Protocol #9: Breast Refusal or Difficulty Achieving or Maintaining a Latch Protocol #9: Breast Refusal or Difficulty Achieving or Maintaining a Latch Breast refusal or difficulty achieving a latch can occur at any stage of breastfeeding and is not limited only to the early weeks of birth. Observation and Assessment delivery, nerve damage related to birth injury, anaesthesia, intravenous therapy, lengthy labour. Assess the baby for: • Medical condition, e.g., jaundice, dehydration, • Repeated inability to achieve or maintain a latch. hypoglycemia, sepsis. • Pushing away from the mother’s breast with arms • Neurological conditions affecting muscle tone, and legs. e.g., hypertonia, hypotonia, prematurity. • Arching and crying when brought to the mother’s • Abnormal nasal, oral, or facial structure, breast. e.g., narrowing or blockage of the nasal airway • Latching and sucking a few times, then letting the (choanal atresia), cleft lip/palate, other alterations in nipple slide out of the mouth. palatal structure, receding chin. • Refusal of one or both breasts. • Abnormal tongue, e.g., ankyloglossia, large or short tongue, tongue curling up to the roof of the mouth, Possible Contributing Factors tongue thrusting, decreased tongue peristalsis. or Causes With an abnormal tongue, the tongue may not be • Breast refusal or difficulty achieving a latch may be able to extend past the lower gumline and cup the mother and/or baby related. areola during breastfeeding. This can be assessed by pulling back slightly on the baby’s lower lip when Early Breast Refusal the baby is at the mother’s breast. There may also be dimpling of the cheeks or clicking/smacking 1. If the baby began refusing the mother’s breast in sounds when the baby sucks. Any of these signs the first 1–2 days after birth, would indicate a latching or sucking problem due to Assess the mother for: the incorrect use of the tongue during breastfeeding • Ineffective positioning and latching techniques (Protocol #10: Ineffective Suck). (Protocol #2: Positioning and Latching). • Swaddling that entraps the baby’s hands and • Flat or inverted nipples, especially with a hard interferes with the baby’s instinctive behaviours in and non-compressible areola (Protocol #8: Flat or finding the breast, triggering letdown and latching. Inverted Nipples). 2. If the baby began refusing the mother’s breast • Long or elongated nipples, especially if the baby is between the age of 2–4 days old, small. Assess the mother for: • Birth interventions, trauma or stress that may delay • Engorgement (Protocol #5: Engorgement). Lactogenesis II or interfere with breast milk production, e.g., caesarean delivery, lengthy labour, intravenous • Breast edema related to intravenous therapy in therapy, pain (Protocol #10: Ineffective Suck). labour. • Breast edema related to intravenous therapy in labour. • Birth interventions, trauma or stress that may delay Lactogenesis II or interfere with breast milk Assess the baby for: production, e.g., caesarean delivery, lengthy labour, • Birth interventions, trauma, stress, and medications, intravenous therapy, pain (Protocol #10: Ineffective e.g., bruising from a forceps or vacuum extraction Suck). Breastfeeding Protocols for Health Care Providers | Toronto Public Health 69 • Forceful letdown or breast milk ejection reflex Assess the baby for: (Protocol #13: Overabundant Breast Milk Supply/ Forceful Letdown or Breast Milk Ejection Reflex . • Preference for an artificial nipple, i.e., nipple confusion when the baby has imprinted • Delayed letdown reflex. preferentially on the stimulus of an artificial nipple. • Inappropriate parental response to infant behaviour • Finger feeding and if the baby has imprinted and feeding cues. preferentially on the stimulus of the finger. • Stress. • Medical conditions, e.g., jaundice, candidiasis, ear Assess the baby for: infection, dehydration, hypoglycemia, sepsis. • Medical conditions, e.g., jaundice, hypoglycemia, • Swaddling that entraps the baby’s hands and sepsis. interferes with the baby’s instinctive behaviours in • Swaddling that entraps the baby’s hands and finding the breast, triggering letdown and latching. interferes with the baby’s instinctive behaviours in 4. If the baby began refusing the mother’s breast after finding the breast, triggering letdown and latching. the age of 1 month, Later Breast Refusal Assess the mother for: • Overly rigorous attempts to breastfeed the baby on 3. If the baby began refusing the mother’s breast a schedule and ignoring the baby’s feeding cues. between the age of 1–4 weeks old, •Decreased breast milk supply, due to regular bottle Assess the mother for: supplements, offering other foods or fluids before • Forceful letdown or breast milk ejection reflex 6 months of age, medications (Protocol #12: (Protocol #13: Overabundant Breast Milk Supply/ Insufficient Breast Milk Supply). Forceful Letdown or Breast Milk Ejection Refle ). • Missing or ignoring the baby’s feeding cues. • Delayed letdown or breast milk ejection reflex. • Forceful letdown reflex Protocol( #13: • Decreased breast milk supply. Overabundant Breast Milk Supply/Forceful • Missing or ignoring the baby’s feeding cues. Letdown or Breast Milk Ejection Refle ). • Change in the taste of her breast milk, • Use of a new soap, shampoo, hair spray, perfume, from onset of menses, mastitis, medications, nipple detergent, or other products that the baby may creams, exercise, smoking, previously frozen breast dislike or be sensitive to. milk, or consumption by the mother of new or • Change in the taste of her breast milk from the onset strongly flavoured foods that the baby may dislike. of menses, mastitis, medications, nipple creams, Strongly flavoured foods may temporarily cause a exercise, smoking, or new or strongly flavoured baby to refuse the mother’s breast. The baby usually foods that the baby may dislike. Strongly flavoured returns to the mother’s breast by 24 hours after the foods may cause a baby to temporarily refuse the ingestion of the food (Lawrence, 2011). Most babies mother’s breast. The baby usually returns to the will accept a variety of flavours. mother’s breast by 24 hours after the ingestion of the • Ingestion of a food or drug that the baby may be food. Most babies will accept a variety of flavours. sensitive to, e.g., cow’s milk, cigarette smoke, • Ingestion of a food or drug that the baby may be caffeine, or other drugs (see Protocol #11: Crying sensitive to, e.g., cow’s milk, cigarette smoke, and Colic in the Breastfed Baby for information caffeine, or other drugs (Protocol #11: Crying regarding sensitivity to cow’s milk or cigarette and Colic in the Breastfed Baby for information smoke, and Protocol #16: Drugs and Breastfeeding regarding sensitivity to cow’s milk or cigarette for information regarding caffeine and other drugs). smoke, and Protocol #16: Drugs and Breastfeeding • Stress – feeling overwhelmed, experiencing for information regarding caffeine and other drugs). coping difficulties related to possible postpartum • Pregnancy. adjustment and/or breastfeeding difficulties. Breastfeeding Protocols for Health Care Providers | Toronto Public Health 70 • The baby biting when the mother has responded by 2. Provide the mother with suggestions to help screaming at or startling the baby. persuade the baby to take her breast. • Stress, emotional distress, feeling overwhelmed or Before breastfeeding, encourage the mother to: experiencing coping difficulties related to possible postpartum adjustment or inadequate support. • Breastfeed in a quiet, relaxed place where she can be comfortable and well supported. Assess the baby for: • Initiate breastfeeding before the baby is overly • Medical conditions, e.g., candidiasis, ear infection, hungry or frantically crying. Breastfeed early when gastroesophageal reflux. the baby is beginning to show early feeding cues and is calm, e.g., rapid eye movements under the • Oral discomforts, e.g., teething, cold sores. eyelids, sucking/licking, hands to mouth, increased • Discomfort when being held, after an injection or injury. body movements, and making small sounds. • Distractibility due to developmental changes; at 4–5 • Clothe the baby only in a diaper when breastfeeding months babies may turn away from the mother’s to promote skin-to-skin contact (Protocol #1: The breast because they are developmentally more Initiation of Breastfeeding). interested in looking at their surroundings. • Ensure that the baby is calm before each attempt to • Emotional upsets, stress, or overstimulation, latch. e.g., radical changes in daily routines, family crisis, • Support the baby in a vertical position, chest-to- baby frequently left to cry. chest, with nose at the level of the mother’s nipple, Suggestions to facilitate the normal neonatal reflexes and baby- led self-attachment behaviours. 1. Assess for possible cause(s) of breast refusal or difficulty latching (see previous section on Possible • Ensure that the letdown or breast milk ejection Contributing Factors or Causes). reflex is initiated. The natural stimuli for letdown are the baby’s rooting, sucking, and hand • The baby will need to be assessed by a primary movements at the mother’s breast. If necessary, she health care provider for any possible medical may try using one of the following techniques: condition, e.g., jaundice, candidiasis, ear infection, hypertonia/hypotonia, cleft lip/palate, tight frenulum. ° Apply heat to her back and shoulders for comfort and relaxation. • If the mother’s breasts are engorged, refer to Protocol #5: