Nipple confusion

Nipple confusion refers to a baby’s feeding challenges when transitioning between a breast and a bottle, or their difficulty latching onto the breast after being introduced to an artificial nipple.

Nipple confusion generally shows up in two ways:

Type A - Difficulty latching: This occurs in younger babies who start having difficulty latching after the introduction of a pacifier or bottle. 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. Premature born babies are more susceptible to struggle with latching.
Type B - Bottle preference: This occurs in older babies which already know how to latch but develop a preference for bottle feeding. Bottle feeding requires less coordination, the flow is usually faster and the baby does not need to wait for the milk let-down. Access to “easy milk” makes some babies either hesitate or straight-up refuse to breastfeed. This is often referred to as “bottle preference” or “flow preference”.

Infant feeding is complex act both for the mother and the baby.

In our study, 83.5% of mothers reported difficulties, indicating the need for early identification and intervention. Similar results were reported in a survey by Gianni et al. [27,28], who found that 70–80% of women experienced breastfeeding difficulties, such as nipple pain, feeling inadequate, or fatigue.
doi: 10.3390/nu17061070

Initial feeding challenges tend to compound over time and become harder to address with time. For example:
A baby suffering from a mild-case of tongue-tie struggles to transfer milk efficiently, parent introduces bottle supplementation to address the low weight gain, the baby is able to nurse better from the bottle developing a preference for it. Eventually the tongue-tie is diagnosed and treated but by this point the bottle preference is firmly established making continued breastfeeding unlikely.

When struggling with breastfeeding the best course of action is to contact a IBCLCs (International Board Certified Lactation Consultants) or a midwife as soon as possible. Minor early tweaks can have large impact in the long term, if addressed straight-away.

Signs of nipple confusion

Signs of nipple confusion fall into two main categories: Inability to latch and frustration at the breast.

Inability to latch: The infant is attempting but failing to establish efficient milk transfer. This can also stem from other factors like poor breastfeeding position or other factors for breast refusal.

Thrust their tongue up while they’re sucking, which can push the nipple out of their mouth.
Fail to open mouth wide enough resulting in a shallow latch.
The baby cannot maintain suction and repeatedly loses their grip on the areola.
Changes in sucking patterns during breastfeeding

Short and impatient breastfeeding sessions.: The baby is getting frustrated and angry at the breast. This can also stem from low milk supply, a stressful prior breastfeed experience for the baby or even baby’s temperament.

Biting on the nipple (which besides other things, can signal frustration)
Crying during feeds and giving up on the breastfeeding session quickly.
Arching their back or pushing the breast away during breastfeeding but not when offering the bottle.

How to fix nipple confusion

Wait until breastfeeding is well established (roughly 4-6 weeks) before introducing a bottle. These initial weeks allow the baby to master the latch and the monther to establish the milk supply. Consider alternative supplementation options if supplementation is required.
Lactation consultants often advice waiting 4-6 weeks before introducing a pacifier. This advice is based on the old WHO policy: see chapter on pacifiers and nipple confusion
Use paced bottle feeding. This technique (an evolution of the Kassing method) mimics the rhythm and flow of breastfeeding. Its primary goal is to support breastfeeding while offering additional benefits such as reducing gas and reflux.
Use a slow flow bottle. See baby bottles for a guide on how to choose a baby bottle.
Create a calm environment for breastfeeding sessions to help the baby form a positive association with nursing.

Is nipple confusion real

Likely yes. Bottle introduction can cause some babies to develop a poor latch or bottle preference.

First off the term “nipple confusion” (nor any of its synonyms) is not a medical condition and lacks a formal definition so it’s not something a doctor can diagnose. So while it’s technically true that it “isn’t real”, whether artificial nipples actually have a negative impact on breastfeeding is still being actively investigated by science.

Studies show that bottle feeding is tied to a shorter overall breastfeeding period. However, critics point out that these studies fail to prove cause and effect. For example, the introduction of a bottle into the infant’s feeding regimen may reflect a parental intention toward early weaning. Another example is that a baby who is already struggling to breastfeed is more likely to be given a bottle in the first place.

The main findings of this study suggest that infants who use pacifiers and/or are bottle-fed have a higher frequency of indicators of BF difficulties when compared with those who do not use these devices.
…
Additionally, infants receiving mixed feeding (breast and bottle) position the tongue as a piston when sucking the breast, a behavior that is common when sucking the bottle, but not when sucking the breast (represented by undulatory movements), emphasizing the muscle pattern change after the introduction of the bottle.22
DOI 10.1016/j.jped.2017.10.005 (Jornal de Pediatria 2018)

Studies have shown that sucking patterns developed by infants in the first 2–4 weeks of life are “path-dependent,” and that early exposure to the mother’s nipple or bottle can lead to the solidification of oral muscle memory, with babies accustomed to the mother’s nipple being reluctant to use a bottle, and babies accustomed to bottle feeding refusing to be fed from the mother’s nipple.
DOI:10.26689/jcnr.v9i5.10652 (Journal of Clinical and Nursing Research, 2025)

The consequences of offering artificial nipples to breastfed infants are mostly negative and associated with the newborn, such as early weaning, refusal to breastfeed, impaired suction technique, incorrect latch-on, interference with orofacial development, and interruption of EBF. Reduced crying and newborn soothing are positive outcomes of the use of artificial nipples during breastfeeding. DOI:https://doi.org/10.7440/res64.2018.03

Historically, researchers have grouped all artificial nipples together under the assumption that any exposure threatened the breastfeeding relationship. However, more recently a distinction has emerged between bottle nipples (nutritive sucking) and pacifiers (non-nutritive).
New research rejects the claim that pacifiers cause nipple confusion.

Do pacifiers cause nipple confusion

Unlikely.
While contested, the current scientific consensus is that pacifiers do not lead to the early cessation of breastfeeding.

Historically WHO and the UNICEF, recommend avoiding use of pacifiers in term infants who breastfeed due to concerns about nipple confusion.
However, in light of new research refuting the link between pacifier use and nipple confusion WHO softened their policy on pacifier use:

The WHO recommends counselling on the use and risks of pacifiers, but no longer prohibits use in term infants.5“

Below are some studies rejecting the link between pacifiers and nipple confusion:

However, evidence suggests that it might not be pacifier use that causes premature cessation of breastfeeding, and that use of pacifiers might only be a sign of a maternal decision to stop breastfeeding. PMID: 23673585

There seems to be no reason to restrict the use of pacifiers in newborns, as the results of our meta-analysis suggest that they are not associated with breastfeeding duration or success rates. doi: 10.1007/s00431-022-04559-9

This meta-analysis shows that pacifier use does not decrease breastfeeding duration in full-term infants. The new evidence contradicts current WHO recom-mendations, however, which are based on less rigorous studies. PMID: 22577637

No difference between restricted and unrestricted pacifier use groups was found in the proportion of infants who were exclusively breastfed at three months of age (RR 1.01, 95% CI [0.96 to 1.07], 2 trials/1228 infants; I²=0.00%) or at four months of age www.who.int

Alternative feeding supplementation

This section exists for you to be aware of the existing options, alternative feeding methods pose their own set of challenges and risks. Alternative supplementation methods should be evaluated on a case-by case basis together with a healthcare professional or lactation consultant.

In some cases short term nutritional supplementation is medically required, particularly when an infant exhibits low initial weight, inability to latch or showing poor weight gain. Several supplementation methods exist that protect the breastfeeding relationship and do not involve a bottle or an artificial nipple.

At six months post-discharge, the overall likelihood of full breastfeeding was increased by 64% among those infants who received additional feeds via gavage tube or cup (RR 1.64, 95% CI [1.14 to 2.36], p=0.0071; I²=52%), and the effect of both interventions remained statistically significant in subgroup analyses (both p≤0.0059). e-Library of Evidence for Nutrition Actions

It was found that the preterm babies in whom spoonfeeding was used as a supportive method in addition to breast-feeding switched to full breastfeeding in a shorter time compared to the babies who were fed by bottle and their sucking success was at a better level. PMID: 26078682

These are intended as a temporary solution most often for newborns until breastfeeding can be established. It is highly recommended that a trained healthcare professional or lactation consultant demonstrate the technique first.

Resources describing alternative feeding methods: