Breast, bottle, cup… Who is confused?! Acute Paediatric Feeding EBP and Discussion Group EBP extravaganza 2008

Breast, bottle, cup… Who is confused?! Recent changes to infant feeding practices: Promotion of exclusive breast feeding for first six months of life / WHO Baby friendly hospital initiative and breast feeding guidelines Alternate methods of supplemental feeding

Breast, bottle, cup… Who is confused?! Policy Statement – NSW Health “Breastfeeding is the biological norm and most beneficial method for feeding infants with immediate and long -term health outcomes for mother and infant and is to be actively promoted, protected and supported by the NSW Health system” (p5) Breastfeeding in NSW: Promotion, Protection and Support Policy Directive, 2006

Breast, bottle, cup… Who is confused?! Maternity Services Ten Steps to Successful Breastfeeding Every facility providing maternity services and care for newborn infants should: 1. Have a written breastfeeding policy that is routinely communicated to all health care staff. 2. Train all health care staff in skills necessary to implement this policy. 3. Inform all pregnant women about the benefits and management of breastfeeding.

Breast, bottle, cup… Who is confused?! 4. Help mothers initiate breastfeeding within half an hour of birth. 5. Show mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants. 6. Give newborn infants no food or drink other than breast milk, unless medically indicated. 7. Practise rooming-in - that is, allow mothers and infants to remain together - 24 hours a day.

Breast, bottle, cup… Who is confused?! 8. Encourage breastfeeding on demand. 9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants. 10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Breast, bottle, cup… Who is confused?! Impact on special care nurseries and premature babies: Other evidence for use of dummies for suck training in premature infants (Ref: Cochrane Database 2005, Pinelli, J; Symington) Extra support required for premature babies to establish any successful suck feeding – specialist caseload

Breast, bottle, cup… Who is confused?! EBP group felt: Recommendations in some breast feeding documents cite ‘nipple confusion’ as a barrier to establishing breast feeding  no evidence for ‘nipple confusion’ ‘suck feeding’ of any kind (bottle / finger feeding with supply line) more normal oral motor process for newborns than cup feeding Cup feeding is not a ‘biological norm’ for newborn infants

Breast, bottle, cup… Who is confused?! Formulating our clinical question: How can we support BF in special care nurseries and still provide appropriate care for babies with special needs? Initially considered looking at “Does ‘nipple confusion’ exist?” Nipple confusion is cited many nursing articles, but not specifically researched  dead-end search!

Breast, bottle, cup… Who is confused?! Preliminary look at cup feeding vs bottle feeding  Cochrane database 2007 Flint A, New K, Davies MW. “ Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed.” Do initial feeding experiences and patterns effect establishment of breast feeding, or breast feeding duration?

Breast, bottle, cup… Who is confused?! Our clinical Question: In newborns, is there a difference in introducing bottle vs cup feeding in establishing and maintaining breast feeding?

Breast, bottle, cup… Who is confused?! 13 potential articles found 5 articles answered both portions of the question (establishing and maintaining BF) 4 of the 5 studies reviewed were specific to preterm infants Articles reviewed were all level II and III evidence * See references for full list of articles *

Breast, bottle, cup… Who is confused?! Results: Overall there was no statistically significant difference between bottle and cup feeding in establishing and maintaining breast feeding. One study indicated that BF rates were higher for cup fed infants at discharge, but hospital stay was longer. There was no significant difference in BF duration

Breast, bottle, cup… Who is confused?! One study indicated that babies delivered by caesarean had better BF duration when cup fed (?? Why) One study indicated that cup fed babies MAY have better BF duration, but the study was too small to elicit significant results

Breast, bottle, cup… Who is confused?! Other comments: Only one study followed babies until 6mths One study was a pilot only, and may elicit better results if a full project were pursued There was poor compliance from parents and nursing staff in one larger study, which reduced the power of the results

Breast, bottle, cup… Who is confused?! Where does that leave us… Still confused?

Breast, bottle, cup… Who is confused?! Cochrane review on bottle vs cup feeding  no significant difference EBP review on cup vs bottle for establishing AND maintaining BF  no significant difference

Breast, bottle, cup… Who is confused?! If there is no significant difference between them  does it matter which method is used?

Breast, bottle, cup… Who is confused?! Clinical application: NICU and special care nurseries can function outside of BFHI guidelines because they have a ‘specialist’ caseload SPs working in NICU / SCBU environments can negotiate with individual teams re feeding methods and still promote breast feeding use of EBM

Breast, bottle, cup… Who is confused?! Combined evidence from Cochrane review and EBP results can support use of bottle feeding (with expressed breast milk - EBM) for pre term infants Bottle feeding can be used as an interim step for babies who will BF in the longer term

Breast, bottle, cup… Who is confused?! Goal / spirit of the breast feeding guidelines is to promote breast milk as best nutrition for babies in the first 6 months of life. Does method of delivery matter? SPs aim to facilitate appropriate suck feeding for newborns with feeding difficulties, and work closely with LCs and nursery staff to achieve this, promoting BF whenever possible.

Breast, bottle, cup… Who is confused?! Case example: Term baby with antenatally diagnosed severe diaphragmatic hernia Surgical repair D19 then ventilated CPAP support on and off for 6wks Mother very keen to BF

Breast, bottle, cup… Who is confused?! First suck feed attempts 8wks after birth (post term) First attempts were suck feeds of EBM from a bottle  can control flow more easily (externally) as well as control volume taken (fluid restrictions)

Breast, bottle, cup… Who is confused?! First breast feeding attempt 6 days later (9 wks after birth)  joint review by SP and LC SUCCESSFUL FIRST BREAST FEED!!!

Breast, bottle, cup… Who is confused?! This baby was not confused!

Breast, bottle, cup… Who is confused?! References: Carmel T Collins, Philip Ryan, Caroline A Crowther, Andrew J McPhee, Susan Paterson, Janet E Hiller. Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial. BMJ published 18 June 2004 Gilks, J; Watkinson, M. Does cup feeding help improve breast feeding rates in pre-term babies? Pediatric Research Volume 56(3), September 2004, p 509

Breast, bottle, cup… Who is confused?! Cynthia R. Howard, Fred M. Howard, Bruce Lanphear, Shirley Eberly, Elisabeth A. deBlieck, David Oakes and Ruth A. Lawrence. Randomized Clinical Trial of Pacifier Use and Bottle-Feeding or Cup feeding and Their Effect on Breastfeeding Pediatrics 2003;111; Mosley, C; Whittle, C; and Hicks, C A pilot study to assess the viability of a randomized controlled trial of methods of supplementary feeding of breast fed preterm babies Midwifery

Breast, bottle, cup… Who is confused?! Rocha NM, Martinez FE, Jorge SM. Cup or bottle for preterm infants: effects on oxygen saturation, weight gain, and breastfeeding. Journal of Human Lactation. 18(2):132-8, 2002 May.

Brodie Warren Leader, Acute Paediatric Feeding EBP and Discussion Group, 2008 THANKS!