If you read some of my breastfeeding advice or talk to me about breastfeeding, you’ll quickly learn that I’m not a fan of giving a bottle to a breastfed baby. So why on earth would I write a post explaining how to do exactly that? Simple: I’m a realist. Sometimes giving a bottle is the only way to go, for example when mom goes back to work. (Even I had to let my babies use a bottle at day care!) So if we’re going to use a bottle, we need to know how to do it so that it doesn’t ruin the breastfeeding relationship. That’s where paced bottle feeding comes in.
The risks of mixing bottle and breast
It is a well-known fact amongst lactation consultants that when you start to give a baby a bottle, some babies start to refuse the breast. The term that is commonly used for this is “nipple confusion”, but I think that’s a misnomer. The baby isn’t confused at all, he has simply developed a preference for the bottle. So perhaps a better term would be “bottle preference”?
Differences between breast and bottle
Bottle preference can develop because it is a lot less work for a baby to drink from a bottle than from a breast. Try this: hold a baby bottle full of milk upside down. What happens? The milk drips out! So when a baby is lying back and drinking from a bottle, the milk is flowing with no effort whatsoever. Needless to say, the breast doesn’t work like that: baby will only get milk from the breast as long as he is actively sucking (except if you have a very strong let-down reflex, but that’s another story for another day). It doesn’t take much imagination to realize that a baby will go for the no-effort meal over the one he has to work hard for.
Often, babies who have gotten used to drinking from a bottle will get frustrated with the slower initial flow from the breast. At the beginning of a breastfeed, there is only a little milk (about 10 ml) available to baby; most of the milk only comes when the let-down reflex happens. So baby has to suck for a good 30-60 seconds on the breast before he is rewarded with a large volume of milk. In contrast, on the bottle, the reward is immediate. So when this baby is asked to drink from a breast, he gets frustrated when the milk is not immediately available in large amounts. Baby may cry and push the breast away, and generally act as if the breast is empty.
The interesting thing is that not all babies develop bottle preference. Many babies will happily switch between breast and bottle, and many others will always prefer the breast, only drinking from the bottle when they have no other option. What makes it tricky is that there is no way of telling ahead of time which babies will develop bottle preference. Fortunately, there are ways to decrease the risks of bottle preference, by using a technique called paced bottle feeding.
Paced bottle feeding – using the bottle as if it were a breast
When you want to combine breastfeeding and bottle-feeding, the best trick is to make the bottle act like a breast. If the bottle is not easier to feed from than the breast, it is much less likely that baby will develop a preference for it. So here’s a few tricks:
1. Get a good “latch”
A bottle nipple is typically a lot narrower than a breast, and this can cause some babies to develop a “lazy” latch even at the breast. You can prevent this from happening by encouraging baby to latch deeply on to the bottle. At the beginning of the feed, with baby sitting upright, put the bottle teat upright in front of his mouth (in the same position you would put a finger when saying “shhh”). This mimics the “nose-to-nipple” method of getting baby to latch deeply on the breast. When baby opens his mouth to take the teat, let him draw it deeply into his mouth so that his lips close on the wider part of the teat, not just on the narrow tip.
2. Simulate the let-down reflex
As I explained above, in the beginning of a breastfeed there is not much milk available; the milk only starts flowing quickly once the let-down reflex occurs. You can mimic this with a bottle: with baby sitting upright, make sure you hold the bottle in such a way that there is no milk in the teat. Let baby suck on this dry teat for a minute or so (adjust the time according to how quick or slow your let-down is) before you tilt the bottle to allow some milk into the teat.
But baby will swallow winds! No he won’t, as long as he is sitting upright. The air will simply move out of his nose. Babies swallow winds mainly when the milk is flowing too fast for them to handle.
3. Use the stop-go method
Watch a breastfeeding baby at the breast, and you’ll notice something interesting: baby will suck for a while, then rest, then suck again, all the while staying latched on to the breast. Baby can do this because the milk only flows as long as he is sucking. In contrast, a bottle-fed baby doesn’t pause during feeding, because the milk is constantly flowing – it’s a situation of “swallow or drown!”
You can simulate this stop-go nature of breastfeeding by following baby’s cues. When you tilt the bottle to give baby milk, only tilt it enough that the hole of the teat is covered in milk – the bottle should be nearly horizontal. This slows down the flow of milk and gives baby more control over the feed. Baby should still be sitting upright on your lap, and not swaddled – you need to be able to see his hands. Watch baby closely for signs that he needs a break: The first sign that baby needs a break is usually that he will suck more slowly or try to turn his head. When you think baby needs a break, simply tilt the bottle down so that there is no milk in the teat, but leave the teat in baby’s mouth. When baby starts to suck on the teat hungrily again, tilt it so that there is milk available again. And repeat.
Look out for the following stress cues: baby is gulping down the milk, wide eyes, frowning, arching his back or splaying his fingers (as if he’s gesturing “stop!”). These things all show that the milk is flowing to fast for baby to handle. Stop and give baby a breather. When you continue feeding, make sure baby is in an upright position and don’t tilt the bottle as far, so that the milk flows more slowly.
4. Don’t overfeed
The biggest risk when giving a bottle is simply giving too much, because we feel that baby must empty the bottle. Remember, a breastfeeding baby is used to determining for himself how much he needs, so allow him to continue to set the pace even when you’re using a bottle.
When baby seems to be getting full, take the bottle out of his mouth. Immediately offer it again – if baby takes it, let him give 10 sucks or so and remove it again. Keep removing and offering the bottle until baby doesn’t take it back – and then stop!
It’s important to know that if you’re not using paced bottle feeding, baby will probably drink more than he needs to – and if you’re the one that has to pump out all that extra milk, that can be a real pain! I’ve often seen cases where the day care complains that the mom doesn’t send enough milk, but when they use paced bottle feeding, baby is suddenly quite content (It’s the same with adults, really: if you eat more slowly, you tend to eat less).
When to introduce the bottle
It is really, really, really not a good idea to introduce the bottle before breastfeeding is well established and going smoothly. Really, you can trust me on this. Usually it takes about 6 weeks for baby to be breastfeeding comfortably and for mom’s milk supply to be well established. So my sincere recommendation is: stick to breast only for at least 6 weeks.
If you need to give a bottle because you are going back to work, about two weeks before the time should be plenty. I’ve often heard women say they want to give the bottle as early as possible so that baby won’t refuse it later on. Strangely, I never saw in practice that this made much of a difference – some babies will take the bottle easily and some won’t, regardless of when it is introduced. I’ve even seen one baby who took the bottle very easily early on, and then flat out refused it a week later. He never took a bottle again, but drank from a cup. So starting early really is no guarantee – there’s no need to rush.
When you introduce the bottle, ask someone else to do it – babies usually don’t want to take the bottle from mom! Just be sure to teach the person who will be feeding baby from the bottle exactly how to do paced bottle feeding. Better yet, let them read this post! If you are careful with the bottle, there’s no need for it to interfere with the breastfeeding relationship.
Choice of bottle
Deciding which bottle to use can be quite tricky; there’s hundreds of different ones on the market. You may see some bottles advertised as being “more like breastfeeding”, but pay it no heed – no bottle is anything like breastfeeding! You also have no way of knowing which bottle your baby will like. That’s why I recommend borrowing different bottles from everyone you know and trying them all out to find one that your baby likes. You don’t want to spend a fortune on a fancy brand of bottle only to find that your little one refuses to drink from it! Ironically, I’ve found that the bottle most babies like is a plain, round teat, no name brand cheapie. So I recommend starting with one of those, and only trying the fancy stuff if it doesn’t work. I also recommend using a straight bottle, not a curved one. The whole idea of the curve is to make the milk flow faster – which is what we’re trying to avoid!
Remember: the secret to successfully combining breastfeeding and bottle feeding is not in the type of bottle that you use, it’s in how you use that bottle. Practice paced bottle feeding and only let other people give the bottle, and you should be able to continue breastfeeding for as long as you want to.
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