I personally never use the term nipple confusion when speaking with parents. 
They often mention it and generally in the context of being frightened of 
bottles or pacifiers. I say that some people do believe that babies might learn 
habits from bottles that they might try to replicate at the breast but that 
they will  learn how to feed from the breast eventually even if they try some 
not so successful tricks on your nipples (which might not be all that 
pleasant)!! But I have to say that based on my experience with babies I am 
really not  sold on the idea of nipple confusion, I have never worked with a 
baby where I felt that the reason the baby wasn't breastfeeding was due to 
confusion. It always seems to boil down to something else like milk supply, 
tongue tie, flat or inverted nipples, engorgement, oroboobular disproportion 
etc etc....That fixing the problem then leads to successful nursing.I have also 
not found pacifiers to be confusing and there are actually studies that point 
to their lack of confusingness :)

What I try to explain to them is that, in the first couple of weeks the baby 
learns to fall in love with their breasts. I emphasize that babies are thoughtful 
and clever little human beings who are  learning to make evaluations of the 
world around them. Until the baby has had enough success at the breast that 
they are able to leave it satiated and hopefully milk drunk,  when bottles are 
offered the baby may fall in love with the bottle instead of the breast. I think 
that describing it in terms of preference helps them learn about the 
appropriate use of bottles. If a baby is struggling to latch onto flat nipples on 
day 2 or desperately sucking away at  breasts that only provides a half ounce 
total on day five, then why on earth wouldn't they learn to associate the 
breast with frustration and the bottle with satisfaction. Under these kinds of 
circumstances I will discuss the pros and cons of their various choices (cup, 
syringe, bottle, SNS) and let the parents choose. I reassure them that 
whatever choice they make we will be able to get the baby to fall in love with 
the breast eventually but that certain choices might make that path smoother 
or quicker. 

To me there is also a big difference between a baby who bucks at the breast 
because there is not enough milk flowing and a baby who bucks due to a flat 
nipple. I generally find that with supply issues once the supply is established, 
babies are usually happy to take the breast and therefore I don't find bottles 
to be  a problem. With flat nipples patience, holding off on a bottles for a few 
days, pumping, getting through engorgement etc etc and offering the milk via 
cup or syringe seems the logical choice because the baby is not getting 
sucking satisfaction from anything else and will keep trying at the breast. This 
is NOT evidenced based though, it is just based on my own gut feelings. Once 
the pump has had a chance to work its magic, help establish the supply and 
extract the nipple the baby will often do beautifully.(Unfortunately I can't take 
that exact same baby, give him a bottle and see whether he learns to take 
the breast as well as he did without. I really wish I could, because sometimes 
I do wonder) I also explain that we are not going to be using alternative 
methods forever, that if the baby doesn't latch within a few days, we will try 
a nipple shield and if that doesn't work, we'll pump and bottle feed until the 
baby can get the nipple.

Explaining the whole process as an act of falling in love also empowers them 
to decide when the time is right to introduce pumping and bottle feeding as a 
choice if that is what they want. Often they are told to wait until four weeks 
to introduce a bottle, but that seems very arbitrary to me. I tell them that 
when the baby has fallen in love - goes eagerly to the breast, sucks for a 
sustained period of time,leaves the breast with their eyes rolling back in their 
head and falls into a drunkenen slumber, and is gaining weight well, then they 
can introduce bottles.

I do think the term is nipple confusion is confusing :) and I try to avoid it.

Kathy Lilleskov RN IBCLC

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