When a baby is not gaining weight as expected, then use of the term ‘responsive feeding’ will no longer mean we are responding to feeding cues, or aiming to slow down the pace at which a baby takes their feed, but that we are instead responding to their needs. Weight concerns indicate they are not transferring enough milk to meet their need to grow at this point, and so need more milk.

In short:

To encourage your baby to take more, in the first 24 hours:

• offer milk at body temperature, the same temperature as your baby’s mouth
• offer a feed as soon as your baby wakes up
• some babies prefer ready to feed formula at this time
• check your bottle has accurate callibrations (by using a few different measuring jugs to measure known amounts of liquid to see if the lines on the side of the bottle match up correctly)
• if your baby is in pain or regurgitating feeds, seek the underlying cause of this problem
• get expert help to choose the best formula feeder for your baby e.g., soft cup feeder, longer teat versus shorter teat and wide neck bottle versus narrow neck bottle
• offer your baby a bottle in a comfortable, quiet and responsive way

Many parents feel a huge sense of guilt and blame for this, but that is not fair and also not at all helpful: what is needed is both some good support for the parents, and some good information on how to boost the baby’s intake of milk so that they start to increase their weight gain as expected.

While much of the information in this article about Responsive Bottle Feeding by my colleague Emma Pickett IBCLC, is still applicable, we cannot rely upon the feeding cues of a sleepy or reluctant feeder, and if your baby is not gaining weight you should not be pacing the feeds to reduce the transfer of milk, but rather encouraging your baby to take a little more he has previously done, and to feed a little more frequently. Over time your baby will begin to ‘ask’ for a little more and so attention needs to be paid to weight gain, so that you can continue to be responsive to your baby’s needs as well as cues, perhaps introducing paced feeding once your baby has done some catching up of weight gain.

Where the increased milk is to be delivered by bottle, there are some tricks which might encourage baby to take in more during each 24 hours.

• Babies will take their milk much more willingly if it is at the right temperature – not too hot of course, but also not too cool. Breastmilk from the breast will be blood temperature, and so this is what the baby is expecting – that the milk will be the same temperature as their own mouth, which is roughly 37.5deg C / 98.5deg F. You can get flexible thermometers designed to measure bath temperature as well as other liquids, which can go onto the outside of the bottle, you can use a food thermometer, or you can use the old-fashioned method of tipping a little onto the inside of your forearm or your wrist, and if you cannot feel it, then it is the right temperature! If you are making up a formula feed using powder and recently boiled water then aiming for warm milk will reduce the time you leave the bottle sitting after it is prepared, as you want it to cool only to 37.5 degrees Celsius  – though remember that the water used to mix the powder should be at least 70 degrees Celsius, which is much too hot to drink!
• Secondly, increasing the frequency of the feeds, which means not waiting for feeding cues but offering a feed as soon as your baby wakes, or whenever he seems like he might be willing to feed, even if it is relatively soon since the last feed.
• Experience in both neonatal units and with older healthy babies tells us that some babies prefer the smoothness of ‘ready to feed’ formula over the powdered feed made up with water. So, either using the ready to feed bottles, or decanting from a larger carton into a bottle then warming it up e.g., in a bottle warmer or simply in a jug of hot water, might work for your baby.
• Surprisingly, it’s worth checking the calibration of the bottles you are using if you are making up powdered formula. You can do this by using a few different measuring jugs to measure known amounts of liquid to see if the lines on the side of the bottle match up correctly. A recent study conducted by scientists in Australia showed that 22% of the tested baby bottles’ calibrations were out by over the standard tolerance of 5%, and some had as much as 43% volume inaccuracies. This was mirrored by a study in New Zealand the following year, and both countries rely upon European Standard EN14350 which obviously is applicable here too. This could result in your baby taking higher volumes of water than expected, and a lower concentration of nutrients and calories, if the formula is being consistently over-diluted because the bottle calibrations are ‘off’ a little.
• If your baby is regurgitating some of the feed he takes in, or is in so much pain that he does not take a full feed, then this is clearly costing him some of his nutrition and calorie intake. So, addressing the cause of the regurgitation or pain is key. See our article on how to burp your baby if your baby is posseting up some feed when he brings his wind up, and for more serious regurgitation or pain, please seek medical attention from your GP, as it might be something medical such as a cows’ milk protein allergy or gastro-oesophageal reflux disease, both of which can be managed with medical help.
• It’s important too, that the supplement is given in way which supports your baby to feed easily – so for example a baby with a restricted tongue or poor muscle tone might need something like a soft cup feeder rather than a bottle with a teat, or babies with high arched palates or other sucking difficulties might do better with a longer teat and wider necked bottle than the smaller or shorter teat of a narrow-necked bottle. What is vital is that baby is able to get the milk efficiently so that they do not tire quickly when feeding.
• Finally, getting your baby into a comfortable position to feed, with low stress and low noise, This means your baby is spending time in a loving and calm environment and feels contented and at ease – this can make all the difference. If his mealtimes are distracted or not pleasant, then you can understand why he would not want to draw them out. Holding your baby supportively so that his whole body is contained by your body and arms, looking into his eyes, and gently communicating with him, can make the difference needed to how long your baby is prepared to feed, and so how much he will take at a feed time.

For information on the responsive feeding of a mix-fed baby, see Emma Pickett’s article, and for information on managing the breastfed baby with faltering weight, see here.