Sheila Gephart, PhD, RN ❍ Section Editor
Evidence-Based Practice Brief Breastfed or Bottle-Fed Who Goes Home Sooner? Carrie-Ellen Briere, PhD, RN, CLC
ABSTRACT A literature search was conducted to answer the clinical question, “Do premature infants who breastfeed have different oral feeding outcomes compared with those who receive bottles?” The CINAHL, PubMed, and PsycInfo databases were queried for articles published in the past 10 years that reported original research available in English. Two studies specifically addressed a comparison between infants who received exclusive direct breastfeeding, mixed direct breast and bottle, and/or exclusive bottle-feeding. Additional studies were included that addressed oral feeding outcomes specific to either direct breastfeeding (n = 2) or those that grouped bottle and breastfeeding together (n = 3). The findings from these studies indicate that the statement that bottle-feeding leads to sooner discharge is not based in evidence. Although more data are needed to fully understand the differences between direct breastfeeding and bottle-feeding, neonatal intensive care unit staff should be aware of the message they send to breastfeeding families when they encourage the use of bottles over direct breastfeeding. Key Words: bottle feeding, breastfeeding, direct breastfeeding, discharge, length of stay, neonatal intensive care, outcomes, premature infant, very low birth weight
B
reast milk in the neonatal intensive care unit (NICU) is the preferred nutrition for infants.1 Neonatal intensive care unit professionals understand the importance of breast milk for premature and ill infants and encourage and support mothers to provide breast milk. Soon after an infant’s birth and admission to the NICU, emphasis is often on the initiation of breast pumping so that infants can receive maternal breast milk at the beginning of enteral feeds. This focus on the importance of breast milk receipt is important; however, some mothers get the impression from staff that providing breast milk is the focus of the NICU and breastfeeding directly at the breast is a separate concept that will occur at home.2 When the time comes for oral feeding, mothers have reported that bottle feeding expressed breast milk is often encouraged over direct breastfeeding by NICU staff with a promise of faster discharge.2 Many mothers who plan to breastfeed do not plan to bottle-feed their expressed breast milk and a Author Affiliation: School of Nursing, University of Connecticut, Storrs; and Institute for Nursing Research and Evidence Based Practice, Connecticut Children’s Medical Center, Hartford. The author declares no conflict of interest. Jacqueline M. McGrath, PhD, RN, FNAP, FAAN, who is Co-editor of Advances in Neonatal Care and mentor for the author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by another member of the editorial team for the journal. Correspondence: Carrie-Ellen Briere, PhD, RN, CLC, School of Nursing, University of Connecticut, 231 Glenbrook Rd, Unit 4026, Storrs, CT 06269 ([email protected]). Copyright © 2015 by the National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000159
NICU admission can often jeopardize this plan.3 Although bottle-feeding expressed breast milk may be needed in instances of maternal unavailability, the ultimate goal of infant feeding should be discussed with families. Mothers who wish to exclusively direct breastfeed (feed directly at the breast vs feeding expressed breast milk by bottle) should meet with NICU professionals early in the NICU admission to strategize their feeding plan during the infant’s hospitalization. Despite its rarity in the United States, exclusive direct breastfeeding, even for very premature infants, is possible at NICU discharge with some units achieving rates of 55% to 68%.4-7 Despite the benefits and importance of longterm breast milk receipt, there continues to be a perception of breastfeeding the premature infant that can be harmful to breastfeeding outcomes, in particular that bottle feeding is easier for premature infants and will lead to sooner discharge from the NICU. An emphasis on bottle feeding with the promise of easier oral feeding transition leaves mothers with immense challenges when they get home when they try to navigate breastfeeding without the support of NICU professionals.2,8 Whether a mother wants to exclusively direct breastfeed or to combine direct breastfeeding with bottle feeding expressed breast milk, she is entitled to appropriate education and support to meet her goals. Although bottle feeding can be an important oral feeding intervention in the NICU, the importance of supporting direct breastfeeding cannot be overlooked. It is important to look at the evidence and determine whether NICU staff are providing
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Copyright © 2015 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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evidence-based care when they advise parents on the best oral feeding intervention to support oral feeding development, readiness for discharge, and long-term breastfeeding success.
CLINICAL QUESTION AND SEARCH STRATEGY To answer the clinical question, “do premature infants who breastfeed have different oral feeding outcomes compared with those who receive bottles (differences in days to full oral feeds, and/or difference in days to discharge)?”, a search of relevant literature was conducted. The CINAHL, PubMed, and PsycInfo databases were used to search for research articles to answer one of the controversial topics on breastfeeding in the NICU. Search terms included “neonatal intensive care,” “premature infant,” “breastfeeding,” and “bottle feeding.” The search was limited to articles published in the past 10 years (2005 to present) that reported original research and had a full-text English version available. Articles were read for inclusion of factors addressing days to oral feeding and/or days to discharge between infants who were bottle-fed versus direct breastfed. Studies were excluded if their purpose was to compare an intervention that replaced bottle feeding (ie, cup feeding) because the purpose of this evidence-based brief was to compare oral feeding outcomes between bottle-fed and breastfed infants. These search criteria yielded only 2 articles that specifically addressed a comparison between infants who received exclusive direct breastfeeding, mixed direct breast and bottle, and/or exclusive bottle feeding.4,5 Because of this low yield of studies, it was decided to include studies that addressed oral feeding outcomes specific to either direct breastfeeding or those that grouped bottle and breastfeeding together. This addition yielded 2 studies with direct breastfeeding6,7 and 3 studies that reported feeding outcomes, irrespective of oral feeding method.9-11 A total of 7 studies were reviewed.
SUMMARY OF EVIDENCE Study Quality The overall study quality was fair, as only 2 articles specifically addressed the outcomes between infants who were direct breastfed and bottle-fed.4,5 Although the other studies did not compare direct breastfeeding with bottle feeding, each provides details on oral feeding initiation and time to full oral feeding and/or discharge. The sample sizes used were relatively large (92-1488)4-6,9-11 other than one study that addressed only breastfeeding with a sample of 15.7 All of the included studies were descriptive in nature, likely because of the questionable ethics that would be involved in randomization of an infant to breastfeeding
or bottle-feeding. However, because randomization is likely not possible to answer the clinical question addressed in this evidence-based brief, a better method than mere observation is to use case-control examples when possible.
Study Findings and Strength of Evidence It is difficult to interpret results between studies that looked at direct breastfeeding alone and those that combined direct breastfeeding and bottle feeding because feeding outcomes vary in each hospital because of overall oral feeding practices. The best method to compare breastfeeding and bottle feeding outcomes is using a study design that examines both within the same study location(s). An important finding of the included studies is that none of the ones that specifically addressed breastfeeding were conducted in the United States.4-7 The studies that were from the United States were two that did not differentiate feeding differences between breastfed infants and bottle-fed infants.9,11 In the 2 studies that specifically compared babies who exclusively received direct breastfeeding versus those who did not, there were no significant differences either in the number of days to transition to full oral feeding4 or in the length of stay.5 The study by Dodrill and colleagues4 specifically compared feeding attainment outcomes (age at first oral feeding, age at full oral feeding, days to transition to full oral feeding) for infants who received exclusive direct breastfeed, mixed direct breastfeeding and bottle feeding, and exclusive bottle feeding. The second study examined infants who were exclusively direct breastfed at discharge compared with those who were not and found that there was no difference in length of stay between the 2 groups.5 Of note, both studies included infants who received breast milk and formula and did not differentiate outcomes between infants who bottle-fed breast milk versus formula. The 2 studies that only examined feeding outcomes related to breastfeeding only included mothers who intended to breastfeed.6,7 The study by Nyqvist7 described specific oral feeding milestones in breastfed infants and it is important to note that infants in this unit began oral feeding sooner than infants in all of the other studies (31 weeks’ gestational age). This is important because the days to full oral feeding appear longer in this study than in other studies if the reader does not look closely at the age of initiation. The other breastfeeding study looked at a larger sample and results showed that the mean transition from first breastfeed to full oral feeding was about 2 weeks.6 A positive part of this study’s design was the breakdown of feeding milestones by specific gestational age at birth. Finally, 3 studies addressed oral feeding outcomes irrespective of feeding method.9-11 All 3 began oral feeding between 32 and 34 weeks and did not separate outcomes between infants who received breast milk www.advancesinneonatalcare.org
Copyright © 2015 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Oral Feeding and Discharge Outcomes of Direct Breastfeeding and Bottle-Feeding Premature Infants Outcomes Citation and Criteria to Measured Study Research Design Introduce Oral Related to EBP Location Sample Feedings Question Exclusive direct breastfeeding vs bottle-feeding (exclusive or mixed) Dodrill et al Retrospective Once infant Compared (2008); descriptive physiologically differences in stable; if no feeding Australia 23-36 wk GA mechanical outcomes for (mean 32 wk, 5 ventilator exclusive d) support, direct n = 472 received breastfeeding, nonnutritive mixed, and suckling at exclusive feeding times bottle-feeding
Zachariassen Prospective et al (2010); descriptive
Not defined
Denmark
24-32 wk GA (median; exclusive direct breast at D/C: 29wk, 5 d; not exclusive at D/C: 30 wk, 2 d; P = .11) n = 478 Direct breastfeeding Maastrup Prospective Once infant et al surveys stable, (2014); initiated with 24-36 wk GA CPAP Denmark (mean 34 wk, 1 d) n = 1488
Results
Study Strengths and Limitations
GA 1st oral feed: 34 wk, 4 d Addressed both direct GA full oral feeds: 36 wk, breastfeeding 4d and bottleMean transitiona: feeding as 2 wk 2 d outcome 55% D/C exclusive direct variables breastfeeding 31% D/C mixed direct breast and bottlefeeding
No difference in any above variables (P value not given) between infants who received exclusive direct breastfeeding, mixed breast and bottle, and exclusive bottlefeeding Compared LOS Exclusively Did not length of stay breastfed: 53.5 d address for infants specific oral Not exclusive: 53.6 d exclusively feeding P = .93 direct milestones 60% D/C exclusive direct breastfed at breastfeeding D/C and those not 5% D/C mixed direct exclusively breast and bottledirect feeding breastfed GA 1st breastfeed: 34 wk, 3d
Large multicenter design GA 1st bottle-feed: 36 wk 6 d GA full oral (exclusive direct Authors break down breast): 36 wk, 4 d (no specific difference between milestones infants using nipple of oral shields and not) feeding for When infants divided into different GA specific groups, infants groups
Evidence-Based Practice Brief Breastfed or Bottle-Fed Who Goes Home Sooner? Carrie-Ellen Briere, PhD, RN, CLC
ABSTRACT A literature search was conducted to answer the clinical question, “Do premature infants who breastfeed have different oral feeding outcomes compared with those who receive bottles?” The CINAHL, PubMed, and PsycInfo databases were queried for articles published in the past 10 years that reported original research available in English. Two studies specifically addressed a comparison between infants who received exclusive direct breastfeeding, mixed direct breast and bottle, and/or exclusive bottle-feeding. Additional studies were included that addressed oral feeding outcomes specific to either direct breastfeeding (n = 2) or those that grouped bottle and breastfeeding together (n = 3). The findings from these studies indicate that the statement that bottle-feeding leads to sooner discharge is not based in evidence. Although more data are needed to fully understand the differences between direct breastfeeding and bottle-feeding, neonatal intensive care unit staff should be aware of the message they send to breastfeeding families when they encourage the use of bottles over direct breastfeeding. Key Words: bottle feeding, breastfeeding, direct breastfeeding, discharge, length of stay, neonatal intensive care, outcomes, premature infant, very low birth weight
B
reast milk in the neonatal intensive care unit (NICU) is the preferred nutrition for infants.1 Neonatal intensive care unit professionals understand the importance of breast milk for premature and ill infants and encourage and support mothers to provide breast milk. Soon after an infant’s birth and admission to the NICU, emphasis is often on the initiation of breast pumping so that infants can receive maternal breast milk at the beginning of enteral feeds. This focus on the importance of breast milk receipt is important; however, some mothers get the impression from staff that providing breast milk is the focus of the NICU and breastfeeding directly at the breast is a separate concept that will occur at home.2 When the time comes for oral feeding, mothers have reported that bottle feeding expressed breast milk is often encouraged over direct breastfeeding by NICU staff with a promise of faster discharge.2 Many mothers who plan to breastfeed do not plan to bottle-feed their expressed breast milk and a Author Affiliation: School of Nursing, University of Connecticut, Storrs; and Institute for Nursing Research and Evidence Based Practice, Connecticut Children’s Medical Center, Hartford. The author declares no conflict of interest. Jacqueline M. McGrath, PhD, RN, FNAP, FAAN, who is Co-editor of Advances in Neonatal Care and mentor for the author, was not involved in the editorial review or decision to publish this article. The entire process from submission, referee assignment, and editorial decisions was handled by another member of the editorial team for the journal. Correspondence: Carrie-Ellen Briere, PhD, RN, CLC, School of Nursing, University of Connecticut, 231 Glenbrook Rd, Unit 4026, Storrs, CT 06269 ([email protected]). Copyright © 2015 by the National Association of Neonatal Nurses DOI: 10.1097/ANC.0000000000000159
NICU admission can often jeopardize this plan.3 Although bottle-feeding expressed breast milk may be needed in instances of maternal unavailability, the ultimate goal of infant feeding should be discussed with families. Mothers who wish to exclusively direct breastfeed (feed directly at the breast vs feeding expressed breast milk by bottle) should meet with NICU professionals early in the NICU admission to strategize their feeding plan during the infant’s hospitalization. Despite its rarity in the United States, exclusive direct breastfeeding, even for very premature infants, is possible at NICU discharge with some units achieving rates of 55% to 68%.4-7 Despite the benefits and importance of longterm breast milk receipt, there continues to be a perception of breastfeeding the premature infant that can be harmful to breastfeeding outcomes, in particular that bottle feeding is easier for premature infants and will lead to sooner discharge from the NICU. An emphasis on bottle feeding with the promise of easier oral feeding transition leaves mothers with immense challenges when they get home when they try to navigate breastfeeding without the support of NICU professionals.2,8 Whether a mother wants to exclusively direct breastfeed or to combine direct breastfeeding with bottle feeding expressed breast milk, she is entitled to appropriate education and support to meet her goals. Although bottle feeding can be an important oral feeding intervention in the NICU, the importance of supporting direct breastfeeding cannot be overlooked. It is important to look at the evidence and determine whether NICU staff are providing
Advances in Neonatal Care • Vol. 15, No. 1 • pp. 65–69
65
Copyright © 2015 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
ANC-D-14-00135.indd 65
19/01/15 2:44 PM
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Briere
evidence-based care when they advise parents on the best oral feeding intervention to support oral feeding development, readiness for discharge, and long-term breastfeeding success.
CLINICAL QUESTION AND SEARCH STRATEGY To answer the clinical question, “do premature infants who breastfeed have different oral feeding outcomes compared with those who receive bottles (differences in days to full oral feeds, and/or difference in days to discharge)?”, a search of relevant literature was conducted. The CINAHL, PubMed, and PsycInfo databases were used to search for research articles to answer one of the controversial topics on breastfeeding in the NICU. Search terms included “neonatal intensive care,” “premature infant,” “breastfeeding,” and “bottle feeding.” The search was limited to articles published in the past 10 years (2005 to present) that reported original research and had a full-text English version available. Articles were read for inclusion of factors addressing days to oral feeding and/or days to discharge between infants who were bottle-fed versus direct breastfed. Studies were excluded if their purpose was to compare an intervention that replaced bottle feeding (ie, cup feeding) because the purpose of this evidence-based brief was to compare oral feeding outcomes between bottle-fed and breastfed infants. These search criteria yielded only 2 articles that specifically addressed a comparison between infants who received exclusive direct breastfeeding, mixed direct breast and bottle, and/or exclusive bottle feeding.4,5 Because of this low yield of studies, it was decided to include studies that addressed oral feeding outcomes specific to either direct breastfeeding or those that grouped bottle and breastfeeding together. This addition yielded 2 studies with direct breastfeeding6,7 and 3 studies that reported feeding outcomes, irrespective of oral feeding method.9-11 A total of 7 studies were reviewed.
SUMMARY OF EVIDENCE Study Quality The overall study quality was fair, as only 2 articles specifically addressed the outcomes between infants who were direct breastfed and bottle-fed.4,5 Although the other studies did not compare direct breastfeeding with bottle feeding, each provides details on oral feeding initiation and time to full oral feeding and/or discharge. The sample sizes used were relatively large (92-1488)4-6,9-11 other than one study that addressed only breastfeeding with a sample of 15.7 All of the included studies were descriptive in nature, likely because of the questionable ethics that would be involved in randomization of an infant to breastfeeding
or bottle-feeding. However, because randomization is likely not possible to answer the clinical question addressed in this evidence-based brief, a better method than mere observation is to use case-control examples when possible.
Study Findings and Strength of Evidence It is difficult to interpret results between studies that looked at direct breastfeeding alone and those that combined direct breastfeeding and bottle feeding because feeding outcomes vary in each hospital because of overall oral feeding practices. The best method to compare breastfeeding and bottle feeding outcomes is using a study design that examines both within the same study location(s). An important finding of the included studies is that none of the ones that specifically addressed breastfeeding were conducted in the United States.4-7 The studies that were from the United States were two that did not differentiate feeding differences between breastfed infants and bottle-fed infants.9,11 In the 2 studies that specifically compared babies who exclusively received direct breastfeeding versus those who did not, there were no significant differences either in the number of days to transition to full oral feeding4 or in the length of stay.5 The study by Dodrill and colleagues4 specifically compared feeding attainment outcomes (age at first oral feeding, age at full oral feeding, days to transition to full oral feeding) for infants who received exclusive direct breastfeed, mixed direct breastfeeding and bottle feeding, and exclusive bottle feeding. The second study examined infants who were exclusively direct breastfed at discharge compared with those who were not and found that there was no difference in length of stay between the 2 groups.5 Of note, both studies included infants who received breast milk and formula and did not differentiate outcomes between infants who bottle-fed breast milk versus formula. The 2 studies that only examined feeding outcomes related to breastfeeding only included mothers who intended to breastfeed.6,7 The study by Nyqvist7 described specific oral feeding milestones in breastfed infants and it is important to note that infants in this unit began oral feeding sooner than infants in all of the other studies (31 weeks’ gestational age). This is important because the days to full oral feeding appear longer in this study than in other studies if the reader does not look closely at the age of initiation. The other breastfeeding study looked at a larger sample and results showed that the mean transition from first breastfeed to full oral feeding was about 2 weeks.6 A positive part of this study’s design was the breakdown of feeding milestones by specific gestational age at birth. Finally, 3 studies addressed oral feeding outcomes irrespective of feeding method.9-11 All 3 began oral feeding between 32 and 34 weeks and did not separate outcomes between infants who received breast milk www.advancesinneonatalcare.org
Copyright © 2015 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Oral Feeding and Discharge Outcomes of Direct Breastfeeding and Bottle-Feeding Premature Infants Outcomes Citation and Criteria to Measured Study Research Design Introduce Oral Related to EBP Location Sample Feedings Question Exclusive direct breastfeeding vs bottle-feeding (exclusive or mixed) Dodrill et al Retrospective Once infant Compared (2008); descriptive physiologically differences in stable; if no feeding Australia 23-36 wk GA mechanical outcomes for (mean 32 wk, 5 ventilator exclusive d) support, direct n = 472 received breastfeeding, nonnutritive mixed, and suckling at exclusive feeding times bottle-feeding
Zachariassen Prospective et al (2010); descriptive
Not defined
Denmark
24-32 wk GA (median; exclusive direct breast at D/C: 29wk, 5 d; not exclusive at D/C: 30 wk, 2 d; P = .11) n = 478 Direct breastfeeding Maastrup Prospective Once infant et al surveys stable, (2014); initiated with 24-36 wk GA CPAP Denmark (mean 34 wk, 1 d) n = 1488
Results
Study Strengths and Limitations
GA 1st oral feed: 34 wk, 4 d Addressed both direct GA full oral feeds: 36 wk, breastfeeding 4d and bottleMean transitiona: feeding as 2 wk 2 d outcome 55% D/C exclusive direct variables breastfeeding 31% D/C mixed direct breast and bottlefeeding
No difference in any above variables (P value not given) between infants who received exclusive direct breastfeeding, mixed breast and bottle, and exclusive bottlefeeding Compared LOS Exclusively Did not length of stay breastfed: 53.5 d address for infants specific oral Not exclusive: 53.6 d exclusively feeding P = .93 direct milestones 60% D/C exclusive direct breastfed at breastfeeding D/C and those not 5% D/C mixed direct exclusively breast and bottledirect feeding breastfed GA 1st breastfeed: 34 wk, 3d
Large multicenter design GA 1st bottle-feed: 36 wk 6 d GA full oral (exclusive direct Authors break down breast): 36 wk, 4 d (no specific difference between milestones infants using nipple of oral shields and not) feeding for When infants divided into different GA specific groups, infants groups
