Oral confusion-how nipple confusion works

Let’s talk about nipple confusion. Wherever anecdotes are valued as useful you’ll find plenty of stories that illustrate either view on nipple confusion. Babies who were given bottles early on and the mothers who had huge struggles getting them back, if ever, to the breast, as well as those who routinely gave their babies bottles and never had any issues at all.  So what’s the deal with nipple confusion? Nipple confusion is a collective name for something that is a combination of factors. Side note: I found this article, which looks like it would be a fantastic resource. Unfortunately, like many of Dr. Neifert’s articles, I can’t get electronic access to it (even at work where I have access to all kinds of journals). I’m sure that would pretty much replace my little post here, but since I can’t read it, I’ll just write this instead.

Teat Confusion:

First off there is teat confusion. How something is sucked. Babies are crafty, tricky little beasts. It’s part of their biological programming to experiment and problem solve in order to figure out how to best get milk out of breasts.  So teat confusion can arise from bottle teats and pacifier teats. Bottle teats as the method of getting fluid out of a bottle teat is different than out of a breast (see Myth 15 and associated citations). With a breast the mouth needs to gape wider and the tongue move to extract the milk via a peristaltic action. So undulation of the tongue.

With a bottle, the mouth does not need to open as wide and the tongue does not need to move out to extract the milk, but instead stops the milk from running down the throat too fast.

With a pacifier the method of suck also can effect musculature changes and the pacifier is inherently a non-nutritive sucking action. So the baby will do it because they enjoy the action of sucking. Something they are also biologically conditioned to like. With pacifiers there is no reward for improved technique (as with breast and in some cases bottle feeding) and the sucking action does not train the tongue appropriately. In addition the baby may associate sucking with no reward and be less enthusiastic about trying their luck with sucking from the breast.  With normal breast feeding let down can take a short while to start, so a baby who is conditioned early to suck an artificial nutritive teat may lose patience with waiting for letdown to produce milk

Flow Preference:

Another factor in nipple confusion is flow preference. Bottles have different flows, slow to fast. Not all slow flows are created equal as well. Probably each bottle/teat type is slightly different. So if a bottle, which has a different sucking method required, produces a faster, more generous flow of milk, or conversely a slower and more manageable flow, then the infant may find that preferable.  There is evidence that bottle fed infants suck less frequently and in different patterns than breast fed infants. Flow from the breast changes over the duration of the feed and a bottle is constant.


The main factor in nipple confusion, however, is how good the latch is. The better the latch, the less likely the infant will experience nipple confusion. So babies with tongue ties or other oral abnormalities, or who have mothers with difficult nipples, will exhibit higher rates of nipple confusion signs. In addition to these conditions often producing issues with appropriate latch and milk extraction, often resulting in early bottle use, extracting food from the bottle is often easier for those without a normal range of oral movement.

Time sensitive:

Another factor to consider is that nipple confusion may not be immediate. I found when I needed to start combination feeding that while things were fine at first with supplementing by bottle, starting at 5 days with expressed milk and moving to formula by 2 weeks, by 4-6 weeks we had had some strong instances of breast refusal. This goes back to babies being tricky beasts. They start learning that if they fuss or refuse the breast that they can get some other potentially easier food. The most common ages for breast refusal due to nipple confusion or flow preference are  under 1 week, 2-3 weeks, 6 weeks, and 4-5 months. These coincide fairly consistently with growth spurts.

This is why it is recommended to not introduce bottles or artificial soothers before 4-6 weeks. By that age it’s assumed that the infant will have figured out milk extraction from the breast and will be less inclined to prefer the bottle over the breast. In addition, the mother’s milk supply will have begun to stabilize and a missed feed here or there under normal circumstances will not unduly affect supply. This guideline obviously errs well on the side of caution.


When you need or want to supplement with breast milk or formula and you want to minimize nipple confusion there are a few ways you can do this

  • The bottle latch: You’ll need a wide base bottle that encourages a wide opening of the mouth. Choose the slowest flow teat you can find to start with. Here is a  guide on choosing a teat. Purely by chance we used the Avent newborn flow. We used these until 12 months of age.
  • Finger, syringe, cup, and spoon feeding. Of these finger feeding may be the least pain in the ass. I’ve done both syringe and cup, as well as suck training with my finger and finger was by far the easiest. I’d imagine spoon feeding is similar to cup feeding in mechanism. This article sums up alternative feeding methods well. It says that cup is often not worth the hassle unless repeated supplementation is required more than 3 times. You can also use an at breast supplementer taped to your finger.
  • At breast supplementation: If you have a latching baby under 6 weeks this is the way to go. After 6 weeks if you have not yet experienced any latching issues or breast refusal you can try bottles. If you have been using bottles up until now and your child is not  yet at that grabby phase you can give this a go. Some babies are ok with it, some hate it. It’s just something to try.
Leave a comment


  1. Hi! I found your blog via the IGT facebook support group :). I have a question: I’ve had 3 babies, all of whom I could not nurse b/c of poor milk supply due to Tubular breasts. I’m pregnant with #4 and am planning on using the Lact-aid full-time. However, all 3 of my boys were in the NICU for anywhere from one week to six weeks. My prayer is that this little girl will not go to the NICU but, if she does, should I ask the nurses to maybe finger-feed with the supplementor when I’m not there? (I wonder if they’ll even do that.) I cannot physically be there around the clock- especially as I have 5 other children. I’m concerned that, if they bottle feed her in the NICU, we’ll miss out on our chance to supplement at the breast :(. What are your thoughts? Thanks!

    • Well take my opinion based on me never having had a NICU kid, but I think finger feeding through something like a sterile NG tube (you can buy them in packs from medical supply companies) might work well. I would be eager to make things easy and convenient for the nurses because in that situation likely a bottle is the easy and done thing and any deviation might be more than they can handle due to workload. So sterile NG tubes and sterile finger cots perhaps?

      That said I have found flow preference and texture preference (the preferences of what I think make up nipple confusion) to arise from stressful situations. I have found that both my kids started breast refusals during growth spurts, and for one after a tongue tie clip and the associated stretches. So they were either impatient, hungry, uncomfortable using their mouth or otherwise just fed up with the whole business of eating. Some things that I have found that combat this is if you are having difficulty latching don’t try for more than 10 minutes every hour. If you can’t get a latch after that time, feed them a bit however they will take it, and just try again later (this is for small babies under birth weight really, after 3-6 weeks once they are gaining I find you can be a bit more firm with them. It’s important to feed the baby, but after they are gaining well you can balance that with feeding method). Also, the bath trick (take baby into the bath with you and try latching there) is a good one to try.
      I always used slow flow nipples and practiced bottle latching when possible (also known as baby led bottle feeding).

      If you do end up having the nurses feed your baby bottles in the NICU just get your tube apparatus ready for any latching attempts. I think a lot of the systems can be helped along with a squeeze to increase milk flow, and I found, and have heard of mothers who needed to supplement at the breast in hospital, that the NG tube in a bottle method is easiest for tiny babies. Increased milk flow-if they can handle it, will make the breast more likeable to the previously bottle fed baby.

      Good luck.

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