I wonder about nipple confusion.  Since I rarely see babies on days
1-3, I can't speak for what happens when a baby's first (or second or
third or 5th) oral contact involves a bottle teat.  But I've seen lots
of babies whose "nipple confusion" was nothing more than poor
positioning or poor presentation of the breast - easily and instantly
eliminated.

Poor positioning:
I think of a baby's suck as involving 3 parts.  Part 1 is the rooting,
recognition of "ground zero", and mouth on breast.  Most babies get
this part okay.  Part 2 is drawing the breast in until it hits some
point well back in the mouth.  This is the part that seems to be
missing
in medicated and "nipple confused" babies.  Part 3 is active sucking,
which tends to occur sort of as if a light bulb went on, once the teat
(breast or bottle) is well back in the mouth.  Just about any baby can
manage this part.

A poorly positioned breast requires that the baby do all three parts
entirely by himself - and maybe doesn't even allow for that.  The
nipple is usually too low, sometimes so low that he can't access it
properly even if he tries.  An active, interested, unmedicated baby
may be able to manage on his own, as Righard's work shows; lots of
"messed-with" babies can't.  So they act as if they don't know what to
do at the breast, then suck down a bottle like a pro.  The bottle, of
course, has that lovely long point that reaches way back to the "suck
now" spot in the baby's mouth no matter how it's positioned (and
goodness knows lots of bottles are poorly positioned, too).

A well positioned breast can usually be offered to the baby in such a
way that it extends well into his mouth without his having to draw it
all the way in.  His lower jaw is allowed to land well back on the
breast.  He may need a small suck to draw it the rest of the way in,
but basically a good bit of the work has been done for him, just by
positioning him well in relation to the breast and stabilizing the
breast in a way that allows it to fit easily into his mouth.

Poor presentation:
A lot of moms seem to have caught this notion of "tickling the baby's
lips" to such an extent that they wave their breast around in the
baby's face and expect him to catch it on the fly.  I've seen babies
look utterly disgusted after trying several times to catch a moving
nipple.  They just shut down and quit trying.  Then mom brings out a
bottle, holds it still, offers it directly, and baby does fine.
 I don't think that's nipple confusion.  I think it's a baby who has
finally found a food source that doesn't fly off the table just as he
picks up his fork.

How many of us have "cured" nipple confusion at the very first latch -
helping a mom attach a baby who "hasn't nursed in days" or perhaps has
never nursed?  Many of these babies look to me like any other baby as
they latch on - no hesitation, no "waffling".  Give them a
well-presented breast and there's simply no problem.

And then there's the "bait and switch" technique of luring a baby to
the breast by giving him a few sucks on a bottle then quickly
presenting the breast instead.  In those cases, it's the bottle that
suddenly makes breastfeeding work.

So I'm increasingly skeptical about nipple confusion, at least as it
involves non-stubby, non-weirdly-shaped teats.  Granted,
there's no need for bottles in the first few days when the milk
quantity is small and the risk of nipple confusion is
probably at its highest. But once a mother is home with a slow-gaining
or non-latching
baby and a lot of milk to be supplied, bottles seem to me to make
sense.  They're simple to feed a baby with, and they
don't seem to interfere with a baby's ability at breast any more than
any other intervention does.  They don't waste precious breastmilk,
they allow for a satisfying feeding time for both mother and baby, and
I've had assorted mothers tell me they feel the baby's ability to
latch and nurse at breast really started to pick up when they switched
to using a bottle instead of another alternate method - perhaps
because a well-presented bottle offers them lip flanging, a reasonably
full mouth, and a good-sized bolus of milk.   I still feel like a
heretic saying it, but bottles have worked just fine for a lot of my
moms.

Diane Wiessinger, MS, IBCLC  Ithaca, NY

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