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Retiro del biberón durante la introducción de la lactancia materna en lactantes prematuros

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Referencias

Referencias de los estudios incluidos en esta revisión

Collins 2004 {published data only}

Collins CT. Does the use of artificial teats (dummy or bottle) affect breast feeding success in preterm infants? A randomised controlled trial and systematic review. PhD thesis. The University of Adelaide.2004. CENTRAL
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 randomised controlled trial. British Medical Journal 2004;329(7459):193‐8. CENTRAL

Gilks 2004 {published and unpublished data}

Gilks J, Watikinson M. Improving breast feeding rates in preterm babies: cup feeding versus bottle feeding. Journal of Neonatal Nursing 2004;10:118‐20. CENTRAL

Kliethermes 1999 {published and unpublished data}

Kliethermes PA, Cross ML, Lanese MG, Johnson KM, Simon SD. Transitioning preterm infants with nasogastric tube supplementation: increased likelihood of breastfeeding. Journal of Obstetric, Gynecologic, and Neonatal Nursing 1999;28(3):264‐73. CENTRAL

Mosley 2001 {published data only}

Mosley C, Whittle C, Hicks C. A pilot study to assess the viability of a randomised controlled trial of methods of supplementary feeding of breast‐fed pre‐term babies. Midwifery 2001;17(2):150‐7. CENTRAL

Rocha 2002 {published data only}

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(2):132‐8. CENTRAL

Simmer 2016 {published data only}

Simmer K, Kok C, Nancarrow K, Hepworth AR. Improving transition time from tube to sucking feeds in breastfeeding preterm infants ‐ novel teat study. Journal of Paediatrics and Child Health 2013;S2:71. CENTRAL
Simmer K, Kok C, Nancarrow K, Hepworth AR, Geddes DT. Novel feeding system to promote establishment of breast feeds after preterm birth: a randomized controlled trial. Journal of Perinatology 2016;36(3):210‐5. CENTRAL

Yilmaz 2014 {published data only}

Yilmaz G, Caylan N, Karacan CD, Bodur I, Gokcay G. Effect of cup feeding and bottle feeding on breastfeeding in late preterm infants: a randomized controlled study. Journal of Human Lactation 2014;30(2):174‐9. CENTRAL

Referencias de los estudios excluidos de esta revisión

Abouelfettoh 2008 {published data only}

Abouelfettoh AM, Dowling DA, Dabash SA, Elguindy SR, Seoud IA. Cup versus bottle feeding for hospitalized late preterm infants in Egypt: a quasi‐experimental study. International Breastfeeding Journal 2008;3:27. CENTRAL

Aloysius 2007 {published data only}

Aloysius A, Hickson M. Evaluation of paladai cup feeding in breast‐fed preterm infants compared with bottle feeding. Early Human Development 2007;83(9):619‐21. CENTRAL

Aytekin 2014 {published data only (unpublished sought but not used)}

Aytekin A, Albayrak EB, Küçükoğlu S, Caner İ. The effect of feeding with spoon and bottle on the time of switching to full breastfeeding and sucking success in preterm babies. Turk Pediatri Arsivi 2014;49(4):307‐13. CENTRAL

De Aquino 2009 {published data only}

De Aquino RR, Osório MM. Relactation, translactation, and breast‐orogastric tube as transition methods in feeding preterm babies. Journal of Human Lactation 2009;25(4):420‐6. CENTRAL

Harding 2014 {published data only}

Harding C, Frank L, Van Someren V, Hilari K, Botting N. How does non‐nutritive sucking support infant feeding?. Infant Behavior & Development 2014;37(4):457‐64. CENTRAL

Kumar 2010 {published data only}

Kumar A, Dabas P, Singh B. Spoon feeding results in early hospital discharge of low birth weight babies. Journal of Perinatology 2010;30(3):209‐17. CENTRAL

Lau 2012 {published data only}

Lau C, Smith EO. Interventions to improve the oral feeding performance of preterm infants. Acta Paediatrica 2012;101(7):e269‐74. CENTRAL

Lopez 2014 {published data only}

López CP, Chiari BM, Goulart AL, Furkim AM, Guedes ZCF. Assessment of swallowing in preterm newborns fed by bottle and cup [Avaliação da deglutição em prematuroscom mamadeira e copo]. CoDAS 2014;26(1):81‐6. CENTRAL

Marofi 2016 {published data only}

Marofi M, Abedini F, Mohammadizadeh M, Talakoub S. Effect of palady and cup feeding on premature neonates’ weight gain and reaching full oral feeding time interval. Iranian Journal of Nursing and Midwifery Research 2016;21(2):202‐6. CENTRAL

Ronan 2013 {published data only}

Ronan CB. Making STARs: reaching successful transition to at‐breast feeds in the premature infant. Journal of Neonatal Nursing 2013;19(4):206‐12. CENTRAL

Referencias de los estudios en espera de evaluación

Garpiel 2012 {published data only}

Garpiel SJ. Premature Infant Transition to Effective Breastfeeding: A Comparison of Four Supplemental Feeding Methods. JOGN Nursing; Journal of Obstetric, Gynecologic, and Neonatal Nursing 2012;41(s1):S143. CENTRAL

Bier 1993

Bier JB, Ferguson A, Anderson L, Solomon E, Voltas C, Oh W, et al. Breast‐feeding of very low birth weight infants. Journal of Pediatrics 1993;123(5):773‐8.

Blaymore Bier 1997

Blaymore Bier JA, Ferguson AE, Morales Y, Liebling JA, Oh W, Vohr BR. Breastfeeding infants who were extremely low birth weight. Pediatrics 1997;100(6):E3.

Bu'Lock 1990

Bu'Lock F, Woolridge MW, Baum JD. Development of co‐ordination of sucking, swallowing and breathing: ultrasound study of term and preterm infants. Developmental Medicine and Child Neurology 1990;32(8):669‐78.

Chen 2000

Chen CH, Wang TM, Chang HM, Chi CS. The effect of breast‐ and bottle‐feeding on oxygen saturation and body temperature in preterm infants. Journal of Human Lactation 2000;16(1):21‐7.

Collins 2008

Collins CT, Makrides M, Gillis J, McPhee AJ. Avoidance of bottles during the establishment of breast feeds in preterm infants. Cochrane Database of Systematic Reviews 2008, Issue 4. [DOI: 10.1002/14651858.CD005252.pub2]

Dowling 2002

Dowling DA, Meier PP, DiFiore JM, Blatz M, Martin RJ. Cup‐feeding for preterm infants: mechanics and safety. Journal of Human Lactation. 2002;18(1):13‐20.

Freer 1999

Freer Y. A comparison of breast and cup feeding in preterm infants: effect on physiological parameters. Journal of Neonatal Nursing 1999;5:16‐21.

Geddes 2012

Geddes DT, Sakalidis VS, Hepworth AR, McClellan HL, Kent JC, Lai CT, et al. Tongue movement and intra‐oral vacuum of term infants during breastfeeding and feeding from an experimental teat that released milk under vacuum only. Early Human Development 2012;88(6):443‐9.

GRADEpro 2008 [Computer program]

Brozek J, Oxman A, Schünemann H. GRADEpro. Version 3.2 for Windows. The GRADE Working Group, 2008.

Gupta 1999

Gupta A, Khanna K, Chattree S. Cup feeding: an alternative to bottle feeding in a neonatal intensive care unit. Journal of Tropical Pediatrics 1999;45(2):108‐10.

Healow 1995

Healow LK. Finger‐feeding a preemie. Midwifery Today and Childbirth Education 1995;33:9.

Higgins 2011

Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. handbook.cochrane.org.

Kuehl 1997

Kuehl J. Cup feeding the newborn: what you should know. Journal of Perinatal and Neonatal Nursing 1997;11:434‐8.

Kurokawa 1994

Kurokawa J. Finger‐feeding a preemie. MIDIRS Midwifery Digest 1994;5:210‐1.

Labbok 1990

Labbok M, Krasovec K. Toward consistency in breastfeeding definitions. Studies in Family Planning 1990;21(4):226‐30.

Lang 1994a

Lang S, Lawrence CJ, Orme RL. Cup feeding: an alternative method of infant feeding. Archives of Disease in Childhood 1994;71(4):365‐9.

Lang 1994b

Lang S. Cup‐feeding: an alternative method. Midwives Chronicle 1994;107(1276):171‐6.

Lang 1997

Lang S. Alternative methods of feeding and breastfeeding. Breastfeeding Special Care Babies. London: Bailliere Tindall, 1997.

Lemons 1996

Lemons PK, Lemons JA. Transition to breast/bottle feedings: the premature infant. Journal of the American College of Nutrition 1996;15(2):126‐35.

Malhotra 1999

Malhotra N, Vishwambaran L, Sundaram KR, Narayanan I. A controlled trial of alternative methods of oral feeding in neonates. Early Human Development 1999;54:29‐38.

Neifert 1995

Neifert M, Lawrence R, Seacat J. Nipple confusion: toward a formal definition. The Journal of Pediatrics 1995;126(6):S125‐9.

Schünemann 2013

Schünemann H, Brożek J, Guyatt G, Oxman A, editors. GRADE Working Group. GRADE handbook for grading quality of evidence and strength of recommendations. www.guidelinedevelopment.org/handbook.Updated October 2013.

Stine 1990

Stine MJ. Breastfeeding the premature newborn: a protocol without bottles. Journal of Human Lactation 1990;6(4):167‐70.

Young 1995

Young S. The effect of feeding method on the oxygen saturation of the premature infant. Neonatal Network Journal of Neonatal Nursing 1995;14(4):59.

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Collins 2004

Methods

Randomised controlled trial, stratified by gestational age < 28 weeks and 28 to < 34 weeks and by study centre. Study duration ‐ 3 years, 1996 to 1999

Participants

Two Australian Neonatal Intensive Care Units

Inclusion criteria: gestational age < 34 weeks (experimental: mean 29.4 weeks, SD 2.6, range 23 to 33; control: mean 30.0 weeks, SD 2.5, range 24 to 33), mother wishes to breast feed, infant had not been fed by cup or bottle, no congenital abnormality precluding sucking feeds, dummy use ≤ 48 hours

Sample size: 319 randomised (161 experimental/cup, 158 control/bottle). 303 included in analysis (151 experimental/cup, 152 control/bottle)

Interventions

Randomised to cup/no dummy, cup/dummy, bottle/no dummy, bottle/dummy

Experimental: supplementary feeds given by cup according to Lang 1994b recommendations; 60 mL medicine cup used

Control: supplementary feeds given by bottle

Both groups: Infants breast fed when mother was present; cup/bottle was used in addition to nasogastric tube.

Outcomes

Breast feeding prevalence any and full at discharge, and 'all' and any at 3 and 6 months; days to all sucking feeds; length of hospitalisation; weight gain from birth to discharge home; necrotising enterocolitis

Notes

Initial analyses showed no clinically important nor significant interaction between use of cups and dummies; therefore, additional comparisons were performed on marginal groups with cup vs bottle.

High proportion of non‐compliance: experimental group: 85/151 (46%) had a bottle introduced; control group: 1/152 (0.7%) had a cup introduced. Participants were analysed in the groups to which they were randomised regardless of the intervention they actually received.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "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 (< 28 weeks, 28 ‐ < 34 weeks)".

Allocation concealment (selection bias)

Low risk

Quote: "Assignments were sealed in sequentially numbered, opaque envelopes. Researchers determined allocation by telephoning an independent ward, available 24 hours a day, within the recruiting hospitals".

Blinding (performance bias and detection bias)
All outcomes

High risk

Quote: "Particpants, care providers, and researchers were not blinded to treatment allocation; data entry and analysis were undertaken unblinded".

Comment: blinding of intervention not possible

Incomplete outcome data (attrition bias)
On discharge home

Low risk

Missing outcome data (n = 16, 5%) due to attrition (experimental 10, control 6):

  • Deaths 4: experimental 8, control 4

  • Withdrawals 4: 2 in each group

Comment: low risk of bias due to incomplete outcome data

Incomplete outcome data (attrition bias)
3 months post discharge

Low risk

Missing outcome data (n = 36, 11%) due to attrition (experimental 17, control 19):

  • Deaths 4: experimental 8, control 4

  • Withdrawals 4: 2 in each group

  • Inability to locate 20: experimental 7, control 13

Comment: low risk of bias due to incomplete outcome data

Incomplete outcome data (attrition bias)
6 months post discharge

Low risk

Missing outcome data (n = 38, 12%) due to attrition (experimental 19, control 19):

  • Deaths 4: experimental 8, control 4

  • Withdrawals 4: 2 in each group

  • Inability to locate 22: 9 experimental, 13 control

Comment: low risk of bias due to incomplete outcome data

Selective reporting (reporting bias)

Low risk

Before clinical trial registration requirements; however, outcomes reported as per PhD thesis

Other bias

Low risk

Gilks 2004

Methods

Randomised controlled trial, stratified by gestational age < 31 weeks and 31 to < 35 weeks. Study duration ‐ 2 years, 2002 to 2004

Participants

Single centre, Neonatal Intensive Care Unit, UK

Inclusion criteria: < 35 weeks' gestation (experimental: median 31 weeks, range 25 to 34; control: median 32 weeks, range 26 to 34 weeks), > 30 weeks' postmenstrual age at trial entry, ability to tolerate full strength, full volume of nasogastric feeds for 48 hours or longer, anticipated stay ≥ 1 week, mother's intention to breast feed

Sample size: 54 randomised, 54 included in analysis (additional information from study author). Number randomised to each group: 27 (experimental/cup), 27 (control/bottle)

Interventions

Experimental: supplementary feeds given by cup when mother not present to breast feed

Control: supplementary feeds given by bottle when mother not present to breast feed

Both groups: Infants breast fed when mother was present; cup/bottle was used in addition to nasogastric tube.

Outcomes

Breast feeding prevalence any and full on discharge home, at term and at 6 weeks post term; postmenstrual age at nasogastric tube withdrawal

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Unclear risk

Quote: “randomized, non‐blinded stratified controlled trial"

Comment: unable to determine whether sequence generation was adequate

Allocation concealment (selection bias)

Low risk

Quote: "randomization was by selection of concealed cards in envelopes, stratified by gestation"

Blinding (performance bias and detection bias)
All outcomes

High risk

Quote: “randomized, non‐blinded stratified controlled trial"

Quote (from correspondence): "No one was blinded in the study once the envelope was opened".

Comment: blinding of intervention not possible

Incomplete outcome data (attrition bias)
On discharge home

Low risk

3 infants not accounted for in paper, additional information provided by study author

14 women counted as withdrawals in the paper, as they no longer wanted to breast feed. With additional information from study author, reanalysed in this review

Comment: outcome data complete

Selective reporting (reporting bias)

Low risk

Before clinical trial registration requirements, all expected outcomes were reported.

Other bias

Low risk

Nil noted

Kliethermes 1999

Methods

Randomised controlled trial. Study duration ‐ 22 months

Participants

Single centre, Neonatal Intensive Care Unit, USA

Inclusion criteria: birth weight 1000 g to 2500 g, < 1 week of age, no congenital or neurological abnormalities that interfered with cardiopulmonary status

Gestational age at birth ‐ experimental: 32 weeks, SD not reported, range 26 to 35 weeks; control: 32 weeks, SD not reported, range 28 to 35 weeks; birth weight ‐ experimental: 1.73 kg, range 1.05 kg to 2.43 kg; control: 1.64 kg, range 1.0 kg to 2.35 kg; twins ‐ experimental: 8 (21%); control: 16 (35%)

Sample size: 99 randomised (47 experimental/tube alone, 52 control/bottle); 84 included in analysis (38 experimental/tube alone, 46 control/bottle)

Interventions

Both groups of infants breast fed when mother was present. Experimental group: feeds given by indwelling size 3.5 FG nasogastric tube when mother not available, or top‐up after breast feed required. Tube was removed during last 24 to 48 hours of parent 'rooming‐in' period; a cup or syringe was used during this time if needed.

Control group: fed by bottle when mother not available, or top‐up after breast feed required. Indwelling nasogastric tube was removed as directed by clinicians.

Outcomes

Breast feeding, exclusive and partial, at discharge home, and at 3 days, 3 months and 6 months post discharge. Length of hospital stay, apnoea/bradycardia, weight gain to discharge home, infection rate

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "Randomization was achieved by using sealed envelopes, which were physically mixed and drawn in random sequence after enrolment of the dyad into the study".

Allocation concealment (selection bias)

Low risk

Quote: "...sealed envelopes"

Blinding (performance bias and detection bias)
All outcomes

High risk

Comment: Blinding of intervention not possible. Blinding of outcome assessment not reported

Incomplete outcome data (attrition bias)
On discharge home

High risk

Missing outcome data (n = 15, 15%) (experimental 9, control 6):

  • Deaths 1: experimental

  • Clinical conditions 4: experimental 2 (chronic lung disease, congenital heart defect); control 2 (NEC, subglottic stenosis)

  • Transfer to another hospital 2: 1 in each group

  • Protocol violation 5: experimental 3, control 2

  • Maternal conditions 3: experimental 2 (scleroderma, +ve cocaine screen), control 1 (+ve cocaine screen)

Comment: high risk of bias due to incomplete outcome data. Difference in proportion of missing data across groups (19% experimental, 12% control). For 4 infants, valid reasons were given for missing outcome data (1 died, 2 were transferred to another hospital).

Incomplete outcome data (attrition bias)
3 months post discharge

High risk

Missing outcome data (n = 15, 15%) (experimental 9, control 6):

  • Deaths 1: experimental

  • Clinical conditions 4: experimental 2 (chronic lung disease, congenital heart defect); control 2 (NEC, subglottic stenosis)

  • Transfer to another hospital 2: 1 in each group

  • Protocol violation 5: experimental 3, control 2

  • Maternal conditions 3: experimental 2 (scleroderma, +ve cocaine screen), control 1 (+ve cocaine screen)

Comment: high risk of bias due to incomplete outcome data

Incomplete outcome data (attrition bias)
6 months post discharge

High risk

Missing outcome data (n = 15, 15%) (experimental 9, control 6):

  • Deaths 1: experimental

  • Infant clinical conditions 4: experimental 2 (chronic lung disease, congenital heart defect); control 2 (NEC, subglottic stenosis)

  • Transfer to another hospital 2: 1 in each group

  • Protocol violation 5: experimental 3, control 2

  • Maternal conditions 3: experimental 2 (scleroderma, +ve cocaine screen), control 1 (+ve cocaine screen)

Comment: high risk of bias due to incomplete outcome data

Selective reporting (reporting bias)

Low risk

Before clinical trial registration requirements, all expected outcomes reported

Other bias

Low risk

Nil noted

Mosley 2001

Methods

Randomised controlled trial, pilot study. Study duration ‐ 3 months

Participants

Single centre, Special Care Baby Unit, District General Hospital, England

Inclusion criteria: gestational age 32 to 37 weeks, mother wishes to breast feed, no congenital abnormality, no maternal preference for cup or bottle, infant had not been fed by cup or bottle

Experimental group: mean gestational age 35.5 weeks, SD not reported; control group: 35.2 weeks, SD not reported

Sample size: 16 randomised (8 experimental/cup, 8 control/bottle); 14 included in analysis (6 experimental/cup, 8 control/bottle)

Interventions

Experimental: supplementary feeds given by cup

Control: supplementary feeds given by bottle

Outcomes

Prevalence exclusive breast feeding on discharge home

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "There were 10 instructions to cup feed and ten to bottle feed. These details were then put in the envelopes, shuffled thoroughly and then the envelopes were numbered sequentially".

Allocation concealment (selection bias)

Low risk

Quote: "Midwife/nurse responsible was asked to select a sealed, numbered, opaque envelope, which contained information on the feeding method to be adopted".

Blinding (performance bias and detection bias)
All outcomes

High risk

Not possible to blind intervention. No information provided on blinding of outcome assessors

Incomplete outcome data (attrition bias)
On discharge home

Low risk

Missing outcome data (n = 2, 13%) (experimental 2, control 0):

  • Protocol violation (Quote: "excluded from the study prior to its start....had been given a supplementary feed")

Comment: Although difference in proportion of incomplete outcome data was noted across groups (25% experimental, 0% control), the sample size was so small that we are unable to sensibly assess the impact of missing data. Low risk of bias due to incomplete outcome data

Selective reporting (reporting bias)

Low risk

Before clinical trial registration requirements, all expected outcomes reported

Other bias

Low risk

Nil noted

Rocha 2002

Methods

Randomised controlled trial, stratified by weight (500 to 999 g, 1000 to 1499 g, 1500 to 1699 g). Study duration ‐ 18 months, August 1998 to February 2000

Participants

Single centre, Neonatal Intensive Care Unit, University Hospital, Brazil

Inclusion criteria: gestational age at birth 32 to 34 weeks (experimental: mean 32.7 weeks, SD 1.8, range not reported; control: mean 32.5 weeks, SD 2, range not reported) and birth weight < 1700g (experimental: mean 1276 g, SD 283 g; control: mean 1262 g, SD 270 g), mothers wished to breast feed, clinically stable, not initially on parenteral nutrition

Sample size: 83 randomised (46 experimental/cup, 37 control/bottle); 78 included in analysis (44 experimental/cup, 34 control/bottle)

Interventions

Infants in both groups fed by orogastric tube until 1600 g. Experimental: supplements or complements given by cup according to the recommendations of Kuehl 1997 and Lang 1994a. Dummy not offered. Control: supplements or complements given by bottle

Outcomes

Breast feeding prevalence on discharge, at first follow‐up visit and at 3 months post discharge. Weight gain (calculated as the difference between weight at the beginning of the intervention and weight at the end of 1 week during feeding observation, reported in g/kg/d). Length of feeding time (1 week after beginning oral feeds). Oxygen saturation

Breast feeding was defined as an infant exclusively or partially breast fed directly at the breast.

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: ". 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 risk

Quote: "Infants were randomly assigned to 1 of 2 feeding groups by drawing lots".

Comment: Mechanism for drawing of lots not reported, therefore unclear whether allocation was concealed

Blinding (performance bias and detection bias)
All outcomes

High risk

Blinding of intervention not possible. Blinding of outcome assessment not reported

Incomplete outcome data (attrition bias)
On discharge home

Low risk

Missing outcome data (n = 5, 6%) (experimental 2, control 3):

  • Control 3: gastro‐oesophageal reflux, bronchopulmonary dysplasia, maternal cocaine use

  • Experimental 2: protocol violation, bronchopulmonary dysplasia

Comment: low risk of bias due to incomplete outcome data. Small difference in proportions of missing data across groups, although protocol violations only in experimental group (4% experimental, 8% control). Overall small proportion of missing data (6%)

Incomplete outcome data (attrition bias)
3 months post discharge

Low risk

Missing outcome data (n = 5, 6%) (experimental 2, control 3):

  • Control 3: gastro‐oesophageal reflux, bronchopulmonary dysplasia, maternal cocaine use

  • Experimental 2: protocol violation, bronchopulmonary dysplasia

Comment: low risk of bias due to incomplete outcome data. Small difference in proportions of missing data across groups, although protocol violations only in experimental group (4% experimental, 8% control). Overall small proportion of missing data (6%)

Selective reporting (reporting bias)

Unclear risk

Before clinical trial registration requirements, all expected outcomes reported

Other bias

Low risk

Simmer 2016

Methods

Randomised controlled trial, stratified by 25 to 29 weeks' and 30 to 33 weeks' gestational age. Twins randomised to same group. Conducted from 1 August 2011 to 30 June 2012

Participants

Single centre, Neonatal Intensive Care Unit, Australia

Inclusion criteria: gestational age 25 to 34 weeks (experimental: 30.1, SD 2.7 weeks, birth weight 1310, SD 422 g; control: 30.1, SD 2.6 weeks, birth weight 1430, SD 507 g); mother intended to breast feed; required 75% enteral feeds by intragastric tube with remainder provided by parental nutrition

Exclusion criteria: congenital anomalies, grade 4 intracerebral haemorrhage, periventricular leukomalacia, oral anomalies (e.g. ankyloglossia, cleft palate)

Sample size: 100 randomised (54 experimental/novel teat, 46 control/bottle with conventional teat), 97 included in analysis (51 experimental/novel teat, 46 control/bottle with conventional teat)

Interventions

Bottles were offered only if a bottle feed was scheduled, and duration of feed was limited to 30 minutes. Non‐nutritive sucking encouraged up to 33 weeks before suck feeds, after which increasing suck feeds replaced non‐nutritive sucking

Experimental: a feeding system (Medela AG, Baar, Switzerland) that combined strategies known to improve oral feeding skills: development of vacuum and self paced feeding. A shut‐off valve incorporated in the system to ensure that milk flowed only when infant created a vacuum; venting prevented collapse of the teat. Two different threshold levels for the valve of ‐10, SD 5 mmHg and ‐30, SD 15 mmHg

Control: conventional teat that allowed milk flow with gravity and compression of the teat (Grow, Growbaby, Icon Health, Victoria, Australia, or Peristaltic Narrow Neck Slow Flow, Pigeon, Seoul, South Korea)

Outcomes

Primary outcomes: time to first and full suck feeds, length of hospital stay, breast feeding (full and any) at discharge

Secondary outcomes: breast feeding rates (full and any) at 3, 6 and 12 weeks post discharge, late‐onset sepsis

Notes

The manufacturer of the feeding system (Medela AG, Baar, Switzerland) provides an unrestricted research grant from which the salaries of 2 authors were paid; the research nurse was partially funded by the manufacturer.

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: " ....computer generated treatment allocation..."

Allocation concealment (selection bias)

Low risk

Quote: "...sealed opaque coded envelopes containing the computer generated treatment allocation
were sequentially numbered for randomization"

Blinding (performance bias and detection bias)
All outcomes

High risk

Not possible to blind families and staff. Analysis done by biostatistician who was not involved in data collection and was blinded to treatment allocation

Incomplete outcome data (attrition bias)
On discharge home

Low risk

Missing outcome data (n = 3, 3%) (experimental 3, control 0):

  • Experimental 3: withdrew (triplets)

Comment: low risk of bias due to incomplete outcome data

Incomplete outcome data (attrition bias)
3 months post discharge

Low risk

As above

Selective reporting (reporting bias)

Low risk

Prospectivley registered on clinical trial register, all outcomes reported

Other bias

Low risk

Nil noted

Yilmaz 2014

Methods

Randomised controlled trial with stratification by gestation (gestational age stratification category not stated)

Study conducted April 2006 to February 2008

Participants

Three Neonatal Intensive Care Units, Turkey

Inclusion criteria: singleton birth, 32 to 35 weeks’ gestation (experimental: gestation 32.8, SD 0.9 weeks, birth weight 1539, SD 332; control: 32.8, SD 0.9, birth weight 1547, SD 330), maternal intention to breast feed, no supplemental oxygen required, fed intermittently by gastric tube only at the time of recruitment

Exclusion criteria: no prerandomisation exclusion criteria stated. Infants excluded post randomisation have been listed in the exclusion criteria (development of a disease that prevented oral feeding for more than 2 consecutive days and non‐compliance with assigned feed method).

Sample size: 607 randomised (299 experimental/cup, 308 control/bottle); 522 included in analysis (254 experimental/cup, 268 control/bottle

Interventions

Infants in both randomised groups were breast fed whenever the mother was available; mothers were welcome to stay in the NICU 24 hours a day and had access to a comfortable chair/recliner, bed, or mattress while nursing. If supplementation required once home, the same assigned method was used (cup or bottle).

Experimental: supplementary feeds (formula or breast milk) given by cup (small plastic medicine cup) by NICU nurses or parents who had been trained in the cup feeding technique described by Lang 1994a

Control: supplementary feeds (formula or breast milk) given by bottle by nursing staff or parents

Outcomes

Primary: weight gain (g/d) at day 7 of study; proportion of exclusively or any breast fed infants on discharge home

Secondary: length of hospital stay and proportion of exclusive or any breast feeding at 3 and 6 months of age. Also reported feeding time (min/feeding during first week of study for cup or bottle)

Notes

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

Quote: "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

Quote: “Assignments were sealed in sequentially numbered, opaque envelopes”.

Blinding (performance bias and detection bias)
All outcomes

High risk

Unable to blind assigned treatment groups

Primary outcome data collected by researcher from data recorded in medical records

Secondary outcome assessment data collection at 3 and 6 months post discharge collected at home visit, not blinded

Incomplete outcome data (attrition bias)
On discharge home

High risk

Missing outcome data: 85/607 (14%) (45/299, 15%, experimental (cup); and 40/308, 13%, control (bottle)):

  • Non‐compliance: 8% (47/607) (26/299, 9%, experimental (cup); and 21/308, 7%, control (bottle) group

  • Development of clinical condition preventing oral feeding for more than 2 days: 6% (38/607) (19/299, 6% experimental (cup) and 19/308, 6%, control (bottle))

Missing outcome data: 14%; reasons missing similar between groups

Incomplete outcome data (attrition bias)
3 months post discharge

Low risk

No further missing data ‐ as for discharge home

Incomplete outcome data (attrition bias)
6 months post discharge

Low risk

No further missing data ‐ as for discharge home

Selective reporting (reporting bias)

Unclear risk

Trial registration not reported in manuscript. All expected outcomes reported

Other bias

Low risk

Nil noted

FG: French gauge.
NEC: necrotising enterocolitis.
NICU: neonatal intensive care unit.
SD: standard deviation.

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Abouelfettoh 2008

Not randomised. Thirty infants received usual practice (bottle supplementation), and the next 30 the intervention (supplementation using cup feeds).

Aloysius 2007

Randomised cross‐over study. Infants fed by paladai or bottle on consecutive feeds. The aim of the study was to assess amount of spillage, volume consumed, time taken and physiological stability during both a cup feed and a bottle feed.

Aytekin 2014

Not randomised. Aim was to determine effects of spoon feeding compared with bottle feeding on breast feeding success. Conducted in 2 neonatal intensive care units ‐ 1 that used bottle feeds and 1 that used spoon feeds

De Aquino 2009

Not randomised, a retrospective study

Harding 2014

Involves non‐nutritive sucking only, not related to mode of sucking feeds nor to breast feeding outcomes

Kumar 2010

Randomised groups do not include a bottle group; nasogastric tube alone compared with spoon feeding

Lau 2012

Involves sucking and swallowing exercises, not related to mode of sucking feeds nor to breast feeding outcomes

Lopez 2014

Randomised cross‐over trial. Assessed swallowing and spilling when fed by cup and by bottle during first sucking feed only; did not include breast feeding outcomes

Marofi 2016

Randomised groups do not include a bottle group, have compared feeding by cup with feeding by paladay (paladai)

Ronan 2013

Qualitative study

Characteristics of studies awaiting assessment [ordered by study ID]

Garpiel 2012

Methods

Four‐group, parallel, randomised controlled trial

Participants

132 infants born at 26 to 36 weeks' gestation

Interventions

Randomised to 1 of 4 groups: (1) nasogastric tube with pacifier, (2) bottle with preterm teat, (3) cup feeding with 30 mL medicine cup, (4) Haberman infant feeder (Medela)

Outcomes

Primary outcome: breast feeding ability at discharge and tolerance to supplementary method of feeding

Secondary outcomes: breast feeding rate at discharge, at 2 and 4 weeks post discharge; weight gain; hospital length of stay; frequency of skin‐to‐skin contact; maternal satisfaction with the feeding method

Notes

Abstract only; review authors have attempted to contact the study author

Data and analyses

Open in table viewer
Comparison 1. Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Full breast feeding at discharge Show forest plot

6

1074

Risk Ratio (M‐H, Random, 95% CI)

1.47 [1.19, 1.80]

Analysis 1.1

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 1 Full breast feeding at discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 1 Full breast feeding at discharge.

1.1 Breast feeding + Cup vs Breast feeding + Bottle

4

893

Risk Ratio (M‐H, Random, 95% CI)

1.41 [1.14, 1.75]

1.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Risk Ratio (M‐H, Random, 95% CI)

2.10 [1.46, 3.03]

1.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.63, 1.82]

2 Fully breast feeding at 3 months post discharge Show forest plot

4

986

Risk Ratio (M‐H, Fixed, 95% CI)

1.56 [1.37, 1.78]

Analysis 1.2

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 2 Fully breast feeding at 3 months post discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 2 Fully breast feeding at 3 months post discharge.

2.1 Breast feeding + Cup vs Breast feeding + Bottle

2

805

Risk Ratio (M‐H, Fixed, 95% CI)

1.54 [1.34, 1.77]

2.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

2.31 [1.28, 4.17]

2.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [0.57, 2.41]

3 Fully breast feeding at 6 months post discharge Show forest plot

3

887

Risk Ratio (M‐H, Random, 95% CI)

1.64 [1.14, 2.36]

Analysis 1.3

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 3 Fully breast feeding at 6 months post discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 3 Fully breast feeding at 6 months post discharge.

3.1 Breast feeding + Cup vs Breast feeding + Bottle

2

803

Risk Ratio (M‐H, Random, 95% CI)

1.40 [1.18, 1.65]

3.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Risk Ratio (M‐H, Random, 95% CI)

2.94 [1.36, 6.34]

4 Any breast feeding at discharge Show forest plot

6

1138

Risk Ratio (M‐H, Fixed, 95% CI)

1.11 [1.06, 1.16]

Analysis 1.4

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 4 Any breast feeding at discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 4 Any breast feeding at discharge.

4.1 Breast feeding + Cup vs Breast feeding + Bottle

4

957

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [1.03, 1.15]

4.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

1.37 [1.08, 1.74]

4.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Risk Ratio (M‐H, Fixed, 95% CI)

1.12 [0.95, 1.33]

5 Any breast feeding at 3 months post discharge Show forest plot

5

1063

Risk Ratio (M‐H, Random, 95% CI)

1.31 [1.01, 1.71]

Analysis 1.5

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 5 Any breast feeding at 3 months post discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 5 Any breast feeding at 3 months post discharge.

5.1 Breast feeding + Cup vs Breast feeding + Bottle

3

883

Risk Ratio (M‐H, Random, 95% CI)

1.24 [0.89, 1.71]

5.2 Breast feeding + Tube vs Breast feeding + Bottle

1

83

Risk Ratio (M‐H, Random, 95% CI)

1.69 [1.19, 2.41]

5.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Risk Ratio (M‐H, Random, 95% CI)

1.20 [0.80, 1.80]

6 Any breast feeding at 6 months post discharge Show forest plot

3

886

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [1.10, 1.41]

Analysis 1.6

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 6 Any breast feeding at 6 months post discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 6 Any breast feeding at 6 months post discharge.

6.1 Breast feeding + Cup vs Breast feeding + Bottle

2

803

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [1.06, 1.36]

6.2 Breast feeding + Tube vs Breast feeding + Bottle

1

83

Risk Ratio (M‐H, Fixed, 95% CI)

2.07 [1.18, 3.64]

7 Days to reach full sucking feeds Show forest plot

3

429

Mean Difference (IV, Random, 95% CI)

2.56 [‐7.17, 12.28]

Analysis 1.7

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 7 Days to reach full sucking feeds.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 7 Days to reach full sucking feeds.

7.1 Breast feeding + Cup vs Breast feeding + Bottle

2

332

Mean Difference (IV, Random, 95% CI)

5.08 [‐6.43, 16.59]

7.2 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Mean Difference (IV, Random, 95% CI)

‐4.0 [‐15.63, 7.63]

8 Weight gain Show forest plot

3

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

Analysis 1.8

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 8 Weight gain.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 8 Weight gain.

8.1 Measured from birth to discharge home (g/kg/day)

1

293

Mean Difference (IV, Fixed, 95% CI)

‐0.09 [‐0.77, 0.59]

8.2 Measured for one week after commencing oral feeds (g/kg/day)

1

78

Mean Difference (IV, Fixed, 95% CI)

‐0.60 [‐3.21, 2.01]

8.3 Measured for one week after commencing oral feeds (g/day)

1

522

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐0.36, 0.16]

9 Length of hospital stay Show forest plot

4

1004

Mean Difference (IV, Random, 95% CI)

2.25 [‐3.36, 7.86]

Analysis 1.9

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 9 Length of hospital stay.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 9 Length of hospital stay.

9.1 Breast feeding + Cup vs Breast feeding + Bottle

2

823

Mean Difference (IV, Random, 95% CI)

4.45 [‐5.57, 14.48]

9.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Mean Difference (IV, Random, 95% CI)

1.60 [‐5.89, 9.09]

9.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Mean Difference (IV, Random, 95% CI)

‐4.90 [‐17.25, 7.45]

10 Duration of supplementary feed Show forest plot

2

600

Mean Difference (IV, Random, 95% CI)

‐0.42 [‐1.96, 1.12]

Analysis 1.10

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 10 Duration of supplementary feed.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 10 Duration of supplementary feed.

11 Episodes of infection Show forest plot

3

500

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.35, 1.42]

Analysis 1.11

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 11 Episodes of infection.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 11 Episodes of infection.

Study flow diagram: review update.
Figuras y tablas -
Figure 1

Study flow diagram: review update.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

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

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 1 Full breast feeding at discharge.
Figuras y tablas -
Analysis 1.1

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 1 Full breast feeding at discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 2 Fully breast feeding at 3 months post discharge.
Figuras y tablas -
Analysis 1.2

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 2 Fully breast feeding at 3 months post discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 3 Fully breast feeding at 6 months post discharge.
Figuras y tablas -
Analysis 1.3

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 3 Fully breast feeding at 6 months post discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 4 Any breast feeding at discharge.
Figuras y tablas -
Analysis 1.4

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 4 Any breast feeding at discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 5 Any breast feeding at 3 months post discharge.
Figuras y tablas -
Analysis 1.5

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 5 Any breast feeding at 3 months post discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 6 Any breast feeding at 6 months post discharge.
Figuras y tablas -
Analysis 1.6

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 6 Any breast feeding at 6 months post discharge.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 7 Days to reach full sucking feeds.
Figuras y tablas -
Analysis 1.7

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 7 Days to reach full sucking feeds.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 8 Weight gain.
Figuras y tablas -
Analysis 1.8

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 8 Weight gain.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 9 Length of hospital stay.
Figuras y tablas -
Analysis 1.9

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 9 Length of hospital stay.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 10 Duration of supplementary feed.
Figuras y tablas -
Analysis 1.10

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 10 Duration of supplementary feed.

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 11 Episodes of infection.
Figuras y tablas -
Analysis 1.11

Comparison 1 Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 11 Episodes of infection.

Summary of findings for the main comparison. Breast feeding with supplemental feeds by other than bottle compared with breast feeding with supplemental feeds by bottle (all trials) in preterm infants

Breast feeding with supplemental feeds by other than bottle compared with breast feeding with supplemental feeds by bottle (all trials) in preterm infants

Patient or population: preterm infants
Setting:
Intervention: breast feeding with supplemental feeds by other than bottle
Comparison: breast feeding with supplemental feeds by bottle (all trials)

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with breast feeding with supplemental feeds by bottle (all trials)

Risk with breast feeding with supplemental feeds by other than bottle

Full breast feeding at discharge

Study population

RR 1.47
(1.19 to 1.80)

1074
(6 RCTs)

⊕⊕⊝⊝
LOWa,b

44 per 100

64 per 100
(52 to 79)

Full breast feeding at 3 months post discharge

Study population

RR 1.56
(1.37 to 1.78)

986
(4 RCTs)

⊕⊕⊕⊝
MODERATEa

36 per 100

57 per 100
(50 to 65)

Full breast feeding at 6 months post discharge

Study population

RR 1.64
(1.14 to 2.36)

887
(3 RCTs)

⊕⊕⊝⊝
LOWa,b

31 per 100

51 per 100
(35 to 73)

Any breast feeding at discharge

Study population

RR 1.11
(1.06 to 1.16)

1138
(6 RCTs)

⊕⊕⊕⊝
MODERATEa

79 per 100

88 per 100
(84 to 92)

Any breast feeding at 3 months post discharge

Study population

RR 1.31
(1.01 to 1.71)

1063
(5 RCTs)

⊕⊝⊝⊝
VERY LOWa,c

60 per 100

78 per 100
(60 to 100)

Any breast feeding at 6 months post discharge

Study population

RR 1.25
(1.10 to 1.41)

886
(3 RCTs)

⊕⊝⊝⊝
VERY LOWa,d

45 per 100

56 per 100
(49 to 63)

Length of hospital stay

MD 2.25 higher
(3.36 lower to 7.86 higher)

1004
(4 RCTs)

⊕⊝⊝⊝
VERY LOWa,c

Episodes of infection

Study population

RR 0.70
(0.35 to 1.42)

500
(3 RCTs)

⊕⊕⊕⊝
MODERATEa

7 per 100

5 per 100
(2 to 10)

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; OR: odds ratio; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to that of the estimate of effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aAttrition bias (14% and 15% attrition in two included studies).

bModerate heterogeneity (I2 = 52%).

cModerate heterogeneity (I2 = 73%).

dModerate heterogeneity (I2 = 71%).

Figuras y tablas -
Summary of findings for the main comparison. Breast feeding with supplemental feeds by other than bottle compared with breast feeding with supplemental feeds by bottle (all trials) in preterm infants
Comparison 1. Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Full breast feeding at discharge Show forest plot

6

1074

Risk Ratio (M‐H, Random, 95% CI)

1.47 [1.19, 1.80]

1.1 Breast feeding + Cup vs Breast feeding + Bottle

4

893

Risk Ratio (M‐H, Random, 95% CI)

1.41 [1.14, 1.75]

1.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Risk Ratio (M‐H, Random, 95% CI)

2.10 [1.46, 3.03]

1.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.63, 1.82]

2 Fully breast feeding at 3 months post discharge Show forest plot

4

986

Risk Ratio (M‐H, Fixed, 95% CI)

1.56 [1.37, 1.78]

2.1 Breast feeding + Cup vs Breast feeding + Bottle

2

805

Risk Ratio (M‐H, Fixed, 95% CI)

1.54 [1.34, 1.77]

2.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

2.31 [1.28, 4.17]

2.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [0.57, 2.41]

3 Fully breast feeding at 6 months post discharge Show forest plot

3

887

Risk Ratio (M‐H, Random, 95% CI)

1.64 [1.14, 2.36]

3.1 Breast feeding + Cup vs Breast feeding + Bottle

2

803

Risk Ratio (M‐H, Random, 95% CI)

1.40 [1.18, 1.65]

3.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Risk Ratio (M‐H, Random, 95% CI)

2.94 [1.36, 6.34]

4 Any breast feeding at discharge Show forest plot

6

1138

Risk Ratio (M‐H, Fixed, 95% CI)

1.11 [1.06, 1.16]

4.1 Breast feeding + Cup vs Breast feeding + Bottle

4

957

Risk Ratio (M‐H, Fixed, 95% CI)

1.09 [1.03, 1.15]

4.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Risk Ratio (M‐H, Fixed, 95% CI)

1.37 [1.08, 1.74]

4.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Risk Ratio (M‐H, Fixed, 95% CI)

1.12 [0.95, 1.33]

5 Any breast feeding at 3 months post discharge Show forest plot

5

1063

Risk Ratio (M‐H, Random, 95% CI)

1.31 [1.01, 1.71]

5.1 Breast feeding + Cup vs Breast feeding + Bottle

3

883

Risk Ratio (M‐H, Random, 95% CI)

1.24 [0.89, 1.71]

5.2 Breast feeding + Tube vs Breast feeding + Bottle

1

83

Risk Ratio (M‐H, Random, 95% CI)

1.69 [1.19, 2.41]

5.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Risk Ratio (M‐H, Random, 95% CI)

1.20 [0.80, 1.80]

6 Any breast feeding at 6 months post discharge Show forest plot

3

886

Risk Ratio (M‐H, Fixed, 95% CI)

1.25 [1.10, 1.41]

6.1 Breast feeding + Cup vs Breast feeding + Bottle

2

803

Risk Ratio (M‐H, Fixed, 95% CI)

1.20 [1.06, 1.36]

6.2 Breast feeding + Tube vs Breast feeding + Bottle

1

83

Risk Ratio (M‐H, Fixed, 95% CI)

2.07 [1.18, 3.64]

7 Days to reach full sucking feeds Show forest plot

3

429

Mean Difference (IV, Random, 95% CI)

2.56 [‐7.17, 12.28]

7.1 Breast feeding + Cup vs Breast feeding + Bottle

2

332

Mean Difference (IV, Random, 95% CI)

5.08 [‐6.43, 16.59]

7.2 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Mean Difference (IV, Random, 95% CI)

‐4.0 [‐15.63, 7.63]

8 Weight gain Show forest plot

3

Mean Difference (IV, Fixed, 95% CI)

Subtotals only

8.1 Measured from birth to discharge home (g/kg/day)

1

293

Mean Difference (IV, Fixed, 95% CI)

‐0.09 [‐0.77, 0.59]

8.2 Measured for one week after commencing oral feeds (g/kg/day)

1

78

Mean Difference (IV, Fixed, 95% CI)

‐0.60 [‐3.21, 2.01]

8.3 Measured for one week after commencing oral feeds (g/day)

1

522

Mean Difference (IV, Fixed, 95% CI)

‐0.10 [‐0.36, 0.16]

9 Length of hospital stay Show forest plot

4

1004

Mean Difference (IV, Random, 95% CI)

2.25 [‐3.36, 7.86]

9.1 Breast feeding + Cup vs Breast feeding + Bottle

2

823

Mean Difference (IV, Random, 95% CI)

4.45 [‐5.57, 14.48]

9.2 Breast feeding + Tube vs Breast feeding + Bottle

1

84

Mean Difference (IV, Random, 95% CI)

1.60 [‐5.89, 9.09]

9.3 Breast feeding + novel teat and bottle vs Breast feeding + conventional teat and bottle

1

97

Mean Difference (IV, Random, 95% CI)

‐4.90 [‐17.25, 7.45]

10 Duration of supplementary feed Show forest plot

2

600

Mean Difference (IV, Random, 95% CI)

‐0.42 [‐1.96, 1.12]

11 Episodes of infection Show forest plot

3

500

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.35, 1.42]

Figuras y tablas -
Comparison 1. Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials)