Expert Advice On Feeding Your Children

Bottle Refusal in Breastfed Babies

8/6/2020

Image via @shafferwoman

"I assumed all babies would willingly take a bottle..."

When you learn about breastfeeding during pregnancy, you hear terms like “supply and demand” and are taught how important a good latch is for successful milk transfer. However, very few people talk about the fact that many breastfed babies refuse to take bottles of breast milk, something many moms don’t expect. We see images of baby bottles everywhere and assume that all babies will drink from them.

Interestingly, the bottle is easier for a breastfed baby to drink out of since it’s a static process. Some babies can drink milk much faster from a bottle than a breast. For this reason, many moms are advised to not introduce a bottle until at least 4-6 weeks, or when breastfeeding is well established. What many moms don’t expect is that not all babies will take a bottle when it’s eventually introduced.

While bottle refusal is OK for some families, many moms need to go back to work or would like more flexibility in feeding. It can be extremely frustrating and isolating for a mom who wants or needs to be away from their baby longer than two hours but cannot due to feeding schedules. Furthermore, bottle refusal can be difficult for care providers and can discourage loved ones from wanting to care for the baby.

It is a blessing to successfully breastfeed, but when baby can’t take a bottle, sometimes mom feels trapped. Perhaps she’s distracted at work because she worries about how much milk her baby is drinking at daycare. These are very valid, real feelings. Fortunately, this situation is temporary.

Both of Megan’s babies refused bottles, as have many of our clients’ babies, so we are fully aware of the emotional toll this can take on a family. We wanted to share some practical tips and alternatives to bottles that can help you survive this temporary phase.

Before you read this article, please know these four things:

There is nothing wrong with you or your baby if they refuse a bottle.
Babies technically don’t need to learn to drink from a bottle if they are successfully breastfeeding – they’re not missing a developmental skill! Many babies skip straight to a cup as early as 4 months.
Many babies eventually take a bottle if they need to, especially if mom is gone all day at work. Most childcare providers have experience with this and will work with you to make it a successful process.
This is so temporary! Eventually your baby will be eating food and drinking from a cup, and one day they won’t be breastfeeding. Try to remind yourself that this won’t last forever!

Oh, and one day your bottle refuser will be a toddler who sees a baby bottle and tries to drink from it. Little stinker.

Let’s talk about how to navigate bottle refusal.

All images used in this blog post were submitted by members of our Feeding Littles Clients Only Facebook Group and are used with permission.

Image via @eechocho

First, an important safety caveat.

This article assumes that your baby is getting enough milk to support adequate growth and development via breastfeeding. If your baby isn’t transferring milk well, is refusing to breastfeed, is away from breastfeeding mom for a prolonged period and isn’t taking milk, or is refusing their formula please work with your health care provider ASAP. Dehydration in infants can be very dangerous and must be addressed immediately. Additionally, it’s important to make sure that your child does not have any medical issues that would prevent them from taking a bottle. For example, babies born prematurely and those with neuromuscular impairments maybe more susceptible to feeding preferences, and these specific concerns should be discussed with your child’s pediatrician, lactation and feeding specialists.

Why do babies refuse bottles?

Unfortunately, we never know which babies will refuse bottles. Many babies have no difficulty transitioning back and forth between breast and bottle, while other babies will fight a bottle and refuse to accept it.

Let’s briefly discuss the mechanics of breast and bottle feeding so we can better understand what your baby is experiencing.

Breastfeeding is dynamic – as breasts fill and empty, a baby’s mouth constantly adjusts to accommodate these changes. Breastmilk changes in consistency and nutrient quality from the beginning of the feed to the end. It starts off more watery and higher in protein, which can help baby quench their thirst and provides amino acids for physiologic processes, and becomes higher in fat and creamier in texture as the feed proceeds. The milk consistency and changes throughout the day, as does the taste of breastmilk depending on mom's diet. Even the color of breastmilk can change from day to day!

What’s more, breastfeeding is a dynamic bonding experience between mom and baby. Babies are used to mom’s voice, her smell, her body and the little routines they have established together while feeding. Of course, you don’t have to breastfeed to bond with your baby, but from a nursing baby’s perspective, feeding time equals time with mom.

That’s why when you try to bottle feed some breastfed babies, they refuse to drink the milk. The bottle is not dynamic like a breast, and the nipple itself is very different than mom’s nipple. Babies know the difference – they’re smart little creatures! What’s more, when mom tries to give baby a bottle, baby might not understand why they can’t have what they’re used to – the breast.

Think about it from your baby’s perspective: all they know is cuddling with mom (warm, comfortable, familiar) and getting their milk from her breast. They have done it only this way for potentially 500-2,000 feeds, depending on when you start to offer a bottle. Suddenly you are asking them to do something extraordinarily different than what they’ve practiced their entire life. It makes sense that many of them refuse the bottle.

Image via Cybele Ponton

Stress can affect this process, big time.

Before we talk about specific strategies (we promise to get there!), we want to emphasize how much stress can affect how well a breastfed baby will take a bottle. When babies refuse bottles, it can understandably be extremely stressful and anxiety-driven. Breastfeeding moms may feel desperate, “trapped” at home or angry that their baby isn’t figuring it out. Similarly, the adult attempting to feed the baby with a bottle may be frustrated or fearful because it hasn’t been going well. They might not be willing to continue to try.

Your baby can pick up on this stress. They sense not only their mom’s anxiety, but also the stress of the person giving them the bottle. Stress in a breastfeeding mom may affect their breast milk production.

Of course…hearing that you need to stress less or “calm down” when faced with an emotionally-charged topic only stresses you out even more. Rather, we (Judy and Megan) just want to highlight how important it is to be emotionally calm and steady when trying to offer the bottle. It’s equally as important for the person doing the bottle feeding to try to remain calm, patient and positive during this process. Notice how your body tenses or how the bottle feeder responds to the baby if your baby is turning their head, spitting out the bottle nipple or crying. If the bottle feeder or the baby begin to get noticeably stressed, take a break and try again. Explain to the bottle feeder that this is a process that might take time.

Image via Tracy Islam

How can I (hopefully) prevent my baby from refusing bottles?

If you are planning to return to work, many lactation professionals recommend offering the bottle every few days starting at 2-4 weeks of age. Of course, if breastfeeding is still a major struggle, work with your lactation consultant first. Be consistent – it can take time for your baby to become accustomed to the feel and the rhythm of a bottle. Ideally, have someone other than the breastfeeding mom do the bottle feeds. This can be a great bonding experience for your partner or another family member.

If possible, start by putting an ounce or two of expressed breastmilk in a bottle with a slow-flow or preemie nipple. Judy recommends Dr. Brown’s bottles because they are known for their venting system. This helps keep air out of the milk, which prevents gas and makes the feeding go more smoothly. If we don’t need to burp the baby as often, then less latching on and off may occur. Many babies get frustrated and somewhat lost the more frequent on/off latching with the bottles when they're used to breastfeeding.

You don’t need to offer a full feed; the goal is to get your baby used to the sucking pattern and nipple feel of a bottle. If you’re consistent with offering a bottle every few days, your baby will be more likely to continue to accept it.

My baby won't take the bottle - what do I do?

Below are some specific tips and multiple things to rule out if your baby refuses a bottle. You don't have to try all of these things! We are simply offering multiple techniques that may help.

Don't forget to read your baby’s cues. We don’t want to force a baby to drink from the bottle by holding it in their mouth when they’re refusing to swallow or if they’re crying without suckling. It can become a safety hazard if milk is in their mouth but they’re not swallowing effectively, and they can develop a negative association with bottles and feeding time. Above all else, don’t force this process.

Start with a happy baby who’s not extremely hungry and is well rested. You can try to offer when a baby is also just waking up or just ready to fall asleep, as many babies will be ready to suckle and try a bottle during these times.
Remember that a breastfed baby might not know what a bottle is until they’re being expected to drink from one. Children learn about new things through play and exposure. Give your baby a chance to see a bottle before you put any milk into it. If they’re old enough to reach for it, let them touch it or hold it first. We want them to think of bottles as a positive thing. Sometimes it helps to see and explore it first.
Find a bottle with a longer nipple – no need to buy bottles that look like a breast. A longer nipple will be easier for the average infant to get into a suck swallow rhythm and develop an anterior-posterior suck pattern. Judy prefers Dr. Brown's bottles first. If that doesn’t work, try a few different bottles and nipple types. Just don’t buy a huge collection of bottles. (Trust us, it will be very expensive and will just cause more stress if they don’t drink from them. Megan spent hundreds of dollars on different specialty bottles and her baby drank from none of them.) Some families find that one type has worked for their breastfed baby, but your baby may be different. Interestingly, the only bottle nipple Megan’s babies would somewhat drink from were made of latex instead of silicone (Playtex brand).
If possible, have a friend or family member – anyone but the nursing mom – offer the bottle to baby. This can really help long-term, as your baby learns that milk can come from other people in a different way.
Try offering freshly pumped breastmilk, as many babies can taste the difference of frozen milk.
Start with small amounts - even ¼ ounce is great! Try no more than 10 minutes at a time to prevent frustration.
Warm the bottle nipple by sticking it under warm water prior to beginning to feed to help mimic the feel and warmth of a breast. If this doesn't work, play with the bottle and nipple temperature too. Your baby may actually prefer the bottle temperature to be slightly different than the breast.
Allow your baby to touch and feel the bottle as they drink from it – learn more about the importance of bringing their hands to midline here. Add a hair tie onto the bottle as a sensory/tactile focus point for their hands to reach for during a feed. Sometimes babies can focus on feeding better if their hands are working in a midline position, similarly to how they may pat the breast while breastfeeding.
Try to support your baby’s feet using your own body, a breast feeding pillow or a Boppy to offer their feet stability and give them the feeling that they are well supported. This is similar to when your baby eats solids - foot support is really important.
Keep the bottle practice sessions short, positive and consistent.
Use movement – a rocking chair or swaying motion can help your infant self-regulate while eating. Some caregivers have success offering the bottle for the first few times while baby is in the stroller and moving. Eventually it's important for the bottle feeder to hold your baby as they take the bottle, but this can help their willingness to drink from it at first. Try to change things and see what may make the baby happier.
Experiment with different holding positions. Try putting your baby more upright - not in a breastfeeding position.
Change up the environment and where you are offering the bottle. Consider offering a bottle in the carseat, in a bouncy seat or in a different room in the house. Go outside if weather permits. Try adding a little distraction. Show them a book or sit/stand facing out a window, as a temporary distraction that allows them to get used to the bottle. We don’t want to make this a long-term solution because we want your baby to focus on eating during bottle feeds, but it can help your baby forget that they’re not eating in their preferred manner. Change up who is offering the bottle too, this can sometimes be a huge strategy that makes the biggest difference. Sometimes a baby will only drink from a bottle if the mom is not in the room, but sometimes they want mom nearby. Try it multiple ways.
Some families find that baby is more willing to take a bottle if you offer it after taking out the pacifier.
Make sure that the milk you’re offering tastes good. Yes, that may mean smelling or tasting it! It could taste metallic, soapy or spoiled, and it’s important to get to the root cause of the taste change. Read more about what can cause milk to change taste, including high lipase in your milk, here.
Even if your baby isn't taking a bottle at home, give it a try at daycare or with your other care provider before worrying that it won’t work at all. Sometimes baby will hold out for a few hours, but after realizing that mom isn’t back yet they’ll eventually drink the milk.
Try different nipple sizes and flows. Many babies who are breastfed like a slow flow nipple, but that might not be the case for your baby.
If you have oversupply or a forceful letdown, your baby might be used to milk pouring out of the breast. A bottle takes more work. (This is actually the opposite of what happens with most breastfed babies, where the breast takes more work.) In the case of oversupply, try a softer-textured nipple like the Como Tomo bottle. A faster flow nipple might also be indicated. Again, try a variety of nipple sizes and flows
Practice, practice, practice. This might take time.

Image via @caramielle

My baby still won't drink from the bottle despite trying everything above. Now what do I do?

First off, it’s important to remember that there’s nothing wrong with you or your baby if they don’t take a bottle. It’s not a required developmental step. Breastfeeding does great things to develop your child's oral-motor skills, so don’t worry that they are “missing out” developmentally if they don’t take a bottle.

However, that doesn’t make bottle refusal easy. Here are some ways to work around bottle refusal:

Breastfeed your baby right before leaving them at daycare or with another care provider.
If possible, have someone bring your baby to you – or go to them - during lunch or pump breaks. This is not feasible for many moms, but depending on your work and proximity to baby, some families are able to do this.
Consider using an open cup with a baby as young as 4 months. Baby must have good head/neck control for this to be successful as a consistent solution. Head to the section below on alternative feeding devices for more on introducing an open cup to a baby 4 months and older.
Once babies become proficient with an open cup, they can try a straw cup – some babies can do this as early as 5 months of age. Learn more about teaching your baby to use a straw cup here.
As of around 6 months, babies can start eating solid foods. Sometimes adding solid foods and small amounts of water in a cup can help keep baby satisfied until mom comes back, especially when coupled with breast milk in cups.
Some babies “reverse cycle” when away from mom. They take in just enough milk to not be starving during the day but feed much more frequently at night. For some families this works well, especially if mom is able to go to bed early to accommodate less sleep.

Image via @ashbcoop

Alternative Feeding Devices

NIf your baby will not take a bottle and you need to give them milk in another manner, sometimes additional tools may help. Before using any of these techniques, please consult a feeding specialist or lactation specialist, especially if your baby has any breathing or swallowing issues. The biggest concern with this type of feeding is a risk for aspiration if your baby isn’t actively drinking the milk.

We are simply offering these techniques to help you safely use these tools and be aware that they exist. This does not replace medical advice or care. Talk with your provider about which specific products and techniques will work best for your baby.

Dropper or syringe:

Place your baby on your lap or another adult's lap in an upright position. Be certain to safely support their head and slightly support the chin with your hand. Some parents swaddle younger babies to help them relax.
Load a dropper or syringe with a small amount of warm breast milk. Insert the loaded syringe or dropper into the gum line near the cheek of your baby’s mouth. It is also possible to put the dropper into the center of their mouth if they are able to demonstrate lip closure around it. In this case, allow the syringe of the dropper to rest comfortably on the tongue. If this technique elicits a gag, you have gone too far back and it is best to try into the cheek area or along the gum line.
Gently squeeze the dropper or syringe, allowing a small amount of breast milk to be released into their mouth. Start with a few drops at a time, allowing your baby to get used to the feeling. With practice, they should start to close their lips around the syringe or dropper and will coordinate their swallowing pattern. Eventually you will be able to offer more liquid.

Open cup, bowl or spoon

We generally recommend introducing an open cup to babies around 6 months when they start solids as discussed in our Ultimate Guide to Cup Drinking. However, if your breastfed baby is refusing bottles, you can try an open cup, bowl or spoon as early as 4 months, or when your baby has good head and neck control.

Note: sometimes spoon feeding colostrum or breast milk is a technique used much earlier than 4 months - lactation specialists often utilize it in the hospital before a baby has figured out how to breastfeed. These are general guidelines to help families whose babies consistently refuse bottles and can't receive milk when mom is away, but every baby and situation will be different. Work with your provider.

Place your baby in an upright position.
Place warm breast milk in the bowl or cup. If using a spoon, capture some breastmilk into the spoon.
Tilt the cup or bowl to your baby’s lips. If using a spoon, bring the spoon toward baby’s lips. Place the edge of the cup, bowl or spoon to the outer edge of their top lip, resting it gently on their lower lip with the tongue inside the cup, bowl or spoon. Leave it in this position during the feed.
Allow your baby to tongue or lap up the milk slowly. With practice, they will be able to swallow more and take in more milk.
When starting this method, allow plenty of time to be with your baby. Try to relax, and do not spend more than 20 minutes practicing this technique. Many babies can become great open cup/open bowl drinkers as long as they have good head support.

Image via @ohhappystatons

Can you continue to breastfeed into toddlerhood if your baby refuses bottles as an infant?

Yes! Many moms decide to breastfeed into toddlerhood (12+ months). At this point, breastfeeding a bottle-refusing baby can be less stressful since they don’t need to breastfeed as much as they did in infancy. Many moms gradually stop pumping at work and only breastfeed when they’re with their toddler. While at daycare (or while mom travels), baby drinks an alternative milk from a cup or gets their nutrition through food and water until mom comes home.

Image via Elaine McDonnell

We know that bottle refusal can be really stressful, but we hope these strategies help you discover some solutions for your family. Soon your baby will be drinking from a cup and eating food like a pro – this is so temporary!