When the Baby will not take the Breast
Myth: If a baby is unable to take the breast during the first few days after birth, he will never take the breast and it is not worth continuing to try. The usual reason is that the mother has flat or inverted nipples.
Fact: It is usual for a baby to take the breast after the first few days. It is worth continuing to try. When the mother has a generous supply of milk, the baby, almost always, will eventually take the breast by the age of four to eight weeks all on his own. Flat or inverted nipples make it more difficult for a baby to latch on, but this is not the most common reason for a baby to refuse the breast.
When a baby cannot take the breast, it can be very disheartening and frustrating for the mother and everyone in her milieu. It is not clear why babies cannot seem to take the breast, but usually a combination of factors come into play. Probably no single factor mentioned below would be the cause of the baby’s refusing the breast, but two or three or more factors are added together, the cumulative effect is that the baby finds it impossible to latch on.
It is interesting that when babies are born after labours with few manipulations, babies rarely have problems latching on. I do not remember ever hearing of this as a problem when I worked in Africa, though, with 1500 deliveries a month, I was not able to be current on all the babies that were born.
Babies “latch on” where they get good flow. Thus, if a baby goes to the breast and does not get flow, he may not latch on. (Many babies will latch on, but not well, so that they are unable to get good flow, and if there is little or no flow they nibble for a while and then fall asleep. This is probably the situation, unfortunately, of most babies during the first days until the mother’s milk becomes abundant.) The baby may struggle and fight, or he may just go limp and seem to sleep, or even do both at one attempted feeding or sleep at one attempted feeding and struggle at another. In all these cases, the baby has not, in fact, latched on. When the baby struggles and cries at the breast, it is obvious to everyone that he has not latched on. However, when the baby only nibbles or sleeps at the breast, it may not be obvious to the inexperienced helper or to the mother, and in that case, the baby may be at risk for serious weight loss (see Chapter “Not Enough Milk”).
Once again, there is enough milk in the first few days. But the baby must latch on well in order to get that milk.
Factors which may result in the baby’s not latching on
1. The baby is not put to the breast early.
The issue of delaying putting the baby to the breast has been discussed earlier in the chapter on “Not Enough Milk”. However, when a baby is allowed to follow his instincts and find the breast and latch on immediately after birth, the chances of his later being unable to latch on are much reduced. Do not forget that although a couple of minutes with the mother immediately after birth are better than none, for the baby to “self-attach”, it takes, on average, close to an hour. Some babies never self attach, some do so immediately. Even those who do latch on immediately should stay with the mother on the breast, at least until they come off themselves or are asleep at the breast, not a token few minutes.
2. Maternal medications during labour
There is no doubt that narcotics given to the mother during labour interfere with the baby’s being able to self attach or to latch on. Narcotics given to the mother during labour enter the baby through the placenta and may depress his nervous system. Occasionally, this depression is so profound that babies need to be given a narcotic antagonist in order to revive them at birth. If something as vital a breathing can be depressed by a narcotic, it does not take a great leap of faith to accept that the narcotics may also interfere with the baby’s coordination needed to latch on and suckle well. Some narcotics are better than others, but it is interesting that probably the worst narcotic from the point of view of interfering with breastfeeding is also one of the ones most commonly used, meperidine (Demerol). It is a problem because is stays in the baby’s body for a long time and may affect the baby for many days. Other narcotics have similar actions, but do not stay in the baby’s body for as long a time. Not all babies whose mothers got narcotics during labour are unable to take the breast, but add in a few more interfering factors, and there may be problems.
Does epidural or spinal anaesthesia cause problems? This question has not been definitely answered, and there are studies which claim to prove both sides. One of the issues which is not often addressed is this issue of other factors added in. It is quite possible that this type of anaesthesia causes only minimal interference with breastfeeding, a definite but usually insignificant problem. If breastfeeding support in hospital is good and hospital routines conducive to initiating breastfeeding are good, then overall there may be no issue. However, if breastfeeding support in hospital is poor and hospital routines not conducive to initiating breastfeeding (an altogether too common situation), the minimal effect of epidural or spinal anaesthesia may be enough to tip the scale for many mothers and babies. But we don’t know, and many studies do not take into account how long the mother has had the epidural, for example. It may make no difference if the mother has an epidural for a few hours only at the end of the labour, say, but could make a difference if she’s had the epidural in place for 24 hours. It is indisputable, however, that, contrary to the belief of many, drugs from the epidural or spinal anaesthesia do get into the mother’s bloodstream, and thus do get into the baby, though usually only in very low concentrations.
3. Separations of mother and babies
Babies learn to breastfeed by breastfeeding. They should therefore be given every opportunity to take the breast in the first few days. Separation of the mother and baby, even, especially, when it is done as a supposed favour for the mother results in missed opportunities. Of course, there are situations when mothers and babies, because of illness of one or the other or both cannot be together, but these situations are far less common than most hospital routines would seem to indicate.
There is no evidence that mothers who are separated from their babies are better rested. On the contrary, most mothers are more rested and less stressed when they are with their babies. Most mothers have too eagerly awaited this baby for too many months to feel the baby must now be somewhere else besides with her. The pleasure most mothers have of holding and stroking their new babies, and, putting their babies to the breast makes the fatigue they had during labour almost magically disappear.
Mothers and babies learn how to sleep in the same rhythm. Thus, when the baby starts waking for a feed, the mother is also starting to wake up naturally. This is not as tiring for the mother as being awakened from deep sleep, as she often is if the baby is elsewhere when he wakes up.
The baby shows long before he starts crying that he is ready to feed. His breathing may change, for example. It is interesting how mothers can often sleep through all sorts of noises, yet wake up with the baby’s change from regular deep breathing to rapid shallow breaths. Or the baby may start to stretch. The mother, being in light sleep, will awaken, her milk will start to flow and the calm baby will be content to nurse. A baby who has been crying for some time before being tried on the breast may refuse to take the breast even if he is ravenous. Mothers and babies should be encouraged to sleep side by side in hospital. This is a great way for mothers to rest while the baby nurses. Breastfeeding should be relaxing, not tiring. And the baby is more likely to take the breast and be patient at the breast if he is not ravenous.
4. Early use of artificial nipples
This issue has already been discussed in the chapter Not Enough Milk. It should be remembered that only extremely rarely do artificial nipples need to be used, even if supplementation is truly necessary (which it would not be, most of the time, if mothers got good help with latching early). The alternatives are not ideal, but they are better than using artificial nipples.
If the baby is fussy all the time, and improving the latch does not improve this, and compression does not help, and the mother cannot be encouraged just to keep the baby at the breast longer, then supplementing sugar water with a lactation aid is preferable, in my opinion, to giving the baby a pacifier or a bottle of sugar water. (Unfortunately, it has to be emphasized that fixing the breastfeeding must come before giving a supplement, because in too many hospitals, giving the supplement is the first step. Even if given by lactation aid at the breast, this is wrong. The latch should be fixed before any supplements are suggested). Sometimes 5 or 10 ml of sugar water extra, and the baby will calm right down. Of course, if expressed breastmilk is available, it is preferable to sugar water.
5. Problems of the nipples and breast
Most mothers often believe that the main reason the baby will not latch on is that they have flat nipples, or inverted nipples or other anatomic problems of their breasts. Women are always ready to believe that they just do not have the “right equipment” to nourish their babies. There is no doubt that a nipple which sticks out makes it easier for the baby to latch on, but only easier. But even inverted nipples do not make latching on impossible. It can be difficult, but time, and experienced help, will usually overcome even inverted nipples, at least most of the time. Remember that mothers and babies change with time, and a breast which is difficult for a baby on day two, may be just fine on day seven or day fifteen. A proper latch always helps, since, with a proper latch, a baby gets more milk, and if a baby gets more milk, he is likely to stay where he gets it.
a) Inverted nipples:
Inverted nipples (photo) can make it more difficult for the baby to get onto the breast, but not impossible. In some cases, as the baby comes on to the breast, the breast tissue seems to move away from him, slipping away so that he cannot grasp the breast. Mothers have more problems if the nipple is not only inverted, but also seems to have a ring of firm tissue around it, also making it more difficult for the baby to grasp the breast.
Inverted nipples can sometimes be pulled out (everted) using a device shown in the photo. There are also commercial gadgets which can be used during the pregnancy to pull out the nipple.
Inverted nipples usually become “uninverted”, or at least less inverted, as the baby starts to latch on, as the days go on, but also within a single feeding. Thus, not trying to keep the baby on the breast when he is not latched on is not only good for preventing the baby from crying and getting upset, but also for helping the nipple start to protrude (see below).
b) Flat Nipples:
Flat nipples (nipples that don’t protrude, but also are not inverted) may also make latching on more difficult (especially in conjunction with inappropriate interference), but far less so than inverted nipples. A good beginning and good latching technique is usually all that is necessary. Do not assume that breastfeeding will be difficult because of “flat nipples”.
c) Large or Very Long Nipples:
In fact, very large nipples can be more of a problem than inverted or flat nipples. They may result in no problems at all, but a very large or very long nipple does make it difficult for the baby to take the breast properly in order to get milk. In such a case, it sometimes takes several weeks to get the baby latching on well enough to get milk well. However, with an abundant milk supply available to him, the baby can often do well even with a latch that cannot get up to the milk sinuses.
d) Engorged Breasts:
Engorgement on the third or fourth day after the baby’s birth may result in a baby not being able to latch on. I do not believe that babies latch on just fine until “the milk comes in” and then refuse the breast because of engorgement. I believe that the baby never really latched on at all, though the baby did allow the breast into his mouth and made some sucking motions. But when it becomes more difficult for the baby to latch on because of the engorgement, the fact that the baby was not latching on before now becomes painfully obvious. Prevention is the best treatment here, which means getting a good latch from very early on. Treatment once engorgement has occurred has been discussed in the chapter “Sore nipples, Sore breasts”, and below as well.
e) Very Large Breasts:
Sometimes women with very large breasts have difficulties latching babies on because of the awkwardness of handling their very large breasts. As well, some women with very large breasts also have flat nipples, complicating what should not really be a big problem in the first place.
The problem of handling large breasts can be made less of a problem by using a sling (made from any reasonably soft material) which holds up the breast in the same way as a sling helps hold up an arm in a cast. Using a sling allows her to use one hand to direct the nipple and areola correctly, rather than using that hand to hold up the breast. Women with very large breasts sometimes find that lying down with the baby makes it easier for them to handle their breasts, and easier for the baby to take the breast.
6. Baby problems which make latching on more difficult
Some babies cannot latch on because they have medical problems which make it more difficult, or in some cases, impossible. In many situations, however, even with anatomical problems babies can latch on if given time and the mothers are given guidance. It is not possible to discuss the range of problems which may interfere with the baby’s latching on, because these are legion (though, luckily, none is common). The mother should not accept, however, that breastfeeding is just not possible. In many cases, few mothers have ever tried, because they were always told that breastfeeding was impossible and it was not worth wasting time trying to get the baby onto the breast. In some situations, this may be true, but one thing is indisputable: if the mother does not even try breastfeeding, for sure it isn’t going to work.
a) Neurologically depressed babies:
Some babies are temporarily depressed, neurologically speaking, usually from the mother’s receiving medication during the labour. Other babies have longer lasting problems. Examples are babies with Trisomy 21 (Down’s Syndrome), or babies who were deprived of oxygen during the labour or beforehand, or babies with anatomical abnormalities of the brain. Even in such cases, however, babies can eventually latch on. Time, patience, encouragement, and skilled help can work wonders. And it is worth it. Babies with problems need breastmilk (and breastfeeding) more, not less.
In fact, my experience with babies with Trisomy 21 is that they can usually latch on and breastfeed well. At first they tend to be very floppy, and many have large tongues (or small mouths, question of interpretation) which can interfere with their taking the breast. As in all such cases, making sure, to the limits of our abilities, that the mother develops a good milk supply is the key to getting the baby latched on.
Babies who have been deprived of oxygen during birth can have very serious medical problems. Their neurological injury, and often the treatment for the injury, may interfere with breastfeeding and their latching on. However, these babies also improve, in general, and again, time, patience, encouragement, and skilled help can work wonders.
b) Babies with anatomic abnormalities of the mouth or oral cavity:
Babies may be born with abnormalities of the mouth or oral cavity. The most common of these abnormalities is a cleft palate, cleft lip or a combination of the two. Babies with cleft lip alone, or cleft lip with an indentation of the gum line usually should have few if any problems breastfeeding at all. A cleft lip may be overcome, if it is causing problems, by positioning the baby in such a way that the mother’s breast will fill in the cleft. Or tape may be used to close the cleft, if necessary.
A cleft palate is more problematic. With our present level of expertise and knowledge, it is true that many babies will not be able to latch on. However, if no attempt is made to get the baby breastfeeding, then the baby will definitely not, obviously, take the breast. Unfortunately, feeding policy of many cleft palate programmes assumes the baby will not take the breast and discourage the mother even from trying, in the belief that she will undoubtedly be disappointed. I believe this is a bad approach. Many mothers wonder later about the loss of breastfeeding and grieve that they had not at least tried. What exactly is the harm in trying? In fact, if more mothers did try to breastfeed their babies with cleft palates, maybe more would succeed. Experience with helping mothers get babies latched on has resulted in a group of lactation specialists who can help the mother get almost any normal baby to take the breast. A few years ago, this was not true, but the skills these specialists have developed have improved the chances for the normal baby. If we made attempts with babies with cleft palates, for example, and got more experience, maybe more of the babies with cleft palates would also be able to breastfeed.
Some cleft palate programmes encourage the use of an obturator, a plastic mouth piece which fills the cleft. Some babies have been able to breastfeed when using an obturator.
Cleft palates may be complete, running right to the front of the mouth, in which case they are pretty obvious. Or they may be partial, involving only the soft palate or part of the soft palate (see drawing). If they are partial, they may not be obvious at first glance. All babies who refuse to latch on, or make an unusual amount of noise when they are trying to suckle at the breast should be examined to see if they have a cleft of the soft palate only. Sometimes these are easier to feel than to see.
c) Tongue Tie:
A tongue tie is not included amongst the abnormalities because, strictly speaking it is not really an abnormality in the sense that a cleft palate is an abnormality. But a tongue tie can be an impediment to successful breastfeeding.
Under the tongue we all have a whitish vertical strip of tissue which attaches to the floor of our mouths at one end and to the tongue at the other. When the frenulum is tight, it can prevent the baby from getting his tongue well enough forward to breastfeed as well as he could if the frenulum were not so tight. If the baby cannot get milk well from the breast, he may refuse to take the breast, not out of orneriness, but out of frustration. Unless the tongue tie is quite severe, I do not believe that a mild or moderate tongue tie alone prevents a baby from latching on, but combined with other factors, such as early introduction of bottles, or poor positioning at the breast, even mild tongue ties could certainly result in a baby being unable to take the breast. Finally, if the tongue does not protrude well, the mother can get sore nipples from the baby’s tongue striking the nipple.
Many physicians are adamant that tongue tie could not possibly cause problems for breastfeeding and that release of tongue tie is completely unnecessary. This belief seems to have reached the level of ideological fervour, with no middle ground available. Parents are often caught between the physician who says that snipping the frenulum is an absurd idea, and lactation specialists who are urging the parents to have it done.
I believe that many physicians’ stand on this is based on the same sort of process by which most of us now refuse to believe in ghosts. “We’ve gotten past believing in ghosts. Just let these ideas lie!”. Snipping the frenulum used to be a common procedure in newborns. In some areas it was actually routine for every newborn to have his frenulum snipped at birth. First the umbilical cord, then the frenulum. However, over the years, evidence began coming forth that in fact, a tight frenulum probably did not interfere with speech development, for example, unless the tongue tie was really severe. These studies were being done however, when breastfeeding was also decreasing in frequency, and probably the question of whether a tongue tie might interfere with breastfeeding was not even considered. In the event, doctors stopped doing releases of tongue tie and the tongue tie has become the equivalent of the ghost. We’ve “gotten over it. Just forget it”.
Our clinic experience, though, suggests that snipping the frenulum can make a difference to the mother’s comfort during breastfeeding, to the ease with which the baby gets milk, and to help babies who are not latching on to latch on. It is an extremely simple procedure, which takes me less than a minute to accomplish. The actual snipping of the frenulum takes less than a second and, in my opinion, rarely causes the baby pain. The babies do usually cry because they are being held down, but it is helpful for me for the baby to cry, because he opens his mouth making the whole procedure quick and easy. Since the frenulum is bloodless, there is rarely more than a drop or two of blood in the baby’s mouth after the procedure, if it is done properly. Bleeding almost always stops as soon as the baby goes to the breast.
Does it do any good to clip the frenulum? Sometimes it obviously makes a difference. Sometimes it does not. Most of the time, because dealing with breastfeeding problems should include more than just cutting the frenulum, I am never sure if it makes a difference. If this procedure were complicated or dangerous, I would not do it. But since it is not complicated, and as long as certain precautions are taken (cut only what is bloodless), not dangerous, I have no hesitation to do it.
d) Suctioning at birth:
Although suctioning the baby’s nose and throat and even his stomach is routine in many hospitals, this procedure is not necessary for a normal baby who is not having any problems. In some circumstances, it is necessary and helpful for getting the baby able to breathe properly. But a healthy full term baby who is breathing fine at birth does not need to be suctioned. There is concern that suction may actually cause some babies to stop breathing. I have seen this happen several times. And there is evidence that suctioning of the stomach may result in the babies’ sucking and nursing less well. It may not be surprising that vigorous suction might interfere with the baby’s desire to take the breast. These procedures may cause irritation to the mouth and throat, but it is more likely that the abnormal stimulation in this way may disorganize the baby’s suckle by sending very strong and unusual signals to the brain.
When the baby refuses to take the breast
Just a reminder that the best treatment is prevention. Avoid narcotics during labour if possible. The baby should be allowed the opportunity and time to crawl up to the breast and “self-attach”. Suctioning at birth should be avoided unless it is medically necessary, which it usually is not.
The first 24 hours:
Most babies do not really have to feed in the first 24 hours. In fact, up until the 1970’s many hospitals had routines which included the provision that babies were not to be fed at all for the first 24 hours. My most poignant memory of obstetrics training as a final year medical student in Toronto (1969), aside from one Italian woman who sang opera beautifully when she was having labour pains, was what an incredible racket came from the nursery—babies crying and crying because they were not supposed to be fed during this time, and were not being fed, because that was the rule: nothing for 24 hours. As mentioned elsewhere, this approach was based on the observations of many nurses that babies fed formulas during the first twenty-hours often were cranky, frequently spit up or had diarrhea. Now that formulas are more like breastmilk from the point of view of concentration of ingredients, this is less a problem, and so everyone goes bananas if the baby has not fed for four hours. But trying to force a baby who may not be ready to take the breast, may result in the baby’s resisting, crying, and developing an aversion to the breast. If we become really really worried because the baby has not fed for six hours, the baby will often be started on supplements. This may further undermine the baby’s willing and ability to take the breast.
If however, it seems necessary to get the baby started feeding, finger feeding is a good method to both not interfere with breastfeeding, while at the same time wake up a sleepy baby. A baby usually will start sucking something in his mouth, even when he is quite sleepy. If he also gets some fluid, he will often wake up and be ready to feed. It is not necessary to use the finger feeding very long, only a minute or so sometimes, until the baby wakes up. In this situation it is not necessary to use formula. The fluid used, of course, should be expressed milk (colostrum) whenever possible. Expressing should begin as soon as it has been deemed necessary to feed the baby, for whatever reason. Even a few drops of breastmilk (colostrum) are worth giving to the baby, and can be mixed with sugar water so that it can be given easily (question of being able to get it up the tubing). If no milk can be easily expressed (remember a. in the first few days many women can express more by hand than the can even with the best industrial sized pump, and b. not being able to express any milk means nothing as far as present milk supply or milk supply to come is concerned), then sugar water is fine in this situation. The idea is not to give the baby sugar water or formula or plain water. We are using whatever we are using as a tool. It does matter if it is colostrum, since the baby gets many benefits from colostrum including a lot of antibodies and active white cells. And it does matter if it is formula, since the message is that this stuff is good, necessary, and helps heal your baby. Besides, it is perfectly conceivable that even one drink of artificial baby milk at this young age may set off a chain of events that will eventually lead to diabetes, for example. If the formula is necessary, fine, we give it. But it rarely is necessary in the first 24 hours or even 48 hours.
Some babies will not wake up when finger fed, but if they feed, they have at least gotten some fluids and some calories. Likely, they will be more alert for the next time they need to feed. Some babies, as they go longer and longer without fluids, will get sleepier and sleepier, rather than more and more upset. This is the danger when babies are only seeming to latch on when they go home.
In the first twenty four hours, however, this hardly ever occurs, and pressure to start feeding comes, essentially, from the fact that new mothers and babies are often leaving hospital within 24 to 36 hours after a normal birth. And I find this quite understandable. It is difficult for both the staff and the new parents to be faced with a 24 hour old baby about to go home who has never ever fed in his whole life. Given the scarcity of resources in many communities for followup of new mothers and their babies, the problem is not only difficult, but a potentially very serious one for the health of the baby.
Once the baby is alert and interested in eating, finger feeding should be stopped, and the baby then tried on the breast (using the best positioning possible). He may take it. If he does, fine. If not, pushing him to take it will not work—he will either go limp, or go ballistic.
Sometimes it will be helpful to use a lactation aid at the breast to help the baby latch on and stay at the breast. Again, expressed breastmilk is the best to use, followed by breastmilk diluted in sugar water, followed by sugar water, at least in the first 24 hours or so. This requires help and some skill, as the tube needs lining up along the mother’s breast as the baby latches on. If the baby sucks a couple of times, he will get something and may stay latched on. This technique, as well as other techniques to help latch on a reluctant baby, will be discussed later when we deal with getting the older baby onto the breast.
The baby can get all the fluids he needs, and all the calories he needs (if the mother is using colostrum), only with finger feeding in the first 24 to 48 hours. Finger feeding can be slow, but in the first couple of days, babies don’t need a lot of fluid or calories, and finger feeding will be adequate to the task.
24 to 72 hours after birth
Many babies who don’t latch on in the first 24 hours will do so during the second or third days, usually because the milk flow is increasing. Again, good positioning, as good a latch as possible, getting milk into the baby, encourages the baby to take the breast.
As during the first 24 hours, if there is urgency to get the baby onto the breast, the same techniques of good positioning and latching, lactation aid and finger feeding as were used during the first 24 hours can all be used.
After 72 hours
Once the baby is getting older than 3 days, his caloric requirements increase significantly. If the mother is able to express her own milk to provide all the baby requires, this is great. In some cases, banked milk may be available. But if the mother is not yet able to express enough for the baby’s requirements, it may be necessary to add formula. Seventy-two hours is not a “line in the sand”, but most babies will do fine with some expressed milk and some sugar water for the first 2 to 3 days of their life. However, feeding significant amounts of sugar water for more than the first 2 or 3 days is not good for the baby. It is for this reason, that expressing of milk should begin early, so that the mother develops a good milk supply, and so that colostrum will be available for feeding. Colostrum not only gives the baby immunity and nutrition, it helps the baby evacuate his meconium so that the risk of developing significant “not enough breastmilk” jaundice (see chapter on jaundice) is less.
Now what?
So the baby is 3 days old, now and still not latching on? First of all don’t despair. Keep working at it. Babies change, develop and learn. Breast tissue changes—it becomes more flexible, nipples elongate, or become “uninverted”. Although many lactation experts might recommend a nipple shield at this point (see photo), I feel strongly that this is not the right way to go. Nipple shields can be tried later, if other approaches have not worked, but not now. Using a nipple shield in the first week after the baby was born is, I believe, a way of saying, “I don’t know what else to do”. It is not giving time a chance to work.
A few principles:
1. A baby will usually latch on if he gets what he wants. What does he want? MILK. This is why it is so important that the baby come to the breast just so, with the lower lip as far away from the nipple as possible. Or, to put it another way, the part of the baby’s face which touches the breast first, is his chin (see photo or drawing). When the baby comes to the breast like that, he gets his gums under the milk sinuses and if he starts sucking, he will start to get some milk. The mother should help the baby get milk by compressing the breast as the baby comes on to the breast, so that he will get some flow as soon as he gets his mouth around the breast.
2. An angry baby will often not latch on no matter how hungry he is.
Sometimes mothers believe that if the baby is really hungry, he is likely to take the breast better. This is almost always untrue. The hungrier, or the more upset the baby, the less likely he is to take the breast. It is also not true that if the baby is hungry he will take his “less favourite side”. If the baby seems to prefer one side over the other, try first with the easier side, not the harder one. Or if the baby does not have a preferred side, but you seem to have more milk on one side than the other, start where you seem to have more milk.
3. There is no use continuing to push a baby into the breast if he has not latched on.
It is so difficult to avoid continuing pushing the baby into the breast if he doesn’t want to take it. The mother obviously wants the baby to take it and urges the baby into the breast as if continued pushing will make him do it. It won’t. On the contrary, the baby is likely either to get angry, or angrier still, or make actually go “limp” and seem to sleep. In neither case will he be more likely to take the breast. It is much better to let the baby come off the breast and retry than to continue pushing him into the breast. Of course, the initial arm movement to get the baby on the breast needs to be fairly vigorous, but continued pushing the baby into the breast will not do any good. You are much better to put the baby to the breast, and let him come off again, trying this six or seven times, on and off, rather than trying to keep him in the breast.
How do you know a baby is not latched on? A baby who does not suck, is not latched on, even if he has the breast in his mouth. Or if the baby slips off the breast, he is not latched on. Even if you are not sure if the baby has taken the breast or not, if the baby is not actually sucking, you are better to take the baby off the breast and start again. If the baby does make sucking motions, then compress the breast to give him some milk flow and he may start drinking. If he drinks, great.
4. You and the baby need lots of skin to skin contact.
Even if you cannot get the baby to latch on right away, skin to skin contact helps. Take the baby into bed with you. The baby should have only a diaper on, and you should be undressed from the waist up. This close contact may encourage the baby to latch on.
How do we get the baby to latch on?
If the baby does not latch on within the first 3 or 4 days, it is important to get help from someone who is experienced with helping babies to latch on. This is very important, as often, with skilled help, the baby will latch on. And sometimes, a baby latches on just once and there is no looking back. He got it and that’s it, he’s a breastfeeding superstar. It’s not always that easy, of course, but it happens often enough that it is worth the expense and effort. The sooner the baby gets on the breast, the more likely that he will continue getting on. I see too many mothers with 3 week old babies who are not latching on. This is waiting too long.
If the baby is not going to take the breast, there is no point in struggling for thirty or forty minutes. Take a rest after a few minutes. Try the other side, he might take it, but if he does not quickly take the second side, go to finger feeding. Not for the whole feeding, that is not the point of finger feeding. The point of finger feeding is to:
1. Calm the baby down. An angry baby will not take the breast better than a calm one, on the contrary.
2. To get the baby sucking as he would on the breast. Finger feeding has to be done correctly for this to work. That is why you need help from someone with experience.
When the baby is finger feeding well, you should be able to feel his tongue wrapped around your finger, and drawing backward. When you have the baby nursing like this for a minute or two, then try again at the breast. Of course, if you are worn out from trying or frustration, let him go longer with the finger feeding, until you feel up to trying again.
If the baby has not latched on with this feeding, you can either finish the feeding with finger feeding, or, with cup feeding. The main disadvantage of finger feeding is that it is slow. And like all alternative methods of feeding, the baby might get to like it too much. The chances are less than with the bottle, since finger feeding is frequently slow and the sucking motions the baby must do are different, but babies do also get “finger feeding spoiled”.
It is sometimes easier, if you have a helper, to have the baby latch on to the breast when the lactation aid (the system you just used for finger feeding) is line up along the breast with the end just at the end of the nipple. The tube will probably be full, as you may have just finger fed the baby. The baby will get faster flow as he attempts to suck and may just remain at the breast nursing. There should be no difference in how the baby is positioned or moved towards the breast because the lactation aid is being used. As far as everyone, including the baby, is concerned, this just a breast which has more flow than it had before. Thus, the helper or you should not be forcing the baby into the breast after the initial move. If the baby does not have the breast, let him come off and start again. He is less likely to get angry. It is better to go off and on the breast several times rather than try to keep the baby at the breast.
Sometimes, it is easier to get the baby to take the breast when you and he are lying down, side by side. Why, when most mothers find that feeding side by side is more difficult at first? I’m not sure, but, if it works, great. I have seen an Australian video which shows a one week old baby, latching on for the first time while in a bath with his mother. The baby is lying on the mother, skin to skin, both are immersed in warm water, and the baby just latches on, all by himself.
Don’t wear yourself out. Give it a few good tries, but save your strength, and don’t get too discouraged.
Avoid artificial nipples.
If at all possible, at this stage, try to avoid using bottles or pacifiers. However, do what you can. It is quite easy to use a cup , but, like many skills in life, it is necessary to learn how. And learning how is most easily done by being shown. Not all health professionals are even aware that a newborn baby can cup feed, so they cannot teach you. Still, if you must give a bottle, go ahead, but try to do it as little as possible. Keeping up your milk supply is more important than avoiding the bottle.
What if the baby still doesn’t take the breast?
There comes a time, when it is more important to maintain the milk supply than avoiding artificial nipples. For some mothers this time comes within a few days of birth. For others, the finger feeding is no problem, and they can keep it up for weeks. The main problem is that finger feeding is usually slow, though some babies can manage to do it as rapidly as if they were drinking from a bottle. Nevertheless, even when finger feeding is not a burden for the new parents, there comes a time to say enough. When something does not work, maybe something else is worth trying.
In my own practice, I believe it is worth changing the approach if the techniques above do not work by the time the baby is about 2 weeks of age. No timetable need be followed, and if the baby is close to latching on, it is not necessarily even advisable. Generally, however, I will then suggest to the mother to express her milk and give it by bottle or to use a nipple shield. A nipple shield is not always the solution, because a nipple shield is not always easy to use, but if it does work, it is easier for the mother than expressing the milk into a bottle and giving the bottle.
Remember! When the mother has an abundant milk supply, the baby will almost always latch on when he is between 4 and 8 weeks of age. There are definitely exceptions, but most will latch on. Be patient. It’s difficult to be patient, but it will pay off. One day at a time.
I will usually see the mother a week later, after she has used the nipple shield and/or the bottle, and try again. Often the baby will then start latching on. Indeed, it would appear that around the 2 or 3 week of age mark, any change seems to make a difference. It is almost as if the baby thinks, “Oh, there’s more than one way to get this stuff!”. Thus, if the mother is bottle feeding when she arrives for the first time at the clinic with her 2 week old baby, I will ask her to finger feed, just before the feeding, because it is unlikely the baby who is used to the rapid flow of the bottle will tolerate the slower flow of finger feeding for a whole feeding. And it is gratifying how many babies do latch on after a few days of finger feeding (just before the feeding), and indeed, sometimes, after one single session.
Keeping up your milk supply.
This is essential. As mentioned several times before, with an abundant milk supply available to him, the baby will almost always eventually latch on, no matter how he is fed.
If your milk supply is not abundant, it is, of course, more difficult. But most babies will still latch on, if the mother has good help. Even if you find you must supplement with artificial baby milk, once the baby latches on, you likely will find that your milk supply increases in response to the baby’s suckling, so that you may eventually not have to use supplements.
Even if the mother has an abundant supply, I sometimes suggest fenugreek and blessed thistle, and sometimes even domperidone, to increase her supply and rate of milk flow if the baby is not latching on. The greater the flow rate, the more likely the baby is to take the breast and stay there. (see section on herbs and domperidone).
And what if he never takes the breast?
Yes, this is unfortunate. But your milk in the bottle is better than formula in the bottle.
It might also be possible to continue breastfeeding with a nipple shield if this has worked, and I am aware of a few mothers who have used one for many months without problem. It is not the best solution, but it is better than expressing and giving, just for the time factor.
And, never say never. I am aware of a few mothers whose babies did not take the breast for 4 months and longer and eventually did take the breast, including one who took the breast for the first time when he was nine months old. This is surely some kind of record.
Keep offering the baby the breast, particularly when the baby is not ravenous, and when he is content. Keep him near you skin to skin whenever you can. Sleep with the baby next to you, with your breasts available to him. You never know, he may latch on in the middle of the night.
Finally, if this is your first who is not latching on, do not assume that what happened with the first is likely to happen with the second. Breasts change not only during the period immediately after birth, but also with the years, and with new pregnancies. So, if you were not able to get your first to latch on at all, get information before the birth of the new baby. Go to have your baby where it is known that the staff have experience with helping mothers breastfeed, and where the staff are sympathetic to your desire to breastfeed. And get help early from an experienced lactation specialist if it looks as if the baby is not taking the breast well.
The “nursing strike”
Some mothers and babies run into a problem, which for want of a better expression has been called a “nursing strike”. A baby, who up until then has been nursing relatively well, suddenly stops taking the breast. Even though obviously hungry, the baby will cry, scream and push away if the mother tries to put him to the breast. Often, the more the mother tries, the more upset the baby gets. This “nursing strike” occurs typically around 3 months of age, and also around 8 months of age, though there is some variability. It is not a common problem, but it is a most distressing one for the mother and the baby as well as the rest of the family.
The nursing strike may occur suddenly without prior warning, or gradually worsen over a few days. Typically the baby does not actually refuse to nurse all the time. He will, in fact, take the breast when he is sleepy, either going into a sleep, or coming out of a sleep, and he will nurse well at night. But though the baby is obviously hungry, when he is alert during the day, he may adamantly fight the breast. Many prefer sucking their hands and not drinking. The vast majority of these babies nurse well enough during the night or when they are sleepy that they continue to gain weight. Perhaps not as rapidly as previously, but the weight gain usually remains at least adequate and sometimes much more than adequate. These were almost always rapidly growing babies from the beginning and the slow down in weight gain may be only relative to what the mother was used to, and still quite good. Some babies I have followed with this problem have gained weight nursing only three or four times in 24 hours.
The nursing strike may last for only a short period of time, or it may go on for weeks. The majority of nursing strikes do not go on for weeks, but gradually get better over a few days to a week or two. Some stop as suddenly as some start.
This problem seems to be the problem of the mother with an abundant milk supply. I believe that the baby probably was not latching on well from the beginning, though, since I rarely see these mothers and babies before the nursing strike begins, I am only guessing here. Many mothers will say they and their babies had problems with an “overactive letdown reflex” (see chapter on Colic). Their babies would go to the breast, and when the letdown occurred, the baby would sputter, choke, and sometimes pull off the breast crying, from getting milk too quickly. This problem of the overactive letdown reflex then seems to get better for a few weeks, and then boom, the baby is on a nursing strike.
This problem is not caused by an ear infection, or thrush in the mouth. Thrush rarely bothers the baby, though occasionally it does.
This problem should be distinguished from the problem caused by the decreased milk supply some mothers experience around three months after birth. In some cases the decreased supply is due to the birth control pill. In others, there is no obvious reason. In this case, the baby wants to go to the breast, but quickly becomes frustrated at the breast and begins to pull. In other words, the baby goes to the breast, obviously wants to nurse, but pulls off and cries because he is not getting milk well. This problem of decreased supply and what to do about it has been discussed in the chapter “Not Enough Milk”. Note, however, that occasionally, babies on a nursing strike will go to the breast for very short periods of time, just long enough to take the edge off their hunger and then pull away. It may not be easy to distinguish this behaviour from the baby who is pulling off because the milk is not coming. This is another reason to know how to know the baby is getting milk (the open->pause->close type of sucking which tells you the baby is getting milk). If the baby pulls off while just nibbling on the breast, it is because he is frustrated, not because he is on a nursing strike.
Why does a nursing strike happen?
No idea. I have never heard an explanation that I find convincing. And I have never come up with a hypothesis that I felt even came close to explaining why.
What to do
Remember that the nursing strike will usually get better spontaneously. Remember too, that if the baby is breastfeeding well even three or four times in a 24 hour period, he will likely get enough milk to keep healthy. Six wet diapers in 24 hours is a good indication that he is not getting dehydrated. The diapers do not have to be soaking to prove the baby is maintaining hydration, though if they are not, he may not be gaining so well. However, should the baby become unusually sleepy, you should get help to make sure he is alright.
It is futile to try to force the baby to take the breast when he does not want to. Do not try. All that will happen is that the baby will get angrier and the chances are you will not get him to the breast in any case. Let him suck his hand if that is what he wants to do.
Try the baby on the breast when he is sleepy. This will often work. If he drinks at the breast, that’s good. When he starts nibbling use gentle compression to keep the flow going.
Make sure to take the baby into bed with you at night, with the baby in a diaper only and you undressed from the waist up. Skin to skin contact may encourage the baby to take the breast. Do not try to get through the night without feedings.
Sometimes the baby will take the breast if you walk around with him in your arms, in breastfeeding position, until he gets a little sleepy and then try him on the breast.
If you are using a pacifier, let him suck on the pacifier until he is calm and a little sleepy and then try him at the breast.
This is not the time to start a bottle or continue with the bottle. Your baby will almost always get enough with breastfeeding only, whatever little he seems to be doing. If you are truly concerned about his intake, give him your expressed milk with a spoon, eyedropper or cup.
This can be a trying time for everyone. Remember, though, that there is a light at the end of the tunnel. Soon your baby will be back to nursing better. Not always as well as he was before this all happened, but well enough.
The approach for the baby on a nursing strike at 8 months of age is similar. There is more leeway because most 8 month old babies are eating solid foods as well and your milk can be mixed in with the solids even if the baby refuses to take the milk directly from you. Nursing strikes at this age usually do not last as long as they do when the baby starts at three months of age.
A couple real situations
Situation #1: Not latching on and then a nursing strike
Anna brought her baby Samuel to the breastfeeding clinic when he was 9 days old. He was not able to take the breast.
Samuel was born after an uneventful pregnancy. The labour began just a few days before the due date, and was essentially also uneventful. Samuel’s birthweight was 3.5 kg (7lb 11oz). Samuel was grunting at birth and was kept in the special care for a few hours until the grunting disappeared. He was treated with antibiotics for two days.
Anna first tried Samuel at the breast a few hours after he was born, but he would not latch on. The mother was instructed on how to finger feed, which she did using sugar water (a).
When I first saw Anna and Samuel the mother was feeding some formula, but mostly expressed breastmilk. The baby was sometimes being finger fed, sometimes bottle fed. Samuel’s weight at this point was 3.55 kg (7lb 13oz) (b).
Anna has very large breasts, and the nipples are flat and difficult to grasp. Nevertheless, with my help, we were able to get the baby to latch on, using, as much as possible, “good positioning and ideal latching technique”. Samuel took the breast, fairly easily, and once he was no longer drinking at the breast, I introduced the lactation aid with the mother’s expressed milk in order to keep Samuel drinking at the breast.
Anna went home with the following plan:
1. She would “prepare” Samuel to take the breast with finger feeding. Only a minute or two of finger feeding is necessary. Then she would try him on the breast.
2. If Samuel took the breast, fine. If he took the breast but did not actually drink, to use breast compression and/or the lactation aid to keep him nursing.
3. Return in 1 or 2 days if he was still not latching.
Anna and Samuel returned the next day. Anna could not manage to get Samuel to take the breast (c). At the clinic, once again, the baby took the breast, but required the lactation aid still to keep breastfeeding. At this visit, the baby weighed 3.57 kg (7lb 13.5oz). Anna was encouraged to keep up the previous approach.
The next visit was six days later. Samuel weighed 3.69 kg (8lb 2oz). For the past couple of days, he was taking the left breast well, and was taking the right breast a little. The mother had developed soreness of the nipples, which was treated with the usual measures (improve latch, “all purpose nipple ointment”).
Over the next few days, the baby took the right side better and better. By the time the baby was 3 weeks old he was nursing very well. The mother returned to the clinic to learn how to breastfeed lying down, which she had not managed on her own (d). He weighed 4.66 kg (10lb 4oz), breastfeeding exclusively.
When the Samuel was 10 weeks old, Anna brought him again. For the past few days he had been nursing less and less well. And now he was refusing the breast most of the time. Nevertheless, he nursed well during the night, and sometimes, if Anna could try him at the breast when he was half asleep, he would also nurse. Though this was occurring a little earlier than usually, but the pattern was obviously that of a “nursing strike”(e). Anna followed our advice, which was to feed him when he was ready, and not try to force him to the breast, which was a futile exercise.
Samuel’s nursing strike lasted only a couple of days, and he was back at it. Anna ran into other problems, including a Candidal infection of the nipples and breast, which required 5 weeks of fluconazole, but she was eventually rid of it.
Anna nursed Samuel until he was over 2 years of age, and, at the time of writing, is nursing her second baby.
Notes on Situation #1:
a) The mother should have been encouraged to start expressing her milk as soon as it was decided the baby needed to be fed. Unfortunately, this was not suggested. Any colostrum could have been added to the sugar water, even a few drops would have been good for the baby.
b) The weight seems good, but nothing can be decided simply on the weight, as the baby was weighed on a different scale than the hospital scale.
c) This is not surprising. Samuel was able to take the breast when experienced extra two hands were there to help the mother. There was a lot new the mother and the baby had to learn, and it is not easy to take it all in at one sitting.
d) I think she came primarily to “show off” her beautiful baby.
e) Nursing strikes are not common amongst the babies who were refusing the breast early on. At least not in my experience.
Situation #2: Roger did it on his own
Catherine brought Roger to our clinic when he was 37 days old. He was refusing the breast. Roger was not tried on the breast until two hours after birth, despite the fact that he was well and the mother was well (a). When he was finally tried on the breast, he refused to latch on. The mother and baby were rooming in together. The baby was fed by finger feeding using formula (b).
Catherine was seen at another breastfeeding clinic, and no one was able to help her get the baby to latch on. She tried a nipple shield, but it did not work well (c). Catherine was expressing her milk and feeding Roger almost only her own milk, but because of difficulties expressing enough, she was also giving a little formula (d).
When I tried to help Roger to take the breast, he went ballistic. There was no way to get him even near the breast. Even holding him in “breastfeeding position” made him angry. There was obviously nothing to do today.
I told Catherine that she should not be discouraged, since many babies take the breast between the ages of four and six weeks (e). I was not completely confident because it had been a long time since I had seen a baby this resistant to taking the breast. Nevertheless, I suggested Catherine try him on the breast when he was content, and not try to push him to take the breast.
Not long after, I received this email (exact copy):
“My almost 8 week old non latching baby, FINALLY got on today for an HOUR!!! AND he has fed again, AND he is comfortable on the breast and sucking and swallowing vigorously.
“It is great to have him on after all that work.
“Yesterday I told him that if he would latch on I would breastfeed him until he was 2 or 3. Of course he can’t understand...but...who knows? It is so exciting. So, now you know a baby older than 6 weeks who has gotten on.” (f)
Notes on situation #2:
a) Two hours too late. I am not saying he definitely would have taken the breast had he been tried immediately after birth, but, he might have. We will never know. Most babies are ready and willing in the first two hours, and, some will “self-attach”.
b) Hospital staff should have encouraged Catherine to start expressing her milk as soon as it was decided the baby had to be fed. Even if she got drops only, this could have been used, dissolved in sugar water, and she would have understood that her breastmilk is very important. As it is, she got the message that formula is very important. Formula is not necessary during the first day or two except under extraordinary circumstances.
c) The nipple shield is not always easy to use. It should not be used except by lactation specialists who have experience with its use. The nipple shield can be a useful tool, but unfortunately, as with all tools, if it is not used correctly, it can do more harm than good. Starting a nipple shield on day 2 or 3 (which was not done in this particularly situation), is poor practice, in my opinion. It does not give time a chance to work.
d) A perfect example of how the pump does not get milk out of the breast as well as a baby who is nursing well, and why pumping is not a good way of knowing how much you can produce. Roger was able to be breastfed exclusively once he was on the breast.
e) This was really going out on a limb. After all the baby was almost 6 weeks old already. I would have been smarter to say between four and eight weeks of age.
f) Actually, I had seen a few babies older than 6 weeks who started taking the breast after months of not latching, but they were definitely the exceptions. If the mother’s supply is good, the baby will usually latch on all by himself between four and eight weeks of age.
The message? Keep your milk supply up. Keep at it. Get good help. Chances are it will work.
Written by Jack Newman, MD, FRCPC.