>>>>She has gotten rid of the red preemie nipples from
>>>>R--- (yeh !).  For freebies, we are left with the yellow R--- nipples
and
>>>>G-----  silicone slow flow nipples.Out closest NICU swears by the NUK
slow flows.....

OK, we don't have to do this coding of brand names.  R---must mean Ross but
is G----- Gerber?  I ask because I am not aware of a free Gerber silicone
slow flow nipple in the NICU I work in.

Wolf and Glass have a chapter called "Tools of the Trade" (chapter 7)
dedicated to bottles, nipples and pacifiers.  The major headings are:

Components of Sucking
        Movement Components
        Pressure
        Impact of Liquid Flow during Sucking
Characteristics of Nipples
        Human Breast
        Artificial Nipples
                Nipple shape (they ask "Does the shape of the nipple support the
oral-motor patterns                               desired during sucking?"
                Nipple size  (they ask "Does the length of the nipple provide adequate
contact                                           between the nipple and the tongue for effective tongue
movements?"
                Consistency  (they ask "Does the firmness of the nipple provide the
appropriate                                       degree of proprioceptive input to the tongue for
effective movement and                            Does the consistency match the strength of the
infant's suck to support                                  an appropriate flow rate?")
                Hole type and size  (they ask "Does the hole provide an appropriate flow
rate?")
Considerations in the Selection of Nipples to Support Feeding Treatment
        Flow of Liquid
                Nipple selection
                Other options for increasing flow
        Sucking Mechanics
                tongue position and movement
                Lip position and movement
                Mouth size
                Strength of sucking
Pacifiers
        Orthodontic versus Conventional Pacifiers
        Pacifier Selection
        Pacifier Use with Non-Orally Fed Infants
Bottles
        Influence of Bottle on Head Position
        Ease of Providing Oral Facilitation
        Monitoring Flow
        Air Swallowing


One more thing from Wolf and Glass.

They summarize two studies by Mathew comparing the milk flow rates of a
variety of term and preterm nipple units.

from page 408 of Wolf and Glass:
Table 7-2 Comparison of Nipples based on Flow Rate
High Flow
        SMA orthodontic
        Enfamil premature
        NUK
Medium Flow
        SMA standard
        Ross premature
        Enfamil Natural nipple
Low Flow
        Enfamil standard
        Ross standard

They also say "the very small premature nipple was not tested, clinically it
also appears to have a fast flow rate"

These studies were done in 1988 and 1990 and things may or may not be the
same with these nipples 10 and 12 years later.

Every hospital should have this book, "Feeding and Swallowing Disorders in
Infancy Assessment and Management". It is that good.  It can be ordered at 1
800 228 0752.  It was published in 1992.  Wolf and Glass have done one
seminar really directed toward LCs and addressing lactation at every level.
I hope they will repeat this in the future and will do a new edition of the
book incorporating more lactation information.  The present book is mostly
oriented toward bottle feeding but does address breastfeeding throughout and
has a chapter on breastfeeding.  The unfortunate reality for most US NICU
babies is bottle feeding does occur.  It behooves us to understand it.  The
book also covers much more and is valuable to LCs even if they never deal
with bottles.

Table of Contents Chapter Headings:
"Functional Anatomy and Physiology of the Suck/Swallow/Breathe Triad...
Diagnostic Tests and Procedures...
Clinical Feeding Evaluation...
Problem-Driven Models for the Comprehensive Multidisciplinary Assessment of
Infant Feeding...
Therapeutic Treatment Strategies for Infant Feeding Dysfunction...
Special Diagnostic Categories...
Tools of the Trade: Nipples, Pacifiers, and Bottles...
Breast-Feeding"

They also have an article "A Global Perspective on Feeding Assessment in the
Neonatal Intensive Care Unit" in June 1994, Volume 48, Number 6 of the
American Journal of Occupational Therapy.  This article doesn't discuss
types of nipples but gives a good overview the assessment of a NICU baby
regarding feeding.  The abstract is available on Medline.

For the NICU selection of nipples, I'd encourage knowing as much as possible
about the different nipples available and selecting a nipple and bottle
based on the individual infant's needs.  A wide variety of nipples, bottles
and pacifiers are needed for different feeding situations in the NICU.  Once
an appropriate nipple is selected for a given infant this should be
communicated and supported by all feeders.  Even the red premature nipple is
valuable at times.  The free NUK like nipples are not the same as the brand
name NUK nipples available in the store.  "Orthodontic" or "NUK" like
nipples don't encourage a central grove in the tongue and are therefore
problematic.  The Avent nipple, newborn (single hole) has a slow flow and
encourages a central grove and is my current nipple of choice for a problem
free bottle feeder who is hoping to become or remain a breastfeeder.
Haberman nipples don't respond to the suction component of an infant's
feeding efforts and this may be problematic for some babies and helpful for
others.

I just saw a nipple unit called the Pigeon nipple. Is anyone familiar with
this nipple or the company that makes it?

Carla (in Maryland)

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