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Bottle propping for infant feeding
May, 1968 T h e Journal o[ P E D I A T R I C S
669
Bottle propping for infant feeding The pros and cons o[ "bottle propping" have been assembled [rom questionnaires distributed to directors o[ pediatric teaching services.
Leon J. Taubenhaus, M.D., M.P.H. BOSTON~ M A S S .
B O T T L E P R O P P I N G is generally considered to be an undesirable practice. The disclosure that bottle propping was practiced in a large hospital during a critical nursing shortage resulted in a strong condemnation by the local press. Articles in the press under the by-lines of reputable medical journalists quoted a number of notable pediatricians who soundly criticized the practice of bottle propping. The medical literature, however, is almost silent on this subject. This study was done to try to document the dangers of bottle propping and to determine, if possible, the extent that it is practiced in hospitals or in the home. The discrepancy between pediatric opinion and supporting literature raises the question "Is bottle propping an empirically perpetuated medical myth or a genuine danger?" METHODOLOGY This study is based on the experience, observations, and opinions of the directors of pediatric teaching services. Fifty hospitals with accredited pediatric residencies representing 40 states were selected. An attempt was made to select large hospitals and to From the Community Health Services, Boston
Department o[ Health and Hospitals, and The Department of Preventive Medicine, Boston University.
represent all geographic regions of the United States. When available within the area, municipal or county hospitals were selected. Preference was also given to pediatric services with higher autopsy rates. A questionnaire was sent to the director of the pediatric service of each of the selected hospitals. Thirty-nine questionnaires (78 per cent) were returned from 29 states. The total average daily census of all the pediatric services replying was 2,838, and the total daily newborn census was 1,985. The average pediatric daily census per hospital was 73 and the newborn census was 51. The annual number of pediatric admissions for the 39 hospitals was 110,341 patients, and the total annual pediatric out-patient load was 876,365 visits. This averaged 2,829 admissions and 22,471 out-patient visits, respectively, per hospital. Statistics were obtained from 1964 American Medical Association data? FINDINGS
When asked whether they thought bottle propping to be physically harmful (Table I) slightly less than half of the respondents (46.2 per cent) answered affirmatively. Almost one third (30.8 per cent) felt that it was a safe procedure, and another 20.5 per cent were not sure. Five pediatricians added Vol. 72, No. 5, pp. 669-672
670
Taubenhaus
The Journal o[ Pediatrics May 1968
Table I. Do you think "propping bottles" is physically harmful?
Reply
]
Number
Yes No Not sure No answer Total
1
Per cent
18 12 8 1 39
46.2 30.8 20.5 2.6
Table II. How prevalent is bottle propping in your community?
Prevalence
I
Number
Frequent Practiced Practiced by certain population groups only Rare Never .
.
[
Per cent
15 1(~
38.5 25.6
1l 3 0
28.2 7.7 .......
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
qualifying remarks. Two stressed the psychological benefits to tile baby from being held. One pediatrician who was not sure conceded that the risk of bottle propping was "probably of an exceedingly low order." Another felt that conceivably the baby might aspirate, although he did not know of such an event. He also felt that the baby might not eat as well. One physician said that if the question was changed to "can be" rather than "is," he woukt answer yes. Another stated it was occasionally dangerous. One pediatrician called the procedure "potentially" dangerous. Table II indicates that bottle propping is practiced country wide and not infrequently. There were some individual remarks suggesting that it is practiced principally by low-income groups. Fourteen respondents (33.1 per cent) indicated that bottle propping was permitted in some hospitals in their own community. Twenty-two others (56.2 per cent) stated that it was not permitted in their community. Three respondents did not know the practices of the other hospitals in their community. One, who stated that it was practiced in other hospitals, said it was done only as a last resort as during critical nursing
shortages. Another, who stated that bottle propping was not permitted in any hospital in his community, stated parenthetically that it was, however, frequently practiced. The respondents were asked if they thought bottle propping may be permitted under certain circumstances. Seventeen (43.6 per cent) said yes and 22 (56.4 per cent) said no. Shortage of nursing personnel was offered as an excuse to prop bottles by a number of respondents. They felt in such a case that the choice was between bottle propping and not feeding the infant. Pressure on the mother of too many children was also noted. Several respondents qualified their permission by allowing bottle propping for the older and healthier babies. One stated that if the infant had good suck, gag, and swallowing reflexes, and was not difficult to feed in the usual manner, it could be fed from a propped bottle. Another limited pernfission to healthy infants and to those admitted to the hospital as alert babies, such as those for plastic surgery or orthopedic therapy who had no respiratory or gastrointestinal illness. Several stated that there was no physical harm in bottle propping, but it was psychologically inadvisable. Nineteen respondents (48.7 per cent) said they had heard of a case of an infant who was physically harmed by bottle propping. An equal number had never heard of any infant adversely affected by this practice. One did not reply to the question. Only twelve respondents (30.8 per cent) claimed to have personally seen a case of an infant harmed by bottle propping. Twentyseven (69.2 per cent) had never seen such a case. All those who claimed to have seen an infant so harmed gave aspiration from regurgitated milk as the adverse result. Most respondents gave little further supporting evidence. One saw this happen only in premature and malnourished infants. Only one respondent cited autopsy evidence of milk throughout the tracheal tree. One described a case of aspiration which led to permanent anoxic brain damage, but admitted the infant might have vomited and aspirated anyway. Another respondent felt that aspiration
Volume 72 Number 5
was particularly likely in infants with pertussis or bronchiolitis. Another respondent stated that, in his 26 years of practice in an area where bottle propping was often practiced, he had never seen a case of an infant so harmed. DISCUSSION Although most pediatricians agree that bottle propping is not an ideal or desirable feeding practice, its use by the public or by hospitals may be justified under certain stress situations if it will not physically harm the baby. Only half the pediatricians queried felt that it might be harmful. Almost one third felt that it was a safe procedure. These same pediatricians did, however, confirm the fact that bottle propping is a reasonably common practice, at least by certain segments of the population. Furthermore, although not endorsed, it was practiced in a significant number of hospitals. The harmful effects of bottle propping were not well documented. Although the respondents represented pediatric departments that served a wide geographic area and a large population base, less than half of the respondents had ever personnally heard of a case of an infant harmed by bottle propping and less than one third, despite a vast pediatric experience, had ever seen a case in which they felt an infant was adversely affected by bottle propping. The documentation of these cases, when presented, often was based on the findings of aspirated milk in the tracheobronchial tree. In view of the fact that aspiration is often an agonal phenomenon in sudden death of infancy,~, 3 the aspiration may have been incidental to the cause of death. This is not to say, that bottle propping may not result in aspiration, but as one respondent said, "This is probably a risk of an exceedingly low order." Almost half of the respondents would permit bottle propping under certain circumstances. A critical nursing shortage is such a circumstance. It would be desirable, if bottle propping is to be carried out in a hospital, that it be limited to babies who are free of respiratory disease or severe mal-
Bottle propping
671
nutrition, and who have a healthy gag and suck reflex. It would also be desirable for these infants to be under observation by a nurse while they are fed in this manner. As this study is based on an opinion survey, it obviously cannot give the final answer on the dangers of bottle propping. It does suggest, however, that this practice is a risk of an extremely low order and that it can probably be safely carried out in hospitals during periods of acute nursing shortages, if the infants are observed while feeding, and if infants with respiratory diseases, malnutrition, or poor reflexes are excluded. As nursing shortages and skilled hospital personnel shortages can be expected in the foreseeable future, some hospitals will necessarily resort to bottle propping from time to time. It is hoped that this study will stimulate others to carry out more definitive research on the subject. CONCLUSION Questionnaires were sent to the directors of 50 teaching pediatric services throughout the United States in order to learn their views and observations on the dangers of bottle propping. Thirty-nine replies were received. There was much difference of opinion among the pediatricians. It appears that bottle propping is fairly extensively practiced by the public, and not infrequently practiced in hospitals. Hospitals usually resort to this practice as a result of personnel shortages. The opinions of a significant number of respondents suggest that the risk of bottle propping is of a very low order. If it is practiced, the infant should be under observation. Infants with respiratory disease, malnutrition, or with poor sucking or gag reflexes should be excluded. Dr. Hope Snyder, Mr. Peter Amaroso, and Mr. Stephan Kaufman were very helpful in assisting with this study. Their help is gratefully acknowledged. REFERENCES
1. Directory of Approved Internships and Residencies, A.M.A., Chicago, 1964,
6 7 2 Taubenhaus
2"he Journal o[ Pediatrics May 1968
2. Cook, R. T., and Welch, R. G.: A study in cot deaths, Brit. M. J. 2" 1549, 1964. 3. Hildebrand, H. E.: Sudden death in infancy, Med. Klin. 61z 169, 1966. EDITORS'
NOTE
This paper has been accepted for publication with some hesitation. The editor acknowledges prejudice against the practice of bottle propping, and did not permit it on hospital services for which he was responsible. Perhaps this is reason in itself to publish the accumulated opinions concerning a practice which it would be difficult to evaluate objectively, except among a large number of infants over a long period only. If we subscribe to tile idea that mealtime should be pleasurable, and considered as an essential in the fullness of family living, then we may ask, when is this concept developed? And is mothering, or lack of it, during the bottle feeding a determining factor in the acquisition of subsequent behavioral patterns? In the case of this paper, we are constrained to violate one of our rules: publish the comments of the two reviewers of the manuscript. They follow: COMMENTS
OF REVIEWER
NO.
!.
The major weakness of this paper is that the information was obtained from a questionnaire, the distribution of which was limited to directors of pediatric teaching services in 50 hospitals; 39 responded. This reviewer can only add his opinion to a subject which has little scientific data to condemn or support its practice. I did take the trouble to question some of our nurses who have had many years' experience in feeding and supervising the care of sick infants. I also questioned members of out" radiology department at some length as to their observations during fluoroscopy about the swallowing act of well and sick children. We believe that this type of practice is somewhat hazardous in our population of infants, many of whom are suffering from such disorders as congenital heart disease,
pulmonary disease, and brain damage. Some aspiration of feedings may be observed even in apparently healthy infants. The possibility of increasing this hazard by leaving the option of the method of feeding to the "busy" nurse strikes me as being very real. I have been impressed that mechanical short-cuts which are used to relieve a nursing shortage have seldom resulted in improvement in patient care. Inadequate numbers of nurses caring for well and sick hospitalized infants have inevitably encouraged poor nursing care. Many of these little babies need the mechanical and social stimulation of a kindly and interested nurse to insure an adequate intake. The doctor who fails to read good nurse's notes describing the feeding habits, and strong or weak suck of his patient, is missing some valuable information in his total evaluation. As a firm and enthusiastic supporter of care-by-parent units, and as one who is much impressed by "grandmother programs" in his hospital, I can find only disappointment for any institution which uses socalled nursing shortages as an excuse to resort to bottle propping. The stimulation which the sick infant lacks and needs because of maternal separation should be sufficient reason to discourage this type of pediatric care. And so my own personal bias becomes another "opinion." I am not convinced that we will benefit from more "definitive research" on this subject. COMMENTS
OF REVIEWER
NO.
2.
In the past few years a number of firmly entrenched "taboos" have been challenged. Among these are (1) feeding of "cold" formulas to young infants, (2) use of tap water in formula construction, and (3) bedrest for all children with fever. Now, the author of this paper challenges, or at least questions, another practice which most pediatricians have accepted for years as gospel. Though there is doubt that many opinions will he changed, this paper ought to provoke some interesting comments.
669
Bottle propping for infant feeding The pros and cons o[ "bottle propping" have been assembled [rom questionnaires distributed to directors o[ pediatric teaching services.
Leon J. Taubenhaus, M.D., M.P.H. BOSTON~ M A S S .
B O T T L E P R O P P I N G is generally considered to be an undesirable practice. The disclosure that bottle propping was practiced in a large hospital during a critical nursing shortage resulted in a strong condemnation by the local press. Articles in the press under the by-lines of reputable medical journalists quoted a number of notable pediatricians who soundly criticized the practice of bottle propping. The medical literature, however, is almost silent on this subject. This study was done to try to document the dangers of bottle propping and to determine, if possible, the extent that it is practiced in hospitals or in the home. The discrepancy between pediatric opinion and supporting literature raises the question "Is bottle propping an empirically perpetuated medical myth or a genuine danger?" METHODOLOGY This study is based on the experience, observations, and opinions of the directors of pediatric teaching services. Fifty hospitals with accredited pediatric residencies representing 40 states were selected. An attempt was made to select large hospitals and to From the Community Health Services, Boston
Department o[ Health and Hospitals, and The Department of Preventive Medicine, Boston University.
represent all geographic regions of the United States. When available within the area, municipal or county hospitals were selected. Preference was also given to pediatric services with higher autopsy rates. A questionnaire was sent to the director of the pediatric service of each of the selected hospitals. Thirty-nine questionnaires (78 per cent) were returned from 29 states. The total average daily census of all the pediatric services replying was 2,838, and the total daily newborn census was 1,985. The average pediatric daily census per hospital was 73 and the newborn census was 51. The annual number of pediatric admissions for the 39 hospitals was 110,341 patients, and the total annual pediatric out-patient load was 876,365 visits. This averaged 2,829 admissions and 22,471 out-patient visits, respectively, per hospital. Statistics were obtained from 1964 American Medical Association data? FINDINGS
When asked whether they thought bottle propping to be physically harmful (Table I) slightly less than half of the respondents (46.2 per cent) answered affirmatively. Almost one third (30.8 per cent) felt that it was a safe procedure, and another 20.5 per cent were not sure. Five pediatricians added Vol. 72, No. 5, pp. 669-672
670
Taubenhaus
The Journal o[ Pediatrics May 1968
Table I. Do you think "propping bottles" is physically harmful?
Reply
]
Number
Yes No Not sure No answer Total
1
Per cent
18 12 8 1 39
46.2 30.8 20.5 2.6
Table II. How prevalent is bottle propping in your community?
Prevalence
I
Number
Frequent Practiced Practiced by certain population groups only Rare Never .
.
[
Per cent
15 1(~
38.5 25.6
1l 3 0
28.2 7.7 .......
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
qualifying remarks. Two stressed the psychological benefits to tile baby from being held. One pediatrician who was not sure conceded that the risk of bottle propping was "probably of an exceedingly low order." Another felt that conceivably the baby might aspirate, although he did not know of such an event. He also felt that the baby might not eat as well. One physician said that if the question was changed to "can be" rather than "is," he woukt answer yes. Another stated it was occasionally dangerous. One pediatrician called the procedure "potentially" dangerous. Table II indicates that bottle propping is practiced country wide and not infrequently. There were some individual remarks suggesting that it is practiced principally by low-income groups. Fourteen respondents (33.1 per cent) indicated that bottle propping was permitted in some hospitals in their own community. Twenty-two others (56.2 per cent) stated that it was not permitted in their community. Three respondents did not know the practices of the other hospitals in their community. One, who stated that it was practiced in other hospitals, said it was done only as a last resort as during critical nursing
shortages. Another, who stated that bottle propping was not permitted in any hospital in his community, stated parenthetically that it was, however, frequently practiced. The respondents were asked if they thought bottle propping may be permitted under certain circumstances. Seventeen (43.6 per cent) said yes and 22 (56.4 per cent) said no. Shortage of nursing personnel was offered as an excuse to prop bottles by a number of respondents. They felt in such a case that the choice was between bottle propping and not feeding the infant. Pressure on the mother of too many children was also noted. Several respondents qualified their permission by allowing bottle propping for the older and healthier babies. One stated that if the infant had good suck, gag, and swallowing reflexes, and was not difficult to feed in the usual manner, it could be fed from a propped bottle. Another limited pernfission to healthy infants and to those admitted to the hospital as alert babies, such as those for plastic surgery or orthopedic therapy who had no respiratory or gastrointestinal illness. Several stated that there was no physical harm in bottle propping, but it was psychologically inadvisable. Nineteen respondents (48.7 per cent) said they had heard of a case of an infant who was physically harmed by bottle propping. An equal number had never heard of any infant adversely affected by this practice. One did not reply to the question. Only twelve respondents (30.8 per cent) claimed to have personally seen a case of an infant harmed by bottle propping. Twentyseven (69.2 per cent) had never seen such a case. All those who claimed to have seen an infant so harmed gave aspiration from regurgitated milk as the adverse result. Most respondents gave little further supporting evidence. One saw this happen only in premature and malnourished infants. Only one respondent cited autopsy evidence of milk throughout the tracheal tree. One described a case of aspiration which led to permanent anoxic brain damage, but admitted the infant might have vomited and aspirated anyway. Another respondent felt that aspiration
Volume 72 Number 5
was particularly likely in infants with pertussis or bronchiolitis. Another respondent stated that, in his 26 years of practice in an area where bottle propping was often practiced, he had never seen a case of an infant so harmed. DISCUSSION Although most pediatricians agree that bottle propping is not an ideal or desirable feeding practice, its use by the public or by hospitals may be justified under certain stress situations if it will not physically harm the baby. Only half the pediatricians queried felt that it might be harmful. Almost one third felt that it was a safe procedure. These same pediatricians did, however, confirm the fact that bottle propping is a reasonably common practice, at least by certain segments of the population. Furthermore, although not endorsed, it was practiced in a significant number of hospitals. The harmful effects of bottle propping were not well documented. Although the respondents represented pediatric departments that served a wide geographic area and a large population base, less than half of the respondents had ever personnally heard of a case of an infant harmed by bottle propping and less than one third, despite a vast pediatric experience, had ever seen a case in which they felt an infant was adversely affected by bottle propping. The documentation of these cases, when presented, often was based on the findings of aspirated milk in the tracheobronchial tree. In view of the fact that aspiration is often an agonal phenomenon in sudden death of infancy,~, 3 the aspiration may have been incidental to the cause of death. This is not to say, that bottle propping may not result in aspiration, but as one respondent said, "This is probably a risk of an exceedingly low order." Almost half of the respondents would permit bottle propping under certain circumstances. A critical nursing shortage is such a circumstance. It would be desirable, if bottle propping is to be carried out in a hospital, that it be limited to babies who are free of respiratory disease or severe mal-
Bottle propping
671
nutrition, and who have a healthy gag and suck reflex. It would also be desirable for these infants to be under observation by a nurse while they are fed in this manner. As this study is based on an opinion survey, it obviously cannot give the final answer on the dangers of bottle propping. It does suggest, however, that this practice is a risk of an extremely low order and that it can probably be safely carried out in hospitals during periods of acute nursing shortages, if the infants are observed while feeding, and if infants with respiratory diseases, malnutrition, or poor reflexes are excluded. As nursing shortages and skilled hospital personnel shortages can be expected in the foreseeable future, some hospitals will necessarily resort to bottle propping from time to time. It is hoped that this study will stimulate others to carry out more definitive research on the subject. CONCLUSION Questionnaires were sent to the directors of 50 teaching pediatric services throughout the United States in order to learn their views and observations on the dangers of bottle propping. Thirty-nine replies were received. There was much difference of opinion among the pediatricians. It appears that bottle propping is fairly extensively practiced by the public, and not infrequently practiced in hospitals. Hospitals usually resort to this practice as a result of personnel shortages. The opinions of a significant number of respondents suggest that the risk of bottle propping is of a very low order. If it is practiced, the infant should be under observation. Infants with respiratory disease, malnutrition, or with poor sucking or gag reflexes should be excluded. Dr. Hope Snyder, Mr. Peter Amaroso, and Mr. Stephan Kaufman were very helpful in assisting with this study. Their help is gratefully acknowledged. REFERENCES
1. Directory of Approved Internships and Residencies, A.M.A., Chicago, 1964,
6 7 2 Taubenhaus
2"he Journal o[ Pediatrics May 1968
2. Cook, R. T., and Welch, R. G.: A study in cot deaths, Brit. M. J. 2" 1549, 1964. 3. Hildebrand, H. E.: Sudden death in infancy, Med. Klin. 61z 169, 1966. EDITORS'
NOTE
This paper has been accepted for publication with some hesitation. The editor acknowledges prejudice against the practice of bottle propping, and did not permit it on hospital services for which he was responsible. Perhaps this is reason in itself to publish the accumulated opinions concerning a practice which it would be difficult to evaluate objectively, except among a large number of infants over a long period only. If we subscribe to tile idea that mealtime should be pleasurable, and considered as an essential in the fullness of family living, then we may ask, when is this concept developed? And is mothering, or lack of it, during the bottle feeding a determining factor in the acquisition of subsequent behavioral patterns? In the case of this paper, we are constrained to violate one of our rules: publish the comments of the two reviewers of the manuscript. They follow: COMMENTS
OF REVIEWER
NO.
!.
The major weakness of this paper is that the information was obtained from a questionnaire, the distribution of which was limited to directors of pediatric teaching services in 50 hospitals; 39 responded. This reviewer can only add his opinion to a subject which has little scientific data to condemn or support its practice. I did take the trouble to question some of our nurses who have had many years' experience in feeding and supervising the care of sick infants. I also questioned members of out" radiology department at some length as to their observations during fluoroscopy about the swallowing act of well and sick children. We believe that this type of practice is somewhat hazardous in our population of infants, many of whom are suffering from such disorders as congenital heart disease,
pulmonary disease, and brain damage. Some aspiration of feedings may be observed even in apparently healthy infants. The possibility of increasing this hazard by leaving the option of the method of feeding to the "busy" nurse strikes me as being very real. I have been impressed that mechanical short-cuts which are used to relieve a nursing shortage have seldom resulted in improvement in patient care. Inadequate numbers of nurses caring for well and sick hospitalized infants have inevitably encouraged poor nursing care. Many of these little babies need the mechanical and social stimulation of a kindly and interested nurse to insure an adequate intake. The doctor who fails to read good nurse's notes describing the feeding habits, and strong or weak suck of his patient, is missing some valuable information in his total evaluation. As a firm and enthusiastic supporter of care-by-parent units, and as one who is much impressed by "grandmother programs" in his hospital, I can find only disappointment for any institution which uses socalled nursing shortages as an excuse to resort to bottle propping. The stimulation which the sick infant lacks and needs because of maternal separation should be sufficient reason to discourage this type of pediatric care. And so my own personal bias becomes another "opinion." I am not convinced that we will benefit from more "definitive research" on this subject. COMMENTS
OF REVIEWER
NO.
2.
In the past few years a number of firmly entrenched "taboos" have been challenged. Among these are (1) feeding of "cold" formulas to young infants, (2) use of tap water in formula construction, and (3) bedrest for all children with fever. Now, the author of this paper challenges, or at least questions, another practice which most pediatricians have accepted for years as gospel. Though there is doubt that many opinions will he changed, this paper ought to provoke some interesting comments.