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”.

It manifests as difficulty latching after introducing bottle feeding in your routine. In order to establish an effective breast latch, your baby needs to shape their mouth and tongue in a specific way that is different from the way they suck on a pacifier or from the bottle. Additionally, bottle feeding requires less coordination, the flow is faster and there is no wait-time for milk let-down.

In some cases the baby will get confused and “loose form” which manifests as them having a shallow and painful latch. In others, they might become fussy or straight-up refuse to breastfeed as they develop a strong preference for the ease of the bottle.

Warning

Very often tongue-tie express itself as nipple confusion. If you are struggling with poor latching I highly recommend getting an “all clear” for that from an ENT specialist or your pediatrician first.

Prevention

To prevent nipple confusion it is most commonly recommended to wait until breastfeeding is well established (usually 4-6 weeks) before introducing a bottle into the feeding routine.

Lactation consultants also advice waiting the same amount 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.

When introducing a bottle the paced bottle feeding technique is highly recommended. This technique has multiple advantages but its primary goal is to promote breastfeeding and avoid nipple confusion.

Slow flow bottles are preferred.

Remediation

If you have problems breastfeeding or suspect nipple confusion contact a lactation consultant as soon as possible. Early intervention is critical, the more you delay the less likely the lactation consultant will be able to help.

Tongue-tie

Unlike nipple-confusion which is about baby’s behavior and preference, tongue-tie (ankyloglossia) is a physical condition which can 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.

You can read more about it from UK’s NHS.

It is also worth noting that there are different levels of severity for tongue tie, and there is a change for light to mild cases to go undiagnosed for long. In our case, my daughter had a mild manifestation of this abnormality, and it went unnoticed even after several consultations with different lactation specialist. It got finally detected when we went to see a pediatric Otolaryngologist (ENT doctor). Obviously this is an anecdotal example, and it does not mean your case will be the same, it’s just something to be aware of.

Tongue-tie is treated with a frenectomy. A frenectomy is 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.