• To provide guidance on the safest alternative ways to feed breastfed babies when not able to attach to the breast or supplements are required, following UNICEF advice on avoiding teats.

• Guidance given on purpose and method on cup and syringe feeding.

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition.

Print copies must be destroyed after use.

Abbreviations

The UN Convention of the child States in Article 24 that all children have the right to “the best possible health”.

Breast milk is the best form of nutrition for all newborn babies. However, if the mother cannot feed her baby directly from the breast or for clinical reasons the infant requires a supplement in addition to breastfeeding, there are alternative feeding methods available.

To support breastfeeding during this period, health professionals should support mothers to initiate and maintain lactation, via hand or pump expression (see Infant feeding guideline).

This guideline explains alternative ways of feeding a baby when attaching directly onto the breast is challenging in the first few days following birth, or when a supplement of milk is clinically indicated (or fully informed maternal choice) without using a bottle and teat.

The UNICEF UK Baby Friendly Initiative advises that teats should be avoided in the initiation of breastfeeding as it can impact on success (2019).

Syringe and cup feeding have been identified as temporary methods of feeding an infant where breastfeeding is delayed, or occasional supplements are required. Syringe feeding allows the baby to receive small amounts of colostrum that is expressed in the early days following birth, or which has been harvested antenatally.

Cup feeding can be used for babies whose parents wish their baby primarily to breastfeed, but who on occasion need an alternative method. A Cochrane review of cup feeding demonstrated a statistically significant improvement in the number of babies leaving hospital exclusively breastfeeding when cup fed (Flint et al 2007). When comparing feeding methods for infants, studies show that cup feeding improves exclusive breastfeeding rates (WHO, 2019).

Syringe feeding

Syringe feeding for babies who are not yet feeding at the breast, syringe feeding is used to give a baby small amount <5 mls of colostrum that would otherwise get lost in a cup. To syringe feed safely, health professionals should teach this skill and support parents until they are confident to syringe feed their baby themselves. Move onto cup feeding once there is more than 5mls of colostrum. Babies should not be discharged home syringe feeding.

Advantages of syringe feeding

• Easier to give small amounts of colostrum

• Enables a baby to feed when they have been unable to latch onto the breast and feed effectively and require a feed

• Helps to reduce the risk of causing confusion between a teat and the breast

• Easier to give to a lethargic baby receiving treatment for hypoglycaemia in the ward area

Cup feeding

Cup feeding may be considered from 34 weeks gestation onwards for the preterm baby who shows signs of wanting to suck and is not yet able to manage a full breast feed.

From 34 weeks gestation, babies should be able to suck and swallow whilst coordinating their breathing (Bird, 2016). Therefore, it had been deemed a safe gestation to start initiating cup feeding if needed.

Cup feeding may not be suitable for some babies with health needs due to prematurity or ill health and consultation with the neonatologist should always occur if there are any concerns about suitability to cup feed.

Advantages of cup feeding

• The baby learns to coordinate their breathing and swallowing during the feed.

• Cup feeding allows the digestion of milk to start in the mouth using the lingual lipases.

• The active tongue movement required to cup feed mimics the motion needed for the baby to remove the milk from the ducts when breastfeeding.

• The baby can pace their feed, enabling them to control the flow and volume of the feed.

• Posseting is less likely during a cup feed.

• When cup feeding the baby’s heart rate, respiratory rate and oxygen saturation levels are maintained. There also appears to be less risk of Broncho aspiration and apnoea compared to bottle-feeding and nasogastric feeds.

• Cup feeding may reduce the need for a nasogastric tube

• The baby needs to be held while cup feeding, promoting relationship building and stimulation rather than the passive feed via a tube.

• Cup feeding is non-invasive.

• It can increase the rate of exclusive breastfeeding at discharge.

Prior to syringe/cup feeding a baby, the member of staff should ensure that the baby is alert and able to feed safely.

Syringe Feeding

This method is appropriate for offering small quantities (< 5ml) of EBM/colostrum using a 1ml syringe to the breastfed baby.

• Wash hands to reduce the risk of cross contamination

• Syringe feeds will be via a 1ml purple syringes

• Staff must demonstrate syringe feeding technique to parents and then observe the parents competency. This must be documented clearly on EPIC.

• Volumes of up to 5mls may be given via syringe feeding, once further volumes are required, syringe feeding should be discontinued and cup feeding commenced.

• Document the feed on EPIC

Cup Feeding

This method is appropriate for offering quantities of EMB or formula >5ml to a breastfed baby.

• Wash hands to reduce the risk of cross contamination

• Sit baby upright on your lap and support their back and neck. With small babies it can help to wrap them with a cloth, to keep their hands from knocking the cup.

• Rest the rim of the cup lightly on baby’s lower lip. Then tilt the cup, keeping the milk at the rim of the cup, just in reach of baby’s lips. Baby should be alert, and open both their mouth and eyes

• Go slow. DO NOT POUR the milk into baby’s mouth. Always let the baby lead the pace of sips, swallows and pauses. Still keep the milk just at the cup’s rim. When baby is full, they will close their mouth and will not take anymore

• Staff must demonstrate cup feeding technique to parents and then observe the parents’ competency. This must be documented clearly on Epic.

As cup feeding should only be used as a short-term method of feeding. It is important to continue to help establish breastfeeding before discharge home, this includes a full Breastfeeding Assessment.

Provide parents with the ‘Information about cup feeding and syringe feeding your baby’ leaflet see Appendix.

Training will be provided during preceptorship, through formal study days and informal training on the ward where the staff member works clinically.

Flint, A., New, K. and Davies, M. W. (2016) 'Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed', Cochrane Database of Systematic Reviews, 8, CD005092. Available at: https://doi.org/10.1002/14651858.cd005092.pub3 (Accessed: 16 September 2024)

Swansea Bay University Health Board (2019) Guideline for Alternative Feeding Methods in the Full Term Breastfed Infant. Available at: https://wisdom.nhs.wales/health-board-guidelines/swansea-bay-maternity-file/breast-feeding-guideline-for-alternative-methods-in-full-term-breastfed-infant-including-cup-feeding-syringe-feeding-and-bottle-feedingswansea-bay-maternity-guideline-2019pdf/ (Accessed: 20 September 2024).

The baby friendly initiative and UNICEF (2019) Working within the International Code of Marketing of Breast-milk Substitutes. Available at: Working-within-The-Code-Guide-for-Health-Workers.pdf (unicef.org.uk) (accessed: 16 September 2024).

La leche league international (2020) Cup feeding. Available at: https://llli.org/news/cup-feeding/ (Accessed: 16 September 2024)

Information about cup feeding and syringe feeding your baby

We encourage all new parents to breastfeed their babies. If your baby is finding it hard to breastfeed, you can hand express breast milk into your baby’s mouth with your clean finger, with a small syringe, or by a feeding cup. The method you use depends on how much colostrum/milk you need to give and how old your baby is. We suggest trying to avoid giving your baby a teat while they are learning to breastfeed as they may prefer sucking on a teat and find it difficult to suck at the breast.

Maternity staff can teach you how to hand express your milk to ensure your supply is stimulated and your baby gets breast milk. The aim is to help your baby learn to breastfeed from the breast. Ensure plenty of skin-to-skin contact with your baby and try the laid-back position (please speak to your midwife or Infant Feeding team if you require more detail or guidance on positioning your baby).

Syringe Feeding

Syringe feeding may be used for the first few days when your baby needs small amounts of colostrum/breast milk (less than 5ml) frequently.

How to syringe feed safely

Syringes are available on the postnatal ward or labour ward at both Frimley Park and Wexham Park hospital. Syringes are sterile and are purple in colour. They are 1ml syringes, these will be the same as the syringes which you may have been given antenatally to harvest your colostrum. It is important that a member of the maternity staff has demonstrated this technique to you, so you feel confident to syringe feed your baby safely.

• Please wash and dry your hands before you start.

• You need to hold your baby upright and gently syringe no more than 0.2ml into their mouth, between their gum and cheek. Allow your baby to swallow before giving them another 0.2ml. Continue to do this until the feed has ended.

Cup Feeding

A feeding cup can be used when your baby needs more than 5mls of breast milk. A feeding cup can help you work towards breastfeeding because it encourages your baby to use their tongue and lower jaw in a similar way as they would when breastfeeding. Some babies need only one or two cup feeds, while some many need more. Remember, your aim is for your baby to breastfeed and we will help you with this.

How to cup feed safely

Feeding cups are available on the postnatal ward or labour ward at both Frimley Park and Wexham Park hospital. These need to be washed before use in hot, soapy water. Ensure your baby is awake before starting a feed. It is important that a member of the maternity staff has demonstrated this technique to you, so you feel confident to cup feed your baby safely.

• Please wash and dry your hands before you start.

• Sit your baby upright on your lap and support their back and neck. With small babies it can help to wrap them with a cloth, to keep their hands from knocking the cup.

• Rest the rim of the cup lightly on your baby’s lower lip. Then tilt the cup, keeping the milk at the rim of the cup, just in reach of your baby’s lips. Your Baby should be alert, and open both their mouth and eyes.

• Go slow. DO NOT POUR the milk into your baby’s mouth. Always let the baby lead the pace of sips, swallows and pauses. Still keep the milk just at the cup’s rim. When baby is full, they will close their mouth and will not take anymore.

Useful websites

Association of Breastfeeding Mothers

www.abm.me.uk

Breastfeeding Network

www.breastfeedingnetwork.org.uk

La Leche League GB

www.laleche.org.uk

National Childbirth Trust (NCT)

www.nct.org.uk

Start4life

Off to the best start booklet

www.nhs.uk/start4life/breastfeeding

UNICEF UK Baby Friendly Initiative

www.unicef.org.uk/babyfriendly

This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This guideline is for use in Frimley Health Trust hospitals only. Any use outside this location will not be supported by the Trust and will be at the risk of the individual using it.

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