Is it ok to Introduce a Bottle before 6 weeks? Is there a risk of nipple confusion if I need to supplement my Baby?

This is a blog I’ve been meaning to write for a long time. In almost every consult I do I think bottles are discussed, and so many new families are conflicted about using them or frightened about the effect they might have on breastfeeding. Some want to introduce them but are worried they will affect the latch. Some really don’t want to introduce them but are being advised to top up by bottle and are scared of doing so. Sometimes they are not giving the extra milk they have been advised their baby needs, because they are so afraid of using bottles. Most have read guidance on the internet or have been told that it’s best not to introduce a bottle until 6 weeks to allow breastfeeding to get established. In an earlier blog I wrote about choosing and using bottles in a way that protects breastfeeding, but that blog didn't specifically look at the impact of the fear around bottles, or the evidence base for it. That's what this blog will address.

If we shouldn’t use bottles till after 6 weeks, why are so many people advised to use them for top ups before then? What is the right approach?

Where does the 6 week idea come from?

All of our hospitals in NI are accredited as Baby Friendly Hospitals, under the WHO/UNICEF Baby Friendly Hospital Initiative, which has 10 steps to facilitate breastfeeding. Step 9 is the following:

Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.

The implementation guidance for BFHI expands on this point, but doesn’t make any mention of 6 weeks. The guidance states the following:

It is possible that the use of feeding bottle and teat could lead to breastfeeding difficulties, particularly if the use is prolonged. However, the only study on this did not demonstrate a specific carry over effect from suckling at a feeding bottle and teat to suckling at the breast

It does note that use of bottles in pre-term babies could interfere with them learning to breastfeed, (note pre-term i.e. under 37 weeks), but not in term babies (over 37 weeks). It then goes to say that pre-term babies who cannot yet breastfeed can benefit from non-nutritive sucking, which may be on a pacifier. So it is certainly not saying that artificial teats should not be used at all, even in pre-term babies.

The implementation guideline also talks about supplementation of milk:

Mothers who intend to “mixed feed” (a combination of both breastfeeding and feeding with breast-milk substitutes) should be counselled on the importance of exclusive breastfeeding in the first few weeks of life, and how to establish a milk supply and to ensure that the infant is able to suckle and transfer milk from the breast.

Although it doesn’t mention 6 weeks specifically, it talks about establishing a milk supply. Milk production (assuming all goes well) is considered to be at full volume around 5-6 weeks at a volume of around 800ml a day. As I explained in the earlier blog about how to choose and use a bottle, a “calibration” takes place around that time where your milk volume becomes kind of “set”. Milk supply is considered to be established and pretty robust at that stage.

What are the risks and concerns around bottles?

So what are the risks to breastfeeding of using bottles in first 6 weeks? Well that very much depends on why the bottle is being used and what is in the bottle.

What’s in the bottle? Effect on Milk Supply

What is in the bottle can pose a potential risk to milk supply. I covered this in a previous blog on bottles, but I thought it might be helpful to look at a few scenarios where breastfeeding is going well or less well and what effect that might have.

Lets take an example of a 3.5kg baby (7lb 11oz) baby who is one week old. That baby will need around 525ml of milk each day. A baby who breastfeeding well and is getting all of that milk at the breast has been building a milk supply over the first week and should continue to build that milk supply up to a full volume of around 800ml a day.

Another 3.5 kg baby may be breastfeeding part of the time and bottle feeding part of the time because they are having issues with feeding. Let’s say that baby is getting 300ml at the breast and 225ml of expressed milk in a bottle. Since that mother is expressing the 225ml she still is providing the full 525ml of milk each day. Continuing to breastfeed and express should build her supply to full volume.

A 3rd 3.5 kg baby may be breastfeeding part of the time and bottle feeding part of the time. Let’s say this 1 week old baby is getting 300ml at the breast and 225ml of formula/donor milk in a bottle. The mum wants to exclusively breastfeed but is finding it hard to get time to express and so is currently using formula. Here is where the counselling mentioned above comes in. Our bodies are primed for milk production in the early weeks. After 6 weeks, when milk production becomes more fixed it can be hard to increase it significantly. Let’s assume this mum continued with this same balance of breastmilk and formula. When they reached 6 weeks her baby was getting 400ml at the breast and perhaps 350ml of formula. At this point the mum is feeling less overwhelmed with parenthood and thinks she would like to exclusively breastfeed, but her body has “calibrated” at the that 400ml level. It may not now be possible for this mum to reach her goal of exclusive breastfeeding.

Now let’s take a 4th 3.5kg baby who at 1 week is drinking 300ml at the breast and 225 ml formula in a bottle. The mum wants to exclusively breastfeed and gets good guidance about what that would entail - she is counselled that there is a window of opportunity in the early weeks which she can capitalise on if she expresses now. She starts expressing each time she gives the supplement and gradually reduces the amount of formula/donor milk she is using each day. The likelihood is that this mum will get to 6 weeks fully breastfeeding (assuming no other medical complications which would prevent a full milk supply).

So what is in the bottle makes a difference to exclusive breastfeeding. For mums who always intended to combi feed this is not really a concern. It’s their intended goal - so whether the bottle is a risk to milk supply really depends on what that family want for themselves and their baby and the kind of support and guidance they get.

Obviously there is an effect to health outcomes whether a baby is breastfed or formula fed and the BFHI guidance says that HCPs should counsel on this as well, but this is a separate issue to whether bottles interfere with the establishment of breastfeeding.

Risk of Changed Latch / Nipple Confusion?

Nipple Confusion is often cited as a risk of introducing bottles in the early weeks. The fear that mothers talk to me about is that their babies will forget to latch or feed from the breast. So let’s address that directly. Babies are born knowing how to latch on and feed. It is an extremely robust instinct. It has to be! It is part of what best guarantees survival for the infant. It is, as Nils Bergman describes, “a highly conserved neuroendocrine behaviour” - i.e. a very stable instinct in the baby. We can clearly see young babies exhibiting the rooting reflex when hungry. They gape and put their tongue out. They try to get their hands, or anything around them into their mouth so they can suck on it. They may grab and suck on your finger. They may even latch and suck on your nose or chin if placed near it. It doesn’t stop them from latching to your breast, and we normally don't worry that it would.

Sucking for a young baby isn’t really a voluntary activity. They respond to triggers to open their mouth, and to suck, and in my experience they generally swap back and forth from breast to bottle easily. It’s when they get a little older and sucking becomes more of a voluntary activity that they may not swap quite as easily. At that stage parents sometimes find that a breastfed baby may then not want to take a bottle - but in that case it’s not a risk to breastfeeding of course! It's a different problem.

What can be quite different on breast and bottle is the way a caregiver gets them to latch on and how the milk flows. The previous blog talks about the shape of the teat and how this affects latch. How we offer the bottle also makes a difference. To latch to the breast we need to get a nice wide gape so that we get a comfortable latch. To latch to a bottle it’s possible to push the bottle teat into a semi-open mouth. If a bottle is used frequently and always inserted into a semi open mouth it’s possible for babies to get used to that. Even when that happens though, in my experience young babies “get it” again very very quickly if you start tickling the lip with the bottle and waiting for a wide mouth at each feed. The flow of milk can be different too. Milk flows constantly from a bottle, but has periods of fast and slow flow from the breast. For more details on that and how to bottle feed in a way that protects breastfeeding see the earlier blog.

So if sucking is instinctual, robust and highly conserved and you can use bottles sensitively in a way that protects breastfeeding - is nipple confusion a thing?

My personal feeling is that I’m not convinced that babies get confused. Yes the sensation and flow will be different on breast and bottle, but babies are smart. What babies want is to feel comfortable and to be rewarded from their effort of sucking and to get good milk flow. It’s basic biological economics - they want to get good rewards for their effort. That will ensure they have more calories coming in than out and can put resources into growth and development.

What many parents I meet worry about, is that their baby will start to prefer the bottle to the breast. Is that a possibility? Let’s think about what babies get from each place. At the breast they get skin to skin contact, they get waves of oxytocin in milk as they trigger a letdown which makes them feel good, and obviously they get milk. With a bottle they are a lot less likely to get that skin to skin contact. They are much less likely to get the same sensory or hormonal experience, but they do get a good volume of milk. So why would a baby prefer a bottle? In my experience it is often down to the volume of milk. If an 10 week old baby is feeding at both breast and bottle and getting good volumes of milk at both they usually swap between them well. If that same 10 week old baby is getting 75% of his milk via formula/donor milk in a bottle (with that bottle held tilted down and a fast flow of milk), and gets just 25% of his milk from the breast, needing topups at every feed then things can start to change. Breasts that are full of milk have a nice fast flow of that milk. Breasts with low milk volume have slower flow. Less milk means less pressure in the breast, less flow speed and the baby has to work harder to get it out. So in that case, the baby might start to prefer the bottle, but it’s not caused by nipple confusion. Rather, it’s a smart baby making a choice. It's like a biological thought process of, “I have to work really hard here (at the breast) and I don’t get a lot of milk and I don’t have to work hard there (on that bottle) and I get loads of milk“. That’s where I think the risk lies. That risk is not with a newborn who latches on instinctively. It’s with the slightly older baby who has started to work out where the milk comes from and how hard or easy it is to get it. This is where something like a supplemental feeding tube can really help with a baby who needs more milk, as it allows the baby to get more milk while still at the breast and to turn that preference around.

Fear/Avoidance of Bottles Doesn’t Help Babies who need more Milk

Every week I see babies who are struggling to gain weight, and I imagine every other IBCLC is the same. Sometimes babies just don’t get off to the best start with feeding. Birth may have been difficult. Maybe they didn’t latch well in the first few days and mum’s milk supply never got stimulated well. Maybe baby and mum were separated for a period after birth. Maybe they got poor breastfeeding advice to stay on one side for long periods to get “hind milk”. Maybe there were medical or hormonal issues meaning that milk was delayed (perhaps gestational diabetes or retained placenta or even thyroid issues). Whatever the reason might be, it’s fairly common that some breastfed babies have issues with weight gain in the early weeks, are slow to regain birthweight and do need supplemented. Part of my role as an IBCLC is to identify those babies that need supplemented and to counsel the family around a feeding plan - one that gets baby the supplemental milk, but protects breastfeeding so that they can wean that supplement out again (if that’s what they want to do). If a baby needs supplemental milk there needs to be a way to get that milk into the baby - whether by bottle or cup or something like a supplemental feeding tube at the breast.

As I work in the private sector I often see babies after there has been poor gain for several weeks. Sometimes those babies are not getting enough milk because the family are afraid of using bottles. Sometimes the baby is getting supplemented with a syringe to avoid using bottles. Syringes are small, and great for supplementing colostrum, but once you get into larger volumes of supplements I think it's questionable whether syringes are a good tool. Where a baby needs a 50ml supplement for example, a 5 or 10 ml syringe isn't great for that hungry baby. A supplement of that size is much more suited to a bottle, cup or supplemental feeding tube. The feeding tube or bottle also give the baby a opportunity to suck when a syringe does not. I've met many families who have not taken the advice to supplement at all because they are concerned about using bottles and the effect that it will have on breastfeeding.

Cups are an option to supplement but in my experience most people aren’t familiar with cup feeding. It’s not something we commonly see and that brings it’s own anxiety around attempting it. It is a skill that needs to be learned. Is there any advantage to using a cup over a bottle? One 2009 study (Huang et al) looked at cup feeding and bottle feeding to see if cup feeding was any more likely to protect breastfeeding. They found:

In our study, there was no significant correlation between infant feeding method and infant sucking competence. It seems that exposing an infant to an artificial nipple has much less effect on infant sucking ability than published reports indicate.
The bottle group displayed more negative suck- ing behavior during attempts to latch on the breast than the breast group on the third day. There was a significant correlation between infant feeding method and infant sucking behavior during breast- feeding on the third day after birth, but no correlation at two and four weeks. Based on this result, we could say that bottle feeding has only a short term effect on infant sucking behaviour

This suggests that bottles can be used without being a long term risk to breastfeeding. They found a specific impact on day 3 only. Before and after day 3 it did not have a significant impact.

For me, in these cases where a baby needs supplemental milk temporarily, the fear of bottles is detrimental to breastfeeding. A few days of supplementing with a bottle may be the right solution to get someone over a tricky period and back to exclusive breastfeeding. Avoiding bottles in those cases can lead to more difficult issues around milk supply and weight gain. Whether tools are helpful or detrimental depends on how we view them and how we use them.

An Evidence Based Approach shows a Middle Way

For me, there is a middle way. We know that exclusive breastfeeding is physiologically best for babies. We know that feeding at the breast is different to a bottle - its a different sensory experience, sucking action is different, milk flow and volume can be different. When breastfeeding is going well, spending time at the breast is enjoyable for both. It’s a beautiful bonding experience. The memories of my own children feeding, then resting their little heads on my breast and drifting off to sleep are some of my most treasured memories, but that doesn’t mean that having all feeds at the breast is the goal for every family. Some parents return to work early and need to use a bottle before 6 weeks. Some families are dealing with illness, some are dealing with low weight gain. Sometimes mums just feel that they need a break and for someone else to do a feed, and sometimes families just want to combination feed. In all of these cases facilitating breastfeeding is the goal, and sometimes how we facilitate that is by having bottles in the mix somewhere. There are routes to supplement without bottles or cups, such as using supplemental feeding tubes at the breast. I use this method quite a bit with clients. I think this is a fantastic method to supplement babies as it keeps babies breastfeeding throughout the process, but it's not a method that everyone is comfortable with. Some are uncomfortable with the idea - again because it is unfamiliar. Some people find them fiddly. They aren't something that we see commonly in public, but bottles are. Bottles are how we see large numbers of babies in NI being fed. Even if we haven't done it before we have seen it often enough that we understand how to do it. So, for all those reasons when the options around supplemental feeding tube, cup or bottle are offered to parents they opt for the bottle. That is just a reality.

Bottles are a tool. They can, of course, be used before 6 weeks if used with care. They do not have to sabotage breastfeeding. Counselling around the risks of bottles doesn't mean that we need to tell people to avoid all bottles. It means giving evidence based information so that parents can make an informed decision. It means counselling about how to protect the latch, protect the milk supply and protect the flow and about how to choose and use bottles safely when parents are in a situation that they need/want to give milk by another means. It means giving parents evidence based information that they can use to choose what is right for them. It doesn’t mean advocating that we avoid bottles entirely. We don’t need to inspire fear around bottles.

A 2002 study (Schubiger 2012) looking at use of bottles and pacifiers in a neonatal nursery found in the first 5 days found:

In our study population fluid supplements offered by bottle with or without the use of pacifiers during the first 5 days of life were not associated with a lower frequency or shorter duration of breastfeeding during the first 6 months of life.

If you want to exclusively breastfeed then lots of time at the breast with frequent breastfeeds are really how you get it established. If everything is going well, waiting till 6 weeks usually makes offering a bottle easier. By then you will have developed some confidence in breastfeeding and it’s easier on a practical level as you have a better sense of when you can fit in expressing during the day and how you will balance it with feeding. If however you find you need to introduce a bottle earlier or are advised to give one there’s no need to be scared about the effect on breastfeeding. It can be done sensitively and carefully and in a way that will protect your future breastfeeding. Look for help in how to do that. If you should find you are starting to offer more bottles than you wanted, or you find the balance of supplement is moving in a direction you are unhappy with - reach out for support. Getting help early is key to getting you on the path to exclusive or predominantly breastfeeding.

If you have any questions about a consultation or would like to arrange to meet, please get in touch.

Get in Touch