Breastfeeding infants who were extremely low birth weight

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.

The evolution of the science of kangaroo (mother) care (skin-to-skin contact)

In the early 1970s, researchers in Ohio, USA, investigated the effects of "Extra Contact" between mothers and their infants early after birth. The "Extra Contact" consisted of the skin-to-skin holding of the newborn infant on the mother's bare chest as soon as possible after birth. In the mid 1970s, Rey and Martinez in Bogota Colombia started investigating the same care method and they called it "Kangaroo Care" (KC). Infants are held upright, skin-to-skin on the mother's bare chest. KC, also referred to as Kangaroo Mother Care or Skin-to-Skin Contact, has been and continue to be investigated for its effects on a plethora of infant, maternal and family outcomes. Evolution of our understanding of the advantages of KC has dramatically changed the care of infants including at risk infants. This article provides a look at the past and present. It also provides insight on how we can shape the future to provide the optimal care for infants, mothers, and the whole family.

A novel sensor design for accurate measurement of facial somatosensation in pre-term infants

Facial somatosensory feedback is critical for breastfeeding in the first days of life. However, its development has never been investigated in humans. Here we develop a new interface to measure facial somatosensation in newborn infants. The novel system allows to measure neuronal responses to touching the face of the subject by synchronously recording scalp electroencephalography (EEG) and the force applied by the experimenter. This is based on a dedicated force transducer that can be worn on the finger underneath a clinical nitrile glove and linked to a commercial EEG acquisition system. The calibrated device measures the pressure applied by the investigator when tapping the skin concurrently with the resulting brain response. With this system, we were able to demonstrate that taps of 192 mN (mean) reliably elicited facial somatosensory responses in 7 pre-term infants. These responses had a time course similar to those following limbs stimulation, but more lateral topographical distribution consistent with body representations in primary somatosensory areas. The method introduced can therefore be used to reliably measure facial somatosensory responses in vulnerable infants.

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.

When is it safe to initiate breastfeeding for preterm infants?

BACKGROUND

Breast milk is the gold standard of nutrition for preterm infants. Yet, initiation of direct breastfeeding before 32 weeks' postconceptional age (PCA) is not common practice in many neonatal intensive care units (NICUs). Our clinical question was, "In preterm infants, when is it safe to initiate breastfeeding in infants <32 weeks PCA receiving enteral feedings?"

SEARCH STRATEGY

A review of the literature was compiled between February 2013 and January 2015 by using the following databases: CINAHL, Cochrane Systematic Review, Scopus, and PubMed. Articles found were written in English and published after 1985. Key words were utilized during searches and references were hand checked.

RESULTS

Our review revealed that stable preterm infants maintain their physiological status during exposure to the breast as early as 27 to 28 weeks' PCA. Several studies demonstrated infants during breastfeeding compared with bottle-feeding experienced minimal variation in oxygen saturation and heart rate during feeding. Some infants exposed to the breast before 30 weeks' PCA were exclusively breastfeeding (direct breastfeeding and breast milk) at 32.8 weeks' PCA. Skin-to-skin mother-infant contact is crucial to the successful transition to direct breastfeeding.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The transition from enteral feedings to direct, exclusive breastfeeding should involve frequent mother-infant skin-to-skin contact requiring support and guidance from the NICU staff. Future research should involve creating standard protocols within NICUs to facilitate breastfeeding transition and exploring barriers that may prevent the preterm infant from achieving direct, exclusive breastfeeding.

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.

Nursing students' views on promoting successful breastfeeding in Sweden

Promoting breastfeeding is important work for health-care personnel in the Swedish context. This promotion is multifaceted and demands the ongoing development of knowledge and competence among both health-care personnel and patients. The aim of the present study was to describe the nursing students' perspectives on breastfeeding in Sweden. Data were obtained in the form of written reflections from nursing students (n=65) and examined using manifest content analysis. The results show that the factors of importance in promoting successful breastfeeding are information about breastfeeding's benefits, traditions and cultural acceptance of the practice, and by government prohibition of infant formula. We conclude that knowledge about the benefits of breastfeeding needs to be prioritized continuously during education.

Perioral movements and sucking pattern during bottle feeding with a novel, experimental teat are similar to breastfeeding

OBJECTIVE

To measure intraoral pressure and perioral movement in infants during breastfeeding (BF) and feeding with experimental teat (ET). The teat has a wide base, firm shaft and a valve at the base, such that milk flows only when the baby provides a hold pressure.

STUDY DESIGN

Twenty healthy term infants, between 1 and 8 months old, were enrolled in the study. Feeding sessions (BF and ET) were recorded using a digital video camera. During both BF and ET feeding sessions, recordings during feeding were taken of jaw and throat movements (n=20) as well as intraoral pressure (n=18). The efficiency of milk transfer and the angle of the mouth were also measured.

RESULT

There was no significant difference in either the jaw or throat movements between BF and ET. The sucking burst pattern, the efficiency (ml min(-1)), and the angle of the mouth did not differ between both feeding methods. The intraoral negative pressure observed during ET was significantly smaller than that observed during BF.

CONCLUSION

There were no significant differences in perioral movements. Although the value was smaller, a hold pressure was observed during ET. From these results, the novel, ET may decrease BF problems related to bottle use.

Influence of housing conditions from weaning to adulthood on the ventilatory, thermoregulatory, and endocrine responses to hypoxia of adult female rats

Housing conditions affect animal physiology. We previously showed that the hypoxic ventilatory and thermoregulatory responses to hypoxia of adult male rats housed in triads during the juvenile period (postnatal day 21 to adulthood) were significantly reduced compared with animals housed in pairs. Because sex hormones influence development and responsiveness to environmental stressors, this study investigated the impact of housing on the respiratory and thermoregulatory physiology of female rats. Since neonatal stress attenuates the hypoxic ventilatory response (HVR) of female rats at adulthood, experiments were performed both on "control" (undisturbed) animals and rats subjected to neonatal maternal separation (NMS; 3 h/day, postnatal days 3-12). At adulthood, ventilatory activity was measured by whole body plethysmography under normoxic and hypoxic conditions [fraction of inspired oxygen (Fi(O(2))) = 0.12; 20 min]. The ventilatory and body temperature responses to hypoxia of female rats raised in triads were reduced compared with rats housed in pairs. Housing female rats in triads did not affect basal or hypoxic plasma corticosterone levels but did increase levels of estradiol significantly. We conclude that modest changes in housing conditions (pairs vs. triads) from weaning to adulthood does influence basic homeostatic functions such as temperature and respiratory regulation. Triad housing can reverse the manifestations of respiratory instability at adulthood induced by stressful neonatal treatments. This should raise awareness of the benefits of increasing social interactions in clinical settings but also caution researchers of the potential impact of such subtle changes on experimental protocols and interpretation of results.

Influence of juvenile housing conditions on the ventilatory, thermoregulatory, and endocrine responses to hypoxia of adult male rats

“Extreme” housing conditions, such as isolation (single housing) or crowding, are stressful for rats, and their deleterious impact on behavior is well documented. To determine whether more subtle variations in housing can affect animal physiology, the present study tested the hypothesis that the hypoxic ventilatory response (HVR) of adult male rats housed in pairs during the juvenile period (postnatal day 21 to adulthood) does not differ from that of animals housed in triads. Because neonatal stress augments the neuroendocrine responsiveness to stress and HVR, experiments were performed both on “control” (undisturbed) animals and rats subjected to neonatal maternal separation (NMS; 3 h/day, postnatal days 3–12). At adulthood, ventilatory activity was measured by whole body plethysmography under normoxic and hypoxic conditions (inspired fraction of O2 = 0.12; 20 min). The ventilatory and body temperature responses to hypoxia of rats raised in triads were less than those of rats housed in pairs. For the HVR, however, the attenuation induced by triad housing was more important in NMS rats. Triad housing decreased “basal” plasma corticosterone, but increased estradiol and testosterone levels. Much like the HVR, housing-related decrease in corticosterone level was greater in NMS than control rats. We conclude that modest changes in housing conditions (pairs vs. triads) during the juvenile period can influence basic homeostatic functions, such as temperature, endocrine, and respiratory regulation. Housing conditions can influence (even eliminate) the manifestations of respiratory plasticity subsequent to deleterious neonatal treatments. Differences in neuroendocrine function likely contribute to these effects.

Infant feeding in the neonatal unit

Infants admitted to a neonatal unit (NNU) are frequently unable to feed by breast or bottle because of ill health or prematurity. These infants require nutritional support until they can start oral feeding. Breastfeeding is advocated for these infants, and mothers are frequently encouraged to express breast milk to be fed via the enteral tube. However, by discharge, breastfeeding rates tend to be low. Oral feeding requires careful management, and although practices may vary because of clinical need, some may be informed by unit norms. There is limited evidence for effective breastfeeding support in this environment and little exploration of the effect of routine feeding decisions. This study aimed to explore feeding decisions and considered how these might affect outcomes. The staff in the two large urban NNUs who participated in the feeding decisions were interviewed and the data were analysed using a theoretical framework. Feeding decisions were made mainly by the unit staff, with limited parental involvement. Subsequent management varied, with differences being related to staff experience and beliefs, unit norms, parent's expectations and physical constraints within the unit. The staff were overtly supportive of breastfeeding, but the need to monitor and quantify milk intake may undermine breastfeeding. Furthermore, feeding breastfed infants during the mothers' absence was controversial and provoked debate. There is a need for clear guidelines and increased parental involvement in feeding decisions. Routine practices within the system may discourage mothers from initiating and persisting with breastfeeding. A change in unit culture is required to fully support the parent's feeding choices.

Patent arterial duct, bottle-meal, and fatal myocardial ischaemia

A patent arterial duct in pre-term neonates is frequent. Systemic complications consecutive to left-to-right shunting are well known but fatal myocardial ischaemia has not been described till now. The presented premature baby died from catecholamine refractory cardiogenic shock. Autoptic examination revealed acute ischaemic changes predominantly in the inner third of myocardium, speaking of coronary hypoperfusion due to a steal phenomenon secondary to the patent arterial duct.

Maturational changes in the feeding behaviour of infants - a comparison between breast-feeding and bottle-feeding

AIM

To obtain a better understanding of the changes in feeding behaviour from 1 to 6 months of age. By comparing breast- and bottle-feeding, we intended to clarify the difference in longitudinal sucking performance.

METHODS

Sucking variables were consecutively measured for 16 breast-fed and eight bottle-fed infants at 1, 3 and 6 months of age.

RESULTS

For breast-feeding, number of sucks per burst (17.8 +/- 8.8, 23.8 +/- 8.3 and 32.4 +/- 15.3 times), sucking burst duration (11.2 +/- 6.1, 14.7 +/- 8.0 and 17.9 +/- 8.8 sec) and number of sucking bursts per feed (33.9 +/- 13.9, 28.0 +/- 18.2 and 18.6 +/- 12.8 times) at 1, 3 and 6 months of age respectively showed significant differences between 1 and 6 months of age (p < 0.05). The sucking pressure and total number of sucks per feed did not differ among different ages. Bottle-feeding resulted in longer sucking bursts and more sucks per burst compared with breast-feeding in each month (p < 0.05).

CONCLUSION

The increase in the amount of ingested milk with maturation resulted from an increase in bolus volume per minute as well as the higher number of sucks continuously for both breast- and bottle-fed infants.

Comparison of neonatal intensive care: Trento area versus Vermont Oxford Network

BACKGROUND

S. Chiara hospital is the only neonatal intensive care unit (NICU) in the Province of Trento (Italy). It serves a population of about 460000 people with about 5000 infants per year, admitting the totality of the inborn and outborn VLBWI of the province. The aim of this work is to compare mortality, morbidity and neonatal treatment of the very low birth weight infants (VLBWI) of Trento area with those recorded in the Vermont Oxford Network (VON) during 2004.

METHODS

In this retrospective analysis, the rates of complications and related treatments reported in VLBWI admitted in the S. Chiara NICU during the period 2000-2005 were compared with those recorded in the VON in 2004. The analysis included both the total populations and different weight groups.

RESULTS

The frequency of inborn infants was significantly higher in Trento than in VON: 91% vs 84% (MH 8.56; p-value 0.003). The administration of prenatal steroids (82% vs 74%; MH 7.47 and p-value 0.006) and caesarean section were significantly more frequent in the Trento area than in VON. In Trento significantly more VLBWI with BW

CONCLUSION

On the basis of this analysis, a less aggressive therapeutic strategy based on perinatal prevention in global management, such as that employed in Trento area, may be associated with an improvement in clinical outcomes in very low birth weight infants.

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Affiliation(s)

Giuseppe De Nisi Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Mariarosaria Berti Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Riccardo Malossi Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Fabio Pederzini Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Anna Pedrotti Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy
Alberta Valente Neonatology and neonatal intensive care, S. Chiara Hospital, Trento, Italy

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Cup versus bottle feeding for hospitalized late preterm infants in Egypt: a quasi-experimental study

Background

Although previous studies have demonstrated beneficial breastfeeding outcomes when cup feeding rather than bottle feeding was used for feeding preterm infants, cup feeding has not been implemented in Egypt. The aim of the current study was to examine the effect of using cup feeding as an exclusive method of feeding preterm infants during hospitalization on breastfeeding outcomes after discharge.

Methods

A quasi-experimental design, with the control group studied first, was used to examine the effect of cup feeding for preterm infants on breastfeeding outcomes after discharge. Sixty preterm infants (mean gestational age was 35.13 weeks and mean birth weight was 2150 grams) were recruited during Neonatal Intensive Care Unit (NICU) stay. Control group infants (n = 30) received only bottle feedings during hospitalization and the experimental group (n = 30) received only cup feedings during hospitalization. Both groups were followed up after discharge for six weeks to evaluate infant's breastfeeding behavior and mother's breastfeeding practices. Data were analyzed using descriptive statistics and repeated measures ANOVA for testing the differences between the cup feeding and bottle feeding groups over six weeks after discharge.

Results

Cup fed infants demonstrated significantly more mature breastfeeding behaviors when compared to bottle fed infants (p < 0.01) over six weeks, and had a significantly higher proportion of breast feedings one week after discharge (p = 0.03).

Conclusion

Cup fed infants were more exclusively breast fed one week after discharge, supporting the Baby Friendly Hospital Initiative recommendations for using cup feeding and avoiding bottle feeding when providing supplementation for preterm infants. The current study provides initial evidence for the implementation of cup feeding as a method of supplementation for late preterm infants during hospitalization.

Trial Registration

Clinical Trial NCT00756587.

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 available and an alternative approach to feeding is needed. Most commonly, milk (expressed breast milk or formula) is given by bottle. There is some controversy about whether using bottles during the establishment of breast feeds is detrimental to breastfeeding success.

OBJECTIVES

To determine the effect of avoidance of bottle feeds during the establishment of breastfeeding on the likelihood of successful breastfeeding and to determine if alternatives to bottle feeds are safe.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL and EMBASE in any language. The search was updated in July 2008.

SELECTION CRITERIA

Randomised or 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. Standard methods of the Cochrane Collaboration and the Cochrane Neonatal Review Group were used.

MAIN RESULTS

Five trials of 543 infants were included. Four trials used a cup feeding strategy and one trial used a tube feeding strategy when supplements to breast feeds were needed. The single study of tube feeding had a high risk of bias. In the analysis of all five trials, significant heterogeneity was evident in two of the primary outcomes. This was reduced when the tube feeding trial was removed from analyses.Cup feeding significantly decreased 'no breastfeeding or only partial breast feeding' on discharge home (summary RR 0.75, 95% CI 0.61 to 0.91). However, cup feeding significantly increased length of hospital stay by 10 days (95% CI 3.87 to 16.29). There was a high degree of noncompliance in the largest study of cup feeding indicating dissatisfaction with this method by staff and/or parents.The one trial of a tube alone approach significantly reduced 'no breastfeeding or only partial breastfeeding' and 'no breastfeeding at all' at all time periods but the results need to be interpreted with caution due to the high risk of bias.

AUTHORS' CONCLUSIONS

Supplementing breast feeds by cup confers no breastfeeding benefit beyond discharge home and delays discharge considerably. There is currently insufficient evidence on which to base recommendations for a tube alone approach to supplementing breast feeds. Further research is needed to evaluate a tube alone approach.

A comparison of the efficiency, efficacy, comfort, and convenience of two hospital-grade electric breast pumps for mothers of very low birthweight infants

OBJECTIVE

Many mothers of very low birthweight infants are breast pump-dependent for weeks or months and need a breast pump that is efficient, effective, comfortable, and convenient.

STUDY DESIGN

This multisite, blinded, randomized clinical trial compared the efficiency, efficacy, comfort, and convenience of the Symphony breast pump (Medela, McHenry, IL) (SBP) to the Classic breast pump (Medela) (CBP) and also compared these same outcome measures for single- and multiphase suction patterns used in the SBP. All 100 mothers initiated lactation with the CBP and were randomized to single- and multiphase suction patterns in the SBP when daily milk output was at least 350 mL/day. Protocol I included 35 mothers who compared each of three suction patterns in the SBP on two separate occasions (six observations) in the neonatal intensive care unit and used the CBP for all other pumpings. Protocol II included 65 mothers who compared single- and multiphase patterns in the SBP for 7 days and then returned to the CBP for 5 days.

RESULTS

The onset of milk ejection was quicker (P < 0.05) for the single- versus multiphase patterns in the SBP, suggesting that mothers had become conditioned to the unphysiolologic single-phase pattern in the CBP. However, all other measures of efficiency and efficacy were not significantly different, including milk output at 5-minute intervals. When asked to compare the SBP and the CBP, mothers in Protocol 1 rated the SBP as significantly more efficient, effective, comfortable, and convenient than the CBP (P < 0.05), regardless of the suction pattern in the SBP. Similarly, mothers in Protocol II rated the SBP significantly (P < 0.05) more comfortable than the CBP, regardless of the specific pattern in the SBP.

CONCLUSIONS

These findings suggest that the SBP was as efficient and effective as the CBP but was significantly more comfortable to use for pump-dependent mothers of very low birthweight infants.

Infants with bronchopulmonary dysplasia suckle with weak pressures to maintain breathing during feeding

OBJECTIVE

Preterm infants with bronchopulmonary dysplasia often demonstrate sucking difficulties. The aim of this study was to determine whether the severity of bronchopulmonary dysplasia affects not only coordination among suck-swallow-respiration but also sucking endurance and performance itself.

PATIENTS AND METHODS

Twenty very low birth weight infants were studied. Infants with anomalies or intraventricular hemorrhage were excluded from the evaluation. Subjects were divided into 3 groups: no bronchopulmonary dysplasia (7 infants), bronchopulmonary dysplasia without home oxygen therapy (7 infants), and bronchopulmonary dysplasia with home oxygen therapy (6 infants). In addition to sucking efficiency, pressure, frequency, duration, and duration of sucking burst, length of deglutition apnea, number of swallows per burst, and respiratory rate were also measured during bottle-feeding at 40 weeks' postmenstrual age. In addition, PCO2 and oxygen saturation were measured at rest and during bottle-feeding.

RESULTS

Infants with severe bronchopulmonary dysplasia demonstrated not only the lowest sucking pressure and sucking frequency, shortest sucking burst duration, and lowest feeding efficiency but also the lowest frequency of swallows during the run and the longest deglutition apnea. The respiratory rate was highest, and the decrease in oxygen saturation was largest, in infants with severe bronchopulmonary dysplasia.

CONCLUSIONS

Feeding problems depend on the severity of bronchopulmonary dysplasia. Infants with bronchopulmonary dysplasia demonstrated not only poor feeding coordination but also poor feeding endurance and performance.

The 3 M's of breast-feeding the preterm infant

Mother's own milk is considered best for preterm infants. Given the often protracted period between birth and breast-feeding for most preterm newborns, a number of challenges exist for mothers and neonatal intensive care unit nurses in establishing lactation, providing mother's own milk, and achieving breast-feeding. This article conceptualizes breast-feeding the preterm infant in the context of the neonatal intensive care unit as a 3-phase process, the 3 M's of breast-feeding: medication, mother's milk feedings, and the mechanics of breast-feeding.

Coordination of sucking, swallowing, and breathing and oxygen saturation during early infant breast-feeding and bottle-feeding

This prospective study compared the coordination of sucking, swallowing, and breathing and its relationship to oxygen saturation in infants during breast-feeding and bottle-feeding. After 4 to 6 wk of exclusive breast-feeding, infants began bottle-feedings of expressed human milk using one of two systems: a soft-walled bottle and nipple (system 1, Playtex) or a hard-walled bottle and nipple (system 2, Avent). Infants' sucking, swallowing, breathing, and oxygenation were measured during breast-feeding and bottle-feeding, and coordination of these activities during breast-feeding and bottle-feeding were compared. During breast-feeding, swallowing occurred nonrandomly between breaths and did not interfere with breathing. The same distribution of swallowing occurred in infants fed with system 1, while swallowing occurred randomly in infants fed with system 2. Swallowing significantly increased during bottle-feeding among infants using system 2, but decreased among infants using system 1. Infants using system 2 also had a greater instability in the coordination of sucking, swallowing, and breathing and more perturbation of breathing. Oxygen saturation was significantly higher in infants fed with system 1 compared with system 2. These results suggest that the overall feeding pattern and oxygenation of system 1 are closer to the physiologic norm than system 2.

A review of the literature examining the benefits and challenges, incidence and duration, and barriers to breastfeeding in preterm infants

Breastfeeding benefits preterm infants from a nutritional, gastrointestinal, immunological, developmental, and psychological perspective. Despite the benefits, the incidence and duration of breastfeeding preterm infants continues to be less than that of full-term infants. The lower incidence is probably related to breastfeeding challenges that preterm infants and parents face, including establishing and maintaining a milk supply and transitioning from gavage feeding to breastfeeding. In order to increase the incidence and duration of breastfeeding preterm infants, researchers must examine breastfeeding experiences longitudinally. This way, researchers and clinicians can begin to understand the barriers to breastfeeding at various time periods in the breastfeeding experience and begin implementing strategies to remove these barriers.

Correlates of lactation in mothers of very low birth weight infants

OBJECTIVE

We sought to determine the correlates of intent to breastfeed and of successful lactation and nursing at the breast in mothers of very low birth weight (VLBW; <1.5 kg) infants.

METHODS

We conducted a prospective observational study of 119 mothers of singleton VLBW infants (mean birth weight: 1056 g; mean gestational age: 28 weeks), 87 (73%) of whom intended to breastfeed. Mothers completed questionnaires at 3 weeks' postnatal age and at 35 and 40 weeks' (term) and 4 months' corrected ages (CAs).

RESULTS

Of the 87 mothers who intended to breastfeed, 30 mothers (34%) continued lactation beyond 40 weeks' CA (postmenstrual plus postnatal age). Compared with mothers who discontinued lactation before this time, those who continued were older (31 vs 26 years), more were married (80% vs 39%), they had more than a high school education (70% vs 42%), and they were white (63% vs 35%). There were no significant differences in their infants' birth data or rates of neonatal morbidity. Significant correlates of lactation beyond 40 weeks' CA included beginning milk expression before 6 hours postdelivery, expressing milk > or =5 times per day, and kangaroo care. These correlates remained significant after controlling for maternal age, race, marital status, and education beyond high school. At 4 months' CA, 14 mothers (16%) were still lactating, 12 of whom were nursing at the breast.

CONCLUSIONS

Increased maternal support specifically directed toward behavioral factors, including early and more frequent milk expression and kangaroo care, may improve the rates of successful lactation among mothers of VLBW infants who choose to breastfeed.

A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed

OBJECTIVE

To compare the safety of cupfeeding, an alternative feeding method, to bottlefeeding, the current standard of artificial feeding in the United States, in preterm infants whose mothers intend to breastfeed.

STUDY DESIGN

In a prospective, randomized crossover study, 56 infants <or=34 weeks at birth, whose mothers indicated a desire to breastfeed, were studied. Skin-to-skin care and attempts at breast were encouraged frequently when babies were physiologically stable. When infants were >or=34 weeks' corrected gestational age, the order of the first two non-breast oral feedings was randomized by coin toss to one cupfeeding and one bottlefeeding. Trained Neonatal Intensive Care Unit nurses provided the feedings. Heart rate, respiratory rate, and oxygen saturation were recorded at 1-minute intervals for 10 minutes before and during the feeding. Volume taken, time required to complete the feed, and any apnea, bradycardia, choking, or spitting episodes were recorded.

RESULTS

Heart rate (p<0.0001) and respiratory rate (p<0.0001) increased and oxygen saturation decreased (p=0.0002) during both cup and bottlefeedings compared to pre-feeding baselines. The amount of change in these three parameters from baseline to feeding period was similar for both feeding methods. The fraction of O(2) saturation <90% during baseline compared to the study period was different between these two feeding methods (p=0.02). There was a 10-fold increase in desaturations <90% during bottlefeeds compared to no change during cupfeeds. When comparing cupfeeding periods to bottlefeeding periods, heart rates were higher (p=0.009) and oxygen saturations lower (p=0.02) during bottlefeeds. There were no differences between methods in respiratory rate, choking, spitting or apnea, and bradycardia. Volumes taken were lower (p=0.001) and duration of feeds longer (p=0.002) during cupfeedings.

CONCLUSION

During cupfeedings, premature infants are more physiologically stable, with lower heart rates, higher oxygen saturations, and less desaturations, than during bottlefeedings. However, cupfed infants took less volume, over more time, than bottlefed for these initial feedings. Based on better physiologic stability and no difference in untoward effects, cupfeeding is at least as safe, if not safer, than bottlefeeding in this population. This study supports the use of cupfeeding as a safe alternative feeding method for premature infants learning to breastfeed.

Breastfeeding in the special care nursery. Prematures and infants with medical problems

In summary, clinical interventions that are focused on increasing the rates with which mothers initiate and sustain lactation for infants with medical problems must reflect the scientific evidence for this vulnerable population. These interventions should include counseling to ensure that mothers may make an informed decision about providing milk; nonpharmacologic and pharmacologic strategies to maximize maternal milk volume; and basing protocols for at-breast feeding on studies conducted with breastfeeding for premature and other at-risk infants, rather than on ideology or research conducted with term, healthy infants.

Zinc and copper in preterm neonates: relationship with breast milk

The study was conducted to assess copper and zinc levels in neonate's serum, mother's serum, neonate's hair and urine and to ascertain association between them. It is of concern whether zinc and copper deficiency is present at birth and maternal blood and breast milk zinc and copper levels have any effect on this. The study sample included 155 neonates with gestational age 26-41 wks and birth weight 0.550-3.800 kg. Mother's serum, breast milk, neonate's serum, hair, urine samples were analysed for zinc and copper by atomic absorption spectrophotometry. Gestational age was estimated either singly or by combination of date of last normal menses, fetal ultrasonography, and postnatal measures of physical and neurological development by clinical examination and weight by Secca electronic balance. The neonates were classified into term and preterm, small (SGA) and appropriate for gestational age (AGA). Neonates over 37 wks and 2.5 kg served as controls. To assess the dependency, relationship and effectiveness of quantitative predictive variables on the predictions of values, multiple regression analysis was used. Neonates between 26-30 wks gestational age and < 2.5 kg birth weight had significantly low serum zinc and copper. Breast milk zinc was low in mothers delivering preterm and < 2.5 kg neonates. Urinary copper and zinc levels were high in preterm appropriate for gestational age (Pre AGA) than term neonates. Multiple regression analysis revealed that neonate's serum Cu, serum Zn, hair Cu, hair Zn, urine Cu and urine Zn had contribution variability of 49.8%, 51.8%, 49.2%, 16.6%, 52.2% and 68.9%, respectively. The effect of mother's serum, breast milk, and neonate's serum copper and zinc collectively was significant for serum copper (F = 29.59) and hair zinc (F = 32.03). Preterm and low birth weight infants during subsequent growth and development should be supplemented with zinc and copper when on breast feeding.