The ideal feeding of the newborn and up to six months of life is exclusive breastfeeding. However, achieving this is often not easy. There is a lot of research being done on what actions can help you be successful in achieving a happy breastfeeding.
The WHO published a decalogue years ago (10 steps for a happy natural breastfeeding) with this purpose and one of the steps is to avoid bottles, teats and pacifiers, due to the risk of teat-nipple confusion syndrome.
What is nipple teat confusion?
The teat confusion is, as its name suggests, confusing the suction of the teat with that of the nipple. It can happen when we offer the baby a pacifier and/or a bottle in addition to the breast.
When it occurs, babies have difficulty suckling : they have a hard time latching on and move their mouths from side to side. They get “angry” at the breast, they jerk and let go easily, cry and even reject the breast altogether.
Why is there confusion with the bottle?
Basically for two reasons.
The first is that sucking at the breast is not the same as sucking on a bottle or pacifier.
To breastfeed, the baby must open his mouth wide, covering as much of the areola as possible and making a good seal with his lips, generating negative pressure. He will place his tongue under the areola and perform peristaltic, undulating movements with it, compressing the breast against the palate and thus helping to pump the milk from the ducts to the nipple. Most babies are able to control sucking, swallowing, and breathing like a dance while nursing.
The bottle, on the other hand, is sucked differently, similar to when we absorb like a straw and the tongue, in this case, is responsible for stopping the flow of milk. Breathing while bottle-feeding is also different: expiration lengthens and oxygen saturation decreases compared to those who breastfeed.
On the other hand, the milk flows much faster from the bottle . At the breast, the milk flows more slowly and they have to make more effort, especially at the end of the feeding. In addition, although the first weeks and even months flow almost immediately, by three months (crisis of three months), the milk can take up to two minutes after the start of suckling to start coming out.
Why can the teat nipple be confused with the pacifier?
As for the pacifier, used to calm the baby, it can also interfere with breastfeeding. The way of sucking it is also different from that of the breast. However, there is less evidence in the scientific literature that pacifiers cause nipple confusion.
Babies who use pacifiers, in addition to suffering from teat-nipple confusion, may breastfeed fewer times a day and this will result in less stimulation of the breast and, therefore, less production of breast milk . Let us remember that the chest is not only food, but also comfort, safety, relaxation.
When babies breastfeed to relax or calm down, we talk about non-nutritive sucking and this also has a role in stimulating milk production. Pacifiers are sometimes used to space feedings and shorten them, and this seems to occur more in those dyads (mother-baby) who have difficulties with breastfeeding.
How to avoid teat nipple confusion?
The solution so that nipple confusion does not occur seems clear: do not offer nipples of any kind . However, sometimes this is not possible or we do not want to do so. Let’s see different scenarios:
– Baby who needs to receive supplements by medical prescription. We must know that there are different ways to give the supplements, and we do not necessarily have to use a bottle. Depending on the baby’s age, the amount to be supplemented and his ability to latch on to the breast and his desire to suckle, we can give milk by finger feeding (finger-syringe), with a cup or by means of a relactator (system by which the milk to be supplemented goes through a tube that is placed next to the nipple so that the baby, when suckling, sucks both from the breast and from the tube). In the case of giving a bottle, we can do it using the Kassing technique to avoid teat-nipple confusion.
– I want the baby to use a pacifier .
Some families want to use the pacifier to soothe the baby. In addition, the use of the pacifier during sleep is a protective factor for sudden infant death. In this case, it is recommended to introduce it when breastfeeding is already established , to avoid nipple confusion and to ensure good production of breast milk. .
Whenever we give a bottle and/or pacifier, do difficulties arise with breastfeeding?
Of course not. Every baby and every dyad (mother-baby) is different. There are babies who use pacifiers from birth or receive some bottles and then have no problem latching on to the breast. And on the other hand, there are others who after a single bottle may have serious difficulties in suckling. Every baby is unique.
How to solve teat-nipple confusion?
If our baby has suckling difficulties derived from having had contact with teats, we must, on the one hand, remove the teats and, on the other, get him to latch on again and suck properly. It is recommended that we have support throughout the process from a professional who is an expert in breastfeeding.
In the event that you take supplements in a bottle, we can change the way of giving it to you by following the Kassing method or, more recommendable still, try giving them in a cup, with a syringe or by means of a relactator, always individualizing each case.
If we are having difficulties for it to latch on, we should offer the breast frequently but never force it. Spending as much time skin-to-skin always helps; We can also sleep to be in contact during sleep, always following the guidelines of a specialist.
Sometimes they don’t have a problem latching on but get upset because the milk is slow to come out or doesn’t flow as fast as they’d like. In this case, we can massage our breasts a few minutes before feeding, to stimulate the ejection reflex and for the milk to flow as soon as they are hooked; and during feeding we can perform breast compression (compressing the breast sandwich type) to increase the flow of milk. It also helps in these cases to give the supplement with a relactator, since the flow during feeding is greater: what comes out of the chest and what comes out of the relactator.
What science says about teat-nipple confusion syndrome…
There are quite a few studies on this subject, although most have many limitations and there are few experimental studies.
The WHO collects in a 1998 document the scientific evidence on the 10 steps to achieve successful breastfeeding and concludes that there is increasing evidence that the use of teats and pacifiers is associated with early cessation of breastfeeding as well as other problems, for so its use should be minimized and avoided if possible.
A more recent study published in the journal Pediatrics in 2003 looked at the effect of cup or bottle supplementation and pacifier use on breastfeeding, comparing early introduction (2-5 days) versus late ( more than 4 weeks). The results showed that supplements shorten the duration of breastfeeding regardless of method, although cup use may be beneficial in those requiring multiple supplements and those delivered by caesarean section. They also conclude that the use of pacifiers in the neonatal period was related to a shorter duration of breastfeeding.
In 2016 Cochrane published a review on limited pacifier use and breastfeeding and concluded that pacifier use in healthy full-term infants does not significantly affect the duration of breastfeeding up to four months of age. However, there is a lack of evidence to assess the short-term difficulties mothers face in breastfeeding and the long-term effect of pacifiers on newborn health.
And a more recent review, from this year 2022, also concludes that the use of pacifiers does not seem to significantly affect breastfeeding rates, and its use could have benefits in premature infants.
As a summary of all the above, the use of bottles and pacifiers can affect breastfeeding in different ways , one of them through the teat-nipple confusion syndrome, since the way of sucking from the breast is very different from that of suck on a bottle or pacifier.
For this reason, although the conclusions of scientific studies are variable, it is advisable to avoid unnecessary bottles and individualize the use of the pacifier, which although it has some benefits, it also has other drawbacks.
