Help! My newborn isn't Latching

Your beautiful little newborn was just laid onto your chest, skin to skin, your birth plan says you want to breastfeed within the first hour of delivery if possible! But this tired little newborn just lays relaxed on his mother's chest...no rooting, lip smacking, or sucking on his fist...just calm and quiet. What now?

There are many reasons that would affect the baby's ability to latch in the time frames we expect, in fact it may take the help of a very experienced IBCLC, cranial sacral therapists, occupational therapists, or even a specifically skilled dentist to help baby latch, and breastfeed effectively!

Consider these scenarios to help make 
sense about why baby may not be ready or 
capable of latching yet:

"Hurdles for Babies"

After laboring for 15 hours, most of that time on IV pitocin...followed by pushing for almost 2 hours, your baby has finally delivered with the assistance of a vacuum extractor. Thankfully, you had an epidural and it was not very painful, however you really couldn't feel "how" to push. Baby's head was acynclitic in the birth canal (his head was presenting at an angle that makes delivering baby's head difficult, and prolonged the second stage of delivery) He delivers with a sore head, some swelling already noted. He must have a major headache! He is tired, he just wants to recover from a difficult delivery. 

Difficult, instrumental deliveries may be necessary, but they often impair infants initial reflex to latch on actively after delivery...although I've seen babies do it!

Baby might have anatomical variations such as a ankyloglossia (tongue tie) which is discussed below, or Micrognathia. Many times they are able to partially latch, but lose the latch after 3-4 sucks. 

There are many congenital illnesses such as cardiac, respiratory, or gastrointestinal defects that can negatively affect initial breastfeeding. Babies can actually be born with an infection requiring antibiotics. Some parents know before hand that their baby will have a cleft lip (which by the way, babies with cleft lips can usually breastfeed well!)

He may also have a cleft in the soft palate, which typically eventually requires surgical correction. These mothers can help their babies best by pumping on a regular basis, and building a sufficient milk supply. Babies with these congenital defects may need to be fed using special nipples and bottles. 

Some babies grow into a tight space with limited room to move, resulting in asymmetry of their spine, face, and/or head. Torticollis is an example of this. These babies often don't feel comfortable feeding on one side, or they are very rigid and difficult to help them relax into a deeper, more comfortable latch. They simply don't feel comfortable. Your pediatrician may refer you to an occupational therapist to work with baby, which in addition to working with a good IBCLC will hopefully result in better breastfeeding.

A baby who was in a breech position may also struggle with breastfeeding initially because of their positioning in the womb. These babies often require extra patience and persistence. Whenever I notice asymmetry in a newborn while still in the hospital, I suggest that parents begin The Tummy Time Method  daily to help baby strengthen his neck muscles, and have better range of motion. You can start with a healthy full term newborn, laying on your chest for the first 3 weeks, then moving to a blanket on the floor. Help him spend time looking in both directions, and encourage any lifting of the head off of your chest as he is strengthening his neck muscles!

What else could be wrong? Might baby have a tongue or lip tie? To be honest most primary care providers are not usually well trained in diagnosing and fully releasing a tongue and lip ties. some don't believe lip or tongue ties are valid breastfeeding problems....If you feel there is a possibility that this is an issue for your baby, first speak with your pediatrician. If you do not get the help you feel you need, you are always entitled to get a second opinion. There are prefered providers in each state. A fantastic website/blog to learn more about TT/LT is www.drghaheri.com and www.kiddsteeth.com/ 

How to choose the right Provider to diagnose and treat tongue and lip ties. 

Unfortunately there are very few qualified/prefered providers in each state. Some states have none! The private FaceBook site "Utah mother's tongue and lip tie support group" lists the top 3 providers in Utah. You must ask to be admitted by the admin of the group. 

Mommypotamus great blog about common signs and symptoms of tongue and lip ties for moms and babies

In my professional opinion, if you have sought out an IBCLC for help with getting a better latch, tried many if not all of the above suggestions, and you can identify many of the above linked signs and symptoms of tongue tie while still not achieving the latch or a comfortably latch, then I believe it is your right as the baby's parents to seek further help from a specialist. Pediatricians may not have expertise in diagnosing babies who have tongue and lip ties. At the same time, many seasoned IBCLC's may not have experience working with babies who have been diagnosed with tongue and lip ties. However, please keep in mind...

The sooner you seek evaluation and possible revision from a specialist, the better!!!

The longer an infant is allowed to practice sucking against oral restrictions, the longer it will take to relearn effective sucking skills! 

"Hurdles Mothers Face"

Mother may have flat or inverted nipples or both flat and inverted, making it very difficult for baby to detect the nipple in his mouth at the upper palate to stimulate the sucking reflex. I have written in previous blogs, it is very helpful for mothers to have a "prenatal lactation consultation" to help her identify where the issues may be, and formulate a plan before and after delivery. 

Surprisingly, some babies are able to take in a flat nipple and elongate it while suckling. Luckily they only know their momma's breasts and nipples and haven't been comparing nippes 😁 

Occasionally mothers have very large or long nippes, making it difficult or almost impossible for baby to accommodate enough of the areolar complex (nipple and areola) to effectively transfer colostrum/mature milk. 
The basic solution to extra large or long nipples is simply time! Time for baby to grow a bigger mouth. Mom will need to pump and bottle feed until baby gets older and bigger. 

Often these variations in size and lack of shape or inversion leads to a mom becoming more sore or damaged than typically expected....further exacerbating the poor breastfeeding. 

Often these challenge require the help of an experienced IBCLC. There are ways to encourage flat nipples to evert during pregnancy, and after delivery. This may include the use of a silicone nipple shield. Some people have a negative opinion of Nipple shields. Generally this is because the older nipple shields mothers used to use were made of thick rubber and they really did negatively affect mom's milk supply. Thankfully the new nipple shields are much better.

My professional opinion on nipple shields is that they can be a valuable tool that can bring a mom and baby together, despite anatomical variations that make latching nearly impossible. I have found more and more that Millennial moms surprisingly prefer using a nipple shield, whether they need it or not....Remember the #1 Rule of nipple shields: you fit the nipple shield according to your nipple size, NOT the baby's mouth size. Most mothers need a size Medium (24 mm) putting their average sized nipple into a small shield will result in undue pain, discomfort, and even nipple damage.

So Back to the Problem at hand...

What can we do When Baby Isn't Latching?

Go back to the basics! 

👶 Skin to skin contact immediately after birth and before any newborn procedures are performed on healthy infants, cesarean sections included. Skin to skin contact should continue for the next couple of weeks, especially when latching is an issue. 

👶 For compromised infants, minimize maternal infant separation as much as possible. I find that most mothers are more than happy to do the one thing that is most helpful for their ill newborn...provide her colostrum and mother's milk!

👶 Use gravity, (especially if the baby has a recessed chin) Biological nursing, also referred to as the "laid back" feeding method.

👶 Don't rush the baby. He needs time to learn just as mom does. If he starts fussing or the efforts to breastfeed starts to become overly stressful, stop! Feed the baby in a less stressful way (spoon, cup, or finger feed expressed colostrum) and then try again when mom and baby are both calm.

👶👩  Know the natural infant feeding cues (Sucking in hands, rooting when lips are touched, etc) and respond sooner, rather than waiting until baby is crying to offer to latch.

👩  Ask for help to initiate breast pumping and manual expression within 1-2 hours if mom must be separated from her infant.

👩  While initially learning to breastfeed, use the most supportive holds such as the cross cradle or football hold. The newborn feeling stable and supported is vitally important to successful latching and breastfeeding. I liken it to being offered a sandwich to eat while walking on a tightrope. It's nearly impossible to focus on eating when we don't feel stable and comfortable! 

👶  Align infant's head and body in one plane, facing inward tummy to tummy with mom. Mom's forearm is ideally aligned with baby's back bone. Hand is placed at the nape of the infant's neck (which may feel wrong initially, but I promise it is right!) There should be no gap between baby's body and mother's body. Aim mom's nipple to baby's nose.

👶   The normal encounter that a baby expects is shown above. Mom is holding baby at the nape of his neck, fingers and thumb extended under baby's ears. Mom helps him extend his neck back slightly, His chin makes contact first, then as nipple brushed over his upper lip, and baby opens widely to take in the nipple and areolar complex. It's similar to taking a bite of a big hamburger. We always start the the lower bun, then open our mouth up over the rest of the hamburger bun...REMEMBER! This process can take time! Be patient, and stop trying when frustration sets in for either mom or baby. "Reboot" baby by bringing his up between the breasts skin to skin. When both mom and baby are calm, resume attempting the latch.

Notice baby's chin is deeply touching breast, mouth widely opened with lips flanged out like "fishy" lips. Baby's nose is not touching breast, and if it is touching, it is not enough that it occludes his ability to breath.
A greater portion of mom's lower areola is included in the deep asymmetric latch, while the upper portion is more visible. Remember, this may vary from mother to mother as areolar sizes differ widely!

A few don'ts:

👩  Do not push the back of baby's head onto the breast. This leads to head flexion (chin tucked down into throat) the proper positioning is "baby's chin buried deeply into her breast, lips slightly flared out, nose may be barely touching breast or not at all. Tip: if you feel you have  to make a "pocket" around your baby's nose so he can breath, you don't have the baby in an optimal position! Also, I have found that it seems to be "second nature" for a new mother to place her free hand around the back of the baby's head to "support" him. Babies have a natural reflex to pull away from the breast when mom places her hand there, leading her to to feel that baby is rejecting her. Nothing could be farther from the truth. Ask your partner to remind you if you find yourself placing a hand on the back of baby's head once he is latched.

👎

No hand on the back of the head! support around the nape of the neck...it's okay to feel awkward initially, but baby will let you know if you are doing something that they are not happy with or that hurts them!!

Remember...No hand on the back of baby's head 😌 It honestly can be extremely easy to forget, and naturally place your hand there.

👍

Very nice "Laid Back" or Biological Nurturing latch soon after birth!

👶  As mentioned before, do not push a crying baby to continue trying to latch onto the breast. Go to the "reboot" position! (baby placed skin to skin, no blankets between you and baby) in an upright position between your breasts as shown below, and try again later.

Keep in mind, no matter what the latch and positioning look like, the true measure is in the answers to these two questions:

#1: Is the latch effective? (Meaning Is baby getting enough milk?)

#2 Is it comfortable?

Even if latch and positioning look perfect (and, yes, even if a lactation consultant told you they were fine), pain past the initial 30 seconds of the latch (particularly after the first two weeks) and/or ineffective milk transfer indicate that something needs to change, and the first suspect is ineffective latch/positioning.

If baby is transferring milk and gaining weight well, and mom is comfortable, then latch and positioning are – by definition – "good," even if they look nothing like the “textbook” latch and positioning that you’ve seen in books.  (From Kellymom.com...My all time favorite breastfeeding website!)

If baby is not latching well, or not latching at all, mom needs to start regular pumping (preferably using a hospital grade pump rental rather than a personal use style breastpump usually provided by insurance companies or Medicaid) 
as well as Hand Expression, 
each about 8 times per day.

Learn How to hand express here

Early milk removal is essential! Breasts calibrate milk supply in first hours, days, and weeks postpartum. I like to call it "Placing a good milk order." It also helps in the proliferation of prolactin receptors. I always recommend hand expressing colostrum onto a spoon, and spoon feeding it to baby. It helps mom see that she really is nourishing her baby!

It is important to remember that many mothers are only able to hand express just 1-2 mls. This is not a reason to be discouraged, this is normal! Keep pumping at least 8 times per day to stimulate a sufficient milk supply while you continue to work with an IBCLC to get baby to latch.

Having your baby "Room in" while in the hospital makes a difference. Mom is much more likely to respond to baby's early feeding cues and feeds baby often.

Many well meaning visitors and even healthcare workers offer to take baby away from his mother in the Well baby nursery. 

Wouldn't this be awesome?!?

Supplementation for the non-latching baby...

What to supplement with?

and for how long?

I learned an important lesson from an very experienced colleague early in my Lactation consulting career. When struggling with breastfeeding focus on these three most important priorities:

#1 Feed the Baby! 

A baby who is well fed will become a better breastfeeder sooner than an underfed infant! How should mom feed this baby? Latching at the breast if possible, using a cup or spoon, using a nipple shield, using a supplemental nursing system (SNS) at the breast, finger feeding using a tube and syringe, or a paced bottle feeding. Mom can use her expressed colostrum, mother's milk, pasteurized donated human milk, or formula. 

Keep in mind that finger, cup, or spoon feeding are all meant to be used for short temporary periods of time only...such as 3-4 days maximum! I typically teach mother's that when they are pumping about 10-15 mls or less colostrum/mother's milk, (2-3 tsp) they can continue to finger, cup, or spoon feed. 

In most cases mother's milk should "come in" at about day 4 postpartum. After day 4, the amount of milk required at each feeding will increase daily, until they reach 30-60 mls/feeding around days 5-7. At this point, if latching is still not working well or at all, parents should move to either supplementing using a commercially made supplemental nursing system at the breast, but keep in mind 

this is labor intensive, and intimidating to many parents. If you have help, and or feel confident in using an SNS system, great! If it makes you feel panicky and overwhelmed, then use a bottle to feed. In order to prevent the biggest issue I see with bottle feeding, "flow preference" it is important that parents to pace the feeding so that the baby doesn't get used to easy, effortless flow from a bottle. Start by using a slow flow bottle nipple, and if that still seems too easy or fast flowing, replace the slow flow nipple with a "preemie" bottle nipple. Click on link below to learn more about paced bottle feeding from one of my favorite breastfeeding websites, "Balanced Breastfeeding."

"It Isn't About the bottle, It's About the Person Feeding the Bottle!"

Take time to watch this helpful video as well.....

How to pace a bottle feeding (Best Feeding Lactation services)

Soooo? What about the baby that isn't even sucking well on a bottle? Even taking up to one hour to finish his bottle feeding! This calls for a referral from your pediatrician to an Occupational Therapist to help infant develop and strengthen his sucking skills!

#2 Protect your milk supply!

This means that if your baby is not actively and effectively feeding from your breasts at least 8 times in 24 hours, you must use a hospital grade breastpump rental to help build and protect your milk supply. It is good practice to pump for about 15-20 minutes after any baby feeding/supplementation. If you are trying to increase your milk supply, you may want to pump for 3-5 minutes past the last active drops of milk while pumping.

Some women respond wonderfully to the breast pump, while others do not. If you are becoming upset by the seemingly small amount that you are able to pump at each pumping, place a towel over the pump flanges...do your very best to relax...I realize this is easier said than done! You might even download a relaxation exercise from iTunes to listen to while pumping. A 25 year old study demonstrated that mothers who pumped while listening to a relaxation technique yielded 30% more milk than mothers who pumped in silence (or more likely to a screaming baby!) Just do the best you can, if you need to skip a pumping now and then, you will not ruin the protected supply!

# 3 Keep Working with Baby

There are many different approaches to help a non-latching baby finally latch. The following link from Kellymom.com lists many ideas to try. 

Helping guide baby back to the breast

Keep in mind that this can be a long, discouraging process. It may take a turn for the better, and it also may become such a negative experience for mom and baby that it is actually better to stop and start really enjoying your baby. Remember, your worth as a woman and a mother has nothing to do with how you feed your baby!!!

There are many Board Certified Lactation Consultants (IBCLCs)
who can help you, in many cases right in the privacy of your own home! 

Go HERE to find a private practice IBCLC in your area.