Pacifiers, Bottles and Pumps, Oh MY!

What does a breastfeeding mother and baby need besides each other? Clearly, they need time and proximity so they can adjust their relationship from a continuous but unconscious provision of warmth, comfort and nutrition by mother of baby to a deliberate but more intermittent provision of those same requirements for baby by the mother. Mother needs the support of those around her to meet her physical and emotional needs while she meets those of the new baby. And this process takes time to develop its rhythm. Like new dancing partners, the dyad must become comfortable and intuitive in their actions, developing trust and coordination over time.

But — what if a separation must occur. Mom can no longer be ever-present to meet her baby’s needs. Or what if baby or mother has a physical issue that affects milk supply or delivery? How can we provide a substitute for both mom and baby that doesn’t undermine the breastfeeding relationship? The market steps in to offer its solutions: bottles, pacifiers and breast pumps! These tools offer and purport to be a temporary solution to bridge the separation on a short term basis, but often present their own challenges to mother and baby.

So, how do we select when presented these “solutions?” First, understand the basic physiology of breastfeeding. How do mothers make and release milk? How do babies obtain that milk? What is the biology that we are trying to mimic? What are the properties of the man-made materials that we use to create these tools? Over the years, inquiring minds have looked at various products on the market to try to determine how these products work and to what degree they either simulate breastfeeding or offer less interference with breastfeeding when used. The problem is, most of the methods used to test products don’t truly match what a baby does when they use the products. Ultrasound studies may show the mechanics baby uses on a bottle, for instance, but can’t really measure the baby’s adaptation to the materials or how the baby changes flow rates by altering the quality or actions used during sucking. Only a very sophisticated real-time system using pressure gauges, ultrasound and sequential weight checks can adequately assess the way a bottle performs for a particular baby. And even that can’t determine how a baby is adapting and accommodating to the bottle.

Some fairly good research has found that pacifiers introduced after the first two weeks and limited to less than 2 hours use during the day do not appear to inhibit milk supply or shorten breastfeeding. In this study, a one-piece pacifier with a rounded nipple and slight flange at the base was used for all babies in the study.(1) In this study, all babies were healthy babies with no identified risk factors such as tongue-tie etc. Early introduction of pacifiers may interfere with baby’s learning curve where he identifies and correlates sucking and swallowing with latching to the breast. Pacifiers are made of materials much firmer than mother’s breasts and do not conform to the baby’s palate. This imprinting period can last up to 6 weeks. An analogy I have sometimes used is this: introducing a pacifier is like giving a young teen porn – it is artificial, highly stimulating, and does not resemble the real shape, feel or action of the real thing. Ear, nose and throat specialists who work with babies with tongue and lip-ties have noted that babies who have used pacifiers a great deal can have issues learning how to open widely and actively extend the tongue to latch onto the breast. If possible, delay pacifiers until they are absolutely necessary, after comfortable and effective breastfeeding is established, and then limit use to less than two hours daily. Avoid orthodontic, flat or bulbous pacifiers.

A skilled IBCLC can assess a baby’s sucking technique, evaluate suck strength and make recommendations for supplementation methods if needed. They can offer suggestions to help the nursing couple to address and overcome any issues encountered.  They can also evaluate mom’s supply and make recommendations for techniques, equipment and supplements as needed.  They can communicate with other healthcare providers to coordinate breastfeeding and family-friendly care.

The research that has been done on bottles includes direct ultrasound and indirect flow studies using a pump setup to mimic the vacuum levels babies use on bottles.(2) Some bottles will deliver nearly an ounce in a minute! This fast of a flow rate will cause a baby to take too much at a time from a bottle, may cause gassiness and fussiness and spitting up. Some bottles will deliver a fast rate of flow if the baby bites on the nipple. When babies must use a bottle and the flow rate or method of obtaining the milk (compression instead of sucking) varies from what is normal during breastfeeding, it can cause bottle or breast rejection. Bottles that drip when held sideways do not necessarily flow fast when baby is sucking. And, bottles that don’t drip, are not necessarily slow flowing when used by the baby. Generally, 5 ounce Newborn Dr. Brown’s bottles with regular size neck, not wide-mouthed, Special Needs Feeders, used with the small line lined up with baby’s nose, Calma feeders, and Munchkin Latch bottle are considered slow-flow, non-compression bottles. Bottles not recommended include Avent, Tommee-Tippee, Momma original, Evenflo original, and many others. This list is subject to change, however, as manufacturers constantly change or quit making products over time. The best way to test a bottle is to buy one only, try squeezing the nipple where baby’s gums would go to check for compression, and offer to baby.

When bottles are recommended for supplementation, it is a good idea to have a lactation consultation to evaluate the baby’s suck and mother’s supply. This can help in choosing the right bottle or another method for supplementation that can help preserve the breastfeeding relationship.

Check out my hand-out on using a bottle under resources. .baby-led-bottlefeeding

(1)Does the Recommendation to Use a Pacifier Influence the Prevalence of Breastfeeding? Jenik AG, Vain NE, Gorestein AN, Jacobi NE, Pacifier and Breastfeeding Trial Group J Pediatr. 2009;155:350-354 (2) Comparison of Flow Rates between Commercial Bottles Karen Gromada, IBCLC unpublished communication.

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