I don't think there are any references pertaining to nipple confusion 
directly.

It is anecdotal experience (as is much of what we do).  In my experience it 
is usually bottle PREFERENCE rather than actual "confusion" that causes a 
baby to refuse the breast after having bottles.  They prefer the fast, 
constant flow.  But sometimes a baby who was doing okay starts getting 
bottles and changes the position of their tongue (humped up in back of 
mouth) to protect themselves from the onslaught of milk, then tries to do 
that at the breast...and depending on mom's anatomy, may be unable to stay 
on, or start pinching from not being on far enough, or park on a long nipple 
and not get any milk.  OR a baby who was not doing okay gets their bad 
habits rewarded by bottle-feeding.

Kathy Leeper, MD, IBCLC 

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