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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

For women who chose to breastfeed their preterm baby, supplementary feeds with a cup, compared with a bottle, led to improved breastfeeding rates at discharge and up to six months later.

Preterm babies who are transitioning from being tube fed to breastfeeds have traditionally been given bottle feeds (of breast milk or formula) to supplement breastfeeding if the mother is unavailable or if additional feeds are thought necessary.

This small Cochrane review found evidence that babies were more likely to be fully breastfed or to have at least some breastfeeds when cup feeds were used to supplement breastfeeding.

In contrast to a 2008 review on the same topic, this updated review that included two new trials found supplementary feeding with a cup did not increase length of hospital stay.

The results suggest a reconsideration of the traditionally used bottle feeds in the transition to breastfeeds for preterm infants. Implications for practice will include delivery of the message within the neonatal unit.

Why was this study needed?

Sixty thousand babies are born prematurely each year in the UK. Babies born prematurely often have low birth weights. Interventions to improve the feeding of low birth weight infants and to help them establish breast feeding are likely to improve the immediate and longer-term health and well-being of the baby.

Premature babies start milk feeds by tube, and as they mature, progress to sucking feeds (e.g. breastfeeding and bottle feeding). Women who choose to breastfeed their preterm baby are not always able to be in hospital each time the baby needs a sucking feed. In the transition from tube to breastfeeds, traditionally bottle feeds have been used.

There is on-going debate as to whether using bottles during the establishment of breastfeeding for preterm babies is detrimental to successful breastfeeding. Possibly due to a difference in the sucking action required.

What did this study do?

This updated Cochrane review and meta-analysis included seven trials up to July 2016. Two new trials were included since a 2008 review.

The review included 1,152 preterm tube fed infants. Trials were selected if they compared supplementing breastfeeding without the use of bottle feeds, e.g. by using a cup or spoon, tube feeds or specialised teats (intervention) to use of bottle feeds (control).

All trials were conducted in neonatal units, and two trials were from the UK. The included trials were of small to moderate size and some had incomplete data because of drop outs. The quality of evidence for the main outcomes was low to medium but this probably has little effect on the overall reliability of these findings.

What did it find?

  • Supplementary feeds given by a cup (five trials) or tube (one trial) improved full breastfeeding rates at discharge to 64 per 100 women compared to 44 for those who used a bottle (risk ratio [RR]: 1.47, 95% confidence interval [CI] 1.19 to 1.80).  Results were sustained over three and six months.
  • Any breastfeeding at discharge was also higher in those using a cup, at 88 per 100 women compared to 79 for bottles (RR: 1.11, 95% CI 1.06 to 1.16).
  • In contrast to the previous 2008 review, no evidence of a difference in length of hospital stay between supplementary feeds with and without bottles was found (mean difference 2.25 days, 95% CI ‑3.36 to 7.86 days)
  • Meta-analyses from trials that reported time to reach full sucking feeds, weight gain and infection showed no clear benefit or harm with the avoidance of bottle feeds.
  • Limited evidence from two trials suggested improved heart and lung stability with avoidance of supplementary bottle feeds.

What does current guidance say on this issue?

Great Ormond Street Hospital recommends using a cup, tube or syringe to supplement feeds. They advise against using a bottle if possible.

UNICEFs 2012 Baby Friendly Initiative Standards provides guidance around breastfeeding and its importance for premature babies. The London based charity, BLISS, have also produced a resource on breastfeeding for premature babies. Neither include specific guidance on the transition from tube to breastfeeding for premature babies.

A 2006 NICE guideline on postnatal care supports breastfeeding. It does not specifically cover an approach to breastfeeding for premature or low birth weight infants. It includes general advice that formula milk should not be given to breastfed babies unless medically indicated. A new guideline on neonatal care is due to be published in April 2019.

What are the implications?

This review provides low to moderate evidence of improved breastfeeding rates when cups are used for preterm babies in the transition from tube to breastfeeds. The results suggest a reconsideration of the traditionally used bottle feeds in the transition to breastfeeds for preterm infants.

As there are no national guidelines on best practice to aid the transition, there is likely to be wide variability across neonatal units. One of the studies in this review from 2004 had found that cups were deemed difficult to use and may have prolonged discharge. The infants were very preterm which may have affected results. High staff and parent acceptance of using cups was found in the other studies. This does however highlight that there may be a need to determine the optimal technique for successful cup feeding and staff training.

Citation and Funding

Collins CT, Gillis J, McPhee AJ et al. Avoidance of bottles during the establishment of breast feeds in preterm infants. Cochrane Database Syst Rev. 2016;(9):CD005252.

This project was funded by the South Australian Health and Medical Research Institute and the Women’s and Children’s Hospital, North Adelaide, Australia.


Collins CT, Makrides M, Gillis J et al. Avoidance of bottles during the establishment of breastfeeds in preterm infants. Cochrane Database Syst Rev. 2008;CD005252.

NICE. Postnatal care up to 8 weeks after birth. CG37. London: National Institute for Health and Care Excellence; 2006.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

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Pre-term babies were considered those born at less than 37-weeks gestation.


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