BREASTFEEDING CONNECTION
BREASTFEEDING CHALLENGES IN THE EARLY POSTNATAL PERIOD – THE NON-LATCHING INFANT The previous article in the March edition of Midwife discussed the initiation of breastfeeding after birth, skin-to-skin care, innate breastfeeding abilities and the nine infant behavioural stages after birth. The beneficial practice of mother-infant skin-to-skin has demonstrated how critical the period of time after birth is, while also exposing how easily the infant behavioural sequences after birth can be derailed.
INFANTS WHO HAVE NOT LATCHED AT THE BREAST
CAROL BARTLE POLICY ANALYST
Numerous neonatal reflexes, (including rooting, sucking, swallowing, crawling, mouth gape, hand to mouth activity, and head bobbing) which are instinctive physiologic responses to endogenous or environmental stimuli (stimuli that can have positive or negative effects), contribute to the infant’s ability to self-attach at the breast (Schafer & Watson Genna, 2015). Early feeding ability requires recovery from birth, minimal disturbance, and infant-mother-contact. These aspects continue to be significantly important to breastfeeding in the days after birth.
respiration and breastfeeding (French et al, 2016), and unlimited skin-to-skin care can provide additional support for infants who continue to have difficulties breastfeeding in the days following birth. Svennson et al. (2013) found that skin-to-skin contact during breastfeeding enhanced positive maternal feelings and shortened the time to resolve latching problems in a cohort of infants (n=103) at one to sixteen weeks postpartum.
This article reviews the management of the non-latching infant in the first few days on the postnatal ward, with a view to exploring support for the ongoing initiation of breastfeeding and the challenges presented when an infant is having difficulties feeding. The challenges for midwives in providing care for breastfeeding complexities in understaffed areas with increased rates of birth interventions is also recognised, and some potential strategies for support for non-latching infants are presented.
All well term infants need to have the time and opportunity to proceed at their own pace through the nine behavioural phases after birth, but ‘derailed’ infants who have had difficult beginnings may take longer to recover from birth and to demonstrate an interest in feeding. Potential contributing factors to infant feeding delay include suction, resuscitation, caesarean birth, ankyloglossia, and any mother-infant
To summarise the previous article, Widström et al. (2020) proposed that the nine behavioural stages are developed and practised by the fetus in utero in the same specific order, which indicates that the newborn has been learning this sequence and is primed and prepared for this experience after birth. Skin-to-skin contact between the mother and infant immediately after birth allows for the development of innate neonatal behaviours such as temperature regulation,
Infants who are having initial latching difficulties are at a significant risk of shortened duration of breastfeeding and loss of breastfeeding exclusivity.
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separation. Other infants who may be at risk of a slow start to breastfeeding are early term births (37-38 weeks). A systematic review found an association between early term birth and lower rates of breastfeeding initiation and a shorter duration of exclusive breastfeeding (Fan et al, 2018). Kalmakoff et al. (2018) also found that early term birth was a predictor for feeding supplementation, although the research found that greater than 65 minutes of skin-to-skin contact reduced the risk of supplementation. Clinically recommended practices, along with skin-toskin contact, also include recognition of the importance of autonomous newborn hand use, which is demonstrated by breast seeking activities, hand-to-breast and hand-to-mouth movements, self-soothing, and shaping and moving the breast. Directing or restraining infant hand movements can cause feeding delays (Schafer & Watson Genna, 2015).
INFANTS WHO MAY HAVE FEEDING DIFFICULTIES
Infants who are having initial latching difficulties are at significant risk of shortened duration of breastfeeding and loss of breastfeeding exclusivity. When an infant is not breastfeeding, lactation is fragile and a multi-pronged strategy is needed; feeding the infant; development of a feeding plan with the mother; provision of appropriate support for the infant to move closer towards latching; protecting lactation; and avoidance of further complications from any intervention. At the same time, reassurance and care for the mother is also essential. The need to express breast milk and feed the infant by alternative means, while continuing to work towards achieving a breastfeed can be stressful, and this can compound maternal-infant difficulties by the down-regulation of prolactin. Identifying the reason/s why an infant may be having difficulties enables a plan to be made to remedy problems, and may make it easier for a mother to understand why her infant is struggling. Sometimes there is no obvious reason that can be identified, but difficulties may also resolve without any specific treatment apart from time, patience, and care. As midwives will be aware, a key aim when offering the infant opportunities to latch at the breast is to keep the infant as calm as possible, as a frustrated infant will be unable to latch. Ideally, taking a break from feeding and calming the infant works well and if supplemental feeds have been started, it can be useful to offer a small amount to the infant at the beginning of the feed to help keep the infant calm. A small amount
