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.