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Is Nipple Confusion a Myth?

With the exception of having to wear downright scary-looking nursing bras, I was thrilled that my experience breastfeeding my now 18-month-old daughter, Amelia, was a snap: She latched on easily an hour after birth, and my milk came in by the gallons about three days later.

Still, when I was ready for Amelia to try her first bottle at 2 1/2 weeks old, I was apprehensive  -- would giving her an artificial nipple cause her tiny head to spin and forget how to nurse? Would she become, to put it in lactation terms, "nipple confused"? In the months before birth, I'd been barraged with breastfeeding materials, and nipple confusion was one of those triple-starred subjects: Don't give your baby a bottle in the first two months, or she'll reject the breast.

As popular parenting advice dictates, I left the house while my mother gave Amelia her first bottle of pumped milk. Strolling around my neighborhood, I was frantic: What if she wouldn't take it? That would be awful, since I was craving a night out with my husband  -- not to mention, in a few months, I'd be going back to work. But what if she took it, then decided my breasts were less than adequate?

As I walked in the door, my mom reported Amelia emptied the bottle, no problem. "And it seems like she's still hungry," she said. So I put her on my breast and  -- what a smart, smart baby!  -- she nursed voraciously for another ten minutes. As she filled her belly, my head filled with all the luxuries I would be allowed, like a solo run to the grocery store, now that my intelligent infant could switch-hit between the bottle and my breast.

Dimity McDowell is a freelance writer based in Santa Fe, New Mexico.

What's the confusion?

My experience wasn't as singular as breastfeeding lore would have you believe. The decades-old term "nipple confusion" has been used to describe the threat that a breastfeeding baby who is offered a bottle too early will stop nursing because he prefers the bottle. In theory, the thinking seems sound: When nursing, a baby draws the nipple far back into his mouth and pumps milk out with his tongue. When taking a bottle, gravity lends a hand, so mouth position and tongue action aren't as vital. Simply put, drinking from a bottle is less work. Because of this, it's assumed that infants will find it hard to switch between the two.


But the reality is that most infants are much savvier than we give them credit for, especially when it comes to something as vital as nutrition. Anecdotally, plenty of moms and pediatricians will tell you that their babies can switch-hit fairly easily. In fact, a Babytalk poll found that 82 percent of breastfeeding babies were also able to drink from a bottle.

Infants who prefer the bottle to the breast probably aren't nursing well to begin with, says Marianne Neifert, M.D., a pediatrician based in Denver, Colorado, and the author of Dr. Mom's Guide to Breastfeeding. "These babies most likely aren't getting what they need from nursing: There may be a problem with latch-on or the mother's milk supply." Dr. Neifert suggests that the term "nipple preference" might be more accurate than "nipple confusion."

Still, like other seemingly sound, but ultimately unproven, parenting theories, nipple confusion continues to thrive in the minds of new parents. Over the years, the concept has gained such momentum that mothers who need to work, would love to go to a yoga class, or want to sleep for more than three hours at a stretch are terrified of giving their happily nursing child a bottle for fear she will never nurse again. The situation has become, to put it mildly, overblown. "People have become absolutely panicked about it," says Dr. Neifert.

The expert opinion

Panicked without much justification, it turns out. Because so many factors go into successful breastfeeding, such as the infant's muscle mechanics and the mother's anatomy to name just two, identifying nipple confusion is a difficult task and only a handful of scientific studies are relevant.

A comprehensive paper, published in Newborn and Infant Nursing Reviews, examined all previous research and declared that the jury is still out whether the phenomenon of nipple confusion even exists. The authors advised health care providers to take "a more moderate position" on bottle-feeding a breastfed infant.

A recent study that looked at bottles and pacifiers -- another supposed "nipple-confusing" item that parents are told to avoid -- found that neither caused "early breastfeeding problems." What the study did find: Early bottles and pacifiers may shorten the overall length of time that a woman ends up breastfeeding, though it's not clear why. "The exact reason women stop breastfeeding sooner isn't known," says Dr. Neifert. "Women who are using bottles and pacifiers may be having trouble nursing already or may have a lower motivation to continue it." On the flip side, she adds, the flexibility of pumping and bottle-feeding can allow working moms to continue breastfeeding longer than they would have otherwise.

The breast advice

Of course, introducing a bottle will be different with every baby: Some will instantly accept it, others may be fussy, but most can learn to switch between breast and bottle. Here are some tips to ease the transition.

  • Wait until nursing is well established, usually when a baby is two- to three-weeks old, before introducing a bottle. (Ideally, the same goes for a pacifier.) "You need to wait until breastfeeding is easy for both Mom and her baby," says Alan Greene, M.D., a pediatrician at Stanford University in Palo Alto, California, and author of From First Kicks to First Steps. "By two to three weeks, neither will want to give up nursing; and it's before the big crying period, usually at four to six weeks, when introducing a bottle might be harder."
  • Let someone else give the bottle, because your baby associates you (and your smell) with breastfeeding.
  • Give expressed breast milk in the first bottle, if possible, since your baby is familiar with its smell and taste. If you use formula, remember that breast milk follows the law of supply and demand. Keep pumping if you want to maintain your supply.
  • Choose the right time. Don't wait until your baby is starving before offering her a bottle for the first time  -- aim for an hour or two after her last feeding.
  • Try skin contact. If Dad is feeding, your baby may find it comforting to rest her head on his bare chest.
  • Stay calm. Your baby can pick up on parental anxiety, so try to stay positive. "Don't force the bottle on your baby; try to give the impression that drinking from one is a pleasant experience," says Barbara Wilson-Clay, a lactation consultant in Austin, Texas. "If she only wants to take a few sips the first time, that's fine."
  • Get help. If you find that your baby begins to prefer the bottle to the breast, seek help immediately from an understanding lactation consultant. "Your baby may be rejecting your breast because she's not getting what she needs from it and is hungry," says Wilson-Clay. Again, be sure to keep pumping to maintain your supply.
  • Don't fret over your preemie's bottle. If a premature baby isn't able to nurse  -- the sucking mechanism might not be fully developed  -- he may end up being fed from a tube or bottle first. But this hardly means he'll never breastfeed, says Wilson-Clay. "Once premature babies reach their due date, they often turn into different babies. Just because all they've known is bottles doesn't mean it's all they'll ever know."

I smile now when I think of my walk around the neighborhood as Amelia drank her first bottle. I had sweaty palms and a heavy, guilty heart. It didn't take me long, however, to realize I wasn't compromising her health or our relationship; in fact, bottle-feeding gave her a chance to become even closer to her dad. The next day, he fed her a bottle, and the following day she took one from me  -- and finished it like a pro. What a smart, smart baby.

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