A Comparison of Oxygen Saturation Levels of Healthy Full-Term Infants during Breast- versus Bottle-Feeding
Introduction
Methodology
Results
Investigations have revealed the sucking and breathing patterns of
preterm, unwell, and healthy full-term infant populations during
feeding; however, research regarding oxygen saturation patterns
during feeding have focused primarily on preterm and unwell
infants. As full term infants may also present with feeding
difficulties, it can be assumed these infants are evaluated and
treated using the existing oxygen saturation pattern data from
premature and unwell infants, who do not represent stages of
development followed by healthy full-term infants.
Research participants were selected based on criteria described in
the following participant flyer:
Descriptive Statistics
Inferential Statistics
Mean saturations for both feeding methods were well within normal
limits of pediatric oxygen saturation levels, remaining above 90%
through all three study phases.
Analysis of Variance
(1)What are the oxygen saturation levels of healthy full-term infants
at three months of age, during both breast- and bottle-feeding?
(2)What respiratory difference (as measured by oxygen saturation),
if any, exists between the two feeding methods?
Previous Research
In previous studies, oxygen saturations of preterm bottle-fed
newborns showed significant decreases in respiration during the
initial phase of bottle-feeding with subsequent recovery of oxygen
levels throughout the remainder of the feed. This pattern of
desaturation followed by recovery was described previously by
Meier (1988). Oxygen saturation patterns of breast-fed preterm
infants were homogenous throughout (Mathew & Bhatia, 1989;
Mathew, 1991; Koenig et al., 1990; Mathew et al., 1985).
Influence of bottle nipple types
At the time of the study no consensus had been reached regarding
nipple type and respiratory efficiency, researchers instead
suggested monitoring control of an infant’s suck-swallow-breathe
may be more beneficial. In one study utilizing preterm infants the
use of a high flow nipple was reported. A standard rubber nipple
was cited in the full-term study.
Breast milk versus formula
Previous studies have found changes in nutrients do not equal
respiratory changes (breastmilk vs. formula); it is instead the
method of presentation which may lead to respiratory changes
(breast/standard nipple/high flow nipple). Several feeding studies
presented both expressed breast-milk and formula using the same
type of bottle nipple and found no respiratory difference between
the two.
Transcutaneous oxygen monitoring vs. Pulse oximetry
Although feeding studies measured oxygen saturation using either
transcutaneous monitors or pulse oximeters, pulse oximetry was
selected for this study as it was a non-invasive, accurate and
reliable measure of arterial oxygen saturation.
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All data collection sessions were conducted within the Minot
State University Communication Disorders Clinic.
Each participant and their caregiver participated in two data
collection sessions—one breast-feeding and one bottle-feeding.
Data sessions were 25 minutes in length with data being collected
every 30 seconds. Each data session was broken down into three
separate feeding periods: (1)five minutes prefeeding (baseline),
(2)ten minutes feeding, and (3)ten minutes postfeeding.
11 mother-infant pairs participated in the study.
Only 10 used for statistical analyses, consisting of 6 female infants
& 5 male infants. At least 25% of each infant’s regular feedings
delivered by either breast or bottle to ensure familiarity and
routine with each feeding method.
Oxygen Saturations Breast-feeding
Prefeed/Feeding/Postfeed
Nutrients
Primary Type of
Delivered
Feeding
by Bottle Breast/Bottle/Equal
Playtex
Expressed
Breast-feeding
Slow Flow
Breastmilk
Playtex
Expressed
Breast-feeding
Slow Flow
Breastmilk
Avent
Expressed
Equal
Breastmilk
Stage One
VentAire Stage Expressed
Breast-feeding
One
Breastmilk
VentAire Stage Expressed
Bottle-feeding
One
Breastmilk
Evenflo Number Expressed
Equal
One
Breastmilk
Dr. Brown’s
Infant
Bottle-feeding
Stage One
Formula
Dr. Brown’s
Expressed
Bottle-feeding
Stage One
Breastmilk
Playtex
Expressed
Breast-feeding
Stage Two
Breastmilk
Soothie
Breastmilk &
Breast-feeding
Stage One Formula Mix
Subject Bottle-Nipple
Number
Used
1
2
3
4
5
7
8
10
11
Feed
Postfeed
100
90
0:
3
1: 0
00
1:
3
2: 0
2:00
3
3: 0
0
3: 0
3
4: 0
0
4: 0
30
5:
0
5: 0
6:30
0
6: 0
3
7: 0
0
7: 0
3
8: 0
00
8:
3
9: 0
9:00
10 30
:
10 00
:
11 30
:
11 00
:
12 30
:
12 00
13:30
:
13 00
:
14 30
:
14 00
:
15 30
:0
15 0
:
16 30
16:00
:
17 30
:
17 00
:
18 30
:
18 00
:3
19 0
:
19 00
20:30
:
20 00
:3
21 0
:
21 00
:
22 30
:
22 00
:
23 30
:
24 23 00
: :
24 00 30
: :
25 30 00
:0 :0
0: 0
00
Time (SaO2/30 sec.)
Bottle
Breast
Prefeed
Feed
Postfeed
100
90
80
Time (SaO2/30 sec.)
Bottle
Breast
Examples of participant oxygen saturation patterns.
When visually examining the oxygen saturation levels recorded during
the feeding phase there were more instances of bottle-feeding than
breast feeding recorded near 100% saturation. Although breastfeeding saturations did not appear as high, they appeared to have less
variation overall, ranging from 85%-100%, possibly signifying a more
constant respiration pattern throughout feeding.
Percentage of Saturation Readings During Feeding
60
55
50
F
η2
Within subjects
1
.023
.003
2
1.328
.129
2
.419
.045
18
p
.883
.290
.664
2.330
As found previously by Hammerman and Kaplan (1995), no
significant differences in oxygen saturation levels between the two
feeding methods were observed.
Chi-Square Analysis
The total number SaO2 measurements less than 90% during
feeding and postfeeding periods were compared using Chi-square
analysis.
Four comparisons were included: breast-feeding to bottle-feeding,
post breast-feeding to post bottle-feeding, breast-feeding to post
breast-feeding, and bottle-feeding to post bottle-feeding.
Chi-square results indicate no difference in the amount of time
spent at or above 90% saturation.
Small effect sizes were also seen, leading to the conclusion that
even with a larger sample size results would remain nonsignificant.
Conclusions
As in previous full-term infant research by Hammerman and
Kaplan (1995), no statistically significant oxygen saturation
differences were identified between the two feeding methods in any
study phase.
45
40
These data support the findings of Hammerman and Kaplan
(1995), for the absence of a physiological drop in oxygen
saturations during typical breast- or bottle-feeding in healthy fullterm infants.
35
30
25
20
15
10
5
0
<80
80-84
85-87
88-90
91-92
93-94
95-96
97-98
99-100
SaO2 Saturations
Breast
Bottle
Breast and bottle post-feeding oxygen saturation levels showed
more congruency, with increased variation and uneven trend lines.
Increased physical activity levels associated with burping or
interacting with their caregiver could be possible causes for these
saturation characteristics.
By using a dissimilar study design and finding like data of previous
full-term, healthy infant feeding studies, additional evidentiary
support was provided to those who treat this distinct population.
Differences & Limitations
An important difference between this and other feeding studies,
regardless of gestation length or research design is the age of the
participants. Having older full-term infants participate increased the
amount of baseline data to expand the scope of knowledge,
allowing professionals to apply normative data to more than just
newborn full-term infants with feeding difficulties.
Percentage of Saturation Readings During Postfeeding
60
55
Supplementary data
regarding participant
feeding practices.
Feeding (F)
Stage (S)
F x S
F x S withingroup error
df
80
0:
3
1: 0
0
1: 0
3
2: 0
0
2: 0
3
3: 0
0
3: 0
30
4:
0
4: 0
3
5: 0
0
5: 0
6:30
0
6: 0
3
7: 0
00
7:
3
8: 0
0
8: 0
3
9: 0
9:00
10 30
:
10 00
:
11 30
:
11 00
:
12 30
:
12 00
13:30
:
13 00
:
14 30
:
14 00
:
15 30
:
15 00
:
16 30
16:00
:
17 30
:
17 00
:
18 30
:
18 00
:3
19 0
:
19 00
20:30
:
20 00
:
21 30
:
21 00
:3
22 0
:
22 00
:
23 30
:
24 23 00
:
:
24 00 30
: :
25 30 00
:0 :0
0: 0
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Oxygen Saturations Bottle-feeding
Prefeed/Feeding/Postfeed
2006
SaO2 Level (%)
1th,
Prefeed
of Total Recordings
Research Questions
Influence of positioning
Previous research has identified prone and semi-upright
positioning to be more beneficial than supine during feeding.
Infant positioning was accounted for in only one study utilizing
preterm infants.
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Each infant presented with a unique saturation pattern. No obvious
patterns observed during either feeding method [Opposed previous
saturation patterns of preterm infants described by Meier (1988), and
Meier and Anderson (1987)].
Future research may focus on any of the following:
Inclusion of rate or amount of nutrients consumed during feeding.
Analysis of Variance for Feeding Type
and Stage
Source
Percent
The purpose of this study was twofold:
(1)Establish the respiratory efforts (as measured by oxygen
saturation) required of three month old, healthy, full-term infants
during both breast- and bottle-feeding.
(2)Determine whether a significant difference exists between the
oxygen saturation levels of breast- and bottle-feeding among
healthy full-term infants.
Feeding procedures
All studies, both with full-term and preterm infant participants,
utilized similar feeding procedures (hunger cues, prepped for
pulse oximetry, fed, post-feeding). All studies had variable data
collection times ranging from a couple minutes to nearly an hour.
Each study also varied on how much
prefeeding(baseline)/feeding/postfeeding data was collected.
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Minot State University, Minot, ND
Future Research
50
45
Percent of Total Recordings
Purpose
Factors from previous research:
Infants serving as their own controls
Only one feeding study was found in which oxygen saturation
patterns of full-term infants were investigated between both
breast- and bottle-feeding. In that single study infants did not
serve as their own controls. All other feeding studies measuring
oxygen saturation patterns during breast- and bottle-feeding,
which examined preterm and unwell infants, had infants serve as
their own controls.
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Bre
SaO2 Level (%)
This study replicated a within subject design similar to that of
premature infant studies, however; looked at a population of fullterm infant studies. The findings of this study will provide speechlanguage pathologists with normative data regarding the typical
oxygen saturation levels of healthy, full-term three month old
infants during breast- and bottle-feeding. This will contribute to the
literature in several ways: (1) Allow speech-language pathologists to
draw more accurate conclusions regarding the oxygen saturation
levels of full-term infants experiencing feeding and swallowing
problems. (2)Assist in the recommendation of safe feeding
methods, and (3)Support speech-language pathologists in the
education of other professionals on pediatric dysphagia and safe
feeding practices.
Findings disputed the assumption that breast-feeding required a
higher level of respiratory exertion than bottle feeding in preterm
infants (Marino et al., 1995). Unfortunately, investigations have
failed to examine the saturation levels of healthy full-term infants
during feeding.
Alissa Steckler MS-CFY SLP
40
35
30
25
20
15
10
5
0
<80
80-84
Post Breast
85-87
Post Bottle
88-90
91-92
93-94
SaO2 Saturations
95-96
97-98
99-100
Considering this research sought to obtain normative data, a larger
sample size would have been beneficial, and may be a consideration
for future research.
Determining any differences or relationships between bottle-nipple
brands and oxygen saturation levels during feeding.
Although a small effect size was found, a larger sample size would
be beneficial for future research considering one of the goals of this
study was to obtain normative data.
Examination the oxygen saturation levels of healthy infants of
different ages during feeding would increase the body of normative
data regarding this population.
An in-depth comparison of SaO2 levels and infant
actions/reactions.
References
Chao-Huei, C., The-Ming, W., Ho-Mei, C. et al. (2000) The effect of breastand bottle-feeding on oxygen saturation and body temperature in
preterm infants. Journal of Human Lactation, 16 (1), pg 21-27.
Chen, C., Wang, T., Chang, H. & Chi, C. (2000). The effect of breast- and
bottle-feeding on oxygen saturation and body temperature in preterm
infants. Biology of the Neonate, 67 (2), 94-99.
Fanconi, S., Doherty, P., Edmonds, J., Barker, G. & Bohn, D. (1985). Pulse
oximetry in pediatric intensive care: comparison with measured
saturations and transcutaneous oxygen tension. The Journal of Pediatrics,
107 (3), 362-366.
Hammerman, C. & Kaplan, M. (1995). Oxygen saturation during and after
feeding in healthy term infants. Biology of the Neonate, 67 (2), 94-99.
Marino, B. L., O'Brien, P. & LoRe, H. (1995). Oxygen saturation during
breast and bottle feedings in infants with congenital heart disease. Journal
of Pediatric Nursing, 10 (6), 360-364.
Mathew, O. P., Bhatia, J. (1989). Sucking and breathing patterns during
breast- and bottle-feeding in term neonates. Effects of nutrient delivery
and composition. American Journal of Disordered Children, 143 (5), 588-592.
Meier, P. & Anderson, G. C. (1987). Responses of small preterm infants to
bottle- and breast-feeding. The American Journal of Maternal Child Nursing,
12 (2), 97-105.
Meier, P. (1988). Bottle- and breast-feeding: effects on transcutaneous
oxygen pressure and temperature in preterm infants. Nursing Research, 37
(1), 36-41.
Mizuno, K., Makoto, I. & Takeuchi, T. (2000). The effects of body
positioning on sucking behaviour in sick neonates. European Journal of
Pediatrics, 159 (11), 827-831.
Acknowledgements
Thank you to Minot State University and Dr. Cheryl Gerard for
allowing me the opportunity to undertake and complete this study.
The help and guidance I was given made this a paper to be proud
of. Thank you to my family and classmates for all their thoughts,
ideas and encouragement through this process, your support helped
me make my ideas a reality.
Contact Information
For more information on this paper please feel free to email me at:
[email protected]