I was doing so well - is topping up so bad?

[monkeypuzzeltree]

Have a 6 day old DS, my second child. With DD bf was a nightmare and fell apart due to late TT diagnosed, and by then I was a broken woman!

Didn't have any expectations on it this time, but DS came out having read the bf books, latched on and got on with it - cannot believe it still!! However although I am feeding him every 2 hours and have lots of milk when it gets to the evenings he's just not satisfied. Last night I fed for half hour each side then ten mins later, I did it all over again, so 2 hours of feeding later and he still wanted more! I was shattered, ended up giving him 50 ml of formula. Then he slept!

So my question really is, is that normal? I know he's feeding we'll, I can hear it going down, how can he eat that much?! I just worry that if I don't top him up for the occasional feed I'm going to end up with really bashed nipples and bfing will fall apart entirely.

Was feeling so proud that I can do this this time, bit deflating to put all the effort in and it's still not enough! Would live to hear if this is normal!! Many thanks.

Sioda My stepmother is a sociologist working in exactly this area, and she's confirmed what I'd suspected: there's very little research done into mixed feeding full stop. State funding into this type of research seems to be very ideologically driven, and almost entirely promotes research designed to prove that EBF is best. This means there's no research (according to my stepmother) that has ascertained what ratios of formula to BM are optimum in terms of benefits to your baby. For example, is a baby who is being bf 50% of the time receiving the same health benefits as a baby who is bf 75%, or 25%, of the time? I've been searching for evidence-based research into mixed feeding for the last 2 months, and have found its lack extremely frustrating! (I wonder if this lack is also part of the reason that many mixed feeding mothers give up bf entirely: ie. no one is able to tell them how much benefit any amount of breastmilk is having on their children; and sometimes the government drive to EBF makes it seem like an all-or-nothing situation).

MigGril - I am familiar with that research. The difference here is that DP gives a bottle at night so that I get a block of uninterrupted sleep. That wouldn't be possible with ebfing. That research, AFAIK, didn't take into account having a second person to share feeding with. Which I also find really odd!

Molly, that's exactly what I've been thinking. I've no doubt there are women who either gave up bfing entirely or never tried it because they either couldn't or wouldn't ebf and didn't believe that mixed feeding was possible, or beneficial at all, thanks to the lack of information about it and the way the choice is presented to them. It would be great if scientists spoke out about the ideological biases behind what gets researched and what doesn't, but then that might affect their funding mightn't it... I'm glad sociologists at least are pointing it out.

There are mountains of research into just those topics - the research showing 'breast is best' is very much a minor player in the field. There is a load of research these days into ascertaining the amount of breastfeeding that makes a difference - eg breast cancer prevention; there is a massive US study showing a 'dose response' to breastfeeding; there are three UK studies I am aware of that differentiate between 'levels' of breastfeeding (ALSPAC; Millennium Cohort; Dundee feeding study). There must be more. All that's off the top of my head and I am not even a sociologist :)

What 'state funding' into breastfeeding? The biggest piece of research I know that is publicly funded is the Infant Feeding survey that has no 'ideological' bent at all - it just asks what mothers do and how long they do it for.

I dont know where you have been looking not to find any of this stuff, to be honest.

If you want a user friendly guide, the NCT's factsheet 'Reasons to be proud' www.nctshop.co.uk/Reasons-to-be-Proud-50-x-Information-sheet/productinfo/3242PAD/ has some of this stuff.

WHO has published research into use of formula alongside breastfeeding.

There is no doubt that the best health outcomes are seen in babies who are excl bf. This is not an 'ideology' but a scientific fact. There is no need to 'prove' it any more. Most research starts off with that, and gets into further detail - what are the effects of less breastfeeding, how are mothers best supported to bf, what public health measures are effective, what is the effect of infant feeding on intelligence, behaviour, development and so on.

To start off with the idea that breastfeeding is the physiological norm for our species, and that anything that is not breastfeeding will have effects, is not to be 'ideological' but to be scientific.

Monkey, well done, you're doing brilliantly. I haven't really got any expert advice to add, except to say 1) your boobs know how to produce enough milk at the right time to feed your baby; and 2) if you do have spare frozen EBM you might be able to donate it to your local Special Care Baby Unit

Interestingly enough the researcher behind the study that showed that ebfing mothers got 45mins extra sleep a night went into the study thinking that it would show ffing/mixed feeding mums would get more sleep so she was actually shocked at the results (I saw her speak at a conference and she 'admitted' that herself!).

Sleep study here.

Well tiktok all I can say is that that info isn't getting out there! And the NCT stuff isn't precise enough about just how much bfing has what benefit. Anyway it's not really the stuff about benefits that I was looking for information on. The research I can't find has been about the practicalities of mixed feeding and supply. I can't see any good reason why that shouldn't be available. If information about the benefits of any breastfeeding is out there then why isn't practical information that I'm looking for there? So many women want to know if they can, say, replace one bf with a ff, for whatever reason. And the advice they're always given is a fairly blanket one - that it will affect their supply. But when some women clearly can get away with it, surely research about why and when that works or doesn't is badly needed?

TruthSweet, it makes perfect sense to me that bfing mothers get more sleep if no one in the other two groups in the study had anyone to share feeds with! I've seen that study quoted a lot and it really doesn't stand up to ignore the effect on sleep of someone other than the mother giving a bottle of formula while she sleeps. Is that not obvious enough? Or did it take that into account and I'm missing it?

Apart from that it's odd that that study had 4,774 mothers who breastfed and only 176 who fully formula fed - surely 176 is not a large enough sample size to usefully compare to 4,774? Of course that study also fails to account for the usual confounder that women who ebf were and are simply different to those who mix feed or ff from the beginning. Even the simple confounder that some of those mixed or ffing might be more depressed and (possibly therefore...) sleeping less because they tried and failed to bf, while those who ebf were less depressed and sleeping better because they were meeting their goal to ebf, doesn't seem to be taken into account! The causation is a mess.

Sioda - I re-read the study and I can't find where it states that the mothers in the study were wholly responsible for all feedings regardless of feeding method/substance. Can you quote that bit to me? I may be not reading it right as I really can't find that bit!

The study did include 1,125 mothers who were mixed feeding which seemed a good number for comparison sake, though 176 is a little low on the ffing side tbf.

That's what I'm asking TruthSweet!! If you're quoting the study you should really be able to answer that to be honest. It's one of the often quoted benefits of mixed or ffing that someone else can take a turn feeding the baby while the mother gets some uninterrupted sleep. Any study claiming to address sleep and feeding methods should not only take that into account, it should address it up front. If most of the mixed feeding or ffing mothers were not sharing feeds with someone else, that would be a very obvious explanation for the result. And it would mean that the results are irrelevant to someone who does have someone else sharing feeds with them. The fact that that study doesn't address that issue on the face of it is thoroughly strange.

Also, I don't think 1,125 mixed feeders vs. 4,774 is a great comparison - it's a quarter- nor are the overall numbers of the study much good in the context of feeding study numbers.

Sioda - I have msged the researcher to see if she could clarify matters so I will let you know when I get a reply (or not - she is pretty busy!).

Sioda, you say "all I can say is that that info isn't getting out there!"

I dont know what you mean by that - the studies are in major journals, easily found with a search. Any academic or student with access to a higher ed library and a half decent competency with searching would find them.

"And the NCT stuff isn't precise enough about just how much bfing has what benefit." - the factsheet is about length of time breastfeeding, not actually exclusive breastfeedin all cases, so you can check the studies. I think the refs are online at the NCT site.

"The research I can't find has been about the practicalities of mixed feeding and supply." That's not what you were saying did not exist - you were complaining about ideology-led research studies.

" ...the advice they're always given is a fairly blanket one - that it will affect their supply. But when some women clearly can get away with it, surely research about why and when that works or doesn't is badly needed?"

I see what you mean - but just as we don't (and can't ever) know which ff babies will get the higher rates of gastro, ear infection, and other malaises and which won't, we can't (and can't ever) predict which mothers will have a robust enough supply to withstand the introduction of formula. We do have stats on risk and what increases it though.

You are asking for the moon if you want studies which involve human behaviour and choice, and where choice is mediated through cultural and emotional issues, to get a pure cause and effect....:)

Tiktok Would you possibly be able to post the references to the studies you mention? I'd be really interested to read them!

My input is purely anecdotal and personal, but I do think that Sioda has a point in that, as far as I've experienced, if there is compelling research into mixed feeding, it hasn't found its way into a public health message. Since DD's birth I've been bombarded with pamphlets by hcps encouraging me to EBF - now, I'd love to EBF, but for various myriad reasons, we've been unable to, and I've been desperate for more evidence-based information about mixed feeding, and noone has been able to give it to me. So even if this research exists, there clearly isn't the willpower to get it out into the general public domain (most of whom don't have access to academic databases). I've never even been given any information about safe formula feeding - and that seems pretty ideological to me. Although, as I've said, my input is purely anecdotal and personal.

Which studies in particular, Molly? The cohort studies?

The research shows clearly that the public health message should be that excl bf gives the best health outcomes, and that getting bf off to a sound start is key.

I am not sure what people are asking for. If you want to use formula (partially or fully) for whatever reason, then of course you need info to do it safely and there are NHS leaflets about this (and many others but any NHS hcp should have the leaflets) and all HCPs should share their knowledge. If you have asked for this info, Molly, and been refused it then this isn't so much ideological as plain poor care. It is common knowledge that if you want to use formula alongside breastfeeding, then keeping formula to a minimum is important - I don't think there is any equation that can tell you '30 mls twice a day is ok but 50 mls three times a day is not'.....it is a continuum, and individual babies and mothers will have individual outcomes. Age of baby, experience of bf so far, are also elements.

If you are breastfeeding a six mth baby all day and night, and giving one formula feed a week, then you are highly likely to continue bf as long as you want to. At the other end of the continuum, giving formula at birth and bf once a day is a surefire way to lose your breastmilk.....all other experiences are somewhere in between those 2 extremes :)

Just to add: I wonder if the question 'where is the research?' and 'no one has shown me anything saying x amount of bf and y amount of ff equals z amount of benefit/risk' is at least partially an expression of a need for validation.

That is, for whatever reason, a mother decides to use formula, either partially, or fully, after a period of excl bf.

She doesn't feel 100 per cent delighted about this decision even though on balance it is what she feels is right for her and/or right for the baby.

In fact, far from feeling 100 per cent delighted, some women are utterly devastated...despite feeling on balance it is the right move.

She looks for ways to feel better. One way is to get a bunch of info, hopefully saying something about whatever percentage 'benefits' of bf the baby has already had, or will continue to have. A further way is for an official looking leaflet with clear instructions not on ff, but on mixed feeding, because that reflects the reality that many women decide on this option. This in itself is validating.

The bunch of info is not there in the form she wants it (though it is there as research showing 'dose' effects of bf). The official, clear leaflet is not there because it is difficult (impossible?) to give generalised clear instructions about mixed feeding.

I think sometimes the less-than-delighted-to-be-using-formula mothers will be helped by two things i) a bit of honesty and insight into their own feelings about it ii) HCPs who can counsel and help the mother work out an individual feeding plan that is likely to protect what bf they are doing

Breastfeeding helplines can offer support with ii) , by the way, because bfcs know how bf works, and they don't judge or criticise the mother but accept her and her decisions.

What I would be interested in reading are studies that research whether the benefits of breastfeeding decrease in the same proportion as the ratio of breastmilk to alternative. So is a baby who is fed 75% BM receiving 75% of its benefits, or is there a different trajectory of decline. And I'd want the studies to (a) isolate individual variables and research one benefit of breastfeeding at a time (eg. BM's statistical propensity to reduce occurrences of gastroenteritis), (b) use a statistically significant size of group, plus a control group, (c) take into account the inevitable social variables (eg. social class and education of parents). Would you be able to point me in the direction of such studies?

I take on board your point about validation: to an extent I think it's probably true about my situation - after all, what mother doesn't want to be told that they're doing "the best" for their child? But I am also genuinely interested in the issue from an academic perspective, and genuinely find the politics of breastfeeding and formula feeding fascinating (of course, having an emotional and intellectual investment in a subject are not mutually exclusive!). My personal situation is that, for medical reasons, I became unable to EBF but have been able, to a certain extent, to decide what ratio of BF to FF I pursue; so I've consistently been asking BFCs etc for information on whether the benefits of BM increase proportionately with the amount of BM consumed.

Molly, this is impossible.

'Benefits' can't be quantified like that. Must dash - more later!

You know if it wasn't for these threads on MN and many of tiktok's posts I'd be thinking my breasts are like reservoirs that empty, with a feed switching from fore to hind milk at a certain point. It's the way the info's being given out: a lot of misunderstandings.

monkey, which side of midnight are your marathon feeding sessions? At least my DD's have been evening rather than the wee small hours - but it is easier once you know it's normal and give in to it.

Tiktok, I don't think pathologizing a desire for more information is particularly helpful. I don't fit your mould and I find the implication that I may be lacking honesty or insight into my feelings quite insulting.

For reasons I won't go into here, I always planned to mix feed. I wasn't seeking information about the benefits of any breastfeeding, I was commenting that the information didn't seem to me to be readily available based on the experiences of people I know. I personally have no ambivalent feelings about mixed feeding, subconscious or otherwise. (By the way, if I did, I would not find anything like an 'official looking leaflet' validating. People have different attitudes to authority which you haven't accounted for.) Of course, the trouble with diagnosing psychological states in other people is that they can't disprove it. I can't prove my absence of negative feelings.

Pathologizing a question allows you to minimize its importance and, with respect, that's what you've done. It's perfectly rational and reasonable to want better information about the likelihood of a given pattern of mixed feeding affecting your supply. I'm not looking for precise equations. But there is a middle ground between that and "it is a continuum, and individual babies and mothers will have individual outcomes". Advice that broad is simply not a very useful basis for making decisions. I accept that more precise advice can't be given because the research hasn't been done. That is why I was looking for that research. Not because I'm in denial about my feelings...

Molly, an explanation why quantifying is impossible :) :

• an increased risk of breast cancer (in the mother) is one effect of not breastfeeding. There is a dose effect - no breastfeeding = higher risk than some breastfeeding

• an increased risk of gastro infections is one effect of not bf. Again, a dose effect

And you can add a lot more to that list, some where there is strong evidence, some where the evidence is weaker, some where there is no dose effect (so it's all or nothing), some where the extent in time of bf is more important than the actual exclusivity of it, some where the risks/bens are to the mother, some to the baby, some where the effects are not really worth bothering about because they are trivial, some where they feel more important to some people than to others (eg breast cancer to a woman whose own mother died of it).....you will never get any equation that leads to '75 per cent of benefits remain if the baby is 75 per cent breastfed'.

Hope I have explained ok - I know what I mean!

Sioda, suggesting people are honest and insightful about their feelings is not to 'pathologise'....there's nothing 'pathological' about needing more insight. It's human.

Pointing out a human tendency to have a need for validation ( = confidence in one's decisions) is not to make a psychological diagnosis. For goodness sake...

You don't need to feel validated. Happy for you :)

A lot of mothers do, especially in a society which has an ambivalent attitude to infant feeding, where bf mothers feel criticised or judged if they are doing it outside or too often or too long or too openly, and where formula feeding mothers also feel criticised for being selfish or lazy or whatever.

I'm afraid I'm not sure what you mean by quantification being impossible: perhaps we have different definitions of quantification. I'm not talking about the quantification of risk/benefit as it pertains to an individual child, but to groups of children in studies. The many hundreds of studies described in a review of breastfeeding and its benefits called 'Quantifying the Benefits of Breastfeeding' entirely consist of quantitative analyses of breastfeeding - ie. from sample groups, they seek to ascertain, say, how many bf children suffered gastrointestinal illnesses in a certain timeframe. My problem with the bulk of these studies is that (a) whereas the term 'breastfeeding' is usually quite rigorously defined, the term 'formula feeding' is not - so that there's very little attempt (in the studies that focus
on first-world countries) to deal with the confounding of results that comes from different methods of preparing formula, and (b) the studies overwhelmingly tend to divide the sample groups into 'breastfed babies', 'mixed fed babies', and 'entirely formula fed babies'. But very few of them (perhaps 3 or 4 out of the many hundreds contained in that review, as an example) seek to probe the relationship between different ratios of formula feeding/breastfeeding and the benefits of breastfeeding (eg. its ability to protect against gastrointestinal disorders). So although many studies conclude that, in industrialised first-world countries, breastfed babies enjoy slightly more benefits than mixed fed babies, there are no studies that I've been able to find that rigorously set out to explore whether, say, babies who are mixed fed 70% breastmilk and 30% formula suffer fewer instances of gastrointestinal disorders than babies who are mixed fed 60% breastmilk and 40% formula (and if so, how much fewer). This type of quantitative research is far from impossible: it requires the same or similar methodology to the existent quantitative studies on breastfeeding. It may seem pernickety to want this kind of research to exist, but I've been craving data like this over the past weeks, as I've been trying to decide how much pain to put myself through in order to up the quantity of breastmilk that I feed my daughter. If you know of any studies like this, I'd be immensely grateful if you could point me in the right direction...

Molly, I meant quantification in the sense you raised it - that is if you bf 75 per cent of the time, do you give 75 per cent of the benefits?

Of course specific effects of bf can be quantified. But not all those effects are equal in strength and impact. Gastro infections affect thousands (millions?) more people than breast cancer, say, but the effect of breast cancer is potentially far more devastating to the individual (in the UK, at any rate) than gastro. You can't shove all the benefits into a giant treasure chest, count them, and then work out what x per cent of them would be.

In addition, you can't quantify, to the extent you are asking anyway, the amount of bf and ff a baby gets. Mothers can't tell how much volume of breastmilk a baby gets.....and in any case it differs day by day, week by week. Take a baby who is excl bf for 3 mths, then mixed fed for 1 mth, and fully ff by 4 mths. Is he 100 per cent bf, then 50 per cent, and then 0 per cent? Or 50 per cent overall? What box is the mother going to tick? :)

Yet you are looking for a difference between a baby who is 70 per cent bf and one who is 60 per cent bf.

The definition of bf is not 'rigourously defined' in many studies. It's a complaint in many systematic reviews - not sufficient definition. Even then they just ask for the WHO definitions, which (from memory) are exclusively breastfed, predominantly breastfed, partially breastfed and formula fed.

When it comes to decisions, mothers need to weigh up their baby's needs, of course, but also their own, including pain and well-being. Make the decision that's right for you - feel good about whatever breastfeeding you have done or can do, but however your baby is fed, do it with love, enjoyment and pride. You won't find any of that, looking at statistics, I promise you :)

Indeed

Sioda - I have got a reply back from the researcher (how's that for service!). She said ''The question we actually used for the analysis was
"Since your baby was born, did you breastfeed, formula feed, or both breast
and formula feed?"
We asked a lot of other questions about this. But this one proved to be an overall good summary. So I'd say the focus was mainly on the mom. But could include other people feeding the baby.''

So from that I gather the ebf mums were doing all the feeds themselves and the mix/ffing feeding mums included mums who were having feeds given by others (as well as just feeding the baby themselves).

Please bear in mind that this study was done in the US where they don't have the 70C water formula preparation guidelines () but they do seem to use more rtf formulas (also a lot of screw teat on bottle and feed kind of rtf) and also have concentrated formula that just needs diluting with an equal volume of water (it's sterile as it's a fluid so can be made up with tap water) so ffing isn't the 'boil kettle, wait no longer than 30mins, make up feed, cool to drinking temp' affair it is in the UK.

Molly, do you understand why the questions you are asking ('does 75 per cent breastfeeding mean 75 per cent of the benefits or what?' and 'what's the difference in health outcomes/risk between 60 per cent bf and 70 per cent bf?') just can't ever be answered?

And that this is not 'ideological' at all?