Episode 82: Bottle Refusal Is Not Always A Feeding Disorder with Jill Rabin M.S. CCC-SLP/L IBCLC

Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Hi and welcome to episode 82 of the Untethered Podcast. Today we have Jill Rabin rejoining us for another podcast episode. I'm excited to have her here. Jill is a pediatric speech pathologist and international Board certified lactation consultant who's been working with the 0 to 3 year old population for 34 years. She's based in the north suburbs of Chicago where she's a private practice working with young babies and their families with feeding and speech language issues. Her areas of specialty include facilitating breastfeeding in at risk populations such as preterm infants and babies with down syndrome, using the modified baby led weaning approach to transition babies with special needs with solids, and using child directed and responsive feeding approaches to improve feeding skills in infants and babies with feeding aversion. She contributed two chapters to the book Breastfeeding and Down Syndrome and has written three posts about breastfeeding and down syndrome on the Julia's Way website. She's she also wrote an essay and was quoted in the 10th anniversary edition of Gil Rackley and Tracy Murquette's Baby Led Weaning book. She was featured as a guest on the untethered podcast episode 31 in December 2019 and spoke about feeding difficulties in children with special needs. Jill has done national and international webinars and presentations on the modified baby led weaning approach, breastfeeding babies with special needs, and managing feeding aversion in infants. She also teaches classes about development and transitioning to solids to new parents at the New Mother Baby New Mother New Baby Lactation center located in Northbrook, Illinois. Jill is bilingual and speaks Spanish and has some knowledge of American Sign Language. Well, Jill, first, I want to welcome you back to the podcast. I'm super excited to have you here again today.

Thank you so much. I'm glad to be back.

I'm also really excited about this topic that we're going to be discussing because I get this all the time, whether it be social media or emails from mamas or just even sometimes moms in my office. But what we're going to talk about today, and you're the expert on this topic, is bottle refusal, right? But really from our neurotypical babies where maybe they've been breastfeeding and mom hasn't had to introduce a bottle and now all of a Sudden mom is going back to work and baby just refuses to transition from breast to bottle. And so again, we know we're focusing more on our neurotypical babies. We're not talking about our babies who have true feedback feeding issues. I'm going to let you take it away, but this is a topic I know that I get a lot of questions on, so let's chat about it.

Often the way the scenario goes is I will get a frantic phone call from a mother two or three days before she has to return to work and she is absolutely losing her mind because her baby has to go to a daycare provider and the baby will not accept a bottle at all. And she is absolutely beside herself and does not know what to do. It's stressful enough for a mom after maternity leave to leave their bab to know that their baby could be crying all day and refusing to eat is just a horrifying experience. I will say that I am hearing it a little bit less during the pandemic because so many moms are working from home and obviously it's not a problem if you're home and your baby refuses to take the bottle. You can feed them while you're there. It's not like you're in a different location than they are. So I have heard it a little bit less that maybe that's one good thing, one silver lining in this pandemic.

But.

But I think what's really, really interesting and what I see a lot on social media and based on what some of my clients are telling me, I'm seeing a very different response to bottle refusal from the speech pathology or feeding therapist community versus the lactation community. And what I would say is that in the lactation community, lactation consultants are more like, sure, that happens all the time. We know that happens with breastfeeding babies. Or you'll hear, my baby never took a bottle and just went right to. They're really relaxed about it and they will give moms ideas of how to get the baby to take a bottle. But we know in some situations these babies may never take a bottle and they develop just fine and they're perfectly normal. Whereas what I see a lot on social media is a lot of the feeding therapists pathologize this particular issue and make bottle refusal. Oh my God, the baby must have a tongue tie or there's a feeding issue or a sucking issue. What I want to say is if you have a thriving baby who's been breastfeeding and growing beautifully from breastfeeding only, this isn't a feeding disorder or a pathology. It's really a preference and more of a behavioral thing with babies that just don't wanna take the bottle. And we can talk a little bit later about why babies might refuse the bottle. And then also what do we do to manage it? How do we help moms get through this?

Yeah, awesome. Well, I mean, I know that breastfeeding is a biological norm, right. And I know that that's something that you talk about. So let's talk about that a little bit because I think I always say we have to understand typical before we can even understand if something atypical is going on. And so understanding that it is the biological norm, you know, how does that differ from, let's say, bottle feeding? Right.

Well, you know, breastfeeding is that that's what babies are born to do, Right. That's their preference. And the whole reason we have bottles is because I think, you know, when men went to war and women had to go to work, we had to have a way for moms to feed their babies. So that's where bottles came. And we certainly come a long way with bottles. I mean, the bottles from way back when are very different than the bottles are some bottle systems that might resemble breastfeeding the same way, but it's certainly a very different experience of your mom putting you to breast, snuggling in with your mom. The soft breasts, the warmness of the nipple, it's just a completely different experience than the bottle. So it is the normal thing. And I think we have to kind of look at things differently and we have to kind of say to moms, look, just because your baby doesn't take a bottle doesn't make your baby abnormal. Your baby is actually the norm. This is what babies are supposed to do. This is how babies lived and survived for of years. So we have to kind of rephrase it and not make moms feel guilty or bad when this happens. And what we have to do is be proactive and preventative and tell them what we can do to prevent this issue from happening. And even when we do that prevention, sometimes it still happens. But if it does happen, we have to be calm and say, look, it's going to be okay. There is ways around this. We're going to help you manage this. I think that makes moms feel so much better. I really do. I think if we can calm them and say, look, your baby is really what's biologically normal, they're gonna feel a lot better about it.

Oh, absolutely. And I think that's such a great point because we get so many moms who they already have mom guilt. And, you know, that's the first thing. Like, anytime I posted something on my social media as of late, I also had this influx of moms following me. And, you know, a lot of the responses are, oh, my gosh, I failed my baby. Oh, my gosh, I feel so guilty. Oh, my gosh. You know, just. You can just see that mom guilt creeping through. And the first thing I always say to them is, you're doing the best you can do with the information that you had. You're not failing your baby. If you had information that you chose to blatantly ignore, maybe that's a different situation. But most of us, as moms, are really doing. We're making decisions that we feel is best for our child with the information that we have at the time. And so, you know, it really. This is a conversation that I haven't really seen in too many places. And granted, I'm an slp, I'm not an ibclc, so it's probably happening in other circles, but it's not happening in my circle. And so that's why I'm really excited that we're, you know, recovering this. You mentioned something that I think is really important for parents and professionals to know, and that is that breastfeeding is more difficult than bottle feeding. And so can we talk about that a little bit just so that people can understand why that is or how that is?

Yes. I mean, think about it, right? We have a whole profession just for breastfeeding babies. We know how complicated it is, Right. It's very rare that we hear that a neurotypical baby is going to have problems accepting a bottle. But we hear about breastfeeding issues all the time. And I think the complication is it's a dyad. It's mother and baby. And it's the way those puzzle pieces fit together. And if the baby has any structural issues or the mom has supply issues, there's so many different things that can go on. So if a baby can breastfeed, well, they're going to be able to take the bottle. There's a lot of information out there that I've seen. Like people will say, oh, well, that's not true, that babies. That the breast molds to the baby's mouth and it can disguise any kind of structural issues. I don't really agree with that. I. I feel like breastfeeding is a way more difficult thing to achieve. This is why we don't Introduce bottles early on to babies. Right. We wait anywhere from two to four weeks before we introduce a bottle. Because getting on the breast and being able to feed sufficiently and be able to transfer milk is a lot more complicated. I mean, you have to wait for a letdown. It has to be a perfect storm. Everything has to work together, right. Synergistically for this to work correctly. And the bottle, really, there's a different bottle out there for every. We can try many different bottles and different flows. There's so many things we can do. We can't really do that with the breast. We can use a nipple shield maybe, but we can't change the mom's anatomy. My feeling is if you can breastfeed, you can certainly bottle feed. When babies do have that bottle refusal, a lot of times it's just really a preference. They don't want to do it. And there's other factors. We can talk about why babies might refuse a bottle. We can talk about some of those. But I think that that's what people have to understand is that again, it's really normal for some of these babies to refus. Breastfeeding is more complicated. So there is. If we can explain to parents that this phenomenon occurs. I mean, a lot of people don't know that bottle refusal occurs. I work at a hospital once a week on a mother baby floor, and I ask every mom that I work with, are you returning to work and if so, when? And if it is six to 12 weeks. I have this conversation with them always because I say there is something that can happen that a lot of people don't know about or not aware of. And I prepare them and I tell them how to prepare it so they can prevent it from happening. And I think if we could do that, if we could all prepare breastfeeding moms that have to go back to work, that this can happen. And that if you present the bottle at the right time and with enough frequency, you're not going to have an issue when your baby returns to work. But we can also say if for any reason your baby decides to bottle strike, and say, I am not taking that no matter what you do. And even if you were preventative about it, we need to let them know there are ways to work around this. Your baby is going to be okay.

Yeah. And I think that's the biggest thing is, you know, the baby's going to be okay. Right. And really allowing the parent to kind of take a deep breath and realize, okay, there is a solution to this. This is normal, this happens. I'M not the only parent who's experiencing this. It's not like all of my other friends went back to work and nobody had any issues with their babies, you know, trying to transition from breast to bottle. Because it's just one of those things that's not discussed enough. And, you know, I see these frantic posts in mom groups, like local mom groups, that's like, I'm going back to work tomorrow and my baby won't take a bottle. Like, what have you guys done? What's your solution? And I'm like, well, nothing like waiting till last minute. But, you know, it's not the mom's fault. Nobody educated this mother. So, you know, this poor mother is now frantic. Which doesn't help anything in terms of feeding the baby. If you want everybody to be nice, you know, calm and collected for those feeds. So, yeah, so it's, it's definitely, you know, like anything else in this space. I just feel like it's another one of those topics that we really need to like scream from the rooftops to help normalize this whole concept, you know. And on that side, is there ever a time where you do feel that it's behavioral or skill based or a sensory issue, like, can that possibly be the cause when mom is introducing a bottle, even if it is at the time she's going back to work? But breastfeeding has been going well up until that point.

I do feel I always watch those babies carefully so those babies that don't flip easily between the breast and the bottle, I always kind of watch a little bit carefully. And I always tell parents, look, if you do have any issues when you transition to sol, let me know. Because I always think, okay, maybe there's a little underlying sensory sensitivity thing that they just don't have the ability to move back and forth between the bottle and the breast. Or maybe it's more of a motor planning kind of kid who might have trouble. Oh, I have this skill set for breastfeeding, but I can't transfer to something different. I definitely pay careful attention. I think for the most part it is a preferential thing that kids just want to be breastfed. I see these babies, you put the bottle in their mouth and they're breastfeeding beautifully, they're thriving. They look, you put a bottle in their mouth and they're moving the bottle nipple all around, like they have no idea what to do with it. And again, think about it. When do most moms return to work? When babies are three to four months. So babies that sucking reflux is becoming integrated and it's more voluntary. So I think that's a part of it too. Because a lot of these babies, what happens is the mom introduces the bottle at around two weeks and the baby does great and they think okay. And they don't try it again until the day before they're going to return to work when the baby's three to four months old. And that's when you get the bottle refusal. That's called a bottle strike. There is a great book called Balancing Breast and Bottle and it's by Amy Peterson, who's an ibclc, and Mindy Harmer, who's a speech pathologist. This is a great resource. This book was originally published, I think, back in 2010, and from my understanding they are updating it. They have great, great information in this book about selecting bottles, what to do with a bottle strike. They mentioned two different things that happen. So one of the things is a bottle strike. And a bottle strike is usually when babies initially will take a bottle as a young infant. And they like to say you need to introduce the bottle by three to four weeks. After that, it would be more of a late introduction. So they'll take the bottle well at that initial presentation. And then when the mom is ready to go back to work is when the baby refuses it. So that's the bottle strike. The other thing that they talk about is they talk about a bottle nipple resistance. And these are babies who just don't get a three to four weeks. And sometimes for them it's really they just want to feed. They prefer the breast nipple to the bottle nipple. So they, they kind of differentiate between a bottle strike and a bottle nipple resistance. And what they say about bottle strikes, and it is true, is that the baby just like nursing strikes, you know, sometimes babies have a nursing strike when they're teething or something's bothering them. Sometimes the babies will take the bottle and then they'll have a bottle strike again. They might return to it. So I thought that was a really good way to describe the two different things that can happen with that bottle refusal and that bottle resistance. There was actually too a great article that was published in the uk. Let me get the name of that for you. It's called UK's Mother's Experiences of Bottle Refusal by Their Breastfed Baby. And this is a really, really interesting study that was done in the UK where they sent out questionnaires to all these moms who were experiencing bottle refusal for their baby. And what was really interesting is a lot of mom with the breastfeeding piece, they kind of felt this societal pressure that, oh, my baby has to take a bottle too. And then when their babies did not accept the bottle, they really felt like they were failure. So it kind of put a negative spin on the breastfeeding experience when this bottle feeding thing occurred. It was a very, very interesting article. And they did say in the article that with some moms that were super, super diligent and really pushed away at doing this, some of those babies accepted the bottle. But I think the statistic was that only 39% of those babies ever accepted a bottle. So it was very interesting article. But a quote from it that I wanted to read that I think is really, really important for everybody to hear. I love this quote. And it talks about how we need to change the way we're referring to bottle refusal. And they said a normalizing of bottle refusal as a natural response by a healthy breastfed baby could alleviate some of the negativity surrounding this scenario. And I really, really liked that. It says that we have to have a sociocultural shift where we would normalize breastfeeding and parents would not feel like there was something wrong with their baby who wasn't accepting a bottle. And I love that spin on it, because it's not how moms feel. They feel like, oh, my baby can't do this. There's something wrong with them. Years ago, when I first became a lactation consultant, I got a mom referred to me that the mom was a administrative assistant in an office next to a pretty therapy place in Chicago. And I guess the mother had told the owner of the therapy place that I'm a single mom. My baby was breastfeeding. Great. I returned to work, and now she nurses all night and she sleeps all day at daycare. She won't take a bottle. And that's something called reverse cycle nursing. And that's what some bottle refusal babies will do when they're in a daycare or a caretaking situation. They will feed all night and they won't eat during the day, which is exhausting for these moms. But anyway, this mom came to me to rent a breast pump. At that point, I used to rent breastfeeding equipment. She came to me, and I'm expecting this child to have some feeding issues because I know that there was a speech pathologist working with this mom weekly on the baby getting to take a bottle, and they had really pathologized like there was something wrong with this baby. This mom shows up to get the pump from me, and as I was talking to Her I'm looking at the. This thriving, normal baby who's breastfeeding, and she was completely normal. And I realized that the speech pathologist that was treating her didn't realize that this is a really normal phenomenon for babies that are breastfeeding normally. So I wound up doing a whole in service to their therapy center to educate them about this. But I do think that this is what happens, that parents think if they get in the hands of someone who doesn't understand that this can be very normal, the next thing you know, they're paying for therapy to work on this. So I feel like we really have to get it out there that this is normal. And we'll talk a little bit about ways to work on that. I think also too, we can talk about why babies might refuse the bottle as well.

Yeah, definitely. I just had a mom either inbox me or respond to one of my Instagram posts about I did a little video on my gold standard. What I love is a bottle or a pacifier. And it wasn't that this is the end all, be all. This is just kind of where I start. And then if it's not working, let's see where we need to go next kind of a thing. But also guiding these families towards working with practitioners that can help them. Because I can't do that over, you know, an Instagram video or post. But yeah, then one of the moms responded and she said exactly what you just said, that she basically is doing that reverse cycle, you know, feeding where she is nursing. Where she is up nursing it all night and not eating it all at daycare during the day. Just went back. Mom just went back to work and this is what's going on. And mom's exhausted, obviously, because she needs to sleep so she can work the next day. And so, you know, I think it's a lot of parents go, what's wrong with my baby? And that you made that point, that they just automatically think, like, what's wrong with me? What's wrong with my baby? What's happening? Why isn't this working? And they don't realize this is normal. This can happen. And so I think, again, normalizing some of these concepts in the feeding community as a whole, because as you keep pointing out, like, a lot of US SLPs that have not taken a lactation course, we don't have that background. Nobody's taught us that. And so we might pathologize it. We might go, hmm, why is this happening all of a sudden? I mean, I personally wouldn't. Because I am familiar with the concept. However, I do see where a lot of other individuals in my space, in our space, that don't have a lactation background, they definitely are very quick to go, what's wrong with the baby? Like, let me do an oral exam, let's see if something's going on, which is not necessarily wrong. We should, sure, we can check the baby out, but at the same time, this is where breastfeeding is involved. We need to be pulling in an IBCLC because either we need to work as a team or they need to see the IBCL first to make sure they're getting the proper support. Because breastfeeding is the goal initially here and this baby is refusing to transition off of that. Right.

And I also see a lot too that the first thing is, oh, it's got to be a tongue tie. It's got to be a tongue tie. And I think if we are not seeing other signs of that and the baby's doing well, do we want to really subject the baby to going to have a release if it's really not something that's necessary? And so then you have a baby who's aversive to the bottle, they get a tongue tie release and then they're going to really hate the bottle when you start presenting it. So I think we have to think about that. The other really scary recommendation that happens a lot is moms will be told, well, you just need to stop breastfeeding and your baby's gonna accept the bottle. That is the last thing you should ever do. That is how this baby is surviving. And until that baby is drinking liquids from a cup or straw and really eating food, as you know, enough food to support nutrition, we never want to do that. Never, ever, ever. So believe me, I hear it a lot. The pediatricians will say, oh, you just need to stop that breastfeeding and then your baby will take the bottle. What happens when they don't? You're in big trouble.

Even to that point. On this latest post that I had on Instagram, I had a lot of moms going, but what should I do? Should I switch to a Dr. Brown's bottle? I'm using the mam and I'm going, hold up, pump the brakes. Whatever your baby is best feeding from right now is the primary means of how they're feeding. If you want to try another bottle, by all means you can try it, but do not remove their primary way of feeding. Our goal is to feed that baby. If you are concerned there's other symptoms, there's Other things going on, that's a different discussion. But you really need to link up with a professional in your area for an EV if there are feeding issues in general. But that's where I think I try to be so careful because I know mamas want to do what's best for their baby. And so if they hear that Dr. Brown's bottle, narrow neck, that's my favorite, that's my gold standard. And using a soothing pacifier or something similar shaped like that as a tool in therapy or as a pacifier, if we're going to offer one in the first six months, do we switch to that? I go, well, if you're going to use one, that's my preference. But that doesn't work for every bab and I never want to cause a problem. And so I think it's really important that that also be put out there since I know a lot of moms are now starting to listen to this podcast that, you know, never walk away from what is working right now and totally go cold turkey to a new thing because somebody said that that is the gold standard or that's what they prefer. Right? We need to make sure that baby is feeding. And if you don't have a baby who's falling off the wait charts and you have some wiggle room to maybe play with trying a new bottle or you know, that you think might be better for oral development, by all means, give. But again, I always caution moms like, do not give up what is working right now unless you have a solution that's working equally as well.

I agree. If it ain't broke, don't fix it. And that also will happen with bottle refusal. You'll go and you'll see the mom has tried 70 bottles and they don't realize it's just the bottle itself that they don't want. So I always say, you have a neurotypical baby. Just pick the bottle you have and stick with it. I do like two bottles that I like a lot are the Lansino Moma bottle. I like that one a lot. I do think it's a lot like the breast. If you watch their, it kind of explains that. There's also one that I like a lot that I've had great success with called the Nanobaby. And it literally looks like a cut off breast. And what I like about it is babies can hold it and it's very similar to the shape of a breast. So I often recommend that for parents if they're kind of struggling of okay, what should I try but again, there's no magic bottle. It's really what works for your baby. And that's what I do like about Amy and Mindy's book. They talk about a lot of the different bottles and based on the baby's mouth shape and everything else, and with that new updated book that's coming out, I think they're updating all the different bottles because there's so many changes in the last 10 years. So I think that's a great resource too. But I do think if it's working for you, don't change it. It's really the bottle that your baby doesn't want. It's not the type of bottle. And a neurotypical baby that's breastfeeding, well, is going to be able to take milk from a bottle if they want to. So that's the thing to remember. So we can talk a little bit too, if you want, about like some of the reasons why, you know, babies might refuse the bottle. And again, that I think the number one thing is they want to be with mom. You know, it's, it's their preference. It's again the biological norm. They like snuggling with their mom, they like the warmth of being with their mom. Also sometimes it's confusing to them when their coveted liquid is coming out of another vessel. They're like, what is, what is this? What is going on here? That's why some babies will never even bottle fed babies won't take milk, breast milk or formula out of a straw or a cup because they're like, nope, this comes out of the bottle. So we see the same kind of concept happening with that. Also about the sucking reflex integration piece of babies integrating that sucking reflex at four months, sometimes that has something to do with it when that suck becomes more voluntary. Also too, another thing that a lot of people don't know about is there's something called high lipase. Some moms have this enzyme called lipase in their milk that can make the milk smell really sour and yuck. I always check with moms, did you give fresh milk or frozen milk? Because you will have that lipase issue with frozen milk. It almost smells like sour or spoiled milk. It won't harm the baby, but it's kind of gross tasting and smelling. So I always say to try fresh milk before you try frozen milk. Because sometimes the high lipase issue is another reason why babies don't want to accept the bottle as well. So that's another thing to think about. And again, a lot of times it just, you know, It's a behavioral preferential thing. They just don't, they don't want to accept the bottle. And what you'll see these babies do is they will cry or arch in response to seeing the bottle. They kind of roll the bottle nipple around in their mouth like they have no idea what to do with it. They look, looks like something's wrong with them. They're just like, they don't know what to do with it. You'll see them turn away or cry. Some of these babies will literally not eat for hours and do that reverse cycle nursing where they nurse overnight. And what we see a lot is just really panicked parents and caregivers. And a lot of times what happens when a caregiver has to feed a baby, they start forcing and pushing.

That's a problem. Yeah.

So we have to train everybody with what to do with it when this happens.

Yeah, no, that's super helpful. I think that's going to really help a lot of our listeners. Now we talked a little bit about transition to solids. Right. So do you feel that a baby who has trouble going from breast to bottle is maybe more at risk for also transitioning to solids later on or what do you see there?

It's possible. I mean, that's why I said that I usually really follow up closely with those babies just to be on the safe side to make sure it isn't kind of a sensitive sensory baby who might have some motor planning issues. So I always keep an eye on it and I always tell parents after I've worked with them and advised them on how to manage the bottle refusal. Okay, you know, when you're transitioning, let's talk if you see any issues coming up with your baby having difficulty transitioning to solids. So yeah, I do think that is a possibility. I think the other thing too to remember is like when you're managing bottle refusal, every baby is different. So what might work for one baby, right? Like maybe one baby is going to take the bottle. If they're facing away from you bouncing and they're distracted, maybe that works for one and it doesn't work for another. So there's lots of different things. It's just really kind of being creative and trying to figure out ways to do that.

This.

But sometimes it's just not going to work. The baby is just not going to take a bottle. And when that happens, we go to alternatives and there's certainly ways to work around it. They're not as easy when you have a young four month old that doesn't want to Take a bottle. But there's certainly ways to work around it.

Maybe we can talk about a few of those things. We're going to have moms going, how.

How do I do that?

So then I guess let's talk about that a little bit. Management of these babies who are refusing the bottle. You know, like what, what can we offer. Offer them? I know we've mentioned some things just in our chats, but to kind of summarize and really bring it home, what can we do with these babies who are refusing the bottle?

Okay, so Mindy and Amy have a great section in their book about that. So that's one great resource. And I feel like it's really outlined very, very nicely on some things that you can do. I think they give great ideas. But first and foremost, when you have a baby that's going to refuse the bottle, what you need to do is it's always education and prevention. So if we can educate parents early on and get the word out there that this may happen, this is what you need to do, we might be able to prevent this from happening altogether. And if we also, the other important thing is just again, letting them know that you have a normal baby. You know, this is the biological norm. Your baby's a breastfeeding baby. They don't take a bottle. They're still normal. It's okay. So I think those are, those are the really most important things to do. But what we need to do is once a mom is going to, or dad is going to present that bottle, what we need to do is we need to do it between two and four weeks. So I usually rec at the two week point, especially if the mom is going back to work. And once we introduce the bottle, we want to introduce it frequently. And what I tell parents is you don't have to waste your milk. I tell them you can put in, you know, a quarter of an ounce, you can put in 5-7mls, like a really little amount and just present that to the baby every other day or every day and then breastfeed them after you give that amount just to keep them in the game until you return to work. So I feel like that's a pretty foolproof way of really, it's presentation and frequency that will help. But still, you still might have that baby. Who does it? Does it, does it. My daughter used to be horrible on Mondays. She'd be with me all weekend breastfeeding. On Mondays. The babysitter would kind of roll her eyes because she knew that she was going to have trouble on Monday and Tuesday, and it would get better by Friday and then the whole cycle would start again. So that's something to remember. But again, frequency in small amounts. And I think we have to just not make a big deal about it. We have to be very calm and we have to be calm with parents. And we always, again, encourage moms to keep breastfeeding. That's the most important thing. When people are going to tell you to stop breastfeeding, don't keep breastfeeding. We also have to find a bottle system that's going to work for the baby. And I do think in Mindy and Amy's book, there's lots of good descriptions of, you know, depending on the baby's mouth size, which nipples work, which flow works. So once you've got a bottle, you'. But I think another important thing is when you try to present the bottle, you want to make sure that the baby is in the right state of mind. And for every baby, that may be different. So most people think, oh, well, if the baby's starving, they're going to take the bottle. That's the worst time to do it. It's better to breastfeed the baby and make sure the baby's in a calm, regulated state before you try it. You might even try it when the baby's sleepy. You have to figure out what works for that particular baby. Does this baby accept it more accepting of it when they're happy, quiet and alert? Do they do it better when they're tired and sleepy? Will they accept it better if they're in a dark and quiet room? Location has a lot to do with it. Will they do better if they're in a different room? You certainly don't want to try the bottle and the chair that you breastfeed them in. Maybe you want to try going for a walk and doing outside. Maybe you want to use a little bit of distraction. I mean, we don't want to do distracted feeding, but if we have a really desperate mom who wants to get her baby to eat, maybe we, you know, do some singing or some bouncing, maybe we face the baby away from us. Lots of different tricks. Again, we want to think about fresh versus frozen. Make sure that it's fresh milk in case we have that lipase issue. And if there is a high lipase issue, what we do is we scald the milk and then we freeze it. And that gets rid of that lipase issue and that smelly, sour taste of the milk. We might want to make sure that the milk in the bottle is pretty warm. Because milk coming out of the breast is warm, so we want to keep with the same temperature. We might want to warm the bottle nipple just like the breast nipple is warm. And sometimes I have moms just like set the nipple into warm to hot water to warm it. We can try a different feeder. Does the baby do better with grandma or the babysitter or dad? Those are things to do. So there's lots of little different things to do. We want to be child directed too. So when we present the bottle, we don't want to force it in or trick the baby. We really want the baby to open their mouth and accept it. We don't want to just shove it in there. We want to be responsive about the bottle just like we're responsive about solid foods. I think when it gets to a point that the baby is absolutely. This is not working. They are not going to accept a bottle. You can do many different things to get liquids in a baby. It's certainly not an easy thing to do. And we very have to teach parents how to do this safely and make sure the baby's sitting in a support way so they're not going to aspirate or do something that's going to be harmful to them with getting a thin liquid in a different way than the bottle. But we can do cup drinking. I like to use cutout cups. I use shot glasses. I use little Motrin or Advil cups. For babies there's so many different things. You can use an easy peasy, tiny cup. There's so many different cups that we can use. Sometimes I'll use a dropper like the squeeze top dropper. We'll do some drops of milk. Sometimes we'll. We'll place a spoon laterally by the baby's mouth and tip it into the baby's mouth. We might do a honey bear straw cup where we. You do very controlled, one sip at a time. I mean that certainly takes forever, but at least we know there's some way that we can get milk into these babies. There used to be a great little feeder called the Hazel Baker, which if you can find a lactation consultant that still has Stock from the 90s, you can often find these. And it's a little thing that you attach to your finger, a little squeeze thing and you can finger feed them. There's so many different ways to do this. Sometimes with these babies we might start solids a little bit earlier, like five and a half months instead of six months if they're developmentally ready to do that. There's lots of ways that we can cushion and path this. And then in the meantime, we start working towards cup and straw drinking. Because we know that by, you know, I have babies that are seven months old that can straw drink. So if we can start to transition to regular vessels that they can drink from themselves, we're fine. The baby's going to get through this. It's going to be nothing but a distant memory by the time they're a year and they're eating solids and drinking from a cup. So it's really what we have to do is find the things that are going to work until we get to that point where the baby is okay and we don't have to rely on just liquids when the baby is separated from the mom.

Yeah, as a new, I'm not a new mom now, but as a two time mom, when I was a new mom, I just, I remember even transitioning to solids. It was so funny because I was a feeding therapist who was working with toddlers, but I was working with mostly picky toddlers. And a lot of these toddlers were already on solids. They weren't transitioning off of liquids to solids. Right. They were just very limited in the solids that they would accept. And so maybe they were, some were still drinking out of a bottle. So we transitioned them to a straw cup and we did oral motor work and whatever else. There were true feeding issues. These were not, you know, maybe they're neurotypical kids, but they had a true feeding disorder going on otherwise. And so, you know, I just, I remember having my own children and being like, how the heck do I get them off the bottle and onto solids? Like, okay. And with my first, even though she was tongue tied, she did great. She took, you know, she took those solids off a spoon and she later became very picky. But she was that kid who really struggled with breastfeeding. But then she did great when I transitioned to solids. And so I just think it's so important that we all keep in mind that there is one right path and that we're gonna hit speed bumps, you know, roadblocks along the way. And it's just about getting creative and figuring out a safe way to feed your baby based on wherever they are on their journey. And just because they're having a little trouble doesn't mean they have a feeding disorder. So I think, and I think that's part of your big message here is that a lot of these children do not actually have pediatric feeding disorders. They're just having a little bit of a struggle transitioning from one feeding vessel to another or from, you know, one stage to the next. And that's to be expected. And I think if we do expect that and we start educating parents on the fact that you should expect this, this is going to happen. And if it doesn't happen, wow, like, that's uncommon. That's where I think we're kind of doing things backwards. Everyone just expects we're going to pop this baby out. They're going to hop right on my breast or bottle. Everything's going to go great. We're going to transition to solids in six months. You know, eat cake at their first birthday, then they'll be drinking out of a cup. No problem. Like, it just magically happens, and it's not, you know. No, we have to teach these things, and sometimes it's hard to teach them. So, yeah, I think this is a really, really great message. I'm excited to be talking about this on the podcast because this is really the first time that we've even brought this topic up.

Yes. And I think you bring up a really great point that, you know, every child is different. And I think our attitude, like, if we're panicked and nervous, don't think that babies are not picking that up. They know it. So if we can be calm. And I think part of one of the things that's going to calm parents is if they realize your baby is. Just because your baby's doing this does not mean that they're abnormal. And I think that's a big message that we have to say, like, okay, it's going to be okay. If we can be calm and relaxed and tell them it's going to be okay, they're going to feel a lot better again. They have enough to worry about in the crazy times we're living in now, but we can tell them it's going to be fine and we can manage this. I think that that's one of the greatest things. I think if we can give parents permission sometimes, like to say, if right now your baby nurses overnight, that's what they have to do. That's okay. We'll figure we're gonna work towards what we want in the future, but it's okay. These things are okay. I think we have to tell parents there's nothing's black or white, and every baby is different, and we just have to do what's safe and what works best for that family. And that's the thing that we need to do. Yeah.

No, I love that.

I love that.

So going back to our conversation then, are There certain bottles I know that you mentioned Your Lance, no MoMA and the Nano baby that you like are. Is that what you typically recommend for breastfeeding babies then?

I do, I like those a lot. I think in the lactation community the Lansino moma, it's recommended a lot. I personally have liked the nanobaby. I found that that's really nice because again when you look at it, when you look at it online, it really, it looks like the baby's holding a breast that was removed from the mom. It's really neat. It's a really neat system too the way it works. So I do like those. I like Dr. Brown's. I really like like any bottle that's going to work for that baby. But if you're going to pick one that I feel like sort of looks more like the breast, I like those two bottle systems because I feel like they're great and everyone has different experiences. Other people might recommend different things. If you've got something in your house that someone gave you and that's what you want to try, really anything is.

Okay and that's great. I think it's great to give permission to parents to use what works for your baby. And yes, there's a bazillion things out there. I think the biggest discussion in my community is more so about, well, what's best for optimal oral function and development. And you know, we know the answer is breastfeeding. Breastfeeding is really what's best. Like we talked about in the very beginning how that is the biological norm. But one, that's not every mom's goal and two, you know, it may have started really well and then maybe it just became too much and mom decided to start introducing bottles because she didn't want to breastfeed all the time or she was breastfeeding and pumping and now we're introducing bottles or mom has decided for whatever reason to move away from breastfeeding onto the bottle. So I get a lot of questions about well, which one is the best for my child's oral development. Do you have any thoughts on that? I mean I know that we're talking more about what works best for baby just to actually feed, but I think.

That anything that's going to replicate the breastfeeding postures like open mouth, wide open mouth, placement of the tongue. So I think any kind of, kind of, I think a wide base nipple can be great, you know. But I do, I will say in Mindy and Amy's book they talk about some babies, it's Too much. With wide base nipples, it stretches their upper lip too much. So I really think if we can have a relaxed mouth flange, the lips, you know, have all the postures that we would see in breastfeeding with a bottle, that would be great. You know, because think about most bottles, a lot of them are the nipples are narrow. So it's more of a narrow attachment to that bottle versus the wide open mouth. I mean, when babies attach to the breast that what they do is they reach with their tongue and then they have that big open, wide mouth gap response. So we can kind of replicate that with a bottle. That would be a really, really good thing. And I do like that about the nanobaby that you do open widely like that because it does look just like the breast. So I think that's what we want to do because we know that prolonged use of the bottles and pacifiers and everything else are going to shape that oral cavity in a way that we don't want. So if the baby is separated from the mom, if we could still work on some of that oral shaping with a bottle, that's going to help that, that would be great.

Awesome. And so I have one last question for you. So what about nipple flow rate? Because I hear a lot that and I'm not a lactation consultant, and I think that I bought into this concept, so hopefully it's correct. But, you know, when we have a breastfeeding baby who is on a bottle, obviously we're going to want to be responsive to what that baby responds best to. As far as nipple flow rate, I know nipple flow rates are different based on the bottle. You know, a size 2 in one bottle is not the same as a size 2 in another. And a size preemie nipple on one bottle is not the same as a preemie nipple another. The flow rates can actually be very different. But in theory, I just heard overall that typically we want to recommend more like a preemie or a level one nipple for breastfeeding babies so that they still have to work at the bottle if the goal is to continue breastfeeding.

That's what the lactation community will say. They'll say to use a slow flow. However, I think the really important thing is we do not want too slow flow and we don't want too fast flow. Flow. We've got to find something in between so we really have to watch the baby's behavior and look how coordinated the baby looks when they're sucking from that bottle. I usually like to stick with a level one Nipple, I feel like that's the fine flow depending on the bottle for most babies. There was an article that was written by a speech pathologist. I think it was something to the effect of the unintended consequences of slow flow nipples. I can find that reference in any add it and send it to you. But what it was saying is that sometimes if the nipple flow is too slow, babies do funky things with their sucking and that's not a good thing either. So it's got to be more of like a natural kind of thing. So we have to really watch and see what the baby looks like. And I think now that, you know, lactation consultants will tell you to do slow flow because what happens if we introduce bottles too early to babies that are breastfeeding? They prefer the bottle to the breast. So that's a whole other issue. So I think that's where that comes from. But again, we don't want to do too slow flow either because it's going to frustrate a baby. So I think we have to find the happy medium between not too fast and not too slow. And I think that's individual to every baby as well. You've got to really watch the baby and see what they look like. If they're gulping and chugging, it's too fast. If they're really compressing the nipple and looking frustrated, it might be too slow. So I think it's really based on the bottle system you're using and the flow of the nipples for that bottle system.

And that's perfect. I'm over here with a big smile on my face because my students in our course always ask, ask us questions and half the time we go, it depends. They kind of look at us like, here comes that answer again. And it really is, it really depends. It depends on the baby, it depends on the situation. It depends on like all of the various factors. And that's why there isn't one right approach or one right answer for every baby. And you know, how easy would life be if we could say, okay mama, take that Dr. Brown bottle and that soothing pacifier and you're good to go? Well, no, we wouldn't be having these discussions if that's actually how normal development responded to these systems. So I think it's so important to realize that as clinicians we have a job to think critically and really evaluate for this individual baby in front of me, is this actually an issue or is this not really an issue? What can we help this parent be creative about? What can we try that is not Necessarily feeding therapy, but, but just some creative ways of maybe getting baby to accept this bottle. But also as clinicians, if we are working with infants, I think it is our job to be able to watch a baby and know if that nipple flow is too slow for that baby or that nipple flow is too fast for that baby, if we are trying to help transition them to a bottle. And so I think that is. I'm gonna get tons of questions about this from listeners and I'm probably just gonna say it really depends. You just watch 100 different babies eat, 100 different neurotypical babies eat, and you're gonna, gonna start to get a good idea of what typical breastfeeding looks like, typical bottle feeding. And then you'll be able to, you'll be more confident in your recommendations, you know, for any baby who is not necessarily following that typical trajectory or who maybe is, but is still struggling just with, you know, a normal transition from one thing to the next.

So I also think other things can affect it too. Like is the bottle nipple heated up? Does that expand a different. Is it an older nipple? Has it been used a bunch? There's so many things and I think a lot of times therapists want a cookbook and there's. That's the hard thing about baby is there's no. Every baby is so individual. Another thing too. And I'll also send you a reference Brit Patos information on. They did all of those studies of the different flow rates of all the commercially available nipples. That's a really good article And I think Dr. Brown's has one too on nipple flow. I think that that would be a great resource for therapists to look at and say, oh look, this one is supposed to be slower flow. Like maybe we have a baby who's having a little bit of difficulty with thin liquids. Maybe we try the slower flow. It gives you a good idea of what the flow rates are of those nipples. But I think there's nothing better than watching the baby. You can have 10 nipples and you got to watch the different ones and see how the baby does best. And that's the one you pick.

Yeah, yeah. And I think even to that regard parents, because I know there's mamas who listen to this. If your baby's on a bottle and, or you're trying to transition them and you see that milk just flowing out the side of their cheeks, it's just dribbling down and you're having to replace that bib because they're just soaking the bib with everything flowing out of their mouth. We know that's too fast. And, you know, I think the parents haven't been given any encouragement or information to know, oh, hey, let's try to drop down one level. You know, let's go from that three to that two or that two to that one and see if baby feeds better. Is baby able to keep more milk in their mouth? And are they, you know, respond, Are they happier when you're trying to give that bottle versus when you're kind of drowning them a little bit with a little too much milk flowing out of that nipple at a very fast pace? Because again, I just don't think that the info is out there. But like you said, said it's. There's no cookbook recipe. And so that's also why it's so hard to even educate parents on this. Because, you know, we can, we can tell you things all day long, but once you have your own little baby in front of you. Even as a feeding therapist myself, I kind of was like, I forget everything.

What do I do with my own child therapist parents? I would say my most complicated parents are speech and OTs. Always I'm like, oh, no, they're coming. But I, I think that we just have to watch babies. And again, when you're sucking from the bottle, if we're looking at what bottle to pick, it should be rhythmical and coordinated. I mean, it should look pretty natural, not lots of stops and starts and fussing. So I think that's a really important thing to know. Awesome.

Well, that is super helpful. Is there anything else that we didn't cover today that you wanted to add? I mean, I know we've talked about a lot.

I don't think so. I just think I want to communicate how, you know, neurotypical babies that refuse the bottle. It can be a very, very normal thing. We cannot pathologize it. We need to support parents and give them ways to manage it. And we certainly want to educate them early on so we can be preventative so it doesn't happen. But I think that's the biggest takeaway from this because I just see so many social media posts where this issue is being pathologized a lot. If pathologize is even a word, that's being pathologized a lot. And I just want to say that I don't really. Coming from both professions and using them together, I don't really see it as a pathology for babies that are neurotypical.

Yeah, no, I love that. And this will definitely inspire some more some posts on my page to help get this message out there because I absolutely love this message. So thank you so much, Jill for joining me. I know that, you know, if you guys have been listening, there's a lot of great resources we've shared. They will all be in the Show Notes. We'll link that UK article that you shared with us and the book and you know, all these other resources that we mentioned that we would get to them. So thank you, thank you, thank you. It's been amazing to have you back on the podcast. I appreciate you so much. Thank you for spending today with us.

Thank you so much. Thanks for having me.

Thanks for listening to this podcast. If you want to hear more of these Myo Tauts, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the Untethered podcast. If you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page at halliebulcan biz, on Instagram @hallebulcan. And you can head over to theuntetheredpodcast.com to grab a copy of the the Show Notes where you can also subscribe to be kept up to date on the latest podcast episodes.