Baby feeding aversion

Aversion to feeding means screaming or crying when offered the breast or bottle, refusing to eat, or needing to be fed while moving or while drowsy/asleep. This is not a temporary nursing strike where baby refuses the breast/bottle for a few days because of periods returning, mom going back to work, teething, or illness, etc. The behaviors seen in baby are much more extreme for a true aversion. Most common causes: 

👅Tongue tie: One of my biggest red flags for tongue tie is reflux and shutting down during breastfeeding (sleepy on the breast, popping on and off, refusing the breast and preferring the bottle but then shutting down on the bottle). Some babies with tongue or lip tie do fine for the first few months by compensating on a full milk supply. The aversion comes around 3-4 months when supply regulates. Address the ties and do oral motor exercises to strengthen the system and the refusal can go away. 

🥛Intolerances/Allergy: This looks similar to reflux, but often with bowel issues as well (constipation, diarrhea, or mucousy/foamy poops). Babies who’s digestive tracts are uncomfortable don’t want to eat. They learn quickly to associate feeding with pain, so they shut down on feeding.

🤮Reflux: Easiest culprit to blame and mask with medication. The medication may mask the pain but won’t actually take the reflux away. Reflux is usually caused by food allergy/intolerance, gut issues, or tongue tie. Address the issue, resolve the reflux. 

🥵Silent aspiration: Milk going into the lungs instead of to the stomach.

🤯Behavioral: The number one concern of parents is feeding the baby. When feeding isn’t going well, it causes extreme stress, which can causes parents to do extreme things to try to fix the problem. It’s easy to spiral out when you’ve tried everything and it’s not working out of stress and desperation. Occasionally the reason for the refusal is no longer there, but it was so stressful in the moment, the panic that it could happen again sets in and perpetuates the problem. Some times the root issue is still there, but you’ve compensated and it’s causing a behavioral manifestation in both you and the baby. 

How many minutes should baby feed per side on the breast?

Not every baby needs 15 minutes per side. Some babies take a full feeding in only a few minutes, and from just one breast per feeding. Other babies may feed for a few minutes off each side. Older, more distractible  babies are efficient eaters with more important things to do than state at your chest. They may graze at the boob a few minutes at a time or want to go back and forth from side to side. 

In general, you know baby is getting enough breast milk when you have a pain free latch where the nipple goes in and out of baby’s mouth the same shape. You can hear baby swallow and don’t need to keep them awake at the breast for them to continue feeding. Baby should be making lots of heavy wet diapers and pooping daily or every other day. They also gain weight to their own curve and are a similar size of your unique family genetics. 

If your baby typically latches for you, and feeds well, and refuses to latch, they most likely are done. Follow your baby’s lead and get to know their feeding habits. Trust your baby and trust your body. If you’re concerned about how your baby is feeding, schedule and appointment with a breastfeeding expert: an IBCLC lactation consultant. 

Signs of an over supply:
😳Baby gulps quickly at the breast, feeds for only a few minutes and then refuses the breast, or bites during let down to slow the flow

😳Baby gains weight quicker than expected

😳Baby has a high amount of spit up, coughing or choking during or after feeding

😳You can pump a large volume in a very short amount of time (I knew one mom that could pump 8 ounces in 5 minutes 😳😳) 

The over supply may be caused by:

🌼Hormone imbalance

🌼Excessive pumping or Haakaa use in the early days after birth

🌼Certain medications 

🌼Some babies’ tongues stimulate the nipple differently, sending a signal to continue to make milk. This can occasionally be seen in the tongue tie population

🌼With every pregnancy you have more milk making glands and it can increase supply with each new baby

Coping with an oversupply:

💗Side lying or laid back nursing uses gravity to slow your milk flow

💗If baby cannot keep up with your flow, pull baby off during your first or fastest let down and allow your milk to flow into a nursing pad or towel. Latch baby once the flow slows

💗Avoid pumping or using a Haakaa as this tells your body to continue making more milk than you need

💗Try block feeding (feed on only one breast for a designated block of time, like 2-4 hours)

💗If baby is gaining weight too quickly (1+ pounds or more per week) and is spitting up heavily, time your feeding to end before baby over eats. Use a pacifier or distraction to help baby’s mouth be satisfied with sucking while the tummy has time to digest and tell the brain it’s actually full

Usually as supply regulates around 11-14 weeks, the symptoms go away and no further intervention is needed. Some of these symptoms can mimic other issues, so work with an IBCLC and weigh baby before and after several feedings can give you an idea of what’s actually going on. 

BREAST CHANGES

Breasts are made of a network of ducts, covered by a layer of fatty tissue. During pregnancy, estrogen and progesterone enlarge the milk ducts and multiply the glandular tissue that produces milk. After birth, estrogen and progesterone drop and prolactin and oxytocin rise. Prolactin makes milk production and oxytocin releases it into the ducts. Extra blood and fluid fill the breast just after birth to supoort your body adding hormone receptors in the breast to make milk. The blood and fluid surrounds the ducts and this extra pressure is what makes your breasts feel full between feeding. This blood and fluid reabsorb around 6-8 weeks once supply is established and you won’t feel that full/soft feeling except when you go a really long time between feeding or pumping. Breasts go back to prepregnancy size when supply regulates around 11-14 weeks but continue to make milk. When you wean from breastfeeding, it can take several months for prolactin levels to return to baseline (which is why you may still see milk for months after weaning). Once you stop breastfeeding, the milk making structures actually self-destruct – a process that involves massive cellular suicide, and the removal of the debris. Around 6 months after weaning, the milk-producing tissue is replaced with fatty tissue. If you return to your pre-pregnancy weight, your breasts most likely will return to the same size. They may not be as “perky” because the skin is a bit more stretched and the connective and fatty tissues in the breasts often shifts during pregnancy and breastfeeding. While they may look smaller after weaning most of us can expect that our breasts will return to a similar size as they were pre-pregnancy. They’re just a little more lived in and well loved. 

Baby constipated

While some things we hear about babies are common, that doesn’t mean they are normal. The idea that breastfed babies don’t need to poop daily has been normalized, but in reality, isn’t true!! The idea that there’s very little waste produced from breast milk is not based on scientific evidence and can actually prevent finding the true reason for baby’s lack of poop. 

In the newborn stage, prior to 6 weeks, pooping tells us if baby is getting the appropriate volumes of milk from the breast. Many times when a newborn isn’t pooping, it’s a sign they’re not getting enough breast milk. As you increase milk volumes, baby starts to poop! Decreased milk intake can happen when baby has a tongue tie and can’t efficiently move milk from the breast, if feedings are scheduled (waiting for every 3 hours) or if baby is being sleep trained too early. Low milk supply can be caused by retained placenta, thyroid or hormone disorders or when there is a breast surgical history like a reduction. 

Constipation can have other root causes. 

🧬For some, it may be that their digestive biome is not ideal… things like antibiotics given to mom during pregnancy/birth or antibiotics given to baby shortly after birth shift the biome where it doesn’t ideally absorb and process milk. Introduction of formula also changes the gut microbiome. Some babies may have difficulty digesting certain formulas and may struggle with pooping until the right one is found. 

💃🏻Not getting enough movement, tummy time or being in one position for too long (sitting in positioning devices like a dockatot for hours a day) decreases movement through the gut. Allergies and intolerances are another culprit. 🦷Babies who are teething may have a temporary change and miss a day or two and then return to daily stooling. 

🤢Illness, change of environment (maybe a holiday/ move of house), change of daily rhythm etc can all play a role, and temporary changes are to be expected.

Every person is unique and so there isn’t any “one size fits all” reason why an infant may be struggling with constipation/infrequent stooling. If you baby isn’t pooping regularly, an IBCLC can help figure out what may be going on and refer you to the right specialist as needed. 

Pump flange fit

Finding the right size pump flange is essential. I’ve found there are 3 F’s to Flange Fitting:

FIT:  🗝Flange fit isn’t based on your breast or areola size, it is JUST the size of the nipple and how it changes with suction

🗝Proper fit isn’t as simple as measuring your nipple, but it’s a start.

🗝A small amount of space around your nipple in the flange tunnel is good. There should be no space around the areola or in the larger bell part of the flange 

🗝The nipple tip shouldn’t hit the back of the flange. This means you have an elastic nipple

FEEL: 🗝Pain or blanching (changing colors to white or red) means it’s the wrong size

🗝Nipples rubbing against the sides of the flange tunnel mean fit needs to be improved and there is a risk of pain and damage

FUNCTION: 🗝It should actually move your milk efficiently. If you feel like there’s still milk left after pumping, you’re getting recurrent plugs or seeing a drop in supply, it’s not functioning well for you and changing the size should help

🗝Every nipple is unique and each side may use a different size (or shape/brand!). There are all kinds of flange sizes, inserts, and cushions to improve the pump experience

When should baby start rice cereal? Never

Starting solid food Myth – Rice cereal is the best first food for practice and will help your child sleep.

FALSE!

Rice cereal is a highly processed food that when prepared as cereal is far from its natural state. There are very few calories in rice cereal and it serves no nutritional value to the body or the gut. The reason rice cereal is often recommended first is because in the processing it is iron fortified (iron is added to it). Most newborns have sufficient iron stored in their bodies for about the first 6 months of life (depending on gestational age, maternal iron status, and timing of umbilical cord clamping). By 6 months, however, babies require an external source of iron apart from breast milk. (Formula contains iron, so it’s less of a concern for formula-fed infants.) Babies need 11 mg of iron per day for normal growth and development, and iron is vital for brain health and red blood cell production. Though rice cereal is fortified with iron, it’s a kind that doesn’t absorb well.

There is also no evidence that rice cereal has a positive impact on baby’s sleep, as it doesn’t digest any slower than milk does. Adding cereal to the bottle is also a huge choking risk. 

Rice cereal is not the best first choice for baby food and may be something you want to avoid. Rice absorbs high levels of arsenic (which is poisonous) from the soil. Ingesting even small amounts can damage the brain, nerves, blood vessels, or skin. In 2012, the Consumer Products Safety Commission (CPSC) came out with a report that said babies who eat two servings of rice cereal a day could double their lifetime cancer risk.

There are other, better first food choices. Spinach and broccoli are naturally high in iron, as are legumes like peas, chickpeas, lentils and beans. Turkey and red meat are very good sources of iron. 

Tongue tie assessment

Assessing for tongue tie takes a true hands on assessment, not just a quick look under the tongue during a cry or looking at a picture. An assessment isn’t complete without the provider’s fingers sweeping under the tongue, lifting the tongue, and seeing how the tongue moves in all direction, and then more importantly, knowing the difference between a normal tongue frenulum and a tied or restricted frenulum. Just because a person is qualified to “assess“ for tongue-tie, does not mean they necessarily know how to do so. And just because a baby has a frenulum, that doesn’t mean it’s tied or restricted. And if your pediatrician told you there’s no tie just because baby can stick their tongue out, that wasn’t actually an assessment. 

As a speech therapist, I look at 3 things when doing an assessment on infants: what does the tongue look like, what can the tongue do, what symptoms is it causing. The tongue needs full range of motion (in and out, side to side, and up and down ) for feeding, dental hygiene and to some extent speech. Some babies with a frenulum can still have range of motion maintained. The frenulum does not impact function. Symptoms to watch out for are feeding difficulties (can not grasp and hold a nipple for breast or bottle feeding, fatigues easily from tension on the tongue and jaw, cannot create the vacuum needed to draw breast milk so weight gain is poor or milk supply suffers, chokes and gags during feeding)

When range of motion is restricted, or is causing symptoms, I will refer to a pediatric dentist who also looks at how the frenulum is impacting structure: is it pulling on the structures of the floor of the mouth and the jaw? Is it putting tension on the bone? In those cases, when function is restricted and it is currently causing symptoms, a revision is warranted.