Problem-Solving Late Preterm Weaning Breast to Bottle

Question:

The parent of a client approached me about a three-month baby refusing bottle feeds. Baby had some issues at birth with feeding and was in NICU for one week due to respiratory insufficiency, born at 36 weeks. Since 37 weeks, baby has been exclusively breastfed with no issues and appropriate weight gain. Does anyone have any techniques to facilitate transition to bottle with pumped breast milk? Any bottles that you have found to work better than others

Answer:

There is likely a myriad of factors that likely are combining to result in this former late preterm’s difficulty transitioning from breast to bottle.

Because she is a former late preterm, it opens up so many possible interacting etiologies that need to be peeled apart and looked at in dynamic relationship with each other. Why she is “refusing” bottle feedings is the key to how we intervene.

Most late preterms born at 36 weeks are in the newborn nursery. The fact that she required neonatal intensive care and had respiratory insufficiency suggests that respiratory co-morbidities were significant. There may have been other co-morbdities, which are not uncommon for late preterms, but we do not know that.

The typical approaches for a healthy term infant with the same challenges cannot be applied to a former late preterm. While she is now 3 months, she is a little over 2 months adjusted age, and that difference is essential to consider, as it provides the context in which we interpret her behaviors. Born 3 weeks early, her sensory-motor experiences early-on were different. Her postural integrity may still be lagging somewhat and may predispose her to more readily breastfeed because less adaptations are required posturally at breast. Because the unique and exquisite physiology of breastfeeding creates ” islands of stability” for breathing for preterms, her preferences for breastfeeding may indeed be physiologic – i.e., at breast she can control the flow to create “windows of opportunity” to integrate breathing with sucking. That isn’t possible with most mad-made nipples. Man-made nipples not only often flow faster, but the infant cannot control the flow from a man-made nipple. It flows based on what nipple the caregiver chooses and the infant can only “respond” to what flow has been selected. The flowrate differences may be part of the picture.

Based on that, I would likely not consider alternative feeding procedure that require this former late preterm to manage a less controllable flow from a Medella Soft Feeder, syringe, cup, straws. While that may be supportive in a former healthy term infant, it may create more struggle for this infant given her history.

I would suggest swaddled sidelying, a slow flow nipple (perhaps Dr. Brown’s preemie flow), ad infant-guided co-regulated pacing to support the kind of flow rate control that this infant has learned and appreciated at the breast. Always offer the nipple via her rooting response, as she is used to rooting actively with breastfeeding, versus” placing the nipple” in her mouth or” putting it in her mouth”. I would also avoid any tendency to prod with the bottle, as she is not prodded at breast. The less adaptability required when she goes from breast to bottle, and the more physiologic stability we create by supporting breathing, the more likely we will be to see progress. We also want to foster a positive feeding experience versus focusing on how much the infant takes, i.e., emptying the bottle, which may unfortunately come into play as bottle feeding is offered. Supporting maintaining the mother-infant relationship will be essential.

I hope this is helpful.

Catherine

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