Parents need feeding alternatives when newborns are not able to breastfeed. However, one method leads to longer hospital stays and possible health hazards for premature infants, according to a new review by Australian researchers.

Traditionally, hospitals and parents have used bottles or tubes to feed infants when breastfeeding is not possible. In some cases, hospitals have turned to cup feeding, in which a baby sips or laps milk in a small cup placed beneath the upper lip.

Professional curiosity prompted the researchers to take a closer look at the practice. "We were all employed in the neonatal nursery at the time and the discussion about cup feeding would often occur," said lead researcher Anndrea Flint, a nurse manager at the Centre for Clinical Nursing of the Royal Women's Hospital in Brisbane.

Researchers examined four studies that involved preterm infants, born at 29 to 35 weeks gestation.

The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates research in all aspects of health care. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing trials on a topic.

For several decades, developing countries have used cup feeding where tubes are not available or where bottle cleanliness is an issue. However, the practice has taken hold in developed countries as well especially for infants needing supplemental nourishment.

Experts have theorized that cup feeding helps infants avoid nipple confusion, which occurs when an infant adjusts to the easy work of drinking from the bottle and consequently has trouble breastfeeding, and some believe cup feeding can enhance the development of suckling as well.

On the other hand, cup feeding can take longer and milk can spill. "Some authors have reported that cup feeding is awkward at first," the study says, "and that the infant is at risk of aspiration pneumonia when the improper technique is used, resulting in milk being 'poured into' the infant's mouth rather than allowing the infant to lap or sip the milk."

"Parents and staff did not necessarily enjoy the experience of cup feeding," Flint said. Problems uncovered included "the infant not managing cup feeds, spilling a lot, not being satisfied or taking too long to feed." Noncompliance in one study was an issue, since 56 percent of cup-fed infants studied had a bottle introduced.

In a positive finding, three studies showed that "infants who were cup fed were more likely to be exclusively breastfed at hospital discharge." Still, "at three to six months, there was no difference in the number of infants fully or partially breastfeeding, whether initially fed by cup, bottle or feeding tube."

However, one study found that cup-fed infants stayed in the hospital 59 days, while the bottle-fed group averaged about 48 days.

The authors concluded that cup feeding "cannot be recommended over bottle-feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in the hospital."

For Flint, strategies aimed at prolonging breastfeeding should focus on regular "skin-to-skin contact, rooming-in and non-separation of mother and baby," as well as "non-introduction of supplemental feeds unless medically indicated," and education.

The results of the review did not surprise one American pediatrician who has studied cup feeding, because the research focused on preterm infants.

"It doesn't surprise me that the cup feeding didn't do as well [with premature infants]," said Cynthia Howard, M.D., pediatric director of the Mother Baby Unit at ViaHealth Rochester General Hospital, in New York.

Premature infants, "are going to take longer to feed; they are going to burn more calories; and, they're more vulnerable," said Howard, an associate professor of pediatrics at the University of Rochester. "They are often not just tiny; they are sick. They have many needs. …The cup feeding might take longer in those babies."

Howard was lead author of a 1999 study in the journal Pediatrics, which found that administration times, amounts ingested and infant physiologic stability did not differ between cup feeding and bottle-feeding. However, the study dealt with "term, healthy newborns," Howard said, noting that in her workplace, "we use cup feeding and have for years," but generally with full-term infants.

Cup feeding "is used as a transient, stopgap method: The mom's gone for tubal ligation. She's gone longer than you expect. You need to feed the baby," Howard said. "You are not expecting to send a baby home cup feeding."

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

Flint A, New K, Davies MW. Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed (Review). Cochrane Database of Systematic Reviews 2007, Issue 2.