Bottlefeeding the Breastfed Infant in the

Neonatal Intensive Care Unit

Jacqueline M. McGrath, PhD, RN, N!P, !!N, Mar" M. #ussier, B$N, RN, IBC#C, Carrie%&llen
Briere, B$N, RN, C#C
Disclosures
N!INR. '()*+)*,)-./%0.
Print
DRUG & REFERENCE INFORMATION
1rans2ort of the Criticall" Ill Ne34orn
Counseling the Breastfeeding Mother
ollo3%u2 of the NICU Patient
It is 3ell 5no3n that 4reast 6il5 is the ideal nutrition for hu6an 4a4ies. $o6e of the 4enefits
of 4reast 6il5 include decreased ris5 for gastrointestinal tract infection, t"2e ' dia4etes,
acute otitis 6edia, asth6a, and sudden infant death s"ndro6e.
7)8
!ll infants ,4oth ter6 and
2reter6- 3ho are ad6itted to the neonatal intensive care unit ,NICU- have an increased
need for the 2rotective 2ro2erties found in 4reast 6il5. 9et, u2on ad6ission to the NICU,
6an" of these high%ris5 infants 3ill require gavage feedings until the" are 6ore
2h"siologicall" sta4le or develo26entall" read" for oral feedings 4" 4reast or 4ottle. 1o
facilitate the transition fro6 gavage feedings to oral feedings, all 2arents, es2eciall" 6others
of 4reast%6il5:fed infants, need to 4e encouraged to 2artici2ate as often as 2ossi4le in s5in%
to%s5in care once the infant is sta4le. $5in%to%s5in or 5angaroo care is 3ell docu6ented to
2ro6ote 4reast 6il5 2roduction
7'8
and 6aintenance of 4reastfeeding duration.
7*8
;nce infants
are not requiring ventilator" su22ort and are res2iratoril" sta4le, the" can 4egin nonnutritive
suc5ing at the 4reast ,snuggling- during these s5in%to%s5in holdings.
7<8
1hese e=2eriences are
i62ortant in su22orting a 6ore successful transition fro6 gavage feedings to direct
4reastfeeding.
>hen infants receiving 4reast 6il5 are a4le to 4egin oral feedings, the 2referred 6ethod is
direct 4reastfeeding. Neonatal intensive care unit caregivers need to 6a5e ever" effort to
ensure that the firstoral feeding o22ortunit" for these infants is 4" direct 4reastfeeding.
Mothers 3ill need 6ore su22ort to 6a5e this a 2ositive and successful e=2erience, 4ut the
re3ards far out3eigh the costs. ! stud" 4" Pineda
7/8
found that having the first oral feeding
e=2erience at 4reast 3as associated 3ith longer and 6ore sustained durations of 4reast 6il5
feedings 3hile in the NICU. 1his stud" also found that increased o22ortunities for
2artici2ating in direct 4reastfeeding in the NICU 3ere associated 3ith a higher li5elihood of
infants receiving 4reast 6il5 at discharge as co62ared 3ith infants 3ho receive 4reast 6il5
in a 4ottle, "et never e=2erience direct 4reastfeeding.
7/8
1he i62ortance of esta4lishing
routine caregiving 2ractices in the NICU that are trul" su22orti
ve of 4reastfeeding 6others is i62erative. Mothers often vie3 4reastfeeding as so6ething
the" can uniquel" 2rovide for their infant. Caregivers 3ho e62o3er 6others to acco62lish
their 4reastfeeding goals 4eginning at ad6ission to the NICU and throughout the NICU sta"
also facilitate continued 4reastfeeding success after discharge.
!lthough evidence is 6ounting regarding the 4enefit of 2roviding 4reast 6il5 and
4reastfeedings during the NICU hos2itali?ation, clinicians 6ust recogni?e the 4arriers
fa6ilies face 3hen tr"ing to 2artici2ate in all of their infant@s oral feeding o22ortunities. a6il"
and 3or5 res2onsi4ilities 6a5e it difficult for 6ost 6others to 4e 2resent for 6ulti2le feedings
each da". 1hhAi 6us, it is vitall" i62ortant that all 6e64ers of the health care tea6
co66unicate 3ith fa6ilies in a consistent, 2ositive 6anner regarding the 2ath to successful
direct 4reastfeeding. &ducation 6ust 4e regularl" 2rovided to all fa6ilies on the 4enefit of
earl" and frequent s5in%to%s5in contact and at 4reast e=2eriences. Parents also need to
understand the 2hiloso2h" under2inning cue%4ased feedings so that alternative feeding
6ethods can 4e i62le6ented and vie3ed as hel2ful tools 3hen 6others are unavaila4le to
4reastfeed. #astl", 2arents need to understand that the Aourne" to 4reastfeeding a 2reter6
infant 4egins in the NICU 4ut 6ost often continues 4e"ond discharge. B" using a22ro2riate
strategies and 2roviding 2arents the antici2ator" guidance that the" need, clinicians 2rovide
fa6ilies the 4est chance 2ossi4le at achieving the 4reastfeeding e=2erience the" so greatl"
desire and deserve.
Research clearl" indicates that a cue%4ased a22roach to feeding 2reter6 infants results in
the 6ost o2ti6al feeding outco6es.
70,B8
Research 4" McCain et al
7C8
found that a cue%4ased
feeding 6ethod for transition fro6 gavage to oral feeding in health" 2reter6 infants 2ro6otes
faster attain6ent of oral feeding and does not co62ro6ise 3eight gain. 1herefore, gavage
feeding 2reter6 infants, 3ho are e=hi4iting oral feeding cues 3hen their 6other is not
availa4le to 4reastfeed, is counter2roductive to the ulti6ate goal of achieving full oral
feedings. 1he question then 4eco6es, D3hat is the 4est 6ethod for 2rovision of oral feedings
to a 2reter6 infant 3hose 6other@s ulti6ate goal is to 4reast feed, 3hen the 6other cannot
4e 2resent for all oral feedingsED
1here is ver" little evidence to su22ort the use of alternative feeding 6ethods such as finger
feeding and cu2 feeding 3ith the 2reter6 infant. ! stud" 4" Collins et al
7F8
in '((C did find that
cu2 feeding 6ight i62rove 4reastfeeding rates u2on discharge of 2reter6 infants. Go3ever,
this stud" also sho3ed that cu2 feeding significantl" increased length of sta". Dissatisfaction
3ith this feeding 6ethod 3as also noted 4" so6e staff and 2arents 3ho 2artici2ated in this
stud". >ithout evidence to 2rove that other alternative feeding 6ethods are efficacious,
4ottlefeeding is the oral feeding 6ethod 6ost often used 3hen 6others are not 2resent to
4reastfeed. Both 6others and caregivers are 6ost fa6iliar 3ith 4ottlefeeding, and this
6ethod continues to 4e culturall" acce2ta4le for 2roviding oral feeding to infants.
$trategies to su22ort successful transitional 4reastfeeding activities 3hile 4ottlefeeding
6aturing 2reter6 infants have gotten little attention in 4oth the literature and clinical setting.
eeding 2osition, ni22le flo3 rate, and ni22le sha2e all have the 2otential to affect
4reastfeeding success. $tudies 6easuring 2h"siologic sta4ilit" sho3ed i62rove6ent in 4oth
heart rate varia4ilit" and o="gen saturation 3hile 4ottlefeeding in an elevated side%l"ing
2osition ,4reastfeeding 2osition- vs the traditional u2right 2osition.
7)(,))8
Bottlefeeding in this
2osition 6a" have a 4eneficial effect on 4reastfeeding 4" creating 2ositive associations 3ith
feeding related to increased 2h"siologic sta4ilit". More research is needed to 4etter
understand ho3 to 4est 4ottlefeed the 4reastfed infant and ho3 to transition the6 in a 6ore
2ositive 6anner to e=clusive 4reastfeeding.
In conclusion, it is i62erative for caregivers to recogni?e that, over the course of an infant@s
NICU ad6ission, 6others 6a" face fa6il" res2onsi4ilities, 3or5 res2onsi4ilities, or 2ersonal
co66it6ents that 3ill interfere 3ith their a4ilit" to 2artici2ate in ever" oral feeding
o22ortunit". In 6ost situations, the 4reastfed NICU 2atient 3ill need to 4e given oral feedings
4" 4ottle in instances 3hen the 6other is una4le to 4e 2resent and gavage feeding is no
longer the a22ro2riate oral feeding e=2erience. It is therefore i62ortant for caregivers to
for6ulate a 2artnershi2 and 2lan 3ith fa6ilies to ensure that the goals of the fa6il" and the
needs of the infant are 6et. 1his requires ongoing honest discussions 3ith fa6ilies a4out
their 4reastfeeding goals, their 4reast and 4ottlefeeding e=2eriences, and their e=2ectations
for oral feedings 3hen the 6other cannot 4e 2resent for direct 4reastfeedings. Mothers need
to understand that 6ost infants 3ill not 4e e=clusivel" 4reastfeeding at discharge fro6 the
NICU. &ducation for 6others needs to focus on 2ro2erl" 2ositioning the infant, su22orting
latch, and 2ractical assess6ent of 6il5 transfer. Gel2ing 6others to cele4rate successfull"
6eeting these goals is i62ortant to 6otivate her to continue these 4reastfeeding activities.
Before discharge, infants should 4e transferring so6e volu6e fro6 the 4reast+ 4ut 6ost 3ill
not transfer full feeds until after discharge. ! realistic 2lan a4out 6oving the 4ottlefeeding
4reastfed infant to all direct 4reastfeeding needs to 4e discussed and 2ut into 2lace 3ith
achieva4le goals to 5ee2 this 2rogress 6oving for3ard in the ho6e environ6ent.
&62o3ering the fa6il" to 6a5e these choices is an i62ortant goal for true 2rovision of 4a4"%
friendl" fa6il"%centered care 3ithin the NICU.