When the Baby Refuses
to Latch On
By Jack Newman, MD, FRCPC
Why would a baby refuse to take the breast?
There are many reasons a baby might refuse to latch on. Often there
is a combination of reasons. For example, a baby might latch on even
with a tight frenulum if no other factors come into play, but if, for
example, he is also given bottles early on, this may very well change
the situation from “good enough”, to “not working at
all”.
- If the mother’s nipples are particularly large, or inverted,
or flat, these nipple variations make latching on more difficult,
not usually impossible.
- Some babies are unwilling to nurse, or suck poorly as a result
of medication they received during the labour. Narcotics are responsible
for many such situations, and meperidine (Demerol) is particularly
bad as it stays in the baby’s blood for a long time and affects
the way he sucks for several days. Even morphine given in an epidural
may cause the baby to be unwilling to nurse or latch on, since medication
from an epidural definitely does get into the mother’s blood,
and thus into the baby before he is born.
- Vigorous suctioning at birth may result in babies not sucking properly
and not wanting to latch on. There is no need to suction a healthy,
full term baby at birth.
- Abnormalities of the baby’s mouth may result in the baby’s
not latching on. Cleft palate, but not cleft lip, causes severe difficulties
in latching on. Sometimes the cleft palate is not obvious, affecting
only the part inside the baby’s mouth.
- A tight frenulum (the whitish tissue under the tongue) may result
in a baby having difficulty latching on. This is not, strictly speaking,
considered an abnormality, and thus, many physicians do not believe
that it can interfere with breastfeeding, but they are misinformed.
- A baby learns to breastfeed by breastfeeding. Artificial nipples
interfere with how the baby takes the breast. Babies are not stupid.
If they get slow flow from the breast (as is expected in the first
few days of life) and rapid flow from the bottle, they will not be
confused—many will figure it out quite quickly.
However, one of the most common causes of babies’ refusing to
latch on arises from the misguided belief that babies in the first few
days must breastfeed every 3 hours, or on some other insane sort of
schedule. This results in anxiety on the part of the staff when a baby
has not fed, for example, for three hours after birth, which results,
frequently, in babies being forced to the breast when they are not ready
yet to feed. When the baby is forced into the breast, and kept there
by force, when the baby is not interested or ready, we should not be
surprised that some babies develop an aversion to the breast. If this
misguided approach then results in panic, and “the baby must be
fed”, alternative feeding methods (the worst of which is the bottle)
are then used, resulting in worsening of the situation and the beginning
of a vicious circle.
There is no evidence that a healthy full term newborn must feed every
three hours during the first few days. There is no evidence that they
will develop low blood sugars if they don’t feed every three hours
(the whole issue of low blood sugars has become a mass hysteria in newborn
nurseries which, like all hysterias, results from a grain of truth,
perhaps, but actually causes more problems than it prevents, including
the problem of many babies getting formula when they don’t need
it, and being separated from their mothers when they don’t need
to be, and not latching on). Babies should be together, skin to skin
with their mothers, 24 hours a day (See handout 1a
The importance of Skin to Skin Contact). When they are ready,
most will start looking for the breast. Having the baby with the mother
skin to skin immediately after birth, and allowing the baby and the
mother the time to “find” each other, will prevent most situations
of the baby not latching on. Mother and baby skin to skin will also
keep the baby as warm as being under a heating lamp. Having the baby
and mother together for 5 minutes though, is not the answer. The mother
and baby should be together until the baby latches on, without pressure,
without time limits (“we’ve got to weigh the baby”, “we’ve
got to give the baby vitamin K,” etc—these procedures can
wait!). This might take 1-2 hours or more.
But the baby is not latching on!
Okay, so how long can we wait? There is no obvious answer to that.
Certainly, if the baby has shown no interest in nursing or feeding by
12 to 24 hours after birth, it may be worthwhile to do something, mostly
because hospital policies usually require the mother to be discharged
by 24 to 48 hours. What can be done?
- The mother should start expressing her milk, and that milk (colostrum),
either alone, or mixed with sugar water, should be fed to the baby,
preferably by finger feeding. If it is difficult to get colostrum
(often hand expression works better than a pump in the first few days),
then sugar water alone is fine for the first few days. With finger
feeding, most babies will start sucking, and many will wake up enough
to attempt going to the breast. As soon as the baby is sucking well,
finger feeding should be stopped and the baby tried at the breast.
Finger feeding is essentially a procedure to prepare the baby to take
the breast, not primarily a method to avoid the bottle, though it
will do that too. Therefore it is done before attempting the baby
at the breast, to prepare him to take the breast. See handout
#8 Finger Feeding.
- Before discharge, early, competent help needs to be arranged so
that the mother and baby are getting help by day four or five at the
latest. Many babies not able to latch on in the first few days will
latch on beautifully once the mother’s milk supply has increased
substantially as it usually does around day 3 or 4. Getting help at
this time avoids the negative associations with the breast that many
babies develop as time goes on.
- A nipple shield started before the mother’s milk becomes abundant
(day 4 to 5) is bad practice. Starting a nipple shield before the
mother’s milk “comes in” is not giving time a chance
to work. Furthermore, used improperly (as I see it often being used),
a nipple shield may result in severe depletion of the milk supply.
I’m home from hospital. The baby won’t latch on. What
do I do?
The single most important factor influencing whether or not the baby
latches on is the mother’s developing a good milk supply. If the
mother’s supply is abundant, the baby will latch on by 4 to 8 weeks
of life no matter what. What we try to do at the clinic is get the baby
latching on earlier, so that you won’t have to wait that long.
So, it is more important you keep up your supply, than avoid a bottle.
The bottle interferes, and it is better you use other methods (such
as a cup) if you can, but if you feel you have no choice, you should
do what you need to do.
- Learn how to get the best position and latch from an experienced
lactation specialist (see also handout A: When Latching and see the
videos at www.thebirthden.com/Newman.html).
As the baby comes onto the breast, compress the breast so that the
baby gets a gush of milk. Try the baby on the breast he seems to prefer,
or the breast that has more milk, not the breast he resists more.
- If the baby latches on, he will start sucking and start drinking
(get information on how to know a baby is actually getting milk at
the breast—see
handout #4. Is My Baby Getting Enough Milk? And see the
videos at www.thebirthden.com/Newman.html
).
- If the baby doesn’t latch on, don’t try to force him
to stay on the breast; it won’t work. He will either get hysterical
or “go limp”. Move him away from the breast and start again.
It is better to go on-off, on-off several times than to push him into
the breast when he hasn’t latched on.
- If the baby goes to the breast and sucks once or twice, he hasn’t
latched on a little; he hasn’t latched on at all.
- If the baby refuses the breast, don’t keep at it until he’s
angry. Try finger feeding a few seconds to a minute or two, and try
again, perhaps on the other side. Finger feeding is to prepare the
baby to take the breast, not primarily to avoid a bottle.
- If the baby doesn’t latch on, finish the feeding with whatever
method you find easiest.
- Using a lactation aid at the breast may be helpful, but often requires
an extra hand.
- At about two weeks after birth, a change in what you have been
doing often seems to send a message to the baby that “there’s
more than one way to do this”. If you have been finger feeding
only, a change to a cup or bottle will sometimes work, or using a
nipple shield will often work. If you have been bottle feeding only,
switching to finger feeding may work (only before attempting the baby
at the breast is good enough if finger feeding is too slow, and finishing
the feeding with cup or bottle).
How to maintain and increase milk supply
- Express your milk as often as is practical, at least 8 times a
day, using a reliable pump that expresses both breasts at the same
time. Using compression while pumping increases the efficiency of
pumping and increases the milk supply (another hand is helpful, but
mothers have rigged up the pump so that they don’t have to hold
onto the tubing or flanges while pumping and thus can compress without
help).
- If the baby hasn’t latched on by day 4 or 5, start fenugreek
and blessed thistle to increase milk flow. See handout #24.
Miscellaneous Treatments. Domperidone may also be useful. See handouts
19a and
19b, Domperidone
1 and 2.
- If you must use a nipple shield, do not use one at least until
the milk supply is well established (at least 2 weeks after the baby
is born). Get good hands on help first.
Do not get discouraged. Even if your milk supply is not up to the
needs of your baby, many babies will still latch on. Get good help.
Do not do this on your own.
Handout #26. When The Baby Refuses to Latch On; January 2005; Jack
Newman, MD, FRCPC. (c) 2005
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