PICO Summary: Does bottle feeding during the establishment of breast feeding reduce the likelihood of successful breastfeeding in preterm infants?


BackgroundPreterm infants start milk feeds by gavage tube. As these infants mature, ‘sucking feeds’ are gradually introduced. Women who choose to breastfeed their preterm infant are not always available and an alternative approach to feeding is needed. Most commonly, milk (expressed breast milk or formula) is given by bottle. There is some controversy about whether using bottles during the establishment of breast feeds is detrimental to breastfeeding success.
ParticipantsPreterm infants < 37 weeks whose mothers were breastfeeding and who had not received ‘sucking’ feeds.
InterventionComplete avoidance of bottles during the transition to breast feeds using any other method to complement or supplement breastfeeding.
ComparisonComplementing or supplementing breast feeds with bottles during the transition to breast feeds.
Outcome(s)Primary outcomes
 • Not breastfeeding or only partial breastfeeding compared with fully breastfeeding on discharge home and at 3 and 6 months post-discharge
 • Not breastfeeding compared with any breastfeeding on discharge home and at 3 and 6 months post-discharge Secondary outcomes
 • Efficacy outcomes: feeding and growth
 • Safety outcomes
 • Satisfaction outcomes
StudiesRandomized and quasi-randomized trials
Study description and settingFive trials with a total 543 infants were included in the review of Collins and coworkers (Collins 2008). Four trials used a cup feeding strategy and one trial used a tube feeding strategy when supplements to breast feeds were needed. All studies included preterm infants, although the limits for gestational age at birth or birthweight differed. All but one were single centre studies, undertaken in the Unites States, England, Brazil and Australia.
ResultsAvoidance of bottle feeding decreased the prevalence of no breastfeeding or only partial breastfeeding at discharge home (typical RR 0.63, 95% CI 0.41, 0.96; NNT 5, 95% CI 4, 10; four trials, 455 infants). There was a substantial degree of heterogeneity among the studies, most likely due to the different intervention or the poor quality of the tube feeding study. Subgroup analyses excluding this study still showed reduction of the prevalence of no breastfeeding or only partial breastfeeding at discharge home with cup feeding (typical RR 0.75, 95% CI 0.61, 0.92; NNT 7, 95% CI 4, 25; three trials, 371 infants). Avoidance of bottle feeding during establishment of breastfeeding showed significant reduction of no breastfeeding or partial breastfeeding at 3 months (RR 0.59, 95% CI 0.40, 0,87; NNT 3, 95% CI 2, 9; one trial, 84 infants), and at 6 months as well (RR 0.65, 95% CI 0.48, 0.89, NNT 3, 95% CI 2, 9; one trial, 84 infants). The latter result was observed in a study at risk of bias due to incomplete outcome data. Length of hospital stay increased with 10 days with breastfeeding plus cup feeding (Mean Difference 10 days, 95% CI 3.9, 16.3; one trial, 303 infants). There was a high degree of noncompliance (56%, one trial, 303 infants) with cup feeding, indicating dissatisfaction with this method by staff and/or parents. Yet, this would have diluted the treatment effects, and the observed difference may be an underestimation of the true treatment effect. Too little information on secondary outcomes precluded firm conclusions.
Confidence in resultsModerate quality evidence preclude firm conclusions.
Key figure(s)Thumbnail image of
Figure captionAvoidance of bottles during the establishment of breastfeeding in preterm infants gives a reduction in ‘no breastfeeding or only partial breastfeeding at discharge’
Search for eligible studiesCENTRAL, MEDLINE, CINAHL, EMBASE through July 2008.
ConclusionCompared to bottle feeding, cup feeding significantly decreased ‘no breastfeeding or only partial breastfeeding’ on discharge home, yet significantly increased length of hospital stay. There was a high degree of noncompliance in the largest study of cup feeding indicating dissatisfaction with this method by staff and/or parents.
CitationCollins CT, Makrides M, Gillis J, McPhee AJ. Avoidance of bottles during the establishment of breast feeds in preterm infants. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD005252. DOI: 10.1002/14 651 858.CD005252.pub2.
Date completed7 February 2010
People who helped prepare this Cochrane PICO:Moniek van de Loo (m.vandeloo@amc.uva.nl), Fellow Neonatology, Emma Children's Hospital AMC, Amsterdam, The Netherlands.

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