Diana West, IBCLC, RLC
http://www.bfar.org

Recommended Nipples for Bottle Supplementation

Many mothers who choose to supplement by bottle wonder which nipple is the best for supporting breastfeeding and minimizing nipple preference/confusion for their full-term babies.

Avoiding artificial nipples is very important for the BFAR nursing couple in order to prevent nipple confusion/preference, which can occur when artificial nipples are introduced to babies who have a difficult time switching back and forth between breast and bottle, either because they develop a strong preference for one over the other or because they use a bottle-feeding tongue and jaw movement at the breast, which does not transfer milk effectively. Not all doctors agree that nipple confusion exists, but most lactation consultants are convinced that it does since they see it so commonly among their clients who have used artificial nipples.

Some mothers have commented that their babies seem to like bottle-feeding better than breastfeeding because they fuss less when being fed from a bottle. The mothers then give their babies more bottles because they want to make their babies happy. While it may be true that some babies prefer bottle-feeding because the flow of supplement is quicker and gives them more immediate satisfaction with less effort, it is important to remember that bottle-feeding is still a vastly inferior feeding method. It deprives babies of all the structural and psychological benefits of breastfeeding, not even taking into account the benefits of the human milk. It is natural and right for a mother to feel empathy for her baby's preferences, but for such an important and far-reaching issue, the bottom line is that you have knowledge about what is best for your baby that he does not have at such a young age, and so you may need to make this critical decision for him in his best interest. In most cases, babies come to vastly prefer breastfeeding because it gives them an intimacy and comfort that bottle-feeding cannot duplicate.

For some BFAR mothers, supplementation by bottle is the best choice for their situations. They are aware of the risks and are careful to maximize the breastfeeding relationship. There are certainly some babies who do not seem to have any trouble switching back and forth from bottle to breast; nipple confusion/preference never happens to them. For some nursing couples, nipple confusion/preference seems to be less likely to occur when the mother has long, rigid nipples and a strong milk supply. Unfortunately, there is no way for you to know beforehand, but by being vigilant and watching for changes in the way your baby takes the breast, you may be able to catch the "confusion" before it becomes entrenched and change your strategy if you need to.

The following discussion of breastfeeding and bottle-feeding explores the mechanics of each feeding method and the differences between them so that mothers can use bottles in a way that best supports her breastfeeding relationship.

Differences Between Breast and Bottle

In order to understand the difference between the way a baby uses a bottle nipple and a human nipple, one lactation consultant suggests this vivid demonstration:

There are also other critical differences between bottle-feeding and breastfeeding. When a baby is nursing at the breast, he has complete control and is able to stop and start when he wishes. Nursing relaxes him thoroughly, which is evidenced by his gradually relaxing hands and body posture. His oxygen levels are stable and high because he can breathe more deeply and regularly. He extends his tongue and cups it around the nipple and areola, compressing it against the roof of his mouth, and moving his tongue in a wave-like motion to move the milk through the ducts. His lips are open, wide, and relaxed.

When being fed by bottle, most babies are cuddled in an almost lying-down position, which greatly accelerates the rate of flow from the bottle. The milk or formula gushes out quickly and the baby must swallow rapidly in order to avoid choking. He has very little control and his oxygen levels are low. These babies have a very tense body posture during bottle-feedings for this reason. In order to exert control of the flow, they quickly learn to retract their tongues and press it up against the tip of the bottle nipple. Their lips will be tight and pursed around the bottle and they do use a jaw motion to move the milk. Because they are swallowing without any effort, their facial muscles cannot develop in the same way as breastfed babies will.

Bottle Nipples that Minimize Nipple Confusion

For mothers who have decided to supplement with bottles, it is important to use nipples closest in form to the human breast. Ultrasound studies by Smith (1988) revealed that perfectly round nipples, with a broad base, best facilitate tongue and jaw motions most similar to suckling at the breast. Artificial nipples that mothers have used with success are the Avent nipple (newborn slow-flow), the Playtex Natural Shape or Natural Latch nipples, and the Evenflo Ultra or Elite. It is also best to use a nipple that is silicone, rather than latex, to protect the baby from latex allergens.

Recommended

Although the Gerber Nuk nipple is frequently recommended for use by nursing mothers, many of the cases of nipple confusion that lactation specialists have worked with have been a result of using the Gerber Nuk nipple. Research by Smith (1988) confirmed that orthodontic nipples, such as the Nuk nipple, cause the tongue to retract and hump ("squash-pump" action) in back of the mouth, instead of extending flat and forward, as is necessary for effective milk transfer. In addition to reducing milk extraction, this type of tongue movement can also cause severely abraded nipples.

Not Recommended

Bottle-Feeding Methods that Minimize Flow Preference

Some mothers have had the experience of deciding to supplement by bottle and finding that the baby will initially consume a large quantity of supplement from the bottle. This is usually not because the baby is so very hungry or thirsty. The baby is either simply using that strong tongue and jaw movement that he knows from breastfeeding or was being fed in a fully-reclined position so that the milk flowed very rapidly and the baby had no choice but to rapidly swallow. When this happen, it can leave a mother with the conclusion that her poor baby was starving and she really must not have had much milk at all. In most cases, this is not an accurate measure of her milk supply.

When supplementing with a bottle, it is important to do so in a sitting-up position so that the bottle is held at as much parallel to the floor as possible. In this way, the milk will not flow too quickly and will more closely approximate the flow from the breast. It also affords more control for the baby, just like he has during breastfeeding. A technique that some mothers have found to work well is to hold the bottle in the pit of the arm, holding the baby in the cradle position. Many mothers also find that pacing the feeding by stopping and gently withdrawing and replacing the bottle every 4-5 sucks helps their babies retain control of the feeding, allowing them to stop when they are full.

Used with a bit of expertise, knowledge of feeding mechanics and risk factors, and empathy for your baby, bottles can be used successfully as a means of supplementation for the breastfed baby.

References:

Kassing D. Bottle-feeding as a tool to reinforce breastfeeding. J Hum Lact 2002 Feb;18(1):56-60.

Nowak AJ, Smith WL, Erenberg A. Imaging evaluation of artificial nipples during bottle feeding. Arch Pediatr Adolesc Med 1994 Jan 148:40-2.

Smith, WL, Erenbert, A, and Nowak, A. Imaging evaluation of the human nipple during breast-feeding. Am J Dis Child 1988 142:76-78.