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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.

Becky 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.

Babies 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 Bonyata )

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" risk??

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 Nipples?

Early introduction of artificial nipples can result in:

*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 and nipple.

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 like this)

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.

Copyright 2000 - 2003  Jim Yount

Send email to Paula Yount for any questions or comments about this site.

Disclaimer:  The pages contained herein are meant purely for informational purposes and every effort is made to provide accurate and up-to-date information. This information, however, is not meant to take the place of your doctor, nor should the information contained on this web site be considered specific medical advice with respect to any specific person and/or any specific condition. The author, therefore respectfully but specifically disclaims any liability, loss or risk - personal or otherwise - that is, or may be, incurred as a consequence, directly or indirectly, from use or application of any of the information provided on this web site.