A study that shows that there is no difference between bottle feeding and
cup feeding does not prove that nipple confusion does not exist. Babies will
go to where the milk comes from. They are not stupid. If they get milk from
anywhere off the breast and that milk comes quickly, they will prefer that
source. So any supplementation should be done *at the breast* with a
lactation aid (nursing supplementer).

Secondly, and this follows from the first, how do they know if nipple
confusion does not exist just because the outcome (say, still breastfeeding
at 6 weeks) is the same. There may be a only a subgroup of mothers and
babies that experience problems. Say 10% or 20% whose milk supply is
adequate but low. If the mother has a ton of milk, the baby may not be
bothered at all by getting bottles or cups or whatever. Also, nipple
confusion is more than breast refusal. It may cause all sorts of problems,
including sore nipples, because the bottle encourages the baby to open less
widely and thus not latch on properly. Mothers have been able to nurse
forever with a poor latch, if their supplies are abundant.

Also, it is not up to us to prove that nipple confusion does not exist. It
is not physiologic for a baby to be fed through a rubber or latex teat. Thus
it is up to those who doubt the existence of nipple confusion to provide
references that it does not exist.

Jack Newman, MD, FRCPC

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