Nipple confusion/syringe/cup feeding policy

Elvish, BSN, DNP, RN, NP · Jul 10, 2009

I'm in the US. Policies are likely to differ in hospitals across the US, but at my facility, these are the normal newborn orders:

Breastfeed on demand or at least every 3 hours. No formula unless by doctor's order or by mother's request.

For late pretermers (34-36 6/7 weeks), the orders read:

Breastfeed on demand and supplement with each feeding:

10-15ml either donor breastmilk, expressed breastmilk, or 22 cal/oz formula.

There's no specificity in the late pretermer orders whether the formula comes from a cup/bottle/syringe/whatever. For a pretermer, these kids spend so many calories just trying to keep warm, I'm perfectly willing to feed them with a bottle, esp when they may not know how to suck really well anyway. Perfect way for them to learn.

Babies are so much smarter than we give them credit for.

stormsurge · Jul 10, 2009

Thanks for that! Your input is very much valued.

It seems there is alot of 'clinician' based decisions. We have that too. And opinions differ, even within an institution.

When you say 'medically indicated', does that mean you have to wait for a Dr to review and give the order, or does the midwife/nurse say 'this baby is dehydrated and lost 8% birthweight and is demanding constantly' so they go ahead with mother and give a supplement?

This issue irritates me, because where I work, there is no paediatrician on site 24/7. It would involve phoning them. Although I've never resorted to ringing them in the night, I imagine they would get irritated. I guess it's a timebomb waiting to go off. :angryfireSomewhere, somtime, the decision will be called into question. Surely we are educated enough to make this decision clearly on our own, but the term 'medically indicated' is haunting literature and discourse. (think it came from the Baby Friendly Hospital Initiative, and now gets bandied about)

Elvish, BSN, DNP, RN, NP · Jul 10, 2009

Medically indicated = doctor's order.

In practice, however, if it's 0100 and I've got a baby that's starving and has lost more than 10% of his birthweight (that's our cutoff) I talk w/ mom and tell her why supplementing would be a good idea. I put a little extra emphasis in there if baby is jaundiced or showing signs of dehydration. Most of the time, at that point Mom will consent to supplementation. It depends on Mom's preference whether we use a bottle or some other form - but most are ok with bottle-feeding.

We have a high Latin American population who combine breast- and bottlefeeding beautifully. I wish the BFHI would take a lesson from them and slacken up. We are kind of in the same quandary at my place as you are at yours, it seems.

stormsurge · Jul 10, 2009

I'm very interested to hear that Latin American women combine breast and bottle. I'm sure there are pockets of Vietnamese communities there as well. We have vietnamese ladies here in my town, they are so polite. They will never argue with you about feeding the baby. They will smile and thankyou. Then, they will ask the next staff member for a bottle. Try as we might, they just don't believe colostrum is enough, and they give bottles for a few days, then breastfeed quite successfully, so I'm told.

One thing that does not seem to be considered by the BFHI is that women have the right to choose what they feed their baby, just as in a years time, 3 years time, 10 years time, nobody tells them what to feed their child. I for one, do not force feed vegetables to my kid. Offerred and encouraged, sure, but not forced. He's happy, I'm not stressed, this is a GOOD thing!

HvnSntRN · Jul 10, 2009

My institution has BFHI plaques up in staff-only areas, mainly because the institution will never be a baby-friendly one, thanks in part to the formula companies who donate product for patient use and perks to management for allowing them to do so. Infant formula is a very political issue, even though we may not be directly involved in the politics.

We have a wide assortment of ethnic populations who combine breast and bottle feeding quite well. I had a huge argument with a former manager about how we respect the rights of these women to make a culturally based choice, but for some reason we don't seem to afford the same right to women from our own country. It seems to me that if you're caucasian, you better exclusively breast feed or you'll be "poisoning your baby with formula" is the prevailing attitude. My position is and always has been that the choice is with the parents (regardless of culture or race), and I am there to inform them of their options and then support that informed choice, whether it's exclusive breastfeeding, bottlefeeding or combination feeding.

If the mom wants to exclusivey breastfeed, but for whatever reason cannot, we will start her pumping within 6 hours of delivery with a double electric pump. We encourage "power pumping" or "cluster pumping" rather than a q3h schedule as it simulates baby's clusterfeeding behaviour. EBM can be given by cup, fingerfeeding, feeding tube or bottle. Some of the late pretermers have so little energy to suck effectively for the period of time required for adequate milk transfer, so we make it easier for them by giving EBM or formula by cup or spoon.

stormsurge · Jul 10, 2009

Hello,

Thanks for your input.

Interesting - plaques in the staff only areas! We are not a BFHI hospital either, but our educators office, the handover room and even the staff TOILET have these posters. Somehow when I work, I dunno, that thing gets moved out of the staff loo. Some things must remain sacred!

My research is at least a year away from publication, but the data analysis is done and here's a snippet:

(for healthy term breastfeeding babies in the first seven days)

I asked mothers whether they knew about alternative techniques, then asked them what they preferred. Only 19 out of 128 preferred something else. 14 of those wanted the nipple shield. One of my conclusions is that our facility does a fine job of offering different kinds of alternative and letting them choose what they judge they can cope with - and that we should bump up the offering of a nipple shield! Supporting their choices does support breastfeeding, because we have a breastfeeding initiation rate of over 98%, and something like 95% at day 7. :yeah:

Formula companies provide it for free to the hospital? I bet it goes on more than we know. I think a particular brand of diaper is supplied to us also free......hmmm.

RNBelle · Jul 11, 2009

We don't really have any policies at all on anything. We don't encourage cup feeding but if someone could provide me with some evidence based research on the benefits of that it would be helpful. Right now or staff is pretty against cup feeding - but like I say we are not armed with good research. Where I work it is moms either breast, bottle or do both for their infants. I had one mom the other night who didn't feed her baby for about 14hrs because the baby would not latch on and she would not give him a bottle and we don't support cup feeding (parent's have to bring their own cups). Are pedis don't tend to care about until it his 24hrs of a baby not eating.

stormsurge · Jul 11, 2009

That's fascinating!

Agreed - cup feeding for healthy term infants has no scientific evidence to support it (in developed countries).

My research was mainly descriptive - and whilst many mothers had knowledge of cup feeding, they did not prefer to use it. (surprise!) I can't see myself moving on to a phd in cup feeding, (which would provide hard facts) because I don't have faith in it. Syringe feeding, yes.

That scenario you mentioned - at the facility where I work, the baby don't feed? The baby gets EBM by the sweat and toil of midwife and mother! By syringe generally, because it's only a few milliliters. Policy dictates 4 hourly feeding - it gets stretched to accomodate demand feeding. Guess it's to prevent 14 hour scenarios, not to enforce regimented feeding. Can't tell you how many times the baby gets a little ebm, then shows some interest in feeding!

I am finding all your replies very helpful and inspiring! Thanks!:heartbeat

HvnSntRN · Jul 11, 2009

can't tell you how many times the baby gets a little ebm, then shows some interest in feeding!

here's a video link that we use to show just this very thing! once staff members see the baby perking up and showing interest after taking just a few drops of ebm, it makes them all jump on the hand expression band wagon.

http://newborns.stanford.edu/breastfeeding/handexpression.html

stormsurge · Jul 14, 2009

Thats a fantastic video! Thanks for posting the link. This is also one of the only demonstrations of spoon feeding I've ever seen. We all have plastic spoons in the workplace, and parents all have spoons at home. There's only so much volume you can put on a spoon, therefore reducing the risk of giving the baby too much at once. Great!