7.3.4 Bottle feeding
Bottle feeding should be a last choice for a breastfed infant.
It is only a feeding method, unlike breastfeeding which is a complete physiological, psychological and nutritional experience. Bottle feeding undermines breastfeeding success.
The physical act of bottle feeding is very different to the normal action which occurs during breastfeeding. Artificial nipples/teats are less elastic than a mother's breast. The infant's tongue works in an up-and-down piston motion during bottlefeeding 1 and overuses the buccinator and orbicularis oris muscles, while deactivating the masseter muscle. 2 3 4
Bottle feeding creates repeated airway closure during swallowing. Rapid milk flow results in more frequent swallowing and less opportunities for breathing. 5
When to use bottle feeding
- is unable to breastfeed for medical reasons or her infant's medical condition precludes breastfeeding ability.
- chooses to use a bottle for supplementation - with adequate education about impact on breastfeeding and health risks associated with bottle use.
- weans her infant when milk is still a major part of the diet.
Considerations when bottle feeding a breastfed infant
- Use a straight bottle rather than a bent bottle.
- Choosing a teat/artificial nipple: 6
- Use a long teat/artificial nipple. 7 (Tip reaches near to junction of soft and hard palates at back of mouth, where the tip of breast nipple would come to.)
- A medium-wide base. (Taken into mouth up to screw cap reminds baby to have a wide-open mouth.)
- Use a slow-flow artificial nipple/teat. Requires baby to suck well to obtain the milk.) A medium-flow artificial may be required for an infant with low tone. nipple.
- Choose a soft artificial nipple/teat. (Texture closer to breast nipple)
-
Rationale:
- Don't use artificial nipples that have a short, narrow shaft and a very wide base. They force the baby to make a tight mouth around the narrow shaft. This short shaft is forward in the baby's mouth changing the tongue position and action.
Bottle feeding technique
- Position the baby so that he is sitting upright. Support the baby's back, neck and base of head with the forearm and hand. Hold the bottle horizontally removing the pressure from gravity. (Kassing (2002) 8 cautions against the mother and/or caregiver using an arm or the crook of an elbow to support the baby's neck, because there is a greater tendency for the baby to lean back a bit rather than remaining upright.)
- Stimulate the rooting reflex using the tip of the artificial nipple brushed gently on the baby's lips. When baby opens his mouth very wide slide the tip of the teat under the top lip, wait for the baby to grasp and draw the entire artificial nipple into his mouth right up to the cap. (By stimulating the rooting reflex and waiting for a wide gape, you are simulating what will occur when breastfeeding.)
- Keeping baby upright, tilt the bottle just enough to keep the artificial nipple filled with milk. As the bottle empties take care not to hyper-extend the baby's neck.
- Closely observe baby for full duration of the feeding. Slow the feed, or pause it if the baby is showing early signs of distress. These signs can be very subtle: frowning, wide-eyed, fist clenching, etc. Baby should not get to the stage where he is gulping, or not pausing to take a breath, or becoming cyanosed.
Assess a bottle feed

© B.Ash, IBCLC

© B.Ash, IBCLC
What is the difference?
Good bottle feeding practices are essential
Positive nurturing and infant feeding are closely aligned. Encourage the bottle feeding mother to make the feeding experience an enjoyable one for her infant by responding to feeding cues promptly, holding her infant during feeding, using an appropriate nipple/teat for milk flow and not forcing the infant to consume more than he wants. Discuss observations the mother can make that indicate:
- early feeding cues,
- infant pleasure (or stress) during the feed,
- adequate intake such as
- signs of satiety
- normal bowel actions,
- expected urine output, and
- appropriate weight gain (neither excessive, nor inadequate).
- signs of satiety
Preventable dangers
In a 2008 study 9 more than 3/4 of mothers reported they did not receive instruction on artificial formula preparation from a health professional. Consequently many mothers did not follow safe practices when preparing their infant's formula feeds.
- Dangers of incorrect preparation
- gastrointestinal infection, serious illness and death from:
- contamination from unhygienic practices contaminating feeding implements
- contamination from bacteria found in the powdered formula when purchased (eg Cronobacter sakazakii) 10
- contaminated water supply.
- gastrointestinal infection, serious illness and death from:
- Incorrect reconstitution - a commonly found error:
- over-dilution causes poor weight gain and inadequate intake of calories and nutrients
- under-dilution causes hypernatremic dehydration, diarrhea and excessive intake of calories.
- Over-feeding and under-feeding by caregivers must also be addressed.
Volume of intake guidelines are available from various sources, however parents should be encouraged to use these as only a guide. Encourage feeding to be initiated when the infant cues and ended by the infant when satiety is indicated. A responsive caregiver is able to observe the infant's behavior so that the infant remains comfortable. The focus is on reading the infant's needs rather than consuming a predetermined volume of milk.- over-feeding causes 'food battles' and obesity,
- under-feeding causes poor growth and development
- both under- and over-feeding cause failure to thrive and malnutrition

Contamination of powdered infant formula
Cronobacter spp and Salmonella enterica bacteria have been cultivated from freshly opened tins of powdered infant formula and is a risk for ALL powdered milks. 11
Cronobacter species are opportunistic pathogens, and a mortality rate of 40 to 80% is found when contaminated infant formula is given to susceptible infants. This pathogen can cause a range of serious diseases such as meningitis, septicemia, necrotizing enterocolitis, and brain abscesses and has been responsible for a variety of sequelae such as quadriplegia. 12
Because it is not possible to produce sterile powdered infant formula it is recommended to use a sterile liquid preparation for newborns less than 1 month of age and preterm or sick infants.

Preparing breastmilk substitutes safely
Click on the title above. This links to a leaflet for mothers that describes, with very good graphics, how to safely prepare breastmilk substitutes. Read this leaflet, print it out and file it in your Workbook.
Go through this leaflet, or a similar one that your hospital or clinic may use,13 as you demonstrate to a mother how to prepare the formula. Then, most importantly, ask her to show you how she would do it by making up another bottle of formula, confirming that she understands each step of the process.
Note the minimum temperature of the water at the time the powdered formula is added - this minimum temperature is necessary to kill bacterial contaminants.
(70 degrees Celcius or 158 degrees Fahrenheit)

What should I remember?
- the different oral actions that occur during bottle feeding and breastfeeding
- the type of bottle and teat/artificial nipple to use when a breastfed infant is being bottle fed
- how to teach a safe bottle feeding technique that encourages positive parenting skills
- the preventable dangers inherent in bottle feeding
- how and why to effectively and clearly teach safe preparation of breastmilk substitutes and safe bottle feeding techniques to caregivers
Skills Competency #4

Teaching formula preparation and feeding
Notes
- # Weber F et al. (1986) An ultrasonographic study of the organisation of sucking and swallowing by newborn infants.
- # Franca EC et al. (2014) Electromyographic analysis of masseter muscle in newborns during suction in breast, bottle or cup feeding.
- # Inoue N et al. (1995) Reduction of masseter muscle activity in bottle-fed babies.
- # Gomes CF et al. (2006) Surface electromyography of facial muscles during natural and artificial feeding of infants
- # Mathew OP (1991) Breathing patterns of preterm infants during bottle feeding: role of milk flow.
- # Peterson A et al. (2009) Breast and Bottle: Reaching Your Breastfeeding Goals
- # Noble R et al. (1997) Therapeutic teat use for babies who breastfeed poorly
- # Kassing D (2002) Bottle-Feeding as a Tool to Reinforce Breastfeeding
- # Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.
- # Siqueira Santos RF et al. (2013) Screening for Cronobacter species in powdered and reconstituted infant formulas and from equipment used in formula preparation in maternity hospitals.
- # Holy O et al. (2014) Cronobacter spp. as emerging causes of healthcare-associated infection.
- # Norberg S et al. (2012) Cronobacter spp. in powdered infant formula.
- # World Health Organisation (2007) How to prepare formula for bottle-feeding at home