Cochrane review: Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed
Authors: Flint A , New K , Davies MW 
Published: September 2008

AbstractBackgroundBreast milk provides optimal nutrition for newborn infants, and the ideal way for infants to receive breast milk is through suckling at the breast. Unfortunately, this may not always be possible, as there are numerous reasons why a newborn infant may not be able to breastfeed and, as a result, require supplemental feeding. Currently, there are a variety of ways in which newborn infants can receive supplemental feeds. Traditionally, bottles and nasogastric tubes have been used; however, more recently, cup feeding has become a popular practice in many nurseries in an attempt to improve breastfeeding rates. There is no consistency to guide the choice of supplementation.ObjectivesTo determine the effects of cup feeding versus other forms of supplemental enteral feeding on weight gain and achievement of successful breastfeeding in newborn infants who are unable to fully breastfeed.Search strategyWe searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2006), CINAHL (1982 ‐ April 2006) and MEDLINE (1966 ‐ April 2006).Selection criteriaRandomised or quasi‐randomised controlled trials comparing cup feeding to other forms of enteral feeding for the supplementation of newborn infants.Data collection and analysisQuality assessments and data extraction for included trials were conducted independently by the review authors. Outcomes reported from these studies were: weight gain, proportion not breastfeeding at hospital discharge, proportion not feeding at three months of age, proportion not feeding at six months of age, proportion not fully feeding at hospital discharge, proportion not fully breastfeeding at three months of age, proportion not fully breastfeeding at six months of age, average time per feed (minutes), length of stay and physiological events of instability such as bradycardia, apnea, and low oxygen saturation. For continuous variables such as weight gain, mean differences and 95% confidence intervals were reported. For categorical outcomes such as mortality, the relative risks (RR) and 95% confidence intervals were reported.Main resultsFour studies were eligible for inclusion. The experimental intervention was cup feeding and the control intervention was bottle feeding in all four studies included in this review. There was no statistically significant difference in the incidence of not breastfeeding at hospital discharge in three included studies (typical RR 0.82, 95% CI 0.62, 1.09) and not breastfeeding at three months in two included studies (typical RR 0.88, 95% CI 0.76, 1.03) or six months for the one study that reported this outcome (RR 0.91, 95% CI 0.78, 1.05). There was a statistically significant difference in not fully breastfeeding at hospital discharge (from three included studies) in favour of cup feeding (typical RR 0.75, 95% CI 0.61, 0.92). However, this was not statistically significant at three months (one study, RR 1.18, 95% CI 0.88, 1.58) or six months (one study, RR 1.31, 95% CI 0.89, 1.92). There was no statistically significant difference in weight gain from one study that reported this outcome (MD ‐0.60, 95% CI ‐3.21, 2.01). In the one study that assessed it, there was a significantly increased length of hospital stay in the cup fed infants [mean difference between groups was 10.1 days (95% CI 3.9, 16.3)]. Time to full breastfeeding was not assessed in any study.Authors' conclusionsCup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in hospital.Plain language summaryIs cup feeding a better way to feed babies, rather than giving bottles or feeding with a tube, when mothers are unable to fully breastfeed?We wanted to identify the best way of offering feeds to babies when mothers are unable to breastfeed, or initially have difficulty with breastfeeding. Alternative feeding methods include using a cup, bottle or feeding tube. Four included studies compared cup and bottle feeding: the results of three of these studies demonstrate that infants who were cup fed were more likely to be exclusively breastfed at hospital discharge. However, at three and six months, there was no difference in the number of infants fully or partially breastfeeding, whether initially fed by cup, bottle or feeding tube. The results of one study demonstrated that those infants feed by cup spent approximately ten days longer in hospital. Therefore, based on available evidence, we cannot recommend cup feeding.