Cracking the Code on Bottle Refusal: Strategies, Myths, and Tools with Susan Howard, IBCLC

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 nursingBecame an educator, support group leader, and IBCLCDeveloped a focus on oral function and bottle refusal through work with tongue-tied infantsNow runs a virtual private practice and teaches live bottle refusal workshopsUnderstanding the Roots of Bottle RefusalSusan explains that bottle refusal is often tied to:Timing: Late introduction or failure to maintain the skillAnatomical or functional issues: Oral tension, tongue/lip tie, breathing or swallowing difficultyBottle and nipple mismatch: Families focus on the container, not the nipple shape or flowFeeding technique: Positioning, pacing, and expectations matterWhen and How to Introduce BottlesSusan recommends:Introducing bottles around 2–3 weeks if breastfeeding is well establishedAvoiding the outdated “wait until 6 weeks” adviceUsing a “maintenance bottle” of ~1 oz every 1–2 daysReframing it as a snack or comfort tool—not a choreTeaching families that it’s about skill-building, not just milk transferStepwise Approach to Bottle RefusalSusan outlines her strategy:Start with an empty nipple to build oral comfortUse cheek support to mimic breastfeeding structureUse bait and switch mid-breastfeeding session for skill transferDesensitize the gag reflex with oral exercises or teether toysReframe milk as a stressor for babies still learning the skillAdd milk drops manually once baby learns to suck the nippleBottle Recommendations and PositioningPreferred 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 ageUse side-lying positioning with horizontal bottle orientationSigns of Preference vs. Feeding DifficultySusan explains how to tell the difference:Babies who push the bottle out or chew may simply not know how to use itA true aversion shows up as visible distress or refusal to engage at allGood history-taking is essential—ask about past bottle use, pacifier acceptance, and oral behaviorsThe Role of Pacifiers and Other CaregiversKey points:Many bottle refusers never took a pacifierPacifier refusal may signal an early oral skill challengeParents often do best as bottle teachers; others can join after skills are developedUse side-by-side bottle handoffs to build confidence with other caregiversWhen to Refer OutLactation professionals should refer when:The case is outside their current skill setThe...

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