5.0 - Bottle feeding

Sources

1. Guide to Childcare by Wong Boh Boi
2. The New Contented Little Baby Book by Gina Ford
3. Your Baby’s First Year by American Academy of Pediatrics
4. Successful Breastfeeding by Kang Phaik Gaik

(5.0) Expressing – Few things to take note

(5.1) Preparation for Expressing Breast milk

(5.2) How to Express Using Breast Pump

(5.3) How to Hand Express

(5.4) Storing Expressed Breast Milk

(5.5) Bottle-feeding with Formula

(5.6) Infant Formula

(5.7) Sterilizing Feeding Utensils

(5.8) Preparing a Feed

(5.9) Giving the feed

(5.10) How Much Does Baby Need?

(5.11) Formula: Overfeeding

(5.12) Burping

(5.13) Spitting Up

(5.14) Choking with Milk

(5.15) Weaning to Food

(5.0) Expressing – Few things to take note

1. Majority of mothers are so successful at breastfeeding is because they use electric expressing machine in the very early days.
2. Breast milk is produced on a supply and demand basis. During the early days, most babies will empty the first breast and some may take a small amount from the second breast. Very few will empty both breasts at this stage.
3. By the end of the 2nd week, the milk production balances out and most mothers are producing exactly the amount their baby is demanding.
4. Some time during the 3rd and 4th week, the baby goes through a growth spurt and demands more milk. This is where a problem often sets in if you have followed the current advice of not expressing before six weeks.
5. In order to meet the increased demand for more food, you would more than likely have to go back to feeding two- or three-hourly and often twice in the night. This feeding pattern is repeated each time the baby goes through a growth spurt and often results in the baby being continually fed just prior to sleep time. This can create the problem of the wrong sleep association, making it even more difficult to get the baby back into the routine. (pg 68-69)

(5.1) Preparation for Expressing Breast milk

1. Mothers who express the extra milk they produce in the very early days will always be producing more than their baby needs.
2. The best time to express is in the morning as the breasts are usually fuller. Expressing will also be easier if done at the beginning of a feed.
3. Express one breast prior to feeding your baby, or feed your baby from one breast, then express from the second breast before offering him the remainder of his feed.
4. Some mothers actually find that expressing is easier when done while they are feeding the baby on the other breast.
5. It is also important to note that expressing at the beginning of a feed allows slightly longer for that breast to make more milk for the next feed.
6. Give babies a bottle either last thing in the evening or during the night by someone other than the mother, thereby allowing the mother to sleep for several hours at a stretch.
7. Don’t offer more than one bottle a day as baby may reject the mother’s breast or becoming confused between nipple and tea.
8. It gives you some flexibility and secondly, the problem of later introducing bottles to an exclusively breast-fed baby doesn’t arise.
9. In the early days, you will need to allow at least 15 minutes to express 60-90ml at the morning feeds, and up to 30 minutes at the evening expressing time. By end of first month, the majority can easily express 60-90ml within 10 minutes at the 9.30pm expressing when using a double pumping system.
10. You can cut back on expressing as your milk supply becomes firmly established. (pg 70-71)
11. Hand pump: Slow method but effective.
12. Battery pump: Makes a whirring noise when you pump
13. Electric pump: For speed and breast stimulation, it’s a good investment although it’s the most expensive. But it’s slightly heavier. It can adjust both the speed (cycle per minute) and suction strength (vacuum level) according to your needs.
14. Storage bottles or milk bags
15. Cooler bag: This has insulated linings which you can pack with ice packs to keep your breastmilk cool.
16. Sterilizer: You will need to sterilize equipment like breastshields and bottles after pumping – either by boiling them or steam them.
17. Breastfeeding shawls: Breathable cotton with patterns on a dark background is a good choice because it will not be too hot for you and baby when you are wearing it; and milk stains will be less visible.
18. The right caregiver: If choosing a childcare centre, ask the principal how the Infant Care department handles the preparation of EBM. Arrange to leave your baby with the caregiver for several hours on one or more occasions before you actually start work. Show her how to hold your baby during feeding and how to comfort him when he is upset. Show him how to store, defrost and handle EBM.
19. Weaning from the breast to the bottle:  Once baby’s feeding is established, after 4-6 weeks, you can wean baby onto a bottle filled with EBM. Give one bottle a day for 1-2 weeks, then add another bottle. Increase the number of bottles gradually according to the number of feeds baby will need when you return to the office. Continue to breastfeed baby in the mornings and nights. Tips: Let the caregiver or a family member give him the bottle. Make it fun – tease his mouth with the teat, let her play with the bottle, do not force the teat into his mouth; He does not have to drain the bottle – the purpose is to introduce him to the bottle, not to achieve a full feed. After you start work, continue to breastfeed him before and after working hours. This is important for bonding and stimulating your milk supply. (pg 119-124)
20. It is important to plan the transition properly. You must allow approximately a week to drop each feed. For example, it can take 6 weeks to establish a good milk supply, and if you decide to give up breastfeeding, you should allow, at the very least, a further 5 weeks to drop all breastfeeds and establish bottle-feeding. (pg 74)
21. When to Express: Pump 15 minutes per side after milk starts flowing. Pumping more times for short intervals will generally yield more milk than one or two long sessions. After you start work, you should fit in 2 expressing sessions at around 10am and 2.30pm. If you express any later than this, it is possible that your breasts will not produce enough for the 6pm feed. It is essential that you pay particular attention to your diet and that you rest well in the evening. It would be advisable to continue expressing at 9.30pm to ensure that you maintain a good milk supply. Make sure that you keep a good supply of breast pads at work, and a spare shirt! (pg 72)
22. Some mothers find that once they are down to two breastfeeds a day, their milk reduces very rapidly. The signs to watch out for are: baby being irritable and unsettled after a feed; or wanting a feed long before it is normally due. If baby shows either of these signs, he should be topped up immediately after the breast-feed with 30-60ml of expressed milk or formula. This will ensure that his sleeping pattern does not go wrong due to hunger. (pg 75) 

(5.2) How to Express Using Breast Pump

1. Wash hands and make sure all equipment is sterilized before expressing.
2. Sit in a comfortable position.
3. Before pumping, massage your breasts. Every 5-7 minutes between pumping, massage again.
4. To promote let-down, think about your baby.
5. Position the breastshield correctly such that it does not press against your nipple.
6. Start your pump at the lowest level. Then increase to the moderate setting.
7. Your nipples should not feel sore during or after pumping.
8. After you finish pumping, rub a little breastmilk over your nipples and areola to protect them. Allow to air dry.
9. Express each breast for about 15-20 minutes. Single pump will take about 30-40 minutes per session and double pump takes about 20 minutes per session. (pg 124)

(5.3) How to Hand Express

1. Wash your hands.
2. Massage breast from the outer edge towards the areola.
3. Place thumb and fingers on the edge of areola.
4. Gently press inward towards the centre of the breast and squeeze fingers and thumb together. Do not slide your fingers forward.
5. Milk should emerge from the nipple pores.
6. Repeat with a rhythmic movement.
7. Move fingers around areola and express to drain all sectors of the breast. (pg 125)

(5.4) Storing Expressed Breast Milk

1. Room temperature (25°C): Up to 4 hours
2. Thawed EBM in fridge (4°C): Up to 24 hours
3. Cooler box with ice packs (15°C): Up to 24 hours
4. Refrigerator (4°C): Up to 48 hours
5. Freezer with separate door (-20°C): Up to 3-6 months
6. Deep freezer (-20°C):  Up to 6-12 months
7. Give freshly expressed milk to your baby daily; then use the frozen milk on first-in-first-out basis whenever needed.
8. If you know in advance that the milk won't be used within 4 days, freeze it immediately.
9. It’s useful to freeze milk in quantities of about 90-120ml - the amount of a single feeding.
10. You can also freeze some 30-60ml portions; these will come in handy if the baby wants a little extra at any feeding.
11. Thawing: Thaw frozen milk in the fridge. 10 minutes before feeding, remove the bottle from the fridge and warm in a bowl of warm water. Do not boil the milk or put in the microwave oven as this will kill the vitamins. Swirl the bottle before feeding. If using milkbags, swirl the bag and pour into bottle before feeding. Discard excess milk after feeding.
12. Once milk is heated, it should never be reheated, as this very rapidly increases the bacteria levels in the milk, which is once of the main cause of upset tummies in formula-fed babies. (pg 78)
13. Thawed milk should be used within 24 hours. Never refreeze it.
14. Always check the milk by smelling and tasting it before you feed your baby. Ensure that it has not gone sour. (pg 73)
15. Because the fats in human milk begin to break down over time, use the frozen milk as soon as possible.
16. It's good idea to place a label with the date on each container so you can use the oldest milk first.
17. Baby may prefer that the milk be heated to at least room temperature (20-22°C) for feeding.
18. Incidentally, once milk is thawed, its fat may separate, but that does not affect its quality.
19. You may swirl the container gently until the milk returns to a uniform consistency.

(5.5) Bottle-feeding with Formula 

1. Studies have shown that the risk of contamination in bottle-feeding is 19 times higher than that in breastfeeding. This happens especially when the feed is not prepared and given properly. Diarrhea is the usual symptom of contamination.
2. Bottles that are designed to promote self-feeding are not recommended, as they may contribute to nursing-bottle tooth decay by promoting constant feeding and exposure of the teeth to sugars throughout the day and night. When milk collects behind the teeth, bacterial growth occurs.
3. Also, self-feeding in a supine position (lying down on the back) has been shown to contribute occasionally to ear infections. Infants and older children should not receive a bottle to suck on during the night. If you give your baby a feeding at bedtime, take away the bottle before he falls asleep.
4. If the nipple of the bottle is too small, your baby may suck too so hard that he swallows too much air; if it’s too big, the formula may flow so fast that he chokes. Ideally, formula should flow at a rate of one drop per second when you first turn the bottle upside down. (It should stop dripping after a few seconds) (pg 137)

(5.6) Infant Formula

1. The base component is usually cow’s milk from which the fat is removed and replaced with mixture of vegetable and fish oils. The sodium is reduced. The composition of infant formulas is designed to be very close to that breast milk.
2. Avoid changing from one formula to another without consulting your doctor first.
3. There are four basic types: milk-based formula, milk-based formula with added whey proteins, soy-based formula and protein hydrolysate-based formula.
4. It is not necessary for baby to be given additional vitamins and mineral supplements as long as he is feeding well.
5. Iron supplements are not necessary for babies up to 6 months old. (pg 22-24)

(5.7) Sterilizing Feeding Utensils

1. Contaminated feeding utensils can cause tummy upset and discomfort. Protect your baby’s health by making sure that all feeding accessories are sterilized and germ-free. The person handling the equipment should also practice a high level of hygiene. (pg 17)
2. Every morning the work-top should be thoroughly washed down with hot soapy water, the cloth used should then be rinsed well under hot running water and the surface wiped again to remove any traces of soap. This should be followed by a final wipe-down using kitchen roll and antiseptic spray.
3. Hands should always be washed thoroughly with anti-bacterial soap under warm running water, then dried with kitchen roll, not a tea towel, which is a breeding ground for germs. (pg 80)
4. Washing dirty bottles: Wash your hands. Fill the bowl in which the dirty bottles are stored with hot, soapy water. Using a long-handled bottlebrush, carefully scrub all the bottles, rims and caps inside and out (Do not scrub too hard as it can damage the inside lining of the bottle). Carefully rinse everything under a hot running tap. Rub the teat first in soapy liquid on both the inside and outside of the teat to remove any milk curd. Wash and rinse the bowl thoroughly, then place all the equipment in the bowl under the running cold water tap. This is to check that everything is thoroughly rinsed – the water should run clear. (pg 81)  Keep them in a clean container until you are ready to sterilize them.
5. The Boiling Method: Using a large stainless steel pot, submerge all clean bottles, teats and caps in clean water. Boil all the feeding items for 10 minutes. You can leave the items in the container and keep it covered until you use them. Ideally, you should take them out using clean pair of tongs, assemble them and keep them in a clean place. All sterilized assembled equipment can be kept that way for 24 hours.
6. The Soaking Method: Special sterilizing liquid or tables are used and no boiling is required. Start by washing your hands with soap and water. Prepare the sterilizing solution in a large plastic or porcelain container according to the manufacturer’s instructions. Submerge all clean bottles, teats and caps into the sterilizing solution and soak them for at least an hour or as indicated in the manufacturer’s instructions. Use clean tongs to remove the items and assembled them and put them in a clean place while awaiting use. The sterilizing solution has to be changed daily. If your baby has a tendency to throw up his feeds, you may have to rinse the utensils first before preparing each feed as the chemicals in the soaking solution can irritate your baby’s stomach. The sterilizing solution is effective for 24 hours.
7. The Steaming Method: It is one of the easiest and quickest methods of sterilizing. Some steam sterilizers take as little as 8 minutes to sterilize bottles. You can also load in your feeding utensils and breast pump all at the same time. Clean the utensils as in the other methods. Then steam the feeding equipment as instructed by the manufacturer. Again, try to assemble the equipment and have them ready for use beforehand. The sterilizer should be rinsed out every day, and the removable parts checked and, if necessary, washed and rinsed. (pg 81)
8. The Microwave Method: This is another form of sterilizing that kill germs effectively. A specially designed rack is needed to hold all the equipment for microwaving. Clean the utensils as in the other methods before you microwave them as instructed by the manufacturer.

(5.8) Preparing a Feed

1. A baby’s feed should be prepared fresh, just before you actually feed him. If you have to leave it in the refrigerator, keep it there for no longer than 24 hours.
2. Always wash your hands with soap and water before preparing each feed.
3. Use tongs to remove a bottle from the sterilizing container or just pick up the already sterilized bottle.
4. Follow the preparation instructions on the milk powder tin. Pour the correct amount of water into the sterilized bottle, using both cool and hot boiled water or simply allow hot water to cool in a clean jug.
5. Add the recommended number of scoops of milk powder, leveling each scoop lightly, then add into the bottle. Always use the scoop provided in the milk tin for measuring. Don’t mix the scoops of different milk formulas or add more scoops. Additional scoops increase the concentration of milk and can put a strain on your baby’s kidneys and cause other problems such as wind, indigestion and obesity.
6. Use a clean teat to close the feeding bottle and swirl gently until all the powder has dissolved. Don’t microwave milk formula as the milk may be heated unevenly. Neither should you shake the bottle vigorously nor stir with a spoon as excessive air bubbles can form.
7. Feed your baby immediately. Be careful not to touch the part of the teat that goes into your baby’s mouth to avoid contamination.
8. Clean and dry the knife or spatula for leveling the milk powder in the scoop after each use and close the milk tin tightly.
9. Always store milk powder in a cool, dry place and away from direct sunlight. Do not keep the milk tin on top of an oven.
10. To avoid interruptions during feeding, check and change baby’s diapers before feeding.
11. Test the temperature of the feed by dripping a few drops on the inside of your wrist. The milk should feel comfortably warm.
12. Don’t keep a feed warm for the whole day. Germs multiply rapidly and can cause tummy upset. It is not necessary to have warm milk although a warm feed is more comfortable for baby. One of the easiest ways to keep milk warm is to let it sit in a mug of hot water or baby food warmer. (pg 19-20)

(5.9) Giving the feed

1. By holding the baby upright with your arm supported by cushion, you will lessen the likelihood of your baby getting air trapped in his tummy.
2. Loosen and screw the teat back on; it should be very slightly loose. If it is screwed on too tightly it will not allow air into the bottle, and your baby will end up sucking and not getting any milk.
3. Check also that the milk is not too hot; it should be just slightly warm. If you get your baby used to very warm milk, you will find that, as the feed progresses and the milk gets cool, he will refuse to feed. As it is dangerous to reheat the milk or keep it standing in hot water for any length of time, you could end up having to make up 2 bottles for every feed.
4. Once feeding, make sure that the bottle is kept tilted up far enough to ensure that the teat is always filled with milk, to prevent your baby taking in too much air.
5. Remove the bottle occasionally during feeding to allow baby to rest. Remove the teat from your baby’s mouth occasionally to let air enter the bottle.
6. Some babies will take most of their feed, burp and then want a break of 10-15 minutes before finishing the remainder of the milk. In the early days, allowing for a break mid-way, it can take up to 40 minutes to give the bottle. Once your baby is 6-8 weeks old he will most likely finish his feed in about 20 minutes.
7. If you find your baby is taking a very long time to feed, or keeps falling asleep halfway through a feed, it could be because the hole in the teat is too small. Most babies have to go straight on to a medium-flow teat as the slow-flow one is too slow.
8. If your baby is taking the required amount of formula at each feed very quickly and looking for more, it may be worthwhile trying a teat with a smaller hole. Offering him a dummy after feeds may also help satisfy his ‘sucking needs’.
9. A baby who is overeating, and regularly putting on more than 240g each week, will eventually become overweight and reach a stage where milk alone is not enough to satisfy his hunger. If this happens before the recommended age for giving solids, it can create a real problem. (pg 81-84)
10. Avoid twisting the teat inside the baby’s mouth to release air. Don’t force or rush feeding.
11. Milk Flow: Ensure that baby is coping well before switching him to a teat with a faster flow. Rubber latex teats are more suitable for newborns. As they grow up, silicon teats are better as the texture of the teat does not collapse easily during vigorous suckling and fewer replacements are needed. They also have a harder texture for baby to chew on.

(5.10) How Much Does Baby Need?

1. For babies older than one week, the formula for calculating suitable amount of feed is 150ml x weight/number of feeds per day.
2. Underfeeding is unlikely with bottle-feeding.
3. If your baby demands more feed but doesn’t finish his milk, it is likely to be a teat problem.
4. 0-1 week: 30-60ml per feed, 7-8 times per day
5. 1-2 weeks: 60-90ml per feed, 6-7 times per day
6. 2-4 weeks: 90-120ml per feed, 5-6 times per day
7. 1-2 months: 120-150ml per feed, 5 times per day
8. 2-3 months: 180ml per feed, 5 times per day
9. 3-4 months: 210ml per feed, 5 times per day
10. 4-5 months: 210ml per feed, 4 times per day
11. 5-6 months: 240ml per feed, 4 times per day
12. Above 6 months: 240ml per feed, 3-4 times per day (pg 20-21)

(5.11) Formula: Overfeeding

1. Some babies take the bottle of formula so quickly that their natural sucking instincts are not satisfied and they end screaming when the bottle is removed from their mouth. Many mother interpret this cry as one of hunger and end up giving them another bottle of formula.
2. A pattern of overfeeding can quickly emerge, resulting in the baby gaining huge amounts of weight each week. If this problem is allowed to continue, the baby quickly reaches a stage where milk alone will not satisfy his appetite, yet he is too young to be given solids (under 6 months).
3. When a formula-fed baby shows signs of being particularly ‘sucky’, offer some cool boiled water between feeds and a dummy afterwards helps to satisfy their sucking needs. (pg 85)

(5.12) Burping

1. Burping baby helps to ease wind discomfort. Almost all babies love being burped.  If baby does not burp up, don’t be too concerned. Some babies does not like to stop halfway to burp so let him pause naturally and then burp him.
2. Avoid stroking upwards if your baby possets easily. As the force of wind may be too great, this may force the milk out through his nose and mouth. If this happens, try cupping his back with your hand instead of rubbing upwards. (pg 22)
3. How to burp a baby: (1) Hold the baby upright with his head on your shoulder, supporting his head and back while you gently pat his back with your other hand. (2) Sit the baby on your lap, supporting his chin and lean him slightly forward. Burp him by cupping your hand and tapping him gently on his back. (3) Lay the baby on your lap with his back up. Support his head so that it is higher than his chest, and gently pat or rotate your hand on his back. (pg 145-146)

(5.13) Spitting Up

1. It is common during infancy. Sometimes it means the baby has eaten more than her stomach can hold; sometimes she spits up while burping or drooling.
2. It is usually no cause for concern. It almost never involves choking, coughing, discomfort, or danger to your child, even if it occurs while she’s sleeping.
3. Prevention: Make each feeding calm, quiet and leisurely; Avoid interruptions, sudden noises, bright lights; Burp bottle-fed baby at least every 3-5 minutes during feedings; Avoid feeding while infant is lying down; Hold baby in an upright position for 20-30 minutes after each feeding; Do not jostle or play vigorously with baby immediately after feeding; Try to feed her before she gets frantically hungry; Elevate the head of the entire crib with blocks (don’t use a pillow) and put her to sleep on her back. This keeps her head higher than her stomach and prevents her from choking in case she spits up while sleeping. (pg 148-150)

(5.14) Choking with Milk

1. If milk is coming out of the baby’s nose and mouth and he is lying on his back, quickly turn the baby to his side and administer a few back blows. Avoid sitting the baby up as he may regurgitate and aspirate the milk back into his airway.
2. After that, put the baby upright and burp him. The baby will usually not choke on his milk if the feeding technique is right. (pg 100)

(5.15) Weaning to Food

1. Babies thrive well on breast milk or formula alone for the first 6 months. However, they undergo growth spurts when they are at 3 weeks, 6 weeks and 3 months during which their appetites may increase.
2. If, after 6 months, your baby seems to be more demanding and unsatisfied during these periods, it is time to introduce solids. The baby’s swallowing mechanism is not developed till around 3 months. All weaning must be done gradually and progressively.
3. After that, your baby needs other foods to supplement his diet. Always consider baby’s size, weight, activities and appetite before you start weaning. (pg 25)
4. 6 months: 5 milk feeds, 1-2 solids 
5. 8 months: 4 milk feeds, 3 solids 
6. 12 months: 3 milk feeds, 3 solids + snacks (pg 25) 
7. No need to rush: Children at this age still have immature immune systems and may develop allergies to certain foods. Introduce solids one item at a time. Wait a week before introducing another new food. In this way, if your child develops an allergic rash or fever, you will be able to quickly isolate which is the ‘culprit’, and discontinue that food until your child is much older.
8. Breastmilk still most important: Solid foods should be seen as supplementing the child’s intake of breastmilk. You should continue to maintain and increase your milk supply by feeding your child about 4-5 times a day. Solid food can be given once or twice daily to children after 6 months of age. (pg 139-142)