Background: Preterm babies who are unable to breastfeed but are able to swallow are commenced on cup or paladai or bottle as&nbsp;alternative feeding methods. Although the World Health Organization recommends the use of cup owing to reduced infection risk,&nbsp;many neonatal units use the bottle for feeding. Objectives: The aim was to compare the two groups with regard to time taken to&nbsp;commence oral feeds, breastfeeds, achieve full oral feeds, complications, gestational age at discharge, discharge weight, and infant&nbsp;formula use at discharge. Material and Methods: This retrospective observational study was performed to compare two cohorts ofpreterm babies who were fed either by bottle or paladai (small feeding cup with a long spout traditionally used in India) during their&nbsp;transition from tube to breastfeeding. Results: During the study period, there were 68 babies in Center 1 where paladai was used&nbsp;and 71 in Center 2 where bottle was used. The gestational age at which oral feeding was commenced, full oral feeds, gestational&nbsp;age at discharge, and discharge weight were similar in both the groups. Breastfeeding was commenced significantly earlier in the&nbsp;bottle-fed group (p&lt;0.05). The use of infant formula was also significantly more in this group. One baby aspirated in the paladaigroup. Conclusion: With adequate training and attention to hygiene, paladai or feeding bottles could be equally safe methods of&nbsp;feeding in hospitalized preterm neonates

Kumar, R Kishore

Prabha, P C Nayana

Shenoi, Arvind

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 4 | Oct - Dec 2017 Indian J Child Health 584
Original Article
Comparison of feeding methods in neonates - A retrospective cohort study from 
India
P C Nayana Prabha, R Kishore Kumar, Arvind Shenoi
From Department of Neonatology and Pediatrics, Bengaluru, Karnataka, India
Correspondence to: Dr. P C Nayana Prabha, Department of Neonatology and Pediatrics, Cloudnine Hospitals, 1533, 9th Main, 3rd Block 
Jayanagar, Bengaluru - 560 011, Karnataka, India. E-mail: poovadan@hotmail.com
Received - 09 June 2017 Initial Review - 09 July 2017  Published Online - 17 September 2017
It is a universal recommendation that neonates be breastfed. However, in preterm infants, the sucking and swallowing coordination occurs around 32-34 weeks. Consequently, these 
babies are often transitioned to breastfeeding from tube feeding 
by adopting various oral feeding techniques such as paladai, cup, 
or bottle. Each method of alternative feeding has its advantages 
and disadvantages in terms of physiological stability during oral 
feeding, safety, breastfeeding rates, duration to breastfeeding, 
length of hospitalization, and weight gain [1-3]. The World Health 
Organization (WHO) and the Baby Friendly Hospital Initiative 
(BFHI) recommend cup feeding during the transition phase from 
tube to breastfeeding [4]. BFHI discourages the use of artificial 
teats and feeding bottles.
Although the exact prevalence of bottle feed use is not known, 
many neonatal units all over the world continue to adopt this 
method [5]. It is in this background that this study was undertaken 
to compare two cohorts of preterm babies of which one group 
was bottle fed and the other fed by paladai. Paladai is a small cup 
with a long spout traditionally used in India during their transition 
from tube to breastfeeding. A small amount of milk is poured into 
the neonates’ mouth slowly allowing the baby to swallow the 
milk before administering a further amount. The aim of this study 
was to compare the feeding with paladai and bottle with regard 
to time taken to commence oral feeds, breastfeeds, achieve full 
oral feeds, complications, gestational age at discharge, discharge 
weight, and infant formula use at discharge.
MATERIAL AND METHODS
This was a retrospective study of all neonates with a primary 
diagnosis of prematurity with no other complicating factor 
and gestation age of  ≤34 weeks, consecutively admitted to the 
neonatal intensive care unit of 2 branches of an urban maternity 
hospital over a period of 18 months between January 01, 2014, 
and June 30, 2015. Before the study, an approval was obtained 
from the Institutional Ethics Committee (IEC) to review the 
clinical case records of patients retrospectively. The data were 
anonymized before analysis. As it was a retrospective survey, the 
IEC deemed that informed consent was not applicable. (Project 
Number IEC/C9791/3004/16008 Dated 30/06/2016).
Babies were excluded from the study if they had concurrent 
diagnoses or conditions that would interfere with oral feedings. 
These included chromosomal defects, congenital anomalies 
involving face, malformation of the digestive tract, neurological 
conditions affecting feeding, babies with grade 3 or 4 
intracranial hemorrhage, hydrocephalus, seizures, meningitis 
or encephalopathy, babies with growth restriction or abnormal 
antenatal Doppler in whom feed advancement may be slow, 
ABSTRACT
Background: Preterm babies who are unable to breastfeed but are able to swallow are commenced on cup or paladai or bottle as 
alternative feeding methods. Although the World Health Organization recommends the use of cup owing to reduced infection risk, 
many neonatal units use the bottle for feeding. Objectives: The aim was to compare the two groups with regard to time taken to 
commence oral feeds, breastfeeds, achieve full oral feeds, complications, gestational age at discharge, discharge weight, and infant 
formula use at discharge. Material and Methods: This retrospective observational study was performed to compare two cohorts of 
preterm babies who were fed either by bottle or paladai (small feeding cup with a long spout traditionally used in India) during their 
transition from tube to breastfeeding. Results: During the study period, there were 68 babies in Center 1 where paladai was used 
and 71 in Center 2 where bottle was used. The gestational age at which oral feeding was commenced, full oral feeds, gestational 
age at discharge, and discharge weight were similar in both the groups. Breastfeeding was commenced significantly earlier in the 
bottle-fed group (p<0.05). The use of infant formula was also significantly more in this group. One baby aspirated in the paladai 
group. Conclusion: With adequate training and attention to hygiene, paladai or feeding bottles could be equally safe methods of 
feeding in hospitalized preterm neonates.
Key words: Bottle feeding, Feeding method, Neonate
Vol 4 | Issue 4 | Oct - Dec 2017 Indian J Child Health 585
Prabha et al. Comparison of feeding methods in neonates - An Indian study
babies who required to be kept nil oral for more than 3 days, 
and babies who needed continuous positive airway pressure or 
ventilator support at 33 weeks. Babies were also excluded from 
the analysis if tube feeds were continued because of poor weight 
gain.
As per the hospital nursing policy, all preterm babies born 
between 28 and 34 weeks on exclusive gavage feeding were 
gradually transitioned to oral feeding when oral reflexes such 
as mouthing, licking, rooting, and sucking were present or 
emerging and demonstrated positive non-nutritive sucking 
(NNS). If positive NNS was demonstrated on two consecutive 
attempts, oral feeding was commenced. The babies in Center 1 
were offered exclusive oral feeds by paladai and those in Center 
2 exclusive bottle feeds. Bottle feeding, though recommended 
not to be used by BFHI, is widely practiced in India as reflected 
from the sales figures of bottles across India. Hence, we wanted 
to compare and contrast the two methods of feeding. Preterm 
infant formula was used only if expressed breast milk was 
not available. The volume and number of feeds offered orally 
were gradually increased depending on the neonates’ ability 
to complete the feed without signs of physiological instability 
such as bradycardia, desaturation, tachypnea, or bradypnea. 
If the neonate did not complete the prescribed volume of feed 
by paladai or bottle, the remaining milk was given by gavage 
feed. The baby was defined to have commenced oral feeds if 
the neonate was able to consume >25% of the prescribed feed 
volume orally. The baby was considered to have achieved 
full oral feeds when the neonate was able to take >90% of the 
prescribed feed volume orally.
The data were obtained from the admission registers and 
by case file review. Baseline information regarding baby’s sex, 
gestational age, birth weight, antenatal Doppler results, mode of 
delivery, indication for cesarean section, birth order, and place of 
birth were recorded. The corrected gestational age and weight at 
which tube feeds and oral feeds (bottle, spoon, paladai, or breast 
feeds) were commenced, the gestational age and weight at which 
baby attained full oral feeds, the type of feeds given during the 
hospital stay (breast milk/formula feeds), the gestational age, 
weight, mode of feeding, and type of feed at the time of discharge 
were recorded. Complications encountered with either feeding 
mode were documented.
Statistical analysis was done using R software. Comparison 
between all the above variables in the study population was done 
using feeding modality as the grouping variable. Chi-square test 
was used for categorical variables and independent t-test for 
continuous variables. All tests were two tailed and p<0.05 was 
considered significant.
RESULTS
There were 103 neonates in Center 1 (paladai group) and 
118 in Center 2 (bottle group) between 26 and 34 weeks of 
gestation out of whom 68 and 71 were included in the analysis. 
Table 1 describes the baseline characteristics of the neonates. 
The mode of delivery, male-to-female ratio, in both centers 
was comparable. Table 2 describes the clinical profile of the 
neonates. The mean birth weight was significantly lesser in 
bottle-fed group. Breastfeeding was commenced earlier in 
bottle-fed group, and the use of formula feed on discharge 
was also more in this group. Both of these were statistically 
significant. One baby aspirated during paladai feeds. There 
were no episodes of aspiration or gastroenteritis in the bottle-
fed group.
DISCUSSION
This was a study from a tertiary neonatal center comparing the 
two commonly used modes of preterm feed supplementation, 
namely, paladai and bottle. Although the study was done in 
a tertiary neonatal unit, the babies included in the study had 
a similar profile of those in a special care baby unit with no 
other complications. This study is limited by its retrospective 
design.
In our study, both paladai- and bottle-fed babies achieved 
full suck feeds at similar gestation. In contrast, few previous 
studies have demonstrated that paladai-fed babies achieved 
oral feeding early [6,7]. We found that the mean corrected 
gestation age and discharge weight were similar in babies 
from both centers suggesting that both the methods of 
feeding could be equally effective. Breastfeeding could be 
commenced significantly earlier in the bottle-fed group. 
There is a limited body of evidence to suggest that bottle-
fed babies achieve better sucking, swallowing, and breathing 
coordination [8]. In this study, more babies in the paladai 
group were exclusively given breast milk as compared to 
the bottle-fed group. Previous studies and the WHO have 
reiterated that introduction of bottle feeds negatively impacts 
future breastfeeding [3-5]. On the contrary, a recent Cochrane 
review found that cup feeding does not result in maintenance 
of breastfeeding beyond discharge [9].
Many complications have been reported during initiation 
of feeding in preterm infants. The commonly reported 
complications with paladai feeding include aspiration, oral 
thrush, and lip laceration [10-12]. There was only a single 
complication of feeding reported in our study. One baby in the 
Table 1: Comparison of baseline characteristics of the study 
population (Center -1 - n-68 and Center 2 - n-71)
Parameters n (%) p
Center 1 (paladai 
group)
Center 2 (bottle 
group)
Male 36 (52.9) 37 (52.1) 0.922
Female 32 (47.1) 34 (47.9)
Cesarean section 60 (88.2) 67 (94.4) 0.198
Inborn 65 (95.6) 67 (94.4)
At discharge
Breastfeeding 68 (100) 71 (100)
Infant formula 
use
22 (32.4) 63 (88.7) <0.001
Vol 4 | Issue 4 | Oct - Dec 2017 Indian J Child Health 586
Prabha et al. Comparison of feeding methods in neonates - An Indian study
paladai-fed group developed aspiration during feeds. This was 
managed with oronasal suctioning. The baby was continued on 
tube feeds for 48 h and oral feeds with paladai commenced. 
During paladai feeds, the caregiver should administer the feed 
slowly in concordance with the speed at which the neonate is 
able to swallow to prevent aspiration. Prolonged feed times 
with paladai can result in fatigue and a consequent increased 
risk of aspiration. Training and comfort of the caregiver in the 
use of paladai is important in prevention of complications [10]. 
There were no complications in the bottle-fed group during the 
hospital stay in our study. Bottle feeding has been associated 
with the development of increased risk bacterial contamination 
resulting in diarrhea and infections both in developed and 
developing countries [13,14]. This has also been reported 
to occur even when expressed breast milk is not handled 
appropriately [15]. The low rate of complications in both our 
groups could be owing to the high standard of hygiene which 
could be offered owing to the high staff-patient ratio and 
maintenance of standards in our centers which are not resource 
constrained.
This finding is limited by its retrospective design. In this 
study, rigorous attention was paid to hygiene and sterilization 
of feeding equipment. The feed preparation utensils, feeding 
bottles and paladai, were sterilized after every use. Hence, further 
generalizability to the use of feeding bottles could be only to 
centers without constraint of resources.
CONCLUSION
Paladai or feeding bottles could be equally safe methods of 
feeding in hospitalized preterm neonates. While the WHO 
recommendations of paladai feeding to be more hygienic with 
less complications in resource-poor setting are still relevant, 
in other institutions with greater access to financial and human 
resources, both forms of feeding could be equally effective with 
no difference in complications. Clear instructions, training, and 
meticulous hygiene are essential with either mode of feeding to 
minimize morbidities.
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Table 2: Clinical profile of neonates
Characteristics Mean±SD p
Center 1 (paladai group) Center 2 (bottle group)
Gestational age (days) 223±12.2 220±12.5 0.092
Birth weight (g) 1716.6±399 1570.3±360.3 0.026
Oral started (corrected gestational age in days) 234.2±6.3 230.3±24.3 0.197
Breastfeeding commenced (corrected gestational age in days) 237.4±5.9 231.2±24.3 0.043
Full oral feeds (corrected gestational age in days) 238.5±5.64 236.8±24.9 0.584
At discharge
Corrected gestational age (days) 243.3±6.4 243.1±6.3 0.923
Weight (g) 1899.3±200.4 1833.1±213.02 0.061
SD: Standard deviation
Funding: None; Conflict of Interest: None Stated.
How to cite this article: Nayana Prabha PC, Kumar RK, Shenoi A. 
Comparison of feeding methods in neonates - A retrospective cohort study 
from India. Indian J Child Health. 2017; 4(4):584-586.


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Comparison of feeding methods in neonates - A retrospective cohort study from India

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