A randomized crossover trial comparing the Nifty cup to a medicine cup in preterm infants who have difficulty breastfeeding at Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana

Autoři: Christy M. McKinney aff001;  Gyikua Plange-Rhule aff002;  Daniel Ansong aff002;  Michael L. Cunningham aff001;  Irene Agyeman aff002;  Patricia S. Coffey aff003
Působiště autorů: Division of Craniofacial Medicine, Department of Pediatrics, School of Medicine, University of Washington, Seattle Children’s Research Institute, and Seattle Children’s Hospital Craniofacial Center, Seattle, Washington, United States of America aff001;  Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, School of Medicine and Dentistry, Kumasi, Ghana aff002;  Devices/Tools Global Program, PATH, Seattle, Washington, United States of America aff003
Vyšlo v časopise: PLoS ONE 14(10)
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pone.0223951



Preterm infants make up the majority of the 9 million babies born in Africa and South Asia requiring supplemental feedings as they transition to exclusive breastfeeding. The World Health Organization recommends the use of a cup to feed newborns with breastfeeding difficulties in low-resource settings. We set out to evaluate the Nifty cup, a new feeding cup designed specifically for infants with breastfeeding difficulties.

Materials and methods

We conducted a randomized clinical trial in Ghana. We hypothesized infants would prefer the Nifty cup and that it would have less spillage as compared to a medicine cup. We enrolled mothers and preterm infants with breastfeeding difficulties indicated to cup feed at Komfo Anokye Teaching Hospital. Each mother-infant pair used the Nifty cup and a standard medicine cup; and two feeding assessments with each cup were conducted. We employed an intent-to-treat analysis comparing cup preference using a Wilcoxon signed rank test and spillage using generalized estimating equations.


We enrolled 200 mothers and 237 infants. Many infants were very low birth weight (62%), less than two weeks old (62%), and multiple birth (29%). In response to separate questions about each cup, more mothers reported liking the Nifty cup a lot as compared to the medicine cup (85% versus 57%, p<0.001). When asked to choose between the two cups, more than 75% preferred the Nifty cup (p < 0.001). There was slightly less spillage with the Nifty cup (8.9%) versus the medicine cup (9.3%), which was not statistically significant (p = 0.35). Mothers reported greater confidence and ease of using the Nifty cup and greater use one-month post-discharge compared to the medicine cup (p-values <0.001). Nearly all mothers were breastfeeding and cup feeding their infants at study initiation and at one-month post-discharge.


This is the first randomized clinical trial of cup feeding in sub-Saharan Africa. Mothers prefer the Nifty cup to a medicine cup for supplemental feeds to their preterm infant. The Nifty cup was used with greater ease and confidence. The Nifty cup can offer an improved feeding experience for the mother-infant pair.

Klíčová slova:

Africa – Breast milk – Global health – Infants – Milk – Neonates – Randomized controlled trials


1. Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, et al. Progress towards Millennium Development Goals 4 and 5 on maternal and child mortality: an updated systematic analysis. Lancet. 2011;378(9797):1139–1165. doi: 10.1016/S0140-6736(11)61337-8 21937100

2. March of Dimes. March of Dimes global report on birth defects. The hidden toll of dying and disabled children. 2006; http://www.marchofdimes.org/materials/global-report-on-birth-defects-the-hidden-toll-of-dying-and-disabled-children-full-report.pdf. Accessed December 22, 2015.

3. March of Dimes, Save the Children, World Health Organization. Born too soon: The global action report on preterm birth. Geneva: World Health Organization.;2012.

4. United Nations Children Fund. Trends in estimates of maternal deaths, 1990–2015. 2015; https://data.unicef.org/topic/maternal-health/maternal-mortality/. Accessed May 7, 2018.

5. United Nations Data, United Nations Children Fund. Annual number of births (Births). 2018; http://data.un.org/Data.aspx?d=SOWC&f=inID%3A75. Accessed May 7, 2018.

6. Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, et al. Breastfeeding in the 21st century: Epidemiology, mechanisms, and lifelong effect. Lancet. 2016;387(10017):475–490. doi: 10.1016/S0140-6736(15)01024-7 26869575

7. Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C. Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC pregnancy and childbirth. 2010;10 Suppl 1:S1.

8. GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;385(9963).

9. Meier PP, Furman LM, Degenhardt M. Increased lactation risk for late preterm infants and mothers: Evidence and management strategies to protect breastfeeding. Journal of Midwifery & Womens Health. 2007;52(6):579–587.

10. Kuehl J. Cup feeding the newborn: What you should know. Journal of Perinatal and Neonatal Nursing. 1997;11(2):56–60. 9391366

11. Lang S. Cup-feeding: An alternative method. Midwives Chron Nurs Notes. 1994;107:171–176.

12. World Health Organization (WHO). Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries. Geneva;2011.

13. World Health Organization (WHO). Managing newborn problems: A guide for doctors, nurses, and midwives. Geneva, Switzerland: World Health Organization; 2003.

14. World Health Organization (WHO). Breastfeeding Counselling: A training course Trainer’s Guide Part One. 1993.

15. Penny F, Judge M, Brownell E, McGrath JM. Cup feeding as a supplemental, alternative feeding method for preterm breastfed infants: An integrative review. Matern Child Health J. 2018;22:1568–1579. doi: 10.1007/s10995-018-2632-9 30328044

16. Yilmaz G, Caylan N, Karacan CD, Bodur I, Gokcay G. Effect of cup feeding and bottle feeding on breastfeeding in late preterm infants: a randomized controlled study. Journal of human lactation: official journal of International Lactation Consultant Association. 2014;30(2):174–179.

17. McKinney CM, Glass RP, Coffey P, Rue T, Vaughn MG, Cunningham M. Feeding Neonates by Cup: A Systematic Review of the Literature. Matern Child Health J. 2016;20(8):1620–1633. doi: 10.1007/s10995-016-1961-9 27016350

18. Glass RP, Wolf LS. Incoordination of sucking, swallowing, and breathing as an etiology for breastfeeding difficulty. Journal of human lactation: official journal of International Lactation Consultant Association. 1994;10(3):185–189.

19. Thorley V. Cup feeding: Problems created by incorrect use. Journal of Human Lactation. 1997;13(1):54–55. doi: 10.1177/089033449701300118 9233187

20. Laerdal. Nifty feeding cup: User guide. 2016; http://cdn.laerdal.com/downloads/f4227/Att_1_to_00035812_Nifty_DFU.pdf.

21. Dubowitz LM, Dubowitz V, Goldberg C. Clinical assessment of gestational age in the newborn infant. Pediatrics. 1970;77(1):1–10.

22. Marinelli KA, Burke GS, Dodd VL. A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed. J Perinatol. 2001;21(6):350–355. doi: 10.1038/sj.jp.7210539 11593367

23. Aloysius A, Hickson M. Evaluation of paladai cup feeding in breast-fed preterm infants compared with bottle feeding. Early human development. 2007;83(9):619–621. doi: 10.1016/j.earlhumdev.2006.12.004 17289306

24. Malhotra N, Vishwambaran L, Sundaram KR, Narayanan I. A controlled trial of alternative methods of oral feeding in neonates. Early human development. 1999;54(1):29–38. doi: 10.1016/s0378-3782(98)00082-6 10195713

25. Conde-Agudelo A, Diaz-Rosello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2016;8(CD002771).

26. Chan GJ, Valsangkar B, Kajeepeta S, Boundy EO, Wall S. What is kangaroo mother care? Systematic review of the literature. Journal of Global Health. 2016;6(1):e1–9.

27. Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S. ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications. International journal of epidemiology. 2010;39(Supple1):i144–154.

28. World Health Organization. Managing newborn problems: a guide for doctors, nurses, and midwives. Geneva, Switzerland: World Health Organization,;2003.

29. Seidman G, Unnikrishnan S, Kenny E, Myslinski S, Cairns-Smith S, Mulligan B, et al. Barriers and enablers of kangaroo mother care practice: A systematic review. PloS one. 2015;10(5):e0125643. doi: 10.1371/journal.pone.0125643 25993306

30. Dowling DA, Meier PP, DiFiore JM, Blatz M, Martin RJ. Cup-feeding for preterm infants: mechanics and safety. Journal of human lactation: official journal of International Lactation Consultant Association. 2002;18(1):13–20.

31. Becker GE, Smith HA, Cooney F. Methods of milk expression for lactating women. Cochrane Database Syst Rev. 2016;9:Cd006170. doi: 10.1002/14651858.CD006170.pub5 27684560

32. Boo NY, Nordiah AJ, Alfizah H, Nor-Rohaini AH, Lim VK. Contamination of breast milk obtained by manual expression and breast pumps in mothers of very low birthweight infants. Journal of Hospital Infection. 2001;49(4):274–281. doi: 10.1053/jhin.2001.1117 11740876

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