2023 References Dr. Brown’s® Medical

∙Pados B, Hill R, et al. Prevalence of problematic feeding in young children born prematurely: a meta analysis. BMC Pediatrics. 2021;21:110. doi: 10.1186/s12887-021-02574-7


Background: Difficulties related to eating are often reported in children born preterm. The objective of this study was to quantitatively synthesize available data on the prevalence of problematic feeding in children under 4 years of age who were born preterm.

Methods: Literature was identified from PubMed, CINAHL, and PsycInfo. The search was limited to English language and publication years 2000–2020. To be included in the meta-analysis, the article had to report the prevalence of problematic oral feeding within a population of children born prematurely (< 37 weeks’ gestation), and the child age at the time of study had to be between full-term corrected age and 48 months. For studies meeting inclusion criteria, the following data were extracted: sample size and subsamples by gestational age and/or child age at time of study; definition of problematic feeding; measures used for assessment of feeding; gestational age at time of birth of sample; child age at time of study; exclusion criteria for the study; and prevalence of problematic feeding. Random-effects meta-analyses were performed to estimate the prevalence of problematic feeding across all studies, by gestational age at birth, and by child age at time of study.

Results: There were 22 studies that met inclusion criteria. Overall prevalence of problematic feeding (N = 4381) was 42% (95% CI 33–51%). Prevalence was neither significantly different across categories of gestational age nor by child age at the time of study. Few studies used psychometrically-sound assessments of feeding.

Conclusion: Problematic feeding is highly prevalent in prematurely-born children in the first 4 years of life regardless of degree of prematurity. Healthcare providers of children born preterm should consider screening for problematic feeding throughout early childhood as a potential complication of preterm birth.

∙Pados B. Milk flow rates from bottle nipples: What we know and why it matters. Nursing for Women’s Health. 2021;25(3):229-235. DOI: 10.1016/j.nwh.2021.03.006


Feeding difficulties are common in infants hospitalized in the NICU and can be a challenge to manage. The purpose of this article is to explain how and why the flow rate from the bottle nipple affects physiologic stability in infants and to describe the current evidence available on the flow rates of nipples used in the hospital and after discharge. Study results have indicated that flow rate varies widely among different types of nipples. Within the same type of nipple, there can be significant variability in flow from one nipple to another. Other factors, such as type of infant formula and thickening, also affect flow. Altering the flow rate of the bottle nipple is a relatively simple intervention that may support safe oral feeding.

∙Pados B, Mellon M. Effects of thickening on flow rates through bottle nipples. JOGNN. 2021;50(1):78-87. https://doi.org/10.1016/j.jogn.2020.09.153


Objective: To compare the flow rates of formula of various thicknesses through bottle nipples. Design: Multiple crossover design. Setting: Laboratory experiment. Participants: No human subjects. Methods: We used established methods to test the flow rates of Ultra Preemie; Preemie; Newborn; and Levels 1, 2, 3, and 4 nipples with three thicknesses of formula: thin, slightly thick, and mildly thick. We used descriptive statistics to calculate mean flow rates (milliliters per minute) and standard deviation, from which we calculated the coefficient of variation. We used cluster analysis to identify nipple types and thicknesses with comparable flow rates. Results: Flow rates ranged from less than 1 ml/min for the Preemie nipple with mildly thick formula to 82.29 ml/min for the Level 4 nipple with thin formula. As expected, within each nipple type, increased thickness of formula resulted in decreased flow. Increased thickness of formula also resulted in an increased variability in flow rate. For nearly all nipple types, mildly thick consistency resulted in the greatest amount of variability in flow. We identified seven clusters of nipple types and formula thicknesses with comparable flow rates.

Conclusion: These data provide clinicians with information to guide decision making about nipple choice when thickened feedings are needed. Thickening increases the variability in flow rates, which is an important consideration for infants who are still learning to safely and effectively feed by mouth.

∙McGrath J, Bromiker, R et al. Correlates and trajectories of preterm infant sucking patterns and sucking organization at term age. Advances in Neonatal Care. 2020;21(2):152-159. DOI: 10.1097/ANC.0000000000000810


Background: Premature infants may experience increased difficulty with nutrition and growth. Successful oral feeding is an important factor associated with discharge readiness. Despite the importance of feeding as a growth-fostering process, little empiric evidence exists to guide recommendations for early interventions.

Purpose: Evaluate whether specific elements of sucking, during preterm initiation of oral feeding, predict sucking organization at corrected term age.

Methods: Sucking performance of 88 preterm infants born between 24 and 34 weeks of post-menstrual age was measured at baseline and term (33-35 and 40 ± 1.5 weeks). Participants were divided into 4 groups (quartiles) based on initial measures of performance including number of sucks, number of bursts, sucks per burst, and maximum pressure. Stability in sucking organization was assessed by comparing changes in infant’s quartile location from baseline to term.

Results: A correlation between quartile location was observed for mean maximum pressure (PMAX): infants with PMAX in the lowest quartile (poorest performance) were significantly more likely to remain in the lowest quartile at term (P < .000); infants in the highest quartile (best performance) at baseline were significantly more likely to be in the highest quartile at term (P < .000).

Implication for practice: Infants with the weakest sucking pressures at 34 weeks of post-menstrual age continue to be at risk for less than optimal feeding skills at 40 weeks of post-menstrual age. Early identification of at-risk infants may allow for effective interventions to potentially decrease long-term feeding problems.

Implications for research: Future research should focus on the development of personalized interventions to address attributes of problematic feeding such as sucking efficiency.

*Further comments by author conclude that infants born prematurely often have delays in discharge due to their inability to orally feed effectively and safely. “Feedings need to be offered with a standardized nipple where flow is well controlled by the pressure provided by the infant.” Using this information, NICU professionals should reconsider inconsistent and highly variable disposable products.

∙Pados B,  Park J,  Dodrill P. Know the Flow: Milk Flow Rates From Bottle Nipples Used in the Hospital and After Discharge. Advances in Neonatal Care. 2019;19(1):32-41. DOI: 10.1097/ANC.0000000000000538


Background: Milk flow rate may play an important role in an infant’s ability to safely and efficiently coordinate sucking, swallowing, and breathing during feeding.

Purpose: To test milk flow rates from bottle nipples used in the hospital and after discharge.

Methods: Bottle nipples used in hospitals (10 unique types) and available nationwide at major retailers (15 unique types) were identified. For each of the 25 nipple types, 15 nipples of that type were tested by measuring the amount of infant formula extracted in 1 minute by a breast pump. Mean milk flow rate (mL/min) and coefficient of variation (CV) were calculated for each nipple type. Comparisons between nipple types were made within brand and within category (eg, Slow, Standard). A cluster analysis was conducted to identify nipples of comparable flow.

Results: A total of 375 individual nipples were tested. Milk flow rates varied widely, from 0.86 to 37.61 mL/min. There was also a wide range of CVs, from 0.03 to 0.35. Packing information did not accurately reflect the flow rates of bottle nipples. The cluster analysis revealed 5 clusters of nipples, with flow rates from Extra Slow to Very Fast.

Implications for practice: These data can be used to guide decisions regarding nipples to use for feeding infants with medical complexity in the hospital and after discharge.

Implications for research: Research on infant feeding should consider the flow rate and variability of nipples used, as these factors may impact findings.

*Article discussion states single-use nipples commonly used for feeding infants with medical complexity were found to be highly variable and that the safety of these products for feeding these infants should be reconsidered. In this study, the Dr. Brown’s® slow flow nipples were rated higher for reliability than commonly used disposable nipples.

∙Zimmerman E, Rosner A. Feeding swallowing difficulties in the first three years of life: A preterm and full-term infant comparison. Journal of Neonatal Nursing. 2018;24:331-335.https://doi.org/10.1016/j.jnn.2018.07.003


Objective: To assess the prevalence of feeding-swallowing difficulties (FSDs), and to examine which FSDs are the most common in young children.

Methods: FSDs were defined as difficulties in sucking, food transitions, gastroesophageal reflux (GERD), food selectivity, salivary control issues, and poor growth. Mothers of children ≤3 years of age completed an online survey.

Results: Twenty-seven percent of our sample (n = 204) reported that their child experienced FSDs. Being born preterm increased the odds ratio of reporting an FSDs by 3.319. 10.90% of our sample reported having more than one FSD. GERD was significantly (p < .001) more reported than the other FSDs. Premature infants had significantly more sucking difficulties (p = .001), poor growth (p = .049), and received more early intervention (p = .033) compared to full-term infants.

Conclusion: FSDs are relatively common in early childhood (27%) with GERD being the most reported by parents. Preterm birth is a significant predictor of FSDs. These findings further motivate the need for more research on FSDs in childhood.

∙Shaker C. Infant-guided, co regulated feeding in the neonatal intensive care unit. Part II: Interventions to promote neuroprotection and safety. Semin Speech Lang 2017;38:106–115. DOI: 10.1055/s-0037-1599108


Feeding skills of preterm neonates in a neonatal intensive care unit are in an emergent phase of development and require careful support to minimize stress. The underpinnings that influence and enhance both neuroprotection and safety were discussed in Part I. An infant-guided, co-regulated approach to feeding can protect the vulnerable neonate’s neurologic development, support the parent-infant relationship, and prevent feeding problems that may endure. Contingent interventions are used to maintain subsystem stability and enhance self-regulation, development, and coping skills. This co-regulation between caregiver and neonate forms the foundation for a positive infant-guided feeding experience. Caregivers select evidence-based interventions contingent to the newborn’s communication. When these interventions are then titrated from moment to moment, neuroprotection and safety are fostered.

∙McGrattan K. et al. Effect of single-use laser-cut slow flow nipples on respiration and milk ingestion in preterm infants. American Journal of Speech-Language Pathology 2017:1-8. DOI: 10.1044/2017_AJSLP-16-0052


Purpose: Single-use, laser-cut, slow-flow nipples were evaluated for their effect on respiration and milk ingestion in 13 healthy preterm infants (32.7-37.1 weeks postmenstrual age) under nonlaboratory, clinical conditions.

Method: The primary outcomes of minute ventilation and overall milk transfer were measured by using integrated nasal airflow and volume-calibrated bottles during suck bursts and suck burst breaks during slow-flow and standard-flow nipple bottle feedings. Wilcoxon signed-ranks tests were used to test the effect of nipple type on both outcomes.

Results: Prefeeding minute ventilation decreased significantly during suck bursts and returned to baseline values during suck burst breaks across both slow-flow and standard-flow nipples. No differences were found in minute ventilation (p > .40) or overall milk transfer (p = .58) between slow-flow and standard-flow nipples.

Conclusions: The lack of difference in primary outcomes between the single-use slow-flow and standard-flow nipples may reflect variability in nipple properties among nipples produced by the same manufacturer. Future investigations examining the effect of both single-use and reusable nipple products are warranted to better guide nipple selection during clinical care.

*Article discussion also concludes that reusable home nipple products that offer a slower, more consistent restriction to milk flow across bottle feedings may provide a greater respiratory benefit. “Preemie and Ultra Preemie Nipples, Dr. Brown’s, provide significantly lower, more reliable rates of milk flow than the disposable, single-use products that were used in the current investigation.”

∙Altimer L, Phillips R. The neonatal integrative developmental care model: Advanced clinical applications of the seven core measures for neuroprotective family-centered developmental care. Newborn & Infant Nursing Reviews. 2016;16(4):230-244. doi.org/10.1053/j.nainr.2016.09.030

This article outlines seven core measures for neuroprotective family-centered developmental care of premature infants: 1) healing environment, 2) partnering with families, 3) positioning & handling, 4) safeguarding sleep, 5) minimizing stress and pain, 6) protecting skin, and 7) optimizing nutrition. Goals for successful infant driven feedings are those where oral feedings are safe, functional, nurturing, and individually and developmentally appropriate. The Neonatal Integrative Developmental Care Model utilizes neuroprotective interventions as strategies to support optimal synaptic neural connections, promote normal neurological, physical, and emotional development and prevent disabilities.

∙Lau C, Fucile S, Schanler RJ. A self-paced oral feeding system that enhances preterm infants’ oral feeding skills. Journal of Neonatal Nursing. 2015;21:121-126. http://dx.doi.org/10.1016/j.jnn.2014.08.004


Aim: Very low birth weight (VLBW) infants have difficulty transitioning to independent oral feeding, be they breast- or bottle-feeding. We developed a ‘self-paced’ feeding system that eliminates the natural presence of the positive hydrostatic pressure and internal vacuum build-up within a bottle during feeding. Such system enhanced these infants’ oral feeding performance as monitored by overall transfer (OT; % ml taken/ml prescribed), rate of transfer (RT; ml/min over an entire feeding). This study hypothesizes that the improvements observed in these infants resulted from their ability to use more mature oral feeding skills (OFS).

Methods: ‘Feeders and growers’ born between 26 and 29 weeks gestation were assigned to a control or experimental group fed with a standard or self-paced bottle, respectively. They were monitored when taking 1-2 and 6-8 oral feedings/day. OFS was monitored using our recently published non-invasive assessment scale that identifies 4 maturity levels based on infants’ RT and proficiency (PRO; % ml taken during the first 5 min of a feeding/total ml prescribed) during bottle feeding.

*Results indicated that VLBW infants exhibit more mature OFS when fed with a self-paced feeding system, due to elimination of hydrostatic pressure and internal vacuum build-up. The Dr. Brown’s® Zero-Resistance™ Bottle system is vacuum free.

∙Ross E. Supporting Oral Feeding Skills Through Bottle Selection. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 2015;24:50-57. https://doi.org/10.1044/sasd24.2.50


Infants who have feeding difficulties often struggle with coordinating sucking, swallowing, and breathing, and have difficulty eating sufficient quantities for adequate growth. Speech-language pathologists (SLPs) need advanced expertise across a number of areas (e.g., development, medical, swallowing) to work effectively with these young infants, and they use a variety of strategies when treating this population. Therapists working with infants who have feeding difficulties use bottles as a primary therapy tool; how the infant tolerates the flow rate from the bottle/nipple is a major consideration. Caregivers must understand the influence of bottle/nipple flow rates on eating skills, so they can support the emerging oral skill development for these fragile infants, and help parents decide what bottle system to use in their home. Both infant and equipment factors influence bottle/nipple flow rates. This article discusses the influencing factors that need to be considered when determining the optimal flow rate for an individual infant.

∙Fucile S, Gisel E, Schanler RJ, Lau C. A controlled-flow vacuum-free bottle system enhances preterm infants’ nutritive sucking skills. Dysphagia. 2009:24:145-151. DOI: 10.1007/s00455-008-9182-z


We have shown that a controlled-flow vacuum-free bottle system (CFVFB) vs. a standard bottle (SB) facilitates overall transfer and rate of milk transfer, and shortens oral feeding duration in very-low-birth-weight (VLBW) infants. We aimed to understand the basis by which this occurs. Thirty infants (19 males; 27 +/- 1 weeks gestation) were randomized to a CFVFB or SB. Outcomes monitored at 1-2 and 6-8 oral feedings/day when infants were around 34 and 36 weeks postmenstrual age, respectively, included: overall transfer (% volume taken/volume prescribed), rate of milk transfer (ml/min), sucking stage, frequency of suction (#S/s) and expression (#E/s), suction amplitude (mmHg), and sucking burst duration (s). At both periods we confirmed that infants using a CFVFB vs. SB demonstrated greater overall transfer and rate of milk transfer, along with more mature sucking stages. Suction and expression frequencies were decreased with CFVFB vs. SB at 1-2 oral feeding/day; only that of suction was reduced at 6-8 oral feedings/day. No group differences in suction amplitude and burst duration were observed. We speculate that oral feeding performance improves without significant change in sucking effort with a CFVFB vs. SB. In addition, we have shown that VLBW infants can tolerate faster milk flow than currently presumed. Finally, the use of a CFVFB may reduce energy expenditure as it enhances feeding performance without increasing sucking effort.

∙Lau, C & Schanler RJ. Oral feeding in premature infants: advantage of a self-paced milk flow. Acta Paediatrica 2000;89:453-9. DOI: 10.1080/080352500750028186


An earlier study demonstrated that oral feeding of premature infants (<30 wk gestation) was enhanced when milk was delivered through a self-paced flow system. The aims of this study were to identify the principle(s) by which this occurred and to develop a practical method to implement the self-paced system in neonatal nurseries. Feeding performance, measured by overall transfer, duration of oral feedings, efficiency, and percentage of successful feedings, was assessed at three time periods, when infants were taking 1–2, 3–5, and 6–8 oral feedings/day. At each time period, infants were fed, sequentially and in a random order, with a self-paced system, a standard bottle, and a test bottle, the shape of which allowed the elimination of the internal hydrostatic pressure. In a second study, infants were similarly fed with the self-paced system and a vacuum-free bottle which eliminated both hydrostatic pressure and vacuum within the bottle. The duration of oral feedings, efficiency, and percentage of successful feedings were improved with the self-paced system as compared to the standard and test bottles. The results were similar in the comparison between the self-paced system and the vacuum-free bottle.

Elimination of the vacuum build-up naturally occurring in bottles enhances the feeding performance of infants born <30 wk gestation as they are transitioned from tube to oral feeding. The vacuum-free bottle is a tool which caretakers can readily use in neonatal nurseries.

* The Dr. Brown’s® Zero-Resistance™ Bottle system is vacuum-free

Cleft Lip/Palate

∙Baylis A, Pearson G et al. A quality improvement initiative to improve feeding and growth of infants with cleft lip and/or palate. The Cleft Palate-Craniofacial Journal. 2018:55(9):1218-1224. DOI: 10.1177/1055665618766058


Objective: The purpose of this quality improvement initiative was to improve feeding and growth outcomes in infants with cleft lip and/or palate (CL/P).

Design: Institute for Healthcare Improvement quality improvement model.

Setting: Large pediatric academic medical center in the Midwestern United States.

Participants: One hundred forty-five infants with nonsyndromic CL/P ages 0 to 12 months.

Interventions: Key drivers included (1) caregiver education and resources, (2) care coordination and flow, and (3) provider education and training. Interventions were designed around these themes and included targeting improved team communication, increased social work consultations, patient tracking, staff education, improved access to feeding equipment, and the launch of a new cleft palate feeding team.

Main Outcome Measure(s): The primary outcome measure was the percentage of new patients with CL/P who met criteria for failure to thrive (FTT) per month. The secondary outcome measure was the frequency of hospitalization for infants with CL/P with a primary reason for admission of feeding difficulties or FTT.

Results: The institutional FTT rate for infants with CL/P decreased from 17% to 7% (P < .003). The frequency of hospitalization for FTT improved from once every 30 days to once every 118 days.

Conclusions: Targeted interventions aimed at improving feeding efficiency and effectiveness, as well as changes in care delivery models, can reliably promote improvements in feeding and growth outcomes for infants with CL/P, even with psychosocial risk factors present.

*Additional findings – During the study, the Dr. Brown’s® Zero-Resistance™ Specialty Feeding System became the preferred and most commonly used feeding treatment tool in the study center. Authors report the QI results suggests specialized feeding equipment along with parent and staff education can prevent growth failure.

∙Snyder M, Ruscello D. Parent perceptions of initial feeding experiences of children born with cleft palate in a rural locale. The Cleft Palate-Craniofacial Journal. 2018:10(10);1-10. DOI: 10.1177/1055665618820754


Background and Hypothesis: An early problem frequently present in infants born with cleft lip (CL), cleft lip and palate (CLP), or cleft palate (CP) is difficulty feeding. In many cases, health-care professionals are not familiar with the appropriate feeding techniques and unable to instruct parents correctly. This problem can be particularly significant in rural areas where health-care resources are limited and children with clefts are seen on an infrequent basis. The purpose of the investigation was to study the initial feeding experiences of parents who reside in rural areas and whose children were born with CL, CLP, or CP.

Method: A 29-item questionnaire was developed and administered to 26 families. The results were analyzed and summarized descriptively.

Results and conclusion: The majority of parents reported initial difficulties with feeding their infants. They indicated the need to seek information and assistance from various sources. As a result of the findings, an informational resource was developed to inform rural health-care professionals of the early feeding issues of children born with CL, CLP, or CP.

*In addition, parents reported on specialty bottles for feeding to result in successful formula intake. Dr. Brown’s Specialty Feeder resulted in the highest percentage of success.

∙Francis J, Rogers K, et al. Comparative Analysis of ascorbic acid in human milk and infant formula using varied milk delivery systems. International Breastfeeding Journal. 2008;3:19. https://doi.org/10.1186/1746-4358-3-19


Background: The expression of human milk for later use is on the rise. Bottle systems are used to deliver the expressed milk. Research has shown that storage of both human milk and artificial baby milk, or infant formula, leads to a loss of ascorbic acid (commonly called Vitamin C). As milk is removed from the bottle during feeding and replaced by ambient air, it is unknown if loss of ascorbic acid occurs during the course of a feeding. The purpose of this study is to investigate the effect of the milk delivery system on levels of ascorbic acid in human milk and infant formula. The objectives are to 1) determine changes in ascorbic acid concentration during a 20 minute “feed,” 2) determine if there is a difference in ascorbic acid concentration between delivery systems, and 3) evaluate if any differences are of clinical importance.

Commonly available bottles were used for comparison of bottle delivery systems. Mature human milk was standardized to 42 mg/L of ascorbic acid. Infant formula with iron and infant formula with docosahexanoic acid were used for the formula samples. Each sample was analyzed for ascorbic acid concentration at baseline (0), 5, 10, 15, and 20 minutes. Each collection of samples was completed in triplicate. Samples were analyzed for ascorbic acid using normal-phase high performance liquid chromatography.

Results: Ascorbic acid concentration declined in all bottle systems during testing. Differences between the bottle systems were noted. Ascorbic acid concentrations declined to less than 40% of recommended daily intake for infants in 4 of the bottles systems at the 20 minute sampling.

Conclusion: The bottle systems used in this study had measurable decreases in the mean concentration of ascorbic acid. More research is needed to determine if the observed decreases are related to lower plasma ascorbic acid concentration in infants exclusively bottle fed. The decrease of ascorbic acid concentration observed in both human milk and infant formula using varied milk delivery systems may be of clinical importance. For infants who rely solely on bottle feeds there may be increased risk of deficiency. Bottle shape, size, and venting should be considered.

*In this study, of all bottle systems tested, the Dr. Brown’s® Zero-Resistance™ Bottle System had the lowest decreased concentration of ascorbic acid.