by Anne Smith, IBCLC

Many babies switch forth effortlessly between breast and bottle from day one. Others become "nipple confused" if artificial nipples are introduced during the early days of nursing.

The mechanics of breast and bottle-feeding are quite different. When a baby nurses, his tongue and jaws must work together rhythmically, cupping his tongue under the areola, and pressing it up against his palate. This flattens and elongates the tissue around the nipple. He then drops the back of his tongue to form a groove for the milk to flow from the nipple to his throat. He swallows, then takes a breath. His lips are flanged out tightly around the breast to form a tight seal.

When a baby drinks from a bottle, the milk gushes out (you'll notice that the milk drips out if you hold a bottle upside down). In order to keep from choking, he lifts his tongue uses it to block the flow of milk. He purses his lips around the hard rubber nipple, and he doesn't have to use his jaws at all. There is a constant flow of milk that he doesn't have to work for, unlike during breastfeeding, where the milk "lets down" initially, then slows to a trickle, and the process repeats as the baby sucks harder and longer. This occurs several times during a feeding, and is one of the reasons breastfed babies are less likely to become obese than bottle-fed babies: they regulate their own intake by how long and vigorously they suck. Bottle-fed infants will often finish a bottle not because they are hungry, but because they love to suck, and the milk flows so easily.

The risk of nipple confusion , whether by introducing a bottle or pacifier, is greatest during the early days of nursing. The longer you wait to introduce artificial nipples, the less risk there is of confusing your baby. Breastfeeding is a learned behavior, in most cases, although there are some babies who seem to be born knowing exactly what to do. Although sucking is a newborn reflex, the mechanics of effective latching on aren't. It usually takes a couple of weeks, and sometimes longer, for mothers and babies to get really good at nursing. By that time, any problems you had in the beginning, such as engorgement or nipple soreness, should be pretty much resolved, and your baby's pattern of weight gain should be established.

If nursing is going along smoothly, there should be no reason to use artificial nipples in the first few weeks of breastfeeding. Nursing frequently and using the breast as a pacifier are what builds a good milk supply and helps you and your baby develop a special closeness during the period immediately after your baby's birth. Use the fact that you are exclusively nursing during the first few weeks to get more rest. Let friends and family wait on you, do your laundry, cook for you, etc. You have a perfect excuse. Yes, if you gave the baby bottles, someone else could take over a feeding while you slept, but missing that feeding during the early weeks while you are establishing your supply for your baby who is growing so quickly during that time may decrease your milk production. Once your supply is well established, skipping occasional feedings won't be a big deal. Your time of baby's total dependence on you will last for a very short time, although it can seem like forever when you are overwhelmed with the twenty-four/seven responsibility for this little person at a time when you are physically exhausted, emotionally drained, and sleep deprived. Nobody ever said it would be easy, and if they did, they were either lying, or they never nursed a baby.

Use of pacifier in the early weeks can also cause problems. If you want your baby to take a pacifier, I would introduce it by the time he is one month old, but preferably not during the first two weeks of nursing. Some babies refuse to ever take a pacifier. Some become addicted to them and are still carrying them to Kindergarten. I think that the babies who become attached to pacifiers would have become thumb-suckers or blanket holders if they didn't attach to a pacifier. Some babies just seem to need security objects, and there isn't a lot you can do about that. Just because you offer a pacifier to your baby, that doesn't mean he will develop a bad habit. I have offered pacifiers to all six of my babies, all took them occasionally, and none of them became attached to them. I did have several children who sucked their thumbs for what seemed like forever, but that's another article.

I think it is great if your older baby will take a pacifier occasionally. If you have ever been driving down the highway with a screaming baby in the backseat and no way to pull over, even though you nursed just before you left, and you KNOW he can't possibly be hungry, you will know what a wonderful thing a pacifier can be (this especially applies if you have older kids and spend half your waking hours car-pooling). Although I have known some large breasted women who could actually lean over the car seat and let their breast hang in the baby's mouth, I have never met one well-endowed enough to sling her breast over the back seat to feed her baby. That's just one example of when a pacifier can be a lifesaver. Another is when your older baby (who is fat and happy and obviously getting enough to eat) has been marathon nursing for hours and nothing is making him happy. Sometimes he just wants to suck himself to sleep, and doesn't want to nurse. Believe it or not, this does happen. He almost gets angry when the milk comes out, and may settle right down with a pacifier. There also may be times when someone other than you may have to soothe your baby, especially if you return to work and he is in day care with other babies. You really can't stick a bottle in a baby's mouth every time he fusses, and caregivers don't have the breast to use as a built in pacifier.

So, I have broken the cardinal rule of lactation counseling by saying that I don't think pacifiers are all bad. This is because I have survived raising six children, and I know that you do whatever works and helps you keep your sanity. This may or may not include bottles, pacifiers, and formula.

There are however, some valid concerns about the use (and abuse) of pacifiers. Aside from the risk of nipple confusion, pacifier use is correlated with early weaning for a variety of reasons. Because newborns love to suck on anything put in their mouth, whether it is a finger or an artificial nipple, they may use the pacifier as a substitute for feedings, especially if they are small, ill, jaundiced, or just have a very laid back temperament. There is a spot in the back of a baby's mouth where the hard palate meets the soft palate. When anything touches it, an automatic sucking reflex is triggered. That's why babies will suck automatically when a finger or a rubber nipple is put in their mouth. The soft, mushy human nipple must be drawn back in the baby's mouth until it hits that spot, so use of an artificial nipple may make him somewhat lazy when it comes to nursing.

Some babies are perfectly content to happily miss a feeding as long as they have something to suck on, and some mothers take advantage of this by plugging their baby's mouth with a pacifier every time he fusses in order to make him sleep longer or go longer intervals between feedings. Young infants should spend their time and energy in nutritive sucking at the breast, not in non-nutritive sucking. Overuse of pacifiers can lead to poor weight gain, plugged ducts and mastitis, and a decrease in milk supply. If you have a yeast infection or your baby has thrush, pacifiers can become contaminated. Boil pacifiers every day during a thrush episode, and throw them away after a week. The same thing applies to bottle nipples.

A little piece of trivia here: did you know that in many countries, pacifiers are called "dummies?" Hmm. Makes you wonder. After all, all a pacifier really is just an imitation nipple, and as such it should be used in moderation and not as a frequent substitution for the real thing.