I find nipple confusion to be a term that is not very specific.  It can
mean different things to different people and there are some (not me) who
think it doesn't exist.  The first things that pop into my mind are tongue
retraction, lack of breast compression, and unwillingness to open wide for
the breast.

Now I'm getting more interested by what Ann quoted about Wolf and Glass
said about incorrect sucking action with the Haberman bottles.  What aspect
of the sucking action is affected?  I've actually seen many babies go on to
fully feed from the breast with supplementation from Haberman bottles who
have not had Cleft palates.  The common denominator that seem to be low
oral tone, infants that are not compressing the breast, or mothers with
acquired low supply that resolve it with pumping.

The two cases where no alternative feeding devices have seemed to work are
two babies that I have seen that, for lack of any better description, seem
to do what I call the fish squirt.  Both these babies suffered from weight
loss of > 10% initially.  One had low oral tone and a moderately tight
frenulum, the other could have hung from the breast with his mouth alone.
Initially both lacked rythmicity at the breast and were essentially staying
on the breast around the clock, with the occaissional 10-20 minute break
when they were inconsolable.  As they gained back birth weight their
feeding behavior changed.  They would take a large bolus of milk in their
mouths (whether from breast alone, tube on the breast, fingerfeeding,
Haberman or Avent bottle) and squirt half of it back out the sides of their
mouths. Having seen that this developed over time, and one had very good
oral tone, I am suspicious that lack of a seal was not a problem, that
these babies were deliberately not making a seal.  The rate of flow seemed
to make no difference in their behavior.

I have actually had a mother, much to my complete and total surprise and
against both my and my colleagues repeated suggestion to use the SNS, get
her baby completely back on the breast from a low supply situation using a
Avent bottle, which I find to be a very fast flow.  She worked diligently
at pumping and her baby went from transferring only about 0.5 ounces from
the breast to complete feeding at the breast.  The key was that she kept
pumping and built up her supply and attended breastfeeding support group
every week where she worked on her latch.  I would have laid bets that she
would have been bottle feeding expressed breast milk and I was so pleased
when that didn't happen.

None of these were babies that had initial problems latching onto the
breast.

Time for dinner so my random thoughts will have to stop now.

Susan Burger, PhD, MHS, IBCLC

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