WHY WOULD A BABY NOT LATCH ON?

There are many reasons a baby might refuse to latch on to the breast. Often there is a combination of reasons. Many of the interventions that occur during labour and birth may make it difficult for the baby to latch on.  Large amounts of intravenous fluids oftn result in swelling of the mother’s nipples and areolas making it difficult for the baby to latch on and get milk from the breast. If, because of the swelling of the nipples and areolas, or for the false notion that 10% weight loss means something, the baby is also given bottles early on, this may very well change the situation from “good enough”, to “not working at all”. In addition, a baby might latch on even with a tight frenulum even if no other factors come into play.

• Some babies are unwilling or unable to latch or they suck poorly as a result of medication they received during the labour. Don’t believe it if you are told that the drugs used in an epidural do not get into the mother’s blood and thus into the baby before the birth. Narcotics are responsible for many such situations.  Fentanyl, morphine and other drugs given in the epidural can indeed cause the baby to be sleepy and unable or uninterested to latch on. Meperidine (Demerol) as an injection to the mother is less used these days but is particularly bad as it stays in the baby’s blood for a long time and may affect the way he sucks for several days.

• Other interventions during labour and birth, in addition to intravenous fluids in large amounts already mentioned, such as vigorous suctioning of the baby at birth, which is simply not necessary for a healthy full term baby can also cause difficulties with the baby latching on. For more information see the chapter when the baby does not latch on from Dr Jack Newman’s Guide to Breastfeeding.

• Abnormalities of the baby’s mouth may result in the baby’s not latching on. Cleft palate, but not usually cleft lip alone, causes significant difficulties in latching on. Sometimes the cleft palate is not obvious, affecting only the soft palate, the part further back in the baby’s mouth. See the photo below. Unfortunately, many cleft palate programmes discourage mothers from even trying the baby at the breast.  But some babies can latch on and some babies can get milk from the breast even if they don’t latch on well, simply because the mother’s abundant milk supply results in the baby drinking the breastmilk as it flows from the breast into the baby’s mouth. See this video of a baby who has not only a cleft palate and cleft lip, but also has Down Syndrome and a heart abnormality. He is drinking at the breast.

• 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, and prefer the faster flow and may not know how to take the breast.

• If the mother’s nipples are particularly large, or inverted, or flat, these nipple variations may make latching on more difficult, but not usually impossible. However most women said to have flat or inverted nipples actually do not have “flat nipples”. In fact, nipples that look flat are almost always normal, but we live in a society where bottle feeding is still the norm, so if a mother doesn’t have nipples that look like the end of a feeding bottle may be told that their nipples are flat. Even “inverted” nipples do not necessarily make it impossible for a baby to latch on. This mother with inverted nipples (photo below) was able to get the baby to latch on with help. The baby was 5 hours old. The mother had not breastfed any of her 3 previous babies. See this video of the baby latched on and drinking. True I helped the baby to latch on but I only did what the nursing staff did not do.

This mother was not able to latch on 3 previous babies. With good hands on help she did get the 5 hour old baby to latch on. Watch the video.

• 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 do not consider it a problem for breastfeeding. In fact most do not know how to diagnose a tongue tie. Several studies now have shown that tongue tie is indeed a problem for breastfeeding, causing not only difficulty for the baby to get milk from the breast, but also causing mothers to have nipple pain and yes, difficulty for the baby to latch on.

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 2 hours, or 3, or on some other aberrant sort of schedule. Babies were not meant to feed by the clock even during the first days. Belief in the schedule and trying to stick to a schedule results in anxiety on the part of the staff when a baby has not fed, for example, for three hours after birth, which then results, frequently, in babies being forced to the breast when they are not yet ready to feed. When the baby is forced into the breast, and kept there by force, especially 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 (or two hours, or whatever) 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 many postpartum areas 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, 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, most of the day (See 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, and, more importantly, not too warm but just right. 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!). Having the baby skin to skin with the mother might take 1-2 hours or more before the baby will latch on.

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 cup feeding or finger feeding (see below and  Finger and Cup Feeding). The real purpose of finger feeding is to prepare the baby to take the breast. See this video of a baby, born prematurely 8 weeks before term, who has never latched on to the breast. Like many babies born prematurely in our area, breastmilk feeding seems preferred over breastfeeding. He is exclusively breastmilk fed by bottle. Finger feeding (less than a minute), prepares him to take the breast. He does not latch on to the right breast because he has already fed there and the flow of milk is slower than during the first, successful, attempt at the breast. But he does latch on to the left breast, because he had not yet breastfed on that side and the flow of milk was faster.

• The mother should start expressing her milk as soon as it has been decided to feed the baby away from the breast or that supplements are necessary. See information sheet, Expressing Milk. If it is difficult to get colostrum (often hand expression works better than a pump in the first few days), then sugar water or physiological water (contains glucose and electrolytes) alone is fine for the first few days, while continuing to help the baby latch on. After all, everyone is worried about dehydration, not calories.

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 (Often a minute or two of finger feeding will do the trick). Watch Finger feeding (same video as in previous paragraph) which is essentially a procedure to prepare the baby to take the breast, not primarily a method of avoiding the bottle, However, finger feeding can be used for avoiding a bottle as well, cup feeding is probably a better option than finger feeding. See photo below showing a newborn being cup fed.. Therefore finger feeding is best done before attempting the baby at the breast, to prepare him to take the breast.

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  Before discharge, early, competent, skilled 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. Unfortunately it is not unusual for babies to be referred to our clinic when they are 4 or 6 weeks old, or even older.

• A nipple shield started before the mother’s milk becomes abundant (day 3 to 5) is bad practice; in fact, we believe that there is no reason ever to use a nipple shield. We do go along with the medical dictum “never say never”, but in the case of nipple shields, we strongly believe this is the exception to the rule.

• But starting a nipple shield before the mother’s milk “comes in” is not giving time a chance to work. Furthermore, a nipple shield usually results in severe depletion of the milk supply, and the baby refusing to ever latch on to the breast without it. See below on the importance of maintaining a good milk supply. There is nothing that can be done with a nipple shield which cannot be done better without one.

WE’RE HOME FROM HOSPITAL, THE BABY WON’T LATCH ON. NOW WHAT DO I DO?

The single most important factor influencing whether or not the baby eventually latches on is the mother’s developing and maintaining a good milk supply. If the mother’s supply is abundant, the baby will usually latch on by 2 to 8 weeks of life no matter what, in almost all cases. What we try to do at the clinic is get the baby latching on before 2 to 8 weeks. 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. Better a bottle than a nipple shield!

• Learn how to get the best position and latch from an experienced lactation specialist. See What is a good latch. 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 s/he seems to prefer, or the breast that has more milk, or the side you feel most comfortable with if neither of the previous apply, but do not start on the breast he resists more.

• If the baby latches on, s/he will start sucking and start drinking.

• If the baby doesn’t latch on, do not try to force him to stay on the breast; it will not work. S/he will either get angry or “go limp”. Move the baby 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 s/he has not latched on. Pushing the baby into the breast will not work and may cause baby to refuse even more.

• If the baby goes to the breast and sucks once or twice, s/he has not really latched on a little; s/he hasn’t latched on at all.

• If the baby refuses the breast, do not keep at it until s/he is angry. Try finger feeding a few seconds to a minute or two, and try again, perhaps on the other side. Finger feeding is primarily used 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. Cup feeding works well and is better than a bottle.

• Using a lactation aid at the breast may be helpful, but often requires an extra hand. The video shows the baby already latched on, but in this video, you can see how the extra flow from the lactation aid helps the baby latch on. The baby is more likely to latch on if the flow is rapid, and the lactation aid increases the milk flow to the baby.

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. The best time to express your milk is right after baby has a feeding. See the information sheet Expressing Breast Milk. Some mothers actually find expressing by hand easier and just as productive or more so as using a pump. Using breast compression while pumping increases the efficiency of pumping and increases the milk supply (another hand is helpful, but some 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, we recommend blessed thistle or fenugreek or moringa to increase milk flow. See Herbal Remedies. However, if the baby has not latched on by 7 to 10 days of life, domperidone is very useful to increase the milk supply and flow. We recommend domperidone even if the mother is able to express all the milk the baby needs. More milk flow results in the baby more likely to latch on.

• In general, when a mother is taking domperidone, we recommend, when she is ready to wean off it (when the baby is eating lots of food after 6 months of age), to go slowly with weaning off the domperidone, 1 pill less/day/week. Thus, if the mother is taking 9 tablets a day, she will take 8 pills a day for a week, and then 7 pills a day for a week, until she is off the domperidone.

• However, if the mother is using domperidone to increase the flow of milk and help the 2 week old baby to latch on and latching on and drinking is successful, she can wean much more quickly, say, over 2 to 3 weeks. But carefully observe the baby for drinking, not just sucking without drinking.

Do not get discouraged. Even if your milk supply is not up to the needs of your baby, your baby is still likely to latch on. Get good hands-on help. Do not try to do this on your own.

The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.

This information sheet may be copied and distributed without further permission on the condition that you credit International Breastfeeding Centre and it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don’t know what this means, please email us to ask!

©IBC, updated July 2009, June 2017, October 2021

Questions or concerns?  Email Dr. Jack Newman (read the page carefully, and answer the listed questions).

Make an appointment at the Newman Breastfeeding Clinic.