RESEARCH AND EDUCATION
Nipple confusion in neonates
By Kelda Hargreaves and Anna Harris
T
he Infant Feeding Survey 2005 found that in the
UK the rate of exclusive breastfeeding at one week
was 45%. By six weeks the percentage of mothers
exclusively breastfeeding had fallen to 21% and at six months
the figure was negligible (Bolling et al, 2007). The World
Health Organization (WHO) and UK government recom-
mend exclusive breastfeeding for all infants until the age of six
months (WHO, 2003; Department of Health (DH), 2004).
The UK figures fall far short of this, including in England,
where a key element of the government’s Maternity Matters
initiative is to increase breastfeeding rates (DH, 2007).
To improve breastfeeding rates the WHO and the United
Nations Children’s Fund (UNICEF) propose ten steps to
successful breastfeeding (Box 1), an ethos that underpins the
baby friendly hospital initiative (BFHI), and a seven point
plan for the promotion, protection and support of breast-
feeding in community health care settings (Box 2). Step 9 of
the ten steps states that health professionals should: ‘give no
artificial teats or dummies to breastfeeding infants’, and if
supplements are indicated on medical grounds they should be
given by cup or syringe (WHO, 1998: 74). This is supported
by point 5 of the seven point plan which encourages exclu-
sive breastfeeding. Midwives play a significant role in public
health promotion through support of exclusive breastfeeding
(Simmons, 2003).
The rationale behind avoiding teats is the phenomenon
of nipple confusion, whereby an infant offered an artificial
teat develops a preference for this and is unwilling to return
to the breast (Neifert et al, 1995). This suggests the baby
is unable to adapt suckling to different feeding conditions,
for example, between free flowing milk from a bottle and
milk from the breast which requires more effort to with-
draw. However, anecdotal reports from local women in
Norwich indicate that they commonly offer some supple-
mentary bottles of expressed breastmilk (EBM) during the
establishment and continuation of successful breastfeeding
and some choose to offer some formula milk by bottle in
addition to breastfeeding. This is contrary to the advice
given by midwives whose trusts’ breastfeeding guidelines
are based on the WHO/UNICEF ten steps. The anecdo-
tal evidence therefore indicates that some breastfeeding
women wish to offer alternative feeds in addition to the
breast. This highlights a need to identify a way of support-
ing them which meets these wishes while continuing to
promote breastfeeding.
The primary aim of this article is to review the evidence
to establish whether nipple confusion is a proven phenom-
enon in healthy term newborns offered supplementary feeds
of EBM by bottle, during and following the establishment
BRITISH JOURNAL OF MIDWIFERY, FEBRUARY 2009, VOL 17, NO 2
Abstract
Breastfeeding is influenced by social factors, some of which
motivate women to seek additional feeding solutions, including
feeding formula milk or expressed breastmilk (EBM) by bottle.
Anecdotal evidence indicates that some women offer bottles
of EBM during and after the establishment of breastfeeding
and continue to breastfeed successfully. The World Health
Organization (WHO) recommends that breastfed infants
should not be offered artificial teats during the establishment
of breastfeeding. This is due to concerns regarding nipple
confusion.
This article confirms that the evidence supporting nipple
confusion is inconclusive and that other issues such as
supplementation with formula milk can lead to problems
labelled as nipple confusion. Breastfeeding advice advocated by
WHO may not meet the needs of all breastfeeding women and
prescriptive advice from health care professionals may lead to
early cessation of breastfeeding which is avoidable. Midwives
should be flexible in their approach to breastfeeding and take
women’s individual needs into account.
of breastfeeding. Secondly it will explore the value of cup
supplementation as a means to avoid nipple confusion, and
the impact on breastfeeding of feeding supplementary EBM
or formula milk. It will also clarify why some breastfeeding
mothers want to offer some feeds by bottle and suggests a
way forward for breastfeeding advice that meets women’s
individual needs.
Nipple confusion – the evidence
The term nipple confusion is used to describe a number of
phenomena where babies have difficulties with breastfeeding
after being offered artificial teats, whether pacifiers (dum-
mies) or bottle teats (Riordan, 2005). Neifert and colleagues
(1995: S125) define two types of nipple confusion: Type A:
‘the interference of artificial nipples with the successful initia-
tion of breastfeeding’ is the focus of this discussion as this is
most relevant to the midwife’s early postnatal advice regarding
feeding. Renfrew and colleagues (2000) refer to the midwife’s
fear of nipple confusion, which is significant despite little
Kelda Hargreaves is Midwife, Norfolk and Norwich University
Hospital; Anna Harris is Midwifery Lecturer, University of East
Anglia, Norwich
Email: kelda.hargreaves@nnuh.nhs.uk
97

evidence that fully identifies the existence of the condition.
The evidence that exists does however shape the baby friendly
hospital initiative ten steps to successful breastfeeding Step 9,
which states artificial teats or pacifiers should not be given to
breastfed babies during the establishment of breastfeeding,
and Point 5 of the seven point plan, which emphasizes exclu-
sive breastfeeding.
Hedberg-Nyqvist and Ewald (1997) studied the impact
that bottle-feeds, given post delivery to term babies separated
from their mothers, had on breastfeeding duration. They
found that early bottle-feeding was more likely to result in
continued mixed feeding or no breastfeeding at all at two
months postpartum. However when considering that the
separation of the babies from their mothers may have contrib-
uted to the lack of breastfeeding success, no significant differ-
ence was found between breastfeeding duration for bottle-fed
babies and those that were not.
Righard (1998) noted that of 52 babies referred with
breastfeeding problems, those already introduced to bottle
feeding were less likely to continue breastfeeding. The author
suggested that this may be because they had developed an
incorrect piston-like sucking technique. However sucking
technique is not the sole physiological requirement for effec-
tive breastfeeding (Walshaw and Owens, 2007). Tongue and
jaw activity, as well as negative pressure and milk ejection,
are all necessary for successful milk expression, although
the extent of their significance and the difference between
bottle and breast suckling methods are still not absolutely
clear (Riordan, 2005; Atkinson, 2007; Jacobs et al, 2007).
It would be inaccurate to draw conclusions regarding nipple
confusion from Righard’s (1998) work because the sample
babies already had breastfeeding problems, not necessarily
caused by bottle use.
Two studies have examined the relationship between
pre-term babies breastfeeding following supplementation
by bottle, cup or nasogastric tube, and found that those
exposed to bottles were less likely to breastfeed (Collins
et al, 2004; Kliethermes et al, 1999). However it is inap-
propriate to relate these findings to term babies because
the suck-swallow-breathe pattern which babies must coor-
dinate in order to feed orally without oxygen desaturation
becomes more organized as they mature (Gewolb et al,
2001). Term babies may therefore be able to comfortably
make the transition from breast to bottle and vice versa
without physiological compromise.
Pincombe and colleagues (2006) investigated the applica-
tion of the BFHI ten steps to successful breastfeeding and
found that Step 9 appears to contribute to a higher breast-
feeding rate. The results indicated that babies given a bottle
in the hospital were at greater risk of weaning. However
when adjusted for other factors that could affect weaning,
including method of delivery, the results were not significant.
Additionally, the results do not allow for the fact that the
mothers giving bottles may be doing so as a result of existing
breastfeeding problems, for which bottle-feeding may not
have been the initial trigger.
Schubiger and colleagues (1997) compared the breastfeed-
ing rates of term breastfeeding babies for whom supplemen-
tary bottle-feeds were avoided and babies who were permitted
BRITISH JOURNAL OF MIDWIFERY, FEBRUARY 2009, VOL 17, NO 2
RESEARCH AND EDUCATION
Box 1: Ten steps to successful breastfeeding
Step 1: Have a written breastfeeding policy that is routinely communicated
to all health care staff.
Step 2: Train all health care staff in the skills necessary to implement the
breastfeeding policy.
Step 3: Inform all pregnant women about the benefits and management of
breastfeeding.
Step 4: Help mothers initiate breastfeeding soon after birth.
Step 5: Show mothers how to breastfeed and how to maintain lactation
even if they are separated from their babies.
Step 6: Give newborn infants no food or drink other than breastmilk,
unless medically indicated.
Step 7: Practice rooming-in, allowing mothers and infants to remain
together 24 hours a day.
Step 8: Encourage breastfeeding on demand.
Step 9: Give no artificial teats or dummies to breastfeeding infants.
Step 10: Foster the establishment of breastfeeding support groups and
refer mothers to them on discharge from the hospital or clinic.
bottles and pacifiers in addition to breastfeeding. This trial
found that there was no difference in breastfeeding frequency
and duration between the two groups. A high rate (46%) of
violation of the BFHI Step 9 because of maternal desire to
feed supplements by bottle rather than cup and use pacifiers
was also found. This echoes anecdotal evidence heard from
women in the early postnatal period.
Fisher and Inch (1996) dispute the existence of nipple con-
fusion. They challenge the notion that a neurologically and
anatomically healthy baby which has a rooting reflex, opens a
wide mouth, grasps a mouthful of breast and begins to suck,
should not be able to do so on a different form of teat. Fisher
and Inch (1996) argue that the piston-like action (also noted
by Righard, 1998) of babies sucking on a bottle teat is simply
a variation on a sucking pattern caused by material that is
more malleable than the breast. Other authors also suggest
that babies are able to adapt sucking technique between a bot-
tle teat and the breast (Dowling and Thanattherakul, 2001;
Scheel et al, 2005). Anecdotal experience of lactation con-
sultants indicates that temporary use of bottle-feeds of EBM
can help women to overcome early breastfeeding problems,
and if managed correctly can lead to successful long-term
breastfeeding (Kassing, 2002; Hacker, 1998). This verifies
the experiences of some women I have worked with who have
offered bottle-feeds of EBM while successfully establishing
breastfeeding.
Cup versus bottle
Consideration of the impact of cup supplementation on
breastfeeding is useful as the rationale behind using cup
rather than bottle is to avoid nipple confusion (WHO,
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RESEARCH AND EDUCATION
Box 2: Seven point plan for the protection, promotion and
support of breastfeeding in community health care settings
Point 1: Have a written breastfeeding policy that is routinely communi-
cated to all health care staff.
Point 2: Train all staff involved in the care of mothers and babies in the
skills necessary to implement the policy.
Point 3: Inform all pregnant women about the benefits and management
of breastfeeding.
Point 4: Support mothers to initiate and maintain breastfeeding.
Point 5: Encourage exclusive and continued breastfeeding, with appropri-
ately-timed introduction of complementary foods.
Point 6: Provide a welcoming atmosphere for breastfeeding families.
Point 7: Promote co-operation between health care staff, breastfeeding
support groups and the local community.
1998). Therefore evidence comparing these methods
should indicate that babies supplemented by cup have
greater breastfeeding success than those supplemented by
bottle. However some studies have found that supplemen-
tary bottle-feeding does not adversely affect breastfeeding
duration any more than cup feeding (Brown et al, 1999;
Mosley et al, 2001; Flint et al, 2007). Mosley and col-
leagues (2001) tested the impact of bottles against cup
feeding on breastfeeding success for pre-term babies and
found that breastfeeding duration was similar regardless
of the method of supplementation. Conversely, Collins
and colleagues (2004) noted a positive impact of cup
feeding on breastfeeding rates of pre-term babies on dis-
charge from hospital. However, similar to Schubiger and
colleagues (1997), this study also found difficulties with
maternal compliance to cup feeding, which limited the
potential to make recommendations. As these studies relate
to pre-term babies it would be inappropriate to apply the
findings to term babies.
Flint and colleagues (2007) conducted a systematic review
of the literature on methods of supplemental feeding and
were unable to recommend cup feeding as an alternative to
bottles and feeding tubes due to the lack of impact on long-
term breastfeeding rates.
Formula milk versus EBM
Breastfeeding is a system of supply and demand regulated by
the baby suckling, the extent to which the breast is emptied
and the mother’s proximity to the baby which all affect the
action of prolactin, the feedback inhibitor of lactation and
oxytocin, (Riordan, 2005; Schanler et al, 2006; Wilde et al,
1995; Neville, 1999). Supplementation with foods other
than breastmilk potentially lessens the baby’s demand for
breastmilk, reduces the time spent suckling and consequent-
ly upsets the woman’s milk synthesis, secretion and ejection
(Wambach et al, 2005). However expressing breastmilk to
use as a supplement supports lactation physiology and milk
100
supply can still be stimulated effectively even if the breast is
artificially emptied via a breast pump (Kent et al, 2003).
Several authors note that supplementation with formula
milk is positively associated with poor breastfeeding out-
comes and diminished milk supply by interfering with the
physiology of milk supply and demand (Howard et al, 2003;
Hill et al, 2005; Hörnell et al, 2001; Merten et al, 2005).
Hörnell and colleagues (2001) identified that the main
reason mothers began to supplement with formula milk
was the perception that they did not have enough milk to
satisfy their baby. The fear of insufficient milk can create a
spiral effect of addressing perceived lack of milk by formula
supplementation, and the resulting decline in lactation cre-
ates a need for further supplementation. This has impor-
tant implications for midwifery practice and breastfeeding
advice. Midwives must ensure that breastfeeding mothers
understand the physiology of lactation, for example, the
importance of breastfeeding at night when prolactin levels
are highest, and that breastfed babies may feed more often
than formula-fed babies and should be fed on demand in
order to maintain lactation (RCM, 2002).
There is a clear and logical link between supplementation
with formula milk and reduced breastfeeding due to interfer-
ence with lactation physiology (Hörnell et al, 2001; Merten et
al, 2005). This indicates that any advice to supplement with
formula milk would be given with the understanding that
breastfeeding is likely to be affected. Supplementation with
formula milk is therefore undesirable for the healthy, term
breastfeeding baby (Howard et al, 2003).
The WHO acknowledges that evidence for BFHI Step 9
does not account for the impact the type of supplement may
have on the infant’s appetite, however this is addressed in Step
6, which recommends giving no food or drink other than
breastmilk (WHO, 1998); and Point 5 of the seven point
plan, which recommends exclusive breastfeeding. The WHO
(1998) recognizes that the evidence does not differentiate
between which supplement is chosen and how it is given, and
the literature search showed no studies specifically investigat-
ing whether babies supplemented by bottles of EBM are able
to continue successfully breastfeeding. Research is needed to
confirm anecdotal reports that women are able to feed EBM
by bottle and breastfeed, including during the establishment
of breastfeeding.
Women’s breastfeeding experiences
The Infant Feeding Survey 2005 (Bolling et al, 2007) found
that three-quarters of mothers surveyed had given their
babies formula milk by the age of six weeks, and by the age
of six months these mothers were mainly feeding formula
milk. The highest rate of breastfeeding problems was for
women who introduced formula milk supplements. To
make recommendations for midwifery breastfeeding advice
it is important to understand why women may choose to
feed bottle supplements.
Partner involvement and space from the baby
Schmied and Barclay (1999: 329), found that 35% of the
women in their study had found breastfeeding to be a ‘con-
nected, harmonious and sensual’ experience. The remaining
BRITISH JOURNAL OF MIDWIFERY, FEBRUARY 2009, VOL 17, NO 2

women found the reality of breastfeeding far removed from
the pro-breastfeeding public health messages with 25% cit-
ing traumatic experiences. These women found the constant
proximity to their baby overwhelming and sometimes wished
for some distance from the baby. For some women the only
answer was to cease breastfeeding completely but the option
of expressing breastmilk and feeding by bottle may have
avoided this.
Several studies have highlighted the significance of the
father’s role in assisting with feeding. Earle (2000) notes this
relieves pressure on the mother and ensures paternal involve-
ment and states that women may choose to introduce formula
milk to achieve this. Other authors discuss the powerful influ-
ence of the father on decisions around feeding and their desire
to be involved in this (Bailey, 2007; Okon, 2004).
Kirkland and Fein (2003) identified that the desire to
have periods away from the baby rated highly among women
of mixed parity in the first five months of motherhood.
Zimmerman and Guttman (2001) describe the perception
among a group of mothers that breastfeeding reduces their
ability to participate in other activities. For these women
social issues were overcome by feeding formula milk. Bulk-
Bunschoten and colleagues (2001) noted that at four months,
when the sample group’s breastfeeding rate had dropped to
21%, 77% of the women were mixing breastfeeding with
feeds of formula milk. This indicates women are still keen
for their infants to receive some breastmilk, but rather than
expressing breastmilk they feed formula milk and risk affect-
ing lactation.
Win and colleagues (2006) studied the long-term breast-
feeding outcomes for women expressing breastmilk to facili-
tate temporary separation from the baby, either for work or
other activities, and found that expressing milk allowed the
women greater freedom and flexibility leading to greater
duration of breastfeeding. Returning to work was cited as a
major reason for women ceasing to breastfeed by Bick and
colleagues (1998) and Zinn (2000) notes that long-term
breastfeeding can be achieved through good planning and
early midwifery support that positively reinforces the fact
that returning to work does not mean an end to breastfeed-
ing. This suggests that the midwife having an open-minded
attitude to feeding EBM at an early stage could be beneficial
to improving breastfeeding duration for some women.
Insufficient milk and baby weight gain
Dykes (2002) identifies women’s fear of not producing
enough milk as a key motivator for discontinuation of breast-
feeding in the UK and describes women expressing their milk
purely to ascertain the quantity produced. The perception
of an insufficient milk supply is common. Schanler and col-
leagues (2006) state that approximately 5% of women do
not produce enough milk. However women interviewed by
Cooke and colleagues (2003) reported a rate of insufficient
milk ranging between 12% and 17%. The rate indicates the
women’s perception of milk inadequacy, which may not be
milk inadequacy as defined by a lactation expert, but is very
significant because it causes these women to cease breastfeed-
ing. This perception should be valued highly by midwives
who can then overcome the issue with appropriate support,
BRITISH JOURNAL OF MIDWIFERY, FEBRUARY 2009, VOL 17, NO 2
RESEARCH AND EDUCATION
istockphoto.com
for example, giving comprehensive advice on attachment
techniques, feeding frequency and voiding (Porter-Lewallen
et al, 2006).
As well as volume of milk produced the other marker of
success in the view of the women described by Dykes (2002)
was baby weight gain. This focus apparently mirrors that of
health professionals who concern themselves greatly with
monitoring weight, a practice which distracts from consider-
ing other indicators of a well baby (Dykes, 2002). Berridge
and colleagues (2005) also recognize this lack of trust in
other signs of wellbeing, such as contentment, and state that
women may compare their baby to a formula-fed baby who
would gain weight more rapidly.
A review of evidence around routine weight monitoring
found that the normal weight gain curves used for growth
charts in the UK do not reflect the reality of the early weight
loss of breastfed babies and can therefore lead to concern that
is unfounded (Sachs et al, 2005). A new growth standard
developed by the WHO in response to such concerns is based
on normal patterns of weight gain for breastfed infants (Garza
and deOnis, 2004). The concern is that fears about subopti-
mal weight gain might lead to supplementation with formula
milk and, thus, adversely affect breastfeeding. The National
Institute for Clinical Excellence (NICE, 2006) guidelines on
postnatal care warn that the limited evidence regarding rou-
tine weighing may do more harm than good and recommends
research into this area to clarify practice.
Despite this McKie and colleagues (2006) found that
routine weighing had no detrimental effect on breastfeeding
provided that targeted additional breastfeeding support was
also offered. Sachs and colleagues (2005) stress the desire of
parents to have their babies weighed noting that alongside
weighing practices attention should be paid to how the nor-
mal physiology of weight gain and other markers of health
are communicated to parents by midwives and other health
professionals. This highlights the importance of the role of
the midwife in reassuring parents that small weight loss of a
healthy baby in the early neonatal period does not constitute
an insufficient milk supply.
The social issues discussed above could be overcome
101
RESEARCH AND EDUCATION
‘
... women’s breastfeeding
experiences identified several
recurring themes, including
social issues and fears about
’
insufficient milk supply ...
if women were shown that feeding EBM by bottle could
be a positive choice that avoids a switch to formula milk.
Expressing milk may also help allay women’s fears about
insufficient milk production, however, it is vastly preferable
to teach women to be reassured by other signs of their babies’
wellbeing. Given the concerns that women express regarding
feeding it is surely only appropriate that midwives show flexi-
bility and take the opportunity during early postnatal support
to discuss feeding options that address short and long-term
needs in order to truly provide woman-centred care.
Midwifery advice
There is potential for breastfeeding advice to be conflicting
and midwives recognize that advice is not always evidence-
based (Robertson, 2000; Graffy and Taylor, 2005). A profes-
sional dilemma seems to exist between providing evidence-
based advice, meeting women’s needs and the public health
breastfeeding agenda of which the BFHI is a key element
(Stein et al, 2000; Furber and Thomson, 2006; Schmied et
al, 2001; Hoddinott and Pill, 1999). Anecdotal evidence
suggests that midwives are reluctant to advise switching
between bottle and breast when in fact they should be
providing information and advice that empowers women
to make the best individual choice for themselves (RCM,
2001). Partnership working to meet women’s individual
needs is an expected professional standard for midwives
(NMC, 2008), and consequently a solution that allows
more individual focus is warranted. Perhaps a more flexible
approach to breastfeeding advice would allow woman-cen-
tred practice and help avoid contradictory advice which, as
Robertson (2000) emphasizes, could contribute to the low
breastfeeding rates in the UK.
Conclusion
The evidence surrounding nipple confusion is mixed: some
studies support and others refute it, and several sample
pre-term babies (Pincombe et al, 2006; Collins et al, 2004;
Schubiger et al, 1997). The major flaw identified with the
body of evidence is that the key studies do not consider the
type of supplement given, despite formula milk supplemen-
tation being a recognized predictor of shortened breastfeed-
ing duration (Howard et al, 2003). As the evidence makes
no distinction between supplementation with formula milk
and EBM, the cause of shortened breastfeeding duration is
not accurately identified and may be attributed to nipple
confusion when it is actually caused by interference with
supply and demand. Therefore the evidence does not help
establish whether nipple confusion occurs when feeding
102
supplementary EBM by bottle and advice to avoid this
practice may be inaccurate. In addition the value of cup-
feeding rather than bottle-feeding to promote breastfeeding
is questionable (Flint et al, 2007).
Exploration of women’s breastfeeding experiences identi-
fied several recurring themes, including social issues and fears
about insufficient milk supply (Scott and Mostyn, 2003;
Win et al, 2006; Cooke et al, 2003). These factors explain
why women might consider supplementing breastfeeding
with some bottle-feeds, and raise implications for midwifery
practice by highlighting the issues which matter to women
and warrant a supportive response.
Research has shown that breastfeeding advice can be
conflicting and to meet women’s individual needs a flex-
ible approach to breastfeeding advice should be adopted
(Graffy and Taylor, 2005; Robertson, 2000). If midwives
continue to feel nervous about supporting women wish-
ing to offer some feeds by bottle they may not be fully
addressing women’s social needs. Breastfeeding guidelines
could be developed which encompass a range of women’s
experiences and allow midwives to work with confidence.
Further evidence to support feeding EBM by bottle along-
side guidelines that promote flexibility would help mid-
wives work with women within the context of their unique
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Key Points
n The evidence regarding nipple confusion is inconclusive.
Midwives should explore all potential causes of breastfeeding
problems, particularly supplementing with formula milk, before
diagnosing nipple confusion.
n There is a clear link between supplementation with formula
milk and reduced breastfeeding due to interference with
lactation physiology. Supplementation with formula milk is
undesirable for the healthy, term breastfeeding baby.
n The evidence in favour of cup feeding as a means of avoiding
nipple confusion is limited.
n Expressing breast milk to feed by bottle is a positive lifestyle
choice for some women who may have otherwise abandoned
breastfeeding, and midwives should be open to this option.
n The fear of not producing enough milk is a key motivator for
discontinuation of breastfeeding in the UK, so midwives should
inform parents about the normal physiology of weight gain and
other markers of good health.
n Breastfeeding guidelines should encompass a range of
women’s experiences by promoting flexibility and allowing
midwives to work with confidence.
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