Cup Feeding Strikes Again!

Specialties NICU

Published

So I had this lovely little guy, about 3700 grams, term, some meconium staining at birth, otherwise completely boring pregnancy and lady partsl delivery. He had some low blood sugars (which we call chemstrips or chems where I work), so they followed their protocal (the chem was still like in the 40's) and put the baby to breast and rechecked, well, turns out the average woman cannot really produce enough milk at hours after birth to raise that kind of blood sugar (sarcasm intended). So they followed their protocol and gave him formula, by cup, because we don't want nipple confusion. Problem is you can only really cup feed so much so he was getting about 20-30mls per feed.

I can understand this if it's like a one time event and gets the kid over the hump, but he had recurring low chems and when he finally dipped under 35 he bought himself a gavage feed and an admission to NICU. Of course we NICU folks aren't quite as concerned about nipple confusion as we are about say; brain damage so we proceeded to bottle feed the kid. So his lowest blood sugar during his entire admission was 63. He wolfs down 60-90 mls of either formula or breastmilk (turns out his mom's milk came in pretty early and abundant). We have had several admissions to our unit that could have been prevented had our General Nursery been permitted to use a bottle (cup feeding only used for babies that moms state want to breastfeed).

So to prevent the threat of nipple confusion this kid had to spend hours separated from his mother until we established that his blood sugars were stable whereupon we started having her breastfeed followed by a pc bottle. He will be going home a day late due to this silliness.

I am so frustrated with cup feeding !!!!!! We are getting frequent admissions of kids who develop tachypnea or resp distress after cup feeding (can you say aspiration?). I know I've ranted about this before, but here I go again.

Oh, and the reason we treat blood sugar so aggressively is (in my opinion) due to the abundant litigation. Try googling "neonatal hypoglycemia", or "newborn low blood sugar" and see how many lawyer's ads and websites you bring up.

:uhoh21: I just got a lot of journal articles. Honest! :lol2:

Specializes in Nurse Scientist-Research.
:uhoh21: I just got a lot of journal articles. Honest! :lol2:

Yea, you're right. Several years ago when I was going through our internship program it was true, but honestly I haven't really checked since then.

Specializes in NICU, PICU, educator.

We use colostrum for priming feeds. We make sure the mom puts the first few days in a separate container so we know which to use first. It helps to get flora growing and mec moving. If we have a kid with a really high bili, we will alternate colostrum with formula (bili binds to formulas and colostrum makes them poop!).

In NICU, we get way hung up on kcal's per kg and ml's per kg and what is the glucose load we are giving.

I am an advocate for breast feeding but this idea of nipple confusion is all wrong. I have been a nurse for 40 years and have never seen any infant with nipple confusion. There were many moms who were being pushed into breastfeeding either by the staff or family when the mom did not want to breast feed.

I think it is terribly wrong to force an infant to cup feed or syringe feed just because the mom or family member feels the infant will develop nipple confusion. I have had many heated discussions with our lactation specialist on this issue. Forcing an infant to feed this way is not helping the infant learn how to suck properly. We have had OT specialist trained in feeding disorders agree that this is an improper way of feeding a newborn.

As several other members have stated that if the infant is allowed to be hydrated with use of bottle feeding, the infant will gladly return to breast feeding because she/he feels better. We have moms continue to breast feed and then give supplement and have moms pump q3h when not able to be with infant. Moms are much happier when she takes infant home healthy.

We are now trying to get banned any syringe or cup feeding in the NICU. We all feel it is a dangerous idea and puts extra stress on an already compromised infant.

quite frankly, i don't understand the whole blood sugar issue in the first place - i've known some homebirth midwives for years, and none of them ever test a newborn's blood sugar, and none of those babies have suffered any harm (actually, their record as far as infant and maternal mortality and morbidity is better than hospitals', even in "high risk" populations). their moms just keep on breastfeeding them until their milk comes in, and that's that. our grandmothers did it that way, and none of our parents died of "low blood sugar." why do doctors think they need to mess with nature?

so midwives don't test the infants of diabetic moms? or lgas, sgas or preemies? and how "high risk" are you talking?

how do you know those babies didn't suffer any harm? where harm from low blood sugar shows up is in learning disabilities and maybe autism.

as far as "our grandmothers" doing it that way - - - people used to live in extended families and/or groups. there was usually a lactating woman around to feed the screaming/starving infant when the mother's milk hadn't come in yet and the colostrum wasn't enough or the mom just couldn't produce for any reason. the rich had wetnurses. today we have bottles.

thank goodness our hospital doesn't allow any of those nutty "alternative" feeding practices, although the lactation consultants still try to pull a fast one now and then. one of our long term preemies visited a while ago- the lc got her to syringe feed the kid after discharge and a year later she was still being fed by syringe!

then there's the practice of giving iv fluids instead of that nasty unnatural bottle when the mom wants to breastfeed exclusively and the kid needs hydration. an iv is soooo much more natural.

in 20 years of neonatal care, the "nipple confusion" i've seen has been the result of flat or inverted nipples that the kid just can't get a latch onto. it's not confusion, it's physiology.

nell

I have seen nipple confusion. I can always tell the BF babies who got bottles the night before - they go back to mom, latch, but then spit the nipple out repeatedly instead of sucking and drawing the nipple in.

Most can be suck re-trained with a gloved finger farily easily. A few can't. The problem is, you don't know which baby it will be who will persist in refusing the breast.

I'm not, however, a 'breastfeeding natzi', but I will bend over backwards to respect a mom's wishes for no bottles if at all possible.

Specializes in NICU.

The only thing that really concerns me about exclusive breastfeeding from the start is hydration. Yes, colostrum is very high in nutrition, I completely agree with that - but it's sometimes not enough fluid volume for a baby. I can't tell you how many babies we've admitted to the NICU from the ER or peds clinic who have bilirubin levels over 25 because they've been exclusively nursing since birth and are incredibly dehydrated. Their blood sugars are fine, that's never the issue with them. These aren't babies with blood type incompatibilities, either. I wish there was some natural way to provide fluid to these babies without disturbing breastfeeding.

Maybe if we still lived outside like cavemen then our babies wouldn't get so jaundiced in the first few days because they'd be getting plenty of sunlight. ;) Seriously, it's an evolutionary theory to ponder...

About hydration -

I had twins (36 weeks, 6 & 7 lbs). One nursed well, the other had a weird suck - not weak, just different - and had trouble transferring enough milk from the breast. He developed a late-onset ('breastmilk') jaundice that never got really bad, but lingered for a couple of weeks. I switched him to EBM by bottle and the jaundice was gone in less than 48 hours. It was not the breastmilk that was the problem, but the fact that he wasn't able to transfer enough of it when he sucked.

My daughter had a similar suck (term, 9 lbs - my first baby). She had 15.6 T Bili on day 3. but with home photo, it went away and never got higher. I gave a couple of 10-15 cc sterile H20 supps., but exclusively breastfed her. In retrospect, her jaundice might have gone away quicker had I pumped and given EBM by bottle some.

I made tons of colostrum and mature milk, but if the baby can't transfer enough of it, what good is it. I think the problem more often lies in the ability of the baby to suck properly and transfer enough milk, not in the mom's ability to produce.

Something to think about.

Specializes in NICU.

These particular babies were dehydrated because the mother wasn't producing much milk - when they'd pump, they'd get drops instead of ounces. Maybe it's because the babies weren't sucking well, who knows. Either way, hydration was their issue, not the breastmilk itself.

I've seen that, too.

I guess the point I was making was that many moms have sore nipples and dehydrating babies. Perhaps it is the baby's suck and not always the mom's supply.

I'd been a nursery nurse for years and adept at latching newborns when mine came along. Even with oral motor therapy I was taught to do, my kids with suck issues still hurt me and had feeding problems. The twin I spoke of never was able to get back on the breast. I pumped 25-30 ounces /day (while also nursing his twin) for him for 5 months just so he could get at least some breastmilk.

Anyhow... It's frustrating to want to breastfeed and not be able to fix the baby's suck. Like you, I too wish there was a way to supplement without hindering the process.

I have had success with syringe feeding (short-term, of course). I am always surprised how much they can take so quickly by just dripping it in a few drops at a time. The baby must be cooperating and swallowing it down. But those dehydrating BF kids usually are eager. LOL

Specializes in Tele/L&D,NSY,PP,Education,Mgmt.

I would like to share my thoughts on this subject. First, nipple preference DOES exsist. I can tell by observing the infant at the breast if he/she has had a bottle. When an infant feeds from a bottle the baby doesn't have to "suck",the milk drips right in the baby's mouth. Babies easily get overfed if the nurse is not careful to limit the amount consumed. When offered the breast after the bottle the baby will latch and then wait for the milk to "drip in". When this doesn't occur, the baby will usually cry and pull away from the breast. Not, only that but formula is not completely digested by the infant, so all the undigested material sits in the infant's stomach and makes him feel full so he doesn't get the hunger signal to want to breastfeed every 2-3 hours as needed for mom to establish and maintain an adequate milk supply. Sounds like a great start to a solid breastfeeding relationship there :banghead: Yes, there are exceptions to every rule, some babies have done well with both feeding methods. I have literally worked with thousands of breastfeeding couplets in my career and have found this in some cases, but certainly not the norm.

Also, the comment was brought up on the hydration issue and that colostrum sometimes isn't enough to sustain a infant to avoid dehydration. If a infant has been exclusively breastfed and is dehydrated then the infant WAS BREASTFEEDING POORLY. Just because an infant is at the breast sucking away doesn't mean he is obtaining adequate milk transfer.

Now, about cup feeding. If your baby aspirates while cup feeding, then you are pouring the milk into the baby's mouth, which should never be done. There is a technique to correctly cup feed a baby, I teach parents and have NEVER had a baby aspirate. Learn the correct technique and baby can easily consume 30 cc. By the way, feeding 90 cc at a time is considered overfeeding where I'm from. A newborn's stomach capacity is about the size of a marble at birth, a typical newborn breastfed baby obtains a couple of teaspoons of colostrum during a good feed.

TiffyRN wrote:

"What is the caloric content of colostrum? Because if it's too far off of 20cal/oz then the NICU's need to modify their feeding policies, many of our micropreemies do not need "high carb" feedings into their delicate undeveloped guts"

Tiffy, micropreemies especially need breastmilk over formula for their "delicate undeveloped guts". There is numerous research that supports this. I would be happy to share my sources with anyone that is interested.

Thank you for listening.

Specializes in Community, OB, Nursery.
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"What is the caloric content of colostrum? Because if it's too far off of 20cal/oz then the NICU's need to modify their feeding policies, many of our micropreemies do not need "high carb" feedings into their delicate undeveloped guts"

Tiffy, micropreemies especially need breastmilk over formula for their "delicate undeveloped guts". There is numerous research that supports this. I would be happy to share my sources with anyone that is interested.

Also, the colostrum content of a mom breastfeeding (or pumping for) a preemie is way different than that of a mom of a full-termer. So probably that mom's colostrum is just right for her particular baby.

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