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. 2021 Oct 21;10(10):CD005252.
doi: 10.1002/14651858.CD005252.pub5.

Avoidance of bottles during the establishment of breastfeeds in preterm infants

Elizabeth Allen  1 , Alice R Rumbold  2 , Amy Keir  1   2   3 , Carmel T Collins  2 , Jennifer Gillis  4 , Hiroki Suganuma  5
Affiliations

Avoidance of bottles during the establishment of breastfeeds in preterm infants

Elizabeth Allen et al. Cochrane Database Syst Rev. .

Abstract

Background: Preterm infants often start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women with preterm infants may not always be in hospital to breastfeed their baby and need an alternative approach to feeding. Most commonly, milk (expressed breast milk or formula) is given by bottle. Whether using bottles during establishment of breastfeeds is detrimental to breastfeeding success is a topic of ongoing debate.

Objectives: To identify the effects of avoidance of bottle feeds during establishment of breastfeeding on the likelihood of successful breastfeeding, and to assess the safety of alternatives to bottle feeds.

Search methods: A new search strategy was developed for this update. Searches were conducted without date or language limits in September 2021 in: MEDLINE, CENTRAL, and CINAHL. We also searched the ISRCTN trial registry and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. SELECTION CRITERIA: We included RCTs and quasi-RCTs comparing avoidance of bottles with use of bottles for preterm infants where their mothers planned to breastfeed.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. We used the GRADE approach to assess the certainty of evidence. Outcomes included full breastfeeding and any breastfeeding on discharge home and at three and six months after discharge, as well as length of hospital stay and episodes of infant infection. We synthesised data using risk ratios (RR), risk differences (RD) and mean differences (MD), with 95% confidence intervals (CI). We used the GRADE approach to assess the certainty of the evidence.

Main results: We included seven trials with 1152 preterm infants in this updated review. There are three studies awaiting classification. Five included studies used a cup feeding strategy, one used a tube feeding strategy and one used a novel teat when supplements to breastfeeds were needed. We included the novel teat study in this review as the teat was designed to closely mimic the sucking action of breastfeeding. The trials were of small to moderate size, and two had high risk of attrition bias. Adherence with cup feeding was poor in one of the studies, indicating dissatisfaction with this method by staff or parents (or both); the remaining four cup feeding studies provided no such reports of dissatisfaction or low adherence. Avoiding bottles may increase the extent of full breastfeeding on discharge home (RR 1.47, 95% CI 1.19 to 1.80; 6 studies, 1074 infants; low-certainty evidence), and probably increases any breastfeeding (full and partial combined) on discharge (RR 1.11, 95% CI 1.06 to 1.16; studies, 1138 infants; moderate-certainty evidence). Avoiding bottles probably increases the occurrence of full breastfeeding three months after discharge (RR 1.56, 95% CI 1.37 to 1.78; 4 studies, 986 infants; moderate-certainty evidence), and may also increase full breastfeeding six months after discharge (RR 1.64, 95% CI 1.14 to 2.36; 3 studies, 887 infants; low-certainty evidence). Avoiding bottles may increase the occurrence of any breastfeeding (full and partial combined) three months after discharge (RR 1.31, 95% CI 1.01 to 1.71; 5 studies, 1063 infants; low-certainty evidence), and six months after discharge (RR 1.25, 95% CI 1.10 to 1.41; 3 studies, 886 infants; low-certainty evidence). The effects on breastfeeding outcomes were evident at all time points for the tube alone strategy and for all except any breastfeeding three months after discharge for cup feeding, but were not present for the novel teat. There were no other benefits or harms including for length of hospital stay (MD 2.25 days, 95% CI -3.36 to 7.86; 4 studies, 1004 infants; low-certainty evidence) or episodes of infection per infant (RR 0.70, 95% CI 0.35 to 1.42; 3 studies, 500 infants; low-certainty evidence).

Authors' conclusions: Avoiding the use of bottles when preterm infants need supplementary feeds probably increases the extent of any breastfeeding at discharge, and may improve any and full breastfeeding (exclusive) up to six months postdischarge. Most of the evidence demonstrating benefit was for cup feeding. Only one study used a tube feeding strategy. We are uncertain whether a tube alone approach to supplementing breastfeeds improves breastfeeding outcomes; further studies of high certainty are needed to determine this.

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Conflict of interest statement

EA: none.

AR: none.

AK: none.

CC was an investigator responsible for one of the studies included in this review (Collins 2004). The study was funded by Women's & Children's Hospital Foundation Midwifery Fellowship; Mercy Hospital for Women Melbourne, Nurses's Research Fund, Australia.

JG: none. She performed data extraction for Collins 2004.

HS: none.

Core editorial and administrative support for this review has been provided by a grant from The Gerber Foundation. The Gerber Foundation is a separately endowed, private foundation, independent from the Gerber Products Company. The grantor has no input on the content of the review or the editorial process (Sources of support).

Figures

1
1
Screen4Me: September 2021
2
2
2021 Flow Diagram
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 1: Full breastfeeding (BF) at discharge
1.2
1.2. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 2: Fully breastfeeding 3 months postdischarge
1.3
1.3. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 3: Fully breastfeeding 6 months postdischarge
1.4
1.4. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 4: Any breastfeeding at discharge
1.5
1.5. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 5: Any breastfeeding 3 months postdischarge
1.6
1.6. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 6: Any breastfeeding 6 months postdischarge
1.7
1.7. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 7: Time (days) to reach full sucking feeds
1.8
1.8. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 8: Mean rate of weight gain
1.9
1.9. Analysis
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 (days)
1.10
1.10. Analysis
Comparison 1: Breast feeding with supplemental feeds by other than bottle versus breast feeding with supplemental feeds by bottle (all trials), Outcome 10: Duration (minutes) of supplementary feed
1.11
1.11. Analysis
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 per infant
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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References to other published versions of this review

Collins 2005
    1. 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 2005, Issue 2. Art. No: CD005252. [DOI: 10.1002/14651858.CD005252] - DOI - PubMed
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Collins 2016b
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Publication types