Responsive Feeding of a Baby Fed by Breast and Bottle

Shel BanksUncategorized

Transferring successfully and efficiently between feeding at the breast and feeding with a bottle, whether the bottle contains expressed breast milk or infant formula, is a skill which many families could do with developing for various reasons. This article describes how families with mixed-fed babies can avoid the so-called ‘nipple teat confusion’, and how they can use bottle feeding effectively to complement breastfeeding, rather than worrying about impacting negatively on the breastfeeding relationship.

Responsive feeding means recognising what baby needs and feeding them as soon as they ‘ask’ for it: mums find that If they wait until baby is screaming with hunger, then they’ll gulp down air both whilst crying and when feeding that can contribute to colic symptoms. But watch carefully and you’ll soon begin to pick up on some of the subtle clues that your baby gives when they are starting to be ready to feed, and be able to feed them sooner rather than later.

Mastering transferrable techniques

There are some great techniques which can help with more easily transferring back and forth between breast and bottle so that your baby learns the cues for both are the same, and so feels more confident and comfortable however and by whomever they are being fed.

When baby is breastfeeding, positioning them carefully as they feed is an important first step, as this affects how easily they can get the milk. What works best is the mother holding baby closely and securely against herself in a near-horizontal position – think of wrapping baby round the ribs like a belt.

Many mothers find that the easiest way to initially position baby so that they attach to the breast and feed effectively, is to use the arm on the *opposite side* to the breast they’re feeding from, to support baby, with palm of hand on shoulder blades, and fingers and thumb round the neck for support, positioning mum’s forearm under the baby’s lower body as if you were holding a set of bagpipes! If you haven’t tried this hold before then try to work through these steps with someone to help.

So first, place the palm of this hand – if left breast then this would be right hand – on baby’s shoulders, with the heel of the hand on the spine. Use middle and index fingers to support the underside of his head, making a little shelf, and thumb goes around the neck on the upper side, with middle finger and thumb pointing towards the corner of the jaw on both sides, and the first knuckle of the middle finger and the knuckle of the thumb at the same point on each side of the neck.

This is really useful as it ‘anchors’ the feeding hold, and allows baby and carers to interchange between bottle and breast more simply. Getting the positioning right for breastfeeding is part of the solution to swapping backwards and forwards, because it allows the baby to become accustomed to effective feeding positions for both, and relate them to one another.

To see a more visual representation of this, you can download LatchAid from the AppStore and watch the interactive 3D animations for more detail.

Positioning your baby to breastfeed

So, for breastfeeding, whilst holding baby with the palm of your hand on their shoulders, and body held into you as described above, move baby round towards the nipple from the middle of your chest until their nose is at your nipple when their mouth is closed. At that point, using your wrist and hand, place baby’s chin against your breast where it is, and do not let it move: an infant’s primitive neonatal instincts mean that the rooting reflex will be triggered when the chin touches skin, and the mouth will open, with baby tipping back their head to reach up, and as the top lip clears the end of the nipple, the mum can move baby nearer into her breast by bringing her wrist (which is on the baby’s back and shoulders) straight in towards her ribs, so baby moves towards her with their chest, without changing the placement of the chin. It might take a few tries to perfect this technique, but take it slowly step by step and once you’ve got it, it will become second nature. And we often find that baby is more patient than we might expect!

Crucially, once attached at the breast and feeding, the nipple should now be pointing up towards the back of the roof of baby’s mouth. This can be difficult to judge from above, so if you don’t have another helpful person with you to check then either use a mobile phone camera or look in a mirror to check from the side. If in your mind’s eye you draw an imaginary line through the breast from mum’s ribs and out of the nipple in the direction in which it points, that line should exit baby’s head at the pointy bit at the top of the back of the head. If the nipple is pointing towards baby’s ear, pull baby’s body round towards their feet a little and re-position until it’s right.

Oh – and one more thing: once baby is well attached at the breast you can, if you like, swap arms so that baby’s head is resting on the forearm of the arm on the same side as the breast you’re feeding from – if that is more comfortable for you. Remembering to check comfort once baby is feeding, thinking about dropping shoulders and relaxing back and neck. Comfort for mum is key when she will be spending so much of her time in the early weeks and months of baby’s life, sitting feeding!

Signs of good attachment at the breast

There are other visual checks you can do to look for signs of good attachment at the breast, for example the chin should be indenting into the breast, but their nose should be free of it, baby should have fill rounded cheeks and mouth wide open, ideally enough that they have a double chin. Check too that more of the dark area surrounding the nipple, the areola, is visible above the top lip than below the bottom lip.

It’s also really important that the baby learns how to make an effective seal at the breast or on a bottle, so they can effectively transfer milk to themselves and avoid transferring air alongside it. Think about drinking through a straw yourself: sucking up a drink through one straw is fine, but try it with two and you’ll draw air through the gaps in the middle. And in the same way, any tiny openings in the seal between your baby’s mouth and the teat or breast will mean that they suck air in along with the milk.

Transferring between breast and bottle

Once you have read the information above and mastered the technique for getting good attachment with a breastfed baby at the breast, you can progress to aiming to position the bottle and baby in a similar way, to mimic the breastfeeding technique as much as possible.

So, this includes using the same ‘hand hold’ as that used for supporting the baby’s positioning for breastfeeding, that is with middle finger and thumb of the adult’s hand round the baby’s neck, pointing to the either corner of the jaw, and with index finger next to middle finger and so providing a ‘shelf’ for the side of baby’s head. Palm of the hand on the shoulder blades, and heel of the hand on the baby’s spine.

However unlike in positioning for breastfeeding, it’s not ‘opposite hand to the breast you are going to use’ but the slightly different ‘opposite hand to the thigh baby will sit on’, so if you are holding the weight of the baby’s shoulders in your right hand, with right thumb around the left side of baby’s neck and pointing up to the corner of their left jaw, and right middle finger doing the same on the other side of baby’s neck, then the weight of baby’s left hip and buttock would be on the left thigh of the adult feeding them, and baby would be turned in slightly towards the stomach and chest of the adult. Essentially, baby is pointed the other way to the way they would point for breastfeeding! It often helps here for the adult to be positioned at the edge of the seat they are sitting on, with left leg in this case bent at the knee and left foot firmly on the floor underneath the knee providing support for baby, while right leg is extended out, with right elbow able to be supported on right thigh.

Then, taking the bottle in the adult’s left hand with the base of the bottle between thumb and forefinger and the teat end of the bottle pointing out from the little finger side of the hand, and gathering the infant’s right hip in to the adult’s body with the elbow of the left arm, and looking into baby’s eyes and talking to them, the base of the teat of the bottle can be introduced to the baby’s chin at the same time as the teat of the bottle is touched onto the nose or upper lip, encouraging baby to, as they do when breastfeeding, open their mouth wide and tip their head back to reach up to get their top lip just over the end of the teat, to accommodate the teat in their mouth.

Signs your baby is well attached to the teat

Signs that baby is well attached to the teat here, would include;

  • that their head was tipped back
  • that there was a large gap between teat/bottle and nose, with chin touching or almost touching the base of the teat
  • baby showing a double chin because baby’s mouth is open so wide, and head tipped back.

    In short, an imaginary line through the bottle and teat should follow the same line as the imaginary line discussed above through your breast and out of the nipple would, when you were breastfeeding; aim the teat at the back of the roof of baby’s mouth so that the straight line would aim at the pointy part at the top / back of his head, rather than between the ears. This is the position that your baby expects, and it’s how their oral anatomy works best.

    Because unlike a breast, there is air in a bottle which increases as the volume of milk decreases throughout a feed, to maintain only liquid in the teat and avoid baby taking in air as they feed, you will want to modify the position though, to ensure the teat stays full of milk. Any air in the teat may mean that your baby draws that as well as the milk, so keeping it full of milk avoids the possibility, which means that you may need to start the feed with your baby relatively upright, before reclining them a little as the bottle empties, so that the teat and head stay in a straight line. Some parents find that the heel of their bottle-holding hand – so the left hand in this example – rests on the baby’s chest, and with the heel of the right hand on the baby’s back, their two hands, baby and bottle form one unit, which stays in formation regardless of the level of the milk in the bottle, as baby is tipped back. It’s really important though that the adult feeding the baby ‘goes with’ the baby as they tip back, and that feeding with the bottle is responsive, looking for cues that baby needs to take a break to rest to decide if they want more, or stop and move position to get some trapped gas up (see the Wonky Winding video), and being on the alert for any signs of baby feeling distressed, including obvious signs such as choking or spluttering, and unlatching from the teat, as well as the more subtle signs like widening their eyes or suddenly averting their eyes from their carer’s, or starting to gulp – gulp – gulp whilst widening their eyes.

Keeping it nice

It’s so important for baby’s continued well-being that feeding is responsive to the baby’s needs, and also pleasant, so that your baby will not resist feeding time, but instead see it as a positive time of bonding and milk given with love.

One of the more unpleasant things which can happen in a bottle fed baby, apart from being fed alone at arms’ length or with bottle propped up or suspended in some sort of purpose-made device so that they are not feeding in someone’s arms, is taking in air as they feed, causing discomfort in their digestive system for potentially many hours afterwards. Luckily there are many ways to avoid this!

Avoiding trapped air

When making up infant milk, whether from formula powder and water, or when warming a bottle of expressed milk, there’s a temptation to vigorously shake your baby’s bottle to mix the powder into the water, or to mix up warming milk to make the temperature consistent, and in doing so you’re inadvertently incorporating air into the liquid, which can lead to trapped wind, which may contribute to colicky symptoms. Formula-fed babies are often less colicky on ready-to-feed formulas for this reason. The solution is to swirl, rather than shake the bottle, so when mixing formula powder with very hot water, swirl to incorporate the powder into the water, and let it stand for 20 minutes while cooling to allow any bubbles to

disperse.’ The same applies if you’re warming expressed breastmilk or even ready to feed liquid formula: swirl it if you want to ensure even heat distribution, don’t shake it.

Whether you’re feeding formula or expressed breastmilk, you can reduce the amount of air your baby swallows from the bottle, by perfecting how you hold your baby and the bottle as described above.

Products to help

There are a huge range of bottles available featuring different valves, vents, air systems and teats which the manufacturers claim are able to mimic breastfeeding or reduce trapped gas or colicky symptoms. However, the evidence base that any is better, materially, than another, is simply not out there, and so personal preference of parent and baby is key.

It’s a good idea to experiment to find one that suits your baby, starting at the cheaper end of the market rather than the more expensive end of the market, to save you money on bottles which baby either won’t entertain or which baby does not feed happily from. You’ll know it’s working if baby is easily able to drain an appropriate amount from the bottle, and is feeding well and comfortably, bearing in mind the signs of good attachment, and the signs of baby’s distress which are noted above.

As your baby grows, you may find that you need to switch to a different size or shape of teat to continue feeding effectively, but many babies who swap happily between breast and bottle actually stay with the ‘newborn’ teat and smaller bottles throughout their first year of life, and then move onto a cup rather than bottle as recommended for continued oral health.

The sort of bottle which works best for the technique above, of tipping baby’s head back and directing the teat towards the back of the roof of the mouth, is a wider-necked bottle with quite a long and wide teat. There are many brands that do this, but the key is to avoid the narrow necked bottles, or teats which slope away from the direction the bottle points or are made of tougher rubber or silicon – babies who breastfeed as well are used to a softer material in their mouths!

Slow down

Too much milk, too fast, can give your baby a bloated, colicky feeling. It seems to works best for a baby if you are able to offer a break from feeding after every ounce (30 ml) or so. Milk in a bottle – formula or breast – is all the same consistency from the first drop to the last, unlike when baby is feeding at the breast, which means your baby doesn’t get the natural cues telling them they are full, which come from a component of the milk called leptin, found in increasing amounts in the fattier richer milk which tends to come later into a breastfeed.

Gently taking the teat from baby’s mouth slows the feeding, giving the baby chance to decide if they are still hungry. You could talk to baby as you do this, telling them what you are doing and asking if they have had enough, or if they are full. It’s tempting to want to use every last drop, but listen to your baby if they ‘say’ they have had enough.

For information on how to get baby’s wind up effectively after a breast or bottle feed, see this video on Wonky Winding.