Virginia Thorley, OAM, MA, IBCLC

It goes without saying that the best possible way for babies to be fed is at the breast, that is, receiving breastmilk directly from the breast. Sometimes this is not possible for a time for a number of reasons, and although the baby may be receiving breastmilk or colostrum (the early milk), the method of delivery may not be directly from the breast. Where this is the case, people in our society tend to think 'bottle', but this is only one option for delivering precious mother's milk to a baby. Bottles of various types go back a long way in history and pre-history, but so do cups. Other options, which will not be discussed here, include tube devices and spoons.

More recently, there has been renewed interest in the idea of using a cup for feeding a baby who cannot for a time go directly to the breast, but who is to be breastfed later. This is usually done in the belief that avoiding use of a bottle nipple/teat will prevent or minimise nipple confusion, that is, confusion between the different mouth actions for breast and bottle.

Is cup-feeding appropriate for this baby, in these circumstances?

However, before any cup-feeding is done, it makes sense to assess whether it is appropriate for this baby and in these circumstances. Cups have been successfully used with premature babies, once their condition has stabilised, as an alternative to nasogastric tubes and bottles. This may be done in the period before a preterm baby develops a suck, or to supplement what he takes from the breast if his suck is too weak. If we think about it, an unborn baby sips the amniotic fluid inside the mother's uterus before being able to suck. Indeed, if they find their thumbs or fists and become avid suckers before they are born, some babies may have difficulties learning the appropriate mouth action for breastfeeding after birth. If cup-feeding is done properly, allowing the tiny premature baby to lap the milk at his own pace, the baby can adjust his intake and also learns to bring forward and use his tongue, an important skill for breastfeeding. A further advantage is that the milk begins digestion in the mouth, rather than starting in the stomach as occurs with tube feeding.

For full-term babies, however, cup-feeding should not be prolonged as they may become 'hooked' on it. It should be done only for brief periods, such as where a baby has to be taken off the breast for a day or two, to allow the mother's nipples to heal if they are badly cracked. If this is the case, the reason for the nipple damage needs to be thoroughly assessed by an ABA Counsellor or an IBCLC-certified lactation consultant. She can check the baby's mouth for tongue or palate problems which may need referral for medical assessment, and observe whether the mother can attach and position her baby in a way which is comfortable for her when she is ready to put her baby back to the breast.

Situations where cup-feeding may be useful

As mentioned above, cup-feeding is most appropriate for premature babies. Reasons for its use with preterm babies include:

• to reduce the need for nasogastric tubes, which some babies find distressing
• to provide an oral experience for the baby, encouraging the use of his tongue and lips
• to provide an alternative feeding method which doesn't cause nipple confusion
• to enhance digestion of the milk by involving the baby's saliva, which is not possible when milk is delivered by tube directly into the stomach
• to top up breastfeeds if there is reason to believe the baby has not fed effectively during his early attempts at breastfeeding; however, the breast should be given first
• to allow more eye contact and interaction during feeding.

For a full-term baby, reasons for cup-feeding may include:

• temporary separation from the mother, eg when the mother is hospitalised overnight, or at a formal social function
• when the mother is at work, provided the baby is going to the breast regularly and is thus less likely to develop a preference for the cup, and provided the caregiver is comfortable with the technique and has been properly taught
• when the mother has cracked nipples which need time to heal, and the time off the breast is likely to be limited
• for some babies with relatively minor clefts of lip and palate, each case being different.

Learning to cup-feed

Cup-feeding needs to be thoroughly taught. If you are about to cup-feed, ask the healthcare provider who has recommended it to watch you doing it, so that she can assess whether you are doing it correctly. It is important not to lie your baby back (so easy to do) because this can cause choking and spluttering, with aspiration (breathing in) of some milk. Don't just watch her demonstrate what to do; ask her to teach you in a hands-on way. This is important for several reasons. One, as just mentioned, is the danger of aspirating milk (having it 'go down the wrong way' into the lungs). Another is the possibility of doing the cup-feeding incorrectly which, especially if cup-feeding of a full-term baby is prolonged, may also actually lose the baby the skills he needs to go to the breast. If he has to put his tongue back to protect his airway, because the milk is being poured in or he is being laid back, or both, he will not associate putting his tongue forward with being fed; remember, he needs to put his tongue forward to take the breast. With prolonged or faulty cup-feeding he may also lose the ability to close his mouth round the breast, because he doesn't need to do this on a cup.

How to cup-feed successfully

The following points are designed to help you understand how to cup-feed safely. However, it is advisable to have hands-on instruction as well. The ABA video on cup-feeding is also a useful learning tool, as is the Ameda video from the UK.

• cup-feed your baby only when he is fully awake and alert
• wrap the baby to restrain his hands, so that he cannot swipe at the cup
• with the cup about half-full, hold it so that it is just touching the baby's mouth and reaches the corners of his mouth, resting it only lightly on his lower lip
• start by allowing him just a tiny sip to encourage him
• DO NOT pour the milk into his mouth; tip it just enough so that he can lap it himself, bringing his tongue forward to do it
• keep the cup in this tilted position
• DO NOT take the cup away when the baby pauses, unless he pulls away
• allow him to resume when he is ready and let him set his own pace
• follow your baby's cues

In conclusion, cup-feeding has a place as an alternative feeding method in a limited number of circumstances and can be effective where it is appropriately used. If you are considering cup-feeding your baby the two most important questions to consider are:

• Is cup-feeding appropriate for this baby and in these circumstances?
• Do I understand how to cup-feed in a way which is safe for my baby and allows him to interact and set the pace?

Note: In this article the pronouns "he/him/his" have been used for the baby, and "she/her" for both the ABA counsellor and the lactation consultant, to avoid awkward grammatical constructions. No offence is intended to mothers of baby girls, nor to the small number of male lactation consultants.

References

Lang S. Cup-feeding: an alternative method. Midwives Chron 1994; 107:171-176.

Lang S, Lawrence CJ, Orme R: Cup feeding: an alternative method of infant feeding. Arch Dis Child 1994; 71:365-369.

Phillips V (Thorley V): Successful breastfeeding, 6th NMAA ed. Melbourne: Nursing Mothers' Association of Australia, 1991: 76, 198.

Thorley V: Cup feeding: problems created by incorrect use. J Hum Lact 1997; 13:54-55.

Thorley Phillips V. Improving breastfeeding attachment of a reluctant infant by encouraging licking (letter) J Hum Lact 1994; 10:153-54.