Cup-feeding Preterm Infants
by Anne Eglash MD, IBCLC, FABM
Preterm infants are more vulnerable to morbidity and mortality than term infants, but they have lower breastfeeding rates at hospital discharge. Although most preterm infants in the USA are discharged bottle feeding to some extent, evidence and clinical experience has taught us that bottle feeding may be associated with breast refusal in this population. Although one may argue that with enough perseverance, a preterm infant will eventually breastfeed, many families are doubtful and stressed by the work involved in transitioning to the breast. Many mothers of preterm infants in the USA become exclusive pumpers, which is associated with early weaning..
According to a 2018 literature review of cup feeding as an alternative method for oral feeding, cup feeding and other similar feeding vessels have been used for many years by several populations world-wide to feed preterm infants. Preterm infants are able to cup feed by 30 weeks gestation, earlier than they are able to bottle feed.
This literature review included 12 peer-reviewed research studies on the use of cup feeding among preterm infants, with 7 being randomized controlled trials. The studies represented populations in the USA, UK, India, Turkey, Australia, Egypt and Brazil.
- Cup feeding was found to be slower than bottle feeding.
- Infants who were cup fed had stable oxygen saturations and heart rates.
- Cup feeding was associated with a longer duration of stay in the NICU.
- Cup feeding was associated with a higher rate of exclusive breastfeeding at discharge.
- Cup feeding was associated with a higher rate of aspiration and pneumonia.
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The benefits of human milk for the preterm infant are well established. Preterm infants have lower breastfeeding rates and often face breastfeeding challenges. It is important that feeding practices for preterm infants optimize their chances of breastfeeding.
The purpose of this integrated review is to synthesize and critically analyze research related to the safety and efficacy of cup feeding as an alternative, supplemental feeding method for breastfed infants.
The electronic data bases of PubMed, CINAHL and were used to identify studies published in English from 1998-2017.
Using inclusion and exclusion criteria, 27 articles were initially assessed. After further screening 19 articles were included in the full review and of these 5 more were excluded. Lastly, an in-depth review of these 14 studies resulted in 2 more exclusions, for a total of 12 studies that met full inclusion and exclusion criteria.
Studies were examined for information on safety and efficacy of cup feeding as an alternative, supplemental feeding method for preterm breastfed infants. Studies were grouped into categories of outcomes that included (a) safety and physiologic properties; (b) breastfeeding outcomes.
Use of cup feeding resulted in more stable heart rate and oxygen saturation than bottle feeding with similar weight gain. Additionally, breastfeeding rates were higher at discharge with continued higher rates at 3 and 6 months post-discharge for cup fed infants.
Premature infants face more breastfeeding obstacles than term infants. The potential for cup feeding as an alternative to bottle- feeding for breast fed preterm infants is positively supported by these results It is fundamentally important for NICU professionals to establish a protocol, education and training for the potential use of this feeding method for this vulnerable population.
The authors found that cup feeding was not associated with harm, was not found to be slower than bottle feeding. Preterm infants who were cup fed did not have a longer duration of hospitalization. One study in the review found a longer length of stay for cup fed preterm infants, but once they accounted for non-compliance among hospital staff in terms of using proper cup feeding technique, no difference in length of hospital stay was found.
The data on cup feeding and increased breastfeeding rates is compelling. Baby Friendly USA has been working on the Baby Friendly Hospital Initiative for Neonatal Wards, which recommends cup feeding as an alternative feeding strategy rather than bottles.
For a free instructional video on cup feeding, check out IABLE’s YouTube channel.