From the Guidelines
Nipple confusion is a minimal concern for newborns when supplemental feeding with formula is necessary, and its risk can be mitigated with proper techniques. When considering the likelihood of nipple confusion in newborns, it's essential to weigh the benefits and risks of supplemental feeding. According to the most recent and highest quality study, the risk of nipple confusion can be managed effectively with paced bottle feeding techniques and regular breastfeeding sessions 1.
Key Considerations
- Introduce bottles after breastfeeding is well-established (usually around 3-4 weeks)
- Use slow-flow nipples on bottles
- Practice paced bottle feeding: hold the baby upright, keep the bottle horizontal, and allow pauses
- Limit bottle use to necessary supplementation only
- Continue to offer the breast frequently, at least 8-12 times per day
Additional Information
- Consider using alternative feeding methods like cup feeding, syringe feeding, or finger feeding for short-term supplementation
- If possible, have the non-breastfeeding parent or caregiver offer the bottle
- Skin-to-skin contact during breastfeeding can help reinforce the breastfeeding relationship The study from 2025 1 provides strong evidence that breastfeeding can be successful even in cases where supplemental feeding is necessary, and that nipple confusion is not a significant concern with proper management. In contrast, the 2005 study 1 highlights the importance of using expressed maternal milk or pasteurized donor human milk for supplementation when possible, but does not provide direct evidence on nipple confusion. Therefore, paced bottle feeding techniques and regular breastfeeding sessions are recommended to minimize the risk of nipple confusion.
From the Research
Nipple Confusion in Newborns
- Nipple confusion refers to an infant's difficulty in achieving the correct oral configuration, latching technique, and suckling pattern necessary for successful breast-feeding after bottle feeding or other exposure to an artificial nipple 2.
- Many early breast-feeding failures are attributed to nipple confusion, although scientific data are lacking to document its prevalence, the mechanisms involved, or various factors that predispose an infant to this phenomenon 2.
Supplemental Feeding Methods
- Cup feeding is becoming increasingly popular as a means of offering supplemental feeds in an attempt to improve breastfeeding rates 3, 4.
- However, cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in hospital 3.
- The use of a supplemental feeding tube device (SFTD) may be useful as a supplementation method for breastfed infants, but high-quality research is needed to evaluate the efficacy of using an SFTD for supporting exclusive and all breastfeeding rates 5.
Practices Regarding Supplemental Feeding Methods
- There is no standard method of supplementation among International Board Certified Lactation Consultants (IBCLC) 6.
- The majority of IBCLCs believed that the SFTD best preserves the breastfeeding relationship, and this was their preferred method of supplementation, but the bottle was ranked as the number one method used in the United States, Australia, and Canada 6.
- Supplementation by alternative feeding methods might help preserve the breastfeeding relationship and help reach the World Health Organization's goal of increasing exclusive breastfeeding rates 6.
Likelihood of Nipple Confusion
- The likelihood of nipple confusion in newborns when supplemental feeding with formula is necessary is not directly addressed in the provided studies, but it is suggested that minimizing the use of bottle feedings and using alternative methods such as cup, spoon, or dropper feeding may help reduce the risk of nipple confusion 2.