Cup feeding: an alternative method of infant feeding.

Artificial methods of infant feeding, ranging from pap bowls, feeding horns, cups with lips, and spouts and bottles have existed since prehistoric times.' Though many of these feeding vessels have now completely disappeared, the bottle and teat have so dominated western thinking in recent years that the use of other artificial methods of infant feeding has been largely overlooked. During four years in Nepal with Voluntary Service Overseas one of the authors (SL) observed mothers cup feeding low birthweight infants with freshly expressed breast milk, using either a cupped hand or a small metal or glass tumbler. Cup feeding is used in several developing countries, not only by mothers2 who have limited access to hospital facilities but also by paediatric and special care baby units.3-8 Its primary and most important use is to provide a safe artificial method of feeding preterm and low birthweight infants until they are strong and/or mature enough to be fully breast fed. The other important function of cup feeding in these countries is to prevent the use of bottle feeding, which is known to result in increased infant morbidity and mortality,9 particularly where hygiene is a problem,2 the sterilisation of bottles difficult, and gastric tubes not easily available. In such an environment cups provide a simple, practical, and inexpensive method of feeding.'0 Experience in the developing world and in several European neonatal"1 12 and transitional care units'3 indicates that cup feeding is a skill easily acquired by preterm infants, at a stage before efficient breast or bottle feeding is possible, and at a point in development when up to now it has been generally assumed that gastric tubes are a necessity.'4 15 According to standard medical and nursing paediatric texts, '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.'6 17 As a result gastric tubes are commonly used in British neonatal units throughout the period of transition to breast or bottle feeding, and are usually the only feeding method available for well, preterm infants of less than 32 weeks' gestation. Infants of more than 32 weeks' gestation may also receive gastric tube feeds, but those who are to be breast fed, in addition commonly receive supplementary bottle feeds, particularly at night. and when mothers are absent. This may not be in accordance with the mothers' wishes but there are few choices open either to staff or parents for an unsettled infant, when gastric tube feeding does not satisfy the infant's psychological and social needs, and the mother is not available to breast feed. Experience in the Exeter neonatal unit has clearly shown that cup feeding in these circumstances can provide a very acceptable alternative. Although little research has been carried out to determine whether bottle feeding interferes with a term infant's ability to breast feed successfully, several authors have drawn attention to the difference between the sucking techniques of breast and bottle feeding.'8-22 To breast feed successfully the infant has to open its mouth widely to accommodate the breast tissue, and protrude its tongue over the bottom lip, which is curled outwards under the areola. In bottle feeding the infant sucks on the teat with a partially closed mouth. When this latter sucking action is used by infants at the breast it can lead to sore nipples, a diminished milk supply, and the cessation of breast feeding. Both bottle teats and pacifiers (dummies)22 encourage this sucking technique, which may affect the eventual success of healthy term infants being able to establish breast feeding. Unfortunately there is no way of predicting which infants will develop problems with breast feeding as a result of learning these two different sucking techniques. Because the establishment of breast feeding in a sick or preterm infant is less straightforward than in a term infant, a method of feeding which does not lead to inappropriate sucking techniques is highly desirable.