Older Baby

Avoiding Nipple Confusion


Breastfeeding with Nipple Confusion

By Barbara Wilson Clay, BSEd, IBCLC

Experts agree that it is best to wait several weeks before offering bottles to the breastfed baby. Because breastfeeding is learned behavior, most babies do better mastering one thing at a time. Normal, term infants generally get plenty of milk directly from mother’s breast. Besides, pumping and bottle-feeding create unnecessary, extra work for the mother as she recovers from childbirth.

Occasionally a baby will have difficulty breastfeeding normally. The reasons for this may include:

• The infant is small, or born before the due date
• A difficult or complicated birth
• The infant or mother is ill, or recovering from illness
• Structural abnormality of the baby’s face or mouth
• Structural abnormality of the breast or nipple

When poorly feeding infants are offered a bottle, they then may appear to reject the breast. This is not nipple confusion, but an indication that the infant needs help to breastfeed successfully. In these cases, the baby’s refusal to breastfeed stems from inability rather than preference.

The term nipple confusion most appropriately refers to an otherwise normal infant who has had too many bottles before breastfeeding has been well established.

Sometimes nipple confusion occurs in an older baby, previously nursing well, whose mother has returned to work or school. If the mother’s milk supply is low due to lack of stimulation during separations, the baby may begin to prefer the quick, easy flow of the bottle. The key to reversing this situation is to re-stimulate the mother’s milk supply. Mothers also can gently re-focus on the breastfeeding relationship by nursing more often when at home with the baby and cutting back on the number of optional bottles.

Another type of nipple confusion refers to a baby who refuses to accept a bottle! Breastfed babies love to breastfeed. In such situations, offer the bottle in a low-key manner. Keep practice sessions playful. Reassure the baby often, and stop whenever baby seems stressed. By continuing to offer tastes from the bottle, baby will soon get the idea. Some babies will not accept a bottle from the mother, but will accept a bottle from a father or a babysitter.

Some older babies prefer to drink pumped milk from a cup, or mixed with solids from a spoon. They may never need to use a bottle.

Pointers: If Your Baby Seems Nipple Confused:

• Seek local help via the Breastfeeding National Network (BNN), call 1 800 TELL YOU, ILCA, LLLI, or consult Medela’s Ask an LC .
• Increase skin-to-skin contact to calm baby
• Use of a nipple shield can help coax these infants back to the breast.
• Use of a feeding tube device such as the SNS can provide an increased milk flow allowing supplementation at breast
• Protect breast milk supply by increased breastfeeding/pumping


1. Hill, P, Humenick, S, Brennan,M, et al: Does early supplementation affect long-term breastfeeding? Clin Pediatr 1997, 36:345-9.

2. Chapman, D and Perez-Escamilla: Identification of risk factors for delayed onset of lactation, J Am Diet Assoc 1999, 99(4):450-54.

3. Chen,D. Nommsen-Rivers,L. Dewey,K. Lonnerdal,B: Stress during labor and delivery and early lactation performance, Am J Clin Nutr 1998, 68:335-45

4. Cronenwett,L: Single daily bottle use in the early weeks postpartum and breastfeeding outcome, Pediatrics 1992, 90:760-66.

5. Neifert,M. Lawrence,R. Seacat,J: Nipple Confusion: Toward a Formal Definition, J Peds 1995, 12(6):125-129.