by Anne Eglash MD, IBCLC, FABM
Do bottles cause problems with successful breastfeeding as premature infants transition to full feedings at the breast? Premature infants who are too young to effectively suck at birth need gradual transition to full breastfeeding. Because mothers are not always present in the neonatal intensive care (NICU) at the time of feeding, and because premature infants need weeks or months to gain the strength and endurance for full breastfeeding, bottles are often used to supplement expressed breast milk. Should NICU staff use something other than a bottle?
A review by Cochrane Library reviewed seven studies that evaluated the use of the following devices: gavage tubes, cups, paladai, bottles, droppers, spoons, and finger feeders, to determine if the use of any of these devices was associated with a greater likelihood of breastfeeding at hospital discharge, or at 3 or 6 months after discharge. The review included a total of 1152 infants who were on average 32 weeks gestation.
What do you think the authors concluded regarding the use of bottles versus other methods of supplementation on the rate and duration of breastfeeding at hospital discharge and beyond? (choose 1 or more):
- A. Avoiding bottles does not have an impact on the duration of breastfeeding after hospital discharge.
- B. Cup feeding as a means of supplementation was associated with more breastfeeding at discharge, 3 months, and 6 months postpartum as compared to bottle feeding.
- C. Cup feeding takes longer than bottle feeding.
- D. Cup feeders had more episodes of aspiration and low oxygen saturation as compared to bottle feeders.
See the Answer
The answer is B
Review question: In preterm infants whose mothers want to breast feed, does using bottles interfere with breast feeding success?
Background: Preterm infants start milk feeds by tube, and as they mature they are able to manage sucking feeds. The number of sucking feeds each day is gradually increased as the baby matures. Women who choose to breast feed their preterm infant may find that it is not always possible to be there every time the baby needs a sucking feed. Conventionally, bottles with mother’s milk or formula have been used. It has been suggested that using bottles may interfere with breast feeding success.
Study characteristics: In searches updated to July 2016, we found seven eligible studies (involving 1152 preterm babies). These studies were of small to moderate size, and most had some problems with study design or conduct.
Key results: Five of the studies (which included two of the largest studies) used cup feeds, and one used tube feeds. One study used a specially designed teat with feeding action suggested to be more like breast feeding than conventional bottle feeding. Most studies were conducted in high-income countries, only two in middle-income countries and none in low-income countries. Overall if bottle feeds (with a conventional teat) were not given, babies were more likely to be fully breast fed or to have at least some breast feeds on discharge home and at three and six months after discharge home. The study with the specially designed teat showed no difference in breast feeding outcomes, so it was the cup alone or the tube alone that improved breast feeding rates. However, because of the poor quality of the tube alone study, we cannot recommend a tube feeding strategy until further studies of high quality are undertaken. We found no evidence of benefit or harm for any of the reported outcomes, including length of hospital stay or weight gain.
Conclusions: Using a cup instead of a bottle increases the extent and duration of breast feeding in preterm infants. Additional studies are needed before a tube alone approach can be recommended.
Milk Mob Comment by Anne Eglash MD, IBCLC, FABM
Families are often eager to take their premature infant(s) home as soon as possible. This means that the infant(s) need to demonstrate effective weight gain by oral feedings before discharge. This can be tricky, especially if infants are on an every-3-hour feeding schedule. NICUs in the USA vary in their use of bottles versus other strategies to supplement premature infants, although bottle use appears to be the most prevalent way of feeding premature infants at the time of hospital discharge.
The Neo-BFHI, also known as the Baby-Friendly Hospital Initiative for Neonatal Wards is a recent set of recommendations that include 3 guiding principles and 10 steps to protect, promote, and support breastfeeding in the NICU. Step 9 states ‘Use alternatives to bottle feeding at least until breastfeeding is well established, and use pacifiers and nipple shields only for justifiable reasons.’ According to the Neo-BFHI document, cup feeding can be introduced at 29 weeks gestation. Supplementation by tube feedings may also be continued during the transition to exclusive breastfeeding. ‘Bottles are not introduced to breastfeeding infants and to infants whose mothers intend to exclusively breastfeed unless the mother explicitly asks for them, and has been informed of the risks.’
Although it will take time for such significant change in the American NICU culture to conform to these recommendations, it is exciting to know that there is evidence for how we can optimize the establishment of breastfeeding for premature infants in the NICU.