Baby-Friendly e-Newsletter : Infant and Toddler Feeding Case Files (Aug 2020)
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Managing Reluctant Feeders in the First Day of Life
Ms Yip Mo King
RNM, IBCLC, Breastfeeding trainer (WHO UNICEF)
Ward Manager
Department of Obstetrics & Gynecology
Queen Mary Hospital
The majority of healthy term babies with uncomplicated delivery are successfully breastfed with skills and psychological support from the healthcare staff. Some babies may fail to latch and feed in their first day of life due to various challenges. This article illustrates the journey of a midwife supporting a mother and her reluctant-to-feed baby in a local Baby Friendly Hospital.
Case History
Mrs. Chan is a 27-year-old first-time mother. Having received one shot of narcotics for pain relief at the 8th hour of medical induction of labour, she eventually underwent an emergency Caesarean Section under epidural anaesthesia because of sub-optimal foetal heart rate. A healthy term baby boy, Aaron, weighing 3.05Kg was delivered. Mrs. Chan started immediate (within 5 minutes) skin-to-skin contact (STSC) with Aaron in the operation theatre. She was taught to recognise the baby’s early feeding cues such as mouthing, tongue movement, hand sucking, etc. while having STSC with Aaron.
Aaron slept through his first hour of STSC without showing early feeding cues. It was not until they were inside the recovery room that Aaron started to have increased limb movements. However, movement signifying an active awake baby such as shoulder and head wriggling was still minimal in his second hour of life.
In the recovery room, the midwife offered skills support to Mrs. Chan in positioning and attachment to facilitate Aaron to latch. Nevertheless, breastfeeding could not be initiated. Aaron’s axillary temperature was borderline low (36.5°C) before the mother-baby dyad were transferred to the postnatal ward. They were kept in STSC throughout the transfer. Upon arrival at the postnatal ward (i.e. 2.5 hours after birth), Aaron’s axillary temperature further dropped to 36.2°C.
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Why are Some Newborn Babies Reluctant to Feed? 6,7 Some babies are particularly sleepy or uninterested in feeding after birth. This can be especially true in babies born:
If these babies are unable to attach to the breast in the first few hours after birth, they may continue to be sleepy to conserve energy. |
Since the early antenatal period, Mrs. Chan had planned to exclusively breastfeed Aaron. She became stressful due to Aaron’s reluctance to latch and feed. She was frustrated and felt guilty for being unable to deliver vaginally and having received narcotics for pain relief.
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How Does a Mother Perceive Her Reluctant Feeder? 1,3,6 An infant who is reluctant to feed can be especially worrisome. The mother may perceive that her baby is rejecting her. This may arouse enormous maternal anxiety which significantly hinders the mother’s milk ejection reflex and exacerbates latching difficulties. |
Mrs. Chan’s feeling was recognised by the midwife. She praised her for trying her best for Aaron. She discussed with her the likely factors contributing to his poor feeding and the relevant management strategies. In view of his lowish body temperature and sleepiness with blue extremities, the importance of keeping Aaron warm was stressed. The midwife ensured that Mrs. Chan understood the benefit of continued STSC. Cold blankets covering the mother-baby dyad were immediately replaced with a double-layered warm blanket and changed every 15 minutes. The room temperature was adjusted to around 24°C. A hat was put on Aaron to minimise heat loss. His body temperature was checked half-hourly. After 45 minutes, Aaron finally regained a normal body temperature of 37°C. Thereafter, his vital signs were monitored frequently until he was stable.
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Keeping the Baby Warm 6,7,8 Hypothermia results in CNS depression leading to lethargy, poor feeding and even apnoea in a newborn baby. Maintaining skin-to-skin contact keeps the newborn baby warm and soothed. A warm towel over the baby is also helpful. |
Mr. Chan was invited to stay with his wife. He was keen to support her. He was taught to perform breast massage and hand expression while the mother-baby dyad was having STSC. He was a fast learner and had successfully collected 1ml of colostrum into a small feeding syringe from both breasts at the end of the 30-minute session.
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Involving and Empowering the Significant Others 7 The father can do a lot to support breastfeeding. His presence and participation such as offering practical help in positioning are often crucial to appeasing a frustrating mother. |
Mrs. Chan was taught to feed Aaron in a laid-back (semi-reclining) position (Photo-1, please refer to page 3 of the PDF version). She was assisted to sit in such a position with her back, shoulders and neck well supported using pillows which were useful in maintaining the correct position in a relaxed way. Aaron was put diagonally across his mother’s chest with his tummy down and feet kept clear of her abdominal wound. His head, resting on the breast, was slightly extended and facing sideways while supported by mother’s arm.
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Several Different Positions May Need to be Explored to Find a Satisfactory One. Some Babies Do Better When the Mother is in a Laid-back Position. 2,4,6,9 Babies are born with the ability to move towards their food source – mother’s breasts. Putting the mother in a “laid-back” position is about using a position that tap into the baby’s natural reflexes that facilitate latching. It is sometimes called ‘Biological Nurturing’ during which the baby becomes an active participant, often self-attaching while maintaining his own positional stability. Gravitational forces help secure the baby close to the mother’s body. It also helps smoothing and coordinating the reflexes e.g. the baby’s chin and tongue are pulled forward triggering mouth opening to facilitate attachment. |
The midwife explained to the parents different ways to wake Aaron up, such as talking to him with variable pitch, stroking his palms or soles, etc. when he was in a light sleep state. They were taught how to tempt him to open his mouth by tickling his lower lip with a finger or a syringe with colostrum (Photo-2 & -3, please refer to page 4 of the PDF version).
A syringe with expressed milk was slid along the corner into the baby’s mouth, pointing towards the cheek. A gloved index finger with the pulp facing up was inserted about 1.5 to 2 cm in when the baby opened his mouth. Colostrum was squirted gently, slowly, and intermittently, with 0.2ml each time, into his mouth. Moving the finger back and forth slightly along the roof of the mouth helped elicit suckling and swallowing reflexes in the baby.
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Stimulating the Baby to Feed 2,5-7,9 Babies are born with the ability to move towards their food source – mother’s breasts. Putting the mother in a “laid-back” position is about using a position that tap into the baby’s natural reflexes that facilitate latching. It is sometimes called ‘Biological Nurturing’ during which the baby becomes an active participant, often self-attaching while maintaining his own positional stability. Gravitational forces help secure the baby close to the mother’s body. It also helps smoothing and coordinating the reflexes e.g. the baby’s chin and tongue are pulled forward triggering mouth opening to facilitate attachment. |
After a minute of finger-syringe feeding, Aaron started to suck the finger rhythmically with swallowing reflex initiated. Soon after, he raised his head and turned towards mother’s nipple. With his mouth widely open over the nipple, he took in a good mouthful of the nipple and breast. After a few attempts, he started to suck and swallow rhythmically, enjoying his first meal from his mother (Photo-4, please refer to page 4 of the PDF version). Mrs. Chan was so touched that she burst into tears when seeing her little baby getting on the breastfeeding track.
Timely support (within 6 hours after birth) in terms of psychological and technical support is crucial to initiating breastfeeding in newborn babies. Apart from avoiding unnecessary formula supplementation, successful initiation of breastfeeding also prevents separation due to hypoglycaemia and dehydration in poor feeders
Key Message:
- Keeping a newborn baby warm is crucial to initiating breastfeeding. 保持初生嬰兒温暖對開展母乳餵哺十分重要。
- Feeding a newborn baby with colostrum provides him with energy and stimulates his suckling. 餵哺初乳可提供初生嬰兒所需能量，並刺激他的吸吮本能。
- Support the mother and baby to find their best latching position. 協助媽媽及嬰兒找出最適合餵哺的體位。
- When feeding a reluctant feeder with alternative feeding methods, try natural breastfeeding positions such as the laid-back position. 當需要用其他方法去餵哺不願吃奶的嬰兒，可採用自然的母乳餵哺體位如半躺臥式。
- Empower both parents and give them timely support. 授予父母能力，並提供適時協助。
For the note of References, please refer to the PDF version.
Views expressed in this article are the author's and do not necessarily reflect the opinion or position of the BFHIHKA.
作者在本文章表達的見解，未必代表愛嬰醫院香港協會的意見或立場。
Editor-in-Chief: Dr Shirley Leung
All rights reserved by Baby Friendly Hospital Initiative Hong Kong Association.
愛嬰醫院香港協會，版權所有。