Avoidance of bottles during the establishment of breast feeds in preterm infants

Preterm infants start milk feeds by gavage tube. As they mature, sucking feeds are gradually introduced. Women who choose to breast feed their preterm infant are not always available and an alternative approach to feeding is needed. Most commonly, milk (expressed breast milk or formula) is given by bottle. There is some controversy about whether using bottles during the establishment of breast feeds is detrimental to breastfeeding success.

To determine the effect of avoidance of bottle feeds during the establishment of breastfeeding on the likelihood of successful breastfeeding and to determine if alternatives to bottle feeds are safe.

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL and EMBASE in any language. The search was updated in July 2008.

Randomised or quasi randomised controlled trials comparing avoidance of bottles with use of bottles in women who have chosen to breast feed their preterm infant.

Two review authors independently assessed trial quality and extracted data. When appropriate, we contacted study authors for additional information. Standard methods of the Cochrane Collaboration and the Cochrane Neonatal Review Group were used.

Five trials of 543 infants were included. Four trials used a cup feeding strategy and one trial used a tube feeding strategy when supplements to breast feeds were needed. The single study of tube feeding had a high risk of bias. In the analysis of all five trials, significant heterogeneity was evident in two of the primary outcomes. This was reduced when the tube feeding trial was removed from analyses.Cup feeding significantly decreased 'no breastfeeding or only partial breast feeding' on discharge home (summary RR 0.75, 95% CI 0.61 to 0.91). However, cup feeding significantly increased length of hospital stay by 10 days (95% CI 3.87 to 16.29). There was a high degree of noncompliance in the largest study of cup feeding indicating dissatisfaction with this method by staff and/or parents.The one trial of a tube alone approach significantly reduced 'no breastfeeding or only partial breastfeeding' and 'no breastfeeding at all' at all time periods but the results need to be interpreted with caution due to the high risk of bias.

Supplementing breast feeds by cup confers no breastfeeding benefit beyond discharge home and delays discharge considerably. There is currently insufficient evidence on which to base recommendations for a tube alone approach to supplementing breast feeds. Further research is needed to evaluate a tube alone approach.