Breast milk is the best gift a mother can provide to her baby. However, refusing to breastfeed is a very common complaint. Possible reasons for breastfeeding refusal can vary, ranging from temporary causes like improper position to serious ones such as sepsis. Understanding “why” the baby is refusing to breastfeed is the key to correcting the problem. In most cases, the problem is temporary and gets solved with minimal help. A physician’s role is to counsel and assure the mother, and thereby help her avoid faulty feeding practices. The practitioner should associate certain danger signs with feeding refusal, so that pathological causes can be identified as early as possible and appropriately be treated.
In day to day practice, general physicians frequently come upon the very common complaint “My baby is not feeding well, what should I do now?” This is very distressing to mothers, especially the first-time mothers. Newborns should be fed when they show signs of hunger. Babies give a lot of subtle cues that they are ready to feed, long before they begin to cry; this ranges from rooting with their mouths to making sucking noises and trying to suck on their fists, as well as little noises. Newborns usually feed every few hours because of their small stomach capacity that cannot hold much milk at one time. A neonate who was initially accepting feeds well but has suddenly stopped taking feeds requires medical evaluation.
As a baby grows older, the number of feeds that the baby requires changes as well. A very young baby commonly requires eight to twelve breastfeeds in 24 hours, but there is a wide variation in the number of feeds an older baby needs.
Reasons for refusal to feed may be benign or pathological. In most cases, the problem is solved with minimal assistance and the baby does not require medical attention. Sometimes it is possible that a baby refuses only one or two feeds in a day but takes all the other feeds well. This occurs when the mother tries to feed the baby when he is not hungry or not ready to feed. Other possible reasons include refusal to bengin sucking, or leaving the breast after a few minutes, both of which are related to the stage of development or baby’s health at that time. Preterm babies, due to developmental immaturity, might refuse to feed or might stop breastfeeding prior to completing the full feeding due to weak sucking efforts. Sometimes a baby may want to feed but there is a maternal issue such as an inverted nipple. This is one of the most commonly encountered problems. In such cases the baby cannot properly latch onto the breast, and becomes frustrated while attempting to breastfeed, due to hunger.
Another reason for refusal to breastfeed is an incorrect latching method. If a baby does not latch properly onto the breast, it becomes very difficult for the baby to suck. Therefore, it is vital to correct improper positioning. A mother should be counseled that she can assume any position in which she is comfortable. She can sit or lie down but she should not be leaning on her baby. The baby’s whole body should be supported; head and body should be in one line, no twisting at the neck, both the abdomens of the baby and the mother should touch each other, and the baby’s nose should be at the level of nipple. Signs of good attachment are – baby’s mouth wide open, chin touching the breast, everted lower lip, most of the nipple and areola in the baby’s mouth with only the upper areola visible.
Sometimes, babies can just be very fussy and difficult to feed; it doesn’t mean they are refusing feeds. Such babies are usually unwilling to feed from the start and take a long time to get going, but once they start feeding, they feed well. A fussy baby may appear to receive little satisfaction from feeding. He sucks for a short while and then breaks away, finishing his feed after a series of stops and starts.
When managing a fussy feeder or a baby who is refusing to breastfeed, it is important to remain calm and patient, and to handle the baby gently. The mother can be encouraged to perform deep breathing; this helps slow her breathing and make it more regular, which can help create a sense of calm. The mother should also be encouraged to concentrate on staying relaxed; she can play soothing music, rock her baby gently or carry him around and use other relaxation methods. This relaxation will help the mother’s milk flow readily, so that the baby will get milk the moment he/she latches on.
Most commonly a baby’s refusal to feed is due to these benign causes however in certain cases, pathological reasons should also be considered. Described below are some factors which, if associated with the baby’s refusal to feed, should arouse a suspicion of pathological causes.
- Lethargy –The baby was initially alert, active and playful but has become lethargic.
- Hypothermia – Normal temperature is 36.5 to 37.5°C. Hypothermia can induce lethargy and can lead to a refusal to feed. Whenever the temperature falls below 36.5°C, all possible measures should be taken to increase the baby’s body temperature: increase room temperature, wrap the baby with warm linen, remove all wet clothes, provide skin to skin contact, try to breastfeed the baby. If the baby is severely hypothermic, he should be referred as soon as possible to a higher medical facility for further workup, after initial stabilization.
- Fever – Rule out dehydration, fever and environmental fever first. If there is a significant decrease in the weight of a baby, it may be due to fever. Remove any overwrapping and correct the room’s temperature. Fever in neonates can be dangerous and might be due to underlying sepsis. Refer to a higher center; detailed work up is necessary in such cases.
- Sepsis – Sepsis is one of the most common pathological causes for a baby’s refusal to feed. Refusal feed and lethargy may be the only initial presentation, so medical attention is often delayed. Other presenting features may be vomiting, abnormal body movements, abdominal distention, fast breathing, and cold extremities.
- Whitish patches in oral cavity – These suggest oral thrush, which renders breastfeeding painful for the baby. Both the mother and baby should be treated simultaneously with antifungals.
- Fast breathing, labored breathing, chest retractions, cyanosis– These suggest a possible lower respiratory tract infection.
- Bluish discoloration of oro-facial area, forehead perspiration while feeding – These signs suggest a congenital heart disease. Congestive heart failure may present as either refusal to feed, or a “suck- rest- suck” cycle may be seen. In congestive heart failure, the heart cannot pump the extra volume of blood flow required during feeding. Therefore, the baby initially sucks well, but tires easily and takes rest. He then regains energy in some time and then can feed again.
- Abnormal body movements, staring eyes – These can suggest neonatal seizures. Common causes include hypoglycaemia, hypocalcaemia, sepsis, electrolyte imbalance, birth asphyxia, cerebral haemorrhage, and inborn errors of metabolism. Such babies should be evaluated in detail.
- Hypothyroidism – Lethargy, hypotonia, umbilical hernia, poor feeding
- Down syndrome – Presents with typical facies, single palmer crease, hypotonia
- Neuromuscular disorders– Although rare, neuromuscular disorders can lead to an inability to feed. Examples include spinal muscular atrophy, congenital myopathies, congenital myasthenia gravis and others.
Some other common causes for a baby’s refusal to feed include the use of pre-lacteal feeds and the use of pacifiers or bottle feeding. Giving honey or sugar to baby is a traditional practice in some parts of India. Honey and sugar may satisfy a baby’s hunger and induce sleep, and therefore render the baby more difficult to feed. The risk of nipple confusion, whether by introducing a bottle or pacifier, is greatest during the early days of nursing. The mechanics of breast and bottle-feeding are quite different. When a baby nurses, his tongue and jaws must work together rhythmically. He cups his tongue under the areola, and presses it up against his palate. This flattens and elongates the tissue around the nipple. The baby then drops the back of his tongue to form a groove for the milk to flow from the nipple to his throat. He swallows and then takes a breath. His lips are flanged out, tightly around the breast, to form a tight seal. This doesn’t happen during bottle feeding, which is a passive process in which the baby has only to control the flow of the milk with his tongue. Some medications given by the mother during labor can also affect her baby’s feeding in the first hours after birth; many pain medications can cause temporary drowsiness in a newborn.
Signs that a baby is getting enough breastmilk are good bowel/bladder movements and a well-nourished baby. Over 24 hours there should be regular, soft, bowel motions, and at least six to eight very wet cloth nappies or at least five heavily wet disposable diapers, with pale, odorless urine. If the baby’s urine is dark and has a strong smell then it is likely that it is dehydrated. The baby is adequately nourished if he/she is reasonably content, looks alert, has bright eyes, good skin color and muscle tone, and has adequate weight gain.
Following are the list of possible reasons for a baby’s refusal to breastfeed:
- Attachment problems
- Nipple confusion
- Recent immunization
- Feeding pattern is changing
- Introduction of other foods
- Overuse of a dummy (or pacifier)
- Discomfort associated with sucking
- Milk supply reasons
- Tired or over stressed
- Illness or taking prescribed or over the counter medications
- Ÿ Unusual food in the mother’s diet
- Mother smells different due to a different perfume, deodorant, smoke
- Hormonal changes
- Menstruation and pre-menstrual tension
- Oral contraceptives
DO’s for the Mother
- Try different feeding positions
- Get help of family members
- Watch breast feeding videos
- Take help from breast feeding counselor
- Wrap the baby properly – use cap and gloves in case of cold hands and feet
- Provide kangaroo mother care in preterm neonates
- Ensure baby is latching well on breast
- Be calm and patient
- Give skin to skin contact
- Play light music or sing nursery rhymes
- Do not feel frustrated
- Spend five minutes in massaging the baby if receptive to this
In most cases, breastfeeding refusal is temporary and minimal assistance can solve the problem. A physician’s role is to be aware of where the difficulty lies and appropriately counsel parents and help the mother gain her confidence. The physician should make parents aware of proper feeding positions and how to avoid faulty feeding practices. Sometimes one may never discover the reason behind a baby’s refusal to feed. A physician should be able to identify certain danger signs, which point towards pathological causes, before it becomes too late. If a baby continues to refuse feeds despite making all possible efforts, the baby should receive immediate medical attention to rule out sepsis and other pathological causes.
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- Cloherty J, Eichenwald EC, Hanson A, Stark AR. Manual of Neonatal care. 7th Edition. Philadelphia: Wolters Kluwer,Lippincott Williams and Wilkins. 2012; 107
- Paul VK, Bagga A. Ghai Essential Pediatrics. 8th Edition. New Delhi: CBS Publishers and Distributors. 2013; 152-154.
- Australianbreastfeeding association. Breast refusal. Melbourne: Australian breastfeeding Association; 2017 Nov. Available from : https://www.breastfeeding.asn.au/bfinfo/refusal.html.