Bottles and breastfeeding

Avoid bottles during breastfeeding in preterm infants

Why is it important to avoid bottles during the establishment of breastfeeding in preterm infants? 

Infants who are born preterm often begin milk feeds by gavage tubes (small tube placed into the nose and extends into stomach or small intestine). As the infant matures, sucking feeds are slowly introduced. Women who have preterm infants may not always be present in the hospital to breastfeed, thus an alternative approach for feeding is required. The most common method for administering breast milk or formula is through bottle feeding. Uncertainty exists around using bottles during the establishment of breastfeeding. Bottles may hinder success with breastfeeding as there are different sucking actions needed for bottle feeding and breastfeeding.

Does avoiding bottles during the establishment of breastfeeding increase the likelihood of successful breastfeeding for preterm infants? 

  • There is low to moderate confidence in the results
  • If bottle feeds are not used, preterm infants have an increased likelihood to partially or fully breastfeed when discharged home and at 3 and 6 months post discharge from hospital  

Equity: Does it work among the disadvantaged? 

  • Majority of the studies were conducted in high-income countries
  • Two studies in middle-income countries & none in low-income countries
  • Avoiding bottles and using cup feeding for supplemental feeds are effective in increasing successful breastfeeding among high and high-to-middle income countries

Intervention Delivery 

  • Updated review
  • 7 RCTs were included with 1152 preterm infants 
    • 5 studies used cup feeding strategy
    • 1 study used gavage tube feeding strategy 
    • 1 study used a novel teat when supplements were needed for breastfeeding
  • Trials were small to moderate in size 
  • Experimental intervention: Infants received feeding via devices other than bottle; spoon, cup, dropper, gavage tube, paladai, finger feeding, and other
  • Control intervention: infants receiving bottle feeding
  • For all studies, bottles or alternative feeding devices never replaced a breastfeed. They were only used when the mother was unavailable to breastfeed or if extra milk was needed after a breastfeed

Population and Setting

  • Infants born less than 37 weeks gestation to mothers who had planned to breastfeed and had not received sucking feeds by bottle or by alternative devices
  • All studies included preterm infants; limits for birth weight and gestational age varied
  • Mean gestational age was 32 weeks
  • Setting: inpatient neonatal intensive care units
  • 2 studies were conducted in upper to middle income countries: Brazil & Turkey
  • High income countries: Australia, United Kingdom, USA

Summary of findings 1. Breastfeeding with supplemental feeds by other than bottle compared with breastfeeding with supplemental feeds by bottle (all trials) in preterm infants

Patient or population: preterm infants
Setting: neonatal units in Australia, Brazil, Turkey, the UK and the USA
Intervention: breastfeeding with supplemental feeds by other than bottle
Comparison: breastfeeding with supplemental feeds by bottle (all trials)

 

Outcomes

 

 

Anticipated absolute effects

 

Relative effects (95% CI)

 

No of participants (studies)

 

 

Certainty of evidence (GRADE)

 
Risk with breastfeeding with supplemental feeds by bottle (all trials)
Risk with breastfeeding with supplemental feeds by other than bottle
 

 

 

 

Full breastfeeding compared with not breastfeeding or partial breastfeeding
Study population (on discharge)
44 per 100                                                20 more per 100
                                                               (from 8 to 25 more)
 
RR 1.47 
(1.19 to 1.80)
 
1074 (6 RCTs)
 
Low
Study population (3 months post discharge)
36 per 100                                                21 more per 100
                                                             (from 13 to 29 more)
 
RR 1.56
(1.37 to 1.78)
 
986 (4 RCTs)
 
Moderate
Study population (6 months post discharge)
31 per 100                                                20 more per 100
                                                               (from 4 to 42 more)
 
RR 1.64
(1.14 to 2.36)
 
887 (3 RCTs)
 
Low
 
 
Any breastfeeding (full and partial combined) compared with not breastfeeding
Study population (on discharge)
79 per 100                                                  9 more per 100
                                                               (from 5 to 13 more)
 
RR 1.11
(1.06 to 1.16)
 
1138 (6 RCTs)
 
Moderate
Study population (at 3 months post discharge)
60 per 100                                                18 more per 100
                                                               (from 0 to 40 more)
 
RR 1.31
(1.01 to 1.71)
 
1063 (5 RCTs)
 
Low
Study population (6 months post discharge)
45 per 100                                                 11 more per 100
                                                               (from 4 to 18 more)
 
RR 1.25
(1.10 to 1.41)
 
886 (3 RCTs)
 
Low
 
Length of hospital stay (days)
                             
   ­­­­  ­­­­__                                                    MD 2.25 higher
                                                 (3.36 lower to 7.86 higher)
 
__
 
 
1004 (4 RCTs)
 
 
Low
 
Episodes of infection per infant
Study population
7 per 100                                                   2 fewer per 100
                                                      (from 5 fewer to 3 more)
 
RR 0.70
(0.35 to 1.42)
 
500 (3 RCTs)
 
Low

CI: confidence interval;   RCT: randomised controlled trial;  RR: risk ratio

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About quality of evidence (GRADE)
High quality: Very confident that the true effect lies close to that of the estimate of effect.
Moderate quality: Moderately confident in the effect estimate: the true effect is likely to be close to the estimate of effect but may be substantially different.
Low quality: Confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of effect.
Very low quality: Very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

___________________________________________________________________________________________

Relevance of the review for disadvantages communities
Findings
Interpretation
Equity-Which of the PROGRESS groups examines

 

Preterm infants less than 37 weeks were included.

 

 

 

Majority of the studies were conducted in high-income counties (5 in total). Two studies were conducted in middle-income countries and none in low-income countries. No mention about socioeconomic status.

 

The results of the review apply to preterm infants less than 37 weeks.  If bottle feeds are not used, they will have a better chance of breastfeeding.

 

The results are applicable to preterm infants living in middle and high-income countries but not for infants in low-income countries. Since most of the studies were conducted in high income countries, more research may be beneficial to be completed in middle and low-income countries. Infants in low- and middle-income countries may have access to different types of supplemental feeds or limited supplies.
Equity applicability

 

All the included studies were conducted in high income countries (Australia, UK, USA) and upper to middle (Brazil & Turkey).

 

Avoiding bottle feeds for supplemental feeds helps preterm infants transition to breastfeeding once discharged from the hospital. If supplemental feeds are necessary for preterm infants, the most effective way is to feed with a cup; allows infant to take sips instead of sucking action. Infection rates can be higher in low- and middle-income countries due to different sanitary conditions. Cups are easier to clean than bottles and can help prevent infections; relevant for infection control. Future studies should evaluate if cup feeds are also effective in low-income countries and if these results are transferable to these populations.

Cost-equity

 

No reference made about cost-equity.

 

There was no mention about the cost to provide supplemental feeds for preterm infants. More research is needed to determine the cost of supplemental feeds and its accessibly and feasibility within different countries. Generally, cup feeding is inexpensive; people in lower-income countries are less likely to face financial barrier with this intervention.
Monitoring and evaluation for PROGRESS groups

Monitor infants ability to feed with breastfeeding.

 

 

Evaluate other forms of feeding such as tube-alone strategies.

 

Bottle feeds should only occur once breastfeeding is going well. As premature infants mature, they are likely able to feed with a bottle and have no problems with breastfeeds. Future research is needed to evaluate how infants feed with bottles.

There are no studies on tube-alone strategies for feedings. Future research should study the impact this intervention has on breastfeeding abilities once the infants are discharged home, at 3 and 6 months post discharge.

This summary is based on the following systematic review: 

Allen E, Rumbold AR, Keir A, Collins CT, Gillis J, Suganuma H. Avoidance of bottles during the establishment of breastfeeds in preterm infants. Cochrane Database of Systematic Reviews 2021, Issue 10. Art. No.: CD005252.
DOI: 10.1002/14651858.CD005252.pub5.

Link for PDF: Avoidance of bottles during breastfeeding.pdf

Comments on this summary? Please contact Jennifer Petkovic.                                                                                                                                                   Summary was prepared by Jessica Tiilikainen.