Responsive bottle-feeding by Emma Pickett

We know breastfeeding is about the milk inside the container but it’s also about a process – of holding the baby in a particular way; of feeding in response to cues; of encouraging certain oral skills; of focusing on the relationship between baby and mother.

Is it possible to bottle-feed in such a way so as to copy breastfeeding as closely as possible?

Breastfeeding has something to do with brain development but it’s not all about the long-chain polyunsaturated fatty acids, it’s about skin-to-skin and connection and bonding.

If we need to bottle-feed, what’s the ideal way to do it? If we are mindful about the WAY we bottle-feed, we will make a difference.

What bottle are we using?

Every bottle manufacturer claims their bottle is ‘just like nature’ or ‘just like the breast’. They all seem to pick different features: texture, shape, sucking difficulty. The one that works best for your baby is the one they can feed from slowly and in a relaxed and calm way. It should be one that can be cleaned easily and one you can afford. When we are nervous new parents, we are vulnerable to messages from commercial companies so don’t be tempted to keep shopping for different brands. If we’re going to encourage good tongue placement and oral skills, ideally we’re going to use a bottle where a baby can gape and feed with a wide open mouth rather than just nipple-feed with pursed lips. Look for bottles which allow that wide gaping mouth on the soft silicon part of the bottle where the bottom lip can flange out like a fish-lip and which therefore gives a chance for the tongue to come over the gum ridge rather than be pushed back as it often is with artificial nipples. The tongue is holding the bottle in place rather than tight lip muscles.

How does baby sit?

We don’t want the baby to be lying back and we certainly don’t want to give a baby a bottle when they are flat as this increases the risk of ear infection. The baby should be sitting fairly upright with their body close against yours. This is an opportunity for closeness. It is not an aim to have a young baby hold their own bottle. It is not recommended to have a baby remain in a pram or high chair or be turned away from you. Think of it a cuddle which has milk as a side-benefit. This is not just about a transfer of nutrition. How about bottle-feeding skin-to-skin? Sounds a bit odd, doesn’t it? It would certainly give Uncle Bob a bit of a shock. But this isn’t about Uncle Bob, it’s about your relationship with baby. I’m not saying it’s something you’ll be doing in Costa Coffee on a Wednesday morning but bottle-feeding skin-to-skin is a lovely way to get that closeness when you can.

Swapping sides

Often bottle-feeding parents have baby on the same arm and hold the bottle with their dominant hand. This means that, over many hours, one of baby’s eyes looks at the world and the other is effectively blinkered. The newborn brain is doing a huge amount of development in the first year of life. Connections are being made and brain tissue forming. It seems wise to give the eye/ brain relationship equal chances on both sides so try and swap round and have a different eye on the outside.

How do you hold the bottle?

The bottle stays horizontal as much as possible. Some brands make this very hard as the bottle has to be tipped up to allow milk to flow so watch out for these. We want the baby to create negative pressure and need to make an effort to take the milk out. When a baby is working hard, they are less likely to overfeed and they are also developing muscles that they are going to need later for speech and eating solid food. This technique of keeping the bottle horizontal is sometimes called ‘paced bottle-feeding’. You can find videos on YouTube.

We start the feed by placing the bottle above the top lip and we then stimulate a gape. The baby will tip their head back very slightly and open their mouth wide. We don’t push the bottle in without an indication from them. Baby is showing they are ready and accepting the bottle. Remember we’re encouraging the bottom lip to be flanged out and the tongue to be extended over the gum ridge if we can. We keep the hole newborn size. This isn’t about the milk needing to flow out more quickly. We also want to take pauses during the feed so the baby can catch their breath. We should never feel as though they are overwhelmed by the flow which is why the paced feeding is important. They should be able to breathe calmly and their hands and body relax as they feed. A baby who has tight little fists, and is moving in an agitated way, could be asking for the feed to slow down. Although baby may fall asleep in your arms, ideally we don’t want to encourage babies to fall asleep when bottle-feeding. When first teeth start to arrive after just a few months, we don’t want them to be washed in formula milk just as a baby starts to fall asleep and saliva production slows. When a bottle feed finishes, we can burp baby and then cuddling continues. A baby could then fall asleep in your arms if that feels natural. At night, the safest place for baby to sleep is close to you in the same room. Lots of mums have the Moses basket next to the bed and they can feed in a chair or sitting up in bed and return baby to the Moses basket or cot for sleeping. If you want to bed share (which is normally associated with breastfeeding), you can get more information here: https://www.isisonline.org.uk/hcp/where_babies_sleep/parents_bed/

How much do we give?

The formula manufacturer will have recommendations on their packaging for amounts according to baby’s weight and age. They may also have recommended times for feeding. You don’t have to feed your baby according to a specific schedule. Ideally we respond to baby’s cues. A baby who is beginning to be hungry will rustle while asleep, perhaps open their mouth or move their head from side to side as if they are looking for something. They may show interest in their hands or something placed near their cheek. They may begin to make little noises. We want to feed in response to early hunger cues rather than wait for a baby to start crying or wait until the clock says it is the right time. We don’t want to try and cram in as much as we can. If we go slow and allow the baby to take control of flow and pause occasionally, hopefully they’ll have a better chance of receiving those fullness signals. Babies suck to calm themselves and their sucking reflex is powerful. They may choose to keep on going beyond the time when it’s best for them if the milk comes out too quickly or if we are too bossy. We’ll know we’re getting it right if weight gain is going well and a baby has 6 or more wet nappies and at least 3 poos a day. A baby who receives formula will need to poo at least once a day as they get older. Some babies exclusively receiving breastmilk may skip several days between poos and be quite happy. If your baby has taken too much, they will usually bring up the excess. This isn’t necessarily ‘reflux’ that we worry about but a safety mechanism that prevents over-feeding and excessive weight gain.

Who’s giving the bottle?

If we recognise that feeding is a job for primary carers and relationship-building then we need to appreciate it’s not a task for visitors and extended family. Grannies may want to help by giving a bottle but it’s actually better if they help with the winding and nappy changing and looking after you when a baby is younger, just as we would recommend during breastfeeding. A young baby may only be awake for feeds and we want those times to be in your arms, skin-to-skin with mum (or partner), looking at your face, using the techniques that feel familiar. When granny smells different, holds the bottle in a different way and you’re not there – it’s not ideal at the beginning.

What’s in the bottle?

Modern breast pumps make the option of exclusive pumping far more realistic than it was even just a few years ago. You can read more about exclusive pumping here: http://www.exclusivelypumping.com
Mums with a low milk supply can still provide several feeds of expressed milk a day for their baby whether or not they choose to breastfeed. Even just one tablespoon of breastmilk contains a host of immunological benefits.

Some mums also choose to give their babies donor milk. Ideally this is accessed from a milk bank where milk is screened and prepared carefully. Home pasteurisation is also sometimes used where this is not an option and the informal milk banking sites can tell you more.

If you are going to feed your baby formula, this is useful guide. Although it is designed for use by healthcare professionals, it contains valuable information about types of formula available in the UK: http://www.firststepsnutrition.org/pdfs/Infant_Milks_May_2015.pdf

This guide from UNICEF Baby Friendly is also useful: http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/Formula_guide_for_parents.pdf

It’s important to note that ‘first’ formula can be used up until 12 months of age and a family need not change onto follow-on formula (which was created to get round the marketing rules in the UK). After 12 months, full-fat cow’s milk can be used.

When you practise responsive bottle-feeding, not everyone around you may appreciate what you’re doing. Friends and family might be a bit confused as it may not be familiar to them but have confidence that developing closeness and responding to your baby rather than the clock is the way to go. Your family will soon understand, even uncle Bob.

Further Resources:

The NHS guide to bottlefeeding talks about making up formula safely and lots of other aspects of bottlefeeding. http://www.unicef.org.uk/Documents/Baby_Friendly/Leaflets/guide_to_bottle_feeding.pdf

If you are interested in re-starting breastfeeding, it can be done at any point. The Association of Breastfeeding Mothers leaflet on re-starting breastfeeding after a gap is a good place to begin:
http://abm.me.uk/restarting-breastfeeding-after-a-gap/

It is possible to supplement the baby while they are still attached to the breast using a supplementary nursing system. You can read more about that here: http://www.expressyourselfmums.co.uk/Expressing-breastmilk/Medela-Supplemental-Nursing-System–#moreinfo

 Emma Pickett

Emma Pickett

About the Author

Emma Pickett IBCLC, Lactation Consultant and Breastfeeding Counsellor

After a career as a primary school teacher and Deputy Head in London, Emma had her own children and soon realised how much need there was for breastfeeding support among new parents. She initially trained as a Mother Supporter and Breastfeeding Counsellor with the Association of Breastfeeding Mothers (www.abm.me.uk) before going on to qualify as an International Board Certified Lactation Consultant in 2011. She volunteers in Haringey, North London at three drop-ins as well as answering calls on the National Breastfeeding Helpline and the ABM helpline. She is currently chair of the Association of Breastfeeding Mothers.

Her eBook, “You’ve Got It In You: a positive guide to breastfeeding” will be published later this year.

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