Scientific Article

“Confusion about Nipple Confusion” – what we know and don’t know

Interview with Prof. Dr. Reinhold Kerbl

Interview with Dr. Reinhold Kerbl, head of the paediatric department of the LKH Hochsteiermark regional hospital in Leoben, Austria

What is meant by ‘nipple confusion’ and at what age are babies most likely to be affected?

Kerbl: The term ‘nipple confusion’ is commonly used to describe breastfeeding difficulties in very young babies caused by the use of bottles or pacifiers. However, this is not the original definition put forward by pediatrician and breastfeeding consultant Marianne Neifert in 1995. She divides nipple confusion into two types: Type A refers to a baby’s difficulty in establishing the necessary oral configuration and latching technique; whereas Type B refers to a baby turning away and refusing the breast.1 In both cases, there are repeated suggestions of a link with the use of bottles and pacifiers; however, scientific evidence is lacking to support this.

Is this an issue encountered by pediatricians?

Kerbl: Midwives, breastfeeding consultants, pediatric nurses and also pediatricians will all come across this issue, especially during pre- and postnatal check-ups, because parents naturally want to voice their concerns if breastfeeding is proving difficult. 

What breastfeeding issues might new parents observe?

Kerbl: Parents may notice that their baby is not latching onto the breast properly or turning away from the breast – basically any sign that breastfeeding is ‘not working’. Midwives, breastfeeding clinics, breastfeeding advisers and even pediatric nurses are all available to provide help and support in these cases.

What can pediatricians do to help prevent nipple confusion?

Kerbl: Instances of genuine nipple confusion are relatively rare overall, so it’s important not to address this problem if it doesn’t yet exist. During prenatal check-ups, pediatricians should generally encourage mothers to breastfeed their babies for as long as possible. If appropriate, they may give some advice on how to breastfeed effectively and comfortably, as ultimately breastfeeding should be a positive experience for both mother and baby. Any advice given should be balanced and objective; parents must not be made to feel anxious or pressured when it comes to breastfeeding.

Pacifiers are often cited as the cause of breastfeeding problems. What is your advice on giving a pacifier to a baby born at full term?

Kerbl: Bottle feeding and pacifiers are often linked to the term nipple confusion; and therefore, the advice associated with this concept is often to avoid using them altogether. However, there is no scientific evidence suggesting that pacifiers have a negative impact on how often or how long a baby breastfeeds. Personally, I see pacifiers as a good way to help soothe babies and satisfy their suckling instinct.

So why does the WHO and Baby Friendly Hospital Initiative discourage the use of pacifiers?

Kerbl: This recommendation is based on the assumption that pacifiers have a negative impact on breastfeeding. However, there are now good studies that show this assumption to be incorrect. Indeed, based on these findings, the Baby Friendly Hospital Initiative has changed its advice from a complete ban to the provision of adequate advice (‘counseling instead of prohibiting’).1

There are a number of different brands on the market offering pacifiers for premature babies. What are the advantages of offering a pacifier to a premature baby? 

Kerbl: Pacifiers for premature babies are a medical product and should be seen in the same way as medication, as they offer a number of benefits for premature babies. They can help alleviate pain during medical procedures and other interventions; they can help sooth premature babies in often difficult surroundings (e.g. a neonatal intensive care unit); and they can help babies gain weight more quickly1 and reduce the time spent in the intensive care unit (even in babies that are still undergoing tests).

Pacifiers are also a relevant discussion topic for other areas of medicine. Why is that?

Kerbl: In addition to pediatricians, dentists frequently encounter issues around pacifiers. This is because long-term or incorrect use of a pacifier can cause teeth and jaws to become misaligned, resulting in a crossbite, overjet or similar. It is, therefore, vital that pacifiers are only used to help children settle and that children are weaned off a pacifier by their third birthday at the latest.

Prof. Dr. Reinhold Kerbl

Pediatrician
Prof. Dr. Reinhold Kerbl is Head of the Department of Children and Adolescents at Leoben State Hospital (LKH) in Styria, Austria, and one of the leading pediatric experts in the German-speaking world. Prof. Kerbl has won several awards for his work.  

1Kerbl R. (2019) Counseling instead of prohibiting: The new Baby Friendly Hospital Initiative. Monatsschr Kinderheilkd 167:89

First publication: Paediatr. Paedolog. 2019;54:238–239; www.springermedizin.at/saugverwirrung-gibt-es-denn-sowas/17286296 © Springer-Verlag GmbH Austria, part of Springer Nature 2019.