The LC in PP in Conference Philadelphia this year was my first international conference to attend in all things breastfeeding; the “Breastars” were in attendance! Some attending the sessions, others giving sessions … and not to forget to mention my lovely Irish colleagues who made the whole experience very worthwhile and fun. Thanks to ALCI for a bursary to attend this conference.

The programme was full and intense, and my wits needed to be on full alert to take all the information in and process it. Given that it was all things lactation I was surprised to see on the programme a session entitled “Bottle Battles, Practical Tips for the Bottle Refusing Baby”, facilitated by Susan Howard IBCLC. Bottle battles at a conference for lactation consultants!? Following an informal chat amongst my colleagues I discovered that some IBCLCs do not as a rule help with bottle feeding problems, even with EBM. In the US where the maternity leave is relatively short many breastfeeding mothers have no other option but to bottle feed EBM as they return to work and want their babies to get breastmilk. I understand that US IBCLCs are more likely to work with bottle feeding dyads. As it turns out I had a call from a mother who was bottle feeding her baby and wanted help just before I left for America. She asked me tentatively if I took appointments from mothers who bottle feed. I asked her to fill me in. She described a 4-month long journey of frustration and failure (her words). She reluctantly finished her breastfeeding journey which was a very emotional for her and started to bottle feed formula to discover to her complete frustration and upset that her problems were not resolving. I felt I could not refuse to offer her help. To be completely honest although this session resonated with me, I thought to myself there was not too much to learn here! When Susan asked her audience to raise their hand those who felt competent and confident to work with bottle refusing babies, I raised my hand without hesitation, flush with the success of my recent consultation!!! OMG when I think of it… morto!!

The session was so well put together, interactive with lots of photos and props. I learned so much that I did not know! Thank you to Susan Howard IBCLC. Anyway, I am here now to share with you all 10 points that I picked up to help with families with “Bottle refusing Babies “

If you work in primary care or on the community, you are likely to have come across babies who play with the teat, chew or chomp the teat but manage to get the milk with the help of a fast flow teat. Or I imagine you have seen babies who appear to have soaking wet Babygro from milk spillage. Or you have encountered parents who have complained to you that it takes ages to feed their baby the bottle. You may find the weight gain is normal but are these babies feeding normally from a bottle? According to Susan, weight gain however should not be the only benchmark for feeding success. In transitioning to bottle feeding a baby should be able to accept a teat into their mouth with no gagging and suck from the teat in an organised manner and with no milk spillage.

First and foremost, in helping overcome the difficulties of transitioning to the bottle Susan would say you need to manage the expectations of the parents; one consult is not necessarily going to solve the problems. She tells families I cannot “make” your baby take the bottle. What we can do as helpers is figure out why there is difficulty with transitioning to a bottle feeding or why the baby is refusing the bottle and then help with a plan.

In figuring out the whys, she looks at the breastfeeding; she observes a breastfeed and watches for leaking, clicking, flow of milk, chewing or active sucking, nibbling, slipping off the breast.

She observes the baby in the same way we all do during a breastfeeding consult, looking for asymmetry, tightness, torticollis, palate shape, cheeks, sensitive gag reflex, hypotonia and hypertonia amongst other observations. All these factors may contribute difficulty transitioning to the bottle and may require other help like bodywork.

1. Mother is in the best position to help their baby transition to the bottle effectively, not their mother or mother in law, child minder or friend. Mothers know their babies and babies trust their mothers.
2. Hunger is not a great sauce. Babies who are fed and rested will be more regulated and less stressed. If the baby is hungry, they will get stressed, cry more, may have negative associations and develop in extreme cases oral aversions. Hungry babies are not motivated to learn
3. Wake the baby’s body up: Do body warm-ups, assessing for tension in the neck and shoulders. Move arms up and down and open arms out and bring them together at the chest, talking and engaging the baby. Use lots of eye contact. Do exercises where the opposite body parts meet in the midline … e.g. arm meet the foot of the opposite side at the midline. Wake the baby’s mouth up: Oral massage, tap lips, massage TMJ, and massage palate. All exercises should be quick and playful and be led by the baby’s cues. Praise and encourage and do all of this before a teat has been taken out of the package.
4. Encourage good baby posture for feeding, upright chest, back supported, hips flexed and positioned so that the baby can make eye contact too.
5. Practice with empty bottle teat, and yes, no milk in the teat at LEAST AT THE START. Get permission from the baby to accept the teat into their mouth, stimulate or tap their lips with the teat, let them feel it. Touch it lick it praise them as they achieve these goals. Aim for hard palate. Sometimes mimic what you want the baby to do. Keep eye contact and let the baby hear the mother’s voice. Get the sucking skills right and then introduce milk in small amounts.Other ways to help baby suck is “Bait and switch” at the breast on to the empty teat when the baby relaxed and full. When babies are sleeping or drowsy and they “sleep suck” practice lots. Teach parents the visual cues for stress.
6. Hold the bottle like a pencil, rest fingers on bottle collar and hand resting on chest. Support the jaw as needed. Stabilise the cheeks which helps with vacuum and support the jaw if there is chomping or jaw tremor. Practice when sucking to pull bottle teat slightly out so baby pulls it back into mouth. Discourage parents from bottle hopping or teat swapping.
7. Success is defined by accepting the bottle into their mouth with a good seal no gagging and an organised suck with no spillage. It is not defined by taking an entire bottle.
8. Use paced bottle feeding however Susan recommends not taking the teat out of the baby’s mouth in this instance.
9. Tummy time improves all sucking skills by bringing the jaw and tongue forward. It encourages head/body extension. Roll into tummy time roll out of tummy time.
10. Progress can and does stall, encourage parents to go back a step and reassure. Need to build into the consultation different stages of success, e.g. first step recognition of the teat, next cuing and opening wide then accepting teat. Following that, good lip seal, no gagging and organised suck. Parents may feel anxious to move quickly as there may be a time pressure for returning to work for example. Short 3 to 5-minute practice sessions 3 to 5 times a day. Pick times when baby is up for “play”.

Finally like all breastfeeding challenges it takes patience and practice and praise or positive feedback.

Pauline McLoughlin IBCLC September 2019

Pauline received a bursary of €200 from ALCI to attend LCinPP.