Bottle Skills + Bottle Refusal

Suck Reflex

First things first, let’s talk about when and why kids often refuse a bottle. This can help us figure out when is best to introduce and master bottle feeding skills to (hopefully!) prevent it, but also provide a roadmap for how to tackle refusal if need be.

At approximately 12 weeks, babies integrate the sucking reflex that they are born with. In these early weeks, we rely on this reflex as a survival skill: in order to learn how to get food, babies will suck on pretty much anything when it taps their upper palate. After about 12 weeks of this, the nervous system assumes baby has this down if they made it this far, and essentially the “volume turns up” on reflexes needed to manage teething (~4-6 months) and eventually chewing (6+ months).

So after this stage, sucking becomes completely voluntary which means that if your baby hasn’t mastered the skill of how to latch and feed from a bottle and has focused solely on the breast (or even if they did bottle feed well early on but for whatever reason the bottle is not a part of their routine at 8-12+ weeks), many babies do not have the coordination to automatically latch onto a bottle. This commonly shows up as bottle refusal, or very disorganized (and slow) bottle feeding at 3+ months and means that they require a lot of patience and persistence to build this skill.

↳ TL;DR: At ~12 weeks, the suck reflex integrates and sucking becomes voluntary. If babies don’t have the skill of bottle feeding mastered and a routine part of their lives, they may refuse bottle feeding at 3+ months of age.

My top recommendation for (hopefully!) preventing bottle refusal is to introduce a bottle by 6-10 weeks of age, and by week 10-14+ be routinely offering the bottle at least 3-4 times per week to ensure they are getting lots of practice with this critical stage of neurological development.

Tips for Bottle Refusal

• If you are discovering this a week before going back to work, you are stressed. I hear you. But keep bottle feeding attempts as low stress as possible. If you and or baby are getting worked up, step away and try again later. I know it’s easier said than done, but getting stuck in negative emotions and experiences around bottle feeding will generally not help you or your baby meet your goals.

• Offer small amounts (1-2 oz) by bottle at about 1-1.5 hours after they have a full feeding if possible. This way they would have enough interest to snack and explore, but are not starving and tense.

• Try a variety of bottle shapes, textures, etc. Go on a local Facebook group or something and ask friends and neighbors to lend you or give-away any bottle you can get your hands on. Nothing is off the table, but when possible prioritize the bottle listed here in order to make the most of your baby’s well-established breastfeeding skills.

• Also on that same page you’ll find a variety of oral motor tools and pacifiers that support sucking skills. Aim for about 5-10 minutes of sensory input - using a pacifier, teething toy, facial massage, tummy time, body stretching, guppy pose - prior to offering the bottle.

• Offer bottle nipples as pacifiers, or find pacifiers that match up with the way the bottle feels. Example Dr. Browns narrow neck bottles and their pacifiers are very similarly shaped.

• Try a variety of positions - side-lying, in an infant seat or car seat, upright, in a baby carrier facing out, start with 10 minutes of skin-to-skin, staring at a houseplant, watching a cartoon.

• Use warmed milk.

• Start with slow flow, but know that medium flow or Y-cut nipples are worth considering. We often assume that bottle refusal is frustration with a slow flow of milk, but by and large that’s not the case and a faster flow is more likely to overwhelm your baby when they are already feeling a bit disorganized.

• Try dream feeding. Many babies can do well on auto-pilot when they are drowsy or only half-awake. This may help them get in practice and make progress during day feedings, or may at least help a caregiver sneak in a feeding when the breastfeeding parent is away.

• And if these tips are not working - don’t hate me - try the opposite. Feed them wide awake and super hungry. Try a bottle shape that “lactation consultants hate” like Nuk, MAM or Comotomo. Try fast flow nipples. Try cold milk.

• Know that whatever magic sauce you come up with that helps your baby make progress is great. No wrong answers. And whatever seems to be working, stick with it for a bit. But also know that this is temporary. Once your baby really gets a hang of what to do with their mouth when they encounter the bottle, you’ll be able to add in flexibility around positioning, nipple flow rate, milk temperature, etc.

Alternative Feeding Methods to Consider:

• Straw: This will also take time to learn but at about 4-6 months, your baby can begin practicing with straw cups.

• Open cups: Babies of any age can learn to drink from an open cup. It’s tricky, and I would generally recommend having baby in an infant seat of some kind for your best shot at avoiding major spills, but it’s possible.

• Spoon: Similar skill to open cups, but a little more control on your end.

Note on Oral Ties: We have probably already addressed this if we’ve had a home visits, but it’s important to note that I find bottle refusal particularly common among babies who have oral ties and/or suboptimal oral development. Whether you already had a release or the tie is newly identified, these neurological transitions are going to be particularly tricky for babies who are struggling to coordinate oral function.