By Ali Weatherford

Nipple confusion is most likely something you will become aware of when you are breastfeeding or preparing to breastfeed. Maybe your friend or a family member warned you about nipple confusion. “Don’t give your baby a bottle or pacifier or they’ll get confused and stop breastfeeding!” or “Don’t wait too long to give your baby a bottle or they might be confused that it’s not a breast and won’t take it!” Maybe you’ve been reading about it and wondering if this is a real thing. You might also see that plenty of people seem to be able to use bottles and breastfeed at the same time.

The term nipple confusion might lead you to think that there is something wrong with the baby! Why do some babies get “confused” while others seem to do just fine? Are some babies smarter than others? I hope I have a smart baby!

Rest assured that this has nothing to do with the intelligence of your baby! And the term “nipple confusion” is maybe too confusing itself. Now we know that a better term for this situation is flow preference.

Here’s What Happens Sometimes….

You start out breastfeeding your baby and after a little bit of learning, you both seem to be doing just fine. Your baby latches on easily, seems to be satisfied after a feed, and is making plenty of wet and dirty diapers. You are not experiencing any significant pain or discomfort. Things are good. And then you might need to offer your baby a bottle for some reason. Maybe you want to have a night out, or your partner wants to feed the baby. You might be going back to work soon, and you want to make sure your baby is comfortable getting milk from a bottle.

So you figure out how to use your pump and make a bottle of breastmilk. You give that bottle to your baby and she takes it ALL down REALLY fast! You might wonder if that was enough milk! It’s never that quick feeding your baby from the breast. You might try offering more, but your baby seems pretty satisfied and doesn’t want it. Later, it’s time to breastfeed but your baby seems a little resistant. She finally does latch on, but it’s more of a struggle than usual. She might even let go a few times and seem frustrated about something. The more you incorporate the bottle, the more intense these behaviors get until your baby just refuses to take your nipple. Did she just forget how to do it? Is your baby experiencing nipple confusion?

What is actually happening is that your baby has developed a preference for the bottle. Without some training, most people will just feed the baby from a bottle without understanding that there is a right way to use a bottle, and a wrong way. Using improper bottle feeding techniques can lead to problems.

Breast vs Bottle

When considering the right and wrong ways to use a bottle, it’s a great idea to first understand how babies get milk from a breast.

Getting milk from a breast takes work. At the very beginning, there is only a very small amount of milk and that’s all babies need. They have to put some effort into it. The baby first has to stimulate the milk letdown by suckling. They don’t immediately get milk. Once the milk arrives, they have to suck some, but in the early days, they don’t have to work too hard since it’s a very small amount that they get. Over the next couple of days, the baby will feed more often, but still get small amounts of milk at each feeding. After a few days of small feeds, the milk supply will increase and babies will get more each time.

In this way, they are gradually developing more muscle strength and more endurance as they spend more time at the breast. Then as your milk supply increases and your baby’s belly gets bigger, they are prepared to put in the extra work of drawing out more milk. The older, bigger, stronger, and more experienced they are, the more milk they can get out of the breast. It works this way for a reason!

Bottles are different. Depending on the type of nipple used, it’s usually much easier to get milk out of a bottle. People tend to lay the baby down in a very horizontal position, tip the bottle straight down into the baby’s mouth, and the milk just pours right down the baby’s throat. They don’t have to suckle to stimulate the milk letdown, or suck very hard or at all! A baby that is used to a slower flow from the breast and that has developed a lot of muscle strength and stamina might feel overwhelmed by that amount of milk flow and show a preference for the breast. A baby that has not yet developed the strength and stamina at the breast might really like how easy it can be to get milk out of the bottle. In that case, the baby might develop a preference for the fast and easy flow of the bottle. In either case, the baby has developed a “flow preference”, formerly known as “nipple confusion”.

How can you Prevent Nipple Confusion?

I interviewed IBCLC, Cassie Terrillion about how to manage this issue and she gave me some great tips!

  1. ALWAYS use the Paced Bottle Feeding method when using a bottle. This makes it less easy to get milk out of the bottle. It is designed to mimic breastfeeding enough so that the baby doesn’t develop a “flow preference” for the bottle. It’s also great for formula fed babies or exclusively pumping parents so that the babies aren’t as likely to overeat. Breastfeeding is designed to prevent overeating, but it’s harder to prevent when bottle feeding.
  2. Use a “slow flow” or “preemie” bottle nipple. The smaller holes in these nipples make the baby have to work a little harder to suck the milk out and help the baby develop their strength and stamina. It also more closely mimics the way milk comes out of a breast. But remember that these nipples are not manufactured in a perfectly consistent way so don’t depend on this completely. Continue to use the Paced Bottle Feeding method in addition to the slow flow nipple.
  3. Wait until 4-6 weeks to introduce a bottle if you can. Cassie calls this the “sweet spot”. Babies tend to be very strong by then and very comfortable breastfeeding. They will rarely develop a preference for the bottle if you wait this long to introduce it. It’s also a time when babies are receptive to new things and won’t likely reject the bottle either. Of course not everyone can wait this long to use a bottle. Your baby might need some supplementation before then for medical reasons, or you might have to go back to work sooner. If you can’t wait until 4-6 weeks, just remember to use the Paced Bottle Feeding method and a slow flow nipple and your baby will still most likely be able to stay flexible and move between breast and bottle feedings easily.

What to Do if your Baby DOES Develop a “Flow Preference”?

All is not lost. If you didn’t know how to prevent flow preference and this happens, you can still likely get your baby back to the breast. Cassie recommends sending a very clear and consistent message to your baby, “You are going to have to put in some effort to get your milk… matter what.” Start using the Paced Bottle Feeding method and slow flow nipples consistently, and your baby will very likely learn to accept the breast again and be more flexible. If you continue to struggle, see a lactation consultant. They may be able to offer more suggestions and find a solution with you. Consider taking a breastfeeding class before your baby comes so that you’ll know how to avoid some of the more common pitfalls. And we also have a great FREE support group called Bosom Buddies every Monday from 1-3pm central time. Cassie leads this group. She is a lactation consultant (IBCLC), so it’s a great place to get some of your questions answered and hear about how other people are managing with new babies.

Our articles are not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment.

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