Mixed feeding – or combo feeding – is when the infant is not only fed with breast milk, but is also supplemented with or takes entire feeds of formula milk. The reasons for mixed feeding can be various: the mother’s decision to do so, the presence of a genuine hypogalactia, and difficulties with removing supplementing, among others.

Mixed feeding is related to a shorter duration of breastfeeding (1). On the one hand, there is a possibility that the baby may reject the breast and that, by limiting the feeds directly at the breast, breast milk supply may decrease. On the other hand, it can be more tiring to maintain these two types of feeding, as can be more complicated to manage than offering breast milk or formula on its own.

There are two things to consider in mixed feeding and whenever additional milk other than direct breastfeeding is given:

Confusion in the infant’s sucking (nipple teat confusion)

There is some controversy regarding nipple-teat confusion (or nipple confusion). Studies on this aspect are not conclusive (2). Even so, we hear of many experiences of mothers with breastfeeding difficulties once they have used teats or pacifiers with their babies. Although there are teats on the market that are marketed by advertising their resemblance to the mother’s breast (3,4), no brand provides quality studies to prove this.

The infant’s latch onto the breast and onto the bottle teat is completely different (5). When a baby breastfeeds, they need to place their grooved tongue by placing the anterior part of the tongue onto the lower alveolar ridge. In this way, they can apply positive pressure with the tongue and lower jaw, which allows them to express milk effectively and without damaging the nipple-areola area. Once a sucking cycle has started, they make peristaltic movements with their tongue to swallow the milk. In the case of bottle-fed infants, these tongue movements change and are usually in front of the tongue instead of on the floor of the mouth. They fold the tongue back into the back of the oral cavity to be able to stop the flow of milk. Although the subject of nipple-teat confusion is in question and there is little scientific evidence on the topic (2,6), we have observed empirically that a majority of infants who are offered a bottle will later reject the breast when they are placed to breastfeed. This is due to their inability to manage and interchange these different sucking and swallowing movements. Similarly, some infants also have difficulty with using bottle teats.

Flow rate and milk quantity

During a feeding at the breast, the infant gets small amounts of milk at each suckling and needs some time to get the required volume of milk to be full. With the baby bottle, milk usually flows very quickly, and in a few minutes, they can ingest a lot of milk. This can generate frustration in infants when trying to get them to suckle again at the breast after taking one or several times a bottle, as the process at the breast is slower.

Recommendations for maintaining mixed feeding

Once we know the main causes of breastfeeding difficulties, let’s see what recommendations we can offer to a woman who wants or needs to maintain mixed feeding:

1. Keep the baby close

It is advisable that the person who gives the bottle stays very close to the baby when giving formula. Try to make the feeding as similar as possible to direct breastfeeding. Maintain eye contact and physical contact with the infant during the feed, and change sides to facilitate the development of both sides.

2. If possible, offer the breast first

Whenever possible, offer the breast first and leave formula milk for last, and only when necessary.

3. Choosing the most appropriate supplementing method

It is always advisable to choose the least invasive supplementing method possible, which allows the infant to regulate the amount of formula they want to have. It is the adult’s responsibility to provide the milk slowly so the infant has time to understand their signs of fullness and know when they had enough. The signs of fullness should be explained to the family so that they are able to notice them. If possible, the method chosen should help avoid the nipple confusion mentioned earlier. If the family chooses to use a bottle, it is recommended to use the technique known as the paced bottle feeding method.

4. Assessing the need for commercial formula milk

Breastfeeding needs to be accompanied well in order to assess the reasons for the mother’s choosing mixed feeding. If the infant is gaining weight within the normal range and there are no milk supply problems, increasing the amount of formula milk offered may be counterproductive. And if possible, the option of relactation should be offered and discussed.

5. Back to breastfeeding

When supplementing has ended, it is recommended to return to breastfeeding so that the infant can relate the pleasant sensations of fullness and well-being to the breast. In addition, sucking helps the infant to relax and fall asleep more easily and provides the necessary suction activity. This is also a good way to stimulate and maintain breast milk supply.

Breastfeeding care and maintenance of mixed feeding can sometimes be difficult. Whether the maternal situation is complicated or because the mother’s choice does not help to maintain it, it is essential to listen to her and accompany her in the process. The most effective approach is to give simple recommendations that she can change if she does not want to or cannot do them and be there for her in this process.

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