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Introducing Bottles and Pacifiers to a Breastfed Baby
by Anne Smith, IBCLC
Many babies switch back and forth effortlessly between breast and bottle from day one. Others become "nipple confused" if artificial nipples are introduced during the early days of nursing.
The mechanics of breast and bottle-feeding are quite different. When a baby nurses, his tongue and jaws must work together rhythmically, cupping his tongue under the areola, and pressing it up against his palate. This flattens and elongates the tissue around the nipple. He then drops the back of his tongue to form a groove for the milk to flow from the nipple to his throat. He swallows, then takes a breath. His lips are flanged out tightly around the breast to form a tight seal.
When a baby drinks from a bottle, the milk gushes out (you'll notice that the milk drips out if you hold a bottle upside down). In order to keep from choking, he lifts his tongue and uses it to block the flow of milk. He purses his lips around the hard rubber nipple, and he doesn't have to use his jaws at all. There is a constant flow of milk that he doesn't have to work for, unlike during breastfeeding, where the milk 'lets down' initially, then slows to a trickle, and the process repeats as the baby sucks harder and longer. This occurs several times during a feeding, and is one of the reasons breastfed babies are less likely to become obese than bottle-fed babies: they regulate their own intake by how long and vigorously they suck. Bottle-fed infants will often finish a bottle not because they are hungry, but because they love to suck, and the milk flows so easily.
The risk of nipple confusion, whether by introducing a bottle or pacifier, is greatest during the early days of nursing. The longer you wait to introduce artificial nipples, the less risk there is of confusing your baby. Breastfeeding is a learned behavior, in most cases, although there are some babies who seem to be born knowing exactly what to do. Although sucking is a newborn reflex, the mechanics of effective latching on aren't. It usually takes a couple of weeks, and sometimes longer, for mothers and babies to get really good at nursing. By that time, any problems you had in the beginning, such as engorgement or nipple soreness, should be pretty much resolved, and your baby's pattern of weight gain should be established.
If nursing is going along smoothly, there should be no reason to use artificial nipples in the first few weeks of breastfeeding. Nursing frequently and using the breast as a pacifier are what builds a good milk supply and helps you and your baby develop a special closeness during the period immediately after your baby's birth. Use the fact that you are exclusively nursing during the first few weeks to get more rest. Let friends and family wait on you, do your laundry, cook for you, etc. You have a perfect excuse. Yes, if you gave the baby bottles, someone else could take over a feeding while you sleep, but missing that feeding during the early weeks while you are establishing your supply for your baby who is growing so quickly during that time may decrease your milk production Once your supply is well established, skipping occasional feedings won't be a big deal. Your time of baby's total dependence on you will last for a very short time, although it can seem like forever when you are overwhelmed with the twenty-four/seven responsibility for this little person at a time when you are physically exhausted, emotionally drained, and sleep deprived. Nobody ever said it would be easy, and if they did, they were either lying, or they never nursed a baby.
Use of pacifier in the early weeks can also cause problems. If you want your baby to take a pacifier, I would introduce it by the time he is one month old, but preferably not during the first two weeks of nursing. Some babies refuse to ever take a pacifier. Some become addicted to them and are still carrying them to Kindergarten. I think that the babies who become attached to pacifiers would have become thumb-suckers or blanket holders if they didn't attach to a pacifier. Some babies just seem to need security objects, and there isn't a lot you can do about that. Just because you offer a pacifier to your baby, that doesn't mean he will develop a bad habit. I have offered pacifiers to all six of my babies, all took them occasionally, and none of them became attached to them. I did have several children who sucked their thumbs for what seemed like forever, but that's another article.
I think it is great if your older baby will take a pacifier occasionally. If you have ever been driving down the highway with a screaming baby in the backseat and no way to pull over, even though you nursed just before you left, and you KNOW he can't possibly be hungry, you will know what a wonderful thing a pacifier can be (this especially applies if you have older kids and spend half your waking hours carpooling). Although I have known some large breasted women who could actually lean over the car seat and let their breast hang in the baby's mouth, I have never met one well-endowed enough to sling her breast over the back seat to feed her baby. That's just one example of when a pacifier can be a lifesaver. Another is when your older baby (who is fat and happy and obviously getting enough to eat) has been marathon nursing for hours and nothing is making him happy. Sometimes he just wants to suck himself to sleep and doesn't want to nurse. Believe it or not, this does happen. He almost gets angry when the milk comes out, and may settle right down with a pacifier. There also may be times when someone other than you may have to soothe your baby, especially if you return to work and he is in day care with other babies. You really can't stick a bottle in a baby's mouth every time he fusses, and caregivers don't have the breast to use as a built in pacifier.
So, I have broken the cardinal rule of lactation counseling by saying that I don't think pacifiers are all bad. This is because I have survived raising six children, and I know that you do whatever works and helps you keep your sanity. This may or may not include bottles, pacifiers, and formula.
There are however, some valid concerns about the use (and abuse) of pacifiers. Aside from the risk of nipple confusion, pacifier use is correlated with early weaning for a variety of reasons. Because newborns love to suck on anything put in their mouth, whether it is a finger or an artificial nipple, they may use the pacifier as a substitute for feedings, especially if they are small, ill, jaundiced, or just have a very laid back temperament. There is a spot in the back of a baby's mouth where the hard palate meets the soft palate. When anything touches it, an automatic sucking reflex is triggered. That's why babies will suck automatically when a finger or a rubber nipple is put in their mouth. The soft, mushy human nipple must be drawn back in the baby's mouth until it hits that spot, so use of an artificial nipple may make him somewhat lazy when it comes to nursing.
Some babies are perfectly content to happily miss a feeding as long as they have something to suck on, and some mothers take advantage of this by plugging their baby's mouth with a pacifier every time he fusses in order to make him sleep longer or go longer intervals between feedings. Young infants should spend their time and energy in nutritive sucking at the breast, not in non-nutritive sucking. Overuse of pacifiers can lead to poor weight gain, plugged ducts and mastitis, and a decrease in milk supply. If you have a yeast infection or your baby has thrush, pacifiers can become contaminated. Boil pacifiers every day during a thrush episode, and throw them away after a week. The same thing applies to bottle nipples.
A little piece of trivia here: did you know that in many countries, pacifiers are called "dummies?" Hmm. Makes you wonder. After all, a pacifier really is just an imitation nipple, and as such it should be used in moderation and not as a frequent substitution for the real thing.
Back to bottles now: we've talked about the possibility of nipple confusion, and the advantages of waiting until your baby is a few weeks old before introducing bottles. But what if he needs to be supplemented during the early nursing period? This doesn't happen often, but it occurs often enough that you should be open to the possibility. Some mothers are so afraid of the dreaded 'nipple confusion' that they refuse to give bottles, even though that might be the most efficient way to get milk into their baby. By the same token, some mothers feel that if they give formula supplements, they might as well give up and not nurse at all. Ideally, in the best of all possible worlds, all babies would nurse and no one would ever use bottles or formula. However, this is not a perfect world, and we are lucky to have options like bottles and formula when babies really need them. If your baby needs to be supplemented, look at it as a means to an end. Helping your baby gain weight rapidly, while working on increasing your milk supply and continuing to offer the breast, most often results in a baby who nurses stronger and more vigorously at the breast until there is no need for supplements.
If your newborn baby (less than two weeks old) needs to be supplemented, due to medical reasons such as jaundice, low weight gain, or severe nipple soreness, you should try to avoid artificial nipples if at all possible. There are many other options for feeding newborns, including cup feeding, tube feeding, spoon feeding, dropper feeding, or syringe feeding. If long term supplementation is necessary, Medela makes several products which may be helpful--the SNS, the SoftCup Feeder, or the Hazelbaker Finger Feeder. See "Medela Products" for description and prices. I recommend the Hazelbaker Finger Feeder, as I have used it extensively and it is simple as well as effective. When cup, spoon, dropper, or syringe feeding, make sure the baby is awake and alert, hold him in an upright position (you may want to swaddle him if he tends to flail his arms around) and gently pour or squirt in a few drops of milk. He will get the hang of it quickly, and set his own feeding rhythm. Use a towel or cloth diaper to protect his and your clothing--these feeding methods tend to be messy at first.
These types of supplementation work well for many mothers and babies--and dad can help too. If you need to supplement for more than a few days, some alternate methods such as syringe or cup feeding tend to become rather overwhelming. In that case, I would suggest that you either purchase one of Medela's products to make feeding easier, or use a bottle. The most important thing is to get milk into your baby so he will grow and become stronger so he will be able to nurse more effectively. Remember that some babies never become nipple confused, and if this does occur, there are techniques you can use to get him back on the breast. Using a bottle to feed your baby is not the 'kiss of death' for breastfeeding, and the most important thing is to lower your stress level and put weight on your baby as quickly as possible. When you are happily nursing six months or two years down the road, it won't matter one bit that your baby had some bottles in the beginning.
Let's assume that breastfeeding has gone along just beautifully for you and your baby. He is two weeks old, has regained his birth weight, and your nipple soreness and engorgement are things of the past. You now have a decision to make. If you plan to stay at home with your baby and take him with you wherever you go, and are comfortable nursing him in public places, you may not care if he ever takes a bottle. In that case, you may not decide to introduce bottles at all. I tend to think that it is better to introduce him to bottles at some point, just in case you have to be separated at some time, or you become too ill temporarily to nurse, or you just want to have an occasional break or night out with your partner.
Your situation is completely different if you know that you will have to return to work or school. In that case, you need to introduce bottles no later than one month, and earlier if you are returning to work at six weeks or sooner.
If you know that you want to have the option of giving your baby bottles, this is what I recommend:
- At 3-4 weeks (or 2-3 weeks if you are returning to work at 6 weeks) begin pumping after feedings for 4-5 minutes if your baby had a good feeding, or 8-10 minutes if he didn't nurse well or only nursed on one breast. This will get out the rest of the high calorie, fatty hindmilk, and will not interfere with your baby's nursing schedule. With babies this young, it's hard to nurse between feedings because they're usually not on that much of a schedule. You may nurse them and have 2-4 hours before they are ready to nurse again, or they want to nurse again an hour after their last feeding. If your baby consistently only takes one breast at a feeding, you can pump the other breast, but if you do this too often, you may over-stimulate your supply. Moms whose babies only take one side at a feeding generally have lots of milk to begin with.
- Pumping for a few minutes after nursing is the equivalent of the baby nursing for a few more minutes on each side, and will not significantly increase your supply, although repeated stimulation will increase it a little. In order to increase your supply significantly, as in the case of the baby who isn't gaining weight, you need to pump after feedings about 8 times a day or more. The type of pump you use is important here. Small electric pumps or manual pumps are not good at getting out the last little bit of milk left between feedings, but may be fine for very occasional use when your breasts are full. You really need the stimulation of a good electric pump that allows you to double pump (Medela's Classic or Lactina pumps, available for rental) or the Pump In Style (available for purchase). The amount you will get when you pump after feedings will vary significantly, depending on variables such as your individual milk supply (some mothers have enough milk for triplets, others barely enough for one baby, with most mothers falling somewhere in between those extremes), how long it has been since the baby nursed, whether he took one breast or two at the last feeding, and the time of day (you tend to get more milk in the morning, with your supply decreasing to its lowest levels late in the day). Some mothers pump for just a few minutes after a morning feeding, and get several ounces. If you are one of those mothers, you may only need to pump once each day and you will have your daily bottle, which you can either offer it to your baby to get him used to bottles, or save for when you go back to work. Other mothers may get 1/4 to 1/2 ounces when they pump after the baby nurses, and they may have to pump several times a day to get a bottle. If you are using a good electric pump, even if you have to pump 5 times a day to get a bottle, you have still only spent less than 30 minutes pumping, and you have your bottle for the day. You won't know how much you'll get until you try. When you are pumping in multiple sessions, be sure to cool the milk you just pumped before adding it to the milk you pumped previously.
- If you are bottle-feeding a newborn, I recommend a slow-flow orthodontic nipple. Medela sells an excellent bottle-feeding set that includes slow flow silicone nipples, bottles, caps, etc. My second choice is the NUK or Avent newborn nipples. If you are offering the bottle to an older baby, I don't think the type of nipple is really important. A baby older than a few weeks is very unlikely to forget how to nurse just because you give him an artificial nipple. The exception to this rule is the nubby Playtex nipple--you know, the one that is kind of square and supposedly looks just like a human nipple. Yes, it does look sort of like a human nipple, but it doesn't look anything at all like a nipple that is stretched out in a baby's mouth and pressed against his palate. That's where they got the idea for the orthodontic nipple, which looks a lot more like a human nipple in a baby's mouth. Babies who use a regular Playtex nipple often 'bite' at their mother's nipple when they go back to the breast. Playtex nurser systems are very popular, and older babies tend to do fine with any type of nipple. However, if you are bottle-feeding a newborn, try to avoid the regular Playtex nipple.
- Try offering the bottle when your baby isn't starving. This may seem illogical, but when a baby is frantically hungry, he is going to be in no mood to try something new. He just wants to nurse.
- Try having someone else offer the bottle at first. Your baby associates your smell and touch with nursing, and may insist on the real thing if you try to give him a bottle. You may have to leave the room entirely in order for the effort to be successful. Let Dad try, and if that doesn't work, let an experienced bottle feeder try. You'd be amazed at how many babies refuse to take bottles at home, but will take them willingly at day care where the provider approaches the process matter-of-factly. Encourage the caregiver to cuddle the baby while offering the bottle, but usually it is better to avoid the cradle position.
- Many babies associate the cradle hold, where they are cuddled against the breast, with nursing, and will refuse to accept the bottle as a substitute. This is especially true of newborns. Have you ever seen someone hold a hungry nursing infant in the nursing position? It doesn't matter if they are male or female, preschool or geriatric, the baby will turn his head, root, and try to nurse. Although some babies will accept a bottle more readily in the nursing hold, most will do better if you prop them up on your knees or in an infant seat, and make eye contact while feeding them.
- Offer a small amount at first. If he takes it readily, you can always offer more. If he doesn't take it, you won't have wasted much. Even taking a few sips is a step toward accepting the bottle.
- You don't have to substitute a bottle-feeding for an entire nursing. In the beginning, have dad try giving an ounce or two in the evening while your supply is lowest and you are the most in need of a break. Leave the room. Take a hot bath. Hope that it works.
- Some babies will take the bottle more readily if you move rhythmically while walking, swaying, rocking, and/or talking to them to distract them.
- If your baby is resistant to taking the bottle (this is seldom a problem in babies less than one month old), try:
- Feeding him when he is half asleep.
- Different nipples. Some babies prefer a slow flow nipple, some a faster flow. In general, orthodontic nipples tend to have a slower flow, which may be an advantage in a newborn, but a disadvantage in an older, more impatient baby.
- Make sure the nipple isn't cold when you offer it. Many babies couldn't care less if the milk you give them is cold (and it doesn't cause digestive problems--that's an old wives' tale) but they don't like the feel of a cold rubber nipple in their mouth. Run it under warm water before you offer it. Newborns especially don't like cold nipples. Sometimes older, teething babies like having a cold nipple to bite down on, so once again, you'll just have to experiment and see what works for your baby.
- Some babies with discerning tastes will refuse to take milk in a bottle, but will accept apple juice. It's almost as though they know that milk is supposed to come from breasts, and they won't take it any other way. Formula is a whole different thing. It tastes nasty (especially the pre-digested stuff like Nutramagen or Progestimil--these are products for babies who have problems digesting regular formula, and they taste and smell like spit-up, plus they cost a small fortune). It's like the difference between powdered or evaporated milk and regular cow's milk; they may have the same nutritional content, and you can use them in a pinch, but everybody knows that they don't taste the same. Breastmilk is quite a bit sweeter than formula. I have heard a toddler describe it as tasting like 'melted ice cream'. If you can overcome your squeamishness, taste it sometime. It really does taste better than cow's milk or formula. Most babies will take breastmilk more readily than they will take formula, but if you have a baby who is really picky, try offering a little bit of apple juice. If you can get him to take a few sips, try mixing milk with the juice a teaspoon at a time until you have more milk than juice.
- When offering the bottle, tickle the baby's lips gently with the nipple until he opens his mouth and explores the nipple. Don't try to force the nipple in his mouth.
- If your baby is older than a month or two when you offer the bottle, and he refuses it completely, try cup feeding. Many older babies bypass the bottle completely during separations from mom and do well with the cup. As long as they are nursing most of the time, their sucking needs will be met.
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