Written by Kate Arquilla, MOC Consultant and owner of Bumble Baby. Photography by  Wonder & Awe.

Positioning DOES matter!

Before becoming a NICU nurse, I didn’t even know there were different “ways” to hold your baby while feeding. I had only ever seen – and done – the “crook of the arm” feeding. This is the way babies, in my mind, were always fed!

Well, the NICU quickly changed that!

Did you know that the instinct to feed is not generally seen in babies less than 36 weeks gestation? This means that babies born before 36 weeks (also known as late preterm) may not show signs that they are ready to take a feeding by mouth (bottle or breast). For this reason, it’s not uncommon to see premature + late preterm babies with a nasogastric (NG) tube. This tube allows baby to be fed breastmilk or formula straight into their tummy without the actual act of eating.

As babies approach their due date and become “term” (36-37 weeks+, sometimes a bit earlier), we test their readiness to feed by bottle. We give them little tastes of milk on a pacifier to help them learn how to suck, swallow, and breathe correctly (we even give preemies a swab of breastmilk very early on to get them familiar with the taste!). But giving tastes does more than just familiarize them with the taste and smell of milk – it actually tells us A LOT of information! 

We can gather baby’s interest in feeding, neurological readiness (sleepy preemies can’t take a bottle!), and read their cues. Have they developed a negative association with oral stimulus (paci, bottle) from having a breathing tube for so long? Is their reflux so painful that they associate feedings with pain? Are they overwhelmed while feeding (sleepy at the bottle, breathing fast, dropping their heart rate low, sticking their tongue out and pushing the bottle out?) Suck, swallow, breathe is a coordination skill that some babies need a little help in mastering.

I say this all the time to my clients, but LOOK at your baby and LISTEN to cues as you feed! We can gather SO MUCH information by looking at our baby feed – including signs of hunger, satiety, oral aversion, reflux, etc.

My baby isn’t a preemie. Do I still need to watch them closely while they feed?

Yes! Bottle feeding should still be to your term baby’s cues. Feeding and taking a bottle is a skill that baby needs to learn how to do. And bottle feeding positioning is important for many reasons which we will get into below.

Why is it so important to know your baby’s feeding cues while bottle feeding? 

  • It tells us a lot about how baby is feeling during a feed.
  • It  tells us if baby needs to slow down the pace (size down on a nipple)   or speed up the pace  (upsize the nipple). See below.
  • It tells us if baby is full.  We often try to feed all the contents of the bottle – but baby may not want all the contents. It’s MORE important for baby to control the amount they take in and have a positive experience, than accidentally force feeding.
  • It tells us if baby is still hungry BUT prevents overfeeding. If a bottle is completely finished, and baby is rooting or sucking, they may want more. We will talk about side lying feeding in a bit, but basically by following baby’s cues with side lying, baby is controlling the pace of the bottle. So if baby does want more, it is available to take at their pace, rather then dripping out of the bottle due to gravity. Signs of being done with the bottle include yawning, sneezing, pushing out of the tongue, pushing the bottle out with the tongue, arching back away from the bottle, gazing up and away from the bottle.
  • It tells us if baby is overwhelmed. Persistent hiccuping, sneezing, yawning, gagging, or pushing out of the tongue all are signs of being “done” or overwhelmed with the bottle.
  • It prevents oral aversion. You wouldn’t like it either if someone was forcefully sticking food in your mouth! Repetitive accidental force feeding creates an oral aversion, refusal of the bottle, fussiness, and refusal to eat by bottle. Try allowing baby to open BEFORE you place the bottle in baby’s mouth by gently tickling their upper lip with the bottle. Once baby opens, they are ready to latch and feed.

But who CARES?! My baby hasn’t shown any of these things and feeds just fine the way I feed her.

YOU are the parent! You have every right to make the decision for your baby! I am here to inform and help you prevent or reverse some possible negative symptoms of gravity-lead bottle feeding positioning. 

Does it matter if the contents are formula or breastmilk?

No! Anytime you are bottle feeding, no matter the contents, side-lying is the way to go.

SO – What do I DO?

SIDE LYING POSITIONING + INCLINED!

What the heck is side lying + inclined  positioning?

Side lying positioning is when baby is laying on their side (ear, shoulder, and hip should all be aligned). Then, incline their head slightly with your hand or a pillow (I even just cross my legs!).

Why is side lying + inclined feeding important?

Side lying + inclined feeding mimics breastfeeding – both in position and flow. It allows baby to control the flow of the bottle, leading to a positive experience with the bottle, less choking and coughing, less flooding, and LESS EAR INFECTIONS! Read my full blog post here for more about preventing ear infections!

A bottle has an opening at the nipple. This opening is consistently open, whether baby is sucking or not. Test by holding a bottle upside down – it drips! This dripping also happens in baby’s mouth when we hold the bottle in a downward position where gravity is pulling the milk out of the bottle, not baby, such as in the “crook of the arm” feeding position. 

When gravity pulls out the milk (aka dripping of the bottle), baby is actually getting more milk flow than they are sucking out. This causes baby to get flooded – meaning there is too much milk in baby’s mouth. This makes it hard to baby to keep up with the amount of milk in their mouth – leading to gulping, choking, coughing, milk dripping out of the side of their mouth. This can happen with a “crook of the arm” positioning because the nipple is angling down, allowing gravity to do the work.

Think about if you were trying to drink something using a straw. Then, someone was simultaneously pushing more liquid in your mouth. It would be really hard for us to keep up! If this was consistently happening, we would pretty soon say, “I’m not drinking out a straw anymore!” This same thing happens to baby – they simply can’t keep up and may start to associate the feeds negatively. 

How do I feed baby in side lying position?

  1. Bend your knees and elevate your legs on a coffee table or ottoman. If you don’t have those available, cross your legs or place a pillow on your lap.
  2. Place baby in side lying position on your lap with their head closest to your knees.
  3. Support baby’s head and neck with your non-dominant hand.
  4. Hold the bottle parallel to the floor.
  5. Feed baby.

I see air in the nipple. Should I be concerned?

No. Air at the top of the nipple is normal – the milk still fills the tip of the nipple so baby won’t suck in air.

My baby is gulping and chokes on the bottle. What can I do?

Your baby may need a smaller size nipple. If you’re already using the smallest size, try paced feedings. Paced feedings allow baby to “catch up” and swallow the milk in their mouth, then breathe, then suck. Too much milk will cause them to gulp, not be able to take a breath, etc. Click here for a demonstration.

My baby gets frustrated at the bottle and when I take the bottle out, the nipple is completely flat and collapsed. 

Time to move up to the next size nipple! Baby is sucking harder than the nipple flow allows.

It takes FOREVER for my baby to feed from the bottle (more than 45 minutes). What can I do?

Try upsizing the nipple! If baby is dripping, gagging or choking, the flow is too fast and move down a nipple size. Or try paced feedings with the larger nipple.

My breastfed baby WILL NOT take a bottle. HELP!

Review your Moms on Call Basic Baby Care book and Online Course for guidance and demonstrations.  Moms on Call’s all-time favorite bottles are the classic NUK First Essentials.  (You do not need breast-like nipples for bottle feeding!)

Need more?

Your wish is my command! I offer 1:1 FaceTime consults to introduce the bottle to your breastfed baby in a way that promotes a positive association with the bottle + tips and tricks to make that happen. I have had a very high success rate so far!