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Cupfeeding May Prolong Breastfeeding Duration Among Infants Requiring Multiple Supplements or Cesarean-Delivered Infants


  • Does early introduction of pacifiers or bottles in the neonatal period have an adverse effect on breastfeeding among healthy breastfed infants?

Clinical Bottom Lines

  1. There was no advantage to cupfeeding in comparison to bottle-feeding for providing supplements to the general population of healthy breastfed infants.
  2. Cupfeeding prolonged breastfeeding duration among mother-infant dyads who required multiple supplements or were delivered by cesarean.
  3. Pacifier use in the neonatal period was detrimental to exclusive and overall breastfeeding duration.

Summary of Key Evidence

  1. 700 breastfed newborns (36-42 weeks gestation, birth weight = 2200 g) were randomly assigned to 1 of 4 intervention groups: bottle/early pacifier (n=169), bottle/late pacifier (n=167), cup/early pacifier (n=185), or cup/late pacifier (n=179). Cup/bottle intervention was invoked for infants who received supplemental feedings: cup (n=251), bottle (n=251).1
  2. Supplemental feedings, regardless of method (cup or bottle), had a detrimental effect on exclusive (HR 1.49, 95% CI 1.23-1.80), full (HR 1.50, 95% CI 1.24-1.81), and overall (HR 1.53, 95% CI 1.24-1.89) breastfeeding duration.
  3. There was no significant difference between cupfeeding or bottle feeding on breastfeeding duration.
  4. Effects were modified by the number of supplements. Exclusive (p < 0.0001) and full (p = 0.0002) breastfeeding were prolonged by cupfeeding in infants requiring > 3 supplements.
  5. Among infants delivered by cesarean, cupfeeding significantly prolonged exclusive (10 days, p = 0.04), full (5 weeks, p = 0.02), and overall (10 weeks, p = 0.04) breastfeeding.
  6. Exclusive breastfeeding at 4 months postpartum was less likely among infants exposed to pacifiers. (early pacifier group; OR 1.5, 95% CI 1.0-2.0).
  7. Early (2-5 days), as compared to late (4 weeks), pacifier introduction shortened overall (adjusted HR 1.22; 95% CI 1.03-1.44), but not exclusive or full breastfeeding duration.
  8. There was no significant effect of the cup or bottle intervention on the frequency of breastfeeding in the hospital or the occurrence of early breastfeeding problems (maternal nipple trauma, infant weight loss, latch problems, peripartum breastfeeding cessation, peak bilirubin level).
  9. In the first 6 months postpartum, there was no significant effect of the pacifier intervention of breastfeeding frequency or in the occurrence of problems (maternal nipple trauma, refusal of infant to nurse, chances of mother seeking help for breastfeeding problems, development of low milk supple, occurrence of jaundice, or time until infant regained its birth weight.)

Additional Comments

  • The population studied was primarily white and well-educated married women and their healthy infants. Study was limited to families who wished to use or were undecided about using pacifiers, as opposed to the general population.
  • This study indicated that less volume of supplement was consumed by cupfeeding in comparison to bottlefeeding. An appealing explanation is that lower volume consumption is the biological mechanism which preserved breastfeeding among cupfeeders.


  1. Howard CR, Howard FM, Lanphear B, et al. Randomized clinical trial of pacifier use and bottle-feeding or cupfeeding and their effect on breastfeeding. Pediatrics 2003; 111;511-518.

CAT Author: Michelle Villarta, MD

CAT Appraisers: Beth Tarini, MD

Date appraised: November 1, 2006

Last updated November 28, 2006
Department of Pediatrics and Communicable Diseases
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