• *Breast Feeding;
  • *Cooking and Eating Utensils;
  • *Infant, Premature;
  • Bottle Feeding [*utilization];
  • Enteral Nutrition [methods];
  • Infant, Newborn;
  • Infant Formula [administration & dosage];
  • Length of Stay;
  • Milk, Human;
  • Sucking Behavior;
  • Female;
  • Humans



Preterm infants start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women who choose to breast feed 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.


To determine the effect of avoidance of bottle feeds during the establishment of breastfeeding on the likelihood of successful breastfeeding and to determine if alternatives to bottle feeds are safe.

Search strategy

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL and EMBASE in any language. The search was updated in July 2008.

Selection criteria

Randomised or quasi randomised controlled trials comparing avoidance of bottles with use of bottles in women who have chosen to breast feed their preterm infant.

Data collection and analysis

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. Standard methods of the Cochrane Collaboration and the Cochrane Neonatal Review Group were used.

Main results

Five trials of 543 infants were included. Four trials used a cup feeding strategy and one trial used a tube feeding strategy when supplements to breast feeds were needed. The single study of tube feeding had a high risk of bias. In the analysis of all five trials, significant heterogeneity was evident in two of the primary outcomes. This was reduced when the tube feeding trial was removed from analyses.

Cup feeding significantly decreased 'no breastfeeding or only partial breast feeding' on discharge home (summary RR 0.75, 95% CI 0.61 to 0.91). However, cup feeding significantly increased length of hospital stay by 10 days (95% CI 3.87 to 16.29). There was a high degree of noncompliance in the largest study of cup feeding indicating dissatisfaction with this method by staff and/or parents.

The one trial of a tube alone approach significantly reduced 'no breastfeeding or only partial breastfeeding' and 'no breastfeeding at all' at all time periods but the results need to be interpreted with caution due to the high risk of bias.

Authors' conclusions

Supplementing breast feeds by cup confers no breastfeeding benefit beyond discharge home and delays discharge considerably. There is currently insufficient evidence on which to base recommendations for a tube alone approach to supplementing breast feeds. Further research is needed to evaluate a tube alone approach.

Plain Language Summary

Avoidance of bottles during the establishment of breast feeds in preterm infants

Preterm infants start milk feeds by tube and as they mature they are able to manage sucking feeds. The number of sucking feeds each day are gradually increased as the baby matures. For women who choose to breast feed their preterm infant it is not always possible for them to be there every time the baby needs a sucking feed. Conventionally, bottles with mother's milk or formula are used. It has been suggested that using bottles may interfere with breast feeding success. Five trials have investigated alternatives to bottles in the establishment of breast feeds; four trials used cup feeds and one trial used tube feeds. The one study that used tube feeds was of poor quality and the results of this study need to be interpreted cautiously. When cup feeds were used, more women were discharged home fully breastfeeding, but there was no effect on any (fully and partially combined) breastfeeding. Using cup feeds also increased the length of hospital stay by 10 days. In the one study of tube feeds, breastfeeding (both fully and partially) was increased at discharge and at three and six months after discharge with no effect on length of hospital stay. However, because of the poor quality of this one study, we cannot recommend a tube feeding strategy until further studies of high quality are undertaken.