Evid Based Nurs 13:27-28 doi:10.1136/ebn1011
  • Qualitative
  • Systematic review

Mothers bottle feeding their babies feel negative emotions such as guilt and worry, and receive little information about bottle feeding

  1. Elizabeth Moore
  1. Elizabeth Moore
    Vanderbilt University School of Nursing, 345 Frist Hall, 21st Avenue South, Nashville, TN 37240, USA; elizabeth. moore{at}

Commentary on: [Abstract/FREE Full text]

Recent cultural changes, such as maternal employment outside the home, have had a negative impact on breast feeding. This systematic review examines the emotions and barriers that women encounter when attempting to formula feed their infants. The reviewers contend that whereas breastfeeding mothers receive much guidance and support, the needs of bottle-feeding mothers are largely neglected.

Twelve electronic databases were searched for research articles relating to mothers’ experiences of formula feeding. The review was restricted to English-language publications from developed countries. Six qualitative studies and 17 quantitative studies were evaluated. One reviewer extracted data and assessed the methodological quality of each study included in the review. This reviewer’s conclusions were verified by one of the two co-reviewers. Results of the studies were summarised and combined using textual narrative and thematic analysis.

The results of the six qualitative studies indicated that women who formula fed their infants experienced many negative emotions. They felt anger regarding excessive pressure to breast feed, a sense of guilt, failure and shame, worry about the effect of formula on their infant’s health and confusion about how to prepare infant formula properly. Women also reported lack of information from healthcare providers about the frequency of feedings and the correct amount of formula to give their infant per feeding.

The reviewers suggest that this lack of information about correct bottle-feeding practices may contribute to overfeeding and subsequent child obesity.

Usually two reviewers independently assess studies for inclusion in a systematic review and the methodological quality of each included study.1 It was unclear from this research report whether two of the reviewers independently carried out these procedures. The methodological quality assessment tool used in this review was a modified version of the Clinical Appraisal Skills Program tool.2 This tool, designed to evaluate qualitative research studies, was used to evaluate all the studies included in this review. However, standard techniques to evaluate the trustworthiness of qualitative data, such as credibility, transferability, dependability and confirmability,3 were not included in their quality assessment. It might have been more appropriate to use separate tools to evaluate the qualitative and quantitative studies.

Five of the 23 studies included only mothers who intended to bottle feed. Eighteen studies included women who intended to breast feed or to combine breast feeding and bottle feeding, but almost all were bottle feeding at the time the studies were conducted. Women who were planning only to bottle feed may have had very different emotions from women who intended primarily to breast feed prenatally but started supplementing with infant formula because of problems with breast feeding or workrelated issues.

Women may choose to bottle feed because they are given emotionally laden misinformation about breast feeding by relatives and friends, such as that breast feeding causes cracked, bleeding nipples. Alternatively, they may elect to bottle feed because of the perceived barriers to breast feeding in their environment. Women may choose to discontinue breast feeding because of unanticipated problems such as a perceived inadequate milk supply. Nurses need to explore women’s reasons for electing to bottle feed before offering infant formula, because many of these issues can be resolved by nursing interventions. If it appears that the best interests of the mother and infant will be served by bottle feeding, then clear, unbiased information needs to be provided to mothers on correct preparation of infant formula, frequency and amount of feedings. Sometimes it is easier for healthcare providers to accept a mother’s reasons for bottle feeding without exploring these issues in depth. This is the only caution that this reader would apply to the recommendations in the article.

The reviewers suggest that enough information needs to be provided to bottle-feeding mothers for them to feed their infants safely. They also suggest that healthcare providers are sometimes reluctant to provide this information because they feel that it will undermine any attempts at breast feeding. Controversy still exists about this issue, which merits further investigation.

It would be helpful if subsequent reviews on this topic focused on women who intend to bottle feed exclusively or partially and the amount of information that they receive about bottle feeding during their postpartum hospital stay. A separate review should be conducted on women who are breast feeding during their hospital stay but develop problems after discharge that necessitate supplementation with infant formula. Where do these women find information on the correct preparation of infant formula, and what can we do to help them resolve their feelings of failure about being unable to exclusively breast feed? These are all avenues for further investigation.


  • Competing interests None.


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