When you were preparing for this breastfeeding thing, you were worried it might hurt. Your sister-in-law worried you that your baby might feed ‘all the time’. You were concerned how you were going to breastfeed in public.

Now you wish you were so lucky to have a baby that ‘fed all the time’. If only you could experience breastfeeding at ALL, even if it hurt a bit. You envy the women who have a problem feeding in Starbucks. You should be so lucky.

Breast refusal is scary. It wasn’t what you were expecting. You thought this little person would come out wanting to do it.  No one told you anything else was possible. Your antenatal class teacher showed you some amazing video of a baby crawling up their post-birth mummy’s body and self-attaching. Trouble is - it seems your own baby hasn’t seen the same videos.

The 2010 infant feeding survey says that 27% of mothers stop breastfeeding in the first week because their baby was completely rejecting the breast or not latching properly. There are lots of people struggling with this problem and a lot of breastfeeding counsellors and lactation consultants trying to help them.

Just to say, it is completely normal for babies to sometimes appear to reject the breast in the course of successful breastfeeding. Just like we sometimes don’t fancy a meal, babies are the same. They don’t care what the clock says. Sometimes they are simply too tired or over-stimulated. Perhaps they are dealing with something to do with lower digestion and a poo is imminent. Sometimes they have some upper wind and although they are apparently hungry, it seems like some mysterious force field is preventing them from latching on. These are babies that may take a few hours before they feed successfully again but they will usually get there in the end. If we are seeing wet nappies, periods of alertness and there are no other medical concerns, we may just have to wait a while. We continue to skin-to-skin. We try different positions. It happens in the end.

Newborn breast refusal is a different thing. Sometimes these are babies who did manage to feed a handful of times over a few days but we are usually talking about babies who have yet to latch on successfully and transfer milk. They may refuse to latch at all and bob on the breast in a frustrated and desperate way. Perhaps they may appear at first to latch with the right gape and positioning. It actually does look like those photos from your antenatal class, but when the baby is ‘on’ nothing seems to actually happen.  It is like the photo – immobile and not the video version. They just sit there and fall asleep quite quickly.

What are we going to do?

Here are the first four rules when a newborn baby isn’t breastfeeding (credit to IBCLC Linda Smith for the last 3).

1. Don’t panic.

   I know that sounds trite but new mums are awash with hormones and especially if your birth wasn’t what you expected, a non-attaching baby can be a very frightening concept. You really weren’t prepared for this. Does this mean you are never going to breastfeed?
   
   It is very very very important to hear this next part: 
   
   With the right information and support, most mums of non-attaching babies will be able to breastfeed after a short while. 
   
   There is a small minority for whom there are further complications but this is a minority.
   
   I have known many many mums (and I was one of them) who had a baby who didn’t attach properly for the first few days and went on to breastfeed happily for as long as they wanted to, for months and even years.
   
   I rarely share my own breastfeeding experience but Sam’s story is relevant here. When I was giving birth to Sam in 2004, my labour moved very quickly for a first baby. When I was in transition and felt ready to push, we called the midwife in and she shook her head with a smile and said, “Honey, no. You’ve got hours and hours to go yet. This is still early days.” This was without any examination or having been in the room with me any time recently. It was a back-to-back labour which can be quite uncomfortable and my birth plan suddenly went out the window. I panicked. She offered me pethidine – an opiate drug. I took it. She explained that it was never sensible to give it just before delivery as it can affect baby but this would be OK as I had ‘so long’ to go. Sam was born less than half an hour later. I was 10 cm dilated while she was administering the injection.
   
   Sam was OK but he was very very sleepy and although we had a bit of skin-to-skin (which I don’t remember being called that then); he really wasn’t up to breastfeeding. Luckily another midwife saw the situation and told me to get pumping and syringe feeding.  He only breastfed properly for the first time on about day 3. He was initially syringe-fed colostrum and never needed any other milk.
   
   Sometimes non-attachment is about the birth experience. Drugs that relieve our pain can annoyingly affect baby too. The first breastfeed and the first few days can be a far greater challenge when we’re waiting for things to get back to normal.
   
   Research is very clear that even drugs seen as less hard core than pethidine, like those in an epidural, impact on early breastfeeding success over the first 24 hours: http://www.ncbi.nlm.nih.gov/pubmed/12583645
   
   And we can get into a cascade where a mum doesn’t get those early feeds to happen, is encouraged to use a bottle or supplement in another way and she’s then not dealing with the consequences of the epidural but the decisions that led from that.
   
   Some babies born with forceps or ventouse can experience cranial nerve bruising and discomfort which make the mechanics of early breastfeeding a struggle. Unfortunately the baby is unable to convey the fact they have experienced compression of the glossopharyngeal, hypoglossal or vagus nerve so please give them a while. If you have a headache, imagine the act of opening your mouth really really wide or someone holding the side of your head.
   
   Are we saying that all babies who have assisted deliveries or whose mums take pain relief will struggle? No, of course not. Many will be fine and breastfeed well but this is about likelihood. I don’t know anyone who has turned down a forceps delivery when it’s recommended to them and that’s not what this is about. It’s about having information. Talk to your doctor when induction is suggested a week after the due date. What’s the evidence base for that decision because that may increase the chance of pain relief or an assisted delivery and that may make breastfeeding more of a challenge? If you are going down a certain road, know that breastfeeding support may be more of a priority. You may need to place an even higher emphasis on skin-to-skin after birth (though I hope it was high on your list anyway) and you may need a breast pump.
   
   But we’re still not panicking because even if things go initially a bit pear-shaped, it’s likely you can still make breastfeeding happen. You follow these rules. You talk to people around you who know about breastfeeding. You look after yourself. You say hello to your gorgeous new baby who isn’t doing this on purpose and would really like to breastfeed too.

2. Rule 2 is feed the baby.

   I know that might sound obvious but you’d be surprised. I’ve known situations where trying to breastfeed takes ages and ages and baby and mum and everyone are tired and baby drifts off to sleep and no actual milk was transferred.  Then baby wakes up and there’s another attempt to breastfeed. Sleepy young babies then start to conserve energy and sleep more (which makes breastfeeding even less likely). If we’re going to work on this, we need some fuel. Plus we obviously want baby to be hydrated and not lose too much weight – though it’s important to note that babies aren’t expected to take in a lot of milk in the first couple of days and are expected to lose some weight. We don’t need to glug huge quantities into them. Early feeds are teaspoons worth. However they get the gut moving, get the poo happening and have a PhD’s worth of useful purposes.
   
   Hopefully if baby isn’t breastfeeding, you are being shown how to take the milk out of your breasts immediately. There’s a nice video on breast massage and hand expression here: http://bfmedneo.com/
   
   This is a time when the mums who did some hand expression antenatally are at an advantage. You can read more about that option here: http://abm.me.uk/expressing-milk-baby-arrives-antenatal-expression-colostrum/
   
   You can collect the colostrum in a syringe and ask someone to show you how to give it to baby using a cup or a syringe. I like syringe feeding as it means there is nothing wasted and you can pop your finger against the roof of baby’s mouth and get some sucking happening with the tongue extended over the gum ridge and a rhythm developing. Baby isn’t flat on their back but elevated enough to reduce the risk of aspiration. Baby starts to suck on your clean finger and you reward with a little bit of milk from the syringe in the corner of their mouth. Cup feeding also gets the tongue extended but it’s usually something you need to be taught.
   
   Bottle-feeding isn’t considered first choice because it can teach incorrect tongue positioning, poor gaping and milk will flow without baby needing to use their muscles in the normal way.
   
   However if it’s day three and baby hasn’t fed for eight hours and you are panicking and you can’t get hold of the midwife, giving a bottle may be a more sensible choice than not. You’re just going to try and do in a way that is as close to breastfeeding as possible. Have a look on YouTube for some videos on ‘paced bottle-feeding’. Some are quite extreme but take the principle that we want the baby to create negative space in their mouth and remove milk with effort. If the bottle is more horizontal and the baby is more upright, that is more likely to happen. The milk should not be so fast that the baby is overwhelmed and they are struggling to maintain breathing. Bottle feeding babies have lower oxygenation rates when they are feeding anyway so let’s be extra careful with flow.
   
   We also want a baby feeding on the bottle to have a mouth that looks like a baby feeding on the breast.  It seems logical to still hope that the baby will gape with a wide mouth. When they breastfeed, they fill their oral cavity with stuff. It seems sensible to do the same thing when we bottle-feed rather than have a baby nipple-feeding with pursed lips. Let’s put the nipple above the top lip, ‘nose to nipple’. When the baby gapes we will bring the bottle into baby’s mouth when it is still wide. If the baby’s bottom lip is flanged down, that’s a good sign that the tongue is extending over the gum ridge rather than being pushed back as it can with artificial nipples. It may be more difficult to get a baby to do anything other than nipple-feed on bottles that have long nipples and very little silicon areola/ breast behind them. And a word of warning – it’s amazing how many bottles seem to be the “closest to the breast”.  It’s never going to be close and it’s going to depend which bit of the experience of breastfeeding you are prioritising. If we used paced bottle-feeding, we can slow the flow so I think it seems wise to try and get a space that allows gaping alongside that.

3. Protect the Milk supply.

   So baby is being fed and at number three, we are protecting the milk supply. That’s still ahead of trying to breastfeed and practising breastfeeding. If we maintain and protect milk supply, we’ll have options once underlying problems have resolved. If we don’t, when baby does start feeding it may not last long if they don’t find time at the breast rewarding.
   
   In the first few weeks, our breast tissue is developing and we are laying down the ground work for our supply that will govern the rest of the time we breastfeed. Stimulating supply now will make difference months down the line. Plus if we don’t protect milk supply, we’re more likely to get blocked ducts, mastitis, engorgement and abscesses.
   
   A lot of people will tell you that colostrum can only be hand expressed. Colostrum is sticky and there isn’t much of it and it can get lost in pumps and flanges. With hand expression, you can gather every drop. However once a day has passed, you may find it useful to start pumping too. It will save time and help your supply really kick in. You could perhaps hand express first and then pump for 5-10 minutes. As your milk transitions to mature milk, you may find it’s more time efficient to keep going with just the pumping. Some mums find hand expression super easy and continue with that but hand expressing 8-10 times in 24 hours can be hard work.
   
   You can hire hospital grade double electric pumps. Your local NCT branch may have a pump agent. You can also hire direct from ardobreastpumps.co.uk. Pumping shouldn’t hurt and take a moment to check you have the right funnel/ flange size. Your pump rental agent can send out alternatives.
   
   When a baby is non-attaching, a typical day may look like this:
   
   Skin-to-skin, try breastfeeding for 15-20 minutes (if it works and milk is being transferred, go longer!); someone else gives a top-up while mums pumps. Everyone naps.
   
   Repeat.
   
   Baby will be feeding roughly every three hours (counting from beginning of feed to beginning) with perhaps one block of not feeding as long as 4-5 hours.
   
   Ideally you are one ahead on the pumping. That means you don’t pump while a hungry baby is waiting for your milk. That’s likely to affect the way the milk flows and won’t help anyone. You should be pumping for the feed that comes after.
   
   Mums often get better pumping results with a bit of breast preparation. Start with breast massage and warm compressions. In research, mums also got a good deal more out when they did some hand expression after the flow from pumping had stopped.
   
   Newborn babies cluster feed so you could cluster pump too. Have an hour or so, perhaps in the evening, when you pump for 10 minutes, pause for 5, pump for 10 minutes, pause for 5, repeat.

4. Work on the Breastfeeding

   When baby is being fed and your supply is being protected, you can work on the breastfeeding.
   
   Skin-to-skin is super important (have I mentioned that already?). We try to breastfeed when babies are quietly alert or a bit sleepy or hungry or not very hungry or not very hungry at all. Try it all. You can also try after a little bit from the bottle. Don’t think the breast always HAS to be first and if you’re giving up on the breast, that’s it. You could give 10ml from a syringe, try some breastfeeding, a bit more from a syringe, trickle the syringe over the nipple to encourage some licking and rooting. Move between breast and non-breast organically.
   
   All feeds happen at a naked breast.
   
   Try different positions. Have a look at www.biologicalnurturing.com and try some laid back breastfeeding. See if you can encourage some self-attachment.
   
   How do you know milk is being transferred? You may hear some swallowing but not always. You should notice baby’s chin moving and occasionally pausing to show a swallow. Dr Jack Newman has a video called ‘really good drinking’ that may help: http://www.breastfeedinginc.ca/content.php?pagename=vid-reallygood
   
   If you have very flat or inverted nipples, it may appear that baby is searching for something but not quite able to get purchase and stay on. You may need some help learning how to shape your breast and nipple. You may even end up using nipple shields to help a non-attaching baby attach. Nipple shields get a bad rep but this is a situation where they can be useful and a baby may end up breastfeeding as a result. It’s always better though to use a shield with some qualified support. They can cause further problems if the wrong sized shield is used, if they are applied poorly and the latch is still a problem.
   
   Getting qualified support is a good idea whatever your nipple look like. You can ask your midwife for local recommendations. Perhaps that person is your midwife or her colleague. You may have a local volunteer breastfeeding counsellor who can meet you at home or who runs a local group. You may choose to pay for a private lactation consultant and you can find one at www.lcgb.org.
   
   It’s also sensible to get someone to look inside baby’s mouth, someone who knows that tongue tie can affect breastfeeding. I know that might sound daft but some healthcare professionals are poorly trained in tongue tie and it’s a leading cause of non-attachment in young babies.
   
   You can read more about tongue tie here: http://www.cwgenna.com/ttidentify.html
   
   Babies can also struggle if they have high palates and this often goes alongside having a tongue tie.
   
   If your baby does have a tongue tie that still doesn’t mean you won’t be successfully breastfeeding soon. You can learn different positions and breast shaping techniques that can help. Your baby may also benefit from a simple procedure where the membrane that holds their tongue tie is cut with a pair of round-ended scissors. This is called a frenectomy. Your midwife or GP should be able to refer you to your local NHS tongue tie service. You can also find private practitioners here: www.tongue-tie.org.uk.
   
   I know this is scary but please believe that if you find the people that can help you this is still likely to work out.
   
   I know mums who have had a baby finally attached at 48 hours, one week, two weeks, three weeks and six weeks. The 27% who gave up in the first week according to the infant feeding survey weren’t speaking to the right people. We were visited at the ABM conference by a mum who attached for the first time at 18 months (that got your attention, didn’t it.) No one can tell you how long to keep going with this but it’s true that you might give up when there’s still a chance your baby will happily attach. You have to decide when it’s right for you.
   
   You could certainly continue exclusively breast milk feeding your baby if that’s what you want to do. I could write another 3000 words on why that’s a good idea. You can read more about exclusive pumping in a useful book written by Stephanie Casemore: http://www.exclusivelypumping.com/
   
   Good luck. Be strong. Find helpers… and did I mention skin-to-skin?
   
   **********************

   Is your baby older and was previously successfully breastfeeding?

   Some babies may start to refuse the breast after a period of successful breastfeeding. That can also be confusing and upsetting. It can happen as a result of flow confusion if they have had regular experience of bottles. In that situation, you could perhaps speed up the flow at the breast (perhaps by increasing supply or using breast compressions). If you’ve been using bottles a fair bit, your supply may have taken a dip and may need a bit of attention. Breast compressions are useful when the milk starts to get fattier and slower and baby may be finding it a bit harder work. A bit more on breast compressions here: https://www.youtube.com/watch?v=Oh-nnTps1Ls
   
   You can also slow things on the bottle in comparison. The section above on paced bottle-feeding talks you through some of that. If you are confused and unsure, visit your local breastfeeding support group. Don’t think they are just for people with new babies and people who don’t use bottles.
   
   Breastfeeding babies who’ve never had a bottle in their lives can also go on nursing strikes. A self-weaning baby doesn’t give up breastfeeding overnight; it’s normally a gradual and gentle process that takes no one by surprise. It also rarely happens under 18 months old. Nursing strikes can be sudden and with no obvious cause.
   
   Some good thoughts on nursing strikes here: http://www.lalecheleague.org/faq/strike.html
   
   Get your GP to check baby doesn’t have an ear infection and check in baby’s mouth. Could your baby have a blocked nose? Most nursing strikes will resolve within a few days. Feed the baby and protect your supply.