Nancy E. Wight MD, FAAP, IBCLC

Background

Artificial methods of infant feeding: pap bowls, feeding horns, cups and bottles, have existed throughout history. 1,2 The bottle and nipple have so dominated western thinking, that the use of other artificial methods of infant feeding has been largely overlooked. Cup feeding is used in several developing countries, not only by mothers who have limited access to hospital facilities, but also by pediatric units and special care nurseries. 3-7It has provided a safe artificial method of feeding pre-term and low birth weight infants until they are strong and/or mature enough to be fully breast-fed, as well as for cleft lip and palate infants. 8,9 The World Health Organization (WHO) and UNICEF, through The Baby Friendly Hospital Initiative (BFHI), have focused attention on cup feeding again as an adjunct to breastfeeding in Step 9: "Give no artificial teats or pacifiers to breastfeeding infants." 10

A 10 year experience with cup feeding at the University of Kansas Medical Center, reported 50 years ago, noted ease of feeding for the infant, less regurgitation and colic, and better weight gain with cup feeding. 8The idea of insituting this type of feeding arose as a way to combat "nursing/hunger strikes" and to ensure bodily contact with the mother during feeding (prevent bottle-propping in non-breastfeeding dyads), but was extended to infants with birthweights as low as 860 gm. Similarly, in a study designed to determine whether the sucking drive was inborn or learned, 60 infants were assigned (with maternal consent) to breast, bottle or cup feeding. 11 Although the study failed to answer its basic question, it was noted that cup feeding required much less time than either breast or bottle feeding, possibly because the cup feeding technique used involved pouring milk "into the mouth as rapidly as the baby swallows". No morbidity was reported. The authors of this 1948 study also stated "It is a well recognized clinical observation that it is usually difficult to get a bottle fed baby to nurse at the breast successfully if the infant has been started on bottle feedings." 11

Recent evidence in term 12and preterm 13,14infants in the US confirms that physiologic stability is maintained with cup feedings, and that apnea, bradycardia, and choking episodes were no different than with bottle feedings. Oxygen saturation was better during cup feedings than during bottle feedings in preterm infants, but larger volumes were taken in a shorter period with the bottle. 13Breastfed infants, however, experience less physiologic variability during feeding than either cup or bottle-fed infants. 12,15,16

Experience in the developing world and in several European neonatal 17-19 and transitional care units 20 has indicated that cup feeding is a skill easily learned by pre-term infants before efficient breast or bottle feeding is possible, and at a stage in development when it has been previously assumed that NG tubes are a necessity. 21,22Standard medical texts suggest (based on bottle feeding information) that oral feeding cannot be successfully started until an infant is able to coordinate its suck, swallow and breathing reflexes, which usually occurs between 32 and 35 weeks gestation. 23 As a result, NG tubes are used extensively in most neonatal intensive care units, neglecting the infant's psychological, social and sucking needs unless the mother is present for breastfeeding during gavage feeding.

Although little research has been carried out to determine whether bottle feeding interferes with a term infant's ability to breastfeed successfully, 11,24-29several authors have drawn attention to the difference between sucking techniques of breast and bottle feeding. 27,30-35To breastfeed successfully the infant has to open his mouth widely to accommodate the breast tissue, and protrude his tongue over the bottom lip, which is curled outwards under the areola. In bottlefeeding, the infant sucks on the nipple with a partially closed mouth. When this bottle technique is applied to a mother's breast it can lead to sore nipples, diminished milk supply and cessation of breastfeeding. In addition, pacifiers encourage this sucking technique, and are associated with a decline in breastfeeding. 25,27,35-39

Unfortunately, there is no way to predict which infants will develop problems with breastfeeding as a result of learning these two different sucking techniques. Because establishing breastfeeding in a sick or pre-term infant is less straightforward than in a term infant, a method of feeding which does not lead to inappropriate sucking techniques is highly desirable.

Why cup feed?

  • To provide a positive oral experience for the baby.
  • To provide an alternative when mother is not available to breastfeed.
  • To reduce the need for nasal and oral gastric tubes.
  • To avoid the use of bottles which may introduce the baby to an inappropriate pattern of feeding (prevent "nipple confusion/preference").

Possible Advantages of cup feeding

  • It enables parents to assume feeding of their baby at the earliest possible time.
  • The baby paces his own intake both in time and quantity.
  • It seems to require little energy expenditure for the infant.
  • It stimulates appropriate tongue and jaw movements.
  • It stimulates olfactory and oral sensory receptors.
  • It stimulates the production of saliva and lingual lipases resulting in more efficient digestion.
  • Antibacterial factors in breastmilk may have a protective effect, even in the infant's mouth (e.g. otitis media).
  • It provides good eye contact, social stimulation and is comforting to the infant. 8
  • Less fat is lost with a cup than via gastric tubes.
  • There is nothing besides milk inside the infant's mouth for him to cope with.

Disadvantages of cup feeding

  • Term babies, and to some extent pre-term infants, tend to dribble.
  • Term healthy babies may become "addicted" to the cup if they do not have the opportunity to breastfeed regularly.
  • The nurses must watch what they are doing. There appears to be no aspiration unless milk is poured into the mouth, which is not the technique for cup feeding. 19,40,42
  • It does not fulfill the infant's need to suck.

Indications For Cup Feeding

  • A baby who is near discharge who is breastfeeding but whose mother cannot be present for all feedings.
  • A baby whose mother is ill after delivery and who could not breastfeed.
  • A cleft lip/cleft palate infant whose mother wishes to breastfeed.
  • A baby who has a uncoordinated suck and swallow.
  • A term baby, when complimentary feedings are needed due to hypoglycemia, jaundice or dehydration, or to give drugs orally.
  • Babies with neurologic problems are often able to sip or lap milk from a cup. Cup feeding encourages the movement of the tongue and muscles of the mouth, allows the baby to enjoy its feedings, and strengthens the relationship between parent and child.

Contraindications to Cup Feeding

  • Any newborn who is likely to aspirate (poor gag reflex, generally lethargic, marked neurologic deficits)

When to introduce cup feedings

  • Introduce cup feedings after the infant is tolerating q 2-3 hour bolus feedings by gavage. Remove the indwelling NG tube after the infant is tolerating 3 cup feedings in a row.
  • Teach all family members to cup feed. This is not difficult.
  • Cup feeding infants take varying amounts. Look at the totals, not single feeding amounts.
  • It can be confusing to use a cup plus a bottle plus finger feeding plus breast. Use cup feeding and breast and gavage tube only to minimize the skills an infant needs to learn.
  • Developmentally, infants tend to lap milk from the cup initially and then sip milk as their suck, swallow, breathing coordination is more mature.

Procedure for Cup Feeding

  • Wrap the baby so the cup will not be knocked.
  • Support the baby in an upright sitting position.
  • Fill the 30 cc medicine cup at least half full with breastmilk or formula.
  • Place the brim of the cup at the outer corners of the upper lip, resting gently on the lower lip with the tongue inside the cup. (Some term infants may prefer their tongue under the lip of the cup.)
  • Tip the cup so the milk is just touching the baby's lips. Do not pour the milk into the baby's mouth.
  • The infant usually laps the milk, or may sip it.
  • Allow time for the infant to swallow.
  • Let the infant pace the feedings, but limit the length of the feeding to approximately 30 minutes to minimize fatigue.
  • Stop to burp from time to time.
  • Leave the cup in position during the feed; that is, while the baby rests, do not move the cup from this position.
  • Do not attempt to cup feed an infant who is not alert or who is excessively sleepy.

Summary

Cup feeding, when done correctly, appears to be a safe and less physiologically stressful alternative to the use of bottles with breastfeeding babies. At the Exeter University Medical Center neonatal unit in Exeter, England, hospital staff have used cup feedings thousands of times and experienced no aspiration or other complications.19 It may prevent nipple preference, encourage correct tongue placement for breastfeeding, costs very little and appears easy to learn. More research is required to ascertain whether cup-feeding promotes a higher success rate for full breastfeeding post discharge; and whether it has any long term effects on oral motor development.

References:

  1. Fildes V. Artificial feeding, feeding vessels, the evidence from artifacts and art. Breasts, bottles and babies. Edinburgh: Edinburgh University Press, 1986: 307-42.
  2. Baumslag N & Michels DL. Milk, Money, and Madness: The Culture and Politics of Breastfeeding. 1995. Bergin & Garvey, Westport, CT, pp 131-140
  3. Muoke RN. Breastfeeding promotion: feeding the low birth weight infant. Int J Gynecol Obstet 1990; 31 (suppl 1): 57-9.
  4. Armstrong HC. Breastfeeding low birthweight babies: advances in Kenya. Journal of Human Lactation 1987; 3: 2.
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  6. Minchin M. Premature babies: why breast is best. New Generation 1987; Sept: 36-7.
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