How to get a baby back to the breast

Getting a baby back to the breast either during a breast refusal or where there is a bottle preference can be very difficult. Unfortunately there is no quick or 'magic' fix, and it can depend on how old the baby is and if they ever breastfed for and if they have, for how long.

Up to about 10 weeks of age, babies use reflexes and instincts to breastfeed. Going back to direct breastfeeding can be a bit easier as their instincts may still be intact. After this time they use the skills they have learned to feed - so if they have never (or rarely) needed to open their mouth wide they may not know how to do it. Sucking on a bottle uses different muscles and skills to suckling on a breast. Plus milk will most likely flow from a bottle regardless of how the baby sucks, whereas a baby suckling on the breast needs to illicit a let-down, so it needs to be done in a certain way.

Ideally, if you want to breastfeed bottles and artificial teats should be avoided for the first 6 weeks or so. This is so the baby and parents can learn as much about breastfeeding as possible and hopefully reduce the chance of a bottle preference happening. If bottles need to be given then they should be given in a 'responsive' or paced way - read this article for more information on what this is

If your baby has developed a bottle preference or breast refusal this is a list of things you can try to get them back to the breast. Keep in mind to keep time at the breast positive.

First, review good positioning and attachment

If there was an underlying issue that led you to bottle-fed in the first place and this has not been addressed, then getting the baby back to the breast might never be possible.

If you are struggling to get the baby to latch, then seeing an IBCLC (International Board Certified Lactation Consultant - the health professional who is an expert in breastfeeding) to help you review good positioning and attachment is a good idea. Keep in mind that up to 10 weeks of age babies use innate reflexes and instincts to help them find and attach to the breast - you might just need to let them take the lead.

If you have been told that baby has a tongue tie but you have not had it cut or lasered then it also might not be possible to get them back to the breast. This should be discussed with an experienced IBCLC.

If you have never seen an IBCLC, now will be a good time to do so.

Next, review how much you are feeding baby, how often, and in what way.

Often when I talk to parents who are predominately bottle feeding but want to get the baby to the breast, I find that the baby is having large amounts via the bottle a few times a day. An example is 150 - 180mls/feed 4-6 times a day.

A study from the University of WA found that directly breastfed babies (who were gaining good amounts of weight) took an average of 750mls/day (+/- 250mls) in an average of 11 feeds/day (+/- 3feeds/day).

So first the bottle feeding amounts may need to come down to how much they would take from the breast. You can still give the total volume they would be having in 24hrs, but feed smaller amounts more frequently - eg, 100mls 8 times a day. At first, they may not be too happy with being 'cut off', but keep in mind they are still taking the total 24hr amount, just in smaller, more frequent, volumes.

Paced or responsive feeding is very important

It might be possible to switch from bottle feeding to finger feeding, which can be more 'breastfeeding friendly'. This involves using a thin piece of silicone tubing with one end in a bottle of milk, the other at the tip of your finger (click here to buy tubing in Australia). You then slip your finger (and the tubing) into the babies mouth and they suck the milk through this tubing, making sure your nail is on the baby's tongue, the pad of your finger on the roof of their mouth.

The positives of doing this is that a. you can gauge how far to put your finger into the baby's mouth, as close to the junction of the hard and soft palate as possible, and b. it will limit how much and how quickly they take milk. While they are taking breaths/a break the milk will not flow. They also have to actually suck to get the milk to flow, vs using a bottle where milk is likely to flow regardless of how hard they suck

Now, try 'reverse supplementing'

This is where you first give milk from the bottle (or finger feeding), then offer the breast. For the first few days you may need to give almost the full amount from the bottle before trying. Over time you can try giving half or 3/4 before trying. If baby takes the breast, try reducing the amount from the bottle before trying the breast. If they don't take the breast, keep the experience positive and try again next time.

Try a 'nurse in'

If possible spend a full day (or a few days would be great) with your top off and your baby as close as possible, for as much time as possible. Let them take naps close to your bare breasts, feed them at your bare breasts. The only time you take breaks is to eat, go to the toilet, and to change their nappy.

This obviously might not be practical if you have older children, but could be with good support.

Feeding with distraction

Some other suggestions are to distract the baby while offering the breast. Some ideas are

• In the bath or shower

• Bounce on a fit ball

• Stand and sway/rock

• While they are lying on the floor or change mat (or a bed)

• Use a favourite toy

• Try when they are half asleep

Use a nipple shield

Normally I am not a fan of nipple shields - I see them mostly being used as a bandaid solution by nurses or midwives in hospital - they can't get a baby to latch and because they don't have the knowledge or skills to help so they give out a nipple shield - it gives the impression that baby is sucking at the breast and they can move on...sorry if that sounds a bit cynical, but this is what I see in private practice with clients who were told to use nipple shields and they are still struggling 6+ weeks later. They can be good in the case of nipple shields - a temporary device to be used until the tongue tie is revised.

But in this situation, a nipple shield can be a good in-between step. The things to know are that the nipple shield should fit the baby's mouth - a 20mm is for a 'late preterm/early term' baby (ie up to 37+6 weeks), 24mm for a term baby (up to about 4kg) and a 28mm for a 4+kg baby.

You need to get as much breast tissue into the shield - fold the shield halfway into itself and suction it onto the breast. You will probably need to hold it in place while getting the baby to latch. It can take a few goes to figure it out. You still need to make sure the baby is using 'proper' positioning and attachment - because the nipple shield is hard it is tempting to just push it into the baby's mouth, like a bottle teat, and this may not be conducive to getting baby to latch directly.

A note on the Haakaa nipple shields - like the majority of lactation consultants, when I first saw the Haakaa nipple shield I was quite shocked at the design. The purpose of a traditional nipple shield is to have the baby stimulating the breast but with a shield between the breast and the baby's mouth. However, the Haakaa nipple shields look more like a traditional bottle teat that would not provide any stimulation to the breast at all. Then I saw one being used in person and I realised they are quite a clever design - they are like a Haakaa milk catcher with a teat attached, so the baby can take the milk immediately. I would ONLY use the Haakaa nipple shield if the baby is completely refusing to go to the breast and also refuses to latch directly to the breast.

Bait and switch

Feed the baby with the bottle as close to the nipple as possible. Take the teat out and see if you can 'trick' them into taking the nipple. The trick with this one is to make sure there's only a second or 2 between taking the teat out of their mouth and getting them to the nipple, so you need to hold them in a way that will allow you to do it with the least amount of fuss as possible.

Another version of this is to hold the baby in the same position you would for breastfeeding but put the bottle under your arm (in line with the nipple). Let them feed at the bottle, then take them off, slip them down slightly and see if they will latch to the breast.

Remember that anything you try may not work the first time, or even the 5th time. Keep the experiences positive. A bit of 'fussing' might be OK, but try to limit distressed crying. If you feel overwhelmed then stop because baby may as well. Try not to be too disheartened by short or unsuccessful attempts - celebrate small wins.

Keep experiences at the breast positive

It might be a good idea to set yourself some small goals - eg 'I'll try xyz for 3 days' and then really do it. If it doesn't work then move onto another attempt.

Remember you will need to be expressing - up to 8 times in 24hrs if baby is less than 12 weeks old. You can maybe do a few less sessions if your supply is good and baby over 12 weeks old.

A note on breast 'strikes'

This is where older babies have been breastfeeding well and then suddenly refuse the breast. The first step is to work out why the strike is happening - sometimes a mother reacts to the baby biting or pinching and the baby took a dislike to it. The baby could be teething or have a cold. Sometimes things like pregnancy or an illness in the mother can change the taste of the milk and cause them to refuse breastfeeding.

Next, express breastmilk and give it to them in a sippy or straw cup. This is both to keep your supply up and see if they will take the milk that way.

Now, offer the breast in small, gentle ways. Distraction may work well in these cases or spending time with your chest bare, so baby can come to you when they are ready.

Sometimes a nursing strike will end as suddenly as it started, sometimes it won't end at all.

Keep in mind that the 'natural' age of weaning is 2-4 years - this generally means that infants/toddlers under 2 won't wean from the breast, unless they are given other options - more food, milk from other sources, etc. Before thinking your baby has 'weaned' from the breast maybe look at how much food you have been giving them and if they have been having milk from a bottle. When older babies/toddlers transition from breast to other sources of nutrition this can be called 'unplanned weaning'. It is not necessarily a bad thing, but if you planned on breastfeeding to 'natural term' (eg 2-4yrs) this may cause feelings of confusion or disappointment.

Justine is a nurse, midwife, and IBCLC - she provides breastfeeding support in Perth, Western Australia (although video consults may be available for those outside of Perth). Follow her Facebook page for regular updates and information on pregnancy, birth, breastfeeding and parenting.