NIHR Signal Supplementary feeding of preterm babies by cup rather than bottle helps breastfeeding success

Published on 13 December 2016

For women who chose to breastfeed their preterm baby, supplementary feeds with a cup, compared with a bottle, led to improved breastfeeding rates at discharge and up to six months later.

Preterm babies who are transitioning from being tube fed to breastfeeds have traditionally been given bottle feeds (of breast milk or formula) to supplement breastfeeding if the mother is unavailable or if additional feeds are thought necessary.

This small Cochrane review found evidence that babies were more likely to be fully breastfed or to have at least some breastfeeds when cup feeds were used to supplement breastfeeding.

In contrast to a 2008 review on the same topic, this updated review that included two new trials found supplementary feeding with a cup did not increase length of hospital stay.

The results suggest a reconsideration of the traditionally used bottle feeds in the transition to breastfeeds for preterm infants. Implications for practice will include delivery of the message within the neonatal unit.

Supplementary feeding of preterm babies by cup rather than bottle helps breastfeeding success

Why was this study needed?

Sixty thousand babies are born prematurely each year in the UK. Babies born prematurely often have low birth weights. Interventions to improve the feeding of low birth weight infants and to help them establish breast feeding are likely to improve the immediate and longer-term health and well-being of the baby.

Premature babies start milk feeds by tube, and as they mature, progress to sucking feeds (e.g. breastfeeding and bottle feeding). Women who choose to breastfeed their preterm baby are not always able to be in hospital each time the baby needs a sucking feed. In the transition from tube to breastfeeds, traditionally bottle feeds have been used.

There is on-going debate as to whether using bottles during the establishment of breastfeeding for preterm babies is detrimental to successful breastfeeding. Possibly due to a difference in the sucking action required.

What did this study do?

This updated Cochrane review and meta-analysis included seven trials up to July 2016. Two new trials were included since a 2008 review.

The review included 1,152 preterm tube fed infants. Trials were selected if they compared supplementing breastfeeding without the use of bottle feeds, e.g. by using a cup or spoon, tube feeds or specialised teats (intervention) to use of bottle feeds (control).

All trials were conducted in neonatal units, and two trials were from the UK. The included trials were of small to moderate size and some had incomplete data because of drop outs. The quality of evidence for the main outcomes was low to medium but this probably has little effect on the overall reliability of these findings.

What did it find?

  • Supplementary feeds given by a cup (five trials) or tube (one trial) improved full breastfeeding rates at discharge to 64 per 100 women compared to 44 for those who used a bottle (risk ratio [RR]: 1.47, 95% confidence interval [CI] 1.19 to 1.80).  Results were sustained over three and six months.
  • Any breastfeeding at discharge was also higher in those using a cup, at 88 per 100 women compared to 79 for bottles (RR: 1.11, 95% CI 1.06 to 1.16).
  • In contrast to the previous 2008 review, no evidence of a difference in length of hospital stay between supplementary feeds with and without bottles was found (mean difference 2.25 days, 95% CI ‑3.36 to 7.86 days)
  • Meta-analyses from trials that reported time to reach full sucking feeds, weight gain and infection showed no clear benefit or harm with the avoidance of bottle feeds.
  • Limited evidence from two trials suggested improved heart and lung stability with avoidance of supplementary bottle feeds.

What does current guidance say on this issue?

Great Ormond Street Hospital recommends using a cup, tube or syringe to supplement feeds. They advise against using a bottle if possible.

UNICEFs 2012 Baby Friendly Initiative Standards provides guidance around breastfeeding and its importance for premature babies. The London based charity, BLISS, have also produced a resource on breastfeeding for premature babies. Neither include specific guidance on the transition from tube to breastfeeding for premature babies.

A 2006 NICE guideline on postnatal care supports breastfeeding. It does not specifically cover an approach to breastfeeding for premature or low birth weight infants. It includes general advice that formula milk should not be given to breastfed babies unless medically indicated. A new guideline on neonatal care is due to be published in April 2019.

What are the implications?

This review provides low to moderate evidence of improved breastfeeding rates when cups are used for preterm babies in the transition from tube to breastfeeds. The results suggest a reconsideration of the traditionally used bottle feeds in the transition to breastfeeds for preterm infants.

As there are no national guidelines on best practice to aid the transition, there is likely to be wide variability across neonatal units. One of the studies in this review from 2004 had found that cups were deemed difficult to use and may have prolonged discharge. The infants were very preterm which may have affected results. High staff and parent acceptance of using cups was found in the other studies. This does however highlight that there may be a need to determine the optimal technique for successful cup feeding and staff training.

Citation and Funding

Collins CT, Gillis J, McPhee AJ et al. Avoidance of bottles during the establishment of breast feeds in preterm infants. Cochrane Database Syst Rev. 2016;(9):CD005252.

This project was funded by the South Australian Health and Medical Research Institute and the Women’s and Children’s Hospital, North Adelaide, Australia.

Bibliography

Collins CT, Makrides M, Gillis J et al. Avoidance of bottles during the establishment of breastfeeds in preterm infants. Cochrane Database Syst Rev. 2008;CD005252.

NICE. Postnatal care up to 8 weeks after birth. CG37. London: National Institute for Health and Care Excellence; 2006.

UNICEF UK. Guide to the baby friendly initiative standards. London: UNICEF UK; 2012.

WHO. Breastfeeding of low-birth-weight infants. World Health Organization; 2016.

GOSH. Nutrition: enteral nutrition for the preterm infant. London: Great Ormond Street Hospital for Children; 2011.

 

Why was this study needed?

Sixty thousand babies are born prematurely each year in the UK. Babies born prematurely often have low birth weights. Interventions to improve the feeding of low birth weight infants and to help them establish breast feeding are likely to improve the immediate and longer-term health and well-being of the baby.

Premature babies start milk feeds by tube, and as they mature, progress to sucking feeds (e.g. breastfeeding and bottle feeding). Women who choose to breastfeed their preterm baby are not always able to be in hospital each time the baby needs a sucking feed. In the transition from tube to breastfeeds, traditionally bottle feeds have been used.

There is on-going debate as to whether using bottles during the establishment of breastfeeding for preterm babies is detrimental to successful breastfeeding. Possibly due to a difference in the sucking action required.

What did this study do?

This updated Cochrane review and meta-analysis included seven trials up to July 2016. Two new trials were included since a 2008 review.

The review included 1,152 preterm tube fed infants. Trials were selected if they compared supplementing breastfeeding without the use of bottle feeds, e.g. by using a cup or spoon, tube feeds or specialised teats (intervention) to use of bottle feeds (control).

All trials were conducted in neonatal units, and two trials were from the UK. The included trials were of small to moderate size and some had incomplete data because of drop outs. The quality of evidence for the main outcomes was low to medium but this probably has little effect on the overall reliability of these findings.

What did it find?

  • Supplementary feeds given by a cup (five trials) or tube (one trial) improved full breastfeeding rates at discharge to 64 per 100 women compared to 44 for those who used a bottle (risk ratio [RR]: 1.47, 95% confidence interval [CI] 1.19 to 1.80).  Results were sustained over three and six months.
  • Any breastfeeding at discharge was also higher in those using a cup, at 88 per 100 women compared to 79 for bottles (RR: 1.11, 95% CI 1.06 to 1.16).
  • In contrast to the previous 2008 review, no evidence of a difference in length of hospital stay between supplementary feeds with and without bottles was found (mean difference 2.25 days, 95% CI ‑3.36 to 7.86 days)
  • Meta-analyses from trials that reported time to reach full sucking feeds, weight gain and infection showed no clear benefit or harm with the avoidance of bottle feeds.
  • Limited evidence from two trials suggested improved heart and lung stability with avoidance of supplementary bottle feeds.

What does current guidance say on this issue?

Great Ormond Street Hospital recommends using a cup, tube or syringe to supplement feeds. They advise against using a bottle if possible.

UNICEFs 2012 Baby Friendly Initiative Standards provides guidance around breastfeeding and its importance for premature babies. The London based charity, BLISS, have also produced a resource on breastfeeding for premature babies. Neither include specific guidance on the transition from tube to breastfeeding for premature babies.

A 2006 NICE guideline on postnatal care supports breastfeeding. It does not specifically cover an approach to breastfeeding for premature or low birth weight infants. It includes general advice that formula milk should not be given to breastfed babies unless medically indicated. A new guideline on neonatal care is due to be published in April 2019.

What are the implications?

This review provides low to moderate evidence of improved breastfeeding rates when cups are used for preterm babies in the transition from tube to breastfeeds. The results suggest a reconsideration of the traditionally used bottle feeds in the transition to breastfeeds for preterm infants.

As there are no national guidelines on best practice to aid the transition, there is likely to be wide variability across neonatal units. One of the studies in this review from 2004 had found that cups were deemed difficult to use and may have prolonged discharge. The infants were very preterm which may have affected results. High staff and parent acceptance of using cups was found in the other studies. This does however highlight that there may be a need to determine the optimal technique for successful cup feeding and staff training.

Citation and Funding

Collins CT, Gillis J, McPhee AJ et al. Avoidance of bottles during the establishment of breast feeds in preterm infants. Cochrane Database Syst Rev. 2016;(9):CD005252.

This project was funded by the South Australian Health and Medical Research Institute and the Women’s and Children’s Hospital, North Adelaide, Australia.

Bibliography

Collins CT, Makrides M, Gillis J et al. Avoidance of bottles during the establishment of breastfeeds in preterm infants. Cochrane Database Syst Rev. 2008;CD005252.

NICE. Postnatal care up to 8 weeks after birth. CG37. London: National Institute for Health and Care Excellence; 2006.

UNICEF UK. Guide to the baby friendly initiative standards. London: UNICEF UK; 2012.

WHO. Breastfeeding of low-birth-weight infants. World Health Organization; 2016.

GOSH. Nutrition: enteral nutrition for the preterm infant. London: Great Ormond Street Hospital for Children; 2011.

 

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

Published on 1 October 2016

Collins, C. T.,Gillis, J.,McPhee, A. J.,Suganuma, H.,Makrides, M.

Cochrane Database Syst Rev Volume 9 , 2016

BACKGROUND: 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 able to be in hospital with their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breast feeds is detrimental to breast feeding success is a topic of ongoing debate. OBJECTIVES: To identify the effects of avoidance of bottle feeds during establishment of breast feeding on the likelihood of successful breast feeding, and to assess the safety of alternatives to bottle feeds. SEARCH METHODS: We used the standard search strategy of the Cochrane Neonatal Review Group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE via PubMed (1966 to July 2016), Embase (1980 to July 2016) and CINAHL (1982 to July 2016). We also searched databases of clinical trials and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials. SELECTION CRITERIA: Randomised and 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. Review authors used standard methods of The Cochrane Collaboration and the Cochrane Neonatal Review Group. MAIN RESULTS: We included seven trials with 1152 preterm infants. Five studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breast feeds were needed. We included the novel teat study in this review, as the teat was designed to more closely mimic the sucking action of breast feeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff and/or parents; the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Meta-analyses provided evidence of low to moderate quality indicating that avoiding bottles increases the extent of breast feeding on discharge home (full breast feeding typical risk ratio (RR) 1.47, 95% confidence interval (CI) 1.19 to 1.80; any breast feeding RR 1.11, 95% CI 1.06 to 1.16). Limited available evidence for three months and six months post discharge shows that avoiding bottles increases the occurrence of full breast feeding and any breast feeding at discharge and at six months post discharge, and of full (but not any) breast feeding at three months post discharge. This effect was evident at all time points for the tube alone strategy and for all except any breast feeding at three months post discharge for cup feeding. Investigators reported no clear benefit when the novel teat was used. No other benefits or harms were evident, including, in contrast to the previous (2008) review, length of hospital stay. AUTHORS' CONCLUSIONS: Evidence of low to moderate quality suggests that supplementing breast feeds by cup increases the extent and duration of breast feeding. Current insufficient evidence provides no basis for recommendations for a tube alone approach to supplementing breast feeds.

Pre-term babies were considered those born at less than 37-weeks gestation.

Expert commentary

There is strong evidence that bottle feeding influences breast feeding success in term babies, and now this review provides evidence (albeit of low-moderate quality) that using a cup rather than a bottle to supplement breast feeding in the preterm infant is beneficial to breast feeding success. Whilst some may argue that as long as the preterm baby receives the benefits breast milk, the route is not important; this review supports the concept that lactation and breast feeding are in fact hampered by bottle feeding, in turn with negative impact on wellbeing of mother and baby. This finding makes it more than worthwhile for health professionals to learn and teach the skill of cup feeding to support family centred care.

Dr Jane M Hawdon, Consultant Neonatologist; Executive Director, Women’s and Children’s Health Clinical Academic Group; Associate Chief Medical Officer, Barts Health NHS Trust

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