Combination Feeding Your Twins

“Combo Feeding” has become increasingly popular and is always a topic of high interest in my Expecting Twins and Breastfeeding Twins Classes. What is this style of feeding twins, why is it done, and how can you implement it in your routine successfully? Read on for those answers and more.

Making the Decision to Combo Feed your Twins

“Combination Feeding” or “Mixed Feeding" refers to regularly providing both your own milk and also formula or donor milk to make up your babies’ daily nutritional intake. The way this is practiced varies family to family — some feed mostly human milk with only a few formula or donor milk feedings per day, while for others formula is the mainstay and human milk is used to a lesser extent.

Families arrive at the decision to combo feed for many different reasons, either by necessity or choice. Genuine low milk supply, anatomical issues with parent or baby, lack of support around feeding challenges, or if challenges in lactation negatively impact mental health - all are reasons I commonly see combo feeding introduced. Fortunately, we have safe and available options for formula feeding (and sometimes to donor milk) for supplementation in those situations. Many people assume lactation consultants are anti-formula…I can’t speak for us all, but I can say for myself and many of my colleagues - we are so thankful to have formula as a resource in those tough situations. Feeding the baby is always the first rule!

This post is going to focus on a different scenario, one that I’m seeing more frequently in the work I do with expecting twin and triplet families. What if a family plans to feed their babies a combination of formula and human milk from the get-go?

It sounds like the best of both worlds; Babies get the superior nutrition human milk provides, yet parents can have more flexibility and help with feedings. Especially with twins or other multiples, parents often worry that building and maintaining a full milk supply may be too overwhelming when combined with caring for more than one newborn.

The reality is, that to be sustainable beyond the immediate postpartum period, combination feeding takes strategy and an understanding of how our bodies build and maintain a milk supply. If combo feeding is started without knowing that it could negatively affect milk production, it could mean providing milk for far less time than parents had originally hoped.

As a lactation consultant, my role is to support my clients’ goals no matter what they are. Ethically, I have an obligation to provide the pertinent evidence-based information so they can make informed choices. When making a twin combination feeding plan for clients, I discuss establishing milk supply, balancing formula/milk ratio, feeding scenarios, avoiding breast refusal, and many other topics outlined below.

The Magic Number Concept

Say your goal is to feed your babies your milk and formula split 50/50 – for example, formula for the evening/overnight feeds, and breastmilk during the day. You may start off being able to reasonably meet that goal (especially since milk production is mostly hormone-driven in the early days), but if you aren’t frequently (every 2-3 hours) and regularly emptying all your milk using a pump or by the babies latching, production almost always slows down over time. You’ll find yourself doing 40/60, then 70/30, and so on.

“Why does this happen? If production eventually is based on ‘supply and demand’ as we hear so frequently, why can’t we pump a few times per day and continue to produce the same amount of milk that we collect?”

The “Magic Number” concept shows us how this reduction in supply happens. Each parent has their own unique “Magic Number”, or the number of times we need to thoroughly empty (we are always making milk, so never completely empty) per day to produce a consistent amount of milk long-term. This can be as low as around 5 times, or as high as 10+ times per day, depending on how much milk storage capacity each person has. For most, 7 is the “Magic Number”, but even that is after milk supply has been well established. For those who can maintain their supply with that many sessions, they still may have had to start off with more to build supply up. We have no way of knowing what our magic number is until we have watched the effects on our daily production consistently over time.

Establishment (or regulation) of milk supply usually happens somewhere around 12 weeks postpartum. The boost our hormones gave us in the beginning gradually declines before this time, and the body settles into producing about the amount of milk we have consistently been removing from it each day. Because of that, the most reliable way to consistently produce an amount of milk daily is to build a supply first, before tapering the pumping/nursing frequency to find your magic number. After this point if you need to increase your supply, it will likely be more difficult than it had before this shift.

Option #1

Fully establish your milk supply before starting to combo feed.

If your goal is to provide your milk for months, a year, or more, this is likely your best option. Plan to pump or latch every 2-3 hours (around the clock) until you’ve hit 2 months postpartum and when you are producing as much milk as you would like to continue making, or more. At that point you can slowly start substituting one feeding at a time and stretching out the time between pumping or nursing. The goal is to eventually settle at a reduced number of nursing/pumping sessions, while also maintaining the amount of milk you desire to make each day.

If supply is established before implementing combo feeding, the ability to continue making a consistent amount of milk will be much easier to maintain and manage.

I realize this takes away some of the convenience using formula brings over the first few weeks. Having gone through the newborn days with twins twice myself, I completely understand the thought process behind wanting to be able to have others help with half of the feedings and offer bottles of formula. There are other options, but establishing supply first would be the most reliable plan for an extended period of time.

A variation on this option is to still maintain the 8-10x/day schedule, but freeze a good amount of milk produced each day, using formula in its place. The frozen milk can then be used in future months if the parent decides to end their own process of lactation but wants to continue providing milk. This also works well for those planning to continue feeding milk after returning to work but are concerned about pumping while away from the babies. With this strategy you still establish a great supply and have more options in the future for feeding. In some ways, pumping instead of latching two babies can still feel like the load is lessened, so it is worth considering if you know nursing every 2-3hrs isn’t for you.

Option # 2

Combo feed from the very beginning, knowing it is likely a short-term feeding plan.

From the magic number theory and reading through Option #1, we understand how to program our body to make milk consistently over a long period of time. Let’s use the 50/50 example again. If we were only to pump or nurse 4-5x/day from the beginning and formula feed the rest, we would be leaving milk sitting without emptying for 5-6 hours at a time. Our body needs much more frequent nursing or pumping sessions in the beginning to signal an abundant, consistent milk supply. We are meant to go 2-3 hour stretches to match a baby’s needs, so by letting 5-6 hours go instead, we are sending our body the message that there is too much milk, and we need less.

Here is an analogy to help explain milk production: If a factory makes lots of product at a fast rate but few orders are placed for it, the product will sit in the warehouse. The factory won’t make more until the rest of the products are ordered, and to avoid having any sit in the warehouse, the factory will just make less next time.

The factory is like our body, the warehouses like our breasts/chest; Less emptying = lower production = less overall milk volume.  

Since hormones are initially responsible for starting milk production and not yet a supply and demand system, we may start off being able to produce a good amount of the twins’ intake even if emptying less frequently.  As we switch over mainly to supply and demand by that 6-12 week mark, only emptying 4-5x/day would take a toll, and the amount of milk produced will gradually drop. For most parents, this means it will be a matter of time before shifting to formula feeding exclusively.

I have worked with parents who took this approach who were still able to provide their milk for many weeks - even months – before making the switch. The length of time really depends on how each individual body makes milk. While taking the temporary nature into account, you may feel Option #2 is still the best decision for your family, and that is ok. If you have weighed the pros and cons and decided on this route, resist the parent guilt that seems to find every choice you make these days.

“Remind yourself that you are a well-informed parent making the best choice for your family.”

Will your babies get all of the benefits exclusively feeding human milk provides? Not to the fullest extent, but even a few ounces per day will provide amazing benefits for your babies. Any amount of milk your babies get is an amazing gift, whether that be one ounce or ten thousand.

Other Combo Feeding Considerations:

Avoiding Bottle Preference + Breast Refusal

For parents combo feeding, paced bottle feeding is a must if you plant on continuing to latch the babies. This style of bottle feeding slows down the flow of milk, reducing the likelihood of baby developing a “flow preference”. When compared to taking a bottle, nursing babies work harder to transfer milk – even when using many of the slow-flow nipples on the market. Paced or responsive feeding better allows a baby to recognize when their hunger is satisfied rather than overeating.

Using a bottle with a gradually sloped, slow flow nipple such as the Lansinoh Momma or Evenflo Balance is important to help keep baby used to opening wide while eating. To avoid frustrations from a baby who has to wait for milk to let down, or with the slower rate of your milk flow when latched, make sure to follow the above tips for bottle feeding.  

Twin Combo Feeding Scenarios

Once you have established a balance in combo feeding (and your supply for Option 1) with whatever ratio of human milk to formula you are using, we can look at scenarios for feedings.

There are lots of variables here - if you are latching vs, exclusively pumping, if you are down to strictly nursing/pumping a few times a day vs. still 8 times a day, if you are able to tandem nurse vs. just individually nurse - the list goes on.

Here are a few options to consider:

• If you are Flying Solo During Feedings:

  • Tandem nurse both babies for a few feedings each day, while the rest of the feedings you tandem bottle feed formula using two bouncy seats, a Twin-Z pillow, your lap, etc to hold them.

  • Nurse one baby while simultaneously bottle feeding the other baby, using a boppy pillow to hold them. Switch at the next feeding who nursed & who had the bottle.

  • If you aren’t nursing the twins, but instead pumping to provide milk: Pump using a hands-free bra to hold flanges or a “wearable pump” while you simultaneously bottle feed both babies sitting in bouncy seats, Twin-Z pillow, boppy pillows, etc. Yes, this takes practice, but is a huge time saver if you need to pump AND bottle feed but are on your own!

• If you Have Help During Feedings:

  • Tandem nurse the babies for some feedings each day, while for others someone else tandem bottle feeds them. You could either pump during that time (if establishing supply) or have the feeding “off”.

  • Tandem nurse the babies for some feedings, while for others you and a helper each bottle feed a baby formula.

  • Nurse one baby while a helper bottle feeds the other a bottle, at the next feeding switch who nursed & who had the bottle.

  • If you are pumping rather than nursing to provide milk — Pump while helper(s) bottle feed, then for feedings you aren’t pumping either take the feeding “off” or bottle feed one baby while a helper feeds the other.

Use a Lactation Consultant to Establish a Plan - the Earlier the Better!

Lindsay Castiglione, BS, IBCLC

Combo feeding twins a situation where working with a private practice Board Certified Lactation Consultant (or IBCLC) can be incredibly helpful. Some parents fear that by reaching out for help from a lactation consultant, they will be shamed for using formula. A private practice IBCLC who works 1-on-1 with you should do whatever she can to support YOUR goals, no matter what they are.

“When I work with families, all details are taken into consideration helping to make a written feeding plan laying out the steps toward their goals. I give them information and personalized tools to support their breastfeeding goals, while reducing any risk combination feeding may bring.”

I’ve found that having first-hand experience with nursing each of my sets of twins is such a benefit for my clients. If you would like my support navigating your twin or triplet feeding journey, click HERE to see virtual consultation options or HERE to inquire about appointment availability or other details. Thanks to my secure telehealth platform, I am able to work with multiples families all over the world.