When mothers are having trouble with their milk supply, supplements may be necessary: expressed mother's own milk, donor human milk or various artificial breastmilk substitutes. In order to give necessary additional nutrition, other feeding methods are used. Alternative feeding methods have been used throughout history with different types of feeding vessels found in many cultures. ¹ The bottle and nipple have so dominated western thinking, that the use of other artificial methods of infant feeding has been largely overlooked. ² Currently, the most common alternative feeding methods include the cup (underdeveloped countries) and the bottle (developed countries). Other techniques include finger-feeding, dropper and spoon-feeding, syringe feeding and various supplemental nursing systems. Recognizing that human infants are amazingly adaptable, the goal of any alternative feeding method is still to achieve or restore full direct breastfeeding wherever possible.

Nipple Preference/Confusion. Radiographic and ultrasound studies show a distinct difference between tongue and jaw movements of breast and bottle-feeding infants. ^3-5 In breastfeeding, breathing is coordinated with sucking and swallowing, usually in a 1:1:1 pattern. The fast easy flow through the bottle nipple generally results in breath holding and shortened expirations. ⁶ Preterm infants seem to have better coordination of sucking, swallowing and breathing during breastfeeding as compared to bottle-feeding with less bradycardia and more stable oxygen saturation. ^7,8 However, in full-term infants, physiologic stability did not differ with cup and bottle-feeding, but was significantly better in breastfeeding infants with lower heart rate and respiratory rate, and higher oxygen saturations in the breastfeeding group. ⁹

Nipple preference/confusion is not a new concept. ¹⁰ Neifert et al suggested a definition: "an infant's difficulty in achieving the correct oral configuration, latching technique and suckling pattern necessary for successful breast-feeding after bottle feeding or other exposure to an artifical nipple". ¹¹ Although several hypotheses have been offered ¹¹ it seems reasonable that breastfed infants who have difficulty in obtaining milk will be more likely to prefer bottle-feeding if given the opportunity. It is likely that the infant learns to protect his airway regardless of feeding method. The infant also adjusts to a rate of flow (bottle faster, breast slower) and may learn to prefer one to the other.

Concerns Regarding Bottle Feeding. Concerns about bottle feeding a breastfed baby include: nipple preference/confusion, breast engorgement due to incomplete emptying of the breast once supplements are given to the infant, sore nipples because of different sucking techniques, reduced milk supply due to supplementation, and an overall shortened duration of breastfeeding. ¹² There is some evidence that bottle-feeding may alter the normal development of the oral cavity, as that development depends on what is contained in the cavity and the motions of the tongue and jaw. ¹³ Tongue thrust, malocclusions, "cross bite" and a collapsed airway with obstructive apnea have all been associated with the altered facial development from lack of breastfeeding. ^14-17 Pacifiers (dummies) have also been implicated in oral maldevelopment. ^18-20

Cup-Feeding. 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. ^21,22 A 10 year experience at the University of Kansas Medical Center, reported almost 60 years ago, noted ease of feeding for the infant, less regurgitation and colic, and better weight gain with cup feeding. ²³ 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. Evidence in term ^9,24-8 and preterm^25,29-31 infants confirm that physiologic stability is maintained with cup feedings, and that apnea, bradycardia, and choking episodes were no different than with bottle feedings. Experience in the developing world and in several European neonatal and transitional care units^22,32,33 indicates 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 gavage tubes are a necessity. ³⁴

Recent studies concluded that cup-feeding extended breastfeeding when > 2-3 supplementary feeds were given full-term infants²⁷ , and that the use of cups increased the proportion of preterm infants discharged home fully breastfeeding. ³¹ However, the cup-fed preterm infants had a longer length of stay than their bottle-fed counterparts. ³¹ Although current research confirms the safety of cup feeding for term and preterm infants, more research is required to ascertain whether cup-feeding promotes a higher success rate for exclusive or any breastfeeding post discharge, and whether it has any long term effects on oral motor development.

Finger-Feeding. Finger-feeding has been used as an alternate feeding method to avoid bottles and nipples, but also to help correct a "disorganized" suck, as correct sucking technique can be rewarded with bolus of milk. ³⁵ It has the advantage over cup-feeding that the amount fed can be measured and either the baby or the caretaker can pace the feedings. Unfortunately it appears harder to learn than the cup, is more intrusive and requires more equipment.

Droppers, spoons and syringes. Droppers and spoons have been used for supplementation and have the advantage of being inexpensive, easy to clean and easy to learn. They tend to be time consuming, messy, imprecise and extremely impractical for long-term use. Periodontal syringes have also been used either alone or with finger-feeding, but remain expensive, hard to find, hard to clean and time consuming.

Supplemental Nursing Systems. Supplemental nursing systems have the advantage of supplying appropriate supplement while simultaneously stimulating the breast to produce more milk. The end of the tubing is taped to the breast with the end at the nipple. The infant latches on to the breast and tube and siphons the supplement from a reservoir. There are various commercial versions (Lact-Aid, Medela SNS), and homemade versions are easy to make. Supplementing at the breast encourages latch-on because of the immediate reward, encourages correct infant suckling technique, allows baby-led pacing of the feeding, as well as measurement of the amount taken. Unfortunately, most supplemental nursing systems are extremely awkward to use, hard to clean, expensive and require moderately complex learning.

Bottle feeding. Bottle-feeding itself as an alternate feeding technique can be done correctly or incorrectly. The infant should be upright or semi-upright ³⁶ in the caregivers lap with a full view of the caregiver's face. As with breastfeeding, the lower lip should be tickled with the nipple to elicit a root and a wide-open mouth before the nipple is introduced. The

Conclusions. When selecting an alternative feeding method we should consider several criteria: cost and availability, ease of use and cleaning, stress to the infant, whether an adequate volume of milk can be fed to the infant in 20-30 minutes, whether the use will be short term or long term, and whether the method enhances the development of breastfeeding skills. We should also recognize that feeding is not just nutrition and try to avoid the "technique of the month" approach. One method does not fit all: finger feeding may be more appropriate for a neurologically damaged infant and cup feeding more appropriate for a growing premie. This remains to be studied. One of the main advantages of supplementing without a bottle is the non-verbal message to parents that the alternative method is temporary. The bottle is often seen as the beginning of the end of breastfeeding. No method is without potential risk (including the bottle) or potential benefit. Anything less than direct breastfeeding without gadgets is an intervention.

References

1. Fildes V: Artificial feeding, feeding vessels, the evidence from artifacts and art. Breasts, bottles and babies. Edinburgh: Edinburgh University Press, 1986, p 307
2. Baumslag N, Michels DL: Milk, Money, and Madness: The Culture and Politics of Breastfeeding. Bergin & Garvey, Westport CT, 1995
3. Nowak AJ, Smith, WL, Erenberg A: Imaging Evaluation of Breast-Feeding and Bottle-Feeding Systems. J Pediatr 1995; 126:130
4. Smith WL, Erenberg A, Nowak A: Imaging Evaluation of the Human Nipple During Breast-feeding. AJDC 1988; 142:76
5. Weber F, Woolridge MW, Baum ID: An Ultrasonographic Study of Sucking and Swallowing by Newborn Infants. Dev Med & Child Neurol 1986; 28:19
6. Mathew OP & Bhatia J: Sucking and Breathing Patterns During Breast- and Bottle-feeding in Term Neonates. AJDC 1989; 143:588
7. Meier P, Anderson GC: Responses of small preterm infants to bottle - and breast -feeding. MCN: American Journal of Maternal Child Nursing 1987; 12:97
8. Meier P: Bottle- and breast-feeding: Effects on transcutaneous oxygen pressure and temperature in preterm infants. Nursing Research 1988; 37:36
9. Howard CR, deBlieck EA, ten Hoopen CB, et al: Physiologic stability of newborns during cup - and bottle-feeding. Pediatrics 1999; 104:1204
10. Davis HV, Sears RR, Miller HC, et al: Effects of Cup, Bottle and Breast Feeding on Oral Activities of Newborn Infants. Pediatrics 1948; 2:549
11. Neifert M, Lawrence R, Seacat J: Nipple confusion: Toward a formal definition. J Pediatr 1995; 126:125
12. Righard L: Are Breastfeeding Problems Related to Incorrect Breastfeeding Technique and the Use of Pacifiers and Bottles? Birth 1998; 25:40
13. Palmer B: The Influence of Breastfeeding on the Development of the Oral Cavity: A Commentary. J Hum Lact 1998; 14:93
14. David D, Bell P: Infant Feeding Practices and Occlusional Outcomes: A Longitudinal Study. Can Dent Assoc 1991; 57:593
15. Labbock MH, Hendershot G: Does breast-feeding protect against malocclusion? An analysis of the 1981 Child Health Supplement to the National Health Interview Survey. Am J Prev Med 1987; 3:227
16. Legovic M, Ostric L: The effects of feeding methods on the growth of the jaws of infants. J of Dent for Child 1991; 58:253
17. Pottenger FM, Krohn B: Influence of breastfeeding on facial development. Archives of Pediatrics 1950; 67:454
18. Bowden B: The effects of digital and dummy sucking on arch widths, overbite and overjet A longitudinal study. Australian Dent J 1966; 11:396
19. Drane D: The effect of use of dummies and teats on orofacial development. Breastfeeding Review 1996, 4:59
20. Viggiano D, Fasano D, Monaco G, Strohmenger L. Breastfeeding, bottle-feeding, and non-nutritive sucking: Effects on occlusion in deciduous dentition. Arch Dis Child 2005; 89:1121-1123 Armstrong HC: Breastfeeding low birthweight babies: advances in Kenya. J Hum Lact 1987; 3:2
21. Lang S, Lawrence CJ, L'eorme R: Cup feeding: An alternative method of infant feeding. Arch Dis Child 1994; 71:365
22. Fredeen R: Cup feeding of newborn infants. Pediatrics 1948; 2:544
23. Brown SJ, Alexander J, Thomas P: Feeding outcome in breast-fed term babies supplemented by cup or bottle. Midwifery 1999; 15:92
24. Malhotra N, Vishwambaran L, Sundaram KR, et al: A controlled trial of alternative methods of oral feeding in neonates. Early Hum Dev 199; 54:29
25. Schubiger G, Schwartz U, Tonz O: UNICEF/WHO baby-friendly hospital initiative: does the use of bottles and pacifiers in the neonatal nursery prevent successful breastfeeding? Eur J Pediatr 1997; 156:874
26. Howard et al. Randomized Clinical Trial of Pacifier Use and Bottle-Feeding or Cupfeeding and Their Effect on Breastfeeding. Pediatrics 2003; 111(3):511-518
27. Kramer MS et al. Promotion of breastfeeding intervention trial (PROBIT): a cluster-randomized trial in the republic of Belarus. JAMA 2001; 285:1-15
28. Gupta A, Khanna K, Chattree S: Cup feeding: an alternative to bottle feeding in a neonatal intensive care unit. J Trop Pediatr 1999; 45:108
29. Marinelli et al. A Comparison of the Safety of Cupfeedings and Bottlefeedings in Premature Infants Whose Mothers Intend to Breastfeed. J Perinatol 2001; 21(6):350-355
30. Collins CT, Ryan P, Crowther C et al. Effect of bottles, cups, and dummies on breast feeding in preterm infants: a RCT. BMJ, doi:10.1136/bmj.38131.675914.55 (published 18 June 2004)
31. Jones E: Breastfeeding in the pre-term infant. Modern Midwife 1994; 4:22
32. Moody J: A revolution in baby feeding. New Generation. 1993; 12:9
33. Steer PA, Lucas A, Sinclair JC: Feeding the low birthweight infant. In Sinclair JC, Bracken M (eds): Effective care of the newborn infant. Oxford: Oxford University Press, 1992, p 125
34. Oddy WH, Glenn K. Implementing the Baby Friendly Hospital Initiative: the role of finger feeding. Breastfeed Rev,2003; 11(1):5-10.
35. Tully SB, Bar-Haim Y, Bradley RL: Abnormal tympanography after supine bottle feeding. J Pediatr 1995; 126:105