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Three Part Question

In [new-born babies] does [bottle feeding compared to cup feeding]increase the [chances of successful breastfeeding]

Clinical Scenario

You see a baby on the neontal unit. There are no contraindications to feeding and you would like to start feeds. Mum is not available for feeding but is keen to breast feed.
The nurse suggests that the baby should be cup fed as bottle feeding will interfere with successful breast feeding
You wonder if this is based on evidence..

Search Strategy

Medline 1966-07/09 using the Pubmed interface
CINAHL 1981-07/09
The cochrane library Issue 3,2009
Pubmed: ((Breastfeeding) AND (Cup feeding)) AND (Bottle feeding) AND ("humans"[MeSH Terms] AND English[lang] AND (Meta-Analysis[ptyp] OR Randomized Controlled Trial[ptyp]) AND "infant, newborn"[MeSH Terms])
Limits: Humans, Meta-Analysis, Randomized Controlled Trial,English, Newborn: birth-1 month
CINAHL and Cochrane library :(breast AND feeding AND cup AND feeding AND bottle AND feeding).ti,ab

Search Outcome

Altogether 12 studies were found,of which 4 randomised control trials addressed the specific question.These 4 papers have been subject to a meta-analysis by the Cochrane review group.The review was published in 2007.
Another cochrane review published in 2008 included 5 papers ( 4 as in the 2007 review and a 5th study comparing bottlefeeding with NG feeds-which was not part of our question)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Flint A, New K, Davies MW 2007 Brisbane, Australia	4 RCTs including 472 newborn infants up to 44 weeks postmenstrual age or 28 days postnatal age that are unable to fully breastfeed.	Meta-analysis	Weight gain, proportion not breastfeeding at hospital discharge , 3months and 6 months of age, Proportion not fully breastfeeding at hospital discharge and at three and six months of age	No significant difference in weight gain, the mean difference was 0.60 g/kg/day [95% CI -3.21, 2.01]. No significant reduction in the proportion of infants not breastfeeding at hospital discharge (RR of 0.82 [95% CI 0.62, 1.09]), at 3 months (RR of 0.88 [95% CI 0.76, 1.03]) and 6 months of age( RR 0.91 [95%CI 0.78, 1.05]). Proportion not fully breastfeeding at hospital discharge RR of 0.75 [95% CI 0.61, 0.92] with a NNT of 7.3 [95% CI 4.6, 22.3], but no significant difference at 3 months (RR was 1.18 [95% CI 0.88, 1.58]) and 6 months (RR was 1.31 [95% CI 0.89, 1.92]).	Small number, high rates of non-compliance with the intervention of cup feeding,non-blinding of intervention

Comment(s)

Of the 4 trials included in the review one trial (collins 2004) dominated the results.Most of the outcomes were consistent in the 4 trials. The meta-analysis showed 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 or bottle.The results of one study demonstrated that those infants fed by cup spent approximately ten days longer in hospital.

Clinical Bottom Line

Cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no benefit in maintaining breastfeeding beyond hospital discharge.

Level of Evidence

Level 1 - Recent well-done systematic review was considered or a study of high quality is available.

References

1. Flint A, New K, Davies MW. Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed John Wiley & Sons, Ltd. Cochrane Database of Systematic Reviews, Issue 3, 2009