I am responding to Anne's letter regarding my post on using precaution when cup feeding. I had written that I had personally observed many infants who did not demonstrate an ability to nurse appropriately following cup feeding. I had emphasized that I had also noticed dysfunctional behaviors in infants who had been cup fed by nurses who were sensitive and had apparently based the feeding on infant participation. 

Anne asked "When you said the babies showed feeding cues, I take this to mean they were rooting, correct? If this is so and they did not latch well to the breast I would not leap to the first assumption that this was caused by cup feeding". 

No I did not specifically mean rooting, rather I was talking about the multiple cues that infants display when they are communicating a desire to nurse. For example, readiness for nursing includes a change in state of alertness from a sleepy to a semi wakeful state, increased body movement, eyes opening and also, rooting behavior. The infants that I had observed had displayed these behaviors. 

I knew that they had been cup fed because I had read their charts. Naturally I had also engaged in open communication with their parents who had revealed their infants' histories to me. 

Anne also added "What I continue to observe is that mothers are told it is "time" to feed their babies but this is not based on feeding cues and therefore the babies do not nurse well ..". 

I absolutely agree with Anne that feeding a baby based on time rather than cues interferes with both the maternal and infant ability to nurse. However, in the cases that I observed nursing was not based on time rather on a gradual internalization of parental ability to read cues. In most cases the parents who I had observed and worked with, had been taught about the importance of cue reading. Their cue reading skills had been gradually reinforced through teaching sessions based on changing parental cues for readiness to learn. I observed that these parents were attempting to appropriately respond to their infants' cues in a manner associated with the early transition to parenthood. 

The infants in question, were displaying early cues and were clearly stating that they were awaiting relief from a state of discomfort, be it hunger, thirst, loneliness, fear or whatever. However, when they were brought close to the breast they did not open their mouths in a manner that would enable them to latch onto the breast nor did they demonstrate the suckling behaviors that would enable them to gain adequate relieving substances (i.e. breastmilk) from their mother's breasts. I had stated in my first letter, they appeared to wait for the milk to pour into their mouth. Their apparent desire and readiness to nurse was further verified by the amount of frustration that they displayed when they did not receive the relief that they had expected. This was indicated by increased muscle tension and crying. 

I came to the conclusion that cup feeding had played a role in their dysfunctional behavior, after I noted that many infants who had a history of cup feeding, displayed similar behaviors. The infants and their families did not have any other significant shared features. It is also important to note that several of my colleagues, some of whom engaged in cup feeding, noted the same behavioral patterns. The similarity in dysfunctional patterns and the similar history of oral interventions most certainly suggests that there is a possible association between the two variables! Naturally, there are intervening factors that determine if and to what degree infants, as individuals, are affected by any intervention, including alternative feeding methods. 

I acknowledge that optimally infants who are cup fed are able to take much more active roles in their feeding sessions than infants who passively receive the quick flowing bottle. A sensitive "feeder", has more opportunities to base the rate and style of feeding on the infant's cues when cup feeding an infant. Based on what Anne has written, I have no doubt that she is indeed very sensitive in her interactions with babies. Yet, it is also important to bear in mind that many infants have difficulties relating to an apparently less efficient comforter (i.e. maternal breast), even if the caregiver is sensitive.

It is important to remember that every experience that an infant has impacts on their sense of self and self in relation to the world. I fully agree with Anne that there are many reasons that an infant might not attach well to a breast. I am also in absolute accord with Anne's suggestion that a birthing experience that is perceived as traumatic to the infant effects subsequent behaviors, including nursing!! This is another reason why we should attempt to provide the infant with as many positive experiences as possible. While infants are individuals and have diverse capacities to cope with stress, for some little humans changing the "good breast" (i.e. the source of breastmilk, in other words changing the method of providing substances) is a very difficult and traumatic experience. 

The developing infant mind is very complex and obviously plays a role in defining infants' perceptions of their experiences. Hence, I emphasize again, that even if an alternative method of feeding infants seems to mirror some of the physiological components of nursing, is done with all of the best intentions, is based on infant cue display and is done out of a realistic necessity, we must still open our eyes to possible side effects. That is the only way that we can facilitate the establishment and continuation of nursing relationships. 

Keren Epstein-Gilboa MEd BScN RN LCCE FACCE IBCLC PhD (Candidate, Human Development/Family Relations) 

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