The question of the breast to bottle transition was raised by one of my readers and, as it is a common problem I thought I’d better address it fully.

This was the question. “Hi there. I am in a similar situation as exclusively breastfeeding my 3 month old baby but need to go back to work soon… I am happy with expressing with the medela pump but unfortunately struggling to get my daughter to accept a bottle. Have tried many different bottles and mam size 2 teat is the best flow. Have dipped teat in milk and gripe water to encourage her to suck but she still won’t drink from it. Any suggestions please? Thank you!”

This is often the subject of trouble shooting jobs that I, and many of my maternity nurse friends, have to deal with on a regular basis and it is frustrating because it is totally preventable by introducing the baby to a bottle (expressed or formula) within the first month.

The problem is…..No one ever tells you this !! Not midwifes, not health visitors, not baby books or magazine articles, so how on earth, as a new, inexperienced parent, are you supposed to know ??

Some of the problems come from breastfeeding extremists who demonise bottles for any reason, and share scare stories about ‘nipple confusion’ and ‘lazy babies’ and ‘bottle ‘addiction, but let me reassure you now that neither I, nor any of the maternity nurses I have spoken to, have ever come a genuine case of nipple confusion.

Think about it. The one thing babies can do, from birth, is to suck. They suck on nipples (of every shape and size), teats, pacifiers, fingers, and noses and chins if they come near enough.

Babies are programmed to suck for their very survival and they can cope with a wide variety of options which is why so many of them are very successfully combination fed

Why Babies Need to be Introduced to a Bottle by 3 Weeks.

A baby of 3 months is not as compliant and passive as a younger baby as they are starting to develop their characters and preferences and have the stamina to be quite/very determined if they are not happy about something so it is sometimes not an easy fix.

Also, they already have a very fixed set of signals that they are responding to, and by signals, I mean the fact that everything has been done a certain way, every feed, every day for their whole 3 month existence and so the associations are very strong.
They associate the process of feeding with signals e.g. the lovely feeling of going from empty to full, the sleepy cosiness of a full tummy, the connected feeling from being at the breast, the position they are being held in, the smell of the mother, the mothers voice, and often being fed at certain times of the day in particular places and these all act together to create a fixed habit, one which they can be very resistant when you try to change it.

Just to illustrate the cleverness of new babies and the strength of signals and associations, one of my babies was combination fed, feeding from the mother for an hour, then topping up with a bottle from me. After just 3 weeks this baby, whenever held by the mum, turned her face inwards and tried to nurse but whenever held by me looked up in to my face and made a very clear sucking shape with her mouth and a slurping noise. When her father held her she did neither, because, though he did sometimes bottle feed her it was not with the regularity needed to set up a strong association.

The good news is that babies are also programmed to be adaptive in order to survive whatever life throws at them, so, with this in our favour, it is just a case of breaking the habit and replacing the signals and associations.
Your best chance is going to involve imagination, persistence, trial and error, and consistency.

The first thing is to try and find a bottle with a slow flow rate, similar to the breast because babies have to suck hard to get milk from a breast and can find a faster flow rate a shock, leading to coughing and choking and upset.
I sat down on my own recently, put fruit juice in lots of bottles and tried them all myself looking for the slowest flow (quite fun really) and found that the slowest was a bottle called the Munchkin Latch (available in the UK but don’t know about elsewhere) followed next by the old style Medela bottle (not the new Calma teat). Try this yourself with whatever bottles you or your friends have between you and focus on the flow rather than the shape because baby will adapt more rapidly to a different teat shape than to a faster flow rate.

When you feed, try and have the milk as near to body temperature as you can and have some warm water nearby so you can pop it back in to warm up if the baby stops feeding.

Once you have found the bottle you want to use don’t change it.
You may be tempted to keep trying others, looking for the ‘magic bottle’ but you will make the transition harder for your baby. Remember, they are adaptive and you will be doing them a favour if you remember this, stay consistent and give them a chance to make the change.

It often helps to have someone other than the mother to do the feed as they will not be associated with breast feeding and sometimes this can be all that is needed to make the switch.
If that is not an option, or doesn’t work, then you need to think carefully about how you hold the baby, where you feed, what you do during a feed i.e. talk to baby, read, watch TV, make calls etc., what baby can see or hear.
These all provide signals and may need to be changed in order to help baby create a new habit and this is where the trial and error and imagination comes in.

You know your baby best so if you think they can cope with a lot of change then try a completely different type of feed and use distraction which can be a great help. If you think massive changes will be too much for them, then try making more subtle, soothing changes.

Feed in a different room, with different sounds (soothing or distracting depending on baby’s temperament), sit near a window or TV, or sit near table lamps or under spotlights.

Try making yourself smell different. Don’t use perfumes which babies find too strong, try rubbing yourself with fresh herbs (sounds nuts, I know lol) or lemon juice, or have strong smelling herbal tea in a cup nearby.

With some babies the answer is movement as this both soothes and distracts so walk around, jiggle them or pat them, have a slow dance. Don’t worry about creating bad habits. You won’t have to do this forever, just for a couple of days to create a new feeding habit with positive associations, then you can gradually wean baby off the dance
Mirrors are also a great way of distracting babies as they love the reflection, light and movement.

Really desperate ? Try the bathroom. I helped one particularly stubborn baby by feeding in a bathroom, with all the bright lights on, perched on the edge of the bath, with the tap on full for white noise !! I got back ache and a numb bum but it worked !! I fed baby there for the next day and a half, until baby was feeding reliably, then started the feed in there but walked out into the hallway, gradually moving over 3 days until I could feed her in the nursery, sitting a comfortable chair.

Another trick to try is swaddling the baby. Even if you have never swaddled before, or have weaned the baby off the swaddle it is worth trying as the feeling of being snuggly wrapped can help some babies (of course, it may also infuriate your baby but you won’t know until you try !)

Also try covering the baby’s eyes with a cloth or a hat so they can’t see you and are more likely to relax. Try it and walk, rock or jiggle baby until they are calm and let them suck on a pacifier or clean finger (use your little finger, with a short nail, and have it with the nail on the tongue and the soft pad up towards the roof of the mouth).

Once you have them sucking calmly, try slowly and gently sneaking the finger/pacifier out and ease the bottle in, and hopefully they will continue sucking (this is why it helps to have a slow flow teat so they don’t get a nasty shock).

You may also try feeding them when they are asleep. Catch them before they wake up and gently slip the bottle in and hope their strong sucking reflex kicks in.

Try feeding them with their backs against you so they are facing out in to the room and can be distracted by other people or TV (don’t worry, it won’t create a TV addiction, just use it for the transition period then stop using it if it bothers you).

Try using a sling with baby facing inwards (just loosen the sling until you can manoeuvre baby into a slightly sideways position). This can help bad backs and makes it easier to cover baby’s eyes, and you can either sit down or move around. Also try it with baby facing outwards.

One baby that was a real challenge ended up having to be fed outside in the park, under trees!! I used this drastic strategy to break the old habit and create a new one. That only took 1 day before I could feed indoors standing up, and another day before I could feed sitting down.

Another baby, extremely highly strung, easily stressed baby responded to being tightly swaddled, with eyes covered and fed in a dark, silent room. I did this for 3 days, then introduced some gentle music (Piano Jazz for Babies by Michael Janisch is my absolute favourite as babies love it and it doesn’t drive me nuts when I have heard it 3 million times).

Over the space of 2 weeks the parents of this particular baby, working with email and phone support from me, gradually opened curtains (eyes still covered), then released 1 arm from the swaddle, then the other but kept him swaddled round his middle for comfort, and made sure both parents could feed him.

Lastly they uncovered his eyes (re-covering them if he got upset) and ended up being able to feed him in any room, with eyes uncovered and un-swaddled but he always preferred to have a peaceful, quiet feed, with his piano jazz.

The best time to try any of this is the morning feed, or after any long stretch of good sleep as baby will be relaxed and hungry so you will have their hunger on your side.

The most crucial factor in making this transition, however, is often the hardest thing for parents to cope with, and that is……..never give in.

This may sound harsh, and obviously will not apply if there are any health issues, but otherwise you have to stand firm.

If you give in because the baby cries and won’t feed, you are not helping your baby to transition, you are just upsetting them for no reason.

Babies never starve themselves to any serious extent during this process, it has never happened. Eventually, and usually within a few hours, their own natural survival instinct takes over and they will feed, I promise you!
Example. – If you try and feed at 8 in the morning and baby refuses, try whatever strategies you can think of for 1 hour (making sure you give things time to work i.e. try something for around 10 -15 mins, before switching to something else. Then stop.

Your baby will probably be upset and still hungry so they need something to suck so give them a pacifier or your finger, or their own thumb if they can do that (again, you are not forming lifelong bad habits here, you are providing comfort for your baby during a stressful time).

You will need to pump now to keep your supply up, so hand baby over to someone else whilst you do this (try and stick to expressing at the regular feed times throughout the day). If you are on your own try putting them in a pram or baby chair, give them a pacifier if they will take one, and rock them with your foot. (One of the reasons women are so great at multitasking lol)

Baby may just go to sleep after their struggle or need to be held, or taken for a walk in pram or sling. Again, don’t worry about sticking to their normal sleep routines, they are having a tough time so, for these first couple of days, they get whatever comfort they need, when they need it…..but not from breast feeding or you will undo all yours and theirs efforts. Having said this, if they are already in a routine, the more you can stick to it the more ‘normal’ you will keep their lives.

If baby sleeps then leave them until their next feed time before offering the bottle again. If they act hungry, try and keep them going as long as possible before trying again because the hungrier they are, the quicker they will give in and accept the bottle. Repeat this process through the day.

You do need to be inventive and willing to try new things, but the sooner you can settle on one strategy the easier it will be for baby to start adapting to the new signals so as soon as you think something might be working, stick with that and persist with it.

Keep going with this all day no matter how exhausting and stressful it is, just remember that the minute you give in, you are setting your baby up to have to start all over again which is not fair on them.

Hopefully, your baby will be taking some milk, even if it is just a few sucks and maybe even have had a good attempt or two so they will not starve, but after all this you will both be stressed and exhausted so for the very last feed of the day you can go ahead snuggle down together and let baby have a really good breast feed so you can both get a good night’s sleep, then, the next day, you go back to working on the transition.

To try and help as many parents as possible I have described some of the more extreme reactions and solutions which I understand  may have frightened some of you, but most cases of babies refusing bottles are nowhere near as severe as this.

To be honest, as long as you are consistent and don’t give in, most babies will start to accept the bottle within a few hours.

The maternity nurses that I know deal with this problem all agree that it never takes longer than 3 days IF the parents stay consistent.

What if you want to go on to do mixed feeding , for example, breast feed baby in the morning, have someone else bottle feed when you are at work, then breast feed again when you get home ?

Not problem. Once you have got the baby reliably bottle feeding, you take whatever signals you find work e.g. in front of a TV, and use them every single time you feed to create a really strong habit with clear signals so baby knows that those signals mean bottle feed. Remember, they are programmed to adapt so will ‘get it’ much quicker than you expect.

When you breast feed you can go back to how you normally fed, but make sure there is no overlap so, in the example above don’t have the TV on when breast feeding. Make it as easy as possible for baby to learn the different cues and you will soon settle down into a nice routine.

Hopefully you will know when you are going to go back to work well in advance so, if possible, get working on this at least 2 weeks beforehand (a month is better as it takes the pressure off you) then you can go back to work knowing that all is well with your baby as I know this is a terribly stressful time for mums. Make sure both parents are united and in agreement about what is involved, set the time aside to get it right, and get as much help or support as you can.

It may help for you to remember that babies are very like animals in that they live in the ‘now’ rather than the past or the future.

In practical terms this means that they don’t worry about what happened yesterday or 2 hours ago, nor do they worry about the next feed or tomorrow. They simply deal with what is happening now and, whilst for a day, or a few days, the ‘now’ may be confusing and upsetting, once it is sorted, they will just go back to being happy and content.

You will not have caused lasting psychological damage nor will you have harmed your bond with your baby, I promise you !

This is just one of the many, many adjustments and adaptations that they will have to deal with in their new lives, so even though you may both be stressed for a short while, try and just think of it as a normal and healthy part of their development.

This is a very long post but I know there is still much more I could tell you so I will continue to monitor this post closely and help anyone with questions or problems, or really ‘determined’ babies.

If anyone has serious problems or feels that they need more help just let me know and I will do my best to help you, or I can put you in touch with some of my friends who offer this sort of help over the phone or by email.

Good luck and let me know how it goes, or share your experiences and tips to help other mums going through this.

Sarah x