As we continue to discuss Step 9: "Counsel mothers on the risks of feeding bottles, teats, and pacifier" of the Ten Steps to Successful Breastfeeding, the topic of nipple confusion arises. This topic has multiple names (nipple confusion, nipple preference, flow preference, etc.) and has been disputed in the literature for years. The most widely cited definition comes from Neifert et al (1995) which divides nipple confusion into two types.
Type A describes a neonate's difficulty in establishing the necessary oral configuration, latching technique and sucking pattern to extract milk from the breast after exposure to an artificial teat. Type B refers to older infants who have already established breastfeeding but begin to refuse the breast or prefer the bottle.
Since 1995, various studies have trialed oral configuration, bottle nipple flow rates, comparison between feeding at the breast or at the bottle, and many other theories to "prove or disprove” the existence of nipple confusion. Most IBCLCs who work with newborns have noted the difficulty for many infants under 28 days to have the skills to vary back and forth between latching well at the breast and latching well at a bottle.
At this point in time, the World Health Organization along with the Academy of Breastfeeding Medicine and most countries' health provision boards recommend avoidance of any type of artificial nipple/teat prior to 4 weeks of infant age or until breastfeeding is well established.
Clinical Protocol #3 from the Academy of Breastfeeding Medicine for Supplementary Feedings in the Healthy Term Breastfed Neonate (2017) states;
When supplementary feeding is medically necessary, the primary goals are to feed the infant and to optimize the maternal milk supply while determining the cause of low milk supply, poor feeding, or inadequate milk transfer. Supplementation should be performed in ways that help preserve breastfeeding such as limiting the volume to what is necessary for the normal newborn physiology, avoiding teats/artificial nipples, stimulating the mother's breasts with hand expression or pumping and for the infant to continue to practice at the breast.
And the American Academy of Pediatrics, who endorsed the Ten Steps to Successful Breastfeeding program in 2009, reinforced the avoidance of pacifiers and artificial nipples/teats in the neonate during the postpartum period.
In your healthcare and birthing centers, what do you see as a problem in giving newborn infants bottles, pacifiers or artificial teats? Is this an on-going problem for you? Have you changed that practice over time, and if so, how did you accomplish it?
These referenced documents might be a beginning for a staff inservice to help change policies and procedures. Be sure to find the healthcare documents for your country to add to these. And then let me know how you're doing!
Kathy Parkes, MSN-Ed, RN, IBCLC, FILCA CHC
Professional Development Educator
Zimmerman, E. and Thompson, K. (2015). Clarifying nipple confusion. Journal of Perinatology; 1-5.
Kellams, A., Harrel, C., Omage, S., Gregory, C., Rosen-Carole, C., and the Academy of Breastfeeding Medicine. (2017). ABM Clinical Protocol #3: Supplementary feedings in the healthy term breastfed neonate. Breastfeeding Medicine; 12(3): 1-11. https://www.bfmed.org/protocols
American Academy of Pediatrics, Section on Breastfeeding. (2012). Breastfeeding and the use of human milk. Pediatrics; 129: e827. https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/3-supplementation-protocol-english.pdf
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