All Babies 

A common thread in professional social media posts and elsewhere is in regard to the difficulties that infants often display in learning or relearning how to breastfeed following a learning experience with an artificial nipple, particularly but not only during early learning.  

Such infant feeding difficulties are addressed in the guidance offered in Step 9 of the Ten Steps to Successful Breastfeeding, which advises, "Counsel mothers on the use and risks of feeding bottles, teats and pacifiers."  These common infant breastfeeding challenges include difficulty with the oral grasp and/or disorganized sucking, and are reflected in three important precepts from the cognitive sciences: 

1) Early memories are fragile, including motor memories.  Consider the challenges of learning a new computer password, as well as the challenges in learning how to perform a new piece of music or a new sports skill.  When parents are teaching their teen how to drive a vehicle with a standard transmission, the initial practice on the standard vehicle will not be immediately followed by a week or month of practice driving a vehicle with an automatic transmission — not if the goal is for the teen to learn how to drive the vehicle with a standard transmission.    

2) Task switching is cognitively demanding across the lifespan.  It's challenging to discern and differentiate between things that are similar yet different, such as differentiating one identical twin from the other, or discerning one type of red wine from another.  

3) The younger we are, the greater the cognitive demands in task switching. Task switching has been heavily studied in the cognitive sciences, with 6,835 search results in PubMed today using the term “task switching”.

The language in Step 9 infers that infants need to be given frequent and consistent practice opportunities that are specific to the task.  The Specificity Principle, also termed learning specificity or practice specificity, informs us that in order for learning to be effective, practice must be specific to the task.  We can expect our performance to improve over time when we have the opportunity for such practice. 

In infancy, even with the support of the primitive survival reflexes, we need enough repetition of task-specific practice over time in order to gradually build robust motor memory for the oral grasp and effective suckling toward the adequate transfer of milk.  In other words, the presence of the primitive survival reflexes does not guarantee the oral grasp and effective suckling for all infant milk-feeding methods all the time.  

Note that parents of exclusively bottle-feeding infants are NOT taught to alternate styles of bottle nipples from one feeding to the next, from one day to the next, or from week to the next. Bottle-feeding parents often discuss which brand of artificial nipple their baby will accept, and the challenges in task-switching for infant milk-feeding skills reflect the cognitive demands for task-switching in all babies all the time.

During the change of shift in hospital settings, the departing NICU nurse gives report to the incoming nurse about a bottle-feeding patient who has begun oral feeds that day. There is always information given to the incoming nurse on the type of artificial nipple the bottle-feeding patient is using, as in “Baby Smith has been doing well today with the Brand A nipple”. The incoming nurse intuitively and implicitly understands this report to mean that Brand A style of artificial nipple will continue to be used in bottle-feeding Baby Smith on their shift, unless a change in the baby’s feeding performance or health status necessitates a change in feeding method.   We do not expect to ever read a medical order in a bottle-feeding baby's chart to alternate the style of artificial nipple from one feed to the next, from one shift to the next, from one day to the next, or from one week to the next.  

Similarly, when the 6-month-old infant begins to learn how to use a sippee-cup, parents do not expect their baby to readily switch back and forth between different styles of sippee-cups. 

The toddler who is learning how to use a spoon and fork often confuses the correct movements for using the spoon and fork (Utensil Confusion Part 1).  For those of us who have invested much utensil-learning time in first learning how to use a spoon and fork correctly, we might later accept an opportunity to learn how to use chopsticks. Even though the trajectory from plate to mouth is identical when using a spoon, fork, and chopsticks, the manual grasp of each of these implements is very different, and Utensil Confusion Part 2 will ensue.

IBCLCs and other infant feeding specialists are often asked to assist dyads in the infant’s transfer of learning from bottle-feeding skills to the learning of breastfeeding skills (motor learning toward motor control for the oral grasp as well as effective suckling). Skin-to-skin contact is a first recommendation in helping infants with this transfer of learning, providing a rich sensory milieu for the infant in regard to smell, touch, taste, and hearing, but also in regard to the infant’s critical need to become familiar with the visual field at the breast and the necessary movement toward the breast, which is in stark contrast to the movement of a pacifier or bottle toward the infant.

Following the infant’s learning experience(s) with pacifiers and/or bottle-feeding, parents as well as clinicians frequently observe the subsequent inhibition of the infant’s reflexive movements toward the breast. Response inhibition is also heavily studied in the cognitive sciences, and we see this inhibition from birth when breastfeeding infants are given a learning experience with an artificial nipple and subsequently display skill decay when returning to the breast.  Skill decay is reflected in the infant’s decreased speed and decreased accuracy for the oral grasp and/or effective suckling at the breast, and this can be measured as the inhibition of return (IOR) — the delay in responding to the previously cueing stimuli. Today’s PubMed search using the term “response inhibition” yielded 408,993 results.

In the hoped-for transfer of learning for the infant from bottle-feeding skills and/or pacifier use to the acquisition of breastfeeding skills, nipple shields are frequently provided to the baby at the breast, utilizing the sensory similarities of nipple shields (nipple shields are more similar to artificial nipples as compared to the sensory milieu of the nipple-areolar complex). 

Finger-feeding is often very helpful in assisting infants with the transfer of learning from bottle feeding to the breast, particularly during early learning.  Nipple shields can often be avoided entirely when employing finger-feeding in such instances.

Finger-feeding is also helpful in assisting infants with a transfer of learning from the use of a nipple shield at the breast to learning the oral grasp at the breast without the support of a nipple shield.

Transfer of learning is one of many formal terms from the field of kinesiology -- the study of human movement, motor learning, and motor control. 

A recent study among many on response inhibition:

Title:  Alpha and Theta Bands Dynamics Serve Distinct Functions during Perception-Action Integration in Response Inhibition.

In:  Journal of Cognitive Neuroscience 2022 May 2;34(6):1053-1069. doi: 10.1162/jocn_a_01844.

Authors:  Astrid Prochnow, Elena Eggert, Alexander Münchau, Moritz Mückschel, Christian Beste.

Abstract only: https://direct.mit.edu/jocn/article-abstract/34/6/1053/109891/Alpha-and-Theta-Bands-Dynamics-Serve-Distinct



With kind regards,

Debbie

Debra Swank, RN BSN IBCLC
Program Director
More Than Reflexes Education
Elkins, West Virginia USA
http://www.MoreThanReflexes.org

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