What is nipple confusion?  What should a parent do if baby is confused by the pacifier nipple and the breast nipple?

How can a parent avoid nipple confusion I am so glad that you asked this question as many moms are not familiar with it and many providers question the validity of it. Nipple confusion is said to occur when a breastfeeding newborn is given a pacifier or a bottle before breastfeeding is well established. Because the act of suckling on a bottle or pacifier is different from the act of suckling on a nipple it is said that early on infant’s become confused and frustrated with their attempts to nurse in the manner they would feed from a bottle.

The infant is then said to become increasingly frustrated, mother becomes frustrated, milk supply ins not established and often a mother who desires to breastfeed may decide not to or an infant may not be able to effectively breast feed and may continue to require bottles.

There are opinions on both sides of the coins. Those who believe a baby should never be given a pacifier or a bottle, those who believe a pacifier can be offered after breastfeeding well established and those who believe a pacifier should still be offered for non-nutritive sucking skills i.e. in premature infants and for analgesic i.e. sucrose pacifier during circumcision.

I support the AAP Policy regarding pacifiers and believe that pacifiers can be used once breast feeding is well established and should be used if needed for analgesia. Per the AAP policy a pacifier should be offered when placing infant in the back to sleep position no earlier than 3-4 weeks of age due to the benefits for reduction in Sudden Infant Death Syndrome ( SIDS) and after breast feeding has been well established.

The vast majority of babies are able to go from breast, to bottle to pacifier without difficulty history and experience have shown us that. But there are babies that have more challenges and mother’s that have more challenges establishing milk supply which is why it’s crucial in the first 48-72 hours to encourage as many attempts at breast feeding as possible to ensure that the milk supply is well established and if possible avoid use of pacifier or bottle during this time.

For babies having challenges latching there are supplemental techniques that can be offered that avoid bottles such as cup/finger feeding and supplemental tube systems, however these techniques should not be used without support of lactation or the pediatric provider as most babies will not require this type of support.

What should mom do if she is having difficulty breast feeding but wants baby to have access to breastmilk?

This is a common problem that I see in the neonatal nursery as many of our babies have been sick and may not have the endurance to breast feed although mom has been able to successful pump and build a good breast milk supply. If it’s a matter of maturity/endurance alone the infant can continue to be supported with lactation, occupational therapist/feeding therapist support until endurance is better.

Many former preemies or sick term infants are able to go home with a combination of breast and bottle feeding which is gradually increased by the pediatrician after discharge. Most of these infants are able to breast feed several times a day once they have been home a couple of weeks. Unfortunately, some babies never take to the breast…in those scenarios I try to remind mother’s that the main goal is for the infant to receive the breast milk and the benefits of the breast milk.

The baby will be able to receive the protective health benefits from an exclusive 6 month diet of breast milk even if the baby is not directly breast feeding and I applaud the mother for her effort. It’s not easy to pump and to continue to work it into your schedule once the baby becomes older and requires more milk. So the ultimate benefit remains even if mom is unable to breastfeed and that is something to be celebrated.

 

What would cause difficulty for mom and/or baby in the breast-feeding experience?

There are many things that can cause challenges for mom/baby in the breastfeeding experience. The first I think, is that many mother’s encounter is that it doesn’t happen exactly the way you think it will or exactly the way the books describe. You have an image in your mind that your baby will be born and that the milk will come and the milk will just flow. Your baby will happily nurse and go to sleep until the next feed.

Well most mom’s do not have breast full of milk at delivery…and colostrum although more than adequate doesn’t quite fit the picture that we have in our minds.  Breastmilk production is truly supply and demand and for most moms…the milk doesn’t really come in until 48-72 hours and many moms have given up by then. They are told their babies are crying because they are hungry. They are told the babies have lost weight so give a bottle. They are told to nurse every 1 to 2 hours so they are exhausted.  Those first 2 to 5 days can be a holy terror for the new mom and we’re just talking milk production.

In my own experience, I had been a pediatrician for 4 years before I had my first. I was horrified and traumatized by how hard those first few days were…and I regretted how many times I had said to a new, exhausted tearful mom just keep pumping. I was ready for my second baby 3 years later…but I have never forgotten the desperation I felt. Other issues that can cause difficulty for the breast-feeding experience include depression/fatigue/anxiety in mom which can affect milk production and the baby’s ability to bond with mom for nursing.

Challenges with location can disrupt breastfeeding if mother is in places that don’t have breastfeeding friendly policies. As for baby in addition the possibility for nipple confusion as discussed earlier the baby may have some challenges with sucking or latching that prevent effective breastfeeding, including a short frenulum (tongue tie), a small mouth, problems with the palate, problems with the nares or developmental problems like prematurity or health problems like heart disease that affect endurance.

• For mother strong lactation, provider and family support is key.
• For Baby if medical conditions are preventing the ability to latch further evaluation by the pediatric provider is warranted.

 

How is breast feeding for a premature baby with birth defects or breathing problems different from breastfeeding a baby without those obstacles?

As we mentioned briefly earlier some of the biggest barriers with breastfeeding have to deal with prematurity , breathing problems or birth defects. Most premature babies will be able to breast feed but most will not go home exclusively breastfeeding  as they often don’t have the endurance to exclusively breastfeed and often need more calories than breastmilk can provide.

They are able to suck and swallow but to suck and swallow without choking they need time, especially those that may go home with oxygen. Often, they will go home breastfeeding only a couple of times a day and gradually have that increased per their provider. For those with breathing problems…eating is exercise so even for term babies or bigger preemies may have to delay breastfeeding until their breathing improves to avoid choking or aspirating with feeds.

Finally, some infants have major birth defects including stomach, esophagus, palate, brain, lung, or cardiac that significantly delay time to breast feeding. Some may even require special feeding supplementation.

If this happens I encourage mothers who have preemies, birth defects, or mothers with infant’s with breathing problems or birth defects to  focus on pumping.  I would encourage any mother who has baby who is unable to breastfeed or if mother has delayed breastfeeding. The main goal is to make sure that the breast milk supply is well established and that the baby ultimately receives breast milk when he or she is ready to eat.

Lactation Support and Occupational Therapists are essential to helping these babies to be successful. Additionally any mother who is having challenges with establishing breast milk supply can also inquire as to whether the hospital or nursery offers donor breast milk that the infant can use until mother’s milk supply is established.

 

 

As always  Dr. Terri can be contacted at