Causes of Latch Problems

with thanks to Dr Jack Newman for permitting the babes to use this..

            In our clinic population, we see many babies, presumably normal in every other way, who cannot latch onto the breast.  This is very strange, and puzzling.  Why would a normal, healthy, full term baby not latch on well or not latch on at all?  A baby who cannot breastfeed well would be in great difficulty in the hunter-gatherer society of our ancestors, and the ability of babies to latch on well to the breast would be a highly conserved evolutionary trait.  Of course, some babies have obvious causes and these will be discussed further on.  Interestingly, such babies who latch on poorly, or not at all, usually manage to take a cup, or finger feed or bottle feed just fine.  It seems that we are interfering with the baby in some way with the result that the baby does not latch on to the breast well. 

What has gone wrong here? Infants are normally born with the instincts and abilities to breastfeed, but from there on it becomes a learning process, like walking or learning to ride a bicycle or learning to talk.  Like these processes, the breastfeeding skill is enhanced and reinforced by doing.  In other words, babies learn to breastfeed by breastfeeding. Anything that interferes with their breastfeeding may result in their not learning how to breastfeed properly. 

While babies learn to breastfeed by breastfeeding, breasts often make milk in abundance, and babies can still gain well when the milk is produced in abundance, even if without the baby latching on well.  In many such cases, the milk essentially falls into the baby’s mouth, without the baby really breastfeeding well, and so the baby the baby gains well.  However, in the longer term, the mother’s milk supply may diminish when the baby does not breastfeed well, resulting eventually (by 3 or 4 months after birth) in the baby no longer gaining well, even after an initial rapid weight gain.

Birthing Practices

            Over the past few years, it has become increasingly obvious that many of the practices we have adopted around labour and birth have resulted in babies not breastfeeding well.  Many such practices were adopted to make labour and birth “easier” for women, but were usually adopted in the era when breastfeeding and the behaviour of the baby at the breast were not taken into account.  Indeed, few studies were designed to evaluate possible effects of the intervention or medication on the mother and even fewer on the baby.  Perhaps, not so co-incidentally, the rise in interventions in childhood paralleled the decline in breastfeeding.  As more and more health professionals and especially lactation consultants have begun asking questions about why a normal baby would not take the breast well, or why a normal baby would have sucking problems, attention to birthing practices is providing at least some of the answers.

            There is no question that fewer and fewer women in industrialized societies are having normal births.  In many North American hospitals, 90% or more of women in labour receive epidural anaesthesia, for example.  In some, caesarean section rates are over 30%.  Despite lack of evidence of benefit, electronic fetal monitoring is widespread.  Induction of labour is similarly almost routine, with many babies being born at “near-term” (37 or 38 weeks). 

            Many physicians, of course, will argue that the interventions are often necessary, preventing morbidity in the mother and/or baby, and saving lives.  Of course, nobody will deny that interventions are sometimes necessary and even lifesaving, but they are not necessary as often as they are being used. Studies in the early 1990’s showed us that many of the interventions that are commonly used during labour and birth are much less likely to be necessary if the mother gets good support during labour.  For example, Kennel and Klaus in 1991 published a study that compared the rates of interventions during labour in three different groups of labouring women.  In one group, each woman was supported during labour by a trained doula.  In the second group, another woman, not trained to support labour, was in the room with the labouring woman.  In the third group, the control, the labouring woman did not get any special support, a situation unfortunately all too common in industrialized countries.  What were the results?  In the doula-supported group of 212 women, the rate of epidural anaesthesia was about 8%, whereas in the group of 204 women with no special support, it was 55%.  The women in the group who had an untrained woman with them had an intermediate rate of epidural anaesthesia of about 23%.  In fact, for all the following interventions, the results were similar: the rate of oxytocin augmentation of labour, the rate of caesarean section and even the rate of forceps delivery.  Furthermore, the rate of sepsis evaluation of the newborn was lower in the supported group as well.  More recent studies have shown that epidural analgesia in itself causes fever in the mother, and as a corollary, results in more frequent sepsis evaluation of the baby. And, finally, the mothers were more likely to be successful at breastfeeding. This is true even if the doulas have not particular training or interest in breastfeeding. The significant point here is that these medical interventions, each of which carries known risks to mother and/or baby, can be avoided by something as simple as having a support person present with the mother. These interventions undoubtedly interfere with the baby’s being able to breastfeed well.

Electronic fetal monitoring

            In a survey of mothers delivering between 2000 and 2002, 93% had electronic fetal monitoring. This is quite amazing for a technique for which there is no evidence of benefit to mother or baby. Everyone insists on “evidence-based” medicine, except when it comes to their own ways of practicing.

            This technique requires a mother to be lying down (actually, it is possible with some advanced technology to allow labouring women to walk around a bit, but most hospitals do not have it available).  The problem with lying down to labour is that the mother cannot find a position of comfort, which, for some women may be lying down, but not for most.  Most women in labour who are allowed to move around freely will find a position in which they feel most comfortable, and the position they choose often changes as the labour progresses and the baby’s position shifts. Walking during labour has been shown to promote shorter labours with fewer interventions. Without this freedom to move around and find the most comfortable position, women often need more pain-relieving medications and perhaps augmentation of labour. 

A review of studies involving 58,000 women in labour, looking at electronic fetal monitoring, showed that compared to the old technique of just listening to the baby’s heart with a fetoscope, electronic fetal monitoring did not prevent perinatal death rates or lower Apgar scores.  On the other hand, in all studies included, the rate of instrumental delivery and caesarean section was increased in the electronic fetal monitoring group.

Intravenous fluids

            In the same survey, 86% of the women had received intravenous fluids during the labour.  Intravenous fluids are given as a routine, when the woman in labour has an epidural, for example, and is obligatory, obviously, if labour is augmented with oxytocin.  This is considered a pretty benign intervention and it has not been obvious to many that receiving intravenous fluids in labour may cause difficulties with breastfeeding.

In fact, receiving intravenous fluids may interfere in several ways.  Again, because she is hooked up to an intravenous and often confined to bed (although the bag of intravenous fluid can be attached to a moveable pole so the mother can walk, this is still cumbersome) the mother may not be able to find a comfortable position so the risk of other interventions and instrumental delivery increases. Whatever makes labour and birth more difficult also makes breastfeeding more difficult. 

However, there are other issues as well.  For example, although this has not yet been demonstrated by research, it is likely that if the mother receives a litre or two of fluid over a relatively short period of time she will experience increased fluid retention, as will her baby. This is particularly true if she receives it in conjunction with synthetic oxytocin, which is an anti-diuretic hormone.  This has two potential side effects.

In the mother, lactation consultants have noted for years mothers having generalized oedema after delivery, which also resulted in oedema of the areola and nipple, making it difficult for the baby to latch on.  When a baby has difficulty latching on, interventions, often inappropriate interventions such as giving bottles, are initiated and the baby’s initial problems may be made worse.

In the baby, the results are somewhat more indirect.  If the mother has fluid retention, there is no reason to believe that the baby also will not be born with extra fluid on board.  What does this have to do with anything?  Well, it has now become the “standard of treatment” that babies can only lose 10% of their birthweight during the first few days after birth (some say 7%, some even 5%).  In many institutions, this has become a rule that is “carved in stone:” “If the baby loses more than 10% or 7% or 5% the baby must be supplemented.” There is no scientific evidence to support this. In fact, one study (get reference) found that breastfed babies who were supplemented with water or formula during the first few days lost more weight and were slower to regain the weight. 

The fact that most babies are weighed on two different scales, which makes comparison of the two weights absurd, does not diminish the focus on this weight loss or the rush to supplement. Helping the baby to get more milk by fixing the breastfeeding (better latch on, use of compression to get the colostrum flowing, switching breasts when the flow slows, not limiting feeding times on the breast), is often ignored in the headlong rush to give supplementation. 

Because in most hospitals, this supplementation is given without fixing the way the baby latches on, and is often given by bottle, the latch often becomes worse, potentially leading to problems later on.  In other words we have “fixed” a problem in the short term (in fact, the problem hasn’t been fixed, only one of the symptoms which may or may not be significant, and not done anything about the true problem, which is that the baby is not breastfeeding well), but not dealt with the issue and the minor initial problem may then become a long term problem.  The interpretation will then be that the supplementation was a “marker” of difficulties rather than a partial cause of the difficulties.

Email received (2005):  This is typical of many I have received, and I know this is what is happening in many postpartum areas.

• “Within 36 hours of his birth, he had lost 9% of his weight – a fact which threw the nurses on the labour ward into a panicked flurry of activity.  Within minutes of having weighed him, I was hooked up to a breast pump, and being shown how to use the feeding tubes and syringe to supplement my baby with formula.”

Another email (2005):  And there are long term consequences as well as the baby is 4 months old when the mother wrote this:

• “Think I got off to a bad start...the nurse told me.. [my baby] was losing too much weight (not even 10 percent of her birth weight in hindsight) and told me to get pumping. I have been worried ever since.”

So what does this mean in relationship to the baby whose mother is given IV fluids during labour? Well, this baby may be born with additional fluid in his or her system as a result, leading to an inflated birth weight. When the extra fluid is eliminated in the first day or two after birth, the baby’s weight will be seen to have dropped significantly – perhaps below the “critical” (actually meaningless) percentage for supplementation.

Epidural anaesthesia

            When a mother is having an epidural (or spinal) anaesthesia, she requires an intravenous infusion as well, because the procedure is sometimes associated with a drop in blood pressure, and it is handy to have access to a vein.  Having an epidural also inhibits the mother from walking around and finding a position of comfort.  After all, it’s not easy to walk around or get on hands and knees or squat when you cannot feel your legs. 

            But the epidural can cause other problems as well.   In a study in 1997, Lieberman et al found that women in labour who had epidurals during labour often had a fever as well, ranging from about 7 or 8% of all women who had an epidural for 6 to 12 hours to over 30% of those who had an epidural for more than 18 hours. 

In what way does this affect breastfeeding? If a woman in labour has a fever, she has tachycardia.  And often, so does the baby.  A baby with tachycardia may be in distress (it may be the fever, but we are not sure, better not take any chances), so interventions click in, interventions such as fetal scalp monitoring and scalp pH.  Does the concern of the staff translate into anxiety in the mother?  Of course it does, and anxiety in the mother is a well known inhibitor to the progression of labour.  So labour may slow, or even stop, so that the risk of instrumental or operative delivery increases.  The mother’s intravenous infusion rate is upped, to make up for increased fluid loss associated with fever, and the mother may receive antibiotics.  In addition, when the baby is born, he is usually separated from the mother, a sepsis evaluation is made, often with blood counts, blood culture, even lumbar puncture, and the baby too is given antibiotics.  The initiation of breastfeeding is delayed.  Babies learn to breastfeed by breastfeeding, but this baby born of a mother with fever during labour, will not have a chance to begin breastfeeding for several hours, perhaps even a day or two (though such long separations are not at all necessary).  Even though everyone knows, deep down, that the fever is caused by the epidural and the baby is fine.

            In yet another study, the authors showed that epidural anaesthesia is associated with a greater incidence of occiput posterior position at birth.  And what happens when a baby is occiput posterior at birth?  There is a lower chance of spontaneous vaginal delivery (only 25% of babies who are occiput posterior experience this kind of birth, compared to 75% of babies who are occiput anterior) the mother has a greater chance of having a significant perineal tear, with a higher risk of postnatal wound infection, and the baby is more likely to have a lower 1 minute Apgar score.  All these results have, as a corollary, the likelihood that the baby will be separated from the mother for variable periods of time (“no skin to skin contact until we repair this tear”, for example, though why repair of the tear requires no skin to skin contact is beyond me). 

            Whatever controversies are involved about the risks of the use of epidural anaesthesia, the studies are in agreement about three things.  The use of epidural anaesthesia is associated with:

1. An increased risk of maternal fever during labour
2. An increased risk of instrumental delivery
3. A longer second stage of labour

All of the above may result in the baby and the mother being separated at birth, for various reasons.  For example, a prolonged second stage of labour is also associated with greater maternal fatigue, and a common response of nursing staff to this situation is:  “We’ll take the baby away so you can get some rest.”

Episiotomy

            One of the most commonly performed interventions is the episiotomy.  For years it was touted as the answer to preventing serious perineal tears in the mother and of helping the baby get delivered more easily and more rapidly.  It has done none of these things, and happily, the rate of episiotomy is decreasing as birth attendants realize that the evidence is just not there to justify its use routinely.  In fact, mothers often have increased pain because of the episiotomy, wound infection is not rare, and less rapid healing occurs than with a natural tear.  In a recent meta-analysis, in which studies comparing “routine” episiotomy to “restricted use” episiotomy (where episiotomy was done only for definite indications), the authors concluded that there was no benefit to routine episiotomy, that “we identified fair to good evidence suggesting that immediate outcomes following routine use are no better than those of restricted us” and that “...routine use is harmful to the degree that some proportion of women...would have had lesser injury instead of a surgical incision.”

            Episiotomy, in itself, should not interfere with breastfeeding success, but in fact, all of the above mentioned difficulties (increased pain, increased use of antibiotics, etc) interfere with the baby getting breastfeeding early and effectively, because of the discomfort of the mother.  The mother may find it difficult to sit up comfortably, for example. Somebody may even tell the mother that she cannot breastfeed if she is taking antibiotics (Wrong, 99.9% of the time)

Narcotic medication

            In addition to other forms of analgesia, narcotics during and after labour may interfere with breastfeeding.  It is obvious that a woman under the influence of narcotics may feel “out-of-control” and cannot react appropriately to her baby.  In addition, the baby often cannot react appropriately to his mother, or anyone else for that matter.  Studies going back many years have shown that babies influenced by maternal narcotics may have central nervous system dysfunction for many days, which may interfere with how they breastfeed.  Meperidine (Demerol), having a long half-life, with an active metabolite that also has a long half-life, may affect a baby for a particularly long time.  When babies do not suck properly or well, interventions are often brought into play that make breastfeeding success even less likely (trying to force babies to the breast, introduction of artificial nipples, for example).

Cæsarean Section:

            Cæsarean section, in effect, combines all the preceding impediments to getting babies to breastfeed early, latch on well, and breastfeed effectively.  In the first place, all mothers who are going for cæsarean section will have an intravenous infusion as well as anæsthesia, general, epidural or spinal and in some situations local.  There is no evidence for local anæsthesia causing difficulties with breastfeeding but there is with the other more commonly used methods. 

            Cæsarean section is also associated with more problems with the baby, such as transient tachypnea, which often, according to hospital policy, requires separation of the mother and the baby. However, it should be noted that babies who are placed skin to skin with the mother immediately after birth have lower respiratory rates than if they are put into an incubator.

            Finally, mothers who have had a cæsarean section are in pain and require analgesia, often narcotic analgesia, with all the problems resulting from that.  They very frequently have difficulty finding a comfortable position to breastfeed.

Caption: Skin to skin immediately after caesarean section, while the mother’s incision is being sewn up.  Why cannot this be done everywhere?  Because “we don’t have a policy to allow it”?—not good enough.

Separation of mother and baby

            For generations now, we have been making excuses about why mothers and babies need to be separated after birth.  Separation at birth often meant, at best, giving the baby a pacifier, or, more likely feeding the baby off the breast, usually with a bottle, which interfered with the baby latching on.  The excuses were legion, and now most have been shown to be invalid.  Here are just some of the reasons:

• The mother should rest after the baby is born. Fact: Studies show the mother is better rested when she has the baby with her.
• After a caesarean section, the baby and mother need to be separated. Fact: Nonsense.
• The baby needs to be observed by nurses in the hospital nursery after the birth, just in case. Fact: There is no better observer of the newborn baby than his own mother.
• Certain babies need treatment for low blood sugar.  Fact: Although this is true in some cases, the best way to prevent a low blood sugar in the majority of babies is early skin to skin contact and early breastfeeding.
• Babies who pass meconium in utero need to be observed.  Fact: The baby who is in trouble from meconium aspiration is in trouble immediately after birth and almost never in trouble after the first few minutes. 
• Premature babies need to be in special care.  Fact: Some do need specific medical interventions, but the bigger premature babies – the majority - are often better off with their mothers.  Even tiny premature babies are better off in Kangaroo Care (skin to skin care) with their mothers.
• If the mother is sick, it is better the baby is not with her.  Fact: Obviously, if the mother is so ill that she is physically incapable of holding her baby, this is one thing, but the fact she has a fever, or a rash (with few exceptions), or a cough etc, is not a reason to separate mother and baby.

Actually, we now have evidence that most babies, particularly those who have not had exposure to central nervous system drugs during the labour and birth, will often take the breast without any help, crawling up from the mother’s abdomen, and latching on all by themselves.  When the baby does this, the latch is usually a good one – and the mother is greatly encouraged by seeing that the baby has done it all by himself.  This should not be surprising, really.  All newborn mammals in the wild must find the breast and latch on, and they need to be able to do it without the presence of a lactation consultant or a nurse; otherwise, they will die.  (Of course, some mother mammals will instinctively guide the newborn towards the teat, but essentially the baby does it on his own.) 

So why does it seem so unusual for human babies do the same thing?  Well, if the mother is on the birthing table and the baby across the room under the warming lamp, it would take a baby of considerably more advanced development than a newborn to find the breast.  The mother and baby need to be in contact, skin to skin, and time needs to be given the baby to find the breast – not the ten minutes many hospitals allow for “bonding.”  Studies show that it takes, on average, about 50 minutes for the baby to find the breast and latch on all by himself.  Even in those facilities that “allow” skin to skin contact immediately after the birth, it is rare that the baby stays with the mother for a full hour or two.  Of course, the baby should stay there until he sleeps or finds the breast, even if finding the breast takes him 75 or 90 minutes. And really, is there any good reason to take the baby away after that? If we could keep mothers and babies together continuously from birth – not just in the same room, but in constant skin to skin contact - our breastfeeding problems would be significantly reduced.

Caption: This baby is less than 90 minutes old (Note his hair is still wet). He has just crawled up to the breast and latched on by himself.  In spite of the mother’s large breasts.  In spite of the mother’s so called “flat nipples” (I think only in our bottle feeding mentality society would we call what most women have “flat nipples” because they don’t look like bottle nipples).

Forcing a baby to take the breast

            This is surely one of the major reasons babies do not latch on well, or, even more commonly, refuse to take the breast at all.  Hospitals tend to have a whole host of rules about infant feeding that don’t match the reality of breastfeeding. Some have the notion that babies must feed every “x” hours – every three hours is the most common one – and if the baby doesn’t take the breast at that point, “alternate feeding methods” are mandated. This often begins as early as three hours after birth.  At the other end of the spectrum is the baby who wants to nurse very frequently in the early days – say, more often than every two hours. This is frequently taken as an indication that the baby isn’t getting enough milk, and once again “alternate feeding methods” are introduced.

This is bad policy, often put into action by hospital staff who are poorly trained in helping mothers breastfeed.  There is no evidence that babies must feed every three hours, not only in the first few days but also at any time.  Babies who feed well will feed again when they are ready.  In the first few days babies have extra fluid on board, often obviating the “need” to feed frequently.  Babies may also want to feed frequently for a variety of reasons – including for comfort. Neither situation indicates an urgent need for supplementation.

Sometimes, in order to avoid supplementation, nurses will attempt to force the baby onto the breast. They help the mother position the baby, wait until the baby’s mouth is open reasonably wide (often the baby is crying) and then rapidly push the baby’s head towards the nipple. If the baby doesn’t latch (the usual result) the nurse repeats the process. Sometimes they will hold the crying baby’s head in place and instruct the mother to express some milk into the baby’s mouth.

Anyone watching this process can see that it is clearly unpleasant for the baby. The baby pushes back against the nurse’s hand or turns his head from side to side to evade the pressure. Because he’s crying, his tongue is up near the roof of his mouth and an effective latch is almost impossible. Not only does he not latch on, he learns that being at the breast is an unpleasant experience. Often these babies will begin to cry as soon as they are held anywhere near the breast, in anticipation of being forced once again.

Nipple and Breast Problems

            Nipples come in many variations. Nipples can be large, they can be rather flat, and they can be inverted.  But none of these types of nipples is abnormal and none should make a good latch impossible.  They may in some cases make achieving a good latch more difficult, but not impossible.  Often the difficulty arises from the fact that the person helping the mother is simply unskilled at helping mothers.

Most so-called flat nipples are actually quite normal.  Unfortunately, too often we get our ideas of what a normal nipple on the breast is supposed to look like by what is called a nipple on the end of a bottle.  The bottle nipple is long, and rigid (photo).  This would not be a normal nipple if it were on the end of a mother’s breast, but unfortunately, we live in a culture where bottles are “normal” feeding devices for babies not breasts.  And so a woman with a normal nipple (photo) is thought to have flat nipples.  If the baby has difficulty latching on, the nipple is often blamed.

Caption: I have seen 20,000+ women in our clinic for breastfeeding problems over the years.  That’s 40,000 nipples and I’ve never seen one woman’s nipples shaped like this.

Caption: Photo sent as an example of a flat nipple.  No, normal.

            Breasts can come in all sorts of shapes and sizes too.  Very large breasts, especially if they are soft, may result in the mother’s having difficulty latching a baby on, but this is due primarily to the difficulty in manipulating the breast and the baby, a mechanical problem, rather than some intrinsic problem with large breasts.  In such cases, persistence and a little creativity often result in the baby’s getting a good latch.  For example, a sling, as used for supporting a broken arm, can be used to support the breast so that the mother has two free hands to latch the baby on.  Some mothers with very large breasts find it easier, with a little help, to latch the baby on while they are lying down facing the baby.  It sometimes helps to have the breast supported on a pillow.

            It is vital, when confronted with a baby who has difficulty latching on, or latching on well, to keep in mind that nipples and breasts change, and so do babies, and that what is not possible on the first day of life, may very well be possible on the third day, or the 10^th day.  One must not assume that if the baby cannot latch on well or at all today, that all hope is gone.  Without hope, many, even most mothers will give up breastfeeding, and that would be a shame.

            We call it “breastfeeding” and not “nipple feeding” for a reason – the baby latches on to the breast and not just the nipple. The main difficulty with a small, flat nipple is that the baby may take the nipple into his mouth but not feel the sensation against the top of his mouth and palate that stimulates him to begin sucking. Getting more of the breast into his mouth usually solves this problem. 

            When nipples are difficult for the baby to grasp, we will sometimes use what can be called a “nipple everter” (photo).  This is made up using an ordinary 12 or 20 cc syringe.  One takes out the plunger, cuts off the end to which the needle is usually attached, and reinserts the plunger through the newly cut end.  The “everter” is then applied to the nipple and the nipple drawn out.  The advantage this gadget has over a pump to draw out the nipple is that it does not extract the mother’s milk at the same time, or only very little milk (photo).  If a baby is reluctant to latch on, he is more likely to latch on if he can get milk easily from the breast; if the mother pumps off the first let-down of milk the baby may be frustrated when he begins to suck because milk isn’t instantly available.  The effect of the “nipple everter” is temporary, and one does not have a lot of time to get the baby latched on before the nipple goes back to its usual shape, but still, sometimes, the “edge” one gets by using the “nipple everter or extractor” is just enough to get the baby to latch on well, and once the baby is latched on he will start to pull the nipple out himself as he suckles.  Personally, I do not use this very frequently, because it’s not necessary, but it is something useful to have in one’s stock of helpful devices.

Caption: Nipple everter or extractor.  Made from a 20 or 12 cc syringe, with the end that usually holds the needle cut off and the plunger put in through the resulting hole. This mother has an inverted nipple which comes out very easily with this technique and would and did evert, once the baby latched on.

            In summary:  with regard to nipples and breasts, most mothers have just the right nipples and breasts to breastfeed successfully.  It is not right to tell them, as I have heard said not infrequently, that they don’t have the right equipment, and better not even try. 

(Jack, I’m just putting in this story in bold for your interest – don’t think we’d actually use it. When my daughter-in-law was pregnant with her first baby, she came over one day and said to me: “I was looking at the pictures of the nursing mothers in the midwife’s office and my nipples don’t look anything like the ones in the pictures. Am I going to have problems breastfeeding?” Before I could even answer, my son piped up and said “Oh, I’ve seen hundreds of women breastfeeding and they have all different sizes and shapes of nipples, and they all work just fine. Don’t even worry about it.” And of course he was right. Another reason why it’s important for women to breastfeed in public!)  Let’s leave it for the people at Hale Publishing to decide.

Breast engorgement

            It is worth saying a word about the engorgement that many mothers get on day 3 to 5 after the birth of the baby.  I believe strongly that a baby who was “breastfeeding fine” for the first few days and then refuses to take the breast, or starts “latching on” poorly on day 3 to 5, never latched on well.  Before the breast became engorged, the baby was allowing the breast into his mouth, not really latching on.  The baby would suckle briefly and then fall asleep without really getting much milk.  This is not latching on.  This is pretending, and it’s a dangerous bit of business.  If the baby continues to do this type of “latching on” after the first few days, the baby can get seriously dehydrated, with possibly very serious consequences.  Luckily, most babies become agitated and refuse the breast once it’s impossible to pretend.  They fight, cry, pull at the breast, open wide and try to grab the breast, but cannot.  This sort of problem can and should be prevented by getting the baby to latch on well and breastfeed well before the milk normally “comes in” (by day 3 to 5). These early days, when the breast is soft and the amount of milk fairly small, provide a good situation for the baby to learn to breastfeed effectively.  Indeed, if the baby is breastfeeding very well during the first few days, mothers would rarely get engorged to the point of having redness, edema and pain, and most importantly, having difficulty getting the baby latch on, when the milk comes in. I do think, though, that many of the bad cases of engorgement I see are caused by the IV fluids – it’s the mothers who have had an epidural for 24 hours or longer and so they’ve been getting fluids all that time – and they have terrible engorgement by day three. It’s not having too much milk, so the baby’s feeding doesn’t make much difference – it’s just that they have all this excess fluid. Their ankles are as bad as their breasts.

Nipple shields

            Although many lactation consultants use nipple shields (photo) to help deal with latching on difficulties with breastfeeding, I find that the kindest thing I can say about them is that they are used too often and too early.  I understand that there are, in fact, situations when a nipple shield can be useful.  This tool can be useful, occasionally, but as with all tools, it can be overused and misused.  Many find it a good tool to help latch on premature babies, and increase the milk flow to the baby.  Perhaps, the advocates of the use of nipple shields in this context see more premature babies for breastfeeding than I do.  But given the evidence of what is possible for getting premature babies to breastfeed, at a much earlier age, without the use of nipples shields in such places as Sweden and our own clinic experience, I believe that the use of nipple shields in this context is also unjustified as a routine.

Caption. “Modern” nipple shield.  Its use should be restricted to those who really have extensive experience helping mothers breastfeed and in my opinion there is no place for its use before the milk supply “comes in” on day 3 or 4.

            The worst abuse of the nipple shield, however, is when it is given to mothers whose full term healthy newborn is only a day or two old but has not yet latched on.  To even consider such an intervention before the milk even comes in is a travesty of breastfeeding help.  We know that many babies who are not interested in taking the breast, or who actively refuse to take the breast, will take the breast once the milk supply becomes abundant, on day 3 or 4 or 5.  To suggest the mother use a nipple shield when the baby is only 2 days old is often blocking the possibility of taking advantage of that rapid increase in milk supply only a couple of days later.  The use of a nipple shield in this situation is bad practice, nothing less. 

I have heard lactation consultants say that if the mother hadn’t gotten the baby on to the breast with the nipple shield, she would not have continued.  But what happened to counselling?  What happened to helping the mother understand that it may still work in a couple of days?  Of course, the mother needs to have knowledgeable and skilful followup around 4 or 5 days after birth to take advantage of the increase in milk supply, but what cannot be done on day 2 can certainly be done, very often, on day 4.

Furthermore, I am convinced that the use of the nipple shield decreases the milk supply.  I realize that many people do not agree with me, especially when using the newer “more advanced” models, but I see these mothers and babies at a later stage of breastfeeding than most of those who say the milk supply is not affected.  And what I see is that the milk supply has gone down, perhaps gradually over time.  The problem then is that babies latch on best and most reliably when the mother has a good milk supply.  Thus, it is better, I think, that the mother express her milk and give it to the baby than to use a nipple shield.  Expressing the milk will maintain the milk supply at a higher level than the nipple shield, and thus the baby is more likely to latch on eventually. If mothers are using a nipple shield, then pumping after each feeding can help to maintain milk production.

When the nipple shield is thought to be necessary, it is imperative that the mother and baby be followed closely, by an experienced lactation specialist, both to make sure the baby is getting enough milk, and also to try to get the baby drinking directly from the breast without the use of the nipple shield.  Simply giving the mother a nipple shield on day two and then checking her out of the hospital with no follow-up plans is just not good enough.

Baby problems

            Breastfeeding is a two person ( and sometimes 3 or more) activity, and, of course, the baby may be a major part of the difficulty in getting a good latch or even latching the baby on at all.

            Babies may have facial and oral abnormalities that may result in their not being able to latch on well or at all.  Amongst these are tongue tie, and cleft lip and palate.  Some lactation specialists discuss “high-domed” palates and “bubble” palates as other causes of poor latches, though I am amazed how frequently these “special” palates look perfectly normal to me. 

            Neurological abnormalities in the baby may also result in the baby’s not achieving a good latch.  Neurological abnormalities may be temporary, as in the baby affected by maternal medication, or longer lasting as in asphyxia or trisomy 21.  The baby with trisomy 21, in addition to hypotonia, also has a large tongue (or small mouth, depending on how one looks at it).  Often the baby also has cardiac problems which may also interfere with his breastfeeding well.  Even longer lasting neurological abnormalities may vary with time, usually, as in the case of hypotonia in the baby with trisomy 21, improving as the weeks go by, thus making it easier for the baby to get a good latch at 4 weeks of age, say, than at 4 days of age.

            Cardiac or respiratory problems in the baby, if severe enough, may result in the baby not being able to take the breast well, usually because of tachypnea or congestive heart failure. 

            Of course any severe disease may interfere with the baby’s latching on well or at all.  There is no need to discuss every illness a baby may be born with or develop, but it is important to mention that the possibility of some medical problem other than “the baby just doesn’t want to take the breast” should at least be kept in mind when evaluating the baby with breastfeeding difficulties. Since breastfeeding is an essential function, in evolutionary and biological terms, if a baby is having difficulties the possibility of underlying medical problems should always be considered.

Tongue tie

            When the baby has a tight lingual frenulum, it is difficult for the baby to latch on well (references).  Many will call this a short frenulum, but in fact, a short frenulum is not a problem.  Rather, it is the long but tight frenulum that causes difficulty, holding the tongue down, and preventing it from doing its job properly; that is, helping to elongate the breast in the baby’s mouth and “stripping” the breast of milk.

Caption: Tongue tie.  The baby’s tongue is held down by a tight frenulum.

Why this issue of tongue tie and breastfeeding has become a battleground between lactation specialists and physicians is something of a mystery.  I suspect it is due to the fact that for many years paediatricians cut tongue ties in babies thinking that tongue tie interfered with the proper development of speech.  Then, when studies showed that tongue tie, at least the usual mild tongue tie that is generally seen, does not interfere with speech development, paediatricians were embarrassed by the many unnecessary tongue tie releases they were doing and rejected tongue tie as a possible problem altogether.  The fact that breastfeeding was never even considered in the rejection of tongue tie as an issue has been forgotten.  In fact, tongue tie became a non-issue at the very time that breastfeeding initiation in industrialized societies was at its lowest point.

            Our experience is that tongue tie can very much affect the success of breastfeeding because it interferes with the way the baby latches on to the breast.  Can babies succeed at gaining well on breastfeeding only, if they have a less than perfect latch, whatever the cause?  Of course, some will do very well, particularly if the mother has an abundant milk supply and the feedings are not restricted or timed.  Can the mother escape without sore nipples even if the baby latches on poorly, for whatever reason?  Of course, because a poor latch does not always cause sore nipples.  Thus, even if a baby has a tongue tie which interferes with his latch, breastfeeding can sometimes still go very well.  But a tongue tie still interferes with breastfeeding, and in many cases problems with milk intake and sore nipples may end up causing early weaning.

            If a tongue tie release involved major surgery, then I would be reluctant to do them.  But it is a simple, safe procedure.  It takes perhaps two seconds to do the tongue tie release itself, and explaining to the parents the possible risks (none really if not done with a meat cleaver:  a drop or two of blood in about 50% of cases is about it) and how the procedure is done usually is by far the longest part of the whole process.

            Although long, complex evaluation tools are available for “measuring” the effect of a tongue tie on the baby’s sucking ability, basically I base my decision on whether it interferes by putting my finger under the tongue, next to the frenulum.  If it feels tight, it is tight and I believe that snipping the frenulum will help with any breastfeeding problems. 

            In theory, the frenulum is bloodless and nerveless and should not cause bleeding or pain for the baby.  In practice, often the snip will cause a very small amount of bleeding that will stop as soon as the mother puts the baby to the breast.  If one cuts only what is pearly-grey and not what is pink, there should be no problems.  However, we do keep a vial of powdered thrombin on hand, in the rare cases when bleeding does not stop.  This has occurred twice in 21 years and several hundred tongue tie releases.

Almost always, babies cry because we hold them down (arms on either side of the baby’s face, held tight, so that the baby does not move) but usually do not cry more because of the procedure.  However, some babies do seem to react to some pain when the frenulum is snipped.  Given the length of time it takes to do the procedure, applying some sort of anaesthetic seems to me unnecessary.

Sometimes after the procedure is done, the mother does not see any obvious immediate or rapid improvement.  In our clinics, we never simply just cut the frenulum.  We also help the mother change the latch she has almost always been taught to an asymmetric latch (see chapter x for how to latch a baby on).  We often will give the mothers an ointment for sore nipples, and use the Protocol to Increase Breastmilk Intake by the Baby to help the baby get more milk.  If the tongue tie release has been delayed, muscle memory may prevent the baby from changing the way he latches on and/or suckles at the breast.

However, in many cases, the change is immediate.  The mother will say that the baby’s latch just feels so different and so much better.  A baby who was refusing the breast completely, may now latch on.  A mother who has had severe pain in the nipples may now be, if not pain free, in much less pain than before - immediately after the procedure!  Given the ease with which it can be done, it seems a pity not to include this procedure in the armamentarium of any physician dealing with infants and their mothers.

A couple of emails from nursing mothers:

·      “Though the tongue tie appeared to be minimal, it was indeed interfering with breastfeeding.  I noticed an improvement immediately in terms of contact with my nipple.  It took a little time for her to learn she did not need to feed constantly.  She is now 7 weeks and everything is much better.  Better latch, more efficient feedings, less gas and longer periods of sleep.”

·      “So now, to try to summarize, just 2 weeks ago I finally got to see a pediatrician who clipped her tongue. The latch was totally amazing immediately!!!! Emmaly nurses great now...”

Cleft lip

            In itself, an isolated cleft lip should not cause too many problems with latching on.  However, once the alveolar ridge is affected, the problems of latching on become more and more difficult. 

            When a baby has a cleft lip and difficulty latching on, the problem is often blamed on the cleft lip.  However, there are plenty of babies who do not have cleft lips who have difficulties latching on, and babies who have cleft lips may have difficulties for the same reasons (see above).  The fact that it is often easy for a baby with a cleft lip to get a good latch suggests that the problem may not be the cleft lip itself. 

            Some mothers find they can adjust the baby’s position on the breast so that the breast “fills in” the cleft lip.  Other mothers have used non allergenic tape to close the cleft.

Caption: This baby has both a cleft lip with extension into the areolar ridge, and guess what, she breastfeeds beautifully.  One thing is sure if one assumes it won’t work and the mother does not even try:  the baby won’t breastfeed.

Cleft palate

            A cleft palate is definitely a more difficult problem.  In most cases, cleft palates are very obvious at birth. In some cases, though, the cleft involves the soft palate only; the baby’s face looks perfectly normal and the problem is not infrequently missed.  For this reason, amongst many others, all babies should be observed breastfeeding.  It is vitally important to evaluate the adequacy of breastfeeding, and this should be done in all mothers and babies within a few days of birth at the latest, certainly by the end of the first week. The adequacy of feeding is as important to evaluate as whether or not the baby has a heart murmur or not, something every baby’s doctor would do as part of the routine physical examination.  In fact, I believe it is more important, since far more babies get sick, some very seriously, and admitted to the hospital because of difficulties with feeding than they do for heart problems.  When a baby with a cleft of the soft palate tries to breastfeed, the baby is rarely truly latched on (the breast will usually slip out of the baby’s mouth very easily), but with every suck, or virtually every suck, the observer will hear a definite “tsah” or clicking noise.  If this is observed, the health professional should make a careful examination the baby’s palate, as it is very likely the baby has a cleft of the soft palate.  In just 2 months we picked up two babies whose cleft of the soft palate was missed, simply by observing a breastfeeding and hearing the “tsah” sound with every suck.

            When there is a cleft of the palate, most North American cleft palate teams simply assume that breastfeeding is impossible and that it is not worth even trying to get the baby breastfeeding.  I believe this is a pity, because first of all, we do hear of mothers who were able to breastfeed their babies with cleft palates.  Perhaps this is a rare occurrence, but it is obvious that if one does not even try, for sure it isn’t going to work.  I also believe that many mothers feel cheated in having had the support to give it a try.  Likely the baby will not latch on, but should not the mother find this out herself, after having given it the old college try?  I believe she will then accept the inevitable, that the baby just cannot latch on.  But when we discourage the mother even trying, she will always be left with the regret and the suspicion that maybe, just maybe the baby will have latched on. 

            This means that attempts to latch on the baby should occur before bottles are given and before the milk “comes in”.  If necessary the baby can be fed by cup rather than by bottle, preferably with the mother’s expressed milk or banked breastmilk.  Finger feeding will usually not work with a baby with a significant cleft palate.  Neither will a lactation aid, since the baby needs to latch on in order to use the lactation aid.  If it doesn’t happen, then at least the mother will have tried.  This presupposes, of course, that the mother is given expert help, not just the old “give it a go” approach.

            In some places obturators are used to fill in the cleft palate, for several reasons, including, according to those who encourage their use, that repair is easier, and that speech is often improved when obturators are used.  However, though I have no experience with the use of obturators (they are not used at the Hospital for Sick Children in Toronto), their use certainly makes it possible, even likely, that a baby who has one will actually latch on to the breast.  Unfortunately, too often, breastfeeding is not considered important in a situation when a baby has a major malformation, because everyone is so concerned about the malformation.  However, helping mothers and babies succeed at breastfeeding is not incompatible with dealing with the malformation. Here is a fertile area for research: how can we best help a baby with a cleft palate (congenital heart disease, cystic fibrosis, meningomyeolcoele etc etc) breastfeed.  It was not that long ago that paediatricians were recommending that if the baby was not latching on in the first few days, there was nothing to do except bottle feed.  This, after some years of experience, has been shown to be completely untrue.  Perhaps, with experience, we will find that some or maybe even many babies with cleft palate could, if helped properly, latch on and breastfeed well.  This will never happen if we simply state that it cannot be done.

Caption: Baby with cleft lip and palate breastfeeding.  Maybe a rare case, but if one doesn’t try, it will never work.

Nipple confusion

            Perhaps this is the place to tackle the contentious issue of nipple confusion.  This issue is contentious only because people do not understand breastfeeding.  Why it has become yet another battleground of paediatricians against lactation specialists, I have never figured out.  There is some emotional baggage hiding in this issue that obviously is driving a lot of the discussion. 

            Let us look at this logically and calmly.  I don’t believe that anyone would argue with the statement that some babies prefer a particular artificial nipple, say an Evenflo nipple to a Nuk nipple, or vice versa.  Or that some babies might prefer a Playtex nipple to an Avent nipple or vice versa, and so on.  This is not some radical statement.  And you don’t have to do studies to know that this is true.  Just ask any parent who uses bottles. We also don’t have to do a double blind randomly assigned study either to know that some babies will prefer the mother’s right breast to her left or vice versa.  When I ask this at conferences at which I speak, about 10%, sometimes many more, of the mothers in the audience will put up their hands to agree that their baby preferred one side to the other.  Now, why would a baby prefer one breast to another?  There are two likely reasons.  One is that the preferred breast produces more milk and the milk flow from that breast is faster.  Babies like fast flow, and they will prefer it to slow flow, or, and this is important, slower flow.  Even if the less preferred breast has a good milk supply, the baby will still often prefer the side with a faster flow.  A mother who has equal amounts of milk in both breasts (more or less, it’s never exactly the same) will not usually have a baby who will prefer one side to the other, even if she has insufficient milk supply.  The other reason that a baby will prefer one breast to the other is that the preferred breast is easier to grasp or easier to latch onto.  Of course, the fact that the breast is easier to latch onto often results in the breast producing more milk, so the two reasons are related.  Are these not the exact same reasons that a baby might prefer a bottle to the breast?  Of course.  A bottle gives a steady flow of milk, usually quite rapid.  The breast can often flow very rapidly, but it is also variable, the flow being fast, particularly during the early part of the feeding, and then slows for a while.  Then, the milk flow can then increase for a while again, before slowing down, so that milk flow may follow a sort of sinusoidal curve.  During the first few days, when many babies receive bottles in the hospital (almost always unnecessarily), the milk flow from the breast is hardly ever rapid, but the bottle still is.  A hungry baby will figure this one out pretty smartly.  “I go to the breast and I don’t get very much.  Then I get a bottle and I get plenty, even more than I really want.  So I’m going with the bottle!”  Bonding, psychology are important, sure, but hunger comes first.

            Furthermore, one cannot force a breast into the baby’s mouth, or more accurately, one cannot force a baby to latch on to the breast.  If one of the mother’s breasts is more difficult to grasp, it is usually because the nipple is different (perhaps flatter or inverted, but these reasons only make latching on more difficult, not impossible, see above), from the other side or the breast tissue is different and more difficult to grasp. 

One can usually force a bottle into the baby’s mouth, even if the baby is reluctant to take it, and the milk flows whether or not the baby sucks. Then the baby must swallow the milk to keep from drowning, and that action causes more milk to flow. Indeed, in medical school, during our paediatric rotation, we were taught that if a baby was failing to gain weight adequately, we should tip the bottle upside down to see how rapidly the milk flowed.  About one drop a second meant the nipple hole was not blocked or flowing too slowly.  We were also told to observe a feeding, which is interesting, because medical students and paediatric residents are not now taught how to observe a breastfeeding, at least not in most training centres.  I’ll bet they are still taught to observe a bottle feeding, however.

Taking all the above into consideration, is it really such a leap to assume that a bottle can interfere with breastfeeding, especially if the milk supply is low or insufficient? 

Thus, it is not the baby who is confused.  The baby knows exactly what is going on.  The baby who is hungry will prefer the method of feeding that gives him the best reward, and in the first few days that is almost always the bottle rather than the breast.  Once the milk becomes abundant, however, many babies will accept the breast and latch on reasonably well, but many won’t, having gotten used to getting rapid, steady flow from the breast and the feel of the firm, long nipple in their mouths.

Does nipple confusion or preference mean only that the baby refuses the breast?  Not at all, breast refusal is only the most extreme manifestation of nipple confusion.  In many cases, it is the final result as well, after other manifestations have made the mother’s and baby’s breastfeeding experience difficult.  In fact, nipple confusion, in my mind, merely means that the baby is not latching on the way he should, and the results are often seen in the mother: sore nipples, blocked ducts and mastitis, insufficient milk production secondary to poor nursing or secondary to blocked ducts and mastitis, which occurs sometimes.  In the baby: colic, frequent feeding, long feedings, even when weight gain is good, poor weight gain and even weight loss, poor weight gain after an initial good weight gain for 1 to 3 or 4 months. 

A few emails from nursing mothers:

·      “The last couple of early mornings, Zachary has begun fighting me when I try to get him to nurse.  It’s like he is saying ‘Give me a bottle, it is easier for me and I want it now!’ Is this my imagination or is he starting to prefer the bottle over me?”

·      “In any case, my attempt at breastfeeding is really making me feel like I’ve failed my six week old son in the breastfeeding feeding department.  As you read, I resort to the bottle out of his cries for food.  He just won’t accept my breast now.  I always try to put him on the breast first.  Up until 2 weeks ago, I was able to breastfeed him for a while and then I would top it up with the bottle which I knew might lead to trouble, but he was still hungry.  Now, he’s exclusively bottle fed and I am so disappointed about this.

One can question here the commonly-heard comment “Don’t make mothers feel guilty for not breastfeeding”.  Who actually does feel guilty about breastfeeding?  As this email (and thousands of others I have received over the years show), it is the woman who wanted to breastfeed but whom we, as health care professionals have failed, who feels guilty.  Why does no one worry about her feeling guilty? 

·      “Hi.  I was wondering if you have any advice on coaxing my 5 month old back to the breast?  She receives bottles at daycare and lately is refusing to nurse except for the middle of the night.  I’m not ready to wean, but I also can’t keep up pumping.  As of now she has had no formula.”

·      “While my nipples feel much better (especially a few hours after I apply the gentian violet) they are not totally pain free and they are still red in the centre.  As a complicating factor, the gentian violet is irritating my baby's mouth so that she cannot breastfeed, though she will still take a bottle.  I should also mention that we have been dealing with thrush since the end of May.”

This one is interesting in that the mother thinks that the baby is refusing the breast because the gentian violet is irritating the baby’s mouth, yet the baby will take the bottle, even though one would think that the hard latex nipple of the bottle would be more irritating than the soft breast.  This is clearly a case of nipple confusion.

·      “I have a one month old son who I was breastfeeding, but due to some weight loss (12%) in his first week my pediatrician suggested I supplement him with formula with a bottle.  (The latch wasn’t the problem because I had .... a private consultation; I think my milk was just slow at coming in.)  Once I did that for about a week, he no longer wanted my breast.”

·      “I have a 10 week old daughter.  I have been exclusively breastfeeding her from day 1.  I attempted to introduce her to a bottle of expressed breast milk two weeks ago.  I would like to be able to have someone else give her the occasional bottle when required.  For the past two weeks I have tried the bottle almost every day and she will take the bottle into her mouth but she will not suck on the nipple.  She will play with it.”

This “problem” is a different one than the breast refusal, in that the baby refuses the bottle not the breast.  But the point is that some babies do both (though some only pretend to breastfeed and are actually only pacifying at the breast and really feeding when they get the bottle), some will prefer the bottle and some prefer the breast.  Almost everyone who says there is no such thing as nipple confusion will agree that the baby needs to learn how to take a bottle, otherwise the baby may not take a bottle ever (though I do not see why this is a big problem, especially when women have decent maternity leave and do not have to return to work before 6 months after the birth of the baby, six months being the absolute minimal length of time I would consider “decent” maternity leave).