Nipple confusion. While many moms who are going back to work trying to get their babies to take their milk from a bottle, many of them are also frustrated when the baby refuses to take one. Their baby turns away, arches her back, pushes the bottle nipple from her mouth, chokes, gags, and becomes extremely fussy. Or the baby was doing struggling at the breast, started taking a bottle well, and now no longer wants anything to do with the breast. These are all symptoms that mothers a tribute to “nipple confusion”. As a speech therapist, this term has always bothered me. In my mind confusion means a mood or emotional mental status. Like, I was confused at the directions. I was confused as to where I was. I was confused as to why he behaved that way. Babies are born, natural feeders, they literally come out of the womb wanting to suck. I would like to rewrite the term nipple confusion instead with flow confusion. Babies are not confused about where their milk is coming from, but how it is coming out. The flow from a breast and a bottle are very different. At the breast when a baby is first placed at the nipple, the baby sucks in a very quick, rhythmical suckling pattern. This stimulates milk flow. After several minutes of this quick, high paced suckling, the mother experiences let down. This is a very fast flowing time in the milk phase. During let down the baby’s sucking rate changes to a slow and rhythmical pattern. After several minutes of this, the baby goes back to that high suckling phase. That is because the mothers milk flow has decreased. The baby then stimulates another let down to occur by changing her rate of sucking. A typical mother can experience anywhere from 2 to 4 let downs during a typical feeding. Bottle nipples, however, do not work on a demand-supply basis. As soon as that bottle nipple is placed in the baby’s mouth, it begins to flow. The baby does not even necessarily need to suck if the hole in the tip of the nipple is large enough. The baby could munch mash on the nipple or even just let it flow into her mouth. It takes much. Less work but much more coordination to drink from a bottle nipple. The baby needs to be able to coordinate her sucking, swallowing, and breathing any typical rhythmical pattern.

Differences in the way a baby sucks on the breast vs. a bottle

• To latch to the breast, baby must open his mouth widely. A baby does not need to open wide to suck on a bottle.
• When sucking on the breast, baby’s tongue makes a wave-like motion; it begins at the tip of the tongue and moves toward the back. The tongue compresses the breast against the roof of the mouth. A bottle fed baby uses his tongue differently and may lift the back of his tongue to stop the flow of milk and protect his airway.
• If a breastfed baby needs a rest, he simply quits sucking and the milk flow slows. Milk may flow from a bottle even when baby is not sucking, forcing baby to continue feeding without a break.
• To breastfeed, the baby needs to take the nipple far back into the mouth to the soft palate and then uses her tongue to compress out the milk (which can take a minute or so before it starts flowing). With a tilted bottle, a baby has gravity on her side: She can suck with her lips and get all the milk she wants right away.
• Babies aren’t confused about what nipples are for, but they may prefer getting milk faster without having to work as hard or be unable to control the flow and become overwhelmed and shut down.

The truth is, most babies have no problem switching from breast to bottle and back again. Others, specifically those who take a little longer perfecting the art of suckling at the breast, can have trouble transition from breast to bottle — and then back to breast. These babies often have difficulty coordinating the intricate act of sucking, swallowing and breathing. Since we don’t know which babies will do well and which will struggle, most experts agree that you should wait until your newborn has established good breastfeeding habits, usually around three weeks of age and after the two week growth spurt, before offering the bottle. If you’re still struggling with breastfeeding at three weeks and it’s still your goal, hold off on the bottle a little bit longer.

At the NICU where I work, if we have a mom who plans in breastfeeding, we will always use a slow flow nipple. It most closely resembles the flow at the breast to make the transition back and forth easier. We also use various positioning and pacing techniques to help babies get the hang of coordinating their sucking, swallowing, and breathing. A slow flow nipple is always best to start with if you plan to continue breastfeeding