Cup feeding versus other forms of supplemental enteral feeding
for newborn infants unable to fully breastfeed
Flint A, New K, Davies MW
Dates
Date edited: 14/03/2007
Date of last substantive update: 11/12/2006
Date of last minor update: 18/01/2007
Date next stage expected / /
Protocol first published: Issue 1, 2005
Review first published: Issue 2, 2007
Contact reviewer
Ms Anndrea Flint
Nurse Manager Retention
Centre for Clinical Nursing, Level 2
Royal Women's Hospital
Butterfield St
Herston
Brisbane
Queensland AUSTRALIA
4029
Telephone 1: +61 7 3636 6487
Facsimile: +61 7 3636 1557
E-mail: Anndrea.Flint@health.qld.gov.au
Contribution of reviewers
Conceiving the review - AF, KN
Data collection for the review - AF, KN
Designing search strategies - AF, KN, MWD
Undertaking searches - AF, KN, MWD
Screening search results - AF, KN
Organising retrieval of papers - AF, KN
Screening retrieved papers against inclusion criteria - AF, KN
Appraising quality of papers - AF, KN
Extracting data from papers - AF, KN
Writing to authors of papers for additional information - AF, KN
Entering data into RevMan - AF, KN
Analysis of data - AF, KN
Interpretation of data - AF, KN, MWD
Writing the review - AF, KN
Revising review - MWD
Providing general advice on the review - MWD
Internal sources of support
Grantley Stable Neonatal Unit, Royal Brisbane & Women's Hospital, Brisbane, AUSTRALIA
Dept of Paediatrics and Child Health, University of Queensland, Brisbane, AUSTRALIA
External sources of support
NoneWhat's new
Dates
Date review re-formatted: / /
Date new studies sought but none found: / /
Date new studies found but not yet included/excluded: / /
Date new studies found and included/excluded: / /
Date reviewers' conclusions section amended: / /
Date comment/criticism added: / /
Date response to comment/criticisms added: / /
Text of review
Synopsis
Is cup feeding a better way to feed babies, rather than giving bottles or feeding with a tube, when mothers are unable to fully breastfeed?
We wanted to identify the best way of offering feeds to babies when mothers are unable to breastfeed, or initially have difficulty with breastfeeding. Alternative feeding methods include using a cup, bottle or feeding tube. Four included studies compared cup and bottle feeding: the results of three of these studies demonstrate that infants who were cup fed were more likely to be exclusively breastfed at hospital discharge. However, at three and six months, there was no difference in the number of infants fully or partially breastfeeding, whether initially fed by cup, bottle or feeding tube. The results of one study demonstrated that those infants feed by cup spent approximately ten days longer in hospital. Therefore, based on available evidence, we cannnot recommend cup feeding.
Abstract
Background
Breast milk provides optimal nutrition for newborn infants, and the ideal way for infants to receive breast milk is through suckling at the breast. Unfortunately, this may not always be possible, as there are numerous reasons why a newborn infant may not be able to breastfeed and, as a result, require supplemental feeding. Currently, there are a variety of ways in which newborn infants can receive supplemental feeds. Traditionally, bottles and nasogastric tubes have been used; however, more recently, cup feeding has become a popular practice in many nurseries in an attempt to improve breastfeeding rates. There is no consistency to guide the choice of supplementation.
Objectives
To determine the effects of cup feeding versus other forms of supplemental enteral feeding on weight gain and achievement of successful breastfeeding in newborn infants who are unable to fully breastfeed.
Search strategy
We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2006), CINAHL (1982 - April 2006) and MEDLINE (1966 - April 2006).
Selection criteria
Randomised or quasi-randomised controlled trials comparing cup feeding to other forms of enteral feeding for the supplementation of newborn infants.
Data collection & analysis
Quality assessments and data extraction for included trials were conducted independently by the review authors. Outcomes reported from these studies were: weight gain, proportion not breastfeeding at hospital discharge, proportion not feeding at three months of age, proportion not feeding at six months of age, proportion not fully feeding at hospital discharge, proportion not fully breastfeeding at three months of age, proportion not fully breastfeeding at six months of age, average time per feed (minutes), length of stay and physiological events of instability such as bradycardia, apnea, and low oxygen saturation. For continuous variables such as weight gain, mean differences and 95% confidence intervals were reported. For categorical outcomes such as mortality, the relative risks (RR) and 95% confidence intervals were reported.
Main results
Four studies were eligible for inclusion. The experimental intervention was cup feeding and the control intervention was bottle feeding in all four studies included in this review. There was no statistically significant difference in the incidence of not breastfeeding at hospital discharge in three included studies (typical RR 0.82, 95% CI 0.62, 1.09) and not breastfeeding at three months in two included studies (typical RR 0.88, 95% CI 0.76, 1.03) or six months for the one study that reported this outcome (RR 0.91, 95% CI 0.78, 1.05). There was a statistically significant difference in not fully breastfeeding at hospital discharge (from three included studies) in favour of cup feeding (typical RR 0.75, 95% CI 0.61, 0.92). However, this was not statistically significant at three months (one study, RR 1.18, 95% CI 0.88, 1.58) or six months (one study, RR 1.31, 95% CI 0.89, 1.92). There was no statistically significant difference in weight gain from one study that reported this outcome (MD -0.60, 95% CI -3.21, 2.01). In the one study that assessed it, there was a significantly increased length of hospital stay in the cup fed infants [mean difference between groups was 10.1 days (95% CI 3.9, 16.3)]. Time to full breastfeeding was not assessed in any study.
Reviewers' conclusions
Cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in hospital.
Background
The optimal milk for newborn infants is their mother's breast milk, and the best way for them to achieve this is by sucking on the breast. However, there are numerous reasons why a baby may not be able to breastfeed. If a newborn infant cannot breastfeed, then an alternative form of enteral feeding is required. Alternatives include gastric tube feeding, bottle-feeding and cup feeding.
Traditionally, bottles and gastric tubes have been used routinely in neonatal units to feed infants who are unable to fully breastfeed, particularly at night and when mothers are unable to be present for all feeds (Lang 1994b). While this may not be desired by either staff or mothers, there are limited options for an unsettled infant when the mother is not available to breastfeed and gastric tube feeding does not satisfy the infant's psychological and social needs (Lang 1994b). Cup feeding has been suggested as an alternative.
It is argued that because cup feeding only requires the infant to 'lap' the milk and then coordinate swallowing and breathing, the preterm infant can be fed using a cup from as early as 30 weeks gestation. This is well before the time that breast and bottle feeding can be introduced as this requires the coordination of sucking, swallowing and breathing, which are often uncoordinated until approximately 32 - 35 weeks of age (Lang 1994a; Lang 1994b; Palmer 1993). Artificial feeding methods consisting of pap bowls (a bowl with a wide brimmed lip), feeding horns (a bowl with a funnel like horn), cups with lips, and bottles have existed throughout history (Foote 1944; Lang 1994a). Originally, cup feeding was used to feed newborns who were born with oral deformities such as a cleft lip or cleft palate (Fredeen 1948). Cup feeding has been used in developing countries for several decades, where the care and hygiene facilities for bottles and nipples have been limited and gastric tubes are not readily available (Dowling 2002; Lang 1994b). More recently cup feeding is gaining increased use as an alternative feeding method in maternity and neonatal units for preterm and term infants who are unable to fully breastfeed (NANN 2004). The theoretical benefits include avoiding the confusion between breast and bottle (Dowling 2002; Gupta 1999; Thorley 1997); enhancing the newborn's ability to develop a suckling action for breastfeeding (Thorley 2004); and facilitating the newborn's ability to self regulate feeds and demand feeds (Vallenas 1998). The Baby Friendly Hospital Initiative (BFHI) training literature and guideline recommends the use of cup feeding for infants intending to breastfeed, so that no artificial nipples are introduced to these infants (Lang 1994b; Vallenas 1998).
The literature suggests that there are many advantages to cup feeding (Cousins 1999; Fredeen 1948; Gupta 1999; Kuehl 1997; Lang 1994a; Lang 1994b). These include the fact that cup feeding is a simple procedure that can involve both parents, early positive body and eye contact is fostered, the infant receives positive tactile and olfactory stimulation, cardiorespiratory and oxygen saturation can be maintained (Dowling 2002; Lang 1994a; Lang 1994b), the infant controls the feed and can pace the intake and the total volume of milk taken, and there is minimal risk of aspiration and minimal energy expended (Lang 1994a; Lang 1994b; Thorley 2004). However, many of these advantages could also be claimed of bottle feeding.
While there may be many benefits of feeding preterm and term infants with a cup, there are also potential risks that need to be considered when introducing this practice into maternity and neonatal units (NANN 2004). Some authors have reported that cup feeding is awkward at first and that the infant is at risk of aspiration pneumonia when the improper technique is used resulting in the milk being 'poured into' the infants mouth rather than allowing the infant to 'lap' or sip the milk (Lang 1994b; Thorley 2004). Other potential risks include physiological instability (bradycardia, apnea, low oxygen saturation) (Freer 1999), and choking and poor weight gain (Kuehl 1997), which can result in extended hospitalisation and additional cost of care. Lastly, undesirable outcomes have been reported: nursing workload may be increased as a result of extra nursing time needed to cup feed, and term infants may refuse the breast, becoming addicted to the cup if use is prolonged and they are not given the opportunity to breastfeed (Lang 1994b; Thorley 1997; Thorley 2004). If infants require treatment as a result of an adverse event or if term infants reject the breast, this may result in increased stress and anxiety to the parents and family.
Before the introduction of cup feeding into neonatal nurseries, this practice must be evaluated for efficacy and safety in terms of clinical outcomes, human resource use, cost and time.
Objectives
To determine the effects of cup feeding versus other forms of supplemental enteral feeding on weight gain and achievement of successful breastfeeding in newborn infants that are unable to fully breastfeed.
To determine if outcomes differ by:
Population:
- born preterm (less than 37 weeks gestation) versus term (greater than or equal to 37 weeks gestation)
- born with oral-facial abnormalities such as a cleft lip and/or cleft palate versus no oral-facial abnormalities
Criteria for considering studies for this review
Types of studies
Randomised and some types of non randomised (i.e. quasi-randomised) controlled trials in which newborn infants who are unable to fully breastfeed were allocated to a policy of cup feeding versus other forms of supplemental enteral feeding. Crossover studies were to be excluded.
Types of participants
Newborn infants up to 44 weeks postmenstrual age or 28 days postnatal age that are unable to fully breastfeed.
Types of interventions
Oral feeding of either expressed breast milk or a combination of expressed breast milk and artificial formula via a cup (or of a similar design so that the infant 'laps' the milk) versus other forms of supplemental enteral feeding (such as tube feeds and bottle feeds).
Types of outcome measures
Primary:
- Weight gain (g/kg/day)
- Time to full breastfeeding with acceptable weight gain (15 - 30 grams/day)
- Proportion not breastfeeding at hospital discharge and at three and six months of age
- Proportion not fully breastfeeding at hospital discharge and at three and six months of age
Secondary:
- Average time per feed (minutes)
- Number of reported choking events per infant or per cup feed over the duration of cup feeding period, depending on how described in individual studies
- Number of reported aspiration events per infant or per cup feed over the duration of cup feeding period, depending on how described in individual studies
- Number of reported infection events per infant or per cup feed over the duration of cup feeding period, depending on how described in individual studies
- Number of reported physiological instability events i.e. bradycardia, apnea, low oxygen saturations per infant or per cup feed over the duration of the cup feeding period, depending on how described in individual studies
- Postnatal age at discharge (days)
- Length of hospital stay (days)
- Cost
- Parental satisfaction (however assessed in individual studies)
- Parental anxiety (however assessed in individual studies)
- Neurodevelopmental outcomes at 18 and 24 months of age (e.g. Bayley's; Griffiths)
- Death prior to discharge
- Death by 28 days of age
- Death by 12 months of age
Full breastfeeding is defined in this review as only having breast feeds and no other supplemental feeds.
Search strategy for identification of studies
The standard search strategy for the Cochrane Neonatal Review Group was used. See: Neonatal Review Group search strategy. This included searches of the following electronic databases:
- The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2006);
- CINAHL 1987 to April 2006
- MEDLINE 1966 to April 2006.
Searches of the electronic databases will be based on the following search terms:
The MeSH terms 'Infant, Newborn' OR 'Nurseries, Hospital' OR 'Intensive Care Units, Neonatal'
AND
The textword "cup"
We also searched previous reviews including cross-references, abstracts, conference and symposia proceedings, expert informants, and journal hand searching in the English language. No other language restrictions applied.
The title and abstract of each retrieved study was examined to assess eligibility. If there was uncertainty, the full paper was examined.
Methods of the review
The standard methods of the Cochrane Collaboration (Alderson 2004) and its Neonatal Review Group were used to assess the methodological quality of the trials. At least two of the review authors worked independently to search for and assess trials for inclusion and methodological quality. Studies were assessed using the following key criteria: allocation concealment (blinding of randomisation), blinding of intervention, completeness of follow up and blinding of outcome measurement. We assigned a rating of 'Yes', 'No' or 'Can't tell' for each. The reviewers extracted data independently. Differences were resolved by discussion. Attempts were made to contact study investigators for additional information or data as required. One author was contacted for additional information and supplied further data as requested (Collins 2004).
Data analysis:
All data were analysed according to the treatment group allocated.
For individual trials, for continuous variables such as weight gain, mean differences, and 95% confidence intervals were reported. For categorical outcomes such as mortality, the relative risks (RR) and 95% confidence intervals were reported.
For pooled results, continuous variables, weighted mean differences (WMD) and 95% confidence intervals were reported. For categorical outcomes, the relative risks (RR) and 95% confidence intervals were reported. Each treatment effect was tested for heterogeneity using the I2 test. The fixed effects model was used for meta-analysis. Sources of statistical heterogeneity were examined.
Description of studies
Fifteen studies were identified as potentially eligible for inclusion in this review. Eight studies were excluded because they were neither randomised controlled trials nor non-randomised controlled trials that used quasi-randomised group allocation (Brown 1999; Davis 1948; Dowling 2001; Dowling 2002; Fredeen 1948; Freer 1999; Gupta 1999; Malhotra 1999; Marinelli 2001). One study was excluded since the study randomised exclusively formula feeding infants to either bottle or cup (did not meet our definition for study participants), and an exclusively breastfeeding group of infants were used as a comparison group (Howard 1999). One further study was excluded since this study did not meet the inclusion criteria for this review since participants were not infants that were unable to fully breastfeed (Howard 2003) . Reasons for exclusion for excluded studies can be seen in the table 'Characteristics of Excluded Studies'.
The remaining four studies were included in this review (Collins 2004; Gilks 2004; Mosley 2001; Rocha 2002). Full details on included studies can be seen in the table 'Characteristics of Included Studies'. Studies enrolled preterm infants with mean gestational ages at birth from 29 to 35 weeks, and all studies compared cup versus bottle feeds as a supplement to breastfeeding when transitioning from full nasogastric feeds to full breast feeds.
Collins 2004
The study of Collins 2004 included preterm infants (mean gestational ages 29.3 and 30.0, mean birth weights 1334 g and 1446 g for the respective study groups; cup and bottle) of mothers who had indicated that they intended to breastfeed. Infants born less than 34 weeks were eligible for inclusion in the study and were randomised to either supplemental feeds via a cup or bottle. This study also randomised infants to either dummy (pacifier) or no dummy within each of the two study groups. The initiation of the allocated supplemental feeds was determined by the attending nurse/midwife or neonatologist and occurred when the mother was unavailable to breastfeed or when additional oral feeds of milk were required after a breastfeed.
The authors report that compliance to the allocated intervention, in particular to cup feeding, was poor and, therefore, reduced the power to identify a real treatment effect. The tertiary hospital that had previously been using cup feeding was more compliant with the intervention than the other tertiary recruiting hospital (where cup feeding was introduced for the study) or the participating fifty-four peripheral hospitals (where the use of cup feeding was uncommon).
The main outcome measures were partial or fully breastfeeding or no breastfeeding on discharge home. Secondary outcomes included length of hospital stay and prevalence of breastfeeding at three and six months post discharge.
Gilks 2004
Participants in the study of Gilks 2004 study were preterm infants (median gestational ages 31 weeks and 32 weeks, median birth weights 1560 g and 1750 g for the respective study groups; cup and bottle) of mothers who had indicated an intention to breastfeed. For infants to be eligible for the study, they needed to be born between 30 and 35 + 5 weeks gestation. Once enrolled into the study, the infant was randomised to receive supplemental feeds either by cup or bottle in addition to nasogastric tube feeds and breastfeeds. It is unclear who determined when supplemental feeds by cup or bottle were begun, the criteria for assessing which feed would be given by cup or bottle, and how often the infants received the allocated treatments as opposed to receiving feeds by nasogastric tube or the breast. Cup feeding had been introduced into the hospital six months prior to the initiation of the study, and staff had received information sheets and attended a teaching programme during the introduction phase.
The main outcome measure was partial or exclusively breastfeeding rates at discharge. Secondary outcomes included breastfeeding rates at term, at six weeks post term and post conceptional age at which the nasogastric tube was withdrawn.
Mosley 2001
The study by Mosley 2001 was a pilot study to establish the feasibility of conducting a randomised controlled trial of supplemental feeding methods. Recruitment of infants took place over a three month period, resulting in the recruitment of 16 preterm infants, only 14 infants of which had data presented. The study compared two methods of supplementary feeding (bottle versus cup) for preterm infants of mothers who indicated a desire to breastfeed. The initiation of oral feeding or supplemental feeding was at the discretion of the physician or advanced neonatal nurse practitioner, which was the normal practice in the study hospital.
The main outcome measure was breastfeeding rates at discharge. Other outcomes were examined retrospectively, following assessment of the data set. These included the use of a pacifier (dummy), influence of assisted delivery on breastfeeding, previous experience of breastfeeding, influence of prematurity on breastfeeding rates, influence of support to breastfeed and the impact of delayed breastfeeding initiation.
Rocha 2002
The study by Rocha 2002 was a stratified randomised control trial; infants were randomised to either cup or bottle. Infants were between 32 - 36 weeks gestation weighing < 1700 grams. Stratification encompassed three groups 500g - 999g; 1000g - 1499g, 1500g - 1699g. All infants were fed by nasogastric tube until they weighed 1600 grams, at which time breastfeeding was encouraged. If supplemental feeds were required, they were offered feeding by the assigned method. Prior to the study, there was education of all staff about cup feeding technique. After a week of oral feeds, monitoring was begun by an investigator who examined oxygen saturation before during and after the feed. Weight gain and feed interval were also recorded. Follow-up was conducted until the third month or when the infant weaned.
The main outcome measure was to examine the impact of cup and bottle feeding on subsequent breastfeeding of preterm infants. Secondary outcomes examined the difference between oxygen saturation levels in bottle, cup and breast fed infants.
Methodological quality of included studies
All the included studies were randomised and allocation concealment was adequate; however, because of the nature of the experimental and control interventions, blinding of the participants and their care takers could not be achieved. As far as can be ascertained, all outcome measures until hospital discharge were complete; however, follow up rates following hospital discharge decreased over time.
Rocha 2002
Allocation concealment (blinding of randomisation): Unclear
Blinding of intervention: No
Completeness of follow up: Yes at hospital discharge; no thereafter
Blinding of outcome measurement: No
Collins 2004
Allocation concealment (blinding of randomisation): Yes (assignments concealed in sequentially numbered opaque envelopes held in an independent ward to the nursery within each hospital).
Blinding of intervention: No
Completeness of follow up: Yes at hospital discharge; no thereafter
Blinding of outcome measurement: No
Gilks 2004
Allocation concealment (blinding of randomisation): Yes (concealed cards in envelopes)
Blinding of intervention: No
Completeness of follow up: Yes at hospital discharge; no thereafter
Blinding of outcome measurement: No
Mosley 2001
Allocation concealment (blinding of randomisation): Yes (sealed numbered opaque envelope)
Blinding of intervention: No
Completeness of follow up: Yes at hospital discharge; no thereafter
Blinding of outcome measurement: No
Results
The results of four trials are included in this review (Collins 2004; Gilks 2004; Mosley 2001; Rocha 2002). All data were analysed according to the treatment group allocated.
SUPPLEMENTAL FEED USING CUP VERSUS BOTTLE (Comparison 01)
Primary Outcome Measures
- Weight gain (Outcome 01.01)
Only one study (Rocha 2002) reported results for weight gain (in the first week) and there was no significant difference between groups - the mean difference was -0.60 g/kg/day [95% CI -3.21, 2.01]. Collins 2004; Gilks 2004 and Mosley 2001 did not report this outcome.
- Proportion not breastfeeding at hospital discharge (Outcome 01.02)
Three studies reported this outcome:
Collins 2004 reported RR of 0.80 [95% CI 0.56, 1.14];
Gilks 2004 reported RR of 0.87 [95% CI 0.52, 1.45]; and
Rocha 2002 reported RR of 0.88 [95% CI 0.36, 2.19].
Mosley 2001 did not report this outcome.
The meta-analysis (I2 0%) of the three trials reporting this outcome showed typical RR of 0.82 [95% CI 0.62, 1.09]. The analysis demonstrates no significant reduction in the proportion of infants not breastfeeding at hospital discharge.
- Proportion not breastfeeding at three months of age (Outcome 01.03)
Two studies reported this outcome:
Collins 2004 reported RR of 0.90 [95%CI 0.75, 1.09];
Rocha 2002 reported RR of 0.83 [95%CI 0.65, 1.05].
Gilks 2004 and Mosley 2001 did not report this outcome.
The meta-analysis (I2 0%) of the two trials reporting this outcome showed a typical RR of 0.88 [95% CI 0.76, 1.03]. The results from Collins 2004 included in this meta-analysis is an evaluation of infants seen at follow-up, not all infants who were randomised. The analysis demonstrates no significant reduction in the proportion of infants not breastfeeding at three months of age.
- Proportion not breastfeeding at six months of age (Outcome 01.04)
Only one study (Collins 2004) reported results for this outcome and there was no significant difference between groups - RR 0.91 [95%CI 0.78, 1.05]. The results from Collins 2004 is an evaluation of infants seen at follow-up, not all infants who were randomised.
Gilks 2004; Mosley 2001 and Rocha 2002 did not report this outcome.
- Proportion not fully breastfeeding at hospital discharge (Outcome 01.05)
Three studies reported this outcome:
Collins 2004 reported RR of 0.74 [95% CI 0.58, 0.95];
Gilks 2004 reported RR of 0.74 [95% CI 0.53, 1.03];
Mosley 2001 reported RR of 1.33 [95% CI 0.26, 6.94].
Rocha 2002 did not report this outcome.
The meta-analysis (I2 0%) of the three trials reporting this outcome showed a typical RR of 0.75 [95% CI 0.61, 0.92] with a NNT of 7.3 [95% CI 4.6, 22.3]. The analysis demonstrates that the group of infants who were cup fed had a reduction in the proportion of infants not fully breastfeeding at hospital discharge (i.e. an increase in the proportion of infants exclusively breastfeeding at discharge).
- Proportion not fully breastfeeding at three months of age (Outcome 01.06)
Only one study (Collins 2004) reported results for this outcome and there was no significant difference between groups - RR was 1.18 [95% CI 0.88, 1.58]. The results from Collins 2004 is an evaluation of infants seen at follow-up, not all infants who were randomised.
Gilks 2004; Mosley 2001; Rocha 2002 did not report this outcome
- Proportion not fully breastfeeding at six months of age (Outcome 01.07)
Only one study (Collins 2004) reported results for this outcome and there was no significant difference between groups - RR was 1.31 [95% CI 0.89, 1.92]. The results from Collins 2004 is an evaluation of infants seen at follow-up, not all infants who were randomised.
Gilks 2004; Mosley 2001; Rocha 2002 did not report this outcome.
Secondary Outcomes
- Average time per feed (minutes) (Outcome 01.08)
Only one study (Rocha 2002) reported results for average time per feed and there was no significant difference between groups - the mean difference was -1.60 minutes [95% CI -3.69, 0.49].
Collins 2004; Gilks 2004 and Mosley 2001 did not report this outcome.
- Number of reported physiological instability events
Rocha 2002 reported episodes of oxygen desaturation. The outcome 'lowest oxygen saturations (%) during feeding' was reported. Mean (SD) oxygen saturation in the cup feeding group was 90.8 (4.8)%, range 75 - 99% and mean (SD) oxygen saturation in the bottle feeding group was 87.7 (7.6%, range 68 - 97%). The difference between means was not statistically significant. They also reported desaturation episodes of less than 85 and 90 percent. However, it is not clear whether the data reported are the proportion of time spent less than the cut-off oxygen saturation (85 or 90 percent) or the proportion of infants who had an oxygen saturation less than the cut-off at some stage.
Collins 2004; Gilks 2004 and Mosley 20012001 did report this outcome.
- Length of hospital stay (days) (Outcome 01.09)
Only one study (Collins 2004) assessed length of stay. The original report included only median days and interquartile range (IQR). In the cup feeding group, the median (IQR) length of stay was 59 (37 - 85) days and in the bottle feeding group it was 48 (33 - 65) days. On request, the authors provided these data as means and standard deviations. This data demonstrates that there was a significantly increased length of hospital stay in the cup fed infants. The mean difference between groups was 10.1 days [95% CI 3.9, 16.3].
Gilks 2004; Mosley 2001 and Rocha 2002 did not report this outcome.
Unreported outcomes
None of the following outcomes were reported in any of the included studies for Primary Outcome: Time to full breastfeeding with acceptable weight gain.
None of the following outcomes were reported in any of the included studies for Secondary Outcomes: Number of reported choking events; number of reported aspiration events; number of reported infection events; postnatal age at discharge; cost; parental satisfaction; parental anxiety; neurodevelopmental outcomes at 18 and 24 months of age; death prior to discharge; death by 28 days of age; death by 12 months of age.
Other outcomes reported
Collins 2004 reported that non-compliance to the experimental intervention was high, with 56% (85/151) of cup feeding infants having a bottle introduced. Of the 44% of mothers who decided to introduce a bottle, 39% reported that they did not like, or had problems with, cup feeding. These problems included the infant not managing cup feeds, spilling a lot, not being satisfied, or taking too long to feed. Twelve percent of mothers reported that staff refused to cup feed their infant.
Collins 2004 reported no adverse events.
Rocha 2002 reported no cases of aspiration or apnea. Rocha 2002 report that there was no difference in mean oxygen saturations between cup fed or bottle fed infants during feeds.
Discussion
Preterm infants are at increased risk of not achieving successful breastfeeding (Dowling 2002). Therefore, all studies included in this review studied pertinent populations of preterm infants who were moving from full nasogastric feeds to full breastfeeds.
The results of this review demonstrate marginal improvements in only one of six breastfeeding outcomes. Pooled results from three studies that assessed whether infants were exclusively breast fed or not at the time of hospital discharge showed an advantage for cup fed infants. However, this result is dominated by one study (Collins 2004), which also reported that non-compliance to the experimental intervention was high, with 56% (85/151) of cup feeding infants having a bottle introduced. Of the 44% of mothers who decided to introduce a bottle, 39% reported that they did not like, or had problems with cup feeding, including the infant not managing cup feeds, spilling a lot, not being satisfied, or taking too long to feed. Twelve percent of mothers reported that staff refused to cup feed their infant. All of the other breastfeeding outcomes (including the more clinically relevant ones at three and six months) did not show any difference between the two groups.
While infants who were cup fed demonstrated marginal improvement in breastfeeding (as described above), they also had a statistically significant longer length of stay in hospital. Once again, this result is dominated by the one study that reported this outcome (Collins 2004). On average, the group of cup fed infants spent 10 more days in hospital when compared with bottle supplemented babies. However, the attainment of full suck feeding may be delayed in those infants who are making the transition with cup feeding because they cannot go home cup feeding (as was the case in the study by Collins 2004). In an environment where hospitals are attempting to reduce length of stay, a finding such as this will significantly affect financial and bed management resources. The cost implications related to length of stay need to be considered against a short term gain in exclusive breastfeeding at discharge. Because the interventions used in the included studies (especially those of the single dominant study by Collins 2004) were unblinded, these results may be open to other interpretations. Overall, results show that while the numbers of infants exclusively breast fed at discharge are higher in the cup feeding groups, this is not sustained and no differences in breastfeeding rates were found between the cup and bottle supplemented infants at three and six months.
Reviewers' conclusions
Implications for practice
Cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no benefit in maintaining breastfeeding beyond hospital discharge and may carry the unacceptable consequence of a longer stay in hospital.
Implications for research
While the limitations of the studies included in the review might lead the review authors to conclude that further large high quality randomised control trials should be undertaken, the issue of high rates of non-compliance with the intervention of cup feeding by both practitioners and parents as reported in the majority of previous studies may make this a futile undertaking. Interventions aimed at maintaining breastfeeding longer term (e.g. early and regular skin to skin contact, rooming in, non-separation of mother and baby as possible, non-introduction of supplemental feeds unless medically indicated, antenatal breastfeeding education as documented in WHO 1998) should be given due consideration before further trials of cup feeding are undertaken.
Acknowledgements
Thanks to Carmel Collins for further data supplied for this review.
Potential conflict of interest
None
Characteristics of included
studies
| Study | Methods | Participants | Interventions | Outcomes | Notes | Allocation concealment |
| Collins 2004 | Randomised controlled trial.
Allocation concealment (blinding of randomisation): Yes
Blinding of intervention: No
Completeness of follow up: Yes
Blinding of outcome measurement: No | 319 Preterm infants (Cup feeding group n=161; bottle feeding group n=158) (mean gestational ages 29.3 and 30.0 weeks); Conducted in Australia; Involved 2 tertiary hospitals and 54 peripheral hospitals (this number of peripheral hospitals were involved as they were the receiving hospitals for the babies from the tertiary hospitals).
Eligibility criteria: preterm infants less than 34 weeks gestational age whose mothers wanted to breastfeed.
| Randomised to supplemental feeds via cup or bottle | Not breastfeeding at hospital discharge: number assessed - cup feeding group N=151; bottle feeding group N=152.
Not breastfeeding at 3 months: number assessed - cup feeding group N=144; bottle feeding group N=139
Not breastfeeding at 6 months: number assessed - cup feeding group N=142; bottle feeding group N=139
Not fully breastfeeding at hospital discharge: number assessed - cup feeding group N=151; bottle feeding group N=152
Not fully breastfeeding at 3 months: number assessed - cup feeding group N=144; bottle feeding group N=139
Not fully breastfeeding at 6 months: number assessed - cup feeding group N=142; bottle feeding group N=139
Length of hospital stay: number assessed - cup feeding group N=149; bottle feeding group N=152 | Results are an evaluation of infants followed at 3 & 6 months and not all infants randomised | A |
| Gilks 2004 | Randomised Controlled Trial
Allocation concealment (blinding of randomisation): Yes (assignments concealed in sequentially numbered opaque envelopes held in an independent ward to the nursery within each hospital).
Blinding of intervention: No
Completeness of follow up: Yes at hospital discharge; no thereafter
Blinding of outcome measurement: No
| 54 Preterm infants (Cup feeding group n=27; bottle feeding group n=27) (mean gestational ages 31.0 and 32.0 weeks); Conducted in the UK; single centre trial
Eligibility Criteria: preterm infants who were less than 35 weeks completed gestation and more than 30 weeks gestation whose mothers intended to breastfeed. | Randomised to supplemental feeds via cup or bottle | Not breastfeeding at hospital discharge: number assessed - cup feeding group N=27; bottle feeding group N=27
Not fully breastfeeding at hospital discharge: number assessed - cup feeding group N=27; bottle feeding group N=27.
This study also looked at the following outcomes: breast feeding rates at term, at six weeks post term and post conceptional age. | | A |
| Mosley 2001 | Randomised Controlled Trial
Allocation concealment (blinding of randomisation): Yes (concealed cards in envelopes)
Blinding of intervention: No
Completeness of follow up: Yes at hospital discharge; no thereafter
Blinding of outcome measurement: No
| 16 Preterm infants (Cup feeding group n=8; bottle feeding group n=8) (mean gestational age of 35.2 to 35.5 weeks); Conducted in the UK; single centre trial
Eligibility Criteria: preterm infants who were between 30 and 37 weeks gestation, admitted to the special care nursery, whose mothers intended to breastfeed. | Randomised to supplemental feeds via cup or bottle | Not fully breastfeeding at hospital discharge: number assessed - cup feeding group N=6; bottle feeding group N=8. | | A |
| Rocha 2002 | Randomised Controlled Trial
Allocation concealment (blinding of randomisation): Yes (sealed numbered opaque envelope)
Blinding of intervention: No
Completeness of follow up: Yes at hospital discharge; no thereafter
Blinding of outcome measurement: No | 83 Preterm infants (Cup feeding group n=46; bottle feeding group n=37) (mean gestational age of 32.5 to 32.7 weeks); Conducted in Brazil; single centre trial
Eligibility Criteria: preterm infants who were born between 32 and 36 weeks gestation, and weighting less than 1700 g, admitted to the intensive care nursery, whose mothers intended to breastfeed. | Randomised to supplemental feeds via cup or bottle | Not breastfeeding at hospital discharge: number assessed - cup feeding group N=44; bottle feeding group N=34.
Not breastfeeding at 3 months: number assessed - cup feeding group N=44; bottle feeding group N=34.
Weight gain: number assessed - cup feeding group N=44; bottle feeding group N=34.
Average time per feed: number assessed - cup feeding group N=44; bottle feeding group N=34.
Other outcomes assessed: differences between oxygen saturation levels in bottle, cup and breast-fed infants. | | B |
Characteristics of excluded studies
| Study | Reason for exclusion |
| Brown 1999 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A retrospective chart review. |
| Davis 1948 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. |
| Dowling 2001 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. Descriptive literature on nipple confusion and alternative feeding methods. |
| Dowling 2002 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A non-experimental convenience sample. |
| Fredeen 1948 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A descriptive report on experience with cup feeding of newborn infants |
| Freer 1999 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A convenience sample of newborn infants exposed to breast and cup feeding |
| Gupta 1999 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A retrospective chart review. |
| Howard 1999 | A randomised controlled trial of formula feeding infants only. Infants randomised to either receive feeds via cup or bottle. A group of exclusively breast feeding infants were used as a comparison group. |
| Howard 2003 | This study did not meet the inclusion criteria for this review as participants were not infants that were unable to fully breastfeed. Participants were infant-mother dyads. Unborn infants were randomised on maternal admission to either early or late pacifier use or cup or bottle supplemental feeding if required. A large proportion of the babies randomised were part of the study because of maternal choice to offer supplemental feeds not because the infants were unable to fully breastfeed. |
| Malhotra 1999 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. Crossover design was employed. |
| Marinelli 2001 | Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. Crossover design was employed. |
References to studies
References to included studies
Collins 2004 {published data only}Collins CT, Ryan P, Crowther CA, McPhee AJ, Paterson S, Hiller JE. Effect of bottles, cups and dummies on breast feeding in preterm infants: a randomised controlled trial. BMJ Online First bmj.com 18 June 2004;BMJ, doi:10.1136/bmj.38131.675914.55.
Gilks 2004 {published data only}
Gilks J, Watkinson M. Improving breast feeding in preterm babies: Cup feeding versus bottle feeding. Journal of Neonatal Nursing 2004;10:118-20.
Mosley 2001 {published data only}
Mosley C, Whittle C, Hicks C. A pilot study to assess the viability of a randomised controlled trial of methods of supplementary feeding of breast-fed pre-term babies. Midwifery 2001;17:150-7.
Rocha 2002 {published data only}
Rocha NM, Martinez FE, Jorge SM. Cup or bottle for preterm infants: effects on oxygen saturation, weight gain, and breastfeeding. Journal of Human Lactation 2002;18:132-8.
References to excluded studies
Brown 1999 {published data only}Brown SJ, Alexander J, Thomas P. Feeding outcome in breast-fed term babies supplemented by cup or bottle. Midwifery 1999;15:92-6.
Davis 1948 {published data only}
Davis HV, Sears RR, Miller HC, Brodbeck AJ. Effects of cup, bottle and breast feeding on oral activities of newborn infants. Pediatrics 1948;2:549-58.
Dowling 2001 {published data only}
Dowling DA, Thanattherakul W. Nipple confusion, alternative methods, and breast-feeding supplementation: State of the science. Newborn and Infant Nursing Reviews 2001;1:217-23.
Dowling 2002 {published data only}
Dowling DA, Meier PP, DiFiore JM, Blatz M, Martin RJ. Cup-feeding for preterm infants: Mechanics and safety. Journal of Human Lactation 2002;18:13-20.
Fredeen 1948 {published data only}
Fredeen RC. Cup feeding of newborn infants. Pediatrics 1948;2:544-8.
Freer 1999 {published data only}
Freer Y. A comparison of breast and cup feeding in preterm infants: effects on physiological parameters. Journal of Neonatal Nursing 1999;5:16-21.
Gupta 1999 {published data only}
Gupta A, Khanna K, Chattree S. Cup feeding: an alternative to bottle feeding in a neonatal intensive care unit. Journal of Tropical Pediatrics 1999;45:108-110.
Howard 1999 {published data only}
Howard CR, de Blieck EA, ten Hoopen CB, Howard FM, Lanphear BP, Lawrence RA. Pyhsiologic stability of newborns during cup and bottle feeding. Pediatrics 1999;104:1204-7.
Howard 2003 {published data only}
Howard CR, Howard FM, Lanphear BP, Ederly S, de Blieck EA, Oakes D, Lawrence RA. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003;111:511-18.
Malhotra 1999 {published data only}
Malhotra N, Vishwambaran L, Sundaram KR, Narayanan I. A controlled trial of alternative methods of oral feeding in neonates. Early Human Development 1999;54:29-38.
Marinelli 2001 {published data only}
Marinelli KA, Burke GS, Dodd VL. A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed. Journal of Perinatology 2001;21:350-5.
* indicates the primary reference for the study
Other references
Additional references
Alderson 2004Alderson P, Green S, Higgins JPT, editors. Cochrane Reviewers' Handbook 4.2.2 [updated March 2004]. The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
Cousins 1999
Cousins R. Breast feeding the preterm infant in the special care baby unit: The first feed. Journal of Neonatal Nursing 1999;5:10-14.
Foote 1944
Foote H.S. Silver in the Service of Medicine. Bulletin of the Medical Library Association 1944;32:369-75.
Higgins 2002
Higgins J, Thompson S. Quantifying heterogeneity in meta-analysis. Statistics Medicine 2002;21:1539-58.
Kuehl 1997
Kuehl J. Cup feeding the newborn: what you should know. Journal of Perinatal & Neonatal Nursing 1997;11:56-60.
Lang 1994a
Lang S. Cup-feeding: an alternative method. Midwives Chronicle & Nursing Notes 1994;107:171-6.
Lang 1994b
Lang S, Lawrence CJ, Orme RL. Cup feeding: an alternative method of infant feeding. Archives of Disease in Childhood 1994;71:365-9.
NANN 2004
National Association of Neonatal Nurses (NANN). Position Statement #3017 Cup and finger feeding of breast milk. www.nann.org/files/public/ (accessed 12 August 2004).
Palmer 1993
Palmer M. Identification and management of the transitional suck pattern in premature infants. Journal of Perinatal & Neonatal Nursing 1993;7:66-75.
Thorley 1997
Thorley V. Cup feeding: problems created by incorrect use. Journal of Human Lactation 1997;13:54-5.
Thorley 2004
Thorley V. Cup feeding. www.breastfeeding.asn.au/bfinfo/cupfeeding (accessed 12 August 2004).
Vallenas 1998
Vallenas C, Savage F. Evidence for the Ten Steps to Successful Breastfeeding. Division of Child Health and Development, World Health Organisation 1998.
WHO 1998
Anonymous. Evidence for the Ten Steps to successful breastfeeding. Geneva: World Health Organisation, 1998.
Comparisons and data
| Comparison or outcome |
Studies |
Participants |
Statistical method |
Effect size |
| 01 Supplemental feed using cup versus bottle |
| 01 Weight gain (g/kg/day) |
|
|
WMD (fixed), 95% CI |
No total |
| 02 Not breastfeeding at hospital discharge |
3 |
435 |
RR (fixed), 95% CI |
0.82 [0.62, 1.09] |
| 03 Not breastfeeding at three months |
2 |
361 |
RR (fixed), 95% CI |
0.88 [0.76, 1.03] |
| 04 Not breastfeeding at six months |
|
|
RR (fixed), 95% CI |
No total |
| 05 Not fully breastfeeding at hospital discharge |
3 |
371 |
RR (fixed), 95% CI |
0.75 [0.61, 0.92] |
| 06 Not fully breastfeeding at three months |
|
|
RR (fixed), 95% CI |
No total |
| 07 Not fully breastfeeding at six months |
|
|
RR (fixed), 95% CI |
No total |
| 08 Average time per feed (minutes) |
|
|
WMD (fixed), 95% CI |
No total |
| 09 Length of stay (days) |
|
|
WMD (fixed), 95% CI |
No total |
01 Supplemental feed using cup versus bottle
01.01 Weight gain (g/kg/day)
01.02 Not breastfeeding at hospital discharge
01.03 Not breastfeeding at three months
01.04 Not breastfeeding at six months
01.05 Not fully breastfeeding at hospital discharge
01.06 Not fully breastfeeding at three months
01.07 Not fully breastfeeding at six months
01.08 Average time per feed (minutes)
01.09 Length of stay (days)
Contact details for co-reviewers
Dr Mark William Davies, MB BS FRACP DCH
Staff Consultant Neonatologist
Dept of Neonatology
Royal Brisbane and Women's Hospital
Butterfield St
Herston
Brisbane
Queensland AUSTRALIA
4029
Telephone 1: +61 7 3636 2245
Telephone 2: +61 (0)408 159 138
Facsimile: +61 7 3636 5259
E-mail: Mark_Davies@health.qld.gov.au
Secondary address:
PO Box 5285
West End
Brisbane
Queensland AUSTRALIA
4101
Telephone: +61 408 159 138
Karen New
Neonatal Nurse
Grantley Stable Neonatal Unit
Royal Brisbane & Women's Hospital
Butterfield Street
Herston
Brisbane
Queensland AUSTRALIA
4029
Telephone 1: +61 7 3636 8918
E-mail: karennew@optusnet.com.au
| This review is published as a Cochrane review in The Cochrane Library,
Issue 2, 2007 (see http://www.thecochranelibrary.com for information).
Cochrane reviews are regularly updated as new evidence emerges and in response
to feedback. The Cochrane Library should be consulted for the most recent
version of the review. |
