Unlocking Cue-Based Feeding with Katia Lourenço, IBCLC & Speech and Audiologist

Bottle feeding for the first time can feel quite intimidating. Standing in an aisle looking at the wall of dozens of bottles before you with all the Google searches you’ve done the night before - words like “volume-based”, “cue-based”, “flow rate”, “teat feel” all bouncing around in your mind. What is the right thing for you and your baby?

We know that it's important to try emulate the baby's experience on the bottle as closely to their experience on the breast as possible. Cue-based feeding is best practice in order to facilitate this transition seamlessly and safely.

Transitioning a baby from breast to bottle or visa versa can involve many variables that can become overwhelming for parents. Fundamentally, what it comes down to, is how can we make our baby’s experience the closest thing to the feel of the breast and the rate of flow of the breast. The closer the baby’s experience is to what they already know for mom’s who are going
back to work, or what they’re about to learn about for those in the NICU. This ensures less room for confusion or changes in feeding behaviors.

Whilst on the breast, baby’s will suck to extract the milk at a rate that they are comfortable managing, they will stop sucking for a few seconds to swallow and ‘take a break’ before starting the suck to again. This is called a ‘Suck, Swallow, Breathe’ pattern which is the baby’s natural way of feeding. No human being can swallow and breathe at the same time, nor can they suck and swallow at the same time. These things need to happen in succession. If we are to break it
down to the basics... the baby will use their orofacial musculature to suck and extract milk from their mother’s breast at a rate that they can manage. Once they’ve had a few sucks and have collected the milk in their mouth, they will then stop sucking in order to swallow that collected
milk. This break in sucking can last for a few seconds, and if you watch closely, you can see them swallowing followed by the sound of a few of their tiny breaths exhaled and inhaled from their nostrils which are closely but gently pressed against your breast. When they’ve had
enough time to ‘catch their breath’, back at it they go again - sucking away! And so the cycle continues..

So what happens when you give them a commercially bought bottle with a flow that is triple or quadruple what they are used to on the breast? Although advertised as ‘slow flow’, most commercially bought bottles have a significantly faster flow than that of the mothers breast. This leaves the baby trying to stop the constant flow of large volumes of milk in order to gulp it down
and somehow try to catch their breath in this time too. This led to a few problems for parents either trying to wean their baby from the bottle to the breast or from the breast to the bottle. Baby’s run the risk of becoming accustomed to this ‘guzzling’ method of feeding and consequently, not wanting to know anything about calmer and slower experience at the breast, or alternatively if they were used to the breast, were completely overwhelmed by this tsunami of milk coming their way. Baffled by these issues, the concept of cue-based feeding was introduced.

Cue-based feeding is an approach to bottle feeding that, much like the breast, allows the baby to control their experience of the feed. Rather than the baby furiously trying to manage a fast flow of milk that needs to be gulped down, they can engage their orofacial musculature to suck out milk at a rate that is comfortable and matched to the same flow of their mothers breast.

Cue-based feeding encourages active engagement from the parent or caregiver giving the bottle to the baby as it falls on them to observe the baby’s behaviours and what they need throughout the feed. But how will you know if they need a break to swallow or breath, how will you know if they want more?

Signs that they are ready to start the ‘sucking’ phase:

• Rooting reflex towards bottle teat
• Sucking at hands
• Moving head around trying to locate food source
• Continuous sucking at the bottle
• Normal breathing rate with teat in the mouth
• Relaxed baby, limbs engaged in movement or relaxed and still towards feeder

Signs that they want to stop, and take the time to swallow and breath:

• Head pulling back or moving sidewards, away from the teat.
• Hands or limbs pushing against the bottle
• Sucking has halted for a while
• Fussing/crying with the teat in the mouth
• Tongue thrusts teat out of the mouth
• Tensed body language
• Hyperextension of the back

Very similar to cue based feeding, paced feeding adopted these principles and placed the control in the feeder’s hands to feed in a specific position using angles of the bottle teat to their advantage to attempt to control the flow.

There is a significantly higher chance of success at mixed feeding (both breast and bottle) with cue-based feeding and importantly, the correct bottle to help facilitate this process. Knowing the exact rate a bottle will flow at or introducing cue-based feeding is the best way to ensure safe, effective and most importantly, bottle feeding behaviors that support and prioritize breastfeeding.