It is well known that breast milk is the ideal nutrition for human babies. Some of the benefits of breast milk include decreased risk for gastrointestinal tract infection, type 2 diabetes, acute otitis media, asthma, and sudden infant death syndrome.[1] All infants (both term and preterm) who are admitted to the neonatal intensive care unit (NICU) have an increased need for the protective properties found in breast milk. Yet, upon admission to the NICU, many of these high-risk infants will require gavage feedings until they are more physiologically stable or developmentally ready for oral feedings by breast or bottle. To facilitate the transition from gavage feedings to oral feedings, all parents, especially mothers of breast-milk–fed infants, need to be encouraged to participate as often as possible in skin-to-skin care once the infant is stable. Skin-to-skin or kangaroo care is well documented to promote breast milk production[2] and maintenance of breastfeeding duration.[3] Once infants are not requiring ventilatory support and are respiratorily stable, they can begin nonnutritive sucking at the breast (snuggling) during these skin-to-skin holdings.[4] These experiences are important in supporting a more successful transition from gavage feedings to direct breastfeeding.
When infants receiving breast milk are able to begin oral feedings, the preferred method is direct breastfeeding. Neonatal intensive care unit caregivers need to make every effort to ensure that the first oral feeding opportunity for these infants is by direct breastfeeding. Mothers will need more support to make this a positive and successful experience, but the rewards far outweigh the costs. A study by Pineda[5] found that having the first oral feeding experience at breast was associated with longer and more sustained durations of breast milk feedings while in the NICU. This study also found that increased opportunities for participating in direct breastfeeding in the NICU were associated with a higher likelihood of infants receiving breast milk at discharge as compared with infants who receive breast milk in a bottle, yet never experience direct breastfeeding.[5] The importance of establishing routine caregiving practices in the NICU that are truly supportive of breastfeeding mothers is imperative. Mothers often view breastfeeding as something they can uniquely provide for their infant. Caregivers who empower mothers to accomplish their breastfeeding goals beginning at admission to the NICU and throughout the NICU stay also facilitate continued breastfeeding success after discharge.
Although evidence is mounting regarding the benefit of providing breast milk and breastfeedings during the NICU hospitalization, clinicians must recognize the barriers families face when trying to participate in all of their infant's oral feeding opportunities. Family and work responsibilities make it difficult for most mothers to be present for multiple feedings each day. Thus, it is vitally important that all members of the health care team communicate with families in a consistent, positive manner regarding the path to successful direct breastfeeding. Education must be regularly provided to all families on the benefit of early and frequent skin-to-skin contact and at breast experiences. Parents also need to understand the philosophy underpinning cue-based feedings so that alternative feeding methods can be implemented and viewed as helpful tools when mothers are unavailable to breastfeed. Lastly, parents need to understand that the journey to breastfeeding a preterm infant begins in the NICU but most often continues beyond discharge. By using appropriate strategies and providing parents the anticipatory guidance that they need, clinicians provide families the best chance possible at achieving the breastfeeding experience they so greatly desire and deserve.
Research clearly indicates that a cue-based approach to feeding preterm infants results in the most optimal feeding outcomes.[6,7] Research by McCain et al[8] found that a cue-based feeding method for transition from gavage to oral feeding in healthy preterm infants promotes faster attainment of oral feeding and does not compromise weight gain. Therefore, gavage feeding preterm infants, who are exhibiting oral feeding cues when their mother is not available to breastfeed, is counterproductive to the ultimate goal of achieving full oral feedings. The question then becomes, "what is the best method for provision of oral feedings to a preterm infant whose mother's ultimate goal is to breast feed, when the mother cannot be present for all oral feedings?"
There is very little evidence to support the use of alternative feeding methods such as finger feeding and cup feeding with the preterm infant. A study by Collins et al[9] in 2008 did find that cup feeding might improve breastfeeding rates upon discharge of preterm infants. However, this study also showed that cup feeding significantly increased length of stay. Dissatisfaction with this feeding method was also noted by some staff and parents who participated in this study. Without evidence to prove that other alternative feeding methods are efficacious, bottlefeeding is the oral feeding method most often used when mothers are not present to breastfeed. Both mothers and caregivers are most familiar with bottlefeeding, and this method continues to be culturally acceptable for providing oral feeding to infants.
Strategies to support successful transitional breastfeeding activities while bottlefeeding maturing preterm infants have gotten little attention in both the literature and clinical setting. Feeding position, nipple flow rate, and nipple shape all have the potential to affect breastfeeding success. Studies measuring physiologic stability showed improvement in both heart rate variability and oxygen saturation while bottlefeeding in an elevated side-lying position (breastfeeding position) vs the traditional upright position.[10,11] Bottlefeeding in this position may have a beneficial effect on breastfeeding by creating positive associations with feeding related to increased physiologic stability. More research is needed to better understand how to best bottlefeed the breastfed infant and how to transition them in a more positive manner to exclusive breastfeeding.
In conclusion, it is imperative for caregivers to recognize that, over the course of an infant's NICU admission, mothers may face family responsibilities, work responsibilities, or personal commitments that will interfere with their ability to participate in every oral feeding opportunity. In most situations, the breastfed NICU patient will need to be given oral feedings by bottle in instances when the mother is unable to be present and gavage feeding is no longer the appropriate oral feeding experience. It is therefore important for caregivers to formulate a partnership and plan with families to ensure that the goals of the family and the needs of the infant are met. This requires ongoing honest discussions with families about their breastfeeding goals, their breast and bottlefeeding experiences, and their expectations for oral feedings when the mother cannot be present for direct breastfeedings. Mothers need to understand that most infants will not be exclusively breastfeeding at discharge from the NICU. Education for mothers needs to focus on properly positioning the infant, supporting latch, and practical assessment of milk transfer. Helping mothers to celebrate successfully meeting these goals is important to motivate her to continue these breastfeeding activities. Before discharge, infants should be transferring some volume from the breast; but most will not transfer full feeds until after discharge. A realistic plan about moving the bottlefeeding breastfed infant to all direct breastfeeding needs to be discussed and put into place with achievable goals to keep this progress moving forward in the home environment. Empowering the family to make these choices is an important goal for true provision of baby-friendly family-centered care within the NICU.
NAINR. 2013;13(1):5-6. © 2013 Elsevier Science, Inc.
