Bottle Refusal - is this really the problem?
Human infants - like all other mammals - are programmed to breastfeed from birth until the natural weaning age. Nature created this system thousands of years ago and has never needed to modify the system. However, modern life for mothers and babies is nothing like Nature had in mind and society has introduced some big changes to how babies are fed.
The separation of mother and baby was never part of Nature’s plan but it is increasingly part of society’s. The support for women to stay at home with their infants has never been lower. Productivity is measured by a contribution in the paid workforce and access to paid maternity leave is far from equitable around the world. In some countries like the USA, there is zero mandated paid leave and women are back at work within weeks or even days after giving birth. In other countries, like Sweden, paid leave is available for as many as eighteen months after having a baby.
This inequity impacts infant feeding. In a country like Australia, where six months of paid parental leave is available to most mothers, babies need alternative ways to receive breastmilk when they are separated from their mother. Common-practice is to introduce bottles and teats for babies to be given expressed breastmilk or infant formula by caregivers.
After the intense weeks or months of establishing breastfeeding, it can come as a shock to discover your baby is - as you planned - exclusively breastfed. As in, they refuse to have anything to do with a teat and bottle and protest at any suggestion of it. This can lead to huge concern as the return to work date looms.
“Bottle refusal” is a new term used to describe this issue. But is this as big a problem as it can seem?
As we have seen, feeding from a teat is nothing like feeding directly at the breast. So these babies aren’t really refusing a teat - they are confused and frustrated by its presentation when they are expecting to go on the breast. Babies have an instinct to suck and will suck on a teat for the reward of milk but they have no idea that is what is on offer.
Even if your baby had occasional or routine bottles in the early days of feeding while you worked through attachment and supply challenges, they simply don’t have the kind of long-term memory to carry that experience forward several weeks or months. What is a very short break to an adult is a lifetime ago to a baby. This is a whole new experience.
The most common age for this situation to arrive is around 3-4 months. There does appear to be a window of opportunity before this when babies will accept a bottle more readily in the 4th trimester. Indeed, to frequent bottle use can lead to the opposite problem - “nipple confusion” describes a baby who struggles to latch after getting used to the teat! By four months, the brain has developed to a point where the infant is much more aware of what is going on around them. Protest at a bottle being presented at feed time is very common at this age.
There are things you can do to encourage your reluctant feeder:
If you are the source of the breastmilk, your baby is going to be extra confused. You smell, feel and sound like the breast is nearby. For all these weeks or months, your presence has signaled a breastfeed is about to happen. Every instinct your baby has is designed to help them access the breast whenever they know it is close by. To avoid this great disappointment, hand your baby and the bottle to another caregiver and move away from your baby. Going into another room can be physically and emotionally challenging as your breasts will still respond to your baby’s feeding cues and confusion, so going outside or for a short walk will help.
Present the teat to the baby, don’t put it in their mouth. Breastfed babies are in control of when the breast comes into their mouth. They draw the nipple and breast into place and commence removing the milk. They find it overwhelming to have a hard teat pushed between their lips. Instead, let them smell and feel the teat near their face and wait for them to gape for it.
Some babies will come around to the idea of a teat if they have some experience of milk from a cup first. The wide surface area of milk in a cup helps them smell it far more than when it is enclosed in bottle. The baby will instinctively poke their tongue towards the smell and taste the milk immediately without anything else in their mouth.
Hold the baby in a very different position. Breastfed babies are used to being held very close to the mother’s body, with their face up against her soft breast. Try a more upright supported sitting position, even facing the baby away from your body altogether. Make the experience very different so the baby isn’t expecting the breast.
It is hard to learn new things when you are hungry, tired or distressed. Choose a time after a breastfeed when the baby is alert and happy. Introduce the bottle as you would a new toy and let them explore what it does. Babies put most things in their mouth and they are likely to do this and maybe even taste some milk. You can do this with a small volume of milk as a learning opportunity.
Breastmilk is body temperature. Its a simple thing but over-warming expressed breastmilk or formula can trigger distress simply because it feels hot near the mouth. Or, a teat cold from storage in the fridge with the bottle can also be refused because it is cold near the mouth! Like Goldilocks, some babies need the temperature to be Just Right when it comes to milk and equipment.
As well as the smell of breastmilk, the smell of the mother can signal a feed to the baby. If you smell strongly of cologne, perfume or other strong scents, the baby might not be able to smell the breastmilk. Take a shower before offering the feed and don’t apply scented products. You might even find wearing the mother’s pajama top or dressing gown draped around you will reassure the baby enough to feed.
Don’t sit in Mum’s feeding chair! In fact, try not sitting at all - try standing and walking around while offering the bottle.
What to do if its just not working?
If your baby is older than six months, you don’t have to get them to take a bottle at all. Instead, focus on introducing liquids from a cup - both water and expressed breastmilk or formula. This is a skill typically learned alongside introducing solids and your baby is already getting used to the idea of food beyond the breast. While you are apart, your older baby needs fluid, food and comfort. For some babies, this looks like water from a sippy cup, food including dairy like cheese and yoghurt and a dummy or familiar toy or blanket. This gets them through the working day in the care of an adult who is caring for them. Once back with Mum, they breastfeed often to catch up. Called “reverse cycling” by some people, this nighttime breastfeeding in the evening and over-night soon equals the feeds they might have been having during the day previously. Hard work but also reconnection appreciated by mother and baby.
Babies under six months cannot rely on complementary foods (solids) and water. Exclusive breastfeeding, mixed feeding or infant formula feeding are the only recommendations from birth to six months. So these babies need a more concerted effort to help them take the milk they need. Cup feeding is the most effective alternative and something caregivers can learn just in case it is needed. Babies can also be given breastmilk or formula from a spoon or syringe. These can be used in the shirt-term while working towards a more practical solution.
Your return to the workplace may need to be renegotiated during this transitional period. If a baby cannot be separated from their mother, then options to keep them together need to be explored. Here are a few options:
Take the baby to the workplace for care by the mother
Take the baby to the workplace for care by the caregiver
Bring the baby to the workplace for feeding
Care for the baby near to the workplace so the mother can go to them for feeds
Return to the home of the baby or their daycare for feeds. Delay the return to work with additional leave or negotiation
Work from home so the baby is nearby for feeds while cared for by the caregiver
None of these options will feel as convenient or ideal as your initial plan. However they might work in the short-term while you support your baby toward alternative feeding methods.
It is always optimal that mothers and babies are supported to stay together. Returning to the workforce is recognised as a significant barrier to breastfeeding for many women. Until we have a society where the needs of mothers and babies to be near to each other through onsite childcare, work from home options, lactation leave and other culture changes, we need to accept the need for some babies to be fed expressed breastmilk by bottle.
