Babies may be unable to breastfeed for a number of reasons and in such situations supplemental feeds of expressed breastmilk or artificial milk have traditionally been given by tube or bottle.
Step 9 of the UNICEF UK Baby Friendly Initiative requires that when a mother is unable to breastfeed use of a teat should be avoided in order to protect breastfeeding and this in part has led to an increase in the use of cup feeding as an alternative.
The advantages of cup feeding are argued to be that as the infant is required only to lap the milk and then co-ordinate swallowing and breathing that cup feeding can begin from as early as 30 weeks gestation; that “nipple-teat confusion” may be avoided; that the infant can pace the feed which enhances oxygen saturation and minimizes energy expenditure; that the oral experience for the infant can be positive and that parents can be involved.
Conversely, other authors have cited difficulties with cup feeding such as a risk of aspiration if an improper technique is used, the length of time taken for feeds, milk wastage and breast refusal caused by long term cup feeding and “cup addiction”. A number of studies have been carried out in recent years to establish the effectiveness of cup feeding and a review was carried out on behalf of the Cochrane Collaboration in order to try to establish the optimum feeding method for babies who are born temporarily unable to breastfeed.
Cochrane reviews aim to help identify which forms of health care work and which do not by bringing together results from similar randomized trials. Trials need to be systematically assessed and those that are good enough can be combined to produce both a more statistically reliable result and one that can be more easily applied in other settings. Due to the strict criteria required for inclusion, many studies which may have relevant findings can be excluded.
In this instance, 15 trials were identified, with only four meeting the inclusion criteria. Of these two were carried out in the UK, one in Australia and one in Brazil. The main outcome measures investigated were:
- Breastfeeding at discharge (exclusive and partial)
- Breastfeeding at three months and six months (exclusive and partial)
- Weight gain
In addition, evidence of time taken to feed, physiological stability, and length of hospital stay was also sought.
The results of the review demonstrated a statistically significant improvement in the number of babies leaving hospital exclusively breastfed in the cup feeding group, and whilst no statistically significant improvement in exclusive or partial breastfeeding was demonstrated at the other times, a trend towards cup feeding improving outcomes can be seen.
There was no statistically significant difference in weight gain, however in the one study that assessed it, there was a significantly longer length of hospital stay recorded in the cup feeding group.
The authors of the review concluded that cup feeding could not be recommended over bottle feeding because it carries an unacceptable consequence of a longer hospital stay. Whilst it is disappointing that a greater beneficial impact of cup feeding could not be demonstrated and note should be taken of the results of future trials in this area, there are a number of factors which render these results less concerning than they may otherwise seem to be.
Of the 472 infants included in the review by far the largest proportion (319) were part of one particular study which reported high non-compliance rates with 56% of babies randomised to cup feed having a bottle introduced. Maintaining the planned intervention in this case clearly proved difficult over a multi-centre site. In addition, this was the one study which reported longer hospital stays. Mothers were not allowed to leave hospital cup feeding, a practice which is different to the care offered by many UK units.
Implementing of the whole Ten Steps to Successful Breastfeeding, including avoidance of teats has been demonstrated in a number of studies to improve breastfeeding outcomes and as such, given the limitations of this review, we would suggest that Step 9 remains unchanged, but will remain open minded to further research evidence should it emerge.
Flint A., New K., Davies MW. (2007) Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database of systematic Reviews; Issue 2. Art. No.:CD005092. DOI: 10.1002/14651858.CD005092.pub2