The Confusion about “Nipple Confusion”

By: Katie Coyne, MS, IBCLC

No, babies do not confuse a bottle for their mom’s breast—which is why the term itself is rather confusing. But as with anything in the lactation world, it’s not that black and white. Let’s dig into why…

There is a lot of controversy around the term “nipple confusion”—experts have been warning parents to avoid pacifiers and bottles for the first 4-6 weeks of the baby’s life because of the potential of nipple confusion. What does nipple confusion even mean? Many experts have a slightly different definition of nipple confusion but the traditional definition is “a phenomenon that refers to an infant's difficulty in achieving the correct configuration, latch technique and sucking pattern necessary for successful breastfeeding after bottle-feeding or exposure to an artificial nipple.”  Some babies will have no problem going back and forth between the bottle and the breast.  This is usually only a problem if the baby has not quite gotten the practice of nursing down. 

Nipple confusion versus bottle preference: the battle of the terminology

While lactation consultants generally don’t use the term nipple confusion anymore, we do know that babies feed differently at the bottle than they do at the breast. Everything from the motion of their tongue to the muscles used are different. 

When babies breastfeed, they control the amount of milk flowing from the breast, but most bottle nipples have flow rates which baby does not have control over.  The problem is not that babies will get “confused” by this change in flow, it’s that they may form a preference. Even with the use of slow flow nipples, a bottle generally flows much quicker than a breast does. In layman's terms, this means that bottle feeding can seem easier to babies than breastfeeding. And who wouldn’t prefer any easier way to eat?!

It is really important to note that babies who are already struggling with breastfeeding—maybe they have a disorganized suck, oral anatomy issues, or are just having a hard time with forming a latch – these babies are at high risk of developing a preference for the bottle (because it’s easier).

Later we will talk about how to best prevent these issues when introducing the bottle.

So what about pacifiers? Does that mean I can use them?

Although nipple confusion isn’t a concern, we still recommend waiting (or at least being cautious) on the use of pacifiers. The reason for this is because in those early days, your baby is going to be hungry pretty much around the clock. We recommend feeding your baby every time they show hunger cues rather than feeding them by the clock. It can be very hard to catch hunger cues if your baby is using a pacifier all the time, which is when we get concerned of missing those hunger cues. Not only does it lead to a fussy, hangry baby who can then be difficult to latch, but it could decrease your milk supply as well. Some babies are happy sucking on a pacifier for hours—which then can lead to missed feedings and lower milk supply.

On the flip side, let’s get real… some infants soothe really well with a pacifier. If your baby cannot be soothed without their paci, then I would recommend using it, but short term. Once the baby is calm, remove the pacifier, rather than letting them go to town for hours on end. And again, we are talking about the first 4 weeks or so. After that, it shouldn’t be an issue.

How can you prevent breastfeeding issues from the use of bottles or pacifiers?

It’s not realistic for most modern moms to avoid bottles their entire nursing career. Many women return to work and will need to pump and provide breastmilk in a bottle. And for moms who stay home, they also want the opportunity to pump and provide breastmilk in the bottle—that way they can maintain their sense of independence by running errands, grabbing coffee with girlfriends, or having a date night with their partner, all the while not worrying about their baby needing to nurse because they have a stash at home. So how do you balance bottle-feeding and breastfeeding?

If your baby doesn’t quite have nursing down yet, then postpone introducing the bottle. It really is best for the baby to be doing well with the breast before we bottle-feed. Unless there is a medical reason to supplement with the bottle or you’re going back to work right away, there isn’t a huge rush. The average baby may be ready to try a bottle around 3 weeks. When you do start bottle-feeding, either use a bottle that allows baby to control the flow or try to pace the feeding. There are plenty of great videos on You Tube explaining paced bottle-feeding. In a nutshell, with paced feeding you are slowing the rate in which the infant feeds from the bottle. This will help prevent that flow preference we mentioned earlier.  And anytime you can, breastfeed the baby. When you are home from work at night and on the weekend, nurse as often as possible.

Any time you sense that breastfeeding isn’t going very well, your local lactation consultant can become your new hero. Don’t wait until you hit rock bottom to reach out for help!