Non-nutritive sucking (NSS) is an important source of comfort and a
mechanism (one of the few within the control of infants) which assists
babies in state regulation.  There has been nice documentation of improved
weight gain in NG-fed preemies who were allowed to suck on soft, air-filled
pacifiers, and also earlier transitioning to oral feeds.  Additionally, the
low tonality of preemies often extends to the soft-palate (which is a
muscle).  Some speech pathologists deliberately exercise suck by using
pacifiers on infants with various oral-motor problems.  I am certainly of
the opinion that nippling of the human breast is (or should be) part of the
"therapy" for preemies and all other infants struggling to achieve normal
feeding ability. I think that the primary reason babies won't nurse is
because they CAN'T. This is often what is happening when the term "nipple
confusion" is used. It's not the nipple so much as the inability of the baby
to function normally.  I refer you to the recent article (J Peds, 1995;
126(6):125-9.) in which R. Lawrence, J. SEacat, and M. Neifert make the same
disctinction in their call for a medical definition of the term:  nipple
confusion.

 The reality is that often mothers are not available 24 hours a day to
provide the opportunity for NNS.  I think kangaroo care is the greatest, but
when mom isn't there, I think it is a hardship for the infants to be
deprived of the comfort NNS can provide. I hope we keep the infant's
well-being in mind, not just our desire to be politically correct.

I also call for more data to support the safety of cup feeding for preemies.
The immature response to fluid in the larynx is not cough, but apnea,
followed by swallowing in an attempt to clear the airways, which is then,
sometimes, followed by a cough.  "Silent aspiration" can and does occur, and
in preemies, the apneaic response to fluid in larynx can be quite pronounced
and lead to bradycardia.  There are studies in the OT/PT lit. which describe
this immature response as persisting in normal term newborns to the end of
the 1st mo. of life-- at which time 20% of infants may still not cough first
as a sign they have aspirated. (Mortola, 1988) Just because cup feeders are
not hearing coughing or sputtering cannot be taken as conclusive evidence
that the infants are not aspirating. I would love to see video fluroscapy
done with cup feeders of various ages and conditions and watch what the
fluid does.

As an interesting aside, I just saw a set of twins, now 6 weeks old and home
for two weeks, both a bit over 7 lbs.  Primarily bottle fed pumped milk the
entire time.  Mom has kept up a good supply pumping and has nice, erect
nipples.  Has been nursing only 1 x per 24 hrs due to sore nipples (very
apparantly fungal:  one baby on antibiotics for kidney reflux, horrible,
resistant diaper rash, and nipples moist, red, etc)  Anyway, after putting
her in touch with MD about tx for fungus, I helped her with positioning
techniques, etc.  Did test weights pre- and post-feed.  Both babies fed at
breast with beautiful coordination and took 3.2 and 3.4 oz respectively.
They are big enough, strong enough, well enough, and mom has nipples and
milk. She also wisely kept them somewhat oriented at breast with her token
feeds while maintaining supply. Why wouldn't they do well?

 A lot of parents get so scared over the "nipple confusion" issue that they
believe us when we tell them that  bottle use has ruined their chances and
hey just give up.  That is nonsense.  Let's avoid all unnecessary bottle
exposure, but let's work on understanding the phenomenon of nipple confusion
-- including getting our nomenclature straight so we all mean the same thing
when we use the term.  Let's understand what the term means and what it
doesn't mean. Let us also give babies the same dignity as older patients and
plan their care on a case-by-case basis.  Some can clearly manage cups, some
can clearly go straight to breast, some are going to need lots of assistance
in various ways until they can feed normally.

Barbara

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Barbara Wilson-Clay, BS, IBCLC
Private Practice, Austin, Texas
Owner, Lactnews On-Line Conference Page
http://moontower.com/bwc/lactnews.html