NIPPLE CONFUSION

There are some basic mechanical differences between how a baby gets
milk from a bottle and how a baby gets milk out of the breast. Giving
bottles or pacifiers to young, breastfeeding babies often leads to nipple
confusion. Baby tries to use the bottle-feeding technique on the breast
and has difficulty latching-on and sucking. Baby gets very frustrated,
and so does mother. Nipple confusion can even lead to baby refusing
the breast. Here's an explanation.

To get milk from the breast, baby must coordinate tongue and jaw
movements in a sucking motion that's unique to breastfeeding.

 When baby latches onto the breast, he opens his mouth wide
and draws the very stretchable nipple and areola tissue far back
into his mouth.
 The tongue holds the breast tissue against the roof of baby's
mouth while forming a trough beneath the nipple and areola.
 The gums compress the milk sinuses underneath the areola (the
pigmented area around the nipple) while the tongue
rhythmically "milks" the breast with a wave-like motion from
front to back, drawing the milk from the areola and the nipple.
 Since the nipple is far back in baby's mouth, it's not
compressed by the gums, so it's less likely to get sore.

Babies suck from a bottle entirely differently:

Thanks to gravity, milk flows from a bottle so easily that baby does
not have to suck "correctly" to get milk.
 He doesn't have to open his mouth as wide or correctly turn out
the lips to form a tight seal.
 The bottle nipple does not need to be far back into the mouth,
nor is the milking action of the tongue necessary.
 Baby can lazily gum the nubbin of the rubber and suck with
only his lips.
 When the milk comes out too fast, baby may thrust his tongue
forward and upward, to stop the flow from the nipple.
 Milk keeps on coming during feedings from bottles--whether or
not baby sucks--so there are no pauses to rest during bottle-
feedings.

Problems occur when babies apply the lessons learned from
bottle-feeding to nursing at the breast:

When you compare the illustration of sucking at an artificial nipple

with the illustration of sucking at the breast, you will see that if baby
sucks from the breast the same way he does the bottle, the tongue
and the gums will traumatize mother's nipple.
  Babies who get bottles soon after birth may thrust their tongue
upward during sucking and push the breast nipple out of their
mouth.
 They don't open their mouths wide enough when latching-on, so
they suck only the tip of the nipple. They don't get enough milk,
and mother's nipples get sore.
 Baby becomes accustomed to the immediate flow of milk that
comes from the bottle; at the breast, babies have to suck for a
minute or two to stimulate mother's milk ejection reflex and get
the milk flowing.

Does this mean that bottle-feeding is easier than breastfeeding?
Yes, and no. Bottles require less sucking finesse and less effort.
However, studies comparing premature infants during bottle-feedings
and during breastfeedings have shown that breastfeeding is actually
less stressful.
 Babies' breathing and heart rate are more stable during feedings
at the breast.
 Babies have more control over the milk flow and can establish a
more regular rhythm of sucking, swallowing, and pausing.
 Feeding at the breast also requires less energy.

PREVENTING NIPPLE CONFUSION:

It is easier to prevent nipple confusion than to fix it--though it is a
problem that can be solved, should it occur (see below). Breastfed
babies should not be given artificial nipples during the first three to
four weeks when they are learning and perfecting their breastfeeding
skills. Avoiding artificial nipples means avoiding pacifiers as well as
bottles. Supplements, if medically necessary, can be given in ways
that don't involve artificial nipples. (See Alternatives to Bottles.)

Will it be more difficult to introduce the bottle later?

Many mothers, because they are going back to work or because they
eventually plan to get out for a few hours by themselves, want their
breastfed babies to accept feedings from bottles. They have heard
stories of babies who adamantly refused anything but the breast.
Getting baby to accept a bottle at age two or three months may take
some patience, but most babies will catch on after a few tries. (Babies
can also be fed with alternatives to bottles when mother is gone.)
While introducing the bottle at one or two weeks of age may insure
that baby accepts the bottle later, you're taking a risk. Some babies
easily go back and forth between breast and bottle, but many others
do not. Don't jeopardize your breastfeeding relationship when it has
barely begun.

UN-CONFUSING THE NIPPLE-CONFUSED BABY

When a baby who is getting bottles begins to balk at taking the breast,
nipple confusion is probably at the heart of the problem. Here's how to
re-teach a baby what to do at the breast:
  Banish bottles and pacifiers. Even if your baby will eventually
have to learn to use the bottle because you are returning to
work, don't ask him to learn both skills at the same time.
 If supplements are needed, they can be given in ways that
don't use artificial nipples. (See Alternatives to bottles.)
 Reacquaint baby with the pleasures of breastfeeding. Give
her lots of skin-to-skin contact. Carry her in a sling near the
breast between feedings.
 Breastfeed when baby is calm, usually in the morning or upon
awakening from a nap. Don't wait until baby is ravenously
hungry--she'll be in no mood to try something new.
 Review the latch-on basics. Be sure that baby is positioned
properly in your arms. Wait until her mouth is wide open and
her tongue is down before latching her on to the breast.
 Show and tell. Open your mouth as you say "open" to baby
during latch-on. Even newborns can imitate adult facial
expressions.
 Provide baby with instant gratification at the breast. Use a
breast pump or manual expression to stimulate your milk
ejection reflex and get the milk flowing before latching baby on.
She'll be rewarded with a hearty flow of milk after the first few
sucks.
 Use an eyedropper or feeding syringe to drip milk into
baby's mouth as she latches on to the breast. (Get some help
with this one.) This may encourage baby to stay latched-on and
to continue sucking.
 For more suggestions and support, get help from a La Leche
League Leader or a lactation consultant.

Babies often act puzzled or uncertain when they are re-introduced to

the breast. Be patient. Praise your baby for every tiny step she takes
back to breastfeeding. It may take a few days to woo baby back to the
breast, but you can do it.