Helpful Guide: Combination Feeding

What is combination feeding? Combination feeding or “mixed feeding” is when a mother feeds her baby a combination of breast milk and formula. A mother might be nursing at breast or expressing breast milk and offering it in a bottle, and then also supplementing feeds with formula at the same time.   Why would a mother combination feed? Sometimes there are clinical reasons for mixed feedings while other times it is a personal choice. A mother might be diagnosed with a low milk supply for medical reasons and needs to introduce extra feedings. Alternatively, a mother makes an informed decision and decides to introduce formula milk for non-clinical reasons (Baby Friendly Initiative, 2018). For example, a mother might want to take a break and let her partner give a bottle of formula or she might be returning to work and has trouble keeping up with expressing milk to give her baby while she is away (NCT, 2020).   How to introduce formula feeds This will depend on whether a mother is exclusively expressing breast milk (and bottle feeding it) and would like to supplement or if the mother is nursing at breast and would like to supplement with formula.   Combination feeding for mothers who exclusively express breast milk Some mothers will prefer to give their baby bottles of breast milk first, followed by a bottle of formula. This way the baby drinks all their mother’s breast milk for the day and the remaining feedings are formula milk. Essentially, mothers keep breast milk separate from formula milk to ensure the baby consumes a breast milk bottle in its entirety and breast milk will not go to waste. However, sometimes it is easier for a mother to mix breast milk and formula together in one bottle (Healthline, 2020). This is possible to do as long as the formula milk is prepared separately according to NHS guidelines. Mothers should not mix breast milk with infant milk that is actively hot as it could compromise the nutrients in the breast milk (Bransburg-Zabary et al., 2015). They should wait until the formula has cooled to body temperature before mixing with breast milk.   Combination feeding for mothers who nurse at breast A mother who is nursing at breast can introduce formula for the first time via a bottle. A sample schedule is shown below. However, a mother can modify which feeding(s) she chooses to offer a bottle of formula. Either way, it is important to do so gradually, dropping one feed at a time, so that it is more comfortable for the mother (avoiding things like clogged ducts, engorged breasts, mastitis) (NHS. UK, 2020). It can take as long as 5-7 days for a mother’s supply to adjust to missing a feeding (NCT, 2020).

	Feed 1	Feed 2	Feed 3	Feed 4	Feed 5
Day 1	Breast	Bottle	Breast	Breast	Breast
Day 2	Breast	Bottle	Breast	Breast	Breast
Day 3	Breast	Bottle	Bottle	Breast	Breast

  Tips for introducing a bottle for the first time

• Baby should be relaxed, and not fussy or super hungry (NHS. UK, 2020).
• Someone other than the mother should offer the bottle. Babies recognise the smell of their mother and may refuse a bottle if they know their mother is nearby and might want to nurse at breast instead (NHS. UK, 2020; Roberts & Eryaman, 2017).

  Will combination feeding affect breast milk supply? Combination feeding before milk supply is established can affect milk production, especially if the mother does not express milk in place of the formula feeding session. Additionally, supplementing with formula can affect the feeding frequency which will signal to the mother’s body that she does not need to produce as much milk (NCT, 2020; Dorset HealthCare, n.d.).   References

1. Unicef UK. (2018, October 4). Maximising breastmilk. Baby Friendly Initiative. https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/implementing-standards-resources/maximising-breastmilk/
2. NCT. (2020, December 10). Mixed feeding: combining breastfeeding and bottle feeding. NCT (National Childbirth Trust). https://www.nct.org.uk/baby-toddler/feeding/practical-tips/mixed-feeding-combining-breastfeeding-and-bottle-feeding
3. Barth, L. (2020, June 11). Can You Mix Breast Milk and Formula? Healthline. https://www.healthline.com/health/baby/can-you-mix-breast-milk-and-formula
4. NHS website. (2020b, December 7). How to combine breast and bottle feeding. Nhs.Uk. https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/bottle-feeding/combine-breast-and-bottle/
5. Bransburg-Zabary, S., Virozub, A., & Mimouni, F. B. (2015). Human Milk Warming Temperatures Using a Simulation of Currently Available Storage and Warming Methods. PLOS ONE, 10(6), e0128806. https://doi.org/10.1371/journal.pone.0128806
6. Roberts, S. C., & Eryaman, F. (2017). Mutual Olfactory Recognition Between Mother and Child. Human Ethology Bulletin, 32(1), 42–52. https://doi.org/10.22330/heb/321/042-052
7. Combination Feeding. (n.d.). Dorset HealthCare. Retrieved August 4, 2021, from https://www.dorsethealthcare.nhs.uk/patients-and-visitors/our-services-hospitals/physical-health/breastfeeding-support/all-about-breastfeeding/combination-feeding

Kendamil recognises that per the World Health Organisation (WHO) breastfeeding provides the best nutrition and protection from illness for babies. As such, mothers should be given guidance and support on everything related to breastfeeding including information on lactation and an appropriate diet while breastfeeding. Mothers should be informed on the drawbacks to not breastfeeding and/or stopping lactation as well as be made aware of the financial cost to formula feed. If a decision to use formula is made, it is important to discuss correct formula preparation techniques and sterilisation.