The advantages of breast milk for premature infants are well known. All new mothers should be encouraged to breastfeed their babies. However, the methods of delivering breast milk to infants who are ready to be fed orally are debatable. Although breastfeeding is the most natural way to feed healthy infants, exclusive breastfeeding may not be beneficial for infants with compromised medical conditions, such as ELBW premature infants. In my opinion, premature infants, especially ELBW infants, should not be breastfed exclusively but should be given the opportunity to bottle feed during initial hospitalization. The reasons are as follows.

* Physiological limitations of preterm infants: Premature infants can express milk by compressing an artificial nipple but require a more mature sucking pattern combining both compression and suction to express milk from a breast. Therefore, oral feeding can be introduced by bottle much earlier than by breast.

* Myth of nipple confusion: Some authors suggest that transitioning premature infants from bottle feeding to full breastfeeding causes "nipple confusion," recommending that the use of bottles be limited. However, no data document that infants have difficulties breastfeeding after exposure to an artificial nipple. Bottle feeding experience does not affect breastfeeding in preterm infants (Collins et al., 2004). Infants who were bottle fed during the first 5 days of life did not demonstrate a lower frequency or shorter duration of breastfeeding during the first 6 months of life (Schubiger, Schwarz, & Tonz, 1997).

* Length of stay in the hospital: A longer length of stay creates a greater financial burden for society. ELBW infants feed more efficiently on bottles than on the breast (Furman, & Minich, 2004), and preterm infants exposed to bottle feeding have a shorter length of stay than those who were not (Collins et al., 2004).

* Safety: Recently, breastfeeding supporters have recommended offering milk via cup as an alternative to the bottle for preterm infant feeding. Cup feeding may increase the risk of aspiration and choking. Excessive weight loss in exclusively breastfed infants is another safety concern. Instead of using a nasogastric tube, supplements given by bottle with carefully measured volume can effectively manage this problem. Some argue it is easier for preterm infants to control milk flow from breast than from artificial nipples and that bottle fed infants are more prone to have oxygen desaturation during feedings. With advanced technology, this issue could be resolved by using commercially available low-flow nipples or positioning.

In addition to these concerns, many mothers desire bottle feeding, and providers should assist mothers whose infants are bottle fed exclusively or as a supplement because of maternal request or medical reasons.

There is no doubt that breastfeeding is the most natural way to feed an infant, and efforts have been made to encourage breastfeeding internationally. However, practical problems with breastfeeding remain, especially for preterm infants, and despite much effort, the numbers of preterm infants exclusively breastfed after hospital discharge remain low. Infants in the NICU are introduced to bottle feeding for various reasons, including maternal choice. In my opinion, parents should be taught about the benefits of breast milk, but exclusivity of breast milk is not necessary. As a matter of fact, it could be that mothers and infants who have exposure to bottle feeding under professional supervision during initial hospitalization may have a safer and smoother transition from breastfeeding to bottle feeding later on. Mothers always should be given choices and opportunities to feed preterm infants directly by breast or by bottle during their initial hospital stay.

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