Newborn term infants who are breathing well at birth and are placed in ventral to ventral, skin to skin contact are able to instinctively crawl to their mother’s breast, unassisted, latch and begin breastfeeding. (1) The most important stimuli that the newborn infant requires at birth to achieve this are the mother’s smell (may be reassuring for continuity) and skin to skin contact which provides touch, warmth stability and movement. This habitat determines the newborn’s behaviour, acts as stimuli which activates the infants autonomic nervous system and hormones and “makes the muscles do the right thing”. (2). Whilst in skin to skin contact the basic biological needs of the newborn infant for oxygenation, warmth, nutrition and protection are able to be met. After the infant has latched to the breast and fed, the infant will go into a sleep cycle which is “recognised as a necessary requirement for healthy brain development” (2). The continuation of these healthy sleep cycles after the initial breastfeed depends on whether the presence of the ‘salient stimuli’ being the maternal presence stays in place. The newborn will then wake in four to six hours on average, however if the newborn infant is separated, the postnatal sleep may be twelve hours or more. (2). Maternal infant separation in the first hour of life, for the newborn infant results in a “brief protest response followed by a profound parasympathetic despair response.”(1). As a result the newborn infant‘s heart rate slows and there is a decrease in their core temperature by one to two degrees celsius within five minutes. This process occurs faster than is possible via evaporative and radiative cooling. (1)
Not all newborn infants latch to the breast immediately after or in first few hours following birth. Factors such as the nature of the labour, mode of birth, the infants need for resuscitation and/or respiratory support soon after birth and prematurity may cause maternal infant separation and therefore interfere with the infants ability to latch to the breast and feed. If the newborn infant is born via operative delivery (either abdominal or vaginal) and/or exposed to anaesthetics or maternal labour medications, they often experience difficulty crawling to the breast, latching and sucking. (1) A newborn infant uses half of its cranial nerves, “twenty two bones connecting at thirty four sutures; and sixty voluntary and involuntary muscles to suck, swallow and breathe in a coordinated activity” and this “...process occurs at forty to sixty cycles per minute, ten to thirty minutes at a feed, and eight to sixteen times a day”. During the normal process of birth the newborn infant’s skull can be exposed to mechanical forces which may affect the bony configuration/alignment of the skull, compress brain and central nervous system structures and “...disrupt nerve function or cause nerve entrapment.”(1) The infant’s suck response is triggered in part by tactile receptors in the lips and palate and any “compromise to the facial nerves could affect latching and sucking” (1) An instrumental birth, namely the use of forceps, may cause bruising and nerve damage to the sides of the infants cranium, where the forcep blades are placed. This may cause the infants jaw to deviate to the paralysed side when the mouth is opened and therefore impede the newborn infant’s ability to latch and suck. The newborn infant may be suffering from muscular Torticollis as a result of intrauterine positioning or vascular injury to one Sternocleidomastoid (SCM) muscle during or before birth. Contraction of the SCM muscle causes the head to be rotated to the opposite side and tilted to the same side as the injury. Associated facial asymmetries may be present including unequal mandible opening and as a result, infants affected by torticollis may have difficulties latching and transferring milk due to their asymmetrical mandible and twisted neck position.(2)
Resuscitation practices such as suctioning and intubation may trigger hyperesponsive gagging which in turn can inhibit deep latch at the breast. (1) When latched to the breast and sucking, the nipple extends to sit close to the junction of the hard and soft palate. If the newborn infant has a shallow latch, nipple damage and trauma may result as well as poor milk flow and a delay in the initiation and maintenance of lactation. Maternal pharmacological pain relief used during labour may also affect the infant’s ability to latch successfully to the breast and feed during the immediate post partum period. Drugs administered to the women during labour do cross the placenta as they are highly lipid soluble and therefore rapidly diffuse into the fetus. (1) Fentanyl and other drugs administered into the epidural space “require a higher absolute dose than those administered intravenously” and because the paediatric half-life of these drugs is longer than the maternal half-life, the infant’s ability to latch and suck may be further hindered. (1) Induction/augmentation of labour, epidural use during labour and birth via caesarean section all involve the use of intravenous fluids and maternal overhydration may result. Maternal overhydration may cause difficulties with latching due to breast oedema. As a result milk removal does not occur which impacts on the newborn infant’s nutrition status and on the maintenance of lactation. Breast massage, “reverse pressure softening”(3) and or expressing prior to assisting the infant to latch will assist in moving the oedema and make latching easier and improve stimulation to the breast in order to encourage milk production.
Premature infants (infants born prior to 37 completed weeks gestation) and term infants experiencing maladaptation to extra-uterine life are more likely to require respiratory support and require medical observation and treatment. For these infants maternal – infant separation is necessitated so that the infant can receive the medical treatment, investigation, observation and care they require. In these instances, the role of the nursing/ midwifery staff in supporting the mother’s lactation and the newborn infants need for nutrition is focused solely on providing the mother with information and support to initiate and maintain her lactation by breast milk expression. “The initiation of breastfeeding in a preterm infant should be based merely on cardio-respiratory stability (with severe apnea, bradychardia and desaturation in connection with handling as exclusion criteria), irrespective of current corrected gestation, postnatal age or weight.”(2) Often, the preterm infant’s ability to coordinate their sucking, swallowing and breathing reflexes is a requirement for commencing oral feeds. The preterm infant’s physiological response to breast and bottle feeding has demonstrated differences in favour of breastfeeding. While breastfeeding, “the infant is in control of sucking, swallowing and breathing in a pattern that permits physiological stability.” (2) There is no cause for concern as long as the infant is allowed to control the pace whereas with feeding via a bottle, control over the flow of the milk is more difficult for the infant to achieve.
In assessing readiness of the preterm infant to breastfeed, it is important to be aware of the special needs and characteristics of this group of infants. A preterm infant spends more time in a drowsy state and frequently shifts between diffuse sleep and active awake. (2) Signs of waking are “...more irregular respirations, gasps, grimaces, movements of lips and tongue, raised eyebrows and diffuse movements.”(2) For the preterm infant, direct light is an obstacle to eye opening and they are easily overloaded by stimuli such as touch, sounds and visual input. Their ability to block out environmental stimuli does not mature until a term age. Some practical tips for assisting the preterm baby to latch include if possible, the provision of information to the parents prior to the birth on how the infant will be fed, initiating breast milk expression and early skin to skin contact(SSC)/kangaroo care to assist with milk production and the initiation of breastfeeding. While in SSC, the mother senses her infants waking immediately, feels his movements and changes in his breathing pattern and learns his cues easily. The mother is then better able to utilise her infant’s wake time to entice him to latch to the breast. Preventing stressful events such as changing nappies and bathing prior to breastfeeds may assist the infant to conserve energy. For the early/initial breastfeeds the infant is more likely to be monitored so that apneas, bradychardias and desaturations in relation to breastfeeding can be observed and recorded. The mother of the infant needs to be provided with as much privacy and comfort as possible, a comfortable maternal breastfeeding position should be facilitated, which encourages relaxation and hence the flow of oxytocin (facilitating the milk ejection reflex).If the infant does not illicit a rooting reflex, encourage the mother to touch the infant’s lips with her nipple or finger to elicit this reflex. ‘The overhand or transitional hold’ is the most practical for small infants.’ The football hold’ also works well ensuring that the infant’s trunk is touching the mothers and that the arms and legs are flexed .The most important point to emphasise to the mother is that the infant requires adequate head support in order to stay well latched. If the infant is not staying latched or stays on for short periods, encourage the mother to pull her infant closer. If the nose is pressed into the breast, she can pull the infant’s buttocks closer which should tilt the forehead back further and free the nose. To encourage the infant to recommence sucking after a long pause, the mother can touch the infant’s palm and /or depress her breast tissue in front of the infant’s nose which pushes the nipple to the hard palate. Both of these actions will assist to elicit the suck reflex. (2)
Ankyglossia or tongue tie classified by a visible lingual frenulum between the underside of the tongue and the floor of the mouth, may have a negative effect on latching, sucking efficiency, milk removal and therefore milk production/supply and maternal comfort. Treatment for tongue tie which is impacting on the infant’s ability to latch and breastfeed as well as on the lactationshelle (in any of the above mentioned ways) is via frenotomy (releasing of the lingual frenulum). Management of tongue tie without frenotomy involves supporting the mother to maintain a full milk supply by expressing her milk seven to eight times/ day with a hospital grade or electric breast pump. Focussing on breastfeeding positions which facilitate the deepest asymmetrical latch possible-chin to breast and philtrum to nipple and laid back breastfeeding positions will assist the tongue tied infant to breastfeed. The use of a silicone nipple shield may also assist the non-latching infant with tongue tie. The widest diameter nipple shield should be used as it will fit completely into the mouth and assist their restricted tongue grooving. (2)
For non-latching infants, ‘Biological Nurturing’ positions, a term used for a range of mother baby positions whose interactions appear to release both mother and baby innate behaviours, aiding breastfeeding initiation.”(4) In biological nurturing positions, the mother neither sits upright, nor does she lie on her side or her back, instead she leans back in a “semi-reclined sitting posture, places her infant on top of her body so that the entire frontal aspect of the infant’s body is facing, touching and closely applied to the mother’s body curves...”. (4) Maternal comfort helps with the release of her oxytocin and prolactin and increases maternal confidence which is vital to the learning process. Suzanne Colson , the author of ‘Biological Nurturing’ (2010) discovered in her research on innate maternal and infant feeding behaviours, that interaction between the mother’s and infant’s body whether in SSC or lightly dressed, “appeared to stimulate a range of innate involuntary (infant) reflexes such as mouthing, licking, smelling, nuzzling and nesting at the breast, crawling and rooting movements, searching and latching onto the breast, sucking and swallowing were commonly followed by sleeping and relatching behaviours”(4) In many situations due to the infant’s position, baby-led latching to the breast occurs and with the aid of gravity, the infant is better supported to move towards the breast independently. If the mother needs to assist her infant to latch by changing the shape of her breast she is able to do this without adjusting her posture, does not need to guide her infants head and shoulders towards the breast and when the infant does latch, gravity may assist with a deeper latch. If the mother is experiencing nipple pain/trauma, she may find biological nurturing positions more comfortable while breastfeeding as gravity assists the weight of her lactating breast to fall back, possibly relieving the pressure from behind her nipple, (Clinical observation).
Finally, another instinctive feeding behaviour revealed by the infant in a biological nurturing position is the use of their hands when latching to the breast to feed. Historically mothers have been told to keep their infant’s hands away when latching them to the breast as they ‘get in the way.’ (5) Newborn infants often use hand to mouth movements prior to breast latchment. Researchers have hypothesized that these hand to mouth movements assist the infant to regulate their state and to self-calm” (5), after all this is a common practice of the fetus in utero. Between the ages of birth to three/four months, infants have been observed to use their hands whilst latching to the breast. If the infants face is touching the breast before latching, “the infant may use his hands to push or pull the breast to make the nipple accessible to the mouth, or to shape a better defined teat. If the face is not touching the breast, infants may use their arms to push away, perhaps to get a look at the nipple location”(5) Once the infant’s hand finds the nipple, it mouths on its hand, clams itself and then will often move that hand away and latch on to the same spot.