Mixed feeding: what you need to know

Mixed feeding from the maternity unit

Many mothers leave the maternity unit with a prescription for supplements for their baby. Healthcare professionals may then consider it appropriate to support the newborn's weight gain by adding bottle feeds alongside breastfeeding. These bottles may contain:

• breast milk expressed by the mother,
• or infant formula.

This particularly concerns babies born prematurely, with a low birth weight, or too tired to feed effectively. In this case, the mother can express her milk and give it by bottle, thereby practising expressed breastfeeding alongside direct feeds.

Healthcare professionals determine the frequency and volume of supplements, but it is still recommended to:

• offer the breast first,
• then give the supplement,
• and to express milk every time a bottle is given, in order to maintain the stimulation needed for milk supply. 

With time and the support of an expert — such as a midwife, a paediatrician, or an IBCLC lactation consultant — it is possible to gradually replace formula with expressed breast milk, then reduce and stop the supplements.

Special circumstances: In certain cases, such as mammary hypoplasia or a history of breast reduction surgery, supplements may need to remain in place throughout breastfeeding.

In any case, the introduction and withdrawal of supplements should always be overseen by a healthcare professional to ensure the baby's wellbeing and the mother's comfort.

WHO recommendations: exclusive breastfeeding until 6 months of age

The World Health Organization (WHO) recommends: exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding until at least 2 years of age, alongside a diversified diet.

Breast milk remains an essential nutritional resource because it:

• provides all the energy and nutrients needed for the first 6 months,
• still covers around 50% of the baby's needs during the second six months,
• provides nearly a third of nutritional needs during the second year,
• continuously adapts to the child's needs,
• contains protective antibodies that support the baby's immune system.

Can you breastfeed for a long time with mixed feeding?

To breastfeed over the long term, the breasts need regular stimulation. Some mothers will not be able to maintain their milk supply if they replace too many feeds with bottle feeds, while others will manage to sustain a good flow by staying attentive to their baby's needs.

There is no universal rule: every mother responds differently. But in all cases, it is recommended to consult an IBCLC lactation consultant to assess breastfeeding management and adjust habits accordingly.

Many mothers find that giving a bottle of formula in the evening to "help baby sleep longer" does not always produce the desired effect. On the contrary, it can cause engorgement which, over time, leads to a reduction in milk supply.

Wait until lactation is already well established

Starting mixed feeding too early is, in practice, the same as initiating a gradual weaning process from the outset. Milk supply generally becomes established within 2 to 3 weeks after birth, sometimes a little later depending on the mother.

Introducing formula before milk supply has stabilised sends a signal to the body to produce less milk. As a result:

• the few bottles given each day risk multiplying quickly,
• milk supply is less stimulated,
• the baby may become restless at the breast because they are not receiving the expected quantity or flow of milk.

To preserve milk supply, it is preferable to wait until lactation is well established before regularly introducing bottle feeds.

Mixed feeding and returning to work

Many mothers consider, when returning to work, breastfeeding only in the morning and evening, and letting bottle feeds (with infant formula) take over during the day.

On paper, this arrangement may seem appealing. But in reality, it carries several risks:

• painful engorgement due to lack of stimulation during the day,
• unexpected milk leaks at work,
• gradual decrease in milk supply,
• a baby who may become frustrated and restless at the breast, as they are no longer getting enough milk in the evening.

Some mothers try to stimulate their flow with a breastfeeding herbal tea or breastfeeding food supplements, but this is generally not enough if the breasts are not regularly drained. Over time, mixed feeding becomes predominant, and some babies may even end up refusing the breast.

Yet, the end of breastfeeding leave does not necessarily mean stopping breastfeeding. With a little organisation, it is possible to maintain exclusive breastfeeding by expressing milk during the day. This helps to preserve milk supply, avoid engorgement, and continue breastfeeding your baby over the long term.

Maintaining regular feeds to make mixed feeding a success

To maintain sufficient milk supply alongside bottle and mixed feeding, it is essential to keep a minimum number of breastfeeds per day. However, there is no universal threshold below which milk supply can no longer be maintained.

To give yourself the best chance:

• always offer the breast first before a bottle of infant formula,
• watch for signs of breast refusal (shortened feeds, a distracted or restless baby),
• use a breast pump if your baby spaces feeds too far apart, to compensate for the missing stimulation.

Tip: even if you supplement with a bottle, maintaining certain "ritual" feeds at the breast with your baby (morning, evening, night) helps to preserve the bond and your milk supply.

Mixed feeding can also be used as a gradual step towards weaning. Progressively introducing bottles alongside certain breastfeeds allows you:

• to support comfort and avoid engorgement,
• to respect your baby's rhythm,
• and to offer a natural, gradual weaning rather than an abrupt one. 

Keep certain breastfeeds that are particularly special, such as the morning feed, the evening feed, or the "reunion" feed after work. These moments strengthen the bond with your baby while helping to maintain milk production. Night feeds also help to sustain mixed feeding over time.

Some breastfed babies can be reluctant to take a bottle. In this case, there are several temporary alternatives for giving breast milk or formula:

• A syringe, practical for small quantities.
• A teaspoon (approximately 5 ml of milk), suitable for the first months of life.
• The babycup, a small graduated cup that is easy to use, free from bisphenol A and phthalates. Place the milk against the baby's lips so they can lap at their own pace. Best used from 6 months of age onwards.
• In flan form. When you start weaning your baby, you can also make breast milk flans using agar-agar. 

The breast milk flan recipe : 

2 g of agar-agar will be sufficient to set 500 ml of breast milk. The powder must be mixed into the cold liquid. The mixture is then brought to the boil for 30 seconds to 1 minute.

As it cools, the mixture will gradually change in consistency.

Please note: the result should be a smooth, creamy flan rather than a set jelly. Do some test runs to find the right texture before offering it to your baby (it must not form a paste that sits on their tongue and could be swallowed in a way that poses a choking risk).

Teat flow rate

Choose one with a slow flow (size 0 or 1), to prevent your baby from getting used to a flow that is too fast.

Teat shape and texture

La Leche League also recommends ensuring that your baby's mouth is well "filled". A teat that is voluminous and not too wide at the base is therefore preferable. In practice, it should reach the junction of the hard and soft palate, just as the breast does during feeding. Opt for a soft tip, which will adapt better to your baby's mouth.

Wait for your baby to take the teat you place near their lips. Allow them, as at the breast, to pause during feeding. A bottle feed should sometimes last around 15–20 minutes. If your baby finishes their bottle in 5 minutes, the flow is probably too fast. If, on the other hand, the feed lasts between 30 and 45 minutes, you should choose one with a faster flow.

How to give a bottle?

Hold your baby in a seated or semi-reclined position on your lap, for example, supporting the top of their back and head with one hand. 

Hold the bottle almost horizontally so that your baby has to draw the milk, and can control the flow. 

Tilt the bottle gradually so that your baby is not unsettled by the flow of milk. 

When the bottle is tilted too much, the baby tends to drink very quickly and swallow air, as they cannot control the flow of milk. 

When mixed feeding is introduced, two main difficulties often arise:

1. Insufficient milk supply

When feeds become less frequent, the breasts are stimulated less and milk production gradually decreases. To counter this, it is important to maintain as many feeds as possible, even if they are followed by a top-up. Expressing milk at certain times of day can also help maintain sufficient production.

2. Painful breast engorgement

When milk is not drained regularly, the breasts can become tight and painful. It is advisable to express a little milk to relieve the pressure and keep the breasts supple. Do not let the situation worsen, as poorly managed engorgement can develop into breastfeeding mastitis. 

Combining bottle and breastfeeding is a journey that requires patience and adjustment. With the right support, most difficulties can be overcome.

If in doubt, do not hesitate to consult an IBCLC lactation consultant, a paediatrician, or a doctor.

Mixed feeding is a feeding approach adopted by many mothers. When poorly managed it can shorten the duration of breastfeeding, but it can also help to extend this precious bond with your baby, offering the family a degree of flexibility.

To prevent mixed feeding from leading to a rapid drop in supply, it is essential to:

• introduce it gradually,
• maintain regular feeds at the breast,
• always offer the breast before the bottle,
• and seek support from a professional if needed.

By following these principles, you can make the most of the benefits that bottle feeding and mixed feeding offer, whilst maintaining a wonderful breastfeeding experience with your child.

Feel free to seek advice from an IBCLC lactation consultant.