The breast refusal dilemma

Following the interest in the story about breast refusal - Twit-Twoo Guru - posted on my Story Blog (https://www.robinbarker.net.au/twit-twoo-guru-a-breastfeeding-story) I’m putting up a post on the topic as it seems to have  struck a chord.

‘Twit-Twoo Guru’ is a story about early breast refusal soon after birth, however breast refusal can happen at any age. Possible causes tend to vary with the age of the baby.

Breast refusal is a broad term describing a range of behaviour at the breast where the baby, for reasons that may not be clear, fusses and fidgets, screams or gets distracted and refuses to feed.

 It’s potentially extremely distressing for mothers. The nurturing instinct strongly revolves around feeding our babies. Feeding babies is deeply preoccupying and emotionally satisfying. When it goes pear-shaped all manner of gloomy thoughts bubble up and spill over. What am I doing wrong? Doesn’t my baby like me? Is there something wrong with my breasts, my milk, my baby?

The up and down nature of breast refusal adds to the anxiety. Wondering whether a feed will be a dreamy, drifty pleasure or a frustrating, miserable ordeal has the potential to wreak havoc on the mother’s well-being and enjoyment of her baby.

 On the plus side, breast refusal is common. It is nearly always temporary and often with patience, some moral support and the right advice the breast refusal will end as mysteriously as it began.

        Breast Refusal – Possible Causes

 In the early weeks when breastfeeding is being established breast refusal can result from difficulties with attachment (flat or inverted nipples, baby sucking ineffectively, engorged breasts, a sleepy baby).

Sometimes during the early weeks, babies are given bottles for unavoidable reasons, for example, prematurity, and will refuse the breast when it is first offered.

 These early problems are often resolved reasonably quickly - sometimes spontaneously, sometimes with patience and help –however there are two specific occurrences of early breast refusal that deserve special mention.

            Babies who fight the breast

When offered the breast, some newborn babies thrash about, move their heads from side to side and scream. Like a lot of things babies do, it’s often difficult to know exactly why they do it. It doesn’t help that the baby can’t tell us.

The cycle can be broken by having a third person, not as emotionally involved with the baby, to help. If there no professional help available – midwife, lactation consultant, doula – a calm neighbour or friend could step up.

  Tips for helpers:

• Separate mother and baby. Calm the baby and see if she will sleep.

• Nurture the mother. A cup of tea, a change of scenery, a bath, a shoulder massage are some suggestions.

• When mother and baby are calm and comfortable try another feed. To encourage the baby to suck the mother should express a little milk before starting the feed. This softens the areola, making it easier for the baby to grasp the nipple and breast.

• Skin-to-skin contact is helpful. If the mother is comfortable with the idea, feeding in the bath helps.

              Floppy, pale baby

• Rare occasions can crop up when refusing the breast – especially in the first 6-8 weeks – is a sign of serious illness especially if the baby has previously been feeding well. If the baby is floppy, pale and not wetting her nappies it is important parents seek medical help immediately.

After the early weeks, there are numerous possible causes of breast refusal. It’s helpful to bear in mind that often a definitive cause and solution to breast refusal remains elusive. Staying calm and working around the problem is often more helpful than endlessly seeking a firm diagnosis and ‘treatment’.

               Baby Causes

• Illnesses such as coughs, colds, sore throats, ear infections or blocked noses. I’m aware that oral thrush is often put forward as a reason for breast refusal however thrush is unlikely to be a cause unless it reaches the raw and bleeding stage. As oral thrush is easy to see and generally treated before it becomes painful this is unlikely.

• Frequent regurgitation and heartburn – to be honest this is a handy diagnosis and, apart from occasionally, unlikely to be the reason behind most breast refusal behaviour.

• Distractions, especially around three to five months, is a common cause of breast refusal. This is a behavioural/developmental reason unrelated to health, milk supply, nipples, attachment and so on. At this age babies become fascinated with the world around them. Feeding is not as important as what is going on elsewhere.

• Shorter sucking time. Breast refusal shouldn’t be confused with a shorter sucking time. Breastfeeding becomes more efficient as time goes by and babies learn to feed very competently so the feeds become shorter.

             Mother Causes

• A change in perfume, soap, talcum powder or a radical change in diet

• Early mastitis which can cause a salty taste in the milk

• Any illness or stress which may deplete the breastmilk supply or inhibit the letdown

• Medication which may alter the taste of the milk.

• Hormonal changes which may alter the taste or amount of the breastmilk. For example, the progesterone-only pill, early pregnancy or menstruation. Usually any problems caused by hormonal changes are temporary – the fussy feeding stops when the baby and breasts adjust. Some women find that breast refusal occurs when a period is due and stops when it is over.

            Possible breastfeeding causes

• Low milk supply

• A slow let-down response – I’ve never found any useful explanations for this apart from illness or stress. Relief of stress and extra rest may help.

• A rapid let-down response that frightens the baby, who then gets a mental block about the breast. Strategies for this include taking the baby off the breast and catching the spray of milk in a tissue, feeding ‘uphill’, using only one breast a feed. These suggestions are somewhat tricky to carry out and help from an advisor is recommended.

           Breast refusal – what to do?

• Most episodes of breast refusal are not related to ill-health (mother or baby) but if concerned see your family doctor.

• Check the milk supply is adequate. Breast refusal is not usually related to low milk supply but in this instance weighing and measuring (weight doesn’t mean much without length) with a competent health professional is the way to be absolutely sure and put your mind at rest.

• If possible extra rest and company from a calm person during the day and evening helps

A basic plan of action

• Try not to see what’s happening as a personal rejection. Breast refusal is common, usually temporary and not because the mother is doing anything wrong.

• When your baby cries, pulls off and refuses the breast, stop the feed. Trying to force the issue usually makes things worse.

• Change tactics – go for a walk, hand her over to a calm person (if one is available), or see if she will have a little doze.

• As often as possible pick your baby up and feed her when she is still drowsy after a sleep before she is fully awake. Feed her in a quiet darkened room away from distractions.

The following strategies may help/work:

• Give your baby suck on a finger then try slipping the nipple in; calm her by singing and rocking before the feed; try alternative feeding positions; hand express some milk into your baby’s mouth; try breastfeeding in the bath.

• Usually the night feeds are good so try to enjoy them and bear in mind that your baby is probably making up for the fussy day feeding by feeding well at night.

• Avoid bottles and formula as much as possible. Extra fluid in bottles is usually not needed. If your baby refuses the breast for twenty-four hours or if she is sick, you might need to use a bottle or a small cup.

• Giving a bottle has the potential to cause more stress – either because the baby won’t take it or because she decides she prefers it to the breast.
  Sometimes though - it has to be acknowledged - a bottle provides a welcome opportunity to ease the tension.

• Express for comfort and to keep the milk flowing if you need to.

          Breast refusal in older babies

All the above reasons apply to older babies (six to twelve months) however a big reason for breast refusal at this time is because some babies simply decide to wean themselves, or to give up some feeds. This can be upsetting whether you planned to breastfeed indefinitely or only for the first year.

Unfortunately, it’s usually something you have to accept unless the breast refusal is temporary because your baby is unwell (for example, a sore throat etc), in which case she might go back to the breast when she is well.

Even at this late stage it’s important to look after your breasts if the feeding dramatically decreases or ceases. Express for comfort and to avoid mastitis.

            Finally

Breast refusal is usually temporary, lasting from a couple of days to a couple of weeks, but occasionally a baby cannot be persuaded to go back to the breast. This doesn’t happen very often but when it does alternatives have to be considered. Younger babies can be weaned onto bottles and formula, older babies who are eating well can drink from cups.