Cup vs. Bottle Feeding

Continuation of exclusive breastfeeding after the volume of milk produced is no longer adequate to provide all nutrient needs of the infant may result in malnutrition. In many locales, however, the introduction of prepared formulas and/or complementary foods to circumvent nutrient inadequacies often increases the risk of infection, particularly diarrhea. This choice between inadequate nutrient intake if exclusive breastfeeding continues vs. adequate nutrition but greater risk of infection if other foods are introduced, has been called the “weanling’s dilemma” (1-3.) The increased risk of infection with introduction of formula and/or complementary foods is related to the greater likelihood of these foods being contaminated during mixing and/or being fed from a contaminated bottle or cup, as is common in areas of the world without adequate sanitation, refrigeration or a dependable and safe water supply. To decrease the risk of infection with introduction of complementary foods, it is often recommended that prepared formula and complementary foods be fed with a cup and spoon, which is thought to be safer microbiologically than feeding with a bottle and nipple (4.)

The logic of this belief is obvious to anyone who has tried to clean both utensils. Clearly, cleaning a cup is much easier than cleaning a bottle and cleaning a nipple thoroughly is especially difficult. In addition, it takes much less time to thoroughly clean a cup. Feeding complementary foods from a cup or bowl with a spoon also familiarizes the infant with textures, flavors and smells, whereas diluting these foods with prepared formula or other liquids, as is necessary to feed them by bottle, deprives the infant of these sensory experiences. Feeding from a cup is also thought to enhance the development of chewing and swallowing mechanisms, including coordination of the two (5.)

Despite the logical assumption that it is microbiologically safer to feed infants who cannot be breastfed by cup rather than bottle, cup feeding is unpopular in most of the world, particularly in developed countries. Objections to cup feeding include the perception that it is more difficult than bottle-feeding, it results in more spillage, and it takes longer (6.) In addition, it is difficult to substantiate that cup feeding is microbiologically safer than bottle-feeding in spite of the logic behind the assumption.

A thorough search of the literature uncovered only one small, randomized, controlled study of the impact of cup vs. bottle-feeding on the prevalence of diarrhea (7.) In this study, 3-month-old infants who were no longer breastfeeding and had experienced at least one episode of diarrhea prior to enrollment were randomly assigned to be fed by bottle or by cup for the next 3 months. Infants assigned to both had fewer episodes of diarrhea than during the previous 3 months, presumably because mothers in both groups received extensive training in the appropriate use of the assigned feeding method. Although fewer infants fed by cup had episodes of diarrhea (8 percent vs. 17 percent), this difference was not statistically significant. In addition, total weight gain of the infants fed by cup was less (an increase of 43.7±15 percent vs. 54.5±15.7percent above weight at onset.) Moreover, more mothers of infants assigned to the cup-fed group expressed dissatisfaction and several switched to bottle-feeding. This might be related to the fact that most were fed by bottle prior to enrollment. In addition to the objections to cup feeding cited above, mothers assigned to this method found night feeding by cup to be particularly tiring.

In other studies, ready-to-use feeding containers in the home were cultured for presence of bacteria associated with diarrhea (8,9.) Although a large percentage of both cups and bottles were contaminated with diarrhea-causing bacteria, more bottles were contaminated than cups. This finding supports the logical assumption that cups are more easily cleaned than bottles. Several additional studies have documented contaminated feeding bottles and nipples as well as contaminated feeding bottle contents (10,11) but none included a direct comparison of bottle-feeding vs. cup feeding.

Other studies have documented high rates of bacterial contamination of foods intended for feeding infants (12-17.) Due to the difficulty of preparing conventional weaning foods, these are often prepared only once daily. Once prepared, feedings are usually stored for hours at environmental temperature and fed throughout the day. Thus, even if bacterial counts were acceptable when the food was prepared, storage at usually high environmental temperatures promotes exponential increases in the number of organisms. Obviously, feeding such foods from a perfectly sterile cup or bottle will not appreciably lower the risk of delivering diarrhea-causing pathogens, usually enteropathogenic E. coli, with the feeding. A number of factors other than improper mixing and storage conditions, per se, tend to increase the likelihood of weaning foods being contaminated with organisms causing infantile diarrhea. These include contaminated water supplies, improper hand washing techniques, a generally unsanitary household and poor personal hygiene (18-20.)

Clearly, the “weanling’s dilemma” is unlikely to be resolved by the exclusive use of a cup vs. a bottle and nipple for providing replacement and complementary feedings. However, it is likely that cup feeding is somewhat safer, microbiologically, than bottle-feeding. As mentioned, cups are easier to clean than bottles and nipples. In addition, formula and other foods are not likely to be stored as long in a cup as in a bottle.

Cup feeding may also have other advantages. One frequently cited advantage is prevention of “nipple confusion” when stored human milk or supplemental formula feedings are given to breast-feeding infants (21,22.) Some infants who receive such feedings by bottle and nipple appear to develop an aversion to breastfeeding, presumably because the mechanics of sucking at the breast differ from those required for bottle-feeding, the latter apparently being easier for the infant. However, despite the widespread belief that bottle-feeding results in “nipple confusion”, most studies show little difference in subsequent breastfeeding success between infants who receive the supplemental feedings by cup vs. bottle and nipple (23,24.) A recent study, for example, showed minimal effects of such feedings on breastfeeding success but a marked negative influence of pacifier use (25.)

The higher prevalence of otitis media in bottle-fed vs. breast-fed infants has been attributed, in part, to the greater intraoral pressure generated while bottle-feeding (or using a pacifier) which, in turn, increases the likelihood that the feeding will reach the middle ear (26-28.) If so, cup feeding should be beneficial. However, this has not been examined. While the prevalence of otitis media is greater in bottle-fed vs. breast-fed infants, it is not clear whether this is related to the type of suck or the type of milk since the prevalence of most infections is lower in breast-fed vs. formula-fed infants.

The different nature of suck required for successful breast-feeding vs. successful bottle-feeding also has been incriminated as a cause of the greater likelihood of malocclusion in bottle-fed vs. breast-fed infants (29.) In one such study, the periods of exclusive breastfeeding as well as the total duration of breastfeeding were shorter in children with posterior crossbite, a specific type of malocclusion, than in those without (30.) This was attributed to the pattern of low-impact muscular activity associated with bottle-feeding and, hence, interference with the normal development of the alveölar ridges and hard palate. Whether introduction of formula by cup would remedy this potential problem is not clear.

Finally, cup feeding may have physiological advantages over bottle-feeding. Oxygen saturation has been shown to be higher and respiratory as well as heart rates lower in preterm infants fed by cup vs. bottle and nipple (31), presumably because coordination of suck and swallow is easier with cup vs. bottle and nipple feeding. In contrast, no difference in heart rate, respiratory rate or oxygen saturation was observed between term infants fed by cup vs. bottle and nipple (32.) However, heart and respiratory rates were lower and oxygen saturation higher in a group of exclusively breast-fed infants that were studied concurrently. Considering the difficulty of feeding preterm infants as well as preterm and term infants with respiratory and/or cardiac problems, the possibility that cup feeding may be advantageous deserves further study.

In summary, despite the logical assumption that cup feeding is microbiologically safer than feeding by bottle and nipple, there is little direct evidence that this is the case. In reality, both cup feeding and bottle-feeding of prepared formulas and complementary foods result in a high prevalence of diarrhea, particularly in developing countries. This appears to be related more to poor hygiene practices in preparing and storing these products than to the method by which they are fed. On the other hand, there may be subtle microbiological advantages of cup-feeding as well as physiological advantages for selected groups of infants (for example, preterm infants or preterm and term infants with cardiac and/or pulmonary problems.) Nonetheless, the lack of popularity of cup-feeding, due in part, perhaps, to inexperience, is likely to prevent its widespread adoption.

References

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32. Howard CR, de Blieck EA, ten Hoopen CB, Howard FM, Lanphear BP, Lawrence RA. Physiologic Stability of Newborns During cup- and Bottle-feeding. Pediatrics 1999; 104:1204-1207.This material has been prepared by members of the IFM's Advisory Committee on Child Health and Nutrition.

July 2003