Dear Pam,

I'm glad you asked your question about partial breastfeeding.  I have asked
about it a lot on Lactnet.  I believe it is an area where we need to know a
lot more.  It's not the standard or recommended way to feed a baby, but it's
the only way that some US moms will consider even "trying"
breastfeeding---("try" in the sense of exploring a possibility, not in the
sense of attempting but expecting to fail).  Since I work in WIC, I encounter
a lot of moms who simply are not ready to make the commitment to 100%
breastfeeding.  Within the WIC system, sometimes we have to settle for
whatever the mom is willing to do.

So it would be nice if we knew what we were talking about.

One thing to remember is that, under the feeding recommendations of WHO and
the other global experts, a normally-fed baby does more "partial bf" than
"exclusive bf."  A baby is taking in calories from complementary foods from
the age of 6 months until weaning at 2+ years.  At some point in that 18+
months, the mom starts making less milk than she was at her peak of
lactation, so it's obvious that women can maintain a partial supply for a
long time.

One interesting article is "Minimal breastfeeding" by Morse JM, MJ Harrison,
M Prowse,  JOGNN July-August 1986, 333-8.  It was a descriptive study of 30
Canadian women who nursed 1-2 times a day, and continued to do so for several
weeks or months, some for over a year.  The researchers identified three
reasons that moms adopted this form of feeding: 1) as a way to wean slowly,
with less disruption for the baby--these moms began the pattern at an average
age of 8 months, range 8 to 60 weeks; 2) as a way to free up the mother for
work or other separation--these moms began at an average age of 5 months,
range 12 to 32 weeks; and 3) to continue "comfort nursing"--this was begun at
close to a year, range 6 to 19 months (not weeks).

The researchers pointed out several questions for further research, such as
Does minimal bf "have any advantage for the infant"?  (by which they meant
immunologic advantage).
Is milk composition the same with minimal bf as with full bf?
How early can minimal bf be initiated, and how late can a bottle be
introduced?
Does it take a special type of baby to make this work?  29 of the babies in
the study were described as "strong nursers."

Last week on Lactnet, Ann Lown asked about bf definitions, under the subject
heading " Characterizing partial breastfeeding."  In my reply, I said I
learned toward the scheme that divides partial bf into three sub-categories: >
80%---20% to 80%---<20%.  If research were designed using that definition,
then we'd be able to discern the effect on infant health of giving 1-2
formula feeds a day (>80% bf), and see whether there was still immunologic
value to giving 1-2 nursings a day (<20% bf).  These are both questions that
need answers.

One thing I believe, though, is that human milk as a FOOD is valuable in any
amount, so it's never wasted effort.  Likewise, breastfeeding as comfort and
communication between mom and child is worth doing, regardless of any
transfer of milk and immunity.

You asked, "How can a mother successfully mix breast and bottle, such that
her milk supply can be continued?"

I think that's at the heart of partial breastfeeding.  It's not so much the
substance that the baby is getting, but the method of feeding the baby is
using.  What effect does sucking from a bottle have on the baby's interest in
breastfeeding?  Is it different with different babies?  at different ages?
Is there a way of offering the bottle that does less harm to breastfeeding?
Is there a bottle/teat design that does less harm?  We all have our theories
and our anecdotes about these questions, but where's the research???

Wow, do I dare ask these questions? Would the breastfeeding advocacy
community accept research into these questions if it was funded by bottle and
teat makers (who would probably LOVE to do studies if they could prove their
design was the best)?  Would there be an ethical way to design such research
to prevent interference with the protection and promotion of exclusive bf?
to prevent spillover?  (I feel like an HIV activist advocating for a needle
exchange program---"they're gonna do this anyway, so let's at least know how
to make it as safe as possible!")

You asked, "Will giving formula definitely mean that the milk will dry up?"

I think it's clear that the answer is no.  Milk production is sustained by
milk drainage.  If the baby still empties the breast, mom will still make
milk.  So the important issues are--how much formula is she giving?  how can
she maintain the baby's skills and interest in breastfeeding?  My guess is
that this population is not too keen on pumping.

You asked, "How quickly is the supply lost if there is no over-night
nursing?"

The answer here comes from moms who continue exclusive breastfeeding after a
baby starts sleeping through the night, or from the employed moms whose
babies adopt a "reverse cycle feeding" pattern.  Anecdotal evidence shows
that, in many nursing couples, the breasts and the baby can sustain full
breastfeeding with one long break every day.  They just need to nurse a whole
lot the rest of the time.

You asked, "Is there a minimum amount of nursing a mom should reach for to
keep up a supply?"

Looks like the answer is no---depending on what you mean by "a supply."  Moms
who nurse toddlers or preschoolers go on making 'some' milk, but we assume
it's not the 25-28 ounces a day that an exclusively bfing mom makes.  And
moms who have nursed toddlers or preschoolers know that the pattern is not
uniform---one day they forget to nurse until bedtime, the next day they're
reaching under your shirt every time you sit down.

My suspicion is that a key to maintaining partial bf while using bottles is
at least partly in the mom's attitude.  If she makes the breast accessible
freely to the baby, if she nurses for comfort and soothing and settling to
sleep and helping with a burp, etc., then I don't see why a baby would not
keep wanting the breast.  But I'm speaking from my own experience here...and
I never used a bottle, so my kids never had an option!

Perhaps another key to partial breastfeeding is to find out what the bottle
of formula means to the mother.  You described the mom who was "calmed" by
getting up at night with a bottle of formula for her baby.  If she feels "put
on the spot" by breastfeeding, then maybe knowing that her baby will stay
settled a little longer after a bottle of formula does help her feel calm.
Another mom might feel that a daily bottle of formula was her insurance that
she would be able to leave her baby if it became necessary---if mom was
hospitalized, had to go to a funeral or a court hearing, had to attend to an
older child's crisis, etc.  I heard an anecdote about African
mothers---Kenyan, maybe---being encouraged to bf exclusively for six months,
and saying "What!? you want to tie us to our babies?!"  Women know they have
other things to do, and nursing mothers don't all cross over that emotional
line into the place where they feel they just CAN'T leave the baby or they
re-arrange their priorities so they never have to leave the baby or they will
go to any lengths needed so that baby gets expressed milk if they can't be
with the baby.

We really need answers to our questions!  In WIC, we especially need to know
whether partial breastfeeding from the first days is ever sustainable, or
whether developing a full supply and then adding limited formula is the only
way to make it work.

Yours in the struggle,
Chris Mulford, RN, IBCLC
working for WIC in New Jersey
WABA Women & Work Task Force





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