Module 2: Bottle Refusal

Introduction

  • This webinar covers bottle refill strategies, assessment, education, and management.

  • It's crucial for IBCLCs to understand bottle feeding as part of infant feeding and nutrition.

  • Strategies are based on multiple resources and experiences.

The IBCLC Role in Bottle Feeding

  • IBCLCs focus on infant feeding, encompassing both breastfeeding and bottle feeding.

  • Many patients are already bottle feeding when they first consult with IBCLCs.

  • IBCLCs can assist with exclusive bottle feeding or combo feeding.

  • Reasons families choose bottle feeding:

    • Separation of parent and baby

    • Supply issues

    • Circumstances

    • Work

    • Pain while breastfeeding

    • BMABs (Breast Milk After Breastfeeding)

    • Personal preference

  • Goals of IBCLC support:

    • Increase or maintain breast milk intake.

    • Build bottle competency while preserving breastfeeding.

    • Ensure adequate feeding.

  • Avoid conflict of interest and protect the WHO code.

  • IBCLCs are uniquely positioned to help both parent and baby in the feeding process.

Basics of Bottle Refusal

  • Basic strategies for bottle refusal:

    • Offer the bottle when the baby is not very hungry.

    • Feed the baby in different positions (bouncing, walking, rocking).

    • Use distractions.

    • Have someone other than mom offer the bottle.

    • Wrap the bottle in a shirt or cloth worn by mom.

    • Try different milk temperatures.

    • Try different bottle nipples (shapes, materials, flow).

    • Tasting and smelling the breast milk.

    • Baby-led latch.

    • Responsive feeding.

  • Before troubleshooting, ask:

    • Do we really need the bottle?

    • Alternatives: open cup, straw cup, spoon, medicine cup, syringe, finger feeding.

  • Assess the circumstances.

    • If the baby is mainly breastfeeding, protect the breastfeeding relationship.

    • Can we shift the schedule or routine to avoid needing the bottle?

Managing Simple Situations

  • Assume a healthy, full-term baby with no oral function issues.

  • If basic strategies work, the issue might have been:

    • Incorrect teeth choice.

    • High passive situation.

    • Milk temperature.

    • Feeding position.

    • Timing

Low Intake and Reverse Cycle Nursing

  • Reverse cycle nursing: baby feeds frequently at night to compensate for missed daytime feedings.

  • Considerations:

    • Some moms like this arrangement.

    • Others find it disrupts their sleep.

  • Solutions instead of bottles:

    • Early bedtime

    • Better sleep routine

    • Referral to a sleep consultant

    • Co-sleeping

    • Night shifts with family support

    • Pumping schedule

Responsive Feeding and Assessing Circumstances

  • Always ask: Do we really need to introduce a bottle? Can we make it work without it?

  • Different scenarios depend on the baby's age and the parents' goals.

  • If a bottle is necessary, practice responsive feeding.

Complex Cases of Bottle Refusal

  • Focus on assessment and management strategies beyond basic training.

  • Causes of bottle refusal in complex cases:

    • Baby-related:

      • Learned response to pressure feeding.

      • Oral anatomy issues affecting latch.

      • Tension.

      • Untreated reflux.

      • Intolerance, sensitivities, allergies.

    • Milk-related:

      • Taste.

      • High lipids.

      • Temperature.

    • Parent/Caregiver-related:

      • Pressure feeding.

      • Bottle feeding techniques (how, when, how often).

      • Misconceptions about normal daily intake.

Progression of Bottle Feeding Difficulties

  • Initial stage: Baby takes the bottle with little difficulty.

  • Difficulties emerge: Decreased sucking reflex, response to gentle nudging, intermittent coughing/choking, bottle hesitation.

  • Sucking becomes volitional: Distractions may work, fussiness, limited intake.

  • Older babies (3-4 months): Distractions stop working, feeding only when sleepy/drowsy, long feedings, bottle refusal when awake.

  • Full refusal: Anticipation of pressure, anger during feeding attempts.

  • Concerns: Weight gain and growth issues, parental frustration and anxiety.

Assessment Components

  • Assess the baby, the parent, and the bottle.

  • Optimal bottle feeding requirements:

    • Baby:

      • Maturity (full term vs. preemie).

      • Oral reflexes and motor skills.

      • Sucking skills.

      • Oral anatomy.

      • Body positioning and tension.

    • Bottle:

      • Shape: Conical teeth shape with adequate thickness and smoothness.

      • Flow: Adequate for the baby's needs.

      • Venting: Decreasing air intake.

    • Parent:

      • Sensitivity and responsiveness to cues.

      • Comfortable body and hand positioning.

      • Informed about responsive feeding.

      • Ability to let the baby lead.

Key Elements for Latch

  • Baby-led latch

  • Organized Suck

  • Suck, swallow, breathe coordination

Assessing Diet and Bottle Checklist

  • Baby:

    • Responsiveness.

    • Stable, supported position with hips flexed.

    • Gape, wide latch, lip seal, cupping of tongue.

    • Lips flanged.

    • Soft swallow-breathe coordination (no gasping, coughing, choking).

    • Satiety and hunger cues.

  • Bottle:

    • Shape, flow, materials (thickness, slipperiness).

  • Parent:

    • Eye contact.

    • Hand positioning.

    • Responsiveness and bonding.

    • Awareness of baby's cues.

Red Flags During Assessment

  • Blanching of lips (oral tension).

  • Dimpled cheeks (overuse of lips and cheeks).

  • Signs of stress (fist clenching, body tension, blinking).

  • Clicking or smacking noises.

  • Leaking milk.

  • Very fast gulping.

  • Coughing or gasping.

  • Pulling or arching.

Educating Parents

  • When to introduce bottles: 4-6 weeks once breastfeeding is established.

  • How often: Consistency is key (at least one bottle a day).

  • How much to offer: Start with one ounce, teach parents to calculate average daily intake.

  • Average daily intake: 3-5 ounces between one to six months.

  • Formula-fed babies may take 20% larger fittings.

  • Optimal bottle feed length: 15-30 minutes (5-10 minutes per ounce).

Bottle Feeding Skills

  • For bottle refusers, milk is a stressor, not a motivator.

  • Building bottle feeding skills:

    1. Introduce the nipple/teeth without the bottle.

    2. Stroke the upper lip.

    3. Encourage the baby to soften the nipple (finger inside the teeth towards the palate, incorporating cheeks for fishy face).

    4. Pour drops of milk into the nipple with a dropper/syringe.

    5. Offer the nipple with the bottle attached.

    6. Encourage sucking and adjust the latch as needed.

    7. Angle the bottle to allow the baby to start drinking (nipple half full, baby controls the pace).

Signs of Satiety and Stress Cues

  • Signs of satiety (babies under 3 months):

    • Sucking slows down or stops.

    • Relaxed jaw.

    • Closing mouth, turning away.

    • Relaxed body (milk drunk).

  • Signs of satiety (older babies):

    • Stop sucking, chew on the nipple.

    • Push out the clamp, turn head away.

  • Stress cues:

    • Fist clenching

    • Forehead furrowing

    • Bringing hands by eyes

    • Tense body

    • Fast gulping and leaking.

Strategies and Flow Issues

  • Offer the bottle when the baby is happy.

  • Hungry babies do not learn well.

  • Strategies include Body warm-up, oral warm-up and positioning

  • Flow Issues:

    • Too fast: Fast Gulping, gasping, milk leaking, furrowed brow. Flow too fast.

    • Too slow: Biting the nipple, sleepy or fussy.

Body Warm-Up and Body Positioning

  • Body warm-up:

    • Arm circles

    • Lateral stretch

    • Leg circles

    • Rhythmic movements

    • Guppy position.

  • Body positioning:

    • Cradle hold (upright, full body support, head resting on arm, hips flexed).

    • Side lying position (for easily stimulated babies or body tension).

Technique for Latch

Aim nipple toward palate, look for an organized sock. (1 to 3 sucks then pause to swallow then go back to sucking)

*Oral dysfunction: use chick and jaw support

Developing Bottle Feeding Skills

So first master the baby sucking without the bottle, then slowly add the bottle. The goal is that milk becomes a motivator, not stressor.

Home work Timeline

  • Average, it takes 2 to 4 weeks to learn bottle skills

  • Progress checks every 3 to 7 days.

  • Transition to hunger pressure for full feed, once fully mastered. Mastered skills means a transition into about 2 to 4 weeks.

Alternative Feeding Methods

  • Educate parents on alternative feeding methods if bottles are not needed or for weaning.

  • Options: open cup, straw cup, medicine cup, finger feeding tube (depending on the baby's age).

    • Under 4 months: Small cup. Spoon or finger feeding.

    • Five months and up open cup or straw cup.

Consultation Structure

  1. Intake form: Parents' goals, main concerns, medical history, feeding history, current routine, 24 history, what has worked and didn't worked.

  2. Infant oral and physical exam: Assess head preference, body positioning, body tension (on back, in parents' arms, tummy time).

  3. Feeding Assessments should come first. (Verbal guidance first then use props) and avoid hands on until assess how they usually do it.