Effect of bottles, cups, and dummies on breast feeding in preterm infants: a randomised controlled trial
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《英国医生杂志》
1 Department of Nursing and Midwifery Research and Practice Development, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia, 5006, Australia, 2 Department of Public Health, University of Adelaide, Adelaide, South Australia, 5005, Australia, 3 Department of Obstetrics and Gynaecology, University of Adelaide, Adelaide, South Australia, 5005, Australia, 4 Department of Neonatal Medicine, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia, 5006, Australia, 5 Department of Neonatal Services, Mercy Hospital for Women, Clarendon Street, East Melbourne, Victoria, 3002
Correspondence to: C Collins collinsct@mail.wch.sa.gov.au
Abstract
Although the benefits of breast feeding preterm infants are well established, practical problems in supporting the transition from tube feeding remain. The most common method of supplementing sucking feeds when the mother is not present is by bottle. This may interfere with breast feeding, possibly because of a difference in sucking action.1 2 An increased prevalence of breast feeding has been reported when bottles were replaced by cups3 or tubes.4 However, randomised controlled trials provide conflicting evidence on their effect on breast feeding.5 6 While the use of dummies is standard practice for preterm infants and is supported by a reduction in length of hospital stay7 their effect on breast feeding is unknown.
We determined the effect of artificial teats (bottle and dummy) and cups on breast feeding in preterm infants < 34 weeks' gestation at birth.
Methods
Participant flow and follow up—We invited 454 women to participate, 176 refused (figure). Reasons for refusal included: wanting to use dummy (45/164, 27%), not wanting to use dummy (23/164, 14%), wanting to use a bottle (16/164, 10%), study did not appeal (36/164, 22%). Twelve infants died before discharge and four were withdrawn from the study at the mothers' request. Thus, of the 319 infants and 278 mothers enrolled, 303 (95%) and 265 (95%), respectively, were available for the primary analyses (cup/no dummy n = 82, cup/dummy n = 69, bottle/no dummy n = 70, bottle/dummy n = 82).
Recruitment and trial participation
Characteristics of participants—Most maternal and neonatal characteristics were balanced between groups (tables 1 and 2). There was, however, a 10% difference between dummy and no dummy for primiparity and number who had breast fed before and between cup and bottle for primiparity.
Table 1 Maternal characteristics at trial entry.* Figures are numbers (percentages) unless stated otherwise
Table 2 Neonatal characteristics at birth.* Figures are numbers (percentages) unless stated otherwise
Compliance—Non-compliance was high (figure). Of the infants randomised to cup feeding, 56% (85/151) had a bottle introduced, and of the infants randomised to no dummy 31% (47/152) had a dummy introduced. Reasons for introducing a bottle were available for 91% (77/85) of the infants, and reasons for introducing a dummy were available for 81% (38/47). For 44% (34/77) the mother decided to introduce a bottle; in 33% (25/77) the decision was taken on the advice of the nurse/midwife (some mothers said both of these had occurred). Of the 77 mothers, 39% (30) did not like, or had problems with, cup feeding, including the infant not managing cup feeds, spilling a lot, not being satisfied, or taking too long to feed. 12% (9/77) said the staff refused to cup feed their infant. Dummies were introduced because the baby was unsettled (37%, 14/38) and to teach the baby to suck (29%, 11/38). Primiparous, tertiary educated women, whose household income was from full time work from either partner, and who had a singleton infant > 28 weeks' gestation were more likely to have complied with the study protocol.
Breast feeding on discharge home—Not using a dummy had no significant effect on the proportion of infants who were being fully breast fed at discharge (0.84, 0.51 to 1.39, P = 0.50) or partly breast feeding (0.83, 0.45 to 1. 05, P = 0.53) (table 3). Cup feeding significantly increased the odds of full breast feeding at discharge (1.73, 1.04 to 2.88, P = 0.03) (table 4). The number needed to treat (where "treatment" means cup feeding) for one extra infant to be discharged home fully breast feeding was seven (95% CI 4 to 41). Infants randomised to cups were more likely to have any breast feeding, but this was not significant (1.37, 0.78 to 2.38, P = 0.27) (table 3). In total 6/265 (2%) women with 7/303 (2%) infants chose to express breast milk and bottle feed on discharge home.
Table 3 Comparison of prevalence of breast feeding at discharge, 3 months, and 6 months between groups randomised to dummy and no dummy
Table 4 Comparison of prevalence of breast feeding at discharge, 3 months, and 6 months between groups randomised to cup and bottle
Breast feeding at three and six months after discharge—There were no significant differences in the prevalence of any breast feeding in infants randomised to no dummy compared with dummy at three (0.99, 0.56 to 1.77, P = 0.98) and six (1.23, 0.66 to 2.30, P = 0.51) months after discharge (table 3). There were minor, non-significant increases in the prevalence of any breast feeding in infants randomised to cup feeds compared with bottle at three (1.31, 0.77 to 2.23, P = 0.33) and six (1.44, 0.81 to 2.57, P = 0.22) months after discharge (table 4).
Length of hospital stay—There was no significant difference (median days, interquartile range) in the length of stay between those randomised to no dummy (53, 35-74) or to dummy (50, 33-78) (hazard ratio 0.98, 0.76 to 1.26, P = 0.87). Discharge from hospital was significantly delayed for those randomised to cup feeds (cup 59, 37-85; bottle 48, 33-65; 0.71, 0.55 to 0.92, P = 0.01). The differences by gestational age remained significant (< 28 weeks: cup 93, 86-113; bottle 93, 72-100; 0.55, 0.32 to 0.94, P = 0.03; 28-< 34 weeks: cup 45, 32-66; bottle 40, 32-55; 0.69, 0.52 to 0.93, P = 0.01).
Adverse events—No adverse events were associated with any of the interventions.
Discussion
Bu'Lock F, Woolridge MW, Baum JD. Development of co-ordination of sucking, swallowing and breathing: ultrasound study of term and preterm infants. Dev Med Child Neurol 1990;32: 669-78.
Neifert M, Lawrence R, Seacat J. Nipple confusion: toward a formal definition. J Pediatr 1995;126: S125-9.
Lang S, Lawrence CJ, Orme RL. Cup feeding: an alternative method of infant feeding. Arch Dis Child 1994;71: 365-9.
Stine MJ. Breastfeeding the premature newborn: a protocol without bottles. J Hum Lact 1990;6: 167-70.
Kliethermes PA, Cross ML, Lanese MG, Johnson KM, Simon SD. Transitioning preterm infants with nasogastric tube supplementation: increased likelihood of breastfeeding. J Obstet Gynecol Neonatal Nurs 1999;28: 264-73.
Rocha NM, Martinez FE, Jorge SM. Cup or bottle for preterm infants: effects on oxygen saturation, weight gain, and breastfeeding. J Hum Lact 2002;18: 132-8.
Pinelli J, Symington A. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev 2004;(4): CD001071.
Lang S. Cup feeding: an alternative method. Midwives Chronicle 1994;107: 171-6.
World Health Organization. Indicators for assessing breast-feeding practices. Geneva: WHO, 1991.
Hill PD, Hanson KS, Mefford AL. Mothers of low birthweight infants: breastfeeding patterns and problems. J Hum Lact 1994;10: 169-76.
Labbok M, Krasovec K. Toward consistency in breastfeeding definitions. Stud Fam Plann 1990;21: 226-30.
Altman DG. Confidence intervals for the number needed to treat. BMJ 1998;317: 1309-12.
Kaufman KJ, Hall LA. Influences of the social network on choice and duration of breast-feeding in mothers of preterm infants. Res Nurs Health 1989;12: 149-59.
Yip E, Lee J, Sheehy Y. Breast-feeding in neonatal intensive care. J Paediatr Child Health 1996;32: 296-8.
Boo NY, Goh ES. Predictors of breastfeeding in very low birthweight infants at the time of discharge from hospital. J Trop Pediatr 1999;45: 195-201.
Nyqvist KH, Ewald U. Infant and maternal factors in the development of breastfeeding behaviour and breastfeeding outcome in preterm infants. Acta Paediatr 1999;88: 1194-203.
Killersreiter B, Grimmer I, Buhrer C, Dudenhausen JW, Obladen M. Early cessation of breast milk feeding in very low birthweight infants. Early Hum Dev 2001;60: 193-205.
Furman L, Minich N, Hack M. Correlates of lactation in mothers of very low birth weight infants. Pediatrics 2002;109:e57. www.pediatrics.org/cgi/content/full/109/4/e57 (accessed Sep 2002).
Prescott R, Counsell C, Gillespie W, Grant A, Russell I, Kiauka S, et al. Factors that limit the quality, number and progress of randomised controlled trials. Health Technol Assess 1999;3: 1-143.
Lang S. Breastfeeding special care babies. London: Bailliere Tindall, 1997.(Carmel T Collins, researc)
Correspondence to: C Collins collinsct@mail.wch.sa.gov.au
Abstract
Although the benefits of breast feeding preterm infants are well established, practical problems in supporting the transition from tube feeding remain. The most common method of supplementing sucking feeds when the mother is not present is by bottle. This may interfere with breast feeding, possibly because of a difference in sucking action.1 2 An increased prevalence of breast feeding has been reported when bottles were replaced by cups3 or tubes.4 However, randomised controlled trials provide conflicting evidence on their effect on breast feeding.5 6 While the use of dummies is standard practice for preterm infants and is supported by a reduction in length of hospital stay7 their effect on breast feeding is unknown.
We determined the effect of artificial teats (bottle and dummy) and cups on breast feeding in preterm infants < 34 weeks' gestation at birth.
Methods
Participant flow and follow up—We invited 454 women to participate, 176 refused (figure). Reasons for refusal included: wanting to use dummy (45/164, 27%), not wanting to use dummy (23/164, 14%), wanting to use a bottle (16/164, 10%), study did not appeal (36/164, 22%). Twelve infants died before discharge and four were withdrawn from the study at the mothers' request. Thus, of the 319 infants and 278 mothers enrolled, 303 (95%) and 265 (95%), respectively, were available for the primary analyses (cup/no dummy n = 82, cup/dummy n = 69, bottle/no dummy n = 70, bottle/dummy n = 82).
Recruitment and trial participation
Characteristics of participants—Most maternal and neonatal characteristics were balanced between groups (tables 1 and 2). There was, however, a 10% difference between dummy and no dummy for primiparity and number who had breast fed before and between cup and bottle for primiparity.
Table 1 Maternal characteristics at trial entry.* Figures are numbers (percentages) unless stated otherwise
Table 2 Neonatal characteristics at birth.* Figures are numbers (percentages) unless stated otherwise
Compliance—Non-compliance was high (figure). Of the infants randomised to cup feeding, 56% (85/151) had a bottle introduced, and of the infants randomised to no dummy 31% (47/152) had a dummy introduced. Reasons for introducing a bottle were available for 91% (77/85) of the infants, and reasons for introducing a dummy were available for 81% (38/47). For 44% (34/77) the mother decided to introduce a bottle; in 33% (25/77) the decision was taken on the advice of the nurse/midwife (some mothers said both of these had occurred). Of the 77 mothers, 39% (30) did not like, or had problems with, cup feeding, including the infant not managing cup feeds, spilling a lot, not being satisfied, or taking too long to feed. 12% (9/77) said the staff refused to cup feed their infant. Dummies were introduced because the baby was unsettled (37%, 14/38) and to teach the baby to suck (29%, 11/38). Primiparous, tertiary educated women, whose household income was from full time work from either partner, and who had a singleton infant > 28 weeks' gestation were more likely to have complied with the study protocol.
Breast feeding on discharge home—Not using a dummy had no significant effect on the proportion of infants who were being fully breast fed at discharge (0.84, 0.51 to 1.39, P = 0.50) or partly breast feeding (0.83, 0.45 to 1. 05, P = 0.53) (table 3). Cup feeding significantly increased the odds of full breast feeding at discharge (1.73, 1.04 to 2.88, P = 0.03) (table 4). The number needed to treat (where "treatment" means cup feeding) for one extra infant to be discharged home fully breast feeding was seven (95% CI 4 to 41). Infants randomised to cups were more likely to have any breast feeding, but this was not significant (1.37, 0.78 to 2.38, P = 0.27) (table 3). In total 6/265 (2%) women with 7/303 (2%) infants chose to express breast milk and bottle feed on discharge home.
Table 3 Comparison of prevalence of breast feeding at discharge, 3 months, and 6 months between groups randomised to dummy and no dummy
Table 4 Comparison of prevalence of breast feeding at discharge, 3 months, and 6 months between groups randomised to cup and bottle
Breast feeding at three and six months after discharge—There were no significant differences in the prevalence of any breast feeding in infants randomised to no dummy compared with dummy at three (0.99, 0.56 to 1.77, P = 0.98) and six (1.23, 0.66 to 2.30, P = 0.51) months after discharge (table 3). There were minor, non-significant increases in the prevalence of any breast feeding in infants randomised to cup feeds compared with bottle at three (1.31, 0.77 to 2.23, P = 0.33) and six (1.44, 0.81 to 2.57, P = 0.22) months after discharge (table 4).
Length of hospital stay—There was no significant difference (median days, interquartile range) in the length of stay between those randomised to no dummy (53, 35-74) or to dummy (50, 33-78) (hazard ratio 0.98, 0.76 to 1.26, P = 0.87). Discharge from hospital was significantly delayed for those randomised to cup feeds (cup 59, 37-85; bottle 48, 33-65; 0.71, 0.55 to 0.92, P = 0.01). The differences by gestational age remained significant (< 28 weeks: cup 93, 86-113; bottle 93, 72-100; 0.55, 0.32 to 0.94, P = 0.03; 28-< 34 weeks: cup 45, 32-66; bottle 40, 32-55; 0.69, 0.52 to 0.93, P = 0.01).
Adverse events—No adverse events were associated with any of the interventions.
Discussion
Bu'Lock F, Woolridge MW, Baum JD. Development of co-ordination of sucking, swallowing and breathing: ultrasound study of term and preterm infants. Dev Med Child Neurol 1990;32: 669-78.
Neifert M, Lawrence R, Seacat J. Nipple confusion: toward a formal definition. J Pediatr 1995;126: S125-9.
Lang S, Lawrence CJ, Orme RL. Cup feeding: an alternative method of infant feeding. Arch Dis Child 1994;71: 365-9.
Stine MJ. Breastfeeding the premature newborn: a protocol without bottles. J Hum Lact 1990;6: 167-70.
Kliethermes PA, Cross ML, Lanese MG, Johnson KM, Simon SD. Transitioning preterm infants with nasogastric tube supplementation: increased likelihood of breastfeeding. J Obstet Gynecol Neonatal Nurs 1999;28: 264-73.
Rocha NM, Martinez FE, Jorge SM. Cup or bottle for preterm infants: effects on oxygen saturation, weight gain, and breastfeeding. J Hum Lact 2002;18: 132-8.
Pinelli J, Symington A. Non-nutritive sucking for promoting physiologic stability and nutrition in preterm infants. Cochrane Database Syst Rev 2004;(4): CD001071.
Lang S. Cup feeding: an alternative method. Midwives Chronicle 1994;107: 171-6.
World Health Organization. Indicators for assessing breast-feeding practices. Geneva: WHO, 1991.
Hill PD, Hanson KS, Mefford AL. Mothers of low birthweight infants: breastfeeding patterns and problems. J Hum Lact 1994;10: 169-76.
Labbok M, Krasovec K. Toward consistency in breastfeeding definitions. Stud Fam Plann 1990;21: 226-30.
Altman DG. Confidence intervals for the number needed to treat. BMJ 1998;317: 1309-12.
Kaufman KJ, Hall LA. Influences of the social network on choice and duration of breast-feeding in mothers of preterm infants. Res Nurs Health 1989;12: 149-59.
Yip E, Lee J, Sheehy Y. Breast-feeding in neonatal intensive care. J Paediatr Child Health 1996;32: 296-8.
Boo NY, Goh ES. Predictors of breastfeeding in very low birthweight infants at the time of discharge from hospital. J Trop Pediatr 1999;45: 195-201.
Nyqvist KH, Ewald U. Infant and maternal factors in the development of breastfeeding behaviour and breastfeeding outcome in preterm infants. Acta Paediatr 1999;88: 1194-203.
Killersreiter B, Grimmer I, Buhrer C, Dudenhausen JW, Obladen M. Early cessation of breast milk feeding in very low birthweight infants. Early Hum Dev 2001;60: 193-205.
Furman L, Minich N, Hack M. Correlates of lactation in mothers of very low birth weight infants. Pediatrics 2002;109:e57. www.pediatrics.org/cgi/content/full/109/4/e57 (accessed Sep 2002).
Prescott R, Counsell C, Gillespie W, Grant A, Russell I, Kiauka S, et al. Factors that limit the quality, number and progress of randomised controlled trials. Health Technol Assess 1999;3: 1-143.
Lang S. Breastfeeding special care babies. London: Bailliere Tindall, 1997.(Carmel T Collins, researc)