Cup Feeding Strikes Again!

[TiffyRN]

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.

[LYRICS84]

arwen u, you are exactly right. here are some reasons to provide mom's ebm or donor milk to preemies.

gastrointestinal benefits

faster transit time in stomach reduces intestinal permeability. the gut of the preterm infant appears to be a less effective mucosal barrier than that of term infants. oral feedings that promote the bacterial colonization with beneficial bacteria are essential for normal maturation and the associated immune system. iga, abundant in breastmilk, "paints" the lumen of the gut inhibiting the penetrating of antigens and microorganisms. less residual milk in the stomach at the time of the next feeding breastmilk is well tolerated laxative effect of colostrum and the enzymes in breastmilk that "pre-digest" nutrients are important for the immature digestive systems of preemies faster progression to full oral feedings stimulate gastrointestinal growth, motility and maturation enzymes help immature infants absorb and utilize nutrients more efficiently improve absorption of nutrients when breastmilk and special formulas are combined less need for tpn (total parenteral nutrition)

anti-infective benefits reduced episodes of bacteremia and sepsis fewer urinary tract infections reduced incidence of necrotizing enterocolitis. research shows that infants who receive breastmilk have a lower incidence of necrotizing enterocolitis and other infections. babies born prematurely miss out on the transfer of calcium, iron and immunoglobulins via the placenta that occurs during the third trimester of pregnancy. the only way premature infants can receive the crucial infection fighting immunoglobulins is from breastmilk from lacation education resources

and from the aap

the american association of pediatrics (aap) states: 1)

"human milk is species-specific, and all substitute feeding

preparations differ markedly from it, making human milk uniquely

superior for infant feeding", 2) "human milk-fed premature infants

receive significant benefits with respect to host protection and

improved developmental outcomes compared with formula-fed premature

infants", and 3) "hospitals and physicians should recommend human milk

for premature and other high-risk infants either by direct

breastfeeding and/or using the mother's own expressed milk."

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/

496

i apologize for the lengthy reply, but felt all of it was important to post.

[TiffyRN, BSN, PhD]

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.

Sorry, I screwed up the quote above but it was from Arwen U I think ?

So, after 4 1/2 yrs in a level III NICU I KNOW micro's need breastmilk over formula, Our unit won't even give formula to a kid under 30 weeks, if mom has none, we will give donor milk, haven't had any parents refuse so far when rationale is given. It hurts me to give initial feedings to any preemie with anything but breastmilk. I love for the babies I'm caring for to get breastmilk. I'm a big fan of breastmilk. Can I make it any clearer?

What I'm not a fan of is not seeing the forest for the trees. What am I talking about? Claiming that colostrum is so powerful it can sustain a stressed (NOTICE, I am saying stressed, not normal) newborn. It must have something like 100cal/oz!! I don't buy it. And part of my doubt comes from the assumption that our Neo's wouldn't put something that rich full-strength into the guts of our itty-bittys. I want to see the research proving that drips of colostrum will raise the blood sugar of an infant struggling with blood sugar issues (as it is the policy of our general nursery to put the baby to breast if the blood sugar is slightly low, even if obviously the mom's milk is not in).

2nd issue for me. The case I spoke of originally. This was obviously an infant right on the edge. His sugars were easily controlled with slightly increased intake. 50-60ml's (on day 2 of life) of 20cal/oz formula raised his sugars to the normal range (62-75). But when this child was breastfed (and he appeared to be doing it well for all we could see with a mom who was an experienced breastfeeder) his sugars dropped. When cup fed 20-35ml's after breastfeeding, his sugars were not good enough (ranging 34-49). So, this poor child in my opinion fell victim to the new breastfeeing/cupfeeding policies in our hospital. Because he couldn't keep his sugars up on BF and cupfeeding, he was admitted to the NICU, thereby separating him from his mother (even with open visitation, you know they are together as much as if he had been in a couplet with his mom) and then having his anticipated discharge delayed about 24hrs.

So what I'm wondering is; which is more harmful to the mother/baby relationship and the breastfeeding relationship? A bottle PC to keep his sugars in the safe range until his mom's milk comes in which holds a disputed possibility of nipple confusion, or an admission to NICU with separation from the mother?

Once more let's review; I am not against breastfeeding. I did not start this discussion to be a breastfeeding vs. formula feeding discussion. What I am is very much anti-cupfeeding. Case in point was this infant though, something was just a little off (he was a slightly stressed infant, had TTNB for a few hours after meconium stained delivery). He could have been spared an admission to our NICU and separation from his mother if our policies had not mandated cupfeeding for breastfeeding infants; or if gasp his mother had not wanted to BF and wanted bottlefeeding instead.

[eandgsma]

Hi all...

I'm not a NICU nurse or a nurse at all. I'm a student nurse with a background in lactation. Anyway, after reading the posts above I noticed one suggestion not mentioned. What about an SNS? That would supply the babe with formula to control the blood sugars but also keep the babe at breast to get that great colostrum AND keep up supply.

Just a suggestion. I'm sure its already been thought of but I was wondering why or why not use a SNS?

- N

[prmenrs, RN]

It IS a good idea to use a Supplemental Nursing System (SNS). It ought to be used more often. They're not a total snap to use, however, and I've met more than one rather precocious infant who figured out where most of the milk was coming from and started sucking on that tiny little tube instead of mom. rotten little kids (JK!!)

[LYRICS84]

I personally don't use an SNS very often for the reason noted above and also, they can be difficult to wean from. Baby MUST be able to suck well. Also, from the point of cost containment (especially since sometimes it is only needed once or twice) SNS costs about $30 per unit as opposed to $2 for a cup. All you guys having trouble with the cup - come and see me I will show you the proper technique and you will no longer dread it :Crash: :Crash:

[prmenrs, RN]

Our hospital is too cheap to get a real SNS--we use a syringe and #5 feeding tube.

We also use a small plastic pipette to squeeze formula onto mom's nipple to keep the baby latched. Works w/some kids, and dad can be taught to do it.

Last time I asked for PT for my back, I blamed it on breastfeeding!

[LYRICS84]

:lol2: Yeah, I always put the bed up in high position before I help anyone - except the few stubborn ones that insist on sitting in a chair. Working as a RN in L&D for many years sure gave me insight before getting my IBCLC. My best friend is an old NICU nurse who rolled her eyes when I said I was pursuing lactation. Yes, there are some rather aggressive characters out there. I am sooo not the obsessive type, and I even recommend formula on occassion sshhhhhhhhhhhhhhhhhhhhhh

[LilPeanut, MSN, RN, NP]

My son had nipple confusion. I think a lot of people don't realize what the signs of it are. He was a 34 weeker that didn't start nippling until he was 36+ weeks because he was a WWB. He had a few great nursing sessions, then got tired, they gave him a bottle, then he would try the breast, either cry or fall asleep because to him, the milk wasn't coming out fast enough.

With finger feeding, you can press on the plunger, but just not quickly. Part of it is to help train them of how to suck correctly, so when you feel the right movement of the tongue, they get a reward of milk.

It took a little over 24 hours of finger feeding at home to get my son to nurse again. I think though a lot of people see the baby falling asleep or crying after a couple unsuccessful sucks and they don't say "oh that's nipple confusion", they assume it's something else (don't get me wrong, it can be other things, but it can also very often be from nipple confusion)

[LYRICS84]

Infants born before 37 weeks often have issues with coordinating suck, swallow, and breathe at the breast. Many tire out too quickly to obtain enough at the breast to sustain them. I've done alot of research with nipple shields and (in my experience) have found that they work great with these little guys. The pressure actually keeps the milk in the shield, so when they stop to swallow, they can readily resume sucking without having to relatch over and over. This prevents them from working too hard and tiring out too quickly.

I agree "nipple preference" or "nipple confusion" does exsist. Sure not every baby will have difficulty with both feeding methods, but how do you know before giving a bottle how your baby will react? Usually after 3-4 weeks babies do well with both, but not right after birth.

[LilPeanut, MSN, RN, NP]

But the point is the minorly ill baby (low blood sugar that will restabilize) who has problems at birth with confusion will often not get the chance to eventually learn because the moms will become confused, tired, sore, think the baby hates them or nursing and will give up before that 4 week mark when they might be ready again.

To some extent, babies are designed to withstand dehydration and low blood sugar as newborns because that's their normal state - colostrum doesn't give much in the way of fluids and milk takes a few days to come in. For some reason, this is how the human body was designed and in many cases, it is ok like that.

Again, this is not saying that every baby is ok with low blood sugar or low fluid amounts, but just that in certain circumstances, it might be ok.

[LYRICS84]

I agree with you 100%. That is why it is in the best interest of both baby and mom if no artificial nipples are introduced before breastfeeding is well established. Unfortunately, there are circumstances that dictate intervention, hence the many alternative feeding devices that are now available (ie- the cup).

I also have a question to all of you who have difficulty with the cup. Are you using a regular hard plastic medicine type cup? I use a "Foley" cup and have had much better success with this particular manufacturer. The cup is soft and flexible, and has a lip on it to pool a small amount of the milk so baby doesn't accidently get a large gulp.

[Sweden]

In my hospital we are not allowed to use bottle feeding (BabyFriendly Hospital). That includes babies in the neonatal unit.

Cupfeeding/breastfeeding and gavage are the only one´s allowed (unless mum request bottlefeedings ofcourse). Cupfeedings are allowed from 29 weeks in our unit!

No more than 2 ways of feeding methods per session/feeding. Cupfeeding is seen as a good way for the baby to train it´s ability to feed correctly (towards breastfeeding). When the baby uses cupfeeding the same facial muscles are used as in breastfeeding, not so with bottlefeeding.

90% of the babies born after 26 week in our unit are on full breastfeeding when they go home!

Anna