SingaporeMotherhood | Baby & Toddler

September 2011

Clearing the air on Nipple Confusion

Taken out of breastfeeding context, the words ‘nipple confusion’ can be confusing indeed. Then again, you’d probably not hear them outside of baby and breastfeeding conversations, would you?

Simply put, nipple confusion happens when a baby has problems latching on and breastfeeding after he has been bottle-fed. He may get frustrated by the difficulties and eventually refuse the breast totally.

The mechanics of breastfeeding and bottle feeding may appear similar: nipple goes into baby’s mouth, baby sucks. But if you could see through a baby’s cheek and watch how his tongue, jaw, and mouth operate, you’d understand that both are clearly different.



Baby opens his mouth wide and takes in the nipple and as much of the areola as possible as he latches onto the breast. His lips turn outwards and form a tight seal over the breast. He coordinates his tongue and jaw movements in a sucking motion to draw milk from the breast. You can’t see this part, but his tongue extends over the lower gum line and cups the nipple and areola area, massaging the underside of the breasts as he suckles from the breast. You can see his jaw working, and his ears wriggling. He may pause to rest and then continue to suckle.

Bottle feeding

Baby does not need to open his mouth wide. His lips do not turn outward to form a tight seal over the rubber or silicone nipple. His tongue does not stretch over the lower gum. Milk flows from the teat without baby having to move his tongue and jaw to ‘milk’ it. In fact, he will thrust his tongue forward and upward at the teat to stop the milk flow when it is coming out too fast. Usually, baby can drink non-stop, not requiring any rest pauses as the milk just keeps coming.

Cynthia Pang, a senior lactation consultant at KK Women’s and Children’s Hospital, counsels about two cases of nipple confusion a month. Still, she reckons that “there may be more cases that do not seek help but continue bottle-feeding with expressed breast milk.”

She recalls a mother of three who had no problem introducing bottle-feds to her first and second children, but encountered difficulties with her third. This baby refused to latch onto the breast after receiving feeds from a bottle.

In another case, an exclusively breastfed baby who was being bottle fed in the night by his grandmother (who did not want to wake the exhausted mother to nurse her baby during the night) refused the breast the very next day.

“There were no structural or technical issues in both of these cases. Both mothers’ milk supplies were established and their babies were able to latch on well initially before they were exposed to the bottle. But in both cases, exposure to the bottle was short and it took only about a week before the babies were able to fully breastfeed again,” she assures.

What are the signs that baby has nipple confusion?

Typically, the baby is able to latch, but refuses to suckle and may cry or scream upon latching.

What are the best ways to prevent nipple confusion?

Avoid giving breastfed babies artificial nipples during the first three to four weeks when they are learning to master breastfeeding. If supplementary feeding is needed, try cup-feeding or spoon-feeding instead of a bottle. It is easier to prevent nipple confusion than to fix it.

Can a bottle-fed baby learn to feed from the breast?

It depends on the baby’s temperament and mother’s patience and perseverance in getting baby back to the breast.

How can nipple confusion be solved?

The mother will need to gradually coax her baby back to the breast.

• If supplements are needed, alternative feeding methods such as cup or spoon feeding should be used instead of the bottle.

• Stop the use of pacifiers.

• Ensure that the latch-on technique is correct. Modified cradle and football holds may be used to get a better latch.

• Use skin-to-skin contact to help baby reconnect with the closeness and pleasures of breastfeeding. You can do this by placing baby on your bare chest.

• Seize opportunities to breastfeed when baby is calm and willing. Do not wait until he is hungry and crying. He will not be in the mood to try and adapt back to the breast then!

• Pump regularly to ensure that your milk supply is maintained. A breast with good milk supply will be more gratifying to the baby when mother attempts to latch the baby to the breast.

• Use breast compression while feeding to help provide baby with instant milky gratification. This will also encourage baby to stay latched on and to continue sucking longer at the breast.

• Be patient and keep trying. Coax, but avoid forcing. Praise baby for every tiny step he makes on his journey back to breastfeeding. It may take a few days to a couple of weeks before you win your baby back to the breast.


Back to the Breast: Overcoming nipple confusion

Celine Low, 34, analyst and mum to Cedric, 3, and Clement, 1

“Before Cedric’s birth, I was adamant that I would exclusively breastfeed him. His first latch after a 14-hour labour was very short; 10 minutes on each breast.

My mother-in-law, who wanted me to ‘rest’, gave him a bottle of formula twice a night on days three and four. She was also concerned that there was not enough breast milk. There were two feeds per night, so he had four bottle feeds altogether.

On day five, he refused the breast. He did not even want to latch on. His paediatrician taught me how to syringe feed: insert finger into baby’s mouth, and only release the milk from the syringe (beside the finger) if he suckles. I was traumatised.

I knew it was nipple confusion when Cedric refused to take to the breast on day five, and I riled at my mother-in-law – within the limits of respect and propriety of course! After two weeks of exclusive syringe feeds, I tried to latch him on again. He still couldn’t, so I called a lactation consultant for help.

She identified that he had a latch position problem. His tongue was stuck to the roof of his mouth every time he tried to latch on. She taught me to run my finger along his lower gum to get him to automatically lower his tongue, before immediately putting him onto the breast. It took a lot of tries (and much heartache) to get it correct.

Cedric was syringe-fed and latched as described above until he was about two months old. By then, he had re-learned how to latch, thank goodness. He had to be bottle fed after three months when I went back to work but I continued to latch him on in the evenings and during weekends. He was 100 per cent breastfed until he was six months old, and supplemented until he was 14 months old.”

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Clearing the air on Nipple Confusion