1. Alternative methods of feeding for small or sick neonates

2. Alternative feeding methods
Objectives:
To describe the options available for alternative methods of feeding
Teach a mother how to use an alternative feeding method
To explain how to express breast milk

3. Alternative feeding methods
Indications:
Baby
Not breastfeeding effectively
Not sucking effectively (e.g. preterm, ill, cleft lip/palate)
Mother
Is ill
Has flat/inverted nipple or engorged breast
Is HIV positive and decides not to breastfeed

4. Assessment Action No Yes No Yes Yes No Yes No
Manage as per guidelines for sick neonates*
Is the baby clinically stable? No
Yes
Is birth weight more than 1250 g? No
Start intravenous fluids
Yes
Is the baby able to breastfeed effectively?
When offered the breast, the baby roots, attaches well and suckles effectively
Able to suckle long enough to satisfy needs
Yes
Initiate breast feeding No
Is the baby able to accept feeds by alternative methods?
Give oral feeds by cup/spoon/ paladai
Yes
When offered cup or spoon feeds, the baby opens the mouth, takes milk and swallows without coughing/ spluttering
Able to take an adequate quantity to satisfy needs
Start intra-gastric tube feeds No
* Assess daily for clinical stability ; once stable, assess for initial feeding method 4

5. Alternative feeding methods
Options available:
Cup
Paladai
Spoon
Irrespective of the method, only expressed breast milk has to be fed to the baby

6. Expressing breastmilk by hand

7. Hand expression of breastmilk
Have a clean dry container
Tell the mother to:
Wash her hands thoroughly
Make herself comfortable
Hold a wide necked container under her nipple and areola
Place her thumb and first finger behind the nipple (at least 4cm from the tip of the nipple)

8. Hand expression of breastmilk…
Compress and release the breast between her finger and thumb
Compress and release all the way around the breast, keeping her fingers the same distance from the nipple
Express one breast until the milk just drips, then express the other breast until the milk just drips
Alternate between breasts 5 or 6 times, for at least 20 to 30 minutes
Stop expressing when the milk no longer flows but drips from the start

9. Hand expression of breastmilk
Different ways to massage the breast

10. Hand expression of breastmilk
Back massage
Mother sits down, leans forward, folds her arms on a table in front of her, rests her head on her arms
Her breasts hang loose and unclothed
The helper works down both sides of the spine at the same time from the neck to just below the shoulder blades
She uses her closed fist with her thumbs pointing forwards
She presses firmly making small slow circular movements with her thumbs and continues for 2-3 min

11. Hand expression of breastmilk
Storing expressed breastmilk
Room temperature : 6 hours
Refrigerator : 24 hours
Freezer : 2 weeks (-40C) to 3 months (-200C)

12. Alternative methods: Cup feeding
Cup and spoon are easy to clean with soap and warm water

13. Cups for feeding newborn babies
An ideal cup can hold 50 to 90 mL of milk
It can be glass or plastic and easily washable
Edge should be rounded and smooth
A cup with a lid is useful for storing expressed breast milk

14. Cups with lips and spouts
Variations of cups with lips and spouts can easily be found
They should be used with extreme caution
It is DANGEROUS to POUR milk into a baby’s mouth

15. Cup feeding

16. Cup feeding Advantages Simple equipment ; easy to clean
Baby can take what it needs in its own time
Mother can do it herself
Good eye contact between mother and baby

17. Cup feeding Steps Put a measured amount of milk in the cup
Infant should be awake and held sitting semi-upright on caregiver's lap; put a small cloth on his or her front to catch drips of milk
Touch the edge of the cup to the outer parts of the upper lip
Tip the cup so that the milk reaches the baby’s lips

18. Pouring the milk into baby’s mouth can cause aspiration
Cup feeding
Steps
Do not pour the milk into the infant's mouth
Allow the infant to take the milk himself (upon smelling the breastmilk, the baby becomes alert, opens its mouth, and puts its tongue into the milk to start the feed)
Feed the infant slowly; some milk may spill from the infant's mouth
When the infant has had enough, he or she will close his or her mouth and will not take any more. Do not force-feed the infant.
Pouring the milk into baby’s mouth can cause aspiration

19. Case study: cup feeding
Measuring the correct amount of milk
To measure 30 mL
Use a desert spoon which holds approx. 10 mL
Take 3 spoonfuls of milk
Put a mark on the outside of the cup to guide her how much milk is needed each time
If the baby does not take the required amount:
feed more often or for longer

20. Paladai feeding A paladai is a small bowl with a long pointed lip
The advantages are that it is usually faster than spoon or even cup feeding and also that there is less spillage
A disadvantage is the risk of pouring large amounts of milk into the infant’s mouth

21. Paladai feeding
Steps
Infant should be awake and held sitting semi-upright on caregiver's lap; put a small cloth on his or her front to catch drips of milk
Put a measured amount of milk in the paladai
Hold the paladai so that the pointed tip rests lightly on the infant’s lower lip

22. Paladai feeding
Steps
Tip the paladai to pour a small amount of milk into the infant’s mouth
Feed the infant slowly
Make sure that the infant has swallowed the milk already taken before giving any more
When the infant has had enough, he or she will close his or her mouth and will not take any more. Do not force-feed the infant.

23. Spoon feeding Advantages Disadvantages
Useful for collecting small amounts of colostrum in the first days of life
Useful in a baby with cleft lip/palate
Disadvantages
Slow method of feeding
Often difficult to manage a spoon and a milk container while holding the infant semi- upright

24. Feeding colostrum with a spoon
A grandmother giving colostrum to her grandson 5 hours after delivery
The mother was recovering from a Caesarean section
A health worker helped the mother express

25. Ensuring adequacy of intake
Weighing him/her once a day and assess weight gain
Check that (s)he has several wet nappies every day
Babies who are growing adequately are receiving enough milk

26. Summary
Alternative methods - indicated in those who are NOT able to breastfeed effectively
Methods available: Cup, spoon, Paladai
ONLY expressed breast milk should be fed
Ensure hygiene and adequacy of intake while giving feeds by alternative methods