I have been reviewing all of the posts on nipple confusion. It seems that in our desire to demonstrate that infants can overcome initial suckling difficulties, we are loosing sight of the significance of this problem and are belittling the problems inherent to providing infants with combined oral experiences.  While I fully agree that infants/ children can be helped back to the breast after non-nursing experiences (otherwise why would I be in this field!), this does not negate the possible existence of difficulties with non-nursing oral interventions. Some of you seem to disagree with this point.  If we analyze the phenomenon called nipple confusion, nipple preference or breast aversion in a scientific way, we might gain insight into argument of whether or not this phenomenon exists or not.

Different observers in diverse settings, over time, have noted that infants who had been or were continuing to receive substances from sources other than the maternal breast, exhibit behaviors that suggest that they are having difficulty latching to the breast. Research on the physiology of suckling has demonstrated that infant oral function when sucking (sucking, not a spelling mistake) from artificial nipples, is different from the oral action displayed when suckling from a maternal breast. Principles of infant psychology indicate that early experiences influence infant emotional and behavioral development. Moreover, psychological research highlights the phenomena of breast aversion.  Hence, the consistency of observations by different researchers in varied contexts over time in combination with physiological and psychological principles, suggest that the evidence, pointing to infantile difficulties at the breast following or in combination with non-nursing oral interventions, is reliable.  

Similar to other aspects of human development, infant behaviors are complex composites and are not the result of linear causality. As such, not every infant is necessarily going to demonstrate nursing difficulties after engaging in alternative feeding experiences. On the other hand, not every infant who initially demonstrates problems at the breast, due to non nursing oral interventions, will be able to overcome and to sustain a long lasting nursing relationship. 

The quality of infant behaviors at the breast is contingent on varied factors. The most obvious variables are infantile factors, (including personality, experiences in utero, during birth and afterwards, infant interpretations of events), maternal factors as well as the characteristics of the family and professional support system. Naturally, the interaction between all of these variables has significance for the nursing outcome.   

Since, we can not predict nursing outcome, we will never knew which infants will or will not react to alternative feeding experiences. Thus, in our ethical quest to cause no harm and to provide clients with optimal, evidence based and client centered care, we must bear the possible detrimental effects of alternative feeding in mind in our practice. 

I wish to emphasize that all health care providers, not only breastfeeding specialists, have the ethical responsibility to base ALL interventions on physiological and psychological principles, and not on personal preference or belief. Those of us who teach other professionals should take this into account in their interactions with other professionals. I fully agree with those of you who have stated that it is about time that all health care providers, who work with families with babies, keep up to date with evidence based research and practices in regard to nursing. 

Keren Epstein-Gilboa MEd BScN RN FACCE LCCE IBCLC
PhD (Candidate), Human Development

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