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Why
would a baby refuse to take the breast?
There are many reasons a baby might refuse to latch on. Often there is a combination of reasons.
For example, a baby might latch on even with a tight
frenulum if no other factors come into play, but if, for
example, he is also given bottles early on, this may very well
change the situation from “good enough”, to “not working
at all”.
1.
If the mother’s nipples are particularly large, or
inverted, or flat, these nipple variations make latching on more
difficult, not usually impossible.
2.
Some babies are unwilling to nurse, or suck poorly as a
result of medication they received during the labour. Narcotics are responsible for many such situations, and
meperidine (Demerol) is particularly bad as it stays in the
baby’s blood for a long time and affects the way he sucks for
several days. Even
morphine given in an epidural may cause the baby to be unwilling
to nurse or latch on, since medication from an epidural
definitely does get into the mother’s blood, and thus into the
baby before he is born.
3.
Vigorous suctioning at birth may result in babies not
sucking properly and not wanting to latch on.
There is no need to suction a healthy, full term baby at
birth.
4.
Abnormalities of the baby’s mouth may result in the
baby’s not latching on. Cleft
palate, but not cleft lip, causes severe difficulties in
latching on. Sometimes
the cleft palate is not obvious, affecting only the part inside
the baby’s mouth.
5.
A tight frenulum (the whitish tissue under the tongue)
may result in a baby having difficulty latching on. This is not, strictly speaking, considered an abnormality,
and thus, many physicians do not believe that it can interfere
with breastfeeding, but they are misinformed.
6.
A baby learns to breastfeed by breastfeeding.
Artificial nipples interfere with how the baby takes the
breast. Babies are
not stupid. If they
get slow flow from the breast (as is expected in the first few
days of life) and rapid flow from the bottle, they will not
be confused—many will figure it out quite quickly.
However,
one of the most common causes of babies’ refusing to latch on
arises from the misguided belief that babies in the first
few days must breastfeed every 3 hours, or on some other insane
sort of schedule. This
results in anxiety on the part of the staff when a baby has not
fed, for example, for three hours after birth, which results,
frequently, in babies being forced to the breast when they are
not ready yet to feed. When
the baby is forced into the breast, and kept there by force,
when the baby is not interested or ready, we should not be
surprised that some babies develop an aversion to the breast.
If this misguided approach then results in panic, and
“the baby must be fed”, alternative feeding methods
(the worst of which is the bottle) are then used, resulting in
worsening of the situation and the beginning of a vicious
circle.
There
is no evidence that a healthy full term newborn must feed
every three hours during the first few days. There is no evidence that they will develop low
blood sugars if they don’t feed every three hours (the
whole issue of low blood sugars has become a mass hysteria in
newborn nurseries which, like all hysterias, results from a
grain of truth, perhaps, but actually causes more problems than
it prevents, including the problem of many babies getting
formula when they don’t need it, and being separated from
their mothers when they don’t need to be, and not latching
on). Babies should
be together, skin to skin with their mothers, 24 hours a day
(See handout 1a The importance of Skin to Skin Contact).
When they are ready, most will start looking for the
breast. Having the
baby with the mother skin to skin immediately after birth, and
allowing the baby and the mother the time to “find” each
other, will prevent most situations of the baby not latching on.
Mother and baby skin to skin will also keep the baby as
warm as being under a heating lamp.
Having the baby and mother together for 5 minutes though,
is not the answer. The
mother and baby should be together until the baby latches on,
without pressure, without time limits (“we’ve got to weigh
the baby”, “we’ve got to give the baby vitamin K,”
etc—these procedures can wait!).
This might take 1-2 hours or more.
But
the baby is not latching on!
Okay, so how long can we wait?
There is no obvious answer to that.
Certainly, if the baby has shown no interest in nursing
or feeding by 12 to 24 hours after birth, it may be worthwhile
to do something, mostly because hospital policies usually
require the mother to be discharged by 24 to 48 hours.
What can be done?
1.
The mother should start expressing her milk, and that
milk (colostrum), either alone, or mixed with sugar water,
should be fed to the baby, preferably by finger feeding.
If it is difficult to get colostrum (often hand
expression works better than a pump in the first few days), then
sugar water alone is fine for the first few days.
With finger feeding, most babies will start sucking, and
many will wake up enough to attempt going to the breast.
As soon as the baby is sucking well, finger feeding
should be stopped and the baby tried at the breast.
Finger feeding is essentially a procedure to prepare the
baby to take the breast, not primarily a method to avoid the
bottle, though it will do that too.
Therefore it is done before attempting the baby at
the breast, to prepare him to take the breast.
See handout #8 Finger Feeding.
2.
Before discharge, early, competent help needs to be
arranged so that the mother and baby are getting help by day
four or five at the latest.
Many babies not able to latch on in the first few days
will latch on beautifully once the mother’s milk supply has
increased substantially as it usually does around day 3 or 4.
Getting help at this time avoids the negative
associations with the breast that many babies develop as time
goes on.
3.
A nipple shield started before the mother’s milk
becomes abundant (day 4 to 5) is bad practice.
Starting a nipple shield before the mother’s milk
“comes in” is not giving time a chance to work.
Furthermore, used improperly (as I see it often being
used), a nipple shield may result in severe depletion of the
milk supply.
I’m
home from hospital. The
baby won’t latch on. What
do I do?
The single most important factor influencing whether
or not the baby latches on is the mother’s developing a good
milk supply. If
the mother’s supply is abundant, the baby will latch on by 4
to 8 weeks of life no matter what.
What we try to do at the clinic is get the baby latching
on earlier, so that you won’t have to wait that long. So, it
is more important you keep up your supply, than avoid a bottle.
The bottle interferes, and it is better you use other
methods (such as a cup) if you can, but if you feel you have no
choice, you should do what you need to do.
-
Learn
how to get the best position and latch from an experienced
lactation specialist (see also handout A: When Latching
and see the
videos. As
the baby comes onto the breast, compress the breast so that
the baby gets a gush of milk. Try the baby on the breast he seems to prefer, or the
breast that has more milk, not the breast
he resists more.
If
the baby latches on, he will start sucking and start
drinking (get information on how to know a baby is actually
getting milk at the breast—see handout #4. Is My Baby
Getting Enough Milk? And see
the videos.
If
the baby doesn’t latch on, don’t try to force him to
stay on the breast; it won’t work.
He will either get hysterical or “go limp”. Move him away from the breast and start again.
It is better to go on-off, on-off several times than
to push him into the breast when he hasn’t latched on.
If
the baby goes to the breast and sucks once or twice, he
hasn’t latched on a little; he hasn’t latched on at
all.
-
If
the baby refuses the breast, don’t keep at it until he’s
angry. Try
finger feeding a few seconds to a minute or two, and try
again, perhaps on the other side. Finger feeding is to prepare the baby to take the breast, not
primarily to avoid a bottle.
-
If
the baby doesn’t latch on, finish the feeding with
whatever method you find easiest.
-
Using
a lactation aid at the breast may be helpful, but often
requires an extra hand.
-
At
about two weeks after birth, a change in what you have been
doing often seems to send a message to the baby that
“there’s more than one way to do this”.
If you have been finger feeding only, a change to a
cup or bottle will sometimes work, or using a nipple shield
will often work. If
you have been bottle feeding only, switching to finger
feeding may work (only before attempting the baby at the
breast is good enough if finger feeding is too slow, and
finishing the feeding with cup or bottle).
How
to maintain and increase milk supply
Ø
Express your milk as often as is practical, at least 8
times a day, using a reliable pump that expresses both breasts
at the same time. Using compression while pumping increases the efficiency of
pumping and increases the milk supply (another hand is helpful,
but mothers have rigged up the pump so that they don’t have to
hold onto the tubing or flanges while pumping and thus can
compress without help).
Ø
If the baby hasn’t latched on by day 4 or 5, start
fenugreek and blessed thistle to increase milk flow.
See handout #24. Miscellaneous Treatments. Domperidone may also
be useful. See
handouts 19a and 19b, Domperidone 1 and 2.
Ø
If you must use a nipple shield, do not use one at least
until the milk supply is well established (at least 2 weeks
after the baby is born). Get
good hands on help first.
Do not get
discouraged. Even
if your milk supply is not up to the needs of your baby, many
babies will still latch on.
Get good help. Do not do this on your own.
Questions?
(416)
813-5757 (option 3) or drjacknewman@sympatico.ca or
my book Dr. Jack Newman’s Guide to Breastfeeding (called The Ultimate
Breastfeeding Book of Answers in
the USA)
Handout
#26. When The Baby Refuses
to Latch On. January 2005
Written by Jack Newman, MD, FRCPC. © 2005
This
handout may be copied and distributed without further
permission,
on the condition that it
is not used in any context in which the WHO code on the
marketing of breastmilk substitutes is violated.
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