Oral Aversion in the Breastfed Neonate
Linda Killion Healow, BSN,
IBCLC and Rebecca Sliter Hugh, IBCLC
from Breastfeeding Abstracts, August 2000, Volume 20, Number 1, pp. 3-4.
Infants are incredibly oral
creatures. Not only is the mouth the preferred route of caloric
nourishment (although essential in some circumstances, gastric
feeding tubes and IVs are less-than- ideal substitutes), but it is also
the way newborns most acutely sense and come to know their new
environment. Infants' mouths can make sounds to let their
needs be known. The mouth serves to satisfy hunger and thirst. The simple act of suckling can
relieve newborns' tension and calm
their fears. The gratification and
safety an infant feels when suckling is immense. Newborns' mouths are their first consistent avenue to access extrauterine bliss. Mobbs states, "The mouth is the
most sensitive organ and the one over which the infant has the most
control."1 As needs are met, a budding mastery over the
environment emerges, and newborns learn that the world is a good
place and they are safe. Thus, newborns' mouths provide the
key first step to learning about love and trust.
The oral experience is also an
integral part of how the newborn learns to recognize his
or her mother. As Ruth Lawrence observes, "Comfort
sucking and formation of nipple preference are genetically
determined behaviors for imprinting to the mother's nipple. The
recognition of the mother is at first through the distinctive features
of the nipple. Although imprinting is multisensory and
varies from species to species, it is oral/tactile for the human and
other higher mammals."2 Thus newborns' mouths are
"virgin" territory. Although the fetus experiences taste and
possibly finger sucking in utero, nothing "foreign
" enters the mouth before birth. A noxious oral experience in the early days of
life is likely to leave a more damaging impression than a
similar experience taking place later in a baby's development. Based
on clinical observations, Klaus and Kennell state that "affectional
ties can be easily disturbed and may be permanently altered
during the immediate postpartum period."3
Widstrom found that gastric suction disrupted prefeeding behavior in
healthy term infants.4 In addition to the introduction of
an object into the mouth, other sensory experiences may also be
harmful. Herbst has shown that taste, odor, and visual stimuli all
have an effect on suckling.5 Because of this, a newborn's
mouth and feeding behavior must be treated with the utmost
respect. While procedures such as inserting a feeding tube or
suctioning a newborn may be necessary to provide quality
health care, they are, nevertheless, invasive.
And while any oral
intervention is less than ideal, a procedure that is roughly done,
however inadvertently, qualifies as an invasion. Some lactation
consultants, faced with the challenges of persuading
justifiably reluctant newborns to take the breast, have described
this type of oral invasion as akin to rape.
One consequence of any type of
poorly tolerated oral contact can be oral aversion, also
referred to as oral-tactile hypersensitivity.6 This outcome
is a very real possibility when a baby's mouth has been traumatized.
Wolf and Glass state that oral-tactile hypersensitivity and
aversive responses can be caused by immaturity and illness, delayed
introduction of oral feeding, and by unpleasant oral-tactile
experiences.6 Oral aversion leaves the baby in actual danger. An
infant with oral aversion may not take anything into the mouth;not
the breast, a pacifier, bottle nipple, spoon, or finger. Some
infants also will not tolerate anything touching their lips, such
as a cup. Infants with an aversion response go through a
period of relative oral deprivation until the aversion subsides. This
is a serious situation, and an ounce of prevention is worth far
more than a pound of cure. The infant's oral aversion may
also adversely affect the mother's perception of her
abilities. The infant's strong negative response to oral stimuli may lead
the mother to feel that her baby is rejecting her. The intricate
bonding feedback process in which mother and newborn learn to recognize each other via oral, tactile, and olfactory modes is short-circuited. Klaus and Kennell note that these disruptions to mother-infant bonding may affect the mother's behavior for the first year of the infant's life,
even when the infant's aversive
behavior has ceased.3
Oral aversion and the potential
for maladaptive imprinting are rarely discussed in
conjunction with infant feeding and newborn care. However, in many
cases the development of oral aversion can be prevented. One of
the most common practices newborns encounter immediately
following delivery is suctioning of the airway. NICU
nurses have identified suctioning as noxious and possibly painful
because it involves potential tissue damage and often elicits
responses that resemble pain. 7 In one study of low birthweight babies,
75 percent of infants displayed all 4 of the specified
signs of pain when suctioned, and 100 percent of the infants
displayed 3 of 4 signs of pain.7 In newborns, any oral discomfort may
cause an aversion to subsequent stimuli touching the
mouth or lips, possibly causing more pain.6
Lawrence notes that aggressive
suctioning may be related to the development of conditioned
dysphagia. Conditioned dysphagia is learned, acquired, and
maintained when a negative stimulus is associated with the
act of swallowing.15 The diagnosis of conditioned
dysphagia may be difficult to make and requires thorough testing, which
may in turn aggravate the problem. The neonate may have
negative responses to the taste of a barium swallow or invasive
exams.8 Intubation for diagnostic study has the
potential to cause damage to the infant's delicate anatomy, causing
pain-related responses to oral stimuli or dysphagia.7,9 Aggressive
suctioning and nasogastric feeding tubes in the NICU have also been
associated with conditioned dysphagia.2 Birth history is
highly relevant.
In addition to suctioning of the
newborn airway and naso-or orogastric feeding tubes, other
potential causes of oral aversion include gastric suctioning,
inappropriate use of rubber nipples, and the inappropriate use of
fingers in finger feeding, assessment of the newborn's mouth, and in
attempts to alter sucking motion. In some
cases, it is not possible
to avoid interventions at birth that involve the baby's
mouth. Some infants do need suctioning to open the airway
and/or intubation to initiate and sustain respiration. Infants born
prematurely or with congenital anomalies are unavoidably at an
increased risk of developing oral aversion because of the many
procedures necessary for life support. Infants with feeding
difficulties whose mouths must be checked carefully for physical
anomalies are also at risk. If suck assessment is indicated, the
evaluation should be performed by a practioner specifically trained
in this procedure, as this again is a situation where an object other
than the mother's nipple is being placed in the baby's mouth.
The evaluation, assessment, and
treatment of feeding difficulties in newborns all
carry the potential of exacerbating the problem. For instance, in some
hospitals finger cots must be used for finger feeding an infant.
Infants do not always respond well to the taste and feel of rubber
in their mouths, and thus reject this feeding method.10 Other
artificial methods of feeding may also meet with rejection due to taste
and feel.6 Infants may also reject the taste of certain fluids such
as artificial baby milks or glucose water.5
Supportive breastfeeding
protocols such as the Baby Friendly Hospital Initiative and
the American Academy of Pediatrics' policy statement
"Breastfeeding and the Use of Human Milk" recommend early
initiation of breastfeeding, uninterrupted
feedings, and
avoidance of artificial nipples and procedures that have the
potential to traumatize the infant, in particular, the oral cavity,
esophagus, and airways. 11, 12 Adherence to these
recommendations would greatly decrease the occurrence of oral aversion. The
potential for problems is decreased by allowing the infant
to establish suckling first at the breast, not on a finger, pacifier,
or artificial nipple. Many studies have demonstrated a
negative impact on the initiation and duration of breastfeeding when
artificial nipples, pacifiers, and finger sucking are introduced
early in life.13,14
The cardinal rule of medicine is
"first, do no harm." Procedures considered routine in
some facilities, such as suctioning, supplemental feeds, and
introduction of pacifiers or dummies, have proven to be not as
risk-free as is widely assumed. Not only do these
procedures have a potential negative effect on breastfeeding
initiation and duration, they may in fact cause real harm to the baby or in
some cases prevent successful breastfeeding.
Fixing a problem once caused may
be difficult and costly. The cost of a lost breastfeeding
relationship cannot be measured in dollars alone or even in days
of hospitalization. It may have long-term negative emotional,
developmental, and health effects on both mother and baby.
Linda Killion Healow
lives in Billings, Montana, where she works
privately as a nurse/lactation consultant. She is a long-time
La Leche League Leader and coordinator of continuing education
events for La Leche League International and the United
States Western Division of LLL.
Rebecca Sliter Hugh,
editor of BREASTFEEDING ABSTRACTS , is a lactation
consultant in Geneseo, Illinois, a long-time La Leche League
Leader, and a frequent continuing education speaker.
References
1. Mobbs, E. J. Human imprinting and breastfeeding: Are the textbooks deficient?
Proceedings 16th Annual Society for Psychosomatic Aspects of Reproductive Medicine, Polkobin, South Wales, March 1989.
2. Lawrence, R. A. and R. M. Lawrence. Breastfeeding: A Guide for the Medical
Profession.5th ed. St. Louis, MO: Mosby, 1999.
3. Klaus, M. G. and J. H. Kennell. Maternal-Infant Bonding, St. Louis, MO: Mosby, 1976.
4. Widstrom, A. M. , A. B. Ransjo-Arvidson, and K. Christensen. Gastric suction on healthy newborns and infants: Effects on circulation and developing feeding behavior. Acta Paediatr 1987; 76: 566-72.
5. Herbst, J. J. Development of suck and swallow. J Pediatr Gastroenterol Nutr 1983; 2 (suppl 1): s131-35.
6. Wolf, L. S. and R. P. Glass. Feeding and Swallowing Disorders in Infancy. San
Antonio, TX: Therapy Skill Builders, 1992.
7. Evans, J. C. , D. G. Vogelpohl, C. M. Bourguignon, and C. S. Morcott. Pain behaviors in LBW infants accompany some "nonpainful" caregiving procedures. Neonatal Net 1997; 16(3): 33-40.
8. Di Scipio, W. , J. K. Kaslon, and R. J. Ruben. Traumatically acquired conditioned dysphagia in children. Ann Otol Rhinol Laryngol 1978; 87 (4 pt 1): 509-14.
9. Weiss, M. H. Dysphagia in infants and children. Otolaryngol Clin North Am 1988; 21(4): 727-35.
10. Riordan, J. and K. G. Auerbach. Breastfeeding and Human Lactation. 2nd
ed. Sudbury, MA: Jones and Bartlett, 1999.
11. Baby Friendly Hospital Initiative. Ten Steps to Successful Breastfeeding from WHO/UNICEF. Protecting, Promoting, and Supporting Breastfeeding: A Special Role of Maternity Services. A joint WHO/UNICEF statement. Geneva: World Health Organization, 1989.
12. American Academy of Pediatrics Work Group on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics 1997; 100(6): 1035-39.
13. Righard, L. and M. O. Alade. Breastfeeding and the use of pacifiers. Birth 1997; 24: 116-20.
14. Victora, C. G. , D. P. Behague, F. C. Barros et al. Pacifier use and short breastfeeding duration: Cause, consequence, or coincidence? Pediatrics 1997; 993:445-53.
15. Di Scipio, W. and K. R. Kaslon. Conditioned dysphagia in cleft palate children after pahryngeal flap surgery. Psychol Med 1982; 44: 247.
Last updated Friday, September 15, 2006 by njb.
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