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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.
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.
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.
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, 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.
INFANTS WHO MAY HAVE FEEDING DIFFICULTIES 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 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 HAVE NOT LATCHED AT THE BREAST 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
of expressed colostrum, if available, may be enough to settle the infant before a return to the breast. Hand expression of breast milk may remove larger volumes of colostrum than a breast pump in the first few days after birth, and gentle breast massage and hand compression may also increase the amounts of available milk (Academy of Breastfeeding Medicine [ABM], 2017).
TYPES OF BREASTFEEDING SUPPORT The introduction of a physiological approach to breastfeeding initiation made a significant impact on clinical breastfeeding support because of the redirected focus towards activation of maternal-infant instincts (Douglas & Keogh, 2017). This redirects support away from a purely mechanical position and attachment model, which views breastfeeding as an acquired skill, to a relationship-centred breastfeeding focus, incorporating innate breastfeeding abilities (Schafer & Watson Genna, 2015). No single breastfeeding support intervention focused on positioning and attachment - whether hands-on or hands-off - has been shown to significantly increase rates of maternal breastfeeding self-efficacy, breastfeeding duration or exclusivity (Schafer & Watson Genna, 2015).
Additional support for breastfeeding is recommended for infants who are experiencing difficulties (Fan et al, 2018), but achieving this in a busy understaffed postnatal ward can be challenging. Infant feeding ability is not related to maternal motivation, intention, desire or ‘skill’ but can be related to infant exposure to intrapartum and early postnatal stressors, which can include interruption of skin-to-skin care, as well as exposure to labour medications. Midwives may find that all the mother-infant dyads on their shift-caseload require additional support. Early feeding difficulties can quickly lead to the need to start breast expression with a resulting loss of maternal confidence. This can increase maternal stress, which can negatively affect the milk ejection reflex and compound any breastfeeding challenges. The iatrogenic effects of introduced interventions, however carefully applied, may also lead to a rapid deterioration into a longer-term mother/ infant ‘hard to fix’ feeding problem, even after the initial infant feeding difficulty is resolved.
BIOLOGICAL NURTURING / INFANT LED NURSING Biological nurturing is a neurobiologic approach based on enhancing neonatal
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Additional support for breastfeeding is recommended for infants who are experiencing difficulties, but achieving this in a busy understaffed postnatal ward can be challenging.
reflexes and maternal instincts by using positional postures that are beneficial to breastfeeding (Colson et al, 2008; Colson, 2005a; Colson 2005b). A laid back position for breastfeeding compliments a physiologic approach. There are more triggers for primitive neonatal reflexes in biological nurturing postures (laid-back breastfeeding) which suggest that human infants are innately abdominal rather than dorsal feeders. The key for biological nurturing, alongside positioning, is the promotion of an oxytocin friendly environment.
PHYSIOLOGICAL BREASTFEEDING – WHAT HELPS AND WHAT DOESN’T Physiological breastfeeding practices incorporate the creation of privacy, appropriate support, patience and time, calmness, opportunities to practice breastfeeding and relationship-centred care.
Midwives support women to prepare a birth space to facilitate the physiology of labour (Bradfield, 2019) and the same attention to the environment is beneficial for breastfeeding – creating a physiological breastfeeding space. This is a space to support oxytocin responses, as free as possible from unnecessary interruptions, which is safe, private and warm. Winberg (2005) describes skin-to-skin care as the “maternal nest” which invokes a vision of calmness, closeness, warmth, loving touch, nurturing contact and relaxation.
These conditions support oxytocin response and require protection and facilitation in order to create a scaffold for breastfeeding. Construction of a maternal nest and creating an ‘illusion of time’ in terms of the midwife being ‘with’ the woman so that she feels there are no time restrictions for the provision of breastfeeding support is important, but challenging. In a busy postnatal ward, creating an illusion of time is complex, but it suggests what is essential to meaningful interactions – creating a feeling of time well spent, relationship building, improving the quality of interactions, satisfaction and reassurance for the woman, and a shared decision-making process.
Burns et al. (2015) described language as an aspect of breastfeeding support that has received little attention in the literature. How maternity staff describe the feeding behaviours of infants during the time of breastfeeding establishment was observed during a study conducted at two maternity units in Australia.
Repeated negative references to infant personality and unfavourable interpretations of infant behaviour, implying that newborn infants have the capacity to think and decide whether to breastfeed, influenced how women perceived their infants. Terms used to describe infants included lazy, impatient, cross, cranky and uncooperative. Burns et al. found that more relationshipbased communication, and focusing on breastfeeding as a relational activity, rather than just a nutritional activity, fostered positive language and positive maternal interpretations of infant behaviour.
SUPPLEMENTATION OF BREASTFEEDS Prevention of the need for supplementation
is supported by the Ten Steps to Successful Breastfeeding (WHO), particularly Step 4 (skin-to-skin), Step 5 (support for initiation and maintenance of breastfeeding and management of common difficulties), Step 7 (rooming-in) and Step 8 (responsive feeding/feeding cues). Implementation of Step 6 (no food or fluids to breastfed infants unless medically indicated) and Step 9 (risks of feeding bottles, teats and pacifiers) also support exclusive breastfeeding and recognise
the importance of decisions made about why, what, how much, and when supplementary feeds are given, and how.
When supplementary feeds are medically necessary for the breastfed infant, the primary goals are feeding the infant, while optimising maternal milk supply. Any supplements should be given in a way that preserves breastfeeding, with attention paid to the volumes of milk given (limiting to what is necessary for newborn physiology), and supporting the infant to continue practising at the breast (ABM, 2017). The optimal supplement is expressed milk from the mother, followed by screened donor milk, with formula being the last choice. If neither expressed milk from the mother or donor milk is available, then formula milk will need to be used. square
The next Breastfeeding Connection article will discuss in detail early infant weight loss and feed supplementation.
References available on request.
Key points and strategies
Newborn infants need time to recover from birth
Skin-to-skin contact is the habitat needed for birth recovery and breastfeeding support immediately after birth and in the postnatal period
Time, patience and supportive breastfeeding opportunities are necessary for infants who are having feeding difficulties
Birth interventions do not help breastfeeding and always need to be taken into account
Facilitate oxytocin releasing conditions - a physiological breastfeeding space (maternal nest), because proximal care (skin-to-skin) develops maternal behaviours, feeding responses, and anxiety regulation in infants and mothers
The maternal nest/oxytocin supportive conditions require a warm environment, low lighting, reduced noise, minimal interruptions, and privacy
Creation of an ‘illusion of time’ despite the shift caseload - relationship building, satisfying interactions, care with language used and shared midwifewoman decision making.
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