Avoidance of bottles during the establishment of breast feeds in preterm infants

The Effect of Supplemental Feeding Tube Device on Time to Transition to Exclusive Breastfeeding and Discharge: A Randomized Controlled Trial with Preterm Infants

Aim: This study investigated the effect of supplemental feeding tube device (SFTD) method on time to transition to exclusive breastfeeding and discharge time in preterm infants. Methods: This randomized controlled trial was conducted in the neonatal intensive care unit of a public hospital in Turkey (Clinical Trial Number: NCT05815706). The sample consisted of 65 preterm infants randomized into a control (n = 32) and an experimental (n = 33) group. The experimental group participants were SFTD-fed until they switched to exclusive breastfeeding. The control group participants were fed according to the routine procedure. Data were collected using a questionnaire, a Preterm Infant Monitoring Form, and the LATCH Breastfeeding Assessment Tool. The data were analyzed using numbers, percentage distributions, means, standard deviations, Pearson's chi-square test, and independent samples t-test. The study was approved by an Ethics Committee. Permission was obtained from the hospital. Informed consent was obtained from all parents. Results: The experimental group (123.64 ± 63.25 hours) demonstrated an earlier transition to exclusive breastfeeding compared with the control group (187.50 ± 95.30 hours) (p < 0.05). The experimental group (361.45 ± 110.46 hours) had significantly shorter hospital stays than the control group (479.25 ± 163.17 hours). The experimental group (35.33 ± 1.14 weeks) had a significantly younger gestational age at discharge than the control group (35.97 ± 1.03 weeks). Conclusion: The SFTD is an alternate supportive feeding method that helps preterm infants switch to exclusive breastfeeding sooner, have shorter hospital stays, and have a younger gestational age at discharge than their bottle-fed counterparts.

Avoidance of bottles during the establishment of breastfeeds in preterm infants

BACKGROUND

Preterm infants often start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women with preterm infants may not always be in hospital to breastfeed their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breastfeeds is detrimental to breastfeeding success is a topic of ongoing debate.

OBJECTIVES

To identify the effects of avoidance of bottle feeds during establishment of breastfeeding on the likelihood of successful breastfeeding, and to assess the safety of alternatives to bottle feeds.

SEARCH METHODS

A new search strategy was developed for this update. Searches were conducted without date or language limits in September 2021 in: MEDLINE, CENTRAL, and CINAHL.  We also searched the ISRCTN trial registry and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.  SELECTION CRITERIA: We included RCTs and quasi-RCTs comparing avoidance of bottles with use of bottles for preterm infants where their mothers planned to breastfeed.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. We used the GRADE approach to assess the certainty of evidence. Outcomes included full breastfeeding and any breastfeeding on discharge home and at three and six months after discharge, as well as length of hospital stay and episodes of infant infection. We synthesised data using risk ratios (RR), risk differences (RD) and mean differences (MD), with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included seven trials with 1152 preterm infants in this updated review. There are three studies awaiting classification. Five included studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breastfeeds were needed. We included the novel teat study in this review as the teat was designed to closely mimic the sucking action of breastfeeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff or parents (or both); the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Avoiding bottles may increase the extent of full breastfeeding on discharge home (RR 1.47, 95% CI 1.19 to 1.80; 6 studies, 1074 infants; low-certainty evidence), and probably increases any breastfeeding (full and partial combined) on discharge (RR 1.11, 95% CI 1.06 to 1.16; studies, 1138 infants; moderate-certainty evidence). Avoiding bottles probably increases the occurrence of full breastfeeding three months after discharge (RR 1.56, 95% CI 1.37 to 1.78; 4 studies, 986 infants; moderate-certainty evidence), and may also increase full breastfeeding six months after discharge (RR 1.64, 95% CI 1.14 to 2.36; 3 studies, 887 infants; low-certainty evidence). Avoiding bottles may increase the occurrence of any breastfeeding (full and partial combined) three months after discharge (RR 1.31, 95% CI 1.01 to 1.71; 5 studies, 1063 infants; low-certainty evidence), and six months after discharge (RR 1.25, 95% CI 1.10 to 1.41; 3 studies, 886 infants; low-certainty evidence). The effects on breastfeeding outcomes were evident at all time points for the tube alone strategy and for all except any breastfeeding three months after discharge for cup feeding, but were not present for the novel teat. There were no other benefits or harms including for length of hospital stay (MD 2.25 days, 95% CI -3.36 to 7.86; 4 studies, 1004 infants; low-certainty evidence) or episodes of infection per infant (RR 0.70, 95% CI 0.35 to 1.42; 3 studies, 500 infants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Avoiding the use of bottles when preterm infants need supplementary feeds probably increases the extent of any breastfeeding at discharge, and may improve any and full breastfeeding (exclusive) up to six months postdischarge. Most of the evidence demonstrating benefit was for cup feeding. Only one study used a tube feeding strategy. We are uncertain whether a tube alone approach to supplementing breastfeeds improves breastfeeding outcomes; further studies of high certainty are needed to determine this.

Predicting risk of early discontinuation of exclusive breastfeeding at a Brazilian referral hospital for high-risk neonates and infants: a decision-tree analysis

Background

Determinants at several levels may affect breastfeeding practices. Besides the known historical, socio-economic, cultural, and individual factors, other components also pose major challenges to breastfeeding. Predicting existing patterns and identifying modifiable components are important for achieving optimal results as early as possible, especially in the most vulnerable population. The goal of this study was building a tree-based analysis to determine the variables that can predict the pattern of breastfeeding at hospital discharge and at 3 and 6 months of age in a referral center for high-risk infants.

Methods

This prospective, longitudinal study included 1003 infants and was conducted at a high-risk public hospital in the following three phases: hospital admission, first visit after discharge, and monthly telephone interview until the sixth month of the infant’s life. Independent variables were sorted into four groups: factors related to the newborn infant, mother, health service, and breastfeeding. The outcome was breastfeeding as per the categories established by the World Health Organization (WHO). For this study, we performed an exploratory analysis at hospital discharge and at 3 and at 6 months of age in two stages, as follows: (i) determining the frequencies of baseline characteristics stratified by breastfeeding indicators in the three mentioned periods and (ii) decision-tree analysis.

Results

The prevalence of exclusive breastfeeding (EBF) was 65.2% at hospital discharge, 51% at 3 months, and 20.6% at 6 months. At hospital discharge and the sixth month, the length of hospital stay was the most important predictor of feeding practices, also relevant at the third month. Besides the mother’s and child’s characteristics (multiple births, maternal age, and parity), the social context, work, feeding practice during hospitalization, and hospital practices and policies on breastfeeding influenced the breastfeeding rates.

Conclusions

The combination algorithm of decision trees (a machine learning technique) provides a better understanding of the risk predictors of breastfeeding cessation in a setting with a large variability in expositions. Decision trees may provide a basis for recommendations aimed at this high-risk population, within the Brazilian context, in light of the hospital stay at a neonatal unit and period of continuous feeding practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-020-00349-x.

Feeding Neonates by Cup: A Systematic Review of the Literature

Objective WHO and UNICEF recommend cup feeding for neonates unable to breastfeed in low-resource settings. In developed countries, cup feeding in lieu of bottle feeding in the neonatal period is hypothesized to improve breastfeeding outcomes for those initially unable to breastfeed. Our aim was to synthesize the entire body of evidence on cup feeding. Methods We searched domestic and international databases for original research. Our search criteria required original data on cup feeding in neonates published in English between January 1990 and December 2014. Results We identified 28 original research papers. Ten were randomized clinical trials, 7 non-randomized intervention studies, and 11 observational studies; 11 were conducted in developing country. Outcomes evaluated included physiologic stability, safety, intake, duration, spillage, weight gain, any and exclusive breastfeeding, length of hospital stay, compliance, and acceptability. Cup feeding appears to be safe though intake may be less and spillage greater relative to bottle or tube feeding. Overall, slightly higher proportions of cup fed versus bottle fed infants report any breastfeeding; a greater proportion of cup fed infants reported exclusive breastfeeding at discharge and beyond. Cup feeding increases breastfeeding in subgroups (e.g. those who intend to breastfeed or women who had a Caesarean section). Compliance and acceptability is problematic in certain settings. Conclusions Further research on long-term breastfeeding outcomes and in low-resource settings would be helpful. Research data on high risk infants (e.g. those with cleft palates) would be informative. Innovative cup feeding approaches to minimize spillage, optimize compliance, and increase breastfeeding feeding are needed.

Breastfeeding education and support for women with twins or higher order multiples

BACKGROUND

There are rising rates of multiple births worldwide with associated higher rates of complications and more hospital care, often due to prematurity. While there is strong evidence about the risks of not breastfeeding, rates of breastfeeding in women who have given birth to more than one infant are lower than with singleton births. Breastfeeding more than one infant can be more challenging because of difficulties associated with the birth or prematurity. The extra demands on the mother of frequent suckling, coordinating the needs of more than one infant or admission to the neonatal intensive care unit can lead to delayed initiation or early cessation. Additional options such as breast milk expression, the use of donor milk or different methods of supplementary feeding may be considered. Support and education about breastfeeding has been found to improve the duration of any breastfeeding for healthy term infants and their mothers, however evidence is lacking about interventions that are effective to support women with twins or higher order multiples.

OBJECTIVES

To assess effectiveness of breastfeeding education and support for women with twins or higher order multiples.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), ClinicalTrials.gov (30 June 2016), the WHO International Clinical Trials Registry Platform (ICTRP) (1 July 2016), the excluded studies list from the equivalent Cochrane review of singletons, and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing extra education or support for women with twins or higher order multiples were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We planned to assess the quality of evidence using the GRADE approach, but were unable to analyse any data.

MAIN RESULTS

We found 10 trials (23 reports) of education and support for breastfeeding that included women with twins or higher order multiples. The quality of evidence was mixed, and the risk of bias was mostly high or unclear. It is difficult to blind women or staff to group allocation for this intervention, so in all studies there was high risk of performance and high or unclear risk of detection bias. Trials recruited 5787 women (this included 512 women interviewed as part of a cluster randomised trial); of these, data were available from two studies for 42 women with twins or higher order multiples. None of the interventions were specifically designed for women with more than one infant, and the outcomes for multiples were not reported separately for each infant. Due to the scarcity of evidence and the format in which data were reported, a narrative description of the data is presented, no analyses are presented in this review, and we were unable to GRADE the evidence.The two trials with data for women with multiple births compared home nurse visits versus usual care (15 women), and telephone peer counselling versus usual care (27 women). The number of women who initiated breastfeeding was reported (all 15 women in one study, 25 out of 27 women in one study). Stopping any breastfeeding before four to six weeks postpartum, stopping exclusive breastfeeding before four to six weeks postpartum, stopping any breastfeeding before six months postpartum andstopping exclusive breastfeeding before six months postpartum were not explicitly reported, and there were insufficient data to draw any meaningful conclusions from survival data. Stopping breast milk expression before four to six weeks postpartum, andstopping breast milk expression before six months postpartum were not reported. Measures ofmaternal satisfaction were reported in one study of 15 women, but there were insufficient data to draw any conclusions; no other secondary outcomes were reported for women with multiple births in either study. No adverse events were reported.

AUTHORS' CONCLUSIONS

We found no evidence from randomised controlled trials about the effectiveness of breastfeeding education and support for women with twins or higher order multiples, or the most effective way to provide education and support . There was no evidence about the best way to deliver the intervention, the timing of care, or the best person to deliver the care. There is a need for well-designed, adequately powered studies of interventions designed for women with twins or higher order multiples to find out what types of education and support are effective in helping these mothers to breastfeed their babies.

Avoidance of bottles during the establishment of breast feeds in preterm infants

BACKGROUND

Preterm infants start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women who choose to breast feed their preterm infant are not always able to be in hospital with their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breast feeds is detrimental to breast feeding success is a topic of ongoing debate.

OBJECTIVES

To identify the effects of avoidance of bottle feeds during establishment of breast feeding on the likelihood of successful breast feeding, and to assess the safety of alternatives to bottle feeds.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE via PubMed (1966 to July 2016), Embase (1980 to July 2016) and CINAHL (1982 to July 2016). We also searched databases of clinical trials and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing avoidance of bottles with use of bottles in women who have chosen to breast feed their preterm infant.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. Review authors used standard methods of The Cochrane Collaboration and the Cochrane Neonatal Review Group.

MAIN RESULTS

We included seven trials with 1152 preterm infants. Five studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breast feeds were needed. We included the novel teat study in this review, as the teat was designed to more closely mimic the sucking action of breast feeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff and/or parents; the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Meta-analyses provided evidence of low to moderate quality indicating that avoiding bottles increases the extent of breast feeding on discharge home (full breast feeding typical risk ratio (RR) 1.47, 95% confidence interval (CI) 1.19 to 1.80; any breast feeding RR 1.11, 95% CI 1.06 to 1.16). Limited available evidence for three months and six months post discharge shows that avoiding bottles increases the occurrence of full breast feeding and any breast feeding at discharge and at six months post discharge, and of full (but not any) breast feeding at three months post discharge. This effect was evident at all time points for the tube alone strategy and for all except any breast feeding at three months post discharge for cup feeding. Investigators reported no clear benefit when the novel teat was used. No other benefits or harms were evident, including, in contrast to the previous (2008) review, length of hospital stay.

AUTHORS' CONCLUSIONS

Evidence of low to moderate quality suggests that supplementing breast feeds by cup increases the extent and duration of breast feeding. Current insufficient evidence provides no basis for recommendations for a tube alone approach to supplementing breast feeds.

Avoidance of bottles during the establishment of breast feeds in preterm infants

BACKGROUND

Preterm infants start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women who choose to breast feed their preterm infant are not always able to be in hospital with their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breast feeds is detrimental to breast feeding success is a topic of ongoing debate.

OBJECTIVES

To identify the effects of avoidance of bottle feeds during establishment of breast feeding on the likelihood of successful breast feeding, and to assess the safety of alternatives to bottle feeds.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE via PubMed (1966 to July 2016), Embase (1980 to July 2016) and CINAHL (1982 to July 2016). We also searched databases of clinical trials and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing avoidance of bottles with use of bottles in women who have chosen to breast feed their preterm infant.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. Review authors used standard methods of The Cochrane Collaboration and the Cochrane Neonatal Review Group.

MAIN RESULTS

We included seven trials with 1152 preterm infants. Five studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breast feeds were needed. We included the novel teat study in this review, as the teat was designed to more closely mimic the sucking action of breast feeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff and/or parents; the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Meta-analyses provided evidence of low to moderate quality indicating that avoiding bottles increases the extent of breast feeding on discharge home (full breast feeding typical risk ratio (RR) 1.47, 95% confidence interval (CI) 1.19 to 1.80; any breast feeding RR 1.11, 95% CI 1.06 to 1.16). Limited available evidence for three months and six months post discharge shows that avoiding bottles increases the occurrence of full breast feeding and any breast feeding at discharge and at six months post discharge, and of full (but not any) breast feeding at three months post discharge. This effect was evident at all time points for the tube alone strategy and for all except any breast feeding at three months post discharge for cup feeding. Investigators reported no clear benefit when the novel teat was used. No other benefits or harms were evident, including, in contrast to the previous (2008) review, length of hospital stay.

AUTHORS' CONCLUSIONS

Evidence of low to moderate quality suggests that supplementing breast feeds by cup increases the extent and duration of breast feeding. Current insufficient evidence provides no basis for recommendations for a tube alone approach to supplementing breast feeds.

The effect of feeding with spoon and bottle on the time of switching to full breastfeeding and sucking success in preterm babies

AIM

This research was conducted to determine the effect of the feeding methods of spoonfeed and feeding by bottle on the time of switching to full breastfeeding and sucking success.

MATERIAL AND METHODS

The study was conducted between September 2013 and January 2014 at the primary level of the neonatal intensive care clinics in two hospitals found in the eastern region of Turkey in a comperative and descriptive fashion. The population was composed of preterm babies who received treatment and care in these clinics during the period when the study was conducted and who met the criteria of the investigators. Without selecting the sample group the whole of the population was studied. The study was conducted with 37 preterm babies who were spoonfed and 35 preterm babies who were fed by bottle. The data were collected with "information form introducing preterm baby", "follow-up form for preterm baby" and "LATCH Breastfeeding Assessment Tool". The data were evaluated using percentage distribution, mean, chi-square test, t-test in independent groups, Cronbach alpha coefficient and McNemar analysis. Ethics committee approval was obtained from Atatürk University Faculty of Health Sciences (dated 08.05.2013) and official approvals were obtained from the related hospitals to conduct the study.

RESULTS

A significant difference was found between the mean times of switching to full breastfeeding from the first breast-feeding in preterm babies in the spoonfed group and bottle fed group in favour of the spoodfed group (p<0.05). No significant difference was found between the two groups in terms of starting breastfeeding, switching to full breastfeeding, the mean weights at discharge and the mean times of discharge (p>0.05). While no significant difference was found between the groups in terms of mean LATCH scores measured initially (p>0.05), the mean scores in the spoonfed group at the second and final measurement were found to be statistically significantly higher (p<0.05).

CONCLUSIONS

It was found that the preterm babies in whom spoonfeeding was used as a supportive method in addition to breast-feeding switched to full breastfeeding in a shorter time compared to the babies who were fed by bottle and their sucking success was at a better level.

Electromyographic analysis of masseter muscle in newborns during suction in breast, bottle or cup feeding

Background

When breastfeeding is difficult or impossible during the neonatal period, an analysis of muscle activity can help determine the best method for substituting it to promote the child’s development. The aim of this study was to analyze the electrical activity of the masseter muscle using surface electromyography during suction in term newborns by comparing breastfeeding, bottle and cup feeding.

Methods

An observational, cross-sectional analytical study was carried out on healthy, clinically stable term infants, assigned to receive either breast, or bottle or cup feeding. Setting was a Baby Friendly accredited hospital. Muscle activity was analyzed when each infant showed interest in sucking using surface electromyography. Root mean square averages (RMS) recorded in microvolts were transformed into percentages (normalization) of the reference value. The three groups were compared by ANOVA; the “stepwise” method of the multiple linear regression analysis tested the model which best defined the activity of the masseter muscle in the sample at a significance level of 5%.

Results

Participants were 81 full term newborns (27 per group), from 2 to 28 days of life. RMS values were lower for bottle (mean 44.2%, SD 14.1) than breast feeding (mean 58.3%, SD 12.7) (P = 0.003, ANOVA); cup feeding (52.5%, SD 18.2%) was not significantly different (P > 0.05). For every gram of weight increase, RMS increased by 0.010 units.

Conclusions

Masseter activity was significantly higher in breastfed newborns than in bottle-fed newborns, who presented the lowest RMS values. Levels of masseter activity during cup-feeding were between those of breast and bottle feeding, and did not significantly differ from either group. This study in healthy full term neonates endorses cup rather than bottle feeding as a temporary substitute for breastfeeding.

Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations

In the World Health Organization/United Nations Children's Fund document Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care, neonatal care is mentioned as 1 area that would benefit from expansion of the original Ten Steps to Successful Breastfeeding. The different situations faced by preterm and sick infants and their mothers, compared to healthy infants and their mothers, necessitate a specific breastfeeding policy for neonatal intensive care and require that health care professionals have knowledge and skills in lactation and breastfeeding support, including provision of antenatal information, that are specific to neonatal care. Facilitation of early, continuous, and prolonged skin-to-skin contact (kangaroo mother care), early initiation of breastfeeding, and mothers' access to breastfeeding support during the infants' whole hospital stay are important. Mother's own milk or donor milk (when available) is the optimal nutrition. Efforts should be made to minimize parent-infant separation and facilitate parents' unrestricted presence with their infants. The initiation and continuation of breastfeeding should be guided only by infant competence and stability, using a semi-demand feeding regimen during the transition to exclusive breastfeeding. Pacifiers are appropriate during tube-feeding, for pain relief, and for calming infants. Nipple shields can be used for facilitating establishment of breastfeeding, but only after qualified support and attempts at the breast. Alternatives to bottles should be used until breastfeeding is well established. The discharge program should include adequate preparation of parents, information about access to lactation and breastfeeding support, both professional and peer support, and a plan for continued follow-up.

Which method of breastfeeding supplementation is best? The beliefs and practices of paediatricians and nurses

The aims of the present study were to assess the practices of breastfeeding supplementation methods, and to explore the opinions and beliefs of health professionals with regard to breastfeeding supplementation methods and the nipple confusion phenomenon. The study was cross-sectional in design, and participants were recruited from five hospitals in Toronto, Ontario. All of the nurses and attending paediatricians in postpartum floors and level II nurseries were invited to participate in the study. A total of 87 nurses and 16 paediatricians completed the survey questionnaire. Bottle feeding was the most common breastfeeding supplementation method used in the nurseries followed by cup feeding. Only 15.0% of the level II nurses agreed that frequent bottle feeds lead to the nipple confusion phenomenon, compared with 44.4% of the postpartum nurses and 56.2% of the paediatricians. Findings demonstrated considerable variation in the practices and beliefs surrounding supplementation methods. A randomized controlled trial comparing the safety, efficiency and subsequent breastfeeding rates of different breastfeeding supplementation methods is warranted.

Current challenges in pediatric nutrition

In pediatric nutrition the most important overall theme is breastfeeding. While there is no alternative in most mammals--and offspring would die if the mother had no milk or could not feed the newborn--human mothers were offered alternative ways of infant feeding. Today restoring breastfeeding is a major goal for pediatricians, midwifes, and lactation advisers. Feeding the premature baby and adding long chain fatty acids and prebiotics to formula is an area of growing interest. Undernutrition is a special challenge for nutritional care because even in recent years severely undernourished children die of inadequate management with too much volume and too much protein in the initial phase. Much knowledge has been gained about parenteral nutrition for children with gut failure. Even children with very short bowel length at birth have a good prognosis and can often achieve enteral adaptation. New solutions for parenteral nutrition, new materials, and new care concepts have been identified. Problems considered inherent to parenteral nutrition are widely preventable.

Management of the vulnerable baby on the postnatal ward and transitional care unit

Many guidelines for the prevention and management of neonatal hypoglycaemia focus on the sick infant admitted to the intensive care unit and pay scant attention to what is known about normal neonatal physiology. It is questionable whether treatment guidelines for low blood glucose levels for sick infants can be applied to a population of well infants on the postnatal ward, especially if such guidelines interfere with the establishment of breastfeeding, which has well recognised long and short term health benefits for mother and baby. What then of the baby who is at risk of abnormal postnatal adaptation, but is not unwell? Can the complications which occur in such infants, such as hypoglycaemia, be safely managed without resorting to admission to a baby unit? Can such vulnerable infants be safely managed in an environment that promotes mother and baby bonding and facilitates breastfeeding?