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Combining Breast and Bottle Feeding
This is a long one - strap in!
I work with many families that are balancing breast and bottle feeding. When breastfeeding is going well, this can be an easy choice - the baby has a bottle at a particular time(s) of day, or when parents are away, etc. This is a great balance for many families, and one that works really well when baby is nursing effectively, milk supply is good, and the plan involves some pumping (or hand expression) when the baby gets a bottle (so the breasts “know” the baby had a feeding and keep supply going).
But, more often, I work with parents who are balancing breast and bottle in a way that’s much more stressful - like when a baby needs supplementary milk/formula to gain weight, or when nursing is painful and it’s not possible to breastfeed as often as desired.
Too often people will blame their milk supply for the problem. And while sometimes milk supply levels are the issue way more often the baby needs extra milk/formula because something about the baby’s latch is less effective. A less effective latch provides less stimulation to the milk supply - and keeps supply lower than it has the potential to be. This becomes a negative downward spiral, and parents feel like they are on a hamster wheel - nursing, pumping, bottle feeding - repeat! We call this Triple Feeding.
Triple feeding is sometimes an essential part of your lactation plan. But, it’s time consuming - so the the most important thing is to keep it effective and time-friendly. And, we always want to have an end-date in mind (ideally that will be when the baby’s latch has improved so they can do the work for you!). The goal of any triple feeding plan is to feed the baby and protect the supply. But, it’s essential to make a plan that keeps feeding and pumping timely, works toward your future goals, and preserves your sanity! We want the plan to feel like a short-term push for a long-term goal!
Most of the time, people are told to nurse first and then give a bottle if the baby needs more milk/formula after. Sometimes this works well. But when it leads to long feedings, baby constantly falling asleep, baby not getting what they need, nipple pain, etc - it’s exhausting. And, it’s emotionally hard too - because the parents feel like they spent all this time (and often had nipple/breast pain) - and then the baby didn’t get enough anyway. That is super discouraging, to say the least! And then on top of that, the nursing parent needs to pump to keep supply and/or to provide milk - and that takes even more time and energy.
One very helpful method for combo feeding is at-breast supplementing - it’s wonderful but it’s not for everyone. So, another very helpful method (and the main point of this blog post - sorry, that was a long ride to get here, right?) - is to combine breast and bottle.
My favorite trick is to reverse the order -
bottle first/breast second
also called “Finish at the Breast”
The reasoning behind Finish at the Breast is that when a baby is nursing well they will tend to get most of the milk at the beginning of the feeding. Then they start to slow down and do more comfort sucking at the end of the feed. When nursing is going well - comfort sucking is your superpower! But, when it’s not going well, it’s can be time consuming and frustrating, or even painful if the baby is not latched well.
The Finish at the Breast method mimics a baby’s natural rhythm - the baby gets some/most of their feeding with a “pre-bottle” (the amount depends on how well they are nursing - see Breastfeeding Math below) - and this pre-bottle takes the place of the faster beginning of a nursing. Then, once you’ve settled the baby’s “hangry”, they can nurse to finish the feeding. This often leads to more relaxed nursing and helps a baby practice their breastfeeding skills when they are calmer. It’s also emotionally very nice to finish the feeding at the breast and see your baby satisfied at the end!
Then, as you start to see the baby’s nursing improve, you can start to lower the amount in the pre-bottle and let the baby finish at the breast sooner and sooner in the feeding. Depending on how things are going, it’s possible to keep reducing the amount in the pre-bottle and get more and more breastfeeding. Work with your IBCLC to make the best plan for your situation!
Breastfeeding Math Details
Caution! This section is going to get into the weeds! Read at your own risk 😂!
We can figure out how much a baby needs by bottle a variety of ways:
The easiest method is to look at how much they have been drinking after breastfeeding so far. Let’s say they have been drinking a 1 oz bottle after every breastfeeding and gaining weight well, then the math is easy - we will start by offering a 1 oz pre-bottle, then breastfeed after until the baby seems satisfied. If those nursing sessions are going well and baby is gaining weight well - great!
Related to this - If a baby had been overgaining, then we can give a smaller bottle compared with before (so in the above example, this might be a 0.75 oz bottle each time, or 1-2 fewer 1 oz bottles per day). If a baby had been undergaining, then we can increase the bottle compared with before (so in the above example, a 1.25 or more oz pre-bottle may be a good choice).
And, absolutely related to this, is keeping track of the baby’s weight gain and diaper counts over time. In this way we can figure out if the baby is doing well with the balance that you’ve picked.
The other method, and this is where the breastfeeding math really comes in - is to figure out how much a baby might need at any given time. We will start the math class by talking about what we know about baby’s intake.
A typical breastfed baby from 1- 6 months drinks ~25-30 oz per day. This happens at around 10 lb or 1 month (whichever comes first). Keep in mind - it’s an average! Your baby may need a different amount - it’s however much that keeps them on their growth curve that matters!
So, if a baby is less than 1 month old and/or less than 10 lb (whichever comes first!), then we do some math. If 10 lb = 25-30 oz/day, then 1 lb = 2.5-3 oz. That means that each day a baby should get ~2.5-3 times their weight in milk/formula. Remember - this is up to 1 month or 10 lbs, then it stabilizes, it does not keep going higher and higher, other than for growth spurts!
So - let’s say your baby is 8 lb, then they may need 8 x 2.5-3 oz - 20-24 oz per day. If they have been gaining well on 10 oz by bottle (formula and/or pumped milk) per day, then we can assume that they are getting the other 10-14 oz directly from nursing. And, let’s say you are nursing/bottle feeding 8 times per day. Then each feeding is ~2.5-3 oz (presumably half from you and half from the bottle). So, in this example - the baby can have a 1.25-1.5 oz pre-bottle, then finish at the breast to get what we expect would be the other 1.25-1.5 oz.
And, if your baby nurses 10x per day, maybe they get 10, 2-2.5 oz feedings (half from the bottle, half from you).
And, of course, use your babies’ hunger cues, diaper output, weight gain, etc - if they need more, give more, and we’ll re-work the plan! Then, over time - as nursing and supply change - we can adjust the amount in the pre-bottle up or down to fit your needs.
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