This information is intended for Healthcare Professionals only.
SUPPORTING COMBINATION FEEDING AS A HEALTHCARE PROFESSIONAL
By Pip Davies, BSc (Hons), MSc New parents feeding choices extend beyond either breast or formula feeding, and the reality is that combination feeding is a very common feeding choice. It is therefore imperative that healthcare professionals understand what combination feeding is and know how to support families in their care choosing to do it. What is Combination Feeding? Combination feeding involves feeding an infant with both breastmilk from the breast and either expressed breastmilk or formula milk from a bottle.1
How to support families to Combination Feed? When supporting new parents in their infant feeding choice it is important to discuss both the challenges and the potential advantages of combination feeding to allow an informed decision to be made by the family. The benefits of breastfeeding babies are well documented and widely recognised and as healthcare practitioners the promotion of breastfeeding is an important part of the role. It is known that any breastmilk for babies is of benefit.2 For some new parents knowing about the option to combination feed may bridge an important gap and mean their child receives some breastmilk rather than none. This resolution has a substantial impact on the health outcomes of the developing child and highlights the importance of the understanding around combination feeding. Understanding the parent’s individual reason for combination feeding is useful when supporting their choice. Combination feeding may be the chosen method of feeding for parents for a variety of reasons such as:3
• To support a journey to exclusive breastfeeding where there are breastfeeding challenges to overcome. • Expressing breastmilk may be used as a method of increasing low milk supply in a mother. • If a parent is required to be away from their baby, for example if returning to work and another care giver is required to feed the baby. • To enable another parent or care giver to bond with the baby through feeding. • To allow the breastfeeding parent a break from breastfeeding or time to gain extra rest. • If a baby has been bottle fed from birth and the parents now wish to breastfeed.
It is generally recommended to establish breastfeeding prior to introducing a bottle, typically this may take 6–8 weeks and parents should be supported as much as possible with positioning and latching their baby at the breast during this time.3
Combination Feeding Challenges: It is important to recognise that combination feeding may come with its own set of challenges for families and to be aware and honest about these with parents. When introducing bottles to a breastfed baby the mother’s breastmilk supply may be impacted and reduced. Breastmilk supply works on a supply and demand process, therefore if the breast is stimulated less, the milk supply will be less. A mother’s body produces the hormone oxytocin when she is close to her baby, and this triggers the release of breastmilk. When the milk stores become emptied, a hormone called prolactin is released, and this hormone stimulates further milk production. It is important that supplementary bottle feeds are spread out with breastfeeds in-between to ensure adequate breastmilk supply is maintained.4
When combination feeding a baby, the mother will naturally begin to have longer intervals in-between breastfeeds and this may lead to her breasts becoming overfull and engorged. It is important to gently hand express off the excess milk to aid her comfort and help prevent complications with blocked ducts. However, to prevent further encouraging an excess supply by stimulating the supply and demand cycle of breastmilk, the mother shouldn’t completely empty the breast when engorged in between breastfeeds.5
Breastfed babies may not feed from a bottle straight away as the suck motion is different from a bottle than from the breast. Patience and perseverance are key, and parents may find using a teat designed to be more like a nipple supports a smoother transition into combination feeding.6
Conclusion: It is important to continually recognise the benefits of breastfeeding babies for both short and long term maternal and child health outcomes. Healthcare professionals should ensure families are empowered to make an informed choice about infant feeding and that the continuum of breastfeeding is supported.
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IMPORTANT NOTICE: Breastfeeding is best. Infant milk is suitable from birth, when babies are not breastfed. Follow-on milk is only for babies over 6 months, as part of a mixed diet and should not be used as a breastmilk substitute before 6 months. We advise that the use of formula milks and the decision to start weaning should be made only on the advice of a doctor, dietitian, pharmacist or other professional responsible for maternal and child care based on baby’s individual needs. Use Toddler milk as part of a varied, balanced diet from 1 year. References: 1. UNICEF. Key Messages Booklet. 2012. Available at: https://www.unicef.org/media/108411/file/Key%20Message%20Booklet.pdf [Accessed: April 2022]. 2. WHO. Long term effects of breastfeeding. 2013. Available at: https://apps.who.int/iris/bitstream/handle/10665 /79198/9789241505307_eng.pdf;jsessionid=501C2F8D4F8DF960921A75170869AE6A?sequence=1 [Accessed: April 2022].3. NHS. How to combine breast and bottle feeding. 2019. Available at: https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/bottle-feeding/ combinebreast-and-bottle/ [Accessed: April 2022]. 4. Britton C et al. Cochrane Library. 2007. Available at: https://www.nhs.uk/conditions/baby/ breastfeeding-and-bottle-feeding/bottle-feeding/combinebreast-and-bottle/ [Accessed: April 2022]. 5. Lee S and Kelleher S. Am J Physiol Endocrinol Metab. 2016;311(2):405–422. 6. Zimmerman E and Thompson K. J Perinatol. 2015;35(1):895–899. Date of preparation: April 2022.