What types of cups should SLPs recommend for babies and toddlers?

Drinking is top of the agenda for most children from the minute they are born. From around six months, many kids request (demand) sips from their parents’ cup or water bottle; and soon after, may start to enjoy a warm drink from a mug, or a smoothie through a straw, just like mom/dad/caregiver-of-choice. But while adults often alternate between open cups, drink bottles, takeaway coffee cups, and straws (for Margarita night), the commercial cup options for children are more… complicated. And plentiful: bottles, soft- or hard-spouted sippy cups, sports-style pop-top bottles, 360 cups, straw cups, open and semi-open cups, and the newest option that’s been invented since the beginning of this sentence.
 

There are also multiple sources of variation within categories—material, size, shape, aesthetics, handles, insulation, spout position, outlet holes, valves, venting, straw weights, ease of disassembly… Some of these features make a difference in ways that are of interest to us as dysphagia therapists, like speed, consistency, cohesion, and direction of flow. Some features make a difference in ways that are of interest to us as behavioral feeding therapists, like how there’s a picture of Elsa on it, and that’s the only way to get your Elsa-obsessed client interested in drinking. Some features make a difference to our OT colleagues, like weight and handles. Some features increase convenience for parents and caregivers, like non-spill valves and insulation. Some probably make very little difference at all. 

That’s the free market for you. Parents are a billion(s)-dollar industry, and companies innovate to stand out from the crowd and attract customers. But this glut of options creates a conundrum for parents—even the parents of typically developing kids. What is the BEST cup? What cup will give my child the best outcomes? And because we know dysphagia, parents come to us with their cup queries. So, what do we tell parents of typically developing kids, when they want to know the best cup for their child from an SLP perspective?

To the evidence!

*crickets chirp*

*the wind whistles across a sweeping plain*

*a tumbleweed tumbles*
 

Folks, to our knowledge, there is not one single paper that demonstrates any impact of the type of cup on eating, drinking, swallowing, or speech outcomes. 
 

You’ll find a few papers associating different types of cups with dental decay and higher energy intake—if the cup contains sugary drinks, and particularly if the child has overnight access—and facial injuries, because toddlers fall on their faces a lot, and if you have something in your mouth and you fall on your face, physics takes over, and that’s bad news for your face. If you’re thinking that it sounds like those outcomes are about the way a cup is used rather than what cup is used, then you and I are simpatico. When dentists and dental organizations recommend against sippy cups, these linked papers are the ones they refer to, and the most common recommendation in the dental literature is “avoid sippy cups containing sugary beverages” and “avoid allowing a child to have a sippy cup in their mouth constantly” not “avoid sippy cups ever.”  Of course, these concerns are out of scope for SLPs—it’s good to know the state of the evidence, but if families are concerned about what cup is best from a dental perspective, our best bet is to refer them to a pediatric dentist.

So, then. What about SLP expert opinion? That’s got to give us something. There are definitely many experts concerned about the use of certain types of cups. They raise questions worthy of consideration. But because expert opinion is more prone to bias than other forms of evidence, we must consider it very carefully, and ask questions about its underlying assumptions. Here are some expert opinions we’ve read or heard:

Expert opinion: Some cups (especially valved, spouted sippy cups) may encourage an immature, back-and-forth suckling pattern, which may affect a child's orofacial development and acquisition of mature eating, drinking, and speech skills.

The immature suckling pattern discussed here is the pattern used by milk-fed infants (although there is notable variation here). It’s interesting to consider that babies are still milk-fed from a breast or bottle until at least 12 months, and sometimes well after (the WHO recommends breastfeeding until 2 years). Yet, this is not thought to inhibit the development of mature drinking. Typically developing children can learn and use multiple motor patterns simultaneously—just as adults can drink from an open cup at home, a pop-top water bottle on the treadmill, and a spouted takeaway coffee cup between home health clients, and manage to swallow a variety of textures with different sensory properties. As long as typically-developing children have a variety of learning experiences with different bolus types and deliveries, they will likely be able to develop a similarly flexible range of oral motor patterns. After all, if sippy cups had substantial adverse impacts on feeding, wouldn’t we have seen an epidemic of oral motor feeding challenges in otherwise typically developing children, coinciding with the commercialization of the sippy cup in the 1980s? There is no evidence of this kind of shift in child development.

A source of bias worth considering here is that as SLPs, we don’t assess many typically developing children. Children with developmental vulnerabilities are more likely to demonstrate maladaptive oral motor skills, but it doesn’t seem reasonable to generalize this assumption to an entire population or to attribute it to the type of cup the child uses. What’s more, SLPs are used to perceiving a tongue-thrust swallow as disordered and linked to sucking habits. The prevalence of tongue thrust swallow in children is around 40% at minimum (here, here, in studies substantially predating the commercialization of valved sippy cups), yet the prevalence of feeding problems seems to be much lower. Does a tongue thrust automatically cause functional eating and drinking issues? It doesn’t seem to be so clear-cut.
 

While we’re here, it’s worth noting that we actually have no idea how much sucking (duration, frequency, intensity) it might take to change orofacial development. It's not the sort of question that lends itself to a large robust experimental study, as the number of confounders and adherence would be really challenging to manage (smaller experimental designs though? Or solid observational studies, like those we've seen for screen-time and safe sleep though? Very possible if you happen to have a couple of years and a grant lying around). But it’s reasonable to assume that a child who sucks strongly on a pacifier, bottle, or sippy cup continually throughout the day might have different outcomes than a child who drinks from a sippy cup for a few seconds at a time at sit-down mealtimes and snacks.

And as for speech, well, we know it’s highly unlikely that changing feeding patterns changes speech outcomes because oral motor development in typically developing children is task-specific.

Expert opinion: Straw cups are preferable to sippy cups because the effort required to suck through a straw builds strength in the oral musculature.

We need to consider why oral strength matters. If straw cups do build oral strength, does this make any functional difference to a typically developing child? Does it make them more able to eat, drink, or speak? Unlikely—otherwise children who don’t have access to straws would struggle more with developing these functional skills, and there is no evidence of this.
 

Expert opinion: Cups designed specifically for children are not a natural or necessary part of development.

This is an interesting one because none of the trappings of modernity are really a natural part of development. And who decides what’s necessary? Necessary for what?

We do know that sippy cups have been around for a long time. Bronze age children drank from sippy cups, so we can assume that adults have seen the need for sippy cups for a long time. Possibly what is meant here is that sippy cups aren’t necessary to acquire the skill of drinking from an open cup, which in most places in the world, at this time in history, is how most adults drink most of the time. This is probably true—but is skill acquisition the only reason we give children sippy cups? Could some use of sippy cups support other skills, like independence, and fitting in with community and family mealtime norms? Oral motor skill development is important, but families have other priorities, and in the context of typical development, in particular, these priorities might matter more.

The main question that I have is: “Why does finding the “right” cup feel so important when we really don’t have strong evidence that it makes a substantial difference?”
 

It probably feels important because the people who sell cups sell more cups if parents think that the cup they give their baby makes a big difference. That’s what has given this issue the most currency with parents. We know parents are incredibly vulnerable to canny, guilt- and fear-based advertising. And SLPs are very vulnerable to the desire to help worried, guilty parents (and are also often parents themselves, and not immune to marketing). 
 

For SLPs, it also feels important because, for children with disabilities, developmental delays/disorders, or orofacial differences, the ‘right’ cup—not the One Cup to Rule Them All, but the cup expertly and carefully selected to meet that child and family’s unique needs—can actually make a big difference to swallow safety, drinking efficiency and effectiveness, and independence. For some kids, that’s an open cup. For others, it’s a sippy or a straw cup. It’s definitely not the same cup, or the same type of cup, for every kid. And none of this means that a typically developing child will necessarily gain a great deal from a new type of cup. Typical development is pretty robust and… well… it’s just a cup.

Does it make sense to encourage a child to practice the skill you want them to acquire? Yes. Giving children a chance to practice with more adult-like cups (whether those are open cups or other types of cups that adults use in the child’s community) will help them to acquire the specific skills required to drink from that type of cup. Will a child fail to acquire the skill of drinking from an adult-like cup if they use a valved sippy cup sometimes? Unlikely. And do parent’s priorities—like having a cup that won’t flood the inside of their handbag with water or soak the fifth outfit today—also weigh in this decision? Yes. Rather than issuing blanket recommendations to the parents of typically-developing children, maybe we could focus on giving recommendations around the pattern of use: for example, avoid putting sugary drinks in sippy cups, try to ensure children drink for a few seconds then put their cup down and leave it, and give children the opportunity to drink from a variety of cups at different times. This ameliorates the possible risks of sippy cup use while preserving its benefits.

Let’s take a breath and recap. What do you say when someone tags you in the sippy cup wars on the daycare social media group? Well:

1. There’s no scientific evidence that the cup your child uses will make any difference to feeding, swallowing, or speech.
2. It’s important to think about what/when/how your child is drinking (mostly water, for discrete periods of time, while sitting or standing still).
3. If you need a spill-proof cup to avoid losing your marble—yes singular; it’s 2021—go for it. You can always practice open-cup drinking in the bath. (All children drink bathwater. Might as well make it a learning opportunity.)
4. If your child has developmental issues, these recommendations may change on the advice of your clinical team, who can find the cup that’s right for your child.
    

Looks like it’s the last call. Drinks are on us… sometimes literally.