Bottlefeeding your Breastfed Baby

We're going to talk about how to bottlefeed your breastfed baby. If you know a bottle is in your baby's future, and hopefully breastfeeding is going really, really well, and now it's time, maybe 2-6 weeks in, to try a bottle to make sure your baby will take it. So, bottlefeeding a breastfed baby is different than if you were, say, formula-feeding from the get-go. It's very different because this milk that you're going to be pumping out is going to be pretty precious to you because you're going to work hard to get it out. Formula, on the other hand, is at every grocery store; it's just there, so mentally it can be a little bit different when it's your own milk and you want every little drop of that getting into your baby. Also, mother's worry: on one hand they want their baby to be able to take a bottle so they have some flexibility, they can go on a date night, they can do this and that, go back to work, but then they also worry if they give their baby a bottle too much, or too soon, or at daycare, will they not want to breastfeed anymore? Will that compromise our breastfeeding relationship we worked so hard for? So, the tips I'm going to review hopefully will even the playing field between the breast and the bottle so the baby will be able to go back and forth easily. Usually they prefer to be at the breast because they are close to you, they love you, you're their mommy, so they prefer to be with you. But there are some challenges to the bottle as it can be faster for them, and they can figure out "Oh, I can get that super fast, like going through the drive-through with this, where I have to work for a gourmet meal here at the breast ". We are going to work on evening the playing field. 


Now, first of all, the starting time: somewhere between 2 and 6 weeks. Somewhere around 5-6 weeks babies developmentally change, and if they choose to, they can choose NOT to take the bottle. So, you'd want to catch them before they get too old. Not too soon, but not too old. So, again, if you're going back to work at 6 weeks, I'd probably try a bottle closer to 3 weeks at the latest. But if you've got 12 weeks off, you could probably push it out to 5-6 weeks. You just don't want to wait until week 11 to try to introduce a bottle, because if your baby balks and doesn't want to do it you're going to be super stressed out. 


So, the second question people ask is "Who feeds the first bottle?" Does mom give the bottle, does grandma? Does mom have to leave the room? When they are super young like this, I don't think they really know or care too much. I know this sounds counter-intuitive, but I find that moms are really good at bottlefeeding that first bottle because they know what the baby's mouth is supposed to look like on them: nice, wide open mouth, their little lips flared out, and they know what the pace of the breast is (suck-swallow-breathe) and they can mimic that on the bottle as best as possible. Sometimes, it's the mom who does the first bottle and that's OK. If the baby does balk, say it's closer to 5-6 weeks old and it's getting smarter, then maybe dad or grandma has to get in there. And if dad or grandma are going to be the caregivers and going to be doing the bottles, it's not a bad idea for them to get comfortable doing this, as well. So share this video with them so everyone is all on the same page about how you're going to be trying to bottlefeed the baby. 

How much to give in the bottle? In the resources, you'll find a PDF talking about how much (generally) your baby would take by bottle per feeding based on their weight and age. It's not exact; babies are just like us as humans—we have a big breakfast, then a light lunch, or skip lunch altogether, then we have a big dinner. It can go all over the place. When you're breastfeeding a baby, there's no gauge on a breast and you really don't know how much they are taking from feeding to feeding. With the bottle, because there are marks on here, you can measure it and will know how much to put in there. In the PDF I will give you an approximate, but no matter what I say, you're going to watch for your baby's signs of hunger versus your baby's signs of satiety. So, if my chart says your baby wants 2 oz. per feeding and you give it 2 oz. and it's still looking crazy, like its brow is furrowed and it's trying to suck on its hand, then it is probably still hungry. But maybe I say "Oh, your baby should take 3 oz." and he gets 2 oz. and is "drunken sailor" looking, he's spitting the bottle out, then he's sated, hungry, full…so you don't have to keep forcing it just because my chart says he should take 3 oz. So, go by your baby's body language and face, and honor their cues. If they are saying they are full, you're good. You'll know when a baby is nursing well, their body is still, they are happy—the only thing moving on them is their jaw. But also this (their forehead) is soft, and their breathing is nice and even. Versus, if they are upset about something, like say you're trying to feed this baby and he is (heavy panting), his eyes look worried, then I'd take a break, stop a minute, and see if they really want this bottle. Is it coming out too fast, is it too cold or warm? Something is bothering that baby. It's important just to stop and take a minute and figure out what's going on. So, that is in a PDF in the resources section, but again, it's going to be clearly based on what your baby wants at that moment.


So, choosing a bottle and a nipple: There are lots of options! You can go to Buy Buy Baby or Babies R Us and find just walls of bottles and nipples; it can be very overwhelming. They ALL say "best for breastfeeding" and "perfect nipple for breastfeeding". Anybody can say anything about that; it's just marketing noise right there. So, it's really more about how you're bottlefeeding your baby. I'm going to go over Paced Bottlefeeding. You really can choose any bottle you'd like. I do like the newborn Dr. Browns and Tommy Tippee nipple just because the baby does tend to have to work a little harder at those, so typically I like to start with those. But if your sister-in-law gave you 500 of the Avent bottle, just start with those; you don't have to start fresh and buy all new bottles. Start with the Avent bottles and bottlefeed in a way that mimics breastfeeding as best you can, which is what we're going to go over. 


Another thing people ask me is "warm versus cold". Babies probably will prefer warm because it comes out of your breast 98.6 F. It's coming out of you warm, so they typically like it warm, but I have had more than a few moms that are on their 6th baby and they do not have time to warm up a bottle. That's just the way life is; they need to just grab it from the refrigerator and go. So they teach their babies from the get-go to take it cold, and they survive. So, "Can babies take it cold?" Yes. "Do they probably prefer it warm?" Yes. It depends on what your situation is; it's not going to hurt the baby to have it cold. Warming the bottle, as a side note: you should never microwave breastmilk or formula. It can cause some uneven heating inside and can scald the baby; there have been some really bad scalding incidents. On the outside it seems OK, but the baby gets scaled. Also, you should never boil breastmilk as it can kill some of the good properties that we are trying to get to baby. So, no microwave, no boiling, and warm is OK, cold is OK. Putting the bottle in a warm basin of water should be fine.


So, let's review from the Anatomy portion, way back in one of the lessons earlier in the course, and talk about how the flow of the breast works. The flow of the breast is what we are going to try to mimic with the bottle. So, the bottle comes out all one speed. First suck he takes on the bottle he'll get a mouth full of milk, and it's going to just flow, flow, flow, flow, usually until you take it out, give the baby a burp, then it will flow, flow again. So, you're pretty in control with the bottle and it comes out like instant gratification – the first suck they get a mouth-full. But if you remember, when you put a baby on the breast and the nipple is stimulated it takes a couple minutes to prime the pump, for that message to get to the brain then come back down to turn on the "faucet" and the milk starts coming out easier. So when the baby is on the breast the baby typically has to wait a minute for the milk to start flowing, while on the bottle it is just instantly right there for them. So, there is the possibility that babies get used to that fast flow and instant gratification; that is one of the risks of introducing a bottle. But one of the things you can do is start them out slower. If you start with a bottle that is not like this, where it's coming out like a beer bong (not that I've ever done a beer bong, but I've seen them done in college:). If you want to get a lot of beer in in a short amount of time, this is the position you'd put it in, right? So, what we're going to do is make it more horizontal so we are working with gravity. Not so much down here so there's air in the nipple, so the baby is sucking in air, but just enough there is milk in the nipple, but it's not like "this" where it's just pouring in. So, you're just going to be sitting up the baby a little bit more, and having him have a nice flow where he has to suck a little bit. You can control it up and down; you have total control on how fast or how slow it goes. If you think the baby needs a break, just stop and take it out a little bit, give him a minute, then go back in. You can kind of pace this out at a nice, leisurely pace instead of a beer bong pace. 


Back to the anatomy: the first let down you have it pretty strong. It's been a couple of hours so there is a lot of milk that comes out initially, so if you're pumping you'll notice "spray, spray, spray" then "dribble, dribble, nothing, nothing, nothing" while the milk cells are refilling. Then once they are full again, they spray out again.  So it's almost like the waves in an ocean hitting the shore. So, the first let down is really big, then there's a refilling period, then another let down, then another refilling, and each let down gets smaller; they have a refilling period then a let down. But the first one is usually the biggest because there's more force because it's been a couple of hours and there's more force behind it. With bottlefeeding, you can stop every half an ounce or so, just stop and mimic that flow where they have to wait for the refilling, if you want to. You can stop even every ounce. Probably at this age, when they are a couple weeks old, they are probably only taking about 2 oz. so it might be frustrating to stop too much for them as it's going to go pretty fast anyway. But even every half to one ounce you can stop, give them a burp, let them catch their breath, then go back in. Another reason it's NOT good to beer bong it and throw it in in 2 minutes flat, is it gives your baby's stomach a minute to stretch. Whenever the stomach is stretched – baby is eating, stomach is getting stretched – there are stretch receptors in the baby's stomach, and ours as well. As our stomach gets fuller, fuller, fuller, a message is sent back to the brain that says "OK, we're full, we're done, we're pushing away from the table". So, if we (Americans) eat super fast, we over-eat. We eat to the point where we didn't give our brain a chance to realize our stomach is full. People in France are eating really slowly, and they tend to eat a little bit less because they are spreading it out and they are not slamming it like a beer bong. So, for babies, it's good to do this same thing. If they normally take 20 minutes to feed from the breast, but then they take 4 minutes to take a bottle, it's possible they would overfeed because they didn't have time to get that message that they were full. So when a baby overfeeds, and they just keep sucking, and sucking, and sucking, and taking in so much milk so fast, it will often come right back at you – they will spit it up more. What they do not spit up will distend their stomach, making them uncomfortable. Just like us; if we have a hot dog eating contest and we are trying to bypass our brain trying to get as many hot dogs in as we can, we are going to be uncomfortable and we might spit that up, too, in a gross way. Making sure you give your baby time to have the bottle kind of be almost like the breast in terms of timing. This is something to share with your daycare provider, as well. They are going to have other babies to take care of, so they may need to be reminded that they need to slow down and bottlefeed almost (not exactly) somewhere in the vicinity of how long it takes to breastfeed. One thing I want you to know, is that as the baby gets older, they can get more efficient. So what used to take 20 minutes, when they are 4-5 months old they can take 7-8 minutes to breastfeed, and this always freaks moms out because they think "There's no way they can be done" because it's only been 8 minutes; but they are done. But I will tell you that they just get more efficient at it. As they get more efficient at breastfeeding, the bottle can get faster as well. So, if it's taking only 10 minutes (it used to take 20 minutes now it's only taking 10 minutes to breastfeed) you can go down in the time it takes to bottle feed. Or if your baby is getting frustrated, you may need to go up to the medium-sized nipple. If it's taking TOO long to bottlefeed (the breast takes 10 minutes but the bottle takes 10 minutes) they may get frustrated with that and it's probably time to go up to a medium-sized nipple. As they get way older, you can try a fast flow nipple if you want to, but usually stopping at the medium is sufficient.


Another trick I wanted to tell you as far as holding the baby: when we are breastfeeding we are doing it inward like this, right? So it's very much different when you're bottlefeeding because they are on their backs, like this. A rookie mistake is to cuddle the baby like this, but then their head goes down and they are curled around you and their head goes down. But if your chin is down and you put your chin down like this, and try to swallow, it's really hard and uncomfortable. There is no way I could take in a full bottle like this. So when you're bottlefeeding, you may need to take your hand, support the upper back, and just like a piece of fruit the baby's head goes back in that area so they can tilt their head back and get in the sniffing position; just like us, when we take a drink, we tilt our head back. So, for swallowing comfort, this might be a nice position with them sitting on your legs. I always like to take my pinky, if they are little, tiny babies, and put it under their armpit so they don't go any where as they are pretty strong. I have a good hold on this baby. So they are at a 45 degree angle, their head is tilted back, and it all about permission. When you breastfeed you can't just shove your nipple in your baby's mouth – it just doesn't work that way – you have to offer it. Your nipple kind of brushes along their upper lip and whenever you touch a baby in this little divot, this little dimple, half way between their nose and their upper lip, there is a reflex that makes babies go like this, a little baby bird shake. They shake their head then gradually open their mouth and when they do, they tilt their head back like this. They tilt their head back automatically into a great swallowing position and gradually open their mouth. You are going to teach them that even though it's the bottle, they have to open their mouth. Because if you don't, and you just shove the bottle into their mouth, when they come back to mom and they don't open wide, that can cause troubles for mom's nipples, pain-wise. So, even with the bottle, make sure that you tap here and wait them out until they open wide, and when they do open wide, you put most of this nipple in. You don't want them just on the tip as that will hurt mom if they get used to doing that. You want them almost to this cap/ring so their lips are fished out and nice and far back on there, just like with breastfeeding. A nice deep latch on the breast, and a nice deep latch on the bottle. Then, you're going to just watch them. Having the bottle more horizontal. If they get a distressed look on their face, stop and let them recover. They may be choking, they may be needing to take a breath. Whatever it is, give them a minute then wait for permission to go in. It just makes for a more relaxed feeding time with the bottle, as well, just like with the breastfeeding. 


So through all of this, it's best to stay as calm as you can. The first time you do this, the baby may not take the bottle and that is why if it's your very first time, I'd only put a little bit in the bottle for practice. You don't want to put the whole thing in here, then they won't take it, you've just pumped everything out and now what do you do? So, when you are just practicing like this, make sure you are using lots of calm affirmations for yourself and talking to the baby "We're going to be trying something new today" and just smaller amounts so you've not having any waste. Another tip to try if they don't want it is to make sure they're really hungry at that time. Or, make sure they're not too hungry; when they get "hangry" they don't want to try new things. Maybe catching them an hour or half of an hour before you think they're going to be hungry to see if they'd want to practice – no pressure – just a little half ounce, a snack, just to try. After they do it, then you can just nurse them. Or, you can nurse them first if they're super mad and "hangry" and then give them a little dessert at the end to see if they'd be more willing to take it if they aren't so mad and hungry. 


Sometimes dads or moms, anybody, (if baby won't take it) can face the baby outward, bouncing or walking them around to distract them, and doing the same techniques here but just facing them out. If that won't work, here's another thing some parents will do: put the bottle under their armpit so then you are facing the baby in, just like this position they are used to eating in. You just kind of position right here and sometimes you can trick them and they'll latch on like that. You're bouncing them and trying to keep them calm and talking to them; sometimes this will work as well. Some other reasons for breast refusal – so if this doesn't work or go like the video is showing – and they still won't take a bottle make sure the bottle is not too slow, but also not too fast. If it is dripping everywhere, choking baby, or if the baby is just frustrated at taking 30 minutes to take the bottle, maybe go up in the flow. Make sure there is not a clog in the nipple, and maybe try a medium flow nipple. There's something called – not to scare anybody – the lipase issue, maybe you've heard of this? And also oxidation. So, lipase is just an enzyme in our milk that helps break down the lipids in our milk. Some people have a little bit more active lipase than others, and some women's milk oxidizes faster than others, so what happens is you'll pump it and if its fresh, from the refrigerator, then you feed the baby – that's no big deal. What happens is when you freeze it and then, say, a month later you take it out and you thaw it and try to give it to the baby and it tastes like vomit, smells horrible, and nobody will touch it. Baby is not refusing the bottle because they don't want to take a bottle, but are refusing the bottle because the milk is gross. So, if that is happening, smell it, maybe taste it, and see if that is the issue. If that is the issue, I want you to know it's not unsafe for baby. The flavor has changed, the molecules have changed, but it has nothing to do with safety – it hasn't gone bad or spoiled. Sometimes you can mix some of your fresh milk in there to hide the flavor and sometimes babies will be OK with that, but just know that if that is the case you're going to want to talk to a lactation consultant about ways of timing and other things you can do to stop that enzymatic process before you even put it in the freezer. Reach out to a lactation consultant if that is happening to you. This is why I recommend freezing your milk pretty fast – don't wait until week 11 1/2 to start thawing your milk and realizing all of this work you've done building a milk stash is ruined because of a lipase issue. So maybe a week or two in, you've frozen some milk, let it be frozen for a couple of weeks then take it out and thaw it and see what you get. You'll know at that moment to reach out to someone so you don't have to waste so much milk. Word to the wise. 


Another worst case scenario: baby just won't take a bottle, no matter what you try. Having someone else do it, having mom leave, maybe a daycare provider (who works with a lot of babies) will have some luck if you are nowhere in sight. But say you are back to work and baby is not taking a bottle, or taking only 1 ounce here or there, or clearly not taking full feedings at the daycare, there's something called reverse cycling babies sometimes do. They will kind of fast during the day, taking just enough to take the hunger off, and they are waiting to see you again and be reunited with you, and when they do they nurse a lot. So, they fast during the day and during the night they're just going to make up the calories. That will mean you're probably up a lot at night breastfeeding because they need the calories at some point. So, hopefully that doesn't happen to you, but worst case scenario, that is something that will get you by. At some point, the baby may be old enough to sit up and take a sippy cup instead, or another cup. Usually it is just a temporary thing, and when they get older they will figure it out, they will start taking solids at some point, and will figure out a sippy cup. Some babies just bypass bottles altogether and they grow up to be fine citizens. It's OK if your baby doesn't take a bottle; they will figure out how to get the milk in another way. 


It's always a good idea to do a dry run right before you go back to work. You know the baby is taking a bottle, but your daycare provider (even if it's your husband staying home with baby) has to know how to do all of this on their own. So maybe a week before the end of your maternity leave I recommend doing a dry run where you pack the bag the night before, you get your lunch packed, everything you normally do to prepare to go to work. Then set your alarm for whatever time you're planning on getting up. Some moms will shower first, have breakfast, then breastfeed baby. Some will nurse the baby then do their shower or dress routine. Whatever your routine is, do it, then actually take the baby to daycare, drop him off, go to the library, go shopping, go get your nails done, go do whatever you're doing during that 8 hour day, but pump 3 times during that 8 hour day. So wherever you are, you still need to stop and pump during that time that baby would normally be taking a bottle. At 5 pm, go to the daycare and pick up your baby and see what the day was like for them. How much did baby actually take by bottle? How did you do with pumping 3 times in a row? How did you feel being away from your baby all day? That's going to be a hard day, but even if you just do half of a day, like a dry run of just 4 hours, that's going to give you a better idea of what your day and mornings are going to be like, trying to get out the door, so you can better prepare for that when it is your actual day back to work it won't be as scary. In the PDF in the resources I have a magnet with CDC guidelines on the milk storage that I encourage you to print off, share with your daycare provider, put it right on your refrigerator so everybody knows how to handle your breastmilk from room temperature to the refrigerator to the freezer to the baby. 

BM Storage Magnet 2019 PDF.pdf
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