This guideline applies to all health professionals caring for a healthy term newborn baby that is reluctant to feed.

The management of these babies includes promoting and protecting breastfeeding if this is the maternal choice, and aims to detect any deterioration in the baby’s condition.

Reluctant feeder

Most babies will seek to feed within the first 1-2 hours of life but some may be more reluctant to feed due to:

• the effects of maternal analgesia
• the effects of a long labour
• requiring resuscitation at delivery

Additionally, some babies may feed well initially but then not actively seek a further feed for many hours (UNICEF 2015).

Feeding cues 

Feeding cues indicate a state of light sleep and the beginning of feeding readiness when babies are more likely to latch and suck.

Cues include:

• rapid eye movements
• mouth and tongue movements
• body movements and mouthing on fists

Crying is a late sign of readiness to feed and indicates that earlier cues have been missed (UNICEF 2015).

Finger feeding

This allows the baby to receive small amounts (maximum of 5ml) of colostrum.

Ensure the mother has short, clean nails and encourage her to hold her baby in her arm with a feeding cup in the same hand. The mother should use her little finger of the opposite hand to dip into the milk and give to the baby to suck with finger pad uppermost in the baby’s mouth.

Syringe feeding

In order to achieve this safely, the baby should be held in the mother’s arms, slightly upright. Draw up the milk in a 3ml enteral syringe which is then put between the gum and the cheek. Approximately 0.2ml should be given at a time. Allow the baby to suck and enjoy the milk.

Volumes of more than 5mls should be given via feeding cup.

The UNICEF Baby Friendly Initiative accreditation status was achieved by NHS Borders in 2012.

The following link gives more information on the process and the benefits of accreditation to care provision:

https://www.unicef.org.uk/babyfriendly/what-is-baby-friendly/

Evidence encourages the baby to feed soon after birth, facilitated by uninterrupted skin to skin contact for at least one hour or until after the first feed or the mother wishes to end it (UNICEF 2015).

• Review feeding cues with the mother to engender confidence in recognising feeding opportunities.
• Rouse the baby by encouraging the mother to handle and talk to the baby, perhaps changing the nappy to encourage wakefulness.
• Undress the baby and place skin to skin with the mother, ensuring that both are covered with a warm, dry blanket.

Think possible sepsis

• A baby that is reluctant to feed may be showing the first signs of underlying illness.
• Assess the baby and perform temperature, heart rate, respiratory rate and observe the respirations for a full minute.
• This should include observation of colour, any sternal recession or nasal flaring.
• All observations should be recorded on a NEWS chart.
• If any concerns are noted, refer for paediatric /ANNP review as soon as possible (UNICEF 2007).
• Observations should be repeated every 4 hours.

• If breastfeeding, encourage the mother to hand express colostrum into a sterile cup. Thereafter teach the mother to finger feed the colostrum to the baby.
• If formula feeding, baby can be offered formula milk by cup or syringe if they refuse to suck on a teat.
• Keep baby skin to skin (regardless of feeding choice) encouraging the mother to observe her baby closely and to inform staff of any concerns.
• Keep the baby skin to skin and repeat the above steps every 2 hours until the baby is feeding effectively. It should be anticipated that the baby will become more interested in feeding and therefore observe closely for feeding cues.

Blood glucose/hyperglycaemia

• Blood glucose measurement is only required is the baby is jittery.
• This is defined as excessive, repetitive movements of one or more limbs which are unprovoked and usually relatively fast, or a symmetrical fine tremor (UNICEF 2007).
• Immediate paediatric/ANNP review is required if the baby appears unwell.

The following link can be used for information on best practice and how to support mothers with hand expressing:

https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/video/hand-expression/

• Many factors may influence the mother's feelings or ability to express colostrum and she may ask to give the baby formula instead.
• It is the responsibility of the midwife to give 1: 1 support to the mother in hand expressing and to clearly discuss the disadvantages of giving a breastfed baby formula milk (see below).
• If, however, the mother gives her fully informed consent, this should be documented in the mother's notes (see below).
• The volume of formula given should not exceed 3ml/kg of birth weight e.g. 3.5kg baby = 10.5 ml of formula.
• This should be given via feeding cup or enteral syringe if the baby is reluctant to cup feed and the amount given documented on a feeding chart.

In all cases ensure the mother has access to the relevant information for her feeding choice. For example:

1. Off to a good start: all you need to know about breastfeeding by Public Health Scotland
2. Local Support for Breastfeeding Parents by BIBS (Breastfeeding in the Borders Support)
3. Formula feeding – How to feed your baby safely by Public Health Scotland

Disadvantages of giving a breastfed baby formula milk

• Giving breastfed babies formula alters the pH in the baby’s gut flora. This can encourage the growth of pathogens that would have otherwise been unable to grow in the previously more alkaline environment. Furthermore, these changes in the gut pH change can take several weeks of exclusive breastfeeding to recover.
• There is also some evidence that the introduction of even one formula feed can reduce protection against atopic disease including asthma, eczema, allergic rhinitis, some food allergies, dermatitis and juvenile onset diabetes (UNICEF 2015).

Documentation

• The discussion between the mother and the midwife regarding the use of formula milk in a breastfed baby must be clearly documented, signed and dated.
• An example of acceptable documentation would be: ‘Following a full discussion with the mother regarding the possible consequences of introducing a formula feed to a breastfed baby, the mother has decided she would like the baby to be given formula milk’.

Outcomes will be monitored by:

• Audit and evaluation of care and advice given to a convenience sample of ante and post natal clients.
• Analysis of supplementation rate of breastfed babies.
• Qualitative data collected through patient stories.

Outcomes will be reported to:

• The Maternity Care Action Planning Group, the Director of Nursing and Midwifery and the Chief Executive of NHS Borders.

United Nations International Children’s emergency Fund (UNICEF) Hypoglycaemia policy guidelines 2007 

United Nations International Children’s Emergency Fund (UNICEF) The Baby Friendly Initiative 2015 

An easy reference flow chart for management of reluctant feeders is available here.