I have decided to do a week focused on the “most frequently asked questions” related to feeding. Today – “How to choose a bottle nipple for your baby.” For a nice overview on feeding and children with Down syndrome please watch Feeding and Swallowing in Children with Down Syndrome from Children’s Hospital of Boston.
I am fortunate to be part of a great team of specialists at the Thomas Center for Down Syndrome. On Tuesday mornings I see children with Down syndrome ages birth to two during an interdisciplinary visit. During these visits I look at the following skills:
- Coordination of the tongue, lip, and jaw
- Structures of the face and mouth (like the palate)
- Reflexes including rooting and gagging
- Suck: Swallow: Breathe coordination when taking a bottle
One of the more common difficulties I see is related to nipple choice. When examining the child I look for a good latch on the nipple, lips that are well sealed, and minimal to no liquid loss when eating.
How do I know if the nipple is the problem with my baby’s poor feeding skills?
It’s important to work with a feeding specialist to determine the exact cause if your child isn’t eating well from a bottle. However, at home you can certainly try a variety of nipples if your baby is losing liquid from their lips, taking a very long time (greater than 30 minutes), or taking the bottle too quickly. If they continue to have trouble get a referral from your pediatrician to see a feeding therapist. Depending on your area this could be an occupational therapist or a speech pathologist.
I nursed my oldest son for 10 weeks before trying to transition him from breast to bottle when I had to return to work. I had registered for the finest bottles speech pathologists could recommend (at that time) and was ready to go with the whole system… And failed miserably. I kept trying for 2 weeks. He would take forever to use a stage 1 nipple and with a stage two milk would pour out like a faucet. It wasn’t until I tried my sixth nipple that he finally took the bottle with success. I didn’t know anything about bottle feeding at that time. To be honest, I had wonderful friends (Thanks Cory!)with children slightly older than mine who loaned me sterilized nipples and bottles to try out. This way I didn’t have to take out stock in Gerber.
When evaluating a baby with Down syndrome I look to see if a baby is losing milk out of the lips, the frequency of loss, and when it’s occurring (at each suck, when swallowing, or when breathing). I try some position modifications like alternating arms, holding the baby more upright, pulling the cheeks forward before experimenting with a different nipple. The shape of the child’s palate, position of the tongue, and coordination of the lips all affect success. You can’t tell is there will be a problem just by looking at the structures – you must have a trained eye watch the whole feeding process.
So with all the choices out there, what type of nipple should I use?
First of all, if your child is not having any problems with the bottle they are already on, don’t change. There is no such thing as “the best nipple.” In my experience with children with Down syndrome have good results using nipples that are narrow and long. We use a hospital grade nipple by Similac in our clinic. The closest thing in shape is Dr Brown’s silicone nipple. You don’t need the whole Dr. Brown’s system (with all of it’s many) parts. Just the nipple and standard bottle will work. I actually used this nipple with my youngest son on a glass bottle. If not Dr. Brown’s Natural Flow Nipple then latex nipples like Evenflo Classic Latex Nipple or NUK First Essentials Latex Nipple are close to this shape. The more narrow base of these nipples allows for slightly more stability in the jaw. If the jaw is stable, this will help coordinate movement in the tongue and lips. Think about how a baby opens it mouth for a wide base versus a narrow one. Now think about you – Is it easier for you to eat a sub-sandwich or a plain old, two-slice ham and cheese?
Which flow is best?
Provided your baby does not have a heart or lung condition that causes fatigue, choose a slow flow nipple initially. Faster is not better. Pacing so it takes between 15 and 30 minutes for a full feeding is essential to proper digestion. If your baby is taking longer than 30 minutes try a medium flow or stage 2 nipple. If he begins to leak formula or breast milk is leaking from one or both sides of the mouth, then try pulling his cheeks forward for support (see picture example). If he continues to leak, change back to the slow flow nipple and talk to your SLP or OT about other suggestions. Taking longer than 30 minutes to eat can cause the child to burn calories, rather than keep calories needed for growth.
What are more serious problems that can occur during bottle feeding?
There are several things we (trained feeding therapists) look for when working with an infant with Down syndrome. If your child experiences the following symptoms please contact your pediatrician feeding:
- Regularly coughing and sneezing, watery eyes, and/or runny nose during feeding but not necessarily other times
- A “wet” sounding voice, like her voice needs to be cleared
- No or little weight gain despite regular feedings
- Respiratory infections including pneumonia
Remember – Children with Down syndrome can be successful bottle drinkers, breast-feeders, cup drinkers, and food eaters! It just takes time and practice, and lots of trial-and-error. The best practice is feeding itself!