One of my issues with words such as "confusion" and "preference" is that both by (Webster's) definition imply choice -- conscious decision making. An infant does not possess the abstract thinking yet to be "mentally uncertain" (confused) or to consciously "like better/select" (prefer). 

The material of a bottle teat may be a more tangible stimulus for suck and the mechanics of bottle-feeding may not require the neuromotor coordination of latching onto, forming the teat and coordinating suckling as per breastfeeding. And if that infant develops oral neuromotor patterns, which they quickly can, that are contrary to those needed for breastfeeding, it may appear that the infant is "confused" or "prefers" the bottle teat. In more than one study, faster-flow teats were associated with lower oral negative pressure within the sample infants' mouths -- to regulate the bolus and protect the airway, these infants sucked less vigorously. 

Working with a lot of mothers of twins/triplets who often have preterms or borderline preterms, I've learned that maternal commitment (patience/persistence), realistic interventions (that respect both the physical management of multiples and the time management element), and a bottle-feeding technique and teat that reinforces BF oral behaviors as much as possible generally leads to effective, direct BF in time -- UNLESS there's an underlying health issue/condition of which an infant's BF behavior is simply the messenger. (I apologize for that run-on sentence!)

Karen

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