When a Baby Won't Nurse
Carol Brussel, BA, IBCLC
Denver CO USA
From: NEW BEGINNINGS, Vol. 18 No. 4, July - August 2001, p. 136-138
A mother seeks help with her infant, who, she says, "has never breastfed." She is pumping her milk for her baby, and longs to be able to feed her baby at the breast instead. When the mother lifts her shirt and exposes her breast and brings her baby close to her, the baby begins crying loudly and pushes at the mother's breast, frantic, until the mother moves the baby away and covers her breast. Tears stream down her face as the baby, offered the bottle, begins sucking contentedly. "He hates me," she declares.
A baby's refusal to breastfeed is a clear example of oral aversion. An aversion is defined as "a tendency to avoid a thing or situation and especially a usually pleasurable one because it is or has been associated with a noxious stimulation." Oral aversion in breastfed infants may be more clearly defined as a resistance to or difficulty feeding from the breast that ranges from a mild disruption of normal feeding patterns, to complete refusal of the breast. Dr. Jack Newman, of the Hospital for Sick Children in Toronto, Ontario, Canada, suggests that what is commonly called "nipple confusion" may be more clearly defined as "nipple preference," and should be considered a form of oral aversion.
Under normal circumstances, breastfeeding is a pleasurable experience for both mother and baby. Researcher E.J. Mobbs states "The mouth is the most sensitive organ and the one over which the newborn infant has the most control" (Mobbs 1989). It is with his mouth that the infant comes to know his mother and communicate with her. The mouth is his avenue for food and love, communication and comfort. This sensitivity is the reason a baby is so acutely affected by anything he experiences with his mouth. If his mouth is hurt, especially before he establishes a secure breastfeeding relationship with his mother, he may respond by refusing to breastfeed. In addition to the loss of the breastfeeding relationship, the overall mother-child relationship may be disrupted, even after oral aversion ends (Klaus 1976).
When a baby who has breastfed well for weeks or months suddenly begins refusing to breastfeed, this is commonly called a "nursing strike." The causes may be obvious (a startled response from the mother when a baby bites during nursing) or unclear. Occasionally, a nursing strike is a signal from the baby that the nursing relationship has been difficult from the beginning.
Feeding problems most commonly associated with oral aversion are usually encountered at birth or immediately thereafter. A newborn who refuses to nurse must first be evaluated to rule out other causes, such as physical abnormalities or illness, the lingering effect of medications used during the birth, birth trauma, or the use of improper positioning or latch-on techniques. When a baby with no other known problems refuses to breastfeed or has great difficulty nursing, it is often the result of experiences from the earliest moments and hours of the baby's life.
Factors in Oral Aversion
Some of the actions that can contribute to oral aversion include suctioning of the newborn's airway or stomach, naso- or orogastric feeding tubes, inappropriate use of artificial nipples and bottle-feeding methods, incorrect placement of fingers in the baby's mouth for finger feeding or suck assessment, and aggressive attempts to alter the baby's sucking pattern. Some of these interventions can be helpful as long as they are done gently and slowly, paying attention to the baby's cues.
Airway suctioning is considered necessary by some health care providers. In some communities, gastric suctioning is commonly done "to promote hunger, as the baby will not eat unless he is hungry, and he won't be hungry unless his stomach is empty." This practice is based on the belief that mucus present in the baby's stomach will suppress hunger pangs, preventing effective breastfeeding. Interventions may become standard practice when health care providers believe that they will prevent problems and that they are harmless. Unfortunately, these interventions are neither harmless nor effective in prevention problems.
Inappropriate use of artificial nipples as a cause of oral aversion seems clear to even the most casual observer. Introducing the nipple into the baby's mouth without waiting for him to open his mouth can overwhelm him, and he is powerless to refuse something forced into his mouth. Stimulating a faster or stronger suck by rubbing the top of his mouth with the nipple, rotating the bottle, and holding the bottle in his mouth despite indications of stress are common techniques that can be invasive and overwhelm a baby's delicate mouth.
Feeding tubes are sometimes used in the place of artificial nipples in an effort to prevent breastfeeding problems caused by nipple preference. However, when feeding tubes are used in the forceful and overwhelming ways described above, they can cause problems too.
Other situations in which an aversion may be created are those in which fingers are introduced into a baby's mouth for suck assessment or therapeutic purposes. Suck assessment can reveal a great deal of information about a baby with feeding problems in the hands of an experienced practitioner. It can be a crucial step in determining how to help a baby breastfeed who is having difficulty. Some practitioners teach various "suck training" exercises to correct perceived problems. However, done incorrectly, both assessment and treatment can create or worsen problems. The first thing to enter a baby’s mouth after his birth should be his mother's nipple.
Health care providers teach various techniques to help initiate or alter a baby's sucking technique. Often a mother is taught to latch the baby on by pushing the baby’s chin down with her finger, and when the mouth is open, to push the back of the baby's head until the open mouth is on the breast. This "forced latch" technique is quite common, although there is very little support for it in the standard lactation literature. However, many babies display increased signs of oral aversion after repeated encounters with the forced latch.
If your baby refuses to breastfeed because he perceives it as unpleasant, what can be done to reestablish the breastfeeding relationship? It is important to remember that your baby loves you despite his refusal of the breast. Activities that encourage a renewal of the physical bond between mother and child are crucial. Skin-to-skin contact, kangaroo care techniques, baby-wearing, co-sleeping and co-bathing are all ways to encourage your baby to experience pleasant physical contact with you. Once he starts to feel comfort while being close to you, he is more likely to go back to the breast. Mothers can get support and information from La Leche League Leaders. Or a board-certified lactation consultant (IBCLC), often in conjunction with the help of an occupational therapist, can help you develop a plan to return to breastfeeding.
Examine any feeding methods you use. Your baby needs to be gentled back to the breast, not forced back to the breast. Alternative feeding methods, usually avoiding the use of artificial nipples, can be an effective means of decreasing the stress associated with feeding. This may mean cup-feeding a baby in order to allow a rest from intrusive oral feeding methods. A nipple shield may allow a baby to make the shift from artificial nipples to feeding from the breast, by providing some continuity in terms of the feel and taste of the artificial nipple while transitioning to the breast. In his new book, The Ultimate Breastfeeding Book of Answers (May be available from the LLLI Online Store.), Dr. Newman also recommends the use of "breast compression" to increase the flow of milk to the baby and so encourage him to nurse more.
Resolving an established problem may be a short and simple task, or difficult and time-consuming. Seek help from experienced and qualified breastfeeding support people. It is vitally important that your baby receive adequate nourishment at all times so that he will have enough energy to work at learning to breastfeed. Your baby's primary health care provider needs to be a partner in the treatment process, and be aware of your determination to return to breastfeeding.
Prevention of oral aversion is easier than fixing it once it has already happened. Encouraging hospitals to become "Baby-Friendly" will help foster an atmosphere of breastfeeding support that questions and discards unnecessary interventions. Mothers can help assure breastfeeding goes smoothly by encouraging their babies to breastfeed early and often, and by insisting that any necessary procedures are performed gently. A mother who trusts her instincts about what is and what is not an appropriate interaction with her baby is off to a good start in establishing the loving, pleasurable relationship that breastfeeding should be.
Tips for Getting Baby Back to the Breast
- Try nursing when your baby is asleep or very sleepy, such as during the night or, while napping.
- Vary nursing positions. (see illustrations.) Some babies will refuse to nurse in one position but will take the breast in another.
- Nurse when in motion.
- Nurse in a quiet, darkened room or a place that is free from distractions.
- Give your baby extra attention and skin-to-skin contact, which can be comforting for both of you.
- When offering the breast, undress to the waist and clothe your baby in just a diaper when ever possible. Use a shawl or blanket around you if the room is chilly.
- Use a baby sling or a carrier to keep the baby close between attempts to nurse.
- Take warm baths together to soothe.
- Sleep together in order to provide closeness and more opportunities to nurse.
Adapted from How to Handle a Nursing Strike (Published by LLLI, No. 290-17).
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.
Klaus, M. G. and J. H. Kennell. Maternal-Infant Bonding. St. Louis, MO. Mosby, 1976.
Newman, J. and Pittman, T. The Ultimate Breastfeeding Book of Answers. Roseville, CA: Prima Publishing, 2001.