Nagihan Sabaz¹, Duygu Gözen²

¹ PhD (student) in Pediatric Nursing,
Istanbul University-Cerrahpasa Institute of Graduate Studies, Istanbul, Turkey
² Professor Doctor, PhD, Department of Pediatric Nursing, Faculty of Nursing, Koç University, Istanbul, Turkey

Received: 26 June 2024

Revised: 1 July 2024

Accepted: 2 July 2024

Published: 2 July 2024

Keywords:

Preterm infant, bottle feeding, oral feeding, neonatal intensive care unit.

Corresponding author:

Nagihan Sabaz

PhD (student) in Pediatric Nursing, Istanbul University-Cerrahpasa Institute of Graduate Studies, Istanbul, Turkey.

nagihan.semin@gmail.com

doi: 10.5281/zenodo.12609923

Cite as:
Sabaz N, Gözen D. Bottle-feeding in the Transitioning to the First Oral Feeding in Preterm Infants in the Neonatal Intensive Care Unit. Med J Eur. 2024;2(4):1-3. doi: 10.5281/zenodo.12609923

ABSTRACT

Preterm infants often face significant challenges in establishing effective oral feeding due to their underdeveloped sucking, swallowing, and breathing coordination. Despite the World Health Organization’s recommendation for exclusive breastfeeding for the first six months, many mothers of preterm infants struggle to achieve this goal due to various reasons. Bottle feeding is one of the commonly used methods in the transition to oral feeding in preterm infants. This paper explores the role of bottle-feeding in transitioning preterm infants to first oral feeding within the NICU (Neonatal Intensive Care Unit). Key factors influencing the success of bottle-feeding include appropriate nipple selection, feeding positions, and careful monitoring of feeding behaviours. Bottle-feeding provides a controlled environment that supports the development of preterm infants’ oral feeding skills, ensuring adequate nutrition and facilitating a smoother transition to breastfeeding or independent feeding at home. Effective bottle-feeding practices help prevent feeding disorders and promote a positive feeding experience, contributing to the infant’s overall growth and development. This study highlights the critical role of bottle feeding in the NICU and provides practical recommendations for caregivers to support preterm infants’ feeding success.

INTRODUCTION

Preterm infants, defined as those born before 37 weeks of gestation, often face numerous challenges in their early lives, one of which is the establishment of effective oral feeding. The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months of life; however, achieving this is often more complicated for mothers of preterm infants who require specialized care in the Neonatal Intensive Care Unit (NICU) (1).

Despite the World Health Organization’s (WHO) recommendation for exclusive breastfeeding for the first six months of life (www.who.int), according to the latest CDC report, only 24.9% of mothers achieve this goal (2). As a result, the majority of infants are fed with expressed breast milk, formula, or a combination of both via bottle before reaching six months of age. The breastfeeding rate for preterm neonate is even lower. During their stay in the NICU, mothers may not always be able to be present to breastfeed their infants. They may even face difficulties in maintaining milk supply due to separation from their babies. Although bottle feeding is physiologically more challenging for preterm infants, many of them may need to learn bottle feeding when breastfeeding is not possible (3).

The success of bottle feeding in preterm infants can be influenced by the infant’s ability to coordinate sucking, swallowing, and breathing, communication ability, position, parental skill, and bottle characteristics. A recent study showed that feeding difficulties such as gagging, tongue thrusting, and choking in preterm infants exist regardless of whether the baby is fed from the breast or bottle (4). Reviewing bottle characteristics can help ensure the safety and success of bottle feeding, whether used as a temporary measure towards breastfeeding or as a standalone feeding method. The choice of bottle and nipple can impact whether bottle feeding is safe, effective, or enjoyable (5,6). In the NICU, preterm infants may be introduced to a bottle and nipple provided by the hospital. A neonate who effectively acquires feeding skills is considered ready for discharge. However, preterm infants might be exposed to different bottles and nipples either in the NICU or when they go home. If the bottle-feeding experience is no longer safe, effective, or enjoyable, feeding disorders and stress may arise (7, 8). Bottles and nipples vary in size, shape, flow rate, texture, and appearance. As a result, preterm infants may face challenges due to changes in bottle characteristics while trying to maintain physiological stability and develop sucking-swallowing-breathing coordination. Preterm infants often struggle to open their mouths widely enough to achieve a good latch and can only latch onto wide nipples. Significant differences in flow rates between nipples have been reported (5). Wide nipples should be avoided until preterm infants grow enough to have adequate latch capabilities. The choice of nipples on bottles should be “slow-flow” or “neonate” nipples (5, 9). To facilitate the transition to home, using the same equipment in the hospital that the neonate will encounter at home can prevent difficulties arising from bottle feeding. The neonate’s behaviours and feeding quality should be monitored to assess the success and safety of bottle feeding. To prevent pressure build-up in bottles, they should be heated without the nipple attached. Evidence of this pressure build-up can be seen when milk sprays out of the bottle nipple when the bottle is tilted horizontally. If bottles are heated with the nipple attached, pressure can be reduced by removing and reattaching the nipple. As the volume in the bottle increases, so does the flow rate of the nipple (10,11). For example, a 120 ml bottle containing 120 ml of liquid has a higher flow rate than a 120 ml bottle containing 60 ml of liquid. Therefore, to help reduce flow rate during bottle feeding, the bottle should contain a smaller volume of breast milk. The nipple ring should be comfortably fitted to the bottle but not too tight. An overly tight connection between the nipple ring and the bottle can create a vacuum, making bottle feeding more difficult (11).

Practices such as bending, shaking, or moving the bottle nipple in the baby’s mouth when the baby pauses to breathe or swallow or falls asleep, allowing the baby to feed too quickly without taking breathing or rest breaks, and force-feeding despite signs of satiety or fatigue should be avoided. These strategies are not recommended as they can disrupt the neonate’s need for rest and breathing (11). Moreover, these harmful experiences can teach the baby that feeding is not enjoyable (12). Since milk drips from the bottle into preterm infants’ mouths by gravity during bottle feeding, they may be overfed. Overconsumption can lead to gastrointestinal discomfort and gastroesophageal reflux (13).

Semi-elevated side lying position for bottle feeding can facilitate feeding for preterm infants. This position, similar to breastfeeding, keeps the ear and shoulder elevated, and the sternum and face aligned. The neonate’s face should be clearly visible to effectively monitor feeding. This position allows for better control of bottle flow, reduces gravitational dripping into the preterm neonate’s mouth, and increases neonate postural stability and comfort (11). Taking short rest breaks of up to a minute during bottle feeding can be an effective strategy to help preterm neonates preserve their respiratory reserves and increase feeding endurance (14).

Satiety cues of preterm neonates should be observed. However, it should be remembered that satiety cues in preterm infants may not be clearly observable yet. Signs indicating failure in sucking-swallowing-breathing coordination during bottle feeding include spilling, fussiness, anxious facial expressions, prolonged sucking without pauses, leaning forward, coughing, or choking. Neonates are naturally programmed to suck rapidly and forcefully at the beginning of feeding to stimulate milk flow from the breast. This behaviour on the bottle usually results in rapid milk transfer, swallowing, prolonged sucking without breathing, and rapid stomach filling. Caregivers can slow feeding by slowing or intermittently stopping the fast-sucking pattern until the baby shows a slower sucking pace (12, 15). Tilting the nipple to stop milk flow can cause the baby to swallow air. Ideally, the nipple should be completely removed from the mouth and rested on the baby’s lip (11). Feeding continues when the baby swallows, takes a few breaths, and shows a desire to continue feeding. Caregivers may need to do this every 3-8 sucks until the sucking pace slows. Eventually, the neonate will progress independently with short pauses, sucking-swallowing-breathing coordination, and enjoyable feeding. Bottle feeding is a common practice for many preterm infants. As preterm neonates’ feeding skills develop over time, bottle feeding can be considered a temporary measure (16).

This paper explores the critical role of bottle feeding in transitioning preterm infants to oral feeding in the NICU, addressing the physiological, developmental, and practical considerations involved.

PHYSIOLOGICAL AND DEVELOPMENTAL CONSIDERATIONS

Preterm infants are born with underdeveloped neurological and muscular systems, making the coordination of sucking, swallowing, and breathing challenging. Effective oral feeding requires the infant to synchronize these actions to avoid aspiration and ensure adequate nutrition (3). Premature infants often exhibit disorganized feeding patterns, which can lead to feeding difficulties and inadequate weight gain.

CHALLENGES IN BREASTFEEDING PRETERM INFANTS

Despite the benefits of breastfeeding, preterm infants often struggle with direct breastfeeding due to their physiological immaturity. Mothers of preterm infants may not always be present in the NICU to breastfeed directly, and maintaining milk supply can be challenging due to separation (4). Consequently, expressed breast milk and formula are frequently used, with bottle feeding serving as a vital tool to ensure that preterm infants receive necessary nutrition.

THE ROLE OF BOTTLE FEEDING IN NICU

Bottle feeding in the NICU helps bridge the gap between tube feeding and breastfeeding or independent bottle feeding. It allows for the gradual development of the infant’s oral feeding skills in a controlled manner. Key factors influencing the success of bottle feeding in preterm infants include:

1. Nipple Selection: Nipple shape, size, and flow rate significantly impact feeding efficiency. Slow-flow or neonate nipples are generally recommended to prevent overwhelming the infant with too rapid a milk flow (5,9,17).

2. Feeding Position: A side-lying, elevated position can facilitate better control over milk flow and improve the infant’s comfort and stability (11,17-19).

3. Monitoring and Adjustments: Caregivers play a crucial role in the transition to bottle feeding. Techniques such as pacing the feeding, allowing for frequent breaks, and monitoring the infant’s cues can help manage feeding difficulties. Observing signs of distress, such as coughing, choking, or prolonged sucking without pauses, allows caregivers to adjust the feeding process accordingly (12). Effective caregiver interventions can prevent feeding-related stress and ensure a positive feeding experience.

PRACTICAL CONSIDERATIONS IN THE NICU

The introduction of bottle feeding in the NICU should be done with careful consideration of each infant’s unique needs. Standardizing the type of bottles and nipples used in the NICU with those that will be used at home can ease the transition for both the infant and parents (16). Additionally, bottles should be prepared in a manner that prevents pressure build-up, which can lead to an uneven flow of milk and potential feeding difficulties (10).

LONG-TERM BENEFITS OF EFFECTIVE BOTTLE FEEDING

Effective bottle-feeding practices not only ensure that preterm infants receive adequate nutrition but also contribute to their overall development and readiness for breastfeeding or independent feeding at home. Properly managed bottle feeding can reduce the risk of feeding disorders and promote a positive feeding experience, crucial for the infant’s growth and development (15).

CONCLUSION

Bottle feeding is one of the commonly used methods in the transition of preterm infants to first oral feeding in the NICU. Nurses can support the development of effective feeding skills in preterms by closely monitoring the baby’s cues for feeding readiness, the nipple with the milk flow rate closest to the mother’s breast, the semi-elevated right side-lying feeding position, and feeding behaviors. This approach not only ensures feeding adequacy, but also forms the basis for successful breastfeeding or feeding in babies who need to be bottle-fed after discharge.

Acknowledegment

This review was prepared based on the doctoral thesis of Nagihan SABAZ in June 2024, under the supervision of Prof. Dr. Duygu GÖZEN, at Istanbul University-Cerrahpaşa, Institute of Graduate Studies, Department of Pediatric Nursing.

CC BY License

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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