Bottle Avoidance in the Establishment of Breastfeeding for Preterm Infants
by Anne Eglash MD, IBCLC, FABM
According to the authors of this Cochrane systematic review, premature infants under 32 weeks gestation typically start gavage enteral (gut) feeding before they are ready to suck. Many NICUs consider infants ready to coordinate sucking and swallowing at 32-34 weeks gestation. As the frequency and success with sucking and swallowing improves, the baby is weaned from gavage feeding, and going home is often dependent upon when the infant can take all nutrition by mouth. The question is whether bottle feeding preterm infants interferes with successful establishment of breastfeeding/chestfeeding.
There are many reasons why premature infants in the NICU are given bottles rather than being offered feedings at the breast/chest. There may be times that the lactating parent is not present or cannot directly feed for a number of reasons. However, some NICUs believe that premature infants can graduate from the NICU faster if bottles are used to transition to full oral feeding. This belief has been recently challenged in a recent study showing that increased direct breastfeeds does not increase length of stay in the NICU.
The Cochrane study reviewed 7 studies, a total of 1152 infants, that tested interventions of complete bottle avoidance, such as cups, spoons, droppers, fingerfeeding, and the paladai.
They determined that there is low-to-moderate-certainty that avoiding bottles while establishing breastfeeding among preterm infants may improve rates of exclusive breastfeeding and any breastfeeding up to 6 months post discharge.
This is a juicy systematic review with other findings—read the question to learn more!
- The infants in these studies who were not given bottles for supplementation took longer to be discharged from the NICU.
- The infants who were cup fed for supplementation gained less weight in the NICU as compared to infants who were bottle fed.
- The infants who were cup fed took their supplement over a longer period of time as compared to those who were bottle fed.
- Infants who were bottle fed had much less choking, gagging, and aspiration as compared to the other methods of supplementation, including cups, finger feeding, tube feeding.
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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.
Just as an FYI- A scoping review of oral feeding guidelines for preterm infant in the NICU identified that 83% guidelines published in the USA recommended starting suckling at 32 weeks gestation.
The authors of the Cochrane review did not find a significant difference in length of hospital stay or weight gain among those who did not use bottles when transitioning to full oral feeding and breastfeeding. Non-bottle interventions of feeding did not cause more aspiration, choking, or a longer time to feed.
In addition to concluding that avoiding bottles for supplementation increases the extent of any breastfeeding at discharge, and may improve any and exclusive breastfeeding for up to 6 months post discharge, they also mention that most of the benefit was for cup feeding.
One of the studies in this review interviewed parents about cup feeding at 3 months after discharge, because they found that 56% of the infants eventually were given a bottle. They reported that 26% of the infants either had problems cup feeding, there were frequent spills, it took too long to cup feed, and there was a general dissatisfaction with it.
Based on this evidence I believe cup feeding should be used for oral feeding in the NICU for infants who are appropriate for it, especially given the impact on improving breastfeeding success. Normalizing cup feeding in the hospital and NICU would likely help families accept this method. I also have found that cup feeding is often accepted by older infants, such as over 2-3 months, who refuse a bottle.
Deb Clayton
Interestingly, mother of 35wk twins found her baby’s were preferring the bottle to suck EBM top ups, and fussing at the breast and reduced attachment after consecutive feeds, while rooming in. Thankyou for your research, I needed some evidence to support mum to persevere in full breastfeeds.