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

  • Review
  • Intervention

Authors


Abstract

Background

Breast milk provides optimal nutrition for term and preterm infants, and the ideal way for infants to receive breast milk is through suckling at the breast. Unfortunately, this may not always be possible for medical or physiological reasons such as being born sick or preterm and as a result requiring supplemental feeding. Currently, there are various ways in which infants can receive supplemental feeds. Traditionally in neonatal and maternity units, bottles and nasogastric tubes have been used; however, cup feeding is becoming increasingly popular as a means of offering supplemental feeds in an attempt to improve breastfeeding rates. There is no consistency to guide the choice of method for supplemental feeding.

Objectives

To determine the effects of cup feeding versus other forms of supplemental enteral feeding on weight gain and achievement of successful breastfeeding in term and preterm infants who are unable to fully breastfeed.

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 1), MEDLINE via PubMed (1966 to 31 January 2016), Embase (1980 to 31 January 2016), and CINAHL (1982 to 31 January 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

Selection criteria

Randomised or quasi-randomised controlled trials comparing cup feeding to other forms of enteral feeding for the supplementation of term and preterm infants.

Data collection and analysis

Data collection and analysis was performed in accordance with the methods of Cochrane Neonatal. We used the GRADE approach to assess the quality of evidence.

The review authors independently conducted quality assessments and data extraction for included trials. Outcomes reported from these studies were: weight gain; proportion not breastfeeding at hospital discharge; proportion not feeding at three months of age; proportion not feeding at six months of age; proportion not fully feeding at hospital discharge; proportion not fully breastfeeding at three months of age; proportion not fully breastfeeding at six months of age; average time per feed (minutes); length of stay; and physiological events of instability such as bradycardia, apnoea, and low oxygen saturation. For continuous variables such as weight gain, mean differences and 95% confidence intervals (CIs) were reported. For categorical outcomes such as mortality, the relative risks (RR) and 95% CIs were reported.

Main results

The experimental intervention was cup feeding and the control intervention was bottle feeding in all five studies included in this review. One study reported weight gain as g/kg/day and there was no statistically significant difference between the two groups (MD −0.60, 95% CI −3.21 to 2.01); while a second study reported weight gain in the first seven days as grams/day and also showed no statistically significant difference between the two groups (MD −0.10, 95% CI −0.36 to 0.16). There was substantial variation in results for the majority of breastfeeding outcomes, except for not breastfeeding at three months (three studies) (typical RR 0.83, 95% CI 0.71 to 0.97) which favoured cup feeding. Where there was moderate heterogeneity meta-analysis was performed: not breastfeeding at six months (two studies) (typical RR 0.83, 95% CI 0.72 to 0.95); not fully breastfeeding at hospital discharge (four studies) (typical RR 0.61, 95% CI 0.52 to 0.71).

Two studies reported average time to feed which showed no difference between the two groups. Two studies assessed length of hospital stay and there was considerable variation in results and in the direction of effect. Only one study has reported gestational age at discharge, which showed no difference between the two groups (MD −0.10, 95% CI −0.54 to 0.34).

Authors' conclusions

As the majority of infants in the included studies are preterm infants, no recommendations can be made for cup feeding term infants due to the lack of evidence in this population.

From the studies of preterm infants, cup feeding may have some benefits for late preterm infants and on breastfeeding rates up to six months of age. Self-reported breastfeeding status and compliance to supplemental interventions may over-report exclusivity and compliance, as societal expectations of breastfeeding and not wishing to disappoint healthcare professionals may influence responses at interview and on questionnaires.

The results for length of stay are mixed, with the study involving lower gestational age preterm infants finding that those fed by cup spent approximately 10 days longer in hospital, whereas the study involving preterm infants at a higher gestational age, who did not commence cup feeding until 35 weeks' gestation, did not have a longer length of stay, with both groups staying on average 26 days. This finding may have been influenced by gestational age at birth and gestational age at commencement of cup feeding, and their mothers' visits; (a large number of mothers of these late preterm infants lived regionally from the hospital and could visit at least twice per week).

Compliance to the intervention of cup feeding remains a challenge. The two largest studies have both reported non-compliance, with one study analysing data by intention to treat and the other excluding those infants from the analysis. This may have influenced the findings of the trial. Non-compliance issues need consideration before further large randomised controlled trials are undertaken as this influences power of the study and therefore the statistical results. In addition larger studies with better-quality (especially blinded) outcome assessment with 100% follow-up are needed.

Resumo

Uso de copo comparado a outras formas de alimentação enteral suplementar para recém-nascidos que não conseguem se alimentar por aleitamento materno exclusivo

Introdução

O leite materno é o alimento ideal para o recém-nascido de termo ou prematuro e a melhor forma de receber esse alimento é por meio da amamentação ao peito. Infelizmente, isso nem sempre é possível por razões médicas ou fisiológicas, como por exemplo, nos casos de bebês que nascem doentes ou prematuros, situações onde é necessário oferecer alimentação suplementar. Atualmente, existem diversas formas de oferecer alimentos suplementares para o lactente. Tradicionalmente, as mamadeiras e as sondas nasogástricas eram utilizadas nas maternidades e nas unidades de tratamento neonatal. Porém, o uso do copo tem se tornado cada vez mais popular como meio de oferecer suplementação alimentar na tentativa de aumentar a taxa de aleitamento materno. Não existem informações consistentes para orientar a escolha da forma de oferecer suplementação alimentar para lactentes.

Objetivos

Avaliar os efeitos da alimentação por copo, em comparação com outras formas de alimentação enteral suplementar, sobre o ganho ponderal e sobre a taxa de sucesso do aleitamento materno em recém-nascidos de termo e prematuros que não conseguem ser alimentados por aleitamento materno exclusivo.

Métodos de busca

Nós utilizamos a estratégia de busca padrão do Cochrane Neonatal Review group que inclui as seguintes bases de dados eletrônicas: Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via Pubmed (1966 até 31 de janeiro de 2016), Embase (1980 até 31 de janeiro de 2016) e CINAHL (1982 até 31 de janeiro de 2016). Nós também buscamos por ensaios clínicos randomizados e quasi-randomizados em bases de dados de ensaios clínicos, em anais de congresso e nas listas de referências dos artigos recuperados.

Critério de seleção

Foram incluídos ensaios clínicos controlados randomizados ou quasi-randomizados comparando alimentação por copo com outras formas de alimentação enteral para suplementação alimentar de recém-nascidos a termo e prematuros.

Coleta dos dados e análises

A coleta e análise dos dados foi realizada de acordo com os métodos do Cochrane Neonatal Review Group. Nós utilizamos a metodologia GRADE para avaliar a qualidade da evidência.

Dois revisores avaliaram a qualidade dos estudos incluídos e extraíram os dados de forma independente. Os desfechos desses estudos foram: ganho ponderal, proporção de recém-nascidos não amamentados na alta hospitalar, proporção de bebês não amamentados aos três meses de idade, proporção de bebês não amamentados aos seis meses de idade, proporção de recém-nascidos não amamentados exclusivamente ao peito no momento da alta hospitalar, proporção de bebês não amamentados exclusivamente ao peito aos três meses de idade, proporção de bebês não amamentados exclusivamente ao peito aos seis meses de idade, tempo médio gasto por alimentação (em minutos), duração da internação hospitalar e ocorrência de episódios de instabilidade fisiológica, tais como bradicardia, apneia e baixa saturação de oxigênio. Para os desfechos contínuos, como ganho ponderal, apresentamos os resultados como diferença de médias (MD) e intervalo de confiança de 95% (CI). Para os desfechos categóricos, como mortalidade, apresentamos os resultados com risco relativo (RR) e CI.

Principais resultados

Incluímos um total de 5 estudos nesta versão atualizada da revisão. Em todos estudos, a intervenção experimental foi a alimentação por copo e o controle foi alimentação por mamadeira. Um estudo avaliou o ganho ponderal em g/kg/dia e não encontrou diferença estatisticamente significante entre os dois grupos (MD -0,60; CI: -3.21 − 2.01). Um segundo estudo avaliou o ganho ponderal nos primeiros sete dias em gramas/dia e também não encontrou diferença estatisticamente significante entre os dois grupos (MD - 0.10; CI: -0.36 − 0.16). Houve grande variabilidade nos resultados para a maioria dos desfechos de amamentação, exceto para a taxa de não amamentação aos três meses de idade: RR 0,83; CI: 0,71 – 0,97, a favor do uso do copo (3 estudos). Realizamos metanálises para os desfechos com heterogeneidade moderada, tais como: taxa de não amamentação aos seis meses de idade (RR 0,83; CI: 0.72 - 0.95, 2 estudos) e taxa de não amamentação exclusiva no momento da alta hospitalar (RR 0,61; CI: 0.52 - 0.71, 4 estudos).

Dois estudos avaliaram o tempo médio gasto por alimentação e não houve diferença entre os dois grupos. Dois estudos avaliaram a duração da internação hospitalar e houve considerável variação nos resultados e na direção do efeito. Somente um estudo avaliou a idade gestacional na alta hospitalar; não encontrou diferença entre os grupos (MD −0.10; CI: −0.54 - 0.34).

Conclusão dos autores

Nenhuma recomendação pode ser feita para o uso de copo em recém-nascidos de termo devido à falta de evidências nessa população, uma vez que a maioria dos participantes nos estudos era de prematuros.

O uso de copo pode trazer algum benefício para os prematuros tardios nas taxas de amamentação no sexto mês de vida. Como o status da amamentação exclusiva e a adesão às intervenções suplementares foram autorrelatadas pelas mães em questionários e entrevistas, é possível que esses desfechos tenham sido superestimados, já que existe uma expectativa social em relação à amamentação e um desejo de não desapontar os profissionais de saúde.

Os resultados da intervenção sobre a duração da internação hospitalar foram heterogêneos. O estudo que envolveu prematuros de menor idade gestacional concluiu que aqueles que foram alimentados com o copo permaneceram cerca de 10 dias a mais internados no hospital. Por outro lado, outro estudo envolvendo prematuros com maior idade gestacional (que iniciaram alimentação com o copo a partir da 35ª semana) não encontrou diferença na duração da internação hospitalar, sendo que ambos os grupos permaneceram em média 26 dias internados. Esse achado pode ter sido influenciado pela idade gestacional ao nascer, pela idade gestacional ao iniciar a alimentação por copo e pela frequência das visitas das mães (um grande número de mães dos prematuros tardios morava na região do hospital e conseguia visitar os bebês pelo menos duas vezes por semana).

A adesão ao uso do copo para alimentação permanece um desafio. Os dois maiores estudos relataram casos de não adesão, sendo que um deles fez análises por intenção de tratar e o outro excluiu esses casos das suas análises (análise por protocolo). Isso pode ter influenciado os achados dos estudos. O problema de não adesão precisa ser levado em consideração antes que outros ensaios clínicos randomizados maiores sejam realizados, uma vez que isso influencia o poder dos estudos e os resultados estatísticos. Além disso, são necessários estudos maiores. com melhor qualidade na avaliação dos desfechos (avalição cega dos desfechos) e com 100% de seguimento.

Résumé scientifique

L'alimentation au gobelet par rapport à d'autres formes d'alimentation entérale supplémentaire pour les nouveau-nés incapables de téter correctement au sein

Contexte

Le lait maternel fournit une nutrition optimale pour les nourrissons prématurés et nés à terme, et la manière la plus efficace pour les nourrissons de recevoir du lait maternel est à travers l'allaitement au sein. Malheureusement, cela pourrait ne pas toujours être possible pour des raisons médicales ou physiologiques, telles que le fait de naître malades ou prématurés et, par conséquent, nécessitant une alimentation supplémentaire. Actuellement, il existe différents moyens par lesquels les nouveau-nés peuvent recevoir une alimentation supplémentaire. Traditionnellement, dans les unités de nouveau-nés et de maternité, des biberons et des sondes nasogastriques ont été utilisés à cette fin. Cependant, ces derniers temps, l'alimentation au gobelet est de plus en plus utilisée comme un moyen d'alimentation supplémentaire pour tenter d'améliorer les taux d'allaitement. Néanmoins, il n'y a pas une cohérence qui puisse guider le choix de la méthode adéquate.

Objectifs

Déterminer les effets de l'alimentation au gobelet par rapport à d'autres formes d'alimentation entérale supplémentaire sur la prise de poids et la réussite de l'allaitement maternel chez les nourrissons nés à terme et prématurés qui ne sont pas en mesure de téter correctement au sein.

Stratégie de recherche documentaire

Nous avons utilisé la stratégie de recherche normalisée du groupe de revue Cochrane sur la néonatologie pour consulter le registre Cochrane des essais contrôlés (CENTRAL 2016, numéro 1), MEDLINE via PubMed (de 1966 au 31 janvier 2016), Embase (de 1980 au 31 janvier 2016) et CINAHL (de 1982 au 31 janvier 2016). Nous avons également effectué des recherches dans les bases de données d'essais cliniques, des actes de conférence et les références bibliographiques des articles trouvés portant sur les essais contrôlés randomisés et les essais quasi-randomisés.

Critères de sélection

Essais contrôlés randomisés ou quasi-randomisés comparant l'alimentation au gobelet à d'autres forme d'alimentation entérale supplémentaire chez les nourrissons nés à terme ou prématurés.

Recueil et analyse des données

La collecte et l'analyse des données ont été effectuées selon les méthodes du groupe de revue Cochrane sur la néonatologie. Nous avons utilisé l'approche GRADE pour évaluer la qualité des preuves.

Les auteurs de la revue ont effectué de manière indépendante l'évaluation de la qualité et l'extraction des données pour les essais inclus. Les résultats rapportés dans ces études ont compris : la prise de poids ; la proportion sans allaitement au sein à la sortie de l'hôpital ; la proportion sans allaitement à l'âge de trois mois ; la proportion sans allaitement à l'âge de six mois ; la proportion sans allaitement exclusif à la sortie de l'hôpital ; la proportion sans allaitement exclusif à l'âge de trois mois ; la proportion sans allaitement exclusif à l'âge de six mois ; temps moyen par session d'alimentation (en minutes) ; la durée du séjour à l'hôpital ; ainsi que les événements physiologiques d'instabilité comme la bradycardie et l'apnée, la saturation faible en oxygène. Pour les variables continues, telles que la prise de poids, la différence moyenne et les intervalles de confiance à 95 % (IC) ont été rapportés. Des critères de jugement catégoriels, tels que la mortalité, les risques relatifs (RR) et les IC à 95 % ont été rapportés.

Résultats principaux

Dans les cinq études incluses dans cette revue, l'intervention expérimentale était l'alimentation au gobelet et l'intervention de contrôle était l'alimentation au biberon. Une étude a rapporté une prise de poids en g/kg/jour et aucune différence statistiquement significative n'a été rapportée entre les deux groupes (DM −0,60, IC à 95 % −3,21 à 2,01). Une deuxième étude a rapporté une prise de poids dans les sept premiers jours en grammes / jour et n'également montré aucune différence statistiquement significative entre les deux groupes (DM −0,10, IC à 95 % −0,36 à 0,16). Il y a eu une variation significative dans les résultats pour la majorité des critères de jugement de l'allaitement, sauf pour l'absence d'allaitement à trois mois (trois études) (RR typique de 0,83, IC à 95 % 0,71 à 0,97), ce qui a été en faveur de l'alimentation au gobelet. Lorsqu'il y avait une hétérogénéité modérée, une méta-analyse était réalisée : absence d'allaitement au bout de six mois (deux études) (RR typique de 0,83, IC à 95 % 0,72 à 0,95) ; absence d'allaitement exclusif à la sortie de l'hôpital (quatre études) (RR typique de 0,61, IC à 95 % 0,52 à 0,71).

Deux études ont rapporté le temps moyen pris pour l'alimentation. Cela n'a montré aucune différence entre les deux groupes. Deux études ont évalué la durée du séjour à l'hôpital et une variation considérable a été observée dans les résultats et dans le sens de l'effet. Une seule étude a rapporté l'âge gestationnel à la sortie de l'hôpital, ce qui n'a montré aucune différence entre les deux groupes (DM −0,10, IC à 95 % −0,54 à 0,34).

Conclusions des auteurs

Étant donné que la majorité des nourrissons dans les études incluses ont été des nouveau-nés prématurés, aucune recommandation ne peut être émise concernant l'alimentation au gobelet chez les nourrissons nés à terme, en raison du manque de preuves dans cette population.

D'après les études chez les nouveau-nés prématurés, l'alimentation au gobelet pourrait avoir certains effets bénéfiques pour les nourrissons peu prématurés et sur les taux d'allaitement jusqu'à l'âge de six mois. L'auto-évaluation concernant l'état de l'allaitement ainsi que le respect des interventions d'alimentation supplémentaire peut mener à un rapport erroné sur l'exclusivité et le respect des consignes, étant donné que les réponses dans les entretiens et questionnaires ont pu être influencées par les attentes sociales sur l'allaitement et pour éviter la déception des professionnels de santé.

Les résultats concernant la durée du séjour à l'hôpital sont mitigés. D'une part, une étude portant sur des nouveau-nés prématurés ayant un âge gestationnel inférieur a rapporté que ceux alimentés par gobelet passaient environ 10 jours de plus à l'hôpital. D'autre part, une autre étude portant sur des nouveau-nés prématurés ayant un âge gestationnel plus élevé et n'ayant pas commencé l'alimentation au gobelet avant leurs 35 semaines de gestation n'a pas rapporté une plus longue durée d'hospitalisation, avec les deux groupes hospitalisés en moyenne pendant 26 jours. Ce résultat peut avoir été influencé par l'âge gestationnel à la naissance et par l'âge gestationnel au début de l'alimentation au gobelet, et la fréquence de visites des mères ; (un grand nombre de mères de ces nourrissons peu prématurés habitaient la même région où se situait l'hôpital et pouvaient visiter leurs enfants au moins deux fois par semaine).

Le respect des consignes concernant l'intervention de l'alimentation au gobelet reste un problème. Les deux plus grandes études ont toutes deux rapporté le non-respect, avec une étude analysant des données en intention de traiter et l'autre en excluant ces nourrissons de l'analyse. Cela peut avoir influencé les résultats de l'essai. La question sur le non-respect doit être prise en compte avant d'effectuer d'autres essais contrôlés randomisés à grande échelle, car cela a une influence sur la puissance statistique de l'étude et, par conséquent, les résultats. En plus, des études à plus grande échelle ayant une meilleure évaluation (spécifiquement en aveugle) des critères de jugement avec un suivi de 100 % sont nécessaires.

Plain language summary

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

Review question:

For both term and preterm infants we wanted to identify the best method for offering supplemental feeds and asked if cup feeding is a better way to supplementally feed rather than bottle feeding or feeding with a tube, when newborn infants are unable to fully breastfeed.

Background:

Most infants born at term or slightly preterm can fully breastfeed following birth. However for a number of reasons some term newborns and many preterm newborns may not be able to fully breastfeed and require supplemental feeding by alternative methods, such as a cup, syringe, bottle or feeding tube, until they are able to fully breastfeed.

Study characteristics:

Our search for eligible studies conducted on 31 January 2016 revealed five studies, all comparing cup and bottle feeding in newborn infants, which we were able to include in this review. These studies were conducted in neonatal and maternity units in hospitals in Australia, the United Kingdom, Brazil and Turkey. The mean gestational age of the infants in most of the studies were similar at the time of entry into the study. In four of the studies the intervention (cup or bottle) commenced from the time of enrolment into the study, when the infants first needed a supplemental feed and were as young as 30 weeks' gestation. In the study conducted in Turkey, supplemental feeding was not commenced on enrolment into the study and at the time of first supplemental feed but delayed until infants were at least 35 weeks of age.

Key results:

For some of the outcomes, the results of the different studies could not be combined. This included not breastfeeding at hospital discharge; not exclusively breastfeeding at three months and at six months; the average time taken for a feed; and the number of days spent in hospital. For each of these outcomes, the results from some studies favoured cup feeding, while the results from other studies favoured bottle feeding.

For some of the outcomes, the results of the different studies could be combined: there was no difference in weight gain or gestational age at discharge between those infants who recieved supplemental feeds by cup compared to bottle. However those infants who received supplemental feeds by cup were more likely to be exclusively breastfeeding at hospital discharge and were more likely to be receiving some breastfeeds at three and six months of age.

As the studies mostly included preterm infants and few term infants, no recommendations can be made for cup feeding term infants.

Quality of evidence:

The quality of evidence for weight gain, length of stay, not breastfeeding at hospital discharge and at six months of age and exclusively breastfeeding at hospital discharge and at six months of age is graded very low to low. In the studies included in this review, it is reported that many infants who were to receive supplemental feeds by cup received supplemental feeds by other means as either the parents or nurses did not like cup feeding.

Resumo para leigos

Uso de copo comparado com outras formas de alimentação suplementar para recém-nascidos que não conseguem se alimentar por aleitamento materno exclusivo

Pergunta da revisão:

Nós quisemos saber qual o melhor método de oferecer alimentação suplementar para bebês que nasceram aos nove meses de gestação (chamados de bebês “de termo”) e para prematuros. Nossa pergunta foi: usar o copo é melhor do que usar mamadeiras ou sondas para dar alimentação suplementar a recém-nascidos que não conseguem se alimentar por aleitamento materno exclusivo?

Introdução

A maioria dos recém-nascidos de termo ou que nascem pouco antes dos nove meses consegue se alimentar exclusivamente por aleitamento materno logo depois do parto. Porém, por diversos motivos, alguns recém-nascidos de termo e muitos prematuros podem não conseguir ser alimentados por aleitamento materno exclusivo e necessitam receber alimentação suplementar. Essa alimentação suplementar pode ser oferecida de várias formas, como por exemplo, pelo uso de copo, seringa, mamadeira ou sondas, até eles conseguirem se alimentar exclusivamente no peito.

Características do estudo

Nossa busca foi realizada em 31 de janeiro de 2016 e cinco estudos preencheram os critérios de inclusão, sendo que todos eles compararam o uso de copos versus mamadeiras em recém-nascidos. Estes estudos foram conduzidos em maternidade e unidades neonatais de hospitais da Austrália, Reino Unido, Brasil e Turquia. A idade gestacional média dos recém-nascidos na maioria dos estudos foi similar no momento em que entraram no estudo. Em quatro dos estudos, a intervenção (copo ou mamadeira) começou no momento em que o recém-nascido entrou no estudo, no primeiro momento em que ele precisou de alimentação suplementar e incluiu prematuros que tinham pelo menos 30 semanas de gestação (um bebê é considerado prematuro quando nasce com menos de 37 semanas). No estudo conduzido na Turquia, a alimentação suplementar não foi iniciada no momento em que o recém-nascido entrou no estudo e quando ele recebeu a primeira alimentação suplementar, mas atrasada até que o bebê tivesse atingido 35 semanas de idade.

Principais resultados

Para alguns desfechos, os resultados dos diferentes estudos não puderam ser combinados. Isto incluiu: bebês não amamentados na alta hospitalar; bebês não amamentados exclusivamente ao peito aos três e seis meses de idade; tempo médio gasto por alimentação e duração da internação hospitalar. Para cada um desses desfechos, os resultados de alguns estudos favoreceram o copo, enquanto os resultados de outros estudos favoreceram a mamadeira.

Para alguns desfechos, os resultados de diferentes estudos puderam ser combinados. Não houve diferença no ganho de peso ou idade gestacional na alta hospitalar dos bebês que receberam alimentação suplementar através do copo comparados àqueles que foram alimentados com mamadeira. Porém, os bebês que receberam alimentação suplementar através do copo tinham maior probabilidade de estar mamando exclusivamente no peito quando receberam alta hospitalar e de estar ainda mamando no peito, mesmo que parcialmente, com três e seis meses de idade.

Os cinco estudos incluíram principalmente bebês prematuros e poucos recém-nascidos de termo. Por isso, nenhuma recomendação pode ser feita quanto ao uso do copo nos recém-nascidos de termo.

Qualidade da evidência

A qualidade da evidência foi considerada muito baixa ou baixa para os seguintes desfechos: ganho de peso, duração da internação hospitalar, não amamentação na alta hospitalar, não amamentação em seis meses de idade, amamentação exclusiva no peito na alta hospitalar e amamentação exclusiva no peito com 6 meses de vida. Os estudos incluídos nesta revisão relatam que muitos recém-nascidos que deveriam receber alimentação suplementar através do copo na realidade receberam alimentação por outros meios pois os pais ou as enfermeiras não gostavam de utilizar os copos.

Notas de tradução

Tradução do Centro Cochrane do Brasil (Atualizado por Andréa Mazzucca). Contato: tradutores@centrocochranedobrasil.org.br

Laički sažetak

Hranjenje šalicom u usporedbi s drugim oblicima dodatnog enteralnog hranjenja novorođenčadi koja ne mogu u potpunosti biti dojena

Istraživačko pitanje

U ovom Cochrane sustavnom pregledu literature analizirani su dokazi koji pokazuju na koji način treba ponuditi dodatnu prehranu djeci rođenoj na termin i nedononoščadi. Postavljeno je pitanje je li bolje hranjenje na šalicu, bočicom ili pomoću cjevčice ako se novorođenčad ne može isključivo dojiti.

Dosadašnje spoznaje

Većina djece koja se rodi na termin ili malo prije termina može se hraniti isključivo dojenjem nakon rođenja. Međutim, zbog niza razloga neka djeca rođena na termin i mnoga nedonošćad se možda ne mogu isključivo dojiti i nužno je davati dohranu drugačijim metodama, kao što je hranjenje na šalicu, pomoću štrcaljke, bočice ili cijevi za hranjenje, dok djeca nisu u mogućnosti isključivo dojiti.

Obilježja uključenih istraživanja

Pretražena je literatura objavljena do 31. siječnja 2016. Pronađeno je 5 odgovarajućih istraživanja. U svima je uspoređeno hranjenje novorođenčadi na šalicu i hranjenje bočicom. Ta su istraživanja provedena na odjelima za neonatologiju i ginekologiju u bolnicama u Australiji, Velikoj Britaniji, Brazilu i Turskoj. Srednja dob većine djece u analiziranim istraživanjima bila je slična prilikom uključenja u istraživanje. U 4 istraživanja je intervencija (šalica ili bočica) počela od trenutka uključenja u istraživanje, kad je djetetu prvi put zatrebala dohrana. Neka su djeca bila u 30. tjednu gestacije. U istraživanju provedenom u Turskoj dodatna prehrana nije započela prilikom uklučenja u istraživanje i u vrijeme prvog davanja dohrane već je odgođeno dok djeca nisu imala najmanje 35 tjedana gestacijske dobi.

Ključni rezultati

Za neke od ishoda rezultati različitih studija nisu se mogli zajednički statistički analizirati. To uključuje sljedeće rezultate: izostanak dojenja pri otpustu iz bolnice, izostanak isključivog dojenja nakon 3 mjeseca i nakon 6 mjeseci, prosječno vrijeme hranjenja i broj dana proveden u bolnici. Za svaki od tih ishoda su rezultati dijela istraživanja pokazali da je bolje ako se dijete hrani na šalicu, dok su rezultati ostalih istraživanja pokazali da je bolja dohrana bočicom.

Za neke od ishoda su se rezultati mogli zajednički analizirati: nije bilo razlika u dobivanju na težini ili gestacijskoj dobi prilikom otpusta iz bolnice između djece hranjene šalicom i one hranjene bočicom. Međutim, djeca koja su dobivala dohranu šalicom imala su veću vjerojatnost da će ih majke isključivo dojiti u vrijeme otpusta iz bolnice te da će barem dijelom biti dojena nakon 3 i 6 mjeseci.

Budući su istraživanja uglavnom uključila nedonoščad i vrlo malo djece rođene na termin, preporuke o hranjenju šalicom djece rođene na termin ne mogu se dati.

Kvaliteta dokaza

Kvaliteta dokaza za dobivanje na težini, duljinu boravka u bolnici, izostanak dojenja pri otpustu iz bolnice i nakon 6 mjeseci te isključivo dojenje pri otpustu dojenja i nakon 6 mjeseci ocijenjena je kao vrlo niska ili niska. U istraživanjima uključenima u ovaj sustavni pregled opisano je da su mnoga djeca koja su dobivala dohranu šalicom također dobivala dodatnu dohranu na drugi način jer se roditeljima ili sestrama nije sviđalo hranjenje pomoću šalice.

Bilješke prijevoda

Hrvatski Cochrane
Prevele: Irena Zakarija-Grković i Livia Puljak
 Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Ringkasan bahasa mudah

Penyusuan menggunakan cawan berbanding bentuk penyusuan enteral tambahan yang lain untuk bayi baru lahir yang tidak dapat menyusu susu ibu sepenuhnya

Soalan semakan:

Bagi kedua-dua bayi yang dilahirkan cukup bulan dan pramatang, kami hendak mengenalpasti kaedah terbaik untuk menawarkan penyusuan tambahan dan melontarkan soalan sama ada penyusuan menggunakan cawan adalah cara penyusuan yang lebih baik untuk penyusuan tambahan berbanding penyusuan dengan menggunakan botol atau tiub, dalam keadaan bayi yang baru lahir tidak dapat menyusu susu ibu dengan sepenuhnya.

Latar belakang:

Kebanyakan bayi yang dilahirkan cukup bulan atau sedikit pramatang boleh menyusu susu ibu dengan sepenuhnya selepas kelahiran. Walau bagaimanapun, atas beberapa sebab tertentu, sesetengah bayi yang cukup bulan dan ramai di antara bayi pramatang yang baru lahir mungkin tidak dapat menyusu susu ibu dengan sepenuhnya dan memerlukan penyusuan tambahan melalui kaedah lain, seperti cawan, picagari, botol atau tiub penyusuan, sehingga mereka dapat menyusu susu ibu dengan sepenuhnya.

Ciri-ciri kajian:

Carian kami yang dijalankan pada 31 Januari 2016 ke atas kajian-kajian yang layak mendedahkan lima kajian, yang kesemuanya membandingkan penyusuan menggunakan cawan dan botol pada bayi yang baru lahir, yang tidak dapat kami masukkan ke dalam semakan ini. Kajian-kajian ini telah dijalankan di unit neonatal dan materniti di hospital-hospital di Australia, United Kingdom, Brazil dan Turki. Min usia kandungan bayi dalam kebanyakan kajian adalah serupa pada masa kemasukan dalam kajian. Dalam empat kajian, intervensi (cawan atau botol) bermula dari masa pendaftaran ke dalam kajian, iaitu apabila bayi pertama kali memerlukan penyusuan tambahan dan berusia seawal 30 minggu kandungan. Dalam kajian yang dijalankan di Turki, penyusuan tambahan tidak bermula pada masa pendaftaran ke dalam kajian mahupun pada masa pertama kali penyusuan tambahan tetapi ditangguhkan sehingga bayi berusia sekurang-kurangnya 35 minggu.

Keputusan utama

Bagi sesetengah hasil kajian, keputusan dari kajian yang berbeza tidak boleh digabungkan. Ini termasuklah tidak menyusu susu ibu pada masa keluar hospital; tidak menyusu ibu secara eksklusif pada tiga bulan dan enam bulan; purata masa yang diambil untuk menyusu; dan bilangan hari berada di hospital. Bagi setiap hasil kajian ini, keputusan daripada beberapa kajian menyebelahi penyusuan dengan cawan, manakala hasil daripada kajian-kajian lain menyebelahi penyusuan botol.

Bagi sesetengah hasil kajian, keputusan kajian yang berbeza boleh digabungkan: tidak ada perbezaan dalam pertambahan berat badan atau usia kandungan pada masa keluar hospital di antara bayi-bayi yang menerima penyusuan tambahan melalui cawan berbanding botol. Walau bagaimanapun, bayi-bayi yang menerima penyusuan tambahan dengan cawan adalah lebih cenderung kepada penyusuan ibu secara eksklusif pada masa keluar hospital dan lebih cenderung untuk menerima beberapa kali penyusuan susu ibu pada usia tiga dan enam bulan.

Oleh sebab kajian-kajian kebanyakannya melibatkan bayi pramatang dan hanya beberapa bayi yang cukup bulan, tiada cadangan boleh dibuat untuk penyusuan menggunakan cawan bagi bayi yang cukup bulan.

Kualiti bukti:

Kualiti bukti untuk penambahan berat badan, tempoh hospitalisasi, tidak diberi penyusuan ibu sewaktu keluar dari hospital dan pada usia enam bulan serta penyusuan ibu secara ekslusif sewaktu keluar hospital dan pada usia enam bulan digredkan sebagai tahap sangat rendah ke rendah. Dalam kajian-kajian yang dimasukkan ke dalam semakan ini, dilaporkan bahawa ramai bayi yang sepatutnya menerima penyusuan tambahan dengan cawan, telah menerima penyusuan tambahan melalui kaedah-kaedah lain kerana sesetengah ibu bapa atau jururawat tidak suka penyusuan dengan cawan.

Catatan terjemahan

Diterjemahkan oleh Foo Sook Lee (Penang Medical College). Untuk sebarang pertanyaan mengenai terjemahan ini sila hubungi fslee@pmc.edu.my. Disunting oleh Ahmad Filza Ismail (Universiti Sains Malaysia).

Streszczenie prostym językiem

Karmienie kubeczkiem, w porównaniu z innymi formami uzupełniającego żywienia dojelitowego u noworodków, u których niemożliwe jest karmienie wyłącznie piersią

Pytanie badawcze:

Chcieliśmy określić najlepszą metodę dokarmiania zarówno noworodków urodzonych o czasie, jak i wcześniaków; w związku z tym postawiliśmy pytanie badawcze: czy u noworodków, których nie można karmić wyłącznie piersią podawanie dodatkowego pokarmu za pomocą kubeczka jest lepsze niż karmienie butelką lub karmienie przez sondę.

Wprowadzenie:

Większość niemowląt urodzonych o czasie, jak również tych, które przyszły na świat nieco przedwcześnie można z powodzeniem karmić po porodzie wyłącznie piersią. Jednak z wielu powodów niektóre noworodki urodzone o czasie oraz duża liczba wcześniaków nie mogą być karmione wyłącznie piersią i wtedy konieczne jest dokarmianie za pomocą alternatywnych metod, takich jak: karmienie kubeczkiem, butelką, za pomocą strzykawki czy też przez sondę, aż do momentu gdy dziecko będzie można karmić wyłącznie piersią.

Charakterystyka badań:

W przeprowadzonym 31 stycznia 2016 roku wyszukiwaniu zidentyfikowaliśmy 5 badań, które odpowiadały tematowi. We wszystkich badaniach włączonych do przeglądu porównano karmienie noworodka za pomocą kubeczka i karmienie butelką. Badania te przeprowadzono na oddziałach noworodkowych oraz położniczych w szpitalach w Australii, Wielkiej Brytanii, Brazylii oraz Turcji. W większości analizowanych badań, średnia wieku ciążowego noworodków w momencie włączenia do badania była podobna. W 4 badaniach stosowanie ocenianych interwencji (karmienie za pomocą kubeczka albo butelki) rozpoczęto w momencie włączenia do badania, kiedy noworodki znajdowały się w 30 tygodniu wieku ciążowego i po raz pierwszy wymagały włączenia dodatkowego żywienia. Natomiast w przypadku badania przeprowadzonego w Turcji, dokarmianie wdrażano nie w momencie włączenia noworodków do badania, ale odraczano je aż do momentu osiągnięcia przez noworodka co najmniej 35. tygodnia wieku ciążowego.

Kluczowe wyniki:

W przypadku niektórych punktów końcowych łączne analizowanie wyników poszczególnych badań włączonych do przeglądu nie było możliwe. Do grupy tej zaliczono: niekarmienie piersią w momencie wypisu ze szpitala, niekarmienie wyłącznie piersią niemowląt w trzecim i w szóstym miesiącu życia; średni czas karmienia oraz liczbę dni spędzonych w szpitalu. W przypadku tych zmiennych, wyniki części badań wskazywały na korzyść z karmienia kubeczkiem, podczas gdy w innych lepsze wyniki zauważano w przypadku dokarmiania butelką.

W przypadku niektórych punktów końcowych wyniki poszczególnych badań można było połączyć. Analiza ta nie wykazała różnic między noworodkami, które dokarmiano za pomocą kubeczka i noworodkami dokarmianymi butelką pod względem przyrostu masy ciała lub pod względem wieku ciążowego w momencie wypisu ze szpitala. Jednak w przypadku noworodków dokarmianych za pomocą kubeczka stwierdzono większe prawdopodobieństwo, że w momencie wypisu ze szpitala będą karmione już wyłącznie piersią oraz że w wieku 3 oraz 6 miesięcy wciąż jeszcze będą karmione piersią.

Ze względu na to, że do badań włączono głównie wcześniaki i niewielką liczbę noworodków urodzonych o czasie, nie można sformułować rekomendacji dotyczących dokarmiania kubeczkiem w odniesieniu do noworodków donoszonych.

Jakość danych naukowych:

Jakość danych naukowych w odniesieniu do: przyrostu masy ciała, długości pobytu w szpitalu, niekarmienia piersią w momencie wypisu ze szpitala oraz w momencie ukończenia przez niemowlę 6. miesiąca życia, a także w odniesieniu do wyłącznego karmienia piersią w momencie wypisu ze szpitala oraz w 6. miesiącu życia niemowlęcia oceniono jako bardzo niską do niskiej. Autorzy badań włączonych do przeglądu wskazali, że wielu noworodkom, które miały być dokarmiane za pomocą kubeczka, podawano pokarm innymi metodami z uwagi na niechęć rodziców lub pielęgniarek do tego sposobu dokarmiania.

Uwagi do tłumaczenia

Tłumaczenie: Joanna Błońska Redakcja: Karolina Moćko

Резюме на простом языке

Кормление с помощью чашки в сравнении с другими формами дополнительного энтерального питания новорожденных, которые не могут находиться на полном грудном вскармливании

Вопрос обзора:

Мы задались целью выявить наилучший метод введения дополнительного питания как для доношенных, так и недоношенных младенцев, а также определить, является ли кормление с помощью чашки наилучшим способом кормления новорожденных младенцев, которые не могут находиться на полном грудном вскармливании, нежели кормление из бутылки или с помощью зонда.

Актуальность:

Большинство младенцев, рожденных в срок или чуть раньше срока, могут сразу после рождения кормиться грудью. Однако по ряду причин некоторые доношенные и многие недоношенные новорожденные не могут находиться на полном грудном вскармливании и требуют дополнительного кормления с использованием альтернативных методов: чашки, шприца, бутылочки или зонда для питания, которые применяются до тех пор, пока младенцы не будут в состоянии перейти на полное грудное вскармливание.

Характеристика исследований:

Наш поиск соответствующих исследований, проведенный 31 января 2016 года, выявил 5 исследований, сравнивших вскармливание новорожденных младенцев с помощью чашки и бутылочки, которые мы смогли включить в этот обзор. Эти исследования были проведены в неонатальных и родильных отделениях больниц Австралии, Великобритании, Бразилии и Турции. Средний гестационный возраст младенцев в большинстве исследований на момент включения в исследование был одинаковым. В четырех исследованиях вмешательство (кормление с помощью чашки или бутылочки) начиналась с момента включения в исследование, когда младенцам впервые потребовалось дополнительное кормление, в 30 недель гестационного возраста. В исследовании, проведенном в Турции, дополнительное кормление не было начато на момент включения в исследование и во время первого дополнительного кормления, но было отложено до того момента, пока младенцам не исполнилось 35 недель.

Основные результаты:

В отношении некоторых из исходов, результаты разных исследований не могут быть объединены. В их число входили отсутствие грудного вскармливания при выписке из больницы; не исключительно грудное вскармливание в 3 и 6 месяцев; среднее время, необходимое для кормления, а также число дней, проведенных в больнице. По каждому из этих исходов результаты некоторых исследований говорят в пользу кормления из чашки, в то время как результаты других - в пользу кормления из бутылочки.

В отношении некоторых исходов, результаты различных исследований могут быть объединены: не было никакой разницы в прибавках веса или гестационном возрасте при выписке младенцев, которые получали дополнительное питание с помощью чашки по сравнению с теми, кто кормился из бутылочки. Однако те младенцы, которые получали дополнительное питание с помощью чашки, с большей вероятностью находились на исключительно грудном вскармливании при выписке из больницы и с большей вероятностью оставались на грудном вскармливании до трех- и шестимесячного возраста.

Так как в большинстве исследований принимали участие недоношенные и всего несколько доношенных младенцев, нельзя дать рекомендации относительно кормления доношенных младенцев с помощью чашки.

Качество доказательств:

Качество доказательств относительно прибавок веса, длительности госпитализации, отсутствия грудного вскармливания при выписке из стационара и в 6-месячном возрасте и эксклюзивного грудного вскармливания при выписке и в возрасте шести месяцев оценивается как низкое и очень низкое. В исследованиях, включенных в этот обзор, сообщается, что многие младенцы, которые получали дополнительное питание с помощью чашки, кормились дополнительно с помощью других средств, так как или родителям, или медсестрам не нравилось кормить из чашки.

Заметки по переводу

Перевод: Алексеева Анастасия Андреевна. Редактирование: Камалова Аэлита Асхатовна и Зиганшина Лилия Евгеньевна. Координация проекта по переводу на русский язык: Cochrane Russia - Кокрейн Россия (филиал Северного Кокрейновского Центра на базе Казанского федерального университета). По вопросам, связанным с этим переводом, пожалуйста, обращайтесь к нам по адресу: cochrane.russia.kpfu@gmail.com; cochranerussia@kpfu.ru

Résumé simplifié

L'alimentation au gobelet par rapport à d'autres formes d'alimentation entérale supplémentaire pour les nouveau-nés incapables de téter correctement au sein

Question de la revue :

Notre but a été d'identifier la meilleure méthode pour offrir une alimentation supplémentaire aux nouveau-nés prématurés et nés à terme. Nous nous sommes également demandé si l'alimentation au gobelet constitue une meilleure façon d'alimentation supplémentaire en comparaison avec l'alimentation par biberon ou l'alimentation par sonde, lorsque les nouveau-nés sont incapables de téter correctement.

Contexte :

La plupart des nourrissons nés à terme ou légèrement prématurés peuvent téter après la naissance. Cependant, pour un certain nombre de raisons, certains bébés nés à terme et un grand nombre de nouveau-nés prématurés peuvent ne pas être en mesure de téter de manière correcte et nécessitent une alimentation supplémentaire par des méthodes alternatives, telles que l'alimentation au gobelet, à la seringue, au biberon ou par sonde, jusqu'à ce qu'ils soient capables de téter correctement.

Caractéristiques de l'étude :

Notre recherche d'études admissibles effectuée le 31 Janvier 2016 a révélé cinq études que nous avons pu inclure dans cette revue, toutes comparant l'alimentation au gobelet à celle au biberon chez des nouveau-nés. Ces études ont été menées dans les unités néonatales et de maternité dans des hôpitaux en Australie, au Royaume-Uni, au Brésil et en Turquie. Au début de l'étude, l'âge gestationnel moyen des nourrissons dans la plupart des études était similaire. Dans quatre de ces études, l'intervention (gobelet ou biberon) a commencé au moment de l'inscription à l'étude, c'est-à-dire, lorsque les enfants ont eu besoin d'une alimentation supplémentaire pour la première fois et lorsque les plus jeunes d'entre eux avaient 30 semaines de gestation. Dans l'étude menée en Turquie, l'observation de l'alimentation supplémentaire n'a pas commencé au moment de l'inscription à l'étude ou au moment de la première alimentation supplémentaire mais, elle a été retardée jusqu'à ce que les nourrissons aient au moins 35 semaines d'âge.

Résultats principaux :

Pour certains critères de jugement, les résultats des différentes études n'ont pas pu être combinés. Cela inclut l'absence d'allaitement à la sortie de l'hôpital ; l'absence d'allaitement exclusif à l'âge de trois et six mois ; le temps moyen nécessaire pour chaque session alimentaire ; ou la durée d'hospitalisation. Pour chacun de ces critères de jugement, les résultats de certaines études ont été en faveur de l'alimentation au gobelet, bien que les résultats provenant d'autres études ont été en faveur de l'alimentation au biberon.

Pour certains critères de jugement, les résultats des différentes études ont pu être combinés : aucune différence n'a été indiquée dans la prise de poids ou dans l'âge gestationnel à la sortie de l'hôpital parmi des nourrissons recevant une alimentation au gobelet comparés à ceux alimentés au biberon. Cependant, les nourrissons ayant reçu une alimentation supplémentaire au gobelet ont été plus susceptibles d'être exclusivement allaités à la sortie de l'hôpital et étaient plus susceptibles de continuer d’être allaités partiellement à l'âge de trois et six mois.

Étant donné que les études ont inclus pour la plupart des nouveau-nés prématurés et peu de nourrissons nés à terme, aucune recommandation ne peut être émise concernant l'alimentation au gobelet chez les nourrissons nés à terme.

Qualité des preuves :

La qualité des preuves concernant la prise de poids, la durée de séjour à l'hôpital, l'absence d'allaitement à la sortie de l'hôpital et à l'âge de six mois et l'allaitement exclusif à la sortie de l'hôpital ainsi qu'à l'âge de six mois est classée de faible à très faible. En effet, dans les études sur lesquelles porte cette revue, il a été rapporté que de nombreux nourrissons étant censés être alimentés au gobelet ont été alimentés par d'autres moyens car les parents ou les infirmières n'aimaient pas l'alimentation au gobelet.

Notes de traduction

Post-édition : Margarita López Mendez (M2 ILTS, Université Paris Diderot)

Laienverständliche Zusammenfassung

Becherfütterung im Vergleich mit anderen Arten zusätzlicher enteraler Ernährung bei Neugeborenen, die nicht voll gestillt werden können

Fragestellung:

Wir wollten die beste Methode für reif geborene und frühgeborene Säuglinge bestimmen, zusätzliche Nahrung anzubieten, und stellten daher die Frage, ob die Becherfütterung eine bessere Möglichkeit der Zufütterung ist als die Flaschenfütterung oder die Sondenfütterung, wenn Neugeborene nicht voll gestillt werden können.

Hintergrund:

Die meisten am Termin oder etwas zu früh geborenen Säuglinge können nach der Geburt voll gestillt werden. Aus verschiedenen Gründen ist es jedoch möglich, dass einige am Termin und viele vor dem Termin geborene Säuglinge nicht voll gestillt werden können und zusätzliche Mahlzeiten brauchen, die mithilfe alternativer Fütterungsmethoden wie Becher, Spritze, Flasche oder Sonde gegeben werden, bis sie voll gestillt werden können.

Studienmerkmale:

Unsere am 31. Januar 2016 durchgeführte Suche nach geeigneten Studien erbrachte fünf Studien, in denen Becher- und Flaschenfütterung bei Neugeborenen miteinander verglichen wurden und die wir in diesen Review einschließen konnten. Die Studien wurden in Neugeborenen- und Wöchnerinnenstationen in Krankenhäusern in Australien, Großbritannien, Brasilien und der Türkei durchgeführt. Das mittlere Gestationsalter der Säuglinge in den meisten Studien bei Eintritt in die Studie war ähnlich. In vier der Studien begann die Intervention (Becher oder Flasche) mit Eintritt in die Studie, als die Säuglinge erstmals eine Zusatzmahlzeit benötigten; das Gestationsalter lag hier teilweise bei nur 30 Wochen. In der Studie, die in der Türkei durchgeführt wurde, begann die zusätzliche Fütterung nicht mit Eintritt in die Studie und der ersten Zusatzmahlzeit, sondern wurde so lange hinausgezögert, bis das Alter der Säuglinge mindestens der vollendeten 35. Schwangerschaftswoche entsprach.

Hauptergebnisse:

Für einige Endpunkte konnten die Ergebnisse der verschiedenen Studien nicht kombiniert werden. Dazu gehörte Nichtstillen bei der Entlassung aus dem Krankenhaus, kein Vollstillen mit drei und sechs Monaten, die durchschnittliche Fütterungsdauer und die Anzahl der im Krankenhaus verbrachten Tage. Bei jedem dieser Endpunkte fielen die Ergebnissen in einigen Studien zugunsten der Becherfütterung aus, in anderen dagegen zugunsten der Flaschenfütterung.

Für einige Endpunkte konnten die Ergebnisse der verschiedenen Studien kombiniert werden: Es gab keinen Unterschied bei der Gewichtszunahme oder dem Gestationsalter bei Entlassung zwischen den Säuglingen, die zusätzlich mit dem Becher gefüttert wurden, und denen, die mit der Flasche gefüttert wurden. Für die Kinder, die Zusatzmahlzeiten aus dem Becher bekamen, bestand jedoch eine höhere Wahrscheinlichkeit, bei der Entlassung aus dem Krankenhaus voll gestillt zu werden sowie mit drei und sechs Monaten noch einige Stillmahlzeiten zu bekommen.

Da an den Studien überwiegend Frühgeborene und nur wenige am Termin geborene Säuglinge teilnahmen, können keine Empfehlungen hinsichtlich der Becherfütterung reif geborener Säuglinge gegeben werden.

Qualität der Evidenz:

Die Qualität der Evidenz für Gewichtszunahme, Länge des Krankenhausaufenthalts, kein Stillen bei Entlassung aus dem Krankenhaus und im Alter von sechs Monaten und Vollstillen bei Entlassung aus dem Krankenhaus und im Alter von sechs Monaten wird als sehr niedrig bis niedrig eingestuft. In den Studien, die in diesen Review eingeschlossen wurden, wird berichtet, dass viele Säuglinge, die zusätzlich mit dem Becher gefüttert werden sollten, Zusatzmahlzeiten über andere Wege erhielten, da entweder die Eltern oder das Pflegepersonal die Becherfütterung ablehnten.

Anmerkungen zur Übersetzung

S. Schmidt-Wussow, freigegeben durch Cochrane Deutschland

Summary of findings(Explanation)

Summary of findings for the main comparison. 
Cup feeding compared with supplemental enteral feeding for newborn infants unable to fully breastfeed

Patient or population: Newborn infants unable to fully breastfeed

Settings: Neonatal and Maternity Units

Intervention: cup feeding

Comparison: supplemental enteral feeding

OutcomesRelative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Weight gain in first 7 days of study (g/day)−0.10 (−0.36, 0.16)522 (one study)⊕⊕⊝⊝
low
The two earlier studies reported g/kg/day
Not breastfeeding at hospital discharge 957 (four studies)⊕⊕⊝⊝
low
Studies have been limited by non-compliance with the intervention.
Not breastfeeding at six monthsRR 0.83 (0.72, 0.95)803 (two studies)⊕⊝⊝⊝
very low
Future studies involving a wide range of gestational age preterm infants with 100% follow-up are likely to impact the estimate of effect.
Not fully breastfeeding at hospital dischargeRR 0.61 (0.52, 0.71)893 (four studies)⊕⊕⊝⊝
low
Studies have been limited by non-compliance with the intervention.
Not fully breastfeeding at six months 803 (two studies)⊕⊝⊝⊝
very low
Future studies involving a wide range of gestational age preterm infants with 100% follow-up are likely to impact the estimate of effect.
Length of stay (days) 823 (two studies)⊕⊕⊝⊝
low
Future studies involving a wide range of gestational age preterm infants with 100% follow-up are likely to impact the estimate of effect.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

Background

Description of the condition

The optimal milk for term and preterm newborn infants is their mother's breast milk; and the ideal way for them to receive breast milk is by sucking on the breast. However, due to a variety of reasons including being born preterm or sick, newborns may not be able to fully breastfeed initially. For these newborns an alternative method for supplemental enteral feeding will be required which may include gastric tube feeding, bottle feeding or cup feeding.

Traditionally, bottles and gastric tubes have been used routinely in neonatal and maternity units to feed newborn 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, and gastric tube feeding does not satisfy the infant's psychological and social needs (Lang 1994b), there are limited options for when the mother is not available to breastfeed. Cup feeding has been suggested as an alternative.

Description of the intervention

Originally, cup feeding was used to feed term infants who were born with oral deformities such as a cleft lip or cleft palate (Fredeen 1948). Instruments to supplementally feed newborns have existed throughout history and include pap bowls (a bowl with a wide brimmed lip); feeding horns (a bowl with a funnel-like horn); cups with lips; and bottles (Foote 1944; Lang 1994a). Cup feeding is successfully used in developing countries where the care and hygiene facilities for bottles and nipples are limited and gastric tubes are not readily available (Dowling 2002; Lang 1994b). Cup feeding is gaining increased use as an alternative feeding method in neonatal and maternity units for preterm and term infants who are unable to fully breastfeed (NANN 2004). It is argued that because cup feeding only requires the infant to 'lap' the milk and then coordinate swallowing and breathing, infants can be fed using a cup from as early as 30 weeks' gestation. In preterm infants, this is generally 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 to 35 weeks of age (Lang 1994a; Lang 1994b; Palmer 1993).

How the intervention might work

The theoretical benefits of cup feeding include avoiding the confusion between breast and bottle (Dowling 2002; Gupta 1999; Thorley 1997); enhancing the infants ability to develop a suckling action for breastfeeding (Thorley 2004); and facilitating the infants ability to self-regulate feeds and demand feed (Vallenas 1998). The Baby Friendly Hospital Initiative (BFHI) training literature and guideline recommend the use of cup feeding for infants intended for breastfeeding, so that no artificial nipples are introduced to infants (Lang 1994b; Vallenas 1998).

The literature suggests that there are many benefits to cup feeding (Cousins 1999; Fredeen 1948; Gupta 1999; Kuehl 1997; Lang 1994a; Lang 1994b): 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 benefits could also be claimed of supplemental enteral feeding including bottle and tube.

Why it is important to do this review

While there may be many benefits of feeding preterm and term newborn infants with a cup, there are also potential risks that need to be considered when introducing this practice into neonatal and maternity units (NANN 2004). Some authors have reported that cup feeding is awkward 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, apnoea, low oxygen saturation) (Freer 1999), and choking and poor weight gain (Kuehl 1997), which can result in extended hospitalizations 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 for the parents and family.

Before the introduction of cup feeding into neonatal and maternity units, this practice must be evaluated for efficacy and safety in terms of clinical outcomes, human resource use, cost and time.

Objectives

To determine the effects of cup feeding versus other forms of supplemental enteral feeding on weight gain and achievement of successful breastfeeding in term and preterm newborn infants that are unable to fully breastfeed.

Further subgroup analysis was planned to determine outcomes according to:

  • gestational age: born preterm (less than 37 weeks' gestation) versus term (greater than or equal to 37 weeks' gestation);

  • oral-facial abnormalities: born with oral-facial abnormalities (e.g. cleft lip or cleft palate or both) versus no oral-facial abnormalities.

Methods

Criteria for considering studies for this review

Types of studies

Randomised and some types of non-randomised (i.e. quasi-randomised) controlled trials that evaluated the effects of cup feeding versus other forms of supplemental enteral feeding in term or preterm newborn infants who are unable to fully breastfeed. Cross-over studies were excluded.

Types of participants

Term and preterm newborn infants, up to 44 weeks' postmenstrual age or 28 days' postnatal age, who were 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

Full breastfeeding is defined in this review as only having breast feeds and no other supplemental feeds.

Primary outcomes
  • Weight gain (g/kg/day)

  • Time to full breastfeeding with acceptable weight gain (15 to 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 outcomes
  • 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, apnoea, low oxygen saturations per infant or per cup feed over the duration of the cup-feeding period, depending on how described in individual studies

  • Gestational age at discharge (weeks)

  • 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 (measured by, for example, the Bayley Scales of Infant and Toddler Development or the Griffiths Mental Development Scales)

  • Death prior to discharge

  • Death by 28 days of age

  • Death by 12 months of age

Search methods for identification of studies

We used the standard methods of the Cochrane Neonatal Review Group guidelines.

Electronic searches

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library, Issue 1, 2016), MEDLINE via PubMed (1948 to 31 January 2016), Embase (1980 to 31 January 2016), and CINAHL (1982 to 31 January 2016), using the search terms Infant, Newborn, Neonatal Intensive Care, Cup feeding, Neonatal, Maternity Units, Postnatal, Oral feeding and Bottle feeding. All languages were included. Full search strategies are detailed in Appendix 1, Appendix 2.

Searching other resources

Published abstracts: we electronically searched the abstracts of the Society for Pediatric Research from 2000 to 2015 through the PAS website (abstract archive). We also searched clinical trials' registries for ongoing or recently completed trials (ClinicalTrials.gov; Controlled-Trials.com; and the World Health Organization (WHO) International Clinical Trials Registry Platform (who.int/ictrp/en/)). The results of the search of trials registries are detailed in Appendix 3, Appendix 4 and Appendix 5.

Data collection and analysis

We used the standard methods of the Cochrane Neonatal Review Group guidelines.

Selection of studies

Independently, two review authors (AF and KN) assessed titles and abstracts of retrieved studies for relevance. After this initial assessment, we retrieved full versions of all potentially eligible studies. Independently, the same two review authors checked the full papers for eligibility and resolved disagreements through discussion. When we could not reach consensus, we consulted the third independent review author (MD).

Data extraction and management

Two of the review authors (AF and KN) independently extracted data. Using an agreed form designed to extract data, we assessed study quality using four key criteria — blinding of allocation, blinding of intervention, completeness of follow up and blinding of outcome measurement — and assigned a rating of 'Yes', 'No' or 'Can't tell' for each. we resolved differences by discussion to reach consensus; and when required we consulted the third independent review author (MD). we contacted the trial authors of studies to clarify published results that were unclear and for missing data.

Assessment of risk of bias in included studies

Two of the three review authors (AF and KN) independently assessed studies for methodological quality and bias using the Cochrane's 'Risk of bias' assessment tool. This tool addresses the following six specific domains and other issues that have the potential to bias the study (Higgins 2011):

  • selection bias

  • performance bias

  • detection bias

  • attrition bias

  • reporting bias

  • or any other bias

We resolved any disagreements by discussion or by consulting a third assessor. See Appendix 6 for a more detailed description of risk of bias for each domain.

Measures of treatment effect

For dichotomous data, we presented results as summary risk ratio (RR) with 95% confidence intervals (CIs). 
For continuous data, we used the mean difference (MD) with 95% CIs if outcomes are measured in the same way between trials.

For individual trials and for continuous variables such as weight gain, we reported MDs and 95% CIs. For categorical outcomes such as mortality, we reported the RR and 95% CIs.

For pooled results, we reported continuous variables, MD and 95% CIs. For categorical outcomes, we reported the RR and 95% CIs. We tested each treatment effect for heterogeneity using the I² test. We used the fixed-effect model for meta-analysis and examined sources of statistical heterogeneity.

Dealing with missing data

We contacted study authors for missing data and to clarify data that was unclear in the published articles. For included studies, we noted levels of attrition.

Review authors extracted data independently and resolved differences by discussion.

Assessment of heterogeneity

We assessed statistical heterogeneity in each meta-analysis using the I² and Chi² statistics. We regarded heterogeneity to be substantial if either I² was greater than or equal to 60% or there was a low P value (less than 0.10) in the Chi² test for heterogeneity (Higgins 2002). 

Assessment of reporting biases

As there were fewer than 10 studies included in analyses we were unable to investigate reporting biases (such as publication bias) using funnel plots.

Data synthesis

We carried out statistical analyses using Review Manager 5 (RevMan) software.

We used fixed-effect meta-analysis where it was reasonable to assume that studies are estimating the same underlying treatment effect: i.e. where studies are examining the same intervention, and the trials' populations and methods are judged to be sufficiently similar.

Quality of evidence

We used the GRADE approach, as outlined in the GRADE Handbook (Schünemann 2013), to assess the quality of evidence for the following (clinically relevant) outcomes: weight in the first seven days of the study (g/day); not breastfeeding at hospital discharge; not breastfeeding at six months; not fully breastfeeding at hospital discharge; not fully breastfeeding at six months; length of stay (days).

Two authors independently assessed the quality of the evidence for each of the outcomes above. We considered evidence from randomised controlled trials as high quality but downgraded the evidence one level for serious (or two levels for very serious) limitations based upon the following: design (risk of bias), consistency across studies, directness of the evidence, precision of estimates, and presence of publication bias. We used the GRADEpro 2008 Guideline Development Tool to create a ‘Summary of findings’ table to report the quality of the evidence.

The GRADE approach results in an assessment of the quality of a body of evidence in one of four grades:

  1. High: We are very confident that the true effect lies close to that of the estimate of the effect.

  2. Moderate: We are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

  3. Low: Our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

  4. Very low: We have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Subgroup analysis and investigation of heterogeneity

Subgroup analyses were planned a priori on the following:

  • Gestational age: born preterm (less than 37 weeks' gestation) versus term (greater than or equal to 37 weeks' gestation);

  • Oral-facial abnormalities: born with oral-facial abnormalities (e.g. cleft lip or cleft palate or both) versus no oral-facial abnormalities

Sensitivity analysis

We planned to carry out sensitivity analyses to explore the effects of adequacy of allocation concealment (including quasi-randomisation) and other risk of bias components, but there were insufficient data to do this. 

Results

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

Results of the search

For the update of this review a further five studies were identified, of which four were excluded (Abouelfettoh 2008; Aloysius 2007; Al-Sahab 2010; Huang 2009); and one was included (Yilmaz 2014) (Figure 1). Therefore the included studies total five and excluded studies total sixteen.

Figure 1.

Study flow diagram: review update

Included studies

The five included studies (Collins 2004; Gilks 2004; Mosley 2001; Rocha 2002; Yilmaz 2014), with a total of 971 participants are described in the Characteristics of included studies.

The studies are RCTs conducted in four countries: the United Kingdom (Gilks 2004; Mosley 2001); Australia (Collins 2004); Brazil (Rocha 2002); and Turkey (Yilmaz 2014, the most recent study).

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 breastfeeds.

Collins 2004 included 319 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 at less than 34 weeks' gestational age were eligible for inclusion in the study and were randomised to supplemental feeds either via a cup or via a 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 54 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.

Participants in Gilks 2004 were 54 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. However 14 infants (11 in cup feeding group and 3 in bottle group) withdrew prior to discharge and data is not presented for these infants. For infants to be eligible for the study, they needed to be born at less than 35 weeks' completed gestation and more than 30 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 postconceptional age at which the nasogastric tube was withdrawn.

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 was a stratified randomised controlled trial; 83 infants were randomised to either cup or bottle, however data for only 78 infants is reported. Infants were between 32 and 36 weeks' gestation and weighing less than 1700 grams. Stratification encompassed three groups: 500 g to 999 g; 1000 g to 1499 g, and 1500 g to 1699 g. 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 breastfed infants.

Yilmaz 2014 conducted a randomised controlled trial in three hospitals in Turkey comparing the effect of cup versus bottle feeding on exclusive breastfeeding rates in infants between 32 and 35 weeks' gestation; however cup feeding was not initiated until infants were 35 weeks of age. Infants became eligible for the study once intermittent feeding by gastric tube had commenced, thus the infants were receiving some breastfeeds. A large number of mothers lived regionally from the recruitment hospitals and were able to visit their infants at least twice per week. Infants were randomised to either bottle or cup feeding and commencement of the allocated feeding method was determined by the attending physician; all infants were late preterm on commencement. A power calculation based on the exclusive breastfeeding rate at six months determined that 766 infants (383 per group) were required. The total number of infants randomised was 607, of which 40 (13%) in the bottle feeding group and 45 (15%) in the cup feeding group were excluded from the analysis due to non-compliance or development of a disease preventing oral feeding. Follow-up was at one week and then monthly until infants were six months of age, at which time breastfeeding status was recorded and compliance to assigned feeding methods was assessed using a questionnaire.

The main outcome measure was weight gain at day seven of the study and the proportion of exclusive or any breastfeeding on discharge. Secondary outcomes included length of stay and prevalence of exclusive or any breastfeeding at three and six months of age.

Excluded studies

Thirteen studies were excluded because they were neither randomised controlled trials nor non-randomised controlled trials that used quasi-randomised group allocation (Abouelfettoh 2008; Aloysius 2007; Al-Sahab 2010; Brown 1999; Davis 1948; Dowling 2001; Dowling 2002; Fredeen 1948; Freer 1999; Gupta 1999; Huang 2009; Malhotra 1999; Marinelli 2001). Howard 1999 was excluded since the study randomised exclusively formula-feeding infants to either bottle or cup (which did not meet our definition for study participants), and an exclusively breastfeeding group of infants were used as a comparison group. Howard 2003 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. One further study — Schubiger 1997 — was excluded as this study did not meet the inclusion criteria for this review as the intervention was supplements by either cup or spoon, not solely via a cup. Reasons for exclusion can be seen in the table 'Characteristics of excluded studies'.

Risk of bias in included studies

Three studies had a high risk of bias and two studies had a low risk of bias (Figure 2; Figure 3).

Figure 2.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Three of the five studies described their method of allocation concealment in detail and specified an adequate method of sequence generation (Collins 2004; Mosley 2001; Yilmaz 2014).

Blinding

The intervention of cup feeding versus other forms of supplemental enteral feeding was not feasible to blind; and although assessment of some outcomes could have been blinded, only Mosley 2001 reported doing so.

Incomplete outcome data

Two studies had complete outcome data (Collins 2004; Mosley 2001). Rocha 2002 enrolled 83 infants, five were excluded, thus data were presented for 78 infants. Of the five infants excluded, two were excluded from the cup-feeding group due to a break in protocol, and three infants from the bottle-feeding group due to reflux and bronchopulmonary dysplasia, although these were not specified as exclusion criteria for enrolment into the study. The outcome data for three-month follow-up does not report number weaned, therefore it is unclear if complete data is presented. Gilks 2004 enrolled 54 infants; however 14 infants were withdrawn post-randomisation, 11 from the cup feeding group and three from the bottle feeding group. Of those who withdrew from the cup-feeding group, eight were because they no longer wished to breastfeed. Yilmaz 2014 analysed data for 522 of the 607 infants randomised. Data analysis was not by intention to treat and the outcome data for 85 infants was not reported. These infants were excluded from the data analysis for either non-compliance or developing a disease that prevented oral feeding for longer than two days.

Selective reporting

One study — Rocha 2002 — was at high risk of selective reporting. Rocha 2002 reported that outcomes would be evaluated monthly until the third month, however no data is reported for the first or second months.

Other potential sources of bias

A self-reporting questionnaire for compliance to the assigned feeding method was used by Yilmaz 2014 during the six months of follow-up which may have introduced response bias. While it is reported that all cup feedings were given by NICU staff nurses or parents the authors report that "the same researcher recorded feed duration for both bottle and cup feeding groups for each patient".

Effects of interventions

See: Summary of findings for the main comparison

Supplemental feed using cup versus bottle (Comparison 01)

Primary Outcome Measures
Weight gain (Outcome 1.1 and Outcome 1.2)

Two studies reported results for weight gain (Rocha 2002; Yilmaz 2014). However Rocha 2002 reports g/kg/day (Analysis 1.1) and Yilmaz 2014 reports g/day (Analysis 1.2). Both studies report no significant difference between groups: Rocha 2002 reports RR of −0.60 (95% CI −3.21 to 2.01); Yilmaz 2014 reports RR of −0.10 (95% CI −0.36 to 0.16).

Proportion not breastfeeding at hospital discharge (Outcome 1.3)

Four studies reported this outcome:

Yilmaz 2014 reported RR of 0.09 (95% CI 0.02 to 0.37);
Collins 2004 reported RR of 0.80 (95% CI 0.56 to 1.14);
Gilks 2004 reported RR of 0.87 (95% CI 0.52 to 1.45); and
Rocha 2002 reported RR of 0.88 (95% CI 0.36 to 2.19).

The meta-analysis (I² = 72%) of the four trials showed a typical RR of 0.64 (95% CI 0.49 to 0.85) demonstrating significant heterogeneity (Analysis 1.3). The results from Yilmaz 2014 included in this meta-analysis indicated higher breastfeeding rates at hospital discharge, however this needs to be considered with caution given the variation in results.

Proportion not breastfeeding at three months of age (Outcome 1.4)

Three studies reported this outcome:

Yilmaz 2014 reported RR of 0.70 (95% CI 0.46 to 1.06);
Collins 2004 reported RR of 0.90 (95% CI 0.75 to 1.09);
Rocha 2002 reported RR of 0.83 (95% CI 0.65 to 1.05).

The meta-analysis (I² = 0%) of the three trials showed a typical RR of 0.83 (CI 0.71 to 0.97) (Analysis 1.4). 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 1.5)

Only two studies reported this outcome:

Yilmaz 2014 reported RR of 0.75 (95% CI 0.59 to 0.95);
Collins 2004 reported RR of 0.90 (95% CI 0.78 to 1.05).

The meta-analysis (I² = 55%) of the two trials showed a typical RR of 0.83 (0.72 to 0.95) (Analysis 1.5). The results from Collins 2004 is an evaluation of infants seen at follow-up, not all infants who were randomised.

Proportion not fully breastfeeding at hospital discharge (Outcome 1.6)

Four studies reported this outcome:

Yilmaz 2014 reported RR of 0.51 (95% CI 0.41 to 0.64);
Collins 2004 reported RR of 0.74 (95% CI 0.58 to 0.95);
Gilks 2004 reported RR of 0.74 (95% CI 0.53 to 1.03);
Mosley 2001 reported RR of 1.33 (95% CI 0.26 to 6.94).

The meta-analysis (I² = 57%) of the four trials showed a typical RR of 0.61 (95% CI 0.52 to 0.71) with a number needed to treat for an additional beneficial outcome (NNTB) of 5 (95% CI 3.6 to 6.8) (Analysis 1.6). 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 1.7)

Only two studies reported this outcome:

Yilmaz 2014 reported RR of 0.43 (95% CI 0.33 to 0.55);
Collins 2004 reported RR of 1.18 (95% CI 0.88 to 1.58).

The intention was to undertake a meta-analysis; however there was considerable variation in results, with substantial heterogeneity (I² = 96%) therefore a meta-analysis was not undertaken.

Proportion not fully breastfeeding at six months of age (Outcome 1.8)

Only two studies reported this outcome:

Yilmaz 2014 reported RR of 0.74 (95% CI 0.62 to 0.88)
Collins 2004 reported RR of 1.31 (95% CI 0.89 to 1.92).

The intention was to undertake a meta-analysis; however there was considerable variation in results, with substantial heterogeneity (I² = 86%) therefore a meta-analysis was not undertaken.

Secondary Outcomes
Average time per feed (minutes) (Outcome 1.9)

Only two studies reported this outcome:

Yilmaz 2014 reported MD of 0.10 (95% CI −0.18 to 0.38);
Rocha 2002 reported MD of −1.60 (95% CI −3.69 to 0.49).

The intention was to undertake a meta-analysis; however there was considerable variation in results, with substantial heterogeneity (I² = 60%) therefore a meta-analysis was not undertaken.

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%) and mean (SD) oxygen saturation in the bottle feeding group was 87.7% (7.6%). The difference between means was not statistically significant. They also reported desaturation episodes of less than 85% and 90%. 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%) or the proportion of infants who had an oxygen saturation less than the cut-off at some stage.

Length of hospital stay (days) (Outcome 1.10)

Yilmaz 2014 reported MD of −0.20 (95% CI −0.58 to 0.18);
Collins 2004 reported MD of 10.08 (95% CI 3.87 to 16.29). 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 to 85) days and in the bottle-feeding group it was 48 (33 to 65) days. On request, the authors provided these data as means and standard deviations.

The intention was to undertake a meta-analysis; however there was considerable variation in results, with substantial heterogeneity (I² = 90%) therefore a meta-analysis was not undertaken.

Gestational age at discharge (Outcome 1.11)

Yilmaz 2014 reported MD of −0.10 (−0.54 to 0.34) for gestational age at discharge (Analysis 1.11).

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; 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 per cent of mothers reported that staff refused to cup feed their infant. Yilmaz 2014 report in the flow diagram that 26 infants in the cup-feeding group and 21 in the bottle-feeding group were excluded for non-compliance and report that a limitation of the study was failure to analyse by intention to treat.

Collins 2004 reported no adverse events and Yilmaz 2014 and Rocha 2002 reported that no case of aspiration and apnoea were observed. Rocha 2002 reported that there was no difference in mean oxygen saturations between cup-fed and bottle-fed infants during feeds.

Discussion

Summary of main results

This review sought to determine the effect of cup feeding as a supplemental feeding method on weight gain and achievement of exclusive breastfeeding in term and preterm infants. We identified five studies that compared cup feeding to other methods of supplemental feeding (e.g. bottle feeding). All five studies enrolled only preterm infants.

Of the five studies, only two reported results for weight gain in the first week (Rocha 2002; Yilmaz 2014), which found no significant difference between the groups.

The results of this update demonstrate considerable variation in results for some breastfeeding outcomes while others showed statistically significant differences favouring cup feeding over bottle feeding. Four studies reported 'not breastfeeding at hospital discharge' (Collins 2004; Gilks 2004; Rocha 2002; Yilmaz 2014); three studies reported 'not breastfeeding at three months' (Collins 2004; Rocha 2002; Yilmaz 2014); two studies reported 'not breastfeeding at six months' (Collins 2004; Yilmaz 2014); four studies reported 'not fully breastfeeding at hospital discharge' (Collins 2004; Gilks 2004; Mosley 2001; Yilmaz 2014); two studies reported 'not fully breastfeeding at three months; or six months' (Collins 2004; Yilmaz 2014). For the important outcomes of exclusive breastfeeding at three and six months the meta-analysis favours cup feeding; however these results should be treated with caution given the high degree of heterogeneity and the very low quality of evidence particularly for these outcomes (Summary of findings for the main comparison).

Further secondary outcomes were average time to feed which was reported in two studies and showed no difference between the two groups (Rocha 2002; Yilmaz 2014). Two studies assessed length of hospital stay and there was considerable variation in results and in the direction of effect (Collins 2004; Yilmaz 2014). Only one study has reported gestational age at discharge which showed no difference between the two groups (Yilmaz 2014).

Overall completeness and applicability of evidence

We found no randomised controlled trials that compared the intervention in the term newborn population. Therefore the results of this review are only applicable to preterm infants.

All of the included trials were conducted in upper-middle income and high-income countries, therefore these data are relevant to current clinical practice in the care of preterm infants in such countries. Evidence was provided on the effect on weight gain and breastfeeding outcomes for preterm infants receiving supplemental feeds by cup. 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.

It is unclear how applicable this evidence is to neonatal care practices in low-income countries and in those countries culturally familiar with traditional implements, such as the paladai cup, compared to 'cups' used in high-income countries. Additionally in those countries with limited or no clean water supplies, or limited sterilisation equipment, cup feeding may still be the practice of choice.

Quality of the evidence

The methodological quality of the included studies was low to very low, suggesting that the results of the meta-analyses need to be treated with extreme caution (Summary of findings for the main comparison).

Generally it was not possible to mask caregivers to the nature of the intervention, thus increasing the likelihood of performance bias. Lack of blinding also increases the likelihood of contamination. All studies included in this review had high rates of contamination in the intervention group, with many infants randomised to the cup-feeding group actually receiving bottle feeds. This may have diluted any effects of cup feeding — both positive and negative. However this may have been due to the impracticality of the intervention: for example in Collins 2004, 56% of those allocated to cup feeding had some bottle feeds (with over 90% of those mothers not liking, or having significant problems with, cup feeding).

There was also little blinding of any outcome assessments in four of the five studies (especially the single dominant study by Collins 2004). Such blinding could have been possible, and if done would have decreased the likelihood of detection bias.

Agreements and disagreements with other studies or reviews

Abouelfettoh 2008 studied cup versus bottle feeding in a preterm population in Egypt. This was a quasi-experimental cohort design. The intention of the study was to report breastfeeding outcomes up to six weeks post hospital discharge. This paper reports a difference between the two groups at one week post discharge only and cites that outcome data up to six weeks was not feasible due to low maternal education. That is, maternal recall regarding breastfeeding practices could not be relied upon over the six weeks. Additionally the authors report that the cup-feeding group displayed more mature breastfeeding behaviours over the six weeks; however this needs to be viewed with caution as only 13 or the 30 infants were assessed at six weeks.

The Baby Friendly Health Initiative (BFHI) is “a global standard based on evidence” WHO 1998. One of the 10 steps of the BHFI initiative includes the need to offer supplemental feeds without the use of bottles and teats and therefore BFHI promotes cup feeding as the alternative when infants are not able to breastfeed (WHO 1998) and that “current evidence related to alternative methods of feeding undergoes extensive review by the World Health Organization” (personal communication, Rachel Ford, Australian College of Midwives). Whilst this is appreciated, there is limited evidence and no high-quality randomised controlled trials involving only term infants in either high- or low-resource settings. In addition there are reports in the literature that cup feeding can create problems in the term population. If accreditation processes such as BFHI state evidence as the basis of practice, the interpretation of current evidence about cup feeding is of a biased perspective. Evidence put forward by BFHI is not 'gold standard' and does not address the issue of increased length of stay and parental choice. Organisations and individuals should be supported in choosing alternative supplemental methods, in addition to cup feeding, until successful breastfeeding can be achieved.

Huang 2009, a longitudinal study undertaken in Northern Taiwan, used questionnaires and telephone calls to obtain information on full-term infant feeding behaviour and mother's milk supply. Exclusively breast-fed infant outcomes were compared to those infants who received supplemental feeds via cup or bottle. Infants were recruited at different times to avoid interaction of the groups. The cup-feeding group was recruited over a one-month period at the end of 2005. The bottle-feeding group was recruited during February 2006. The reported result in the abstract was that "the bottle group was significantly more fretful during breastfeeding". The authors measured negative sucking behaviours, in which there were no difference in negative behaviour on initial feeding or at two and four weeks, only on day 3. Thus it is difficult to ascertain how and when 'fretful' was measured as fretful was not a measured outcome presented in the paper. Additionally the authors conclude that "cup-feeding was better than bottle-feeding", although there is a lack of data in this paper to draw such a conclusion. Furthermore the authors state that they found "no significant correlation between infant feeding method and infant sucking competence". Thus the commentary by Han 2010 reporting that the study by Huang 2009 showed cup-feeding had beneficial effects over bottle feeding needs to be viewed with caution. Additionally the second study referred to in this commentary (Gupta 1999), conducted in India, may suggest that cup feeding is a viable option in under-resourced countries; however the scientific data are inconclusive and further robust, well-designed studies are needed.

Authors' conclusions

Implications for practice

The current evidence from randomised controlled trials does not reliably demonstrate that cup feeding over bottle feeding confers a benefit in maintaining breastfeeding beyond hospital discharge for newborn infants. Supplemental feeding by cup may result in a longer stay in hospital.

Implications for research

While the limitations of the studies included in the review might lead us to conclude that further large high-quality randomised controlled trials should be undertaken in developed countries, 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. Should nipple confusion and supplementation with bottles, and impact on breastfeeding rates and duration remain a concern, then this should be the focus for future research rather than cup feeding. Traditional interventions aimed at maintaining breastfeeding longer term (e.g. early breastfeeds, early and regular skin-to-skin contact, rooming in, non-separation of mother and baby as much as possible, non-introduction of supplemental feeds unless medically indicated, and antenatal breastfeeding education as documented in WHO 1998) should also be given due consideration before further trials of cup feeding are undertaken.

Acknowledgements

Our thanks to Carmel Collins for providing additional data for the initial review.

Data and analyses

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)178Mean Difference (IV, Fixed, 95% CI)-0.60 [-3.21, 2.01]
2 Weight gain in first 7 days of study (g/day)1522Mean Difference (IV, Fixed, 95% CI)-0.10 [-0.36, 0.16]
3 Not breastfeeding at hospital discharge4957Risk Ratio (M-H, Fixed, 95% CI)0.64 [0.49, 0.85]
4 Not breastfeeding at three months3883Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.71, 0.97]
5 Not breastfeeding at six months2803Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.72, 0.95]
6 Not fully breastfeeding at hospital discharge4893Risk Ratio (M-H, Fixed, 95% CI)0.61 [0.52, 0.71]
7 Not fully breastfeeding at three months2 Risk Ratio (M-H, Fixed, 95% CI)Totals not selected
8 Not fully breastfeeding at six months2 Risk Ratio (M-H, Fixed, 95% CI)Subtotals only
9 Average time per feed (minutes)2 Mean Difference (IV, Fixed, 95% CI)Subtotals only
10 Length of stay (days)2 Mean Difference (IV, Fixed, 95% CI)Subtotals only
11 Gestational Age at Discharge1522Mean Difference (IV, Fixed, 95% CI)-0.10 [-0.54, 0.34]
Analysis 1.1.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 1 Weight gain (g/kg/day).

Analysis 1.2.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 2 Weight gain in first 7 days of study (g/day).

Analysis 1.3.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 3 Not breastfeeding at hospital discharge.

Analysis 1.4.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 4 Not breastfeeding at three months.

Analysis 1.5.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 5 Not breastfeeding at six months.

Analysis 1.6.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 6 Not fully breastfeeding at hospital discharge.

Analysis 1.7.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 7 Not fully breastfeeding at three months.

Analysis 1.8.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 8 Not fully breastfeeding at six months.

Analysis 1.9.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 9 Average time per feed (minutes).

Analysis 1.10.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 10 Length of stay (days).

Analysis 1.11.

Comparison 1 Supplemental feed using cup versus bottle, Outcome 11 Gestational Age at Discharge.

Appendices

Appendix 1. Search strategy for CINAHL

Intensive Care Units, Neonatal.mp. or newborn intensive care/ (1912)

1    neonatal intensive care.mp (4894)

2    infant, newborn.mp (53119)

3    cup feeding.mp (27)

4    1 and 3 (7)

5    2 and 3 (20)

6 cup feeding AND newborns (4)

7 cup feeding AND Neonatal (17)

8 cup feeding AND maternity units (3)

9 cup feeding AND postnatal (3)

10 cup feeding AND oral feeding (13)

11 cup feeding AND bottle feeding (40)

Appendix 2. Search strategy for MEDLINE

Intensive Care Units, Neonatal.mp. or newborn intensive care/ (3771)

1    neonatal intensive care.mp (10736)

2    infant, newborn.mp (462199)

3    cup feeding.mp (33)

4    1 and 3 (6)

5    2 and 3 (21)

6 cup feeding AND newborns (2)

7 cup feeding AND Neonatal (10)

8 cup feeding AND maternity units (0)

9 cup feeding AND postnatal (2)

10 cup feeding AND oral feeding (22)

11 cup feeding AND bottle feeding (45)

Appendix 3. Search strategy for http://clinicaltrials.gov

# cup feeding AND infants - result 7

# cup feeding AND newborns - result 1

Appendix 4. Search strategy for http://current controlled-trials.com

# cup feeding AND infants - result 0

# cup feeding AND newborns - result 0

# cup feeding - result 1

Appendix 5. Search strategy for International Clincial Trial Registry Platform (http://who.int/ictrp/en)

#  cup feeding AND newborns - result 0

# cup feeding AND infants - result 1

#  cup feeding - result 2

Appendix 6. Risk of bias tool

1. Sequence generation: was the allocation sequence adequately generated? For each included study we described the method used to generate the allocation sequence.
We assessed the methods as:

  • low risk (any truly random process, e.g. random number table; computer random number generator);

  • high risk (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);

  • unclear risk.

2. Allocation concealment: Was allocation adequately concealed? For each included study, we described the method used to conceal the allocation sequence and determined whether intervention allocation could have been foreseen in advance of, or during recruitment, of changed after assignment.
We assessed the methods as:

  • low risk (e.g. telephone or central randomisation; consecutively numbered sealed opaque envelopes);

  • high risk (open random allocation; unsealed or non-opaque envelopes, alternation; date of birth);

  • unclear risk.

3. Blinding of participants, personnel and outcome assessors: was knowledge of the allocated intervention adequately prevented during the study? Of the four included studies blinding of the intervention was not possible for participants or personnel. However blinded assessment of some outcome measures were possible.

4. Incomplete outcome data: were incomplete outcome data adequately addressed? For each included study and for each outcome, we described the completeness of data including attrition and exclusions from the analysis. We stated whether attrition and exclusions were reported, the numbers included in the analysis at each stage (compared with the total randomised participants), reasons for attrition or exclusion where reported, and whether missing data were balanced across groups or were related to outcomes.
We assessed the methods as:

  • low risk;

  • high risk;

  • unclear risk.

5. Selective outcome reporting: are reports of the study free of suggestion of selective outcome reporting? For each included study we described how we examined the possibility of selective outcome reporting bias and what we found.
We assessed the methods as:

  • low risk (where it is clear that all of the study's pre-specified outcomes and all expected outcomes of interest to the review have been reported);

  • high risk (where not all the study's pre-specified outcomes have been reported; one or more reported primary outcomes were not pre-specified; outcomes of interest are reported incompletely and so cannot be used; study fails to include results of a key outcome that would have been expected to have been reported);

  • unclear risk.

6. Other sources of bias: Was the study apparently free of other problems that could put it at a high risk of bias? For each included study, we described any important concerns regarding other possible sources of bias.
We assessed whether each study was free of other problems that could put it at risk of bias:

  • low risk;

  • high risk;

  • unclear risk.

Feedback

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, breast fed 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 randomized 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 randomized 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 gestational age) who are unable to fully breastfeed. The authors have the view that term infants who can be fully breast fed 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

DateEventDescription
6 February 2017AmendedAdd external source of support

History

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

DateEventDescription
22 April 2016New citation required but conclusions have not changedThis updates the review 'Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed' (Flint 2007). Protocol indicated would report secondary outcome of postnatal age at discharge; changed to report gestational age at discharge,
31 January 2016New search has been performedUpdated literature searches were performed in January 2016.
Protocol indicated would report secondary outcome of postnatal age at discharge; changed to report gestational age at discharge.
8 May 2013Amended

Change of wording. The term nurseries did not adequately convey that all infants in neonatal units and maternity units in which trials have been conducted would be included in this review. Therefore the word nurseries/nursery has been changed to neonatal unit and maternity units.

Change of wording. Due to feedback regarding that this review did not include term infants, there appears to be some confusion over the use of the word newborn especially referring to preterm infants only. Therefore the term 'newborn' has been replaced with term and preterm infants.

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

Contributions of authors

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

None

Sources of support

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

  • Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA.

    Editorial support of the Cochrane Neonatal Review Group has been funded with Federal funds from the Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA, under Contract No. HHSN275201100016C

  • National Institute for Health Research, UK.

    Editorial support for Cochrane Neonatal has been funded with funds from a UK National Institute of Health Research Grant (NIHR) Cochrane Programme Grant (13/89/12). The views expressed in this publication are those of the authors and not necessarily those of the NHS, the NIHR, or the UK Department of Health.

Differences between protocol and review

We added the methodology and plan for 'Summary of findings' tables and GRADE recommendations, which were not included in the original protocol nor in the last version of the review.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Collins 2004

MethodsRandomised Controlled Trial.
Allocation concealment (blinding of randomisation): yes
Blinding of intervention: no
Completeness of follow up: yes
Blinding of outcome measurement: no
Participants319 preterm infants randomised (cup-feeding group n = 161; bottle-feeding group n = 158) (mean gestational ages 29.3 and 30.0 weeks); conducted in Australia; involved 2 tertiary hospitals and 54 peripheral hospitals (this number of peripheral hospitals were involved as they were the receiving hospitals for the babies from the tertiary hospitals).
Eligibility criteria: preterm infants less than 34 weeks' gestational age whose mothers wanted to breastfeed.
InterventionsRandomised to supplemental feeds via cup or bottle
OutcomesNot breastfeeding at hospital discharge: number assessed - cup-feeding group N = 151; bottle-feeding group N = 152.
Not breastfeeding at 3 months: number assessed - cup-feeding group N = 144; bottle-feeding group N = 139
Not breastfeeding at 6 months: number assessed - cup-feeding group N = 142; bottle-feeding group N = 139
Not fully breastfeeding at hospital discharge: number assessed - cup-feeding group N = 151; bottle-feeding group N = 152
Not fully breastfeeding at 3 months: number assessed - cup-feeding group N = 144; bottle-feeding group N = 139
Not fully breastfeeding at 6 months: number assessed - cup-feeding group N = 142; bottle-feeding group N = 139
Length of hospital stay: number assessed - cup-feeding group N = 149; bottle-feeding group N = 152
NotesResults are an evaluation of infants followed at 3 and 6 months and not all infants randomised
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"an independent researcher developed a separate randomisation schedule for each recruiting hospital by using a random number table to select balanced blocks of varying size with stratification for gestation"
Allocation concealment (selection bias)Low risk"assignments were sealed in sequentially numbered opaque envelopes"
Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the intervention, participants and personnel cannot be blinded
Blinding of outcome assessment (detection bias)
All outcomes
High risk"data entry and analysis were undertaken unblinded"
Incomplete outcome data (attrition bias)
All outcomes
Low risk 
Selective reporting (reporting bias)Low riskAll outcomes reported

Gilks 2004

MethodsRandomised Controlled Trial
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
Participants54 preterm infants randomised (cup-feeding group n = 27; bottle-feeding group n = 27) (mean gestational ages 31.0 and 32.0 weeks); conducted in the UK; single centre trial
Eligibility criteria: preterm infants who were less than 35 weeks' completed gestation and more than 30 weeks' gestation whose mothers intended to breastfeed.
InterventionsRandomised to supplemental feeds via cup or bottle
OutcomesNot breastfeeding at hospital discharge
Not fully breastfeeding at hospital discharge
Breast feeding rates: at term; at six weeks post-term and post-conceptual age.
Notes11 mothers in the cup-feeding group withdrew prior to discharge and 3 in the bottle-feeding group yet data have been presented as number assessed at discharge as 27 in each group. Total number assessed for each outcome is unclear.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"randomised, non-blinded, stratified controlled trial"
Allocation concealment (selection bias)Unclear risk"concealed cards in envelopes"
Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the intervention, participants and personnel cannot be blinded
Blinding of outcome assessment (detection bias)
All outcomes
High riskThis was an "unblinded randomised trial"
Incomplete outcome data (attrition bias)
All outcomes
High riskMore than 25% withdrew from the study
Selective reporting (reporting bias)Low riskAll outcomes reported

Mosley 2001

MethodsRandomised Controlled Trial
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: yes
Participants16 preterm infants (cup-feeding group n = 8; bottle-feeding group n = 8) (mean gestational age of 35.2 to 35.5 weeks); conducted in the UK; single centre trial
Eligibility criteria: preterm infants who were between 30 and 37 weeks' gestation, admitted to the special care nursery, whose mothers intended to breastfeed.
InterventionsRandomised to supplemental feeds via cup or bottle
OutcomesNot fully breastfeeding at hospital discharge: number assessed - cup-feeding group N = 6; bottle-feeding group N = 8.
Notes2 infants (randomised to cup-feeding group) were excluded as they had been given a supplementary feed prior to starting cup feeds.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low risk"control and intervention details (10 of each) placed in envelopes and then shuffled thoroughly and then the envelopes were numbered sequentially"
Allocation concealment (selection bias)Low risk"sealed, sequentially numbered, opaque envelope"
Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the intervention, participants and personnel cannot be blinded
Blinding of outcome assessment (detection bias)
All outcomes
Low risk"Blinded assessment of outcome was undertaken by a midwife who was unaware of the study's purpose"
Incomplete outcome data (attrition bias)
All outcomes
Low risk 
Selective reporting (reporting bias)Low riskAll outcomes reported

Rocha 2002

MethodsRandomised Controlled Trial
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
Participants83 preterm infants (cup-feeding group n = 46; bottle feeding-group n = 37) (mean gestational age of 32.5 to 32.7 weeks); conducted in Brazil; single centre trial
Eligibility criteria: preterm infants who were born between 32 and 36 weeks' gestation, and weighing less than 1700 g, admitted to the intensive care nursery, whose mothers intended to breastfeed.
InterventionsRandomised to supplemental feeds via cup or bottle
OutcomesNot breastfeeding at hospital discharge: number assessed - cup-feeding group N = 44; bottle-feeding group N = 34.
Not breastfeeding at 3 months: number assessed - cup-feeding group N = 44; bottle-feeding group N = 34.
Weight gain: number assessed - cup-feeding group N = 44; bottle-feeding group N = 34.
Average time per feed: number assessed - cup-feeding group N = 44; bottle-feeding group N = 34.
Other outcomes assessed: differences between oxygen saturation levels in bottle, cup and breastfed infants.
Notes3 infants excluded from the bottle-feeding group for medical and social reasons and 2 from the cup-feeding group due to break of protocol
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Unclear risk"controlled experimental study with stratified randomisation" "within each stratum, the infants were randomly assigned to 1 of 2 feeding groups by drawing lots"
Allocation concealment (selection bias)Unclear riskNot stated
Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the intervention, participants and personnel cannot be blinded
Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot stated
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot clearly stated, report on only those that attended the outpatient clinic.
Selective reporting (reporting bias)High riskDo not report outcomes for each of the monthly visits

Yilmaz 2014

Methods

Randomised Controlled Trial
Allocation concealment (blinding of randomisation): yes (sequentially numbered, opaque envelopes
Blinding of intervention: no
Completeness of follow up: yes at hospital discharge, data collected at 3 and 6 months

Eligibility criteria: preterm infants were singletons, between 32 to 35 weeks' gestation, maternal intention to breastfeed, no supplemental oxygen and being fed intermittently by a nasogastric tube.

The calculated sample size was not achieved.

ParticipantsPreterm infants of 32 to 35 weeks' gestation fed only by intermittent gastric tube at the time of recruitment; mean gestational ages 32.8 and 32.8 weeks; 607 infants were randomly assigned to 2 groups: the cup-fed group (n = 299) and bottle-fed group (n = 308). Conducted in Turkey in 3 neonatal intensive care units.
InterventionsRandomised to cup or bottle supplemental feeding.
Outcomes

Weight gain (gram per day) at day 7 of the study: number assessed - cup feeding N = 254, bottle feeding N = 268

Exclusive Breasfeeding at discharge: number assessed - cup feeding N = 254, bottle feeding N = 268

Exclusive breastfeeding at 3 months: number assessed - cup feeding N = 254, bottle feeding N = 268

Exclusive breastfeeding at 6 months: number assessed - cup feeding N = 254, bottle feeding N = 268

Length of stay: number assessed - cup feeding N = 254, bottle feeding N = 268

Feeding time, min/feeding in the first week of life: number assessed - cup feeding N = 254, bottle feeding N = 268

Gestational age at discharge: number assessed - cup feeding N = 254, bottle feeding N = 268

NotesThe primary author was contacted to confirm that 100% of infants were followed up at 3 and 6 months for any breastfeeding and exclusive breastfeeding. The primary author confirmed via e-mail that 100% of infants were followed up at 3 and 6 months for any breastfeeding and exclusive breastfeeding. Initiation of cup feeding commenced when infants were 35 weeks.
Risk of bias
BiasAuthors' judgementSupport for judgement
Random sequence generation (selection bias)Low riskAn Independent researcher developed a separate randomisation schedule for each recruiting hospital by using a random number table to select balanced blocks and stratification for gestation.
Allocation concealment (selection bias)Low riskSealed sequentially numbered opaque envelopes.
Blinding of participants and personnel (performance bias)
All outcomes
High riskDue to the nature of the intervention, participants and personnel cannot be blinded.
Blinding of outcome assessment (detection bias)
All outcomes
High riskResearcher recorded the duration of feeds whilst in hospital and collected follow-up questionnaires and interview data for all infants.
Incomplete outcome data (attrition bias)
All outcomes
Unclear riskIt is not clearly described that 100% follow-up was achieved for mothers and infants at 3 and 6 months. Also data on number of infants by gestational age group stratification is not reported.
Selective reporting (reporting bias)High riskWeight and breastfeeding status were to be recorded at follow-up but weight data was not reported post 7 days.

Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion
Abouelfettoh 2008Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A quasi-experimental cohort design.
Al-Sahab 2010Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A cross-sectional study.
Aloysius 2007Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. An observational study.
Brown 1999Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A retrospective chart review.
Davis 1948Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation.
Dowling 2001Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. Descriptive literature on nipple confusion and alternative feeding methods.
Dowling 2002Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A non-experimental convenience sample.
Fredeen 1948Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A descriptive report on experience with cup feeding of newborn infants.
Freer 1999Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A convenience sample of newborn infants exposed to breast and cup feeding.
Gupta 1999Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A retrospective chart review.
Howard 1999A randomised controlled trial of formula feeding infants only. Infants randomised to either receive feeds via cup or bottle. A group of exclusively breastfeeding infants were used as a comparison group.
Howard 2003This study did not meet the inclusion criteria for this review as participants were not infants that were unable to fully breastfeed. Participants were infant-mother dyads. Unborn infants were randomised on maternal admission to either early or late pacifier use or cup or bottle supplemental feeding if required. A large proportion of the babies randomised were part of the study because of maternal choice to offer supplemental feeds not because the infants were unable to fully breastfeed.
Huang 2009Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. A prospective longitudinal study.
Ize-Iyamu 2011This study did not meet the inclusion criteria for this review as participants received supplements by either a syringe (intervention group) or cup and spoon (control group). The intervention did not include supplementation solely via a cup.
Malhotra 1999Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. Cross-over design was employed.
Marinelli 2001Was neither a randomised controlled trial nor a non-randomised controlled trial using quasi-randomised group allocation. Cross-over design was employed.
Schubiger 1997This study did not meet the inclusion criteria for this review as participants received supplements by either cup or spoon (intervention group) or by bottle after breastfeeding (control group). Data were not presented for those supplemented by cup alone and therefore we were unable to elicit data for those infants who received supplementation solely via a cup.

Characteristics of studies awaiting assessment [ordered by study ID]

NCT00703950

MethodsRandomised block design
ParticipantsInfants: very low birthweight, < 1500 grams and between 26 and 32 weeks' gestation. Enrolled 56 infants
InterventionsCup feeding and bottle feeding
Outcomes

Primary outcome: Sucking patterns after use of bottle or cup

Secondary outcomes: Weight gain, days of life to begin full oral feeding, length of hospital stay and breast feeding rates

NotesStudy details listed at URL: ClinicalTrials.gov/show/NCT00703950. Study completion date: December 2013. Author contacted 28 February 2016

Puapornpong 2015

MethodsSimple randomisation method
ParticipantsNewborns weighing > 2500 grams with no complications
InterventionsFeeding tube (intervention group), cup feedings (control group)
OutcomesLatch scores were significantly higher in the tube-feeding group
NotesAuthor contacted on 28 February 2016, awaiting further clarification on randomisation and data

Ancillary