The UNICEF/World Health Organization Baby Friendly Hospital Initiative recommends avoiding the use of pacifiers or bottle feeding to establish successful breastfeeding; however, the evidence supporting this recommendation is limited. Cup feeding has been suggested as a safe alternative to bottle feeding in breastfed infants who require supplemental feedings to prevent “nipple confusion” or future problems with breastfeeding. Howard and colleagues conducted a dual-intervention, randomized trial to investigate the effects of pacifier use, cup feeding, and bottle feeding on 700 breast-fed newborns.

Inclusion criteria were uncomplicated singleton pregnancy, mother's intention to breast-feed for at least four weeks, and parents' indecision about pacifier use or desire to use a pacifier in the infant. On admission to the hospital, the unborn infants were randomized to receive supplemental feeding with either a cup or bottle (only if medically indicated or requested by parents), and to receive a pacifier early (two to five days) or late (after four weeks). A total of 129 infants received cup feedings and early pacifier introduction, 122 infants received cup feedings with late pacifier introduction, 119 infants had bottle feedings and early pacifier introduction, and 111 infants had the bottle feedings with late pacifier use. At discharge, parents were counseled about the advantages of breastfeeding and the potential adverse effects of supplementation on milk supply. No specific instructions on supplemental feeding methods were given.

Mothers were interviewed at several intervals up to the 52nd postnatal week. The investigators and nurse interviewers were masked to group assignments. No differences existed in maternal race, parity, employment status, smoking status, breastfeeding experience, age, or education between the study groups. The majority of mothers whose infants received supplementation were primiparous, receiving federal assistance, breastfeeding for the first time, or had cesarean delivery.

The researchers conclude that early pacifier introduction is associated with fewer mothers exclusively breastfeeding at one month and decreased overall breastfeeding duration when compared with later pacifier introduction. Supplementation by cup or bottle led to a decrease in overall breastfeeding duration compared with infants receiving no supplementation. In mothers who had cesarean delivery, cup feeding was significantly associated with higher rates of exclusive breastfeeding and overall duration of breastfeeding compared with bottle feeding.

editor's note: In the study by Howard and colleagues, infants requiring supplementation received cup feedings in small plastic medicine cups. Although bottle feeding is a far more common method of supplementation in the United States, cup feeding is an important alternative to consider. Studies have shown that it has the same, and perhaps better, effects on infant heart rate, respiration rate, and oxygen saturation when compared with bottle feeding. (See Marinelli KA, et al. A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breast-feed. J Perinatol September 2001;21:350–5).