Causes of latching problems

Why is my baby unable to latch and stay latched onto the breast?

There are various reasons why babies cannot latch and breastfeed. The breastfeeding technique may be the cause, the nipple may be inverted, or the nipple root too firm. Other problems start with the baby, who may be unable to create enough suction because of a medical problem or weakness caused by prematurity. However, many babies with latching problems are normal and so are their mothers. It just takes some babies more time to learn to latch. Some never learn. Nipple size is rarely a problem unless the nipple is very big and the baby is very small. A baby who cannot suck or create a vacuum on anything, such as a finger, pacifier, or bottle nipple, likely has a major health issue.

Consider using our quick assessment tool, “How can I help my baby latch onto the breast?” to guide you through this concern.

A) Describing the causes of latching problems

In our clinic, mothers frequently report that their babies have latching problems. However, these are often normal situations and these babies are being forced to breastfeed when they are not hungry. Sometimes babies can latch and breastfeed once the latching technique or positioning is adjusted. We have found the laid-back hold can be helpful for getting babies to latch. If this is not effective and babies need more help latching, the sandwich technique is often very useful.

True latching problems have a range of causes that can originate with the baby, the mother, or both.

Rarely babies may feed poorly both at the breast and when other feeding methods are used. If your baby cannot suck or create a proper vacuum on anything, such as a breast, finger, bottle, or pacifier, see your health-care providers as soon as possible. Your baby may have a major health issue.

B) Nipple characteristics

Some mothers believe or are told that something is wrong with their nipples; they are too big or small or too long or short. However nipple size rarely affects latching.

1) Large nipple

Some mothers have very large nipples, possibly 2.5 cm (1 inch) in width and in length. This is more common in Asian mothers.

It may be difficult for a premature or other very small babies to latch onto these nipples. Once the baby has grown, large nipples may no longer be a barrier.

 2) Irregular nipple

Rarely nipples have unusual shapes that affect latching.

C) Nipple root problems

The pinch test is used to examine the nipple root to see if it is abnormal. It can reveal an inverted nipple or a firm nipple root; Both can cause latching problems.

Breastfeeding when an inverted nipple is present may be impossible. Similarly, breast trauma or surgery may cause permanent changes in the nipple root and keep the baby from latching. 

Other problems can be fixed. For example, swelling of the nipple root caused by excess fluid given during labour or by the mother’s milk coming in is easily fixed with areolar massage.

D) The baby’s problems

This baby was born with Bell palsy, a paralysis of one side of the face. He needed extra milk for a few weeks after birth until his palsy settled.

Some babies have medical or mechanical problems that make latching difficult. In order to latch, a baby needs to create enough suction to hold the nipple and nipple root in place. An abnormal mouth or a weak tongue, cheek, or jaw may make this difficult.

1) Premature birth

Any baby born at 39 weeks or less should be closely watched to make sure they can latch and breastfeed effectively. Babies who are born premature at 37 weeks or less are at very high risk of latching and other breastfeeding problems and are expected by parents and health-care providers to need support. Those born at 38 and even 39 weeks are often assumed to act like full-term babies and their feeding challenges are often not discovered until the baby is very underfed

Premature babies generally improve at latching and breastfeeding as they grow and become stronger but there is a wide range in their abilities and rate of progress.

2) Being born weak

Some newborns are born sleepy or weakOnce this has passed, they go on to breastfeed well.  

Other babies are born healthy but quickly become sleepy after birth, as they have latching problems and are not taking in enough milk. They may or may not learn to breastfeed.

3) Medical problems

Babies can be born with medical problems that prevent latching and sucking. Examples include:

  • A cleft palate or partial cleft (submucous) palate
  • tongue-tie 
  • An abnormal growth in the baby’s mouth (Tobuti 2017)
  • Abnormal tightness of one of the neck muscles (torticollis) (Genna 2015)
  • Down syndrome or other genetic problems
  • Bell palsy (facial paralysis)
  • Other medical causes of weakness such as a disorder of the nervous system

Some, such as a Bell’s palsy will clear with time, allowing the baby to breastfeed. Other problems are permanent.

4) Pain

Some babies have a broken bone from birth. These are painful and can interfere with breastfeeding but should not cause a true latching problem. Such babies should be positioned so there is no pressure on that side. For example, with a broken right collar bone, the baby should not be in the cradle or cross-cradle hold on the left breast. 

Similar steps should be taken to avoid other painful areas. These may include: 

  • The scalp, from a prolonged labour. 
  • The jaw, from a forceps delivery.
  • The neck, from a difficult delivery.

E) When no cause can be found

Our clinic has found that many of the babies with latching problems are totally normal and so are their mothers. While it is possible that certain events during labour and delivery contribute to such latching problems, there is no research showing this. 

These babies can suck on other things such as fingers, bottles, and pacifiers, and otherwise grow and develop normally if given enough milk. It just seems to take some babies a little more time than others to learn to latch onto the breast and some never learn.

In general:

  • Most full-term babies learn to breastfeed by 12 weeks of age.
  • If they have not learned to breastfeed by 12 weeks, they are less likely to ever learn.
  • Babies who latch but cannot stay latched usually learn to breastfeed a little sooner than babies who cannot latch at all.
  • Babies are more likely to learn to breastfeed if they are able to breastfeed effectively with a nipple shield. Those who cannot use a nipple shield are less likely to do so. 

F) Unlikely causes of latching problems

It is natural to try to find the cause of a latching problems but there may not be one. This search can lead to misdiagnoses and inappropriate treatments. 

Latching problems are not caused by:

  • low milk supply: When there is not enough milk, babies can latch and suck but tend to have feeds that are too long or short compared with the average length. They may  come to reject the breast over time, which is different from a latching problem.
  • Milk not coming fast enough: The let-down is rarely too slow with breastfeeding.
  • Milk coming too fast: This is common when mothers have a large milk supply. These babies tend to come off the breast a little more often but they can still latch and suck and grow well.
  • A baby being lazy, stubborn, or difficult: Babies with latching problems are willing to try to breastfeed but just can’t do it. This is not a reflection on their character.

Some mothers believe that bottle-feeding caused their baby’s latching problem when in fact the bottle was given because the baby could not latch after birth. The bottle was the response to, and not the cause of the problem in this situation. Extensive bottle use can however, cause babies to reject the breast over time.

One common assumption is that an anterior (classic) tongue-tie is preventing the baby from latching (Miller 2017). We have not found that clipping a tongue-tie consistently helps a baby latch. Currently posterior tongue-ties and lip-ties are popular diagnoses. We have seen many mothers whose baby had extensive and expensive surgery but still could not latch. 

References

Genna CW. Breastfeeding infants with congenital torticollis. J Hum Lact. 2015 May;31(2):216-20 

Miller AS, Miller JE, Taylor AM, et al. Demographic profile of 266 mother-infant dyads presenting to a multidisciplinary breastfeeding clinic: a descriptive study. Journal of Clinical Chiropractic Pediatrics. 2017;16(1):1350-55
 
Tobouti PL, Pigatti FM, Martins-Mussi MC, et al. Extra-tongue oral granular cell tumor: Histological and immunohistochemical aspect. Med Oral Patol Oral Cir Bucal. 2017;22(1):e31–e35