Comparison of Effect of Feeding Premature Infants with Either Cup,Bottle,and Syringe on Transition to Breastfeeding,Breastfeeding Success,Weight Gain,and Duration of Hospitalization

Abstract

Objective:

This study was completed with the aim of determining the effect of cup feeding (CF), bottle feeding (BF), and syringe feeding (SF) methods on the transition to breastfeeding, breastfeeding success, physiological parameters, weight gain, and discharge duration for preterm neonates in the neonatal intensive care unit (NICU).

Materials and Methods:

The study was designed to be randomized, controlled, and single blinded. The study was completed with 102 premature neonates between 29–34 gestational weeks abiding by the case selection criteria receiving treatment and care in the NICU. The 1st group comprised premature neonates receiving CF, the second group received BF, and the third group received SF. For collection of data, the Premature Infant Descriptive Information and Monitoring Form, Bristol Breastfeeding Assessment Tool (BBAT), and Infant-Focused Feeding Scales (IFFS) were used.

Results:

Comparison of mean peak heart rate in the groups found that the BF group was significantly high (p = 0.047) and comparison of mean SO₂ found that the SF group was significantly high (p = 0.000). Infants in the SF group were determined to have significantly higher BBAT scores compared to the infants in the BF and CF groups (p = 0.015). In addition, SF infants were determined to transition to full enteral feeding and breastfeeding in a shorter duration (p < 0.05). There were no significant differences between the groups for weight gain and discharge duration (p > 0.05).

Conclusions:

The SF method was determined to more positively affect breastfeeding success, transition to full breastfeeding duration, and vital signs compared to the CF and BF methods. In line with the results obtained in the study, the use of the SF method may be recommended to increase breastfeeding success of neonates, to shorten the transition to full breastfeeding and for stable physical parameters.

Introduction

Ensuring early discharge comprises the focal point of preterm infant care, and it is highly important that the infant gains the desired functional skills at discharge.¹ These functional skills were determined by the American Academy of Pediatrics (AAP) to be good physiological status, regular body weight increase, and the infant's ability to feed orally.² Successful oral feeding is one of the most important tasks that a preterm infant must achieve before discharge.^3,4 Research revealed that feeding problems are the most frequent cause of long-term hospitalization.^5–8

The method used to feed premature neonates varies linked to gestational age (GA), whether they are sick or not and individual tolerance. Premature neonates who reach the 32nd to 34th week and have no additional health problems generally may be able to feed with the oral route as they are able to provide coordination between sucking, swallowing, and respiration. The hope is to ensure oral feeding by breastfeeding in the shortest duration possible.⁹ However, preterm neonates experience difficulties to varying degrees during the transition to breastfeeding. As a result, it is necessary to sustain oral feeding by methods like bottle, spoon, dropper, cup (glass), or syringe until they reach maturity to be able to breastfeed, and it is necessary to ensure transition to breastfeeding in the shortest duration.^10–18

The bottle feeding (BF) method is encountered as the most frequently used enteral feeding method for the transition of the premature neonate to oral feeding and breastfeeding after sucking and swallowing coordination develop in the 32nd week of gestation.^14–16 Due to the convenience of feeding with a bottle, it is the most commonly chosen method in neonatal units.^15,16 The use of bottles in the neonatal intensive care unit (NICU) is a very common practice, while it is reported to cause “nipple confusion” resulting from inability of the infant to suckle at the breast due to sucking as if from a bottle. For this reason, health authorities see feeding of the infant with a bottle as a factor making it more difficult to transition to breastfeeding.¹²

The cup feeding (CF) method is assessed as an alternative method easing the transition to breastfeeding for infants who cannot feed from the breast.^19,20 In recent years, the use of CF as an alternative to BF for neonates who cannot breastfeed has increased.^13–15 The theoretical benefits of CF may be listed as easing the transition to breastfeeding by avoiding nipple confusion caused by bottle use, developing sucking skills in the neonate, developing the neonate's ability to self-regulate when feeding, supporting body and eye contact with the parent in the early period, and making it easier to sustain cardiac and respiratory stability. Most of these advantages may also be defined for BF.^19,21

In recent years, CF was reported to increase the nursing work load, and cause difficulties in the transition to breastfeeding if used for a long duration.^21,22 A systematic review assessing four randomized controlled studies about the results of CF and BF published by Cochrane revealed that CF did not have adequate evidence of advantages compared to BF, and there was a need for more comprehensive randomized controlled studies about this topic.²¹

The syringe feeding (SF) method began use as a method supporting the transition to breastfeeding especially for premature neonates older than 30–32 weeks gestation in recent years as an alternative to cup and BF. Its use is becoming more common to support the transition to oral feeding of premature neonates in the NICU. The SF method has less aspiration risk compared to CF and is reported to have fewer problems like deficient nutrition of the infant as dribbling of milk during feeding is not possible.^23,24 Although the use of the SF method is very common in NICUs in our country, when the literature is investigated, there are limited numbers of studies researching the efficacy of the SF method in the transition to oral feeding.^23,24

A study comparing the effect of CF and SF in the transition to full oral feeding reported that cup-fed infants transitioned to full breastfeeding in a shorter duration; however, syringe-fed infants were discharged in a shorter duration.²³ Another study comparing the effect of bottle and SF on duration of breastfeeding after discharge found no difference between breastfeeding durations after discharge of infants fed with bottle and syringe. However, the group fed with a syringe were breastfed for longer durations.²⁴ As it is, there is inadequate evidence showing that the SF method is effective and safe in the transition to oral feeding of preterm neonates. Outcomes related to support of the transition to oral feeding by SF are limited to the experience and observations of nurses working in NICUs.

Although there are limited studies revealing the effect of bottle, cup, and SF methods on the transition to breastfeeding in the literature, there was no study encountered revealing which of the three methods is the ideal method for the transition to breastfeeding. Research results from the limited studies researching the effect of one or two methods on the transition to breastfeeding do not have consistent results.^{10,13,21,23,24} In addition, the studies comparing the effect of these methods on breastfeeding success, physiological parameters, weight gain, and discharge duration for these infants are limited.

Research Hypotheses

H0: For preterm neonates, SF, CF, and BF methods will have no effect on the duration of the transition to full breastfeeding, breastfeeding success, weight gain, and discharge duration.

H1: SF infants will transition to breastfeeding in a shorter duration compared to BF and CF infants.

H2: SF infants will have higher breastfeeding success scores than BF and CF infants.

H3: SF infants will have more stable life signs than BF and CF infants.

H4: SF infants will have better weight gain than BF and CF infants.

H5: SF infants will have shorter discharge duration than BF and CF infants.

Methods

Study design and participants

This research was completed as a randomized, controlled experimental study with the aim of determining the effect of CF, SF, and BF (control group) methods on duration of transition to breastfeeding, breastfeeding success, weight gain, and discharge duration for preterm neonates admitted to the NICU in Giresun University Gynecology and Pediatric Diseases Education and Research Hospital linked to Giresun Provincial Directorate of Health.

Setting

The NICU where the research was performed comprises 3 levels and 18 incubators set up for the treatment requirements of neonates. The unit uses 1 neonatal specialist, 3 pediatrists, 15 nurses, and 1 physiotherapist. GA of neonates in the NICU is noted to begin first oral feeding and initiation of oral feeding is decided by the specialist doctor and nurse together. There is no written protocol for initiation of oral feeding and maintaining nutrition for premature neonates in the unit.

The population for the research comprised premature neonates with gestational weeks 29–34 treated and cared for in the NICU. The sample for the research comprised 102 premature neonates treated and cared for in the NICU between these dates, abiding by the case inclusion criteria and with parents who accepted participation in the research. With the aim of determining the sample number, the G*Power (v3.1.9.2) program was used for power analysis. According to Cohen's effect size coefficient, assuming a large effect size (f = 0.40) for assessments to be performed between three independent groups, α = 0.05 and 1 − β = 0.95 (95% power), the groups should include at least 34 subjects requiring a total of 102 individuals (Fig. 1).²⁵

FIG. 1.

CONSORT diagram showing the flow of participants (Study enrollment, randomization, and procedures).

Allocation of participants in the research into groups was completed with the “simple randomization method.” The researcher created three groups with random number tables using the following website: https://www.random.org. The first group was CF, the second group was BF, and the third group was SF. Each group in the study included 34 premature neonates, and the study was completed with a total of 102 premature neonates.

Selection criteria

Neonates born from 29 to 34 weeks gestation, with physical measurements appropriate for gestational week (using the Fenton growth curve revised by Fenton and Kim),²⁶ with 1st and 5th minute APGAR scores above 4, without congenital anomaly or severe complications, 48 hours after stability was ensured for neonates requiring mechanical ventilator or continuous positive air pressure or both, without interventricular hemorrhage, able for full enteral feeding, able to feed orally at least once within the first 24 hours in the transition from nasogastric/orogastric tube to oral feeding, fed with breast milk or formula, and with mothers who wished to breastfeed and who agreed to participate in the research voluntarily.

Exclusion criteria

Neonates born with low birth weight according to gestational week, with severe asphyxia, with unstable vital signs, with congenital anomaly or severe complications, craniofacial anomaly such as cleft palate, cleft lip, or paralysis of facial muscles, with any gastrointestinal, neurological, and genetic disease (necrotizing enterocolitis, periventricular leukomalacia, hydrocephalus, Down syndrome, omphalocele, gastroschisis, short intestine syndrome, and so on), severe bronchopulmonary dysplasia, and patent ductus arteriosus requiring surgical treatment were excluded from the study.

Blinding

The researcher was not blinded to the group in which the preterm neonates were allocated due to the nature of the study. However, to prevent detection bias, output measures for the study were obtained by a neonatal nurse employed in the NICU, not included in the research team, without conflict of interest and without knowledge of which neonate was in the experimental groups or control group. The researcher informed the nurse about the data collection forms and scales used in the research. With the aim of preventing bias during assessment of data, the study groups were labeled A, B, and C coded by someone other than the researcher.

Data collection tools

Premature Infant Descriptive Information and Monitoring Form

The form was prepared by the researchers in line with the literature^10,13,14 and included questions about the descriptive information of the premature neonate such as sex, GA, birth weight, height, head circumference, diagnosis, discharge weight, and discharge duration. In addition, with the aim of following the premature neonate from the time of beginning oral feeding, oral feeding initiation duration and independence in feeding were recorded on the form.

Infant-Driven Feeding Scales

This comprises three scales developed by Waitzman et al. to meet the need for a feeding intervention guide and standard document for caregivers to measure readiness for oral feeding and feeding quality of preterm infants.²⁷ The Infant-Driven Feeding Scales Readiness Scale (IDFS-R) is a 5-point numerical scale, whereby 1 and 2 describe feeding readiness behaviors that may lead to oral feeding (breast or bottle), and 3–5 describe behaviors and factors that lead to tube feeding. The Infant-Driven Feeding Scales Quality Scale (IDFS-Q) is a 5-point numerical scale defining a range of oral feeding behavior and factors observed when infants begin oral feeding.

Receiving 5 points from both the IDFS-R and IDFS-Q automatically shows that the infant is not clinically stable and draws the caregivers' attention to the safety of oral feeding. Infant-Driven Feeding Scales (IDFS)-Caregiver Techniques include support from caregivers arranged from letters A to E. This category was designed as a communication method between caregivers. This differentiation is used to emphasize caregiver behavior (supportive techniques) during feeding in response to infant behavior. The scale was adapted to Turkish by Alemdar et al.²⁸

Bristol Breastfeeding Assessment Tool

This was developed in 2015 by Ingram et al.²⁹ and is a scale with Turkish validity and reliability studied by Dolgun et al. in 2018.³⁰ The scale comprises four assessment criteria of positioning, holding the nipple, sucking, and swallowing. Each item is assessed with points from 0 to 2. The lowest points that can be obtained is 0, with highest points of 8. High points indicate high breastfeeding success of the infant, while low points indicate poor success. The Cronbach's alpha coefficient for the Bristol Breastfeeding Assessment Tool (BBAT) was reported to be 0.77 by Dolgun et al.³⁰

Data collection procedure

Data collection and feeding in the research included assessment of data obtained during the first two feedings and at discharge. In addition, before the first feed of each day (09.00 feed), nurses monitored the infants' weight by weighing them. The feeding plan for infants included in the research was determined by the pediatric specialist doctor included in the study team as researcher in line with the NICU feeding protocol. According to the feeding protocol in the clinic, readiness of preterm neonates for the transition from gavage feeding to oral feeding was assessed with the IDFS-R

In line with points obtained from the scale, the decision was made to begin the transition to breastfeeding. Infants assigned to randomized groups were given breast milk amounts recommended by the doctor using the method appropriate for their group. The ability of neonates to tolerate oral feeding was assessed with the IDFS-caregiver technique scale. The first attempt by infants beginning breastfeeding was assessed with the IDFS-Q and breastfeeding continued. The breastfeeding success of neonates was assessed with the BBAT.

Breastfeeding success of infants was assessed with the BBAT by the NICU nurse at the first attempt (first measure), 24 hours after the first attempt (second measure), and before discharge (final measure). In order for infants in the three groups not to be affected by individual differences in practice, they were fed by the same nurse employed in the NICU. From the time the infant finished feeding, 30 minutes of monitoring began. In this stage, the neonate was placed in the incubator and all neonates were placed in right lateral position with the aim of easing gastric emptying. Feeding success was recorded during feeding and physiological parameters were recorded by a nurse following three feeds in 1 day using the monitor for each infant before, during, and after feeding.

Neonates in all three groups were laid in a semi-lying position with 45° slope and one hand was used to support the head and neck. The feeding methods were implemented as follows according to the group to which premature infants included in the research were assigned.

CF group

Infants in this group were fed the determined amount of breast milk with a cup. For feeding, a 35 mL cup that did not contain BPA was used. The infants were given a semivertical position with head and back support and given breast milk or formula. For CF, the edge of the cup was touched to the infant's lower lip to stimulate rooting. All cup feeds were performed by an NICU nurse who had received education about the cup-feeding technique.

Syringe-fed group

Infants in this group were given the determined amount of breast milk with a syringe. For feeding, a 10 mL syringe not containing BPA was used. Milk was dripped toward the inner cheek, not toward the tongue or pharynx. The infant was held in a 45° semi-lying position and milk was administered by pushing the piston so that no more than 0.2 mL entered the infant's mouth at any time. The mean feeding rate with the SF method was 1.5 cc per minute.³¹

Bottle-fed group

Infants in this group were fed the determined amount of breast milk with a bottle. For feeding, an 80 mL bottle not containing BPA was used. During feeding, the teat of the bottle was touched to the infant's lips to prepare the infant for feeding, when the mouth opened and tongue lowered, the teat of the bottle was inserted into the infant's mouth.

Ethical statement

Before collecting data in the research, permission was granted by Giresun University Faculty of Medicine Clinical Research Ethics Committee (KAEK/31) and by Giresun Provincial Directorate of Health (E.1817). Parents of neonates abiding by the selection criteria were met, given information about the study, told that they could leave the study any time, that information would be kept confidential, and that the collected data would only be used for the research purpose. Parents were asked whether they wished to participate in the study or not. Parents wishing to participate in the study provided verbal and written consent. In the study, the ethical principles related to “Informed Consent Policy,” “Volunteer Policy,” and “Privacy Protection Policy” were fulfilled since the use of human subjects requires the protection of individual rights.

Data analysis

Before beginning the research, power analysis calculations to determine the sample size were completed with the G-power 3.1.9.7 program. As preterm infants would be comparatively assessed in three different groups, the main test in power analysis was the analysis of variance (ANOVA) test. Statistical analysis was conducted using the SPSS Statistics software for Microsoft Windows XP (Version 25.0; SPSS, Inc., Chicago, IL). Data obtained as a result of the research are given as number, percentage, mean, and standard deviation values from descriptive statistical tests. Fit of variables to normal distribution was assessed with the Shapiro Wilk normality test, Q-Q graphs and histograms. With the aim of determining differences between the experimental groups in terms of demographic characteristics, the Pearson chi-square and ANOVA tests were used to assess qualitative data.

Data were normally distributed. Comparisons of three sequential measurements for the three groups were carried out using ANOVA for measures and the post hoc advanced analysis Bonferroni test for binary comparisons was deployed for statistical analyses. To compare the physiological parameters and BBAT mean points over time, the variance analysis for repeated measures (R-ANOVA) and generalized linear models were used. The level of significance was set to p < 0.05.

Results

The characteristics of neonates included in the research are given in Table 1. There were no statistically significant differences determined in terms of descriptive statistics like GA of neonates (CF: 32.26 ± 1.68, SF: 31.88 ± 1.77, BF: 32.44 ± 1.63), birth height (CF: 42.14 ± 4.59, SF: 42.88 ± 3.85, BF: 44.14 ± 4.07 cm), and birth weight (CF: 1,855.44 ± 543.47, SF: 1,728.23 ± 416.30, BF: 1,911.91 ± 539.15 g) (Table 1, p > 0.05). Other comparisons in terms of descriptive characteristics are included in Table 1. In light of these results, the neonates appeared to be similar in terms of variables that may affect duration to breastfeeding, breastfeeding success, physiological parameters, weight gain, and discharge duration.

Table 1.

Comparison of Descriptive Characteristics of the Groups (N = 102)

Characteristics	Groups test value
Characteristics	Cup-feeding group (n = 34), n (%)	Syringe-feeding group (n = 34), n (%)	Bottle-feeding group (n = 34), n (%)	χ²	p
Gender
Girl	15 (44.1)	15 (44.1)	18 (52.9)	0.708	0.702
Boy	19 (55.9)	19 (55.9)	16 (47.1)
Birth
Spontaneous	3 (8.8)	2 (5.9)	2 (5.9)	0.307	0.858
Cesarean	31 (91.2)	32 (94.1)	32 (94.1)
Morbidities
Prematurity (<37-week GA)	22 (64.7)	20 (58.8)	27 (79.4)
TTN	7 (20.6)	3 (8.8)	2 (5.9)	8.059	0.089
RDS	5 (14.7)	11 (32.4)	5 (14.7)
Nutrient content
Breast milk	23 (67.6)	26 (76.5)	28 (82.4)	2.014	0.365
Breast milk+Formula	11 (32.4)	8 (23.5)	6 (17.6)
Feeding status
Parenteral	31 (91.2)	29 (85.3)	29 (85.3)	0.705	0.703
Enteral+Parenteral	3 (8.8)	5 (14.7)	5 (14.7)
	Mean ± SD	Mean ± SD	Mean ± SD	F	p
GAs	32.26 ± 1.68	31.88 ± 1.77	32.44 ± 1.63	0.972	0.382
Birth weight (g)	1,855.44 ± 543.47	1,728.23 ± 416.30	1,911.91 ± 539.15	1.189	0.309
Birth height (cm)	42.14 ± 4.59	42.88 ± 3.85	44.14 ± 4.07	1.984	0.143
Birth head circumference (cm)	31.26 ± 2.94	31.08 ± 2.70	31.02 ± 2.57	0.068	0.935
Apgar Score 1	6.79 ± 1.00	6.61 ± 1.27	6.20 ± 1.40	2.003	0.140
Apgar Score 5	7.85 ± 1.01	7.38 ± 1.12	7.38 ± 1.10	2.136	0.124

GA, gestational age; RDS, Respiratory Distress Syndrome; SD, standard deviation; TTN, Transient Tachypnea of the Newborn.

When groups are compared in terms of physiological parameters before, during, and after feeding, in before and after feeding, there was no difference in mean peak heart rate (PHR) and SO₂ between the groups (p > 0.05). In the BF group, PHR was statistically significantly high during feeding (p = 0.047), while oxygen saturation was lower by a significant degree compared to the other groups (p = 0.000) (Table 2).

Table 2.

Comparison of Physiological Parameters of the Control and Intervention Groups (N = 102)

Physiological parameters	Groups
Physiological parameters	Cup-feeding group¹ (n = 33), mean (SD)	Syringe-feeding group² (n = 33), mean (SD)	Bottle-feeding group³ (n = 33), mean (SD)	Test	Value
Before feeding heart rate	149.76 (16.49)	147.58 (13.76)	142.14 (15.77)	Time	F = 2.188, p = 0.124
During feeding heart rate	147.94 (13.29)	142.91 (9.34)	149.97 (11.45)^*	Group^a	F = 3.257, p = 0.047
After intervention heart rate	153.03 (12.74)	146.92 (10.98)	149.65 (13.13)	Time × Group	F = 0.856, p = 0.644
Before feeding SO₂	98.44 (1.84)	98.41 (1.45)	95.29 (8.28)	Time	F = 0.036, p = 0.965
During feeding SO₂	97.91 (2.15)	98.20 (1.80)^*	94.58 (8.30)	Group^b	F = 9.895, p = 0.000
After feeding SO₂	98.14 (1.52)	98.50 (1.56)	95.14 (6.36)	Time × Group	F = 0.255, p = 0.836
Before feeding respiratory rate	41.44 ± 1.75	43.64 ± 1.77	42.26 ± 1.76	Time	F = 0.326, p = 0.715
During feeding respiratory rate	44.94 ± 1.75	43.11 ± 1.77	47.14 ± 1.76	Group	F = 0.745, p = 0.558
After feeding respiratory rate	42.14 ± 1.75	43.97 ± 1.77	42.73 ± 11.35	Time × Group	F = 2.289, p = 0.107

Bold indicates significance at 0.05.

Significance levels for Bonferroni test comparing Cup feeding–Syringe feeding (1–2), Cup feeding–Bottle feeding (1–3), and Syringe feeding–Bottle feeding (2–3) paired comparisons: ^*Cup feeding–Bottle feeding (1–3), and Syringe feeding–Bottle feeding p < 0.05; ^*Post hoc advanced analysis result.

Significance levels for Bonferroni test comparing Cup feeding–Syringe feeding (1–2), Cup feeding–Bottle feeding (1–3), and Syringe feeding–Bottle feeding (2–3) paired comparisons: ^*Cup feeding–Syringe feeding (1–2), Cup feeding–Bottle feeding (1–3), and Syringe feeding–Bottle feeding (2–3) p < 0.05.

SD, standard deviation.

When the respiratory values before, during, and after feeding for preterm infants included in the research are compared, there was no significant difference (Table 2, p > 0.05). When infants are compared in terms of duration to full enteral feeding, duration to full breastfeeding, discharge weight, and duration of hospitalization, there were statistically significant differences between the groups for transition time to full enteral feeding (days) and transition time to full breastfeeding (days; p < 0.05). As a result of advanced analyses, the difference between the groups was determined to be due to the SF group (Table 3).

Table 3.

Comparison of Full Enteral and Breastfeeding Days, of the Control and Intervention Groups (N = 102)

Physiological parameters	Groups
	Cup-feeding group¹ (n = 33), mean (SD)	Syringe-feeding group² (n = 33), mean (SD)	Bottle-feeding group³ (n = 33), mean (SD)	Test value
	Cup-feeding group¹ (n = 33), mean (SD)	Syringe-feeding group² (n = 33), mean (SD)	Bottle-feeding group³ (n = 33), mean (SD)	F	p
Transition time to full enteral feeding (days)	12.44 (12.06)	9.50 (8.33)^*	17.58 (16.23)	3.573	0.032
Transition time to fully breastfeeding (days)	14.70 (12.90)	11.08 (8.68)^*	19.70 (16.87)	3.627	0.030
Duration of hospitalization (days)	19.23 (13.98)	18.67 (14.26)	26.94 (18.25)	2.971	0.056
Discharge weight (g)	2,236.029 (386.246)	2,085.147 (314.819)	2,107.647 (305.483)	1.978	0.144

Bold indicates significance at 0.05.

Significance levels for Bonferroni test comparing Cup feeding–Syringe feeding (1–2), Cup feeding–Bottle feeding (1–3), and Syringe feeding–Bottle feeding (2–3) paired comparisons: ^*Syringe feeding–Bottle feeding (2–3) p < 0.05; ^*Post hoc advanced analysis result.

SD, standard deviation.

The mean number of days for transition to full breastfeeding (19.70 ± 16.87) was longer by a significant level for infants fed by bottle compared to SF (11.08 ± 8.68) and CF (14.70 ± 12.90) infants. There were no statistically significant differences identified between premature infants in terms of discharge duration and mean weight (Table 3, p > 0.05).

Table 4 includes the comparisons of IDFS-R, IDFS-Q, BBAT 1, BBAT 2, and BBAT 3 for neonates in the SF, CF, and BF groups. There were no statistical differences between the IDFS points for neonates in the SF, CF, and BF groups. The difference in BBAT scores was statistically significant according to feeding method for preterm infants (CF, SF, BF), and SF infants were determined to have significantly higher BBAT scores compared to BF and CF infants (p < 0.001) (Fig. 2). In addition, when in-group comparisons according to feeding time are investigated, there was a statistically significant difference between the groups and this difference was between the SF and BF groups (Table 4, p = 0.000).

FIG. 2.

Comparisons of BBAT 1, BBAT 2, and BBAT 3. BBAT, Bristol Breastfeeding Assessment Tool.

Table 4.

Comparison of Infant-Driven Feeding Scales and Bristol Breastfeeding Assessment Tool of the Control and Intervention Groups (N = 102)

Parameters	Groups
Parameters	Cup-feeding group¹ (n = 33), mean (SD), median (minimum–maximum)	Syringe-feeding group² (n = 33), mean (SD)	Bottle-feeding group³ (n = 33), mean (SD)	Test value
IDFS-R	1.47 (0.86)	1.47 (0.86)	1.73 (0.86)	F = 1.099	p = 0.337
IDFS-Q	1.64 (1.06)	1.67 (1.03)	1.97 (0.96)	F = 1.034	p = 0.359
BBAT 1 (first breastfeeding)	5.61 (1.87)	5.64 (2.00)	4.67 (1.87)^*	Time^a	F = 59.882, p = 0.000
BBAT 2 (second breastfeeding)	6.64 (0.69)	6.85 (0.43)^**	6.36 (1.05)	Group^b	F = 4.412, p = 0.015
BBAT 3 (discharge breastfeeding)	6.82 (0.45)	6.94 (0.23)	6.57 (0.87)	Time × Group	F = 1.349, p = 0.264

Bold indicates significance at 0.05.

Significance levels for Bonferroni test comparing Cup feeding–Syringe feeding (1–2), Cup feeding–Bottle feeding (1–3), and Syringe feeding–Bottle feeding (2–3) paired comparisons: ^*Cup feeding–Syringe feeding (1–2), Cup feeding–Bottle feeding (1–3), and Syringe feeding–Bottle feeding (2–3) p < 0.05; ^*Post hoc advanced analysis result.

BBAT, Bristol Breastfeeding Assessment Tool; IDFS-Q, Infant-Driven Feeding Scales Quality Scale; IDFS-R, Infant-Driven Feeding Scales Readiness Scale; SD, standard deviation.

Discussion

This research was completed with the aim of determining the effect of CF, feedings, and BF on preterm neonates in the NICU on duration to breastfeeding, breastfeeding success, physiological parameters, weight gain, and discharge duration. The findings revealed that infants fed by bottle had higher mean PHR compared to infants in the SF and CF groups. This result leads to consideration that the BF method requires more effort compared to SF and CF methods and may be associated with fatigue. Goldfield et al. compared BF, bolus gavage, and slow gavage feeding techniques with PHR values in their study and determined that the three feeding techniques had no significant effect on PHR.³²

In the study, the oxygen levels in the syringe group were observed to be better. This result leads to consideration that infants fed with syringe requires less effort and may be associated with easier feeding. There is insufficient evidence comparing oral feeding transition techniques in terms of SO₂ and heart rate.³³ It is possible that the form of feeding of premature neonates affects heart rate fluctuations and arterial oxygen saturation. A study by López et al. showed that SO₂ was <85% after CF. The authors emphasized that the possible fall in SO₂ may be associated with intense attempts to suck milk from the cup.³⁴ Araújo et al. observed that oxygen saturation and heart rate variations before, during, and after feeding were within normal limits for both syringe and finger feeding methods. Oxygen saturation increased between the moments before and after SF.³¹

A study by Alinezhad Shebilouysofla et al.³⁵ assessed the effect of cup, syringe, and finger feeding methods on time to achieve full oral feeding and weight gain among preterm neonates. They did not show a significant difference between the three groups for daily weight gain, oxygen saturation, and mean heart rate after feeding.

When the groups in the study are compared in terms of transition to enteral feeding and transition to full breastfeeding, infants fed with a bottle appeared to have longer transition to enteral feeding and to full breastfeeding compared to the other groups. When compared in terms of discharge duration, although not at statistical levels, the hospitalization of the BF group was longer compared to the CF and SF groups. These results may be interpreted as showing that the bottle group had later discharge due to longer duration to transition to breastfeeding and enteral feeding compared to the other groups.

Previous research reported that cup-fed infants displayed more mature breastfeeding behavior by a significant degree compared to bottle-fed infants.^16,36,37 Dalal et al. found that increasing experience of the paladai feeding method and maturity ensured rapid improvement in feeding performance.³⁸ In addition, they proposed that paladai or BF may be equally safe feeding methods for preterm neonates in hospital. A Cochrane investigation found that CF caused longer duration of breastfeeding after discharge.³⁹ Another investigation found that use of a cup instead of a bottle increased the scope and duration of breastfeeding for preterm infants.¹⁶

Due to these contradictory results related to breastfeeding rates, there is a need for additional studies before recommending a feeding approach on its own with gavage. Say et al.¹⁷ showed that the duration to full oral feeding was significantly shorter for preterm neonates fed with syringe compared to preterm neonates fed with a bottle. A study performed with the aim of comparing the effects of feeding by syringe and feeding with a bottle in the first 12–24 hours of life for term infants on breastfeeding 1.5 months later stated that SF had no difference to feeding with only breast milk compared to BF.²³

Ensuring full oral feeding is an important criterion for discharge of neonates and is an important step in terms of showing the maturity and health of preterm infants.⁴⁰ Any delay in fulfilling this very important physiological function may cause delays in discharge of the neonate from intensive care and cause growth retardation and worse neurodevelopmental outcomes.^41–43 In the study, although not at statistically significant levels, the SF group had shorter discharge duration, which is thought to be related to the shorter duration to full enteral feeding and breastfeeding in this group compared to the BF and CF groups. Çamur and Çetinkaya⁴⁴ reported that bottle and CF methods were equally effective in achieving full oral feeding and there was no statistically significant difference between these groups.

However, the study by Say et al.¹⁷ found that preterm infants fed by syringe had significantly shorter durations to breastfeeding and to discharge compared to BF.

When the groups in the study are compared in terms of mean weight at discharge and IDFS points, there was no statistically significant difference identified (Table 3, p > 0.05). This situation may be affected by the form of transition to enteral feeding and breastfeeding, while it may be interpreted as showing that the form of feeding did not significantly affect weight increase and IDFS scores. However, when the groups are compared in terms of BBAT scores, the SF infants appeared to have higher BBAT scores by a significant level compared to BF infants (Table 4, p < 0.001). In line with this result, feeding by syringe may be concluded to be a more helpful method to develop sucking ability at the breast compared to BF. In line with this, H2 hypothesis is confirmed. When studies with bottles in the literature are investigated, there appear to be different study outcomes.

Similar to this study, when spoon and BF techniques are compared, it was concluded that breastfeeding success assessment was significantly higher in favor of spoon feeding.⁴⁵ Due to the BF technique being different from breastfeeding, it causes nipple confusion in the infant, and as feeding from a bottle is easier compared to breastfeeding, it was mentioned that preterm infants may have difficulty transitioning to breastfeeding. In addition, in the literature, there are studies reporting that BF is effective in developing sucking ability and effective feeding.^17,20 There are studies showing that feeding by syringe provides oral stimulation, which accelerates the transition to full oral feeding and ensures more milk intake.⁴⁶

In line with these results, it may be said that SF is an easy to apply feeding method that provides oral stimulation, gives the preterm neonate oral swallowing control, and supports breastfeeding success and the transition to breastfeeding and oral feeding. It may be recommended that SF be considered the first choice to support the transition to breastfeeding.

Limitations

This study has some limitations. The first is that the research was completed in a single center and included only infants from 29 to 34 weeks gestation. In the research, the researchers could not be blinded due to the nature of the oral feeding methods. Moreover, another limitation of the research is that it does not include data after discharge.

Implications for Practice

First, it is necessary for all health professionals responsible for the treatment and care of premature neonates, including neonatal nurses, to have current information about evidence-based practices supporting the transition to breastfeeding and the use of these methods. The results of our research are thought to provide support and motivation about the use of the most effective method in the transition to oral feeding of premature neonates. The research results are thought to contribute to improving short- and long-term outcomes for premature neonatal health. This study is important in terms of emphasizing the role of neonatal nurses in improving neonatal health.

Conclusions

The SF method is more effective to increase breastfeeding success of infants compared to feeding with bottle or cup. In addition, the SF method ensures infants achieve full enteral feeding and full breastfeeding in a shorter duration. Although there was no significant difference in the mean discharge duration and discharge weights of infants, bottle-fed infants had longer discharge durations. Moreover, the PHR in the BF group and SO₂ levels in the SF group were higher compared to the other groups. In line with the study results, it is recommended that the SF method should be considered the first choice to support the transition to breastfeeding in the NICU, its use should be popularized in the clinical field, and neonatal nurses should update their information about the SF method.

Footnotes

Authors' Contributions

All authors made substantial contributions to the conception and design of the study and to the acquisition and interpretation of the data. All authors drafted the article or critically revised it for intellectual content. All authors read and approved the final version of the article.

Disclosure Statement

The authors have declared no conflict of interest.

Funding Information

The authors have not disclosed any funding.

References

Daicampi

, Comoretto

, Soriani

, et al. Protocols for early discharging of premature infants: An empirical assessment on safety and savings. J Perint Med, 2019; 47(8):885–893; doi: 10.1515/jpm-2018-0420

American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics, 2008; 122 (5):1119–1126; doi: 10.1542/peds.2008-2174

Browne

, Ross

. Eating as a neurodevelopmental process for high-risk newborn. Clin Perinat, 2011; 38(4):731–743; doi: 10.1016/j.clp.2011.08.004

Hwang

, Ma

, Tseng

, et al. Associations among perinatal factors and age of achievement of full oral feeding in very preterm infants. Pediatrics and Neonatology, 2013; 54(5):309–314; doi: 10.1016/j.pedneo.2013.03.013

Lawn

, Davidge

, Paul

, et al. Care for the Preterm Baby. Born Too Soon: The Global Action Report on Preterm Birth. World Health Organization Press: Geneva, 2012; pp. 61–92.

Murray

, Mckinney

. Foundations of Maternal-Newborn and Women's Health Nursing (Fifth edition). Elsevier Saunders Publishing: 2010.

Atasay

, Okulu

, Akın İM, et al. The Early Clinical Outcomes of Late Preterm Newborns. Türkiye Çocuk Hastalıkları Dergisi, 2010; 4:30–35.

Bache

, Pizon

, Jacobs

, et al. Effects of pre-feeding oral stimulation on oral feeding in preterm infants: A randomized clinical trial. Early Hum Dev, 2014; 90:125–129.

Yurttutan

, Uras

Breastfeeding of Premature Baby. In: Bülbül A, Uslu HS, Nuhoğlu A. (eds). Enteral nutrition of the premature baby. 1st Edition, Istanbul Medical Bookstore: Istanbul; 2013; pp. 27–37.

10.

Maggio

, Costa

, Zecca

, et al. Methods of enteral feeding in preterm infants. Early Hum Dev, 2012; 88(2):31–33.

11.

Nyqvist

, Häggkvist

, Hansen

, et al. Expansion of the ten steps to successful breastfeeding into neonatal intensive care: Expert group recommendations for three guiding principles. J Hum Lact, 2012; 28(3):289–296.

12.

World Health Organization. 2017. Protecting, Promoting and Supporting Breastfeeding in Facilities Providing Maternity and Newborn Services. Geneva. Available from: www.who.int/nutrition/publications/guidelines/breastfeeding-facilities-maternity-newborn/en [Last accessed: February 20, 2021].

13.

Lau

, Smith

. Interventions to improve the oral feeding performance of preterm infants. Acta Paediatr, 2012; 101(7):269–274.

14.

Bandara

, Nyqvist

, Musmar

, et al. Round Table discussion: Use of alternative feeding methods in the hospital. J Hum Lact, 2012; 28(2):122–124.

15.

Yilmaz

, Caylan

, Karacan

, et al. Effect of cup feeding and bottle feeding on breastfeeding in late preterm infants: A randomized controlled study. J Hum Lact, 2014; 30(2):174–179.

16.

Collins

, Makrides

, Gillis

, et al. Avoidance of bottles during the establishment of breastfeeds in preterm infants. Cochrane Database Syst Rev, 2016; 4:1–39.

17.

Say

, Bu¨yu¨ktiryaki

, Okur

, et al. Evaluation of syringe feeding compared to bottle feeding for the transition from gavage feeding to oral feeding in preterm infants. J Pediatr Res, 2019; 6(2):94–98.

18.

Moreiraa

CMD

, Cavalcante-Silva

RPGV

, Fujinaga

, et al. Comparison of the finger-feeding versus cup feeding methods in the transition from gastric to oral feeding in preterm infants. J Pediatr, 2017; 93(6):585–591.

19.

Dowling

, Meier

, DiFiore

, et al. Cup-feeding for preterm infants: Mechanics and safety. J Hum Lact, 2002; 18(1):13–20.

20.

Rocha

, Lucena

, Costa

, et al. Cup or bottle use and their effect on exclusive breast feeding rates in preterm infants: A randomized clinical trial. Acad J Ped Neonatol, 2017; 3(2):555–607.

21.

Flint

, New

, Davies

. Cup feeding versus other forms of supplemental enteral feeding of newborn infants unable to fully breastfeed. Cochrane Database Syst Rev, 2016; 3(1):CD005092.

22.

Penny

, Judge

, Brownell

, et al. Cup feeding as a supplemental, alternative feeding method for preterm breastfed infants: An integrative review. Matern Child Health J, 2018; 22(11):1568–1579.

23.

Aatif

, Jalil

, Basheer

. Syringe feeding versus bottle feeding; impact on breast feeding. Pak Armed Forces Med J, 2018; 68(1):154–158.

24.

Rahmani

, Armanian

, Namnabati

. Effects of feeding nozzle and cup feeding on reaching the time of full oral feeding in the premature infants in the neonatal intensive care unit. Iranian J Neonat, 2018; 9(1):65–70.

25.

Cohen

Statistical Power Analysis for the Behavioral Sciences. Lawrence Erlbaum Associates: Hillsdale, NJ; 1988.

26.

Fenton

, Kim

. A systematic review and meta-analysis to revize the Fenton growth chart for premature infants. BMC Pediatr, 2013; 13:1–13.

27.

Waitzman

, Ludwig

, Nelson

. Contributing to content validity of the Infant-Driven Feeding Scales^© through Delphi surveys. Newborn Infant Nurs Rev, 2014; 14:88–91.

28.

Alemdar

, İnal

, Bulut

29.

Ingram

, Johnson

, Copeland

, et al. The development of a new breast feeding assessment tool and the relationship with breast feeding selfefficacy. Midwifery, 2015; 31:132–137.

30.

Dolgun

, İnal

, Erdim

, et al. Reliability and validity of the Bristol Breastfeeding Assessment Tool in the Turkish population. Midwifery, 2018; 57:47–53.

31.

Araújo

VCD

, Maciel

ACM

, Paiva

MDAR

, et al., (eds). Spilled volum, oxygen saturation, and heart rate during feeding of preterm newborns: Comparison between two alternative feeding methods. CoDAS, 2016; 28:212–220.

32.

Goldfield

, Richardson

, Lee

, et al. Coordination of sucking, swallowing, and breathing and oxygen saturation during early infant breast-feeding and bottle-feeding. Pediatr Res, 2006; 60(4):449–455.

33.

Nunes

JDA

, Bianchini

EMG

, Cunha

, (eds). Oxygen saturation and heart rate in premature: Comparison between cup and finger feeding techniques. CoDAS, 2019; 31:1–7.

34.

López

, Chiari

, Goulart

, et al., (eds). Assessment of swallowing in preterm newborns fed by bottle and cup [in Portuguese]. CoDAS, 2014; 26:81–86.

35.

Alinezhad Shebilouysofla

, Mostafa Gharebaghi

, Sattarzadeh Jahdi

, et al. Effect of cup, syringe, and finger feeding on time of oral feeding of preterm neonate's: A randomized controlled clinical trial. J Health Popul Nutr, 2022; 41(1):1–9.

36.

Aloysius

, Hickson

. Evaluation of paladai cup feeding in breast-fed preterm infants compared with bottle feeding. Early Hum Dev, 2007; 83:619–621.

37.

Abouelfettoh

, Dowling

, Dabash

, et al. Cup versus bottle feeding for hospitalized late preterm infants in Egypt: A quasi-experimental study. Int Breastfeed J, 2008; 3:27.

38.

Dalal

, Mishra

, Agarwal

, et al. Feeding behaviour and performance of preterm neonates on Paladai feeding. Acta Paediatr, 2013; 102:147–152.

39.

Hanif

HM.

Trends in breastfeeding and complementary feeding practices in Pakistan, 1990–2007. Int Breastfeed J, 2011; 6:15.

40.

Lubbe

Clinicians guide for cue-based transition to oral feeding in preterm infants: An easy-to-use clinical guide. J Eval Clin Pract, 2018; 24(1):80–88.

41.

Walsh

, Bell

, Kandefer

, et al. Neonatal outcomes of moderately preterm infants compared to extremely preterm infants. Pediatr Res, 2017; 82(2):297–304.

42.

Hatch

, Scott

, Walsh

, et al. National and regional trends in gastrostomy in very low birth weight infants in the USA: 2000–2012. J Perinatol, 2018; 38(9):1270–1276.

43.

Lainwala

, Kosyakova

, Power

, et al. Delayed achievement of oral feedings is associated with adverse neurodevelopmental outcomes at 18 to 26 months follow-up in preterm infants. Am J Perinatol, 2020; 37(5):483–490.

44.

Çamur

, Çetinkaya

. The effects of oral feeding methods in preterm infants on transition to direct-breastfeeding and discharge time: A retrospective cohort design. Clin Lactat, 2022; doi: 10.1891/CL-2021-0018

45.

Aytekin

, Albayrak

, Küçükoğlu

, et al. The effect of feeding with spoon and bottle on the time of switching to full breastfeeding and sucking success in preterm babies. Turk Arch Pediatr, 2014; 49:307–313.

46.

Fucile

, Gisel

, Lau

. Oral stimulation accelerates the transition from tube to oral feeding in preterm infants. J Pediatr, 2002; 141(2):230–236.