by Debra Swank
"Motor skills do not just come as birthday presents. They must be nurtured, promoted, and practiced."
- Kinesiologist Jane E. Clark (2007)
The six-month-old baby latches quickly and feeds contentedly, pausing now and then to grin at his mother, and doing so without even losing his latch. He can simultaneously nurse and explore his immediate world, reach for his toes, then play with a button on his mother’s shirt, all without losing the latch and without any interference in his ability to swallow big gulps of milk. This is Advanced Breastfeeding, a brilliant display of automaticity(1) in which his feeding movements have become nearly automatic – more smooth and fluid, with less attention focused on the task.
Reflecting on their own increase in skill, his parents recall the awkward difficulties in learning how to pick up and carry their newborn, how to diaper, bathe, dress, and embrace him. Although automaticity is impossible for the novice, the repetition of practice helps to build motor memory, and now the parents have become so highly skilled that bathing, diapering, and dressing the baby is no longer a stressful ordeal. While the baby feeds at the breast, now his mother can also coordinate a walk to the sink, then pours a glass of water to quench her own thirst. How did this family learn to do so much?
We begin learning during our gestation, building auditory memory for familiar sounds and olfactory memory for familiar smells, and some of us even build early motor memory for sucking on one’s tongue, thumb, or fingers while in utero. As newborn mammals, we enter the world in possession of the primitive survival reflexes, pre-adapted motor behaviors that support our earliest sensory-perceptual-motor learning (or more simply, motor learning) in the acquisition of motor memory for infant milk-feeding motor skills.
The crawl reflex and the rooting/search reflex enable us to locate our food source, and once found, the oral grasp reflex supports our learning for attaching to or latching onto the maternal nipple-areolar complex. As the mother’s nipple touches the baby’s palate, the sucking reflex is stimulated, and when milk release soon occurs, our swallow reflex is stimulated, as we learn how to better coordinate sucking and swallowing with breathing. Should we become disorganized during a swallow, our cough reflex supports us across the lifespan in becoming reorganized for the feeding. As babies rehearse their feeding movements, the sequenced coordination of these reflexes is a marvel of motor learning in the young, yet the presence of these primitive reflexes does not guarantee latch and effective suckling in all babies all the time. Our primitive reflexes are better viewed as training wheels on the bicycle, hastening our motor learning toward motor control for milk-feeding in dramatic support of our survival.
Lactation specialists often cite the “hard-wired” nature of the primitive survival reflexes, but clinicians also frequently observe the baby’s newly acquired feeding difficulties or skill decay(2) for latch and/or effective suckling that often follows the baby’s use of an artificial nipple, and this skill decay is displayed as decreased speed and accuracy for task. In the 3rd edition of La Leche League International’s Breastfeeding Answer Book, authors Nancy Mohrbacher and Julie Stock note that supplements have been associated with breastfeeding problems ranging from breast refusal, incorrect sucking technique, and severe breastfeeding problems(3). The authors advise, “Although most babies may be susceptible to breastfeeding problems caused by early bottle and pacifier use, it is generally agreed that once a baby has been breastfeeding well for three to four weeks, problems are less likely to develop, so if a mother plans to give her baby bottles or pacifiers, suggest she wait until after her baby’s first month or so to introduce them”.(4) Exclusively bottle-fed babies often display feeding difficulties when given a different style of artificial nipple, and some mixed-fed babies (who have learned how to breastfeed as well as bottle-feed) often display a preference for a particular style of artificial nipple while bottle-feeding, struggling with or refusing a new style of artificial nipple, followed by acceptance of a previously learned style of artificial nipple. The term motor memory consolidation(5) refers to the process by which an initially labile memory trace reaches a robust and relatively fixed state for motor control, a process that is heavily reliant upon sleep(6-10).
More months go by, and the baby becomes a toddler who is soon willing to practice eating with his first spoon and first fork, but more months of practice are needed to build rudimentary skill for these new feeding techniques. “Utensil confusion” (a close relative of “nipple confusion”) is often displayed by the toddler who attempts to use the fork in a spoon-like manner and the spoon in the manner of the fork, and further combines the feeding movements in mixed-up fashion. Frustration frequently arises during the early learning of this new skill, as evidenced by the toddler who pushes away the spoon and the fork, then happily returns to his skilled manual grasp of the food.
While continuing to observe his family at mealtime, the toddler is soon motivated to practice again with his utensils. Motivation(11) is a factor in learning, and some of us are sufficiently motivated to further add to our motor skill repertoire by learning, with much practice, to eat with chopsticks (Utensil Confusion Part 2), while the rest of the family refuses to ever attempt that awkwardness again. This does not result in a feeding crisis or dilemma, since our remaining skills for eating and drinking are more than enough to support our survival.
And so it goes. The challenges in discerning the similarities and differences in people, objects, and experiences are not limited to the newborn, the older baby, or the toddler. We often experience a challenge in differentiating one very identical twin from the other, and years of sensory-perceptual learning are needed in order to be able to discern various types of red wine from another (for the sommelier, even more intensive learning is required). Across the lifespan, sensory-perceptual-motor learning is easiest and most effective when practice is specific to the task, termed practice specificity(12).
The greater the difficulty of the task, the greater the need for practice that is specific to the task.
Should a young child receive a traditional tricycle from his parents as well a big-wheeled tricycle from his grandparents, the child will rapidly display a preference by spending far more time learning to ride just one of these trikes. Having quickly learned that it’s too difficult to learn tricycle-riding by practicing with one tricycle today and another similar yet different tricycle tomorrow, most (if not all) early rehearsals are naturally and voluntarily spent on just one tricycle for the most rapid skill acquisition.
When the professional musician is preparing for a critical audition using a clarinet, he will never choose to practice the clarinet on even days and the oboe on odd days, since there is a world of difference in the oral grasp for each of these similar but very different instruments. Rather than surfing in the ocean, the elite snowboarder will rehearse for the Olympics by using a snowboard, and furthermore, the Olympian will use only her own snowboard for practice. The elite baseball athlete will never prepare for the World Series by rehearsing with a softball instead of the baseball, and the professional classical singer will not prepare for a Mozart opera by rehearsing only Verdi or Wagner. Should the athlete or musician rehearse by task switching(13-14) between similar yet different equipment, adaptation will surely take place, but such adaptation is considered costly in regard to the subsequent and observable performance decrements or switch costs(13-14) of less speed and less accuracy upon returning to performance of the original task.
On Interference, Flow Confusions, and Flow Preferences
For much of the day, our skills are casual and non-competitive. On the way to work, we may drive a loaner car while our own vehicle is being repaired, but when we’re back behind the wheel of our own car, there’s a bit of happiness for the feel of it – our sensory-perceptual-motor memory for our own motor vehicle. After arriving at the office and sitting down at the computer, we frequently experience interference in memory retrieval when our encoded memory for an old password interferes with our ability to recall a newly created password. To build robust memory for the new password, the repetition of practice is necessary to form and strengthen new synaptic connections for that specific numerical sequence.
During proactive interference(15-16), old memories interfere with the retention of new learning, such as the common difficulty in remembering a new password. During retroactive interference(17-18), new learning interferes with the retention of old memories. When switching from your old car to a new car, have you ever reached incorrectly for the gear shift or radio knob in the new vehicle? In this case, robust spatial memories (memories for the layout of the space in your old car) have interfered with your spatial and motor memories for the location of the gear shift or radio knob in the new car, but following a little more practice, and you’ll be back in a groove of automaticity once again.
In 1995, Neifert, Lawrence, and Seacat(19) provided an early formal definition for the phenomenon of “nipple confusion,” utilizing the learning term interference. When a baby learns the requisite shallow latch with an artificial nipple, followed by a learning experience at the breast, many babies are subsequently unable to achieve the oral grasp (latch) in spite of observable attempts to do so, in an example of proactive interference. When a newborn learns how to latch and suckle well for the first breastfeed after birth, then is subsequently bottle-fed and/or given a pacifier, there are often new displays of difficulty with latch and/or effective sucking and/or the inability to latch at all for a subsequent breastfeed, as an example of retroactive interference in breastfeeding skills from the sensory-perceptual-motor learning experience with an artificial nipple. Lactation specialists are frequently consulted to assist nursing dyads in uncomplicated as well as complex motor learning for infant feeding, including newly acquired breastfeeding difficulties that follow the infant's use of an artificial nipple.
Many other babies are able to achieve and sustain the latch at the breast following a learning experience with an artificial nipple, but continue to perseverate(20) with a shallow latch at the nipple-areolar complex by displaying the shallow latch technique that must be used with an artificial nipple, in contrast to the optimal deep latch with a wide open gape well onto the areola (the wide gape so often displayed by youngest newborns very soon after birth). Such perseverating motor behavior has frequent and well-known repercussions: a shallow latch has long been correlated with nipple pain and visible nipple damage; maternal depression has been associated with nipple pain(21); mothers often cite debilitating nipple pain as rationale for early cessation of the entire breastfeeding course; nipple damage is a risk factor for mastitis; and untreated or inadequately treated mastitis is a risk factor for breast abscess.
Further, clinicians are educated and trained that a deep latch is the ideal oral grasp technique for adequate and efficient transfer of milk by the baby, in support of optimal weight gain in the infant. A shallow latch is a risk factor for low transfer of milk by the baby, and when the infant perseverates with a shallow latch, the maternal milk supply can be compromised due to inadequate emptying that stimulates only partial refill, a risk factor for low milk supply. Until infants become skilled in feeding effectively from the breast, mothers require education and support in how to otherwise build and maintain an abundant milk supply by frequent draining of the breast, which stimulates frequent refill toward a robust milk supply.
Much learning is reward-based associative learning(22), in which we learn to associate an action or experience with a pleasant or desired outcome, as in the newborn who associates the calming effects of sucking (via the hormone oxytocin) with the discovery of milk for one’s efforts, followed by the rewards of decreasing hunger and then satiety for that feeding. We also learn by associating our actions with an unpleasant outcome, as in the baby who has returned to the breast following a bottle-feed with its immediate gravity-flow of milk, but who does not experience the immediate gravity-flow of milk from the breast with the first suck. The mammalian milk ejection reflex (MER) is not stimulated in response to gravity, but in response to the gradual rise of oxytocin, the milk-releasing hormone. This hormonal stimulation typically elicits the initial release of milk to the infant within one to 2 minutes of beginning the feed, an important learned consequence for the baby's feeding actions, and the fastest food service on the planet at any time in the lifespan.
Upon returning to the breast following a bottle-feed, the baby may display the motor control to achieve the latch, suck two to three times, then release the latch and cry. This common feeding behavior is considered by many clinicians to be a display of the baby’s frustration – often referred to as flow confusion – due to the lack of an immediate gravity-flow for milk release from the breast with the baby's first suck. In addressing this infant feeding difficulty, the clinician often gives milk to the baby at the breast via feeding tube or syringe, thereby calming and encouraging the baby to continue suckling in order to stimulate the mother’s physiologic milk release. Regardless of whether a bottle contains expressed mother’s milk, human donor milk, or artificial infant milk, the reward of an immediate gravity-flow with the first suck is quickly learned when bottle-feeding, a significant source of competition with the mother's own remarkably efficient milk ejection reflex. This gradual but efficient rise of oxytocin is often experienced elsewhere in our humanity. For example, there is a gradual rise of oxytocin toward the reflex of orgasm, as well as a gradual rise in oxytocin with each uterine contraction during the labor of childbirth, and oxytocin rises even during teamwork between colleagues in the workplace.
This feeding difficulty of “flow confusion” will surely be seen again in the preschooler who has his or her first experience with a non-functioning straw. Typically after two to 3 sucks without the expected results (the reward for one’s efforts), the child returns the container to Mom or Dad and states, "It’s broken.” The straw may indeed be defective, or the milkshake or smoothie may be too thick to be transferred at that moment, and the parent can share their wisdom on how to address this concern. Perhaps replacing the old straw with a new straw will solve the problem, or waiting a bit for some melting to occur will take care of the frustration. When advancing hunger or thirst is a pressing matter, stirring the drink up a bit may hasten the melting process, and happy straw-drinking can then proceed.
sensation ∞ perception ∞ cognition (action planning) ∞ action (response) ∞ consequence
Yet it’s not possible to explain to the preverbal infant that mother’s breast provides the most rapid preparation and delivery of any food or drink he will ever experience in his lifetime. For thousands of years at this ancient yet contemporary restaurant, the menu has included standard nutritional fare as well as immunologic daily specials tailored to the specific needs of each diner, nature’s elegant merger of kitchen/chef/server as one mother offering The Original Fast Food and The Ultimate Fine Dining Experience, one course at a time (“Just give me a minute or two, and I’ll have it right there”). Ultrasound studies of the lactating breast show multiple MERs during any one session of milk expression, with typically three to 5 MERs per 15-minute session(23-24), similar to a 3 to 5 course meal for other members of the family, but with far more rapid service at the mother’s breast. For the infant who is undertaking sensory-perceptual-motor learning for both breastfeeding and bottle-feeding over a close time span, the mother’s onset of milk release may very well seem to the infant to be not fast enough or not happening at all, merely because it hasn’t happened yet – as compared to the gravity flow that is learned during bottled feeds.
Feeding confusions and feeding preferences occur across the lifespan, in spite of the adult’s vast repertoire of feeding skills. Learning to drink from a new style of water bottle with a novel closure (cap) can be a confusing process, and requires voluntary practice for motor learning toward motor control for effective transfer of the water.
What is your water bottle preference? In your impressive repertoire of drinking skills acquired over years of practice, do you prefer to drink from a water bottle by using the sports closure, which requires a particularly accurate oral grasp with strong sucking effort, or do you prefer to remove the entire cap from the bottle for a more rapid gravity-flow accompanied by less physical effort? Perhaps your water bottle preference depends on when and why. When out for a run, using the sports closure affords greater control during your running movements, but after the run, removing the sports cap for a more rapid quenching of thirst is the least frustrating and most gratifying way to drink.
The Exuberant Learning and Forgetting of Infancy
Regardless of age, we humans display individual differences in learning (we are not pseudo-robots, responding to the same stimuli in the same way and at the same moment). Babies learn faster than adults in all species studied, including humans, and the younger the infant, the faster the learning (25) and the forgetting ("the exuberant learning and forgetting of infancy"). As compared to older infants who have had much bottle-feeding experience prior to practice sessions at the breast, very young infants who have used an artificial nipple may display the most rapid relearning for latch, particularly if the infant is in the first three days of life, particularly if the mother’s nipple is well-protracted and the areolar tissue is fairly elastic, and particularly if the learning experience with an artificial nipple has been very limited.
Nipple confusion behavior can defined as the delayed reaction time to the maternal stimuli, prolonged movement time for completion of the latch, prolonged response time, as well as an inhibition of return - the delay in responding to a previously orienting cue or stimulus. Manual guidance from the clinician in positioning and latch may be all that is needed by some newborns who are displaying nipple confusion behavior, while other babies are able to achieve and sustain the latch with the temporary support of an ultra-thin silicone nipple shield, since a nipple shield often stimulates the newborn's reflexive yet voluntary lunge toward the breast for the oral grasp. A nipple shield provides the sensory experience of similarity to the baby, i.e., the nipple shield is similar to the greater length and firmness of an artificial nipple, and babies who have displayed nipple confusion behavior often respond more quickly to the maternal anatomy when the nipple shield is used to support the baby in his transfer of learning from the experience of bottle-feeding or pacifier use to the breast, i.e., the baby displays a faster reaction time, faster movement time, and faster response time to the maternal stimuli that has been augmented with the artificial texture and shape of the nipple shield. Finger-feeding also supports many bottle-fed babies in their transfer of learning to the breast by providing the baby with the rich sensory milieu of the mother’s skin (smell, touch, and taste) in the pairing of associates when sucking on the mother’s finger for the consequence/reward of milk. Similarly, the use of finger-feeding supports many infants in transferring their learning from the use of a nipple shield for the oral grasp, to the ability to latch onto the breast without the support of a nipple shield.
We often must inhibit one response in order to accomplish a different response(26-29), and inhibition is heavily studied in the cognitive sciences. When babies have had one or more learning experiences with an artificial nipple followed by a subsequent return to the breast, there is often an observable display of inhibition of the baby’s reflexive lunging movement toward the breast for the oral grasp. In bottle-feeding an infant, the bottle is moved toward the baby, rather than moving the baby toward the bottle (moving the baby toward the bottle would be far more difficult for the mother or other caregiver to coordinate, as compared to moving the bottle toward the baby). This inhibition of the newborn's reflexive lunge toward the breast is yet another aspect of the newborn’s difficulty in task-switching during practice sessions in breastfeeding and bottle-feeding, and lactation consultants often assist with this difficulty by providing manual guidance to the infant in moving quickly and accurately toward the breast as the infant relearns this lunge for the oral grasp. (Imagine the difficulty in learning how to throw a ball if you’re only given practice sessions in learning how to catch the ball.) This phenomenon of inhibition for the reflexive lunge that precedes the reflexive oral grasp at the breast is not unique to breastfed infants. Exclusively bottle-fed infants frequently display a reflexive lunge toward the artificial nipple during early learning sessions with a bottle, but in upcoming bottle-feeding sessions as bottle-feeding movements become increasingly more controlled, bottle-fed infants display an increasing inhibition of this reflexive lunge toward the artificial nipple.
Breastfeeding specialists spend much time in support of babies who are motor-learning how to feed in an unfettered manner without any learning interference from an artificial nipple. In birth settings that do not yet adhere to Baby Friendly practices (as in the Ten Steps to Successful Breastfeeding[30-31] advised by WHO and UNICEF), a great deal of clinical support is also given to both members of the dyad for the acquisition and reacquisition of the baby’s oral grasp (latch) and/or effective sucking, wherever and whenever such support is available to mothers and their infants.
When a new mother has both breastfed and bottle-fed her newborn and subsequently utilizes a bottle-feeding position for a breastfeeding attempt, the new mother has forgotten how to hold her baby for feeding at the breast (motor forgetting). The mother can readily relearn how to hold her infant in a breastfeeding versus bottle-feeding position, often with verbal and manual guidance from the clinician, and most importantly, the mother can relearn with the repetition of practice that is specific to the task. Due to the presence of the primitive survival reflexes and the newborn’s lack of a feeding method repertoire at the moment of birth, as well as the exuberant forgetting of infancy, the newborn faces far greater learning challenges in the acquisition of feeding skills when expected to perform task-switching for similar yet very different feeding methods during early learning. This is frequently observed in the unequal weighting of the primitive survival reflexes for one feeding method over another, particularly during early learning when cognitive flexibility is limited, and notably limited in the young. In contrast to the newborn’s experience, his mother already has her own robust repertoire of feeding and drinking skills as well as an immense repertoire for so very many other motor skills, learned long ago and remembered through many years of practice.
The newborn is just beginning to learn and remember how to feed, the first of many skills learned with voluntary, reward-based practice – albeit with early support from the pre-adapted movements of the primitive survival reflexes. Many insights into skill acquisition for infant feeding can be gathered from the integration of precepts from breastfeeding science, developmental cognitive neuroscience, and kinesiology - the study of human movement, motor learning, and motor control. After all, one must learn how to eat in order to live.
Ten Steps to Successful Breastfeeding (2018)
Critical Management Procedures
1a. Comply fully with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions.
1b. Have a written infant feeding policy that is routinely communicated to staff and parents.
1c. Establish ongoing monitoring and data-management systems.
2. Ensure that staff have sufficient knowledge, competence and skills to support breastfeeding.
Key clinical practices
3. Discuss the importance and management of breastfeeding with pregnant women and their families.
4. Facilitate immediate and uninterrupted skin-to-skin contact and support mothers to initiate breastfeeding as soon as possible after birth.
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties.
6. Do not provide breastfed newborns any food or fluids other than breast milk, unless medically indicated.
7. Enable mothers and their infants to remain together and to practise rooming-in 24 hours a day.
8. Support mothers to recognize and respond to their infants’ cues for feeding.
9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers.
10. Coordinate discharge so that parents and their infants have timely access to ongoing support and care.
Source for the Ten Steps to Successful Breastfeeding: World Health Organization, 2018. Retrieved on April 24, 2018. http://www.who.int/nutrition/bfhi/ten-steps/en/
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3. Mohrbacher N, Stock J (2003). The Breastfeeding Answer Book, 3rd revised edition. Schaumburg IL: La Leche League International, p. 29.
4. Ibid., p. 30.
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10. Korman M, Doyon J, Doljansky D, Carrier J, Dagan Y, Karni A. Daytime sleep condenses the time course of motor memory consolidation. Nature Neuroscience 2007 Sep;10(9):1206-1213. Epub 2007 August 12. DOI:10.1038/nn1959
11. Padmala S, Pessoa L. Motivation versus aversive processing during perception. Emotion 2014 April 7 [Epub ahead of print].
12. Schmidt RA, Lee TD (2011). Motor Learning and Motor Control: A Behavioral Emphasis (5th ed.). Champaign IL: Human Kinetics, p. 452.
13. Wylie G, Allport A. Task switching and the measurement of “switch costs.” Psychological Research 2000 August;63(3-4):212-233.
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15. Baddeley A, Eysenck MW, Anderson M (2015). Memory (2nd ed.). London and New York: Psychology Press, p. 245.
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18. Rossi-George A, Rovee-Collier C. Retroactive interference in 3-month-old infants. Developmental Psychobiology 1999;35:167-177.
19. Neifert M, Lawrence R, Seacat J. Nipple confusion: Toward a formal definition. The Journal of Pediatrics June 1995;126(6):S125-S129.
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21. Amir LH, Dennerstein L, Garland SM, Fisher J, Farish SJ. Psychological aspects of nipple pain in lactating women. Journal of Psychosomatic Obstetrics and Gynaecology 1996;17:53-58.
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23. Ramsay DT, Kent JC, Hartmann RL, Hartmann PE. Anatomy of the lactating human breast redefined with ultrasound imaging. Journal of Anatomy 2005;206:525-534.
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30. World Health Organization (2018). Ten Steps to Successful Breastfeeding. Source: Protecting, promoting, and supporting breastfeeding. The special role of maternity services. A joint WHO/UNICEF statement. Geneva: World Health Organization. http://www.who.int/nutrition/bfhi/ten-steps/en/
For More Information
Some texts on learning and memory, including sensory-perceptual-motor learning:
Baddeley A, Eysenck MW, Anderson MC (2015). Memory (2nd ed.). New York, NY: Psychology Press.
Breedlove MS, Watson NV (2013). Biological Psychology: An Introduction to Behavioral, Cognitive, and Clinical Neuroscience (7th ed.). Sunderland, Massachusetts USA: Sinauer Associates, Inc.
Coker C (2018). Motor Learning and Control (4th ed.). Abington, Oxon; New York, NY: Routledge.
Gallahue D, Ozmun J, Goodway J (2012). Understanding Motor Development: Infants, Children, Adolescents, Adults (7th ed.). Columbus, Ohio USA: McGraw-Hill Education.
Kalat JW (2019). Biological Psychology (13th ed.). Boston, Massachusetts USA: Cengage Learning.
Kandel ER, Dudai Y, Mayford M, Eds (2016). Learning and Memory. Cold Spring Harbor, New York USA: Cold Spring Harbor Laboratory Press.
Schmidt RA, Lee TD, Winstein CJ, Wulf G, Zelaznik HN (2019). Motor Control and Learning: A Behavioral Emphasis (6th ed.). Champaign, Illinois USA: Human Kinetics.
A memoir by Nobel Laureate Eric Kandel:
Kandel ER (2006). In Search of Memory: The Emergence of a New Science of Mind. New York NY: W.W. Norton & Company, Inc.
©Debra Swank 2015 - 2019. The author is a registered nurse and International Board Certified Lactation Consultant (IBCLC), and can be reached at firstname.lastname@example.org. This article may be copied and shared when the author's name and copyright are included with the article.
A video from Yuko Munakata on task-switching and perseveration with Piaget’s A-not-B error:
A video from researcher Yuko Munakata on task-switching and perseveration with Zelazo's card sorting task: