Meet Hazel. She’s six weeks old and her mum Pam has been exclusively breastfeeding up until now. It’s not been without some struggles but Pam has found drop-in groups, found people to help her and been supported by her husband Rob.
Today Hazel is going to have her first bottle of expressed breastmilk because Pam and Rob feel the time is right. Pam’s latching issues have resolved and breastfeeding is definitely established.
Pam is really keen to make sure Hazel’s breastfeeding skills are protected as much as possible.
She knows that introducing a bottle teaches Hazel to feed in a different way and that leaving her breasts unused for a block of time could impact on her supply or leave her at risk of blocked ducts.
Pam has pumped for the first time and has brought a bottle along to a drop-in session to talk about responsive bottle-feeding.
The video here is a clip of our conversation. It’s rough around the edges. You can hear my colleague at the beginning pressing record and the video runs out at the end because my iPad memory is full of my children jumping off sofas using ‘time lapse’! But hopefully it gives you an idea.
Ten things that are important:
1.Put yourself in baby’s shoes (or Babygro feet).
This is WEIRD. It isn’t at all like breastfeeding. Breastfeeding smells of mummy and tastes of mummy and it’s warm and comfy. Baby can control the flow and when she gets sleepy the milk gets thicker and slower. Bottles look different. They taste different. Mummy is holding me differently (sometimes with a tense look on her face). Someone else might be giving me milk. The temperature is different and lots of stuff that is really special about breastfeeding just isn’t there.
Is the baby showing stress cues? What are they doing with their hands? What is their facial expression like? What do you think your baby is asking?
2.If it doesn’t work out the first time, that’s OK.
It can take time. It might take a different mood or a different place or a different time of day or a different person. A first bottle refusal is not the end of the world. It is very very likely that things will work out in the end. It’s just time for carers to be scientists and experiment with different variables and try different things out.
It’s easy to panic but the vast majority of breastfeeding babies move between breast and bottle without too much trouble. There isn’t evidence to suggest that you HAVE to give the bottle before a certain age. There isn’t evidence to suggest a baby who refuses a bottle today might refuse tomorrow. And let’s imagine your nightmare scenario – they continue to refuse. There are a bunch of other ways to get milk into a baby without a breast or a bottle being involved: cup feeding, sippy cup feeding, finger feeding with a tube, syringe feeding.
3.Every bottle manufacturer claims their bottle is ‘the best’.
Let’s use some logic. No bottle is going to be quite the same as the breast. Babies remove milk from the breast by moving their tongue in a wave-like motion that causes a fluctuation between positive and negative pressure. The milk comes out of the breast to fill a vacuum created by the drop of the rear tongue and the tongue compresses the breast while the mother has occasional milk ejection reflexes. Meanwhile the milk in the breast gets gradually thicker. No bottle comes close to that.
Milk from the breast isn’t removed by a hard suck.
An initial suck gets the nipple into the correct position in baby’s mouth and holds it there but after that it’s really about the rise and fall of the tongue and there isn’t a continued hard sucking action removing milk.
We can’t use a bottle that works like breastfeeding but let’s try and use one that LOOKS like breastfeeding in the way the baby’s lips and tongue are positioned and let’s encourage the baby to do something to remove milk rather than let it pour out through gravity.
It seems logical that wide bottles (that don’t have the longest thinnest nipples) and that allow baby to get an entire mouthful will help us to maintain the association that feeding means a wide gape and the tongue touching against something.
4.Let’s allow baby to have as much control as possible.
We’ll start with touching the bottle teat to the nose or under the nose and see if we can stimulate a gape. When they ask for the bottle, we gently place the bottle on the tongue (which ideally should be down over the gum ridge and extended). It might be helpful at the beginning to touch the teat to the roof of baby’s mouth to help stimulate the sucking reflex. Then if we keep the bottle as horizontal as much as possible, the baby can control flow. If the teat really starts to empty (and you can see that by looking through the inside of the bottle), you may need to start tipping it a little so they don’t just swallow air.
Let’s respect them if they really start to protest. Are they saying the milk is too fast? Do their hands look tense? Do they want the bottle to come out completely so they can take a breather?
5.If we focus too much on avoiding air getting in, we may not be using the optimum flow.
If our focus is on tipping up the bottle and filling the entire teat with milk, the flow could be too fast. The baby may struggle to catch their breath and may take more milk than they want to (which could cause discomfort and impact on future breastfeeds). If the hole in the centre of the teat is covered with milk, that’s fine and if sometimes it isn’t, that’s OK. You’ll hear that swallowing sounds different and you’ll respond. And baby will appreciate a burp afterwards.
6.Babies like to be close.
When they are held close, they feel anchored and supported. We can use our bodies to help them stay semi-upright too. They might even be calmed by using skin-to-skin. If you are using bottles regularly, it‘s recommended to swap the side of your body you hold baby on and the hand you use to bottle-feed. This means baby’s vision is stimulated equally and one side isn’t always blinkered against the body. Perhaps less of an issue for Pam and Rob when Hazel is probably going to get no more than one bottle of expressed milk a day.
7. It might not always be perfect.
You’ll notice Hazel is dribbling milk a bit. It’s her first time having a go with the bottle so we’ll cut her some slack. As time goes on, mum will get more experienced at getting the balance of flow right for Hazel. Perhaps you don’t know why, but today baby just isn’t in the mood and the grumpiness continues. She might be overtired or need a nappy change or something else could be going on. That’s normal and that’s OK.
8.Who gives baby the bottle can matter.
Sometimes babies take the bottle more easily if it isn’t the breastfeeding mum who gives it. However, it’s also true that whoever gives a bottle should be someone baby can trust. It’s not the role for extended family and visitors who don’t know baby well and may have their own ideas about how to do things. Bottle-feeding is also an act of communication – responding to baby and respecting baby.
9. A baby may take more than they need to so we may have to be careful.
Even with responsive bottle-feeding, it’s possible a baby may overfeed. They can’t easily switch off their sucking reflex and it is easier than breastfeeding, partly because the milk isn’t gradually getting thicker and slower as the fat content rises. It’s tempting to keep going but pause and see what cues your baby is showing. Maybe they need a chance to receive their feeling of fullness.
After about six weeks, a baby on average takes 30ml for each hour in 24hrs. But some take a little less and some a little more. The time of day may also make a difference. So while a baby feeding every two hours will on average take around 60ml, we’re not going to force that in. We’re going to give baby a chance to take the lead.
10.Think about WHEN you give a bottle.
I don’t mean in terms of how old the baby is – that’s about when breastfeeding is established and you’ve thought about whether you need to give a bottle at all.
I mean what time of day and what impact that might have on your breastfeeding. We know that removing milk from your breasts between about midnight and 5am is particularly valuable because that’s when your prolactin hormone levels are higher and removing milk sends precious signals to maintain supply. So a bottle being given by someone else at 2am may not be doing a breastfeeding mum the ultimate favour.
In the evening, when baby seems very restless and fussy might seem like a logical time. It's really normal for babies to be fussy for several hours often in the late afternoon and evening. We might even feel ‘empty’ and worry we don’t have enough milk and a bottle might seem like a sensible choice but… it could be the worst time of all. Your baby may well be cluster feeding and sending crucial messages to develop your supply to meet their future needs. They are tanking up on really high fat content milk (that comes from an emptier breast, breasts can NEVER be entirely empty). They are coming to the breast for lots of other reasons that aren’t just about milk. Giving a bottle at the end of a session of cluster feeding is probably less damaging than giving one to try and stop cluster feeding happening.
Talk to your breastfeeding counsellor or whoever is supporting you with breastfeeding if you feel you need to give a bottle. They can talk to you about your baby’s history and behaviour and help you decide when is the right time for you.