Gentling Baby to a Bottle: When a Breastfed Baby is Bottle-fed
Front Royal, VA, USA
From: Leaven, Vol. 45 No. 1, 2009, pp. 12-15
More often than we would like, babies and mothers cope with less than ideal circumstances. Not too long ago I worked with a mother whose baby's mouth was too small for her nipple. This mother was able to express her milk but the baby refused to accept any artificial nipple -- whether on a bottle or a pacifier. The baby surprised her parents by being adept at taking mother's milk from a medicine spoon.
More recently I've worked with a family in which baby could not latch and the mother's supply was compromised. This baby readily took formula supplement from a bottle. One of my contributions to the family was teaching them how to pace feedings so that the baby could pause, breathe, and rest when he wanted to. This made bottle-feeding as much like breastfeeding as possible so that he could return to breastfeeding with less difficulty when the problems were resolved.
The paradoxical truth is that sometimes teaching a baby to drink from a source other than mother can save breastfeeding. When breastfeeding is challenged we need to feed the baby, protect the milk supply, solve the problem, and get the baby and mother together again. The situation of an employed mother can be looked at this way, too.
As aware as we are of the nature of the breastfeeding relationship and the difficulties inherent in all the alternatives, La Leche League Leaders may well have mixed feelings about situations that involve the use of a bottle. Sometimes there are undeniable reasons why a baby cannot breastfeed directly. At other times we may wish that a mother were making other choices. In places where people are heavily reliant on technology, we encounter women who firmly believe that they must pump milk and must give bottles, though objectively there is no compelling reason to do so. Some women who intend to stay at home with their babies still buy pumps and bottles because they believe they are necessary for breastfeeding. Others return to work while their babies are still quite young and most of these mothers automatically assume bottle-feeding is a way of life.
These ideas are deeply ingrained and not easily changed. Working empathically with a woman, respecting her and her authority as the mother of the baby, we build rapport. Whether over the phone, by email, or after a meeting, when we work one-on-one with a mother so that she feels heard and respected, she may become receptive to hearing other ideas about how to handle her situation. Perhaps she isn't aware that there are means of feeding her baby other than a bottle, such as a cup or spoon, a periodontal syringe, or a supplemental nursing system at the breast. Perhaps a mother who called for help with the bottle will be moved to come to a meeting and gain a new perspective there.
Working with a mother who asks for help to transition her baby to bottle-feeding can require tact and all our communication skills. Our obligation to help her includes providing her with relevant information so that she can make an informed choice. The International Code of Marketing of Breastmilk Substitutes, often referred to as the WHO Code, gives us guidelines, spelling out our responsibility to provide the information as to:
a. the benefits and superiority of breastfeeding;
b. maternal nutrition, and the preparation for and maintenance of breastfeeding;
c. the negative effect on breastfeeding of introducing partial bottle-feeding;
d. the difficulty of reversing the decision not to breastfeed.
Care needs to be taken so that a woman who has decided to use a bottle does not hear these cautions as an unwillingness to help her. A warm tone of voice and positive body language should assure her we want to help. We may need to help the mother explore her long-term goals in the context of this information. We might even state that we are obliged to cover certain information. If the mother is certain that bottle-feeding is her choice at this moment, the following information, offered in a respectful way, can help her to bottle-feed in ways that are more likely to preserve the breastfeeding relationship.
Most parents are unaware of the amount of control the baby has when breastfeeding. It is the baby who opens up and takes in the nipple. The pace of the baby's suckle determines the milk flow. After the letdown, the baby can pause at will. In contrast, bottle-feeding is typically a more passive activity for a baby. Most bottle teats will drip when the bottle is held vertically, even when the baby doesn't suck. He may have to swallow just when a rest was desired. Having a firm nipple inserted into a baby's mouth suddenly and unexpectedly can be startling for a baby. In addition, the strong suck of the typical breastfed baby on a bottle may result in far more milk than the baby expected and may alarm him.
Many people are not aware of what is normal infant feeding behavior. Some will nestle a baby in the corner of their elbow, insert teat and bottle into the reclining baby's mouth, observe him chug-a-lug down the milk and assume that he was very hungry. It is not normal or even comfortable for the baby to have to swallow continuously to keep up with the incoming flow.
Bottle-feeding can be made to more closely approximate the normal through the following steps:
1. To begin, choose the bottle teat with the slowest flow. The baby needs to suck to get milk. Our goal is to preserve breastfeeding. To avoid the possibility of latex allergies, avoid latex (brown) teats. Avoid short, stubby teats. Generally, longer teats that widen at the base encourage the baby to make a wide-open gape, even on the bottle. This can make it easier to transition back to the breast.
2. Support the baby securely. Offer the bottle with the baby in as close to a sitting position as is comfortable for him. This allows the baby to control the flow of milk more easily and requires active suckling on his part.
3. With the bottle teat held to his lips, the nipple base resting on his chin and the nipple pointing up toward his nose, stroke the baby's lips with the teat, using a feather-like touch, to elicit a wide open mouth -- as if the baby were going to breast. Avoid forcing the teat between closed lips. Let the baby mouth it.
4. Use a straight bottle and hold it horizontally so that gravity is not forcing fluid into the baby's mouth. The baby needs to suckle for food, in a manner as similar to breastfeeding as possible. These measures avoid possible choking and/or aspirating. Let's not frighten the baby.
5. The mother's nipple reaches the point in the baby's mouth where the hard palate meets the soft palate. The bottle nipple should, too, so that it feels to the baby as much like breastfeeding as possible. Nipples having a very wide base may look a bit like a breast but are so big and firm that the baby gets only the tip of the teat in his mouth.
6. Use a teat that is narrow enough for the baby to get his mouth around and encourage him to take as much of the bottle teat as possible into his mouth. Generally, the baby's lips will look nicely flanged out and will be touching the bottle. The baby should "latch deeply" onto the bottle, just as the baby would latch deeply onto the mother's breast.
7. Initially, the baby may need to be burped much more often than one might expect. While he's learning, he may swallow a lot of air.
8. As a rough guide, the bottle-feeding should take about 20 minutes. If a baby finishes a full feeding in less than 10 minutes, it may mean the bottle is flowing too quickly. Feedings that regularly take 30 or more minutes may indicate the baby is not able to remove milk effectively from the bottle being used. Since bottles are subject to manufacturing errors, it is important to check to make sure there is a hole in the nipple when a baby is unable to feed from a bottle. Even within a package of three teats, there may be significant variations in flow. Discard any teats with a flow that is too fast or too slow.
9. One additional step may ensure that the baby doesn't overeat: Before you believe he is full, slip the bottle from his mouth and rest it against his lips as you did at the start of the feeding. He may eagerly and immediately gape for it. As soon as he does, give it back. After another 10 or so swallows, repeat. This is your way of asking him, "Would you like more?" His answer will change through the feed from "Yes," to "Perhaps," to "No."
More information on this method of feeding is found in Dee Kassing's article in the Journal of Human Lactation, "Bottle-Feeding as a tool to Reinforce Breastfeeding." Kassing includes a message parents need to know: "When a baby is put in control of the feeding and allowed to take as much as he needs, there is less chance the baby will be underfed or overfed supplement" (p. 59).
When Mother Will Be Separated From Baby
A mother who anticipates separation from her baby, either because of work situations or other circumstances, often worries about how her baby will eat in her absence. She may worry that her baby might not take a bottle, and may be unaware of other possibilities as well.
Before she introduces the change to her baby, it would be helpful for her to consider how any human being learns a new skill or how to handle a new piece of equipment. Think about someone with a new car. Even experienced drivers want to look it over, to see where things are and to get a feel for it before driving on a road. Likewise, in gentling a baby onto a bottle, baby's first experience should be an introduction, not a meal. As Jane Bradshaw, Lynchburg, Virginia (USA), puts it, "Look honey, here's a new toy, a new game, and -- by the way -- it has some milk in it. Surprise!"
Jane advises mothers to:
Only put a small amount of milk in the bottle and be happy if the baby even accepts the nipple in his mouth. Keep trying daily but don't pressure the baby for long sessions. Offer it as a toy, something interesting to chew on. Be happy if that is all baby does with it. That is progress. Don't be discouraged if baby won't take a full feeding.
Parents are frequently amazed by this point of view, Jane observes, because they had thought of it as all or nothing.
The mother will want to know when a bottle should be introduced. Two weeks before she returns to work allows the baby time to adjust and lets the mother know how things will go. It should be done when the baby isn't very hungry.
Then there is the question of who should introduce the bottle. Conventional wisdom is that it should be someone other than mother. Since her smell and presence remind the baby of breastfeeding, the baby may not accept a bottle from her. A good choice would be an experienced bottle-feeder who is comfortable coaxing a reluctant baby. "Often it is best for the person who will be giving the bottle -- perhaps the baby sitter -- to be the one to introduce it" advises Jane. "On the other hand some babies will only take the bottle from mom." Considering the baby's close and trusting relationship with his mother, that makes sense, too.
The mother may have very mixed feelings about all this. On the one hand, she may feel trapped and panicky if her baby doesn't take a bottle easily. On the other hand, she may feel too easily replaceable if her baby does, and she may ask, "Where is that special mother/baby bond?" In this case, someone else may have better luck with the bottle than the mother. Dad is a likely candidate for the job but his feelings may be hurt, too, if the baby fusses.
When Baby Resists the Change
Some techniques that have worked to overcome resistance:
A. Stand up, walk around, dance, or sing while offering the bottle. Rhythmic movement distracts and calms.
B. Try a different nipple, longer or shorter -- the baby may prefer that it hit a different point on the palate.
C. Run the nipple under warm or cold water. While some babies will like it warm, others -- such as those who are teething -- may like it refrigerated.
D. Some do better if placed in an infant seat with the adult not even holding them. (Not good for bonding, but helpful toward a short-term goal.)
E. Make a milk "slushie" with semi-frozen milk and spoon feed it. Warm milk may remind the baby of his mother, while cold milk is something new to be tried.
F. Anticipate feedings so that the baby hasn't gone a long time between feedings and become very hungry.
G. Gently turn the bottle nipple in the baby's mouth, similar to turning a light bulb, until the baby's lips are flanged around the nipple.
If the caregiver is someone other than the mother:
H. Use something that really smells like the mother to wrap around the bottle or snuggle baby close, her nightgown or a cloth with some of her milk on it.
I. Sometimes it helps to look like the mother. Jane read that one father put on his wife's fuzzy pink robe, strapped on her nursing pillow and baby took the bottle after having refused mightily before that.
J. One sitter put a paper grocery bag over her head because baby did not like seeing a face other than mother's when he was feeding. It worked.
K. With some babies, the nursing position reminds them too much of nursing. Hold your baby in your lap with his back against your chest. Or prop the baby on your slanted forelegs, like in an infant seat, and give the bottle while looking at him.
L. Some babies prefer the traditional nursing position, and will accept the bottle while lying on their side. The sitter may have to tuck the bottle under his or her arm. It may look funny, but it may work.
Lisa Jones, LLL of Wellington, Florida, USA, recommends the use of a sling for caregivers familiar with them. "Carry the baby in a sling in such a way that he can't see the bottle-giver's face," she suggests. "This helped feed a bottle-feeding baby who did not like to take bottles from anyone but her Mommy."
The Bottle is Not the Only Option
How the baby will be fed when not at the breast varies greatly according to where in the world mother and baby are. In some places, supplement is commonly given by cup. In those places where the bottle has become the expected means of feeding a baby, it is a big surprise to parents that there are other means. Jane, in the USA, says:
I always remind parents that the goal is for their baby to be happy and fed during their absence and that the bottle is only one method of attaining this goal. Cup, spoon, eyedropper and periodontal syringe are all feeding implements. Sometimes starting with one of these will get some milk into baby and will calm him enough so he may be willing to take the bottle. Or the other implement can be used for entire feedings.
Before cup feeding a baby, cup feed another adult, and have that adult cup feed you. This will give you a much clearer sense of what will and will not work. To cup feed the baby, place the rim of the cup on baby's lower lip and tilt the cup until the milk approaches the baby's lips. The baby's tongue will explore and find the liquid. This may take a few minutes at first. He will then lap or sip the milk. Do not pour the milk into the baby's mouth. Keep the level constant at his lower lip. Allow the baby to rest and pause at will but do not remove the cup. When the baby has finished, he will let you know by turning his head away or by other clues. Be aware that cup feeding can result in considerable loss of precious milk -- as much as a third in some studies. Some babies lose very little milk, others lose more. When the baby can be fed by one of these methods, it is important that the mother breastfeed when she and the baby are together to maintain that skill.
Some parents find all this rather overwhelming. When Lisa was asked, "Wouldn't it be better to wean completely so my baby has an easier time?" she replied, "Babies need time to adjust to 'other-care' when they have spent weeks with 'mother-care.' This transition can be a challenge regardless of feeding method."
Not everything can be worked out ahead of time. The situation that requires the use of a bottle may arise suddenly. A patient and sensitive caregiver will work out a relationship with baby. One grandmother pinched a bottle nipple to drip milk onto the tip of her grandson's tongue until he caught on. Another Leader relates the story of a baby who refused a bottle and sucked on the caregiver's arm instead. The caregiver developed little tiny baby hickeys on her arm before the baby made the switch to the bottle.
It is likely, almost inevitable, that in helping mothers we encounter those whose lactation has been sabotaged by the use of bottles. Many of us develop an antipathy toward bottles. It can be hard to recognize that they are tools and that there are situations in which their use is appropriate. In emergencies these techniques can help keep a baby fed until he can be transitioned completely to the breast. In situations where a mother has simply chosen to use a bottle, we can help her make breastfeeding doable. All that may be in our power is to help prevent breastfeeding from being totally undermined.
Although teaching a baby to take a bottle isn't why we became Leaders, helping parents become sensitive to their babies' cues is a part of what we do. By helping parents with the bottle we may not only preserve breastfeeding, but also promote cooperative rather than coercive parenting. Perhaps the approaches and attitudes used here will carry forward to introducing solids, weaning and toilet training.
Kassing, D. Bottle-feeding as a tool to reinforce breastfeeding. J Hum Lact 2002 Feb; 18(1): 56-60
For Further Reading
Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book, third revised edition. Schaumburg, IL: La Leche League International, 2003; 157, 172-174 (Weight gain issues); 241, 252-254 (Employment); 311 (Prematurity); 634-640 (Alternative Feeding Methods).
The Womanly Art of Breastfeeding. Schaumburg, IL: La Leche League International, 2004; 159, 238.
A situation has come up where I need to feed my baby from a bottle. Can you help? www.llli.org/FAQ/bottle.html
Editor's Note: Over 884 million people in the world do not have access to safe drinking water sources (UNICEF). In these communities, bottle-feeding is not safe. This article refers to countries and communities where bottles can be washed and sterilized.
Among those contributing to this article are Jane Bradshaw, Virginia (USA); Ann Grider, Ohio (USA); Lisa Jones, Florida (USA); Pamela Willet, New York (USA); Sue Roenke, New York (USA); Janet Jendron, South Carolina (USA); and Diane Wiessinger, New York (USA).
Thanks to Sara Dodder Furr, Nebraska, (USA); Melissa Vickers, Tennessee (USA); and Rachel O'Leary, Cambridge (UK) for their assistance in preparing this article for Leaven.
Woman and Mother