Diane and Karen especially,

Excellent and thought provoking posts about Nipple Confusion.

My friends and I have begun using the term Nipple preference.

Regardless of what one calls it, I want to add one very obvious reason
why a baby might develop the condition. I think there is often a missing
piece of the puzzle we need to consider.  Diane made momentary reference
to it in saying:

< 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.>

Post delivery, especially if the mother has had IV's, and particularly,
long IV Pitocin augmentation or induction, each day - - - in fact,
sometimes each hour, - - - - the contour, indeed the graspability and
pliability of a mother's nipple/areolar complex begins to change.
In addition to tissue edema,  the onset of milk production compounds the
problem. This is especially true if no early feeds "imprint" the baby's
"oral memory" before all these changes start to alter the topography and
"latch-compliance" (we medical types love that word compliance!) of the
breast.

During this time period, of course the shape of the reliable artificial
nipple remains predictably the same, especially if all the staff uses the
same brand.

I think it may be  the constantly changing FEELING  of the mother's
nipple and areola  that may cause any confusion involved in these early
situations. And having seen some of the cases of engorgement I continue
to see in the first 10-14 days,  I can understand why the baby (and the
mother) might easily prefer the unambiguity of the rubber nipple, and
soon learn to "give up" on the mother's nipple.

I am personally opposed to the use of vacuum to try to deal with the
situation, because "Suction does not pull on milk. It pulls on flesh."
And a pump pulls on all components of the flesh, including excess
interstitial fluid. In many such cases, a pump will simply bring more
edema to the nipple/areolar complex, adding insult to injury.

I think it is extremely valuable to provide anticipatory guidance by
teaching mothers to hand extract, so that if any difficulties are
encountered in the first 10-14 days postpartum,  mothers will know how to
do this before they attempt latching. It triggers the MER, and helps
facilitate Part 1 of Diane's excellent analogy.   "Part 1 is the rooting,
recognition of "ground zero", and mouth on breast."

More important in my estimation, it helps to soften the deep areolar
structures and free up their maximum elastic potential so that the
MOTHER'S BREAST WILL RESPOND when baby attempts "Part 2. . . 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."

And then, add Diane's excellent suggestion that "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 [softening the areola-addition
mine} and positioning him well in relation to the breast and stabilizing
the breast in a way that allows it to fit easily into his mouth."

Then, maybe we (in-hospital and out-of-hospital caregivers) can  arrive
more quickly, with fewer bottles, at "Part 3 . . . 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."

Not "research-based". Just my clinical experience over many years.

K. Jean Cotterman RNC, IBCLC
Dayton, Ohio

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