Mixed milk feeding: a systematic review and meta-analysis of its prevalence and drivers

Context: Extensive literature is available on exclusive breastfeeding and formula-feeding practices and health effects. In contrast, limited and unstructured literature exists on mixed milk feeding (MMF), here defined as the combination of breastfeeding and formula feeding during the same period in term infants > 72 hours old (inclusion criterion). Objective: A systematic review and meta-analysis were performed, following the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines, on the global prevalence of MMF (primary outcome) and related drivers and practices (secondary outcomes). Data Sources: The search of MMF in generally healthy populations was conducted across 6 databases, restricted to publications from January 2000 to August 2018 in English, Spanish, French, and Mandarin. Data Extraction: Two reviewers independently performed screenings and data extraction according to a priori inclusion and exclusion criteria. Data Analysis: Of the 2931 abstracts identified, 151 full-text publications were included for data extraction and 96 of those were included for data synthesis (the majority of those were cross-sectional and cohort studies). The authors summarized data across 5 different categories (feeding intention prenatally, and 4 age intervals between > 72 hours and > 6-23 months) and 5 regional subgroups. The overall prevalence of MMF across different age intervals and regions varied between 23% and 32%; the highest rate was found for the age group 4-6 months (32%; 95% confidence interval, 27%-38%); regional comparisons indicated highest MMF rates in Asia (34%), North and South America (33%), and Middle East and Africa together (36%), using a random effects meta-analysis model for proportions. Some drivers and practices for MMF were identified. Conclusion: MMF is a widespread feeding reality. A shared and aligned definition of MMF will help shed light on this feeding practice and evaluate its influence on the duration of total breastfeeding, as well as on infants' nutrition status, growth, development, and health status in the short and long terms.