The pain of an incorrect latch can be anywhere from uncomfortable to excruciating. Newborns come with the instinctual drive to suckle, but usually have to be guided to latch and feed correctly the first few weeks.

No mommy starts breastfeeding a new baby with the intention of sabotaging her own efforts, so parents are naturally concerned that introducing a bottle or pacifier too early could undermine their breastfeeding attempts.

You have probably been told that introducing artificial nipples within the first month of life can confuse a breastfed baby and cause them to latch improperly or refuse the breast altogether.

But is nipple confusion a legitimate concern backed by evidence and research, or a wives’ tale spread and perpetuated by well meaning practitioners?

In this post, you’ll learn:

  • The theories on nipple confusion and where this concern comes from;
  • Whether nipple confusion is serious according to academic research, and whether you need to worry about it;
  • Whether you should wait to introduce bottles and pacifiers based on the pros and cons;
  • How you can reduce the chances of nipple confusion;
  • What the best bottles are for breastfed babies to encourage proper latching techniques;
  • Eight Steps to Enjoy Breastfeeding in my FREE printable that will encourage you through even the toughest nursing sessions.

Just so you know, I incorporate affiliate links, from which I may receive a small commission at no extra cost to you, to help showcase products I personally own and love, as well as to illustrate certain points or product features.

Are We Confused About Nipple Confusion?

What is Nipple Confusion?

The Simple Version

The popular understanding of nipple confusion is the inability of a baby to correctly latch at breast with a nutritive suck after being exposed to an artificial nipple, such as a bottle or pacifier. Because the mechanics of extracting milk from Mother’s nipple are very different than the suck needed to drink from a bottle or hold onto a pacifier, a baby must learn to differentiate between real and fake, adjusting its methods accordingly. When it cannot or does not, we announce it has nipple confusion. This is a very simplified explanation that might not adequately explain what’s occurring.

A Better Explanation

We should distinguish between at least two types of nipple “confusion.”

  • Babies who genuinely become retrained to latch and suck in a way that only works with a rubber bottle nipple or pacifier, and are seemingly unable to latch correctly at breast; those who do not learn and apply sucking patterns for both breast and bottle.
  • Babies who develop a preference for the bottle because it is easier and quicker, not because they lack the ability to differentiate between the two; those who display distinct sucking patterns, but exhibit a clear preference for the bottle.

Thus, the latter occurrence does not work well as a definition for nipple confusion since these babies are not really confused–they know exactly what they want, it’s just not what we want them to want. Unfortunately, though, most people don’t separate out the preferential babies from the confused ones, making genuine nipple confusion seem to be more common than it actually is.

Is Nipple Confusion Serious?

Opinionated blog posts will tell you that it is. The World Health Organization will tell you that it is. Many medical practitioners will tell you that it is. But what will the actual research tell you?

The assumption behind nipple confusion is that infants cannot learn more than one pattern of sucking. For nipple confusion to be a legitimate concern, we need to see evidence that this assumption is true.

A study conducted in 2010 found that infants who received feedings by both breast and bottle (older than two weeks of age) did display different sucking patterns depending on the method of delivery. This finding would seem to refute the idea of nipple “confusion,” but not necessarily of nipple preference (Moral et al).

While we might apply the misnomer nipple “confusion,” the terminology is of little importance if the result is still the same: cessation of breastfeeding. The question then becomes…

Do artificial nipples undermine breastfeeding?

Many studies have been conducted on the early introduction of artificial nipples and the impact on breastfeeding, and many studies do show a negative association between the two. (As early “dummy” use rises, the likelihood of successful breastfeeding falls). Numerous studies conclude that introducing artificial nipples too early in a baby’s life make it more likely that breastfeeding attempts will fail, and babies will be prematurely weaned.

Because of this conclusion, the WHO strongly discourages parents from introducing bottles and pacifiers in the first month following a baby’s birth.

However, researchers are calling into question whether this correlation is actually causative, or perhaps just indicative of other underlying challenges in breastfeeding.

Some even speculate a “reverse causation,” where difficulties or failures to breastfeed lead to the increased use of bottles and pacifiers rather than the other way around (Thompson & Zimmerman, 2015).

Unfortunately, the vast majority of research is aimed at simply proving the link between artificial nipples and breastfeeding cessation, and little attention is devoted to finding the cause.

An older study from 1997 divided infants less than a week old into two randomized groups. One group was permitted the use of bottles, supplemental feedings, and pacifiers, while the other was strictly prohibited within the first five days of life. Both groups were encouraged to breastfeed. After day five, there was no difference between the groups in either breastfeeding frequency or duration. The same was true at two, four, and six months of age (Thompson & Zimmerman, 2015).

Bottle feeding vs. pacifier use: is one safer than the other?

To make nipple confusion more confusing, the World Health Organization and the American Academy of Pediatrics can’t seem to find a consensus. The WHO adamantly discourages both bottle and pacifier use until after a baby’s first month, but the AAP actually recommends using a pacifier to help reduce the risk of SIDS.

So which is it? Are we now forced to decide between successful breastfeeding and potential infant death? Thankfully, no. If nipple confusion or preference does occur, it’s not irreversible. It takes work to correct, but it is doable and there are resources to help you.

Pacifier use is still debated, but is less likely to contribute to nipple confusion than a bottle (since it is the ease of bottle feeding that may become preferential). A 2011 study conducted two trials on over 1300 newborns and did not find a significant impact on breastfeeding due to pacifier use.

However, an experiment in Oregon did seem to show an association between restricting pacifiers and exclusive breastfeeding. When pacifiers were wholly restricted, breastfeeding was less likely to be exclusive (Goldman, 2013). (Because breastfeeding is exhausting and we mamas need a break sometimes!)

In summary, more evidence points to the bottle as a greater potential interference with breastfeeding than do pacifiers.

What’s the verdict?

My personal opinion based on the research I have done is that nipple “confusion,” in the sense that babies can’t tell the difference between artificial nipples and the real deal, is largely a myth. There does seem to be an argument for babies developing a preference for the ease of bottle use, but I believe that in the majority of cases, this will be catalyzed by underlying breastfeeding difficulties.

Most babies love to nurse. They love the closeness and security, no matter how closely parents simulate the experience with bottle feeding, and studies show suckling at breast provides greater comfort and relaxation than the bottle.

Every parent needs to evaluate the research and come to their own conclusions on what they feel comfortable with. As part of your evaluation, consider the following pros and cons of waiting to introduce bottles and pacifiers.

Pros and Cons of Waiting to Introduce Bottles and Pacifiers

Our intent from the beginning was to breastfeed Carrots. I had seen a lot of hype about nipple confusion on the blog posts I read during my pregnancy, and the hospital made quite a big deal about it as well. They were adamant that breastfeeding mothers not introduce artificial nipples until after 3-4 weeks. So we waited. I think we used a bottle one single time in the first couple of days because Carrots was nursing around the clock and I was in so much pain that I just needed a break.

When our recommended wait time was up, we tried introducing both bottles and pacifiers, and…she would have nothing to do with them. She took personal offense that we would even offer. She was five months old before showing interest in a pacifier, or agreeing to accept a bottle. The next time around, I have no plans to wait 3-4 weeks.

Pro: Baby’s latch becomes routine and well practiced

If you’re comfortable waiting the recommended four weeks, and it doesn’t make much difference to you whether Baby readily takes a bottle or pacifier after that, then by all means, wait. The month will ensure that your breastfeeding is well practiced, and by then it should be second nature to both you and Baby. You won’t have to worry that you’re squelching a hunger cue with a pacifier because the correct answer to most cues will be nursing.

Con: Babies may decide they ONLY want the real deal

The primary downside to waiting is that your baby might refuse bottles and pacifiers altogether. It’s like eating rich, delicious milk chocolate your whole life and having someone occasionally substitute your fix with sugar-free dairy-free nonsense. You would not take kindly to such a substitution. If you’re planning to return to work and it’s imperative that Baby accept a bottle and pacifier, you may decide the risks of waiting outweigh the benefits. From my personal experience, I have seen far more women struggle with bottle refusal than breast refusal.

Pro: Parents can more introduce bottles and pacifiers with more confidence

Waiting will take away much of the guessing game. By the end of a month, you should have a pretty good idea if you’re facing any underlying challenges with breastfeeding and not have to wonder whether they’re caused by artificial nipples. At the end of a month, you can bring bottles and pacifiers into your day without as much worry that doing so will mask other problems.

Con: More work may be required to get Baby to accept artificial nipples

If you decide waiting is better than having to retrain a baby to latch at breast, you might instead be choosing to train Baby to accept artificial nipples. Is one more difficult than the other? The answer will vary from child to child. It can be done, but it may require purchasing multiple different types of baby bottles and working through different resources until you find a bottle/method combo that works.

Pro: More intimate bonding time for Mom and Baby

Waiting means that both Mom and Baby are in it to win it. There’s no bottle or pacifier to fall back on. They have to work together to learn to succeed at breastfeeding, and the process will provide an immense amount of bonding time for the pair, especially if you nurse on demand (which I highly, highly recommend).

Con: Less opportunity for Dad to bond/Fewer breaks for Mom

On the flip side, waiting to introduce bottles means fewer opportunities for Dad to give Mom a break and have this bonding with Baby himself in the first month. Obviously, parents can bond with babies in many ways, not just through feeding, but there is something uniquely special about feeding.

Reducing the Risk of Nipple Confusion

Like I mentioned in the last section, I do not plan to restrict bottles and pacifiers for a full month again. I believe the next time around, I can introduce them sooner with more confidence because I’ve breastfed before; I know what to expect as far as how it should feel and what a baby’s cues look like. If you feel comfortable introducing artificial nipples within the first month, here are my tips for avoiding both nipple confusion and nipple preference.

Use artificial nipples infrequently during the first month

My biggest concern, personally, is not that my infant will prefer bottle to breast, but rather than an artificial nipple, especially a pacifier, may mask breastfeeding challenges by improperly squelching cues. In addition, if a Mom’s milk supply is low for some reason, Baby may learn to prefer a bottle because it’s the only way to get full.

As an example, a baby with an undiagnosed tongue or lip tie may not be able to extract milk as efficiently or effectively, and thus be hungry more often. The frequent cues to nurse may be misunderstood as fussiness and be answered with a pacifier, when actually Baby was hungry.

For those reasons, my plan would be to introduce pacifiers and bottles, but use them sparingly.

Seek help for breastfeeding challenges early on

If you have any inkling of concern that something is off in your breastfeeding endeavors, see a lactation consultant and discuss it with your pediatrician as well. Don’t be afraid to question multiple sources.

I wish I had seen a lactation specialist from the start. I was experiencing excruciating pain (like, worse than labor, no joke) learning to nurse, but I though I was just sensitive. Seven months later, I’m realizing that my baby has an upper lip tie that might have been causing all or most of our difficulties. No one caught it at the hospital when she was born, and neither pediatrician we saw afterwards checked.

Fully investigating any suspicion of tongue/lip ties

I had read plenty of blog posts and articles on tongue and lip ties while I was pregnant, but they were quite shallow and presented symptoms in a very WebMD sort of way with only cherry-picked issues and minimal details. Because of this, I though Carrots didn’t have any tongue or lip ties.

I should have sought help with the amount of pain I was in and the frequency with which Carrots fed. I was so tempted to quit because the pain was almost more than I could endure. It was little wonder to me that so many women do abandon breastfeeding.

Breastfeed on-demand

Breastfeeding on-demand will be the best way to both cement your baby’s latch and sucking patterns, and quickly identify any abnormalities in frequency, duration, or otherwise. It also secures the bond between Mom and Baby to vastly reduce the risk of bottle preference.

Choose a bottle specifically designed to encourage proper latch and sucking mechanics

A lot of bottles are designed to just get the job done. They have a continual drip, rather than requiring Baby to suck for nutrients; the nipples are shaped in such a way that babies only have to suck with their lips; and the shape of the mouth is positioned differently than when they breastfeed. See the next section for a few examples of bottles for breastfed babies.

Best Bottles for Breastfed Babies

Full disclosure: I do not own any of these bottles. I have not tested them myself. I am including them because they fit the recommended size and shape to encourage the best latch for breastfed babies, and I have seen them highly recommended by other breastfeeding moms. Certainly, research them more before purchasing; I am presenting them as a starting point to streamline your research.

Nanobebe

  • The most innovative design I’ve come across.
  • Shape and feel are intended to mimic the breast and encourage a proper latch.
  • Stackable.
  • The concave bottom keeps milk fresh longer by cooling it faster; warms more quickly when heated back up.

Mimijumi

  • The no-flow nipple is a great option to prevent bottle preference (over breast) since it most closely mimics nursing experience.
  • Looks like a boob–made to have a natural texture and appearance.
  • Company claims it can be opened and closed with one hand.

Tommee Tippee

  • Breast-like nipple for natural latch.
  • Straw changes color if liquid is too hot.
  • Anti-colic ventilating system.
  • May be more difficult/time consuming to clean because of the straw.

Dr. Brown’s

  • Unique ventilation system to prevent milk oxidation as well as air ingestion.
  • Contoured for proper latch.
  • Glass bottles warm more easily and are safer to use than plastic.
  • May be more difficult/time consuming to clean because of the straw.

Munchkin Latch

  • Marketed as having a stretchy nipple, which is more true to life than a stiff nipple.
  • Stretches, pumps, and moves, as opposed to providing continual drip.
  • Reduces colic by preventing air bubbles from traveling through milk.

Comotomo

  • Specifically designed to prevent both nipple confusion and bottle rejection.
  • Squeezable to mimic soft skin.
  • Very highly rated on Amazon.com.

Free Printable

If you’re reading this post, chances are you’re interested in breastfeeding! I’ve created this special printable to hang at your nursing station. Learning to breastfeed is hard. This printable contains the little things that motivated me to push through the worst pain of my life.

A Final Note

Nipple confusion or preference is a legitimate concern for parents who are committed to breastfeeding, but our confusion with what’s really going on skews the statistics and may be masking the real issues. In my opinion, nipple confusion gets more hype than it deserves. It seems to me the greater concern should be whether bottles and pacifiers are being used because of breastfeeding challenges.

As always, give heed to your instincts and consider what approach you feel most comfortable and confident with. Every family is different, and every child is different. No one knows your baby like you do, and no one should make the decision for you.

If you’re a new mama, what are your goals for feeding your baby? Have your plans changed at all after reading this post? If you’ve been momming a while, what has your experience been with bottles and pacifiers? Share in the comments below!

Sources:

Goldman, R. (2013). Pacifier use in the first month of life. Child Health Update. Retrieved from
http://www.cfp.ca/content/cfp/59/5/499.full.pdf

Moral, A., Bolibar, I., Seguranyes, G., Ustrell, J.M., Sebastiá, G., Martínez-Barba, C., & Ríos, J. (2010). Mechanics of sucking: Comparison between bottle feeding and breastfeeding. BMC Pediatrics. Retrieved from
https://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-10-6

Thompson, K., & Zimmerman, E. (2015). Clarifying nipple confusion. Journal of Perinatology. Retrieved from http://nuweb9.neu.edu/snl/wp-content/uploads/2016/03/Clarifying-Nipple-Confusion.pdf

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