Mom can also start bottle feeding at the bare breast, with baby's cheek 
resting on the breast (so baby is in a breastfeeding position). Then 
moms starts wearing a nipple shield, and placing the bottle nipple right 
next to the nipple shield teat. As baby tries to latch onto the bottle, 
take the bottle away and snuggle baby onto the breast. I call this "Bait 
and Switch".

If baby gets frustrated when milk doesn't instantly flow from the nipple 
shield, try pre-filling the teat with expressed milk (a curved 
tip/periodontal syringe tip fits into the holes on the nipple shield). 
Dad or a helper can do this repeatedly as the baby comes on and off the 
breast to give an instant reward. Once baby figures out how to suck so 
that milk comes out of the breast, you can stop putting it in the shield 
with the syringe.

If you have Supporting Sucking Skills in Breastfeeding Infants, the Bait 
and Switch technique photos are in there, and a photo of the Pre-filling 
the shield technique is in Selecting and Using Breastfeeding Tools.

You can also start making the bottle less rewarding. Have the parents 
change the nipple to one the baby doesn't like as much. Slow the flow by 
having the bottle be horizontal and the baby sidelying against mom. 
Don't give any milk from the bottle during the first few seconds of the 
feeding (the fear of air is way over-rated)to mimic the time the baby 
has to wait for the MER. And make sure the baby is "latching" onto the 
bottle, not just having it shoved in the mouth. The way we bottle feed a 
baby should help to sustain/reinforce breastfeeding behaviors (see Dee 
Kassing's article on this in JHL).

Diane Wiessinger says that we can teach tigers to jump through fiery 
hoops by gradually modifying their natural behaviors a tiny step at a 
time. This is the way we get non-bf babies back to the breast as well. 
First we have to remove any obstacles, that has been done here, now it's 
changing the familiar feeding one step at a time until the actual thing 
that's being fed from is the last thing to change.

Catherine Watson Genna, BS, IBCLC  NYC

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