How to transition from formula use to exclusively or predominantly direct breastfeeding

When is it time to start the transition from formula use towards exclusive and direct breastfeeding?

Many women expect to be able to breastfeed their baby, and are shocked and saddened to find that so many things can go wrong. The grief can be quite awful. You can find out more about this special kind of grief here.

If you find yourself formula feeding when you'd intended to breastfeed, and the immediate crisis in baby's weight gain is past, you might be wondering if you'll ever be able to exclusively breastfeed, and what steps you can take now to head in that direction.

Here are the key facts to be across when you want to build your breast milk supply so that you are able to transition your baby away from formula to exclusively or predominantly direct breastfeeding. You'll most likely need to attempt this transition with the close support of your local GP or breastfeeding support health professional.

• What is your baby's age? What is the proportion of your baby's caloric needs which are currently being met by formula? A six-week-old baby who has four-fifths of her caloric needs met by formula is in a different situation to a three-month-old who has just one or two bottles of formula a day and who is otherwise directly breastfeeding. It will be much easier to shift that three-month-old to exclusive direct breastfeeding than to do the same with the six-week-old. If your baby is still very young, you'll need the help of your local GP or other breastfeeding support professional to monitor your baby's weight and ensure baby's safety.

• Have the underlying issues that resulted in baby's poor weight gain early on been addressed? Our health system has blind spots which often make it difficult or impossible for parents to return their baby to exclusive or predominant direct breastfeeding. These crucial blind spots about breastfeeding problems are discussed here, here, and here.

How to transition from formula use to exclusively or predominantly direct breastfeeding

You need to take milk from your breasts to make milk in your breasts. The use of formula decreases your milk production because it decreases your baby's hunger (or appetite drive) to take milk directly from your breast. This is why your breastfeeding support professionals may have recommended that you pump the equivalent amount of milk from your breasts that your baby is taking in formula, to develop or maintain your supply. But this raises the question: why can't your baby take that milk directly from your own breasts?

Consider offering the breast only, frequently and flexibly, for the first part of the day, until say early or mid-afternoon, when you might then start to bring in the required bottles of formula. In this time, you'd

1. Switch feed (take baby off every five or ten minutes, and put on the other breast

2. Offer very frequently. Never think your baby can't be hungry because she's just fed.

3. Take your baby off if he's not transferring much milk and you've had enough – don't allow marathon feeding.

4. Use your two superpowers for making the days as enjoyable as possible with your baby. Perhaps baby is dialling up after feeds because of need for richer sensory experience, best experienced outside the home, rather than from a need for another 'top-up'.

Your baby will need to be allowed to develop hunger

Often the dilemma is that baby's caloric needs are largely satisfied with the formula use, and he has less drive to transfer milk from the breast. This means that we need to allow your baby to develop a hunger, by gradually decreasing formula offers, so that your baby develops an appetite drive to the breast. This is safer to try, for example, in an older baby than a newborn whose weight needs careful monitoring.

Frequency of milk removal in the first days postpartum determine the settings on your milk supply (though this varies from woman to woman)

And yet it's frequent and flexible milk removal from the first hours and days after birth that is responsible for the settings on your milk production. It can be much harder to build a full supply which meets your baby's caloric needs if your baby has used a lot of formula from very early life.

For some women, it seems as if the settings never reach full production if there has not been very frequent amounts of postpartum nipple and breast stimulation and milk removal. And yet for another woman, especially if she has breastfed an older child, milk production may prove to be incredibly robust, and ramps up nicely when the time comes. We can really only find out how responsive your breasts are able to be once you try.

Underlying fit and hold problems and conditioned dialling up at the breast need to be addressed

Often fit and hold problems haven't been properly addressed, and unless they are addressed, it's difficult to move to more direct breastfeeding. Or your baby has had a conditioned dialling up at the breast, which is still unresolved. You can find out about this here. You can see why our health systems' blind spot about babies' fit and hold (and any resultant conditioned dialling up) constitutes - in my view - such a health system crisis!

Misunderstandings about baby behaviour can make it hard to return baby to the breast

Here are other important facts to consider as you start the transiton away from formula use.

• It doesn't help to think of feed times as 'meal-times' when you need to get certain amounts of milk into your baby. You can find out about this here. Instead, think of your use of the breast or bottle as a tool which dials your baby down.

• Your baby might dial up after a breastfeed for a range of reasons. This doesn't mean that your baby needs a formula 'top-up' because he isn't satiated. Consider changing your baby's sensory motor experience (for instance, by stepping outside the house), and then offer the breast again next time baby dials up. Feeling as though you need to offer a bottle of formula when your baby dials up is one of the main reasons parents have difficulty transitioning baby from formula use to predominantly or exclusively breastfeeding.

If you decide it's time to accept your baby will always be predominantly formula fed

Sometimes women decide it's time to stop the struggle and the stress of trying to make breastfeeding work, do the grieving, and accept that their baby will always be predominantly formula fed. So much in life is outside our control, actually, and the challenges women face with breastfeeding are much bigger than any individual parent - they are health system problems, which themselves arise from broader sociocultural problems (such as not enough research funding).

But you can still use the breast for as long as you like and as often as you like to dial your baby down and to enjoy the physical closeness. It's not an 'either/or' situation. (If nipple pain has been the underlying problem though, your capacity to use the breast as a tool to dial your baby down might always be limited, depending on your situation.)

It doesn't matter how much or how little milk your baby removes from the breast. Usually our little ones just like to snuggle up and suckle regardless, perhaps even drowsing off to sleep. Even when they're not receiving much milk, it's the rhythmic suckling that brings our little ones profound psychological and physiological comfort. You can offer this gift to your baby whenever you want, regardless.

Recommended resources

You can find out about paced bottle feeds here.