Supplementary feeding in the maternity ward shortens the duration of breast feeding

In a prospective study, feeding routines of a maternity unit and the subsequent feeding patterns of 521 newborns were analysed. During the stay in the maternity unit, 69% of newborns were exclusively breast fed and 1% received only donor's milk from the milk bank and/or formula. Nine percent received their mothers' milk by bottle at least once and 21% received one or more supplementary feedings with donor's milk from the milk bank. One-quarter of the children received supplementary feeds on the third day of life, the indications for this being birth weight less than 3.0 kg, maternal diabetes or gestational diabetes, "insufficient amounts" of milk or fussiness. At three months, 65% were being exclusively breast fed and 15% partially breast fed. In a multiple logistic regression analysis, the potential determinants (neonatal feeding, maternal characteristics, characteristics of the delivery and the child) for the duration of breast feeding were included. The adjusted relative risk (estimated as odds ratios, OR) of not being breast fed at three months was associated with maternal age (< 25 years, OR 4.2), maternal smoking (OR 4.0), neonatal feeding (supplements given, OR 3.9) and initial weight loss (10% or more, OR 2.8). Thus the administration of supplementary donor's milk or formula during the early neonatal period was associated with an increased risk of a short duration for breast feeding, even after adjustment for a number of potential confounders.

State of the science: feeding readiness in the preterm infant

Finding ways to consistently prepare preterm infants and their families for more timely discharge must continue as a focus for everyone involved in the care of these infants in the neonatal intensive care unit. The gold standards for discharge from the neonatal intensive care unit are physiologic stability (especially respiratory stability), consistent weight gain, and successful oral feeding, usually from a bottle. Successful bottle-feeding is considered the most complex task of infancy. Fostering successful oral feeding in preterm infants requires consistently high levels of skilled nursing care, which must begin with accurate assessment of feeding readiness and thoughtful progression to full oral feeding. This comprehensive review of the literature provides an overview of the state of the science related to feeding readiness and progression in the preterm infant. The theoretical foundation for feeding readiness and factors that appear to affect bottle-feeding readiness, progression, and success are presented in this article.

Do infants fed directly from the breast have improved appetite regulation and slower growth during early childhood compared with infants fed from a bottle?

BACKGROUND

Behavioral mechanisms that contribute to the association between breastfeeding and reduced obesity risk are poorly understood. The purpose of this study was to evaluate the hypothesis that feeding human milk from the breast (direct breastfeeding) has a more optimal association with subsequent child appetite regulation behaviors and growth, when compared to bottle-feeding.

METHODS

Children (n = 109) aged 3- to 6- years were retrospectively classified as directly breastfed (fed exclusively at the breast), bottle-fed human milk, or bottle-fed formula in the first three months of life. Young children's appetite regulation was examined by measuring three constructs (satiety response, food responsiveness, enjoyment of food) associated with obesity risk, using the Child Eating Behavior Questionnaire. Multinomial logistic regression analyses were used to test whether children bottle-fed either human milk or formula had reduced odds of high satiety and increased odds of high food responsiveness and high enjoyment of food compared to children fed directly from the breast. Current child weight status and growth trends from 6-36 months were also examined for their relation to direct breastfeeding and appetite regulation behaviors in early childhood.

RESULTS

Children fed human milk in a bottle were 67% less likely to have high satiety responsiveness compared to directly breastfed children, after controlling for child age, child weight status, maternal race/ethnicity, and maternal education. There was no association of bottle-feeding (either human milk or formula) with young children's food responsiveness and enjoyment of food. There was neither an association of direct breastfeeding with current child weight status, nor was there a clear difference between directly breastfed and bottle-fed children in growth trajectories from 6- to 36-months. More rapid infant changes in weight-for-age score were associated with lower satiety responsiveness, higher food responsiveness and higher enjoyment of food in later childhood

CONCLUSION

While direct breastfeeding was not found to differentially affect growth trajectories from infancy to childhood compared to bottle-feeding, results suggest direct breastfeeding during early infancy is associated with greater appetite regulation later in childhood. A better understanding of such behavioral distinctions between direct breastfeeding and bottle-feeding may identify new pathways to reduce the pediatric obesity epidemic.

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.

Origins of human milk microbiota: new evidence and arising questions

Human milk contains a diverse community of bacteria. The growing appreciation of commensal microbes and increasing availability of high-throughput technology has set the stage for a theory-driven approach to the study of milk microbiota, and translation of this knowledge to improve maternal and child health. We recently profiled the milk microbiota of healthy Canadian mothers and applied theory-driven causal modeling, finding that mode of breast milk feeding (nursing directly at the breast vs. pumping and feeding breast milk from a bottle) was significantly associated with milk microbiota composition. This observation could reflect an increased exposure to pumps and/or a decreased exposure to the infant mouth. Either way, it provides evidence for the retrograde mechanism of milk inoculation. Here, we discuss the implications of this research and related controversies, and raise new questions about the origins and function of milk bacteria.

Quantitative evaluation of infant's nonnutritive and nutritive sucking

Two important aspects of the clinical feeding evaluation of infants are the assessment of their nonnutritive and nutritive sucking skills. Nonnutritive sucking is monitored routinely by using a gloved finger and nutritive sucking by observing infants' sucking while bottle feeding. This approach, however. provides only a subjective and descriptive evaluation. In this study, we developed a finger pressure device that allows for quantification of specific measures of nonnutritive sucking. We are proposing that its use, in combination with the nipple/bottle system developed for the monitoring of nutritive sucking. will allow therapists to conduct objective and quantitative evaluations of infants' nonnutritive and nutritive sucking. The suction and expression components of sucking are monitored via two catheters placed at the tip of the index finger of a disposable glove and at the tip of a bottle nipple. The observations made from the standard clinical feeding evaluation and from these two instruments were compared. In addition to providing quantitative measures of sucking, the latter techniques allowed the review/reassessment of data, the monitoring of the maturation of oral motor skills over time, and the comparison of these measures between infants. It is proposed that the concurrent use of these devices will allow therapists to conduct more objective and detailed evaluations of infants' feeding skills than can be obtained at present.

Pacing as a treatment technique for transitional sucking patterns

OBJECTIVE

To ascertain whether the implementation of a paced feeding protocol in a sample of preterm infants with respiratory diagnoses will result in the development of more efficient sucking patterns, increased weight gain, decreased incidence of bradycardia during feeding, and shorter length of hospital stay.

METHOD

A total of 36 premature infants were enrolled into a nonrandomized clinical trial conducted in a neonatal intensive care unit (NICU). The first 18 infants were traditionally bottle-fed. Following this cohort's discharge from NICU, nursing staff completed continuing education on implementing a paced feeding protocol and the next 18 infants were delivered paced feedings.

RESULTS

The two cohorts were equivalent at the initiation of oral feedings on gestational age, birth weight, 1 and 5 minute Apgar scores, weight, and postconceptual age. The paced infants demonstrated statistically and clinically significant decreases in bradycardic incidences during feeding and gains in development of more efficient sucking patterns at discharge. Discharge and average weekly weight gain did not differ between the two groups.

CONCLUSIONS

The incorporation of pacing into NICU care practices appears to be beneficial for preterm infants with respiratory disease.

Effects of non-nutritive sucking on nutritive sucking, breathing, and behavior during bottle feedings of preterm infants

PURPOSE

The purpose of this study was to examine the effect of prefeeding non-nutritive sucking (NNS) on breathing, nutritive sucking (NS), and behavioral characteristics of bottle feeding.

SUBJECTS

The convenience sample was composed of 10 preterm infants who were 33 to 40 weeks postconceptual age (PCA) at the time of the observation.

DESIGN

Randomized, crossover; each infant was observed twice during the first 48 hours of bottle feeding.

METHODS

Ten preterm infants received NNS before 1 bottle feeding and served as their own control at a second bottle feeding. Sucking was measured using a chin strain gauge and breathing was measured with a nasal thermistor. Behavioral characteristics included behavior state, measured using the Neonatal Individualized Developmental Care and Assessment Program (NIDCAP) behavior state scale, and feeding efficiency.

MAIN OUTCOME MEASURES

Characteristics of NS (number of suck bursts, sucks/burst, suck burst length) and breathing (number of breath bursts, breaths/burst, breath burst length), as well as behavior state during bottle feedings and feeding efficiency (percent of prescribed formula consumed, formula consumed/minute of feeding).

PRINCIPAL RESULTS

NS waves were smoother and more regular than NNS waves. Time to onset and duration of the first non-nutritive suck burst were positively correlated with time to onset for the first nutritive suck burst. Prefeeding NNS had no statistically significant effect on characteristics of breathing or on any other characteristics of NS. Behavioral state during feedings and feeding efficiency were not affected by prefeeding NNS.

CONCLUSIONS

In this sample, the use of prefeeding NNS did not affect NS, breathing during feeding, or select behavioral characteristics of feeding.

Cup or bottle for preterm infants: effects on oxygen saturation, weight gain, and breastfeeding

The impact of cup-feeding or bottle-feeding on weight gain, oxygen saturation, and breastfeeding rates of preterm infants was studied in 34 bottle-fed and 44 cup-fed preterm infants. At initiation of oral feeding, postconceptional age and weight were 37.2 +/- 2.2 weeks and 1676 +/- 83 g for the bottle-fed group (BF) and 37.0 +/- 1.6 weeks and 1637 +/- 40 g for the cup-fed (CF) group, respectively. No significant differences between groups were found with regard to time spent feeding, feeding problems, weight gain, or breastfeeding prevalence at discharge or at 3-month follow-up. Possible beneficial effects of cup-feeding were lower incidence of desaturation episodes (13.6% vs 35.3%, CF vs BF, P = .024) and a higher prevalence of breastfeeding at 3 months among those still breastfeeding at the first follow-up visit (68.4% vs 33.3%, CF vs BF, P = .04).

Multiple factors related to bottle-feeding performance in preterm infants

BACKGROUND

A great deal of attention has focused on understanding preterm infant feeding behaviors and on strategies to support the preterm infant during this period; however, comprehensive descriptions of the feeding behavior of preterm infants that incorporate an examination of multiple subsystem levels are lacking.

OBJECTIVE

To examine various physical indicators related to preterm infants' bottle-feeding performance.

METHODS

This was a retrospective, descriptive, exploratory study using a convenience sample. Medical records of 116 preterm infants were reviewed from the initiation of bottle-feeding until discharge from the neonatal intensive care unit. This study examined bottle-feeding performance (volume intake in milliliters per minute) as well as postmenstrual age, weight at each observed feed, oral motor skills, signs of distress, feeding techniques, feeding experience, gender, and Apgar scores at 5 minutes. Oral motor skills were measured by the Neonatal Oral Motor Assessment Scale.

RESULTS

Linear mixed-effects models were used to examine the relationship between bottle-feeding performance and the remaining variables. Postmenstrual age, weight at each observed feed, oral motor skills, feeding experience, and feeding techniques were found to be significant predictors of feeding performance at the .05 level.

CONCLUSIONS

Multiple factors, both intrinsic and extrinsic, play a role in determining an infant's bottle-feeding performance. In addition to age and weight, the presently employed conventional criteria, oral motor skills, feeding practice, and feeding techniques also contribute to infants' feeding performance. Arbitrary age (34 weeks gestational age) and weight criteria (1,500 g) should not be the only indicators for oral feeding.

Coregulated approach to feeding preterm infants with lung disease: effects during feeding

BACKGROUND

Very preterm (VP) infants are at risk for poor oral feeding endurance, early cessation of eating, poor fluid management with aspiration risk, behavioral distress, and unstable heart rate (HR) and oxygenation during feeding.

OBJECTIVE

The study aims to determine the preliminary effectiveness of a coregulated approach (CoReg) to oral feeding for VP infants at risk for lung disease.

METHODS

A randomized, within-subject, cross-over design was used with 20 VP infants requiring oxygen at the start of oral feeding. Infants were bottle-fed by the Usual Care approach and by the CoReg approach on two consecutive days for an average of four feedings each. Intervention components included coregulation of suck, swallow, and breathe rhythms using enhanced auditory assessment, infant-guided feeding onsets, and infant positioning in a semielevated, side-lying position. Infant physiology metrics (HR and SaO2) were collected continuously before and during the feeding. Behavioral and auditory indicators of regulation were coded continuously from videotape during the feeding.

RESULTS

Up to 75 feedings were analyzed (40 Usual Care and 35 CoReg) using repeated measures modeling. CoReg feedings were characterized by more frequent preparation of the infant for the feeding, were more commonly initiated in response to infant readiness cues, had more rest periods and breath regulation events, and had fewer sucking stimulation events. CoReg feedings had less SaO2 variability, decline, and time spent in a desaturated state; less HR fluctuation and decline; less behavioral disorganization; better fluid management; and less observed effort to breathe.

DISCUSSION

Support is provided for an approach to feeding vulnerable infants. Enhanced auditory assessment of infant feeding rhythms increases the responsiveness of the feeder and improves infant behavioral and physiological responses.

Feeding modes shape the acquisition and structure of the initial gut microbiota in newborn lambs

Early gut microbial colonization is important for postnatal metabolic and immune development. However, little is known about the effects of different feeding modes (suckling versus bottle-feeding) or microbial sources on this process in farm animals. We found that suckled and bottle-fed newborn lambs had their own distinct gut microbiota. Results from 16S rRNA gene sequencing and qPCR showed that, compared with suckling, bottle feeding significantly increased the abundances of Escherichia/Shigella, Butyricicoccus, and Clostridium XlVa, while significantly decreased the abundance of Clostridium XI. The higher levels of Escherichia/Shigella in bottle-fed lambs suggest that artificial feeding may increase the number of potential pathogens and delay the establishment of the anaerobic environment and anaerobic microbes. Feeding modes also affected the direct transmission of bacteria from the mother and the environment to newborns. The SourceTracker analysis estimated that the early gut microbes of suckled lambs were mainly derived from the mother's teats (43%) and ambient air (28%); whereas those of bottle-fed lambs were dominated by bacteria from the mother's vagina (46%), ambient air (31%), and the sheep pen floor (12%). These findings advance our understanding of gut microbiota in early life and may help design techniques to improve gut microbiota and health.

Reinforcing properties of ethanol in neonatal rats: involvement of the opioid system

Toward understanding why infant rats ingest high levels of ethanol without initiation procedures, the authors tested effects of mu and kappa receptor antagonists on ethanol reinforcement in neonatal rats. After an intracisternal injection of CTOP (micro antagonist), nor-Binaltorphimine (kappa antagonist), or saline, newborn (3-hr-old) rats were given conditioning pairings of an odor with intraorally infused ethanol or a surrogate nipple with ethanol administered intraperitoneally (to minimize ethanol's gustatory attributes). In each case, these opioid antagonists reduced or eliminated ethanol's reinforcement effect. The same effects occurred with saccharin as the reinforcer in olfactory conditioning. The results imply that activation of mu and kappa receptors, apparently acting jointly, is necessary for reinforcement or that antagonists of this activity impair basic conditioning.

Regional neonatal oral feeding protocol: changing the ethos of feeding preterm infants

The Calgary Health Region Neonatal Oral Feeding Protocol is the culminating work of a broad range of healthcare professionals, including staff nurses, nurse practitioners, nurse educators, nurse managers, dietitians, lactation consultants, clinical nurse specialists, and occupational therapists. The protocol represents a synthesis of research evidence and expert opinion pertaining to the introduction and management of oral milk feedings for high-risk infants in the neonatal intensive care unit. This evidence-based neonatal oral feeding protocol is presented to share knowledge and skill required to create positive feeding experiences while assisting high-risk infants to achieve full oral feedings. Goals of this project include promoting consistent neonatal nursing feeding practices and changing the ethos in relation to feeding interactions between caregiver and infant in the neonatal intensive care unit. This culture change will assist nurses to identify what is unique about their professional practice, which is of particular importance given the skill mix resulting from hospital understaffing and a growing nursing workforce shortage.

Nipple feeding preterm infants: an individualized, developmentally supportive approach

Many NICU infants present with complex issues that affect the transition to full nipple feeding. At a time when length of stay is critical, this transition can be facilitated by an individualized, developmentally supportive approach. The approach described in this article involves (1) observing the infant for behavioral cues of stability or stress during nippling, as reflected in change in color, state of alertness, breathing, and swallowing; (2) individualizing intervention to help the infant regain and maintain coordination; and (3) facilitating parents' competence and confidence in feeding their infant. Contingent interventions are used to promote physiologic homeostasis and self-regulation.

Nipple feeding premature infants in the neonatal intensive-care unit: factors and decisions

OBJECTIVE

To rank factors considered important by neonatal intensive-care unit (NICU) nurses in identifying hunger in infants weighing 1,800 g or less, to rank factors considered important in making decisions about nipple feeding such infants, to determine whether the two rankings varied among hospitals, and to identify the caregiver with the greatest influence over feeding decisions.

DESIGN

Descriptive comparative survey.

SETTING

NICUs of three metropolitan hospitals.

PARTICIPANTS

Forty-seven NICU nurses in those hospitals.

MAIN OUTCOME MEASURES

Nurses ranked factors indicating hunger in preterm infants and factors contributing to feeding decisions for such infants.

RESULTS

Vigorous sucking, rooting, and crying were ranked as hunger cues. Nonnutritive sucking and a gestational age of 34 weeks or more were considered indicators of readiness to begin nipple feeding. The centrality of the nurse's role in feeding decisions was confirmed.

CONCLUSIONS

Additional research is needed to determine whether nonnutritive sucking predicts nutritive sucking performance and to study the nurses' responses to infants who suck poorly or refuse to nipple feed.

Oral support measures used in feeding the preterm infant

BACKGROUND

Evidence that bottle-feeding is a stressor for inefficient preterm infant feeders is seen in untoward changes in the physiologic system and nutritive sucking patterns.

OBJECTIVE

To determine whether a therapeutic technique, oral support (cheek and jaw support), would influence the cardiopulmonary functions or nutritive sucking patterns of preterm infants during feeding.

METHODS

A crossover repeated measures design was used with 20 preterm infants for a total of 40 bottle-feeding sessions. The Whitney Mercury Strain Gage and a Nonin Cardiopulmonary monitor were used to observe sucking characteristics and cardiopulmonary functions during feeding.

RESULTS

Infants not receiving support paused longer (F= 6.37, df= 5, p < .001) and more frequently (F= 5.01, df= 5, p < .001) than supported infants. There were no differences between the groups in the number of sucks and bursts, the burst duration, the stability of the total sucking activity, or the rate of sucking. Oxygen saturation (SaO2) values, heart rate, and respiratory rate did not differ between the groups during feeding. Postfeeding SaO2 levels were lower than prefeeding levels for infants not receiving oral support (t= 0.96, df= 19, p= .03).

CONCLUSION

Oral support provided stability for the jaw and fostered the return of the infant's prefeeding SaO2 values, but it did not interfere with cardiopulmonary function during feeding. Further research is needed to determine whether there is a cumulative effect of oral support, and whether it influences state behavior.

Direct Feeding at the Breast Is Associated with Breast Milk Feeding Duration among Preterm Infants

BACKGROUND

In spite of high rates of initiating breast milk feeding (BMF) among preterm infants, a significant rate of discontinuation occurs shortly after discharge.

AIM

To investigate the effect of mode (direct feeding at the breast vs. expressing) and exclusivity (breast milk combined with formula vs. breast milk only) as well as maternal perceptions on the duration of BMF among preterm infants.

METHODS

The study included mothers whose infants were born before 32 weeks gestation, between January 2012 and August 2015 at Sheba Medical Center (SMC). Perinatal data were collected retrospectively from infants' computerized charts. Mothers were approached >12 months postpartum and were asked to complete a questionnaire. Those who agreed to participate were asked (during their visit to the follow-up clinic or by phone or mail) to complete a questionnaire regarding mode and duration of BMF as well as reasons for its discontinuation. Mothers were also asked about their pre-partum intentions to feed directly at the breast.

RESULTS

Out of 162 eligible mothers, 131 (80.8%) initiated BMF during their intensive care unit (ICU) hospitalization. Of these, 66 (50.3%) discontinued BMF earlier than six months postpartum. BMF ≥ 6 months was significantly associated with direct feeding at the breast, duration of exclusive BMF, and singleton birth. Regression analysis revealed that direct feeding at the breast (any or only) and duration of BMF exclusivity were the only significant variables associated with BMF duration (Odds ratio (OR) 5.5 and 95% confidence interval (CI) 2.00-15.37; OR 1.5 and 95% CI 1.25-1.88, respectively). Milk supply (inadequate or nonexistent) was the most commonly reported cause for BMF discontinuation <6 months. Direct feeding at the breast was significantly associated with BMF duration and was more common among singletons.

CONCLUSIONS

Direct feeding at the breast and duration of exclusive BMF are associated with duration of BMF among infants born <32 weeks of gestational age (GA). These findings suggest that targeting these two factors may play a key role in prolonging BMF duration among preterm infants.

Feeding responses to free-flow formula in term and preterm infants

OBJECTIVES

Although introducing freely flowing formula into the infant's mouth is a common feeding practice, its effect on feeding behavior is largely unknown. We evaluated the effects of free flow of formula from the nipple on infant feeding activity (sucking, swallowing, ingestion rate) and documented potential adverse behaviors such as cough, restless behavior, drooling, apnea, and bradycardia.

METHODS

We studied 13 preterm and 7 term infants. During a feeding, bottle pressure was adjusted every 2 to 3 minutes to increase or decrease free flow from the nipple.

RESULTS

Increase in free flow of formula from the nipple caused rapid increases in suck and swallow frequency in term and preterm infants and increased ingestion rate. The response was reversed by decreasing flow and was repeatable throughout the feeding. Peak suck and swallow rates were highest in term infants. Although drooling increased with increased milk flow, no effect of flow on coughing, restless behavior, or apnea was observed.

CONCLUSIONS

Free-flow formula is a potent stimulus for feeding activity in both preterm and term infants and is not associated with increased apnea or other adverse behaviors. The ability of the infant to divert excess formula flow by drooling is an efficient airway protective behavior. Reduced maximum suck and swallow frequency may be a primary basis for slow feeding in preterm infants.

HIV transmission through breastfeeding: problems and prevention

The greatest burden of HIV infection in women and their children is disproportionately borne by the poorest countries, especially in sub-Saharan Africa. Breastfeeding is a major health-promoting factor for infants and children in developing countries but the risk of mother-to-child transmission (MTCT) of HIV by this route is challenging traditional practices and health policies in low-resource countries. Maternal and infant factors contributing to the risk of MTCT through breastfeeding are still poorly understood and not well researched. Factors identified include: advanced clinical stages of infection in the mother; high maternal plasma HIV-1 load; presence of mastitis; and infant oral thrush. In many developing countries, international agencies are providing support and recommendations for preventing MTCT of HIV-1 by breastfeeding. Preventive strategies supported by WHO/UNICEF and charitable agencies in some sentinel centres in sub-Saharan Africa include routine antenatal voluntary counselling and testing (VCT), PCR testing of infants of seropositive mothers at 6 weeks of age, various combinations of a shortened period (3-6 mths) of exclusive breastfeeding, perinatal administration of antiretrovirals (ARV) such as nevirapine and provision of affordable and safe infant replacement feeds (presently given free by UNICEF in some centres). Many problems, however, have hindered effective implementation of these interventions. In many poor communities, even where VCT facilities are available, acceptance of HIV testing is low because there is fear of stigmatisation by the spouse, family or community and compliance with complex drug regimens is therefore poor. Other problems include the exorbitant cost of antiretroviral drugs, inadequately resourced health care systems and unavailability or poor acceptance of safe breast-milk alternatives. The rate of mixed feeding is high and so the risk of MTCT is increased. Continued promotion of exclusive breastfeeding for at least 6 months, irrespective of HIV status, followed by a properly prepared, high energy, nutritious complementary diet, with the possibility of early weaning to an animal milk formula, still appears to be the most appropriate option for the poor in countries with high levels of MTCT not deriving any benefit from the above strategies. While a longer period of breastfeeding would probably increase the risk of MTCT in vulnerable communities, a shorter duration would certainly increase infant morbidity and mortality. Results of investigations of the efficacy of ARV for protecting the infants of HIV-infected mothers during the breastfeeding period are awaited.

A pilot study to assess the viability of a randomised controlled trial of methods of supplementary feeding of breast-fed pre-term babies

OBJECTIVES

to compare the impact of two methods of supplementary feeding of pre-term babies (bottle vs cup) on subsequent breast feeding and to assess the feasibility of using a randomised controlled trial (RCT) to investigate the topic.

DESIGN AND METHOD

small scale prospective RCT. Data on breast feeding, as defined as the exclusive method of feeding, were collected. A range of relevant bio-data was also collected and their impact on breast feeding assessed.

SETTING

a special care baby unit in a District General Hospital in the UK.

PARTICIPANTS

over a three-month period, all pre-term babies (32-37 weeks' gestation) who fulfilled the inclusion criteria and has been born to mothers who had expressed a pre-partum desire to breast feed, who had consented to take part, were included (n=14).

PROCEDURE

the eligible babies were randomly allocated to supplementary feeding of breast milk, via either a cup or a bottle. Whether or not the baby was being breast fed at discharge was noted.

FINDINGS

the study suggested that this RCT framework is a viable method of investigating baby feeding. Because of the small-scale nature of the project, the actual database must be treated with extreme caution. No significant differences were found between the two groups in terms of breast feeding. However, the mothers reported high levels of support and also the breast-feeding rates were above the national averages. These two findings could have contributed to the non-significant results observed in this analysis.

CONCLUSIONS

if the present findings could be supported by further research, then the non-significant results relating method of supplementary feeds to subsequent breast feeding could be explained by reference to three factors. Firstly, there is, in fact, no real effect of method of supplementary feeding and subsequent breast feeding; secondly, the method adopted differed from existing research and thus may be expected to produce non-corroborative results; and finally, the overall levels of breast feeding within the Unit generally were higher than the national average. The relevance of the RCT for investigating this subject is also discussed with reference to the present data set. Further experimental work to develop these ideas and to identify causal links is required.

Plasma concentrations of vitamin K1 and PIVKA-II in bottle-fed and breast-fed infants with and without vitamin K prophylaxis at birth

Plasma vitamin K1 and proteins induced by vitamin K absence (PIVKA) were assayed simultaneously 1-4 days and 29-35 days after delivery in three groups of infants: breast-fed not receiving vitamin K at birth (n = 12), bottle-fed without vitamin K administration at birth (n = 7) and breast-fed receiving 1 mg vitamin K1 administered by intramuscular injection at birth (n = 13). The bottle-fed infants had a significantly higher vitamin K1 plasma level than breast-fed infants who did not receive vitamin K1 at birth. Extremely high levels of vitamin K were obtained 1-4 days after intramuscular administration. At the age of 1 month, breast-fed infants had the same plasma vitamin K1 concentration whether or not they had received vitamin K1 supplements. Decarboxy prothrombin (PIVKA-II) a reliable indicator of biochemical vitamin K deficiency, was found in 5 out of 12 breast-fed and in 2 out of 6 bottle-fed infants who had not received supplemental vitamin K1 after birth. In a separate study, we followed up to 90 days after birth a larger group if infants. PIVKA-II was found with significantly greater frequency in breast-fed infants receiving no vitamin K than in breast-fed infants receiving 1 mg vitamin K intramuscularly at birth, or in bottle-fed infants without extra vitamin K1. These data form a strong argument for routine vitamin K prophylaxis after birth for all breast-fed infants. The optimum dose and manner of administration require further study.

Assisted feeding is more reliable for infants with clefts--a randomized trial

OBJECTIVE

To compare the effectiveness of squeezable and rigid feeding bottles for infants with clefts.

DESIGN

Patients were randomly assigned at birth to feeding with a squeezable bottle (assisted feeding) or to feeding with a rigid bottle and were followed for 1 year. The data were analyzed on the basis of intention to treat.

SETTING

The trial was conducted within the existing arrangements for hospital and home care for children with clefts within the National Health Service in the north of England.

PATIENTS

The patients were 101 consecutively born children with cleft lip and/or palate who were otherwise healthy. All patients completed the trial. Two were excluded from the analysis when unrelated developmental problems became apparent.

MAIN OUTCOME MEASURES

Anthropometric measures-nude weight, crown-heel length (CHL), and occipito-frontal circumference (OFC)-were recorded.

RESULTS

There were statistically significant differences between the two groups in weight at 12 months (p = .038, with an adjusted mean difference of 0.43 kg) and in head circumference (p = .004 with an adjusted mean difference of 0.77 cm), indicating increased growth in the squeezable bottle group. The difference in CHL was not significant at conventional levels (p = .082). Whereas 25 of 52 (48%) rigid bottles required modification by the health visitor, this was needed for only 4 of 49 (8%) squeezable bottles. There was a highly significant difference when numbers of modifications for each method were compared (p < .0001). Despite modifications, six infants feeding with a rigid bottle (11%) were transferred to a squeezable bottle due to problems with feeding, but none were transferred from squeezable to rigid bottles. Thus, the squeezable bottle generally appeared to be a more satisfactory method, requiring less support or intervention after initial instruction.

CONCLUSIONS

Both feeding methods achieved similar anthropometric outcomes, with a beneficial effect on head circumference and weight in the assisted feeding group. We recommend that this last observation be treated with caution. The squeezable bottles were easier to use, and we recommend that they be routinely prescribed.