Definition

Nipple confusion occurs when a baby struggles to switch from bottle-feeding to breastfeeding or breastfeeds using the same technique they use when feeding from a bottle.

Breastfeeding involves coordinated mouth and jaw movements, which follow this mechanism:

• For proper latch, the baby must open their mouth wide enough to take both the nipple and a large part of the areola (the dark area around the nipple) into their mouth.
• The baby uses their tongue and lower jaw to hold the breast against the roof of their mouth.
• The baby's gums compress the areola while the tongue moves rhythmically from front to back to express milk.
• The baby seals their lips to create a sucking motion.

In contrast, bottle-feeding involves a different technique:

• Milk flows from the bottle without the baby needing to suck, due to gravity.
• The baby does not need to open their mouth wide, seal their lips, or create a sucking motion.
• The baby does not have to compress the nipple or perform a back-and-forth tongue motion to express milk.
• The baby only needs to suck with their lips or gums on the bottle's rubber nipple.
• If milk flows too quickly, the baby can stop it by pushing their tongue up and forward.

Causes

Some babies are more prone to nipple confusion. Certain factors can increase the likelihood of nipple confusion. Generally, if a baby is given a bottle or pacifier too early, they may develop improper sucking patterns for breastfeeding.

Risk Factor

Risk factors for nipple confusion can come from both the mother and the baby.

Maternal factors:

• Variations in nipple shape, such as flat or inverted nipples
• Low breast milk production.
• Health problems affecting the breast or other conditions that prevent breastfeeding
• Early introduction of bottle-feeding due to the mother returning to work

Infant factors:

• Premature birth
• Low birth weight
• Newborn hypoglycemia (low blood sugar levels)

Symptoms

If a baby breastfeeds using the same technique they use for bottle-feeding, they may show the following signs:

• Pushing their tongue upwards when sucking, which may push the nipple out of their mouth.
• Inability to open their mouth wide enough while nursing, resulting in minimal milk intake and potentially causing nipple pain for the mother.
• Frustration because breast milk does not flow immediately. It takes one to two minutes of sucking to stimulate milk let-down.
• Crying during breastfeeding due to frustration.

Mothers may experience:

• Irregular breast emptying due to the baby's sucking difficulties, which can reduce milk production.
• Breast engorgement due to inadequate milk removal, leading to milk accumulation in the breast.

Diagnosis

Nipple confusion can be identified through a discussion with the mother about the baby’s feeding behaviors or by observing the breastfeeding process directly. If a baby shows signs of nipple confusion, as described above, mothers can start trying some management steps to prevent worsening nipple confusion and avoid complications.

Management

What to do if a baby refuses to breastfeed?

For babies who prefer bottle-feeding, maintain your milk supply by regularly pumping when you are not with your baby. When you are together, make time to breastfeed. It is recommended to breastfeed more often when you are home and store breast milk in a bottle for times when you are away.

What to do if a baby refuses bottle-feeding?

Some babies may also struggle with bottle-feeding. If this happens, mothers can try the following steps:

• Ask your partner or another caregiver to offer the bottle. Observe whether the baby accepts bottle-feeding.
• Create a positive experience when offering the bottle. Avoid forcing the baby and keep the atmosphere calm and pleasant. Use similar actions as when breastfeeding, such as plenty of cuddling and eye contact. If the baby seems stressed, take a break.
• Experiment with different types of bottle nipples. Find one that releases enough milk to encourage the baby to feed.

After being exposed to bottle-feeding and realizing it is another form of feeding, most babies will soon understand the difference between a breast nipple and a bottle nipple.

Complications

Nipple confusion can affect the breastfeeding relationship between a mother and her baby. Other problems that may arise due to nipple confusion include:

Latching Problems

Babies with nipple confusion often struggle to latch correctly onto the breast. When feeding, babies become accustomed to the shape of the mother's breast. For example, if a mother has flat or inverted nipples and introduces bottle-feeding too early, the baby may find it easier to latch onto a bottle with a protruding nipple than onto the breast.

Milk flow from a bottle nipple is also faster than from the breast. Therefore, switching from bottle-feeding back to breastfeeding after the baby is used to the easier method can lead to frustration.

Sucking Problems

Babies with nipple confusion may also develop improper sucking patterns due to getting used to bottle-feeding. This can cause issues for the mother, such as nipple soreness and reduced milk production. When drinking from a bottle, a baby's mouth does not have to latch onto the nipple in the same way as with breastfeeding. The baby can gently attach to the bottle, but they must open their mouth wide to latch onto the breast. Improper latching can cause nipple pain, and disrupted milk flow due to inadequate sucking can affect milk production.

Refusal to Breastfeed

Mothers may worry if their baby is not getting enough breast milk in the first few days after birth. To encourage feeding, they might offer a bottle. The baby may seem satisfied but could drink more milk than they actually need. On the first day after birth, a baby's stomach is the size of a marble. Overfeeding with a bottle can unnaturally stretch the baby's stomach. After using a bottle, if the baby returns to breastfeeding for the next feeding, the mother may feel anxious, noticing that the baby is not getting as much milk as they did from the bottle. This is often when babies start to refuse to breastfeed.

Breast Disorder

Breast engorgement can occur due to insufficient milk removal and inadequate breast emptying. Milk accumulation in the breast can block milk ducts. If the engorgement is not promptly addressed, inflammation or even breast infection may occur. Infections happen when bacteria enter through a sore on the nipple. Inflammation of the breast is called mastitis.

Prevention

The best way to prevent nipple confusion is to wait for the right time to introduce a bottle, usually when breastfeeding is well-established. This typically takes four to six weeks. You may introduce a bottle nipple slightly earlier, but it is best to wait until your milk supply is sufficient and the baby's weight is stable, typically around three weeks of age.

If the baby struggles to return to breastfeeding after bottle-feeding has been introduced, try these tips:

• Continue breastfeeding as much as possible. If you are unable to breastfeed directly, try to limit bottle use.
• Ensure proper breastfeeding techniques so that both you and the baby are comfortable.
• If the baby seems frustrated because milk is not coming out, pump a little to stimulate milk flow before breastfeeding.
• Do not wait until the baby is very hungry to nurse. Try to set feeding times so that both you and the baby are comfortable, allowing the baby to adjust back to breastfeeding.

When to See a Doctor?

If a baby shows signs of nipple confusion as described above, mothers can try the suggested management steps. However, if nipple confusion persists or complications such as nipple pain and breast engorgement develop, it is important to consult a doctor to prevent more severe conditions.