The effect of feeding with spoon and bottle on the transition time to the full breastfeeding and the sucking success in preterm babies Aynur AYTEKIN, PhD, RN Ebru Betul ALBAYRAK, MSc, RN Sibel KUCUKOGLU, PhD, RN Ibrahim CANER, MD Atatürk University, Erzurum, Turkey. e-mail: aynur.Aytekin@atauni.edu.tr

Introduction For a preterm infant that feed orally in an effective and safe manner, it is necessary for them to be able to combine the actions of sucking, swallowing and breathing1,2. 1. Koenig JS, Davies AM, Thach BT. Coordination of breathing, sucking and swallowing during bottle feeding in human infants. J Apply Physiol 1990; 69: 1623-9. 2. Mizuno K, Ueda A. The maturation and coordination of sucking, swallowing and respiration in preterm infants. Journal Pediatr 2003; 142: 36-40.

Introduction Preterm infants are not successful to the sufficient milk intake in their first breastfeeding experiences. Therefore, one of the complementary feeding methods may be also required until the infants can meet their nutritional needs by the breastfeeding.1 Complementary feeding methods bottle-feeding cup feeding spoon feeding dropper feeding finger feeding 1. Collins CT, Makrides M, Gillis J, et al. Avoidance of bottles during the establishment of breast feeds in preterm infants. Cochrane Db Syst Rev 2008; Issue 4.

The purpose of study This study was planned to investigate the effect of feeding with spoon and bottle on the transition time to full breastfeeding and sucking success in preterm infants.

Methods Methods A descriptive and correlational study was conducted at the neonatal intensive care clinics of two hospitals in the eastern region of Turkey between September 2013 and January 2014.

Study population The population of this study consisted of preterm infants that were hospitalized in the NICU on the date of the study and met the inclusion criteria of the study. This study was performed on the whole population without selecting the sample group. In this study, there are 72 preterm infants which are 37 in the spoon group and 35 in the bottle group.

Power analysis A power analysis was conducted with 35 preterm infants included in each study group at a confidence interval of 95%, and the power of the study was found to be 0.72 with a margin of error of 0.051. 1. Lenth R. Java applets for power and sample size. http://homepage.stat.uiowa.edu/~rlenth/Power/.30.12.2013.

Inclusion criteria The following inclusion criteria were used in this study: The preterm infants were, • born at the 30-34th gestational week, • having a birth weight of 1000 g or more, • having an apgar score of >6, • with stable health condition (did not have any congenital malformation that may cause asphyxia and affect respiration and who had spontaneous respiration did not have cranial bleeding and hyperbilirubinemia that may lead to blood abnormalities), • fed only by gavage with breastmilk and ready for the transition to oral feeding, • having a mother which was willing to breastfeed her baby.

Data collection Data were collected by the researchers with following forms. Preterm infant descriptive information form Preterm infant follow-up form LATCH Breastfeeding Assessment Tool

Data Collection Preterm infant descriptive information form was prepared by the researchers in line with the literature and included the descriptive questions about the preterm infant. It was filled in by face to face interview technique. The preterm infants in the study were followed until they were discharged from the hospitalization. The information obtained during this follow-up period were recorded in the preterm baby follow-up form.

LATCH Breastfeeding Assessment Tool The LATCH Breastfeeding Assessment Tool was developed by Jensen and Wallace in 1994 in Oregon. The Turkish validity of the LATCH was performed by Koyun in 2001. The LATCH Breastfeeding Assessment Tool form is composed of five evaluation criteria. Each item is evaluated between 0–2. The lowest (0) and the highest (10) scores can be obtained from the charting system. The highest score shows the infant’s sucking success. Because the LATCH tool is an observation-based form, it was filled out by the researcher and an observer (the nurse) through observations at the same time and independently from each other. Agreement between the independent observers evaluated by McNemar test was found that there was no difference between the observers (p>0.05).

Study Groups While the bottle feeding method was used in one of the NICUs, the spoon- feeding was used in the other.

Spoon feeding group The babies were initially breastfed by their mothers. Then, they were fed with their mother’s milk by the spoon feeding method. The amount of the milk were determined by the neonatologist according to the premature infant’s body weight and the total liquid amount she or he had to receive.

Bottle feeding group The babies were initially breastfed by their mothers. Then, they were fed with their mother’s milk by the bottle feeding method. The amount of the milk were determined by the neonatologist according to the premature infant’s body weight and the total liquid amount she or he had to receive.

Ethical Considerations Approval of the ethics committee (Atatürk University Health Sciences Faculty Ethics Committee) and official permissions from the hospitals were obtained. Additionally, informed written consent was obtained from each family included in the study.

Data Analysis The data obtained from this study were evaluated with computer software. Percentage distribution, mean, chi-square test, independent t-test, Cronbach alpha coefficient calculation and McNemar test were used to assess the data.

Spoon feeding group (n=37) Bottle feeding group (n=35) Results Table 1. Comparison of the spoon and bottle feeding groups according to the descriptive charecteristics of preterm babies   Characteristics Spoon feeding group (n=37) Mean±SD Bottle feeding group (n=35) Test ve p Gender (n,%) Male Female 23 62.2 14 37.8 18 51.4 37 48.6 χ2=0.845 p=0.358 Gestational age (weeks) 32.16±1.19 32.37±1.00 t=0.804 p=0.424 Birth weight (g) 1619.46±303.03 1704.43±202.58 t=1.391 p=0.169 Height (cm) 41.05±2.69 41.80±2.37 t=1.240 p=0.219 Head circumference (cm) 29.35±1.64 29.86±0.69 t=1.690 p=0.095 APGAR at the first minute 7.14±0.42 7.29±0.46 t=1.456 p=0.150 APGAR at the fifth minute 8.11±0.74 8.25±0.51 t=0.995 p=0.323

Spoon feeding group (n=37) Bottle feeding group (n=35) Results Table 2. Comparison of the groups in terms of mean weights at the time of starting breastfeeding, at the transition time to full breastfeeding and at the time of discharge   Characteristics Spoon feeding group (n=37) Mean±SD Bottle feeding group (n=35) Test ve p Weight at the time of starting breastfeeding (g) 1859.16±201.94 1930.28±142.51 t=1.718 p=0.090 Weight at the transition time to full breastfeeding (g) 1965.24±187.45 2039.00±270.72 t=1.363 p=0.177 Weight at the time of discharge (g) 2106.03±105.51 2131.88±234.77 t=0.608 p=0.545

Spoon feeding group (n=37) Bottle feeding group (n=35) Results Table 3. Comparison of the groups in terms of mean period at the transition time to full breastfeeding and at the time of discharge   Characteristics Spoon feeding group (n=37) Mean±SD Bottle feeding group (n=35) Test ve p The period between the first breastfeeding and the transition time to full breastfeeding (h) 104.43±72.66 148.91±109.84 t=2.037 p=0.045 The period between the first breastfeeding and the time of discharge (h) 140.11±107.41 164.91±123.38 t=0.911 p=0.365

Spoon feeding group (n=37) Bottle feeding group (n=35) Results Table 4. Comparison of the groups in terms of the mean scores of the LATCH assessment tool   Characteristics Spoon feeding group (n=37) Mean±SD Bottle feeding group (n=35) Test ve p LATCH-First measurement 6.59±1.34 6.74±1.09 t=0.512 p=0.610 LATCH-Second measurement 8.29±1.54 7.54±1.46 t=2.127 p=0.037 LATCH-Final measurement 9.83±0.55 9.22±0.54 t=4.695 p=0.000

Conclusion It was found that the preterm infants used the spoonfeeding method had a shorter transition time to the full breastfeeding than that of the bottle feeding method. In addition, they had the sucking success in a better level.

Clinical Relevance Consequently, the spoonfeeding method can be recommended as a complementary feeding method for preterm babies until they reach the maturation level where they can meet their nutritional requirements by way of breastfeeding.