Bottle Refusal Among Breastfed Infants
by Anne Eglash MD, IBCLC, FABM
Breastfeeding families are encouraged to avoid introducing a bottle too early, to prevent newborn preference for the rapid flow and ease associated with bottle feeding. Many families opt to finger feed, supplement at the breast, or cup feed instead of using a bottle for supplementation in the first few weeks.
However, there has been little research on when it is best to introduce a bottle, in order to prevent bottle refusal.
A recent study from the UK explored the background and characteristics of bottle refusal among breastfeeding mothers in the United Kingdom. The researchers’ definition of bottle refusal was 'When a breastfed baby initially or continuously refused to accept a bottle containing either expressed breastmilk or infant formula.'
The researchers recruited 841 UK mothers who experienced bottle refusal by their breastfed infant (gest age >37 weeks) in the last 5 years. All filled out an online questionnaire. Over 95% of the participants were Caucasian, >29 years of age. More than 50% were dealing with bottle refusal during the time of the survey. More than 75% of the mothers wanted to give a bottle occasionally, since only 14.4% cited 'returning to work' as the reason to introduce a bottle (YAY for paid maternity leave!).
59% of the mothers reported that no strategy worked and their babies never took a bottle. Only 8.8% of mothers tried going cold turkey from breastfeeding, yet 42.4% reported that it worked, so this was the most effective strategy. The most common strategy was having a partner or other family member give the bottle, and that worked 21% of the time.
- Families that intended to switch to primarily bottle feeding, rather than to occasional bottle feeding, were more likely to experience bottle acceptance.
- Mothers who experienced bottle refusal with one infant had a higher likelihood of experiencing it again with a subsequent infant.
- The older the baby was at the time of bottle introduction, the shorter the time to eventual bottle acceptance.
- Most mothers in this study believed that early introduction of the bottle might have prevented their infant’s bottle refusal.
See the Answer
Little is known about bottle refusal by breastfed babies; however, an informal review of global online forums and social media suggested large numbers of mothers experiencing the scenario. This study aimed to explore UK mothers' experiences of bottle refusal by their breastfed baby in order to provide understanding of the scenario and enhance support for mothers experiencing it. A 22-point online questionnaire was developed and completed by 841 UK mothers. Findings suggest that mothers introduced a bottle to their breastfed baby due to physical, psychological and socio-cultural factors. Advice and support for mothers experiencing bottle refusal was not always helpful, and 27% of mothers reported bottle refusal as having a negative impact on their breastfeeding experience. When compared with eventual bottle acceptance, bottle refusal was significantly associated with previous experience of bottle refusal (p < .001), how frequently mothers intended to feed their baby by bottle and babies being younger at the first attempt to introduce a bottle (p < .001). This study provides a unique insight into the complexities of bottle refusal by breastfed babies and the impact it can have upon mothers' breastfeeding experiences. It generates knowledge and understanding that can help to inform practice and policies. In addition, a 'normalising' of the scenario could enable mothers, and those supporting them, to view and manage it more positively.
It would be interesting to follow up with bottle-refusers, to explore their behavioral characteristics as teens or adults. They might be the very best lawyers or car salespeople ever!
Among the breastfeeding dyads participating in this survey, the average infant age at the time of bottle introduction was 8 weeks, and the average duration of time to eventual acceptance was 9 weeks. They found that babies who were on average 12 weeks at the time of bottle introduction were more likely to eventually take a bottle, and they had a shorter time to bottle acceptance. This is opposite of what many typically believe. In fact, the majority of the mothers themselves wondered if earlier bottle introduction would have helped to improve bottle acceptance.
The bottom line is that we don’t have any evidence for the best time to introduce a bottle, to ensure that infants are ‘switch-hitters’- breastfeeders who accept bottles. Given the average duration of time it took for many of these infants to accept a bottle, patience and perseverance appear to be important strategies. Given the relatively short amount of maternity leave time, it would make sense to introduce a bottle by 3 weeks for those returning to work in the USA. If breastfeeding is not going well by then, the baby has probably received a bottle at that point anyway. This is another good reason to advocate for paid maternity leave!