Clearing Up the Nipple Confusion

One of the first challenges that new parents encounter is feeding their baby. It can be tough. It’s an emotionally charged topic for many moms–one that’s prompted a constant stream of “mommy wars.” People on both extremes can get downright nasty towards those who disagree. New mothers often realize quickly that, while breastfeeding may be “the most natural thing in the world,” it doesn’t always come naturally. It can be physically and emotionally exhausting. It requires persistence–and often some significant outside help. In the other corner are parents who choose, for whatever reason, to feed their infants formula. Their struggle tends to be more external; formula-feeders can face tremendous social ridicule, sometimes being accused of not loving their children enough to provide them with optimal nutrition.

Let me start by saying this

I think breastfeeding is fantastic. It does have some health benefits over formula (although the difference isn’t as significant as you might think). For moms who want to make breastfeeding work, I’ll do whatever I can to help them. But I also think that formula feeding is a totally respectable option for parents who can’t (or choose not to) breastfeed. There are a number of reasons why great parents choose to feed their infants formula, and for those parents, I do everything I can to keep them from feeling guilty for this choice. Feeding your baby isn’t something you should feel guilty about. That said, today’s topic is pretty specific to breastfeeding.

I remember the night we brought our first daughter home from the hospital. My wife was planning to exclusively breastfeed, and she had been warned numerous times that introducing artificial nipples (pacifiers or bottles) would destroy her chances of success–a phenomenon known as “nipple confusion.”

The theory is that the different mechanics of sucking on a breast vs. an artificial nipple may make it difficult for an infant to resume breastfeeding after exposure to a bottle or pacifier. When taken to the extreme, nipple confusion is sometimes used to justify a nearly-religious opposition to pacifiers and bottles. But even in smaller doses, these concerns can cause significant stress for new mothers who are struggling with breastfeeding.

Anyway, our first night at home, breastfeeding wasn’t going well–it rarely does during the first few days. My wife felt guilty for not being able to provide the life-sustaining milk that our daughter needed (although, again…it’s typical for a mother’s milk to take a couple days to come in). She was stressed, sleep-deprived, and emotionally drained. She was torn between feeding her baby and avoiding a bottle at all costs. And she was bawling.

I did my best, but she needed help from someone who had been there before. Fortunately, we had a fabulous friend who gave up a couple hours of her night to drive to our house and help out. With her reassurance (and an ounce or three of Enfamil), we made it through the night…and she breastfed successfully for the next 12 months.

And that leads me to my topic–how much of a role does nipple confusion play in feeding a newborn? Much like other areas of newborn care, this is a matter of endless debate in the medical field. There’s a difference of opinion among physicians, nurses, and lactation consultants. Some feel that nipple confusion causes significant issues, and go so far as to place pacifiers in a locked closet within the hospital or remove them entirely. Others don’t believe in it at all.

The debate isn’t a new one. Pacifiers (in various forms) have been around for hundreds of years. And, for just as long, people have insisted that using them is “lazy” parenting, that they will cause dental problems, that they’ll interfere with breastfeeding, or that the lead in the rubber they used was toxic. (OK, they may have had a point with that last one.)

To get an idea of current attitudes surrounding nipple confusion, I posted a survey on my Facebook page (thus obtaining an admittedly non-random sample with significant selection bias). Here are the results:


Based on these results and the comments I received, it seems like most people (at least those who follow me on Facebook) think that nipple confusion probably plays a role, but that we shouldn’t be all that worried about itInteresting, but totally non-scientific–let’s see what the evidence has to say.

In 1989, the WHO (the World Health Organization, not The Who) published a document called Ten Steps to Successful Breastfeeding. I want to take a closer look at steps 6 and 9–those of particular relevance to our topic:

Step 6: “Give newborn infants no food or drink other than breast milk, unless medically indicated.”

If you read the evidence used by the WHO to support this position, you may notice that the studies tend to come from around the globe. And that’s an important point, because the WHO is an organization that exists to promote health throughout the world–not just in developed nations where clean water and quality infant formula are available. While some of the studies are performed in the US or similarly-developed nations, others are difficult to apply to our population. Also, you’ll notice that most of the studies are old–some of them performed 30-40 years ago. And finally, the “supplementation” in most of these studies refers not to offering formula after breastfeeding attempts, but to the routine administration of sugar water or formula to all infants.

Certainly, nursing drives milk production, so infants who receive nothing but breast milk will maximally stimulate the mother’s milk supply. But I’ve also admitted lots of infants to the hospital for excessive weight loss and dehydration because the mother’s milk hadn’t come in yet and the mothers were so worried about supplementing. By the time they got to me, it was “medically indicated.” But I have to wonder how many new moms would be better off if they weren’t quite as scared to supplement…when they need to.

Step 9: “Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.”

Here are a couple quotes from the WHO’s justification for this step:

“Only two experimental studies have been identified and both have limitations. Cronenwett et al (1992) followed 121 infants…At 12 weeks postpartum 93% of the total breastfeeding group were still breastfeeding compared with 83% of the planned bottle group. At 6 months 69% and 59% were still breastfeeding, respectively. The trend shown may have become significant if the sample size had been larger.” In other words, there weren’t enough babies in the study to draw a conclusion.

“Schubiger et al (1997), in a multicentre study in Switzerland, randomized 602 mothers and infants during their hospital stay either to an intervention group, who were intended to receive only medically indicated supplements, given by cup, with no artificial teats, or to a control group. At six months, no difference in the numbers breastfeeding was found between the two groups (57% versus 55%, respectively).”

The report goes on to cite several other studies–mostly small, observational studies from the 1990’s–which suggest that infants who use pacifiers may be less likely to continue breastfeeding, and that cup feeding may be preferable to bottle feeding when supplementation is required.

These Ten Steps have enjoyed overwhelming acceptance, and they have undoubtedly helped many women around the world breastfeed successfully, saving the lives of countless infants. The American Academy of Pediatrics (AAP) has aligned with the WHO stance, adding the qualification in 2005 that pacifiers may be introduced after breastfeeding is well-established (due to compelling evidence linking pacifier use to a decreased risk of sudden infant death syndrome). And the Ten Steps have been adopted by hospitals around the world who are clamoring to obtain certification from the Baby-Friendly Hospital Initiative.

But in 1999, just after the WHO published a 118-page document citing evidence for the Ten Steps, another study came out. It, too, showed decreased breastfeeding rates in infants who used pacifiers–but only after 3 months of age (although to me, it looks like the groups are pretty equal until 6 months):

This finding made the researchers question whether pacifier use caused decreased breastfeeding, or if mothers who don’t plan to breastfeed long-term are simply more likely to use pacifiers. Furthermore, because the difference in breastfeeding rates didn’t show up until later, they couldn’t pin it on nipple confusion: “These findings fail to support breastfeeding attachment problems or nipple confusion as the biologic mechanism whereby pacifier use affects breastfeeding duration… [we] found minimal evidence of any problems attributable to suckling technique.”

As I’ve said before, study design is important. Most of the studies cited by the WHO as evidence for nipple confusion are observational studies–meaning that they watch different groups over time and see what happens. The problem with that (and it’s a big problem) is that a study of that design can’t establish a causal relationship–that is, it can’t determine if breastfeeding rates dropped because of pacifier use. More recently, there have been some randomized controlled trials that paint a different picture:

  • This 2001 randomized controlled trial showed no association between pacifier use and weaning before 3 months.
  • This 2004 randomized controlled trial showed no difference in breastfeeding with pacifier use in preterm infants. It did, however, show a possible advantage to giving supplemental feeds with a cup instead of a bottle.
  • A large randomized controlled trial in 2013 showed that, in one hospital, the percentage of breastfeeding infants went down when pacifiers were banned from the hospital. This is a particularly interesting study, because it was the opposite of what we might have expected. The authors tried to explain that away, but their “findings stubbornly persisted despite these efforts to embrace BFHI [Baby-Friendly Hospital Initiative] principles.”
  • A 2012 Cochrane review of all available evidence showed no connection between pacifier use and decreased rates of breastfeeding: “Pacifier use in healthy term breastfeeding infants, started from birth or after lactation is established, did not significantly affect the prevalence or duration of exclusive and partial breastfeeding up to four months of age.”
  • Another 2008 Cochrane review showed higher rates of exclusive breastfeeding for infants who received supplemental feedings from cups vs. bottles. This effect was seen only at the time of hospital discharge; by 3 months, the groups had evened out.

Based on this newer evidence, nipple confusion doesn’t seem to play a huge role in infant feeding. And it really shouldn’t be a reason for already sleep-deprived new moms to lose even more sleep.

I wish that every mother that wants to breastfeed could do so without difficulty. I wish there were no barriers to breastfeeding imposed by work schedules, cultural norms, or other external pressures. I wish that all breastfeeding mothers had the support they need from their spouses, friends, family, physicians, and lactation experts. And that, if breastfeeding isn’t going well–when a mom is sleep-deprived, stressed out, and feeling like a failure–we could support her without adding the fear of supplementation to her list of concerns. Based on the evidence available, there’s little reason to believe that the use of a pacifier or temporary formula supplementation while breastfeeding is established will prevent a mother from successfully breastfeeding.

I also wish that any parent who can’t–or chooses not to–breastfeed could do so without ridicule, shame, or guilt. I wish that people would realize that, while breastfeeding is nutritionally ideal, it doesn’t work out for everyone, and that formula is a perfectly acceptable alternative–one chosen by many fantastic parents of children that, in the vast majority of cases, grow up perfectly healthy.

And, most of all, I wish that every child could have someone who loves him enough to spend a ridiculous amount of time trying to figure out the best way to feed him. Because you know what will make an even bigger difference in that baby’s life than breast milk? Having someone who loves the heck out him–no matter what he eats.

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