Bottle feeding problems


Signs & Symptoms

If a baby displays troubled or concerning behavior in relation to bottle feeding this could indicate a problem. Examples of troubled or concerning behaviour.

  • Turning away from the bottle
  • Refusing to close mouth around the nipple
  • Lying with nipple in the mouth but not sucking
  • Taking only a small amount and then refusing to continue
  • Crying when placed into a feeding position
  • Milk pouring out of baby's mouth
  • Feeding too quickly
  • Feeding too slowly
  • Falling asleep before the feed is completed
  • Coughing and spluttering when feeding
  • Not consuming as much milk as expected
  • Wanting more milk than expected
  • Throwing up milk

Reasons

There are numerous reasons why a baby might display fussy feeding behavior; partial or complete refusal of bottle-feeds; or appear to have difficulty feeding. Commonreasons include:

1. Misinterpreting baby's cues as signs of hunger

If a baby's behavioral cues have been mistakenly interpreted as hunger, and therefore a feed offered, the baby will either take a small amount and refuse the rest or refuse to feed from the start. This can be confusing and frustrating for parents who at the time believed their baby was showing signs of hunger. If parents try to make their baby take the feed, the baby is likely to fuss.

Without understanding how a baby's developmental stage will affect her behaviour, its easy and common for parents to misinterpret infant behavioral cues as a sign of hunger, when in reality the baby's behavior may have nothing to do with hunger.

Babies are in an oral stage of development. Most babies under the age of 6 months love to suck. A baby may want to suck when tired, bored, uncomfortable, upset, and simply for the pleasure of sucking. A baby's desire to suck for these reasons can be easily mistaken as hunger.

Babies are born with reflexes - such as the rooting reflex and sucking reflex -which help them to feed instinctively. A reflex is an automatic or involuntary response. The rooting and sucking reflex can be triggered when a baby is hungry, but they can also be triggered at times that have nothing to do with hunger.

Please note:Because of the presence of their sucking reflex newborn babies are at increased risk of overfeeding compared to older babies when hunger cues are misinterpreted.

RECOMMENDATIONS:

  • See ourhungry babyarticle for more about these reflexes and other reasons why babies can appear hungry.
  • Also see ourinfant reflexarticle.

2. Unrealistic expectations

Influenced by amounts calculated according to how much formula the 'average baby' of a certain age and weight might require, or on the recommended amount of formula depicted on the side of the formula tin, many parents worry that their baby is not drinking enough formula. This could result in parents either intentionally or unintentionally pressuring their baby to drink more milk than their baby wants or needs. Babies will fuss if they don't want to feed and parents try to make them.

Babies are individuals and should be treated as such. They come in all shapes and sizes, and grow at different rates. Not all babies will drink the 'average' amount of milk calculated for age and weight. The amounts depicted on the side of the can are a guide only, and a rough one at that.

RECOMMENDATION:

  • Consider your baby's genetic predisposition and previous pattern of growth when estimating formula requirements
  • Follow your baby's feeding cues. Don't try to make her take more when she indicates she has had enough.

3. Tiredness

Sleeping and feeding are closely related when it comes to the needs of babies. Both are equally important to a baby's health, growth and development. Most of us are well aware that if a baby does not feed well she might not sleep well. The the opposite is equally true.If a baby does not sleep well this can negatively impact on her feeding.Tiredness can result in fussy, unsettled feeding behavior or falling asleep before the feed is completed.

In many cases, feeding difficulties will resolve spontaneously once a baby receives adequate sleep.

RECOMMENDATIONS:

  • Ensure your baby gets enough sleep.
  • Try to establish a flexible feeding and sleep routine.
  • Feed your baby before she becomes too tired.
  • See our sleep section.
  • 'Your Sleepless Baby: The Rescue Guide' written by Rowena Bennett explains reasons and provides effective solutions to various infant sleeping problems.

4. Feeding equipment

The most important piece of feeding equipment is the nipple. The nipple needs to be the right size and speed for your baby's size, age and sucking ability. If the nipple is too long, too short, too fast or too slow for your baby, she may experience feeding difficulties and/or fuss during feeds as a result.

RECOMMENDATIONS:

  • See our article on feeding equipment for more information on choosing a feeding nipple.
  • Experiment with nipples of different lengths, shapes and speed.

5. The nipple ring is attached too tightly!

in order to maintain a balance in air pressure within the bottle,air needs to be able to enter the bottle to replace the void left by the milk the baby is removing. With regular baby bottles, air enters the bottle between the nipple ring and rim of the bottle andthrough the holes at the end of the nipple. Air is prevented from entering the bottle if the nipple ring is screwed on too tightly and the baby also maintains a seal over the holes of the nipple with her tongue.

When air can't get into the bottle to replace the milk removed a negative pressure begins to build within the bottle. This pressure will start to hold the milk back. A healthy baby can suck against this pressure initially and continue to extract milk from the bottle. However, the more milk that is taken (without being replaced by air) the greater the negative pressure within the bottle. As the negative pressure continues to build it requires increasingly more effort on the baby's part to suck against this to access the milk.

This situation is more likely to cause problems for a newborn baby compared to an older baby. Older babies usually learn to let go of the nipple from time to time. This allows air to access the bottle through the holes at the end of the nipple. But it requires experience for a baby to learn this. Newborns who have not yet learned to do this, may tire and fall asleepbefore completing the feed as a result of the increased effort to feed.

To appreciate how negative pressure affects a baby's ability to feed picture what its like to drink from a juice box. As you suck the juice out through the straw the sides of the box progressively collapse inwards. Once you let go of the straw air can then enter the box replacing the space previously taken up by the juice and the sides pop out a little. The reason the sides collapse in the first place is because of the negative pressure that builds within the juice box as the juice is taken. This change in pressure is the same when a baby drinks from the bottle in situations where air is prevented from entering the bottle. But you won't see the sides of a hard plastic or glass bottle collapse. What can happen if the pressure becomes high is that nipple collapses in the baby's mouth as she is feeding. (Even before or without the nipple collapses its becoming harder for baby to feed.)

Some manufacturers produce vented or 'anti-colic' bottles and/or nipples. These do nothing more than enable the free flow of air into the bottle to replace the milk consumed, which can be achieved simply by loosening the nipple ring.

So how can you tell if this problem might be troubling your baby during feeds? The following signs may point to this problem.

  • You can't see any (or not many) bubbles replacing the milk when she feeds.
  • The nipple collapses in her mouth.
  • You notice lots of bubbles rush into the bottle once you remove the nipple from her mouth.

If you intentionally wanted to slow your baby down during feeding time, perhaps because she feeds too quickly, then tightening the nipple ring might help. If your baby has a strong suck and feeds quickly it might be helpful to start the feed with the nipple ring tightened, thereby using the pressure to slow her down. If she slows too much, loosening the nipple ring will counteract the negative pressure problem and make it easier for her to suck.Alternatively, you could slow down your baby's feeds by using a slower nipple.

You might wonder why a parent would knowingly want it make it harder for their baby to suck. They would only do so if their baby fed too quickly. A little extra sucking effort during feeds is not necessary a bad thing. It can help a baby to develop strength in her facial muscles. Also slowing down the time it takes for a baby to feed can be an effective strategy to minimize the risk of overfeeding. However, its necessary to maintain the right balance. You wouldn't want to make it so hard for a baby to feed that she is not consuming enough milk

RECOMMENDATIONS:

  • Experiment with tightening or loosening the nipple ring to control the speed of the flow. You will know you have it right, when you can see a steady and continuous flow of bubbles entering the bottle as your baby drinks. If you can't see any bubbles, loosen the nipple ring just a little more. But take care not to loosen it too much or milk will leak onto your baby's chest.
  • Ormake sure you remove the nipple from her mouth every few minutes, to allow the air to enter through the end of the nipple.

* A common myth is that a baby will swallow these bubbles and will get gas or colic as a result. This is not true. So long as the there is milk in the tip of the nipple as your baby feeds she cannot swallow the bubbles of air that enter the bottle.

6. Feeding management

Some feeding problems can be related to what may appear like insignificant details but which can make feeding difficult or uncomfortable for a baby. For example, how you hold your baby will affect her ability to feed from a bottle. If her head is too far forward or too far back or her neck is twisted this can make it difficult for her to suck and/or swallow.

RECOMMENDATIONS:

7. Feeding patterns

Some babies develop a grazing or snacking feeding pattern where they will only drink small amounts of formula at a time and then want to be feed frequently, possibly every hour or two. Although this will not cause any problems for a baby, provided she drinks enough formula in total over a 24 hour period, it can become very tiring for parents to keep up with her constant demands for feeding.

RECOMMENDATIONS:

  • Try to encourage your baby to take as much milk as possible within 45 minutes. But don't try to make her feed if she doesn't want to. Stop sooner if she does not want to continue.
  • Support your baby to extend the time between feeds, by offering a little water, a pacifier, a nap, playing with her, or taking her for a walk. Aim to encourage her to wait at least 3 hours from time you started her previous feed, but only if its reasonable to do so without distressing her. If necessary extend the time between feeds gradually. As your baby gets used to going longer periods between feeds she will gradually take larger amounts at each feed.

8. Night feedings

Unless your baby was born prematurely or is very small for her age, developmentally she no longer requires feeding during the night beyond the age 6 months. If night time feeding continues past this age it can affect her feeding patterns and behavior during the day.

Your baby only needs a certain number of calories in her day (24 hours) to provide for her growth and energy needs. If after the age of 6 months she continues to receive calories from night time feeds this will dampen her appetite during the day and she will not need to drink as much formula during daytime feeds. You might find she is content to go for long periods of time between feeds (which is usually what would happen at night). She might fuss or refuse some of her daytime bottles when they are offered simply because she's not hungry at the time. Or she might graze during the day.

Night time feeding will cause your baby no harm, so if you're happy to continue feeding her during the night there's no reason to change a thing. However, it is important that you don't expect her to consume as much milk during the day as she may have otherwise taken if she did not feed at night.

Many babies will give up night time feedings on their own accord, but others will continue to wake and demand feeds overnight for months and possibly years while parents continue to provide feeds at night. Usually the reason babies continues to demand night feeds beyond the age of 6 months is because they have learned to rely on feeding as a way to fall asleep, or because their internal body clock gets turned around - where the baby has decreased appetite during the day because of the continued night feeds and as a consequence of small feeds during the day the baby wakes hungry during the night. Body clock problems can easily become a cyclical pattern that will continue over the long term unless parents take steps to change the situation. Healthy, thriving babies who continue to demand feedings at night beyond the age of 6 months often require guidance and support from parents to cease feeding at night and turn their body clock around to a normal day-night feeding pattern.

RECOMMENDATION:

  • Aim to cease overnight feeds after 6 months of age. However, before attempting to do this its important to address any feeding to sleep issues your baby might have. She would need to learn to fall asleep in a different way before you will be able to successfully encourage her to cease night feeds.

9. Early introduction of solids

6 month is the recommended age for starting solid foods. Although a small number of babies may benefit from solids prior to this age, it's generally not recommended to start a baby on solid foods before the age of 4 months. An early start on solids has the potential to cause bottle feeding problems because solid foods may decrease the baby's appetite for milk (breast milk or formula).

RECOMMENDATIONS:

  • If your baby is less than 6 months old, either cease or reduce the amount of solids you offer to see if this helps to improve the situation.
  • See our article on starting solids.

10. Solids eaten before or between formula feeds

If solids are offered prior to bottle feeds, either directly before or mid way between feeds, when it's time for your baby's bottle feed she might be feeling full from the solids, in which case she's probably not going to take much milk from her bottle.

RECOMMENDATIONS:

  • For babies 4 - 9 months (when milk is still the most important food) offer solids 15 - 20 minutes after bottle feeds.
  • For babies 9 - 12 months (when solids are becoming increasingly more important to a baby's diet) offer solids shortly before or shortly after her bottle, whichever you find works best. Babies at this age are often down to 3 bottles per day plus 3 main meals and 1 or 2 snacks.

11. Too much solid foods

In these early stages of learning to eat solids (4 - 7 months) solids are not needed to add value to a baby's nutritional intake, rather they are offered primarily to provide learning experiences. The baby is exposed to new food proteins that help prime her immune system. She gets to discover new tastes and textures and become accustomed to eating from a spoon. Its at this age that babies are most willing to accept new tastes. So variety rather than quantity is what solids are about.

Many babies, particularly very young babies, experience difficulty self-regulating their dietary intake. Some babies will continue to eat solid foods for as long their parents keeps offering. Somebabies will prefer eating solids compared to drinkingformula. However, too much solids and not enough milk is not a balance diet for a baby. It may be necessary for parents to limit the amount of solids they offer in order to encourage their baby to have a greater appetite for milk feeds.

RECOMMENDATION:

12. Illness

A sudden change in appetite and feeding behavior could be an early sign that a child is becoming unwell.

RECOMMENDATION:

  • Have your baby examined by a doctor if you observe any signs of illnessorif she's not drinking enough formula in a 24-hour period.

13. Teething

While teething, a baby might fuss with feeding or fail to drink as much formula as normal. Feeding difficulties related to teething generally don't last longer than a couple of days.

RECOMMENDATIONS:

  • See our article on teething for more information.
  • Consult your doctor before using painkillers or teething gels.

14. Oral thrush

Feeding difficulties associated with a thrush infection in a baby's mouth are rare.

RECOMMENDATION:

  • See our article on thrush for more information.

15. Distractibility

Babies over the age of 4 months can easily become distracted while feeding. They are often much more interested in the activities going on around them than they are in feeding.

RECOMMENDATION:

  • Feed your baby in a quiet environment away from noise and distractions of other children.

16. Natural slowing of growth

The 'average baby' will double her birth weight by around 4 months of age and triple her birth weight by around 12 months of age. The largest weekly weight gains usually occur from birth to 4 months. During this time, the amount of formula a baby drinks per feed will slowly increase.

As a baby matures her rate of growth gradually slows down. Around 5 - 6 months* of age, the average baby's may no longer require as much formula as she did previously. At this stage she might start to leave some milk in her bottles. If she repeatedly leaves milk in her bottle this could be a sign that she is ready to drop one of her bottle feeds, ideally this would be a night feed.

*Larger babies, who were off to a good start with large weight gains in the early months, will often display a reduction in the amount of milk taken from as early as 3 months.

Around the age of 9 months the 'average baby' is ready for further reduction in the number of bottle feeds. By then baby is well established on solids foods and does not require as much milk as she did previously. You will know when your baby reaches this stage as she will once again start to leave some formula in her bottles or she might refuse to feed when a bottle is offered.

RECOMMENDATION:

17. Weaning difficulties

Although some breastfed babies willing accept milk from a bottle many will not, at least not straight away.

Difficulty weaning from breast to bottle is rarely resolved by finding the 'right' feeding nipple. (All feeding nipples will feel equally foreign to a breastfed baby.) Nor does a solution lie in finding a formula with the 'right' taste. (All formula will taste strange to a breastfed baby).

The difficulty associated with weaning to a bottle most often lies in the fact that bottle feeding requires a very different sucking action to breastfeeding.Whilebreastfeeding the movement of your baby's tongue milks the breast, where as bottle feeding requires a sucking action. A baby who has been exclusively breastfed beyond the age of 3 months will often refuse milk from a bottle because it "doesn't feel right" and she doesn't know how to suck from a bottle.

It take time and practice before your breastfed baby learns how to suck on a bottle.

RECOMMENDATION:

  • Try offering expressed breast milk in a bottle initially. (Don't be too optimistic and put too much in to start with. It would be a shame to waste it.)
  • A soft flexible nipple often works better.

* Many breast fed babies will refuse to accept a bottle while they are still being breastfed at times. They will simply wait until a breastfeed is offered. For these babies it will be the case of breastfeeding or bottle feeding, but not both.

18. Feeding aversion

A baby can develop an aversion to feeding when past experiences have taught her that feeding is unpleasant, stressful or painful.

The baby may fuss, kick and scream when she sees realises that a feeding is about to commence. Alternatively, she might accept the bottle, feed hungrily but then stop suddenly after consuming only a small amount and refuse to complete the feed. Some babies with an aversion to feeding will only feed while asleep.

Fussy feeding behavior associated with afeeding aversion often first becomes evident around 2 months of age. If the problem remains unresolved the baby's fussy feeding behavior may become progressively worse as she matures and becomes stronger and increasingly more aware. By 4 months of age an aversion to feeding can be fully entrenched and all feeds can feel like battle.

An effective solution to an infant feeding aversion relies heavily on identifying the cause. Typically, babies with feeding aversions will be diagnosed with reflux. While acid reflux is one reason for babies to develop an aversion to feeding, there are many other potential causes.

RECOMMENDATION:

See our article onFeeding Aversionfor more information.


What to do

Feeding strategies

  • Get your to start sucking on a finger or pacifier then quickly replace it with the bottle.
  • Try applying gentle pressure under a newborn baby's chin using your finger - in time with the sucking.
  • Try feeding her while she is drowsy or asleep.
  • Gently rock and pat or even walk with her during feeding.
  • Try feeding in a quiet dark room, alternatively try distraction by singing to her or watching a mobile or toys.
  • If feeding is difficult, stop trying after 20 minutes or sooner. Give yourself and your baby a break, play with her for 10 or 15 minutes and then try again. If she continues to resist, wait until the next feed.

Check baby's weight

Plotting your baby's weight gains on an infantgrowth chart can provide valuable information about the cause and severity of a bottle feeding problem.

If your baby is not gaining enough weight or is losing weight,she needs to be seen by a doctor to rule out any illness or physical problem. Also see 'When baby's weight gains decline'.

If your baby is gaining well,its may be possible that she does not require as much milk as you think she does, or that she is consuming too much juice or solid foods, which is then negatively impacting on her milk intake. There could also be other explanations.

In cases wherea babyis physically well and gaining enough weight, feeding difficulties are unlikely to be due to a physical or medical problem.

Don't try to force baby

If your baby is fussing during feeds this means there is a problem. Trying to force her to feed will not solve the problem and may in fact complicate the situation as it could cause her to develop a feeding aversion.


How we can help!

Its obvious that identify and correcting the cause of bottle feeding problems (listed above) will be the most effective way to resolve a baby's bottle feeding problem. However, without an understanding of infant growth and development, and age-appropriate infant feeding practices this can be achallengingtask for parents.

Some feeding problems are more complex than others. Its often the small details, which can be easily overlooked, that can make the biggest difference.

By booking a consultation through Baby Care Advice, this will enable us to undertake a thorough assessment of all factors that influence your baby's feeding patterns and behaviour, and assist you to pinpoint the reasons for his or her feeding difficulties and/or growth concerns. We will then provide you with an individually tailored plan describing ways you can improve the situation. Should you require ongoing support to ensure the problem is resolved, this can be arrange through our Support Package.

If you would like more information about our consultation options click here.

Written by Rowena Bennett
RN, RM, RPN, CHN, IBCLC, Grad Dip Health Promotion and author of 'Your Sleepless Baby:The Rescue Guide'.

Copyright www.babycareadvice.com 2003. All rights reserved. Permission from author must be obtained to copy or reproduce all or any part of this article.

Added Nov 2003. Reviewed Aug 2008; Oct 2013.