Hypoglycæmia of the Newborn (Low blood sugar)

Introduction

The fear of low blood sugar of the newborn has become the new “acceptable” reason to separate mothers and babies and give babies supplements of formula in the immediate hours and days after the baby’s birth. The reason paediatricians and neonatologists are worried about low blood sugar is that it can cause brain damage, so there truly is a concern. However, there has developed a sort of ‘hyper’-concern about low blood sugar that is simply not warranted. As a matter of fact, most of the babies who are tested for low blood sugar do not need to be tested and most of those who receive formula do not need formula. By giving the formula, especially as it almost always is given by bottle, we interfere with breastfeeding and give the impression that formula is good medicine.

Some truths about hypoglycæmia of the newborn

1. The best way to prevent low blood sugar is to feed the baby with milk. However, formula and breastmilk (specifically colostrum in these early days) are not equivalent and colostrum is far better to prevent and treat low blood sugar than formula (See point #5 below). A little bit of colostrum maintains the blood sugar better than a lot of formula.1,2,3
2. Having the baby skin to skin with the mother immediately after birth maintains the baby’s blood sugar higher than if the baby is separated from her. (See the information sheet The Importance of Skin to Skin Contact).
3. There is no lowest level of blood sugar that is universally accepted as meaning the baby has low blood sugar. Because of this atmosphere of hyper-concern about low blood sugar, the level of sugar keeps being raised to absurd levels. In many hospitals now, 3.4 mmol/L (60 mg %) is now considered the lowest acceptable blood sugar. This is patently aberrant and there is no evidence to back up such a level as the lowest acceptable blood sugar concentration.
4. There is no reliable method of measuring the blood sugar outside the laboratory. The use of paper strips to measure the blood sugar is not reliable. Paper strips tend to underestimate the true value. Only the laboratory gives a reliable measure of plasma glucose or sugar (plasma is the part of the blood which does not contain red blood cells and which is what we are really interested in, but we’ll leave this aside).
5. If the baby’s blood sugar is low, it does not mean he will be brain damaged. This is due to the fact that other constituents released by the baby’s body will protect his brain. These include compounds called ketone bodies, as well as lactic acid and free fatty acids. In fact, babies who are receiving colostrum or breastmilk have much higher levels of ketone bodies, for example, than formula fed babies or even breastfed babies with supplements of formula.¹
6. Babies born of a normal pregnancy and normal birth and who are at term and of a good weight do not need to be tested for low blood sugar. Yet, so pervasive is the anxiety about low blood sugar that more and more postpartum units are testing every baby at birth for low blood sugar. This is painful for the baby, anxiety producing for the staff and parents, costly, useless and contrary to evidence.²
7. It is normal for the blood sugar to drop in the first hour or two after birth. Yet many babies are tested first at birth then an hour later and given formula because the blood sugar has dropped. Babies are being tested without reason, then given formula for a normal situation! Incidentally, even if the baby is not fed, the blood sugar will rise after the initial (normal) drop.¹,³
8. A baby is not at risk of low blood sugar just because he weighs a lot at birth, if his mother is not diabetic. Yet many hospitals have protocols that call for automatic testing of a baby, and some even automatic feeding of formula (unbelievable) if the baby weighs more than 4 kg (8lb 12oz); others use 4.5 kg (10 lb). This approach seems to have been started because infants of diabetic mothers tend to be born very large. In fact, large babies whose mothers are not diabetics are not at increased risk of low blood sugar². In fact, they are at less risk because their livers are full of glycogen (glucose molecules connected together in long chains) ready to be called into action by the need for more sugar, and they also have lots of fat ready to be called into action to produce ketone bodies, lactic acid and free fatty acids.
9. A baby who is born small for the length of the pregnancy(under 2.5 kg or 5lb 8oz if born at term is one definition) maintains his blood sugar just as well if breastfed or formula fed². Of course, it’s important the baby is breastfeeding. Also see the video clips of young babies breastfeeding.

How should we prevent low blood sugar?

1. Diabetes in the mother, particularly type 1 (insulin dependent, juvenile), is a high risk situation for the baby. This is due to the fact that at birth high insulin levels in the baby (as a result of the baby’s being exposed to high sugars during the pregnancy) not only drop the blood sugar but also prevent his body’s formation of ketone bodies, lactic acid, and free fatty acids. Therefore the baby needs to be watched and may require an intravenous to maintain the blood sugar.
   • Good control of diabetes during the pregnancy can help prevent low blood sugar.
   • Good control of diabetes during the labour and birth also is important.
   • We, and postpartum departments all over the world (particularly in New Zealand and Australia), have suggested to our prenatal patients whose babies are at high risk to express their colostrum before the baby is born, starting at about 35 or 36 weeks gestation. Most can get a few millilitres a day by hand expression and a mother can often get 30 or 40 millilitres saved before the baby is born. If the baby needs to be supplemented to control the blood sugar, the baby is given colostrum, not formula.
2. Intravenous fluids containing glucose (it is usual) given rapidly to the mother should be avoided. If the mother’s glucose tolerance (her ability to handle glucose) is impaired, a lot of glucose given her may increase her blood sugar and provoke a similar response in the baby with a corresponding rise in the baby’s insulin secretion.
3. It is best to put the baby skin to skin with the mother immediately after birth. As mentioned above and in the information sheet The Importance of Skin to Skin Contact, the baby maintains his blood sugar better when skin to skin with the mother. The baby should be dried off but not bathed before he is put skin to skin with the mother. It is possible and desirable to put the baby skin to skin with the mother even if she’s had a caesarean section.
4. The baby should be encouraged to breastfeed as soon as possible after the birth. Having the baby skin to skin with the mother helps a lot as the baby may latch on all by himself. A good latch also helps, so the baby gets the colostrum. Compression while breastfeeding gets more colostrum into the baby. Also see the video clips.

Treating low blood sugar

If there is a concern about the baby’s blood sugar dropping too rapidly or being too low and good breastfeeding doesn’t seem to be correcting the problem, the baby should get an intravenous infusion of glucose rather than formula. Babies often spit up formula in the first few days because they get so much. If there is a real concern, taking formula by mouth does not guarantee the blood sugar will be raised.

Every postpartum unit should have banked breastmilk available on site. Banked breastmilk is preferable to formula as a supplement whenever the supplement is truly necessary. Even if the baby needs treatment for low blood sugar, there is rarely a reason for the baby not to breastfeed as well. A baby can be at the breast even if he has an intravenous. A baby can get supplements (preferably pre-expressed colostrum or banked breastmilk) even while being breastfed.

References:

1. De Rooy L, Howden J. Nutritional factors that affect the postnatal metabolic adaptation of full-term small and large for gestational age infants: Pediatrics Vol. 109 No. 3 March 2002, pp. e42
2. Cornblath M, Hawdon JM, Williams AF Aynsley-Green A, Ward-Platt MP, Schwartz R, Kalhan SC. Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds. Pediatrics 2000;105:1141-5
3. Hoseth E, Joergensen A, Ebbesen F, Moeller M. Blood glucose levels in a population of healthy, breastfed, term infants of appropriate size for gestational age. Arch Dis Child Fetal Neonatal Ed 2000;83:F117-9

See also the WHO document on hypoglycaemia at
http://www.who.int/child_adolescent_health/documents/chd_97_1/en/index

Information sheet Hypoglycaemia, Jack Newman MD, FRCPC, IBCLC, 2009©
Revised by Edith Kernerman, IBCLC, 2009©

How Breast Milk Protects Newborns

Some of the molecules and cells in human milk actively help infants stave off infection.

Doctors have long known that infants who are breast-fed contract fewer infections than do those who are given formula. Until fairly recently, most physicians presumed that breast-fed children fared better simply because milk supplied directly from the breast is free of bacteria. Formula, which must often be mixed with water and placed in bottles, can become contaminated easily. Yet even infants who receive sterilized formula suffer from more meningitis and infection of the gut, ear, respiratory tract and urinary tract than do breast-fed youngsters.

The reason, it turns out, is that mother’s milk actively helps newborns avoid disease in a variety of ways. Such assistance is particularly beneficial during the first few months of life, when an infant often cannot mount an effective immune response against foreign organisms. And although it is not the norm in most industrial cultures, UNICEF and the World Health Organization both advise breast-feeding to "two years and beyond." Indeed, a child’s immune response does not reach its full strength until age five or so.

All human babies receive some coverage in advance of birth. During pregnancy, the mother passes antibodies to her fetus through the placenta. These proteins circulate in the infant’s blood for weeks to months after birth, neutralizing microbes or marking them for destruction by phagocytes-immune cells that consume and break down bacteria, viruses and cellular debris. But breast-fed infants gain extra protection from antibodies, other proteins and immune cells in human milk.

Once ingested, these molecules and cells help to prevent microorganisms from penetrating the body’s tissues. Some of the molecules bind to microbes in the hollow space (lumen) of the gastrointestinal tract. In this way, they block microbes from attaching to and crossing through the mucosa-the layer of cells, also known as the epithelium, that lines the digestive tract and other body cavities. Other molecules lessen the supply of particular minerals and vitamins that harmful bacteria need to survive in the digestive tract. Certain immune cells in human milk are phagocytes that attack microbes directly. Another set produces chemicals that invigorate the infant’s own immune response.

Breast Milk Antibodies

Antibodies, which are also called immunoglobulins, take five basic forms, denoted as IgG, IgA, IgM, IgD and IgE. All have been found in human milk, but by far the most abundant type is IgA, specifically the form known as secretory IgA, which is found in great amounts throughout the gut and respiratory system of adults. These antibodies consist of two joined IgA molecules and a so-called secretory component that seems to shield the antibody molecules from being degraded by the gastric acid and digestive enzymes in the stomach and intestines. Infants who are bottle-fed have few means for battling ingested pathogens until they begin making secretory IgA on their own, often several weeks or even months after birth.

The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body’s tissues. First, the collection of antibodies transmitted to an infant is highly targeted against pathogens in that child’s immediate surroundings. The mother synthesizes antibodies when she ingests, inhales or otherwise comes in contact with a disease-causing agent. Each antibody she makes is specific to that agent; that is, it binds to a single protein, or antigen, on the agent and will not waste time attacking irrelevant substances. Because the mother makes antibodies only to pathogens in her environment, the baby receives the protection it most needs-against the infectious agents it is most likely to encounter in the first weeks of life.

Second, the antibodies delivered to the infant ignore useful bacteria normally found in the gut. This flora serves to crowd out the growth of harmful organisms, thus providing another measure of resistance. Researchers do not yet know how the mother’s immune system knows to make antibodies against only pathogenic and not normal bacteria, but whatever the process may be, it favors the establishment of "good bacteria" in a baby’s gut.

Secretory IgA molecules further keep an infant from harm in that, unlike most other antibodies, they ward off disease without causing inflammation-a process in which various chemicals destroy microbes but potentially hurt healthy tissue. In an infant’s developing gut, the mucosal membrane is extremely delicate, and an excess of these chemicals can do considerable damage. Interestingly, secretory IgA can probably protect mucosal surfaces other than those in the gut. In many countries, particularly in the Middle East, western South America and northern Africa, women put milk in their infants' eyes to treat infections there. I do not know if this remedy has ever been tested scientifically, but there are theoretical reasons to believe it would work. It probably does work at least some of the time, or the practice would have died out.

An Abundance of Helpful Molecules

Several molecules in human milk besides secretory IgA prevent microbes from attaching to mucosal surfaces. Oligosaccharides, which are simple chains of sugars, often contain domains that resemble the binding sites through which bacteria gain entry into the cells lining the intestinal tract. Thus, these sugars can intercept bacteria, forming harmless complexes that the baby excretes. In addition, human milk contains large molecules called mucins that include a great deal of protein and carbohydrate. They, too, are capable of adhering to bacteria and viruses and eliminating them from the body.

The molecules in milk have other valuable functions as well. Each molecule of a protein called lactoferrin, for example, can bind to two atoms of iron. Because many pathogenic bacteria thrive on iron, lactoferrin halts their spread by making iron unavailable. It is especially effective at stalling the proliferation of organisms that often cause serious illness in infants, including Staphylococcus aureus. Lactoferrin also disrupts the process by which bacteria digest carbohydrates, further limiting their growth. Similarly, B12 binding protein, as its name suggests, deprives microorganisms of vitamin B12. Bifidus factor, one of the oldest known disease-resistance factors in human milk, promotes the growth of a beneficial organism named Lactobacillus bifidus. Free fatty acids present in milk can damage the membranes of enveloped viruses, such as the chicken pox virus, which are packets of genetic material encased in protein shells. Interferon, found particularly in colostrum-the scant, sometimes yellowish milk a mother produces during the first few days after birth-also has strong antiviral activity. And fibronectin, present in large quantities in colostrum, can make certain phagocytes more aggressive so that they will ingest microbes even when the microbes have not been tagged by an antibody. Like secretory IgA, fibronectin minimizes inflammation; it also seems to aid in repairing tissue damaged by inflammation.

Cellular Defenses

As is true of defensive molecules, immune cells are abundant in human milk. They consist of white blood cells, or leukocytes, that fight infection themselves and activate other defense mechanisms. The most impressive amount is found in colostrum. Most of the cells are neutrophils, a type of phagocyte that normally circulates in the bloodstream. Some evidence suggests that neutrophils continue to act as phagocytes in the infant’s gut. Yet they are less aggressive than blood neutrophils and virtually disappear from breast milk six weeks after birth. So perhaps they serve some other function, such as protecting the breast from infection.

The next most common milk leukocyte is the macrophage, which is phagocytic like neutrophils and performs a number of other protective functions. Macrophages make up some 40 percent of all the leukocytes in colostrum. They are far more active than milk neutrophils, and recent experiments suggest that they are more motile than are their counterparts in blood. Aside from being phagocytic, the macrophages in breast milk manufacture lysozyme, increasing its amount in the infant’s gastrointestinal tract. Lysozyme is an enzyme that destroys bacteria by disrupting their cell walls.

In addition, macrophages in the digestive tract can rally lymphocytes into action against invaders. Lymphocytes constitute the remaining 10 percent of white cells in the milk. About 20 percent of these cells are B lymphocytes, which give rise to antibodies; the rest are T lymphocytes, which kill infected cells directly or send out chemical messages that mobilize still other components of the immune system. Milk lymphocytes seem to behave differently from blood lymphocytes. Those in milk, for example, proliferate in the presence of Escherichia coli, a bacterium that can cause life-threatening illness in babies, but they are far less responsive than blood lymphocytes to agents posing less threat to infants. Milk lymphocytes also manufacture several chemicals-including gamma-interferon, migration inhibition factor and monocyte chemotactic factor-that can strengthen an infant’s own immune response.

Added Benefits

Several studies indicate that some factors in human milk may induce an infant’s immune system to mature more quickly than it would were the child fed artificially. For example, breast-fed babies produce higher levels of antibodies in response to immunizations. Also, certain hormones in milk (such as cortisol) and smaller proteins (including epidermal growth factor, nerve growth factor, insulinlike growth factor and somatomedin C) act to close up the leaky mucosal lining of the newborn, making it relatively impermeable to unwanted pathogens and other potentially harmful agents. Indeed, animal studies have demonstrated that postnatal development of the intestine occurs faster in animals fed their mother’s milk. And animals that also receive colostrum, containing the highest concentrations of epidermal growth factor, mature even more rapidly.

Other unknown compounds in human milk must stimulate a baby’s own production of secretory IgA, lactoferrin and lysozyme. All three molecules are found in larger amounts in the urine of breast-fed babies than in that of bottle-fed babies. Yet breast-fed babies cannot absorb these molecules from human milk into their gut. It would appear that the molecules must be produced in the mucosa of the youngsters' urinary tract. In other words, it seems that breast-feeding induces local immunity in the urinary tract.

In support of this notion, recent clinical studies have demonstrated that the breast-fed infant has a lower risk of acquiring urinary tract infections. Finally, some evidence also suggests that an unknown factor in human milk may cause breast-fed infants to produce more fibronectin on their own than do bottle-fed babies.

All things considered, breast milk is truly a fascinating fluid that supplies infants with far more than nutrition. It protects them against infection until they can protect themselves.

Further Reading

• MUCOSAL IMMUNITY: THE IMMUNOLOGY OF BREAST MILK. H. B. Slade and S. A. Schwartz 
  in Journal of Allergy and Clinical Immunology, 
  Vol. 80, No. 3, pages 348-356; September 1987.
• IMMUNOLOGY OF MILK AND THE NEONATE 
  Edited by J. Mestecky et al. 
  Plenum Press, 1991.
• BREASTFEEDING AND HEALTH IN THE 1980’s: A GLOBAL EPIDEMIOLOGIC REVIEW 
  Allan S. Cunningham 
  in Journal of Pediatrics, 
  Vol. 118, No. 5, pages 659-666; May 1991.
• THE IMMUNE SYSTEM OF HUMAN MILK: ANTIMICROBIAL, ANTIINFLAMMATORY AND IMMUNOMODULATING PROPERTIES 
  A. S. Goldman 
  in Pediatric Infectious Disease Journal, 
  Vol. 12, No. 8, pages 664-671; August 1993.
• HOST-RESISTANCE FACTORS AND IMMUNOLOGIC SIGNIFICANCE OF HUMAN MILK 
  by Ruth A. Lawrence 
  in Breastfeeding: A Guide for the Medical Profession, 
  Mosby Year Book, 1994.
• SCIENTIFIC AMERICAN 
  December 1995 Volume 273 Number 6 Page 76 
  Scientific American (ISSN 0036-8733), 
  published monthly by Scientific American, Inc., 
  415 Madison Avenue, New York, N.Y. 10017-1111.

  Copyright 1995 by Scientific American, Inc. All rights reserved. Except for one-time personal use, no part of any issue may be reproduced by any mechanical, photographic or electronic process, or in the form of a phonographic recording, nor may it be stored in a retrieval system, transmitted or otherwise copied for public or private use without written permission of the publisher.

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How Breast Milk Protects Newborns 
Written by Jack Newman, MD, FRCPC 
May be copied and distributed without further permission

Finger and Cup Feeding

Finger feeding

Finger feeding is a technique the main purpose of which is to prepare the baby to take the breast when the baby is reluctant or refuses to latch on. See the information sheet When baby does not yet latch. Though finger feeding can be used to feed a baby and thus avoid artificial nipples, this is not what it is meant to do really. Furthermore, if the baby is actually taking the breast (latching on) and requires supplementation, this supplementation should be given with a lactation aid at the breast not by finger feeding. See the information sheet Lactation aids and the video clips. Too often finger feeding is used to feed the baby when a mother has sore nipples and the baby is taken off the breast. This is seen as not interfering with breastfeeding while, at the same time, the “nipples are given a rest”. Taking a baby off the breast for any reason, including sore nipples, should be a last resort only. See the information sheets Latching On, Sore nipples, All purpose nipple ointment (“all purpose nipple ointment”), Candida protocol - Toronto, Gentian violet, Fluconazole (Diflucan) and video clips showing how to latch a baby on.

Finger feeding may be used if:

1. The baby refuses the breast for whatever reason, or if the baby is too sleepy at the breast to breastfeed well. It is also a very good way to wake up a sleepy baby during the first few days of life and there are concerns about intake.
2. The baby does not seem to be able to latch on to the breast properly, and thus does not get milk well. (However, if the baby is latching on, even not well, then it is better to use a lactation aid at the breast to give extra milk).
3. The baby is separated from the mother, for whatever reason. However, in such a situation, a cup is probably a better method of feeding the baby. Since finger feeding should be used primarily to help a baby take the breast when he is reluctant or temporarily unable, the best technique is not finger feeding if the mother is not present to breastfeed him.
4. Breastfeeding is stopped temporarily (there are very few legitimate reasons to stop breastfeeding. See the information sheets Drugs & breastfeeding and Maternal illness & breastfeeding.
5. Your nipples are so sore that you cannot put the baby to the breast. Finger feeding for several days may allow your nipples to heal without causing more problems by getting the baby used to an artificial nipple. However, see the first paragraph about taking the baby off the breast. Cup feeding is also more appropriate in this situation and takes less time. Taking a baby off the breast should be a last resort only but too often is done as a first resort. Proper positioning and a good latch help sore nipples far more than finger feeding (see the information sheet Sore nipples). And a good “all purpose nipple ointment” will help as well. This so called “nipple holiday” is not advisable and if suggested within the first few days of life may be a terrible mistake. Taking the baby off the breast does not always result in painless feedings once you start again and sometimes the baby will refuse to latch on.

Finger feeding is much more similar to breastfeeding than is bottle feeding. In order to finger feed, the baby must keep his tongue down and forward over the gums, his mouth wide (the larger the finger used, the better so using a baby finger to do finger feeding is not a good idea), and his jaw forward. Furthermore, the motion of the tongue and jaw is similar to what the baby does while feeding at the breast. Finger feeding is best used to prepare the baby who is refusing to latch on to take the breast. It needs to be done only for a minute or two, at the most, just before trying the baby on the breast if the baby is refusing to latch on. See video clip Finger feed to latch. If the mother is not present to feed the baby or if the baby still doesn’t latch on after the finger feeding is attempted, then feeding the baby with a cup is better than finger feeding which can be slow.

Please Note: If the baby is taking the breast, it is far better to use the lactation aid tube at the breast, if supplementation is truly necessary (See information sheet Increase intake of breastmilk and Lactation aids). Again, finger feeding is not a good method of supplementation in the latching baby.

Finger feeding (best learned by watching and doing). See also the video clip Not Yet Latching; Finger feed to Latch

1. Wash your hands. It is better if the fingernail on the finger you will use has been cut short, but this is not necessary.
2. It is best to position yourself and the baby comfortably. The baby’s head should be supported with one hand behind his shoulders and neck; the baby should be on your lap, half seated. It may be easiest if he is facing you. However, any position which is comfortable for you and the baby and which allows you to keep your finger flat in the baby’s mouth will do. See the video clip Finger feed to latch.
3. You will need a lactation aid, made up of a feeding tube (#5French, 93 cm or 36 inches long), and a feeding bottle with an enlarged nipple hole, filled with expressed breast milk or supplement. The feeding tube is passed through the enlarged nipple hole into the fluid.
4. Line up the tube so that it sits on the soft part of your index, thumb, or middle finger. The end of the tube should line up no further than the end of your finger. It is easiest to grip the tube, about where it makes a gentle curve, between your thumb and middle finger and then position your index finger under the tube. If this is done properly, there is no need to tape the tube to your finger.
5. Using your finger with the tube, tickle the baby’s upper lip lightly until the baby opens up his mouth enough to allow your finger to enter. If the baby is very sleepy, but needs to be fed, the finger may be gently insinuated into his mouth. Pull the baby’s lower lip out if necessary by exerting some downward pressure on the baby’s chin. Generally, the baby will begin to suck even if asleep and as he receives liquids he will then wake up.
6. Insert your finger with the tube so that the soft part of your finger remains upwards. Keep your finger as flat as possible, thus keeping the baby’s tongue flat and forward. Usually the baby will begin sucking on the finger, and allow the finger to enter quite far. The baby will not usually gag on your finger even if it is in his mouth quite far, unless the baby is not hungry or he is very used to bottles.
7. Gently pull down the baby’s chin, if his lower lip is sucked in.
8. The technique is working if the baby is drinking. If feeding is very slow, you may raise the bottle above the baby’s head, but usually this should not be necessary. Try to keep your finger straight, flattening the baby’s tongue. Try not to point your finger up, but keep it flat. Do not apply pressure to the roof of baby’s mouth.
9. The use of finger feeding with a syringe to push milk into the baby’s mouth is, in my opinion, too difficult for the mother to do alone and definitely not more effective than simply using a bottle with the nipple hole enlarged and the tube coming from it. The idea of finger feeding is not to feed the baby! The idea is to train the baby to suck properly so that pushing milk into his mouth defeats the whole purpose of finger feeding.

If you are having trouble getting the baby to latch on to or to suckle at the breast, remember that a ravenous baby can make the going very difficult. Take the edge off his hunger by using the finger feeding technique for a minute or so. Once the baby has settled a little, and sucks well on your finger (usually only a minute or so), try offering the breast again. If you still encounter difficulty, do not be discouraged. Go back to finger feeding and try again later in the feed or next feeding. This technique usually works. Sometimes several days, or on occasion a week or more, of finger feeding are necessary, however.

Cup Feeding (best learned by watching and doing)

Cup feeding (and similar vessels like spoon, etc) is a method of feeding baby that has been around for a very long period of time. It should be used to feed a baby who is not yet taking the breast and is better than a bottle. This should not be used to supplement a baby who is taking the breast (see the information sheets Lactation aids and When baby does not yet latch).

1. Sit baby upright on your lap with baby’s head supported while you have one hand behind his shoulders and neck
2. Use a small medicine cup or shot glass when first learning how to cup feed
3. Place the edge of the cup gently on baby’s lower lip
4. Bring the liquid to baby’s lower lip so baby will lap it up like a pussycat. Do not pour the liquid in baby’s mouth
5. It is important to maintain the level of the liquid as best as possible so baby can continually lap it up.
6. Go slowly as the two of you learn how to do this. Eventually, this can become a very fast and efficient way of feeding until baby learns to take the breast, and this is a good method to use to avoid artificial nipples and teats.

If you are leaving the hospital finger or cup feeding the baby, make an appointment with your doctor within a day or so of discharge, or get other good hands-on help quickly. The earlier the better. Once the baby is taking the breast, he may still require the lactation aid to supplement for a period of time; because although the baby may take the breast, the latch can still be less than ideal, and the suck may still not be efficient enough to ensure adequate intake (See information sheet Is my baby getting enough milk?).

Written and revised (under other names) by Jack Newman, MD, FRCPC, 1995-2005 
Revised by Jack Newman MD, FRCPC, IBCLC and Edith Kernerman IBCLC, 2008, 2009