In this episode of Behind the Latch, Margaret Salty interviews Susan Howard, IBCLC, about the complex and often frustrating issue of bottle refusal in breastfed infants. Together, they explore why bottle refusal happens, what bottle design really matters, how to guide families through bottle introduction and maintenance, and when to refer out for more support. Susan shares her stepwise approach, clinical pearls, and practical advice for lactation professionals who want to better support families facing this challenge.

Susan’s Path to Becoming the “Bottle Whisperer”

Susan shares her journey into lactation:

• Started in public health and labor & delivery nursing
• Became an educator, support group leader, and IBCLC
• Developed a focus on oral function and bottle refusal through work with tongue-tied infants
• Now runs a virtual private practice and teaches live bottle refusal workshops

Understanding the Roots of Bottle Refusal

Susan explains that bottle refusal is often tied to:

• Timing: Late introduction or failure to maintain the skill
• Anatomical or functional issues: Oral tension, tongue/lip tie, breathing or swallowing difficulty
• Bottle and nipple mismatch: Families focus on the container, not the nipple shape or flow
• Feeding technique: Positioning, pacing, and expectations matter

When and How to Introduce Bottles

Susan recommends:

• Introducing bottles around 2–3 weeks if breastfeeding is well established
• Avoiding the outdated “wait until 6 weeks” advice
• Using a “maintenance bottle” of ~1 oz every 1–2 days
• Reframing it as a snack or comfort tool—not a chore
• Teaching families that it’s about skill-building, not just milk transfer

Stepwise Approach to Bottle Refusal

Susan outlines her strategy:

• Start with an empty nipple to build oral comfort
• Use cheek support to mimic breastfeeding structure
• Use bait and switch mid-breastfeeding session for skill transfer
• Desensitize the gag reflex with oral exercises or teether toys
• Reframe milk as a stressor for babies still learning the skill
• Add milk drops manually once baby learns to suck the nipple

Bottle Recommendations and Positioning

Preferred features:

• Triangle-shaped, shoulderless nipples (Pigeon, Lansinoh, etc.)
• Avoid short, stubby nipples (e.g., Comotomo, Avent)
• Focus on oral cavity growth and matching shape to baby’s age
• Use side-lying positioning with horizontal bottle orientation

Signs of Preference vs. Feeding Difficulty

Susan explains how to tell the difference:

• Babies who push the bottle out or chew may simply not know how to use it
• A true aversion shows up as visible distress or refusal to engage at all
• Good history-taking is essential—ask about past bottle use, pacifier acceptance, and oral behaviors

The Role of Pacifiers and Other Caregivers

Key points:

• Many bottle refusers never took a pacifier
• Pacifier refusal may signal an early oral skill challenge
• Parents often do best as bottle teachers; others can join after skills are developed
• Use side-by-side bottle handoffs to build confidence with other caregivers

When to Refer Out

Lactation professionals should refer when:

• The case is outside their current skill set
• The infant may have swallowing or coordination issues
• Additional evaluation is needed (e.g., ENT, SLP, OT, CST, PT)
• It’s important to preserve milk supply while working on bottle skills
• Referrals should be breastfeeding-aligned and collaborative

Advice for Aspiring IBCLCs

Susan offers guidance:

• This is a profession, not a hobby—know your worth and set boundaries
• Never stop learning: invest in continuing education and seek mentorship
• It's okay not to know everything—build a trusted referral network
• You'll never be bored in this field, and there’s always more to discover

Guest Info:

Susan Howard, IBCLC, is a virtual lactation consultant specializing in bottle refusal, oral function, and return-to-work support. She also teaches live workshops on bottle refusal several times a year.

🌐 Website: susanhowardibclc.com

📸 Instagram: @susanhowardibclc

Resources Mentioned in This Episode:

📌 Supporting Sucking Skills in Breastfeeding Infants – A foundational text for understanding infant feeding complexity

📌 Pigeon and Lansinoh Bottles – Triangle-shaped, shoulderless nipples

📌 Mombella Mushroom Teether – For oral desensitization

📌 Susan’s Bottle Refusal Workshop – Available several times a year live (not recorded)

Connect with Me:

Have questions or suggestions for future episodes? Reach out!

📧 Email: [email protected]

📸 Instagram: @margaretsalty

📘 Facebook: Margaret Salty’s IBCLC Community

Credits:

🎙 Hosted by: Margaret Salty

🎧 Guest: Susan Howard, IBCLC

🎵 Music by: The Magnifiers, My Time Traveling Machine

Hashtags & Keywords:

#BehindTheLatch #BottleRefusal #BreastfeedingSupport #LactationConsultant #InfantFeeding #PacedBottleFeeding #OralFunction #LactationEducation #FeedingSkills

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