Bottle-feeding your baby

NICE guidance on bottle-feeding
The National Institute for Health and Care Excellence (NICE) recommend that if you are thinking about or need to bottle feed (with or without breastfeeding), you should:

• Have your decisions respected.

• Be given face-to-face support to bottle feed.

• Also have access to written, online or telephone information and support if you need it.

• The advice you are given should include:

  • The differences between breast milk and formula milk.

  • That the only formula milk your baby should need in the first year of their life (unless they have specific medical needs) is first formula milk.

  • How to bottle feed safely, including how to sterilise feeding equipment and prepare feeds.

  • If you are trying to breastfeed and are thinking about adding formula feeds on top, how you can keep your breast milk supply going and the impact that bottle feeding might have.

  • The best positions to feed your baby and the dangers of propping your baby against a pillow or other support, rather than being held by you while feeding.

  • How to recognise when your baby is hungry or has had enough (it is possible to overfeed your baby if you are bottle feeding).

  • How to bond with your baby.

You should speak to your midwife or health visitor for advice about, and support with, feeding your baby.

How do I prepare to bottle-feed?

Bottle-feeding is something you need to prepare for by buying equipment, choosing formula and making up bottles in advance of needing them.

Buying bottle-feeding equipment

You will need to buy equipment in advance - you'll need bottles, teats and sterilising equipment. Some babies seem to like some teats better than others but there is no clear pattern. Teats also come with different 'flow rates' and you may want to purchase one of each flow rate, so that you can see what your baby gets on with best.

Your baby will adapt to and learn to feed from whichever teat and bottle system you choose. Most bottles and teats need sterilising, although some bottle systems involve single-use plastic bags to hold the milk. Some teats aim to mimic the human nipple more closely than others, but your baby will learn to manage whichever system you choose.

Some babies - for instance those with cleft palate - may have difficulty sucking from a normal teat, and may need a specially adapted teat. Bottles for feeding babies with a cleft palate are typically soft, so they can be gently squeezed to help milk flow. Teats come in various shapes which suit different babies depending on their age and the size and shape of their cleft. Your specialist nurse or doctor will advise on what your baby will find most helpful.

Choosing bottles for breast-fed babies

If you are introducing bottle-feeding after your baby has learned to breast-feed, your baby will need to learn a new sucking action. This will take gentle perseverance from you, and initially your baby may not be keen to try something new. Some teats are marketed to be more like the human nipple in order to make this transition easier.

Some mums make the transition in two stages, by first introducing the teat with expressed breast milk in the bottle (so that the taste is the same, even though the teat isn't), and then afterwards (once their baby has learned to manage the teat) introducing formula milk.

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How do I prepare bottle feeds?

Bottled feeds may be bought already made up, or may be made from mixing dried formula milk with boiled water (whilst it is still hot). Follow the instructions on the packet carefully when you make up the feed.

• Don't make the formula too dilute, or your baby may not be able to drink enough to get the nutrition he or she needs.

• Don't make the formula too concentrated, or your baby may become lacking in fluid (dehydrated) and constipated.

• It's important to make sure that you make up formula with boiled water that has been cooled for no more than 30 minutes, so that the temperature is still above 70C. Powdered formula is not sterile and using water at this temperature will kill any harmful germs (bacteria).

• Make sure that the formula is not too hot when you give it to your baby. If warming the formula in a microwave oven be particularly careful, as microwaving can lead to 'hot spots' in liquids. Shake the bottle well to mix it up before you test the temperature.

How do I feed my baby from the bottle?

Make sure you are sitting comfortably. Hold your baby close, in a similar position to breast-feeding, making eye contact as you feed them. Your baby, even when newborn, can focus on your face, and this is an important part of the way in which they bond with you.

• Your baby needs to be fairly upright for bottle feeds, so they can both breathe and swallow (your baby breathes through the nose whilst feeding). Support their head, and brush the teat against your baby's lips - your baby will open his/her mouth; then let him/her draw in the teat.

• Give your baby time to feed, as feeding should not be rushed. Keep the teat full, as otherwise your baby will take in air. If the teat becomes flattened while you're feeding, gently slip your little finger into the corner of your baby's mouth to release the suction. If the teat gets blocked, replace it with another.

• If your baby seems frustrated and keeps flattening the teat you may need a teat with a faster flow. You can enlarge the holes yourself using a hot needle, although you will then need to resterilise the teat.

• If your baby is spluttering and keeps coming off the teat, it may be that the flow is too fast and you need a slower-flow teat.

Winding your baby

Your baby will swallow a little bit of air and may need to burp. When they stop feeding actively, hold them upright and rub their back to bring up any wind. Then see if they want to feed a little more. Throw away any unused formula in the bottle when your baby has finished, as this will no longer be sterile.

Being sick and possetting

Some babies bring up more milk than others during or just after a feed. This is sometimes called possetting or reflux, and is usually harmless. If it happens often, or your baby is forcefully sick or appears to be in pain, you should talk to your health visitor or GP.

Check that the hole in your baby's teat is not too big - giving milk too quickly can cause sickness. Sitting your baby upright on your lap after a feed, and winding gently when they take a break from feeding, may help.

How much formula should my baby take?

Babies vary in how often they want to feed and how much milk they want to take. Feed your baby when they're hungry, and don't worry if they don't finish a bottle.

The best measure of how well your baby is feeding is how well they grow from week to week, not how much they take at every single feed. From the age of a week until when they are 6 months old and start to be weaned, most babies need around 150 to 200 ml of formula per kilo of their weight per day. This will vary from baby to baby and may also change if your baby is unwell, is in pain due to teething or is having a growth spurt.

Your baby's weight gain and the number of wet and dirty nappies are the best guide to whether your baby is getting enough formula. Your baby should have around six wet nappies a day, soaked through with clear or pale yellow urine. After the darker poo of the first week, your baby should start to pass pale yellow or yellowish brown poo, and should pass a poo most days.

Your baby will usually be weighed at birth and again at around 5-10 days. After that healthy babies only need to be weighed no more than once a month up to 6 months of age.

Will formula feeding make my baby constipated?

Constipation is more common in formula-fed babies than in breast-fed babies. If your baby is under 8 weeks old and hasn't had a dirty nappy for two to three days, discuss this with your health visitor or GP.

Which kind of formula should I give to my baby?

For the first six months your baby should only have breast milk or infant formula. Almost all babies should start with first infant formula. The only exceptions would be very premature babies and babies with particular medical conditions which are known about at birth. The vast majority of babies need only first infant formula until they move on to normal cow's milk at the age of 1 year.

What is first infant baby formula?

First infant formula is made from cow's milk which has been modified to make it suitable for human babies. It is available as a powder for reconstituting, or as ready-constituted liquid. The liquid has a much shorter shelf life and is a more expensive option, but it can be very useful if you are in a situation when it's not easy to make up formula hygienically.

What is cow's milk allergy?

Cow's milk allergy (or cow's milk protein allergy, CMPA) is an allergy to one or more types of the main proteins in milk, casein and whey. It affects around 1 in 15 babies under a year old, although it is less common in exclusively breast-fed babies (only around 1 in 200), it is more common in babies who have, or whose parents have, asthma or eczema or food allergies themselves. More than half of children who are allergic to cow's milk under the age of 1 year are tolerant of it by the age of 5 years.

Symptoms tend to include skin rashes, itching and eczema, together with digestive problems such as tummy pain and diarrhoea, sometimes together with wheezing. If your baby develops any of these symptoms you should talk to your health visitor or doctor.

• If your baby develops an allergy to cow's milk then your doctor will prescribe a special formula in which the cow's milk proteins have been broken down.

• Soya milk is not recommended to treat cow's milk allergy, partly because its use under the age of 6 months can lead to soya allergy, and partly because some children who are allergic to cow's milk are also already allergic to soya milk.

Cow's milk allergy is not the same thing as food intolerance. Intolerance is caused by an inability to process or digest milk completely, usually due to a shortage or absence of one of the enzymes (such as lactose) that you need to break it down. It does not involve an allergic reaction. See the separate leaflets called Cow's milk protein allergy and Lactose intolerance.

What infant formulas are out there?

There are lots of different formulas on the market, some of which are specifically for babies with allergies or intolerances, and some of which are aimed at all babies. Most babies never need to change milk, but breast-milk manufacturers would like you to change to their brand.

You will see a number of other baby milks being marketed, some of which claim they will be more satisfying for your baby, or will settle your baby better. We have listed the milks that you are most likely to see on the shelves:

First infant formula (first milk)

This should always be the first formula you give to your baby. The cow's milk in infant formula contains two types of proteins - whey and casein. First infant formula is based on whey protein, which is easier to digest. It remains the closest formula to human breast milk.

Goat's milk formula

Different kinds of goat's milk formula are available. They are developed from modifying goat's rather than cow's milk and not less likely to cause allergies in babies than cow's milk formula. They are unsuitable for infants with cow's milk allergy, as the proteins they contain are very similar.

Manufacturers of goat's milk formula claim that it is easier to digest, although there is no good evidence for this. However, goat's milk formula is produced to the same nutritional standards as cow's milk formula and is an acceptable alternative.

Hungrier baby formula (hungry milk)

This type of formula contains more casein than whey. Casein is harder for babies to digest. This formula is often described as suitable for 'hungrier babies' but there's no evidence that babies settle better or sleep longer when fed this type of formula.

Anti-reflux (staydown) formula

This is a thickened formula aimed at preventing reflux or severe possetting in babies who bring up milk very frequently during or after a feed. A thickened formula should be used only on the advice of your midwife, health visitor or GP, who may advise trying it if your baby brings up milk frequently and seems to be distressed.

Comfort formula

This type of formula contains cow's milk proteins that have already been partly broken down (partially hydrolysed). This is said to make it easier to digest and reduce infant colic, but there is no evidence that it works. It's sometimes mistakenly called hypoallergenic formula, but it isn't suitable for babies who have a diagnosis of cow's milk allergy, as the cow's milk proteins are not completely broken down.

Lactose-free formula

This formula is intended only for babies who are lactose-intolerant. This means they can't absorb lactose (a sugar found in milk and dairy products) because they are deficient in the enzyme lactase which is needed to break it down.

True lactose intolerance is rare in babies. This is as you would expect, as breast-milk also contains lactose and it is designed for babies. Breast-milk contains some lactase too but not enough to digest the milk alone.

• Symptoms of lactose intolerance include diarrhoea, tummy pain, wind and bloating, but these can be hard to detect in babies who may have colic and runny poo (stools) without lactose intolerance. See the separate leaflet called Lactose intolerance.

Lactose-free formula is available over the counter but it is recommended that you only use it if advised to by a doctor. This is because:

• Lactose may play an important role in your baby's bowel in maintaining friendly bacteria.

• Lactose is broken down in the body into a sugar called galactose, which babies don't get from lactose-free milk. It is not known whether this matters.

• Lactose in the bowel plays a part in absorbing calcium.

Lactose intolerance is over-diagnosed in babies, as it's easy to blame formula for babies' fussiness. Lactose-free formulas can be tried temporarily in babies recovering from a diarrhoea illness, who can have a temporary lactase deficiency while the intestinal lining is healing.

Hypoallergenic formula

If your baby is diagnosed as being allergic to cow's milk, your GP will prescribe an infant formula with fully broken down (hydrolysed) proteins. This can't be purchased over the counter. It's used for babies with cow's milk allergy until they are 6 months old, after which they can have soya milks instead.

Follow-on formula

This contains added calcium, iron and protein, and replaces lactose with corn syrup to make the milk sweeter.

Follow-on formula should not be fed to babies under 6 months old. Babies over 6 months old don't actually need follow-on formula either, and manufacturers have been criticised by the World Health Organization (WHO) promoting it as a sensible 'switch' from breast-feeding, particularly in third-world countries. Research shows that switching to follow-on formula at 6 months has no benefits for your baby, and some doctors worry that it may also encourage a sweet tooth later.

Your baby can carry on having first infant formula as their main drink until they are one year old.

Good night milk

This is a follow-on formula with cereal added to it and is sold as a helpful formula for bedtime. However, there's no evidence that babies settle better or sleep longer after having it, and your baby doesn't need it. Good night formula should never be given to babies under 6 months old.

Soya formula

Soya formula is made from soya beans instead of cow's milk. It's used as an alternative to cow's milk formula after 6 months of age for babies who have been diagnosed with cow's milk allergy (although babies can also be allergic to soya milk).

Soya formula is not recommended for babies aged under 6 months as it can increase the risk of soya allergy. Soya formula also contains glucose instead of lactose and it is more likely to harm babies' teeth.

There are also concerns that soya contains phytoestrogens (similar to the female hormone oestrogen), and that these may affect the development of a baby's reproductive organs. Older children and adults can consume soya in their diet, however.

You should only use soya formula if it has been recommended or prescribed by your health visitor or GP.

Growing-up milk (toddler milk)

Growing-up and toddler milks are marketed as an alternative to whole cow's milk for toddlers and children over 1 year old.

Formula isn't necessary at this age as your child will be weaned and can get extra vitamins and minerals from many sources. Whole cow's milk is a suitable choice as a main drink for your child from the age of 1 year.

Vitamin supplements

It's also recommended that all children aged 6 months to 5 years have vitamin drops containing vitamins A, C and D every day. They are not needed for a baby having 500 ml of formula or more, as formula is fortified with vitamins.

You can give the following milks to babies aged 6-12 months as mixers, but not as drinks

• Whole (full-fat) cow's milk.

• Goat's milk or sheep's milk.

These can be introduced, not as a drink but as a mixer for food, from 6 months. (Whole cow's or goat's milk can be given as a drink from one year.)

You should not give the following types of milk to a baby under 1 year old

• Condensed milk, evaporated milk or adult dried milk.

• Adult soya, oat or almond drinks.

• Semi-skimmed milk - can be introduced once your child is 2 years old, provided they eat generally well.

• Skimmed and 1% milk - aren't suitable for children aged under 5 years, as they don't contain enough calories.

• Unsweetened, calcium-fortified milk alternatives (such as adult oat, almond and soya milk) - can be given to children over the age of 2 years

• Rice milk should not be given until the age of 5 years, as it contains higher levels of arsenic.

What if my baby doesn't like the formula?

Some mums repeatedly change infant formula in order to try to find one that their baby likes. 'Formula hopping' (frequent changes to find one your baby seems happier with) can result in babies refusing each new formula and becoming increasingly grumpy and windy at mealtimes, further convincing their parents that the formula is the problem.

Babies often have grumpy days, or days when they seem uncomfortable, and it's understandable that you want to find the right formula for your baby. If a baby becomes colicky or has a spell of difficult feeding it's simple to blame the formula and move on - but in truth the right formula for almost every baby is the one they have the chance to get used to. Babies adapt to the taste of the formula you give them.

They are programmed not to like change at this age, so persuading them to accept a change in formula (or any formula after they have had breast milk) can take a little time. Changing formula will not help this and can actually make it harder, as your baby will be confused and, without time to get used to any one formula, may continue to seem fussy.

If you are advised to introduce a new formula then you need to persevere calmly and without anxiety. It can take several days for your baby to accept formula after breast milk, or to accept a change of formula that has been advised by your doctor or health visitor, as it will taste different and small babies don't like change.