Helping a Mother with a Baby Who Is Reluctant to Nurse
A challenging situation can become a rewarding experience
when a Leader knows how to help.
Karen Zeretzke, MED, IBCLC, RLC
From: LEAVEN, Vol. 35 No. 5, October-November 1999, pp. 99-103
Ed. Note: We provide articles from our publications from previous years for reference for our Leaders and members. Readers are cautioned to remember that research and medical information change over time.
One of the most frustrating situations a Leader can face is trying to help a mother who has a healthy, full-term baby who does not seem to know what to do when offered the breast. For whatever reason, the baby seems unable or unwilling to latch on and breastfeed, or falls deeply asleep immediately after latching on.
The mother may feel demoralized and may even believe her baby doesn't like her. She may think she isn't a good mother because she doesn't seem to be able to comfort or feed her baby. She might feel that her baby doesn't like breastfeeding. Or even think that wanting to breastfeed her infant is not the right thing to do because of how her baby is acting. She may think she is being selfish by continuing to try to nurse her little one.
A Leader can share possible explanations for the baby's reluctance to nurse and offer encouragement that recognizes the mother's likely sleep-deprived and emotional state. A Leader may also offer practical suggestions to improve the situation. Once a mother can identify some possible causes for her baby's non-nursing behavior, she is more apt to be understanding and find the patience to work through the situation until it is resolved.
There are several categories of reluctant nursers:
- babies who resist the breast
- babies who belligerently resist the breast
- babies who cannot latch on
- babies who do not stay attached
- babies who will not suckle
Sometimes these babies latched on and fed well immediately after birth; other times they have never nursed will. Some feeding reluctance may resolve with tincture of time; other times the baby may benefit from some intervention. Waiting to see if the newborn will spontaneously feed at the breast may be fine for most babies for the first 12-24 hours, but after that, he must be fed. Rule #1: Feed the baby!
If the mother can hand-express or pump even drops of colostrum, that accomplishment should be greeted with enthusiasm and the colostrum offered to the baby on a small spoon or even dripped on a clean finger to allow the baby to suck or lick it off. Pumping or expressing as regularly as the baby needs to eat is important if he isn't actively nursing to help establish the mother's milk supply. The amount of colostrum a mother produces varies widely; every drop is valuable. If parents are not comfortable feeding by spoon, then a cup, eyedropper, small syringe or tube feeder on a finger (finger-feeding) may be used.
Avoid placing the baby in a nursing position when administering medical treatments, drawing blood or performing other procedures that may cause the baby discomfort.
Babies Who Resist the Breast
In general, one of the best remedies for babies experiencing a reluctance to nurse is skin-to-skin contact. This can stimulate the baby to awaken and know he needs to feed. The mother can strip the baby down to his diaper and allow him to snuggle against her bare chest. Tuck a blanket or sheet (or a large t-shirt) around them both if more warmth is needed. This skin-to-skin contact comforts both mother and baby and allows them to become intimately acquainted, relax together, and fall in love with each other.
Sometimes refusal to nurse may simply reflect that the baby is too sleepy to wake up and make the effort. After the first hour or so of post-birth quiet alert time, most babies sleep very soundly for several hours - labor is rough on babies, too. Insisting on feeding the baby during this time may result in what seems to be reluctance to nurse; waiting a few hours until the baby naturally wakes up may make all the difference.
if the mother was exposed to medications during the birth, or is taking strong medication for pain, her baby may be sleepy and need stimulation to awaken to eat. Skin-to-skin contact is very helpful to arouse a sleepy baby. Another idea is to repeatedly - and gently - sit the baby up by bending him at the hips and laying him back down. This is known as the "doll's eyes" technique because it is reminiscent of watching a doll's eyes open and close when it is lifted up and laid down. Although this will usually wake the baby, it does not guarantee he will be very happy when he awakens.
Nipple Preference or Suck Confusion
Although not well documented in the literature, many of those who work with babies are convinced that certain babies can become confused when they have been introduced to artificial nipples, dummies, pacifiers or soothers, their own fingers or thumb - anything other than mother's breast - before four to six weeks of age. (Some babies actually seem to be born with suck confusion from sucking on handy body parts in utero.) In the BREASTFEEDING ANSWER BOOK Kittie Frantz, retired La Leche League Leader and pediatric nurse practitioner, is quoted as saying that 95 percent of all babies will become confused if given artificial nipples in the first three or four weeks of life.
This nipple preference fortunately does not affect all babies, but since it is impossible to predict which babies are vulnerable to becoming confused, it works best to treat all babies as if suck confusion were a possibility. Teaching a baby who demonstrates nipple preference to accept his mother's breast and suck properly can be tedious and difficult; it is much better to avoid the opportunity to develop a preference for something other than his mother's breast. After four to six weeks of exclusive breastfeeding, most babies can transition well between breastfeeding and using artificial nipples.
Why does this nipple preference/suck confusion happen? Some theories suggest that since artificial nipples require no particular coordination to extract liquid, the baby's suck/swallow mechanism may be weakened. The baby may become lazy and not wish to work for his milk, since breastfeeding requires a specific set of actions. Most artificial nipples are designed to drip at the rate of one drop per second when the bottle is inverted, which can teach the baby to either thrust or hunch his tongue to block the hole in the nipple and slow the flow of milk. Any movement of tongue, jaw or lips results in milk entering the mouth and the baby's placing his tongue forward is a defense mechanism against choking.
Rubber or silicone teats are firm; human nipples are not. Some babies seem to be waiting for that firm feeling before they are willing to suckle. Artificial nipples are far more inflexible than human nipples and some babies get used to that feeling. Other babies try to push their mother's nipple out of their mouth.
Signs of suck confusion may include:
- The baby opening his mouth but not latching on;
- The baby shaking his head from side to side, rearing back, looking for the nipple and appearing puzzled;
- The baby reacting by screaming and/or arching his back;
- The baby not opening his mouth widely enough to latch on to the breast;
- The baby's tongue not extending to the lower gum line, but instead being retracted or raised;
- The tongue not curling around the nipple the way it should (like the bun around a hot dog);
- The baby seeming to latch on well but not suck.
Suggestions for Helping a Baby with Suck Confusion
Whatever it is called and for whatever reasons it happens, the important thing is to make it go away! Since there are many ways a baby reacts to suck confusion, there are varied suggestions to work through it. First, be sure the baby's nutritional needs are being met with either expressed breast milk or artificial baby milk - remember Rule #1: Feed the baby! Suggest discontinuing all teats/nipples and dummies, soothers or pacifiers, rubber or silicone, and using other artificial feeding methods such as cup feeding, finger feeding, or using a syringe or eyedropper to feed the baby. Remind the parents that much, much patience and understanding will be needed; this may be a good time to reiterate some of the many benefits of breastfeeding.
Babies who are not desperately hungry are more cooperative at feedings, so suggest that the mother watch for early signs of hunger. These signs include REM (Rapid Eye Movement) sleep, where the baby's eyes are moving rapidly under his closed lids; lip movements, especially those that also involve the tongue; turning the head back and forth and bringing the hands up toward the face. Sometimes a baby will actually find a fist, finger or thumb and suck vigorously. Remind the parents that crying is the baby's last hunger cue - if crying does not produce a feeding, the baby will continue to cry until he is so exhausted that he will fall asleep, hungry and weakened by lack of nourishment.
For babies whose tongues are retracted (not extended over the bottom gum line), using the "Charm" hold before attempting to breastfeed is often helpful, since gravity is working with the parent (see box).
Flexing the baby's hips is relaxing and holding him in such a way to continue this flexion can be beneficial. In the cradle hold, the mother can snuggle the baby's legs under her arm, curving him around her body. in the clutch or under-the-arm (also known as football) hold, the baby's legs should extend upward, so the soles of his feet are facing the ceiling. The mother may need a pillow behind the baby's bottom if his torso is not long enough for his hips to reach the mother's backrest.
Trying to feed the baby as he is just awakening or very drowsy works well for many families. As we drift to sleep or awaken, we are in a more primitive state of mind and since breastfeeding is a survival behavior for babies, sometimes they revert to feeding well at this time. Co-sleeping makes it easier to recognize early hunger cues and either wake the baby to feed or become aware of baby's self-awakening.
Babies who Belligerently Resist the Breast
These babies don't just refuse the breast, they are quite adamant about doing so. There is usually no identifiable cause and these little ones behave this way from the moment they are born. There is generally nothing unusual about the pregnancy, labor or delivery. There are no evident medical problems. But the baby vehemently objects to being asked to breastfeed - and often to being held as well. These babies don't feed particularly well no matter how they are fed and their parents may have quite a job just being sure the baby gets enough milk. These babies are often very fussy and colicky. They can tolerate little stimulation and they often sleep a lot.
Mothers of such babies often feel that they are somehow responsible for what they perceive as their baby's rejection of them. It is essential for the mother to realize that, for whatever reason, the problem is the baby's, not hers. She will need much emotional support as well as practical suggestions. It may be reassuring for the mother to see that her baby behaves in the same manner when others handle him - that it's not just happening to the mother.
It can be difficult to get a baby who exhibits this distressing behavior to take the breast. It will often take several weeks and the mother will need to establish and maintain her milk supply by frequent, scheduled pumping (preferably double-pumping with a hospital-grade electric pump) while using other means to give her baby her milk. These feeding times may be stressful if the baby doesn't feed well. Using a bottle may be the only choice the mother feels will work for her, as she may view other alternate feeding methods as too troublesome and/or time consuming. Once the baby is willing to go to the breast, any suck confusion can be rectified. For these infants, using the method that is most acceptable to the baby and his family is paramount. After presenting options for alternative feeding methods, remember to acknowledge the mother's difficulties and encourage her to verbalize her goals. Leaders need to accept the mother's decision and work from there to assist her to meet her goals. Human Relations Enrichment (HRE) skills can help a Leader give the mother the encouragement and information she needs to continue.
The mother may also need to simplify her life during this period. A Leader can act as a sounding board to help the mother decide which tasks are essential that she do and which ones she could delegate to others or simply ignore for a while.
If the baby is not content being held, feeding him will likely be quite nerve-racking for both the parent and the baby. He may do better if he is fed in an infant seat or a carseat rather than in the parent's arms. The mother may wish to enlist helpers for some feedings to reduce the anxiety she is experiencing.
The revised BREASTFEEDING ANSWER BOOK lists nine stages of observed behavior through which a baby progresses on his way to breastfeeding well:
- The baby aggressively fights the breast.
- The baby cries more when being held than when he is put down.
- The baby is willing to be held in some positions, even if not in a cradle hold.
- The baby tolerates being held in the cradle hold.
- The baby will attempt to root.
- The baby will lick at the milk on the nipple.
- The baby will attempt to suck, using an in-and-out movement.
- The baby will take milk at the breast (using a nursing supplementer, eyedropper, or feeding syringe).
- The baby nurses well, even before the let-down occurs.
Using these behavioral guidelines, the Leader can help the mother document the progress her baby is making. She can suggest what to look for next. She can give suggestions to support and encourage the mother through each stage. When mothers can acknowledge progress, they are often motivated to continue working toward having a breastfeeding infant.
Babies Who Cannot Latch On
Some possible causes of babies who cannot latch on are birth trauma, reactions to medications the mother has been given in labor or postpartum, unsuitable handling of the baby, inappropriate positioning of the baby, the baby's tongue not positioned properly, baby's mouth not opening widely enough, maternal nipple or breast anomalies, engorgement, neurological impairment, jaundice, babies who are small for gestational age, of low birth weight or low stamina and babies with cleft palates, high palatal grooves, or a short frenulum (tongue-tie).
Babies who have had a difficult or traumatic birth, had forceps or vacuum suctioning used in the delivery or whose heads have molded more than normal may experience a disruption in the cranio-sacral nerves, which are essential to breastfeeding. This is usually transient, although it may take a few days to resolve. For more resistant cases, many lactation consultants have suggested cranio-sacral therapists with good success.
Mothers who have had analgesia or epidurals during labor - especially more than once - often have babies who are very sleepy. Strong painkillers postpartum may have the same effect. Skin-to-skin contact will help wake these sleepyheads and the parents need to be sure that the baby wakes and is fed often until the medications wear off and the baby is waking on his own. Occasionally a mother will feel obligated to finish the bottle of pain relievers the doctor has prescribed. A mother may wish to ask her health care provider about taking whatever over-the-counter analgesic works for her to relieve a bad headache and see if that is strong enough to relieve her discomfort.
Handling the baby gently and respectfully will assist him in nursing - and in learning to trust the world. Many babies take exception to having the back of their heads touched, so supporting the head with the thumb under one earlobe and the middle finger under the opposite earlobe works well. (The index finger rests alongside the middle finger.) This gives the mother excellent head control as well as avoiding touching the back of the baby's head. Babies dislike being pushed to the breast. Shoving a baby's face into the breast generally makes him angry and uncooperative.
For babies who cannot seem to latch on, encourage the mother to use good positioning techniques. The side-lying or clutch (under- the-arm) holds are often preferred as they give the mother more control over the baby's head. It is necessary to offer the baby sufficient breast tissue when he latches on so he is able to get milk, so he needs to open his mouth very wide. Tickling the inner sides of his lips with the nipple, or running the nipple along his upper lip facilitates this wide open mouth. Colostrum or milk may be expressed onto the baby's lips to encourage him to lick his lips and the nipple to familiarize himself pleasantly with pre-latch behavior. His tongue must be down toward the floor of his mouth (rather than up toward the roof) for latch on to be effective.
Breasts and nipples come in a wide variety of shapes and sizes. What may seem unusual to a Leader or lactation consultant may work very well for a mother and baby. Most babies will adjust to their mothers' nipples - after all, those are the only nipples the baby has ever known! Occasionally, though, there will be mothers who have nipples larger or longer than can be accommodated by a newborn baby's mouth. They may need to express their milk and feed it to the baby by alternate means (cup, finger or even bottle with a slow-flowing teat/nipple with a wide, bulbous base which teaches the baby the open-mouth technique needed to more easily transition to breastfeeding) until his mouth has grown enough.
Engorgement is usually limited by good breastfeeding management - emptying the breasts on a regular basis, "early and often." It is much easier to prevent engorgement than to treat it. Discerning between normal fullness when the mother's milk increases and true engorgement should also be discussed with the mother. While all engorgement interferes with the baby's ability to compress the areola and elongate the nipple to breastfeed, severe engorgement may also permanently shut down parts of the breast from making milk.
If some engorgement does occur, the mother can use massage, wet heat and hand expression to soften the areolar tissue. Cold packs may help the mother feel better between feedings. Engorgement is usually self-limiting, lasting only a few days—long, long days for the mother. Short-term use of cabbage leaves applied to the breasts may also afford the mother relief.
Babies Who Do Not Stay Attached
Infants who can latch on but not stay on the breast may do so because they cannot breathe through their nose, have an undiagnosed cleft palate, are poorly positioned, have their lips tucked in rather than flanged out, are unable to deal with an overactive let-down reflex, find their mothers' nipples difficult to grasp, or are hypotonic (poor muscle tone or "floppy" babies).
Observe the baby before he feeds to determine if he is a mouth breather. This could mean that he is not able to breathe through his nose. Reasons can include anything from a physiologic blockage to too much mucus. Dripping a few drops of colostrum, human milk or infant saline nasal solution in the nose and then gently suctioning may clear mucus and allow the baby to breathe.
Clefts of the soft palate are sometimes missed during the initial well-baby exam and discovered by those who are trying to ascertain why the infant is not nursing well at the breast. A small flashlight illuminates the back of the baby's mouth to determine if the palate is intact.
Poor positioning can result in babies who are physically unable to remain at the breast. Be sure the mother is using effective positioning, the baby is tucked in close to her body, and the baby's body is aligned so he can suck and swallow efficiently. She may need to support her breast for the first few weeks until the baby becomes a more adept feeder and gains more control of his head.
Some babies tuck in one or both of their lips when they latch on, rather than flanging them outwards to make a good seal. This can cause a baby to become easily detached from the breast. The mother can usually see if the top lip is caught under and flip it out with her finger; she may have to feel for where his bottom lip is. A little practice allows a mother to become quite adept at identifying tucked lips and maneuvering them to project outward while the baby continues to breastfeed.
Mothers who have an overactive letdown can hand express until their milk lets down and let the milk flow into a towel until it stops spraying and then offer the breast to the baby. They can also try feeding on just one side per feeding (unless the baby seems unsatisfied). In the early days, the side not used can be expressed or pumped to minimize engorgement; if the baby continues feeding on only one side per feeding, the mother's milk supply will adjust.
Occasionally a mother has one or both nipples that are hard for her baby to grasp. She may have large nipples; flat nipples (either naturally or from engorgement); nipples that are dimpled; nipples divided by fissures; nipples damaged by trauma or surgery; nipples that have an unusual shape, etc. Usually patience and support will result in successful breastfeeding, although alternate feeding methods may need to be used until the baby learns to attach well.
Suggestions for mothers with babies who don't stay latched on include: offer no teats/nipples or dummies/pacifiers; maintain excellent positioning of mother, baby and breast; limit engorgement by using good breastfeeding management techniques; express milk until the let-down, then offer the breast so the baby gets milk with any sucking he does; be sure the baby's head is not over-flexed; use the clutch hold with the mother's hand well behind the baby's ears; and use artificial feeding methods to feed the baby until he can stay attached and complete feedings on his own.
Hypotonic or "Floppy Babies"
Hypotonic babies have poor muscle tone and are difficult to position well. They are often characterized by apathy and disinterest in breastfeeding - not just for a feeding or two, but all the time. Floppiness is often associated with babies who have Down syndrome, cerebral palsy, spina bifida or hydrocephalus.
Good support for the baby, the breast and the mother is essential. Using the Dancer Hand position to support the baby's chin can be useful. Supporting the weight of the breast so it doesn't rest on the baby's face helps, too. Placing a rolled-up washcloth between the underside of the breast and the chest wall may help support the breast without the mother having to physically support its weight. Sublingual pressure - placing the fingertip or thumb firmly under the baby's chin on the soft tissue inside the horseshoe-shaped jaw bone under the baby's tongue - can also be effective. The finger may be jiggled or "pumped" to stimulate the baby and to help keep him nursing.
Each feeding should begin at the breast. If the baby tires before he has received enough milk, alternate feeding methods (cup, finger feeding, eyedropper or syringe) may be used to keep feeding times enjoyable for both mother and baby. As the baby matures, he may become more able to sustain breastfeeding for longer periods.
Babies Who Will Not Suckle
Babies who are ill, premature, weak, small for gestational age (SGA), not hungry, very sleepy or whose sucking needs were met with a dummy, soother or pacifier or a handy body part may not be willing to suckle.
Sometimes a baby who will not suckle is ill. He may have a fever, a virus, or an infection. A persistent high-pitched, keening/wailing cry often can be a sign that the baby is sick. The parents should be encouraged to take him to see his health care provider, hospital, or clinic for medical assessment. A white blood count should either confirm or rule out an infection. Once the baby is feeling better, he usually begins feeding well.
It is especially important to offer only the breast to babies who are not willing to suck. Healthy babies are born knowing how to suck; it is a survival skill. However, meeting the baby's inborn need for sucking elsewhere than the breast can negatively affect breastfeeding. Expressing milk on the nipple to entice the baby and let him taste what he is missing may be effective. Watching the baby for the early hunger cues discussed earlier in this article and then rousing him to eat may also work.
When the baby is alert, he should be offered the breast. If he is not willing to suck at the breast, he can be fed using alternative feeding methods that do not include sucking.
General Management Suggestions for Reluctant Nursers
Support, encouragement and positive reinforcement for a mother with a baby who is not nursing well are critical to her breastfeeding experience. Much patience is needed by the mother and her family and the Leader. The Leader will not only find herself providing information to the family, but also being their breastfeeding cheerleader. Mothers who are pumping or expressing and working through feeding difficulties are under great strain. They are also likely grieving not having the perfect baby and the perfect breastfeeding experience they envisioned while pregnant. A big part of the Leader's job can be to provide emotional support as well as respecting and affirming the mother's decisions.
Using pumped or hand-expressed milk instead of artificial baby milk whenever possible gives the baby the very best nutrition to help him grow, mature and develop until he is able to effectively breastfeed. Many mothers who choose to use a pump find double-pumping (pumping both breasts simultaneously) is more efficient than one-side-at-a-time pumps. Hospital grade pumps are recommended when a baby is not nursing well enough to maintain his mother's milk supply at the level of his needs.
Suggestions that are soothing and pleasurable for both mothers and babies include rocking, snuggling, skin-to-skin contact, listening to soothing music and bathing together These offer both physical and mental relaxation ... and can lead to babies beginning to breastfeed.
A technique known as "rebirthing" has been helpful for many nursing couples. Mother draws a nice warm bath at least deep enough to cover her knees. The bathroom is darkened, perhaps lit with candles with appealing scents. Quiet, calming music may be softly played. The mother gets in the bathtub and her helper hands her the baby. The mother floats the baby in the water, tummy up, supporting his body firmly and holding his face always above the water. After a time, the mother picks up the baby and snuggles him at her bare breasts. Many times the baby will nuzzle, then latch on and nurse! The mother can place a small towel over the baby and splash warm water from the tub on him to keep the baby nice and warm. When the mother is ready to get out of the tub, her helper can take the baby and wrap him in a towel and diaper him while mother dries off. They can continue their snuggle in a favorite chair. Even if this doesn't result in the baby nursing, it is an enjoyable experience for both the mother and the baby.
Mothers who are anxious about their babies often neglect themselves. A Leader can remind the mother that she needs lots of rest, good nutrition and fluids to satisfy thirst. Suggest the mother or her partner prepare healthy finger snacks which the mother can eat one-handed while she is holding or feeding the baby. A large thermal cup can be helpful to keep water or juice handy for the mother. Because some mothers feel that caring for themselves can be selfish, a Leader may provide reassurance that taking good care of herself is the first step in helping the baby. If the nurturer is not herself nurtured, it may be more difficult for her to care for her baby.
There are both medications and herbs which might help a faltering milk supply. The mother can check with her health care provider or a certified herbalist if she chooses to explore this possibility. If a drug or herb is suggested, a Professional Liaison Leader can check resources regarding its effects on the infant.
For at least the first week, record keeping is critical. Some of the things that need to be noted each day are maternal intake of both liquids and food; baby's intake (frequency and duration of feedings and frequency and amounts of any supplements used); baby's output of both urine and stool; maternal fatigue level; and every few days, the baby's weight and length.
It is important to follow up with the mother. At the end of the week, the Leader can call and ask the mother how things are going, how she feels about the level of support she is receiving at home, her confidence level, the baby's response to breastfeeding and suckling, the number and frequency of wet and soiled diapers, the frequency and amount of supplements and if they are increasing or decreasing, how supplements are being given and how well this method is working for the family.
Sometimes babies will spontaneously begin to breastfeed when they are between four and six weeks of age. The oldest baby this author has heard of who suddenly decided to feed at the breast was four months old. Even when other alternate feeding methods are primarily used to feed the baby, the breast should still be offered at least once a day.
When a baby who didn't do so at first learns to nurse well, it can be a rewarding experience for a Leader as well as for the mother and her family. A frantic, unhappy mother and baby have turned into a calm, united breastfeeding couple. Isn't facilitating that peaceful ending, while being aware that it may not happen, why we became and remain Leaders?
Possible Causes for a Baby to Refuse the Breast:
- Overhandling by caregivers or family members
- Inappropriate handling
- Poor positioning
- Baby experiencing pain
- Nipple preference/suck confusion
- A long or difficult birth (especially if forceps or vacuum extraction was used)
- Deep or vigorous suctioning of the baby after birth
- Medications the mother may have been given during labor, delivery, or post-delivery
- Engorged breasts
- Inverted nipples
- Cleft lip or palate
The Charm Hold
Lay the baby across his parent's lap face down toward the floor with his hips flexed (bent). The parent supports the baby's forehead with the heel of the hand and extends a clean index finger with smoothly trimmed fingernail for the baby to suck until the tight tongue relaxes and comes forward to snuggle around the finger. It may take several minutes for this to happen. It is called the Charm hold because it "works like a charm. " As soon as the baby's tongue relaxes, he can be gently turned right-side-up and immediately offered the breast. Carefully pull down the corner of the baby's mouth and peek to be certain the tongue is extended over the bottom gum and wrapped around the nipple. If the mother cannot manage this, the father or another helper could do so as the baby nurses.
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