Cheryl Muller's observations are consistent with my own, and surely many
others'.

It probably matters more how we handle babies (and mothers' anxieties about
them) who, whatever the reason, have been fed with artificial nipples and
have problems taking the breast, than what we call it.  Likewise, whether we
'believe' in the phenomenon of nipple confusion.

Like Cheryl I see differences in babies' approaches to feeding, and indeed
to life in general.  Some are laid back and don't mind waiting, can tolerate
many unsuccessful attempts to latch before succeeding, and can feed from a
bottle or a breast, and switch without agony, depending on what's on offer.
Others can't.  Some really seem to have a confused, questioning facial
expression when confronted with a different way of getting food, and some
are extremely distressed, which is distressing to the mothers too.

Since we can't always tell who's who beforehand, we can minimise harm by
giving any needed supplementary feeds by other methods, like cup.  There are
lots of reasons to avoid other nipples, not least of which is the
undermining of mother's confidence which can result.  As Jack Newman has
said so often, babies learn to breastfeed at the breast.  If that is the
goal, then use the best means effective while ensuring that baby gets fed.
Personally I am extra cautious about other nipples for babies who are
reluctant to open wide, as it only seems to prolong their reluctance.

Babies prefer eating to starving, except in very rare cases.  If they learn
that the bottle nipple is the most generous and reliable source of food,
they learn to like it too.  But it is a rare baby that doesn't want to come
to the breast, even after repeated bottle feeds, as long as there is some
reward to be had there - like food.

Saturday I met with a mother who had phoned me late Thursday evening.  Baby
was 2 weeks old.  Due to early soreness mother had on her own initiative
begun pumping and giving EBM by bottle, and when despite her 'frequent'
pumping her supply began to dwindle, she supplemented with ABM.  She phoned
because her total daily production had dropped to about 50 ml (under 2 oz.)
but she wanted to breastfeed.  Baby was also refusing the breast after a
couple of sucks, apparently because it was not satisfying his need for food.
He didn't open his mouth very wide either, so it was uncomfortable to
mother.  Her soreness seemed to be due to the same factor.  Turns out
'frequent pumping' to her meant 4 times/24 hours, and she didn't know how to
elicit the MER first.  I encouraged her to increase pumping to 6 times/24
hr, including once at night if baby woke her to feed, and skin-to-skin when
baby not desperate, until we could meet on Saturday, and discussed the
possibility of getting an oxytocin nasal spray then if it seemed warranted.
By Saturday her production had increased to 50 ml/pumping, or about sixfold,
which of course was very encouraging to her.  Baby still would not take the
breast.  He was asleep so we spent the time on a quick practical lesson in
manual expression.  Milk started to flow immediately, and then to spray, and
leak from the other breast, so no nasal spray was necessary.  She had never
experienced this much leaking before.  Baby started to rouse and she offered
the breast, with some guidance from me to ensure good positioning and
asymmetric latch.  As soon as he got the breast in his mouth the baby
started to suckle well, and opened his eyes in surprise as he gazed at his
HAPPY mother.  He finished calmly on the first side after a short time, and
she latched him on to the other breast with no help at all (I had to leave
the room so wasn't even there).

Nipple confusion?  Not exactly, but he had been using poor technique and the
bottle nipple didn't complain, nor withhold food, because of it, while his
mother's breast, containing sensory nerves connected to her brain, was more
particular.  Without this very small amount of skilled help I think it would
have been difficult for her to get him back on the breast.  She was afraid
of a recurrence of her pain, and afraid of upsetting her baby, and afraid
she didn't have enough milk.  The feed was painless, baby was happy, and
contented afterwards.  She got to see how pleased he was to be at her
breast, and that was the most powerful part of it, because that's where she
wanted him to be too.

This consultation took 10 minutes of face-to-face contact, plus a 10 minute
phone call.  Her pumping to increase supply was essential so that the baby
would see the point of suckling at her breast.  The rest was elementary
stuff.  We didn't talk about nipple confusion, we just dealt with the
problem.  Not all babies make the switch so easily, and because of that we
should have a valid reason for letting them suckle for food at anything but
a breast.  But once a baby has got off to a bad start, we needn't add to the
mother's worries by giving her the impression that she or someone else has
bungled things beyond recovery, unless that truly is the case, which it
almost never is.  If they missed the first breastfeeding boat, they can take
the next one, or take a bus, or a train, or a plane, drive themselves or
just WALK.  There are so many ways to get to the destination.  The key is
having a good travel agent.

Rachel Myr
Kristiansand, Norway

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