Tag Archives: bottles

Home Visit Info (Boston or San Francisco areas)

Breastfeeding, Feeding, Infant Health & Safety, New Moms, , , , ,

Only By Direct Referral.

Home Visits for New Parents –
To help answer some logistical questions about a home visit, here’s some general information.

Who am I?
I’m a board-certified pediatric nurse (RN, CPN) as well as a board-certified lactation consultant (IBCLC), with over 25 years of experience helping new mothers, families and babies.

My areas of focus are maternal health and lactation, newborn and infant care and development, infant feeding (breast, bottle, solids) and newborn sleep. (Learn more Here and Here)

Initial Home Visit: During our consult, I will come to your home for about 2 hours, complete a detailed history, observe or assist with a breastfeeding and/or pumping session, including pre/post feeding weights with a highly accurate scale if indicated, answer all your questions, and together we will come up with a workable plan you are comfortable with. After the consult, I’ll email you a visit summary with reminders, suggestions and resources based on your specific situation. A check-in by phone or email is included after your visit, and Follow Up visits are available as desired.

Consultation Fees (San Francisco)
Initial Home Visit is $350 for the initial visit (about 2 hours) including phone/text/email check-in.
Follow Up Home Visits are $250 and about 75 minutes.
Phone consults are $150 and 50 minutes.
Day, Evening, Weekend and Next-Day Appointments May Be Available

For questions or to schedule, leave a message at 617.803.5614. 

All consults, including phone consults, include a brief summary and resources, receipt for insurance or FSA reimbursement and a check-in by phone, text or email within several days of the consultation.

I do not accept insurance, however, your insurance company may reimburse you if your policy covers lactation visits. Clients are expected to pay by cash or electronic payment at the time of the visit. I will provide you with a detailed receipt appropriate to submit to your insurance company or Flexible Spending Account (FSA) to request reimbursement.

Please DO:

  1. Have baby’s weight history and any recent feeding, supplementing and pumping  app data or logs available. (If possible, email me any summaries ahead of time)
  2. Plan to have baby ready for a feeding about 30 minutes after the start of our appointment. I will want to collect information first – but – babies are not predictable! Don’t try to “hold off” baby for too long, we’ll make whatever the situation work.
  3. Have pump and pump parts ready to use in case we want to also observe/improve a pumping session.
  4. Plan for payment at time of visit (cash or electronic payment please).
  5. Your partner, friend or a support person is welcome to be present during our consultation.
  6. Keep pets in another room. I love animals, but they are often curious or anxious with a stranger in their home and near their “people”.
  7. We’ll visit and feed where you typically care for your baby, using your usual chairs, pillows and environment.
  8. If possible, have available: a cloth diaper or burp-cloth, a receiving blanket (thin cotton),  a firm bed pillow, and a small pillow such as a couch pillow or decorative pillow. Don’t stress over this though!

Please Don’t:

  1. Worry about clutter, laundry and dishes – your home should look lived in!
  2. Shower or dress yourself or baby specially for the visit.  Be comfortable.

 

Tips for Selecting a Bottle Nipple

bottles, Breastfeeding, , , , ,

Materials and shape

Despite bold marketing statements from manufacturers, no bottle or bottle nipple will work or feel like a mother’s breast.

Bottles are the milk containers. They vary in shape, size, material and features (some are vented, some are wide-necked), but what’s usually most relevant is the bottle nipple, and not the bottle itself. Bottle nipples are commonly available in either silicone or latex. Silicone bottle nipples are clear and firm. Latex bottle nipples are usually tan-colored and are a little bit softer and squishier than silicone. Your baby may have a preference.

Considerations when selecting a bottle nipple are the shaft length, the base of the shaft (that still fits in baby’s mouth), the material, and the flow rate of the nipple. Slow-flow bottle nipples may be labeled “slow flow”, “newborn”, size 0 or size 1, or by listed by age: 0 to 3 months.

Avoid bottle nipple shapes or latch positions that keep the baby’s mouth tightly pursed or encourage clamping or chomping to control flow. These behaviors don’t translate well when practiced back at the breast! A bottle nipple with a wide base may encourage your baby to keep her mouth open wide, with jaw dropped and lips flanged out like a fish.

Go with the Slow flow: Join the Slow Food Movement

For a breastfeeding baby, almost always, slower bottle feeding is the way to go. It should take about 15 to 30 minutes for a baby to do a “full” feeding from the bottle. The same 3 ounces of milk, offered with a slow flow nipple, will be so much more satisfying to the baby when given over 20 minutes using the slow flow nipple. If he guzzles the same 3 ounces of milk rapidly, in just 5 or 10 minutes, he may not seem relaxed and content at the end, so the caregiver will assume the baby is still hungry, and reach for more milk. In this way, a baby can plow through an alarming volume of milk in a short amount of time.

Slow Flow: Avoid creating a “Flow Rate Preference”

If a baby becomes accustomed to the instantaneous, rapid and easy flow of milk from the bottle, he may become impatient and fuss when needing to work and wait a bit more when at the breast.

Keeping the bottle flow slow and requiring the baby to suck for more than just a few minutes to get their full feeding may help reduce the risk of impatience when back at the breast.

Though people talk about “nipple confusion” – a related and significant issue is this “Flow Rate Preference”. Keep the bottle feeding slow, requiring time and work, in hopes to avoid this flow rate preference with negative consequences back at the breast. Maintaining a strong milk supply is another critical factor: a baby will soon learn to cry and wait for the bottle, if they work hard at the breast for little payoff.

When or why change to a faster flow?

There is no need to move to a faster flow nipple simply because your baby’s age is beyond the ages listed on the package. The flow rate controls the speed in which a baby can drink the bottle, and for breastfeeding babies, slower is almost always better.

It should take about 15 to 30 minutes for a baby to take a “full feeding” from the bottle. A full feeding may be about 2 or 3 ounces at 1-2 months, gradually increasing to about 4 to 6 ounces by six months. Just because a baby usually finishes a bottle doesn’t mean the milk wasn’t enough, or that he should be offered more. Drinking large volumes of milk too quickly may lead to a baby feeling less satisfied, even though the milk volume (meal size) was enough. Babies usually need lots of sucking time to feel content when bottle feeding.

Move to a faster flowing bottle only when an older baby is taking too long to drink a bottle (30+ minutes), or seems frustrated at the slower flow. There is no reason to move simply due to the age suggestions on the nipple package. A 6 month old can still use a 0-3 month bottle nipple. Many babies continue to use the newborn or stage one nipple all through their first year.

If your baby drinks a large amount of milk in a short time (under 10 minutes) and still does not seem satisfied, rather than assuming he needs more milk, consider switching to a slower-flowing nipple and also pacing the feeding by offering more pauses and breaks during bottle-feeding.

Different brands of bottle nipples will work differently, even if they are each labeled “slow flow” or “newborn”. Holding the bottle upside down to see drip rate is not an accurate way to assess flow rate. Most bottles will drip several times and then stop. Try for yourself with the bottle, nipple and water – take a few sucks from several different nipple sizes and brands. You’ll easily be able to assess flow rate differences!

Help, Baby Won’t Take the Bottle!

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One of the biggest stressors for a new mom preparing to return to employment is the baby who WILL NOT take the bottle.

In my experience, there are two types of “bottle refusal” – Passive Refusers, and Active Refusers. A “Passive Bottle Refuser” will allow the bottle nipple into his mouth but then doesn’t really seem to know what to do with it – he may just chew or play around with it, rather than latch and transfer milk, and eventually will get frustrated, hungry or bored, and begin to fuss. The “Active Bottle Refuser” doesn’t want the bottle nipple in (or sometimes, even near!) his mouth, and will resist or protest attempts to feed him with the bottle: he may cry (or scream), arch, fight or pull away as the bottle nipple approaches or enters the mouth.

The Passive Refuser seems like he doesn’t know what he’s supposed to do with the bottle. The Active Refuser is angry and upset about the whole scenario!

If you have an Active Refuser, the first step is to reduce the stress and negative associations already established around bottle-feeding attempts. Avoid reinforcing negative associations with the bottle/nipple. If your baby is crying and fighting and trying to push the nipple out of his mouth, don’t keep pushing it back into his awareness: take a break or stop for that session. Forcing it on the baby, or making him gag and cry with the nipple in his mouth will not magically result into drinking from the bottle. It just reinforces the negative experience and makes the baby anxious the next time the bottle presented.

Here are a variety of suggestions that can be successful. Some may seem non-traditional, but when the usual suggestions aren’t working, sometimes you need to think out of the box.

Timing: Consider Morning, Not Evening

If the non-nursing partner is offering the bottle, try mornings rather than evenings. In general, everyone’s stress level is lower in the morning, and most babies are happier in the morning and grumpier in the evening. If the bottle isn’t going well, working on it during an already stressful time of day won’t help.

Positioning

Try some non-traditional feeding positions if the usual “sit, cuddle, feed” position isn’t working for you.

Up and Out: Hold baby in a sitting position, facing out against your chest, as you walk around the room, or better yet, walk around outside. Movement and distraction can be very helpful.

Bounce: Sit on a physioball (gym-, yoga-, birth ball) and bounce while offering bottle. Try both a cradled position and a facing out position.

Wear the Baby: Does baby like his carrier? Wear baby in the ERGObaby, Moby Wrap or BabyBjorn, walk around indoors or out, while offering bottle.

The “Disembodied Arm” Technique: Just what it sounds like! Have baby in a car seat or bouncer seat facing something distracting (television?). Sit behind baby, out of sight, with bottle coming around from behind.

Don’t worry that you’ll need to feed your baby using these unusual methods in the long term, we’re taking it step by step. The first step is to encourage baby to allow the bottle nipple into his mouth, latch and transfer milk effectively. Once this is happening reliably, you can work on transitioning that skill to occur in different settings and positions, such as sitting in a rocking chair.

Bottle nipples

Try a few, not dozens: If you’ve had any success with a particular bottle nipple, stick with that one. It’s generally not an issue of trying 20 different bottles/nipples until you find the magic one that baby will accept. It does make sense to try a few but then try working with the one you think baby did the best with.

Nipple flow rate: The flow rate can be another helpful factor. I usually recommend a slow-flow bottle nipple for most breastfed babies, but if you know that your baby gets a lot of milk at the breast in a short amount of time (for example, if you have a heavy milk letdown), then you might want to try the next flow rate up (size 1-2 or 3+ month size). Just make sure to hold her upright and keep the bottle almost horizontal, so she doesn’t feel flooded out with too much milk if she does start sucking.

Latex or Silicone? Bottle nipples are usually available in two different materials. Even with the same shaped bottle nipple, a latex (tan-colored) nipple will feel softer and squishier than a clear, firm silicone nipple. It’s worth trying both latex and silicone to see if your baby has a preference regarding texture and firmness.

Read more on Selecting a Bottle Nipple.

Tease-Remove Technique

Have you seen your baby, sound asleep still attached at the breast, barely flutter-suckling, body relaxed, arms limp? Yet, the moment you try to break the latch and take baby off the breast, he’ll start sucking frantically, like saying “wait – wait – no – don’t take that away, I wasn’t done!” Try eliciting that response with the bottle nipple: when you feel baby tentatively latching on the nipple, gentle traction back as though you’re teasing to take the nipple away. Some babies will respond by sucking harder to draw the nipple back in and keep it there. If this happens, try using some movement and distraction (quick!) and see if baby will continue sucking and get into a suck-swallow-breathe pattern. Remember to always aim the tip of the bottle nipple toward the roof of the baby’s mouth.

Milk for the Discerning Palate

Some babies are very particular about what’s in the bottle. Try using freshly expressed milk, if your baby has been refusing frozen. And, though I’m not usually particular about the temperature of the milk offered (most babies don’t mind lukewarm or even cool milk), if you have a bottle-refusing baby, try making the milk quite warm. For some reason, very warm milk seems to work better for many babies who are reluctant about the bottle. If your baby is over four months old, you could consider trying one ounce of white grape juice and one ounce of water. Some babies will initially refuse milk, but readily take juice from the bottle. Though the recommendation is exclusive breastmilk close to six months, other pediatricians (and certain groups within the AAP) do suggest solid foods (cereals, fruits and vegetables) any time after four months. Again, this is an untraditional approach (and I’m not one to encourage juice intake, especially from a bottle!), but one that may help bridge the ability to bottle feed an older baby.

Recruit a Confident and Experienced Feeder

Have a very experienced bottle-feeder offer the bottle. A professional caregiver who feeds many babies regularly or a friend or fellow new-moms-group attendee who bottle feeds her own baby may have body language, tricks and methods that you or your partner haven’t yet tried. Make sure s/he knows NOT to force the bottle, and that it’s perfectly alright if it doesn’t end up happening that day. You don’t want her to push too hard in her attempts to be successful and save the day! Experiment with sitting right in front of your baby so she can see you, or leaving the room or having the caregiver walk around in another room while offering the bottle.

Don’t Try a Holding out Game

Do not attempt to withhold the breast for an extended period in order to force the baby to take the bottle out of hunger. It is unkind, unnecessary, and usually unsuccessful, especially if baby has not been able to successfully transfer milk from the bottle before. Slow, consistent, unstressed encouragement tends to yield the best longer-term success.

Which brings us to perhaps the most effective and successful technique: Intermittent Bottle By Mom (IBBM)

Intermittent Bottle by Mom

One less-traditional, but highly successful technique I find works well is to have mom work on the bottle feeding since you are the person your baby most associates with feeding, and you are both comfortable and relaxed together. Also, you have the “luxury” (ha!) of time in the morning to work together over several subsequent feeds, whereas your partner is usually trying to work on bottle feeding in the evening during the hardest time of the day, when no one has much energy or patience left.

During an early morning feeding, begin nursing at the breast as usual, and then interrupt the breastfeeding and offer the bottle. If she doesn’t accept the bottle, don’t force it, just put her right back on the breast for another minute or two, and then try once again with the bottle. Go back and forth between the breast and bottle without forcing it at her. Try to have the attitude of “you can get milk here (breast), you can get milk here (bottle), it’s all milk, it’s all good, either is fine!”. Pretend like you don’t mind if she refuses the bottle, just put her back on the breast. If she ends up not taking any of the milk at that early morning feeding, you can leave it on the counter (or refrigerate and rewarm) and try again at the next feeding, 2 hours later before deciding to toss it – that’s why I suggest only using an ounce or two of milk in the bottle, so you won’t be wasting much if she refuses it altogether.

Try this Intermittent Bottle By Mom (IBBM) technique for several feedings during the day, for several days in a row. Remember, never let baby get distressed with this method: If she resists or refuses the bottle, allow her to go right back to the breast. Almost always, moms begin to see success by day 3 or 4, and by 7 – 10 days, baby is often readily taking an ounce or more from the bottle. Success!

Introducing the Bottle to your Breastfed Baby: Feed the Baby but Protect the Breastfeeding

bottles, Breastfeeding, Feeding, New Moms, solids, , ,

Focus on Breastfeeding First

bottle feed 2During the first few weeks after birth, just focus on getting breastfeeding up and running – that’s enough. You may need to express milk in certain situations, but in general, just work on establishing a comfortable nursing relationship and milk supply through breastfeeding. Once breastfeeding is well established, you may consider expressing some breastmilk and introducing the bottle, perhaps around week three or four of your baby’s life.

Why 3 to 5 weeks?

A newborn’s sucking is reflexive until about 5 to 6 weeks, so introducing the bottle between 3 to 5 weeks is an optimal time, if bottle-feeding skills are required. Most babies will accept the bottle without much difficulty when it is introduced between 3 to 6 weeks. It may be more challenging to wait until later before introducing the bottle. Of course, not all babies need to take a bottle, and many babies can begin learning to drink from a spouted cup as early as 4 to 5 months, but this post is focused on parents who do want to introduce the bottle to their breastfed infant. Beginning to express milk around week three or four may establish and maintain a strong milk supply, if storing milk for the return to work is desired. Slowly beginning to store several ounces of milk every few days once baby is about a month old,  will gradually create a stash of back up milk you’ll appreciate once you’re back at work.

Relax: Offer, Don’t Push!

Introduce the bottle in a stress-free, low-pressure manner. Let your baby draw the bottle nipple into his mouth – don’t force the nipple into the baby’s mouth. Try stroking the bottle nipple against baby’s cheek, then lips. See if he’ll turn slightly or open his mouth to seek out the nipple – called the rooting reflex. When the bottle nipple enters the baby’s mouth, angle the tip slightly upward, toward the roof of the mouth rather than pushing the nipple against the tongue.

If your baby cries or resists, take a break or try again later or the next day. Avoid creating a struggle or reinforcing a negative association with bottle-feeding.

Use Expressed Milk

If your baby is exclusively breastfed, don’t casually introduce formula “just to see if he’ll take it” or “to get him used to it”. This introduces foreign proteins (cow’s milk protein, or soy) unnecessarily, and also interferes with the breastfed infant’s normal intestinal flora. There is something very special and beneficial about the immune and digestive system of an exclusively breastfed baby. Avoid introducing anything other than breast milk during a baby’s early months unless medically necessary.

Offering the Very First Bottles

When preparing the very first bottle for a breastfed baby, start with just one ounce of expressed milk. This way, you won’t end up wasting milk if baby doesn’t take the bottle, or doesn’t finish a larger amount. If you’re offering just an ounce and baby finishes it and seems to want more, you can either offer another ounce, or put baby to the breast to “finish” their meal.

Continue offering a small (one ounce) bottle each day until the baby seems fairly comfortable with the bottle feeding process and finishes it reliably, then gradually increase the volume, moving to 1.5, then 2, then 2.5, then 3 ounces over several weeks’ time.

Three to four ounces of milk, given over 15-30 minutes, should be plenty for most babies at 2 to 4 months. Babies gradually increase their volume slowly over the next few months, typically “maxing out” around 5 to 6 ounces at 5 to 6 months. Don’t be in a rush to increase the milk volume just because your baby finishes the bottle. If the volume seems to keep him content for a couple of hours, it’s probably the right amount of milk. Babies love to suck, and enjoy milk, and will often take more milk than perhaps they actually need, if it is continually offered. Finishing a bottle or being willing to drink more doesn’t necessarily mean your baby is still hungry.

Helping Your Baby Adjust to the Bottle

Some babies will take a bottle easily the first time, while other babies require more time to become comfortable with accepting a very new way to eat. Be patient, calm, positive and consistent. This is a new skill for your baby (and for you). Consider this: If we took an exclusively bottle fed baby and put him to the breast, would we expect him to know exactly what to do the first time, without prior experience or practice? He might, but far more likely, would take a little time to get used to this new way of eating.

Some babies are more willing to drink from a bottle when drowsy, or when not frantically hungry. You might try nursing for a few minutes, then switching to the bottle half-way into the feeding.

Some babies are more willing to take the bottle from someone other than mom. Have a family member or helper try offering the bottle, either while sitting, or while walking around the room with the baby sitting up and facing out – the movement and distraction may be helpful.

Some breastfed babies are more willing to take the baby from mom, since they already associate mom with milk and with feeding. See more tips for the reluctant bottle feeding baby.

What counts as “Taking the Bottle”?

Offer the bottle once a day until your baby seems to begin drinking an ounce or two easily (this may be the very first and second tries – right off the bat.). Then you may switch to one bottle every other day or so. It’s a good idea to offer one bottle every couple of days so that your baby remains comfortable with the skill.

If your baby can drink an ounce from the bottle without difficulty, that is successful. If they are able to transfer milk from the bottle effectively (and the skill remains familiar with regular practice), they have the ability to drink more if necessary, even if they don’t particularly love the bottle.

Beware of the Bottle Feeding “Vacation”

One of the biggest anxieties for a new mom as her return to work approaches, is the baby who will not take the bottle. If it’s important to you that your baby be able to drink a bottle reliably, make sure to keep it familiar. Don’t assume that because baby drank the bottle once, many weeks ago, it’s a checkmark in the “will-take-a-bottle” box and the skill will be retained indefinitely. This skill needs be kept familiar or all bets are off.

Avoid the “bottle feeding vacation” or going 5 or 7 days without a practice bottle. Some babies will do fine with a rare or occasional bottle, but other babies, even those who had previously taken a bottle readily, will refuse after many days “vacation” when the bottle is re-introduced. Once the bottle is introduced, keep it familiar. Every other day, or about 3 or 4 bottles a week is usually enough to do so. If you don’t need to do a full feeding with the bottle, just one ounce in the bottle is enough to “count” as practice to keep it familiar. Give the ounce, and then finish the feeding at the breast.

Paced, Responsive Feeding Positions

Encourage family members and caregivers to bottle-feed with close physical contact, change positions several times throughout the feeding, and pause often to interact with your baby.

Babies should be bottle-fed in a semi-upright position with the bottle nipple almost horizontal (though filled with milk). This allows the baby to better control the flow and avoid being overwhelmed by too much milk. In the typical “reclined and cradled” bottle feeding position, the bottle milk will flow faster by gravity, and baby will need to drink faster in order to keep up with the flow. The more upright position will help pace the feeding better.

When baby pauses to rest or take a deeper breath, this is a cue for the care-giver to remove the bottle, talk to the baby, burp or take a little break from the bottle feeding. There’s no need to pull the bottle away from a baby who is actively sucking happily just because it’s been five minutes, or one ounce. Instead, wait for a natural pause to remove the bottle for a break, engage with eye contact or interaction, or a burp.

Remind caregivers to never prop a bottle – this can lead to choking or aspiration of milk. Babies deserve physical and social interaction during feeding. Finally, don’t put an older baby into a crib with a bottle of milk or juice. This is associated with increased incidence of ear infections and tooth decay.

Pump, Store, Feed Care Plan

Breastfeeding, Feeding, New Moms, , , , ,

expressingearlymilkPumping, Storing and Feeding Expressed Milk
(Or, Preparing for Eventual Return to Work  

  • Begin expressing and storing milk once day in the morning immediately or shortly after breastfeeding (week 2-3).
  • May add a 2nd pumping session later in the day (also after breastfeeding) if desired.
  • Double pump (both breasts at the same time) for 12-15 minutes.
  • Adjust vacuum to the maximum level that is still comfortable. Pumping shouldn’t hurt!
  • While pumping, massage and compress the breasts every few minutes
  • Reposition nipple within flange tunnel 2 or 3 times during session
  • Midway into pumping session when milk flow/collection slows down, press the “let-down button” (“speed toggle switch”) for another stimulation-mode (rapid shallow pumping) if your pump has this feature.
  • Introduce the bottle before 5 weeks old. Week 3 or 4 is perfect.
  • Use a SLOW FLOW bottle nipple and paced bottle feeding (upright position, bottle almost horizontal to baby, take pauses for interaction or burping)
  • Begin by offering one ounce by bottle. This can be increased to 2 and gradually 2.5-3 ounces, if a “full” bottle feeding is desired.
  • Continue to offer at least an ounce by bottle every 2-3 days right up until the return to work. AVOID a “bottle feeding vacation” where no bottle is given.
  • Store freshly expressed milk in the back of the refrigerator for about 4 to 7 days.
  • Store milk in milk storage bags in the freezer by lying them flat to freeze overnight, then stacking them up in a container in the back of the freezer.
  • Write the date and volume on the storage bag prior to placing in the freezer.
  • Thaw frozen milk in the refrigerator over 12-24 hours, or place bag directly in a bowl of hot (not boiling) water for a few minutes.
  • If you have additional questions or difficulties pumping or introducing the bottle, contact me for suggestions.
  • My Golden Rule of Breastmilk for Healthy Babies:
    If it LOOKS ok, SMELLS ok and baby will take it (TASTES ok), it’s FINE to use.