What Is Paced Feeding?
Paced feeding was first introduced in the Journal of Human Lactation in 2002.[1] The article was called “Insights in Practice: Bottle Feeding as a Tool to Reinforce Breastfeeding.” Dee Kassing, the author, developed her own method of bottle-feeding for feeding breastfed babies while they were separated from their mothers.
Kassing named her bottle-feeding method the Kassing method, modeled after a similar technique called paced feeding, a therapeutic feeding strategy prescribed by speech-language pathologists for premature infants or other babies with medical conditions who have immature feeding reflexes and cannot easily manage milk or coordinate sucking, swallowing, and breathing. To date, no clinical trial has been done to demonstrate that paced feeding promotes successful breastfeeding.
In brief, the Kassing method includes sitting the baby upright (which research supports) and encouraging the baby to find the nipple by touching it to their cheek and rooting. The nipple should be a round (non-orthodontic) slow flow nipple in a straight bottle (non-angled).[2] According to an article about the Kassing method, “You should control the duration and the amount of milk your baby drinks. Furthermore, you need to stay in control by touching their cheeks and removing the bottle from time to time.[3]”
The Kassing method quickly gained popularity among lactation professionals, for all bottle feeding babies regardless of age, because at that time nipples labeled “slow flow” were in fact very fast, and babies struggled to master the flow. Once they did, they preferred the fast flow from bottle feeding, which commonly resulted in breastfeeding refusal. However, the Kassing method was developed 19 years ago and was based on experiences with bottle feeding equipment available at the time, during a period when bottle feeding and nipple flow research was scant.
Paced feeding has its limitations however. It is highly parent controlled and requires them to stop and even unlatch a baby from the bottle intermittently. As a result, the baby cannot learn the very important skill of feeding when hungry and stopping when full if feeding is constantly interrupted or is limited by the parent. It can lead to infant and parent frustration and may do nothing in the end to promote continued breastfeeding.
Instead of paced feeding, the AAP and global feeding organizations recommend a different method of feeding called responsive feeding, which is vastly different from paced feeding. Responsive feeding is also done in the upright position but instead of the parent being “in control” of the feeding, the bottle is offered to the baby in response to signs of hunger and stopped when signs of satisfaction occur. It is a more intuitive method of bottle feeding and allows the baby to regulate their own intake rather than having to be interrupted multiple times during a feed.
The following are commonly cited reasons why paced feeding is promoted and what current research supports:
Note to mobile users: The following table is best viewed in landscape or horizontal view.
Reasons Cited for Promoting Paced Feeding [4] | Current Research |
Requires babies to expend effort and use their oral anatomy in ways very similar to breastfeeding | The majority of studies show that bottle feeding and breastfeeding babies use their oral anatomy to obtain milk in a similar fashion.[5,6] |
Provides frequent pauses that are “consistent with a breastfed rhythm…mimic[king] the breastfeeding mother’s let-down patterns.” | Term, healthy babies who use the correct nipple flow and feed in an upright position have the ability to coordinate their suck–swallow–breathe pattern, while pausing as needed. Changing from high flow nipples to slow flow nipples can change the suck-to-swallow ratio from 1:1 to 4:1.[7] Stopping an actively feeding baby and forcing them to pause or unlatch mid feed does not recreate natural breastfeeding patterns, as breastfed babies typically don’t unlatch, but simply slow the flow of milk by pausing on their own when they need to. |
Reduces the risk of nipple confusion. | There is no substantial evidence for nipple confusion.[8] Most breastfed babies in the world are in fact combo fed and don’t develop confusion because they are exposed to artificial nipples.[9] Even the WHO 2017 breastfeeding guidelines failed to find sufficient evidence that artificial nipples and bottles interferes with continued breastfeeding leading them to abandon the recommendation to avoid them.[10] |
Reduces bottle preference or flow preference due to the baby having to work harder | Nipple flow rates have changed significantly over the last few decades and slower flow nipples that are now widely available can help an infant regulate this intake without having to be “paced” or interrupted mid-feed.[11] Babies should not have to “work hard” to bottle feed. Feeding experiences should be a comfortable and positive interaction. |
Reduces risk of overeating | There are evidence based ways of reducing the risk of overeating, like responsive feeding strategies, which is recommended by the AAP.[12] Using a nipple with an appropriate flow rate and following babies’ cues allows them to take the amount of milk they need to grow at a healthy rate. |
Supports breastfeeding. | There are no clinical trials that show babies who are pace fed are more successful at breastfeeding than babies who are not. |
Reduces gas and reflux. | Again, there are no clinical trials to support this claim. Correct nipple flow and bottle venting may reduce air swallowing better than paced feeding. |
Facilitates healthy eating patterns by slowing down the feeding. | Paced feeding does not allow a baby to learn self regulation, because the parent intermittently removes the bottle nipple, or stops the flow of milk, while the baby is still actively feeding. Modern nipples are designed to function similarly to the breast and require a baby to actively suck at the bottle to continue dispensing liquid. |
Table 1: Kassing method or paced bottle feeding for breastfed infants versus more current methods of bottle feeding
None of the claims regarding the Kassing method or paced feeding have been proven with clinical studies, with the exception of upright positioning.
Significant advancements have been made in the bottle feeding arena since the Kassing method was developed. With currently available slow flow nipples, healthy, full term babies should not require paced feeding as they did almost two decades ago, as long as a parent is using responsive feeding methods.
While choosing the right flow and the right nipple shape are important to delivering milk at the right speed, responding to their cues of satisfaction allows babies to practice self-regulating their milk intake; an important skill that may reduce overeating and the risk of childhood and adult obesity.
Pacing Strategy for Premature and Medically Vulnerable Infants
Pacing strategies are appropriately applied to premature and medically vulnerable infants who have immature reflexes and whose breathing can be compromised by failure to adequately pause sucking and swallowing to breathe.
What do speech language pathologists say about paced feeding in healthy term babies as a method to promote breastfeeding?
“Paced feeding is very misunderstood. The purpose of pace feeding is to support an immature sucking pattern, not to slow babies down. Even if paced feeding is used initially for high risk [medically vulnerable] babies, the goal is to work on developing sucking skills so pacing is no longer necessary.
—Tara Garhart MS CCC-SLP
“As an SLP, external pacing [or paced feeding] is a therapeutic bottle feeding strategy, so in general, pacing should not be required in a healthy term infant. Pacing is used to compensate for an immature or abnormal suck-swallow-breathe pattern to allow oral feedings…Imposing pacing can disrupt the natural feeding rhythm of a baby and cause harm when overused. Babies who are ‘good’ feeders—meaning they have a normal, rhythmic suck/burst cycle—do not need pacing. It has been our experience that once a baby has mastered bottle feeding, it is no longer necessary for the parent to impose pacing.”
—Kathleen Ferguson, CCC-SLP, NDT(neurodevelopmental therapy)
Take Home Points
While paced feeding may be appropriate for premature and medically vulnerable infants who do not have all the reflexes necessary for coordinated sucking, swallowing, and breathing, applying it to full term babies may add to your and your baby’s frustration without providing any benefits. Responsive feeding is not only a more common-sense method of feeding, but also one that can teach your baby healthy eating habits by giving them the ability to regulate their intake in response to internal signals of hunger and satisfaction.
To learn more about this topic, read the Fed Is Best book available on paperback, e-book, and audiobook.
References
- Kassing D. Bottle-feeding as a tool to reinforce breastfeeding. J Hum Lact. 2002 Feb;18(1):56–60. doi: 10.1177/089033440201800110.
- “Do You Know the Kassing Method?,” You are Mom, December 15, 2017, https://youaremom.com/babies/do-you-know-the-kassing-method/.
- “The Kassing Method: How to Bottle Feed Without Risking Your Lactation,” Step To Health (blog), September 10, 2018, https://steptohealth.com/the-kassing-method-how-to-bottle-feed-without-risking-your-lactation/.
- Dee Kassing, “Bottle-Feeding as a Tool to Reinforce Breastfeeding,” Journal of Human Lactation 18, no. 1 (February 2002): 56–60, https://doi.org/10.1177/089033440201800110.
- Judith Kotowski et al., “Bottle-Feeding an Infant Feeding Modality: An Integrative Literature Review,” Maternal & Child Nutrition 16, no. 2 (2020): e12939, https://doi.org/10.1111/mcn.12939.
- Moral, A., Bolibar, I., Seguranyes, G. et al. Mechanics of sucking: comparison between bottle feeding and breastfeeding. BMC Pediatr 10, 6 (2010). https://doi.org/10.1186/1471-2431-10-6
- Lagarde MLJ, van Alfen N, de Groot SAF, Geurts ACH, van den Engel-Hoek L. Adaptive capacity of 2- to 5-month-old infants to the flow, shape, and flexibility of different teats during bottle feeding: a cross-sectional study [published correction appears in BMC Pediatr. 2020 Jan 30;20(1):44]. BMC Pediatr. 2019;19(1):477. Published 2019 Dec 5. doi:10.1186/s12887-019-1859-y
- E. Zimmerman and K. Thompson, “Clarifying Nipple Confusion,” Journal of Perinatology: Official Journal of the California Perinatal Association 35, no. 11 (November 2015): 895–99, https://doi.org/10.1038/jp.2015.83.
- “WHO | Infant and Young Child Feeding Data by Country,” accessed February 17, 2021, https://www.who.int/nutrition/databases/infantfeeding/countries/en/.
- “WHO | Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services,” WHO, accessed April 11, 2019, http://www.who.int/nutrition/publications/guidelines/breastfeeding-facilities-maternity-newborn/en/.
- Lagarde MLJ, van Alfen N, de Groot SAF, Geurts ACH, van den Engel-Hoek L. Adaptive capacity of 2- to 5-month-old infants to the flow, shape, and flexibility of different teats during bottle feeding: a cross-sectional study [published correction appears in BMC Pediatr. 2020 Jan 30;20(1):44]. BMC Pediatr. 2019;19(1):477. Published 2019 Dec 5. doi:10.1186/s12887-019-1859-y
- “Is Your Baby Hungry or Full? Responsive Feeding Explained,” HealthyChildren.org, accessed August 4, 2021, https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Is-Your-Baby-Hungry-or-Full-Responsive-Feeding-Explained.aspx