Nipple confusion

Nipple confusion is when a baby has difficulties switching between the breast and a bottle. Sometimes this is called “flow preference” or “bottle preference”.

In order to establish an effective breast latch, your baby needs to shape their mouth and tongue in a specific way which is different from the way they suck on a pacifier or from the bottle. Additionally, bottle feeding requires less coordination, the flow is usually faster and the baby does not need to wait for the milk let-down.

Usual symptoms of nipple confusion are:

• Short impatient breastfeeding sessions: The baby gets frustrated by the slower pace of the nipple and gives up before being full.
• Bad latch: Baby tries to nurse from the breast “as if it were a bottle” resulting in a shallow latch, chewing on the nipple, butting the nipple in their mouth but not sucking.
• Refusal to breastfeed: The baby becomes upset when trying to breastfeed them (but not when offering the bottle). In more extreme cases the baby will arch their back, or push away the breast entirely.

Other causes for breast refusal

There are other several common feeding challenges that look like as nipple confusion but need to be addressed very differently. The major complicating factor is that pre-existing conditions reinforce bottle preference:

-> A pre-existing condition prevents the baby from breastfeeding effectively, resulting in poor weight gain
-> The parent introduces bottlefeeding to address the weight gain issue
-> Baby starts preferring the bottle and develops bottle preference (justifiably)
-> The early weaning is attributed to “nipple confusion” and the initial condition is never discovered.

Anecdotally we spent months trying to fix nipple confusion with several lactation consultants, when in fact the root cause of the issue was tongue-tie.

The most common other causes for breast refusal:

• Tongue tie: A physical condition that limits tongue’s range. See tongue-tie annex for a detailed description.
• Flat or inverted nipples: See https://laleche.org.uk/inverted-nipples/
• Oversupply of milk: https://laleche.org.uk/too-much-milk-and-oversupply/
• Undersupply of milk: https://laleche.org.uk/how-to-increase-your-milk-supply/
• Poor breastfeeding positioning: https://laleche.org.uk/positioning-attachment/

If you suspect any of this might apply to you and your baby, book an in-person appointment with lactation consultant.

Preventing nipple confusion

• Wait until breastfeeding is well established (usually 4-6 weeks) before introducing a bottle into the feeding routine.
• Use the paced bottle feeding technique. Besides having multiple other advantages this technique was designed primarily to promote breastfeeding and avoid nipple confusion. This way of offering the bottle has multiple other advantages
• Use a symmetrical slow flow bottle nipple. See baby bottles for guide on selecting a bottle.
• Lactation consultants also advice waiting 4-6 weeks before introducing a pacifier. However, there is less consensus about this, with studies showing conflicting outcomes on breastfeeding and the introduction of a pacifier being recommended by the safe sleep guidelines.

Annex: Tongue-tie

Unlike nipple-confusion which is about baby’s behavior and preference, tongue-tie (ankyloglossia) is a physical condition that limits tongue’s range of movement, Tongue-tie is diagnosed by a pediatric Otolaryngologist (ENT doctor) and might require medical intervention.

In some babies the lingual frenum (the membrane connecting the underside of a tongue to the floor of the mouth) is abnormally short or thick. The abnormal frenum limits the mobility of tongue causing poor latching and inefficient milk extraction. Babies with tongue-tie have low-weight gain and require excessively long and frequent breastfeeding sessions. This condition is common, genetically heritable and often runs in the family.

Tongue tie both exhibits like and reinforces bottle preference:

• Parents introduce supplementary bottle feeds as a means for their baby to gain weight.
• Baby develops a preference for the bottle as extracting milk from the bottle does not require the same tongue mobility needed to breastfeed.

It is worth noting that there are different levels of severity for tongue tie, and light to mild cases can go undiagnosed for a very long time before being detected.

Tongue-tie is treated by a with a frenectomy (minor surgery where the doctor cuts frenum to restore mobility of the tongue). The procedure is complete within seconds, performed without anesthetic, and does not require hospitalization.
However after the procedure you might be instructed to perform post-frenectomy massages at home for several weeks. These exercises are designed to prevent frenum reattachment and premature closing of the wound. Performing these massage is highly unpleasant, both for the baby and for the caregiver. There is ongoing debate about the efficacy of these post-frenectomy massages, but this is a discussion you must have with your ENT. More info can be found here.