Archives of Disease in Childhood 1994; 71: 365-369

PERSONAL PRACTICE

Cup feeding: an alternative method of infantfeeding

Sandra Lang, Clive J Lawrence, Richard L'E Orme

Artificial methods of infant feeding, rangingfrom pap bowls, feeding horns, cups with lips,and spouts and bottles have existed since pre-historic times.' Though many of these feedingvessels have now completely disappeared, thebottle and teat have so dominated westernthinking in recent years that the use of otherartificial methods of infant feeding has beenlargely overlooked.

During four years in Nepal with VoluntaryService Overseas one of the authors (SL)observed mothers cup feeding low birthweightinfants with freshly expressed breast milk,using either a cupped hand or a small metal orglass tumbler. Cup feeding is used in severaldeveloping countries, not only by mothers2who have limited access to hospital facilitiesbut also by paediatric and special care babyunits.3-8 Its primary and most important use isto provide a safe artificial method of feedingpreterm and low birthweight infants until theyare strong and/or mature enough to be fullybreast fed. The other important function ofcup feeding in these countries is to prevent theuse of bottle feeding, which is known to resultin increased infant morbidity and mortality,9particularly where hygiene is a problem,2 thesterilisation of bottles difficult, and gastrictubes not easily available. In such an environ-ment cups provide a simple, practical, andinexpensive method of feeding.'0

Experience in the developing world and inseveral European neonatal"1 12 and transitionalcare units'3 indicates that cup feeding is a skilleasily acquired by preterm infants, at a stagebefore efficient breast or bottle feeding ispossible, and at a point in development whenup to now it has been generally assumed thatgastric tubes are a necessity.'4 15 According tostandard medical and nursing paediatric texts,'oral' feeding cannot be successfully starteduntil an infant is able to coordinate its suck,swallow and breathing reflexes, which usuallyoccurs between 32 and 35 weeks' gestation.'6 17As a result gastric tubes are commonly used inBritish neonatal units throughout the period oftransition to breast or bottle feeding, and areusually the only feeding method available forwell, preterm infants of less than 32 weeks'gestation. Infants of more than 32 weeks' ges-tation may also receive gastric tube feeds, butthose who are to be breast fed, in addition

commonly receive supplementary bottle feeds,particularly at night. and when mothers areabsent. This may not be in accordance with themothers' wishes but there are few choices openeither to staff or parents for an unsettled infant,when gastric tube feeding does not satisfy theinfant's psychological and social needs, andthe mother is not available to breast feed.Experience in the Exeter neonatal unit hasclearly shown that cup feeding in thesecircumstances can provide a very acceptablealternative.

Although little research has been carried outto determine whether bottle feeding interfereswith a term infant's ability to breast feedsuccessfully, several authors have drawn atten-tion to the difference between the suckingtechniques of breast and bottle feeding.'8-22To breast feed successfully the infant has toopen its mouth widely to accommodate thebreast tissue, and protrude its tongue overthe bottom lip, which is curled outwards underthe areola. In bottle feeding the infant suckson the teat with a partially closed mouth.When this latter sucking action is used byinfants at the breast it can lead to sore nipples,a diminished milk supply, and the cessationof breast feeding. Both bottle teats andpacifiers (dummies)22 encourage this suckingtechnique, which may affect the eventualsuccess of healthy term infants being able toestablish breast feeding. Unfortunately there isno way of predicting which infants will developproblems with breast feeding as a result oflearning these two different sucking tech-niques. Because the establishment of breastfeeding in a sick or preterm infant is lessstraightforward than in a term infant, a methodof feeding which does not lead to inappropriatesucking techniques is highly desirable.

Cup feeding in ExeterIn this paper we define cup feeding as amethod of feeding milk to an infant from asmall polypropylene or glass tumbler without aspout or lip (see figure).

In Exeter, infants from 30 weeks' postcon-ceptional age at the time of the first cup feedhave demonstrated their ability to coordinatetheir tongue movements, to swallow, and tobreathe without difficulty while cup feeding.

Department of ChildHealth, Royal Devonand Exeter Hospitaland Department ofMathematicalStatistics andOperational Research,University of ExeterS Lang

Department ofMathematicalStatistics andOperational Research,Laver Building,University of Exeter,Exeter EX4 4QEC L Lawrence

Department of ChildHealth, Royal Devonand Exeter HospitalR L'E Orme

Correspondence to:Dr Lawrence.

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Baby being cup fed.

Their technique is, however, subtly different tothat of more mature infants. The cup is tiltedso that the milk just touches the infant's lips.The initial sensory stimulation therefore, isthrough the infant's lips and possibly alsothrough the olfactory nerves. This is usuallyfollowed by observable tongue activity,particularly in infants of 30-34 weeks' gesta-tion. These infants 'lap' by protruding theirtongue into the milk to obtain small boluses,which are often then held in their mouth forsome time before swallowing. As the infantmatures 'lapping' becomes less obvious and a

'sipping' action develops. Tongue action isvital for successful breast feeding, because theability to extend the tongue is essential forefficient 'stripping' of the milk ducts.23 Duringcup feeding, particularly when breast milkis used, a range of facial expressions arefrequently observed that include 'blinking','smiling', and 'frowning'. It is also a commonreaction when the cup is prematurely with-drawn for an infant to protrude its tongue andactively 'look' for the milk, even though the lipstimulus has been removed. These reactionsare also more apparent in infants of 30-34weeks' postconceptional age.

In the Exeter neonatal unit more than 500infants have received cup feeds on one or moreoccasions since 1989. It was initially intro-duced to the unit for breast fed infants nearingdischarge, whose mothers were unable to bepresent for each feed; and, secondly, as anadditional method of feeding preterm infantsintended to be breast fed, but who were notsatisfied orally by gastric tube feeds, or inwhom the staff found the development ofinappropriate sucking patterns.Cup feeding was introduced gradually over

the first year. This was because of experiencein the Kenyatta National Hospital in Nairobi,where inadequate preparation had resulted instaff opposition.3 It was equally important toproceed slowly because at that time no

precedent existed for its use in neonatal unitsin the UK. This was despite the fact that it is a

method recommended for use with sick andlow birthweight infants in World HealthOrganisation and Unicef publications,24 25including those relating to the baby friendlyhospital initiative.25 It is also a feeding tech-nique familiar to health professionals withexperience in developing countries.8By the end of the first year it was apparent

that cup feeding was appropriate for six groupsof infants. These were:

(1) Infants nearing discharge who werealready established on the breast but whosemothers were not resident on the unit.

(2) Preterm infants, who were to be breastfed but who would not settle after gastric tubefeeds. These included infants who were awakeand alert when a feed was due, but who wereeither too immature to breast feed or unable tocomplete a breast feed, or whose mothers werenot present at the time of a feed.

(3) Infants with a cleft lip and/or palatewhose mothers wished to establish breastfeeding, but who were also likely to require anadditional method of feeding until surgicalrepair of the defect was completed.

(4) Infants with an uncoordinated suck,swallow, and breathing pattern caused byasphyxia or some other neurological conditionthat interfered with the successful establish-ment of breast or bottle feeding.

(5) Infants born by caesarean section, ifbreast feeding was not possible within the firstfew hours of surgery, or whose mothers wereinitially unwell but who intended to breastfeed.

(6) Term or preterm infants at dischargewho became tired before they were able tocomplete a breast feed.Cup feeding was introduced either immedi-

ately after admission or as soon as the infantwas able to tolerate two to three hourly bolusfeeds by gastric tube. Removal of the tubeoccurred once the infant could take at leastthree successive cup feeds, the combinedvolumes of which were considered to be satis-factory by the unit staff. Otherwise a cup wasused intermittently with the gastric tube untilthe infant was able to go to the breast success-fully on three or more occasions a day. Cupfeeding was not used whenever breast feedingwas possible.Two studies undertaken since 1989 have

collected data on more than 80 cup fed infants,involving over 800 episodes of cup feeding.The first of these, a prospective study examin-ing the feeding and growth patterns of 600infants included the first 65 infants to be cupfed. The second more recent study examinedthe variation in nutritional content of breastmilk depending on the method of expressionand included 20 infants who received some oftheir mothers expressed breast milk by cup.

In these studies cup feeding was usedaccording to the infants needs and in situationswhere previously a health professional wouldhave introduced a bottle. The following resultstherefore, are not part of an organised trial ofcup feeding.

Ethical approval for both studies was givenby the Exeter Health Authority.

Summary dataA summary comparison of the 85 infants in thetwo studies, for four gestational age groups(<28, 29-31, 32-36, and >37 weeks), isprovided in the table. It is evident that regard-less of gestational age at birth, cup feeding is

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Summary statistics, median (with lower quartile - upper quartile) for the 85 cup fed infants

Gestational No of Age at first cup fed Age atfirst breastfeed Age at discharge Total days Breastfeeding atage (weeks) cases (weeks/days) (weeks/days) (weeks/days) cup fed discharge (Go)

<2829-3132-36

>37

693931

35/4 (31/6-36/3)32/2 (30/5-32/5)35/2 (38/4-40/5)39/5 (38/4-40/5)

33/5 (31/1-36/0)31/5 (31/2-31/6)34/3 (34/1-36/1)40/1 (38/2-40/3)

41/0 (36/3-44/1)35/1 (34/1-36/1)36/3 (36/0-37/4)40/4 (39/1-42/0)

10-7 (9-12)8-0 (2-14)4-0 (2-11)2-0 (1-4)

67897777

possible once the infant has reached 30 weeks'postconceptional age. At this stage it is usualfor the infant to take a comparatively smallvolume, 5-15 ml. Within a very short period oftime, however, infants would take the fullamount prescribed and frequently substan-tially more. Initially one cup per day was

offered and thereafter the infant would beoffered the cup on demand.

Infants of 28 weeks' gestation and less atbirth usually require ventilatory assistance,which may delay oral feeding. In the table itcan be seen that the six infants in this group,compared with those born between 29 and 31weeks' gestation, began cup feeding far later(at around the age of 35 weeks' postconcep-tional age) and were also discharged muchlater. For many of the infants born very pre-maturely the initial attempt at the breast tookplace before the first cup feed. This is becausethe aim of cup feeding is solely to provide an

alternative nutritive method of feeding wherebreast feeding is not possible. Breast feeding,on the other hand also encourages skin-to-skin contact between mother and infant,familiarises the infant with the breast, andallows the infant to taste a little breast milkhand expressed onto the nipple.

In the initial eight months of the first studyeight infants were given cup feeds and in theremaining seven month period 58 infantsreceived cup feeds. In the early months of thestudy it was common practice to give supple-mentary bottles to infants who were to breastfeed, including cup fed infants. As cup feedingbecame more established this practice becameunnecessary.

Forty of the 58 infants received no bottlesduring their period in hospital. Of these 40infants, 36 were discharged exclusively breastfeeding (90%), that is, they received all theirnutritional needs from the breast. Of theremaining four infants, two were dischargedcup/breast feeding and two were transferred toother units cup and tube feeding. Of the 18infants who received both bottle and breastfeeding only nine (50%) succeeded in estab-lishing breast feeding by the time of discharge- six infants were discharged breast and bottlefeeding, all of whom had discontinued breastfeeding within six weeks.Of the 84 cup feeding mothers in the two

studies 76 (90%) intended to breast feed. Atdischarge, 62 of the 76 (81O%) mothers were

exclusively breast feeding; four mothers (5%)had changed to bottle feeding; six (8%) were

both breast and bottle feeding; two (3%) were

cup and breast feeding; and two (3%) were

using other methods. This pattern can becompared with a group of mothers whointended to breast feed and whose infants werenot cup fed. There were 365 mothers (372

infants) in this group. At discharge, 231 (63%)mothers were exclusively breast feeding; 60mothers (17%) had changed to bottle feeding;33 (9%) were both breast and bottle feeding;and the remaining 41 (11%) were transferredto other units while still fed by gastric tube.The mothers of the two groups were compar-able with respect to age, parity and socialstatus, and the infants similar with respect togestational age and condition at birth. Theonly major difference between the two groupswas in the method of feeding, which stronglysuggests that cup feeding can contribute to theestablishment of successful breast feeding.Without conducting a fully controlled and

randomised trial it is not possible to makeclaims of earlier establishment of breastfeeding through the use of cups, or to stateprecisely the extent to which they lessen theuse of gastric tubes. Nevertheless, we believethat where cup feeds have been given, gastrictube feeds or bottles would previously havebeen used in their place.

Uses of cup feeding in specialcircumstancesThere is also little published work to demon-strate the use of cup feeding in infants withparticular feeding problems. We offer thefollowing two case studies as examples.One infant was born at 26 weeks' gestation

and had Apgar scores of 1, 2, and 5 at 1, 5, and10 minutes with severe birth asphyxia. He was

able to be discharged at 40 weeks' gestationcup feeding, though still unable to bottle feed.At the age of 9 months (6 months adjustedage) he had been weaned off the cup onto thebottle. His mother was happy with the methodof feeding, and developed a close and easyrelationship with her son. It is doubtfulwhether long term tube feeding, in hospital or

at home, would have allowed bonding todevelop in such an agreeable way.A girl was born at term with unilateral cleft

lip and palate; her father also had a cleft lip andpalate. His wife was initially determined tobreast feed, but both parents realised an

additional method of feeding was likely to berequired. The father was taught to cup feedwithin the first 48 hours. In the circumstancesit was important to involve him as early as

possible, without compromising the mother'swishes to breast feed. The infant was able tofeed well from a cup, which gave the mothertime to try to establish breast feeding withoutbeing pressurised into introducing a bottle.The policy of discharging preterm infants

cup and breast feeding rather than tube feeding(when appropriate) has been implemented inNorth Staffordshire neonatal unit. A recentlypublished audit has shown that cup feeding

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along with other changes to their breast feedingpolicy has also resulted in a dramatic increasein mothers breast feeding at discharge.12 Astudy in France also concluded that cupfeeding low birthweight infants reduced boththe length of time that gastric tubes werenecessary, and also the number of admissionsto the neonatal unit.13

DiscussionIn situations where an alternative to bottle andgastric tube feeding is required, cup feedingprovides a simple, practical, and effectivesolution. If offers several potential benefits. Itis non-invasive, thus any real or theoreticalpossibility of sucking confusion is avoidedbecause the infant does not have to cope with anipple or teat in its mouth. The infant can paceits own intake as long as the cup is held so thatthe milk is just touching the infant's lips andnot poured into its mouth. Furthermore, as thepace of lapping/sipping is dependent on theinfant itself, respiration is easier to control, andswallowing occurs when the infant is ready.As a result very little energy is required. Infantsas young as 30 weeks were observed to becapable of maintaining heart rate, respirations,and satisfactory oxygen saturation while cupfeeding.

For infants with a problem of uncoordinatedsucking or who cannot cope with a nipple/teatand a bolus of milk at the same time, it isbeneficial to have an alternative oral method offeeding that encourages a controlled use of thetongue while allowing feeding to take placeat the infant's own pace. It has also beensuggested that there may be a relationshipbetween abnormal infant feeding and laterspeech development. Selley et al have identi-fied seven common factors in 'co-ordinatedneonatal feeding and speech production',namely rhythm, breath control, lip tone,delicate tongue movements, speed of musclemovements, well developed sensory feedbacksystems, and a relaxed feeding situation.26 Cupfeeding appears to encourage the developmentand maturation of these factors, which we haveobserved in sequential observations of preterminfants from 30 to 35 weeks' gestation. Positiveearly feeding experiences may therefore haveimportant consequences for those infants whorequire further specialist help and are at risk ofdeveloping long term speech and feedingproblems. It may also be important to providea positive oral experience to an infant who hasbeen intubated, experienced frequent nasal/oral suctioning, had an oral plate in itsmouth,27 or has been fed by nasal or oralgastric tubes.Cup feeding is a simple method of feeding

that encourages the involvement of bothparents at a stage when oral feeding is notnormally considered possible. The fosteringof early positive body and eye contact betweenparents and their infant is essential, partic-ularly when the infant may have suffereddiscomfort, isolation, and possibly pain in itsearly life. Parents need to be helped andencouraged to 'nurture' their infant, and not to

view feeding simply in terms of nutrition. Itcannot be overemphasised, therefore, howimportant it is for parents to be given controlof their infant's feeding as soon as is feasible.This helps to ameliorate what can be forthem, a very abnormal situation in terms ofparental expectations of the outcome ofpregnancy.

Oral feeding is important physiologically.The effect of pancreatic lipases are consideredto be minimal in an infant. The lingual lipasestherefore, are vital to the breakdown of dietarytriglycerides.28-30 Though the amounts ofbreast milk taken initially may be small they areable to prime the oral phase of digestion. Thetotal volume of milk taken may vary from feedto feed. Because the infant controls theamount taken, it may exceed that prescribedon the fluid chart. Whether this also correlateswith the energy content of the milk is notknown. It is significant, however, that vomitingis unusual after cup feeding regardless of thequantity taken.To introduce an unfamiliar procedure into a

neonatal unit is undoubtedly a challenge, par-ticularly if it is seen as time consuming. Ourexperience, however, suggests that the timetaken in cup feeding can vary as widely as thetime taken for bottle or tube feeding, and byteaching the skill to parents, health profes-sionals are free to attend to other tasks. "IHelping a mother and infant to establish breastfeeding in a neonatal unit is also not a quick oreasy task and any safe measure that will con-tribute to a successful outcome should be used.Cup feeding is one such measure, which inaddition allows the introduction of a 'no-bottle' policy where appropriate.Cup feeding is an alternative method of

feeding that broadens the options available toboth parents and health professionals, whomay require unconventional solutions to diffi-cult feeding situations. Cup feeding should beseriously considered for use in neonatal andtransitional care units.

Current and future research into cupfeedingTwo further trials of cup feeding are currentlytaking place. In Switzerland a multicentre trialis underway examining the cup as an alter-native to bottle feeding for supplementaryfeeding of term infants, and in Sweden, a trialin the Karolinska Hospital is looking at thefeasibility of cup feeding hypoglycaemic infantsrather than using bottles. In addition aresearch team in Canada, possibly with Britishcollaboration, is planning a multicentrerandomised controlled trial of cup feeding inneonatal units to start in 1995.

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