sleeping patterns, then EVERY fully breastfed baby is likely to fail to meet them!! In the first three months of an infant's life, you can expect to spend most of the day with your baby at the breast, in your arms or against your body - that is the human normal. Or the Fourth Trimester.
In fact, This is what your average day is most likely to look like (although hopefully without the crowds watching on!!)