The Truth About "Nipple Confusion"
Many mothers hear the words "nipple confusion" and wonder
exactly what it is. Many health care providers, when asked about
nipple confusion, will state they "don't believe in it".
Some are not even sure what exactly it is.
- The truth is that "nipple confusion"
(also called bottle preference, especially when it involves older
babies) is real.
- The truth is that there is no way to know which
baby will have a problem with nipple confusion or bottle preference
until the bottle or pacifier is given.
- The truth is that unless one has experienced
this, they often have no idea what it's all about, or how significant
an impact it can have on a breastfeeding relationship.
Breastfeeding experts recommend waiting to introduce
any artificial nipples (includes pacifiers) until baby is at least
3 weeks of age. There is good reason for this. One bottle,
or one day of pacifier or bottle use in a newborn can,
and has resulted in nipple confusion. We often hear "just
one bottle" won't hurt, but the truth is - yes it can.
Flora, IBCLC, noted "For some babies it may take many
bottles before they show any nipple confusion; for others it can
take only one or two."
So what IS nipple confusion?
Nursing from the breast is a very different action
than sucking milk from a bottle, or sucking on a pacifier. Simply
put, it is a sort of "confusion" between the different
types of sucking used when nursing, and when using artificial nipples
(bottles or pacifiers).
When nursing a baby's tongue extends down over
the lower gum line and gently "cups" the breast (nipple
and some of the areola), in effect, "massaging" the underside
of the breast as baby nurses. The anatomy of a suck as described
by Woolridge (Woolridge, Michael W.,
"The 'anatomy' of infant sucking", Midwifery, 1986, Dec;
2(4): 164-71 ) and Escott (Escott,
Ros, "Positioning, Attachment and Milk Transfer", Breastfeeding
Review, 1989 May 1(14) pp31-37) state that during breastfeeding,
a compression wave moves from the tip to the back of the tongue
against the underside of the nipple and breast tissue. This peristaltic
like motion pushes the milk ahead of itself, until it is expressed
out of approximately 9 pores near the tip of the nipple in a volume
the baby can easily swallow. A small amount of "suction"
or negative pressure is created to hold the nipple in place at the
junction of the soft palate, but the act of feeding from a breast
is quite different to sucking from an artificial nipple. Experts
often describe the suckling motion from the breast as a "rocker
like" suckling motion.
When an artificial nipple (bottle or pacifier)
is used, the entire placement in the mouth and the manner used to
"suck" from the nipple is completely different. Babies
use a "piston-like" type suck when drinking from a bottle,
with the tongue up near the tip of the bottle nipple. With an artificial
nipple the infant does not caress the bottom side of the nipple
like he does at the breast, but rather has to squeeze it to express
the contents. Depending on the hardness of the composition and the
size of the hole at the end of the nipple, the milk either "gushes"
or squirts in a thin hard stream out the end, causing baby to posture
its tongue at the back of the throat to prevent too much liquid
from going down its throat. This sets up a tongue habit described
by some as a tongue thrust or deviate swallow.
can develop nipple confusion when artificial nipples (bottles or
pacifiers) are introduced prior to breastfeeding becoming well established,
or prior to about four weeks of age. Babies also may have problems
later on with the rate of flow from a bottle. Note that nipple confusion
is often defined as a problem that crops up with the difference
in the way a baby sucks from bottle as opposed to breast. And bottle
preference is often defined as preference to bottle because of easy
flow of milk not "just" the difference in sucking. Either
situation, or both, can apply at any age,or at any time during
the breastfeeding relationship; it just depends on the baby as well
as the individual circumstances.
(Picture reprinted with permission from Dr
Brian Palmer, D.D.S.: - Bottlefeeding can separate the epiglottis
/ soft palate connection, elevate the soft palate, drive the tongue
back and alter the action of the tongue. The
Importance of Breastfeeding as it Relates to Total Health )
It is also important to note that for many babies,
any "oral insult" (like suctioning at birth, someone
pushing baby's head into mom's breast to "force" nursing,
forcing a bottle, etc) can result in breastfeeding problems. After
something like that happens, baby may be trying to keep anything
out of his mouth that he doesn't put there himself. (Kelly
Is There a Real Risk?
Unfortunately there are those (moms, grandmas, health
care providers) who don't take this risk seriously, and/or say they
introduced bottle "from day one" (or prior to 3 or 4 weeks)
and they never had a problem. The problem with this attitude is
that experts have provided the information for our benefit, and
if we know it is a risk for babies and mommies, why give the impression
that it is not significant, or imply it's not a "real"
I might not believe it if I hadn't experienced
it, not once, but twice. Because of these personal experiences,
and having seen others experience it as well, I would stress to
moms its just not worth the risk. Remember - there
is no way to tell prior to introducing artificial nipples of any
kind, whether or not your baby will be affected.
It can be very difficult trying to cope with nipple
confusion issues when you don't know what is going on. Even if you
do understand what's wrong you might not know how to fix
it. And it is very frustrating to find that the risk could
have been reduced and/or be prevented with the right info/support.
Nipple confusion may not happen, but
at least if one is educated regarding the risk/possibility, one
can make an informed choice, and have some experienced support to
help get back on track.
Not providing appropriate information about nipple
confusion or bottle preference, or downplaying the risks or concerns,
is very unfair to new mothers who need to be aware of these possibilities.
What Sort Of Problems Might Occur With Early Use of Artificial
Early introduction of artificial nipples can result
*difficulty in latching
*unresolved nipple soreness
*difficulty staying at the breast
*total breast refusal
How Do We Avoid Nipple Confusion?
Experts recommend exclusive breastfeeding for the first three weeks
minimum, and preferably waiting till week 4 or 5 to introduce
a bottle or pacifier. They also recommend if it's important that
baby accept a bottle, to offer it prior to 6 weeks
of age, because after that time, many babies are reluctant to accept
a bottle (or pacifier).
It is also recommended to use slow flow or newborn nipples, and
offering the bottle in a manner that "mimics" breastfeeding
as much as possible.
Never "force" a baby to accept the bottle. Gentle persuasion
is best, reducing risk of negative associations baby might have
toward bottle - or breast.
Use bottles only when needed. Using bottles too often increases
risk of baby preferring bottles over breast.
Use pacifier only when necessary. Over-using pacifier
can also have negative effects on the breastfed baby.
What Bottles or Nipples Are Best To Reduce Risk?
Most breastfeeding experts agree there really is no conclusive research
to show any one nipple type is better than another at reducing the
risk of nipple confusion, or cause less of an impact to the baby's
suckling pattern. This is partly because the human nipple elongates
and is molded to fit the inside of the baby's mouth, where as the
artificial nipple must be made of a firm material in order to "hold
its shape" (otherwise it will stay compressed after a suck
and not refill easily). Thus the human nipple is pliant, the artificial
nipple is not, rendering "similar" sucking patterns for
both to be an impossible feat.
In addition, mothers breasts and nipples come in all shapes and
sizes, so what works for one baby well, may not work for another
in part due to the anatomical individuality of its mothers breast
Finally, the shape of the nipple is not as
important as the flow rate of the nipple. Bottle nipples that flow
too freely, too fast, raise the risk of baby having problems with
normal nursing from the breast.
Taking in to consideration all of the data above,
it seems that the best idea might be to choose a nipple that provides
as close a simulation as possible to baby's mouth position at the
breast. Mothers might want to avoid any nipples that are shorter
or "stubbier" which might result in baby wanting to grasp
the nipple only instead of achieving a wide open latch.
Kathy Kuhn, IBCLC, has noted
"It's important to note that there is
no research on nipple types with regard to 'nipple confusion'.
So any answer anyone provides is based on his or her experience
or opinion. There is no definitive answer for this one.
Most LC's opinion is that the longer nipples that make the baby's
lips flange widely ala bf are the best since they 'seem' to be
most like bf. Generally we shy away from the shorter stubby nipples
that encourage the baby to pucker the lips and suck only on the
tip of the nipple. The Avent fits into the former category."
Help! I think We Have Nipple Confusion Problem
- What Can I Do?
There are many options available to help resolve problems that might
have arisen from early introduction of artificial nipples or frequent
use of bottles. Some options work better than others, depending
on the specific situation or circumstances.
First, try to stay calm. This can be difficult
if baby is actively refusing breast and both mother and baby are
frustrated. Contact a board certified lactation consultant (IBCLC)
or a La Leche League leader (LLL) not only for emotional support,
but also for additional information to help get things back on track
again. (A board certified LC has expert training to help with situations
The goal is to gently
encourage baby to accept the breast, so avoid "forcing"
the issue. Depending on the circumstances it may be helpful to eliminate
all bottles, using alternative
methods of feeding baby instead.
Additional tips and ideas can be found here:
Woolridge, Michael W., "The 'anatomy' of infant sucking",
Midwifery, 1986, Dec; 2(4): 164-71
5) Escott, Ros, "Positioning, Attachment and Milk Transfer",
Breastfeeding Review, 1989 May 1(14) pp31-37.