- Choosing a Bottle & Nipple
- Bottle-Feeding Dos & Don’ts
- Nipple Confusion/Bottle Preference
- Swaddling While Feeding
- Understanding Overfeeding
*Read the first part of this post here.*
**Learn about cup feeding as a bottle feeding alternative here.**
Bottle Feeding Basics
You probably already know this, but…
Breast milk in a bottle is virtually always preferred to formula in a bottle, nutritionally speaking. If you cannot nurse but can provide expressed breast milk, most infant feeding experts would recommend you do so.
For some babies, syringe feeding and finger-feeding are alternative options. You may also consider cup-feeding, which the WHO actually states is a better and safer method than feeding with a bottle and artificial for babies who are not being fed at the breast. Even newborns can learn to cup-feed if need be! If the reason for giving pumped milk is not due to the mother’s absence (for work, perhaps), a lactation aid may be a route worth consideration, and Dr. Jack Newman says even using it sometimes is better than never.
CHOOSING A BOTTLE & NIPPLE
- MYTH: Wide-necked nipples are always best for breastfed babies.
Manufacturers categorize their nipples as having narrow or wide necks based on their own judgement, not by a standard measurement. What they’re actually referring to is the nipple base, which really makes no difference at all in how the baby latches because the baby latches close to the plastic nipple collar (the lid that screws on around the nipple), not the base of the rubber nipple itself.
A helpful tip for working with a nipple that might not be perfectly suitable: squish down the tip of the nipple first, allow baby to latch, then release it (mimicking what happens when baby pulls in mom’s nipple). Be consistent; make sure all other caregivers do this during their feedings, too.
- MYTH: The speed of milk flow can be judged by the rate of drip.
Flow rate, which is listed on bottle packaging and the base of the nipple, refers to how quickly milk leaves the nipple. This is important because a fast flow can overwhelm the baby (think of the unremitting GUSH of a busted fire hydrant). Bottle companies, again, are the ones who get to choose what ‘fast’ or ‘slow’ flow means.
Amy Peterson and Mindy Harmer, the authors of Balancing Breast and Bottle: Reaching Your Breastfeeding Goals, say “you can have a lot of small drips yet still have less milk” overall. Together they conducted a series of experiments assessing the true relationship between number of drips and total volume, and further determined that “dripping is different than flow. You cannot judge flow by tipping a bottle upside-down.”
- MYTH: The manufacturer’s claims on it’s product packaging, ads, and web site are reliable clues about how well the bottle/nipple actually works.
Remember, they can claim anything they want! Some company claims you may have seen:
“For Babies Switching Between Breast & Bottle” (Playtex Ventaire Advanced – also claims to have wide nipple and slow flow)
“Mimics breastfeeding like no other bottle.” (Mimijumi)
“Perfect for breastfed babies!” (The First Years Breastflow – also claims to be “ideal for breastfeeding moms”)
“Patented nipple helps extend breastfeeding” (The First Years Breastflow)
“Switching from bottle to breast has never been easier” (Medela Calma)
“…makes the difference…because your baby can feed with their own individual rhythm.” (Medela Calma – also claims that it doesn’t leak, so *clearly* you can trust it has a slow flow. Yet in fact, the Calma system has been shown to have the fastest flow on the market today)
They can even make their product look more like a breast. Or whatever they think a breast looks like, because I’m pretty sure baby knows this isn’t mom. (Tell me the truth: if I stuck this in my bra, do you think I could pass through security without raising suspicion? 😉 )
And, of course, they can name it something like “Latch,” “Nurser,” “Breastflow,” “Nursin’ Smart,” or “NaturaLatch Nipple” to convince you that drinking from this bottle is equivalent to drinking from the breast.
My point is, the best bottle that works for a mom’s baby is…the best bottle that works for her baby — no matter what it’s called, what it looks like, or what it says on the package. Ignore the ‘educational’ information provided by the company because it’s simply a sales pitch and nothing more. A baby will ‘teach’ mom which bottle is best for him; a bottle is not supposed to teach a baby.
No one bottle is ‘most like’ breastfeeding because every baby has a unique latch and sucking rhythm, each mother has a different breast feel and shape, and even the rate of milk flow is variable between breasts, time of day, and other factors. So, mom may need to try out a few different kinds of bottles before finding which one her baby latches onto and takes milk from most happily.
- MYTH: All babies need a different nipple or bottle type as they age.
This is untrue. It’s bottle companies that need moms to keep buying new bottles and nipples as their babies age. Some babies do fine with the same bottle and nipple type as they get older because their mom’s milk flow rate hasn’t changed either. Other babies may want a faster flow when they’re older because they don’t want to linger on the bottle like they would on the breast, and being forced to do so can be frustrating when they’ve learned that the bottle doesn’t also offer snuggles and comfort sucking.
*Remember, babies can start transitioning to cups at any time.*
Here is an example of a guide you’ll see on bottle company web sites (though they want you to presume it applies to every baby, it most certainly doesn’t):
- MYTH: Professional texts are always up-to-date.
Sometimes certain advice has never actually been corroborated by science, yet it still remains in print and circulated among professionals who are supposed to be the experts.
“…a teat with a very wide base…encourages a wide-open latch…it is best to select a wide-based teat.” – Breastfeeding and Human Lactation
“To determine which [nipple] has the slowest flow, fill the bottle with water and turn them upside down over a drain.” – Breastfeeding Answers Made Simple
What you want is advice that is going to actually help your baby feed comfortably from a bottle. If you’re confused, unsure, or wondering whether what you’re reading/hearing is backed up by science, remember that we live in the Information Age and getting second and third and limitless opinions from trusted sources has never been easier.
Use the SIMPLE Method
Authors Amy Peterson, BS, IBCLC and Mindy Harmer, MA, CCC-SLP literally wrote the book on integrating bottles into the breastfeeding relationship: Balancing Breast and Bottle: Reaching Your Breastfeeding Goals. They developed a method called SIMPLE that will help you select the right bottle system for your baby. The book also discusses how to introduce bottles, solutions to bottle-feeding difficulties, comparisons between brands, and more. Make things easier on yourself and pick up this book before shopping the baby bottle aisle!
BOTTLE-FEEDING DOS & DON’TS
- Do hold the baby in an upright position, not supine or reclined.
- Place baby’s mouth on the bottle as if it were a breast, even if the baby never nurses, because that’s the normal way a baby eats. Mouth around the nipple with no leakage, some of the mouth covering the base of the bottle-top (not solely the nipple), and lips splayed apart rather than rolled under. See photos here.
- Use a bottle nipple that mimics your breast nipple (orthodontic/NUK type don’t fit the bill). Learn about how to pick the right nipple shape here and which level of flow is best here. General rule of thumb: don’t (literally) buy into a bottle/nipple manufacturer’s claim of being “most like a breast” with controlled flow, wide base, and so on; all babies have different mouths and latches so you must find the one bottle/nipple that gives your baby an enjoyable, non-stressed feeding.
- A helpful tip from BfB: “If you are supplementing a breastfed baby, or pumping and bottle feeding in the hopes of getting baby back to nursing, it is beneficial to let your baby suck on the nipple for a minute or two without getting anything, and then tip the bottle so your baby is getting milk [to mimic the cause-reaction of letdown]… Babies who have been bottle fed sometimes get used to the immediate reward from the bottle and then are impatient at the breast and don’t want to wait for letdown.” This can help keep a baby accustomed to the breast or able to transition back to it more easily. BfB also notes: “There is no need to worry about your baby taking in air, one end or the other it will come back out!”
- Remember the Tortoise and the Hare, slow and steady wins the race? The same principle applies here. Bottle feedings should take about as long as a typical session of breastfeeding. If four ounces get downed in four minutes, put on the brakes now because something’s up.
- Infant feeding is not just feeding — it’s how a baby learns to socially interact and emotionally bond. This means propping a bottle or forcing a bottle into a baby’s mouth is never appropriate or beneficial. Just…no!!
- Infants are biologically primed to get their nutrition and comfort from only one person (mom) for months. Don’t toss baby around with many different caregivers for bottle feedings like the world’s cutest hot potato, if this can be avoided. It’s confusing, stressful, and inconsistent. Designate a ‘Baby Feeder,’ preferably mom (despite the misconception that moms should avoid giving bottles) because she’s the person best acquainted with her baby’s feeding cues and style.
- Feeding on-cue isn’t just for exclusively breastfed babies. This means avoiding a strict feeding schedule. Babies need to eat when they want to eat, not because it’s ‘bottle o’ clock.’
- Do switch sides during a feeding to mimic nursing and to avoid side preference.
- Don’t bottle-feed when a normal, healthy baby is swaddled or has limited use of hands. A baby’s hands offer many cues for hunger, satiety, stress and relaxation that need attention before and during a feeding.
- Overfeeding is easy to do when using bottles; do learn how tell when a baby is getting overfed. Read about the difference between swallows on bottled milk as opposed to milk at the breast here.
- Is the baby choking when bottle-fed? Gagging? Is the bottle leaking? What if you need to return to work soon but baby still won’t take a bottle? Get answers to frequently asked questions about supplementing here.
- Don’t feel guilty or ashamed if you give a bottle for ‘no good reason’ other than desperately needing a break.
If you truly feel like your sanity will be at stake if someone else doesn’t take over for a feed pronto after surviving through a straight week of cluster-feeds, then do what you need to take care of yourself. You know the disadvantages of bottle-feeding, and you know the disadvantages of a crazy-angry mommy — only you can weigh the risks and benefits on this one.
Have you ever noticed articles and books about bottle-feeding titled something like “How to Bottle-feed Without Guilt”? Did you notice how many articles and books about breastfeeding include the words “How to Breastfeed Without Shame?”
These are sister emotions, mamas. We can never win, huh? We should be able to cry on each other’s shoulders when we’re struggling, or to look each other in eye and genuinely say we’re happy for one another when we share our parenting successes even if they’re related to the different ways we feed our children. No guilt or shame, okay?
NIPPLE CONFUSION/BOTTLE PREFERENCE
It seems like it should be pretty simple to understand. A nipple that’s designed to be suckled + baby with a primal need to suckle = mammary magic. It is pretty magical, but it seems that many people still don’t know how baby humans actually breastfeed. If you guessed “By sucking, duh!” then you might want to guess again. Even many health providers still claim that nipple confusion/nipple preference is a myth, but ask those providers if they can explain how a baby breastfeeds and you’ll get your first clue about who and what to believe.
Sucking in the way that most people imagine is called ‘negative pressure,’ which is the eating behavior that has imprinted upon the parents who raised my generation and some generations prior entirely on bottles. Nope, that’s the way babies bottle-feed. Extracting milk from a breast requires what’s called ‘positive pressure,’ which means the baby is pressing more than actually sucking. Ah, suddenly that whole ‘nipple confusion’ thing makes sense, right?
So, a baby’s entire mouth acts in a different (actually opposite) manner to suck from a bottle than to suckle from a breast. Let’s recap: a baby uses negative pressure (suction) to procure liquid from a plastic teat. However, a baby uses positive pressure to breastfeed (pushing against the areola with the tongue once it’s drawn back against the palate).
Ever wonder why young babies sometimes take an hour to finish a nursing session but can down four ounces of bottled milk in, like, six minutes? No one said just because they can, that means they should (be sure to get your babysitters or daycare providers on the same page).
A baby does much less work to get milk from a plastic teat. He sucks on the teat like a straw, the milk continues to flow, and he cannot pace the milk flow as it goes down his throat so he ends up consuming more than he would’ve at the breast, and at a much quicker rate, too. FYI, that’s not a good thing! You don’t want nipple confusion to turn into bottle preference — with your baby ultimately rejecting the breast to get the instant gratification of bottles.
This is also why experts recommend avoiding all artificial nipples (bottles and pacifiers) until the baby is about a month old, or later if breastfeeding is not yet well-established.
- “Nipple Confusion” – Dr. Sears
- Pacifiers – Balancing Breast and Bottle
- “The Trouble with Calma and the Quest for the Perfect Bottle Nipple” – The Breastfeeding Mother
- “The Truth About ‘Nipple Confusion'” – Mother-2-Mother.com
SWADDLING WHILE FEEDING
A baby expresses hunger not only by crying, rooting, mouthing and gumming, but also by clenching his hands, grabbing, and waving for the breast. Babies also use their hands to help them “instinctively to locate, move, and shape the nipple area” (Genna, 2010). When a baby’s arms become relaxed and fists open up, this is a good sign that she’s satiated. These reflexive clues work the same when bottle-feeding.
If a healthy, normal baby is swaddled during a nursing, it can interfere with the baby’s ability to use her arms to position herself, remain stable, and communicate about her satiety. In this case she’d only have her mouth at her disposal to help her eat, and she may become stressed. If a healthy, normal baby is swaddled during a bottle feeding, the same results can occur from such movement restriction. Healthy, normal babies will outgrow swaddling by the end of the newborn period.
Some babies might benefit from being swaddled during feedings, however. Amy Peterson and Mindy Harmer say that “when a baby is disorganized [with its movements] or has low [muscle] tone, swaddling can be used as an intervention for calming and feeding.” Disorganized movements include lots of flailing that results in eating troubles, and movements that don’t come from the ‘midline.’ Babies with abnormal arm and leg movements or with low tone/floppiness can be swaddled with extremities in flexion and held in midline by using a blanket, muslin cloth, or tucking baby into a sling. Baby’s hands should remain outside of the swaddle (under the chin) so she can use them for hunger/satiety cues, self-soothing, and decreased stress.
Look around, the evidence is rolling and heavy: the obesity and overweight crisis in America is still epidemic. Bottle feeding during infancy (especially formula, but any bottled milk is capable of being overdosed in bottled form) has been targeted as a cause for early/late childhood and adult weight problems, particularly for boys. In fact, one study found that bottle feeding more than doubled the risk of later obesity. Though it compared babies fed formula in bottles to those being breastfed, it did also show that simply using bottles in bed can contribute to obesity as well.
Breastfed babies between one and six months old consistently take about 3 ounces of milk per feeding (newborns take less) and the amount they consume doesn’t change because the nutritional content of the breast milk itself changes to match the baby’s changing needs as he ages. Formula-fed babies must take in more milk per feeding as they grow because the formula remains the same (one large study found that they took 49% more milk at 1 month, 57% at 3 months, and 71% at 5 months). Babies who are fed breast milk in bottles are also at risk of consuming too much because of the difference between artificial vs. real nipples.
If you do give bottles, a good tip is that a bottle feeding should take just about as long as a typical nursing session, which is the normal eating pattern of a young child (many older babies just want to get the bottle feeding ‘over with,’ and prefer to linger on the breast longer). With alternative types of feeding you should strive to mimic this. It would take more patience and time to feed a baby from a cup or finger than a bottle, of course, but when you’re feeding your baby, what else are you doing but feeding the baby? There’s no need to rush, so try to avoid doing so.
Likewise, don’t try to stretch out a feeding unnecessarily just to avoid spit-up, burping, gas (anything butt that!), colic, or whatever else is typically blamed on quick bottle feedings. If the wrong type of nipple is used and bottle feedings are quick, overfeeding can happen pretty easily.
Check out “Breast Versus Bottle: How much should baby take?” by Nancy Mohrbacher, IBCLC, FILCA.
Know Your Baby’s “Suck Burst Cycle”
Become acquainted with your letdown pattern and baby’s sucking pattern at the breast to determine what is ‘normal’ pacing for him, then allow him to mimic this on the bottle. Amy Peterson, BS, IBCLC and Mindy Harmer, MA, CCC-SLP discuss this in greater detail in their book Balancing Breast and Bottle: Reaching Your Breastfeeding Goals.
With nutritive sucking (taking milk), a baby will swallow after every one or two sucks (the suck:swallow:breathe ratio; 1:1:1 or 3:1:1). A suck burst cycle (SBC) typically has the baby swallowing 20-30 times in a row. Each feeding will have a few of these SBCs, with the baby resting briefly between.
The authors advise to get help when:
Baby feeds with eyes closed
More than 3 sucks before a swallow
Less than 8 swallows in a burst
Less than 4-5 bursts in a feed
Count SBCs during a nursing session. You’ll notice that a normal, healthy baby starts with an SBC with a higher number of swallows, and each subsequent SBC has less.
Now let’s take what we’ve learned to the bottle. Keep in mind that pacing isn’t necessary once the baby can pace himself well, unless he has developed bottle preference over the breast.
Steps to Bottle Pacing
Adapted from Amy Peterson and Mindy Harmer:
1. Hold baby semi-reclined (halfway between sitting up and lying down).
2. Rest nipple on baby’s lips and allow him to draw it in.
3. After he starts sucking, tip the bottle up to allow the milk to flow (mimicking letdown).
4. Count the swallows. When this number is the same as his SBC on the breast, let your baby take a break from sucking.
5. Tip the bottle back down and sit the baby up. Don’t remove the nipple from baby’s mouth, though — you just want to stop the milk flow, not interrupt the feeding.
6. Baby will resume sucking when he’s ready for another SBC. Start again at Step 2.
7. Baby is finished with the feeding when he no longer sucks after resting.
Bottle Feeding Resources
BOOKS & BLOGS
- Balancing Breast and Bottle web site
- Balancing Breast and Bottle: Reaching Your Breastfeeding Goals – Amy Peterson, BS, IBCLC, and Mindy Harmer, MA, CCC-SLP.
- Bottle Babies blog
- “Bottle-Feeding as a Tool to Reinforce Breastfeeding” – Dee Kassing, BS, MLS, IBCLC
- “Guide to bottle feeding” – NHS
- “How to Bottle-feed as You’d Breastfeed” – Amy Peterson, BS, IBCLC, and Mindy Harmer, MA, CCC-SLP
- “The Babe’s Guide to Bottle Feeding” – Fleur Bickford, BSc., RN, IBCLC
- “Can Breast AND Bottle Be Best?” – Amalah, Alpha Mom
- “Why not just switch to formula?” – Connected Mom