June 24, 2025
Bottle-Feeding Pitfalls: Podcast Episode #296
Kristin Revere and Barbara Nelson, CLC discuss bottle-feeding pitfalls on the latest episode of Ask the Doulas Podcast. Barbara is a Pediatric Speech and Language Pathologist and Certified Lactation Counselor who specializes in infant feeding. She creates educational content to help parents feel confident in feeding their babies and recognize red flags early. She is the host of the How to Feed Your Baby Podcast.
Hello, hello! This is Kristin Revere with Ask the Doulas, and I am thrilled to chat with Barbara Nelson today. Barbara is a pediatric speech and language pathologist and a certified lactation counselor who specializes in infant feeding. She owns January Consulting, creating educational resources to help parents feel confident in feeding their babies and recognizing red flags early.
Barbara is also the host of How to Feed Your Baby Podcast, and she provides free resources on her website, Feeding by January.
Welcome, Barbara!
Hi! Thanks, Kristin! I’m excited to be here!
I am so excited to chat about recognizing those red flags early on and any sort of issues that we can come across with bottle feeding. Those pitfalls can happen and throw you off course. I would love to pick your brain about how as postpartum doulas and birth doulas we can better support our bottle feeding families.
Absolutely! There are definitely a few common pitfalls that I see pretty frequently. Before we get to those, just sort of knowing the general red flags. Obviously, if weight gain is an issue. Baby is gaining weight too rapidly; there’s reflux, pain, discomfort, coughing or choking. Wet, gurgly, or funky-sounding meals – those would all be signs that we need to figure out why, and sometimes it’s a super simple solution, and sometimes it’s something that surprises us that still needs to be addressed. So obviously if there’s something funky going on and a baby’s not settled after the feeds as they should be, then those would be pretty obvious red flags to get additional help.
But there’s also some really super simple, common pitfalls that I see a lot that parents, especially with the right support, can avoid. For example, one really common pitfall is that we tend to treat bottle fed babies differently than breast fed babies. And what I mean by that is because we can see how much milk is in the bottle, whether you’re formula feeding or expressing your breast milk, we tend to watch the bottle instead of the baby. We tend to watch the paper schedule instead of the baby’s. I always encourage families to learn infant cues. Take some type of class that teaches you to watch the baby instead of the bottle. Because although it is really reassuring – for myself included. I come from a background of a hospital, so I measure everything. I understand that those are really helpful and important facts to have or write down and that the doctors are always going to ask you. But when we only look at that, we miss signs of satiation. We miss the sign that the baby needs to slow down. We miss the sign that the baby is done. Their belly can’t take anymore. And when you think about the difference in experience – you know, how you are fed as a baby absolutely shapes your meal time experience for the rest of your life. Not that you can’t have a problem and recover and meal time be positive, but it is really important. And you can imagine if someone’s pouring liquid down your throat too fast. You’re going to be a little more defensive at meal time. Whereas if it was slow, they were following your cues, it felt comfortable, it felt social, it felt cozy, you were comfortable and took a little nap afterward – that is going to be something you lean into.
These things are important. So I always say first that you can still do cue-based feeding, even if you’re bottle feeding, even if the doctor gives you that 1980s schedule of this many ounces, this many hours. If your baby tells you something different, let’s listen to the baby. And after that, if they’re not getting what they need or there’s a problem – well, then there’s a problem the paper schedule wasn’t going to fix anyway.
So that’s the first thing that I think we need to consider. You can cue-based feed your baby even if you’re using a bottle.
Then another bottle thing that I see a lot is sort of mixing and matching bottle nipples by accident. There have been plenty of studies on this. There was a study where they took the same pressure pump – they made all the factors to see how quickly these different bottle nipple flow rates were based on their label. And what they learned and what we know is that the way that a bottle nipple is labeled – so when you go to Target or wherever you get your bottles and it say 0+ months, slow flow, newborn, anti-colic, whatever – there’s actually no standardization for that. The company made it up. It’s marketing. They just want you to buy their bottle. So what happens is families might be gifted several different bottles; at a baby shower, for example. Well, we’re using 0 months or we’re using slow flow, or we’re using Avent. Well, according to that study, the Philips Avent natural flow nipple, which is labeled 0+ months, had a flow rate of about 2.25 milliliters per minute. Okay, but the same brand, the Philips Avent anti-colic nipple, which is also labeled for 0+ months, was tested to have a 17.44 milliliters per minute of flow rate when given the same suction. So same brand, same age recommendation, same suction. It made a huge difference. I mean, you’re talking about less than a half an ounce in five minutes and almost three ounces in a five-minute period. That is a huge distinction.
So again, it’s important to watch your baby. Even if it say 0 months, you want to watch your baby. If they’re dribbling or gulping, it’s too fast. And understand that when you switch around, even within the same brand, that you’re not always getting a stair step. So maybe you picked a brand and you love the brand. See if you can go down in that brand instead of changing around the bottle type. Unless, of course, there’s a reason to change the bottle. But so often, they’re on this roller coaster, and they’re learning. It’s hard to learn when you’re sometimes learning on a Capri Sun straw and sometimes learning on a smoothie straw.
The baby’s like, what’s going on?
Yeah, it can be a little trick. Some babies will eat whatever and they do fine even though you and I might look and say, well, they’re gulping a lot. They’re just surviving this meal. But people don’t seem to notice and they seem to move on. But I would argue that it’s probably better to keep it simple and not switch it out. But that’s a common pitfall that parents might have. You know, they buy a Dr. Brown’s bottle, which comes with a level one nipple. Maybe they buy a size down nipple, and they’re all in the same drawer. And you can’t see that number on the side of them. You have to hold it up to the light. You can’t see that at night.
Exactly, and if you have other caregivers like grandparents or doulas or nannies or partners, and they’re just grabbing whatever they see and whatever might be sterilized…
Yeah, so set the environment up. If these are the nipples we’re using, the other ones have to be somewhere that it would be hard to get to them. Then nobody makes a mistake, and it’s so much easier. But that’s a common one. And I just want to point out, too, that those rates and the ounces that I quoted from the study, that’s not how fast your baby will take it or any given baby will take that milk. That was a study with a pump. Baby’s oral shape, suction, strength, size – there’s a ton of unique factors that go into how fast baby drinks a bottle, including how big that nipple pull is. But that’s not saying that’s how fast that baby should take the bottle. That’s just saying apples to apples, that there’s a huge difference in the size and the shape of the bottle. That’s all that means.
Good point, yes. And I feel like there is that reassurance where you can visually see whether it’s a formula fed baby or a pumped milk bottle fed baby where how much intake is, where with breastfeeding, you don’t fully know how a feed goes, other than the weighted feeds to measure. Families often feel like they’re underfeeding, and then they supplement or they’re talking to other medical professionals, like a pediatrician or a lactation consultant and they’re feeling like they can’t produce enough. So they get into this cycle of either adding pumping or supplementing.
Think about most of the new parent books or the newborn care books. They’re all volume based. And we’re coming off of generations who were primarily bottle fed. So I think this is more of lack of trust because our language hasn’t aligned yet with what moms want. And what I mean by that is that there absolutely are signs that your baby is getting enough. But because it’s not the norm that we focus on, we don’t yet trust it or we don’t know it because nobody tells it to us. Your baby’s output, having adequate wet diapers and stools, that is absolutely trustworthy. I would argue more trustworthy than weighted feeds, because a weighted feed is one snapshot, and while it’s really very important and I always recommend it if a mom is concerned. Whether I see concerns or not, a weighted feed brings such comfort because it gives you that measurement. And there are babies who look like they’re eating and they’re not transferring. So it’s such a helpful tool.
But when you have a baby who is pretty perky and vigorous at the breast, not upset but active, and their output is good, and at the end of a feed, they have relaxed hands, like Thanksgiving dinner; their belly is bigger, your breast is less full. Like, thanks, Mom, that was great; let’s nap. You can trust that. We don’t talk about that. The doctor wants to know the schedule. They want to know the volume. So I just think as the language changes, I think we will get more trust in those other kinds of measurements.
So, Barbara, with other caregivers – we’ve talked about nipple size and flow and so on – but even the way a bottle is held or feeding is done by different caregivers, whether it’s a nanny, a grandparent, a partner, or the mother – we should talk a bit about different techniques. I’m a big fan of paced bottle feeding to mimic breastfeeding and slow things down a bit. What are your thoughts as a professional in this space?
This is such a good question, and I have an unpopular view on this among the lactation community, but I’m going to share it anyway.
So I will say that I understand the value of paced bottle feeding because I think with bottles, we tend to hurry and high volume feed our kids. And when they don’t have adequate breaks and they don’t have a good, appropriate pace at feeding – just like all of us; when we shovel, right, we’re uncomfortable afterwards because we’re like, oops, we were just shoveling and we didn’t realize. So I will say that I’m a fan.
However, the reason that I don’t recommend it very frequently is because I find that it is really hard for caregivers sometimes and it is really hard for other family members to appropriately pace bottle feed. What happens is mom is really in tune with that baby, and she’s sort of following the baby and giving those breaks as needed. Great. However, then grandma comes along and she’s like, one, two, three, four, five, break – and it’s actually more disorienting to the baby. So in some cases, I would almost prefer that the baby be on a very slow flow, like a Dr. Brown newborn or maybe a Pigeon super slow flow rate. One of the bottles that we know is actually slower. And of course, you watch the baby and you adjust as they need it. But if it’s slow enough – not too slow, but if it’s slow enough, then the baby will pace themselves. They take breaks, and you will see them drink and swallow and then take breaks as they need. And then the caregiver can just sort of take the bottle out as needed, give them burp breaks. But I always find that if it’s done well, great. If it’s not done well, it’s probably creating more tension and frustration and coordination confusion than good. Does that make sense? It’s kind of a double sided answer.
It does, it does. Especially with different caregivers and confusing the baby with different styles of feeding. Trying to maybe gulp it down as quickly as possible versus slowing things down. But if you already have a bottle system that is slower, then it would be easier for any caregiver to help with feeding. So I totally agree with that. We try to educate our clients in different bottle feeding techniques, but it can be challenging when there are a lot of people involved in baby’s care.
Yeah, and I think the more you can standardize the things that can’t be messed up – picking the right nipple and things like that and supporting them to have the baby in the right position – those, I think, are helpful. Because some people really naturally do paced bottle feeding, and some don’t. And I also want to make the distinction between paced bottle feeding as far as trying to support and follow baby’s cues and have sort of a natural rhythm and natural breaks in the feed compared to medical strict paced bottle feedings. In the speech pathology world, if I have an infant with dysphagia who’s not coordinating their suck, swallow, and breathing – so they might be sucking and swallowing but not breathing, or they might be sucking in milk or having a hard time coordinating that – we may, especially with a NICU baby who has an immature sucking, swallowing, breathing pattern – we may do what’s called strict pacing. So we may be counting three sucks and then you gently tip the bottle so that they can take a break. So you are cuing them to get that pattern and learn that skill. And I just want to make the distinction that it’s a separate, different type of pacing.
Absolutely, yes. The NICU babies, their needs are much different, or any medically complex baby.
And that baby – grandma has to get on board if she’s feeding. We can’t just change the nipple.
But yeah, every family is so unique. So I would sort of defer to, what is it looking like when that particular caregiver is offering the bottle? Does it look like baby is getting frustrated and swallowing more air and getting more uncoordinated, or are they taking the bottle all the way out? How is the baby handling it, and how is the caregiver able to respond? That’s how I sort of coordinate my recommendations as far as the normal, natural paced bottle feeding that we try to offer for a healthy newborn.
That makes sense. So what other pitfalls are you seeing?
Oh, gosh. Well, a big one is when it comes to formula, improper mixing. That’s a big one. So most powdered formulas – always read the label because you have to read the label to know for sure, but most of them, you are supposed to measure the water out, and it should be sterilized water for a newborn. Not always because the water has an issue. We think, oh, is the water clean? Okay, I’ll get distilled water; I’ll get baby safe water. The formula has been through a factory. That powder has been through an entire factory, bacteria. I mean, it’s processed food. So to also make sure that the formula is safe for the babies, particularly very little babies. So when they’re newborn, you actually are supposed to boil that water. First you measure the water. Then you put the scoop in, and it should be that even scoop. And when we’re sleep deprived, we’re like, here’s a heaping scoop. Oops, I put it in the bottle first. There’s all different ways, easy ways. But when we do it out of order, it changes the calorie content. And when it comes to formulas, particularly powder formulas, there is a higher iron content. There’s higher additives because they’re not as bioavailable to the gut as breastmilk, which means that more is put in, to hopefully offset that. It also means you can get more constipated. So it just depends on everybody’s makeup. But when you are not mixing properly, we might be accidentally giving baby a higher calorie formula, a more condensed caloric version. And those change the hydration content. All of these things impact the gut and how we digest and how we grow and things like that. And while it’s not this common – oops, you put a tiny bit more than a leveled scoop. I don’t mean to freak anybody out. If you really drill in ahead of time the order, and it is important, and I think it’s such a simple thing to learn ahead of time and kind of keep an eye on or make a little visual for grandma. Grandmas are great. This is not, you know…
But it’s hard to read those containers, especially in the middle of the night.
They’re tiny, yeah. So learn it and know it ahead of time. But I think those are common ones. People don’t wash their hands. And your baby is putting their mouth all over you; whatever. But anybody that comes into the house, they need to be washing their hands before they mix that formula. I mean, arguably, everyone. But the improper mixing is a really common one, and I think when you combine improper mixing and then you are looking at, oh, we have to finish all these three ounces, and the baby is not able to tolerate it – now we’re looking at reflux. Now we’re looking at, it’s hard for me to sleep. Now we’re looking at, I’m not comfortable. So we can have issues that wouldn’t otherwise be issues just by avoiding these very simple things.
You talked about sanitation and safety and making sure that bottles are properly sanitized and cleaned.
Yes, nothing is more off-putting than seeing a dirty, crusty bottle nipple when you come into the clinic. This is going in your baby’s mouth and their entire digestive system. Again, if they’re not getting breastmilk, they’re also not getting those immune supporters. So it’s arguably even more important to be extra careful.
When we think about how we store it – I mean, formula should not be stored in a hot car. If you use water that’s been sitting in plastic, it definitely should not be sitting in a hot car. We’re busy; it’s hard. But these are important things. Once you get the system down, I think it’s easy.
And the other thing I’d like to say about formula and even donor breastmilk would be, I meet a lot of moms who have supplementation without education. So their feeding plan was to breastfeed, or at least to initiate breastfeeding. And for maybe whatever reason, it didn’t go quite as planned, or they ran into a couple of speedbumps or roadblocks with that. So while they’re trying to figure that out, the doctor says, the baby’s not gaining. Here’s some sample formula or whatever to supplement. However, they never educated the mother on how to support her breastmilk supply. So if you do that for a week, now it’s going to take you doubly long. Now you have missed time. It’s much harder to recover from a decrease in supply than it is to just build it from the get go. So that happens a lot.
Your body doesn’t think that it needs to make milk if you’re supplementing.
Exactly. And that happens for moms who go back to work sometimes, too, because our culture has a lot of oversupply. What’s normal is a freezer full of milk here, and that is oversupply. Anything you supply that is beyond your baby’s caloric needs is technically oversupply. And that can come with a whole host of issues, actually. When you have that freezer milk and you go back to work, if you’re using it and then you’re not still pumping or removing that daily amount of milk – I’m not saying one time; I’m saying like your regular routine – your supply will go down because your body thinks, I don’t need to make as much. Everybody’s happy.
So when that happens, again, you can accidentally mess with your supply. It’s harder to recover. It’s better to be aware. But I find that doctors aren’t always mentioning this, or even providing the name of someone and saying, hey, we need to make sure baby gets a few more calories, but this is the person who can help you. We can use this tool, but we don’t want to lose sight of what mom’s goal is at any given point. That happens a lot. By the time they see a lactation consultant, we’re several days in, which means a harder road to get back to where she wants to be. That’s sad to see.
So how did you transition from working in a clinical setting to pivoting to starting your own educational resource business and podcast? I’m curious, before we end this, to get more of your personal passion and perspective on feeding.
I worked for over a decade in a clinic. Very Western medical setting. But even in the outpatient clinic, I really enjoyed the infant feeding perspective. I’ve always really enjoyed supporting families with that. And we would have parents come in, and their baby may have dysphagia, or they’re doing a NICU follow up, and they really want to breastfeed. And I found in my system, and I think you’ll find across many hospital systems, that it’s really not set up. Even though we have great NICU lactation consultants, we didn’t have any outpatient lactation. We really did not have a system set up to support that. So I felt like you can only speak to what you know. By nature, we’re very bottle biased. And particularly in the medical system, we’re not thinking about, can we use a scale to give that baby credit for that feed?
I went on to get my CLC and get all the hours for the IBCLC and things like that. Basically, I felt like it was a huge gap in the system, and I still feel like it is. And I do still think in home support for that when babies are really little is best because it is very disrupting to a feeding schedule to go to appointments and sit in a waiting room and be off schedule. If you tell a mom, well, you’ve got to pump this many times a day, but they are out for three hours with their two-week old baby – it’s very disruptive. So recognizing all of that, but still wanting to support whatever mom’s feeding plan is. And for some of our really dysphasic babies, or babies with craniofacial abnormalities, sometimes that means you get part of breastfeeding. Sometimes they can suckle. Sometimes they can do an alternative supplemental system. Sometimes, that means skin to skin. Sometimes that means mom’s breastmilk, but in a bottle. I mean, when we think about the benefits of breastfeeding, there’s a long list. You can still get many of them if there is a barrier to exclusive breastfeeding for you. You can still get so many of those benefits in many other ways. So wanting to support that was what got me interested in it.
And then after my son was born, I just didn’t want to go back to that work schedule anymore. But I needed to do something because I just need to be busy and do something. So that’s when I started to have a few private clients and really wanted to start making resources. These are the kinds of conversations to change the language from, here’s the schedule to, what is your goal? How can I help you support your goal and educate you so that you can be your own advocate and get the support you need and understand infant cues instead of just the schedule? So that’s sort of what led my path, so to speak.
So how can our listeners connect with your amazing resources and all of the different channels in which they can reach out?
I have the How To Feed Your Baby Podcast, which has a lot of infant feeding information on it. It’s a little misleading because I also do interview other maternity and postpartum professionals because it turns out, what’s good for mom is good for baby, and we really can’t dissect this period. It has to be a whole thing. So the How To Feed Your Baby Podcast. I also have a lot of free resources on Feeding by January. And that’s where you can contact me if you have any questions. I don’t mind emailing back. There’s free resources and downloads on there. There’s a link to a feeding course, which basically goes over a lot of cue-based feeding and things like that and how to prepare. Half of that is free. I made that for a company that we collaborated with. There’s a lot of free options on there. I don’t want there to be any barriers to this information. I do feel like everyone should have access to it. But those would be the ways to get more info.
Thank you so much, Barbara! I’ll have to have you back on again. You are a wealth of knowledge!
Thank you for having me, Kristin!
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