FEEDING METHODS

3. FEEDING METHODS

Enteral feeding is defined as the administra- (251). No studies were identified that com- tion of any feed into the gastrointestinal tract

pared spoon feeding or direct expression of and includes intragastric feeding, feeding

breastmilk into the infant’s mouth with other by cup, bottle, spoon or paladai, and breast-

oral feeding methods.

feeding. In this section we review the types of Only one RCT (Level II evidence) from enteral feeding options available. Intravenous

Australia, which compared the effect of cup fluids and total parenteral nutrition are not

feeding with bottle feeding on breastfeeding discussed. A pre-term infant’s progression to

patterns (see Table 3.1.1) (252), reported that breastfeeding must pass through a number

infants randomized to cup feeds were more of stages before the infant begins to swallow,

likely to be fully breastfed (with no other types coordinate and then learn proper attachment

of milk or solids other than breastmilk) on and sucking. Different forms of enteral and

discharge home (odds ratio [OR] 1.73, 95%CI oral feeding have been used during this transi-

1.04 to 2.88), and had a longer length of stay in tion.

hospital (hazard ratio [HR] 0.71, 95%CI 0.55 to 0.92). The prevalence of any breastfeed-

3.1 Oral feeding

ing was apparently higher in the cup-feeding group compared with the bottle-feeding group

Oral feeding methods discussed below include at 3 and 6 months, but the differences were

administration of any feed directly into the not statistically significant. Another small

oral cavity by a method other than breast- RCT showed no differences in the proportion

feeding: cup, paladai, spoon, syringe, direct of infants receiving any breastfeeding at dis-

expression and bottle feeding. In this section, charge between cup-fed and bottle-fed pre-

studies that compared these different oral term infants, but there was a higher prevalence

feeding methods are compared. The studies of breastfeeding at 3 months among those who

utilized small medicine cups, standard infant were breastfeeding at the first follow-up visit

feeding bottles, standard 10 or 20 ml syringes, (253). This study did not report the effect on

or a paladai shaped like a small cup with an exclusive or full breastfeeding rates.

open spout on one side. Small observational studies (LIII-3 evi-

dence) from the UK, US and India have Results reported mixed effects of cup, bottle and

Effects on mortality, serious morbidity,

paladai feeding on breastfeeding rates, milk

neurodevelopment or malnutrition

volume intake, feeding duration, and feeding No studies were located which compared the

difficulties at the time of hospital discharge effects of different oral feeding methods (cup,

in LBW infants (32–42 weeks gestation) (251, bottle, paladai, spoon, direct expression) on

254–256). These studies all had problems with mortality, severe morbidity, neurodevelop-

observer and selection biases, insufficient dis- ment, growth or malnutrition rates in LBW

cussion of confounding factors, and lack of infants.

follow-up after hospital discharge. The impact of oral feeding on physiological

Effects on other important outcomes

parameters in LBW infants has been reported Breastfeeding rates, at the time of discharge

in four studies (251, 253, 256, 257). Rocha et from hospital or at subsequent follow-ups, and

al reported no significant differences between physiological parameters were the outcomes

cup-fed and bottle-fed infants with regard to reported in studies that compared different

the time spent in feeding, feeding problems, feeding methods. Most studies compared cup

weight gain, or breastfeeding prevalence at feeding with bottle feeding. One Indian study

discharge or at the 3-month follow-up (253). compared cup, bottle and paladai feeding

A possible beneficial effect of cup feeding was

62 OPTIMAL FEEDING OF LOW-BIRTH-WEIGHT INFANTS: TECHNICAL REVIEW

SUMMARY TABLE 3.1.1 Effects of cup feeding compared with bottle feeding on breastfeeding patterns in LBW infants

Study, Design

Approximate proportion of

(Level of Inclusion participants with gestation age a Effect measure evidence)

Comparison groups

Outcome measure [95% CI]

Collins et al Gestational age

After breastfeeding or Proportion of infants OR 1.73 (252)

fully breastfed at [1.04, 2.38] RCT (LII)

<34 weeks, no

when mother unable

previous cup or to be present, infants hospital discharge bottle feeding,

fed by cup (n = 151)

mother intended compared with infants Proportion of infants OR 1.37 to breastfeed

fed by bottle (n = 152) receiving any BF at [0.78, 2.38] hospital discharge

Proportion of infants OR 1.31 receiving any BF at

[0.77, 2.23]

3 months after discharge

Proportion of infants OR 1.44 receiving any BF at

[0.81, 2.57]

6 months after discharge

Proportion of infants RR 1.03 (253 )

Rocha et al Gestational age

Infants randomized

32–36 weeks to cup feeding (n=44) receiving any breast- (0.83, 1.28) (RCT LII)

compared with those

feeding at discharge

randomized to bottle feeding (n=34)

a If gestational age was not available in the publication, infants with birth weight <1500 g are assumed to be <32 wk gestation, those weighing 1501–2000 g to be 32–36 wk gestation, and those weighing 2001–2500 g to have a gestation of 37 weeks or more.

a lower incidence of desaturation episodes Conclusions and implications (13.6% versus 35.3%, CF vs. BF, P = .024).

None of the available studies examined the Another US study used a randomized cross-

effects of different oral feeding methods on over trial in pre-term infants (LII evidence)

mortality, morbidity, neurodevelopment or (257) to receive either 1 cup feed followed

malnutrition. The findings are largely based by 1 bottle feed, or 1 bottle feed followed by

on three RCTs and small observational stud-

1 cup feed when they reached 34 weeks cor- ies which examined the effect of cup feeding rected gestational age (there was a minimum

compared to bottle feeding on breastfeed- of 1 intragastric feeding between the two oral

ing rates at the time of hospital discharge in feeding sessions). Lower mean heart rate and

pre-term infants. Some studies, including the oxygen saturations in bottle-fed compared to

larger RCT, reported modest benefits of cup cup-fed infants were reported in this study,

feeding on EBF rates at discharge from hospi- but all other physiological parameters were

tal. Evidence was insufficient to allow conclu- not significantly different. Finally two small

sive statements on the safety of the methods. observational studies, which examined the

Overall, the above findings suggest that cup impacts of different oral feeding methods in

feeding has some benefits over bottle feeding LBW infants (LIII-3 evidence) (Malhotra et

with regard to achieving full breastfeeding and al (251): cup, bottle and paladai; and Howard

physiological stability in pre-term infants. et al (256): cup and bottle), reported small

Most of the studies comparing cup feeding deteriorations in physiological parameters in

with bottle feeding were conducted in devel- bottle-fed infants.

oped countries. Avoidance of bottle feeding

63

RESULTS

64 OPTIMAL FEEDING OF LOW-BIRTH-WEIGHT INFANTS: TECHNICAL REVIEW

is likely to have greater benefits in developing countries because of the higher risk of con- tamination of bottle feeds in these settings.