Kathryn Stewart, CCC-SLP, C/NDT
Most full-term infants are born with innate reflexes to survive outside of the womb. The three most important reflexes for early feeding are the rooting reflex to locate the source of nourishment, the suck-swallow reflex to transfer breastmilk or formula, and the gag reflex to protect their airway. Although these automatic, reflexive patterns support the infant’s survival early on in life, they begin to integrate into volitional motor patterns around 3 months old. Most of these automatic reflexes are fully integrated between 4-6 months old. This transition from automatic to voluntary happens over time and provides the building blocks for more advanced feeding skills such as eating solids and cup drinking.
When the transition from automatic to voluntary eating is interrupted by necessary medical interventions, such as tube feeds, it is common for infants to lose their suck-swallow pattern as their reflexes begin to be integrated. Infants born premature, or who require medical intervention early after birth, may also lose their suck-swallow pattern if eating isn’t safe for them in the first few months of life. Infants (like all of us) need motivation to continue learning and practicing a skill. This is aligned with the concept of motor learning – the ability to learn and execute a motor skill as a result of experience, practice and the environment.
There are many things can happen during this transitional phase of eating, or early in the infant’s life, that disrupts their ability to integrate their suck-swallow reflex and make the decision to continue eating. For example, if there is no reason to practice the skill of bottle or breast feeding, then it doesn’t make sense to the infant to continue practicing eating. This is common when infants are tube fed: they don’t have a reason to eat! If the environment is not safe, trusting, or consistent, then infants often won’t practice eating. If they experience pain, discomfort, or have an unsafe swallow, they will not practice eating.
When this happens, practitioners often tell families to focus on solids, or a cup, because the child “cannot learn to suck from a bottle again,” but this has not been our experience. In fact – quite the opposite! Infants can still learn to drink from a bottle or breast, even well after their suck-swallow reflex is integrated, and we often recommend re-introducing the bottle to infants under 12 months during weaning. Infants under 12 months are dependent on formula or breastmilk to meet their nutrition and hydration needs, and the most efficient way for an infant to get that nutrition, is typically from a bottle or breast. A bottle is also the most developmentally appropriate drinking vessel for infants, especially if they need to wake at night to feed. Learning to suck and swallow also helps provide the foundational building blocks for more advanced eating skills later in life.
Our philosophy around re-learning the bottle stems from the motor learning principles described above. During weaning, we strive to create a trusting environment by having families follow the Division of Responsibility (DOR), ensure a safe swallow has been established and all medical issues are resolved/treated (such as reflux), and create motivation through hunger to practice the skill of bottle drinking. When all of these are aligned (trusting environment, physical comfort, hunger) and are paired with opportunities to practice the bottle, we see the suck-swallow motor pattern begin to re-emerge. This motor pattern is akin to all the other motor skills your child will learn – crawling, walking, running, riding a bike. It takes a trusting environment, motivation, and repeated practice to learn a new skill.