Before becoming a NICU nurse, I didn’t even know there were different “ways” to hold your baby while feeding. I had only ever seen – and done – the “crook of the arm” feeding. This is the way babies, in my mind, were always fed!
Well, the NICU quickly changed that!
Did you know that the instinct to feed is not generally seen in babies less than 36 weeks gestation? This means that babies born before 36 weeks (also known as late preterm) may not show signs that they are ready to take a feeding by mouth (bottle or breast).
For this reason, it’s not uncommon to see premature + late preterm babies with a nasogastric (NG) tube. This tube allows baby to be fed breastmilk or formula straight into their tummy without the actual act of eating.
As babies approach their due date and become “term” (36-37 weeks+, sometimes a bit earlier), we test their readiness to feed by bottle.
We give them little tastes of milk on a pacifier to help them learn how to suck, swallow, and breathe correctly (we even give preemies a swab of breastmilk very early on to get them familiar with the taste!).
But giving tastes does more than just familiarize them with the taste and smell of milk – it actually tells us A LOT of information!
We can gather baby’s interest in feeding, neurological readiness (sleepy preemies can’t take a bottle!), and read their cues. Have they developed a negative association with oral stimulus (paci, bottle) from having a breathing tube for so long?
Is their reflux so painful that they associate feedings with pain? Are they overwhelmed while feeding (sleepy at the bottle, breathing fast, dropping their heart rate low, sticking their tongue out and pushing the bottle out?)
Suck, swallow, breathe is a coordination skill that some babies need a little help in mastering.
I say this all the time to my clients, but LOOK at your baby and LISTEN to cues as you feed! We can gather SO MUCH information by looking at our baby feed – including signs of hunger, satiety, oral aversion, reflux, etc.
We understand that bottle feeding can be challenging! We are here to help you! Click here to learn more about the supportive services we offer!
My baby isn’t a preemie. Do I still need to watch them closely while they feed?
Yes! Bottle feeding should still be to your term baby’s cues. Feeding and taking a bottle is a skill that baby needs to learn how to do.
And bottle feeding positioning is important for many reasons which we will get into below.
Why is it so important to know your baby’s feeding cues while bottle feeding?
It tells us a lot about how baby is feeling during a feed:
- It tells us if baby needs to slow down the pace (size down on a nipple) or speed up the pace (upsize the nipple). See below.
- It tells us if baby is full. We often try to feed all the contents of the bottle – but baby may not want all the contents. It’s MORE important for baby to control the amount they take in and have a positive experience, than accidentally force feeding.
- It tells us if baby is still hungry BUT prevents overfeeding. If a bottle is completely finished, and baby is rooting or sucking, they may want more. We will talk about side lying feeding in a bit, but basically by following baby’s cues with side lying, baby is controlling the pace of the bottle.
- So if baby does want more, it is available to take at their pace, rather then dripping out of the bottle due to gravity. Signs of being done with the bottle include yawning, sneezing, pushing out of the tongue, pushing the bottle out with the tongue, arching back away from the bottle, gazing up and away from the bottle.
- It tells us if baby is overwhelmed. Persistent hiccuping, sneezing, yawning, gagging, or pushing out of the tongue all are signs of being “done” or overwhelmed with the bottle.
- It prevents oral aversion. You wouldn’t like it either if someone was forcefully sticking food in your mouth! Repetitive accidental force feeding creates an oral aversion, refusal of the bottle, fussiness, and refusal to eat by bottle.
- Try allowing baby to open BEFORE you place the bottle in baby’s mouth by gently tickling their upper lip with the bottle. Once baby opens, they are ready to latch and feed.
But who CARES?! My baby hasn’t shown any of these things and feeds just fine the way I feed her.
YOU are the parent! You have every right to make the decision for your baby! I am here to inform and help you prevent or reverse some possible negative symptoms of gravity-lead bottle feeding positioning.
Does it matter if the contents are formula or breastmilk?
No! Anytime you are bottle feeding, no matter the contents, side-lying is the way to go.
Correctly bottle feeding
SO – What do I DO?
SIDE LYING POSITIONING + INCLINED!
What the heck is side lying + inclined positioning?
Side lying positioning is when baby is laying on their side (ear, shoulder, and hip should all be aligned). Then, incline their head slightly with your hand or a pillow (I even just cross my legs!).
Why is side lying + inclined feeding important?
Side lying + inclined feeding mimics breastfeeding – both in position and flow. It allows baby to control the flow of the bottle, leading to a positive experience with the bottle, less choking and coughing, less flooding, and LESS EAR INFECTIONS!
A bottle has an opening at the nipple. This opening is consistently open, whether baby is sucking or not. Test by holding a bottle upside down – it drips!
This dripping also happens in baby’s mouth when we hold the bottle in a downward position where gravity is pulling the milk out of the bottle, not baby, such as in the “crook of the arm” feeding position.
When gravity pulls out the milk (aka dripping of the bottle), baby is actually getting more milk flow than they are sucking out. This causes baby to get flooded – meaning there is too much milk in baby’s mouth.
This makes it hard to baby to keep up with the amount of milk in their mouth – leading to gulping, choking, coughing, milk dripping out of the side of their mouth.
This can happen with a “crook of the arm” positioning because the nipple is angling down, allowing gravity to do the work.
Think about if you were trying to drink something using a straw. Then, someone was simultaneously pushing more liquid in your mouth.
It would be really hard for us to keep up! If this was consistently happening, we would pretty soon say, “I’m not drinking out a straw anymore!”
This same thing happens to baby – they simply can’t keep up and may start to associate the feeds negatively.
How do I feed baby in side lying position?
- Bend your knees and elevate your legs on a coffee table or ottoman. If you don’t have those available, cross your legs or place a pillow on your lap.
- Place baby in side lying position on your lap with their head closest to your knees.
- Support baby’s head and neck with your non-dominant hand.
- Hold the bottle parallel to the floor.
- Feed baby.
Ear infections + how they related to feeding position
Ear infections are also called otitis media. They are very common, especially in infants. Side note – ear infections are NOT contagious.
The eustachian tube in the ear connects the middle ear with the back of the throat. If formula or breastmilk continually is entering the eustachian tubes, this causes bacteria from the mouth (naturally occuring bacteria) to enter the middle ear, causing ear infections.
Bacteria feed on the nutrients in breastmilk and formula, making easy for them to multiply, causing and infection.
“Crook of the arm” is gravity lead, which leads to flooding, making the risk of formula or breastmilk entering the eustachian tubes much higher (and therefore the middle ear), which in turn increases the risk for ear infections.
Side lying feeding is baby lead, meaning baby is pulling the amount they can handle from the bottle. This prevents flooding, and therefore, the risk of ear infections is much lower.
I heard that breastfeeding lowers the chance of ear infections. Is that true?
To an extent. Breastmilk does contain antibodies that can help prevent infections, including ear infections. However, bottle-fed breastmilk poses basically the same risk as formula since the positioning is actually what causes the ear infections.
Breastfeeding from the breast does help reduce the risk for ear infections due to proper positioning and flow, however, it does not eliminate the risk.
I see air in the nipple. Should I be concerned?
No. Air at the top of the nipple is normal – the milk still fills the tip of the nipple so baby won’t suck in air.
My baby is gulping and chokes on the bottle. What can I do?
Your baby may need a smaller size nipple. If you’re already using the smallest size, try paced feedings. Paced feedings allow baby to “catch up” and swallow the milk in their mouth, then breathe, then suck.
Too much milk will cause them to gulp, not be able to take a breath, etc. Click here for a demonstration.
My baby gets frustrated at the bottle and when I take the bottle out, the nipple is completely flat and collapsed.
Time to move up to the next size nipple! Baby is sucking harder than the nipple flow allows.
It takes FOREVER for my baby to feed from the bottle, more than 45 minutes. What can I do?
Try upsizing the nipple! If baby is dripping, gagging or choking, the flow is too fast and move down a nipple size. Or try paced feedings with the larger nipple.
My breastfed baby WILL NOT take a bottle. HELP!
Your wish is my command! We offer 1:1 virtual consults from the comfort of your own home to introduce the bottle to your breastfed baby in a way that promotes a positive association with the bottle.
We also offer in home bottle feeding consultations for the Chicagoland area!
Click here to view the consultations we offer!
Watch our workshop! Watch our recorded workshop, “Bottle Refusal and Tips.” Join Lauren, NICU RN and mother of 2, discuss tips for bottle refusal in infants. She discusses different strategies for avoiding bottle refusal along with tips and tricks for reversing bottle aversions. She also goes over alternative methods for giving breast milk/formula to babies who have ongoing issues with bottle refusal.WATCH BOTTLE WORKSHOP NOW
Have more questions? Schedule a text or video chat consult with Kate, Lauren or Natalie (NICU RNs) and they can help answer any questions that you have!BOOK CONSULT NOW
Other helpful blog posts:
- How to supplement with formula
- Everything you need to know about acid reflux
- Transitioning from formula to milk
- Everything you need to know about formula
- Diaper bag essentials
- How to travel with kids
**This post is educational and not meant to take the place of your provider. Bumblebaby makes a small commission on some of the items listed above