I'm not sure I believe in nipple confusion, but I certainly do believe in *suck* confusion. When I use the term suck confusion with the parents and the doctors, it seems somehow less threatening and more workable. Perhaps I just take 'em off guard: They're only programmed to react to the nipple confusion tag! Showing the normal sucking sequence at breast (I use the Childbirth Graphics pics) and how a baby gets milk from a bottle helps explain what's going on inside baby's mouth. In my experience, once folks understand what's happening and why its happening, they're ready to talk about fixing it. I'm a *big* proponent of alternate feeding methods, but have also needed the flexibility to accept parents who "needed" to use a bottle. Using the Avent nipple or the one from J&J (that comes on that silly angled bottle--now *that's* a hoot: bottle feeders aren't capable of holding the darned thing at an angle so the baby doesn't get air?!) seem to create less of a problem than do the freebies that come from the abm companies via the nursery. Nuk and Pur are what I find work next best. I personally have had numerous horrendous experiences with the Playtex nipple but have heard some LCs say it works for their clients. It's too bad we're so culturally oriented to "the bottle" so that other feeding methods take so much explaining to win acceptance from parents, doctors, nursery staff, etc. In my practice, I see so many suck confused babies that I rejoice when I have one that's not! Often, there's no traceable reason why the baby is a tongue huncher/sucker but I've *very* suspicious of epidurals and postpartum pain relievers! Sometimes, though, an unmedicated birth has a baby that won't suck nutritively at breast; I've seen a bunch of them w/in 24 hours who have huge sucking blisters midline on the top lip! I tell the parents they must have developed a bad habit in utero (< big grin>) and go from there. I try not to use gadgets (and talk myself out of a lot of pump sales/rentals!) but I've found the real (not starter) SNS on my index finger to apply pressure to unbunch that tongue is a real winner--never had it fail, even with a few neurologically challenged babes. Sometimes the parents need to continue fingerfeeding for as long as the baby took to develop the problem or at least until they don't feel him bunching his tongue at all; then we transition to SNS at breast for a day or so and then straight to breast. It's fairly quick, gentle and effective; babies who don't feed well at breast look so worried; you can see them relax and enjoy once I've gotten their suck to work well. The parents are *so* relieved that it's fixable and can see how to do it; once the baby's going well, both mom and dad (plus any stray grandparents who might be interested) are taught and try. I've had mothers fingerfeed with tears running down their cheeks; they'd though something was horribly wrong with either themselves or the baby. Dads are grateful than mom is happy...and the baby is doing what he wanted to do but just couldn't get the hang of, so everyone's happy. The expresssions on the babies' faces are so peaceful and contented I get teary-eyed too! The primary concern is getting food in the baby. Of course EBM is best, but abm may be necessary. (In an ironic twist, one ped partnership here will *not* order abm unless the baby is near or at dehydration levels; that's scary to me when these parents are my clients! They seem to view the abm as the antagonist, not how it's delivered to the baby.) Of course, close follow-up is necessary, as these parents need an extra measure of support. But the SNS is portable (so long as the tubes are flushed immediately after use!) and fingerfeeding is do-able in public--everyone wins!