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Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed

  1. Anndrea Flint1,*,
  2. Karen New2,
  3. Mark W Davies3

Editorial Group: Cochrane Neonatal Group

Published Online: 18 APR 2007

Assessed as up-to-date: 10 DEC 2006

DOI: 10.1002/14651858.CD005092.pub2


How to Cite

Flint A, New K, Davies MW. Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005092. DOI: 10.1002/14651858.CD005092.pub2.

Author Information

  1. 1

    Royal Women's Hospital, Centre for Clinical Nursing, Level 2, Brisbane, Queensland, Australia

  2. 2

    Royal Brisbane & Women's Hospital, Grantley Stable Neonatal Unit, Brisbane, Queensland, Australia

  3. 3

    Royal Brisbane and Women's Hospital, Dept of Neonatology, Brisbane, Queensland, Australia

*Anndrea Flint, Centre for Clinical Nursing, Level 2, Royal Women's Hospital, Butterfield St, Herston, Brisbane, Queensland, 4029, Australia. Anndrea.Flint@health.qld.gov.au.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 18 APR 2007

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Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

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

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

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

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

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 methods 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.

 

Data collection and analysis

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.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded 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.

 

Risk of bias in 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

 

Effects of interventions

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

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

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.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

 

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

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Thanks to Carmel Collins for further data supplied for this review.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
Download statistical data

 
Comparison 1. Supplemental feed using cup versus bottle

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Weight gain (g/kg/day)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 2 Not breastfeeding at hospital discharge3435Risk Ratio (M-H, Fixed, 95% CI)0.82 [0.62, 1.09]

 3 Not breastfeeding at three months2361Risk Ratio (M-H, Fixed, 95% CI)0.88 [0.76, 1.03]

 4 Not breastfeeding at six months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 5 Not fully breastfeeding at hospital discharge3371Risk Ratio (M-H, Fixed, 95% CI)0.75 [0.61, 0.92]

 6 Not fully breastfeeding at three months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 7 Not fully breastfeeding at six months1Risk Ratio (M-H, Fixed, 95% CI)Totals not selected

 8 Average time per feed (minutes)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 9 Length of stay (days)1Mean Difference (IV, Fixed, 95% CI)Totals not selected

 

Feedback

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Rajiv Bahl Feedback October/07 and Review Author Response

 

Summary

Date of Submission: 19-Oct-2007

Name: Rajiv Bahl
Email Address: bahlr@who.int
Personal Description: Occupation Medical Officer WHO

Feedback:
Conclusions of the Cochrane review on cup feeding for newborns unable to fully breastfeed are not supported by the findings 

This recently published systematic Cochrane review based on four relatively small studies makes a general conclusion "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 longer stay in hospital" (1). We feel that the findings of the review do not support this conclusion. Justification for this feeling is provided below. 

The risk of infection should be an important consideration in the choice of feeding method. One of the major potential advantages of cup feeding over bottle feeding is in reducing the risk of infection, particularly in developing countries. All studies (2-4) included in the review except a small study from Brazil (5) are from developed countries and none has reported on the risk of infection. Although infection was included as an outcome in the protocol for this Cochrane review, the lack of data on this important outcome is not discussed. 

On the outcomes on which data is presented, the number of participants in all studies is small. The total number of infants included in the meta-analysis on any breastfeeding is about 400. For comparison, in another study in term infants, Howard et al estimated that at least 700 infants would be needed to detect a  10% difference in breastfeeding cessation with 90% power and 5% significance level (6). The lack of significant effect on many outcomes could therefore have been just because of lack of statistical power. We think that the "lack of evidence of effect" cannot be taken as the "evidence of lack of effect".

The authors base their conclusions on their findings related to the lack of significant benefit of cup feeding beyond hospital discharge. However, all the studies included in the review were hospital studies with the primary outcomes limited to the time of hospital discharge. Only two studies reported effect at 3 months and one study at 6 months after discharge, as a secondary outcome. It is clear that even in these studies, sample sizes were not calculated, follow up was not complete and the quality of data cannot therefore be considered to be same as that for the primary outcome. Considering only the primary outcomes, there was a 18% non-significant benefit in any breastfeeding and 25% significant benefit in full breastfeeding rates associated with cup feeding. While these findings cannot be considered conclusive in favour of cup feeding, they are certainly indicative of a benefit. In any case, this is clearly not evidence of lack of benefit.  

One of the possible reasons for only a modest benefit of cup feeding on subsequent breastfeeding could be the lack of compliance with the allocated intervention. Although the authors of the Cochrane review have recognized this, we think that they have not discussed it appropriately. For example, the researchers in the largest included study (2) considered the lack of compliance as the main limitation of their study which could have lead to an underestimate of the effect. Indeed, the researchers state in their paper that "Compliance analysis showed a significant increase in the prevalence of any breastfeeding with cup feeding (Odds ratio 21.09, 95% CI 2.62 to 169.75, P=0.004) with no significant difference in length of hospital stay (hazard ratio 0.82, 95% CI 0.58 to 1.17, P=0.27). Such compliance analysis needs to be interpreted with caution and highlight the need for further research." Further, they state that "Compliance differed between recruiting hospitals, the hospital with the better compliance has used cup feeding before, in the other it was introduced for the trial. Most peripheral hospitals had not used cup feeding before. Some staff had strong feelings against cup feeding?". The authors of the Cochrane review have not considered the lack of previous experience of staff with a new feeding method as one of the potential causes of lack of compliance with cup feeding. 

The finding related to length of hospital stay (about a 15% increase in the duration of stay) needs to be interpreted with caution as it comes from a single study. Further, a possible reason for this could again be the lack of confidence of the treating physicians about the ability of the mother to feed the infant related to less experience in having used cup feeding relative to bottle feeding. 

The conclusions and the plain language summary seem to indicate that the findings of this review are generalizable to all infants, in all settings. However, the studies reviewed included only those preterm infants who are not able to fully breastfeed. In this regard, it is important to consider the findings of an excluded study in term, healthy, breastfed infants (Howard et al), which show that for infants who received more than 2 supplemental feeds per day, cup feeding has distinct advantage over bottle feeding on breastfeeding duration. Also the findings may not be applicable to preterm infants in developing country settings. 

Finally, we find the authors' conclusion that conducting further large, high quality RCTs on this issue may be a "futile undertaking" highly questionable. As stated above the problem of compliance in previous studies is an argument for doing better designed studies in health facilities that have experience in both cup and bottle feeding. Further, the importance of other factors like skin to skin contact, rooming in etc. should not be used an argument for not conducting research on appropriate feeding methods for infants who are not able to fully breastfeed. In our opinion, this meta-analysis underscores the need for further well-designed studies on this subject, in both developing and developed countries. 

Rajiv Bahl, Constanza Vallenas, Jose Martines
Department of Child and Adolescent Health and Development
World Health Organization, Geneva

Disclaimer: The authors of this feedback are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or the stated policy of the World Health Organization. 

References  

1.    Flint A, New K, Davies MW. Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005092. DOI: 10.1002/14651858.CD005092.pub2. 

2.    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. 

3.    Gilks J, Watkinson M. Improving breast feeding in preterm babies: Cup feeding versus bottle feeding. Journal of Neonatal Nursing 2004; 10:118-20. 

4.    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. 

5.    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. 

6.    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.

 

 

Reply

Thank you for your comment on our review "Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed".

The authors disagree with the statement from Rajiv B et al that the findings from the review do not support the conclusion. The conclusions were drawn from the evidence presented in the four included randomised control trials. 

The author’s acknowledge that infection is important and thus, it was included as an outcome. A thorough literature search was undertaken on all published and unpublished studies and no data from either randomised nor non-randomised trials was found for this outcome. Several other papers from India (Gupta 1999, Malhotrata 1998) were found. Whilst they were not eligible to be included in the review, again neither of these two papers considered or discussed risks of infection, despite one discussing different utensils for delivering milk. Given that milk delivered by any utensil, irrespective of whether it is a bottle, teat, spoon or cup, each require cleaning. The authors do not feel that conducting a trial on comparing different delivery utensils and infection rates is of benefit. Without any supporting evidence or discussion in any papers regarding cup feeding in developing countries, the authors are reluctant to discuss and draw conclusions regarding this outcome We have acknowledged in the text of the review under unreported outcomes, "that none of the following outcomes were reported in any of the included studies". 

Rajiv B et al comment on methodological influences which the authors have no impact on, such as sample size calculation. The statement made by the authors in the review is based on the evidence available; inferences cannot be made about design and sample size estimation by the authors. At this point in time there is a lack of evidence of effect. 

Rajiv B et al again comment on design and methodology. The authors disagree with the comments and are adamant conclusions can only be based on the evidence found to be included in the review. 

It is not the role of authors of Cochrane reviews to hypothesise on potential causes for lack of compliance for any intervention. 

Again, the authors have presented the data available from included studies. 

In reference to the excluded paper of healthy term newborn infants; this study was excluded because the population studied were healthy, term infants that were able to fully breastfeed; with supplemental feeds being offered as maternal choice, not because these were infants who were unable to fully breastfeed. This review is addressing the issue of supplemental feeds in the population of infants (irrespective of gestation age) who are unable to fully breastfeed. The authors have the view that term infants who can be fully breastfed should not be offered supplemental feeds as per the Baby Friendly Hospital Initiative (WHO1998). In addition, there are reports in the literature that caution needs to be exercised when cup feeding term infants due to the different tongue action required from that of breastfeeding, and term infants may reject the breast. 

In the majority of the articles reviewed, the authors of these papers made a comment about the difficulty of ensuring compliance with this intervention. This is often the reality of conducting clinical trials in clinical settings with clinical staff. In this case, the authors do not feel that it was a question of poorly designed clinical trials.

Based on the current literature and the evidence that was reviewed, the authors disagree with the closing comment and maintain their conclusion. 

The authors look forward to updating this review should further randomised controlled trials be conducted.   

In conclusion, if WHO have any unpublished data regarding term infants that are unable to fully breastfeed, we would be happy to include it in future updates of the review. 

References  

Gupta, A., Khanna, K., & Chattree, S. (1999). Cup Feeding: An Alternative to Bottle Feeding in a Neonatal Intensive Care Unit. Journal of Tropical Paediatrics, 45, P108-110. 

Malhotra, N., Vishwambaran, L., Sunaram, K.R., & Narayanan, I. (1999). A controlled trial of methods of feeding in neonates. Early Human Dvelopment, 54, p. 29-38. 

World Health Organisation, (1998). Evidence for the Ten Steps to successful breastfeeding. Division of Child Health and Development, World Health Organisation. 1998. 

 

Contributors

A. Flint, K. New, M. Davies

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Last assessed as up-to-date: 10 December 2006.


DateEventDescription

14 February 2008AmendedConverted to new review format.

14 February 2008Feedback has been incorporatedFeedback comments and response to comments included in review.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

Protocol first published: Issue 1, 2005
Review first published: Issue 2, 2007

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

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

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms

None

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Feedback
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Index terms
 

Internal sources

  • Grantley Stable Neonatal Unit, Royal Brisbane & Women's Hospital, Brisbane, Australia.
  • Dept of Paediatrics and Child Health, University of Queensland, Brisbane, Australia.

 

External sources

  • No sources of support supplied

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
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 studies excluded from this review

  1. Top of page
  2. Abstract摘要Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Brown 1999 {published data only}
Davis 1948 {published data only}
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}
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}
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}
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.

Additional references

  1. Top of page
  2. Abstract摘要Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Feedback
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Sources of support
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
Alderson 2004
  • Alderson 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
Kuehl 1997
Lang 1994a
  • Lang S. Cup-feeding: an alternative method. Midwives Chronicle & Nursing Notes 1994;107:171-6.
Lang 1994b
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.