Bottle feeders - please stop twisting it.

I am a self confessed people watcher.  I love nothing more than sitting watching the world go by, as all the colourful characters it is filled with wander past - and last Friday was no exception.  Sitting on the terrace of a quaint cafe, window boxes overflowing, sun beaming down, both children occupied, drinks ordered; I sat back watching people mill about.

Before long a couple with a baby arrived and took a seat next to us.  Dad ordered the drinks whilst mum sorted baby's bottle for a feed, and my first thought was what a cute baby; only a few months old and with obviously doting parents. The mum caught my eye and I smiled as she adjusted her position to move baby's face out of the sun, remembering those early months when the world seems to stop and revolve around this tiny being.

Mum started feeding the baby, positioning him in the crook of her knee so she could have her drink and use her mobile - and I went back to the business of watching people passing down the lane.

After a while my attention was drawn back in their direction with the movement of her shifting him for winding. I smiled to myself again as she carefully supported his wobbly young baby head and he produced a burp his dad would have been proud of, before she laid him back down to resume his feed.

Only baby had other ideas. Obviously satiated he turned his head away from the bottle and tried to shift slightly; mum and bottle followed. He turned away again, twisting from side to side to try and prevent the teat re-entering his mouth. Still it followed and as mum finally managed to squeeze it past his lips, she twisted it quickly to release milk. Baby took a few gulps before again releasing the bottle and turning his head. Mum winded baby again, picked up the bottle and examined how much was left - before the game of cat and mouse resumed; the baby unable to make it any more obvious he didn't want more (after all two or three month olds can't physically push someone away) the mum ever determined to get more milk in.

I packed up and we left the courtyard, my mind still on the obviously loving mother who I suspect had no idea what the impact of her behaviour could be long term.

It is well documented that non breastfed infants are at higher risk of obesity both in childhood and in later life, and how the feed is delivered appears to play a large part.

A study in May 2010 of over one thousand older infants, found those who had had more than two-thirds of their feedings via bottle in early infancy, were twice as likely to routinely empty their milk cups as toddlers who'd had less than one-third of their feedings via bottle. This was the case regardless of whether it was breastmilk or a substitute in the bottle. Whilst only 27% of toddlers exclusively breastfed in the first six months routinely finished their cup or bottle, this figure sat at 68% for those exclusively bottle fed.

Losing the ability to self regulate intake has life-long impact, as a popular adult diet book now highlights. Paul Mckenna's "I can make you thin", is based upon re-learning what your body's sated cues are. Focusing on consuming each mouthful s-l-o-w-l-y (for exactly the same reason - to give your body chance to recognise it's full) and stopped when you are full (even if it's scrummy chocolate cake!).  In fact he claims there is no need to calorie count (or live off salad), providing you only eat what your body requires and stop when full - you will obtain and maintain a healthy weight.

So why is bottle feeding linked to reduced appetite self-regulation?

Firstly, bottle fed infants receive a later satiated cue than their breastfed counterparts. Breastmilk isn't released in one constant stream like a bottle, mum has multiple let-downs during a feed, resulting in regular pauses. These "breaks" slow the feed down, and allow baby to recognise satiety and stop feeding, long before the stomach is over full. As soon as a breastfed baby stops sucking, milk ceases immediately.

In a bottle fed baby, the feed is more parent led - once the bottle is upturned, milk is released and each suck swallow pattern causes the teat to refill and more milk to be released. Baby can have finished the bottle, long before their system has had chance to recognise they are full.

Secondly, as observed in the cafe, before an infant can physically push the bottle away, the only thing they can do is turn their head and try and prevent it entering their mouth. Eventually mum will often manage to get the teat in, milk flows and baby is forced to swallow, usually at least a couple of times before they manage to force the teat out with their tongue and again turn their head.

In both the above scenarios, the ability to only eat to satiation is being overridden from a very young age - instead infants are used to finishing the lot and feeling overfull. The over feeding stretches their stomach to accommodate the larger amount of milk, so next time after consuming the same amount - they may no longer feel sated.  At the "worst case" end of the spectrum you end up with a baby consuming vast amounts of milk, yet still not settling or appearing full - maybe even suffering colic from his distended stomach.  An older report found found bottle fed babies consumed approximate 30,000 more calories per year than a breastfed infant - which the authors felt was due to a combination of incorrect preparation and tactics to encourage infant to drink more or finish each bottle.

Many babies prefer small, more frequent feedings as they have small stomachs and again this mimics the breastfed baby; however, bottles shouldn't be used as the primary way to comfort baby - if he appears hungry shortly after a feed and weight gain is good, consider offering a clean finger or pacifier (Sears)  If your baby is taking above the guidelines on the tin per 24 hours, contact your health care provider for advice.

The risks increase again with the introduction of solids - which may account for at least some of the 27% of breastfed infants who has diminished appetite regulation. Mums tend to spoon feed purees much faster than a baby could feed themselves (ie baby led weaning) and again, this gives the system little chance to recognise satiation and encourages over-eating.  As with bottles, mums often employ all sorts of tactics to encourage their child to consume more - from distracting with a toy whilst they shovel it in, to playing aeroplanes.

Can a bottlefeeding mum do anything to reduce the risks?

• An average bottle feed should take approximately ten to twenty minutes. Regularly pausing to slow the feed down and mimic a breastfed pattern, can help baby recognise sated cues earlier. It also prevents guzzling!
• Hold baby regularly when not feeding, to prevent baby asking for food in order to be held. 
• Non nutritive sucking (ie comfort sucking) is important to babies. If not breasfeeding, consider offering a finger/thumb or pacifier between feeds, so baby doesn't have to feed to meet this need. 
• Watch baby closely for his cues. If he turns, twists or pushes the teat out with his tongue - he's finished. He may need winding and will perhaps then take more, or he may repeat his behaviour to indicate he is satiated. 
• Some sources suggest that mums may confuse signs of overfeeding with an intolerance to a particular breastmilk substitute, and may try swapping brands to reduce symptoms. Watching your baby closely and observing for any of the following behaviours can help to reduce the risks of overfeeding.

 Is baby getting too much formula?

Signs that your baby may be consuming too much at each feeding are:

• a lot of spitting up or profuse vomiting immediately after the feeding  
• colicky abdominal pain (baby draws his legs up onto a tense abdomen) immediately after feeding  
• excessive weight gain

 If these signs of overfeeding occur, offer smaller-volume feedings more frequently, burp baby once or twice during the feeding, and occasionally offer a bottle of water instead of formula.  (Sears)