I would like to start off by saying that I have only worked with a handful of
preemies in my experience as a LLL Leader.  Actually, I wrote the paper for
my CLE in order to learn more about this area since I was so inexperienced.
So, my book knowledge in no way compares to those of you out there who have a
lot of practical knowledge.

Having said that, I will quote you some of the research from my paper if I
may (in response to someone's request for it).  My personal concern is that
there are some NICU moms and babies who could benefit from a successful
breastfeeding relationship if the breast in general was trusted.  But it
seems that too often we rely on the bottle as the norm and assume that the
breast is a mountain to be climbed [now that's an amusing analogy :-) ] by
only the most fearless and physically capable.

Here are some parts of my paper:

"Perhaps some of the more immediate breastfeeding advantages for preterm
infants include better oxygen sturation, respiration, and sucking rates as
well as better body temperature control.  In D.A. Dowling's study,
'statistically significant differences were found in that [preterm] infants
breathed more during sucking bursts for breast-feeding sessions when compared
to bottle-feeding sessions and had fewer episodes of oxygen desaturation
during breast-feeding.' (Dowling DA. Physiological responses of preterm
infants to breast-feeding and bottle-feeding with the orthodontic nipple.
Nurs Res. 1999;48(2):78-85.)  Another study in the Journal of Human Lactation
(JHL) found that 'oxygen saturation and body temperature of the preterm
infants were significantly higher when they were directly breastfed.'  (Chen
CH, Wang TM, Chang HM, Chi CS. The effect of breast- and bottle-feeding on
oxygen saturation and body temperature in preterm infants. J Hum Lact.
2000;16(1):21-27.)  Furthermore, the authors of the JHL study observed '2
episodes of apnea (breath pause more than 20 seconds) and 20 epsiodes of
oxygen destaturation (PaO2<90%) during bottle-feeding and none during
breastfeeding.'  (Ibid.)  That was enough for these authors to 'conclude that
breastfeeding is a more physiological feeding method for the preterm infant.'
 (Ibid.)"

"...special techniques can be employed in NICUs for the breastfeeding
premature infants.  Marinelli, Burke, and Dodd found that cupfeedings were
better than bottlefeedings for breastfeeding preemies in need of
supplementation.  They commented, 'During cupfeedings, premature infants are
more physiologically stable, with lower heart rates, higher oxygen
saturations, and less desaturations, than during bottlefeedings...Based on
better physiologic stability and no difference in untoward effects,
cupfeeding is at least as safe, if not safer, than bottlefeeding in this
population.' (Marinelli KA, Burke GS, Dodd VL. A comparison of the safety of
cupfeedings and bottlefeedings in premature infants whose mothers intend to
breastfeed. J Perinatol. 2001;21(6):350-355.)  Gupta, Khanna, and Chattree
found similar results from their study: 'It was concluded that cup feeding is
a useful alternative to bottle feeding and an effective method of feeding
preterm and small infants in NICU.  Cup feeding allows successful
breastfeeding without causing 'nipple confusion'.'  (Gupta A, Khanna K,
Chattree S. Cup feeding: An alternative to bottle feeding in a neonatal
intensive care unit. J Trop Pediatr. 1999;45(2):108-110.)  One study found
that spoon feedings were an acceptable and safe feeding method for premature
infants as well.  (Nair PM, Narang A, Mahajan R, Arora U. Spoon feeds--an
alternative to bottle feeding. Indian Pediatr. 1994;31(12):1566-1567.)  Yet
other studies have found gavage feedings to work well for breastfeeding
preemies.  Gavage feedings are accomplished through a feeding tube that has
been placed in the infant's nose and threaded down to the stomach.  This
allows the infant supplementation without nipple confusion.  Stine tracked a
program at Methodist Hospital in Indianapolis where they used gavage feedings
to develop a no bottlefeeding protocol for nursing premature infants.  He
said in his study, 'The hospital stays are not prolonged by this approach and
most of the babies whose mothers intended to breastfeed are discharged
exclusively breastfeeding.'  (Stine MJ. Breastfeeding the premature newborn:
A protocol without bottles. J Hum Lact. 1990;6(4):167-170.)  Another study
from Children's Mercy Hospital in Kansas City, Missouri, found similar
benefits.  The authors wrote, 'There were significantly fewer apnea and
breathing episodes in the group receiving nasogastric supplements...Using
nasogastric tube supplementation during transition to oral feedings increases
likelihood of breastfeeding at discharge, 3 days, 3 months, and 6
months...Odds ratios (confidence intervals=95%) showed that the group
receiving nasogastric supplements was 4.5 times (1.4 to 15) more likely to be
breastfed at discharge and 9.4 times more likely to be fully breastfed (3.1
and 28.4)...This intervention requires a program with skilled personnel and
an environment that allows the mother and infant to be in close proximity.'
(Kliethermes PA, Cross ML, Lanese MG, Johnson KM, Simon SD. Transitioning
preterm infants with nasogastric tube supplementation: Increased likelihood
of breastfeeding. J Obstet Gynecol Neonatal Nurs. 1999;28(3):264-273.)"

Hopefully the research cited above will be helpful in some way to someone.
Sorry for the lengthy quotes.  I just didn't want to leave anything out!  :-)

To add more to this discussion, I question the assumption that the
suck-swallow-breathe rhythm must be learned on a bottle first.  For one
thing, breast can much more effectively and safely assist any sucking
pattern.  For another, unlike with bottlefeeds, breastfeeds allow a baby to
suck-swallow-breathe all at the same time without compromising the baby's
oxygen integrity.  So the rhythm and suck that a baby learns on the bottle
does not really help with the rhythm and suck of breastfeedings at all.  In
fact, it would most probably be counterproductive as the baby would have to
relearn a different sucking and rhythm when finally allowed to the breast.
This, in my opinion, is why so many babies choose not to go to breast after
having been trained on a bottle in the beginning.  It's just too much work
for them to relearn everything.  So they refuse breast and stick to the
bottle (termed "nipple confusion" though it is really about the intelligence
and energy conservation efforts, not confusion really, of the baby), and Mom
never gets to breastfeed.  Moms are then told (inaccurately) that preemies
often do not or cannot learn to breastfeed, even at an older age.  (A kind of
"them's the breaks, kid!" attitude.)  Whereas, if breastfeeding had been the
first and ONLY suck and rhythm the babies had learned, the course of events
would most likely have been COMPLETELY different.

Anyway, those are my thoughts.  As I said in the beginning of my email, these
thoughts are mostly academic and not really experiential.  I am sure as
experienced NICU nurses and LCs some of you may be able to see how the
academic ideals are sometimes not practical in real-life application.

Sorry again for the lengthy post!  Thanks for your time!

Jessica Harrison Carlyon, CLE
Gentle Birth Comforts
2810 Iroquois Drive
Thompsons Station, TN  37179
(615) 595-9213

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