The use of bottles for feeding babies is a very common practice in Western society. Compared to other artificial infant feeding devices, bottles are easy, convenient, and socially acceptable. Breastfeeding mothers are usually warned to avoid unnecessary bottles because of the risk of nipple confusion and flow preference that could jeopardize their breastfeeding relationship.(1) We commonly hear warnings that the use of bottles could interfere with a baby’s ability to breastfeed effectively. Recently, however, some breastfeeding specialists have introduced the idea that bottles can be used in a way that is supportive of breastfeeding and that dramatically reduces the risks of nipple confusion or flow preference.(2), (3)
Debra Swank, IBCLC, explains that nipple confusion and flow preference are very different problems. Nipple confusion happens when a baby has been given an artificial nipple or pacifier and no longer remembers what to do at the breast. He wants to breastfeed and roots toward the breast, but cannot latch on or uses a dysfunctional suck or tongue movement when he does latch on. Nipple confusion is more commonly seen in a newborn who has had only limited opportunities to breastfeed and is given a bottle before he has mastered the art of suckling at the breast. When brought to the breast for the next feeding, he no longer seems to remember how to latch on or suck. A lactation consultant can help you overcome nipple confusion by showing you methods of re-teaching the baby to latch onto the breast.
Nipple preference, on the other hand, is a clear preference expressed by the baby. He may show he prefers the breast by refusing to take a bottle or he may show a preference for the bottle by refusing to take the breast. The way that he communicates this preference is in his body language and vocalizations. He may show great emotion by arching, crying, screaming, or actively pushing away the breast. Other babies simply turn away from the breast in a quiet manner, as if they have no interest in it.(4)
Many breastfeeding specialists believe that some cases of apparent nipple preference are actually flow preference. They believe a baby’s preference for an artificial nipple is sometimes less about the structure or feel of either nipple but rather about the faster flow of milk from a bottle. The baby prefers the faster flow and begins to associate the breast with slow flow, even in the presence of increased milk production. It is simple human nature that we would rather have our meals in the easiest way possible. When baby is breastfeeding, a mother's milk ejection reflex may not occur until a minute or so after baby first latches on. However, babies experience an immediate “milk ejection” from the bottle, so they may become frustrated when the flow at the breast is not as immediate as the bottle. Breastfeeding is truly "fast food," ready whenever baby needs it, but from baby's point of view, the bottle flow is faster. For this reason, methods of bottle-feeding that minimize the rate of flow have been developed and are described below.
True nipple preference does happen when there is a significant mismatch between the mother’s nipple shape and the shape of the artificial nipple, especially when one seems to deliver milk much better than the other. For instance, when a mother has very small nipples that only protrude slightly and the artificial nipple is very long, the baby may prefer the shape or firmness of the more prominent artificial nipple. If her milk production is also low, his preference may be even stronger. When the flow from the bottle does not compete with the flow rate at the breast and the shape of the artificial nipple does not compete with the mother’s nipple shape, babies tend to have much less difficulty accepting both bottle and breast.
Bottle-Feeding Methods that Minimize Flow Preference
To avoid undermining breastfeeding, it is important to help baby maintain breastfeeding behaviors while he feeds from the bottle. One way to do this is to approach baby with the bottle in a way that makes bottle-feeding similar to breastfeeding. This means that the bottle nipple is not poked into his mouth, when it is barely open. Instead, point the nipple up toward the ceiling and lay the side of it across the baby's lips, stroking downward, so he has to open widely to accept it. This helps preserve the wide open gape he needs for a good latch at the breast. It may take a minute or two for him to do this, but by consistently waiting for him to open his mouth wide before giving him the bottle, you will teach him what he needs to do in order to be fed. Once he opens his mouth very wide, place the lower part of the nipple on his lower lip with the nipple pointing straight up and then roll it into his mouth so that it goes in deeply.
Many mothers also find that babies feed better when the bottle feedings are paced so that they are more like breastfeeding. Bottle feedings are paced by stopping and gently withdrawing the nipple after four or five sucks or whenever the baby expresses tension through facial expressions. The nipple stays in contact with baby’s lower lip, allowing the baby to draw the nipple into his mouth again when he is ready. This helps the baby retain control of the feeding, reminding him to stop when he is full. It also allows better coordination of the suck/swallow reflexes. This technique is known as “paced feeding.” For those babies who object strongly to having the nipple even partially removed, simply tip the bottle briefly, so that the milk stops flowing for a few seconds, without removing the nipple from baby’s mouth.
Holding the baby so that he is more upright allows him better flow control. There is no need to keep the nipple full of milk; he will fill it when he sucks. Indeed, the problem of swallowing air is more about marketing than reality; any air that a baby takes in from a half-filled nipple generally comes back up as a burp.
Another technique that some mothers have found works well is to hold the bottle in their armpit while holding the baby in cradle position, to simulate the posture of feeding at the breast. This position also allows mothers to have a free hand during bottle-feeding.
If the bottle is offered after breastfeeding instead of before, the mother can give the baby the opportunity to signal when he is done with the feed. She removes the bottle before the baby is likely to be full, laying the nipple across his lips as described above. He will most likely open his mouth for more. After another swallowing bout, the mother removes the bottle again, repeating this every quarter to half ounce. Baby’s gape will be slower or less enthusiastic each time, until the mother removes the bottle and the baby responds by failing to open his mouth again. This way the baby can say, “No more, thanks,” which is much easier for him than to stop swallowing from a bottle that stays in his mouth.
When the bottle is given during the feeding can make a very important difference. Traditional wisdom has been to only give them after the baby has had an opportunity to breastfeed. There are many lactation specialists who believe breastfeeding first when baby is most hungry ensures that he sucks most actively at breast and removes all of the mother’s available milk. Their concern is that giving a bottle first would fill the baby up so that he would not suck as actively at breast and may not even want to take the breast at all. This premise has not been studied, however, and many mothers have found that when bottles are given after breastfeeding, babies have increasingly less patience to nurse and tend to actively suckle at breast for less and less time so that it seems necessary to give increasing amounts of supplementation by bottle. When babies do not remove all the milk in the breast, milk production slows down, resulting in the need for more supplementation. This is known as the "downward spiral" effect of bottle supplementation and may be the reason bottles have acquired such a poor reputation among breastfeeding advocates. To avoid this negative impact on milk production, it is helpful to either bring baby back to breast after the bottle-feeding or use a pump to ensure that the breast is fully drained.
Christina Smillie, MD, IBCLC, suggests an alternative way to use bottles for supplementation that she believes results in less supplementation, improved feeding at breast, less need for pumping, and an ultimately greater milk supply as a result of improved milk removal. In her private practice, she has observed that when babies have had their initial hunger and thirst satisfied by a bottle containing a limited (controlled) amount of supplement given before breastfeeding, they tend to have more patience to suckle at breast when the flow is slower due to suppressed supply. This results in their removal of more milk, which increases milk production. For more information, see our page about Dr. Smillie's "Finish at the Breast" method of bottle supplementation.
If, despite your best efforts, your baby begins to show signs of breast refusal, try not to be discouraged. Know that your baby is not rejecting you as his mother and this does not have to be a permanent refusal of the breast. It just means you need to change some conditions to make feeding at the breast more desirable. This may mean making the flow at the breast stronger or faster than the artificial nipple by using a slow-flow nipple and increasing your milk production. Using an artificial nipple with a different shape that more closely matches your own nipples may also be helpful. Gentle methods that tap into your baby's natural reflexes may coax your baby back to the breast. A lactation consultant can help you find ways to overcome nipple confusion or flow preference.
When trying to coax a baby back to the breast, it is also important to understand that trust issues are involved. Baby’s past experience is that more milk comes from the bottle, and he may not trust the breast, even when milk production is improved. Consider it from his perspective: he has found something that works for him, so why change? He does not realize what is best for him or you. Efforts to woo baby back to the breast can be draining, and you may question whether it is right to “force the issue” with your efforts. Try to remember that building trust takes time. First baby needs to be convinced to try the breast again, and then he needs multiple experiences of successful feedings to reinforce the idea that the breast is a trustworthy source of nourishment. Over several feedings or days he gradually learns to trust the breast again, and then feedings become the enjoyable experience that they were meant to be. A gentle approach will work better than trying to impose your will on your baby.
Used with a bit of expertise, knowledge of feeding mechanics, and empathy for your baby, bottles can be used successfully as an effective means of supplementation for the breastfed baby.
See the Finish at the Breast Method of Bottle Supplementation
See Bottle Nipples that Minimize Nipple Confusion or Flow Preference
(1) Neifert, M., Lawrence, R., Seacat, J. Nipple confusion: toward a formal definition. J Pediatr 1995 Jun; 126(6):S125-9.
(2) Noble, R., Bovey, A. Therapeutic teat use for babies who breastfeed poorly. Breastfeed Rev 1997; 5(2):37-42.
(4) Swank, D. Personal correspondence with Diana West, Oct 28, 04.