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org When a Baby Refuses to Nurse Problems that Can Lead to Breastfeeding Refusal and Possible Solutions
by Kim Evangelisti with Beverly Morgan
"Babies were born to breastfeed." We often read ads such as this from a breastfeeding awareness campaigns, and of course, this is true. But what is a mother to do when her baby does the unthinkable and refuses to feed from the breast? Many mothers are not prepared for this as a possibility. My own baby did not latch on properly until almost 4 months of age. As a mother who was broadsided by this heartbreaking problem, I (Kim) wanted to share what I have learned in the hope that if you find yourself in a similar situation, you will be able to resolve it in a timelier manner, or at least rest assured that you have tried everything you could to get your baby back to the breast. My co-author, Beverly Morgan IBCLC, has seen the despair many times as mothers and babies struggle through the break in their precious relationship. She also wants to offer comfort, strategies and hope to you. In this article we will talk about what can cause breast refusal, and how to protect your milk supply and meet a baby's need for food during this stressful time.

Why does a baby refuse the breast?

When a baby refuses to breastfeed, he is having some type of difficulty with breastfeeding which may be obvious or mysterious. Sometimes the difficulties may show up from the first feeding. At other times they may occur during the learning period, when at first it looks as if nursing is going well. Breast refusal might also show up after baby has been nursing effectively for a while.

Possible issues for a baby refusing the breast from the first nursing
Pain- A baby may be in pain from a birth injury. Birth injuries are more common in premature babies and with difficult labors. If the pain is aggravated by being held, the baby may cry at the first attempt at nursing. Examples of birth injuries are: a broken clavicle, bruising, misaligned neck vertebrae, or a pinched nerve. Breathing issues- A baby having trouble coordinating suck, swallow, and breathe reflexes may well have a problem with breastfeeding. Breathing or eating - which would you choose? Oral aversion- Some babies resist having anything in their mouth, often due to a trauma such as being deeply suctioned. The invasion of their oral cavity may make them resistant to anything in their mouth. Additionally, many babies who were suctioned also have impaired respiration which can also affect breastfeeding.

Possible Issues for a baby refusing the breast during the learning period
Sometimes the breast refusal comes after it looks as if nursing was off to a good start. Baby may have had wet diapers and bowel movements for the first couple of days but suddenly things change. Prematurity- A baby born early, even at 37 or 38 weeks, may not have the skill or strength to suckle well. Being born "early" can have a big impact on a baby's ability to get enough milk. Left to his own devices he may not stimulate mom's milk supply. Even if the baby seems to enjoy nursing at first, he may not get enough milk and could become frustrated at the breast. Preference to other form(s) of feeding- A baby will prefer what stresses her less. She will be more cooperative to the feeding method she has already mastered. "Nipple Confusion" generally refers to a baby preferring to feed from a bottle rather than from the breast. If baby has had bottles and breast, and the breast does not get her the milk she wants at the speed she wants it, she will have a nipple preference. So even though it is called nipple confusion, Beverly sees it as a bottle preference because the baby is not confused at all. She will tell you so with loud protest! Pain- The pain may be unresolved from early days or may be caused by a new situation such as ear infections. Reflux- A baby with reflux may come to realize that when he eats, he hurts. If he is making this association, he may refuse the breast and protest with loud screaming. Colic- Colic is basically a catch-all phrase for a baby who cries a lot and is difficult to comfort. Sometimes a baby with reflux is said to have colic. Immature digestion, an immature nervous system, a foremilk/hindmilk imbalance, food sensitivities and flatulence can cause a baby to show signs of colic. Allergies- Food sensitivities can cause colic-like symptoms, such as cramps, as well as stuffiness, or ear infections which can interfere with babies' enjoyment of eating. A baby may be able to detect when a mother has eaten an allergenic food from the taste in the mother's milk. The baby may learn to avoid breast milk with this taste because she associates it with the discomfort that follows. Sensory Issues- A baby may have increased or decreased sensation to light, sound or touch, or have balance issues that interfere with breastfeeding. An example of this is a baby who is very difficult to wake during the day, but prefers to be up at night when there is less sensory input.

There are mechanical issues that can cause a baby to have an ineffective suck. If baby's food intake is not assured, he may give up on nursing. These issues include: Cleft palate- A baby with a cleft lip may be able to nurse effectively, with mom using her finger to close off the cleft, for example, but if he has a cleft palate, he will need extra help and long-term strategies to keep the breastfeeding relationship going. Tongue tie- Tongue tie is when the frenulum beneath the tongue is too short or tight to allow full range of tongue movement. If a baby doesn't get full movement of his tongue, he may well have a difficult time getting the milk he needs. One sign of tongue tie is when the tongue does not extend over the gum line. Mom will likely have sore nipples too.

Clamp-down reflex- A baby with tongue tie may use the clamp-down technique, using his gums for the job of holding the breast that his tongue can't do. Other babies with a range of issues also use this technique. Clamp-down reflex may be evident when it is very difficult to unlatch a baby from the breast. Mom may have a nipple that is misshapen and she may feel bruised. She may have areas of the breast that don't drain well because the baby has stopped the flow from the areas. A baby may enjoy nursing, or he may be frustrated if his clamping stops the milk from flowing well or because breastfeeding is difficult for him.

Possible Issues for a baby refusing the breast after demonstrating effective nursing skills
When a baby suddenly refuses the breast after having nursed effectively for some time, this is also called a "nursing strike." Some possible reasons for this are: Taste of milk- Some foods or medicines can affect the taste of the milk, or a baby could be sensitive to a substance on the mom's skin, such as soap, spray deodorant or Lansinoh or PureLan or other lanolin product. Sore mouth- Soreness from an injury to the mouth, teething or thrush can cause a baby to go on strike if it hurts to nurse. A toddler may go on strike if he falls and hurts his mouth. Illness- A baby suffering discomfort from a sore throat, ear infection, stuffy nose, breathing difficulties, upset stomach, and mouth infections may refuse to nurse until the discomfort is gone. Milk Flow- A baby may refuse the breast if the mother's milk supply is reduced and the baby wants more milk.

What is a mother to do when her baby refuses the breast?

When a baby will not feed from the breast, the mother's immediate concerns are feeding the baby and protecting her milk supply, while trying to get the baby to accept the breast. It can be very helpful to consult with a professional Internationally Board Certified Lactation Consultant (IBCLC). If the breast refusal is not resolving in a timely manner, a therapist such as a Speech and Language Pathologist (SLP), or Occupational Therapist (OT) may also help determine and treat the underlying causes for the breast refusal.

Feed the Baby

Lactation consultants say that the first rule is to "feed the baby" in whatever way causes less stress for the baby and his/her parents. In many cases a baby needs to increase her strength to be able to nurse. There are several different ways to offer supplementation of breast milk or formula. Each feeding device has pros and cons to its use. When a mother is trying to get a baby back to the breast, she should weigh these pros and cons when choosing a method of supplementation.

Syringe Feeding - This device can be used directly at the breast or for finger feeding. Feeding the baby at the breasts is the first choice. When a baby is showing distress at the breast in the early days, this is a good method of supplementation. Although the syringe does not hold much liquid, the volume of colostrum is also small. When the baby feeds from a syringe held at the breast, he can feel successful feeding at the breast while the underlying breastfeeding difficulties are being identified. Feeding devices that allow supplementation at the breast - Supplemental Nutrition System (SNS) and Lact-aid are commercially available feeding aids that consist of bottles to bring milk to the breast by means of thin tubing. The milk flows from a bottle or bag. Beverly advises, "in general using the tool that best fits the baby's needs will keep the baby feeling most successful. The SNS works well for a child who has an effective suck, but needs more milk to flow from the breast. A Lact-aid works with gravity so it works better for a baby with difficulties removing the milk from the breast as it does not depend so much on good suction and breastfeeding skills." Cup feeding - Cup feeding can work for getting food into a baby without introducing nipples. Liquid is placed in a smooth rimmed, shallow little cup. The cup is place at baby's lips and baby can sip the milk. There are specially designed cups for cup feeding an infant. Finger feeding - The finger feeding method involves a tube or syringe that delivers milk to the baby. It can be the tube of a supplemental feeding device or a special fingerfeeder. In the case of tube, a small flexible tube is connected to a container of milk--think of it as a small soft drinking straw. It can be taped on a caregiver's finger. The baby sucks on the finger and receives milk by sucking on the caregiver's finger when using a feeding syringe. The milk from the syringe is released to run down the finger into the baby's mouth feeding the baby. Nipple shield (under guidance of an IBCLC) - "A nipple shield can help control milk flow for a baby who is getting too much milk. If the baby is struggling with too much milk, a nipple shield and changing the baby's breastfeeding position may be the only tools you need. The positions commonly taught may not be the ones that work for your baby" Beverly advises. To help a baby become more confident at the breast, the mother can use a supplemental feeding device for milk flow and a nipple shield to keep the flow more regular. If the baby is confident with bottle feeding, the nipple shield may help him feel more sure at the breast because the shield feels more like the bottle nipple. It is imperative to make certain he gets the food he wants though or he will quickly reject the shield too. The SNS tube can be placed under or over the nipple shield if supplementation is required. Bottle and nipple - Some moms are nervous that use of a bottle will further damage the breastfeeding relationship by causing bottle preference or "nipple confusion". Other moms or caregivers find alternate forms of supplementation stressful and prefer to use a bottle, especially when the baby's struggle with breastfeeding continues for more than a few days. "A baby refusing the breast needs to be fed. It is not necessarily the bottle and nipple that cause the difficulty, but the way the baby feels about the method of feeding and the underlying reason why the baby is having problems in the first place." Beverly says, "Choose a bottle and nipple that seem to help a baby have a relaxed feeding without causing him to get the milk so fast he can hardly breathe or so slow he uses all his energy getting his food. A lactation

consultant can help parents find the right balance of breastfeeding and supplementing if needed. Each child and situation is different." I (Kim) found that most "breastfeeding friendly" bottles have wide-mouthed nipples that my baby could not fit in his mouth. Instead he ended up sucking on the end of nipple. An LC I saw suggested using a 'regular' nipple so the baby could fit the whole thing in his mouth, thus encouraging him to open his mouth wider. I also found it helpful to take the time to coax my son's mouth open to accept the bottle nipple, rather than impatiently pushing it in. There is an article by IBCLC Dee Kassing that describes a method of bottle feeding that promotes breastfeeding and includes these concepts and more. The link is at the end of the article. Haberman Feeder - If the baby is refusing to breastfeed and is having difficulties with other feeding methods because his technique is not effective enough, you may find a specialty feeding nipple like the Haberman Feeder by Medela assures his nutritional needs are being met. A Haberman Feeder is a specialized nipple designed for babies with facial or oral problems that interfere with their ability to breastfeed effectively. The nipple has a variable flow rate that can be controlled by the caregiver and the baby, and a one way valve that prevents flooding.

Protect the Milk Supply

If a baby is not nursing at all, or not emptying the breast completely, a mother's milk supply will probably be hurt. If this goes on for a long time, especially early on, the mother's milk supply may be affected to the point where it could take great efforts to rebuild it. This was the case with me (Kim) and my baby. When we discovered he was not sucking efficiently at 6 weeks, it took quite a bit of pumping to rebuild my supply, and I always struggled with supply thereafter. If you have a newborn and suspect you have a low supply, or your baby has a poor latch or weak suck, pump after nursing as often as possible to protect your milk supply. See an IBCLC as soon as possible to try to determine what is going on and make an appropriate plan. Here are some other tips for establishing milk supply:" Breast pump- Pumping with a good quality pump is essential to protecting milk supply when a baby is refusing to nurse. Be sure to get advice from an IBCLC as to what pump to use and how often to pump. If you are trying to build your supply, renting a hospital grade pump is generally your best bet, but each woman responds uniquely to different pumps. You need to make sure that you are pumping frequently enough to maintain and/or build your supply. This can vary based on things like the age of the baby and your supply. It is a good idea to pump at least as many times as your baby is feeding. For a newborn who is not nursing, pumping every 2 hours around the clock is usually recommended (with a 4 or 5 hour stretch to sleep in every 24 hour period.) This pumping schedule will likely be a more relaxed one with longer times between pumping as time goes on, so don't despair. Stay Hydrated- Make sure you drink plenty of water. Drink to thirst. Carry a bottle of water with you, and put one by your bed.

Food and Herbs that affect milk supply- A mother's diet can influence her milk supply both in quantity and quality. Some mothers see drastic changes (increase or decrease) in their milk supply after changing the foods they eat or taking dietary supplements. The book Mother Foodby Hilary Jacobsen is an excellent resource for nursing mothers. This landmark book details what foods and herbs can help to increase or decrease a mother's milk supply, as well as providing information on allergies and reflux. Medicines that can increase supply- Reglan (Metoclopramide) and Domperidone are two drugs that increase prolactin levels as a side effect, and which often stimulate an increase in milk supply. Reglan can be prescribed by your doctor in the US, but can cause depression as a common side effect, especially if taken for longer than a few days to two weeks. Domperidone is available over the counter in many countries, but in the US it must be obtained at a compounding pharmacy or from an overseas pharmacy. It does not cause depression, but like any medication can have side-effects so dosage prescription should be closely followed. Try to relax- If you are experiencing breastfeeding troubles, it is probably a stressful time, but try to relax as much as you can. Stress can be a big supply-reducer. Forget about household chores that aren't absolutely necessary, accept people's offer to help and give them specific tasks, tell your husband or partner what you need. If you don't have family around to help perhaps you could hire a neighbor girl or boy to help with chores or caring for other children.

Woo the baby back to breast

It is a good idea for a mother to offer her breast frequently and gently to a baby who is refusing to nurse. It is important not to try to force the baby to nurse in such a manner as upsets the baby. This could cause further negative associations at the breast. Other techniques for encouraging a baby to return to the breast are: Adjust the baby's position at breast- IBCLC Beverly Morgan has noticed that the tummy to tummy position nearly universally recommended does not work for all babies. She writes, "An example I often use is to think of a water fountain and the way you would approach it. You would turn it on and adjust your position depending on how the water comes from the fountain. So it is with a baby. If she has trouble catching her breath when she is nursing, she will not want to have her head pushed on the breast and held there with the breast deep in her mouth, when the milk is spurting out at a fast pace. A baby with reflux will do better if his bottom is down and his head is up. This applies to breastfeeding as well as other times. So holding him parallel will likely make him uncomfortable and resistant to feeding. These are just two examples of adapting a baby's breastfeeding position to meet the baby's needs. I think of breastfeeding as a dance between mom and baby. Baby should lead in this dance and mom should follow his cues. If he pulls back, she should not resist and pull him in closer." Encourage baby to comfort nurse- When offering the breast, if the baby wants to comfort nurse rather than sucking for food, go with that. As he starts taking comfort from the breast he will be more willing to spend even more time there. Substitute the breast for other comfort measures such as rocking using pacifiers, etc. The more comfortable the baby feels at the breast, the better the chances he will start nursing again. Mothers have also reported that

comfort nursing helped increase their supply when a baby is refusing to nurse even if she had to pump it out to give to the baby in a bottle later! Skin to skin contactis extremely important to help the baby relax and feel comfortable being close to the mother. Mothers have also reported that skin to skin contact with their baby helped increase their supply when their baby was refusing to nurse. Skin to skin contact can be achieved by putting your baby next to your skin and removing all but his diaper. Close your drapes and hold your baby close while lying down or sitting. You can use a sling to hold your baby close while standing, walking and going about your daily business. Especially if you are trying to nurse a preemie, learn more about "Kangaroo Mother Care", which is being used in some children's hospitals throughout the world as a way for improving the outcomes for infant health and to encouraging breastfeeding in premature infants. Kangaroo care is good for all babies, not only for preemies. Co-sleep- Co-sleeping is when a mother shares a bed with her baby for naps, or for all or part of the night. When co-sleeping, care must be taken to ensure the safety of the infant. A sleepy baby is a relaxed baby, so sleep times are perfect opportunities to try to coax a baby to the breast. Kim advises, "After almost three months of blood-curdling screaming at the breast during the day, my son finally started latching back onto the breast in the middle of the night while co-sleeping. From there it was not long before I was able to lure him back to the breast in the morning upon waking, and then finally to exclusive breastfeeding!" Co-bathing- Taking a warm bath with your baby can relax both the mother and baby and possibly encourage nursing. The skin-to-skin contact and warm bathwater provide comfort similar to the womb, and combined with the easy access to the breast, can relax a baby to where she may eventually desire to nurse. Whether or not a baby breastfeeds, co-bathing is a very bonding experience that can provide both mother and baby a rewarding time together. For the safety of the infant, a support person must be present to assist the mother when attempting to bathe with an infant. Pump or hand express before nursing- Pumping or hand expressing before nursing to achieve a letdown can either help get the milk flowing for a baby that is conditioned to bottle feeding, or in the case of over-active letdown, remove some milk so flow meets baby's preference.

Therapies or procedures that may address breastfeeding issues

When convincing her baby to breastfeed is taking more than a week, or the baby has already been diagnosed with an underlying oral-motor issue that is interfering with breastfeeding, it is time to consider other therapies or procedures. Clipping the frenulum- This procedure is used on tongue-tied babies to release the tongue so that it is able to move around freely. It is usually performed by a pediatrician or ENT specialist. It is often a very quick, low-risk procedure, but depending on the doctor, and the severity of the tie, it may have to be done in a hospital under anesthesia which adds time and risks to the procedure. The sooner the tongue is freed to function properly the better for all concerned. Oral-Motor therapies and exercises- A Speech and Language Pathologist or Occupational Therapist specializing in feeding difficulties can help babies with problems such as inefficient

sucking, not opening their mouths wide enough or oral aversion. While there are some exercises that can be done at home by a caregiver, these should be done under the guidance of a professional therapist. Craniosacral therapy- Some mothers have reported that this therapy has helped their breastfeeding relationship. It is a bit like a gentle therapeutic massage. CranioSacral Therapy was defined by Dr. John Upledger as a "gentle, hands-on method of evaluating and enhancing the functioning of ... the membranes and cerebrospinal fluid that surround and protect the brain and spinal cord."

If your baby is refusing to nurse, please remember that your baby is having issues with the method of feeding, not with your mothering. Remind yourself that no matter what your baby does at the breast, he still needs you more than anything. It is possible for babies to latch on a few days, weeks, or months after birth, so don't lose hope before you have given you and your baby a chance. Take care of yourself, take the time you both need to bond, protect your milk supply and meet baby's need for food. Take a candle-lit bubble bath and remember what an amazing mother you are. Unfortunately even though many people come to understand the things that contributed to their baby's breast refusal, sometimes there are no answers that can result in a breastfeeding baby. This can be extremely frustrating to the mother who has invested so much time and emotion in seeking help for herself and her baby. MOBI mothers find ways to reach a special closeness with their babies whether or not they are breastfeeding. Bottle nursing, infant massage, co-bathing, and good old fashioned hugs and kisses are just a few of these ways.