Chapter 24: Newborn Nutrition and Feeding
The best reason for recommending formula over breastfeeding is that: a. The mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b. The mother lacks confidence in her ability to breastfeed. c. Other family members or care providers also need to feed the baby. d. The mother sees bottle-feeding as more convenient
ANS: A Breastfeeding is contraindicated when mothers have certain viruses, are undergoing chemotherapy, or are using/abusing illicit drugs. A lack of confidence, the need for others to feed the baby, and the convenience of bottle-feeding are all honest reasons for not breastfeeding, although further education concerning the ease of breastfeeding and its convenience, benefits, and adaptability (expressing milk into bottles) could change some minds. In any case the nurse must provide information in a nonjudgmental manner and respect the mothers decision. Nonetheless, breastfeeding is definitely contraindicated when the mother has medical or drug issues of her own.
According to the recommendations of the American Academy of Pediatrics on infant nutrition: a. Infants should be given only human milk for the first 6 months of life. b. Infants fed on formula should be started on solid food sooner than breastfed infants. c. If infants are weaned from breast milk before 12 months, they should receive cows milk, not formula. d. After 6 months mothers should shift from breast milk to cows milk.
ANS: A Breastfeeding/human milk should also be the sole source of milk for the second 6 months. Infants start on solids when they are ready, usually at 6 months, whether they start on formula or breast milk. If infants are weaned from breast milk before 12 months, they should receive iron-fortified formula, not cows milk
A new mother asks whether she should feed her newborn colostrum, because it is not "real milk." The nurse's most appropriate answer is: a. Colostrum is high in antibodies, protein, vitamins, and minerals. b. Colostrum is lower in calories than milk and should be supplemented by formula. c. Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. d. Colostrum is unnecessary for newborns
ANS: A Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Supplementation is not necessary; it will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge; however, the importance of the colostrum to the infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse the gastrointestinal system, among other things.
A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is most accurate? Bottle-feeding using commercially prepared infant formulas: a. Increases the risk that the infant will develop allergies. b. Helps the infant sleep through the night c. Ensures that the infant is getting iron in a form that is easily absorbed. d. Requires that multivitamin supplements be given to the infant
ANS: A Exposure to cows milk poses a risk of developing allergies, eczema, and asthma. Bottle-feeding using commercially prepared infant formulas helps the infant sleep through the night is a false statement. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and resemble breast milk.
The nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. What statement would indicate that the mother needs additional teaching? a. I can store my breast milk in the refrigerator for 3 months. b. I can store my breast milk in the freezer for 3 months. c. I can store my breast milk at room temperature for 8 hours. d. I can store my breast milk in the refrigerator for 3 to 5 days.
ANS: A If the mother states that she can store her breast milk in the refrigerator for 3 months, she needs additional teaching about safe storage. Breast milk can be stored at room temperature for 8 hours, in the refrigerator for 3 to 5 days, in the freezer for 3 months, or in a deep freezer for 6 to 12 months. It is accurate and does not require additional teaching if the mother states that she can store her breast milk in the freezer for 3 months, at room temperature for 8 hours, and in the refrigerator for 3 to 5 days.
Nurses providing nutritional instruction should be cognizant of the uniqueness of human milk. Which statement is correct? a. Frequent feedings during predictable growth spurts stimulate increased milk production. b. The milk of preterm mothers is the same as the milk of mothers who gave birth at term. c. The milk at the beginning of the feeding is the same as the milk at the end of the feeding. d. Colostrum is an early, less concentrated, less rich version of mature milk.
ANS: A These growth spurts (10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after which infants resume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).
A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she: a. Waves her arms in the air. b. Makes sucking motions. c. Has hiccups. d. Stretches her legs out straight
ANS: B Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding-readiness cues. Waving the arms in the air, hiccupping, and stretching the legs out straight are not typical feeding-readiness cues.
Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a. A premature infant more easily digests breast milk than formula. b. A glass of wine just before pumping will help reduce stress and anxiety. c. The mother should pump only as much as the infant can drink. d. The mother should pump every 2 to 3 hours, including during the night
ANS: A Human milk is the ideal food for preterm infants, with benefits that are unique in addition to those received by term, healthy infants. Greater physiologic stability occurs with breastfeeding compared with formula feeding. Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mothers milk ejection reflex. To establish an optimal milk supply, the mother should be instructed to pump 8 to 10 times a day for 10 to 15 minutes on each breast.
Examples of appropriate techniques to wake a sleepy infant for breastfeeding include (Select all that apply): a. Unwrapping the infant. b. Changing the diaper. c. Talking to the infant. d. Slapping the infants hands and feet. e. Applying a cold towel to the infants abdomen.
ANS: A, B, C Unwrapping the infant, changing the diaper, and talking to the infant are appropriate techniques to use when trying to wake a sleepy infant. Slapping the infants hand and feet and applying a cold towel to the infants abdomen are not appropriate. The parent can rub the infants hands or feet to wake the infant. Applying a cold towel to the infants abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infants face to wake the infant.
A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion (Select all that apply)? a. Breast tenderness b. Warmth in the breast c. An area of redness on the breast often resembling the shape of a pie wedge d. A small white blister on the tip of the nipple e. Fever and flulike symptoms
ANS: A, B, C, E Breast tenderness, breast warmth, breast redness, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurses discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis. It is commonly seen in women who have a plugged milk duct.
To prevent nipple trauma, the nurse should instruct the new mother to: a. Limit the feeding time to less than 5 minutes. b. Position the infant so the nipple is far back in the mouth. c. Assess the nipples before each feeding. d. Wash the nipples daily with mild soap and water.
ANS: B If the infants mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. This will also limit access to the higher-fat hindmilk. Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding
The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth. Which suggestion by the nurse is most appropriate? a. Slowly remove the breast from the babys mouth when the infant has fallen asleep and the jaws are relaxed. b. Break the suction by inserting your finger into the corner of the infants mouth. c. A popping sound occurs when the breast is correctly removed from the infants mouth. d. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries
ANS: B Inserting a finger into the corner of the babys mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple that makes it sore. A popping sound indicates improper removal of the breast from the babys mouth and may cause cracks or fissures in the breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.
A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. The nurse can explain to him that beginning solid foods before 4 to 6 months may: a. Decrease the infants intake of sufficient calories. b. Lead to early cessation of breastfeeding. c. Help the infant sleep through the night. d. Limit the infants growth
ANS: B Introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. It is not true that feeding of solids helps infants sleep through the night. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula
The hormone necessary for milk production is: a. Estrogen. b. Prolactin. c. Progesterone. d. Lactogen.
ANS: B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced.
The process whereby parents awaken the infant to feed every 3 hours during the day and at least every 4 hours at night is: a. Known as demand feeding. b. Necessary during the first 24 to 48 hours after birth. c. Used to set up the supply-meets-demand system. d. A way to control cluster feeding.
ANS: B The parents do this to make sure that the infant has at least eight feedings in 24 hours. Demand feeding is when the infant determines the frequency of feedings; this is appropriate once the infant is feeding well and gaining weight. The supply-meets-demand system is a milk production system that occurs naturally. Cluster feeding is not a problem if the baby has eight feedings in 24 hours.
The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would be inaccurate and provide conflicting information to the patient? a. Women who breastfeed have a decreased risk of breast cancer. b. Breastfeeding is an effective method of birth control. c. Breastfeeding increases bone density. d. Breastfeeding may enhance postpartum weight loss.
ANS: B Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of quicker postpartum weight loss. Breastfeeding delays the return of fertility; however, it is not an effective birth control method
Late in pregnancy, the woman's breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth. These include (Select all that apply): a. Everted nipples b. Flat nipples c. Inverted nipples d. Nipples that contract when compressed e. Cracked nipples
ANS: B, C, D Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infants mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells is debated. A breast pump can be used to draw the nipples out before feedings after delivery. Everted nipples protrude and are normal. No intervention will be required. Cracked, blistered, and bleeding nipples occur after breastfeeding has been initiated and are the result of improper latch. The infant should be repositioned during feeding. Application of colostrum and breast milk after feedings will aid in healing.
While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the patient accordingly. Which statement as part of this discussion would be incorrect? a. Breastfeeding requires fewer supplies and less cumbersome equipment. b. Breastfeeding saves families money. c. Breastfeeding costs employers in terms of time lost from work. d. Breastfeeding benefits the environment.
ANS: C Actually less time is lost to work by breastfeeding mothers, in part because infants are healthier. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. It saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.
As the nurse assists a new mother with breastfeeding, the client asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" The nurse's best response is that it contains: a. More calories. b. Essential amino acids. c. Important immunoglobulins. d. More calcium.
ANS: C Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is about the same. All the essential amino acids are in both formula and breast milk; however, the concentrations may differ. Calcium levels are higher in formula than in breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly.
How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? a. 50 to 65 b. 75 to 90 c. 95 to 110 d. 150 to 200
ANS: C For the first 3 months the infant needs 110 kcal/kg/day. At ages 3 to 6 months the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases again to 100 kcal/kg/day until the baby reaches 12 months.
With regard to the nutrient needs of breastfed and formula-fed infants, nurses should be understand that: a. Breastfed infants need extra water in hot climates. b. During the first 3 months breastfed infants consume more energy than do formula-fed infants. c. Breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months. d. Vitamin K injections at birth are not needed for infants fed on specially enriched formula.
ANS: C Human milk contains only small amounts of vitamin D. Neither breastfed nor formula-fed infants need to be given water, even in very hot climates. During the first 3 months formula-fed infants consume more energy than do breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the babys stomach at birth
With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she: Will need an extra 1000 calories a day to maintain energy and produce milk. b. Can go back to prepregnancy consumption patterns of any drinks, as long as she ingests enough calcium. c. Should avoid trying to lose large amounts of weight. d. Must avoid exercising because it is too fatiguing.
ANS: C Large weight loss would release fat-stored contaminants into her breast milk. It would also likely involve eating too little and/or exercising too much. A breastfeeding mother need add only 200 to 500 extra calories to her diet to provide extra nutrients for the infant. The mother can go back to her consumption patterns of any drinks as long as she ingests enough calcium, only if she does not drink alcohol, limits coffee to no more than two cups (caffeine in chocolate, tea, and some sodas), and reads the herbal tea ingredients carefully. The mother needs her rest, but moderate exercise is healthy.
To initiate the milk ejection reflex (MER), the mother should be advised to: a. Wear a firm-fitting bra. b. Drink plenty of fluids. c. Place the infant to the breast. d. Apply cool packs to her breast.
ANS: C Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but this alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex
Which type of formula is not diluted before being administered to an infant? a. Powdered b. Concentrated c. Ready-to-use d. Modified cows milk
ANS: C Ready-to-use formula can be poured directly from the can into babys bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform in consistency. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cows milk is more difficult for the infant to digest and is not recommended, even if it is diluted
In assisting the breastfeeding mother position the baby, nurses should keep in mind that: a. The cradle position usually is preferred by mothers who had a cesarean birth. b. Women with perineal pain and swelling prefer the modified cradle position. c. Whatever the position used, the infant is belly to belly with the mother. d. While supporting the head, the mother should push gently on the occiput.
ANS: C The infant inevitably faces the mother, belly to belly. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast
A breastfeeding woman develops engorged breasts at 3 days' postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman: a. Skips feedings to let her sore breasts rest. b. Avoids using a breast pump. c. Breastfeeds her infant every 2 hours. d. Reduces her fluid intake for 24 hours.
ANS: C The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not feed adequately and empty the breast, the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.
At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to: a. Begin solid foods. b. Have a bottle of formula after every feeding. c. Add at least one extra breastfeeding session every 24 hours. d. Start iron supplements.
ANS: C Usually the solution to slow weight gain is to improve the feeding technique. Position and latch-on are evaluated, and adjustments are made. It may help to add a feeding or two in a 24-hour period. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle-feeding may cause nipple confusion and limit the supply of milk. Iron supplements have no bearing on weight gain.
According to demographic research, the woman least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding would be: a. A woman who is 30 to 35 years of age, Caucasian, and employed part time outside the home. b. A woman who is younger than 25 years of age, Hispanic, and unemployed. c. A woman who is younger than 25 years of age, African-American, and employed full time outside the home. d. A woman who is 35 years of age or older, Caucasian, and employed full time at home.
ANS: C Women least likely to breastfeed typically are younger than 25 years of age, have a lower income, are less educated, are employed full time outside the home, and are African-American.
A new mother wants to be sure that she is meeting her daughter's needs while feeding her commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant care. The mother meets her child's needs when she: a. Adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition. b. Warms the bottles using a microwave oven. c. Burps her infant during and after the feeding as needed. d. Refrigerates any leftover formula for the next feeding.
ANS: C; Most infants swallow air when fed from a bottle and should be given a chance to burp several times during a feeding and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, and this may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infants saliva has mixed with it.
A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who: a. Sleeps for 6 hours at a time between feedings. b. Has at least one breast milk stool every 24 hours. c. Gains 1 to 2 ounces per week. d. Has at least six to eight wet diapers per day.
ANS: D After day 4, when the mothers milk comes in, the infant should have six to eight wet diapers every 24 hours. Sleeping for 6 hours between feedings is not an indication of whether the infant is breastfeeding well. Typically infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster fed. The infant should have a minimum of three bowel movements in a 24-hour period.
Which statement concerning the benefits or limitations of breastfeeding is inaccurate? a. Breast milk changes over time to meet changing needs as infants grow. b. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. c. Breast milk/breastfeeding may enhance cognitive development. d. Breastfeeding increases the risk of childhood obesity.
ANS: D Breastfeeding actually decreases the risk of childhood obesity. There are multiple benefits of breastfeeding. Breast milk changes over time to meet changing needs as infants grow. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. Breast milk/breastfeeding may enhance cognitive development.
All parents are entitled to a birthing environment in which breastfeeding is promoted and supported. The Baby Friendly Hospital Initiative endorsed by WHO and UNICEF was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which instruction is not included in the "Ten Steps to Successful Breastfeeding for Hospitals"? a. Give newborns no food or drink other than breast milk. b. Have a written breastfeeding policy that is communicated to all staff. c. Help mothers initiate breastfeeding within one half hour of birth. d. Give artificial teats or pacifiers as necessary.
ANS: D No artificial teats or pacifiers (also called dummies or soothers) should be given to breastfeeding infants. No other food or drink should be given to the newborn unless medically indicated. The breastfeeding policy should be routinely communicated to all health care staff. All staff should be trained in the skills necessary to maintain this policy.
When responding to the question "Will I produce enough milk for my baby as she grows and needs more milk at each feeding?" the nurse should explain that: a. The breast milk will gradually become richer to supply additional calories. b. As the infant requires more milk, feedings can be supplemented with cows milk. c. Early addition of baby food will meet the infants needs. d. The mothers milk supply will increase as the infant demands more at each feeding.
ANS: D The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. Solids should not be added until about 4 to 6 months, when the infants immune system is more mature. This will decrease the chance of allergy formations
Nurses should be able to teach breastfeeding mothers the signs that the infant has latched on correctly. Which statement indicates a poor latch? a. She feels a firm tugging sensation on her nipples but not pinching or pain. b. The baby sucks with cheeks rounded, not dimpled. c. The babys jaw glides smoothly with sucking. d. She hears a clicking or smacking sound.
ANS: D The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The tugging sensation without pinching is a good sign. Rounded cheeks are a positive indicator of a good latch. A smoothly gliding jaw is a good sign.
A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infant's correct latch-on by helping the woman hold the infant: a. With his arms folded together over his chest. b. Curled up in a fetal position. c. With his head cupped in her hand. d. With his head and body in alignment.
ANS: D The infants head and body should be in correct alignment with the mother and the breast during latch-on and feeding. Holding the infant with his arms folded together over his chest, curled up in a fetal position, or with his head cupped in her hand are not ideal positions to facilitate latch-on.
A newly delivered mother who intends to breastfeed tells her nurse, "I am so relieved that this pregnancy is over so I can start smoking again." The nurse encourages the client to refrain from smoking. However, this new mother insists that she will resume smoking. The nurse will need to adapt her health teaching to ensure that the client is aware that: a. Smoking has little or no effect on milk production. b. There is no relation between smoking and the time of feedings. c. The effects of secondhand smoke on infants are less significant than for adults. d. The mother should always smoke in another room.
ANS: D The new mother should be encouraged not to smoke. If she continues to smoke, she should be encouraged to always smoke in another room removed from the baby. Smoking may impair milk production. When the products of tobacco are broken down, they cross over into the breast milk. Tobacco also results in a reduction of the immunologic properties of breast milk. Research supports that mothers should not smoke within 2 hours before a feeding. The effects of secondhand smoke on infants include sudden infant death syndrome.
The nurse providing couplet care should understand that nipple confusion results when: a. Breastfeeding babies receive supplementary bottle feedings. b. The baby is weaned too abruptly. c. Pacifiers are used before breastfeeding is established. d. Twins are breastfed together.
Nipple confusion can result when babies go back and forth between bottles and breasts, especially before breastfeeding is established in 3 to 4 weeks, because the two require different skills. Abrupt weaning can be distressing to mother and/or baby but should not lead to nipple confusion. Pacifiers used before breastfeeding is established can be disruptive, but this does not lead to nipple confusion. Breastfeeding twins requires some logistical adaptations, but this should not lead to nipple confusion.