When the baby does not yet latch on
When a baby does not yet latch on, it can be very distressing for the mother, her partner, for the hospital staff, and for the rest of the family. A baby who does not latch on represents the third most common problem we see in our clinic, not far behind the baby not getting enough from the breast and the mother who has sore nipples.
Why would a baby be incapable of latching on to the breast?
This problem would seem completely contrary to assuring survival of the baby and a baby not latching on must have been a very uncommon problem before modern medicine. In southern Africa where I worked for 18 months as a pediatrician, I don’t remember a single baby who did not latch on. But then, my memory is not as good as it used to be.
Many babies do not latch on because of the way women now give birth in the 21st century.
1. Overhydration of the mother with intravenous fluids during labour, birth and after the birth resulting in swelling of the mother’s areolas and nipples may make it very difficult for the baby to latch on. And too often, when the baby does not latch on immediately, instead of the hospital staff letting the mother and baby have some time to get used to each other and to get the baby latched on, the baby is started on bottles and/or the mother is given a nipple shield. The idea that a nipple shield actually does something good is an illusion. In fact, a baby on a nipple shield is not latched on at all, and the milk supply decreases sooner or later.
2. Suctioning the baby after birth. The first experience of the baby after birth – if negative – may result in the baby refusing to latch on. Oral stimulation in the newborn baby is a very powerful experience. Suctioning is a brutal procedure and a very strong, negative one for the baby who may develop an aversion to something, anything, being put into his mouth. And the worst of it all, is that suctioning is rarely necessary. Once, not that long ago, it was done to every baby.
3. Medications given during labour and birth given during labour and birth. For example, medications given for pain. Despite what many anesthetists say, it is simply not true that medication given through an epidural does not affect the baby. See these studies: Birth 2015;42(4):319-328, Eur J Clin Pharmacol 2005;61(7):517–522, Birth 2001;28(1):5–12, Midwifery 2009;25(2):e31–e38, Anesthesiology 2005;103(6):1211–1217, Matern Child Health J 2013;17(4):689–698, Int Breastfeed J 2006;1:24
4. If the baby is separated from the mother after birth instead of being allowed to be skin to skin with the mother for at least 2 hours postpartum, he is much less likely to latch on, especially if he receives artificial nipples. A baby should be allowed to crawl to the breast from the mother’s abdomen, but this is rarely done in most hospitals in the world because it takes time, about 50 minutes and more, but sometimes less. But in the long run, this time is well spent. Here’s an anecdote: A friend of mine’s husband fainted during the birth of her first baby. The staff, gave her the baby to hold while they attended to the father who had hit his head and was out cold. My friend, looking anxiously at her husband, did not notice at first that the baby, all by herself, had latched on and was suckling.
5. A baby who is swaddled or wrapped up after birth is less likely to latch on. The layers of clothing may prevent the baby from being able to latch or from finding an easy way to latch on to the breast. Layers of clothing may also make the baby sleepy instead of alert and search for the breast. In a sense, a baby swaddled or wrapped up is separated from his mother.
6. Studies have shown that the baby finds the breast by smell. Washing the nipples and areolas may make it more difficult for the baby to find the breast and latch on.
7. Babies who have experienced problems such as lack of oxygen during birth and shortly afterwards and had to be resuscitated, may have difficulty latching on to the breast. This could be due to damage to the nervous system (temporary or long lasting) or to the manipulations involved during resuscitation.
8. Forcing the baby into the breast and trying to force the baby to stay there, is not going to work. The baby will either go limp or fight the breast, pushing away from the breast. Some babies may go limp one time and cry and push away from the breast another. Too often the “helper” will keep trying to force the baby into the breast, which only makes things worse.
Other reasons a baby may not latch on:
1. Tongue tie alone, unless very severe, probably does not prevent a baby from latching on, but combine a tongue tie with a mother’s breasts that are swollen from intravenous fluids and early introduction of bottles because the baby is not latching on and we have a problem. Breastfeeding problems, including a baby who will not latch on, are usually due to several issues acting together. The tongue tie is only one of a combination of things that result in the baby not latching on.
Photo 1. This baby’s tongue tie is quite obvious, though the mother was told in hospital he didn’t have one. Tongue ties may make latching on more difficult for the baby. Tongue ties also often cause the mother sore nipples.
2. Babies with cleft palates have difficulty latching on. But some babies do manage it. Unfortunately, some cleft palate programmes assume the baby will not latch on and tell the mother not even to try breastfeeding. Obviously, if the baby is not even tried on the breast, he won’t latch on. In some cleft palate programmes babies are immediately fitted with an obturator to close the gap and babies with these obturators apparently do latch on, at least many of them do.
Photo 2: This is a typical cleft of the soft palate. It was missed in hospital because too often physical examination of the newborn is perfunctory. In the case of a cleft of the soft palate, often the baby allows the breast into his mouth (but doesn’t really latch on) and makes a typical clucking sound when sucking
Video 1: This baby latched on despite having a cleft of the soft palate. He is being supplemented with a lactation aid at the breast and is drinking very well.
3. Some mothers have very large nipples or infolded nipples (sometimes called inverted nipples). Infolded nipples in themselves should not make breastfeeding impossible.
Video 2: Despite the appearance of the nipple, which was the same on both sides, with good help to latch the baby on, the baby did in fact latch on and drink very well. This is the 4th baby of this mother, none of whose previous babies ever latched on. This baby is 5 hours old in the video.
In fact, very large nipples are probably more of a problem than infolded nipples. But taking the time for the baby to learn how to latch on to those breasts with very large nipples will eventually pay off. Feed the baby, by cup, by spoon. The lactation aid at the breast will often work even if the nipples are very large. The baby gets used to getting milk from the breast and eventually the baby will “get it” and latch on. Patience is a virtue in these situations. Rushing in with bottles or a nipple shield is not a virtue.
4. Babies with neurological or some other (facial/oral) abnormalities may have difficulties latching on.
If the baby is not latching on, what do we do?
1. Have patience, don´t interfere straight away after birth and rush in with “solutions” such bottles and nipple shield.
2. Skin to skin contact, as much as possible, and the baby may find the breast and latch on, sometimes without any help at all. A nurse or other qualified health professional should be with the mother and baby, as the mother may some residual effects from the medication she has received.
3. If the baby has not latched on within a few hours, the mother should get help to express her milk and feed the baby with a spoon or open cup. Hand expression often works better than a pump before the milk increases on day 3 or 4. And often even if the milk has increased.
Photo 3: This newborn is being cup fed with his mother’s expressed colostrum. Why is a bottle better? It’s not.
Video 3: This 4 month old baby is being cup fed so as to avoid using a bottle. Cup feeding is possible even if the baby is a day old or and even in premature babies.
4. The mother should get qualified, skilled help with trying to get the baby to latch on well.
5. Use of breast compression to increase the flow of milk from the breast which will encourage the baby to latch on and stay on.
6. Hospital staff should create a relaxed atmosphere around babies that do not latch on and not panic. If the staff panic, so will the mother. Many babies will latch on when the milk supply increases on day 3 or 4.
7. After day 3 or 4 when the mother´s milk supply has increased and the baby is still not latching on, finger feeding is a technique that frequently works to prepare the baby to take the breast. The video below shows how finger feeding works to latch the baby on. Note that the finger feeding need be done only a very short time before trying the baby on the breast. Finger feeding wakes up a sleepy baby and also calms down an fussy baby.
Video 4: Finger feeding is a useful technique to help a baby who is reluctant to latch on to latch on. Finger feeding calms an upset baby and wakes up a sleepy baby. Once the baby is sucking well, move the baby over to the breast. Do not try to force the baby to take the breast. As seen in the video, it took a couple of tries to get the baby to latch on. Letting the baby come off the breast if he has not latched on works better than trying to force him into the breast when he resists staying there, does not work at all, but only makes things worse. This baby was born several weeks prematurely, is now 2 months old in the video and has never in his life latched on.
8. Using the lactation aid at the breast after finger feeding may be a good way to help the baby stay on the breast. See video 4.
9. Some babies are willing to experiment with latching on if they were first fed a little bit of milk via finger feeding or cup feeding.
10. Trying to latch the baby on right after the baby wakes up or just as the baby is falling asleep sometimes works very well.
11. Babies who are crying and screaming are difficult to latch on. Showing the mother how to calm the baby can help the baby to latch on.
12. Making sure the mother expresses her milk and builds up a very good milk supply is a main determinant in whether the baby will latch on. More milk means faster flow, faster flow means the baby is more likely to latch on.
Patience, yes, is a virtue. Even at the beginning of the 19th century, before epidurals, before intravenous infusions, babies did not always latch on immediately. What does it tell us? Not to put too fine a point on it, that babies do not always latch on immediately, but patience, and often the baby will do it. Read this small part of Goethe’s long poem, Faust, and you will get good advice and at wisdom’s copious breasts, you too will know how to do the right thing for a baby who is not latching on.
The child, offered the mother’s breast,
Will not in the beginning grab it;
But soon it clings to it with zest.
And thus at wisdom’s copious breasts
You’ll drink each day with greater zest.
So nimmt ein Kind der Mutter Brust
Nicht gleich im Anfang willig an,
Doch bald ernährt es sich mit Lust.
So wird’s Euch an der Weisheit Brüsten
Mit jedem Tage mehr gelüsten.
—Goethe. Faust. Mephistopheles speaking to the student
And domperidone?
Even if the mother is able to express all the milk the baby needs, we will often use domperidone to increase the mother’s milk supply. Why? Because more milk means faster flow of milk from the breast and faster flow means the baby is more likely to latch on. Go back to the video of the baby latched on after finger feeding. You will notice that the baby is latched on with a lactation aid at the breast. The baby gets more flow of milk and thus latches on and stays on the breast, though it takes a couple of tries.
Need breastfeeding help? Make an appointment at our clinic.
Copyright: Jack Newman, MD, FRCPC, Andrea Polokova, 2017, 2018, 2021