by Katie Madden & Ariana Powers

Bottle or boob? Formula or breastmilk?

Yes, please. All of these.

A little known way to feed your baby is to “Hybrid Feed.” Hybrid feeding is not “I do both” or using formula for convenience. It is a very deliberate and strategic method to protect breastfeeding when a mom doesn’t have quite enough milk.

When done properly, moms who hybrid feed can often go on to nurse their babies for twelve or more months. Some of them even have trouble weaning!

There are three major principles of hybrid feeding that help to protect the long term success of the nursing relationship. You may notice that these don’t seem to match common breastfeeding recommendations, nor will you find these in any breastfeeding books. This is simply what I have discovered after years of working with low supply moms.

  1. Early introduction of small amounts of formula, offered frequently to prevent excessive weight loss. Supplements should be given after breastfeeding with the Paced Bottlefeeding Method.
  2. Early stimulation and protection of milk supply with subsequent recognition of when mom’s “milk ceiling” is reached.
  3. Removal of pumping to maintain sanity and balance.

Now, you really only know a mom will be a true “Hybrid Feeder” after weeks to months of hard work and dedication from both mom and IBCLC. I am sad to say that once it even suspected that a mom has a low milk supply and needs to supplement with formula, many lactation consultants are done. They see breastfeeding as somewhat of a failure and believe that it will eventually extinguish itself once formula is introduced.

This is one of those things that gets me really, really mad.

It takes multiple visits to truly diagnose a low milk supply. Once identified, low supply moms who are supplementing with formula need extra support, loving attention, and management. Oftentimes, I work with these moms for eight to twelve weeks before they feel they have reached a breastfeeding steady state, both technically and emotionally. These moms also need special instruction when preparing to return to work. After all, they worked extra hard to establish this precious relationship and are at high risk for losing it when they return to work.

Ariana and Layla are Hybrid Feeders. Ariana came to me a little later than I would have liked. It took a few weeks of building rapport before she was comfortable introducing formula. Ideally, I would like a mom to go into breastfeeding with a “formula is a tool” mindset rather than a “formula is failure,” or even worse, “formula is poison” mindset. Ariana, like so many other new mothers, saw formula as the enemy. A slippery slope that would inevitably lead to the demise of her nursing relationship. For Ariana, nothing was further from the truth.

Ariana’s breastfeeding story must start with the two babies that came before Layla. I have noticed that mothers who have lost pregnancies or have undergone extensive fertility treatments have a notably stronger investment in the outcome of breastfeeding.

Here is how Ariana’s story starts:

“My breastfeeding story starts with our road to pregnancy. It took us a really long time to decide we were ready for children. We wanted to do a lot before having kids. However, once we decided to try, we got pregnant right away. We were excited and nervous at the same time. I knew I loved the baby right away and I would do anything for that child. We started planning for the baby right away. At this point, I thought I would try to breastfeed, but if it didn’t work or it was too hard, I wouldn’t care. A few weeks later, we had a miscarriage. I was devastated. I didn’t know I could love so fiercely, especially a child I hadn’t met.

We found out I was pregnant again about eight months after our miscarriage. This time, there was no excitement. We just wanted to wait until we were sure we were having a baby. Unfortunately, we had a miscarriage again. Again, I was devastated. I wouldn’t hold my baby in my arms and try to nurse him or her.

After a battery of genetic testing, we were told there was no medical reason for our issues and that we could try again whenever we were ready. And finally, it happened. We were having a baby! This time, we were confident. We had weekly ultrasounds and every kind of test under the sun. In one of our visits, my midwife asked if the plan was still to breastfeed, and my answer was “absolutely.” We worked so hard for this baby; I wanted to give him or her the best chance in life. Since I work in the medical field and we had medical issues on our road to baby, to me, that meant breastfeeding.

My due date came and went and I didn’t go into labor. I had planned all along to have a baby at the end of July, I planned that I would go into labor spontaneously, that I would not need any medications, and that breastfeeding would work. After all, I had taken a breastfeeding class.

I finally had to be induced. After more than 24 hours of Pitocin and labor, I ended up with a C-section. I was so happy to have a daughter that I just couldn’t wait to hold her. It didn’t matter that none of my plans had panned out; I had a baby, and we were going to move on with our lives.

While doing skin-to-skin Layla found her way to my breast. I couldn’t believe it! It felt weird and natural at the same time. And I finally, something was going to work the way I planned it. I continued to nurse every two hours, and they checked her sugar multiple times; everything seemed to be working fine.

The next day, I noticed that my nipples were bruised and I was having some pain. The lactation consultant came to see me and said that everything was fine and Layla was latching fine and to continue to do what I was doing. When I told her about my nipples, she said that it happens and it would get better. She was in my room for less than ten minutes and then she left. I asked my nurse for help and she said she would call a different lactation consultant. That night, the baby barely slept. She was up every hour, and every hour, I fed her. I was walking the baby outside the room because we needed a change of scenery when my nurse asked if she could weigh the baby. She had lost 12 ounces in a day and a half. When I asked if that was okay, I was told it was because my milk had not come in. Later that day, we were discharged with instructions to see the pediatrician the next day not because of her weight, but because her bilirubin was on the higher side of normal.

We went to the pediatrician and Layla had lost another four ounces. Now I was very worried. The pediatrician said that it was likely because my milk had not come in yet but that he would want to see her again two days later. On our next visit, she had lost more weight.”

So, here is where I want to point out how Ariana and Layla were, in my opinion, mismanaged. I understand the value of exclusive breastfeeding, and I admire the healthcare professionals’ patience with the process, but with each passing day, Layla became more frantic and more lethargic at the breast, which in turn means that Ariana’s milk supply wasn’t being properly stimulated. Ariana became more scared and unsure of herself. Ariana’s intuition was ignored on multiple occasions by multiple professionals. In essence, she was being reminded “you don’t know what you are doing.”

There are two major risks in letting a baby lose this much weight (the equivalent of more than ten percent of birth weight). First, obviously the baby is at risk for complications of excessive weight loss including dehydration and jaundice. Second, when this baby is offered a supplement, they often reject the breast. Smart cookies, they know where the food is and where it isn’t. This isn’t nipple confusion. It is survival.

So, after the third drop in Layla’s weight, the pediatrician recommended offering a bottle. It was after the third drop in her weight that she was encouraged to see a lactation consultant.

Ariana writes, “Now the pediatrician wanted me to supplement with formula or breastmilk and pump after every feed. He also gave me Katie’s number and said he would e-mail her.”

At each feeding: Breastfeed. Pump. Bottlefeed. Anyone who has ever done this knows it is a fast trip to crazy town. Necessary, yes, but dangerously exhausting to everyone.

When Ariana first got to me, I wanted to fix her baby’s latch and her nipple pain (which nobody had yet fixed for her but could have been a major contributing factor to Layla’s weight loss) and support her plight to provide Layla with only breastmilk if I felt it was safe.

“During my appointment, Katie identified an issue with the latch and helped me fix it. She also taught me a ton about breastfeeding and pumping.  Layla had gained a couple of ounces in two days and she transferred one and a half ounces that day. It seemed like things were getting better, and finally I felt like I was doing things right.”

I always have tight follow-up after an appointment like this. Ariana’s milk transfer to her baby was close to normal, but not quite. I encouraged her to continue to pump and supplement during daytime hours using the Paced Bottlefeeding Method. Knowing this process was extremely difficult, I needed to make sure she had a defined length of time for this plan to protect her sanity. We planned to see each other for a follow-up visit in one week.

Ariana recalls, “The next week, I was having issues again. The baby kept fussing and pulling back when nursing. At this appointment, we figured out that my supply had not increased.”

Now came step two:

Fixing the latch and extra pumping wasn’t enough. We had to push the milk supply to see how high it would go. Also, it was critical to maintain Paced Bottlefeeding with small, frequent supplements. Layla was starting to get frustrated at the breast as evidenced by the fussing and pulling off. Too much in the bottle too quickly and she might turn away from the breast completely.

“I started taking fenugreek; I was still pumping and even started taking Domperidone. Katie talked about supplementing with formula, but I was not ready for that yet. I figured that this time, it was all going to work. After two weeks, Layla had only gained two ounces. I went to see Katie again, and this time, the baby transferred even less milk than before. This was my breaking point; she was almost a month old and not even back to her birth weight. I felt like I had been starving her. I had to supplement with formula.”

This is one of the hardest moments in a mom’s breastfeeding journey and in my job. I call it the “come to Jesus” conversation. I wish it weren’t so hard, but it is. For a lot of reasons. It is hard because it is the moment when a mother needs to acknowledge that “her body failed her.” It is the moment when she realizes she must feed her baby a food that she sees as inferior, a food she never planned to feed her baby.

It is the moment when she begins to panic that breastfeeding is over.

Ariana remembers that “again, things did not work the way I planned. Accepting my low supply was very hard, but Katie assured me that we did not have to stop breastfeeding and that our breastfeeding relationship could be successful. I still did not understand what a ‘breastfeeding relationship’ meant.

I followed Katie’s advice about how to feed the baby and how to supplement her. She started gaining weight. She started sleeping more. Katie taught me that it was not about the milk, it was about the relationship. Finally, things seemed to be getting better.”

Step three:  Removal of pumping to maintain sanity and balance.

Usually, there comes a point when I encourage the mom to stop pumping after breastfeeding unless she misses a breastfeeding session entirely or until she is working to build her back-to-work stash. What Ariana does not mention in this story is that she had a lot going on in the early months of Layla’s life. She took little to no break time from the last semester of her Master’s Degree. When Layla was four weeks old, she returned to school. When Layla was eight weeks old, she returned to work. So, she opted to continue to pump quite a bit, both for storage and to offset the amount of supplemental formula she needed to use.

But, by and large, once we have established that after our best efforts, baby is draining mom’s breasts well and no amount of pumping will yield a significant amount of milk or increase milk supply, we dump the pump. Why? Because pumping sucks. The sooner we can get rid of it and go just to Hybrid Feeding, the better.

Ariana wrote her original breastfeeding story for me when Layla was four months old. Here is what she had to say then:

“We have nursed everywhere, including on-the-go in Disney World! She loves nursing and it calms her down. She knows when she is okay with eating on-the-go or when she wants to slow down. She now smiles at me while nursing and would rather nurse than bottlefeed. Her mommy is important and she wouldn’t trade it for anything. By wanting to nurse, she has taught me that she doesn’t care about the milk, but that the time we spend together is priceless.

There is no doubt in my mind that without Katie, I would not have a breastfeeding relationship. I didn’t know it, but I had a lot to learn about breastfeeding. I was determined to breastfeed for the wrong reasons, but when it wasn’t working, I did not want to give up. I never thought I would fight this hard for something that, at one point, I didn’t think was that important. Through breastfeeding, I have learned a lot about what kind of mother I wanted to be. Katie was there every step of the way to help me in many ways, including listening to my frustrations and reassuring me. Thank you, Katie, for teaching me the importance of a nursing relationship and for helping me to maintain it.”

I contacted Ariana last week to let her know I wanted to feature her story again in this Hybrid blog. Here is what Ariana has to say now:

“My little one is a little over ten months and still nursing! I think she would nurse forever if I let her! Our nursing relationship has been going strong since Katie helped us fix our issues. It hasn’t always been easy since she discovered boob acrobatics and biting, but we figured out how to make it work (boob acrobatics are sometimes still an issue, but no biting anymore!).

We have started to take some slow steps towards weaning. I have had issues with an overactive thyroid in the past and unfortunately it has come back. I will have to take action to fix this issue at some point, especially if we would like to have another baby. Since I may need surgery, it seems like the right time for me to start the weaning process. I want to make it clear that weaning is my decision and not my endocrinologist’s decision, as he point-blank told me I needed to stop breastfeeding cold turkey. He made me doubt myself and my ability to make decisions for my child. Instead of blindly following his advice, I consulted with many people, resources, and lactation specialists. I came to the conclusion that I did not have to wean or much less stop abruptly. To this day, I am still fighting for our nursing relationship. And we will make it to a year!

It took me a long time to accept the fact that I would not be able to solely nurse or feed breastmilk to my daughter. Today, I am extremely grateful for the availability of formula and bottles. Without these tools, I would not be the woman and mother that I am now. I am also undoubtedly indebted to Katie Madden for all her help and wisdom. I would have quit had it not been for her, and I could never forgive myself for quitting. In the future, I hope my story helps more moms with low supply get the opportunity to feel as successful as I do in my breastfeeding journey and become the fierce nursing/pumping mamas they dreamed to be.”

Ariana is a Hybrid Feeder. And we are damn proud of it.

Little bonus for you: Now Layla paces herself at the bottle!