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. 2022 May 24;14(11):2190.
doi: 10.3390/nu14112190.

Mixed Milk Feeding: A New Approach to Describe Feeding Patterns in the First Year of Life Based on Individual Participant Data from Two Randomised Controlled Trials

Nikolaos G Papadopoulos  1   2 , Theodor A Balan  3 , Liandre F van der Merwe  3 , Wei Wei Pang  4 , Louise J Michaelis  5   6 , Lynette P Shek  7   8 , Yvan Vandenplas  9 , Oon Hoe Teoh  10 , Alessandro G Fiocchi  11 , Yap Seng Chong  4   7 , On Behalf Of The Tempo Study Group, On Behalf Of The Venus Study Group
Affiliations

Mixed Milk Feeding: A New Approach to Describe Feeding Patterns in the First Year of Life Based on Individual Participant Data from Two Randomised Controlled Trials

Nikolaos G Papadopoulos et al. Nutrients. .

Abstract

'Mixed Milk Feeding' (MMF), whereby infants are fed with both breastmilk and infant formula during the same period, is a common feeding practice. Despite its high prevalence, knowledge regarding MMF practices and their association with (health) outcomes is limited, potentially because MMF behaviours are highly variable and difficult to standardise longitudinally. In this paper, we applied a statistical clustering algorithm on individual infant feeding data collected over the first year of life from two clinical trials: 'TEMPO' (n = 855) and 'Venus' (n = 539); these studies were conducted in different years and world regions. In TEMPO, more than half of infants were MMF. Four distinct MMF clusters were identified: early exclusive formula feeding (32%), later exclusive formula feeding (25%), long-term MMF (21%), and mostly breastfeeding (22%). The same method applied to 'Venus' resulted in comparable clusters, building trust in the robustness of the cluster approach. These results demonstrate that distinct MMF patterns can be identified, which may be applicable to diverse populations. These insights could support the design of future research studying the impact of infant feeding patterns on health outcomes. To standardise this in future research, it is important to establish a unified definition of MMF.

Keywords: breastfeeding; formula feeding; infant; k-means clustering; mixed milk feeding.

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Conflict of interest statement

N.G.P. reports personal fees for advisory and/or speaker services from Novartis, Nutricia, HAL, MENARINI/FAES FARMA, SANOFI, MYLAN/MEDA, BIOMAY, AstraZeneca, GSK, MSD, ASIT BIOTECH, Boehringer Ingelheim and Capicare. T.A.B. and L.F.v.d.M. are employees of Danone Nutricia Research. L.J.M. reports investigator led research grants, Speaker, Steering Committee, Advisory Board and Expenses fees paid to Newcastle University from Danone Nutricia and Sanofi Pharmaceuticals. Y.V. has participated as a clinical investigator, and/or advisory board member, and/or consultant, and/or speaker for Abbott Nutrition, Ausnutria, Biogaia, By Heart, CHR Hansen, Danone, ELSE Nutrition, Friesland Campina, Nestle Health Science, Nestle Nutrition Institute, Nutricia, Mead Johnson Nutrition, Pileje, United Pharmaceuticals (Novalac), Yakult, and Wyeth. None of the other authors have declared a conflict of interest.

Figures

Figure 1
Figure 1
Percentage of subjects in different MMF clusters and reference groups in the MMF + Ref population for Tempo and Venus. FF: formula feeding; BF: breastfeeding; MMF: Mixed milk Feeding; Ref–BF: Subjects who had no, or limited infant milk formula intake recorded during the first year (on ≤5% of total recorded days).
Figure 2
Figure 2
Feeding status trajectory for all MMF subjects in TEMPO per cluster. Each subject’s feeding pattern is represented by a horizontal line ranging from birth (leftmost) to 350 days of age (rightmost). The colour at each age describes whether the subject was exclusively BF, exclusively FF, or mixed feeding. The black dots indicate the recorded day of starting complementary feeding.
Figure 3
Figure 3
Summary of feeding variables in TEMPO per cluster from birth (leftmost) to 350 days of age (rightmost). First row: % started compl. feeding—percentage of subjects introduced to complementary feeding; Avg. SP Volume (mL)—average of the estimated daily study product volume intake across all subjects in the cluster; Avg. SP Vol (while MMF)—average of the estimated study product volume intake in ml per day, across the subjects in the cluster who are mixed feeding at that time point. Second row: Avg. BF Meals—average of the estimated daily number of daily BF meals; Avg. SP Meals—average of the estimated daily number of daily study product meals; Prop. BF Meals (while MMF)—proportion of BF meals from the total of BF meals and study product meals.
Figure 4
Figure 4
Feeding status trajectory for all MMF subjects in Venus per cluster. Each subject’s feeding pattern is represented by a horizontal line ranging from birth (leftmost) to 350 days of age (rightmost). The colour at each age describes whether the subject was exclusively BF, exclusively FF, or mixed feeding. The black dots indicate the recorded day of starting complementary feeding.
Figure 5
Figure 5
Summary of feeding variables in Venus per cluster from birth (leftmost) to 350 days of age (rightmost). First row: % started compl. Feeding—percentage of subjects that introduced complementary feeding; Avg. SP Volume (mL)—average of estimated daily study product volume intake across all subjects in the cluster; Avg. SP Vol (while MMF)—average of estimated study product volume intake in ml per day across the subjects in the cluster who are mixed feeding at that time point. Second row: Avg. BF Meals—average of the estimated daily number of daily BF meals; Avg. SP Meals—average of the estimated daily number of daily study product meals; Prop. BF Meals (while MMF)—proportion of BF meals from the total of BF meals and study product meals.
Figure 6
Figure 6
Race distribution within each MMF cluster, highlighting the population differences between TEMPO (left) and Venus (right).
Figure 7
Figure 7
Similarities between birth weight, maternal age, and maternal body mass index (BMI) pre-pregnancy among the MMF Clusters. The three variables are shown for TEMPO (above) and Venus (below).
Figure 8
Figure 8
Distribution of mothers’ highest level of education completed within each MMF cluster for TEMPO (left) and Venus (right).
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