Hi all.  I hope I don't get scalped for this, but I don't know if I think it
is such a great idea to be dogmatic about anything, including this issue of
nipple confusion.  I am tremendously against baby's having first feeds on
bottle teats -- esp. for no good reason, however, I see plenty of babies for
whom bottle use does not appear to be a major big deal.  I also see a lot of
babies -- like the one I saw yest. on day 3 with over 12% loss of body weight
and inverting nipples in mom which no one commented on in hospt.  Mom was
sent over immed. from her pedi visit with hideous engorgement and a baby who
was lethargic, jaundiced, and totally discombubulated.  This little guy
couldn't make anything work for him, and the parents were freaked.  We tried
several feeding methods unsuccessfully (he blew bubbles a lot.)  Ultimately
we stuck a bottle in his mouth and got an oz in him.  Bottles work well and
they work fast, and some of the babies I see are in such sad shape that we
feed them first and get some energy in them, then we resolve the
breastfeeding problems.  Now maybe this means I'm not very skillful with
teaching alternate feeding methods, but I think many of the crises I'm handed
would result in weanings if I was too rigid with parents.  Most of them say
they will cup, SNS or finger feed, but they get home and don't have 17 yrs of
practice feeding this way and because its 'hard' they panic.  If they have
the option of a bottle with expressed HM (human milk) they see baby get fed,
feel less frightened, and can begin the follow through on salvaging things as
baby's energy returns to normal.  I use thin silicone nipple shields to coax
these babies back to breast with a familiar sensation if they get bonded to
the teats.  Then we fix the primary prob.ie getting the nipples sucked out
with a pump, re-do the positioning, monitoring weights closely all the while.
 Now I certainly don't handle all my babies this way, and there are some
where I strongly warn against bottle exposure, but I have reasons for all my
protocols, and I also try to evaluate on a case by case basis what will or
won't work.  I monitor my results to see if I get ok outcomes.  This argument
is similar to the pacifier discussion.  I like to use long, round pacifiers
with some babies:  to exercise a weak, low tone soft palate in some preemies
or hypotonic infants, or to train down the tongue in babies for whom this is
a problem.  I would be very annoyed to have these items banned because
sometimes they are useful tools.

I stand by my belief that what used to 'happen' to some of the poorly sucking
infants we sometimes see was that they died.  For whatever reason, they
aren't 'normal' at least not in the early neonatal period.  Some of this is
doubtless iatrogenic from delivery issues. maybe some relates to what Phillip
Zeskind discussed at the Atlanta ILCA conf.  when he talked of ponderal
indices and the need for another, more subtle 'Apgar' which measures issues
such as the kind of interuterine exposures to stress, drugs, environmental
contaminants etc. to which babies arrive having been exposed to. LCs see many
babies who will recover completely, and some who will ultimately show up as
having problems.  I'm committed to saving breastfeeding for these babies --
all of them, and I'll use whatever works to strengthen them quickly and get
them going at breast. Even bottles, even nipple shields, even pacifiers.  But
there has to be knowledge and intent behind the choice of a tool. Instead of
trying to pass laws or make rules prohibiting things, perhaps we should be
sharing how we make these clinical decisions appropriately and what kind of
outcomes occur.
Barbara Wilson-Clay, BSE, IBCLC
priv. pract. Austin, Tx