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      <h1 id="top">7.5.4 Bottle feeding</h1>
      <div>Bottle feeding is 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.<br />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<sup><a href="#note1">1</a></sup> and overuses the buccinator and orbicularis muscles.<sup><a href="#note2">2</a>,</sup><sup><a href="#note3">3</a></sup> Bottle feeding creates repeated airway closure during swallowing. Rapid milk flow results in more frequent swallowing and less opportunities for breathing.<sup><a href="#note4">4</a></sup> <br /></div>
      <div class="section" id="When_to_use_bottle_feeding"><h2>When to use bottle feeding</h2>
    <div>Bottle feeding may be considered when the mother: <br /> <ul><li> is unable to breastfeed for medical reasons or her infant's medical condition precludes breastfeeding ability. </li><li> chooses to use a bottle for supplementation - with adequate education about impact on breastfeeding and health risks associated with bottle use. </li><li> weans her infant when milk is still a major part of the diet. </li></ul></div>
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      <div class="section" id="Considerations_when_bottlefeeding_a_breastfed_infant"><h2>Considerations when bottlefeeding a breastfed infant</h2>
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      <ul>
        <li> Use a straight bottle rather than a bent bottle. </li>
        <li> Choosing a teat/artificial nipple: <br /> <ul><li> Use a long teat/artificial nipple, with a rounded end and a medium-wide base. <sup><a href="#note5">5</a></sup> </li><li> Use a slow-flow artificial nipple/teat. This requires the baby to suck well to obtain the milk. A full feed, bottle-fed, should take about 15 - 20 minutes. Babies with low tone who take longer than this to be fed may require a medium-flow artificial nipple. </li><li> Choose a soft artificial nipple/teat if possible. </li><li><span style="font-weight: bold;"> Rationale </span> : <ul><li> When the artificial nipple is taken into the baby's mouth the tip of the artificial nipple is well back in the mouth, close to the junction of the hard and soft palate. The baby is reminded that something is always supposed to be towards the back of his mouth as he feeds, as occurs during breastfeeding. </li><li> The medium-wide base, up to the screw cap, causes the baby to have a wide mouth when he makes a seal around the base of the artificial nipple, similarly to how he holds his mouth for breastfeeding. </li><li> 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. </li></ul> </li></ul> </li>
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      <div class="section" id="Bottle_feeding_technique"><h2>Bottle feeding technique</h2>
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      <ul>
        <li> 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. Without gravity helping to pour milk into the baby's mouth, baby will have better control of the volume taken at each mouthful and will suck a little harder. Kassing (2002) <sup><a href="#note6">6</a></sup> 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. </li>
        <li> Using the tip of the artificial nipple brush the baby's lips gently, stimulating the rooting reflex. 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. </li>
        <li> 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. </li>
        <li> 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. </li>
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    <div class="section" id="Assess_a_bottle_feed"><h3>Assess a bottle feed</h3>
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          <div class="captionBox"><img width="250" height="188" src="images/britton_bottle_003_250.jpg" alt="" /><p> <br />&copy; B.Ash, IBCLC</p></div>
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          <div class="captionBox"><img width="250" height="188" src="images/britton_bottle_009_250.jpg" alt="" /><p> <br />&copy; B.Ash, IBCLC</p></div>
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      <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><h3>What is the difference?</h3>
        <div></div><div class="activity" id="activity_re">
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	{ c : 'Look closely at the two photos above. Compare and contrast the artificial nipple position in the baby\'s mouth, the gape used by the baby, the tilt of the bottle, the body position of the baby and briefly explain the significance of each of these.<br/>', r : '<span style=\"font-weight: bold;\"> Photo on left </span><br/><span style=\"font-style: italic;\"> Infant\'s lips are tight </span> - this indicates overuse, whereas lips would be more relaxed when properly positioned. <br/> <span style=\"font-style: italic;\"> Gape is narrow </span> - tongue can\'t come down and forward if gape is not wide. <br/> <span style=\"font-style: italic;\"> Infant is recumbent </span>- this causes the tongue to retract and makes swallowing difficult; <br/> <span style=\"font-style: italic;\"> Teat is only partially in infant\'s mouth </span> - the teat is only half filling the oral cavity so the milk is being delivered too far forward in the mouth causing the posterior tongue to lift. <br/> <span style=\"font-style: italic;\"> The tilt of the bottle indicates that the tip of the teat will be applying pressure on the back of the infant\'s tongue </span> - stimulation should be along the palate except when using special suck modification techniques. Milk flow will be fast with gravity forcing it, another reason the infant will retract tongue, lifting the posterior tongue in an attempt to control flow. <br/> <br/> <span style=\"font-weight: bold;\"> Photo on Right </span> <br/> <span style=\"font-style: italic;\"> Artificial teat is fully in infant\'s mouth </span> - this encourages maximum filling of the oral cavity. <br/> <span style=\"font-style: italic;\"> Gape is more relaxed and fairly wide </span> - indicating that the oral cavity is well-filled. <br/> <span style=\"font-style: italic;\"> The tilt of the bottle </span> indicates that the tip of the teat is along the palate - the mother\'s naturally pliable breast would fill the oral cavity and touch most of the palate. It does not create any downward pressure on the infant\'s tongue. Milk flow is much easier to control in this position. Infant is less likely to become distressed from a fast, uncontrollable flow.<br/> It is difficult to see, however it appears that the infant could be positioned for better head extension. <br/> <span style=\"font-style: italic;\"> </span>' }
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      <div class="section" id="Good_bottle_feeding_practices_are_essential"><h2>Good bottle feeding practices are essential</h2>
    <div>A sound nutritional foundation for growth of the child is laid down during the first two years. A critical aspect of care to ensure bottle-fed infants receive appropriate nutrition during this time is to ensure the infant's caregivers receive education on the importance of proper feeding.<br />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:<br /><ul><li>early feeding cues, <br /></li><li>infant pleasure (or stress) during the feed, <br /></li><li>adequate intake such as <br /><ul><li>signs of satiety <br /></li><li>normal bowel actions, <br /></li><li>expected urine output, and <br /></li><li>appropriate weight gain (neither excessive, nor inadequate).<br /></li></ul></li></ul></div>
    <div class="section" id="Preventable_dangers"><h3>Preventable dangers</h3>
      <div>
        <p>In a 2008 study <sup><a href="#note7">7</a></sup> 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. </p>
        <ul>
          <li> Dangers of incorrect preparation <ul><li> gastrointestinal infection, serious illness and death from: <ul><li> contamination from unhygienic practices contaminating feeding implements </li><li> contamination from bacteria found in the powdered formula when purchased (eg enterobacter sakazakii)<br /></li><li> contaminated water supply. </li></ul> </li></ul> </li>
          <li> Incorrect reconstitution - a commonly found error: <ul><li> over-dilution causes poor weight gain and inadequate intake of calories and nutrients </li><li> under-dilution causes hypernatremic dehydration, diarrhea and excessive intake of calories. </li></ul> </li>
          <li> Over-feeding and under-feeding by caregivers must also be addressed. <br />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. <ul><li> Over-feeding causes 'food battles' and obesity, </li><li> under-feeding causes poor growth and development </li><li> both under- and over-feeding cause failure to thrive and malnutrition </li></ul> </li>
        </ul>
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    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><a href="images/formula_prep_DOH_UK_2011.pdf" target="_blank"><img src="design/article.png" class="icon" alt="" /></a><h3><a href="images/formula_prep_DOH_UK_2011.pdf" target="_blank">Preparing breastmilk substitutes safely</a></h3>
      <div>Click on the title above. This links to a leaflet produced by the Department of Health in the UK 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.<br />Go through this leaflet, or a similar one that your hospital or clinic may use, 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.<br /></div>
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            <td class="body"><img src="design/remember.png" class="icon" alt="" /><h3>What should I remember?</h3>
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      <ul>
        <li>the different oral actions that occur during bottle feeding and breastfeeding</li>
        <li>the type of bottle and teat/artificial nipple to use when a breastfed infant is being bottle fed</li>
        <li>how to teach a safe bottle-feeding technique that encourages positive parenting skills</li>
        <li>the preventable dangers inherent in bottle feeding</li>
        <li>how to effectively and clearly teach safe preparation of breastmilk substitutes and safe bottle-feeding techniques to caregivers<br /></li>
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      <div class="section" id="Skills_Competency_4"><h2>Skills Competency #4</h2>
    <table class="callout"><thead><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_01.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background: repeat-x url(design/callout_02.png);"><img src="design/callout_02.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_03.png" width="10" height="10" alt="" /></td></tr></thead><tfoot><tr class="decoRow"><td class="topleft" style="width: 10px"><img src="design/callout_07.png" width="10" height="10" alt="" /></td><td class="topcenter" style="background-image: url(design/callout_08.png);"><img src="design/callout_08.png" width="59" height="10" alt="" /></td><td class="topright" style="width: 10px"><img src="design/callout_09.png" width="10" height="10" alt="" /></td></tr></tfoot><tbody><tr><td class="middleleft" style="background: repeat-y url(design/callout_04.png);"><img src="design/callout_04.png" width="10" height="80" alt="" /></td><td class="body"><a href="images/competencies4_formula.pdf" target="_blank"><img src="design/group.png" class="icon" alt="" /></a><h3><a href="images/competencies4_formula.pdf" target="_blank">Teaching formula preparation and feeding</a></h3>
      <div>When you have successfully completed this topic and practiced what you have learned you will be ready to do your Skills Competency. Click on the title of this box to download <i>Teaching formula preparation and feeding</i> competency form for you to complete with your Supervisor.<br /></div>
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      <div id="footnotes">
        <h3>Notes</h3>
        <ol>
          <li id="note1"><a href="references.html#webe86" title="See full details">#</a> Weber F et al. (1986) An ultrasonographic study of the organisation of sucking and swallowing by newborn infants.</li>
          <li id="note2"><a href="references.html#inou95" title="See full details">#</a> Inoue N et al. (1995) Reduction of masseter muscle activity in bottle-fed babies.</li>
          <li id="note3"><a href="references.html#gome06" title="See full details">#</a> Gomes CF et al. (2006) Surface electromyography of facial muscles during natural and artificial feeding of infants</li>
          <li id="note4"><a href="references.html#math91" title="See full details">#</a> Mathew OP (1991) Breathing patterns of preterm infants during bottle feeding: role of milk flow.</li>
          <li id="note5"><a href="references.html#nobl97" title="See full details">#</a> Noble R et al. (1997) Therapeutic teat use for babies who breastfeed poorly</li>
          <li id="note6"><a href="references.html#kass02" title="See full details">#</a> Kassing D (2002) Bottle-Feeding as a Tool to Reinforce Breastfeeding</li>
          <li id="note7"><a href="references.html#labi08" title="See full details">#</a> Labiner-Wolfe J et al. (2008) Infant formula-handling education and safety.</li>
        </ol>
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      <h1>Breastfeeding Essentials</h1>
      <ol>
        <li>1.0 <a href="topic_1-0.html">Why Breastfeeding is Important</a><ol><li>1.1 <a href="topic_1-1.html">Biochemistry</a></li><li>1.2 <a href="topic_1-2.html">Immunology</a></li><li>1.3 <a href="topic_1-3.html">Relative risks</a></li></ol></li>
        <li>2.0 <a href="topic_2-0.html">Communication Skills</a><ol><li>2.1 <a href="topic_2-1.html">Non-verbal</a></li><li>2.2 <a href="topic_2-2.html">Listening skills</a></li><li>2.3 <a href="topic_2-3.html">Building confidence</a></li><li>2.4 <a href="topic_2-4.html">An example</a></li></ol></li>
        <li>3.0 <a href="topic_3-0.html">Pregnancy Care</a><ol><li>3.1 <a href="topic_3-1.html">The feeding decision</a></li><li>3.2 <a href="topic_3-2.html">The barriers</a></li><li>3.3 <a href="topic_3-3.html">Physical preparation</a></li></ol></li>
        <li>4.0 <a href="topic_4-0.html">The Birth Experience</a><ol><li>4.1 <a href="topic_4-1.html">The first hours</a></li><li>4.2 <a href="topic_4-2.html">Labor interventions</a></li><li>4.3 <a href="topic_4-3.html">Postnatal interventions</a></li></ol></li>
        <li>5.0 <a href="topic_5-0.html">Breastfeeding the Baby</a><ol><li>5.1 <a href="topic_5-1.html">Positioning Principles</a></li><li>5.2 <a href="topic_5-2.html">Breastmilk transfer</a></li><li>5.3 <a href="topic_5-3.html">Assessing breastfeeding</a></li></ol></li>
        <li>6.0 <a href="topic_6-0.html">A time to learn</a><ol><li>6.1 <a href="topic_6-1.html">Practical skills</a></li><li>6.2 <a href="topic_6-2.html">Breastfeeding messages</a></li><li>6.3 <a href="topic_6-3.html">Normal growth</a></li><li>6.4 <a href="topic_6-4.html">Sleep</a></li><li>6.5 <a href="topic_6-5.html">Psychological support</a></li><li>6.6 <a href="topic_6-6.html">Discharge planning</a></li></ol></li>
        <li>7.0 <a href="topic_7-0.html">Infant Challenges</a><ol><li>7.1 <a href="topic_7-1.html">Late preterm infant; Non-latching</a></li><li>7.2 <a href="topic_7-2.html">Hypoglycemia; Jaundice</a></li><li>7.3 <a href="topic_7-3.html">Supplementation</a></li><li>7.4 <a href="topic_7-4.html">Crying baby</a></li><li>7.5 <a href="topic_7-5.html">Inadequate weight gain</a><ol><li>7.5.1 <a href="topic_7-5-1.html">Feeding-line device at the breast</a></li><li>7.5.2 <a href="topic_7-5-2.html">Cup feeding</a></li><li>7.5.3 <a href="topic_7-5-3.html">Finger Feeding</a></li><li class="current">7.5.4 <img src="design/bullet_arrow_right.png" alt="*" title="You are here" /><a href="topic_7-5-4.html">Bottle feeding</a></li></ol></li></ol></li>
        <li>8.0 <a href="topic_8-0.html">Maternal Challenges</a><ol><li>8.1 <a href="topic_8-1.html">Engorgement</a></li><li>8.2 <a href="topic_8-2.html">Nipple Pain</a></li><li>8.3 <a href="topic_8-3.html">Breast Problems</a></li><li>8.4 <a href="topic_8-4.html">Insufficient breastmilk</a></li><li>8.5 <a href="topic_8-5.html">Medical, Surgical Issues</a></li></ol></li>
        <li>9.0 <a href="topic_9-0.html">Promotion, Protection and Support</a><ol><li>9.1 <a href="topic_9-1.html">The International Code of Marketing of Breastmilk Substitutes</a></li><li>9.2 <a href="topic_9-2.html">The Baby Friendly Initiative</a></li><li>9.3 <a href="topic_9-3.html">Young Child Feeding</a></li><li>9.4 <a href="topic_9-4.html">Local initiatives</a></li><li>9.5 <a href="topic_9-5.html">Infant feeding in emergencies</a></li></ol></li>
        <li>10.0 <a href="topic_10-0.html">Closing session</a><hr /></li>
        <li class="appendix"> <a href="references.html">List of references</a></li>
        <li class="appendix"> <a href="contents.html">Course contents</a></li>
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