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

Carmel T Collins; Jennifer Gillis; Andrew J McPhee; Hiroki Suganuma; Maria Makrides

doi:10.1002/14651858.CD005252.pub4

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Figure 1

Study flow diagram: review update.

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Figure 2

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊕⊝ MODERATE^a
	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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊕⊝ MODERATE^a
	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 LOW^a,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 LOW^a,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 LOW^a,c
Episodes of infection	Study population		RR 0.70 (0.35 to 1.42)	500 (3 RCTs)	⊕⊕⊕⊝ MODERATE^a
	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%).

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

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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]

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

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