Running head: EVIDENCE BASED PRACTICE PAPER 1

Evidence Based Practice Paper

Charity L. McKinnon
Ferris State University














EVIDENCE BASED PRACTICE PAPER 2

Abstract
This paper will discuss the debate on introducing a bottle or pacifier causing nipple confusion
when a new mother is breastfeeding her infant. This paper will discuss whether it is appropriate
to alternate between breast and bottle feeding for successful breastfeeding. Original research
studies discussing the effects of nipple confusion in breastfed infants will be observed. The
content of this paper will explore the benefits and negative effects of alternating between a breast
and bottle nipple.












EVIDENCE BASED PRACTICE PAPER 3


Evidence Based Practice Paper
Every patient who comes into an obstetrical birthing center will be faced with the
decision of whether to breast or bottle feed their baby. Breastfeeding has become increasingly
popular over the last few years due to the research done on the numerous health benefits for both
mother and baby (Vida Health Communication, 1998). However, with concerns such as
rejoining the workforce and more patients having surgical procedures done on their breasts, the
issue of bottle feeding while also breastfeeding raises questions. Evidence based practice has
proven most infants do suffer from nipple confusion when a bottle or pacifier is introduced and
the clinical studies are well documented to prove this (Brown, 2007).
I encounter this issue on a daily basis as an obstetrical unit staff nurse, primarily caring
for labor, delivery, and post-partum patients. The department I work in has a lactation specialist
and the staff nurses primarily take direction from the knowledge she has on breastfeeding if this
is the nourishment route the patient chooses to pursue. Her recommendations are to refrain from
introducing a pacifier or bottle for at least the first three weeks of life due to nipple confusion
issues. Working the night shift, I have experienced mothers that wish to exclusively breastfeed.
Yet in the middle of the night when extreme fatigue settles in, they are more likely to request a
pacifier if the infant is not content after feedings. It is important as nurses that we are as
supportive to the patient as possible and also inform them of the possible problems that they may
encounter alternating back and forth between a breast and bottle nipple. If a nurse introduces a
bottle or pacifier to the infant without the mothers consent or neglecting to inform them of
possible issues that may arise, it might discourage mothers from breastfeeding, causing
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frustration and distress for both mother and infant. The latch-on process could be difficult for
the infant to re-learn, infants may experience more infection and breathing issues, and the
bonding relationship could be affected between mother and baby (Walters, 2007).
Dr. William Sears, an expert pediatrician with over thirty years of experience, explains
the anatomical differences between the breast and bottle nipple. Breastfed infants need to open
their mouth wider than when feeding from a bottle in order to draw back the mothers nipple and
areola to stimulate milk excretion (Sears, 2006). Drawing the areola along with the nipple to the
back of the infants mouth creates a channel between the two, presenting the baby with a
milking of the nipple as the baby sucks (Sears, 2006). When bottle feeding, the infant is able
to use just their lips to suck because the formula flows freely from these types of nipples. This
eliminates the need to milk the nipple with the tongue, thus making it easier for them to feed
from a bottle and provide instant gratification (Sears, 2006). Infants are able to thrust the tongue
up and forward in the mouth to stop the flow of formula during feedings (Sears, 2006).
The first research study topic is whether or not bottle-feeding can mimic breastfeeding.
According to this study reviewed by Roy Brown, MD of Columbia University, nipple confusion
is a real issue. Brown (2007) states,
The infant who is successful at breastfeeding must develop a set of skills vital for
the coordination of the processes studied, to gain the nutrition from breast milk, to
continue to have adequate oxygenation for function, as well as avoiding the
potential for aspiration (p. 119).
The study also observed that infants demonstrated better oxygenation at the breast due to better
coordination relative to sucking and breathing (Brown, 2007, p. 119). The study did not include
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research on pre-term infants. Therefore, comparison to full-term infants in this study to pre-term
infants would vary considerably. With the experience I have had in the practice setting, infants
that are pre-term need to be supplemented by syringe or other feeding devices to maintain
adequate nutrition due to inability to suck because of immaturity (Vida Health Communications,
1998). Every case is different, it is however vital that each infant is given the opportunity to
learn to suck, pre-term or otherwise, if the mother wishes to exclusively breastfeed. It is our
responsibility as providers to make this happen.
The next research study reviewed was an international child care study done involving
breastfeeding and pacifier use from twenty-one study centers in seventeen different countries.
The results from these studies indicated that both breastfeeding and pacifier use could protect
infants against sudden infant death syndrome (Nelson, Yu, Williams, and The International
Child Care Practices Study Group Members, 2005, p. 289). Although both sides of the spectrum
were addressed in this research study, the results were vague on whether breastfeeding reduced
the risk of sudden infant death syndrome, stating pacifier use kept a patent airway open for the
infant (Nelson, et al., 2005). Otitis media was also addressed, yet statistics were not available to
support the idea that pacifiers caused more infections in infants compared to strictly breastfed
infants (Nelson, et al., 2005). Again, as mentioned before, the key concept is reviewing all
pertinent information with patients to make an informed decision on whether to breast, bottle, or
use a pacifier. Breastfeeding has many benefits and the World Health Organization recommends
exclusive breastfeeding for optimal infant nutrition for the first six months of life (Nelson, et
al., 2005, p. 289).
This research study also concurred that whether nipple confusion is real has not been
challenged (Nelson, et al., 2005, p. 289). The study indicated where there was a pacifier
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introduced to the infant, breastfeeding declined greatly, no matter which country was observed
(Nelson, et al., 2005). The bottom line of this study was to inform patients and health care
providers of the detriments and possible benefits of pacifier use while breastfeeding. In my
experience, I have seen and heard about more infants who acquire more illnesses by not being
exclusively breastfed. According to Vida Health Communications (1998), their statistics show
the same results.
In the last research article that reviewed whether alternating between breast and bottle
feeding is beneficial, the Ten Steps to Successful Breastfeeding recommended by UNICEF
(United National Childrens Fund) states give newborn infants no food or drinks other than
breast milk unless medically indicated and give no artificial teats or pacifiers to breastfeeding
infants (Koletzko, Michaelsen, and Hernell, 2002, p.6). However, in the same research study,
after summarizing the issue of nipple confusion, the ending statement was this,
when mothers are confident about nursing and motivated to breastfeed, the use of
pacifiers will not affect breastfeeding duration. On the other hand, pacifiers may
contribute to early termination of breastfeeding in situations where mothers are
uncomfortable with breastfeeding and are using the pacifier as a weaning tool,
trying to make the intervals between feedings longer and more regular, thus
decreasing the total number of feedings (Koletzko, et al., 2002, p. 6).
I think that this research article has a valid point. I agree that mothers who are bound and
determined to nurse their children do succeed. Even with introducing a pacifier or giving a
formula supplement with a device other than a bottle nipple. I believe as staff nurses on a post-
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partum unit that we can be very supportive and also determined to make the breastfeeding
mother a success.
Ramona T. Mercer developed a nursing theory that relates to the information discussed
throughout this paper called Maternal Role Attainment-Becoming a Mother. Mercer reports that
the maternal role attainment is an interactional and developmental process occurring over time
in which the mother becomes attached to her infant, acquires competence in the caretaking tasks
involved in the role, and expresses pleasure and gratification in the role (1986, p. 608). This
idea relates to the crucial choice of deciding whether or not to breast or bottle feed her child,
along with all of the other decisions she will need to make throughout the childs life. Mercers
theory tells us as nurses we need to constantly be listening to the patient as she develops into this
role. As nurses it is a part of our job to be aware of non-verbal ques as well so that we can assist
her in the maternal role and identity as a mother.
In conclusion, alternating between breast and bottle feeding shows evidence of either
being detrimental to overall breastfeeding or a welcomed break for the mother. The studies
relating to this subject will keep evolving peoples opinions and therefore advancing knowledge
for them to make informed decisions. The evidence attained from the research studies will
continue to make people realize they have a choice and the power to make the right decision for
themselves and their personal situations with the support of medical staff.



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References
Sears, W., & Sears, M. (2006). Re: Breastfeeding nipple confusion. Retrieved from:
http://www.askdrsears.com/html/2/to22400.asp
Vida Health Communications. (1998). Breastfeeding: the why-to, can do video [cassette tape].
Available from www.vida-health.com
Brown, R. (2007). Can bottle-feeding really mimic breastfeeding? Journal of Human Lactation,
23 (1): 118-119. doi: 10.1177/0890334406297688
Nelson, E.A.S., Yu, L., Williams, S., and the International Child Care Practices Study Group
Members. (2005). International child care practices study: Breastfeeding and pacifier use.
Journal of Human Lactation, 21 (3): 289-297. doi: 10.1177/0890334405278489
Koletzko, B., Michaelsen, K., & Hernell, O. (2002). Advances in experimental medicine and
biology. (V.487). New York Kluwer Academic Publishers.
Tomey, M. A., & Alligood, M. R. (2006). Nursing theorists and their work (6
th
ed.). St. Louis:
Elsevier.





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