Hospitalization for Nipple Confusion A Method to Restore Healthy Breastfeeding

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Background: The World Health Organization has encouraged all facilities providing maternity services and care for newborn infants to adopt the “10 steps” of successful breastfeeding. This includes not giving artificial teats to breastfeeding infants because they may cause nipple confusion. We present a multimodal hospitalization protocol for infants with nipple confusion, a multimodal relactation method that supports breastfeeding couplets. Purpose: To investigate the effectiveness of hospitalization as an intervention for nipple confusion. Method: Data related to nipple confusion in patients hospitalized between January and December 2012 at Kemang Medical Care, Jakarta, Indonesia, was reviewed. Survival analysis was performed to evaluate the relationship between infant age and intervention outcomes. Results: There were 58 cases of nipple confusion during the study period. Most subjects (96.6%) totally rejected breast contact. Forty-six cases (79.3%) used bottles because of tongue-tie. The length of hospitalization varied from 1 (56.9%) to 5 days (3.4%). Fifty-three cases (91.4%) were able to successfully breastfeed using our protocol. Younger babies had greater breastfeeding success. Conclusion: Hospitalization for nipple confusion with multimodal management is effective for treating nipple confusion. Tongue-tie can lead to difficulties in initiating breastfeeding, and early introduction to artificial teats can lead to nipple confusion. Early detection and treatment is desirable.

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... The literature is rich with observations and studies of the differences between breast-and bottle-feeding. These studies highlight the disadvantages of bottle-feeding, especially the problem of nipple confusion: changes in feeding behavior that make breastfeeding more difficult after exposure to bottles (Batista et al., 2019;Mizuno & Ueda, 2006;Moral et al., 2010;Praborini et al., 2016). However, the observations are based on subjective descriptions of the tongue and orofacial muscles, specifically using visual analysis of videofluoroscopy swallow (Hernandez & Bianchini, 2019), EMG measurement of facial muscles (França et al., 2014), recording of swallowing sounds (Tamura et al., 1996), and rates of sucking and breathing (Taki et al., 2010). ...
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Tongue motility is an essential physiological component of human feeding from infancy through adulthood. At present, it is a challenge to distinguish among the many pathologies of swallowing due to the absence of quantitative tools. We objectively quantified tongue kinematics from ultrasound imaging during infant and adult feeding. The functional advantage of this method is presented in several subjects with swallowing difficulties. We demonstrated for the first time the differences in tongue kinematics during breast- and bottle-feeding, showing the arrhythmic sucking pattern during bottle-feeding as compared with breastfeeding in the same infant with torticollis. The method clearly displayed the improvement of tongue motility after frenotomy in infants with either tongue-tie or restrictive labial frenulum. The analysis also revealed the absence of posterior tongue peristalsis required for safe swallowing in an infant with dysphagia. We also analyzed for the first time the tongue kinematics in an adult during water bolus swallowing demonstrating tongue peristaltic-like movements in both anterior and posterior segments. First, the anterior segment undulates to close off the oral cavity and the posterior segment held the bolus, and then, the posterior tongue propelled the bolus to the pharynx. The present methodology of quantitative imaging revealed highly conserved patterns of tongue kinematics that can differentiate between swallowing pathologies and evaluate treatment interventions. The method is novel and objective and has the potential to advance knowledge about the normal swallowing and management of feeding disorders.
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Background When breastfeeding is difficult or impossible during the neonatal period, an analysis of muscle activity can help determine the best method for substituting it to promote the child’s development. The aim of this study was to analyze the electrical activity of the masseter muscle using surface electromyography during suction in term newborns by comparing breastfeeding, bottle and cup feeding. Methods An observational, cross-sectional analytical study was carried out on healthy, clinically stable term infants, assigned to receive either breast, or bottle or cup feeding. Setting was a Baby Friendly accredited hospital. Muscle activity was analyzed when each infant showed interest in sucking using surface electromyography. Root mean square averages (RMS) recorded in microvolts were transformed into percentages (normalization) of the reference value. The three groups were compared by ANOVA; the “stepwise” method of the multiple linear regression analysis tested the model which best defined the activity of the masseter muscle in the sample at a significance level of 5%. Results Participants were 81 full term newborns (27 per group), from 2 to 28 days of life. RMS values were lower for bottle (mean 44.2%, SD 14.1) than breast feeding (mean 58.3%, SD 12.7) (P = 0.003, ANOVA); cup feeding (52.5%, SD 18.2%) was not significantly different (P > 0.05). For every gram of weight increase, RMS increased by 0.010 units. Conclusions Masseter activity was significantly higher in breastfed newborns than in bottle-fed newborns, who presented the lowest RMS values. Levels of masseter activity during cup-feeding were between those of breast and bottle feeding, and did not significantly differ from either group. This study in healthy full term neonates endorses cup rather than bottle feeding as a temporary substitute for breastfeeding.
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Breastfeeding is associated with numerous health benefits to offspring and mothers and may improve maternal-infant bonding. Ample evidence suggests breastfeeding can improve child neurodevelopment, but more research is needed to establish whether breastfeeding is linked to the development of child psychopathology. This paper aims to explore the effects of both breastfeeding and mother-child interactions on child behavioral outcomes at a later age. Children from the China Jintan Child Cohort Study (N = 1267), at age six years old were assessed, along with their parents. Children who were breastfed exclusively for a period of time in the presence of active bonding were compared to those who were breastfed in the absence of active bonding as well as to children who were not exclusively breastfed, with or without active bonding. Results from ANOVA and GLM, using SPSS20, indicate that children who were breastfed and whose mothers actively engaged with them displayed the lowest risk of internalizing problems (mean = 10.01, SD = 7.21), while those who were neither exclusively breastfed nor exposed to active bonding had the least protection against later internalizing problems (mean = 12.79, SD = 8.14). The effect of breastfeeding on internalizing pathology likely represents a biosocial and holistic effect of physiological, and nutritive, and maternal-infant bonding benefits.
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Background: Infants with latch-on problems cause stress for parents and staff, often resulting in early termination of breastfeeding. Healthy newborns experiencing skin-to-skin contact at birth are pre-programmed to find the mother's breast. This study investigates if skin-to-skin contact between mothers with older infants having severe latching on problems would resolve the problem. Methods: Mother-infant pairs with severe latch-on problems, that were not resolved during screening procedures at two maternity hospitals in Stockholm 1998-2004, were randomly assigned to skin-to-skin contact (experimental group) or not (control group) during breastfeeding. Breastfeeding counseling was given to both groups according to a standard model. Participants were unaware of their treatment group. Objectives were to compare treatment groups concerning the proportion of infants regularly latching on, the time from intervention to regular latching on and maternal emotions and pain before and during breastfeeding. Results: On hundred and three mother-infant pairs with severe latch-on problems 1-16 weeks postpartum were randomly assigned and analyzed. There was no significant difference between the groups in the proportion of infants starting regular latching-on (75% experimental group, vs. 86% control group). Experimental group infants, who latched on, had a significantly shorter median time from start of intervention to regular latching on than control infants, 2.0 weeks (Q1 = 1.0, Q3 = 3.7) vs. 4.7 weeks (Q1 = 2.0, Q3 = 8.0), (p-value = 0.020). However, more infants in the experimental group (94%), with a history of "strong reaction" during "hands-on latch intervention", latched-on within 3 weeks compared to 33% in the control infants (Fisher Exact test p-value = 0.0001). Mothers in the experimental group (n = 53) had a more positive breastfeeding experience according to the Breastfeeding Emotional Scale during the intervention than mothers in the control group (n = 50) (p-value = 0.022). Conclusions: Skin-to-skin contact during breastfeeding seems to immediately enhance maternal positive feelings and shorten the time it takes to resolve severe latch-on problems in the infants who started to latch. An underlying mechanism may be that skin-to-skin contact with the mother during breastfeeding may calm infants with earlier strong reaction to "hands on latch intervention" and relieve the stress which may have blocked the infant's inborn biological program to find the breast and latch on. Trial registration: Karolinska Clinical Trial Registration number CT20100055.
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To evaluate the effect of mother-infant early skin-to-skin contact on breastfeeding behavior of infants. A randomized controlled trial. The study was conducted in the Department of Obstetrics of Pakistan Institute of Medical Sciences, Islamabad, from November to December 2009. Eligible mothers were assessed for the successful breastfeeding by using IBFAT tool. The time to initiate the first feed, time to effective breastfeeding, maternal satisfaction with the care provided, preference for the same care in future and level of exclusive breastfeeding at the age of one month were also noted. The data was compared by using X2 and t-test. Significant p-value was taken as < 0.05. A total of 183 mother-infant pairs (92 in skin-to-skin care [SSC] group and 91 in conventional care [CC] group) were analyzed for breastfeeding behavior of the infants. The first breastfeed was 26.25% more successful in SSC group (58.8% in SSC group as compared to 32.5% in CC group with p-value of 0.001). In SSC group, the mean time to initiate first breastfeed was 61.6 minutes shorter than CC group (40.62 vs. 101.88; p < 0.001). Mean time to achieve effective breastfeeding was 207 minutes earlier in SSC group (149.69 vs. 357.50; p < 0.001). The level of satisfaction in the mothers of SSC group was significantly high as compared to controls (56% vs. 6.2%). Similarly, 53.8% mothers of SSC group showed preference for similar care in future as compared to 5% in CC group. In SSC group 85.3% infants were exclusively breastfed at one month as compared to 65.7% in CC group (p=0.025). Maternal-infant early skin-to-skin contact significantly enhanced the success of first breastfeed and continuation of exclusive breastfeeding till one month of age. It also reduced the time to initiate first feed and time to effective breastfeeding.
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There is very little evidence of the similarity of the mechanics of maternal and bottle feeding. We assessed the mechanics of sucking in exclusive breastfeeding, exclusive bottle feeding, and mixed feeding. The hypothesis established was that physiological pattern for suckling movements differ depending on the type of feeding. According to this hypothesis, babies with breastfeeding have suckling movements at the breast that are different from the movements of suckling a teat of babies fed with bottle. Children with mixed feeding mix both types of suckling movements. Cross-sectional study of infants aged 21-28 days with only maternal feeding or bottle feeding (234 mother-infant pairs), and a randomized open cross-over field trial in newborns aged 21-28 days and babies aged 3-5 months with mixed feeding (125 mother-infant pairs). Primary outcome measures were sucks and pauses. Infants aged 21-28 days exclusively bottle-fed showed fewer sucks and the same number of pauses but of longer duration compared to breastfeeding. In mixed feeding, bottle feeding compared to breastfeeding showed the same number of sucks but fewer and shorter pauses, both at 21-28 days and at 3-5 months. The mean number of breastfeedings in a day (in the mixed feed group) was 5.83 +/- 1.93 at 21-28 days and 4.42 +/- 1.67 at 3-5 months. In the equivalence analysis of the mixed feed group, the 95% confidence interval for bottle feeding/breastfeeding ratio laid outside the range of equivalence, indicating 5.9-8.7% fewer suction movements, and fewer pauses, and shorter duration of them in bottle feeding compared with breastfeeding. The mechanics of sucking in mixed feeding lay outside the range of equivalence comparing bottle feeding with breastfeeding, although differences were small. Children with mixed feeding would mix both types of sucking movements (breastfeeding and bottle feeding) during the learning stage and adopt their own pattern.
Although there is evidence to suggest that frenotomy improves breastfeeding outcomes for tongue-tied (ankyloglossic) infants, less is known about the optimal timing of treatment. In this retrospective cohort study, the timing of frenotomy and its impact on infant and maternal factors were examined in 31 tongue-tied babies with breastfeeding difficulties in a hospital in Jakarta, Indonesia. After frenotomy, all infants improved latching and mothers experienced a subjective improvement in nipple pain and breast engorgement. Frenotomy improved weight gain in infants regardless of type of tongue-tie (p = .001), but greater mean weight gains were achieved in tongue-tied babies who underwent early frenotomy (prior to Day 8) compared to babies who underwent late frenotomy (after Day 8; p = 0.002). Tongue-tie and frenotomy issues need to be addressed during the very first few days of an infant's life to ensure optimal breastfeeding outcomes.
When ankyloglossia is relatively severe and generates mechanical limitations and functional challenges, surgical reduction of the frenum is indicated. Laser technique is an innovative, safe and effective therapy for frenectomy in both children and adolescents. Erbium:YAG laser (2940nm) can be useful for paediatric dentist: 1.5W at 20pps is a commonly used average power to easily, safely and quickly cut the frenum. Usually after laser frenectomy, the postoperative symptoms and relapse are absent. Early intervention is advisable to reduce the onset of alterations correlated to the ankyloglossia. A multidisciplinary approach to the problem is advisable, in collaboration with orthodontist, physiotherapist and speech therapist, to better resolve the problem.
Breast rejection is a common cause of breast-feeding failure. We describe 51 mother-infant pairs who visited the Hospital for Sick Children breast-feeding clinic because the baby refused to take the breast. Management was successful in 21 (40%), partially successful in 11 cases (22%), and unsuccessful in 16 (31%). (Three mothers were lost to follow up.) We believe that the early introduction of bottles results in the baby's developing an ineffective suckle, which then causes frustration when the baby tries to breast-feed. Good management of breast-feeding in the newborn period involves avoiding bottles and teaching the mother proper positioning and latching, as well as signs that indicate whether her baby is getting adequate milk. A method of giving supplemental fluids without direct bottle-feeding is described.
The purposes of this article are to introduce a formal definition of nipple confusion and to propose various hypotheses concerning its cause. The term nipple confusion refers to an infant's difficulty in achieving the correct oral configuration, latching technique, and suckling pattern necessary for successful breast-feeding after bottle feeding or other exposure to an artificial nipple. Many early breast-feeding failures are attributed to nipple confusion, although scientific data are lacking to document its prevalence, the mechanisms involved, or various factors that predispose an infant to this phenomenon. Two classifications of nipple confusion are recommended to distinguish the impact of artificial nipples during the newborn period from their influence after breast-feeding is well established. Maternal and infant risk factors making an infant more susceptible to nipple confusion are discussed. Future studies are planned to help elucidate the nature of nipple confusion and identify the circumstances under which infants are most vulnerable to this phenomenon. Meanwhile, it would seem prudent for clinicians to identify newborns at risk for nipple confusion and to minimize the use of bottle feedings in such babies. Medically indicated supplements in the early days of life could be provided by alternative methods, such as cup, spoon, or dropper feeding, until breast-feeding can be established.
Considerable advances have occurred in recent years in the scientific knowledge of the benefits of breastfeeding, the mechanisms underlying these benefits, and in the clinical management of breastfeeding. This policy statement on breastfeeding replaces the 1997 policy statement of the American Academy of Pediatrics and reflects this newer knowledge and the supporting publications. The benefits of breastfeeding for the infant, the mother, and the community are summarized, and recommendations to guide the pediatrician and other health care professionals in assisting mothers in the initiation and maintenance of breastfeeding for healthy term infants and high-risk infants are presented. The policy statement delineates various ways in which pediatricians can promote, protect, and support breastfeeding not only in their individual practices but also in the hospital, medical school, community, and nation.
  • Breastfeeding
Breastfeeding. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 44(1), 145-150.
Supporting sucking skills in breastfeeding infants
  • C W Genna
Genna, C. W. (2012). Supporting sucking skills in breastfeeding infants. Sudbury, MA: Jones & Bartlett.
Medications and mothers' milk
  • T W Hale
  • H E Rowe
Hale, T. W., & Rowe, H. E. (2004). Medications and mothers' milk. Amarillo, TX: Pharmasoft Medical.
Counseling the nursing mother
  • J Lauwers
  • A Swisher
Lauwers, J., & Swisher, A. (2010). Counseling the nursing mother. Sudbury, MA: Jones & Bartlett.
The regulation of pharmaceutical compounding and the determination of need: Balancing access and autonomy with patient safety
  • R Riley
Riley, R. (2004). The regulation of pharmaceutical compounding and the determination of need: Balancing access and autonomy with patient safety. Harvard Law School, Cambridge, MA.
Clinical management of oral disorders in breastfeeding
  • M T C Sanches
Sanches, M. T. C. (2004). Clinical management of oral disorders in breastfeeding. Jornal de Pediatria, 80(Suppl. 5), S155-S162.
Evidence for the ten steps to successful breastfeeding
  • C Vallenas
  • F Savage
Vallenas, C., & Savage, F. (1998). Evidence for the ten steps to successful breastfeeding. Geneva, Switzerland: WHO Child Health and Development Unit, 1997.
Breastfeeding management for the clinician
  • M Walker
Walker, M. (2013). Breastfeeding management for the clinician. Sudbury, MA: Jones & Bartlett.