Bottles

How do I feed my baby with a bottle?

Bottle-feeding is the most tool for supplementing a baby. It requires less suction than breastfeeding, so it’s helpful for weaker babies, but strong, healthy babies may struggle with the rapid flow. Babies tend to take in more milk with bottles, which can lead to obesity. This can also result in fewer feeds in one day and can cause a reduced milk supply, among other problems. It is very important to watch the baby for signs of hunger and fullness and not give more milk than the baby needs. Bottles are quick to use and relatively cheap, but there’s a risk that bottle-fed babies will start refusing the breast. They sometimes have trouble settling after receiving a bottle and may have a higher risk of other health problems such as ear and chest infections.

A) Describing how bottles work

The most common way to give a baby a milk supplement or a replacement feed is to use a bottle.

Most authorities discourage the use of bottles after one year of age.

1) Why babies take in more milk when bottling

Babies tend to take in more milk by bottling then when breastfeeding because bottle-feeding:

  • Allows milk to stream steadily into the baby’s mouth.
  • Needs less suction for the milk to flow.
  • Provides milk at a faster rate.

Babies are born with reflexes that allow them to breastfeed and they apply these reflexes to every nipple, whether on a breast or a bottle.

Babies feed by latching on and applying suction. Once their jaws and tongue start working (sucking), they stimulate the let-down and take in milk. If there is no let-down, they will not take in much milk.

By comparison, once a baby is latched onto a bottle, the suction causes the milk to steadily stream into the mouth. The baby can only stop the flow by letting go. This forces the baby to swallow or choke and results in taking in more milk than breastfeeding at each feed (Wood 2016b).

In addition, obtaining milk from a bottle needs less suction (Lau 2000) and the milk flow may be faster.

In general, bottle-fed babies tend to take in more milk at each feed and feed a little less often (for example, six times a day) when compared to breastfeeding babies.

2) Dealing with the rapid milk flow

Babies may struggle with the rapid flow from a bottle, causing:

  • Panting and shortness of breath
  • Choking
  • Quick feeds

Premature babies in particular can have trouble coordinating their breathing and swallowing while taking milk from a bottle.

B) Pros of using bottles

Bottles are:

  • Quick to use
  • Reasonably easy to clean 
  • Relatively cheap
  • Familiar to most caregivers
  • Easy to find in stores
  • Good for sleepy newborn or weak, underfed babies

Using them safely becomes much difficult for families in emergency situations.

C) Cons of using bottles

Babies who use bottles may:

  • Learn to suck differently (Aizawa 2010).
  • Get used to them and start refusing the breast (Zimmerman 2015). 
  • Choke a lot if the milk flow is too fast.
  • Find the rapid milk flow stressful if they are premature.
  • Not easily settle after receiving one.
  • Not develop the ability to control their food intake (Li 2010; Li 2014).
  • Have an increased risk of developing crooked teeth.
  • Tend to overfeed on the bottle (Li 2010).
  • Have an increased risk of obesity (Appleton 2018; Li 2008; Wood 2016a).
  • Become contaminated with bacteria if not properly stored and cleaned.

Babies should not be given bottles while in bed as this increases the risk of dental caries.

D) Equipment

Orthodontic bottle nipple.

There are many different types and shapes of bottles and bottle nipples and both can be made of a number of different materials.

1) Bottle nipple materials

Bottle nipples can be made of latex or silicone.

Some babies can be allergic to latex (Holme 1999; Kimata 2004; Kimata 2005). Signs include wheezing, hives, or swelling of the face, lips, or throat.

2) Bottle materials

Bottles can be made of a variety of materials; the main division is between plastic and glass.

Some mothers opt for glass bottles. These can break and pose a risk to the baby but avoid the concerns about plastic bottles adding unwanted chemicals to the baby's milk.

a) Bisphenol A

There have been concerns about bisphenol A in some plastic bottles (Health Canada 2014; Nam 2010). This chemical has been identified as dangerous to health and has been largely withdrawn from use in baby bottles. However, this doesn’t eliminate the risks of other possibly harmful chemicals getting into the milk.

b) Microplastics

Plastic baby bottles have been found to release millions of very small pieces of plastic (microplastics) during the process of sterilizing, rinsing, and preparing baby formula in a bottle (Song 2021). This effect is increased as the water or formula temperature increases and by shaking (Li et al. 2020).

Once ingested, microplastics can travel throughout the body. The effect of microplastics on human health is unknown but possible negative effects may be caused by their (Campanale 2020):

  • Physical properties (size, shape, and length)
  • Chemical properties (introducing and releasing harmful chemicals such as hormone blockers)
  • Concentration
  • Providing a surface for bacteria to grow on

3) Flow rates

Many breastfeeding specialists recommend a slow flow nipple. These are thought to minimize nipple confusion, over-eating, and choking. However, there is very limited research on this topic.

Some nipple-and-bottle combinations are rated as slow flow, fast, or somewhere in between. One study (Pados 2019) showed that milk flow rates varied widely (0.86 to 37.61 millililitres/minute [0.03 to 1.3 US fluid ounces/minute]) and the packaging did not accurately report the flow rate. The flow can even vary between nipples made by the same manufacturer (Pados 2016).

In general, the best guide to the preferred flow rate is the baby’s behaviour while bottling. Babies are generally able to adapt to a variety of flow rates and teats and will show signs of stress if the bottle or nipple is not appropriate for them (Lagarde 2019).

4) Venting

Some bottles are vented, allowing air to enter the bottle during feeding. There are no major differences between vented and unvented bottles (Kreitschmann 2018).

5) Nipple shape

There have been concerns about nipple shapes interfering with breastfeeding or affecting the shape and function of the baby's mouth. The evidence supporting the use of orthodontic nipples is limited (Corrêa Cde 2016; Lima 2017). Until more research emerges, caregivers will have to rely on the baby’s behaviour while bottling as a guide to nipple type (Lagarde 2019). Our clinic has found that the simple, thumb-shaped nipple works best. We generally avoid short or stubby nipples and orthodontic nipples.

E) How to use a bottle

Thumb-shaped bottle nipple.

Mothers should always try to offer both breasts at each feed. If a supplement is needed, this can be given with a bottle. For babies who are not breastfeeding, a replacement bottle may be used.

1) Bottle-feeding technique

To give the baby a bottle when holding the baby with your right arm: 

  1. Wait for the baby to show hunger signs.
  2. Hold the baby’s body at a 45-degree angle with the head higher than the rest of the body to minimize choking.
  3. Use the bend of your right arm to support the baby’s head and shoulders.
  4. Curl your right arm around the outside of the baby’s body and hold the baby’s thigh with your right hand.
  5. Use your left hand to hold the bottle.
  6. Touch the baby’s top lip with the bottle nipple to get the mouth to open.
  7. Put the nipple into the baby’s mouth when it is open. Don’t force or push it in.
  8. Expect the baby to take about 30 ml (1 oz) in 5 minutes or about 90 ml (3 oz) in 15 minutes.
  9. The amount of milk depends on the baby’s hunger signs.
  10. If the baby is no longer actively sucking, take the bottle away and check for hunger. If there are none, the baby is done.

Consider changing the nipple if:

  • The flow is too fast and the baby chokes throughout the feed and feeds too quickly. Use a nipple with a slower flow.
  • Bottle-feeding takes more than 20 minutes. Use a nipple with a faster flow.

2) Keep the baby at a proper angle

Bottle-feeding is best for babies when they are held at about a 45-degree angle. If they choke frequently or show signs that the milk flow is too fast, they may even need to be held a little more upright.

Keeping the baby too flat (horizontal) during bottle-feeding may increase the rate of milk flow, resulting in overeating or choking. It may also increase the risk of ear and chest infections, fevers, and medication and antibiotic use (Avital 2018).

Keeping the baby too upright (vertical) may prevent the milk from covering the nipple hole and the baby taking in air instead of milk. Younger babies will not have enough control of their heads to feed safely in this position.

3) Hold the baby when bottle-feeding

It is better to hold the baby when bottling instead of leaving the baby to bottle alone. The latter is done by either propping the bottle (giving the bottle by leaning it against a support) or having the baby hold the bottle. Propping supports can be pillows, blankets, sides of baby chairs, or manufactured devices.

Holding babies while bottling is recommended as it creates a bit of quiet time for the baby and the caregivers to be together. Babies are warmed and comforted by the contact with a loving person who monitors and interacts with them. It may also limit later obesity and encourage healthy eating habits (Savage 2018).

Propping the bottle or allowing the baby to hold the bottle may result in the bottle being in the baby’s mouth for longer periods. This can increase the risk of choking, chest problems, ear infections, and dental caries, and negatively affect the development of the structures of the mouth (Brecher 2018; Kim 2011). Propping devices may increase the risk of sudden infant death if the baby falls asleep with them (Volpe 2013).

F) Bottling tips

1) Avoid overfeeding the baby

Taking in larger amounts of milk may be helpful if the baby does not feed well, as with a very sleepy or weak, underfed baby.

On the other hand, healthy babies may take in very large amounts of milk and may need to feed less often. For mothers with a low milk supply who are breastfeeding before supplementing, infrequent feeds may cause infrequent breastfeeding and further reduce the milk supply.

Bottle-feeding a lot of milk at one feeding:

  • Increases the risk of rapid weight gain and later obesity (Wood 2016b).
  • Makes it harder for the baby to digest and increases the baby’s tummy cramps.
  • Increases the chance the baby will vomit.

To prevent this, caregivers should watch the baby for signs of hunger and fullness and not give more milk than the baby needs; this is also known as responsive feeding (Ventura 2021).

2) Help the baby control the flow of milk

If it looks as if the baby is going to choke, point the nipple into the inside of the cheek. This:

  • Breaks the suction.
  • Slows the milk flow.
  • Lets the baby take a few breaths.

Once the breathing relaxes, return the nipple to the middle of the mouth and resume feeding.

Some babies get angry if you take the bottle away. Our approach tends to keep them calmer as the bottle is still in the mouth.

If you do remove the bottle from the mouth because the baby is struggling with the milk flow, leave it touching the top lip. This too lets the baby know that the milk is not far away and allows you to quickly return the bottle into the baby’s mouth when the baby is ready to resume feeding.

3) Use the breast to help the baby go to sleep after bottle-feeding

Many babies won’t fall asleep on the bottle. The baby may need to breastfeed to fall asleep. Consider offering the breast if the baby:

  • Is not actively sucking on the bottle.
  • Is not happy when you take the bottle away.
  • Shows sleep signs. 
  • Is no longer hungry.

Offering the breast after a milk supplement is called using the third breast.

4) Drooling milk while bottle-feeding

Some bottle-fed babies let milk leak out of the mouth and run down the chin. This is normal.

5) Babies who can’t use a bottle

Some babies can't use a bottle but latch and suck normally at the breast. They should not be forced to use the bottle; Parents need to look at other ways of supplementing the baby.

A small number of babies are physically unable to create suction in the mouth because of a medical problem. They may have an abnormality in their mouth or have a disease that causes muscle weakness. These babies cannot take in milk from the breast or the bottle and will quickly lose weight if not diagnosed. They need immediate attention from a health-care provider.

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