Nipple confusion is a term used to describe the disruption or confusion a breast-fed baby might experience when they are presented with bottle or dummy teats.
There is some discussion around whether this is a myth or a true effect. In reality, it may be more likely that this impact occurs for some babies while others adapt to the different feeding methods without issue.
In this article we explore what the basis of this concern is, what the research says about it and how it can be managed.
What is nipple confusion?
A paper published in 1995 set out to create a formal definition for this phenomenon. They state, ‘the term nipple confusion refers to an infant’s difficulty in achieving the correct oral configuration, latching technique, and suckling pattern necessary for successful breast-feeding after bottle feeding or other exposure to an artificial nipple.’
However, they go on to say, ‘Many early breast-feeding failures are attributed to nipple confusion, although scientific data are lacking to document its prevalence’.
Suggesting that at the time there was a lack of evidence available to substantiate how common this effect was.
What does the research say?
Multiple research papers on this topic begin by addressing the debate around nipple confusion. They acknowledge that whilst some people believe it is a prominent issue, others feel there is a lack of quality evidence to support it.
The concern underpinning this term is based on the belief that creating nipple confusion for babies will have a negative impact on breastfeeding. This is likely based on the recommendation by the World Health Organisation, within their ‘Ten Steps to Successful Breastfeeding’, that artificial teats should never be given to babies.
A recent systematic review aimed to collate the reported consequences of using artificial teats on exclusive breastfeeding. They included 38 articles in their review and concluded that multiple negative neonatal factors (such as early weaning, incorrect latch and refusal to breastfeed) were associated with the use of artificial teats.
However, this paper does not provide details on how the recorded neonatal factors were documented in original studies. Further, how the authors determined true causality of the documented neonatal factors is not discussed anywhere in the paper.
Another, systematic review on the subject did identify the difficulty ascertaining causality of the negative impacts on breastfeeding reported in the included studies. The authors describe the difficulty in ‘determining whether bottles’/pacifiers’ nipples are causing infants to refuse the breast or whether they are simply markers of other maternal/infant characteristics’.
The same paper noted that most of the associations between artificial teat use and negative impacts on breastfeeding were related to bottle use, and they found little evidence to support evidence of pacifiers / dummy’s causing nipple confusion.
What is the difference between breastfeeding and feeding with an artificial teat?
During breastfeeding, the breast and baby engage in a process that creates high- and low-pressure environments in the breast and baby’s mouth. The process is described in detail below:
- Baby latches on to the breast and stimulates the nipple and surrounding breast tissue with flutter sucks.
- Mum’s body receives signals to feed, the let-down reflex is stimulated, and milk is released into the milk ducts.
- When milk enters the ducts, it creates high pressure within the breast.
- Baby’s tongue compresses and releases the nipple rhythmically. When the nipple is released this creates a negative pressure in baby’s mouth.
- Milk moves from the high pressure in mum’s breast to the low pressure in baby’s mouth, baby swallows then compresses and releases the nipple again to repeat the process.
Research suggests that the creation of vacuum in baby’s mouth is integral for breastfeeding. Studies show that babies draw the nipple and surrounding breast tissue into the mouth. They stabilize the nipple beyond the hard palette / soft palette junction and maintain a seal with their lips to create a vacuum. Their tongue and jaw work in tandem to create a peristaltic, or wave-like, motion while suckling.
A Japanese study has shown that the movement of the mandible (jawbone) is different when babies are breast fed vs bottle fed and suggests that more energy is required to breast feed.
Work done by an Australian group used ultrasound imaging and intra-oral vacuum measurements to explore the necessity of creating a vacuum in breastfeeding. They fashioned an artificial teat made of silicon that would only release milk when enough vacuum was applied by baby.
Two of the 18 included babies refused the experimental teat. For those who accepted and fed via breast and the artificial teat, the authors reported the following:
- Both nipple and teat were brought to similar positions in the mouth.
- As babies tongues lowered, the nipple and teat expanded evenly. However, the breast expanded more than the teat.
- Higher vacuum was applied during breastfeeding than during feeds via the artificial teat.
- More milk intake, measured by test weighing babies before and after feeds, was recorded during breast feeds than feeds with the artificial nipple.
How do I manage the impact of introducing artificial teats?
If you wish or need to introduce alternative feeding methods while breastfeeding, being aware of the potential impact is key. Keep in mind that babies may become confused when a new teat is introduced, but that many adapt well and experience no adverse outcomes.
Monitor baby for any signs of distress or disruption at the breast. If you find there is no change, it is likely baby has adapted well to the introduction of another teat.
If baby does exhibit signs they are struggling or are frustrated at the breast, go back to basics. Focus on perfecting attachment and positioning at the breast, you can find tips for this on our previous blog post here. By supporting baby as much as possible to latch and feed effectively, you may be able to assist them as they learn to switch between the two different techniques.
If you are introducing a bottle, there are ways you can reduce the difference experienced by baby. Feeding responsively, as discussed in our previous post ‘What Is Responsive Feeding?’, will enable baby to remain in control of their feed. Keeping them in an upright position, with the bottle horizontal, can help to pace the feed and will better resemble their experience at the breast.
If you and baby continue to struggle despite applying the above, reach out to a lactation consultant or breastfeeding professional for support.
Lastly, while nipple confusion has been related to the disruption of breastfeeding there are other (potentially more impactful) effects related to introducing bottle feeds. When a breastfeed is replaced with a feed from a bottle, this changes the amount of milk baby removes from the breast. In turn, the amount of milk the breast replaces will be lower. The potential here is that introducing bottle feeds may impact your milk supply, an important consideration for mums wishing to introduce combi feeding or for babies who require top ups.
Conclusion
Nipple confusion may arise in breast fed babies when new forms of feeding and different teats are introduced. Research into the actual impact or prevalence of nipple confusion is contradictory and at the moment we require more quality evidence on the subject.
If you wish to introduce an artificial teat to your baby, there are some things to keep in mind. Be prepared for potential impacts but keep in mind that many babies transition between feeding methods easily.
When breastfeeding does appear to have been disrupted, return to the basics of ensuring good positioning and attachment at the breast and reach out to a lactation consultant for support if needed.
References
Cavalcante, V. d. O., de Sousa, M. L., Pereira, C. d. S., da Silva, N. O., Rodrigues de Albuquerque, T., & Callou Cruz, R. d. S. B. L. (2021). Consequences of Using Artificial Nipples in Exclusive Breastfeeding: An Integrative Review. Aquichan.
França, E. C. L., Sousa, C. B., Aragão, L. C., & Costa, L. R. (2014a). Electromyographic analysis of masseter muscle in newborns during suction in breast, bottle or cup feeding. BMC Pregnancy and Childbirth, 14(1), 154. https://doi.org/10.1186/1471-2393-14-154
França, E. C. L., Sousa, C. B., Aragão, L. C., & Costa, L. R. (2014b). Electromyographic analysis of masseter muscle in newborns during suction in breast, bottle or cup feeding. BMC Pregnancy and Childbirth, 14(1), 154. https://doi.org/10.1186/1471-2393-14-154
Geddes, D. T., Sakalidis, V. S., Hepworth, A. R., McClellan, H. L., Kent, J. C., Lai, C. T., & Hartmann, P. E. (2012). Tongue movement and intra-oral vacuum of term infants during breastfeeding and feeding from an experimental teat that released milk under vacuum only. Early Human Development, 88(6), 443-449. https://doi.org/https://doi.org/10.1016/j.earlhumdev.2011.10.012
Matsubara, M., & Inoue, M. (2019). A comparison of the movement of the mandible in infants between breastfeeding and bottle-feeding.
Neifert, M., Lawrence, R., & Seacat, J. (1995). Nipple confusion: toward a formal definition. J Pediatr, 126(6), S125-129. https://doi.org/10.1016/s0022-3476(95)90252-x
Newman, J., & Wilmott, B. (1990). Breast rejection: a little-appreciated cause of lactation failure. Can Fam Physician,36, 449-453.
Praborini, A., Purnamasari, H., Munandar, A., & Wulandari, R. A. Hospitalization for Nipple Confusion. A Method to Restore Healthy Breastfeeding(2), 69-76. https://doi.org/10.1891/2158-0782.7.2.69
World Health, O. (2017). Guideline: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services. World Health Organization.
